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

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    Tuesday, March 30, 2010
    Grand Rounds is Up

    This edition focuses on health care reform. Check it out.


    Sunday, March 28, 2010
    Academy Award™ Meatballs

    Okay, it's recipe time again. Recently I decided to make meatballs for a party and was pleased with my efforts, so thought I would post my recipe here. The title comes from the fact that I made it for an Oscar™ party, but I got the recipe from About.com. I altered it a bit to serve with homemade barbecue sauce. (Sorry about the trademarks, but those Academy people play hardball if you don't use them.)

    Here's my big issue with most meatball recipes: they assume you're going to be serving an Italianate type dish, such as meatball sandwiches or spaghetti and meatballs. I was looking for the sort of meatball you could serve as a Swedish meatball or with barbecue sauce - a gender neutral meatball, if you will. I found one online; here is the original recipe, and here is what I did.

    Academy Award™ Meatballs

    1 beaten egg
    1/2 cup breadcrumbs
    2 tsp Worcestershire sauce
    2 tsp finely shredded lemon peel
    1 large carrot, finely shredded (if you don't have a Microplane grater, this recipe is a really good reason to get one. The coarse grater will not do here.)
    2 pounds ground turkey, ground chicken or lean ground beef

    Before you start to mix, get out a large Dutch oven and mix all the ingredients for the barbecue sauce in it [see below] but don't start cooking yet. Take a large plate and line it with paper towels to drain the meatballs. Get out your frying pan and put a small amount of cooking oil in it. (I was making beef meatballs, and used a nonstick pan, so used no oil and they were fine.)

    Now combine all of the above ingredients in a large bowl, wash your hands, and go to town. Smoosh the ingredients until well combined. Turn on the heat under the barbecue sauce and the frying pan, and start rolling your meatballs (slightly smaller than Ping-Pong ball size). What you will do is the following: drop a batch of meatballs into the pan and brown them on all sides. You are not trying to cook them through - just brown them. Drain on the paper towels and then throw them into the simmering barbecue sauce. Repeat with successive batches of meatballs. Cook the meatballs for at least 45 minutes, or you can cook longer, which is nice if you're having a party and want to make this in advance. I highly recommend using a flame tamer if you're going to cook them longer.

    This recipe will make more meatballs than will fit in the sauce, so take the final batch of browned meatballs and spread them out on a cookie sheet. Put in the freezer till frozen, then bag them in a Zip-Lock freezer bag and put them back into the freezer. Hooray, you have extra meatballs to cook up on a moment's notice!

    The barbecue sauce is courtesy of Peg Bracken, of blessed memory. She is the author of The I Hate to Cook Book, the first cookbook I ever read. Despite the title the recipes are surprisingly good and reliable. I actually found the recipe for the sauce in The I Hate to Housekeep Book, which also contains several good recipes. (As Peg says, cooking and housekeeping are inextricably intertwined.) Here we go:

    1 bottle Heinz chili sauce - this comes in a bottle that looks a lot like ketchup and is not highly spiced at all. It's my secret weapon for barbecue sauce and meatloaf.
    2/3 cup water - put it into the emptied chili sauce bottle and shake it around well to rinse out all that Heinz goodness.
    1/4 cup vinegar, cider or plain white distilled
    1 tsp prepared mustard
    1 tsp sugar
    1/2 tsp onion salt or garlic salt or celery salt (I used 1/4 tsp celery salt and 1/4 tsp each garlic powder and onion flakes)

    Combine all of the above and simmer on very low heat for at least 15 minutes. You can then use it on barbecued meat or for the meatballs.


    Saturday, March 27, 2010

    It's officially official: 24's run on television ends in May. [Warning: if you aren't caught up on the show, spoilers to follow!]

    I have been watching the show since Day Five (haven't yet watched the previous four seasons) and thoroughly enjoyed it, even when the show was not at its best. That would be Day Six, in case you were wondering. The news that the show is ending kind of makes me sad, but on the other hand I have to admit that 24 has run its course. Day Eight has been better than either season six or seven, but the writers are definitely in the recycling-old-plot-lines phase. For example, this season I had been mentally awarding kudos to the writers for avoiding the timeworn "mole in CTU" plot line. This past week we learned that Katee Sackhoff's character is - surprise - The Mole in CTU! ::headdesk::

    The 24 producers have a gift for landing wonderful character actors for the show, which adds greatly to the fun of watching it. On the other hand it's frustrating to see said really good actors mouthing bad dialogue and playing cardboard characters whose function is to develop a specific plot point and then get killed in some fashion or other. Usually in their last fifteen minutes or so they are allowed to flash an intriguing bit of character development, only to get killed off or erased from the show just as the viewer starts to get interested (see also: Kurtwood Smith as the Senator in S7, Sean Astin as Lynn McGill/CTU head in S5, Jurgen Prochnow as the head of the Russian crime syndicate this season). Sometimes though the show excels itself and we get great actors who are allowed to go to town. Season 5 was perhaps the last time this happened. It featured Gregory Itzin as slippery President Logan, Jean Smart as his crazy-but-not-really-crazy wife (some reviewers compared her to the prophet Cassandra), and Peter Weller as Jack's former boss gone bad, Christopher Henderson. It rocked, and that was the season I got addicted.

    Are the plots ridiculous? Yes they are. Of course they are. As I said when I first started watching the show, 24 is basically an updated version of the cliffhanger serials from the 1930's. This is what makes Dave Barry's real time blog posts poking fun at every episode so much fun. The first season started with Jack protecting a senator who was running for President - reasonable. But the plots escalated and every season since has involved a sitting President and the White House; in fact, last season involved terrorists swimming the Potomac, breaking into the White House (from the river, through the foundation of the White House) and taking the President hostage. This is impossible as the Potomac River doesn't run anywhere close to the center of Washington, D.C. Stuff like this is unnecessary. You could put a strong character like Jack Bauer anywhere in any situation and the show would still be good.

    My final recommendation is this. When it comes to TV I have the attention span of a gnat. Usually even when I find a show that I like, I'll watch a few episodes and then quit. This has not happened with 24. I've seen every episode of the past four seasons, and for me, this is unheard of. When this season is over and the show ends I plan to log on to Netflix and start renting the previous four seasons. No other TV show has grabbed my interest like this one. If you've never seen it, give it a try; start with Season 1 and go from there, or at least start with Season 5 as I did. You won't regret it.


    Thursday, March 25, 2010

    I have two meetings later today but I'm enjoying my Thursday morning immensely, reading blogs and my Amazon recommendations and checking lab results. I slept in till 7:15! (Two hours later than usual.)

    I love having a four day workweek. I don't spend my Thursdays sitting around and watching TV though. Usually I do paperwork, call patients with lab results and/or attend meetings. Last week the Sears repair guy came to fix my oven (the door handle was falling off); the week before that it was the plumber. It's much faster to get service on weekdays than it is on weekends.

    Speaking of Amazon, this book was recently recommended to me in an email from their salesbot. I think it may win the title of Most Useless Craft Book Ever. "25 Bread Cloths for the Holidays"? Do people even use bread cloths anymore? I can see having one bread cloth for, perhaps, Thanksgiving and Christmas; those seem to be the only times anyone serves hot bread these days. But embroidering one of them, let alone several, is completely beyond me.

    As to why it was recommended, I do have a thing for craft books. I love reading them though I rarely make any of the projects. I find them soothing reading last thing at night. Some are more practical than others, like the ones that explain how to sew curtains and pillows. When civilization collapses it might be useful to know how to knit a sweater, but I don't think it will help to be well stocked with bread cloths.


    Monday, March 22, 2010
    The Future of Healthcare: One Doc's Opinion

    So, looks like the healthcare bill is passing. (I am writing this on Sunday afternoon.)

    My feelings are mixed about this. Over the years I have seen many cases of patients who have lost their health insurance and come to me in flat out panic. If applying for individual coverage, they have been denied due to their health history or even, in some cases, incredibly minor things. If the bill will solve their problems that is a good thing but I'm not so sure it will. Plus it comes with a lot of baggage, not least the fact that nobody knows WTF is contained in the bill. Congress now faces the challenge of thrashing this thing into shape after passage, since they had to rush it through sloppily to get it passed at all. Even Obama doesn't know what all is in the bill and what isn't: see this interview. This procedure makes about as much sense as a museum buying a chunk of marble and then hiring someone to sculpt the Venus de Milo out of it.

    Also, as I mentioned previously, there aren't enough doctors/healthcare providers to provide care to all these newly insured patients who presumably are going to sign up. Check out this Newsweek article, which I think explains rather well what is going on. The process of finding a doctor is going to be like musical chairs: when the triumphant "We Passed Healthcare" music stops playing, a lot of potential patients are going to find themselves with no place to go. Though I will report one piece of cheering news. The number of students entering family practice residencies has picked up this year. Perhaps, in a recession, med students have finally figured out that if you go into primary care you will never lose your job.

    Prices will be higher for insurance all the way around. Employers will either go out of business (if they're small) or fire part of their staff and insist that those who are still employed pay a higher share of the bill. Your taxes will go up, I guarantee it. National debt will also skyrocket. If we - the employed/insured - are willing to put up with this, then so be it.

    Why do I say all this? Can the government provide good, basic healthcare for less money? They probably can. Unfortunately nobody wants basic healthcare. My definition of basic healthcare is the following: Infertility isn't covered. Viagra and similar drugs aren't covered. Organ transplants: may or may not be covered, but the antirejection drugs you'll need probably won't be. Breast reconstruction after mastectomy? Not covered. You get a beanbag to put in your bra. Seeing a dermatologist for acne: not covered, your primary care doc can do that. And so forth. Most of this stuff won't shorten your lifespan if it is not covered, but my impression is the American public will be pretty pissed off to hear this.

    The other issue is the iffy circumstances under which the bill was passed. A large portion of the population is against the bill, will remember who voted for it, will do their best to vote those who did out of office. Many states are preparing to sue the Federal government to fight the passage of the bill. They may well lose, but the money spent and the bitterness engendered will leave a lasting legacy.

    The next few weeks are going to be a bumpy ride.

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    Sunday, March 21, 2010

    Week In Review

    In honor of the L.A. Marathon today, I'm doing... nothing. As little as humanly possible. I don't mean to claim laziness is healthy, mind you, it's just that the marathon is being run very near me and traffic is a mess as a consequence. I'm not sorry to have an excuse not to stir from the house as it was a busy week. In no particular order, we have:

    • A case of domestic violence. For obvious reasons I'm not giving any details here, but it gave me a chance to brush up on the details of reporting such incidents. I am so grateful that The Firm's risk manager is right down the hall; he was extremely helpful. The Beverly Hills police were also accommodating and sent an officer to take a statement from the patient. The one thing I will say is that no one should ever be afraid to report such an incident even if you started it. If someone responds to a relatively mild push, let's say, with significantly more force and intimidation, that is a serious problem.

    • Getting peed on while trying to perform a pelvic exam. No big deal: the patient in question is demented so naturally I cut her some slack, and I was of course wearing gloves at the time. Still, it was worthy of note as that hasn't happened to me before. I learned that golden showers are not my thing.

    • A truly awesome St Patrick's day party. V. and her spouse have an annual tradition of throwing a corned-beef dinner, with pizza for those who don't like corned beef, and it gets bigger every year. She called me the next morning and invited me to guess how many people attended altogether... there were 87 guests. I brought my green cheesecake and it was much appreciated. Also I lent her my slow cooker for the beef: they had six or seven cookers going. It's good to know mine still works, as it has to be at least 35 years old by now and it's still going strong. (I swiped it from my mother, who never uses it.)

    • A training class for our new EMR (electronic medical record) system. The Firm has been using our current system for over three years now, and we're switching to a different one - mostly, I guess, because Tertiary Medical Center is implementing this particular system and since we're joined at the hip with them that means we have to switch too. The Firm is lauding the flexibility of this particular program, and it does in fact have many ways to enter information. You can use a point and click menu, or you can use a slightly different menu, or you can free text. The thing is there are so many different options that it's rather confusing. Still, I think in the long run we'll manage quite well and our current system has a nasty habit of freezing and crashing, which drives me nuts. I do need to spend more time practicing in the "playground," as the system personnel call the training area. I wish they'd chosen a more grown up phrase for it.

    • A board meeting. Again, I'm not giving details here, but at every meeting I learn a lot about the issues our administrators have to deal with. As a doc it's easy for me to grouch and complain but I am trying not to do so much of that. I have sent more than my share of flaming emails about a problem, only to get embarrassed when the recipient responds with additional information about the problem that I did not know (funny how that works, isn't it?)

    • Which brings me to the last event: I got an anonymous letter. I won't give details here except to say that it consisted of a series of complaints about one of the administrators, and it purported to be from one of the medical staff. I'm quite sure no doctor wrote this letter. I debated it, ran it past V. and decided to inform the medical director. I have passed it on to him. The weird thing is, it clearly had come through the mail - canceled stamp and all - but someone put it in my desk drawer. I wouldn't be surprised if it came from one of my office staff, though it could have come from any of the more than 200 personnel employed by the group. I may have gotten it because I have been known to complain about this particular person (who I believe is quite competent), which makes me feel lousy. If so it serves me right and gives me a reason to bite my tongue in the future, or at least not go off half-cocked.

    At any rate, that was my week. How was yours?

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