Feet First

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

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    Saturday, September 14, 2013

    > START

    > You are facing north, looking at the mouth of a cave.
    You have a walking stick.
    You have a torch.
    You have a knife.
    You have one bag of jewels.
    You have a handful of magic beans.

    > GO NORTH

    > You are in a dark cave. A woman wearing a headset is approaching you.


    > I don't understand that.


    > She shakes her head. "That depends on your employer," she says. "You must go back to Start."

    > GO EAST

    > You are in a maze of twisty little passages, all alike.

    > GO EAST

    > You are standing in a vast underground cavern. Many confused people are wandering around it. There is a display with numbered cards.


    > You are number 1,752.

    > WHAT.

    > You are number --


    > I don't understand that.


    > The crowd scatters and you find yourself at the head of the line. There is a counter with computer terminals. Behind it a man is standing.


    > He tells you your deductible is $750 per year. You have $650 left on it.

    > OH NO


    > He tells you that you have been reassigned to a different medical group without your prior knowledge.


    > You show the man your magic beans and his face lights up. After a delay of 45 minutes, he tells you that he has been able to assign you back to your original PMD.


    > He tells you your copay for PMD is one bag of jewels. If you go to the ER it is three bags of jewels. Specialist: two bags of jewels.

    > FIND PMD

    > This is a quest, remember?


    > You are in a narrow dimly lit passage. The ground is rough here.


    > The stick helps keep you from stumbling. Suddenly as you move forward you realize the ground is opening up. Before you can react you have fallen into a large pit just ahead of you.


    > You raise the torch above your head to see better and realize the pit is filled with... pharmaceutical representatives.


    > You fight them off and scramble out of the pit just in time.


    > You are in a maze of twisty little passages, all alike.

    > GO LEFT

    > It is pitch dark. You are likely to be eaten by a grue.


    > You are in a chamber filled with smiling people wearing white coats.


    > You must be more specific.


    > The chamber is filled with physicians' assistants, nurse practitioners and pharmacists, all of whom are eager to help, but none of them is an MD. Do you wish to continue?


    > You are in a maze of twisty little passages, all alike.


    > I don't understand that.

    > GO RIGHT

    > There is a light ahead of you and a trail of discarded cardboard coffee cups and donut boxes on the ground.


    > You are in a lighted chamber. There is a stethoscope here. There is a reflex hammer here. There is a tired looking person in a white coat here.


    > The person in the white coat is your PMD. Congratulations. You have won the game.


    Tuesday, March 05, 2013
    A Really Good Headline

    As a good Stepford staff member of Tertiary Care Center, TCC's intranet web page doubles as my home page. Every morning when I fire up the box I am greeted by perky articles about the Star Safety Team Member of the Week, the latest blood drive/fundraiser/politically correct spokesperson for Disease X, or warnings about parking restrictions due to construction. There is nothing intrinsically wrong with this. It's just part of working for a big corporation (which, let's face it, I do).

    My complaint here is that whoever writes the headlines for Tertiary Care Center's intranet web page needs some remedial education. This morning the top caption reads:

    A Benign Brain Tumor, a Malignant Tumor, a Love Story and a Doctor's Reassuring Presence

    I haven't read the story, but I'm sure it is heartwarming. No doubt. Unfortunately when I read this, my twisted brain immediately produced the following:

    ...and a Partridge in a Pear Tree
    ...and Two Hard Boiled Eggs. Make That Three Hard Boiled Eggs
    ...and Six Weeks To Live

    Rewrite, people! Rewrite!

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    Thursday, February 07, 2013
    State of January

    Dementia is like a sinkhole. It erodes from within. Particularly with Alzheimer's, the social graces are preserved until late in the disease. You see someone who is clean, properly dressed, gracious and smiling, able to carry on a conversation - although they might seem a bit vague. It isn't until you start asking detailed questions that you begin to see what's behind the facade. What's there is a vacuum.

    Patient Gracious Lady, GL for short, has been my patient for many years. She would sometimes be brought by a family member, but often came alone. I usually see her about twice a year, as she has been in pretty good physical health. During her appointments nothing about her demeanor said dementia or struck me as unusual. She was recently hospitalized for a fairly minor problem, but the admitting MD warned me that she had been quite confused and the family member who brought her to see me for a post-discharge visit confirmed it.

    "She'll ask me a question and I answer it. Then five minutes later, she asks the same question again."

    "Who's been paying her bills? Are they getting paid?" - if you suspect dementia, this is always a good question to ask as finances are one of the first things to go by the wayside. In this case though it didn't help.

    "I'm paying them." It turned out that family members had been helping her pay her bills for the past several years. During this discussion, GL sat quietly with a calm smile on her face, divorced from the entire conversation.

    "I'm going to do something called a mini mental state exam." This is a fairly quick test which covers vocabulary, short term memory, math and orientation to place and time. It isn't perfect as even someone with early dementia will likely get the questions right. But sometimes, as today, the results can be quite striking.

    I held up a pen and she named it immediately. But when I tapped the object on her wrist and asked her to name it, it took her 45 seconds to remember that it was called a wristwatch.

    Time to test location. "What state are we in?"


    Oh crap, I thought. Wait a minute.

    "Is it someplace like Wisconsin? Rhode Island?"

    "No, those aren't right." She pondered for a while. "It's January."

    I stole a look at the relative, who was looking pretty devastated. Every answer revealed another deficiency. To be brief, the maximal score on the MMSE is 30 points; she scored less than half that.

    There are tests that can and should be run if you suspect dementia, to rule out medical causes. You check thyroid, vitamin B12 and syphilis titers among other tests. I ordered them, but I am not really optimistic that her problem is treatable. Her MMSE score is probably too low for her to benefit from medication.

    The one blessing that I have seen in dementia is that the patients themselves don't seem to be aware that they have a problem - or if they are aware, it doesn't really bother them. When a patient comes in with a complaint of "I keep forgetting things and I'm really worried that I have a problem," you can almost guarantee that they are not dementing. It's when the family or friends bring the patient in that you have to be concerned. GL had that same calm, detached air. The good news is that she has caring family who will look after her, and I firmly believe that social interaction helps in this disease.  Still, it is not something that one would ever wish for a relative or loved one.


    Sunday, February 03, 2013

    I say, Your Majesty, you know how to handle a weapon. Rumor has it Jack Bauer took lessons from you.

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    Saturday, February 02, 2013
    On Children

    Sometimes patients will bring their children to their appointments - this usually means they are very young children and that the parents couldn't make arrangements for the kids. It doesn't bother me. In fact, on a tough day it invigorates me to have a baby in the room. My favorite trick for the young ones is to hand them a tongue depressor; it is wonderful to see them eyeing it, grasping it with both hands (what is this? I imagine them thinking) and then, of course, eventually gnawing on it.

    I also remember one energetic two-year-old who entertained himself by opening the bottom drawer of the exam table and taking out, one by one, the small plastic jars of  preservative fluid contained therein. The jars are for Pap smears. Don't worry, they were safely sealed and there was no way he could have opened them. The worried father asked if this was a problem. "As long as he's not screaming, I'm happy," I reassured him.

    The older ones find it interesting to look over my shoulder as I'm typing and especially to look at pictures of X rays. Or sometimes they will just stare at me, The Doctor, as I interview and examine their parent. Or they may even ask questions, which I love. Rarely a child will announce that he or she wants to be a doctor and I encourage them heartily.

    Pediatrics, though, I could not do. I realized that as a medical student the first night a neonate came in with a fever and we had to do a spinal tap on the infant. Now that my office is right next to the Pediatrics Department and I hear the wails of children echoing through the air vent on a regular basis, I am even more certain I made the right choice.


    Monday, January 28, 2013
    Flu B Gone

    The flu has hit. Some years it's not so bad, some years it's worse. We don't have tents out in the parking lot or anything, but it sure has been busy around here. Today my suitemate and two nurses are out and I have the feeling it's going to be a bad day... a long, bad day.

    On those days you grasp at anything to cheer yourself up. Like today, when I was ordering antiviral for yet another patient down with influenza and typed "Tamifly" instead of Tamiflu. (That's oseltamivir for you pedants out there.) Doesn't that sound like a much cooler name? A whole marketing campaign sprang to life in my head, fully formed.

    Don't be flu. Be fly. With Tamifly.
    Fly above the flu. Tamifly can help you too!

    More coffee. I need more coffee...


    Saturday, January 05, 2013
    "As God Is My Witness, I'll Never Go Hungry Again!" Said the Dieter

    So I'm counseling a patient on weight loss. She mentioned that she goes to a fair number of social functions and has to eat what she's served there; which is often a problem.

    "You could always do a Scarlett O'Hara and eat before you go," I suggested.

    She looked blank. "Huh?"

    "Surely you know your Gone With the Wind?" She didn't.

    "Well, early in the book Scarlett O'Hara is getting ready to go to a barbecue at a plantation nearby. Apparently in those days ladies weren't supposed to have an appetite, or to eat much in public. So she eats a whole meal before she goes to the barbecue. Then she gets there, and the host is serving wonderful food that nobody's eating, and it's just like Beverly Hills!"

    She laughed with delighted recognition. That she got. And if I'm lucky, I may have even inspired her to read Gone With the Wind. (If you haven't, do give it a try; it combines the best qualities of the soap opera and the historical novel.)

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    Wednesday, September 26, 2012
    "I Look Forward to Your Next Article, 'How to Breathe'"

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

    How To Eat Breakfast Cereal

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


    Tuesday, August 28, 2012
    The British have a real talent for desserts. (Have you noticed this?) I may be more prone to their charms because of my UK heritage, or because I'm not a chocoholic. Most traditional Anglo desserts aren't based on chocolate. Or because I think everything goes better with gravy - the dessert variation is a baked or steamed dessert with a sauce on top. As a med student many years ago I wangled my way into a plastic surgery rotation at Oxford, and whenever the hospital canteen served rhubarb crumble with custard sauce I was the happiest camper in town. Yes, the custard was lumpy and made from Bird's dessert powder, but even so.

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

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

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


    Thursday, August 23, 2012
    "I won't quit smoking"
    You said, after the tumor
    You died yesterday.

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    Tuesday, August 21, 2012
    Having been seduced by the likes of Facebook and Twitter, I have come to realize that maybe I would blog more if I settled for shorter posts. I feel the need to do this, just to share the madness of actual medical practice. Here is one actual conversation from yesterday:

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

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

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

    Me: Maybe you should turn off the news.


    Sunday, April 08, 2012
    Easter Dinner

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

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

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

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

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

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

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

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

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


    Sunday, February 26, 2012
    That Old Time Casserole Rock and Roll

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

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

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

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

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

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

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

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

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

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

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

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

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


    Wednesday, February 22, 2012
    This Is Counterproductive

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

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