Half of the Story

Today's Philadelphia Inquirer has a front-page discussion about expensive surgical interventions in the very aged. They find a few examples of unusually vigorous geriatric patients (including the world-renown cardiac surgeon Michael DeBakey himself, who had an aortic repair at age 97 and lived productively for another two years) and indulge in the usual extrapolation of costs multiplied by the numbers of aging baby boomers. Once again, they get half the story right.

Pennsylvania Hospital's chief of cardiothoracic surgery, Charles Bridges, is correctly quoted thusly:

You have to get out of the idea that there's a threshold age where we think about this surgery differently. With each patient, you have to lay out: What are the risks if I do this? What are the risks if I don't?

This is an accurate statement of the clinical reasoning required in these scenarios. I agree that there is no arbitrary age threshold above which any given medical intervention should be withheld. Treatment needs to be individualized based on the clinical condition of the patient.

The actual problem is that people in really crappy condition undergo all kinds of heroic interventions all the time, because they're "so young!" Or because some hotshot surgeon thinks he can pull them through, because, yanno, his skills are so extraordinary they can overcome the effect of years of diabetes, smoking and inactivity. (Hint: no, they can't.) Or because the family feels so guilty about neglecting poor demented granny in the nursing home that when she becomes septic and her kidneys fail, of course she need dialysis! You can't let her die!!

There's another great line further on in the article:

[We] are all suffering from a terminal, sexually transmitted disease called life.

So true, yet so difficult for Americans to accept.

A better way to address the issue of health care rationing (yes, I said the r-word) is to base treatment decisions on the patient's clinical condition. Things like whether or not they are still working (like my 81-year-old father), their mental status (why are we performing elective procedures on patients with advanced dementia?), and their co-morbidities (there's a huge difference between the active 85-year-old on only 1 or 2 meds -- yes, they exist -- and the bloated, diabetic, smoking couch potato in his 60s).

A cost-effective, medically appropriate way to address this issue is to curb overtreatment in those patients with advanced dementia and multiple co-morbidites, whatever their age. They are the ones who make all this expensive technology respectively futile and dangerous. Both patients and doctors need to get over the mentality that just because something can be done, it ought to be done. This includes eliminating so-called "screening" tests like annual echocardiograms and stress tests for anyone who's ever seen a cardiologist. It means not starting kidney dialysis in the face of advanced dementia. Perhaps it even means not transferring septic nursing home patients to hospitals in the first place.

We shouldn't be arguing about operating on healthy 90-year-olds. It's the frail, fragile folk in their 70's and younger, bodies wrecked by years of abuse, who ought never to see the inside of an OR in the first place, but who all too often are whisked there without a second thought. We need to start telling the other half of the story.

Ad Shame

Doesn't anyone have any shame anymore?

Apparently some people still do. PalMD of White Coat Underground and Orac of Respectful Insolence have recently seen the light. More specifically, they've seen the ads on their blogs placed there by automated algorithms that supposedly select ad content based on the content of the blog posts, and have been appropriately ashamed and appalled.

It turns out that the results of those automated algorithms are embarrassingly inaccurate. Most of the time, they come up with ads for the very things -- chiropractic, colon cleanses, homeopathy, all kinds of alt med woo -- that are being ridiculed, taken to task and otherwise being deconstructed in the very posts they appear beside.

Unfortunately there is another blog, one that prides itself on its skeptical slant to the point that its name is actually "Science-Based Medicine," that has had these ads on the blog's sidebar from its inception. Worse, I've pointed it out to them. Several times. To more than one of them. Their answers ranged from, "Our webmaster can't do anything about it," to "We trust our readers to understand that we don't choose the ads and that we don't endorse their content."

cough*rationalization*cough

Doesn't even the appearance of conflict embarrass them? That's why I don't have any ads on my blog at all, and I don't think I ever will. There are better ways to make money from writing than passive income from ads for quackery, and there are better reasons to write blogs than to make money. Or at least there ought to be.

We need to be clear not just about what we're doing when we blog, but why we're doing it. Some of the SBM editors have pointed out to me that their blogging takes time, and their expertise is their stock in trade. Blogging costs money (actually, it doesn't have to, or it can cost very little), time is money, and therefore revenue from the ads is justifiable.

I call bullshit.

If you're a doctor like me, you make your living taking care of patients. Ditto if you're a nurse. If you're a doctor who does research, then you are paid by your grants. Writing (which includes blogging) is not the equivalent of patient care. It is possible (and a lot of fun) to be paid for writing, but entering into a contract to be paid a certain sum for writing a something specific is not the same as passively collecting revenue from sidebar advertising on a blog. It's kind of like charging rent to leeches for allowing them to suck your blood.

So Kudos to PalMD. Orac, I'm reserving judgment. Although he states his tolerance will be zero by Monday, I wonder what -- if anything -- he will do about Science-Based Medicine. As it turns out, he blogs there too.

Tall Tales

Cute:

Potential Benefits of an Online Presence

I recently read yet another in a series of blog posts about all the "potential pitfalls of an online presence" penned by the estimable PalMD over at WhiteCoat Underground. I usually enjoy Pal's stuff, but this one felt like a lawyer-ghost-written piece I'd already read a dozen times before. After the litany of the various pieces of an online presence (FaceBook, Twitter, blogs) he rattles off the usual trifecta of legal, ethical and professional considerations (complete with a genuflection to HIPAA), summing up with the old "there's no such thing as anonymity" riff.

Ho, hum. Old news.

Yes, we all know about Flea bloggers whose indiscretions forced them offline. Yes, we know about protecting confidentiality, not posting drunken images on facebook, and the value of our reputation. Yes, we are smart enough (most of us, I would hope) to realize that internet anonymity is an oxymoron. But anyone reading this and other similar pieces could easily come away with the idea that every touch of the "enter" key is a catastrophe waiting to happen.

If someone were to go on and on about the dangers of automobiles, rattling off crash fatalities and stories of lives ruined by injuries sustained wrecks of those devil-carriages, who would ever have the nerve to again set foot in a car? Without some sense of perspective on the upside of the internet, the significant potential negatives for doctors might deter some of them from the possible rewards of this powerful new medium. I therefore submit the following as benefits that might be gained from an online presence:

Practice Web Site and Marketing

At the same time as Pal's fear-mongering, we have just about every other authority proclaiming the necessity for every doctor's practice to have a web presence via a customized website. Various benefits include accessibility to patients (though I've always wondered why I need to be accessible to patients around the world, when I can only be of benefit to those in relatively close geographic proximity to me), ability to publicize things like office hours, location and practice philosophy, and direct patient communication via special portals that allow email.

Although it took me longer to come around to having an office website than it did to get online in other ways, I will admit that the main upside at present is meeting patients' expectations for online capability. Even when there is amazingly little practical use for a website, patients in the 21st century expect that a medical practice will have one. That said, there are a few logistical advantages. It is easier to direct patients to the website's awesome directions (penned by moi; you've heard the expression "directionally challenged"? I'm "directionally gifted") than it is to give directions over the phone. Office polices are there, updated and edited more easily than a paper brochure. All in all, it's turned out to be an inexpensive, positive addition to the practice.

FaceBook and Twitter

Although FB originated by and for college kids as a way of both keeping in touch with old friends and staying current with new ones, these benefits have been adopted by an older demographic (much to their horror), including their parents. Social networking is a function of social animals. Even those of us who are old and decrepit (you know, who graduated from high school back in the 70's) enjoy renewing old friendships and maintaining current ones. Posting random updates on what we're doing (some in fewer than 140 characters) and comments on others' updates is fun.

One might consider limitations on "friending" or "following" patients, but, just as in Real Life(tm), it is possible to establish reasonable boundaries, analogous to those set on socializing with patients outside the office. Why should the simple fact of our profession make these kinds of social interactions off-limits to us? As long as we observe the same kinds of reasonable cautions online as we do offline, doctors ought to be able to enjoy internet social networking as much as anyone else.

Blogging

My first and most extensive online presence consists of blogging, and I feel I have reaped enormous benefits from it without having fallen prey to any of the hazards so direly warned of by PalMD.

First and foremost, blogging is writing. Blogging is its own form, different from a novel, short story or article, but it's still writing, and the more you do it, the better you get at it. For those of us who happen to enjoy writing as well as doctoring, why should we not avail ourselves of the opportunity afforded us by blogs to have our writing read by a wider audience than we could ever hope for otherwise, just because we happen to be physicians?

We can also use our blogging platforms to persuade, inform, and educate; functions inherent in medical practice that we can now use the internet to share with an enormously expanded number of folks than may happen to darken our doorways. What about our professional and ethical responsibility to spread useful health information for the greatest good? Shouldn't those factors serve to mitigate at least some of those terrible risks some claim can come from our online presence?

Finally, it's all about the people you meet. In order to be a good blogger one must read other blogs. Appropriate commenting and linking results in the formation of a community of people joined by mutual interests and respect (crayzee flaming notwithstanding, though seeing "-eur" appended to all kinds of nouns has become pretty amusing). Deepening those relationships one-on-one, whether electronically or in person ("meat-space" is the most interesting way I've heard it put) has been fun and rewarding. I've heard it said time and again that this ability to connect with more people, especially those whom we would never have met otherwise, is the best thing about the internet. I agree heartily, and not just because it's how I met Darling Spouse.

So even though doctors must take special care with their online presence, as they do in all other areas of their lives as well, the benefits of participating in this new virtual world can be wonderful; certainly positive enough to outweigh the potential pitfalls.

Best Line of the Day

From a comment on Margaret and Helen, originally linked from an anonymous comment on the Daily Kos, about South Carolina's Governor Sanford:

It was a slight miscommunication between Sanford and his staff. He told them he'd be "spiking some Argentina tail," and they thought he'd said, "hiking the Appalachian trail." It was an honest mistake.

Inadvertent Therapeutic Trial

The definition of a therapeutic trial is when the diagnosis of a particular condition is established by a trial of specific treatment.

Not that this lets physicians off the hook for making the diagnosis. You still have to do a history and physical. In fact, you basically have to make the diagnosis first, then use the treatment to see if you're right. In everyday practice, the application of a therapeutic trial is quite limited. It is not valid, for example, to give penicillin to everyone with a sore throat and see if they get better. The regimen has to be very specific to the condition; it's the only way to be sure it's really the treatment that's having the observed effect, if any. There are very few conditions that have treatments specific enough to qualify as a true clinical therapeutic trial.

But what happens when you give someone a medication to treat one thing, and something else happens?

A patient with longstanding irritable bowel symptoms and a known allergy to cats (no relationship between those two conditions) broke out in really bad hives from inadvertent exposure to cats, and was treated with steroids. Three months later, she called to tell me that while she was on the steroids and for about two months afterward, her IBS symptoms resolved completely. Now they were coming back.

Oops! Perhaps her GI symptoms weren't due to irritable bowel syndrome -- something you wouldn't expect to be affected by corticosteroids -- after all. Perhaps she really had something completely different, like inflammatory bowel disease (Crohn's disease or ulcerative colitis) or celiac disease. Sure enough, her tissue transglutaminase antibodies came back elevated, indicating celiac. She's off to the gastroenterologist for confirmatory biopsies, followed by lifelong avoidance of gluten. The good news is that her GI symptoms should resolve completely (again). The bad news is that she's at increased lifetime risk of assorted other conditions like diabetes and cancer, although some of these can be lessened with the gluten-free diet.

All because she broke out in hives.

(And noticed the change in her IBS symptoms and called me.)

(And because I knew what to do.)

In Which I Discover That I May, in Fact, be (Gasp!) Human

Got a phone call from a long-time patient the other day telling me that she was switching doctors. Something had been bothering her -- that she never told me about -- that she really needed to get taken care of, so she was switching.

Believe it or not, this kind of nonsense happens all the time. People switch doctors at the drop of a hat. Whether the office location or hours aren't convenient, or their insurance changes to a plan they don't think I participate in (though I probably do), or I didn't call them back when they paged me after hours (leaving a message on the regular message line instead of the default emergency line, and not leaving a phone number), or whatever. This is not at all uncommon, and it doesn't bother me a bit.

That's what I tell myself.

That's what I try to keep telling myself again and again as I drive home, mulling over the call in my mind. "What, am I supposed to be a mind reader now?" I ask myself. Of course not. I know that it's just one of those things. It happens all the time, and I tell myself it doesn't bother me a bit.

Of course it does. A bit.

A little bit.

I also know from experience that although there's a little heaviness to my step for the rest of today, once I sleep on it I will shake it off. These things are always better the next day.

I decide not to say anything to Darling Spouse. After all, I've already told myself everything that can be said. DS isn't going to say anything different, so what's the point?

It turns out that marriage doesn't work that way.

"How was your day?" comes the regular question.

I sigh a little as I answer, "A long-time patient switched doctors because I didn't take care of a problem she never told me about."

"What, are you supposed to be a mind reader now?"

Although they are, in fact, exactly the same words I have already said to myself (several times), just hearing them out loud is startlingly soothing. I have no idea if hearing it through my ears instead of just in my imagination is what makes it so different, or if it's the validation of another person that no, I don't really have to be a mind reader; either way, I feel my mood lift immediately.

Wow. So this is what this feels like. Accepting the comfort and empathy that comes from hearing something I already know. I dole it out all day long, all the while telling myself I don't need it. Maybe I don't need it, but it sure feels good.

I may be a dinosaur, but I guess I'm human after all.


(Thanks, DS.)

Obesity is NOT a Disease

I've had enough!! It's time for another lesson in basic terminology. Words like "disease," "risk factor" and "epidemic" mean specific things, not just whatever someone happens to want them to mean at any given moment. Pronouncements from government and even from organized medicine about the "obesity epidemic" are meaningless. Let me tell you why.

Obesity is a risk factor for diabetes, high blood pressure, and a host of other medical conditions.

Now listen up, because I'm only going to scream at the top of my lungs until the blood vessels in my eyes burst say this once:

HAVING A RISK FACTOR FOR A CONDITION
IS NOT THE SAME
AS HAVING THE CONDITION.

Really. It's not. A family history of colon cancer is not the same as colon cancer. Smoking isn't the same as chronic lung disease. Alcoholism isn't the same as cirrhosis of the liver. A blistering sunburn isn't the same as skin cancer. And obesity is NOT THE SAME as having diabetes and high blood pressure.

In fact, obesity is different from all the other risk factors above, in that all "obesity", defined as a body mass index over 30, is so not created equal.

Here's what I tell my patients:

1. If your blood pressure is normal, and
2. If your cholesterol is normal, and
3. If your blood sugar is normal, and
   
4. If you don't smoke, and
5. If you are active (defined as 30 minutes daily of walking too fast to talk), then

I DON'T CARE WHAT YOU WEIGH.

As it happens, it's actually pretty tough to be really morbidly obese and have all the above points apply to you. Then again, look at Sumo wrestlers. Still, if you don't actually have any of the conditions for which obesity puts you at risk, AND if you continue to get monitored for those conditions on a regular basis, what's the big deal? Answer: it isn't.

So for everyone who wants to charge for health insurance on a BMI sliding scale, get your head out of your ass and start looking at what really matters: the presence of actual medical conditions like diabetes, hypertension, and so forth. Metabolic syndrome? Osteoarthritis of the knees? Weight loss is absolutely the treatment of choice; no argument there. But quit blaming every complaint on someone's weight if the BMI happens to be over 30.

From the standpoint of public health policy, absolutely encourage walking and exercise, a varied, healthful diet low in processed foods and high in fruits, vegetables and whole grains, and discourage smoking. But quit wasting time and resources railing against the "obesity epidemic", a meaningless term that detracts from real medical issues.

What a Difference a Year Makes (Not)

My father turned 80.

Last year.

He celebrated his 80th birthday by taking us all to Bermuda. "All of us" consisted of 7 kid-equivalents, 6 spouses, 12 grandchildren, and his sister. Lest you labor under the mistaken assumption that he, my mother and aunt are stereotypical little old people who eat dinner at 5:00 and go to bed at 8:00, suffice it to say that they partied the rest of us under the table.

Here he is, just about to blow out the candle on his birthday (cheese)cake:

Please note that he has just finished a deep inhalation in preparation for said candle-blowing, but has not yet begun the impending forceful exhalation. This means that at the instant of this image, he is still full of hot air.

The trip was a truly magnificent gathering, enjoyed by one and all, and of which fond memories linger.

Today, finally, he can stop walking around telling people that he is 80. This is because today, he is 81.

He still works, though not full time. He stopped that just a few years ago. In order to avoid confusion (his), he has re-labeled the days of the week. Because he only works Monday through Thursday, he states that he no longer has a Friday, so he has re-named it Saturday I, with the next day, "Saturday" to the rest of us, now being Saturday II. He continues to enjoy all his old hobbies: flying, reading about flying, crossword puzzles, and arguing outrageous positions just for fun (as opposed to earlier in his career, when he did so for fun and profit. Yes, he's a lawyer.)

He's sharp as a tack, has all of his marbles, and even remembers what to do with them (both tacks and marbles.) He was at a huge professional convention a few weeks ago, and will be coming to visit next week in conjunction with a friend's 80th b-day party. As long as I make Liptauer (separate post, recipes included, to follow) for him, he will be happy as a clam. All things considered, he really is quite easy to please; when he's not driving me crazy, of course. Such is the way of fathers and children, I suppose.

So Happy Birthday, Dad; and Happy Father's Day to boot.

I suppose I can wait another nine years to go back to Bermuda.




(Edited, at the insistence of Darling Spouse, to add: We have beer in the fridge, Dad. You don't need to bring your own can of Bud.)

Why Discussing "Outcomes" is Meaningless

Dr. Centor and others often write about measurement of outcomes, lately calling them the "Holy Grail of quality." (edited to add: which, like the Grail, even he agrees are unattainable.) Quality, of course, is the latest meaningless buzzword applied to health care, as people other than doctors and patients (the only true "stakeholders" in this endeavor) try to justify pocketing a larger share of the benjamins ripped from the pockets of employers and consumers.

Everyone is struggling to define quality. The reason for all the conflict is simple: quality in healthcare, as in many other facets of life, is undefinable inasmuch as it means different things to different people. Akin to both beauty and pornography, quality is in the eye of the beholder, and one knows it when one sees (or experiences) it.

Now along comes the concept of looking at "outcomes" as a measure of quality. Even as some people seem to feel that, although trying to study outcomes is difficult it is still worthwhile, I submit that in the larger sense of what we do, it is as meaningless to define "outcomes" as it is to define "quality", much less use one to get at the other.

An outcome implies a static state of being at a specific point in time. It makes more sense to apply the term to discrete events like surgical procedures. Whether a patient emerges from an operation alive or dead, better or worse off, are distinctions that make sense to track. But when it comes to chronic medical conditions -- or even just caring for healthy people through their entire lifetime -- the situation becomes far more fluid.

Take diabetes, a disease caused by a genetic predisposition triggered by lifestyle issues, and one in which measurement of "outcomes" is frequently discussed. Say I diagnose a patient with diabetes, provide appropriate education about diet and exercise, and in six months the patient has lost 40 pounds and brought her A1c from 10% down to 6%. (This is not the least bit unrealistic, by the way.) By most current quality metrics, this is considered a "good outcome." Now what? I continue to see her every 3-6 months. After a year or two, say she slips up a bit; puts a bit of the weight back on, and sees her A1c rise to 8.5%. Is that a bad outcome? Say she comes back in and we do some more dietary counseling and brainstorming, understanding that the disease is not going to go away and needs constant vigilance on her part. Say she gets things back under control; for another year or two, and then relapses again. Back and forth; over and over. What are we looking for as the "outcome"?

Age to first MI or stroke? How long the patient can go before needing dialysis? Legitimate rubrics for population research, but meaningless for a given patient, say, trying to select a "quality" doctor.

Blood pressure control that waxes and wanes as someone's weight balloons up and down. Fitness that comes and goes as someone enjoys exercise during the pleasant summer weather but can't get around to it during the school year. Arthritis pain that peaks after a hiking vacation. This up and down course of exacerbations and remissions, ups and downs, is not only common, but virtually universal in managing just about every chronic disease there is. Congestive heart failure; ulcerative colitis; depression; you name it, there are countless conditions that cannot be cured, only managed, as they come and go with the ebb and flow of fickle humanity.

If you want to look at outcomes, consider oncology. Even if a patient is "cured" of their disease, they will surely succumb eventually, either to their cancer or to something else. Using "outcomes" as a quality measurement, why would anyone ever refer to hospice? Every last one of their patients has exactly the same outcome.

Then again, isn't that really the ultimate "outcome" for all of us?

Many of us feel that the quality (there's that unmeasurable, undefinable word again) of our days is more important the just their mere quantity. What is lost in the discussions of outcomes measurement is the idea of life as an ongoing journey, where any given "outcome" is so temporary as to be meaningless.

I'm reminded of one of my favorite parts of the Jewish liturgy, a poem by Rabbi Alvin Fine:

Birth is a beginning
and death a destination
And life is a journey:

From childhood to maturity
and youth to age;

From innocence to awareness
and ignorance to knowing;

From foolishness to discretion
and then perhaps to wisdom.

From weakness to strength or
from strength to weakness
and often back again;

From health to sickness
and we pray to health again.

From offense to forgiveness,
from loneliness to love;

From joy to gratitude,
from pain to compassion;

From grief to understanding,
from fear to faith.

From defeat to defeat to defeat
until looking backwards or ahead

We see that victory lies not
at some high point along the way
but in having made the journey
step by step,
a sacred pilgrimage.

Birth is a beginning
and death a destination
And life is a journey;
A sacred journey to life everlasting.

We have the honor and privilege to accompany our patients on this journey of theirs, as we walk alongside as fellow travelers. This is what we have lost sight of: the outcome is the same for us all.

It Happened Again!

Almost two years later, I get a phone call eerily similar to an earlier letter:

"Hi, this is Dr. Oddi's office. We have a mutual patient here who says she had a colonoscopy done by Dr. Oddi several years ago, but we can't find it in our fancy-shmancy new EMR that we paid an arm and a leg for that isn't worth shit records. Do you have any record of it in your files?"

I go to the shelf. That's right: an actual metal shelf full of pasteboard folders containing bits of dead trees known as "paper." It takes me three seconds to find the right folder, and four more seconds to locate the report of a colonoscopy done less than a decade ago by none other than good old Dr. Oddi himself.

"Yep," I say, "I've got it right here"

"Could you please fax it over?"

Just think: If I were a modern electonophile with a completely paperless office instead of a luddite dinosaur with superbly organized paper records, poor Dr. Oddi would have been shit out of luck.

Amen!

One of the commenters from my previous post hit the nail right on the head:

We don't have a national health system in the US, only a national health payment system.

I vote against any plan that includes the word insurance, because all the dough goes to the middlemen, not to the patients or the actual health care providers.

Marketing is highly developed here, and in my lifetime, we as a people have gone from personal responsibility for health to believing the hype about both products and procedures. The latter don't work, frankly, except for very small instances (magnified by fudging numbers and hand waving statistics -- I know, having done same for clinical trials).

If we HAD a health care system, it would allow for health clinicians to treat each patient individually, and use appropriate products and procedures, no matter how small the population (irrespective of market share) for whom they worked well....

I'm not against paying for the expert services of a good clinician or health system. I am against obscene profits paid to middle mismanagement.

You sing it, baby!!

So This is What Being Thrown Under the Bus Feels Like

I caught a little snippet of President Obama's speech to the AMA yesterday evening on my way home. Accompanied by groans, the president chuckled as he admitted, "I'm not advocating caps on malpractice awards..." (full text here for context. Hint: it makes no difference.)

I had a powerful sense of deja vu:

Sitting in my office facing a diabetic with an A1c over 10, stating unequivocally that he had no intention of discontinuing his daily diet of potato chips and ice cream or beginning an exercise program. Yet somehow he still considered me responsible for controlling his diabetes.

I'm sorry: it just doesn't work that way.

Mr. President, you can talk all you want about reining in runaway health care costs, but malpractice litigation is a powerful whip helping to drive those costs. What you claim to want simply cannot happen in the current malpractice climate that is the United States of America, and no amount of eloquent speechifying can make it so.

Sigh.

Darling Spouse's cynicism (proven right) aside, my prediction that nothing effective will come of all the DC health care reform sturm und drang also seems to be coming true.

How Insurance Companies Can Dictate Your Sex Life

If you happen to be a guy suffering from ED (that's erectile dysfunction, not Emergency Department) who requires certain drugs in order to have a satisfactory sexual encounter, you are at the mercy of your insurance company if you expect them to pay for your medication. If the company deigns to pay for it at all, they usually have limits on the number of pills allowed per month. What this means is that your insurance company essentially decrees how often you can have sex.

That's if they cover it at all. The last patient I wrote it for had it "contractually denied" by his company. He wanted me to write a letter of medical necessity so he could appeal it, but if his contract specified that they wouldn't cover it, then nothing I could write would make any difference.

I had occasion last week to prescribe one of these drugs for another patient. I happen to be aware that one of the two behemoth plans in my area pays for 8 pills a month, so I explained to the patient that according to his insurance company, he is allowed to have sex twice a week. I do this so that patients realize it isn't ME who is limiting them to that frequency, but rather their insurance company. I wrote the script and sent the patient on his (soon-to-be) merry way.

Not shockingly, I get a call later in the day from the pharmacy informing me that the drug requires pre-certification. I call the number provided and end up speaking with actual protoplasm somewhat sooner than usual. After being transferred only once, a second piece of protoplasm informs me that the drug in question does not, in fact, appear on the list of forbidden pre-cert-requiring medications.

WTF? Then why did the pharmacy tell me it did?

Answer: Because I wrote for 8 tablets. This company only allows 6 per month. More than that requires a "quantity override" (which will probably be denied contractually). Sorry, dude. You'd have gotten 33% luckier if only your employer had gone with the other company.

I suppose he should be grateful that they approved anything more than a popsicle stick and duct tape.

Epic Definitions

I've been having a discussion with one of my niecelings that boils down to some basic definitions in epidemiology, the study of causes, distribution, and control of disease in populations. In speaking with her and perusing assorted articles on the subject, I find there is a significant misunderstanding of the terminology. So I'm going to say this as clearly as I can:

Epidemiology has nothing to do with the severity of disease.

Here's an excellent discussion of the terms involved:

The distribution of disease events in populations in time and space can be described by three basic descriptive terms. These are: endemic, epidemic and sporadic.

An endemic disease is a disease that occurs in a population with predictable regularity and with only minor deviations from its expected frequency of occurrence. In endemic diseases, disease events are clustered in space but not in time. Note that a disease may be endemic in a population at any frequency level, provided that it occurs with predictable regularity...

An epidemic disease is a disease that occurs in a population in excess of its normally expected frequency of occurrence. In an epidemic disease, disease events are clustered in time and space. Note that a disease may be epidemic even at a low frequency of occurrence, provided that it occurs in excess of its expected frequency.

A sporadic disease is a disease that is normally absent from a population but which can occur in that population, although rarely and without predictable regularity.

Note that nowhere in those definitions is there any mention of severity of disease. Technically, one could describe an epidemic of hiccups.

Here is how that same source describes a pandemic:

A pandemic is a large epidemic affecting several countries or even one or more continents.

It is a quantitative description (how big), not a qualitative one (how bad).

Thus, the newly announced status of the swine flu as a pandemic deserves the yawn with which it was greeted by my above-referenced nieceling. Nevertheless, if the issue remains unclear, I will try one last time:

EPIDEMIC is to PANDEMIC as

1. "Dare" is to "Double-dog dare" (pre- and elementary school level)
2. FAIL is to EPIC FAIL (middle, high school and college level)

ie, a somewhat subjective superlative (everyone else).

Everybody got that now?

Good.

(EPS: Please get your mother to read this.)

Doggy Intuition

As I may have mentioned, I have a dog in the office with me. We call her the Rolling Peke because of her hind-end weakness, a result of a ruptured T12-13* disk in her back on her second birthday. After her surgery, she required constant care, so I began bringing her along to the office and nursing her between my (other) patients. That was more than four years ago and she has made an excellent recovery. She is now able to walk well enough without her wheelchair to get wherever she wants to go, though the cart does make toileting easier. And she continues to come to the office with me every day, where she has become a fixture.

Although she spends a great deal of her time sleeping, she also frequently interacts with patients. She's gentle with little kids as long as they're quiet; she tends to shy away from the loud ones. Not infrequently she'll scratch on the exam room door when she wants to come in with me and the patient. Then she usually flops down by the door, falls asleep and ignores us. But it's quite clear that she forms relationships with specific patients.

Most of the time she's friendly, sometimes milking her disability by dragging her back end laboriously over to the patient (usually a woman or girl with a high-pitched voice saying something along the lines of, "Oh you poor baby!") soliciting strokes and belly rubs.

Then there are other people she barks at incessantly, literally from the moment they walk into the office until they're finally out the door. She'll actually follow them out, barking continuously, as if to say, "And STAY out!" That can be pretty annoying because, ironically, she does it to some of my favorite patients. This is why I've generally discounted the idea that dogs (this one at least) are a good judge of character.

There are others she routinely greets and hangs out with in the waiting room until I'm ready to see them. Some of those folks sit on the ground with her, either stroking or playing with her depending on their mutual mood. Others pick her up on their laps for a cuddle.

The point is that her reaction to people doesn't change from one visit to another. If she likes you the first time you come in, she's your friend for life. If you're one of the "barkers", you're stuck with that too.

One day last week I entered the waiting room to find the next patient sitting on the floor next to the flopped-over dog, respectively giving and receiving a nice belly rub. The patient looked up at me through misty eyes and said, "She's never come over to me before."

"Really?" I said. "She's usually pretty friendly."

"Oh, she's been friendly, but this time she came over to me as soon as I sat down. She's never done that before. She must know that I had to put my dog down yesterday, and I needed this."

She reached over and gave the dog another stroke. The dog's soulful brown eyes melted as she gazed up at the distraught patient.

"I guess they just know," said the patient.

I guess they do.


* It threw me for a loop the first time I heard it too. It turns out dogs have 13 thoracic vertebrae, as opposed to 12 in humans.

Resident Work Hour Restrictions: My Solution

I trained back in the dark ages, befitting a dinosaur, when there were no restrictions on the hours worked by resident physicians in training. One of my most difficult memories is the post-call Monday after finding out at 7:00 am that my mother had died. Not only was I not allowed to leave early, but I remember hating my director by 4:30 as he made me stay and discuss the pathophysiology of heart failure with the medical students.

Not so in the modern era. There has been plenty of discussion by Dr. Centor and others about the pitfalls of blanket adoptions of limitations on trainees work hours, specifically the contention that any reduction in errors from fatigue is more than offset by errors from handoffs. Shift-worker mentality seems to be creeping into medicine as well, with new graduates stunned at the realities of actual practice work hours. Still, the greatest failing of the concept of limited hours in training is the lack of actual evidence that it affords any benefit either to patient care or physician education.

I have a better idea.

Medical training is a process. You don't go in on Day One expected to know and do everything perfectly. You also don't immediately have full responsibility for patient care (even though it may feel that way). As you learn, your skills improve. With experience, you gradually take on more responsibility both for patient care and for your own education. By the end of training, most physicians are functioning fairly independently, although in retrospect most of us are acutely aware of how green we still were.

One dirty little secret about residency training that I have not seen addressed elsewhere is that although long hours without sleep are indeed stressful, the major source of anxiety in residency -- and therefore of stress -- comes from the uncertainty of knowing what you are doing. As your training progresses and your confidence grows, you are capable of performing better at any given level of fatigue. By the time I was a third-year resident, I realized that (even though I no longer had to do it) in-house night call wouldn't be as big a deal as it was the first year. I'd be tired, sure; but knowing more about what I was supposed to do went a long way toward alleviating the stress. By the time I started practice, of course, I was on call for myself 24/7. If I was up in the middle of the night admitting a 6-week-old febrile infant, I still had a full appointment book the next day, and I had to be ready for that. Or, as Dr. Bob put it:

Would I rather have [a fully trained trauma surgeon] at 2 am - tired but experienced, or a general surgeon without specific trauma training.

Here's my suggestion for both forced humanity in medical training, coupled with the necessary rigor to produce competent physicians:

Taper work hour restrictions down as residents progress through the training program.

I have no problem with 16 hour shifts, post-call days off and night float in the first year. Lose the post-call restrictions second year, say, and then gradually increase the allowable hours per week so that by the final year of training there are no limits. The moment they graduate, those physicians are no longer going to be subject to the protections afforded by all those cushy regulations. Just as residency is a huge step forward over medical school in training for practice, becoming an attending is just as big a step. We do our trainees a disservice by failing to prepare them for the reality that not every baby comes in less than 16 hours, not every operation is finished by 5:00 pm, and patients crash regardless of how much sleep you got the night before.

Medscape Article

I'm thrilled to announce the appearance of yet another article of mine on Medscape, this time on Adolescent Medicine.

Credit Where Credit is Due

My heart sings!

A letter in today's mail from an oncologist (granted, a cc on a letter to the surgeon, but still). Directly quoted:

As you know, Patient is a [age-and-menopausal-status-redacted] female who was in her usual state of excellent health until her primary care physician, Dr. Dino, astutely palpated a mass in the [specific location redacted] breast on routine physical examination.

Yes!! She mentioned me BY NAME! And even used the word "astutely"!!!

Now THIS is how to take a history. Pay attention, all you orthopods out there.

Why I Do Blood Draws

From the comments:

Do you really do lab draws for other (i.e., lazy) docs?

You're taking on all the responsibility for handling, tracking, follow-up, and payment just to make life a little easier for those over-worked specialists?

Please explain!

Okay, I will.

I don't do it primarily to make life easier for those other lazy docs, but for my patients and myself. For patients who still insist on galivanting about to all the various partialists, coming to me for all their blood work has significant advantages:

1. I can avoid duplicate testing.

This happens all the time. I recently had a patient with newly diagnosed celiac disease whose gastroenterologist wanted several tests. I was able to send only half the ones he'd ordered, because the others had been done two weeks earlier. I copy the endocrinologists on lipid panels ordered by cardiologists, and grab a PSA for the urologist while I'm at it. All told, I would say this is the single greatest advantage to sending the lab work myself.

2. I can add other tests that are due or indicated.

If it's been more than three months since an uncontrolled diabetic's last A1C and he comes from the urologist for a PSA, it's as easy as checking off a box on a requisition and drawing an extra tube. I once had a patient come in for an electrolyte panel and noticed that he was jaundiced as all hell! I added appropriate liver function tests, and drew an extra tube for hepatitis serologies. Not infrequently, a patient will ask me to add other tests, as in, "Could you just check my cholesterol while you're at it?" Assuming they haven't just had it done within the last six months, I'm happy to oblige. A lab tech doesn't have that option.

3. It keeps me in the loop.

As I may have mentioned a thousand times once or twice, I can't always count on specialists letting me know what's going on with my patients. When I send the lab, I know I'm going to get a copy of the results. Although my policy is to tell the patient the specialist is responsible for letting them know about the results, I know I'm going to get a copy if I'm the one sending it. That way, if the patient calls and complains that the specialist never got back to them, at the very least I know whether or not there's anything to worry about. This is also why I don't mind being in charge of the tracking process. If the specialist lets something fall between the cracks, it will be the patient who suffers for it, and who may decide it was my fault for sending him to that particular doc in the first place.

4. It's an opportunity to review the chart and see if the patient needs anything else while they're in the office.

Usually I scan the inside front cover of the chart, which is where I keep my preventive care flowsheets. Flu shot? Tdap due? Do they need prescriptions refilled? Note for a mammogram? Phone number to schedule a colonoscopy? Time to schedule a pap or physical? There's a reason I code these as Level 1 visits, since I can almost always get in at least 5 minutes of discussion or counseling of some kind.

5. I'm a really good stick.

I have patients who go to what might be considered ridiculous extremes to let me -- and only me -- draw their blood. A bad experience at a lab can be traumatic. I have some tricks that result in large proportions of surprised and grateful patients.

And that's why I send labs from my office.

Appointment Catch-22

Patient is discharged from the hospital and told by the specialist to make a follow-up appointment in 10 days.

Patient calls the specialist's office for an appointment...

and is told that the first available one isn't until August.

Whiskey, Tango, Foxtrot; over.

Note: The patient is telling me this story two weeks after the hospitalization, presenting for "blood work." What blood work? I ask. Did the doctor give her a slip or requisition or any indication of what blood work he wanted? No. I peruse the discharge summary I have been sent and sure enough, there at the bottom it says, "Comprehensive metabolic profile [actually it just says CMP, but I'm smart enough to know what it means] and magnesium level in two weeks."

"Why does he want a magnesium level?" the patient asks me.

I look through every other piece of paper I received detailing all the minutiae but none of the substance of her hospital stay and cannot for the life of me figure out why he wants a magnesium level. I resort to my standard answer for questions about other doctors:

"I don't answer any questions that begin with 'why'."

More Disrespect

I know, I know; I should consider myself lucky just to get letters from specialists when I refer patients to them without being so picky about what those letters actually say. Still, it's the little omissions in their letters that add up to the persistent, niggling disrespect for family medicine that really pisses me off.

I saw an older lady who stepped into a hole (covered with grass; it wasn't her fault), fell about two feet straight down, and hurt her ankle. I asked her to come into the office where I took a history and examined her. Based on my evaluation, I diagnosed a fracture of the distal fibula and sent her for confirmatory x-rays. As it happens, my patient demographic expects an automatic orthopedic referral for any and all fractures, so the positive x-ray prompted the referral.

Today I got the letter about her visit.

In it, the orthopedist duly repeats the history he obtained from the patient. (I suppose I should consider myself particularly lucky in that it was the same as the history I obtained) followed by this line:

She called her PCP, who ordered x-rays and referred her here.

[Great gnashing of saurian jaws]

Wait one dang-blasted minute! Talk about omitting pertinent details!! In order to be accurate, that note should have read

She called her PCP, who saw her in the office, examined her, diagnosed a distal fibular fracture and ordered confirmatory x-rays, and referred her here.

Remember, if it isn't documented, it wasn't done. So as far as anyone in this orthopedic office is concerned, they were the ones who diagnosed the fracture. I'm sure there are those who will accuse me of making a mountain out of a molehill, but I don't think so. These little slights may seem insignificant in and of themselves, but over time they result in a gradual wearing away of the esteem in which family medicine is held by other doctors.

And that pisses me off.

A Moment

Every now and then, I'm blessed with a moment; an aliquot of time apart from the usual hustle and bustle, the endless rushing here and there between appointments and obligations to just stop and be, quietly at one with the universe.

It was one of the those glorious days last week when the spring sun was warm but not prematurely stifling. I stopped at the post office on the way home to pick up the mail. There wasn't much money in the deposit that day, so I didn't feel compelled to get it to the bank. I was meeting the NinjaBaker and NinjaCutie for dinner later, but didn't have to be anywhere for a good half hour. So I took the Rolling Peke out of the car and went for a walk.

The post office is a quaint little stone building just outside Valley Forge Park, surrounded on three sides by occasionally tended greenery. Its next door neighbor on the fourth side is a tiny church, complete with a graveyard in back. Separating them is a falling-down fence consisting of low concrete posts connected by metal pipes.

Although the Rolling Peke still uses a wheelchair for her daily toileting walks, she can actually walk quite well on her own now, four years after her back surgery, so it didn't matter that I didn't have the cart with me. She wobbled off into the pasture, fervently inhaling the grass like Bill Clinton never did. I walked ahead a little, doubling back after her as she veered toward the cemetery. The lower of the two pipes that made up the fence was maybe twelve inches off the ground; the dog doesn't clear nine, so it was no barrier to her at all. The other pipe wasn't more than two feet up; not much of a barrier to me either, as we moseyed into the cemetery and wandered among the headstones.

RP galumphed along gaily until she reached the shade of a small tree, where she planted herself and waited patiently for me. I have no idea how long it was -- not long, but long enough -- that I meandered up and down the rows of headstones, taking in names and dates. I didn't calculate actual ages; rather I got a sense of who had been really old and who had succumbed earlier in life. From names and dates, I extrapolated families. Several graves were clearly those of servicemen. There were few epitaphs, all the more memorable for their paucity. One said simply, "He was a nice guy."

As I meandered, I noticed that there were no specific emotions flowing through me. I noticed that it was neither too hot nor too cold, that the breeze felt good, and that the RP was smiling as she panted in the shade under her tree. The grass was freshly cut, and very green from the preceding week of rain. I noticed everything, yet as soon as anything came into my conscious mind, I let it go. Almost like the description of meditation, when they tell you to stop thinking. It's impossible to do that, but it is possible not to pay attention to your thoughts. That's what I did. For a few minutes, I wasn't thinking about the office, that day's patients, or the next day's. I wasn't thinking about what I was going to make for dinner, or whether or not the dishwasher had been run, or the last time the cat boxes had been emptied. I wasn't even thinking about life and death, even as I wandered through the very essence of its distal terminus. I just was. On a gorgeous spring day, with my dog lying in the shade smiling at me.

Eventually the moment passed. I picked up the Rolling Peke and nuzzled her in my arms as we returned to the car, back to our regularly scheduled lives; grateful for the moment.

Ahead of the Curve

Physicians are often castigated for not keeping up with and following the latest recommendations for clinical care. The reality of innumerable "guidelines" issued by countless specialty societies and other entities (cough*federal government*cough) that feel empowered to do so is that just keeping track of all of them can be a full time job. Still, there have been some major sea changes over the years as good science comes up with some pretty definitive findings. I'm referring specifically to broad brush guidelines about the treatment of that ubiquitous triad of high blood pressure, diabetes and LDL cholesterol.

Those of us who have been practicing for a few decades now recall that recommended goals for blood pressure, blood glucose, and lipid levels have tended to shift ever downwards over the years. When I was in training, the threshold definition for hypertension was a BP measurement of 140/90. Anything below that was fine; above it required treatment. Some of the older attendings even scoffed at that, recalling when an acceptable systolic blood pressure was "100 + age", a nod to the fact that blood pressure tends to increase with age, making isolated systolic hypertension common in the elderly. Diabetes outcomes seem to improve with lower blood glucose levels, and the advent of statin medications for lowering cholesterol has truly revolutionized lipid management. Further, growing evidence seems to support the lowering of all three parameters to decrease cardiovascular risk.

Now it seems that among patients with stroke and LDL levels already under 100 -- with or without statins -- those ON the statin lipid-lowering meds had better oucomes. Current guidelines for use of these drugs takes into account how many cardiovascular risk factors a patient has aside from the cholesterol reading. The greater the number of risk factors, the lower the threshold for starting cholesterol meds. Here's the thing: those numbers have also been trending downwards as the accumulating research points towards better outcomes for patients who take statins.

Here's where I'm going with this: whether or not to offer statins to non-diabetic non-smoking patients with controlled hypertension and moderately elevated LDL cholesterol levels.

According to current formal recommendations, a patient like that would not qualify for statins unless the LDL was over 160. At this time, that is. Every time those guidelines have been revised, it's been in the direction of starting statins at lower and lower levels of LDL. What if 10 years from now we have the data to support lowering LDL cholesterol to at least 130 in everyone? What if it turns out that taking a statin confers added protection against macrovascular events (stroke and heart attack) whatever level of LDL reduction is achieved (ie, goal or no goal)?

It sure looks like this is the way things are headed to me, and I would like my patients to have the benefit of an extra 10 years -- or however long it is until the jury returns -- of cardiovascular protection. Statins are now cheap ($40.00 a year) and extremely well-tolerated, with very rare adverse reactions that are easily reversed with stopping the drug. There just doesn't seem to be much of a downside to wider statin use, and the distinct possibility of a significant advantage.

Believe me, I am not a pill pusher. The more favorable evidence that accumulates for the damn statins, the more pissed off I get. The last thing I want is to be writing more drugs. Still, it's getting harder to deny my patients the benefits implied by the old "better living through chemistry" line.

The bottom line is that I have gingerly begun offering cholesterol-lowering meds to more of my patients, complete with extensive counseling and discussion (much like that above.) I'm curious about what other clinicians are doing, and how they feel about trying to get ahead of the curve a bit with primary prevention of cardiovascular disease.

Bass-ackwards

I received an envelope in the mail today containing a thick sheaf of papers. It turned out to be from a management company, an intermediary specializing in worker's compensation and auto insurance, that was trying to get us to join their network. Actually, you had to read the first paragraph pretty carefully to figure that out. Here's how it began:

As our network expands, we continue to seek facilities that can provide quality care for our claimants. Kindly review the enclosed information and return it to us so that you can be included in our growing network. In order to expedite this process, we are enclosing and application and contract for your convenience and review. If you choose to complete these documents, we would be pleased to count you among the providers already servicing our clients! [emphasis decidedly not theirs]

Here's the problem. Following the next page, which lists the documents that need to be returned (signed service agreement; completed application; license; DEA; current malpractice insurance; board certification; CV; W-9), comes a blank "network application" and a 19 page contract labeled PARTICIPATING PROVIDER AGREEMENT. At least this one actually includes all the appendices it refers to; not all of the contracts I receive do. But the cover letter concludes:

...Once credentialing has occurred...you will also receive our manual that describes [our] policies and procedures.

Ahem. Why would anyone in their right mind sign a contract before reviewing the company's policy and procedure manual? Hell, right there in the contract, it states that I'm agreeing to:

Comply with the rules, regulations, policies and procedures as...summarized in the Provider Manual.

Hell, there are two full pages devoted to "Obligations of Provider" without ever mentioning any obligations on their part (like prompt payment of clean claims, for example.)

Interestingly, they have a website. After perusing it for 10 minutes, I can say this is 15 minutes of my life I'll never get back. It's so incredibly generic, I could probably co-opt several sections of it for myself! Here's what they say about their "commitment":

Our organization understands that our clients have a variety of needs and expectations. We also recognize they share common goals, for outcome based solutions that address their needs, while also enhancing their performance. We deliver services how, where, and when requested and make a difference where it counts: by achieving measurable results.

How do they do this? With these "Strategies":

[We] prides [ourselves] on our basic structure of client service teams. We first understand and evaluate each client's specific needs and then tailor an organized program, with individual or combined services, that will make a difference. Our strategy is to formulate innovative, visionary and technology enhanced solutions that meet our common delivery of excellence, exclusively to our clients.

Wow. That could just as easily be a motorcycle repair shop! I also love their all-purpose Mission Statement:

Our mission is to understand and respond proactively to our client's needs, to exceed all expectations, and to devote ourselves to quality, innovation and service.

We will continue to strive towards excellence and to ensure a consistently high level of service to all involved parties.

Our goal is to initiate and develop a total customer-centered program by providing uncompromising professionalism and responsiveness.

We vow to maintain our competitive edge and adjust to the ever-changing health care environment without relinquishing the integrity we've achieved and maintained throughout the years.

WTF? Talk about meaningless gibberish.

The worst part is that deep in the fine print, it turns out that the rate they're offering to pay me is 20% below my usual charge. Er, given that my two largest payers are currently compensating me at only 95% and 88% of Medicare, all I can say is take this contract and shove it where not even the colonoscope shines.

Atheist Hypocrisy

Once more, PZ Myers has his diapers in a bunch. It's perfectly legitimate: an illiterate columnist, after calling atheists to task for being boring (never a good way to begin a column, as PZ points out), proceeds to babble on about the usual nonsense that passes for "religion" in the media, and that PZ has such fun deconstructing. As usual, of course, he limits himself to shooting fish in a barrel, which is why he can brag about such a great kill ratio.

This line made me sit up and take notice, though:

My usual theme instead is to show what a botch theists have made of the country, and how hypocritical they are, and how absurd their beliefs are.

Holy shit, PZ; are you really that naive?

Of course politicians are hypocrites, and of course many of them use religion as an excuse for their hypocrisy. But if you really think that it is the sincerity of their beliefs in God that are the root cause of the mess they've made, think again. News flash: atheism offers no protection from corruption. Look at communist Russia. Surely those "godless commies" did just as good a job, if not better, at fucking up a country.

Corruption/integrity and theism/atheism are completely separate axes, with all four quadrants very well populated indeed, with hypocrisy liberally sprinkled throughout.

Atheism is no talisman against corruption, nor does it preclude hypocrisy. Exhibit A, of course, is PZ Myers' cry for tolerance of atheist beliefs while mercilessly ridiculing the beliefs of others who dare to find strength and solace in difficult times from a social support system grounded in what they call "religion." This, by the way, is the only proper function of religion, and I agree wholeheartedly that billions of people mis-use it every day. I also share PZ's contempt for them.

As I've said before, though, ridicule is a most pernicious form of intolerance. The hypocrisy of disrespectfully blasting all religion as "superstitious nonsense" while demanding respect for atheist views is mind-bendingly hypocritical, with PZ Myers the Hypocrite-in-Chief.

In Case You Were Wondering

For anyone following major league baseball who might have thought Manny Ramirez's explanation of his recently disclosed use of human chorionic gonadotrophin ("a medication, not a steroid, prescribed by a physician for a personal health issue") was legitimate, allow me to point out that there is no medical indication for prescribing hCG to a male that cannot be more safely and effectively treated with other agents.

Luckily, not many people seem to be buying it.

When More is Less (or Vice Versa?)

A lady comes in on the day she takes her last blood pressure pill for a checkup and a refill.

Her blood pressure is well controlled, the rest of her exam is normal, she's all caught up on her preventive care, so I go to write her refill.

Would she prefer a 30-day or a 90-day supply of her medication, I ask.

30 days, please. She can get them for $4.00 at her supermarket's pharmacy.

Ah, I respond. Did she know they would also give her 90 pills for $10.00?

Yes, as it happened; she was aware of this fact. But it turns out that for every four prescriptions she fills at the pharmacy, they give her a coupon good for 10% off her next grocery order, so she makes sure it's a big one; $250.00 at least.

Hmm:

12 x $4.00 = $48.00 per year for pills.
3 x $25.00 (10% of her $250 grocery bill) = $75.00 off on food ---> up $27.00 on the year.

vs:

4 x $10.00 = $40.00 for pills
1 x $25.00 = $25.00 off on food ---> down $15.00 per annum.

Can you tell she used to work as an accountant before she had kids?

I Don't Get This

Can someone help me with this? I mean, really; I just don't get it.

Patient calls and schedules an appointment.

(No, no; that, I get.)

Then they call back and say,

I have to talk to the doctor.

Er, you have an appointment tomorrow.

Yes, but I have to talk to the doctor first.

Why, in the name of the great and powerful FSM, do you have to talk to the doctor today if you have an appointment tomorrow?

If you're having crushing chest pain or something like that and that's why you think you're coming in (not having bothered to tell my Wonderful Staffer who asked you, "Are you having a particular problem?" anything other than, "It's personal,") then it will serve you right to wake up dead from the massive heart attack you're trying to ignore. It doesn't work that way. God made 911 for a reason, you know.

Granted, there are occasions where family members will call ahead to let me know things like, "his leg has really been bothering him for three months instead of the three weeks he's going to tell you about." But the whole point of making the appointment was to, um, TALK TO THE DOCTOR!!

If I'm going to see you tomorrow, there is absolutely no way you need to talk to me today. Think about it: what the hell are you going to say to me on the phone that you couldn't be saying to me tomorrow, in private, face-to-face, when I have a prayer of a chance of actually doing something about it; ie, something other than saying, "Why don't you make an appointment so we can talk about this in the office?"

In the words of the lovely and talented CrankyProf: Whiskey, Tango, Foxtrot?

Everything is Relative

Two different responses to the same exchange:

Kid: Daddy, could I have some money?

Dad: What do you want it for?

Kid: To be rich.

Household A, an upper middle class family living in a suburban neighborhood of a large east coast city: [hilarity]

Household B, the Bush family: Sure. Would $50,000,000 be enough to start? You can get a nice baseball team with that.

Geek Heaven

It brings a tear to my eye (and a rumble to my stomach) to share this:

Original recipe here (with the nifty title, "Periodic Table of the Aliments")

In the words of the NinjaBaker (and his faithful companion, the NinjaCutie):

According to the Ninja code of scientific baking, we must detail all changes to the procedure:

1. We only chilled the dough 1-2 hours while we made lunch because we only had so much time.
2. We used a smaller cookie size, so we only doubled the basic sugar cookie recipe.
3. All the frostings (except the chocolate non-metal one) were home/dorm-made from powdered sugar, milk, and food coloring (at a ratio of 1 cup : 1.5Tbsp : 6 drops : however much we felt like changing it so it would look right)
4. We reduced the rare earth metals (the 2 row insert) to 2 long cookies because we underestimated the amount needed.

Entire cooking time: ~6 hours.

The Obligatory Flu Post

Many other people have posted all kinds of useful information about this little Spring hiccup of a swine flu pandemic we seem to be experiencing on our planet this year. But I've still been getting I'm-not-really-worried-but-should-I-be? emails and calls from assorted patients, friends and others, so I suppose the most efficient way to address the topic is by posting on it.

Actually, most of this is re-posting. Good information is available here and here. Here is my bottom line answer to the question, "Is this whole swine flu thing a just lot of hype?"

Yes.

Here's why. I heard Governor Corzine of New Jersey put it rather well on TV the other night. To paraphrase, we have to keep in mind that "pandemic" refers to geography, not to severity. Its anomalous timing is also part of what's keeping it in the news. Flu is usually a winter thing. Did anyone bother monitoring the spread of flu 24/7 online over the winter? (Actually, yes, some people did. They were widely felt to have had no life.) As far as news coverage, flu in winter is too "Dog bites man" to warrant much excitement. Flu in spring is so much sexier.

I think the main reason the word "pandemic" engenders so much visceral fear is that it is (INCORRECTLY) used as a shorthand reference to the 1918 Spanish flu pandemic that was, in fact, unusually virulent and lethal to populations who do not ordinarily succumb to the flu, ie, healthy young adults aged 20-40. The very old, the very young, and the already-sick are always susceptible to complications from any kind of flu, be it human, bird or pig. There is no evidence that the current swine flu strain is especially virulent. Most cases have been mild; few hospitalizations have been required; the single US death was a toddler with a pre-existing illness.

So yes, closing schools and canceling events is definitely overkill. The real question we should be asking is why wasn't everyone worried over the winter, when the "regular" seasonal flu killed 36,000 people in this country alone? As of today, there have been a whopping 141 cases and 1 death. This is not something rational people should be losing sleep over.

Of course, "rational" and "American" do seem to be mutually exclusive much of the time.

Proof That Some People Have Way Too Much Time on Their Hands

For the realists:

Do I have swine flu?

For the pessimists:

Do I have swine flu?

Thanks to Kensington, MD, who, as some have long suspected, probably has way too much time on her hands. Although this line was pretty good:

"Blog fodder" always sounds to me like someone with a cold addressing Don Corleone.

Now I Get It

It's been said that the only way you can understand your parents is to have children. Having had both parents and children, I agree with this statement. Yet even raising your kids lets you come to know your parents better, there are things about them you still don't get. And every now and then, new moments of insight present themselves.

When I was a younger physician, the following interaction with my parents used to annoy the hell out of me:

Parent: Hello, Doctor Child, I just got the following prescription filled. [starts to spell name of common medication]

Me: [cutting to the chase] Oh, yes, that's such-and-such; it's used for (this condition), and its side effects include (this, this, and this.) Anything else you need to know about it?

Parent: You're right!

Me: Why are you so surprised?! I do this for a living. Of course I know about medications, diagnoses, and all kinds of treatments and stuff. Hell, you paid for my education; I'd hope you would expect me to know this stuff.

I thought they were idiots to get so excited over something so obvious.

Then I had kids. The start out as blobs and progress to rug rats. Finally they become bipedal and learn how to talk. But as a parent, in the beginning, you already know everything your child knows. His world is a subset of yours. You already know the answer to every question you ask him. And just think about how much of your conversation with an infant or toddler consists of questions. ("Where's that baby?"; "What color is the kitty?"; "What's this?" pointing to common object like a cup)

As he begins to go out into the world -- even if it's just daycare -- his experience expands beyond yours. I was kind of surprised at how incredibly cool I found this to be.

I'll never forget the first time I asked one of my kids a question I didn't know the answer to:

"Where's your baby brother?"

"Upstairs getting his diaper changed."

For the first time, I had an exchange with my three-year-old wherein he provided me with information I did not already have. I was amazed and thrilled! This was so cool!! And I'm sure he thought I was an idiot for getting so excited over something so obvious.

As time went on, my kids knew more and more stuff I didn't already know. And every time they did it, I was amazed and thrilled. And I suddenly realized that this was how my parents felt whenever I told them something they didn't already know.

Still, I didn't get what the big deal was about birthdays to my parents.

My father was 30 when I was born, which means that each time he turns the corner on a new decade, so do I. Each time he had one of those milestone birthdays, he'd recite the same old litany:

I don't mind turning 60/70/80, but I can't believe you're turning 30/40/50.

Geez, Dad; what's the big deal? I certainly don't mind any of those "zero" milestones any more than you do. Hell, you're the one who spawned me. Why is this such a significant event for you?

Now I know.

Today, my youngest son is 20. No more teenagers. He's 20. How did this happen? He's 20. I didn't mind turning 50. I loved it! It doesn't feel any different at all. No big deal. But this, my baby turning 20, has caught me unawares.

And all of a sudden, I understand my father a lot better.

Happy birthday, NinjaBaker; my little one, little no more, but always a baby in my heart.

(Gee, now I know why my father says that about me, too.)