“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






Email Dr. Alice

 
Chupacabra vs. the Alien


In the past few months I have acquired a Secret Shame so delightful I feel compelled to share. The Shame in question goes by the name of Sci Fi Original Movies. If you ever wondered what happened to made-for-television films (remember the "Movies of the Week" from years ago on major networks?) they are alive and thriving on cable. The Lifetime channel is the proud progenitor of its own set of shameful films, but given the choice between women's exploitation and cheesy science fiction I'll take the movie with the alien in it every time.

A couple of years ago the Sci Fi channel changed its name to the horrendous SyFy but the production company, still known as Sci Fi Pictures, continues to be the savior of underemployed members of the entertainment industry everywhere. These films usually contain one or two reasonably good, recognizable actors to anchor the thing as well as terrible CGI effects and/or guys in monster suits. They are generally filmed in out-of-the-way parts of the world on the cheap; I award bonus points if they are filmed in Bulgaria.

What are the movies about? You can get a pretty good idea by casting your eye down the list of titles linked above. Aliens are quite popular - five movies on the list have the word "alien" in the title; natural disasters such as volcanoes, tornadoes and massive storms; horror flicks featuring monsters or the supernatural. Someone at Sci Fi Pictures really has a knack for coming up with titles: How can you read the words "Reign of the Gargoyles" or "Android Apocalypse" and not be tempted to watch? (Full disclosure: the scriptwriter for "Frankenfish" is a friend of mine. Do him a favor and rent it even if you don't watch it.)

You'd probably appreciate these films more if you're a fan of Mystery Science Theater 3000 and are comfortable with the idea of screaming abuse at your television. Most recently I found myself yelling "That doesn't make any sense!" at poor Xander Berkeley, playing a vulcanologist out to save the world in Magma: Volcanic Disaster. He was expounding his character's theories about what would cause all the volcanoes in the world to erupt at the same time, and none of it was the least bit logical or realistic. Still it was great fun to watch, especially if you are a fan of Mr. Berkeley as I am.

And this is the real reason why I watch these movies. My hobby is crushing on character actors. The chance to see Xander Berkeley in a starring role, playing a good guy for a change? Awesome. I'd watch the guy read the phone book. Want to see Bruce Campbell playing an "astronaut and osteopath" in Alien Apocalypse? Sure you do. John Rhys-Davies as a ship's captain in Chupacabra: Dark Seas, Ron Perlman as an evil corporate head in Absolon - there are many more. It's a delight to watch these actors do their thing, manfully keeping straight faces in the midst of monster makeup and really bad acting from their compatriots.

I wouldn't recommend these films over, say, Citizen Kane but if you're looking for a pleasant way to waste time and laugh your head off I can't think of too many better ways than watching these movies. You can find the SyFy channel's schedule here. Click and soon you too can be watching Bruce Campbell and Stacy Keach in Man with the Screaming Brain.

Which was filmed in Bulgaria. Ten points!

Labels: Pop Culture, Science?

posted by Dr. Alice at #

 
A Pain Chart for the Real World

You know those silly pain charts that are used in hospitals and nursing homes, the one you point to to show your level of pain? Go read this. She's developed a much better one.

Labels: Medicine

posted by Dr. Alice at #

 
Dots on a Map

Lately I seem to spend a lot of my online time on Mapquest. I look up the small towns where my parents grew up, revisit the parts of Philadelphia I remember from college and medical school. I spend a lot of time virtually wandering California's Central Valley, heading north on Route 99 and zooming in on the small farm towns that dot the valley floor. Some of these towns are only a few blocks long. I eyeball the bar scale at the bottom of the map, trying to estimate their dimensions: are they half a mile wide? Less?

Then I wonder what it would be like to live there. Hellish, no doubt: if these towns were thriving they would be bigger, plus the farm economy isn't doing well these days. Not to mention that the Central Valley is hot as hell in the summer. Nevertheless I can't keep myself from daydreaming about retiring there. On the map every one of these tiny little towns is an idyll. Everyone knows one another, it's peaceful there, there's a little high school with a scrappy football team that the whole town supports. Folks sit on porches and drink iced tea.

In real life, the denizens of these towns are probably either dead-eyed clerks at the local convenience store/gas station or toothless geezers who cook up meth in their spare time. I don't want to chance my fantasies being shattered, or ending up like Janet Leigh in the Bates Motel, so for the foreseeable future I'll confine my travels to Mapquest. And when I drive through California it will probably continue to be on boring Interstate 5.

Labels: Random Thoughts, Travel

posted by Dr. Alice at #

 
Head Meets Desk

Annnnnnnnnd today, we have the patient who needs approval for life insurance, whose insurance company faxed a form marked "urgent" in sixteen different places, who hasn't had a physical since MARCH 2008. FAIL.

Give her credit, when I called to explain she was horrified and offered to come in right away, but still.

Labels: The Doctor's Life

posted by Dr. Alice at #

 
Don't Read This Post While Eating

Medicine has long been apostrophized as a field in which its practitioners shield themselves behind a layer of fancy words, and rightly so. Sometimes though the words serve a useful purpose: if you have to discuss bodily functions, it helps to use a word that won't gross people out. A case in point is a word I came across in a gastroenterologist's report today: "scybalous." As in, "The patient passed a scybalous stool with mucus."

What the hell does that mean? I wondered. Wormy? Skinny? Scythe-shaped? My imagination ran riot, and I was forced to look it up immediately. Turns out that scybalous is defined as "composed of hard feces" or "pebbly feces." Not an attractive thought to be sure, but using a word like "scybalous" distances the reader from the concept a bit. Gets your head out of the toilet, so to speak.

My search led me to an online medical dictionary, one of those books it's impossible to stop reading. You may find me at that site for the forseeable future.

Labels: Medicine, Random Thoughts

posted by Dr. Alice at #

 
Consider the Following.

Setting up the shot took nearly an entire workday - before they were even ready to begin filming.

Culver City was operating under a water shortage.

He wasn't feeling well, in fact was running a temp of 101° F. The director told him to go home, but he refused and wanted to try one take.

They hadn't choreographed the dance except for the "start" and "end" marks, essentially, he IMPROVISED THE WHOLE THING.

That first take was the take they used for the film.

So now, ladies and gentlemen, I present to you: Singin' In the Rain.

http://www.youtube.com/watch?v=p7QL46cK7B8&feature=related

Labels: Pop Culture

posted by Dr. Alice at #

 
Medicine and the Media, Part Deux


Strap in, people: It's time for another round of controversy. The latest article making the rounds of the medical Twitter world is this piece published in the New York Times - "Don't Quit This Day Job." The author, a female anesthesiologist, makes the case in this essay that women doctors should not be encouraged to work part-time or to leave medicine for family reasons. Since primary care specialties such as pediatrics, internal medicine, and OB-GYN are now largely female, primary care is suffering because of female doctors' choices to either quit or work part time. For her efforts she's been pegged "misogynist" by at least a couple female doctors I follow.

I agree with her. I am not a fan of part-time medicine, and I am one of those annoying old-school docs who feel that a career in medicine is every bit as much of a commitment as a marriage. Full disclosure here: I'm not married myself, never have been. I don't have children and likely never will. I can stay in the office till midnight if I want and I won't disrupt anyone's dinner or miss any Little League games. My father, now retired, was an old school doc who spent a lot of nights and weekends at the hospital - though he made a big effort to come home and eat dinner with us kids, put us to bed, then went back to the hospital to finish rounds. I learned from him that medicine requires total commitment. I never expected anything else. Therefore, feel free to read the rest of this post with a grain of salt.

The part-time medical gig? In my opinion it can't be done, at least not well. Even when you aren't in the office, patients are still calling. Prescriptions need to be filled. Questions have to be answered, labs have to be reviewed. Who's doing this if you aren't? One of your resentful partners who doesn't know the patient, that's who. Face the facts: no one wants to clean up after you. The patients, also, don't appreciate being told that "Doctor So-and-So is out today, she'll call you tomorrow." Trust me, for most patients tomorrow is Not Good Enough. And for a really sick patient, delay can make the difference between being hospitalized and being able to be treated as an outpatient. I think of medicine as a jealous mistress: Anything you do that takes time away from her, she resents. And she will make you pay. But she does reward loyalty.

When I went into practice I joined a group that (in large part) shares my attitude toward medicine. The Firm does employ part-time docs, but we expect people to show some level of commitment to medicine and to your fellow members of the group. If you show up for a job interview and your first questions are about the availability of part time work and how much vacation time you get, you aren't going to endear yourself to the folks who do the hiring around here. We've seen our share of doctors who join the group, get pregnant, give birth and leave the group a year or two later because they find the hours too much (even when working part time). If you're planning a career in medicine you need to know this basic rule: take the number of hours you work per week seeing patients. Multiply it by 1.5 to 1.8. That's the amount of time you're going to spend practicing medicine. The extra 0.5-0.8 goes for phone calls, charting, wrestling with insurance companies for authorizations, etc. It cannot be ignored; you have to factor it in somehow. What I'm trying to say is, There is no such thing as a nine-to-three job in primary care. To quote the author of the NYT piece, "If you want to be a doctor, be a doctor." Don't do this dip-your-toe-in-the-water crap. Be a help to your patients and partners, not a hindrance.

I think often of one doctor who used to be a member of our group. She was a great doctor and a joy to work with, but she left for a hospitalist gig where she could work one 24-hour shift and one 12-hour shift per week and spend the rest of her time with her kids. I can understand her choice, but the group lost a good doctor (after paying for her childbirth leave of absence, I might add) and the patients lost continuity of care. Again. I can't tell you how many times I have been asked by a patient who's been through three or four doctors in our group, "Are you going anywhere?"

I probably should clarify my attitude toward part-time docs here: I respect women who somehow manage to juggle child rearing and work. Frankly, I can't imagine how they do it. No matter what you're doing, you're plagued by guilt that you aren't doing something else: Either your family or your patients are getting shortchanged. Professional women also tend to put off childbearing, so often they are coping with fertility treatments on top of everything else. I absolutely could not do that. But when I hear some of the older docs in The Firm complaining about how all the doctors joining the group want to go part-time, I have to confess my empathies are with the old school. If my fellow doctors are out with fertility treatments/pregnancy issues/sick kids, we have to pay extra to hire locum tenens coverage and/or the other docs in the group get stuck with the burden of caring for their patients. But what about feminist solidarity? I hear from the audience. Screw it, I respond cheerfully. Medical solidarity trumps feminist solidarity. Heck, it even trumps relationships. We have plenty of docs in the group whose careers have lasted longer than their marriages.

But is that healthy? Is that right? they persist. Honestly, it's the way medicine is - at least the way primary care is. The doctor-patient relationship is the anchor of primary care, and if medicine changes to become more family-friendly, it will be the first thing to go. Those of you who disagree: have you had ill friends or relatives? Have you noticed any difference in their medical coverage in the last few years? Are you finding that the doctor you knew simply is not available, or has been replaced by a covering physician whom you don't know? Bet you the answers are yes.

Medicine is a club - not an elitist club, but you do have to earn your way in. Once you're in you are expected to do your share of the heavy lifting. It's an obligation, but also an honor. The more doctors come to view medicine as a part-time responsibility, the more patients will suffer for it. And remember, we're all patients sooner or later. So are our parents, our kids, our friends. I think this is what the author of the article was trying to say. Instead of slapping the label of "misogynist" on her, it might help to think this through. Can you really say that she's not right?

Labels: If I Ran the Universe, Medicine

posted by Dr. Alice at #

 
Gonna Stay Where I Am


As is the standard after any vacation, I had a small mountain of mail piled on my desk to greet me when I came back. Sorting through it I found a pamphlet entitled "Non-Clinical Careers for Physicians: Your Action Plan for the Future." Good Lord, I thought. Are there that many cranky docs out there fantasizing about never seeing patients again?

Apparently there are. The inside cover pitches this seminar as follows:

This course is designed for physicians who:

Don't enjoy going to work anymore
Are interested in making more money than what clinical medicine provides
Want to explore their options [the world's biggest cop-out line - Ed.]
Are frustrated and dissatisfied with their current career

And many other reasons listed, but I think you get the idea.

The seminar includes meetings with employers and recruiters, lectures and 'breakout sessions' on topics like "The Physician Inventor" (OK, that one intrigues me), "Communicate and Network Your Way to a New Career," "Opportunities for Physicians in the Biopharmaceutical Industry" [and in other fields: disability insurance, consulting firms, medical device companies and so forth]. All of this in two days for only $1295 US!

At this point my inner red flag started waving. This sounds like a ripoff. Not in the sense that it's illegal at all, just that any doc who knows how to network could probably figure out a lot of this stuff by asking around. Specialists, drug reps, insurance company staff, talking to their medical school's alumni association... you know, what people who aren't doctors do when they look for jobs.

More to the point, none of these career options sound interesting to me. I do not want an administrative job. I like primary care and interacting with patients, and through good fortune I belong to a stable medical group which pays me a salary. My checks don't bounce; I don't have to worry about paying the office rent. I know not all doctors can say the same. But if I were in that position and money was tight I might moonlight somewhere or (as above) would try a spot of networking on my own first.

The back of the pamphlet offered a fiction writing seminar for physicians later in the year. Now that I may find harder to resist! I've got this idea. There's this primary care doctor, see, who uncovers a bioterrorism plot in between filling out disability forms and fighting drug plans for authorizing medications. It's guaranteed to be a bestseller... if I can just sit down and write it...

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
So Delicious. Must Share.


Last week I returned from a two-week vacation in Italy. Half of said vacation involved a cooking class, which was great fun. It was taught by Arthur Schwartz, a food writer from New York who loves Italy and Italian food. Arthur doesn't do fancy or complex recipes and neither do I, which is a big reason why I was attracted to the class. We made a few different kinds of frittata over the week, but my favorite was this spaghetti and broccoli rabe frittata. We made it with regular broccoli, as the broccoli rabe wasn't available; but tonight I made it with the rabe and OMG, people. You have to try this.

We were blessed with some great kitchen staff who helped out during the class (they washed a lot of dishes and did some of the prep work). One of the women helping out could flip a frittata like nobody's business. She took a big, flat metal pan lid, slid the frittata out of the pan onto the lid, then flipped the whole thing back into the pan to cook the other side. All of us amateur cooks in the class instantly worshiped her. And tonight, by golly, I successfully flipped the frittata myself. Someone should give me the Nobel prize for cooking, I am telling you. (The secret is to cook it until it is really set, which means you have to be patient.)


So, here is my recipe, adapted from Arthur's.

1 bunch broccoli rabe
3 T. olive oil, divided
1 large clove of garlic
salt, black pepper (or you could use hot red pepper flakes)
5 eggs - I used six
1/4 cup of grated Parmesan
about 6 oz of spaghetti, cooked
recipe calls also for 6 oz mozzarella, which I skipped.


There is some prep work involved here, but not that much, and it is oh so worth it. First, clean the broccoli rabe and peel the thick stems. Bring a large pot of water to a boil, salt it and throw in the veg. Boil for five minutes and drain. Then, add the chopped garlic to 2 T. of the oil in a 10-inch skilet, preferably nonstick. When garlic is sizzling add the chopped, drained broccoli rabe and stir it around for a few minutes until tender. Add some salt and pepper.

While you are doing all this, boil the spaghetti till done - I broke it in half first, which worked well.

Beat five eggs in a large bowl very well, add the cheese, cooked and drained pasta and the broccoli rabe. Add another tablespoon of oil to the frying pan and then put in the mixture. You can poke it with a fork now and again to make sure any loose egg on the top filters down. If it looks like there is not enough egg to bind the mixture, beat and add another one. (The egg is not supposed to be the main ingredient, but more of a binder; it is supposed to be heavy on the pasta and veg.)Cook over low to medium heat.

Give this a good seven to ten minutes, then loosen the frittata, slide it onto a plate or a pan lid, then pray to your deity of choice, carefully flip the frittata back into the pan and cook the other side. Try not to eat the whole thing by yourself. Leftover frittata makes a great lunch or snack.

Labels: Ingestion

posted by Dr. Alice at #

 
Medical Twittergate


Those of you who don't inhabit the medical Twitterverse may be surprised to know that quite the storm broke loose in that sheltered cove these past two days. An anesthesiologist who tweets under a pseudonym posted a few comments about a case she was called in on (it involved priapism, to be specific) and a self-anointed social media medical cop named Dr. Bryan Vartabedian called her out on it. I should emphasize here that there was absolutely no way to identify the patient Doctor #1 referenced and the patient's privacy was not violated. If you want to see the tweets in question, they are linked at the end of his article. I am revealing the name of Dr Vartabedian specifically because he used Doctor #1's tweets and identity without disguising them, despite wondering aloud whether the patient's privacy had been violated (again, in my opinion, it was not). The word "unprofessional" was tossed around - very carelessly, I should add.


I read the posts and was not convinced that Doctor #1 had done anything unprofessional or inappropriate. If you read the comments at the end of Dr. V's post (there were over 130) you will see that there was a vast divide between the "appropriate" and "inappropriate" sides of the debate. Doctors, nurses, pharmacists and even patients felt that the idea of making even mildly joking anonymous comments about patients and work frustrations was either human and understandable or appalling and horribly unprofessional, depending on what camp you fall into. My comment was the last of the bunch (I guess Dr. V. got his nuts kicked in and decided to close the comments. How... unprofessional!) and I supported Doctor #1.


The best way to explain my take on all this is, I think, to reference the movie and TV show M*A*S*H. Healthcare professionals are under fire on a daily basis (metaphorically speaking). The show is a perfect reference for what we go through all the time. Black humor is our only defense. Doctors, nurses and everyone else in healthcare have been making sick jokes and complaining about patients since the dawn of time. That doesn't mean we aren't dedicated to what we do. I love my interactions with patients and I love primary care, but if you cut off my ability to crack wise, I'd quit tomorrow. It's a stressful profession and we see terrible things. That's just all there is to it.


Medical "social media," and how I hate that term, is an updated version of the doctors' lounge. However, Dr. V is correct in that now anyone can peer in to see what we're saying and we do need to watch ourselves. I limit my posts about specific cases for this very reason. When I do post I change ages, genders and other minor details. The underlying issues, though, are the same and will remain the same no matter how many changes I make. It's a relief to air my frustrations and a relief to see that other healthcare professionals face the same problems I do. Were Dr. V to make the rules, I daresay none of us would be allowed to post. The hell with that. I need my vent just as much as my fellow posters do. Instead of complaining, Dr. V should observe more... he might learn something.

Labels: Medicine, Pop Culture, Random Thoughts

posted by Dr. Alice at #

 
Osama Eats Lead



YEAH BABY. YEAH.

Unapologetically, I'm thrilled that asshole is dead. And thank you President Bush (and to our current president, who authorized the mission). So freakin' glad this guy is dead. Click here to join the celebration.

What with this and the recent missle attack on Khadafi, I do rather wonder what the folks who voted Obama the Nobel Peace Prize are thinking right now.

Labels: Politics

posted by Dr. Alice at #

 
Yakisoba


About a year ago the food writer Mark Bittman published an intriguing-sounding article about yakisoba, a quick meal involving noodles and vegetables. Japanese food has always intimidated me - I am not a big fan of sushi, and I would never make tempura at home. (Why mess with a deep fryer if you don't have to?) But this sounded simple and quick, a good dinner for one. As is my wont, I printed his article and added it to my overstuffed notebook of recipes. There it sat patiently waiting for months while I kept forgetting to look for the noodles and mirin mentioned in the recipe.

What really attracted me to yakisoba was Bittman's encouragement to personalize it. I must confess that I like to play with my food, and any recipe that tells you to improvise and experiment is a recipe that I will probably try. You can basically add any vegetable and/or protein that you want to the noodles - I used onion, cabbage and mushrooms. I think thinly sliced celery would also work. You cook the add ins first, then take them out of the pan and put in the noodles. I finally found fresh yakisoba in the refrigerated section of my local Albertson's. Any grocery with a decent selection of ethnic/Asian foods should have them. You do have to add some water to the pan as you cook the noodles to help separate them. Then add your veg back in, add the sauce (which you have mixed prior to beginning the cooking process) and voila!

Ah, the sauce. What to put in it? My noodles came with a packet of powdered flavoring, and I might try this next time just to see how it tastes. But Bittman's description of the sauce is really what inspired me to try the recipe. He says that yakisoba recipes "use everything from applesauce to mustard, neither of which works for me" and recommends a combination of ketchup, soy sauce, Worcestershire, mirin and Tabasco. To me this tasted kind of like Spaghetti-O's, but I think I used too much ketchup. I'll use less next time. I like mustard much more than ketchup, so I may go hunting for a mustard-based sauce to see if this works better.

If you think this combination sounds high in sodium, you would be correct. I found a low-sodium recipe for yakisoba here; you may want to give this a try if sodium is an issue for you. All told, this was a worthy experiment and one I will make again. Yakisoba is the sort of thing I can tweak and polish for years, and that's just the kind of recipe I like.

Labels: Ingestion

posted by Dr. Alice at #

 
Weekend Off


This past weekend was my first weekend off in, I calculated, five weeks. Factor in the ACP meeting in San Diego, two weekends in Guatemala and a weekend on call and you will understand why I did a faceplant into my bed Friday night and spent the weekend doing as little as possible. It felt goooood. I did a little cleaning, a little writing (a very little), some office scutwork and began to rewatch Season Five of 24. Man, what a great season that was. Jam packed with great character actors and a star who was generous enough to step back and give Gregory Itzin and Jean Smart breathing room to do what they do best. They stole the show out from under him (and I mean that in the very best way). Part of the problem with the three seasons that followed is that the writers fell back on the Jack Bauer character to do most of the heavy lifting, instead of trusting the other characters and storylines more. Seasons Six, Seven and Eight were not nearly as good. I guess lightning only strikes once.

This week I'm covering for the medical director and I really don't think I want to do this again. In the past it's been a formality with not much for me to do, but this time the administrative second-in-command has also been out and I am getting snowed with vacation requests and patient complaints to review. Unlike the guys who usually do this job, I don't have any administrative time built into my schedule to handle this stuff. At least it's only for a week.

Office drama: the Old Doc who moved into my office two years ago had a blowup with his secretary last week and she has cleared out. This means he's now on his third secretary. (The other two were extremely competent, IMHO; he's just an exasperating micromanager.) Number Three is a nice young woman who's worked here for a while, but I honestly don't know how long she's going to last. I wish to high heaven that Dr. Oldguy would retire and leave us all alone. However, I don't see that happening any time soon.

And lastly, a co-worker has been going through some very difficult changes in her personal life (I won't say more except that I feel for her, and it isn't something that's her fault). She has been needing to take some time off to deal with these issues, and that means I've been trying to cover for her as well. So, it's been busy. We'll see how this week goes.

Labels: Pop Culture, The Doctor's Life

posted by Dr. Alice at #

 
Raclette


I've been meaning to post about my experience with raclette for awhile, but as usual have put it off. At least now I can tell you that I have made it several times and have been extremely happy with the result. If you're in an area with chilly weather, this may still be a useful post for you...

I came across this post on raclette at Tea and Cookies some time ago and was instantly riveted. I had certainly read about raclette, but had always thought of it as the sort of dish you would have to experience in its native land (in this case, Switzerland). Who knew that raclette cheese was so widely available? And doesn't melted cheese and potatoes sound like the most delicious dinner ever?

So off I went and found myself some raclette (try Trader Joe's or the fancy cheese section of an upscale supermarket). While I was at it I also bought the cornichons, a traditional garnish for raclette, and some baby potatoes. Tara of Tea and Cookies also suggested brussels sprouts as a side, which I think would be excellent. You really do need something pungent and/or spicy as an offset to the smooth, rich, bland combination of melted cheese and potatoes.

Raclette in its natural state is a somewhat strong-smelling cheese, though not unpleasantly so. Melted it is deliciously mild. The website recommends heating it in a toaster oven, which I think would work great. Not having a toaster oven I used a lidded glass dish and stuck it in at 275-300° while boiling the potatoes.

I like the look of the little potatoes, but you can also boil regular sized potatoes and cut them up. When done, put the potatoes on plates, throw on a dab of mustard, a spoon of cornichons and divvy up the cheese. I am here to tell you, this is delicious. Best served with white wine, but any beverage will do.

Labels: Ingestion

posted by Dr. Alice at #

 
Somewhere Ayn Rand Is Cackling With Glee


The film version of Atlas Shrugged is being released this week on April 15. For those of you not in the US, that's Income Tax Day. How absolutely appropriate.

Apparently the book has been filmed in three parts; this is Part I. I never have read it, but I have read The Fountainhead, which she also wrote, and found it pretty interesting. I'm probably going to go see AS, unless it gets terrible reviews.

The book has a long history in Hollywood. People have been trying to film it for decades. According to IMdB, there was talk in the 1970's about turning it into a TV miniseries - and Rand wanted Farrah Fawcett to play Dagny Taggart! Who knows, perhaps Fawcett could have pulled it off. I do think Clint Eastwood would have made a great John Galt.

Labels: Pop Culture

posted by Dr. Alice at #

 
"My Knee Hurts When I Meditate,"


said the patient. "I stopped for a while and it got better. But when I started meditating again, the pain came back."

"What position do you meditate in?"

"The half-lotus."

"Ah. You have 'movie theater knee.'"

"Uh, okay..."

"It has to do with the patella. The kneecap. When you hold one position for some length of time, like driving or sitting in a movie theater - or meditating - it gets stiff and painful. The good news is, you didn't tear your meniscus or your ACL or any other ligament. I can give you some exercises to try at home. But you might want to try meditating in a different position."

The patient accepted the exercises. As I wound up the visit I couldn't resist adding, "I bet Buddha had painful knees."

The patient laughed. "After fifty years of doing this, I bet he did."

Labels: Medicine

posted by Dr. Alice at #

 
To Kindle, or Not?


My roommate on the Guatemala trip had a Kindle. She loves it. I had never considered purchasing one, but after checking hers out I am having serious thoughts about it. She says the battery lasts forever, and that Amazon has a large selection of copyright-free books which cost nothing to download. It's light and takes up very little room. I can see where it would come in really useful while traveling.

My inner Scrooge McDuck is telling me, "You don't NEED this." And I could certainly get by without it. But it would be a great gadget to have.

Any thoughts from the audience? Do you have a Nook or Kindle, and if so, what do you think of it?

Labels: Random Thoughts

posted by Dr. Alice at #

 
Home Again, Home Again...


jiggety jig...

I was home for all of 60 hours and then packed up for the annual ACP meeting in San Diego. I am now home from that and am happy to report that it was a great meeting. Basically, you sit in lecture halls all day and listen to talks on various aspects of medicine. These talks begin at 7 am and go till about 5 pm, every day, for three days.

It is less exciting than it sounds. But you learn a lot.

In an effort to save money on the trip I shared a hotel room with three of my fellow partners from The Firm. (I'm getting quite used to this whole roommate thing by now.) I am sure I bored the hell out of them by mentioning Guatemala's lack of showers, hot water and working toilets every time someone complained about sharing the bathroom.

Do I have anything else to say about Guatemala? Well. The clean air regulations we have here, they don't have there, and it shows. The air quality is terrible whether you're in or out of the city.

Guatemala has great buses. In Antigua we went to the crafts market and while wandering around found ourselves in the bus depot. Their buses are all deactivated school buses from the States, shipped down to Central America and treated to bright, eyecatching paint and chrome jobs. Mostly they run shuttles between Guatemala City and Antigua but they run to other towns as well. "I love these buses!" cried one of my fellow internists (who had a lot of experience in third world countries). "Nepal, Guatemala, Peru - it's all the same bus!"

We went to Antigua for the last two days of the trip, which is traditional for the group. It's always wonderful to get there after a hard week's work but it was doubly so this year, partly because of our no-water ordeal and partly because we got accomodations at the best hotel in the city. It's called Hotel Casa Santo Domingo and, if you ever get to Antigua, I highly recommend it. Breakfast was included and was outstanding: The best breakfast buffet I have ever been to. They had custom made omelets, fantastic homemade tortillas and pupusas, delicious fruit and great beans and rice. I am all about the beans and rice.

So now I'm home and making lentil soup. I posted about lentil soup previously, but I'm going to do it again because I have found a better recipe, courtesy of Nigel Slater. To make it, first, you need better lentils than the standard brown grocery store lentils (although they will do in a pinch). I highly recommend ethnic markets for cheap, good quality, fine green lentils. If you're in Los Angeles, Pico Boulevard has a stretch heavily populated with Israeli markets which are a great source for lentils, barley and dried beans. So you've got the lentils. Chop and saute some onion, celery and mushrooms and throw in a chopped garlic clove. Sort, wash and add the lentils once the vegetables are soft. Cover with chicken broth and bring to a boil. Add a splash of Worcestershire. Once the soup is on its way, wash, chop and add some baby broccoli and let cook until done - I usually give it 45 minutes to an hour. It is SO GOOD and is even better the next day. This recipe is cheap, delicious and good for you and makes a lot. It lasts me a week for work lunches.

Labels: Ingestion, Medicine, Travel

posted by Dr. Alice at #

 
Life In Guatemala


I walked in the back door of my house at 1:30 this morning, having left ten days previously. The Friday night of week before last I caught a shuttle to LAX, destination Guatemala City. I last went on this sort of trip four years previously and it had taken a little time for me to nerve myself to do it again.

Our destination was a town in Guatemala called San Cristobal. I don't know exactly where it is, as I never saw a map. All I can tell you is that it is not the Mixco suburb of Guatemala City; it is about four and a half hours away from the airport by bus. San Cristobal is home to an actual hospital, built in a fit of generosity by the United States government in 1962 back when they were making the world safe for democracy. Sadly, most of it has stood empty as the local government has neither the money nor locally educated providers to staff it.

I loved the building as soon as we walked in; I am old enough to remember the classic 1950's sort of hospital with green walls, linoleum floors and tile, and engraved plastic placards mounted over the door to tell you where you were. (e.g., "Emergencias.") This building was exactly like that. Hello, Dr. Ben Casey!

The organization I worked with, HELPS International, emphasizes surgery on these trips. The surgeons (Plastics, ENT, OB/GYN, General) do much more good than we primary care MD's or GP's can do. If you are looking for a cause to support, I can highly recommend them. Despite the relative luxury of having an actual hospital to operate in, this was our toughest year yet - as I was told by several old hands who have been on many more trips than I have. Allow me to demonstrate.

• A serious water shortage to the point that we were not allowed to flush the toilets or bathe. We were driven to use the bottled water (intended for drinking) to sterilize instruments in the autoclave before the water truck finally showed up.


• Random power outages.


• The hospital was host to a local Peds ward and emergency clinic. This meant that we were regularly woken by crying babies in the middle of the night. Let me tell you, those babies can raise the dead at that hour.


• Our first night there we had a sobering experience: a hospital employee dropped dead of cardiac arrest. The locals threw him into an ambulance and rushed the poor guy into the ward in a wheelchair... I caught a glimpse as he was rushed past and instantly thought that he looked dead. The surgeons did CPR on him and got a pulse back, but he coded again in the ambulance and was DOA at the local "real" hospital. It turned out that he had a history of diabetes and had had a pacemaker placed three months before. In addition, he had been hospitalized the previous week for pulmonary edema.


• A thyroidectomy patient who couldn't be extubated and needed MedEvac to Guatemala City.


• This is a minor point, but our chef's skills were off. We were treated to undercooked bean soup, "vegetable lasagna" (veg cooked in tomato sauce without noodles. It would have been fine if they had explained that before we sat down to eat) and cold canned pea salad with mayo, cheese and chopped onion. I will pass over this chapter of the trip without comment.

All that said, the camaraderie among the staff was outstanding; this is why people return year after year. I shared a dorm with five other women, mostly internists and one pediatrician. We chatted every night about spouses, medicine, the day's patients and everything else you could imagine. We got laughs out of the smallest of things. For instance, in most parts of Guatemala you can't drop used toilet paper into the toilet - the plumbing can't take it. You have to throw it into the trashcan. A couple days into our stay, one of my roommates glanced at the overflowing toilet bin and commented acidly, "I see maid service didn't come today." It sounds like a small thing, but we laughed like maniacs. We slept on cots I firmly believe were designed for Satan's Army - even our inflatable air mattresses didn't really help. After a full day of work they were comfortable to start with, but by the end of the night we were tossing and turning with every muscle in our torsos protesting.

After the first rush of presurgical clearances was finished we clinicians were subject to, as one of my roommates termed it, "the bullshit parade." Duele todos in corpo soon became the last phrase any of us wanted to hear. Not to mention dolor in cabeza or back or foot pain. Our pediatrician announced one day at lunch, "I saw this lovely baby today, she was really kind of fat. Her mother told me she wasn't eating and hadn't eaten for a month. I'm looking at this Buddha baby and just said to the mother, "I don't believe you." (Not eating is apparently a favorite complaint among Guatemalan mothers.)

I came up with a haiku one day, in a haze of clinic induced fatigue: Feet hurt all the time/Headache, neck ache and back ache/Gastritis, she says

Next installment later... I have to get some sleep.

Labels: Medicine, The Doctor's Life, Travel

posted by Dr. Alice at #

 
Cheap and Cheerful

Via Instapundit, 30 Ramen Hacks. I especially liked the "ramenepherd's pie" idea. (Shepherd's pie with ramen on top instead of mashed potatoes.)

Labels: Ingestion

posted by Dr. Alice at #

 
You're Wrong, Albert Hammond. Oh, and Zombies.

They say it never rains in Southern California...

Well, I'm here to tell you it does. Even on the first day of spring. Even on Marathon Sunday. It has been pouring nonstop for at least the past nine hours. We didn't see the Supermoon, as it was clouded over; the lights have been flickering and I have heard the occasional banging outside which may be coming from a local transformer. Still, I'm rather enjoying it as this could be the last rain of the season and certainly it's likely to be the last storm of any significance.

This apocalyptic weather has led me on to other thoughts. Recently I have been trying to blog more, but at the best of times I tend not to blog much about major world events. There are several reasons for this (see above, dilatory blogger). There are better sites on the web by far to pick up analysis of world news; I don't really think that reading "OMG, how horrible" on yet another website offers any insight. That said, after seeing everything that has happened in Japan my main resolution for the rest of this year is to be better prepared for disasters. Instapundit has been very good about offering links to disaster preparedness sites, and another favorite site of mine - Home Ec 101 - offered a recent update with some good, basic hints. One important one: try not ever to let your gas tank go below half full. Me, I think it wouldn't hurt to also keep a couple of extra gallons of gas in the garage; of course I haven't bothered to do anything about this yet.

Another simple hint. Save your two-liter plastic soda bottles, rinse them out and fill with water. It's a simple and cheap way to keep an emergency supply of H2O on hand. Refill bottles with fresh water every six months. Also, keep a manual can opener and reasonable supply of canned food on hand. I would like to get a propane fired grill later this year, too. With that and a few tanks of propane you can boil water and cook food. I personally am not into the dehydrated food storage thing, but if you are, that wouldn't be a bad idea either.

My former neighbor (who has since moved) was on the Emergency Preparedness committee of her alma mater, Redlands College. Redlands, in case you are unaware, basically lies atop the San Andreas Fault. A few years ago we went out to breakfast with another neighbor who lives across the street - it was our habit to do this every few months. Neighbor # 1 had just been to her annual committee meeting, which lasted an entire weekend, and she had brought a notebook stuffed with information for us to peruse. It even had suggestions on what to do with dead bodies (wrap in plastic sheeting and leave in a cool place).

Redlands has to plan like this, not only because they have to protect the student body but because they have to assume that the locals will be coming to campus seeking food, water and shelter. They are also working on the assumption that the government will not be able to help for two to three weeks in the event of a major disaster. I was impressed with their thoroughness.

I recently came across a mention of a novel about the aftermath of an EMP called One Second After. I haven't read it yet but it sounds ghoulishly intriguing. The protagonist's daughter, for instance, is a 12 year old with Type 1 diabetes, dependent on insulin. I think I can guess what happens to her. The book is structured around the effect on the population of a sudden return to 19th century technology. There are waves of "die offs" - the first being hospitalized and nursing home patients; then those with chronic illnesses who can't get their medication; then those with mental illnesses who can't get their antipsychotics. The review I read said that only about 20% of the population was left alive after a year. Scary stuff.

The wind has picked up and I'm going to sign off before the power goes out - not such an unusual thing around here. Tree branches take out power lines nearly every time the wind kicks up. Los Angeles doesn't plan well for its winter storms; I hate to think what might befall us in the event of a true disaster. The state is close to bankrupt as it is.

On that note, enjoy the rest of your weekend.

Labels: Los Angeles, Random Thoughts

posted by Dr. Alice at #

 
Day of Reckoning

Nothing blitzes a good mood faster than seeing a new lung mass on the chest X-ray of a smoker. Damn it.

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
How to Tell if your Doctor is Having a Bad Day

Is your doctor huddled over the computer keyboard muttering "F...! F...! F...!"?
Does your doctor scream when you hand over your jury excuse form?
Have you overheard your doctor mutter "If I have to write one more Letter of Medical Necessity, I'm gonna puke"?
Is your doctor hooked up to an IV bag of coffee?
Is your doctor swigging from a suspicious looking bottle of clear liquid, explaining that "it's my nerve medicine"?

Your doctor may be having a bad day.

Labels: The Doctor's Life

posted by Dr. Alice at #

 
Butt, Kicked


Happy freakin' Mardi Gras, everybody.

A few weeks ago I made the decision to start seeing patients earlier in the morning, with the goal of getting out earler in the evening. Let me tell you just how well that's working out: I had dinner at 8:30 pm tonight.

Still, it could be worse; last week at our monthly staff meeting our CEO put up a PowerPoint slide of the number of patients seen by each doctor in the group one day earlier in the month. For me it was all entertainment, as the day chosen was a Thursday and I don't see patients on Thursdays. The names of the doctors weren't given; too bad, I thought. That would have made it more entertaining. Number of patients seen ranged from 1 to 73. In case you are wondering the doc who saw 73 patients in one day was an orthopedist (that's par for the course). A lot of docs saw fewer than 18 patients. I always see more than that.

I have noticed that I am getting a steady flow of new patients, which is a great blessing. The economic problems of Southern California continue to hit us hard and our total number of patients seen is down. With the improved employment numbers from this week, maybe things are getting better; I certainly hope so.

And now off to bed. I have to get up and do it again tomorrow.

Labels: The Doctor's Life

posted by Dr. Alice at #

 
Taking Care of Patients: You Do What You Have To

Today the Food Librarian posted a piece about today being the Day of Remembrance for Japanese-Americans. On this day in 1942 FDR signed Executive Order 9066, authorizing the internment of Japanese-Americans. Her father and his family were interned in camps during the Second World War.

This post brought to mind a story my father told me many years ago. When he moved to Southern California he got a job in a medical practice in Westminster, in Orange County. The founding member of the practice was named Dr. Johnson. (I vaguely remember him; we were invited to dinner at his house once a year.) Dr. Johnson had founded the practice in, I think, the ninteen-thirties. He was the old-school type who delivered babies at home. There was no hospital in the area until he got a group of doctors together and built one. Sadly, Westminster Hospital now no longer exists.

At the time the area was largely agricultural and many of the farmers were Japanese-American. Once the Executive Order was signed these farmers knew they'd lose their land. Having nowhere else to go, they went to their doctor - the only Caucasian authority figure they could trust. They sold Dr. Johnson their farmland for a dollar.

When the farmers were released from internment, they returned home and went to Dr. Johnson to buy back their land. He sold it back to them.

For a dollar.

My dad told me this story to teach me something about medicine and about the relationships doctors build with their patients. Those farmers stayed with the practice for decades, even after Dr. Johnson retired; they and their children became my father's patients. The trust they had in him overwhelms me. Would you sell someone everything you had for a dollar and expect to get it back? But then, people entrust their lives to doctors every day and think nothing of it. Nor do I, really. Maybe I should think about it more.

A favorite philosophical question of medicine is "Is medicine an art or a science?" The answer is it's both: You can't have one without the other. I think that's what this story illustrates. Medicine is changing every day, but the heart of primary care is still the relationship between doctor and patient. I will defend that relationship with everything I have, because when it is gone medicine as we know it will no longer exist.

Oh and by the way. Dr. Bernard Micke of Madison, Wisconsin? YOU'RE DOING IT WRONG.

Labels: Medicine, Random Thoughts

posted by Dr. Alice at #

 
"Lydia, oh Lydia, that Encyclopiddea..."

Lately I've been unable to get this song out of my head:



Check out Groucho's "gesture" at 1:04 (apparently one of his trademarks). Why Mr. Marx!

Labels: Pop Culture

posted by Dr. Alice at #

 
Now With Extra Funny

The Monkeys You Ordered takes cartoons from the New Yorker and recaptions them. That's all, but it's hilarious. Those droll, cerebral, unfunny cartoons have been paired with literal captions that simply state what is going on in the drawing. You might think this doesn't sound funny, but you'd be wrong. Take a look.

Labels: Comix

posted by Dr. Alice at #

 
A Good Cause

If you've got any spare cash lying around and you're wondering what to do with it, may I suggest you donate to this couple. Long story short, they're newlyweds and he was diagnosed a few months after their marriage with glioblastoma multiforme stage four. This is about as bad as a brain tumor gets. Their full story can be read here. I first heard of them through Jo (who runs a great blog, BTW). Tashi had to quit her job to take care of her husband and they have only state aid, and not much of that.

It's hard to believe life can be so unfair.

Labels: Medicine, Money

posted by Dr. Alice at #

 
Retirement Secrets of a 107 Year Old

Personal finance has always been a topic of interest to me. I am no expert, but love to read about it. (I think it's the fantasy of retirement that intrigues me.) Via Instapundit, here is a story of a 107 year old man retired since 1969. He never made more than $10,000 in a year but still has savings left. His advice: be thrifty and buy real estate. He was never a big investor and did not buy commercial real estate, but did buy and sell several houses, making a bit on each. His financial instruments of choice are bonds and CDs; he never invested in stocks. (His son pointed out that after the market collapse in 2008, he was left a lot better off than the majority of investors.)

Amazingly he's still sharp and pretty healthy. Perhaps the challenge of managing money is good for the brain cells.

Labels: Money

posted by Dr. Alice at #

 
If You Bought These In the First Place, You Deserve What You Get


A candy bar called Toxic Waste Nuclear Sludge Bars? What could possibly go wrong?

Almost 28,000 prophetically named Toxic Waste Nuclear Sludge bars have been pulled from the market for lead levels that are more than twice the U.S. government's tolerance. The problem was found after tests by the California Department of Public Health.

Oh, here's the kicker: they're imported from Pakistan.

(h/t Dave Barry)

Labels: Ingestion, Random Thoughts

posted by Dr. Alice at #

 
Conformity Trumps Iconoclasty


So last night at The Golden Globes Glee picked up several awards. I know several people who love this show; I am not one of them. It's like The West Wing set to music, combining arch, rapid-fire dialogue with an overwhelming sense of political correctness. Multiethnic cast? Check. Kid in wheelchair? Check. Gay character who's "proud of being different?" Check. Character who dresses Goth and is persecuted by those in authority? Check.

These days the gestalt presented by the Glee characters is neither groundbreaking nor courageous. It's all over the airwaves. It's par for the course. You know what would have made the show brave and original? Casting a bunch of untalented Caucasians who can't dance. I'm serious: A show that reenacted the whole Lawrence Welk/ "Up with People" nightmare that was the Seventies (and, incidentally, is still true of Glee clubs all over the country today) would be as watchable as a slow-motion car crash and ten times more fun than the hectoring, nanny-minded show we're stuck with.

The real problem with Glee, in my opinion, is that it propagates the dirty lie that Being Yourself is all you need to do. Why work an after-school job to save up for college when you can dress up like Lady Gaga and prance around instead? Guess what, kids. Those thuggish football players mocking your artistic statements? They're the ones going to college -- on scholarships. You are not. Studying and sports practice may be a drag, but they're investments in your future which will pay off much, much more than waving your freak flag high will ever do.

But Alice, we're talking about a one-hour diversion once a week. Aren't you reading too much into a harmless TV show? I don't think so and I'll tell you why. I know people who center their lives around Glee and other TV shows. Instead of getting out into the world and being themselves, they're watching shows that tell them to celebrate The Wonder That Is You. Their personal lives have narrowed to an incredibly small circle of similar thinkers, both in real life and online. Instead of (dare I say it?) working for a living, they live in semipoverty and spend huge chunks of time on work no one in their senses would ever reimburse them for - like fan websites and fanfiction. Don't get me wrong, these things are fine for a hobby. But at some point, you have to turn the modem off and go make a living. Join the real world!

Oh, and when their parents try to intervene? My family doesn't understand me! Only (sob) you guys do! Yeah, right, only your fellow navel-gazers really "get" the real you. Now let's get back to that Battlestar Galactica fanfic and forget about your mean family, who want you to get a job. News flash: being understood is not as important as you think it is. Too often, in my experience, this phrase translates to "If you don't appreciate me exactly as I am, there must be something wrong with you."

Full disclosure here: I write fan fiction myself. And I know, either in person or online, plenty of people with iconoclastic interests - one of whom is a Star Wars fan who leads a squadron of Imperial Stormtroopers. (Yes, they have all the armor and look completely authentic.) The difference? We do this stuff in our spare time. It adds fun to our lives; it has not become the center of our lives. The Stormtroopers, for instance, show up at the kids' section of the library every once in a while to entertain them. They volunteer their time to help the wider community.

Who sounds more attractive to you: the buttoned-up banker with the stormtrooper soul or the guy who lives in his parents' basement, collecting action figurines and defending the "vision" of George Lucas against all who dare to question it? I know which one I'd choose.

Oh, and to the characters of Glee, I close with the immortal words of William Shatner: GET A LIFE!

Labels: If I Ran the Universe, Pop Culture

posted by Dr. Alice at #