“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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"I Look Forward to Your Next Article, 'How to Breathe'"

I have come to enjoy reading the Guardian's "Word of Mouth" food articles (for a conservative, this is akin to explaining that you read Playboy for the interviews). One writer, Tony Naylor, has a series titled "How to Eat" various food items (i.e., what is your favorite way to serve a hamburger?) Today's article may have hit a new low, however:

How To Eat Breakfast Cereal

Dear Lord, Tony. I may not be at my best in the morning, but give me a little credit. Do read the comments: they are hilarious. The title for this post is taken from one of them.

Labels: Ingestion

posted by Dr. Alice at #

 
The British have a real talent for desserts. (Have you noticed this?) I may be more prone to their charms because of my UK heritage, or because I'm not a chocoholic. Most traditional Anglo desserts aren't based on chocolate. Or because I think everything goes better with gravy - the dessert variation is a baked or steamed dessert with a sauce on top. As a med student many years ago I wangled my way into a plastic surgery rotation at Oxford, and whenever the hospital canteen served rhubarb crumble with custard sauce I was the happiest camper in town. Yes, the custard was lumpy and made from Bird's dessert powder, but even so.

Though I adore it, trifle may not be to everyone's taste... but if you haven't tasted sticky toffee pudding, put it on your bucket list. Yes, it is that good. Steamed desserts like Spotted Dick (it has currants in it, and in Britain it comes in a can. No, really) and sticky toffee pudding are good but best reserved for cold weather. Not to worry, the Brits excel at summer desserts too. They pioneered the class of desserts known as "fools," usually a mixture of fruit and cream, chilled. The fruit can be cooked as in gooseberry fools, or raw, crushed and macerated with sugar, such as raspberry fools. You whip the cream, chill the fruit, and mix the two together.

A variant of this idea is Eton Mess. The name comes, I think, from the fact that the schoolboys at Eton would mash everything on the dessert plate together with their spoons and then eat it. It sounds unappetizing but it is really delicious. It is now past high strawberry season and I should have posted this earlier, but here we go. The recipe is made easier by the existence of Trader Joes, which sells vanilla meringues in large plastic buckets. If you don't have a TJ's near you, you may be forced to make your own, or look around at any local specialty stores.

Ingredients are simple: strawberries, meringues, whipping cream. You will use equal parts of each. Crush the meringues, but not too finely. Mix with sliced strawberries and whipped cream. Let chill for a little while, maybe half an hour, and eat. You want the meringue to still be a little crunchy. Yum.

Labels: Ingestion

posted by Dr. Alice at #

 
"I won't quit smoking"
You said, after the tumor
You died yesterday.

Labels: Medicine, Random Thoughts

posted by Dr. Alice at #

 
Having been seduced by the likes of Facebook and Twitter, I have come to realize that maybe I would blog more if I settled for shorter posts. I feel the need to do this, just to share the madness of actual medical practice. Here is one actual conversation from yesterday:

Patient: I'm depressed. I think maybe it's because of global warming.

Me: ...um. Are you doing stuff about it? Like recycling, and trying to drive less?

Patient: yes, but I still feel sad. Maybe I need medication.

Me: Maybe you should turn off the news.

Labels: The Doctor's Life

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Easter Dinner

It's no secret that holiday dinners are quite often anchored in ritual. There's something comforting about anticipating your favorite dishes every year, and I also enjoy trying holiday foods traditional to other families. I have never forgotten the Thanksgiving Eve I spent shelling Brazil nuts with my brother and new sister-in-law (they were going into the turkey stuffing, which was one of her traditional family recipes; it was delicious). The magazine articles that appear every November, urging new Thanksgiving menus on us, I always find pointless. Nobody wants to change the foods they remember from childhood - unless it's something they really couldn't stand. If you ever find yourself at a holiday gathering with a bunch of people you don't know and need to break the ice, try asking about the foods they hated; everyone has one. Remind me to tell you about my aunt's creamed chestnuts sometime.

But one of the things I like about Easter in our family is our total lack of any Easter dinner tradition. When I was a kid we went to the local country club for Easter brunch after church, where the buffet held all the scrambled eggs and bacon we could eat and there was an Easter egg hunt afterward: perfect for a kid. Unfortunately I am not seven years old any more and I have been known to entertain guests for Easter dinner on occasion. What to fix?

You might think: Lamb. But no. Since my father doesn't really like it, we never had it when I was growing up and it never really occurred to me to try cooking it. Ham, another tradition, simply scares me as I have never baked one. Besides, they're huge and the thought of coping with leftovers for weeks was enough to put me off. Asparagus? Too much of a cliche. While there's nothing wrong with a dinner of baked ham or lamb, asparagus and scalloped potatoes, something in me rebelled at the entire concept.

When in doubt, research. I went to my trusty cookbook collection and found the idea for my first real Easter dinner in the Silver Palate Cookbook: an aioli platter. Aioli is a mayonnaise made with garlic. It is easy to make in a food processor, can be made in advance, is delicious and impresses the hell out of your guests. The cookbook suggested serving it with cod and carpaccio, but I was not about to serve raw meat; instead I roasted an eye of round and served it with a variety of steamed vegetables. Cauliflower, artichoke hearts, new potatoes, asparagus (all right, we had asparagus, but there is nothing that goes better with aioli). It was an absolute smash hit and even the lone vegetarian in the group was happy. If red meat is not your thing, I think a large poached salmon filet would do just as well. This would probably have become my Easter dinner tradition if I entertained more often and if my father and I weren't on diets, at least in theory.

This year I needed something low-cal and low-carb. Letting my mind wander between patients one day last week, I brainstormed baked chicken breasts, green beans, mashed cauliflower and fruit salad for dessert. The dinner was more adventuresome than it may sound, as I had never tried mashed cauliflower. I had read about it many times as it has been a mainstay for those on low-carb diets for years. The green beans broke new boundaries for me, too: I microwaved them. The only veggies I'd ever cooked in the microwave until today were frozen peas. It worked remarkably well, which is encouraging me to try to expand my use of the microwave beyond reheating leftovers and cooking frozen dinners.

For the green beans: trim and cut two cups of green beans into one-inch pieces. Place in a covered microwavable dish with 1/2 cup water. Nuke for four to five minutes on high.

Silver Palate aioli recipe:
8 to 10 garlic cloves, peeled (I often use less, as this is a LOT.)
2 egg yolks at room temp
salt and white pepper
juice of one lemon
1 tsp Dijon mustard
1 1/2 cups oil (half olive, half peanut) at room temp. Note: if peanut allergies are an issue, substitute good quality canola or safflower oil. What you are trying to do is cut the strong olive oil taste.

Puree the garlic in a food processor or blender. Add egg yolks, lemon juice, mustard, salt and pepper (I'd go easy on the salt). Process to a smooth paste. Then with the machine running, add the oil slowly - almost drop by drop at first. As the mixture forms an emulsion you can slightly increase the pouring speed, but don't dump it in. When all the oil has been added, transfer to a bowl, cover with a lid or plastic wrap and refrigerate. It will last a few days.

Mashed califlower: steam until soft, drain and return it to the hot pan with a few tablespoons of milk. If you have a stick blender, use it to puree the cauliflower - otherwise you may have to do it in the food processor. Add a couple tablespoons of Parmesan, salt and pepper. It doesn't taste like mashed potatoes, but it's pretty good.

Labels: Ingestion

posted by Dr. Alice at #

 
That Old Time Casserole Rock and Roll

I have a weakness for casseroles. They're just so retro, with overtones of old-school church suppers and comforting, ideal moms who were home ec majors. Most casseroles taste great and they stick with you, plus you generally are left with lots of leftovers for lunches.

Casseroles are also billed as "economical," but I would not necessarily agree with this claim. As the late, great Peg Bracken pointed out they generally call for expensive ingredients such as pimento, mushrooms, almonds or other nuts, and cheese. Casseroles can be made without these extras, but you lose a lot of flavor and the end result is likely to be one of those heavy, gloppy, beige dishes loathed by today's food writers. Still, they feed a lot of people and are especially useful because they will fill the need of either protein + veg or protein + starch. You then need only a salad or something like rice to serve the casserole on.

They are high-calorie; no way around that. You can lighten them up a bit by subbing vegetables in for the pasta (broccoli and asparagus work well here). If you are looking for a binding sauce that's lower in calories than the usual butter/flour/milk white sauce, use either skim milk or fat-free broth and add cornstarch to thicken. I have tried this and found that it works very well. If you use the milk/cornstarch option, get ready to drag out every herb in your arsenal because the resulting sauce has very little taste!

Another bonus of casseroles is that they can be made ahead and frozen, then produced on short notice. Hence the ubiquity of casseroles as "crisis food." If someone dies or is hospitalized, you bring a casserole. It's one less thing for the bereaved or stressed-out family to worry about. If you are planning to freeze your creation, I recommend undercooking the vegetables and pasta slightly so you don't wind up with a mushy, textureless final product.

I recently came across a casserole recipe billed as a good Christmas gift which I've been meaning to try; I finally got around to it this weekend. Let me just say you wouldn't catch me making this to give away at Christmas, not because it isn't good but because it is a fair amount of work. I might give it to a dear friend who had recently been bereaved. If I could bring myself to part with it.

Chicken, Mac and Cheese Casserole
from Better Homes and Gardens "Food Gifts" Magazine 2011
serves 6 to 8

8 oz. dried penne pasta
1 lb. skinless boneless chicken breast
1 T. olive oil
1-2 tsp dried Italian seasoning, crushed (I used 1/2 tsp each basil, oregano and dried parsley)
1/8 tsp each salt and pepper
3 T. butter
1/2 C. chopped onion
2 minced cloves garlic
3 T. flour
2 T. tomato paste
3 C. milk
2 C. shredded cheese (8 oz) - I used Cheddar but recipe says Swiss or Gruyere will also work.
2 C. soft bread crumbs
1/2 C. shredded Parmesan
3 T. melted butter

Okay. Get a big pot of water on the stove for the pasta and then get started. I found it helpful to prep the ingredients ahead of time. Chop the onion and garlic, mix the herbs, salt and pepper, dice the chicken breast and grate the cheese. To make the breadcrumbs I tore up three slices of bread and put them through the Cuisinart.

In a large skillet, heat the 1 T oil over medium heat. Add the diced chicken breast and sprinkle as it cooks with the herbs, salt and pepper. Cook till no raw or pink chicken can be seen and then take it out of the pan and drain on paper towels.

In the same skillet melt the butter and add the onion and garlic. Cook gently till tender, then add the flour and stir well till combined. Let this cook for a minute then add the tomato paste; incorporate this and then gradually add the 3 cups milk. Cook till thick and bubbly and stir in the cheese till melted. Check for seasoning and add more salt and pepper if needed.

During all this, you will have gotten the pasta cooked. Drain it, put back in the pasta pot, add in the chicken and cheese sauce and stir well. Place the mixture either in a 9x13 inch pan or two smaller pans (the total surface area should be about 117 sq. in, which is the area of the 9x13 pan. I try to use this rule if I am splitting a recipe into smaller serving sizes to freeze).

The topping: mix the breadcrumbs, Parmesan and melted butter. Place this into a plastic bag or bags for topping later. To cook, place the casserole (covered with foil) in preheated oven at 350 degrees for 20 minutes, then remove foil and cover with breadcrumb mixture and bake another 30-40 minutes. If you are freezing casserole, cover tightly with foil and attach the bag of crumbs. Thaw overnight in refrigerator before cooking.

This is good stuff and I highly recommend it, if you can put up with the workload and number of dishes you will dirty in the process.

Labels: Ingestion

posted by Dr. Alice at #

 
This Is Counterproductive

Reading food blogs while counseling patients on their diabetes... that's just wrong. Bad doctor.

Labels: Ingestion, The Doctor's Life

posted by Dr. Alice at #

 
I Used To Do That With Hawaiian Punch and a Straw


Today a patient told me how he kept himself entertained in the hospital during his admission for a GI bleed: he kept clenching and unclenching his stomach muscles to vary the level of blood in his NG tube. To each his own, I guess.

In other news, almost over my jet lag. Thank goodness.

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
Kona the Wonder Dog


OK, just to cheer you up from the previous post here are some pics of the recent snowfall in Colorado, courtesy of my sister. Included are pictures of their lab puppy Kona - I met him over Christmas and he is adorable.









Brrr! I'll stick to Los Angeles, thank you.

Labels: Doggies, Snow, Travel

posted by Dr. Alice at #

 
Mediball


My flight home from Australia included Moneyball as one of the featured movies. In this film Brad Pitt plays Billy Beane, the general manager of the Oakland A's baseball team. He is faced with the challenge of putting together a winning team on a very tight budget. Fortunately he meets Jonah Hill's character Pete, an Econ nerd recently graduated from Yale, who believes he can find undervalued baseball players by analyzing their stats. For example, if a player does not have a great batting average but often gets on base via walks, that player is more likely to score (although his low batting average causes him to be undervalued). Billy hires Pete to help him find these undervalued players. Although they meet a lot of resistance at first, Pete's theory proves to be correct.

In the course of the film we learn via flashbacks that Beane was drafted out of high school as a promising baseball player. He never lived up to his early promise and eventually quit the sport to become first a baseball scout and then general manager. His experiences give him a very clear-eyed view of professional sports. He does not find baseball romantic; in fact, immediately after the climax of the film in which the A's set a new League record, we see Billy Beane explaining to Pete that he isn't interested in setting records or winning World Series rings. What he wants is to change the game. Left unanswered is the question, is he changing it for the better?

Today at work I sat through a very dispiriting meeting and was irresistibly reminded of Moneyball. The issue is that The Firm has to reduce the cost of patient care. We are at risk of losing several insurance contracts, as we're being told that we as a group are simply too expensive. We, the primary care doctors, have been divided into "pods" and told that we will be meeting monthly to analyze our practice habits; the meeting today was for the pod leaders. (I'd make a "Pod People" joke here, but it is simply too close to the truth to be funny.)

We were handed sheets of paper listing the number of studies and lab tests each of us had ordered in the past year. This included EKG's, echocardiograms, radiologic studies, neurologic studies and so forth. Our "efficiency score" was also included. We were told that the doctors in general are undercoding patient diagnoses. The higher you code, the sicker the patient and the better your efficiency score is (but if you overcode, woe betide you! You will be cast into the seventh circle of Hell - meaning the Feds will sue your sorry ass off.)

Nothing on these sheets of paper said anything about patient satisfaction... or doctor satisfaction, for that matter. Nothing about the pleasure we take in treating three generations of one family, or congratulating a patient on their retirement or a grandchild's marriage, or in saving somebody's life. Nothing, in other words, about the romance of medicine. Our performance was boiled down to a handful of statistics presented to us by a clear-eyed, hardbitten MD in charge of numbers. Now to be fair I know this guy to be a great doctor, one of the Founding Members, who really knows what he's doing. And I also know that he's right and we have to be more efficient in what we do. But today was a new emotional low for me.

I come from a medical family and I often think back to the stories my mother has told me. Her father and his brother ("Uncle Doc") were a dentist and a doctor respectively. They lived in the same small Southern town and shared office space. In that time and place tobacco was the main cash crop. The farmers were flush with cash once a year, after the tobacco auctions, and that was when they paid off their accounts. My mother remembers them coming in: "They'd say 'How much do I owe ya, Doc?' and they'd pull a wad of bills out of their overalls that could choke a horse." My grandfather carried them on account the rest of the year, knowing they were good for it.

Obviously this billing method has its weak points. But as I sit through these meetings belabored with statistics and ICD-10 coding, I often find myself visualizing that 1940's office and wishing I worked there instead of here. At least no one there was reduced to a statistic.

Labels: Medicine, Pop Culture, Random Thoughts

posted by Dr. Alice at #

 

Recognize this?

Australia, ladies and gentlemen.

The Great Barrier Reef, taken from a helicopter (apologies for the poor image).

More pics forthcoming. I wish to thank Tim Blair and his lovely partner Nadia for their generosity and hospitality while I was in Sydney (including letting me ransack their library) and for introducing me to Turkey Flats rosé. If you ever come across this wine, get some. It is great.

Labels: Travel

posted by Dr. Alice at #

 
Catchup Time

(I apologize for brevity here, but I am on the clock at an Internet cafe.)

I only just realized it's been six months since I posted. Unbelievable. I promise more posts will be forthcoming, but not right away. Currently I am in Australia on vacation - a place I have always wanted to go - and am in Melbourne riding trams and drinking coffee. I will post a few pictures as well upon my return.

Yesterday was Australia Day, a sort of combination of the US holidays Memorial Day and Columbus Day. We the newswatching and -reading populace were treated to any amount of guilt from the "indigenous people" of Australia. They actually went after the Prime Minister, who was at a ceremony in Canberra giving awards to emergency relief personnel, and security had to be called to escort her from the mob (who were beating on the glass walls of the restaurant and trying to attack her).

After seeing that spectacle on the news I make no bones about suggesting that the British who "stole" Australia from its indigenous people have accomplished a lot more in 200+ years than the indigenous types who lived here for thousands of years prior to that. And I don't care who hears me say it.

Labels: Random Thoughts, Travel

posted by Dr. Alice at #