I treated a high school senior today suffering from acute depression, anxiety, and panic attacks all precipitated by the fact that he was not accepted to any of the four Ivy League colleges to which he had applied, but several of his friends had. It wasn’t that he had been rejected everywhere. In fact, he had multiple acceptances at excellent schools. Nevertheless, he was beating himself up over his perceived inferiority. He just couldn’t understand why his friends with identical grades and test scores were somehow more worthy than he.

I explained to him that in this day and age, all of the Ivy League schools — as well as many, many other top tier colleges — have enough ideally qualified candidates to fill their entire classes ten times over, or more. After a certain point — a point well passed by my patient and many other students — acceptance to any of these schools is basically a lottery. Although my patient understands this intellectually, emotionally he still doesn’t quite believe it. His friends must have had something he didn’t to receive that coveted thick letter.

So here is my modest proposal. Listen up, Ivy League admissions folks:

Go through your regular admissions process. Evaluate each applicant according to whatever criteria you want. Decide whether or not each one has what it would take to succeed at your institution, and whether or not you would want him or her there. Sort them all into two (and only two) piles: Yes, and No. Go ahead and send out your graciously worded rejection letter to the kids in the “No” pile, bearing in mind that the group almost certainly includes future presidents, entrepreneurs, Nobel and Pulitzer prize winners, etc.

Next: Take all the names in the “Yes” pile, throw them into a hat, and run an actual lottery.

If you have 40,000 applicants for 6,000 places, go ahead and pull out 6,000 names (plus however many extras you want.) Send them those nice thick letters. Then — and this is the important part — everyone else on that “Yes” list gets a letter telling them that they were good enough. They were fully qualified; there was nothing wrong with them, with their application, with their qualifications. Their number just didn’t come up, you’re so very sorry, and you wish them well.

There are several advantages to this scheme.  In addition to preserving the sanity of the poor high school seniors stuck in the middle of this mess, the job of the Admissions Committee will be infinitely easier; all you have to do is decide yea or nay on a truly individual basis. Additionally, it’s much more intellectually honest. All that crap about “balancing” your class, fine-tuning the precise makeup of your student body is all a bunch of bull anyway, since as you know, you can’t control who accepts you once you send out those letters. Just run the damn lottery and let the thick and thin letters fall where they may.

You’re welcome.

Florida grouper with parmesan ramp risotto, asparagus, spring ramps, shaved crimini mushrooms, lemon vinaigrette:

Desserts: Signature chocolate tower:

Vanilla creme brulee:

No, I didn’t make any of it (though my creme brulee is better.) We are in Cape May, NJ celebrating our anniversary, beginning with dinner at the Washington Inn, attentively waited upon by the delightful Godfrey of Uganda and London.

The dermatologist diagnoses eczema, gives him a prescription for a steroid cream, and tells him to follow up with GI, Pulmonary, Ortho, Uro, and Cardiology.

The gastroenterologist orders blood tests, a CT, does an EGD and colonoscopy, diagnoses him with GERD, gives him a prescription for a PPI, and tells him to follow up with Derm, Pulmonary, Ortho, Uro, and Cardiology.

The pulmonologist orders a chest x-ray and PFTs before even seeing him, then diagnoses cough-variant asthma and gives him a prescription for an albuterol inhaler, Advair, and singulair, then tells him to be sure to follow up with Derm, GI, Ortho, Uro, and Cardiology.

The orthopedist orders x-rays and an MRI of the knee (again before seeing him), diagnoses osteoarthritis, and gives him a prescription for Mobic and a pamphlet about knee replacement, telling him to think about it, but also to follow up with Derm, GI, Pulmonary, Uro, and cardiology.

The urologist orders a PSA (because he’s breathing; the urologist, that is), does a rectal exam, diagnoses BPH, gives him prescriptions for Proscar and Urotraxal, and tells him to follow up with Derm, GI, Pulmonary, Ortho, and Cardiology.

The cardiologist diagnoses him with hypertension, sends him for a nuclear stress test and echocardiogram, then starts him on Exforge and tells him to be sure and follow up with Derm, GI, Pulmonary, Ortho, and Uro.

Each of these doctors also brings him back for a checkup annually for the rest of his life.

Same guy comes to see me. I proceed to:

1. Take a complete history, do a thorough physical exam, and order some basic blood work (including a PSA in this case) which allows me to:
2. Diagnose eczema, and tell him to start by trying moisturizers
3. Suspect that his stomachache is actually heartburn, tell him to consume less alcohol, caffeine, and tobacco, lose some weight, and try some antacids first (then OTC H-2 blockers, ie first generation anti-acid meds)
4. Realize that the cough is probably coming from the GERD and tell him to wait and see if it persists after treating his heartburn
5. Diagnose osteoarthritis and tell him to start by trying two extra-strength Tylenol (1 gram total) four times a day, and that losing weight will help his knee as well as his GERD.
6. Diagnose BPH and give him prescriptions for generic finasteride and flomax, and
7. Tell him to come back and re-check his blood pressure, as the diagnosis of Hypertension requires that elevated readings be found on three separate occasions.

Total cost for the first: Multiple thousands of dollars.

Cost for my care: a few hundred dollars at most.

Total time available in the specialty appointment books for patients who actually need to see them: you do the math.

Why on earth do people voluntarily board this ridiculous runaway referral-go-round instead of seeing a good family doctor (and paying us appropriately) first?

I’ll never know.

For years, nay, literally decades, you remind and cajole and bug and nag them: please pick up your stuff. Please throw that away instead of just leaving it on the floor. Please, please, please.

Eventually, (if we’re smart) we learn not to worry so much about the bedroom. It has a door that can always be closed. So we concentrate our efforts on the common spaces.

Please don’t leave your shoes lying around.

Are you done with this soda can?

Is this junk mail that came for you, or do you want to hang onto it? (And if so, could you please take it up to your room.)

On. And on. And on.

Months dragging into years blooming into decades.

Then one day it all ends. They’re gone. Really gone. And you finally have a chance to clean up the house once and for all; and then savor the joy of watching it stay picked up. Because there’s no one but you and a well-trained spouse living there who enjoy the clutter-free ambiance of trash in the can, folded laundry in drawers, and old newspapers in the garage.

Bliss.

What could be better?

This:

Coming by after a week in the new house with the new roomies, you overhear him lament,

“I wish Frick and Frack were neater.”

I would say it brought a smile to my face, but that’s not exactly true. What it brought was a 10-minute laugh to my belly.

There is a large group of urologists in my neck of the woods. Actually, it began as many small groups of urologists who joined forces and became a “group practice without walls“. One of the desired effects of this new arrangement was increased clout in dealing with large insurance companies to negotiate better payment rates.

As it happens, one of these large insurances took umbrage at their requests, so when it came time to re-negotiate, they played hardball, and in a full-blown game of chicken, ended up walking away from the table. Letters were sent to patients informing them that they had to find new urologists. I had one guy in his 90s who’d been seeing the same doctor for decades who called asking me what he should do. I told him not to worry, go ahead and keep any scheduled appointments, pay the guy out of pocket for one or two visits (if it came to that). Mainly I reassured him that the standoff wouldn’t last.

It didn’t.

After a short time, the insurance company caved, agreed to the urologists’ contract terms, let the patients go back, and all was right with the world.

While discussing the situation with my patient’s urologist (who happened to have been the chief negotiator for the group) I realized that the moral of the story was this:

Never get into a pissing contest with a bunch of urologists.

(Documentation here and here.)

The first time I made this, I used a package of Wegmans pre-cut veggies because I thought it was an interesting combo. It was. But this time around, I bought the veggies separately and cut them myself. Not only was this (a lot!) cheaper, it also allowed me  to make the vegetables more uniform and a little smaller. This helped them cook more evenly. I also did the onions alone for the first few minutes before adding the asparagus and mushers; another advantage of prepping them separately. My original thought was to toss some small bay scallops into the pan, but we couldn’t find any (in packages under two pounds), so DDS did the big ones on the grill.

Yum.

We notice that he has an unpaid balance from an earlier visit a year ago. We have billed it to his insurance, which denied the claim, stating that the visit was for a pre-existing condition and was therefore not covered. We explain this to the patient. He is not pleased.

He states that the previous visit was not, in fact, for his pre-existing condition of asthma (for which the documentation clearly states the visit was scheduled), but rather to discuss his erectile dysfunction, which he states is a new problem. Because it is not a pre-existing condition, the insurance should pay it. He is pleased to explain this.

Never mind that we evaluated, discussed, and managed his asthma during the visit (clearly documented) as well as his ED (also documented). Never mind that neglecting to include the asthma diagnosis on the claim would constitute insurance fraud. Never mind that we’ve gone round and round with the insurance company for six months, and then billed him for the next six months. Never mind that he has been told that his insurance contract is between him and the insurance company, whereas we are merely the ones actually providing him with medical care.

We request payment owed for services rendered. He is not pleased.

His precise words:

“I don’t think I should have to pay.”

Really? For services already rendered? Does he think the water, electric, and phone companies would be perfectly happy to continue providing me with services if I decided randomly that I shouldn’t have to pay for them? My lawyer and accountant would have me in small claims court in a jiffy if I decided after the fact not to pay up. Why are doctors any different?

Why do people seem to think that the terms of their contract with their medical insurance company doesn’t really apply to them?

Talk about entitlement!

And the emptiness of the nest is legitimate. Less laundry to do; not as much noise; lower grocery bills (often counterbalanced by tuition, but that’s another story.) I don’t deny that it’s a big adjustment.

But it’s not entirely real, because it is often not permanent. They still come home for holidays, vacations, and summers. Their driver’s license still lists our address, as does their car registration and insurance. Their legal residence is usually still “home”.

Sometimes that changes after college graduation.

Sometimes they go off to graduate school confident that they are finding their own way in the world. Even when you go along to help find that first apartment, they take the lead. After a year, when they buy themselves a condo and get a cat (all the while refusing to take money from you), you know they are well and truly launched.

Sometimes they get married and set up housekeeping, including their own menagerie of cats, snakes, and other reptiles. Even if we happen to be helping out with student loan payments, it still counts. They’re not coming back.

And then there are the boomerangs. The ones who come back home after college or grad school and stay a while as they get started on their life. Nothing wrong with that, especially when they have a full time job, their own car, friends, activities, and schedule. It’s more like having a housemate than a kid, when general consideration (noise, hours, etc) is practiced by all parties. The difference is that this time, it’s more open ended.

But eventually the exam is passed; certification achieved. The soul-killing retail job is eagerly ditched in exchange for the professional one. Life continues, even while living at home. But however you cut it, however pleasant (and cheap) the situation may be, it’s still anathema to be “living with your mother.” And so the next steps begin.

House hunting ensues. A property is located. A deal is struck. A mortgage secured. Settlement is made and a truck is rented.

Moving day: the truck is loaded, unloaded, and re-loaded again for a final trip. This one is truly final, though. This time, he’ll be filing change-of-address forms for his driver’s license, car insurance, credit cards, and so on. He is moving to his new home. His. Not ours, which is to say mine. He’s outta here.

He’ll be back of course. Tonight, in fact, to watch the season finale of the Walking Dead, since he doesn’t get cable until Tuesday. But never the same. He’s gone.

I know they’ll still come to visit, but it’s just to visit. Home is elsewhere for all of them now. Now the nest is empty in a way it hasn’t really been before. There’s a new freedom to clean up, clear out, re-arrange, discard; maybe even consider downsizing.

Melancholy? Bittersweet? Regrets? Actually: no.

Because it’s time. They were all ready, and now the first to come is the last to go. Even as they fly away from my arms, I will always hold them deep in my heart.

But now I get to order new carpeting.

As I read her screed against  the ND who conducted a cursory history and exam before checking off $750 worth of supplements on a pre-printed sheet (Visa, Mastercard, and Discover accepted, I’m sure) I felt my heart lift. Yes, I thought. Now you’re getting it. When she advocated hiring a naturopath who doesn’t do this, I found myself telling the screen, “Good luck with that.”

The poster was also, rightfully, concerned about “the heart of the practitioner.” She places great emphasis on intent. Question for her: what about the practitioner who really, truly feels that the only supplements good enough for her patients are the ones she is selling? You’d probably think she’d been hoodwinked by marketing, and you’d be right.

Here’s the thing, though: you yourself have been hoodwinked by the marketing of the entire “Natural Health” industry. Naturopathic medicine, energy healing, homeopathy, chiropractic, acupuncture, and all the rest are nothing but non-scientific hokum.

Some of it emerged before science had developed sufficient understanding of the human body. Others, like chiropractic, were actually invented in order to make money selling them to practitioners (who were understood to then turn around and use them to take money from patients.) There is no way to learn — and really understand — chemistry and then turn around and believe in homeopathy. Emerging consensus reveals that acupuncture is nothing more than an elaborate placebo.

Recognizing the ethical shortcomings inherent in the sales and marketing of supplements is the first step. The next is the painful understanding that those who sell “education” and “training” to become a “Natural Health care provider” are just as unethical, selling nonsense in lieu of science to people whose disappointments with “regular” (ie, real) medical care leave them vulnerable to the wish fulfillment that is “holistic” care. I’ve written about this before.

It’s important not to confuse the message and the messenger, or rather the material and the teacher. It’s possible, even likely, that the vast majority of natural health practitioners really believe that what they’re doing is legitimate; just like that Naturopath who really feels that her supplements are so much better than cheaper alternatives.

This friend of a friend goes on to give this advice:

Bottom line is this – if you are in the natural health field, or are planing a career in it – choose which side of the coin you want to be on – 1) patient care, consulting, advocating and teaching, or 2) retail, sales, product marketing. Both of these are perfectly fine when apart – it is the mixing of the two that causes my heart to sink.

The existence of the whole “natural health field” is what causes MY heart to sink. I ache for those whose bad experiences with “conventional medicine” — that is to say, medicine — have caused them to look for alternatives. But for anyone looking for a career in the health field, make it a real health field, like nursing or medical school, EMR/paramedic/first responder training, or become a doula or lactation consultant. As for those already there, please take a long, hard look in the mirror, and think about what you are really selling.

Over the years, I’ve been to all kinds of seders: at my home, at someone else’s. I’ve done Seder with a hundred people at synagogue, and six people around my table. I’ve done seder with my family, my children, siblings, friends, and every combination thereof. I’ve had a former nun, and a priest at my seder.

This year, first seder falls on a Monday. (Outside the State of Israel, many people have a full seder on each of the first two nights of the eight-day Passover holiday, the thinking being that outside Eretz Yisrael we can never be absolutely certain exactly when it begins. This way, we’re covered. It also comes in handy for families of divorce, allowing kids to have seder with both parents each year.) DDS had been asking me for weeks what I wanted to do for Passover.  Options included making a seder in our home, traveling to family in another city, or soliciting an invitation from friends.

I didn’t feel like doing anything. Not this year. I’m not sure why. I’ve been a little down lately, and the work involved in pulling together what is basically an elaborate dinner party was just too daunting. I don’t want to do anything this year, I said. Fine, he replied. He made chicken soup over the weekend, and we planned for nothing.

But then the day arrived. And the thought of sitting around watching NCIS while chowing down on a nondescript dinner knowing that virtually every other Jew in the world was sitting around a table with loved ones breaking matzah, blessing wine, making horseradish and chopped-apple-and-nut-relish sandwiches (maror and charoset, known as a Hillel sandwich)…I couldn’t bear it.

So I threw together some matzah balls, made the smallest batch of charoset ever (just one apple and a small handful of pecans, as it turned out I was out of walnuts), and laid it out with some parsley, lettuce, horseradish, and a hard boiled egg on a simple plate. I stirred some salt into water, folded a napkin around three matzahs, got out candles and wine, and just two copies of the Maxwell House Haggadah, and sat down with just DDS. We sang the blessings, lit the candles, drank the wine, told each other the short version of the story of every Jewish holiday (“They tried to kill us; we survived; let’s eat”), and had a delicious dinner together, just the two of us. The matzah balls were exquisite (natch!); DDS made a wonderful farfel stuffing to go with our feast of roasted chicken.

It was different from every other seder I’ve ever been to. Yet in every way that matters, it was pretty much the same. The dry, sandy texture of matzah on my tongue; the crunch of the nuts in the charoset; the wonderful sweet alcoholic grape juice that is Manishevitz Concord Grape. This is Passover. This is freedom. It is sweet, which is good to remember; this night, just like every other night.