Panic Defined

Definition of panic: discovering that you somehow inadvertently saved an incomplete version of Chapter 8 on both your flash drive and your home computer.

Symptoms include running around the house cursing up a storm that would make CrankyProf blush, frantically booting up the computer upstairs that used to be in your office, followed by more cursing upon discovering that the machine in question only holds backups through Chapter 7.

Treatment: jumping into car and flying out to office, discovering that Chapter 8 is indeed backed up on paper (an ancient substance used for writing) as well as at least one machine there. Symptoms are further relieved by copying the complete version of the chapter onto flash drive AND emailing it to self, as well as printing out Chapter 9, the latest completed chapter. Equanimity restored by triple-backing up the bulk of completed Chapter 10. (Note: number of chapters in completed work = 10)

"Being a Doctor"

Once again, I seem to have started a bit of a dust-up with this post. Comments have ranged from "right on" to "you hypersensitive twit" and other, less printable versions thereof. In this case, not only do I stand by my original take, but I feel the need to clarify precisely how the dissenters are being jerks.

A recurring comment was something along the lines of "just because I'm a specialist doesn't mean I stop being a doctor." [emphasis mine] What exactly is meant by that oh-so-innocent-sounding phrase?

It seems to imply that there is some basic skill set learned in medical school; certain things that one is capable of doing just by virtue of being awarded that magical MD degree. Gee; what might that skill set contain?

We all dissected a cadaver and did a surgical rotation during medical school, so we all ought to be able to do surgery.

Didn't most of us rotate through oncology as part of our medicine rotations? What's the big deal about writing for chemo?

We all did orthopedics, too. I can look at an x-ray and prescribe an air cast and rehab for a sprained ankle.

How about ophthalmology? I can look in a patient's eyes and prescribe drops. What's the big deal?

I know, I know: all of those things, and many more, represent skills we learned in our post-graduate training and honed over years of practice. So here's my point: Why do you think that dietary counseling and lifestyle intervention requires any less training, skill and experience to do (well) than any other medical procedure? What you specialist commenters are actually saying -- in code that is so insidious you may not even realize it -- is that primary care is so easy, any "doctor" can do it. You are disrespecting my special skill set in a way that is deeply offensive. (Far more than just consulting behind your back, HH. Next time you ask for respect from your colleagues, maybe you can start by giving it.)

What we all take from medical school is the knowledge base to learn how to become whatever kind of "doctor" we end up becoming. Without special training and experience to become a surgeon, we're just assaulting people. Without special training in oncology, we're just poisoning them. Without ophthalmology training, we're just poking them in the eye. And without the special training and experience that comes from years of practicing primary care, you are just rudely telling people that they are fat.


PS: Smoking cessation is different. I agree that any doctor ought to have the knowledge and expertise to understand why smoking is bad. Then again, any fifth grader who has attended a Tar Wars presentation has the knowledge and expertise to understand why smoking is bad. Don't exactly need an advanced edumacation to figure that one out. Interestingly, though, providing effective smoking cessation counseling is also harder than it looks.

Time and Place

There's a new columnist in the Philadelphia Inquirer; a young ophthalmology resident named Rachel K. Sobel MD. She generally offers a fresh view of residency training, albeit from her vantage point not just of a specialist but of a specialist training at a specialty hospital. But her column yesterday headlined "Prescription: Shape Up" has me flexing my saurian claws:

My patient came in to the Wills Eye Emergency Room with red eyes and the kind of pain that felt as if he had had a headache inside his eyes for several days. I diagnosed a recurrence of uveitis, an inflammation inside the eyes, and treated him with eye drops.

My attending, Donelson Manley, agreed with my plan, and gave some advice: "Sir, we can treat your eyes and your eye headaches," he said. "But you need to take care of yourself and lose weight. That's going to give you a bigger headache. If you don't lose weight, you run the risk of developing arthritis, diabetes, heart problems and more."

The patient looked shell-shocked and maybe a little mad. He weighed 350 pounds and was less than 6 feet tall.

I too wanted to encourage him, but I kept quiet because he looked somewhat embarrassed and I didn't want him to think we were ganging up on him. But I was glad my attending had seized the opportunity. Even though the patient's eye problem was unrelated to his size [emphasis mine] his weight was and would be his biggest medical problem.

The author goes on not only to defend the actions of her attending, but also to express the desire to emulate them in her future practice. The patient, she reports, responded by admitting they were "only doing their job" by alerting him to the health hazards of his weight.

No, Dr. Sobel; you were not doing your job. You were trying to do my job, and you (or your attending, at any rate) weren't doing it very well. I can virtually guarantee you that any person weighing 350 lbs is all too well aware that he weighs too much. His current physique is NOT the result of ignorance, so whatever "education" you believe you are providing is meaningless. So what have you actually accomplished by pointing out the obvious to your patient, especially when it has nothing to do with the problem for which he specifically sought out your expertise?

What would you have done if the patient had said, "You're right, doc. What should I do to lose weight and shape up?" Do you have any training or experience in dietary, nutrition or exercise counseling? Do you know what the literature has to say about the efficacy of different kinds of interventions in the treatment of obesity? I doubt it. You'd probably say, "Go talk to your family doctor." Besides, as an ophthalmologist, you get paid six times as much just for flushing out a plugged lacrimal duct as I would for an hour-long evaluation and management visit, including intense counseling on obesity management as well as other health matters, so it's not really worth your time.

Do you advise the mother of the baby sleeping in the stroller with a juice bottle in his mouth about the dangers of dental caries? How about warning the teen with the IPod volume turned up to a million about the dangers of hearing loss? Does setting foot in your emergency room turn these patients into a captive audience for all your generic health advice, no matter how badly statistics appear to show that the American public needs it?

Once you choose the identity of specialist, your right to intervene in a patient's health matters unrelated to that for which he sought you out is forfeit. Your "MD" now gives you no more right to advise patients about unrelated health hazards than anyone else on the street. Do you feel your standing as a physician would permit you to make a comment to an obese individual you happened to encounter at a bus stop? I would hope not.

The concept here is of time and place. I submit that an ophthalmologic emergency is not the appropriate time and place for lifestyle interventions unrelated to the problem at hand. So cut it out.

Pastry Proposal

Dear NinjaBaker,

I have a proposal for you:

Hypothesis: I can tell the difference between pastry made with butter vs. shortening, specifically butter-flavored, but you cannot.

Background: Pastry has several attributes, among them taste and texture. It seems intuitive that taste is a function primarily of ingredients, whereas texture is a function both of ingredients and technique. Technique, while not difficult, is directly related to experience making pastry. Therefore to explore the above hypothesis, I propose that we perform an experiment while you are home for the Thanksgiving holiday (either during your weekend "hang-out" time allotted here, or elsewhen.)

Experimental design: Each of us will prepare two batches of pastry (utilizing the same recipe, of course), one using butter (unsalted; pre-softened at room temperature) and one using butter-flavored commercially available shortening. Each pastry batch will then be rolled into an oblong, spread with melted butter and sprinkled with cinnamon sugar, rolled up and sliced into slabs of a pre-determined, agreed-upon thickness, and baked in an appropriately pre-heated oven for an adequate period of time.

This 2 x 2 matrix design allows us to control for both the variables of ingredient and technique. Comparative, paired taste tests both of dough aliquots and finished cinnamon swirls will seek outcome measures not of "which is better" but "are they different," yielding binary yes-no results, as opposed to having to devise a quantitative scale of how good they are.

Blinding: Each batch will be labeled with a letter (me/butter: A, you/butter: B, me/Crisco: C, you/Crisco: D.) We will then generate a numbered list of paired samples to be provided for us blindly and in a random order by either Darling Spouse or one of your siblings. I recommend using milk (white) as a palate cleanser between samples, although further preliminary research could be conducted comparing chocolate milk, hot chocolate, water and orange juice for this purpose.

IRB review: This study has not been presented to this institution's ethics committee regarding research involving humans, because this institution ("Home") does not have one. However, I did ask the cats, and they couldn't care less.

Analysis of Data: to be determined

If nothing else, we'll wind up with a shitload of cinnamon swirls.

What say you?

Moved to Tears

I am not a night person, so I don't stay up until all hours watching late night TV. But I do enjoy watching the 8:00 and 8:30 rebroadcast of The Daily Show and The Colbert Report, respectively. Last night's Colbert (Tuesday night's show) included an interview with Paul Simon, the silver-throated -- now silver-haired -- troubadour of my youth.

It wasn't a "typical" Colbert interview in that it wasn't particularly funny. The guest seemed a little shy and Stephen had to draw him out a bit. At one point, Simon grabbed his guitar to help answer a question, underlining the answer he had just given about whether words or music come first when he's writing a song. (Music.) But it was fine.

Simon wasn't wearing a baseball cap, as he usually does to hide his thinning gray hair. He looked like an older man; completely recognizable, just older. It was good to see him, though the only emotion watching him was of gentle nostalgia.

As is his custom when the guest is a performer, Stephen invited Simon to share a song to end the program.

He stood alone on a small oriental area rug; guitar in hand in front of a single stand microphone, and began to play. It was a familiar song. So familiar that I knew every note, every word, every squeak of his fingers on the strings. Still, I had to mentally fast-forward through the lyrics to come up with the title: An American Tune.

His voice was like the rest of him: older; a bit rougher, but still recognizable and familiar; comfortable. And as he sang each familiar word, each note and chord wafting across the room to me, my eyes welled up; then they spilled over, and I was crying; silently, so as not to miss one word; one note. It was the intensity of emotion that brought me to tears. But here's the funny thing: I had no idea which emotion it was.

Joy, that perhaps now as a people and a country we might finally be turning away from greed and selfishness? Fear, that this hoped-for and longed-for change might yet slip away? Longing for the past; a time when his voice was as buttery smooth as his skin? Pure nostalgia; viscerally recalling the emotions of times past spent listening to this and his other music?

I couldn't tell.

I just sat there and cried silent tears of...what? I have no idea.

Baseball Hardware, or Chutzpah: Foot in Mouth Edition

The time: 2006

The occasion: voting for Major League Baseball's Most Valuable Player

The front runners: Albert Pujols of the St. Louis Cardinals, who had just won the World Series, and Ryan Howard of the Philadelphia Phillies, who hadn't even made it into the playoffs.

The winner: Ryan Howard of the Phillies

The upshot: Albert "Sore Loser" Pujols called a press conference, in which he opined that no player whose team hadn't even made it into the playoffs had any business being voted MVP.

Fast forward to 2008:

The front runners for MVP: Pujols and Howard again, only this time it was the Phillies who had won the World Series and the Cardinals who hadn't made it out of the regular season.

This year's winner: Albert Pujols

Question for the space-time continuum: is it possible to request a do-over of a press conference two years ago?

How Skin Heals

Over the years I've been foolish fortunate enough to have invited medical students into my office for preceptorships. With my new blog persona, of course, what else to call them but The Hatchlings. I find myself thinking about them even after they've left, and when interesting things happen with patients they saw with me, I want to find a way to share it with them.

Dear Hatchling #3:

Remember that patient we did a home visit on back when you were in the office with me? The diabetic amputee with the wound on her (one remaining) leg that wouldn't heal? Well, the good news is that it finally healed. The bad news is that she spilled some hot gravy on her lap while cooking (since she has to do everything from a seated position) and sustained some nasty burns to her thighs a few weeks back.

The really good news is that they were fairly shallow second degree burns. This means that the epidermis was destroyed and sloughed off as blistering, leaving the underlying dermis exposed, painful and vulnerable to infection. All I did was keep the wounds clean and dressed them with an antibacterial/vaseline coated gauze while they healed, which they did beautifully after about two weeks. I went back to see her once or twice a week to make sure they weren't getting infected or anything (they didn't) and were healing ok (they were.)

By the last visit, the wounds had healed completely. If you ran your fingers over the skin, it was smooth; completely epithelialized, but its appearance demonstrated something really cool about the anatomy of the skin that I wished I could show you. Then I thought of a way I could: after asking the patient's permission, I whipped out my trusty cell phone and voila!

Going back to the anatomy of skin, recall that the epidermis doesn't sit flat on top of the dermis like a bedspread. Rather, the dermis has little fingerlike projections that poke up into the epidermis, kind of like a foam "eggcrate" mattress; pink in this picture:

The epidermis and top of the dermis were destroyed by the scald wound, but the three dimensional structure of the dermis meant that there were regularly arrayed indentations where little bits of the basal layer were preserved. Those little brown/black dots you see represent the migration of pigment cells from the dermal crypts moving up and spreading out into the newly regenerating epidermis. Eventually, the area's pigmentation will become uniform, as the "dots" appear to spread and coalesce. That's what "healing without scarring" means.

Hope second year is going well for you.

Best,
Dr. Dino

Edited to add Hatchling Index:

1. KK
2. JB
3. CW

(Defined as students in the office subsequent to the adoption of my blog persona)

Maudlin Parental Pride

It may come as a surprise to all six of my regular readers, but I have a daughter in addition to my two sons (the Jock and the NinjaBaker, formerly the Nestling.) She and the Jock are twins. I like to tell my friends that I have good news and bad news: the good news is that both of my twins have completed three years of college. The bad news is that no one will graduate this year. The Jock is on the 5-year plan (Darling Spouse calls him a red-shirted senior) and his sister has left the university setting to attend art school.

Make no mistake: I'm fine with this. She's happy, and we are on the same page about the purpose of education: being able to support herself. Hence her likely major in a commercially viable field such as Graphic Art, although I understand her designation of a major is still technically up in the air.

She's begun doing some really neat stuff that I can't resist sharing:

"Line Abstract"

"Sewing Abstract"

Thank you for your indulgence. This ends the test of the Maudlin Parental Pride System. If this were actually a site dedicated to bragging about children, you would have been subjected to countless illustrated posts of the intellectual, artistic, athletic, and other myriad accomplishments of my progeny instead of the occasional such entry. We now return you to your regularly scheduled cynical, curmudgeonly blogging.

More on Hospitalist Economics

Many thanks to all those who commented on my recent post. Just a few more points to clarify my position:

Several people pointed out that Emergency Room (Emergency Department, if you're WhiteCoat) doctors also have difficulty generating cash flow for their hospitals. The difference is that for the most part, they are aware of the basic economics of their situation. Hospital administrators can and do come down to the ER (EDiyWC) and let it be known when the income produced isn't enough to cover the salaries of the doctors working there. There is the understanding that such a situation is not viable over the long haul. Doctors are expected to take some kind of action; either addressing billing and efficiencies to enhance income, or accepting pay cuts to reduce expenses. ERs (EDiyWC) have closed, as have hospitals, because of these financial realities. At least the docs don't go crowing on the internet that the value they bring to the hospital somehow exempts them from the basics of economics.

While we're on the subject of "value," recall that this is a concept that works in two directions. Look at it this way: Happy the Hospitalist generates a certain amount of income for his hospital via billing for the services he provides. The amount he draws in salary above this amount (the part "subsidized" by the hospital) presumably represents compensation for all the extra "value" he brings. As it happens, there are other ways that a hospital (or any employer, for that matter) can express its appreciation for the things an employee brings to the job above and beyond money. So what's to stop a hospital from paying Happy a salary more commensurate with what he actually brings in, along with an annual "Hospitalist Appreciation Day," complete with bad coffee, stale donuts, mugs with the hospital's logo on it and a lapel pin. Surely HH and his colleagues would begin laughing uproariously, not stopping until they were well out the door on the way to their new jobs, because the only real way to convey that an employee is "valued" is with cold, hard cash. (Funny how the hospitals seem to think the former works fine for nurses.) (They are wrong, by the way.)

Perhaps what really annoys me is Happy's claim that he has somehow managed to rise above the rough and tumble, no-win economic reality of the Medicare National Bank, as he has christened it. He reminds me of a young doc just out of training, working as an employed phsyician (so that he doesn't have to "worry about the business, but just practice medicine," as so many of my friends in residency used to say.) He may start out proudly taking as much time as he wants with his patients without paying heed to the income he's producing for his employer, but sooner or later that employer is going to have to sit him down and explain that it doesn't work that way. Happy can either take the talk to heart, or go out and find another employer who recognizes all the (non-monetary) "value" he brings to the enterprise.

Here's what's really happening: we are in a Hospitalist bubble. Just like the dot-com boom, bubble and bust and the houseing boom, bubble and, now, bust, eventually the hospitalist model will have to address this economic reality.

I recognize that hospitalists are here to stay, so all those commenters warning of dire consequences if the positions were eliminated are completely off-base. I am just pointing out that they are not immune from the basic economic principles of supply and demand, even though Happy seems to believe otherwise. Just as the housing market eventually collapsed, hospitals will not be able to indefinitely pay hospitalists significantly more than they are able to generate in revenues.

Another Waster of Time

Fair warning: don't go here if you have work that must get done:

How old is your brain?

The instructions are in Japanese, though I figured them out after I'd done it once. Here they are for the impatient:

1. Click "Start"
   
2. Wait for the countdown from 3
   
3. Memorize the numbers' positions on the screen, then click the circles from the smallest (0 is smallest) to the largest
   
4. At the end of the game, the computer will tell you how old your brain is.

Have fun, but don't say I didn't warn you.

Edit: I'm pretty sure younger is better. You can improve your score with practice, too. My most recent score was 23 and I'm 49. ie, NinjaBaker: your brain is old beyond your years.

Prevention Myths

Preventive care saves money.

Wrong; wrong and...wrong!

This has been pointed out over and over in the blogosphere and other places in the media. It is not true. Prevention can be damned expensive, as the latest addition to the medical literature demonstrates. The Jupiter study, paid for by the makers of Crestor, the most expensive statin on the market, is pretty darn convincing from a statistical point of view. Dr. Wes and others point out, though, that the impressive risk reductions seen come at rather a significant monetary cost; to whit, $213,000 to prevent one cardiovascular event, by Dr. Wes' (corrected) calculations. Happy the Hospitalist then goes off on a tear about "Should America pay $1,400 a year per person per year to prevent an event that lifestyle changes can do far better, for free?" A straw man argument if ever there were one, because of course other lifestyle changes are free, but presumably what the Jupiter study showed was that Crestor reduced cardiovascular risk even further.

Although "Prevention" does not save money -- in fact, it can be quite expensive -- the question remains "Is it worth it?" Because we live in the United States, each individual gets to make that decision for him or herself. Because guess what, Happy, you aren't paying for anyone's Crestor but your own. Whether or not an insurance company chooses to cover the drug for low-risk patients is also an individual decision. Hell, I'd probably offer my patients cheap generic statins, because so far just about every benefit turns out to be a class effect. $40 a year ($10 for a 90-day supply) for simvastatin at Target? To halve the risk of a cardiovascular event? I bet Happy (and most other active people) pay more than that for shoes in one year.

Just to make it even more convincing, though, I looked at Dr. Wes' numbers and found them a little unrealistic:

• $250 for LFTs? Quest charges me $12; I charge the patient $20.
• $150 for lipids? My charge is $35.
• Knock the statin cost down to $40 a year

Here's how it adds up now:

• Lipid level evaluation ($35 per test x 5 years) = $175
• C-reactive protein level ($20 per year x 5 years) = $100
• Annual liver function tests: ($20 per test per year x 5 years) = $100
• Annual statin costs ($40 per year x 5 years) = $200
• Number of people needing to be treated over 5 years to prevent one cardiovascular event: 25
• TOTAL DOLLARS TO SAVE ONE CARDIOVASCULAR EVENT: $14,375

More than an order of magnitude less, and it actually comes down to less than $100 per person per year. Add in a good pair of running shoes for that exercise regimen, and you're still talking less than $20 per month; way less than what most smokers spend on cigarettes.

Look, I agree wholeheartedly with HH and others that people need to take more responsibility for their health. But you have to admit that the ones eating those McBypass burgers from the drive-through on their way to buy cigarettes to go sit on the couch watching TV are NOT the ones beating down our doors looking for the latest and greatest ways to cut their cardiovascular risk. But for those conscientious patients paying their own bills who are looking to optimize their health, you have to admit this is an exciting study.

Preventive care does not save money. Never did; never will. Just because lots of people make the claim doesn't make it true. Preventive medicine needs to be looked at for its own sake instead of strictly from a financial point of view. The whole concept of risk is an individual one: you may not mind going out in a thunderstorm knowing that the risk of being struck by lightning is remote; your little sister may cower inside in terror. Preventive medicine is, at its heart, the exercise of reducing risk. Just don't go about it thinking you're going to save money.

What the Happy Hospitalist and Subprime Mortgages Have in Common

There is a hospitalist physician who blogs under the name The Happy Hospitalist, whose blog I read from time to time. Aside from some mediocre writing and way too many ads, Happy seems to be a competent internist specializing in the care of hospitalized patients. He also blogs at great length about the economics of American medicine, much of the time with great insight. A few months back, I pointed out to him (in a comment, I believe) that his job -- that of hospitalist -- was not financially viable in the long run, even though the "long run" in this case may very well be greater than the span of his professional career. All I got in response was some gobbledygook about how his hospital recognized the "value" he brought to his job, and so it didn't matter that his salary was greater than what Medicare paid the hospital for his services.

Given the current situation (please note this stipulation; Happy and some other bloggers have a way of switching back and forth between discussing things as they are and as they would like them to be) I submit that at the most basic economic level, Happy's job is not financially viable over the long run. Here's why:

Happy admits that his salary is greater than what Medicare pays his hospital for his services.

Think about that. Happy's hospital (or independent contracting group; it really doesn't matter) pays Happy more money than they are able to collect for the services he provides. In order for that to happen for any period of time without going broke, there have to be some other things going on.

Certainly Happy's payor mix is something other than 100% Medicare. Perhaps other insurers pay more; perhaps enough to cover not only Happy's salary, but also enough to make up what the hospital is losing paying him to care for Medicare patients. (I doubt it.) Perhaps the hospital is able to recoup enough extra money somewhere else in its operations. (I have no idea where.) Perhaps he performs other services for the hospital aside from direct patient care. (He hasn't mentioned anything.) Maybe the hospital administrators agree to smaller salaries to make up the difference. (Yeah; right.) Or maybe they're just shifting funds around here and there to pay the hospitalists according to the contract they negotiated, even though it is more than what they are bringing in.

This is strikingly similar to purchasing a house you really can't afford. There are all kinds of ways a fast-talking banker can structure a mortgage so that you can scrape together the payments for awhile. But eventually the adjustable rates go up, your ability to afford the payments collapses and the whole house of cards has to come tumbling down. For the homeowner, this can mean foreclosure. What about Happy?

What has to happen eventually is that the hospitals won't be able to afford him. At that point they'll either have to lower Happy's salary, find other hospitalists who will work for less (FMGs?) or close their doors.

Happy doesn't care; he says he'll just find another job at another hospital. (See Addendum) And I'm sure he will. There will always be other, richer hospitals with more cash lying around to offset the loss-leader services of hospitalists. My point is that if he cannot produce enough income to cover his salary, benefits, etc. and the hospital cannot find other monies with which to pay him, then eventually the same situation will occur at every hospital. It may take a very long time for this basic fact of economics to percolate through to the critical point -- perhaps longer than Happy's professional career, at which point he'll just retire and laugh at the rest of us struggling to take care of patients, who will always be there. But the situation is not financially stable. Eventually it will break down. It has to. It's just basic economics.

Look at the housing market. It took decades, but because of the fundamentals of subprime lending, it had to happen. You cannot go on indefinitely spending more money than you make.

The bottom line is that I don't understand how hospitalists can survive as a profession if they insist on being paid more than they can produce for their employers. Just because they do -- for now -- does not mean that basic economic principles stop working.

No one has been able to explain this to me adequately. I'm pretty smart, and I've discovered that if someone can't explain something so that it makes sense to me, they're trying to fool either me or themselves.

Again, please note that this analysis only encompasses the situation as it is today. If (and that's one enormous "if") Medicare does begin bundling physician services into its hospital payments then all bets are off; though unless they increase rates to cover those services, the whole thing comes tumbling down all that much quicker.

So what will happen?

We shall see.

Addendum 1: Perhaps the system is already starting to falter. This article (h/t Dr. RW) discusses the issue of job turnover among hospitalists. It points out the difficulties of comparing hospitalist jobs directly, because the relationships between salaries, benefits, working conditions and workloads are so diverse, and the general volatility of the hospitalist job market. Still, nothing I read in that article addressed my primary observation: the system is only functioning now because hospitals are willing to pay doctors more than they can collect for their services. This cannot continue indefinitely.

The Emperor's birthday suit is wearing a bit thin.

Addendum 2: Are those experts who claim that Hospital medicine will continue as a growth industry for the foreseeable future in the same group as the ones who were absolutely certain that the price of oil would continue to rise?

Crazy Cat

Due to some responses to certain past posts, I have become aware that my humble blog occasionally attracts the attention of some members of the Veterinary-American population. I was wondering if any of those fine folks could help me gain some insight into the behavior of one of my cats.

Party Cat (nickname courtesy of the Jock & Friends) is 10 years old and has been with me since he was about 1 year old. I don't know much about his kittenhood, but I do know he was fostered for awhile in a farm-like environment (ie, outdoors) where he shadowed people quite closely but had no other reported behavioral anomalies.

From the time I've had him he has been strictly an indoor minion of Satan cat. Yet from time to time he manages to slip out behind me into the great outdoors -- upon which he goes feral! If I can catch him within about thirty seconds or ten feet (whichever comes first) he's ok, but if he goes any longer or farther than that, he becomes a different animal; he hisses and spits at me, ears pinned back. If I try to reach out to grab him -- or even touch him -- the claws are out to the point of drawing serious blood.

We've learned the hard way not to try going after him with bath towels or the like. If we just wait, he comes in on his own eventually. I know what you're saying to yourselves: no problem. But it is a problem because he's not out there happily exploring.

This happened yesterday, and the poor kitty was not happy. Even as he crouched out of reach in the bushes, ears menacingly low, the growls and noises he was emitting sounded more like wails of desperation. He came onto the front porch and wound himself around the furniture like he does around my legs when he wants love, but he still bolted whenever I tried to pet him. I tried tempting him with treats. He came and took them, but wouldn't come in and still hissed at me when I reached out to touch him. Eventually (ie, hours later) he finally made it all the way across the porch to the door and came in on his own.

Here's the weird part: the moment he's back inside, he's back to his normal, loving self; warp-drive purr and all.

I don't get it. Any ideas from someone who knows more about cats than I?

Edited to add responses to comments:

Vetnurse: Thanks, I think.
Marcia: We're up to four. I know for a fact Darling Spouse won't permit more.

3rd year vet student: Best line evah!! To whit:

Cats are crazy.
Learn it. Live it. Love it.

Post Partisan Depression

There is a newly described psychiatric malady sweeping America these days known as Post Partisan Depression. There are two distinct subtypes with subtly different manifestations.

Type D:

--Obsessive use of the term "President-Elect Obama"
--black & blue marks from pinching oneself to ensure that oneself is awake
--idiot/savant-like awareness of precisely how much time is left until noon on January 20th, 2009.

Type R:

--Obsessive use of terms such as "Socialism," "Marxism," and "Goodbye to my hard-earned paycheck."
--Compulsive waving of the book Atlas Shrugged while commanding everyone to read it and exclaiming, "Who is John Galt?"
--idiot/savant-like awareness of precisely how much time is left until noon on January 20th, 2009.

Manifestations common to both subtypes include tachycardia, sweating, restlessness, insomnia, tendency towards assorted spontaneous verbal outcries (specific to each subtype) and generalized activation of the sympathetic nervous system.

There appears to be no predilection for one sex or the other; reported male to female incidence is 1:1.

There is some question over whether or not age is a relative risk factor. In some parts of the country there seems to be an increased incidence in younger populations, but this is not borne out globally.

Treatment is mainly supportive, as the condition will likely subside with time. Both types respond to sympathetic head nodding and utterances such as "You betcha!" (albeit with different inflections.) Hugs should be administered liberally to both types.

(Credit to my brother, RFS MD for coining the term, and my sister, MSD Esq., for the first set of diagnostic criteria.)

An Open Letter to President-Elect and Mrs. Obama

Dear Mr. & Mrs. Obama;

First, let me congratulate you on your momentous achievement and allow me to wish you well as you prepare to embark on what will no doubt be among the greatest challenges of your lives. (The greatest challenge, of course, is child-rearing; and the hardest part of that, as we all know, is keeping a straight face.)

I would like to offer a modest suggestion on a topic that you, Mr. Obama, broached in your uplifting acceptance speech: you mentioned that your family would be getting a dog.

Please consider adopting one of the far-too-plentiful animals available at one of the assorted animal shelters in Chicago or elsewhere. Many are abandoned pets, beautifully behaved and extremely well-trained, doomed to a life of misery or even early euthanasia due to nothing more than mere thoughtlessness. Please recognize that whatever you decide, the purebred puppy you would have purchased from a licensed breeder is certain to find a good home elsewhere. The same cannot be said for rescued animals.

As you have demonstrated numerous times on the campaign trail and in all areas of your lives, the best leadership is that of a good example. What a gift to expose your daughters to the concept of animal ownership in such a thoughtful way.

Best of luck in all your ongoing endeavors.

Best,
#1 Dinosaur

Do Not Go to This Website

...if you want to get anything done at work, or at home for that matter. Not only has it monopolized my time at home, but now I've gotten both of my computer-phobic staffers addicted to it:

The Eyeballing Game

(Hat tip: Janet Reid)

Chip Off the Old Block

My little Nestling is certainly enjoying himself at college. Witness his latest communication (minimally edited):

I had a rather interesting conversation about fire with my lab partner. We both like the smell of extinguished candles. This led us to the idea that we should bake a cake. ... I decided to make it a rather interesting experiment. I looked up the most basic cake recipe for proportions and methods and did crazy math and extra ingredients with it, and this is what I came up with:

Here's how it might look as a normal recipe:

2 1/2 cups flour
1 Tbsp baking powder
1 tsp salt
1/3 cup cocoa powder
1 Tbsp cinnamon
12 Tbsp butter
1 1/2 cups sugar (preferably from a container with vanilla beans)
5 large eggs
1 1/3 cups half and half
2 tsp vanilla
2 bananas

Makes 2-9" cakes. Procedure: typical.

As you might be able to tell, this is a chocolate banana cake. I also wanted to make a little more than 2-9" cakes...so here's how I did it.

3 1/2 Cups flour
1 Tbsp baking powder
(1 tsp salt)
1/2 cups cocoa powder
2 Tbsp cinnamon
16 Tbsp butter
2 1/2 cups sugar (a little over 2)
6 extra large eggs
2 cups half & half
1 tsp vanilla
3 bananas

First, keep in mind that there's a time limit. I left for [the grocery store] around 6:00, got back around 7:00, and had to start my [work] shift at 9:00.

1. Get RA friend to open quad office so baking is possible without invading freshman dorm. Quickly run to C-store for bananas. Start taking off the packaging of all items bought at [grocery store].

2. Put butters in mixing bowl. Realize they're not quite soft enough and start hacking with fork. Start adding sugar. Continue hacking. Wonder why the mixture creates weird butter balls. Keep adding in sugar and mixing with butter until all sugar is added.

3. Upon frustration with texture of butter/sugar mixture, start using the big spoon to mix. That's why it was bought.

4. Start mixing in eggs one at a time at the sink. Look in vain for a light over the sink. Give up and go back to other table hoping no mess is made. Add eggs one at a time and beat with fork after each one. After 3 or 4 eggs, begin to worry about consistency of batter.

5. Put flour in measuring cup. Realize that other dry ingredients won't fit in it. Add cocoa and baking powder to other, smaller measuring cup. Add cinnamon to flour measuring cup because it makes an interesting contrast. Look around for salt and worry that none can be found. Relax because it doesn't matter. Add some flour and half & half. Mix. Add cocoa and a little flour and half&half. Mix. Suddenly be proud that it looks like beautiful chocolate batter. Continue adding some flour and half&half until all of each is added. Lick a drop of batter that got on fingers. Enjoy. ^_^

6. Preheat oven to 350º. Move rack to middle shelf.

7. Peel first banana. Slice with fork in ninja style. Attempt to cut up banana half from within the batter. Settle for banana chunks and make note to try mashed bananas next time. Cut rest of banana and subsequent bananas using smarter method (using one part of peel against finger like cutting board). Have minor concerns about freshness regarding dark spots in bananas. Mix bananas in as much as possible.

8. Pour into three 8"x8" pans. Don't worry about not having greased them because there would not have been enough butter otherwise. Wonder if disposable aluminum pans will stick and/or burn much.

9. Place pans in oven. Realize that there's not enough space for all 3 on one shelf. Kick self in ass for moving rack to just above other rack. Move lower rack down one level and wonder how it might affect outcome. Put third pan in. Wonder how anyone could function with an oven 1' wide x 2' deep squeezed in corner of room. Glance at watch to note relative time for baking.

10. Lick various utensils. Enjoy. ^_^

11. Wash used dishes in bathroom on own floor (for some odd reason.) Use hand soap instead of dish soap. Try not to be phased by temperature of water. Place all dishes in mixing bowl and set on floor to dry. Look at time and plan ahead by taking stuff needed for [work] shift. Look around room and double check that nothing else needs to be taken down.

11. Go back to quad office. Notice dirty measuring spoons. Return to own floor, wash them, and throw into mixing bowl. Go back to quad office and check cakes (15 min point). Check obsessively every 5 minutes. Call [work] coordinator and tell him there may be a slight delay.

12. Once cakes seem about done (~30min), remove from oven using single pot holder pulling straight onto cooling racks. Wait impatiently for them to cool before decorating. Hastily decorate with rainbow chip frosting and various icings. Decorate one for Grandmother's birthday, one with "I was bored", and one with "Cake Ninja" (don't ask). Enjoy excess frosting, but reluctantly realizing time crunch, quickly wash rubber spatula and put with other dishes. Take pictures for posterity and emails.

13. Put "I was bored" cake in room. Leave messages on friends' doors for them to eat it. Rush down to main gate so as not to be too too late for shift. Carry 2 cake pans on one cooling rack. Try not to burn fingers, with moderate success. Set up work station. Leave message for friend to pick up Cake ninja cake. Dig into cake.

14. Take pictures of myself enjoying cake. Spend over half the shift sending emails regarding cake baking instead of studying for upcoming tests/class stuff.

The result:

I may have to change his blog nickname to NinjaBaker.

Anything to Keep from Doing Real Work

I finally got around to updating my sadly outdated blogroll (see right; unless you're too far gone into the medical field to be helped, in which case it's to the left; the screen's left, that is.) Whatever. At long last, I've updated links to blogs I read regularly (don't always agree with them, but read them) and deleted those that have gone blank. (Dr. Dork: whatever became of ye?)

With that task accomplished, I suppose I have no choice but to get back to my paid writing. Unless --

Hmm...I wonder if there's anything on YouTube?

My New Favorite Blog

One of my new favorite blogs has to be the "Fail Blog":

Graphic design Fail...big time: