Posted by: notdeaddinosaur | February 4, 2014

In for the Long Haul

Comment in relation to the new house:

Do you mind telling your legions how long you intend to work?

Certainly. The short answer is, “Indefinitely.”

The more detailed answer (technically, the answer to “Why do you answer that way?”) has two parts:

First: I love what I do. Just about every part of it. I love it. I wake up eager to get to work each morning. Being continuously on call is an opportunity, not a chore. I love my office; I love my staff; I love what I do. Why would I ever want to voluntarily stop doing it?

Second, and the reason for the first: I love my patients. Well, most of them…no, pretty much all of them. Some drive me a little nuts, but the ability to (mostly) meet their needs, whatever they may be, is about as fulfilling as anyone could possibly imagine.

Is everything really all unicorns and rainbows at work? No. It’s been a real struggle financially of late; so much so that I’ve thought long and hard about various ways to address the issue. Sell the practice and become an employee of one of the competing local health systems? Take another job (or two; or more) at a nearby Urgent Care? Go concierge or direct pay? All those options and more have come under consideration, and all have been discarded.

Taking another job would mean being unavailable to my patients while I’m there. Selling my practice would be a nightmare for them. Many have come to me to get away from the huge practices that keep hiring more people for the “team” to supposedly help the doctor take care of them, but who in reality just serve as more layers between them and the doctor.

Switching to a concierge or direct pay model would be a betrayal to those patients who can’t afford to see me without insurance. I’ve hung in there this long; I have no plans to change that just yet. If more of the country moves toward direct pay, I may very well reconsider. But it has to be okay with my patients. They are and always will be my first priority.

I saw a new patient the other day who was totally charmed by me, by my practice, by my perseverence in getting a medication approved for him from his drug plan (quite an adventure, let me tell you.) He asked, as many patients have, the not unreasonable question to someone in their fifties, “You’re not going to retire any time soon, are you?” I replied without hesitation, “Nope. I’m not going anywhere.”

I am in a long term relationship with my patients. I’m not going anywhere anytime soon.

Except to a new house. Stay tuned.

Posted by: notdeaddinosaur | January 27, 2014

Building a House (4)

Foundation:

photo (5)

I guess that should be, “Foundation and Snow” (with apologies to Asimov fans.)

Posted by: notdeaddinosaur | January 19, 2014

Building a House (3)

House -3- Footings

Footings, the beginnings of the foundation. Here’s a closer view:

Footings - closeupHere we go…

Posted by: notdeaddinosaur | January 16, 2014

Building a House (2)

Hole in the groundPicture from 12/31/13.

We have a hole in the ground. Clearly, this means the permits have been obtained. First session at the design center in a few weeks. Stay tuned.

Posted by: notdeaddinosaur | January 15, 2014

Cleaning up for the Cleaning Lady

A good friend has waxed poetically indignant about why his wife (all three of them, actually — don’t worry: sequential, not contemporaneous) insists on “cleaning up for the cleaning lady.”

His points appear valid. The cleaning lady is being paid to clean. Why bother with preparatory cleaning? The principal hypothesis seems to be that she (and by extension, all women who clean before the cleaning lady arrives) is worried that the cleaning lady will think she is a bad housekeeper.

Um, no. We don’t give a rodent’s patootie what the cleaning crew thinks of us. Well, I don’t, at any rate. Here’s what’s really going on:

The confusion is partly semantic. I do not “clean” — as in “remove dirt” — before the cleaning lady arrives. What I do is pick up, straighten up, and put stuff away, even though it might be referred to as “cleaning up”. There are two significant (and perfectly valid) reasons why I and other women do this:

1. It makes life easier for the cleaning lady, who is being paid to come in and actually remove the dirt from floors, furniture, windows, etc. It’s much quicker for her to vacuum if the floor is clear, dust if there’s not a ton of junk all over tables, and so on. Since many cleaning people are paid on the basis of time, arranging the home so that she can get her work done more quickly can be significantly more economical.

2. I clean up for the cleaning lady so I can find things after she leaves. Listen, it’s hard enough for me to find stuff even when I’m the one putting it away. FSM only knows where she thinks they ought to go.

Now I will admit to a little bit of “chore ADD”. As in, Hey, now that the coffee table is clear, I really should dust it. In that sense, I will admit, it takes a little self-control to recognize that you’re paying someone to do that. (Even if you think you’re saving them time, you’re not. They’re going to do it again anyway.)

But “cleaning up for the cleaning lady” is a perfectly sensible thing to do.

Posted by: notdeaddinosaur | January 11, 2014

Alarming the Herd

As I have previously mentioned, I am building a house. It’s in a very nice little development that will have just over a hundred houses when it’s finished. One of the things that comes with each house is a complete security system, however it’s up to the homeowner to activate it…and pay for the ongoing  monitoring.

I’m toying with the idea of not activating the system. Here’s my reasoning:

Every other house in the development will have an alarm, therefore the chances are overwhelming that a burglar choosing a house at random will encounter a security system. Presumably this means he will be promptly caught, or, preferably, run away and never come back. There is less than a 1% chance that the house he happens to pick will be mine. Therefore I can rely on my neighbors’ alarms to de facto protect me.

Alarms don’t always work of course. Houses with security systems are robbed every day. Nothing is 100%. Anyone who really wants to get in is going to be able to do so, if they’re smart enough and determined enough. Still, no one can deny that the presence of an alarm is a reasonable way to lessen your chance of being targeted.

But what would happen if someone got up at a meeting of the homeowners association and started spouting off about the evils of alarm systems. Don’t we realize that the monitoring company uses the system to eavesdrop on us? We should all purge our homes of this terrible technology. (Maybe she just happens to be selling a proprietary electonic cleanse for houses.)

Think about what would happen if people began listening to her and disconnecting their alarms. Once about 10% of them were off, we may start finding an increased number of break-ins. If the number fell as low as 50%, the place could become a crime magnet, since a burglar would have a 50-50 chance with any given house. Disaster!

It occurred to me that this is just like vaccination and herd immunity. When everyone else around you has been vaccinated against a given disease, germs trying to enter the community can only find homes prepared to rebuff them. When people start skipping it — counting on their neighbors to protect them — that protection quickly disappears.

Objections to vaccination make even less sense than arguments against security systems. Not only does it make sense both to immunize your kids and to activate your security system, it is your moral obligation to your community.

 

 

Posted by: notdeaddinosaur | January 9, 2014

Just Because Everyone Says So…

Truth is not a matter of concensus. Lots of people used to believe the earth was flat and that the sun revolved around it. Sadly, many people continue to reject the concepts of evolution, germ theory, and even historical realities like the Holocaust and the moon landing. None of this makes any of these things less true.

To no one’s surprise, similar stuff is on the morning news. Yesterday morning, my local CBS affiliate breathlessly told of a woman with a Facebook petition trying to get artificial coloring out of M&Ms because she felt they were making kids hyper. She’s already got over 100,000 signatures.

*sigh*

As if that weren’t bad enough, though, at the end of the report the anchors ad libbed along the lines of, “Of course it’s the sugar that makes kids hyper.”

*exasperated sigh*

It’s actually been shown — over and over — that sugar does NOT influence children’s behavior.  Even Dr. Oz, who has gone over to the dark side on so many other things, has gone on record against the sugar-behavior connection. Yet there it is again on the morning news.

Kids are hyper because that’s what they do. Young mammals are full of energy. Ever see puppies playing? Actually, youth probably doesn’t really have “more” energy than other ages. It’s just released in more intense spurts. Young children run hard during the day (ideally with a nap or two, of course) and then conk out solidly for the night (despite parental laments.) There’s a kernel of truth behind the cliche “sleeping like a baby.”

It’s not the artifical coloring. It’s not the sugar. Kids are hyper because kids are hyper. I just wish the news would stop spreading nonsense already.

For totally made up, fact-free reporting, we always have the weather girl.

Ed: That last line is totally intended as a joke. Katie is awesome. Then again, how do YOU like it when your hard work is denigrated by so-called “popular wisdom”?

Posted by: notdeaddinosaur | January 7, 2014

Electronic Detox

Ah, New Years. Resolution time. Time to start that diet, begin that exercise regimen; time to get healthy. Yay!

All too often, that “get healthy” thing includes the purchase and consumption of assorted vitamins, minerals, and other supplements. And how better to get started than to “detox. Ah, detox, the scam of scams. Science Based Medicine has a great article about how it works (the scam, not the detox, which does nothing.) I heartily recommend reading it (here). The interesting irony is that your body sees all those new unnecessary vitamins and supplements as actual toxins, and handily disposes of them without you even knowing.

Reading about detoxification and New Year’s resolutions made me think about another kind of cleansing. What if we all took this opportunity to clean up our electronic “bodies”?

Prune that Facebook friend list. Go through those bookmarks and delete anything you haven’t clicked in the last year. Edit that blogroll. (Note to self: take own advice sometime.)

Think about the people in your life. Make more of an effort to reach out to those who nourish you, even if it takes a little extra effort. But consider not going out of your way to respond to people who just bug you; you know, those who are “toxic.”

Now that’s a detox I can get behind.

Posted by: notdeaddinosaur | January 5, 2014

Bare Bones Baking

Less than a month. That’s how long I made it without baking.

Six months isn’t that long, I told myself. I can go six months without baking. There’s virtually no room in my new (temporary) kitchen:

Ktichen Now

especially compared to what I’ve had since 1985:

Kitchen Then

Off into storage went all my baking gear: pans, mixer, food processor. I did bring my ingredients with me: 

Spare pantry

 

There they are on the top two shelves. The bottom shelf contains my cleaning supplies, and the shelf above that is my linen closet. (Here’s what is currently labelled “linen closet” on the apartment’s floor plan:)

Pantry Now

But on a cold winter morning complete with icy rain, I found myself craving something baked. Not just to eat, but to make: measuring, stirring, pouring…and of course licking out the bowl. But what to make? I perused my latest non-ccokbook cookbook, Ratio, for inspiration. Pancakes? No griddle. Coffee cake? No pans (and way too treacherous to venture out and purchase any disposable version, which had been my backup plan.) Biscuits? No rolling pin, no board. (Sure, there are granite countertops, but there’s no way to clean up the stuff that would fall down next to the stove and the fridge.) Muffins? No tins. But wait! My new favorite cookbook mentions that they can also be baked in a loaf pan. Substituting in brown sugar and adding cinnamon and cloves yields:

Brown Sugar Cinnamon Muffin LoafBrown Sugar Cinnamon Muffin Loaf

And voila, a lovely breakfast for a cold winter morning:

Breakfast

 

 

Posted by: notdeaddinosaur | January 4, 2014

The Magic of Tincture of Time

A patient came to see me the other day for a physical.

Anything bothering you? I ask.

Nope. Oh, a few days ago I had a lump on my arm. Didn’t bang it or bruise it or do anything to it. There was just this huge lump. I was going to call you about it, but it went away after a couple of days.

That’s nice.

If it ever comes back, I’ll be sure to call you.

That would be great. I’d love to see it.

 

Posted by: notdeaddinosaur | January 3, 2014

Dipping a Toe into the Homeschooling Debate

There’s a piece going around on Facebook; a link to this blog post by a guy named Matt Walsh about home schooling, specifically about a ridiculously misguided piece of legislation (since withdrawn) proposing that all homeschool parents undergo background checks and social services investigations. I find myself wanting to respond more extensively than would be possible in a comment trail.

Let’s start with where we agree: the legislation is outrageous. Homeschooling parents should not be singled out because of their choice to educate their children at home. Most people who homeschool their children are intelligent, conscientious, caring, and are not trying to cover up blatant child abuse.

However I do have issues with some of his other points. It starts near the top:

…[W]e don’t have any rights at all if we don’t have the unquestioned and absolute right to teach and raise our own children.

No sir. You do not have any “absolute” rights to your children. They are not your chattel. They are citizens of this country, entitled to the same protections as any other citizen. They also have the right to an education, which is where much of the kerfuffle ensues. What “should” a child be learning? Obviously each homeschooler’s answer to that is, “What I’m teaching them.” It turns out that even outside the realm of the homeschoolers, the “ideal curriculum” is a chimera. There’s ridiculously little agreement on what people, let alone kids, should know. It’s no wonder that local school board meetings are so contentious.

The vast majority of parents love their children, and take very seriously the job of seeing to it that they are protected, cared for, and educated. Nevertheless, the rest of us/society/the government have an obligation to watch out for those (hopefully) few children whose parents aren’t up to the task. This surprisingly thankless job has been relegated to the poorly paid field of Social Services, whose failures never fail to make the front page, and whose successes are invisible to the general public. As they should be. But just because you never hear about these overworked, underpaid professionals when they do their job right does not mean that they don’t serve a vital role in our society.

Here’s a question for all you homeschoolers: What constitutes “educational abuse”? Would you recognize it if you saw it? What would you do about it if you did? And don’t go trying to tell me it never happens. That’s just naivete on your part.

What about the kid who wants to be a doctor, but whose parents refuse to teach him anything but creation science because anything else “conflicts with our religious beliefs.” Does that count?

Oh, but none of you would do that, would you. Nor take your kids out of school so your boyfriend could beat them to death. Oh no. It’s just “other people” who do that. The problem is that you can’t always tell who “the others” are.

Imagine the following scenario: A father regularly brings his three homeschooled sons to the library. They don’t go to your church, but they do go somewhere; they’re good, God-fearing folk, just like you. You frequently exchange pleasantries with them. You’ve never seen the mother, but that doesn’t seem strange. She’s a busy home-schooling mom, probably grateful to Dad for taking them out so she can get stuff done around the house. One day you notice that there are only two boys there. No biggie; kids get sick. Except that when the father takes the 8-year-old to the bathroom, the 10-year-old mentions that the 11-year-old isn’t there because he’s being punished. That’s okay; withholding a privilege is reasonable. Except then the kid tells you it’s because his brother was caught teaching his sisters to read. Turns out there are four little girls at home as well, whose “home schooling” consists entirely of cooking, cleaning, and other “womanly arts.” Dad doesn’t believe girls need to know how to read or write. Mom can’t read very well either. Dad hits her when he catches her sneaking a look at the newspaper.

What do you do?

In Matt Walsh’s world of “Family Sovereignty” those kids are shit out of luck.

I am NOT saying that government always gets it right. And one manipulative homeschooling parent is not an indictment of homeschooling by any means. The default assumption should always be that everything is fine, but circling the wagons and refusing to cooperate with any government effort to “check in” on homeschoolers is similarly unhelpful. Some may say it makes you look like you have something to hide.

Just because you’re not abusing your kids, and just because the “system” is flawed doesn’t mean we don’t need it.

Posted by: notdeaddinosaur | January 1, 2014

The End of Sibling Rivalry

Growing up with sisters felt like living in a snake pit of estrogen. Though we’ve all mellowed with the decades, there are still times we tend to, shall we say, rub each other the wrong way. That all ended a few weeks ago.

One of my sisters was visiting along with her husband and young daughter. As a treat, I made pancakes for breakfast. I should mention that not only do I make them from scratch (recipe memorized), my stove has this really cool griddle module. No greasy frying pans tipping unevenly, yielding spotty/burnt elliptical pancakes, no sirree. Of course there is also an art to flipping them. Knowing just the right time to slide that spatula under, the quick wrist pronation, and voila.

As I was demonstrating my technique for my niece, I wanted to ask my sister if she used a griddle to make her pancakes. So I asked, “Has your daughter ever seen pancakes like this?”

My sister regarded the batch on the griddle and said, “Perfect? No.”

My heart stopped. Then it filled with love. That was hands down the nicest thing my sister had ever said to me. (Possibly the nicest thing she will ever say to me, but I’ll take it.)

Posted by: notdeaddinosaur | December 14, 2013

Not Enough Guns

Ho hum; another school shooting yesterday.

At least we’re moving in the right direction. No one was killed except the shooter. I’m sure the two students he shot will be fine. So will all the other kids, once they get over their PTSD. Who cares how long that will take; at least they’re alive.

According to the unassailable logic of those stalwart proponents of the Second Amendment, the more guns we have, the safer we’ll be. Therefore the occurrence of another shooting simply means we don’t yet have enough of them.

And don’t believe anything from this site. It’s nothing but liberal propaganda.

As for the 9,900+ people killed since this date last year — oh, yeah; didn’t something happen in Connecticut then? School called Sandy Hook, I think? Anyway, if only we’d had more guns, maybe the carnage would be abating by now.

Oh well. Rest in peace.

 

Posted by: notdeaddinosaur | December 12, 2013

Street Names for Drugs You’ll Never Find on the Street

New game to play with your pharmacist friends: coming up with street names for prescription meds you’ll never find on the street.

RULES: nothing that already has a street name or has any street value at all. That’s the joke. Nothing addictive, no benzos, no narcs.

Here’s what I’ve come up with so far:

  • Moxies: Amoxicillin (of course)
  • Vixens: Plavix
  • Lippi-loos: Lipitor
  • Zacs: Prozac
  • Pissers: lasix
  • Dynamite: nitroglycerin (duh)
  • Lexies: Lexapro
  • Throids: assorted versions of levothyroxine (*love* this one)
  • Z-pack: Who are you kidding? It is a street name.

To be edited as I think of more. Feel free to add in the comments.

Awesome additions from the comments:

  • Snorts – fluticasone
  • Brownies – Senna
  • Bleeders – warfarin, heparin, and high end friends
  • Puffles – inhalers, all types
  • Chalk – calcium carbonate

Thanks, Alexis.

  • Floxies – any of the fluoroquinolones [LOVE this!]
  • ‘Zide – hctz
  • Runners – fleet enemas or supps of all varieties
  • Slow b’s – beta blockers

Well done, Medstudentitis.

Posted by: notdeaddinosaur | December 6, 2013

I Think of Nelson Mandela Every Day

Have you read Playing the Enemy, John Carlin’s biography of Nelson Mandela? If not, I highly recommend it. I read it about two years ago, and found it both interesting and moving.

One thing that stuck with me was the following: every morning, the first thing Mr. Mandela did upon arising was to make his bed. Twenty-seven years in prison on Robben Island, where he slept on a pallet with nothing more than a thin blanket, still each morning, he would make his bed. Every morning after that, as President of South Africa, Nobel Peace Prize winner, and everything else this wonderful man accomplished in his long, influential life, the first thing he did upon arising was to make his bed.

I make my bed every morning. Always have. And as I do it, I think of Nelson Mandela. As I pull up the sheet, straighten the blanket, bedspread, and pillows, I think of his pallet and thin blanket. Sometimes I marvel at his forbearance, his fortitude, his intellect (I wouldn’t have been able to learn Afrikaans), all that kept him going through 27 years of captivity.

I think about his strength of character and generosity of spirit, all on display as he pulled South Africa away from apartheid, trying to guide his country toward equality. I think of him as a sports fan, using athletics to unite his people. I remember the movie Invictus: Morgan Freeman, hand-picked by Mandela to play him, and Matt Damon, a physically small man portraying a large rugby player (so well!)

As I make my bed every day, I try to imbue the menial task with mindfulness, thinking of Nelson Mandela.I will never lead a country. I will never win a Nobel prize. I am not great.  But perhaps I can be a little more like him today, I think. All I can do is try.

Some mornings when I’m rushed or tired, the thought may cross my mind not to bother making the bed right then. But then I think that if Nelson Mandela can make his bed every morning, so can I. The only thing different from now on will be, “If Nelson Mandela could make his bed;” past tense.

May his brilliant soul rest in eternal peace, and may his memory always be a blessing.

Posted by: notdeaddinosaur | November 28, 2013

Thanksgiving Prayer/Quiz

We give thanks to you,

  • A. Almighty God
  • B. Adonai
  • C.  Goddess of the Earth
  • D. My Higher Power
  • E. Dumb, stupid, blind luck
  • F. All of the above

as we sit here surrounded by

  • A. Family
  • B. Friends
  • C. Children
  • D. Parents
  • E. Spouses
  • F. All of the above

We are profoundly thankful that we all have

  • A. Enough to eat
  • B. A roof over our heads
  • C. People who love us
  • D. People whom we love
  • E. All of the above

May the coming season be filled with

  • A. Love
  • B. Laughter
  • C. Health
  • D. Happiness
  • E. Short checkout lines for holiday shopping
  • F. All of the above

and may we always remember

  • A. Those who are less fortunate than ourselves
  • B. The brave men and women of our armed forces
  • C. The Holocaust
  • D. Where we put our keys
  • E. All of the above

And let us say:

  • A. Amen
  • B. Omein
  • C. Blessed be
  • D. Let’s eat
  • E. All of the above

Happy holidays to all!

Posted by: notdeaddinosaur | November 27, 2013

Two More Days? Really?

Hey WOGL FM in Philadelphia:

You almost did it. I was so pleased to be able to switch back to you when hearing all that ridiculously premature yuletide crap on other stations. Not my ‘OGL. Not them. No sirree. They could wait.

But you couldn’t. Two more days! Really? You couldn’t manage to wait just two more lousy little stinking days to join the onslaught of Christmas music, could you.

I gnash my teeth at you.

Oh well. Since I only listen to you in the car going to and from work, I don’t have to tune in again until Monday, when at least it will be December.

Happy Holidays!

 

Posted by: notdeaddinosaur | November 9, 2013

The Most Cherished American Right

Dr. Bob Centor has a nice piece today on paternalism. I like the way he reviews the various permutations and varieties of the concept. Reading it, I found myself continually reminded of something I’ve been saying for a long time:

The most cherished American right is the right to be stupid.

Americans have the right to smoke. In many states, they have the right to operate motorcycles without wearing helmets. American patients have the right to refuse lifesaving medical procedures, including vaccination and chemotherapy for curable cancers. Attempts to prevent people from being stupid are decried as “paternalistic” applications of the “nanny state.”

Many will say that one man’s stupid is another’s free choice. Assault weapons, health insurance, and fast food consumption come to mind.

They’re right.

Voting for shameless liars against one’s own best interests is also our “right.” Red state hypocrites who take many more federal dollars than they send to Washington are also allowed to spew forth whatever they want in their gerrymandered districts. It’s called Freedom of Speech. But they’re also allowed to gut school funding to flush science and history education down the toilet in order to limit any critically thought out response.

The real problem with the right to be stupid is that people who are smart are allowed to manipulate the system to enrich and/or empower themselves. Money is not speech, and yet it managed to purchase one of the worst Supreme Court decisions in recent memory.

Many things in this country are profoundly stupid yet completely legal. The scary thing is that by and large, those who founded our nation were actually pretty smart. Maybe they were under the erroneous impression that future generations would continue to value intelligence, instead of parsing their work to allow the nascent republic to descend into its current sorry state.

I repeat: The most cherished American right is the right to be stupid.

Posted by: notdeaddinosaur | November 7, 2013

Building a House (1)

Making the decision to downsize isn’t easy; except when it is. When the last kid moves out, and when all of them make it excruciatingly clear that vague parental fantasies of an eventual multigenerational household are *so* not going to happen, and when you find a house that makes you go “Wow!” Well, that’s not a hard decision.

Fixing up the old house to sell is a time and effort-consuming endeavor, crowding out usual activities like blogging and writing. But once it’s done, the results are worth it. Papers signed with the listing agent last week; deposit put down on the new place the next day.

And here it is:

photo (3)

That’s DDS standing just in front of the fireplace (we think).

More to come as we progress.

Posted by: notdeaddinosaur | October 28, 2013

Foxes and Guidelines for Guarding Henhouses

I am furious.

For anyone hiding under a rock the last year or so, the latest recommendations about prostate cancer screening have changed from earlier iterations of “screen everyone with a prostate with a PSA (prostate specific antigen, a blood test) and a DRE (digital rectal exam, where the “digital” equipment referred to is a finger) every year” to DON’T DO IT AT ALL.

The United States Preventive Services Task force reviewed the literature and came to the conclusion that routine prostate cancer screening does more harm than good, and should not be done. Hear the emphasis on ROUTINE. In men with a urinary problem suggestive of prostate cancer, certain men with worrisome family histories for the disease and so forth, the above does not apply. We’re talking about blindly screening all comers. And the bottom line is: Don’t.

Screening is to be offered to patients in the context of “shared decision making,” involving a detailed discussion between doctor and patient about the pros and cons of screening (generally PSA testing).

Great. No problem.

Here’s the thing, though: I just had a patient come back from a urological consult for a problem that had nothing to do with the prostate (again) with an order for a PSA. Oh, I said. Did you have a detailed discussion with the urologist about the pros and cons of PSA screening for prostate cancer?

No.

What did the urologist say to you?

Answer: “He said that there were no urologists on the panel that made that recommendation.”

WTF??!?

It’s a non sequitur of an ad hominem, perilously close to the barely disguised antisemitism that  discounts evidence of any medical advantages of circumcision.

But it’s the urologist’s hypocrisy that infuriates me the most. If he attributes the negative recommendation to the lack of urological involvement in the guidelines, perhaps he should check out HIS OWN SPECIALTY’S GUIDELINES:

Guideline Statement 1: The Panel recommends against PSA screening in men under age 40 years. [emphasis mine]

Guideline Statement 2: The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk. [emphasis mine]

Guideline Statement 3: For men ages 55 to 69 years the Panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the Panel strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man’s values and preferences. [emphasis mine]

Guideline Statement 4: To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce overdiagnosis and false positives.

Guideline Statement 5: The Panel does not recommend routine PSA screening in men age 70+ years or any man with less than a 10 to 15 year life expectancy. [emphasis mine]

Reading the whole thing is pretty informative. Urologists should try it.

Follow the money: Annual PSAs on everyone from age 40 generate gobs of abnormal results, leading to biopsies galore and of course a plethora of early cancer diagnoses. “We offer watchful waiting,” they say. Ha! Once a patient hears the word “cancer,” they stop listening and start screaming, “Get it out! Get it out!”

See, urologists treat prostate cancer. Find it, cut it out, nuke it; whatever it takes. Never mind that the patient would never have had symptoms from a disease that was never going to kill him. It’s cancer.

But I treat patients; men who end up incontinent and impotent from overzealous treatment by those same urologists who impugn preventive care recommendations because there are no urologists on the panel, but who can’t be bothered to follow their own fundamentally similar specialty guidelines.

Guess what: There are no foxes on the panel developing guidelines for guarding henhouses either.

Posted by: notdeaddinosaur | October 15, 2013

A Deal You Can’t Resist

It’s flu shot season. Everyone and their daughter wants a flu shot.

No problem; happy to oblige. I typically recommend flu shots to anyone who doesn’t want to get the flu. (Technically, that should be, “wants to reduce their chances of getting the flu,” but why quibble.) I’ve also discovered that most people start getting flu shot the year after their first really bad case of the flu.

Lots of people worry that the flu shot will give them the flu. It won’t.

Let me say that again: THE FLU SHOT CANNOT GIVE YOU THE FLU.

Many people start getting sick this time of year. Many people get flu shots. It is therefore inevitable that some will get sick within close temporal proximity to receiving the flu shot. This does not mean the flu shot gave them the flu.

To prove how strongly I feel about the importance of flu shots, here’s what I’m going to do for anyone to whom I give a flu shot who gets sick within a week: I will make you homemade chicken soup and bring it to your house. (Only if you want me to, of course.)

This offer is for real. And I make an awesome chicken soup. So come on in and get your flu shot, backed up with a chicken soup guarantee.

Edited for Domestic Tranquility: My dearest darling spouse, the most wonderful man in the world, and I, will make you the above-mentioned awesome chicken soup.

Posted by: notdeaddinosaur | October 12, 2013

Getting Old

You know you’re getting old when your children are old enough to be your doctor, to which this crotchety old guy in his 80s whom I’ve known for years can attest. But when your son is old enough to be your flight instructor, well…

COG Master Pilot

Also, when they submit your logs to the FAA demonstrating 50 years of flying without an accident or violation and surprise you with the Wright Brothers Master Pilot award, you know you’re getting up there.

Congrats to my favorite COG.

Posted by: notdeaddinosaur | October 3, 2013

You Don’t Want to be Special

Everyone is special, precious, unique; worthy of dignity and respect. However when it comes to getting sick, trust me, you don’t want to be special.

You don’t want to go downtown to the super-sub-specialist for your hard-to-control seizures and be told, “I’m stumped!”

You don’t want to have the one-of-a-kind tumor that no one’s ever seen before, let alone knows how to treat.

Whatever disease or condition you come down with, trust me, you don’t want it to present in a way no one recognizes.

When you’re sick, you want to hear your doctor say that he’s seen this a million times, and treated it that many times as well! Yes, it may be the first time you’re dealing with this particular condition, and yes, it’s your life with which it’s wreaking havoc. But to your doctor, you want to be boring. Same old, same old. Something they’re all comfortable with because it’s so familiar — no matter how alien it may be to you.

You don’t want to hear, “Wow, I’ve never seen this before.” You want to hear, “Oh, yes; we can handle this.”

Of course you’re special. I know that. We all know that. And we strive to respect and cherish your individuality throughout the course of your treatment.

But trust me: you don’t want to be “special” to your doctor. Not like that.

Posted by: notdeaddinosaur | September 28, 2013

Hearing Voices

The chief complaint made my heart skip a beat: a patient with mild dementia who is now hearing voices. Oh no. Is he developing new psychotic symptoms? Has he begun wandering? Leaving the stove on? Has sundowning become an issue? Hopefully he’ll bring someone else along so I’ll be able to get a fuller picture of his overall behavior.

I walk in the room; greet the patient.

What’s going on? I ask.

“I’ve been hearing voices, Doctor.”

Wince.

Tell me more.

“It started three days ago, and it’s only in my left ear.”

Strange. But I have to find out more.

Do the voices ever tell you to hurt yourself or other people?

“No.”

That’s good.

What are they saying?

“Battery.”

Pardon?

“They just say ‘Battery’. Every five minutes or so. ‘Battery’.”

Hm. Anything else?

“Well, about six months ago I got this new fancy hearing aid. Top of the line. Really high tech.”

I see. Um, which ear is that?

“My left.”

Okay then. My recommendation is that you consult your audiologist about servicing your new hearing aid.

“Really? What’s wrong with it?”

I think it’s telling you it needs a new battery.

Posted by: notdeaddinosaur | September 26, 2013

By the Numbers

Patient calls, upset and panicky. She needs an appointment RIGHT AWAY!

Fine. Come on in.

What’s the matter?

She did a health screening at work, and was told her HDL cholesterol was (gasp) TOO LOW! As she described it, the nurse practitioner was very insistent that she see her doctor as soon as possible (though the form actually said it should be within two months) because her HDL was…wait for it…35.

Okay. At first glance, that looks pretty low. For women, it really should be over 50. But wait! Her total cholesterol was only 136. Given that “total cholesterol” consists of the LDL (bad cholesterol) + the HDL (good cholesterol) + 1/5 of the triglycerides, she didn’t have that much room for an HDL over 50. And indeed, another number reported on the form was the total cholesterol to HDL ratio, which is how to correct for this. “Desirable” is marked as less than 4.5; my patient’s ratio: 3.9.

Perusing the actual results form, I saw that the HDL result was highlighted, along with the line about “See your Doctor within 2 months”, but the ratio was not. I don’t know if the NP didn’t look at it, or didn’t understand its significance.

The bottom line is that my perfectly healthy (albeit somewhat excitable) patient was thrown into a tizzy over completely normal results. I’m not saying that all NPs incompetently ignore important information, but this time, this one did.

I reassured my patient as best I could, and told her to stay away from Health Fairs from now on.

Posted by: notdeaddinosaur | September 25, 2013

A Pendulum Too Far: Breast Cancer Treatment Then and Now

Once upon a time, women with suspicious breast masses were put under general anesthesia for surgery not knowing whether they were going to wake up with or without their breast. If the biopsy showed cancer, the surgeon went right ahead with the mastectomy. No time to lose; it’s cancer, you know. Breast reconstruction? Don’t be silly. No one does that. You should feel lucky to be alive!

Can you imagine? Doctors making decisions for patients without consulting them, assuming they know best “what women want.”

Thanks to advances in technology allowing ultrasonically guided outpatient biopsies, and our understanding of the biology of cancer, management of breast lumps is very different today. No more signing a “blank check” surgical consent. Waiting a week (or a month) doesn’t materially affect treatment or outcome. And immediate reconstruction is now the rule, complete with mandated insurance coverage. 

Wonderful. 

But have they gone too far in the other direction?

I’ve had patients with breast cancer who, for their own reasons, are not interested in breast reconstruction. Some want reconstruction so they can look normal in clothes, but don’t care about a nipple (surgically reconstructed or tattooed.) Surprising numbers of these women tell me with dismay of confronting the disapproval of their other doctors. You don’t want reconstruction? Don’t be silly. It’s covered by insurance. Everyone does it. What’s wrong with you?

Can you imagine? Doctors assuming they know best what their patients want, without listening when women actually tell them things they don’t expect to hear.

And it’s not just surgeons. I got a letter from an oncologist seeing a patient three years after completing treatment that included this:

She did not pursue getting fitted for a mastectomy bra and prosthesis when I gave her a prescription three years ago.

Yeah; so? I thought as I read, assuming he was just being informative. Further down, though, the peeved tone comes through more strongly:

I strongly recommended that she be fitted for a mastectomy bra and prosthesis, and gave her written information regarding insurance reimbursement, local fitting stores, and another prescription. She does not appear interested in Plastic Surgery evaluation.

Honestly, dude. Back off!

Posted by: notdeaddinosaur | September 24, 2013

What They Don’t Know

Recommendations. Specialists are full of recommendations. Sometimes they’re helpful, even lifesaving. Other times, not so much. I try to make a point of calling ahead and letting them know about special circumstances, but it’s tough getting past their nurses. Then again, even when I do get through to them, I’m never sure I’m getting through to them, if you know what I mean.

Specialist’s recommendation (ortho, seen for fracture):

Frequent falls resulting in head trauma as well as the current injury should be addressed. Recommend workup for balance/equilibrium disturbances.

Do you think the fifth of gin the patient admits to consuming daily may have something to do with that? I called your office and let them know of my concerns. Thanks for the recommendation though.

Cardiology recommendation:

Patient appears to have signs of early dementia.

Actually, he told me his hearing aid was broken on the day of his appointment with you. He’s sharp as a tack when he has it in.

Gastroenterology note:

Patient was non-compliant with colonoscopy prep, medication and dietary instructions.

I told your office manager that this patient has “limited literacy skills.” He can’t read. I’ll bet you handed him a stack of papers containing the bowel prep, directions for the three new meds you gave him, plus detailed dietary information, said, “Any questions?” and left the room before he could say, “Um…?” How compliant would you be if I threw you all that information in, say, heiroglyphics?

I know how hard it is for specialists to admit I may know more than they do about my patients. That may be why my attempts to provide extra information fall so often on deaf ears. But if they listen to me, they may find it easier to make meaningful recommendations.

Now watch me get inundated with comments about dreadful primaries who never call to share the most basic information about the patients they refer, leaving the heroic specialist to save the day. There are bad apples everywhere, and everyone believes their experience is “reality”. These are actual [well, modified for anonymity] letters I’ve gotten from specialists making nonsensical recommendations based on incomplete information. It cuts both ways.

Posted by: notdeaddinosaur | September 5, 2013

Happy New Year

Rosh Hashanah.

First cool snap in the air; the sweetness of apples and honey. Hurry through dinner for shul at 8:00. Best clothes; break out the fancy jewelry. Hugs and air kisses for twice a year friends. Upholstered seats, floral carpet, special red prayerbooks. Listening to the strange cadences of the right-to-left language, catching familiar phrases here and there: Baruch atah Adonai. The sound of the shofar, loud and commanding. Watching the clock, eagerly awaiting the end, the drive home, to sleep.

Not this year.

Closest coolness is an ocean away. Temperature 100, humidity 110. Glasses fog up, sticky sweat appears instantly. Cotton pants, conservative t-shirts, scrubs if you have them. Bouncing on an open air truck sandwiched between boxes of supplies and medications. Listening to the strange rapid cadences, picking out words here and there: Gracios, buenos dias, de nada. Bear hugs and real kisses for cooperadores, newfound friends and colleagues. Bedsheet and tablecloth-defined exam rooms in the shelter of a stifling cinderblock church. Practicing tikkun olam one soul at a time, laboriously translated word for word. Streets of dirt turned to mud, unimaginable squalor at every turn. The sound of the rain pummeling the tin roof, loud and commanding. Ignoring the clock — stuck on noon anyway; seeking out the stray breeze as welcome as a swallow of water in the desert. Reverse the loading process as the sun dips low, the open air truck a vertable limousine. No shower ever felt better, no dinner more savory, no company more jolly. Sleeping the sleep that follows the hard work of mitzvot.

L’shanah tovah.

Posted by: notdeaddinosaur | September 1, 2013

Low Hanging Fruit

Insurance companies take such good care of patients — sorry, members — these days. Silly me: I thought I was the one taking care of them. But no. Nowadays, instead of paying me to take care of you, they have all these nifty programs to proactively contact you, have a nurse come to your house, go over your meds, answer your questions, and offer really cool suggestions for staying well. These are programs for people over 65, which you’d think would be a good idea as older folks tend to have more medical issues, though in fact it’s mainly so they can comply with Medicare regulations.

I have plenty of patients over 65. Many of them have lots of problems, require many medications, and would greatly benefit from this kind of case management. I’m also lucky to have more than my fair share of the very vigorous elderly. People in their 70s and older who are quite active, who play tennis every day, go biking every week, and take no meds at all.

I received a mailing from an insurance company the other day proudly informing me that they had enrolled several of my patients in one of these home assessment programs. I looked over the list. You guessed it: the only patients on it were the ones taking few if any meds, with ridiculously short problem lists, and who were plenty savvy enough to take their single pill every day.

What about the homebound double amputee who can’t read his med bottles because of his diabetic retinopathy? No luck. He’s on his own. I guess anyone they sent out to visit him would have to do something other than read through their boilerplate wellness shpiel sitting in a sunny kitchen in a nice neighborhood. They might have to wade through a laundry list of meds (more than two), and actually think about possible interactions between drugs prescribed by multiple physicians.

FSM forbid they try assessing someone who actually needs assessment!

Posted by: notdeaddinosaur | August 21, 2013

One Ringy-Dingy, Two Ringy-Dingies

Playing a game of, “What’s the funniest foreign body you’ve ever seen in an ear?” with an ear doctor is a little like playing Marco Polo with Michael Phelps. You’re clearly at a disadvantage. I held my own for a while, though. But she won:

The funniest foreign body she’d ever seen was in a little girl’s ear: a Barbie cell phone.

Why did she put it in her ear? She wanted to hear it better. Perfectly logical.

Then, however, the thorough and conscientious specialty physician felt compelled to inquire about tinnitus. It’s not particularly germane in this clinical situation, but by gum, they’re going to ask all their routine questions (including about a sense of fullness in the ear, drainage coming out, etc etc).

So the doctor asks, “Do you hear ringing in your ears?”

The exasperated parent fixes the doc with a withering gaze.

“It’s just a toy.”

 

Thanks to AH for permission to blog.

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