Feet First

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

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    Sunday, February 26, 2012
    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.


    Wednesday, February 22, 2012
    This Is Counterproductive

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

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    Thursday, February 09, 2012
    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.

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    Wednesday, February 08, 2012
    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.

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    Monday, February 06, 2012

    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.

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    Sunday, February 05, 2012
    I'm Back, Baby

    Jet lag is kicking my butt, so this will be brief. Australia is awesome and you should all go there.

    Well, perhaps a little more than that. How about some pics?

    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.