The browser is my shepherd, I shall not want. He maketh me lie in green desktop backgrounds: he leadeth me beside the still anti-virus programs. He restoreth my GUI: He leadeth me in the paths of kitties for His LOL’ sake.

Yea, though I walk through the valley of the blue screen of death, I will fear no evil: For Norton art with me. Thy mouse, thy keyboard, they comfort me. Thou preparest a popup before me in the presence of my youtube videos. Thou annointest my RAM with files, my hard drive runneth over.

Surely Google and Facebook shall follow me all the days of my life, and I will dwell in the Tubes of the Internet forever.

Original work by the NinjaBaker.

First off, does it work? You may have noticed that almost every alternative practitioner starts his spiel with reasons why “the medical establishment” (that would be me) doesn’t want you to know about their new super-secret cure-all that everyone in China has known about for millenia. Look, I want my patients to be healthy. Trust me: we doctors can make a perfectly good living simply caring for the manifestations of genetic misfortune (cancers, birth defects, etc) and random happenstance (trauma, infections, etc). We have absolutely no reason to “keep people sick” just to maintain our incomes, so let’s not even go there. Ditto Big Pharma. If they found a cure for cancer, they’d market the crap out of it, make an obscene amount of money curing everyone in sight, then quit making it once it went off patent and they couldn’t keep raking in the bucks hand over fist, and not care one bit when people started dying again.

So does this stuff work? Turns out it doesn’t. Legitimate medical scientists have studied just about every kind of alternative medicine out there quite extensively. The US government has spent billions supporting this research through something called the National Center for Complementary and Alternative Medicine (NCCAM). What kind of results have they gotten? This: every single truly alternative therapy studied does nothing. Got that? Nothing. Nothing at all. That doesn’t stop the government from spinning their non-results, though.

Consider acupuncture, a pre-scientific theory of energy meridians practiced in China before they had access to real medicine (and which, by the way, isn’t even mentioned in current Chinese health care policy). The more it is studied, the more it is revealed to be nothing more than an elaborate placebo. That didn’t seem to stop the Director of the NCCAM from writing:

A systematic review of randomized controlled clinical trials of acupuncture for postoperative pain, published in the August 2008 issue of the British Journal of Anaesthesia, demonstrated that acupuncture had clear value,[emphasis mine] that it decreased pain intensity and lowered opioid side effects.

That journal article was something called a meta-analysis. It was a study of other studies of acupuncture, which included all kinds of different methodologies, surgeries, acupuncture techniques; everything. Furthermore, all they looked at were subjective symptoms like pain and nausea, two things that are notoriously responsive to placebos (and that tend to get better with time after surgery). Here’s the actual conclusion from the article:

Perioperative acupuncture may [emphasis mine] be a useful adjunct for acute postoperative pain management.

Can you say “marketing”?

Why are otherwise savvy consumers taken in by this crap? Several reasons:

• Persuasively misleading salesmen
• Testimonials
• Plain old greed and laziness

In many ways, alternative medicine and its hucksters resemble the deceptive financial practices of the unbridled, unregulated denizens of Wall Street. Junk bonds are the homeopathy of investment banking; derivatives are the acupuncture of the stock market; Dr. Oz is the Bernie Madoff of alternative medicine. Didn’t your broker sound like he knew what he was talking about while going on and on about those new mortgage-backed securities? Just like all that talk about “like cures like”, colon cleanses, and energy fields sounds so scientific! Alternative medicine hucksters and boiler room salesmen both know how to dazzle you with impressive terminology that doesn’t actually mean anything. By the way, there are plenty of “real” doctors and “legitimate” financial advisers who fall for this stuff, and unwittingly perpetuate the fraud. Just because your chiropractor or banker believes in something still doesn’t make it true.

Testimonials are for advertising, not for advising. Just because something happened to one person (if it actually happened at all to the paid spokesperson) doesn’t mean you’re going to achieve the same result. Hey, Bernie Madoff made lots of money for lots of people for many years. Lots of those people were telling lots of other people about him before it all went to hell. Just because your mother’s hairdresser’s cousin’s boyfriend’s roommate won a gold medal after taking glucosamine for his knee doesn’t change the fact that the stuff does absolutely nothing.

Consumers fall for bad financial deals out of greed. Many patients succumb to alternative medicine out of laziness. There is no way to lose weight except by eating less. Fat burners, colon cleanses, and cookie diets that promise quick, easy weight loss are nothing but scams. Elaborate vegetable diets won’t cure cancer. Back pain generally goes away, though it may take three months. Quick fixes that sound too good to be true pretty much always are.

If consumers looked at alternative medicine as carefully as they scrutinized their investments, they’d have a lot more money available for investing.

Good morning, I’m Dr. Dinosaur. What can I do for you today?

Oh, nothing much, Doctor. I’m just here for a physical. I’m perfectly healthy.

Wonderful. So you’re not under medical care for anything?

No, nothing. Unless you count the high blood pressure and the diabetes. Maybe the arthritis. And I suppose the irritable bowel, sciatica, and bursitis are sort of medical conditions.

Sort of. Have you ever been operated on for anything?

No. Wait; does a hip replacement count?

Yes.

Oh, okay. But that’s all. Not including the gall bladder, tonsils, appendix, and c-sections, of course.

Of course. Anything else?

No, nothing. That little thing they took out of my breast last year wasn’t anything.

You had a breast biopsy last year? Was it malignant?

No, nothing malignant. There may have been a little bit of cancer in it, but that’s all.

You didn’t need any further treatment?

Nope. Once they were finished with the chemo and the radiation, I didn’t need any more treatment.

Okay then. Do you take any medications?

No, none. Unless you mean the blood pressure pills and the cholesterol pills, plus the pain pills, the nerve pills, and the pills I take for my stomach. The insulin doesn’t count, does it? I mean, it’s not a pill, right?

You’re right about that. Are you allergic to any medications that you know of?

No, nothing at all. Except that erythro-something makes me vomit, penicillin gives me hives, and I got some guy’s rash from sulphur once.

Whose rash?

Steve someone. Steven Johnson, I think. Something like that. Anyway, once I got out of intensive care from it, I was fine.

I see. Let’s move on; when was the last time you had a period?

Oh my goodness, that was sometime in the 1980s.

Nothing since?

No, not unless you mean the bleeding I’ve had off and on for about a year now. I’d hardly call that a period.

That’s true, though we may have to look into that. Let’s see; we should also address your weight.

Why? I’m only 298.

But you’re only 5′ 2″. 

I’m big boned.

Of course. Is there anything else I should know about you?

Oh no, Doctor. I’m perfectly healthy.

• Nutrition is not taught in medical school.
• Pain management is not taught in medical school.
• Practice management is not taught in medical school.

All three of those statements, and the vast majority of others bemoaning the shortcomings of medical education just because “XYZ isn’t taught in medical school” are right, but oh so wrong.

“Nutrition” is not taught in medical school. What we learn is biochemistry, metabolism, gastrointestinal and endocrine anatomy and physiology. We may not learn “nutrition” per se, but we learn what we need to know to understand nutrition in a more fundamental and comprehensive way than can be gleaned from any course in “nutrition”. This also means we understand nutrition differently — and more completely — than anyone without that same level of medical education can, however much they’ve read about nutrition.

“Pain management” is not taught in medical school. What we learn is neuroanatomy, pharmacology, behavioral psychology, and neurophysiology, so that we have the basic knowledge to understand pain management. Narcotics dosing, epidural steroid injection techniques, rehab protocols and so on are learned in residency. I agree that pain is often not well managed, but not because “it’s not taught in medical school.”

Practice management is not taught in medical school. Why should it? Not every doctor is going to have to manage a practice. Many of them are going to become employees. Should everyone leave medical school knowing how to read an employment contract? Well, yes, but is medical school really the right place to learn that? How about the basics of money management and investing? You should have learned that around the kitchen table from your parents before you started high school. That’s not what medical school is for.

Medical school is where you learn the basics about the human body, its structure and function in health and disease, and the disease processes that afflict it. You learn about the microorganisms that make people ill and the drugs that make them well. And that’s just the first two years. The second two years is when you put those basics to work at the bedside, discovering what all those things you learned the first two years look like in real life. Hopefully by the time you’ve gone through those four years, you’ve decided what kind of physician you want to be, so you can move on to postgraduate (residency) training, where you learn how to do what you need to do. Almost all of the knowledge and skills physicians use in day-to-day practice are learned in residency, not medical school. That’s where a surgeon learns to surge, where OBGs learn to deliver, and where family docs learn everything. Even after training is completed, there’s Continuing Medical Education to help us keep up to date. (There’a also UpToDate.)

Family doctors, internists, pediatricians and all other primary care doctors need training in nutrition. Surgeons, hospitalists, oncologists, and all doctors who take care of sick people need training in pain management. Everyone needs to understand the basics of running a business, including the underlying principle of receiving payment for providing professional services. But medical school is not where these things need to be taught.

Doctors also need to know how to respect others, how to manage their time, even how to wash their hands. Ideally they should know these things long before medical school. If not, they shouldn’t be accepted in the first place.

Most of the hue and cry about alleged med school deficiencies is really a set of straw man arguments made by non-physicians trying to demean medical education because “doctors aren’t taught about this,” whatever it is they’re selling. Don’t but it. By the time you see a doctor, he knows what he needs to know  in order to figure out what’s wrong with you and what to do about it. If not, any deficiencies are not because of things “not taught in medical school”.

Why it wins:

Are you kidding me? Because it rocks! Now I have no choice but to get back to writing.

Well, no; but, yes. The dirty little secret about the relationship between documentation and payment is similar to the concept of the speed limit.

Medicare and other insurance companies do not require that I submit copies of my documentation along with a claim in order to be paid for regular, everyday kinds of services. It’s not hard to see why. They’d quickly become swamped with — and paralyzed by — mountains of paper and/or bytes of data that, for the most part, are completely routine. I’m told that some surgical procedures and perhaps some other specialists do indeed need to routinely include such documentation, but I do not. I’ve gotten requests for documentation for some high-level services (level 5 office visits, which occur rarely), and auto accident claims generally require  office notes to be included. But Medicare generally just processes the claim and sends off the check. Same thing with most of the other insurance companies.

Is it just the honor system that compels me to maintain appropriate documentation? Not exactly. My agreement with Medicare and my contracts with insurance companies do indeed state that I agree to do so, but beyond that I’m pretty much on my own. They do have the right to come in and check up on me after the fact (ie, after they’ve already paid me), so all it really comes down to is the risk of getting caught. All risks can be calculated. In this case, I present the analogy of obeying the speed limit and other traffic laws to medical documentation.

The major variables involved with driving are time and place. I’ve run red lights at three in the morning because I’m exhausted, dying to get home, and just don’t want to wait the two minutes for the damn light to change, and there’s no other car as far as they eye can see. I’ve never gotten caught. On the other hand, I know of a stretch of road not far from my house that’s crawling with police cars and speed traps, especially on Sunday mornings. Zip along at 80 mph and there’s a better than even chance of getting pulled over for a close encounter of the cop kind. Similarly, everyone is familiar with highways where traveling the posted speed limit makes you an actual road hazard as everyone else zips by you five, ten, twenty miles per hour faster.

How do you go about calculating the risks of getting caught fudging medical documentation? Let’s see:

How many people of your acquaintance have ever received a speeding ticket? It’s not rare.

How many doctors do you know who have been audited by Medicare?

Oh, it happens. In fact, President Obama has recently called for intensification of audit attempts to detect theft and fraud. There are all kinds of scary stories out there about bounty-hunting companies incentivized to produce by promises of percentages paid to them. For the most part, though, they’re after the big fish: hospitals, large groups, phantom DME suppliers. Little fish like me, solo docs with less than $20,000 in Medicare billings a year, aren’t worth their trouble.

As a practical matter, while my chances of needing to show those frantic tap-tap-tappings in order to get paid (more likely to keep money I’ve already been paid) are somewhere between slim and none. Don’t get me wrong: my documentation is flawless. Not like certain specialists with their new EMRs who use templates to document out their asses, laughing all the way to the bank. Because if I do get audited and my documentation is lacking, I could potentially end up in jail, though more likely just bankrupt. Either way, I don’t mean to imply that it’s something to fool around with.

The major purpose of medical documentation is medical care. That’s the real reason I keep immaculate records; to reflect the excellence of my care. Protection against litigation is a distant second, with payment issues behind that. I write all my records as if they are going to be pored over by a lawyer, even though it’s very unlikely. Medicare and other payers shouldn’t have any trouble finding what they need, at least according to assorted reviewers who have perused them over the years.

It’s also a little like trying to cheat on your taxes. The chances of getting caught may be small, but the consequences are significant.

So no, I don’t need to write all that to get paid, any more than you follow the speed limit to avoid getting a ticket. You drive safely to be safe. And I write what I need to take care of you.

Here is what antibiotics do: they kill bacteria. (Actually, some of them just stop bacteria from growing, which ends up doing the same thing, since the body will then get rid of the non-growing bacteria on its own. But I digress.) That’s basically all. They have to be absorbed and eliminated, which means some of them can have adverse effects on the GI tract (going in) and the liver and kidneys (going out). Sometimes, like any other foreign substance, they can elicit allergic reactions. Other bad things associated with antibiotics are really the result of them doing what they’re supposed to do, even when we don’t want them to, ie, killing off “good” bacteria normally present in assorted areas of the body. There are a couple of other odd antibiotic toxicities to be aware of (deafness; tooth staining) but killing bacteria is pretty much all they do.

Different antibiotics work differently. Some damage cell walls; some interfere with bacterial protein synthesis; some damage the bacteria’s genetic material. There are many different kinds of bacteria. Some have thick cell walls, which help keep antibiotics out (except for the ones that destroy cell walls); others have different ways of combating antibiotics. The point is that not all antibiotics kill all bacteria. So in order for antibiotics to work properly, you have to:

1. Know what kind of bacteria you’re trying to kill, and
2. Use an antibiotic that will kill that bacteria.

How do we know what bacteria we’re trying to kill? Bacteria are very small. We can identify them, but only if we have a lot of them to work with.  So what we do is take a sample of the infected material and incubate it under whatever conditions it takes for the bacteria to grow, then examine the colonies to figure out what kind of bacteria was in the original sample. This is called a culture. Once we have a lot of the bacteria around, the other thing we can do is divide them up into several little groups and subject each group to a different antibiotic. This way we can actually see in the lab that a certain antibiotic kills the bacteria from the patient. This is known as bacterial sensitivity testing.

Therefore ideally, every infection would be treated by taking a culture, identifying the bacteria, and testing it against different antibiotics so the patient can be treated with exactly the right one. It’s a little more complicated, of course, because different antibiotics penetrated different parts of the body to different degrees. There are also various routes; some antibiotics can’t be given orally; others can be given any which way (intravenously, jabbed into a muscle to be absorbed into the bloodstream, even injected directly into the spinal fluid surrounding the brain). However it goes in, though, it has to be able to get to the bacteria, and then kill it.

What if the patient is too sick to wait until we’ve gone through all that rigamarole to begin treatment? In that case, we look carefully at the likely source of the infection (lung/pneumonia, gut/diverticulitis, brain/meningitis, etc), weigh other patient-specific factors (age; travel; recent hospitalization or institutionalization; is the patient’s immune system intact?) plus other random circumstances (time of year; geography; known bacteria causing other acute infections in the community) and come up with an educated guess about what bacteria is most likely to be causing the problem. We call this empiric therapy. Note that after beginning antibiotics empirically, it’s still important to obtain a culture in order to confirm that the guess was indeed correct, and that the chosen antibiotic is indeed capable of killing the observed bacteria, especially if the patient is very sick.

Empiric therapy is often used without obtaining a culture, at least in primary care. There’s nothing wrong with this in principle, but you still have to know what you’re doing: using antibiotics to kill bacteria.

What about “preventing” infections with antibiotics? No such thing. If there are no bacteria, then there’s nothing (good) for the antibiotic to do. The use of “prophylactic” or “preventive” antibiotics technically applies to situations where there may be some bacteria involved (as in surgery, or  a contaminated wound), and if there’s an appropriate antibiotic around to kill those first few, they won’t grow into a full-fledged infection. This is one of the most misunderstood aspects of antibiotic management. If I had a nickel for every patient who insisted on having an antibiotic “so my cold won’t go into pneumonia”, I’d be rich beyond the dreams of avarice. There are very specific guidelines for prophylactic antibiotics; not that they’re followed as well as they should be. Sometimes it seems like the favorite words of every ER doc and pediatrician are, “Just in case.”

So the correct way to treat bacterial infections when you can get a sample of infected material (urine, in the case of a bladder infection, for example) is to send the culture and begin treatment with an antibiotic known to kill bacteria commonly causing the infection. If the culture shows that the bacteria happens to be resistant to whatever antibiotic you chose, it should be stopped (since it’s not killing the bacteria that are there) and the patient switched to one of the antibiotics that do kill their particular bacteria, according to the sensitivity report. This is why the commonly heard sentiment, “Isn’t it dangerous to stop an antibiotics before finishing the course?” makes no sense at all. It’s important to take an antibiotic long enough to kill all the bacteria causing the infection. After that, it’s useless.

What about when you can’t get a sample of infected material? Or, more likely, when obtaining the sample is far more involved, invasive, or expensive than the condition warrants. That’s when you have to go with your best guess, taking into account as many factors about the patient and the disease (the who, where, what, and when) as you can. References like the Sanford guide are invaluable in these cases.

What if a patient doesn’t get better with antibiotic treatment? There are several possibilities.

Sometimes the doctor has chosen the wrong antibiotic (one that isn’t effective against the patient’s bacteria.) Sometimes the patient’s bacteria is resistant to the antibiotic (even if other versions of the same bacteria are susceptible to it.) Note that these two things are not the same. Sometimes the dose wasn’t high enough. Sometimes the antibiotic can’t get to the bacteria (say, if it’s destroyed in the stomach and should have been given by injection instead of by mouth.) Sometimes the patient never took the antibiotic. It may have been too expensive, or the pills were too big, or they were too scared of the potential side effects.

Most frequently, thought, the patient didn’t have a bacterial infection (often not an infection of any kind at all). Why is it so hard for people to understand that you need an accurate diagnosis if you’re going to expect any kind of treatment to make you better? Viral upper and lower respiratory infections (colds, sinus infections, bronchitis) are almost always caused by viruses, not bacteria. Green mucus is caused by myeloperoxidases in white blood cells, not bacteria. It means nothing! Unnecessary antibiotics represent billions of dollars of wasted healthcare money every year.

Aside from the money, though, what’s the big deal about unnecessary antibiotics? “Isn’t it better to be safe than sorry?” I hear patients say all the time, to my eternal discouragement. “What’s the harm?” they ask.

There’s plenty of harm to be had from antibiotics, even when used correctly. Aside from nausea, vomiting, diarrhea, and other assorted direct adverse effects, the major harms are from allergic reactions, from killing off the body’s normal bacteria, and the emergence of resistant bacteria (that is, bacteria that cannot be killed by antibiotics).

Up until a few years ago, the phrase “resistant bacteria” made the eyes of everyone who wasn’t a doctor glaze right over. Now all you have to say is MRSA. Methicillin (or multiply) resistant staph aureus, also incorrectly called the flesh-eating bacteria is all over the news. I admit it’s gotten a tiny bit easier to talk patients out of unnecessary antibiotics by saying, “This causes MRSA, you know.” Resistant bacteria are a real danger because eventually a bacteria will emerge that cannot be killed by anything. That’s scary.

True allergic reactions to antibiotics are relatively rare. Still, they can be catastrophic. You can die from an allergic reaction to an antibiotic. If you have a life-threatening bacterial infection, that may seem like a reasonable risk to take. When it’s not actually necessary, not so much.

Perceived “allergic reactions” are actually more of a headache than real ones. Hives, throat swelling, and dropping your blood pressure to the point of collapse are signs of potentially dangerous allergic reactions. “I don’t know. Something happened when I was a baby and my mother said I was allergic to penicillin,” is the usual story behind far too many antibiotic “allergies”. According to UpToDate, as many as 85-90% of patients stating they were allergic to penicillin did not show true allergy upon appropriate testing.

Then there’s the problem of “cross-reactivity” between penicillin and another class of antibiotics called cephalosporins. Although the figure thrown around from med school onward is that 10% of people who are allergic to penicillin will also be allergic to cephalosporins, actual research shows it to be significantly less. In fact, only 2% of patients confirmed penicillin allergic by skin testing will actually react to cephalosporins.

What happens in real life, though? Anyone who says they’re allergic to penicillin (90% chance they’re not) is also immediately removed from consideration for treatment with cephalosporins, which just happen to be the drug of choice for most small minor skin infections, even though there’s only about a 2% chance of a problem. Putting those numbers together means that someone who says they’re allergic to penicillin has only a 2 in 1000 chance of reacting to a cephalosporin. So instead of a cheap, effective antibiotic, most of them are given clindamycin, a drug notorious for causing antibiotic-associated colitis (by killing off good bacteria in the lower bowel and letting dangerous bacteria proliferate unchecked), which can be fatal.

To sum up:

• Antibiotics kill bacteria.
• If you don’t have a bacterial infection, you should not be taking antibiotics.
• Appropriate antibiotic therapy consists of the right drug for the right reason at the right dose for the right time/duration, and no more.

Why is it easier to talk about quality of life with patients who are dying? Why don’t we factor these considerations into the decision-making for patients with conditions that aren’t fatal?

The presence of a terminal illness serves to focus everyone’s attentions. Widespread cancer metastases? Concerns about tight blood glucose control fade away. End-stage liver disease? Blood pressure control doesn’t matter so much any more. Bony pain from prostate cancer? Narcotic and sleeping pill addiction doesn’t even occur to anyone. I find it far more problematic to deal with patients with debilitating but non-fatal conditions when treatment options are perceived as limited because of co-existing diseases that produce so-called contraindications to certain medications.

I have a patient in his mid-70s with severe pain from osteoarthritis. Several fractures and a couple of unsuccessful joint replacement surgeries haven’t helped matters. Several years ago he found that a little drug called Vioxx worked extremely well for him, reducing his pain considerably and allowing him to do pretty much watever he wanted. As we all know, however, that drug was pulled from the market because of an unacceptable increased risk of heart attacks and other untoward cardiovascular events. Interestingly, one other drug (Celebrex) from the same medication class (COX2 inhibitors) remains on the market. However because of this gentleman’s diabetes, high blood pressure, high cholesterol (all treated to acceptable guidelines, as it happens) and age, all the red flagged warnings about increased cardiovascular risks go off if I were to try prescribing it for him.

Actually, most other doctors would probably make the unilateral determination that the risk from this medication class outweighs any potential benefit, and would therefore not even broach the topic with the patient. I disagree (surprise, surprise!) Here’s why:

“Risk” is an abstract concept. Having a risk factor for a disease or condition is not the same thing as having it, or even a modified or mild version of the condition. Right up until the moment the brain of an un-helmeted motorcyclist splatters across the pavement, he’s feeling just fine. This is also why diabetic hypertensive smokers with cholesterols of 300 walk around obliviously content to continue stuffing their faces with Big Macs. Discomfort with risk is purely emotional, and is a function of one’s perception of the risk. This is why doctors can seem more uncomfortable than patients about certain courses of medical treatment. We know more about what can go wrong, so there are times that we really fear for our patients, for whom ignorance can be quite blissful. It’s like when  little kids barge into a busy street, only to have their mothers freak out as they haul them back. The kid has no idea why Mom’s so upset; he’s just fine.

In this case, though, we have a patient for whom a particular medication holds a real chance for significant improvement in quality of life despite a known, documented increased risk of an adverse cardiovascular event. Why don’t we factor quality of life considerations into the decision-making for patients who aren’t dying? The RISK of a heart attack is not the same as a heart attack. Whose comfort level with risk is more important here, the doctor’s or the patient’s?

I explained all this as best I could to the patient, providing him with various educational materials and information online as well as handouts from my office. I also included prescribing information for Celebrex, complete with all the warnings. Obviously a significant risk issue is medicolegal on my part. But I’ve known this guy long enough, and I plan to explain (and document) out my ass to make sure he understands the trade-offs here. Bottom line is that I offered him a prescription if he wants it. (By the way, he’s currently taking OTC naproxen for his pain, a drug with exactly the same cardiovascular risk profile, but not nearly as much bad press as the COX2 inhibitors.)

What happens if (hopefully when) I try actually writing the prescription, though? First, his pharmacy benefits manager will likely require prior authorization. (Why can’t he use cheaper meds? Because they don’t work well enough.) Second, a pharmacist will probably call and tell me that the drug is contraindicated in the elderly because of increased cardiovascular risk. True. But what we have here is a case where guidelines conspire to keep someone miserable. Shouldn’t the patient be the one to decide if he wants to live ten more years as a crippled invalid, or risk maybe five more while living his life the way he wants?

Take home message: Here in the trenches of primary care, “quality of life” doesn’t apply just at the end of life. It’s something we have to help our patients consider every day.

It has a lab.

Hat tip to LC

Approximately eight inches high, it feels like it’s made of bronze. Can’t you almost hear them playing, “Maoz tsur*…”

There you have it. Another Hanukkah; another eight nights; another eight menorahs. Until next year everyone. Happy Hanukkah!

* “Rock of Ages” in Hebrew

Edited to add this year’s everyday menorah all lit up for the Eighth Night:

Here’s hoping everyone had a lovely holiday.