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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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    Sunday, July 26, 2020
    Crack Chili Con Carne

    So I acquired a tenant some time back who thinks my chili is truly awesome. Any time I make it, I freeze most of it and she will devour it over the next few weeks. I thought I'd post the recipe here. If you will allow me a detour into pedantry, chili basically means some type of stew or liquid flavored with chilis. (Chiles? However you spell it, you know what I mean.) Chili con queso: with cheese, chili con carne: with meat. Technically, I suppose meatless chili would be chili con frijoles though I have never heard that term used. At some time in the past few decades, however, chili con carne was shortened to simply "chili," in the assumption that the dish is going to contain meat. 

    My chili is not gourmet in the slightest. It's made with ground beef, not chunk or stew beef, and the base recipe is the 1:1:1 of one pound meat, one 1-lb can tomatoes (technically we now have 15-ounce cans, but whatever), and one 1-lb can of beans. I'm sure it sounds pretty pedestrian, but allow me to suggest a few choices which can add up to a significant improvement in the final product.

    Beans: I go with either small red beans or pink beans, though you can use pinto or black beans if you like. Do not drain the beans.The starch in the bean liquid will help thicken the chili. 
    Tomatoes: diced fire-roasted for preference, and I also add a small can of tomatoes and green chilis (the best known brand in the States is Ro-Tel). Don't drain the tomatoes, either.
    Additional liquid: Rinse the cans with a small amount of water and add that in. In addition, I use beef broth. Beer is an alternative (at least a small amount) and some cooks add coffee.
    Flavorings/spices: This is where you can get creative. I dice an onion and two cloves of garlic and cook these after the meat is browned and drained. Then add the meat back in and add the beans/tomatoes/Ro-Tel and the beef broth. Now, keep in mind that chili powder also is a thickening agent. Standard prepared chili powder consists of pulverized dried chilis, oregano and cumin and often paprika. You can also purchase powders of individual chilis such as ancho chili, but I go with the old tried and true. What I like to do is to start with pouring in some chili powder - I really don't measure but I would estimate 1.5 to 2 tablespoons - and then add in varying amounts of oregano, paprika, garlic powder (yes, on top of the garlic), maybe some celery salt, cumin and a little cayenne. Depending on what is available and my whim, other options would be crushed red pepper or hot sauce. And if you're going for that gourmet touch, a small amount of cocoa powder or bitter cooking chocolate can be added, though I've never tried that either. Be sure to taste as you go. Don't forget the salt, though with the sodium in the canned vegetables you may need less than you think.

    Once all this is in, I bring it to a boil, lower to a simmer and let it go for at least an hour. Don't let it go at a hard boil, because the beans are already cooked and they will fall apart. Lastly, another authentic touch if you want to thicken your chili is to take a small amount of cornmeal, mix it in a cup with some water or liquid from the chili until you have a smooth, loose slurry, and stir it into the chili. You should not use a lot, maybe a couple of tablespoons of cornmeal, and it will need to cook for 20 minutes or so. 

    You can serve with diced onions, grated cheese, sour cream if you like. You can also put chili on baked potatoes or cooked rice, or even on spaghetti. Warm leftovers and toss with romaine or iceberg lettuce, corn chips and cheese and you have taco salad. Enjoy. 


    Tuesday, July 21, 2020
    Thoughts Before Work

    I sit here waiting for my first patient of the day, desk fan set up, coffee ingested. The iPad is set up for video visits and charging cords snake over the desk. A freshly charged phone is at hand for the inevitable telephone visits for our older patients and the telephone number for the translator service is within reach. All set to go.

    My parents' 60th wedding anniversary is this week (my sister reminded me yesterday; I ordered a cake for pickup and she has taken care of the flowers). We will have a little Zoom meeting to celebrate after Dad gets back from his visit to the cardiologist. Yesterday I was on the receiving end of a telephone appointment - for my parents, not for me. With the primary care doctor on the phone I reviewed their medications, blood pressures and symptoms. I also have to talk to them about completing an advance directive form (not the most pleasant conversation I've ever had).

    This is a weird way to live. I veer between doing nothing and being booked with patients all day long. Later this week I plan to go back into the office to see patients in-person for the first time since February. I suppose you could call this a working retirement. I have to pay for my own benefits now, and that comes expensive; but the ability to say "no" to work when I feel like it makes it all worth it. 

    Here in the US there is a growing drumbeat of resistance against the ongoing lockdown orders. I have no objection to wearing a mask, but I am concerned about all the small businesses that are at their last gasp because they aren't being allowed to open. This stressful atmosphere, added to the fact that this is an election year, combine to create a fertile support system for conspiracy theories and accusations. I'm about ready to give up Twitter, because I just get angry every time I log on and start reading. I do wonder whether there was a similar atmosphere in the time of the Spanish flu, post WWI, a time of even greater social upheaval. My mother once told me that her father was prevented from enlisting in the Army due to the flu, but she has very few details. It's too bad; I would have liked to know more. 

    At any rate, it's time to start work. It's been good to start blogging again; it gives me time to get my thoughts down without the constant background static that comes with other social media. It does have a calming effect. 

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    Friday, July 17, 2020
    Feral Cat Land

    Here we are on another tour of my neighborhood, one of my frequent morning walks. Today we embark on an east-west walk, rather than north-south. I start out heading south on the big boulevard I mentioned in my previous post for a block or so, then make a ninety degree turn and head east. 

    This neighborhood is nice and quiet, a bit on the exclusive side, and becomes more so as you head further east away from the boulevard: The reason being that all the streets in this section dead end at the local movie studio. Once upon a time this area used to be farmland until it was purchased in the 1920s by Twentieth Century-Fox. The surrounding neighborhood was sold off to become housing and what is now known as Century City, but the studio remains, an island of Hollywood commerce in the middle of Westside suburbia. 

    I like to check out the homes in the neighborhood as I walk along. The styles and sizes of the houses vary. Some are still the one-story ranch type homes that were originally built here but many have been renovated and are now much larger (read: taller). In this area, if the homeowner wants to enlarge the house there is nowhere to go but up. The newer homes are two, sometimes even three, stories and really are too large for the lots they are built on. Many are starkly modern and, to my mind, not very attractive when compared to the Olde California mission or classic ranch styles of their smaller brethren. Some front yards are drought proofed with cactus and gravel; some are tangled webs of rose bushes and overgrown grass with winding paths of brick or stepping stones glimpsed when you crane your neck or venture onto the driveway (with caution, at 5:30 am).

    There are a few north-south cross streets here which run between the two defining east-west streets of the area. They are lined with apartment buildings, most of which are new and look fairly nice. As I approach the terminus of my walk, however, there are a few holdout buildings which are older and shabbier - the chief of which is a faceless two story building, which could best be described as a single block of stucco dotted with a few minimalist windows. It is surrounded by a blasted patch of dry earth which likely has not seen water since the last rain months ago. As I plod up to the dead end of the street the side of the stucco block is enlivened by a small side porch lined with potted plants and an oil-stained driveway on which usually lounge two wary cats. 

    Welcome to Feral Cat Land, the most exclusive amusement park in Southern California. Population: two cats and me. As per my custom I chirp to the cats, which either ignore me or give me a shocked look and disappear. The attraction of Feral Cat Land, other than the cats, is a battered pickup truck several decades old painted teal blue and bearing the International Harvester logo. The truck is a fixture on this street: it's always there every time I come here.  Based on my (minimal) online research, it dates to about 1951. By the time I reach this part of my walk I usually lean on it and pant for a while.

    Feral Cat Land is bordered by a tall wrought-iron gate edged by two impressive Art Deco-styled concrete pillars, painted white. The pillars are topped by two lovely, elaborate street lamps which burn bright in the predawn twilight. If you look more closely you will see a placard on the gate which states that, per municipal code, you can't go through the gate without permission - although you can peer through at the little bungalows by the gate (probably administrative buildings) and a large filming stage looming in the background. Occasionally a golf cart will zip across the parking lot. This is the closest most Angelenos who are not employed by the entertainment industry will ever get to a studio or film set. I always linger here for a minute or two, wondering what it would be like to slip through that gate. The whole matter-of-factness of the location fascinates me: six inches on one side you're looking at a rundown apartment building and feral cats; six inches the other side and it's Movieland!

    If you turn away from the gate and walk north you will find several similar streets dead-ending in similar pillars, marking the borders of the studio. It's rather like traveling from Main Street U.S.A. to Tomorrowland in the Kingdom of the Mouse. Except here, Tomorrowland is strictly off limits. 

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    Monday, July 13, 2020
    Architectural History: The Apartment House

    Around the corner from my house is a large north-south boulevard that begins a couple of blocks south of me and runs north into the San Fernando Valley; it's often used by commuters as an alternative to the dreaded 405 freeway. The south end of this road is lined by apartment buildings and terminates at the local public golf course. As the road runs north into the hills, the apartment buildings disappear and are replaced by individual homes. I walk in the mornings for exercise and my route often takes me up this street. Therefore I have had plenty of opportunity to ponder the differences among the buildings as I wander. 

    As with all of Los Angeles, the buildings here are constantly being renovated or torn down and rebuilt. An architectural historian would probably have a field day identifying the styles and dates of the various apartment complexes lining this street. The appearance of the buildings gives most of the clues you need. First, the size:  are they two stories, or three or four? Do they extend for half a block, or are they only one or two units wide? The design of parking spaces alone would be enough, in most cases, to tell you when the place was built. The newest buildings have underground parking accessed by an automatic gate; the older ones have parking slots on the ground floor of the buildings, which may have garage doors or be open to the street. Most tenants of this type of building park their cars on the driveway apron extending onto the sidewalk, because everybody knows that if you park in the garage your car will be blocked by another car and you'll never be able to move it.

    The detailing of older buildings often gives information about the decade in which they were built; buildings from the Fifties and Sixties will have fancy detailing known as "dingbats" - in fact, the nickname has transferred to the buildings themselves. More information, and a nice photo, are here. (Love those garage doors.) In older buildings, more time and effort was spent on windows; you may see French windows, bay windows or windows curved to fit the corner of a building rather than those  Bauhaus-inspired flat atrocities. Scattered around town, a few complexes dating from the 1940s still survive which can be identified by their auto-court design (garages in the back) and curved corners echoing Art Deco streamlining.

    Light fixtures and paint color are also good indications of when a building was constructed. Seventies buildings are noted for their dark wood detailing, overall blocky and squarish design, and globed light fixtures. Sometimes you'll see some wrought iron detailing as well. Everything built after 2000 has that awful Tuscan-inspired pinkish ocher stucco and white trim. Eighties buildings tend to be a little more froufrou - the architectural equivalent of big hair and shoulder pads. There is one building I pass on my walks which is painted blue with fancy metal detailing on the balconies; for whatever reason, it reminds me of a French chateau.

    The buildings I truly love are the garden apartments, which are slowly dying off. They are being torn down and huge, efficient hivelike buildings are appearing in their stead. One such building directly behind me was torn down over the past few weeks; nothing is left of it but dirt and the concrete stairs at either side leading up to the back of the property.  In a garden apartment the living space lines the edges of the lot, with a narrow path leading into a central garden space shared by the tenants. Granted, it isn't the most efficient use of real estate but there is a peace and graciousness to these spaces that will be sorely missed when all of them are gone. Our local architecture conservation group is fighting to save some of them, but it is an uphill battle as developers have no compunction about rewarding our City Council with cash, cash, cash for getting their plans approved. 

    I will try to post soon about one of my other favorite neighborhood landmarks that I visit on my walks.

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    Friday, July 10, 2020
    Cake or Death

    The comedian Eddie Izzard has a wonderful routine called "Cake or Death." It's sort of a meditation on religious and geopolitical history and you can see it here (language warning). Basically, he's saying that if the Church of England tried to mimic the Spanish Inquisition everybody would  wind up getting cake. Why would you choose death if you were offered cake?

    But I seem to be entering that part of the life cycle in which you're surrounded by death. Patients I have known for years are dying. My trainer has lost both parents in the three years we've been working together, and another trainer I work with occasionally is about to lose his mother to breast cancer. A close relative of mine has metastatic lung cancer. My parents are reasonably stable - for the moment - but the question is for how long; they're both in their eighties. 

    Several friends of mine have lost parents or other family members recently.

    I guess what I'm saying is it would be nice to be offered some cake for a change. 


    Thursday, July 09, 2020
    In Which Dr. Alice Enriches an Orthodontist

    So this morning I pulled out my credit card and made a hefty payment to my new orthodontist. In my mid-fifties, I apparently need my teeth straightened... forty years after the last time I endured it. I have a widening gap between the two front teeth in my upper jaw ("incisors," or as Ortho Guy refers to them, Eight and Nine) and crowding of the teeth in my lower jaw. Estimated time for treatment: fourteen months. 

    He's a nice fellow, if a little too prone to making tooth-related puns. Such as, "If you don't treat this it'll come back to bite ya!" Sigh. But he was recommended by my regular dentist, whom I have been seeing for years. He certainly has a lovely office and I'm pretty sure I just made his next month's rent payment for him. Very well organized, everyone masked and hand sanitizer everywhere.  They have incredibly fancy equipment which allowed my teeth to be scanned and a mold visualized in less than five minutes. No more biting into a concrete filled mold and fighting gag reflex for what feels like forever. There is something to be said for the twenty-first century after all. 

    In related news, this afternoon I drafted a query to the administrators of my medical group about my lack of remuneration for the past five weeks. I'm still working there as an hourly employee now that I have retired (semi-retired, I suppose, is more accurate) and had to fight the temptation to email "WHERE MY DAMN PAYCHECK AT" instead of substituting something more diplomatic. Well, I can't spend money on a vacation this year due to the Virus, so I may as well spend it on my teeth instead. I go back in about a month for my first fitment.

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    Tuesday, July 07, 2020
    Virtual Medicine

    When I retired in early January of this year I planned to come in to the office one week a month to see patients.  Then COVID came along and I found myself jumping right back into medical practice to help out my medical group. I had never done a telemedicine video visit in my career until March; turns out it isn't all that difficult. Now I work from home several days a week. I'm not going into the office for now, as I have three elderly relatives who need my help and I'm trying to minimize any potential exposure so as not to put them at risk.

    My group uses a video program which is part of our electronic medical record system, as well as an alternative which is simpler to use called Doximity. (We can also use FaceTime or Zoom, but these systems are discouraged because they don't have the same privacy protections as the other two options.) Mostly they work well, but there are issues from time to time. 

    • There's the visit where I can't hear the patient, or they can't hear me, although we can visualize each other on video. Frantic gesticulating ensues. Sometimes I have to resort to telephoning the patient while having them hold their rash, or whatever it is, up to the camera. Shingles is particularly easy to diagnose on a video visit as it can't be mistaken for anything else.
    • There's the poor data quality visit where the video screen freezes or pixilates. Watching the patient dissolve into little cubes can be offputting to say the least. ("Mr. Smith, how long have you been falling apart like this?")
    • There are occasional complications with pets - the patient's dog gets jealous or nervous and starts barking, or the cat walks across the camera's field of view.
    • And then there's my favorite, the patient (usually elderly) who simply cannot figure out how to use either of the video options. Yesterday I had a particularly memorable example of this problem. I connected to the patient via the Doximity app but they didn't pick up, so I called the cell phone and got voice mailbox which was full. I finally tried the patient's home number, they picked up - the cell phone was shut off. ("Oh, so you can't do this on the laptop?" "No, you can't... did the medical assistant explain that?" followed by a tooth grindingly long delay as the patient turned on the phone and waited for the link to come through.)  As we are booked in with patients every twenty minutes, it's easy to run late if you get more than one of these in a session.
    We can always resort to telephone visits, but the group strongly emphasizes video visits when possible. The amount of data you can get on a video visit is obviously greater than on a phone call - you can check the patient's appearance as well as their surroundings (are they dressed neatly, disheveled, short of breath, pale?) And to be honest, reimbursement for video visits is better than for telephone visits. These days that is no minor issue. The clinic has reopened but patients continue to be reluctant to come in.

    Certainly not all patient issues can be addressed via video, but I would say that overall this system has worked well. My biggest problem with telemedicine is that I need a chair with better back support. After sitting at my desk for four hours straight it's almost impossible to move...

    Oh, and edited to add that it's really special when you realize after a four-hour shift that you've been interacting with patients all the while you have a big food stain on your shirt. On the up side, though, you can work barefoot and wearing shorts because no one can see you below the waist. So there's that. 

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    Saturday, July 04, 2020
    Thoughts on Fan Fiction

    Fan fiction, for those who don't know, is a term for writings or artwork based on a preexisting work, written by fans of said work. The work in question could be a film, a television show, literature, radio program, comic strip or even other works such as video games.  Fanfic has been around for decades and first really made it into the public eye with Star Trek, I believe. Fans of the show wrote stories about the characters which were collected, mimeographed and stapled into fanzines and then mailed to subscribers. Nowadays fan fiction is published on websites (the two best known are Archive of Our Own and FanFiction).

    Traditionally fanfic has not been highly regarded; if you say the phrase "fan fiction" most people will either be unaware of what you are talking about or will cringe in revulsion. There are reasons for its poor reputation. Unfortunately, although some fan fiction is well written the genre as a whole has a reputation for bad writing. Consider the term "Mary Sue." The original Mary Sue was the main character of a Star Trek fic, a Starfleet cadet who wound up on the Enterprise somehow. She was depicted as impossibly gifted and accomplished, although the story contained no scenes showing her doing anything which would justify this portrayal. Readers expecting Kirk and Spock got Mary Sue, plus main characters basically drooling over her and how amazing she was. The author of the story was named Mary Sue Something-or-Other, and the story was immediately recognized as nothing more than wish fulfillment. It was reviled by other fans and "Mary Sue" is now used as shorthand for this type of character. But there are other reasons for the critical view of fan fiction: often it is simply viewed as derivative and lacking in imagination since it is based on other works. "Create your own characters!" critics will cry. "Do your own thing!"

    Everything above pretty much describes what my opinion of fan fiction used to be... until I started writing it. I blame Season 5 of 24 for starting me on this hobby. Every season of 24 had loads and loads of characters and enough subplots for three other shows. Some of the subplots were more compelling than others. I got drawn into the Season 5 saga of the First Lady and her stalwart bodyguard Aaron Pierce, who were investigating the web of intrigue surrounding the President... as well as developing a relationship of their own. It may sound cliched but in the hands of two gifted actors, Jean Smart and Glenn Morshower, it worked incredibly well. Some of the online 24 commenters were also fans of these characters. We formed a discussion group and several members began contributing stories about them. I was coaxed into writing an initial story and then found that I could not stop. It was just too much fun, as well as being good writing practice. The next thing I knew I was embarked on an epic story that took me two years to write and ran to over 100,000 words.

    What's good about writing fan fiction? If you want to write, it's a good place to start because it allows you to concentrate on plot, dialogue and settings. The beginning writer does not have to focus on creating characters because readers familiar with the source work know who the characters are; that work has been done for you. Original characters can be created one at a time and allowed to interact with established characters. You can also get critiques and suggestions from other writers (this is called "beta" (noun or verb). If you want your story to be beta'd before you publish it you can request input on it. Most critiques I have seen are supportive. With this kind of practice writers can become successful: "Fifty Shades of Grey" started as fan fiction of the "Twilight" series; the author changed the controlling vampire character to a controlling billionaire character. I won't claim it's great art, but the author sold tons of books and got a movie deal, so there you go.

    What isn't so good about fanfic... for me this divides into two categories: stylistic errors and terrible plot ideas. The style stuff is usually pretty basic: misspellings and grammar mistakes such as changing tense from paragraph to paragraph, or even sentence to sentence. Using quotation marks erratically, a more common mistake than you'd think, drives me nuts. Sentence fragments may or may not be a problem, especially if these occur in dialogue; they can add realism and an informal tone, if that's what you are aiming for.

    Terrible plot ideas: Oh, God, don't get me started.

    • "What if [Character X] had a long lost sister/brother?" [Mary Sue ahoy!]
    • "What if [Character X] was gender flipped?" [It's pointless! Work on your plot.]
    • "What if Show X and Show Y characters met and started working together?" [A.K.A. the crossover - most of these are awful.]
    • "What if [Characters X and Y, who clearly are not in love with each other in the original work] fell in love?" Especially if X and Y are the same gender... "Hey, let's make them gay, even though they weren't in the original story!" There are TONS of these stories in fanfic land. And they're total crap.
    • "Take That" fics, written by someone who really hated what happened in the story or how one or more of the characters were portrayed. Often related to politics or gender issues. I call this the "Why Was Aslan So Mean to Susan" category, after the denouement of the Chronicles of Narnia series.

    Let me turn the subject to my bias in favor of plot. Many of the works I read rely on romantic scenarios between characters and have little or no plot, another reason I will give a thumbs down judgement on a piece (mental judgement only; I don't post negative reviews). I love lots of plot, and subplots make me really happy.  I am heavily biased in favor of Gen (for general) fics for this reason. Usually Gen fics contain little or no romance, or at least the romance is not the focus of the piece. My 24 fic did have romance between the main characters, but this was well-established in the show and I spent a lot more time on my plot, which involved the unwinding of a major political conspiracy.

    Going back to the ever popular idea of slash fiction (gay romance between characters): The authors do have a point. It's true that there are not a lot of LGBTQ heroes in pop culture, even today. My response to that is to write some original new ones. It makes a lot more sense to me to create original characters to fill a need rather than to radically change a well-established character.

    Another motive for writing, if I am honest, is positive feedback. A complementary review on something I have written is an ego boost like no other. As I tend to write about works that are not so well-known, I don't get that many of these but I certainly enjoy them when I do.

    Reading fanfic is like panning for gold, basically. The good stuff requires a search but it's there. If you have a favorite book, TV show or film it's worth doing a website search (see the sources above); you may be pleasantly surprised at what you find.

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