I had a silver-and-gold Passover. Hearkening back to the old Girl Scout song I learned from my mother:

Make new friends, but keep the old;
One is silver and the other’s gold.

With no space or equipment to have a seder myself, I was nevertheless the lucky recipient of not just one, but two invitations. The gold was thanks to a quarter-century-plus friendship; the silver was from a family we met the week before Passover. Who should I meet at the seder but a legitimate health policy guru, with whom I promptly struck up the first of hopefully many spirited discussions on the state of healthcare (or, as it is correctly called, “medicine”) in the US today.

How would you fix it? I asked him.

He responded that he would allow any payment structure at all, except fee for service, which he would outlaw.

Hm, I thought. What’s so terrible about fee for service? Doesn’t nearly every other private enterprise in the country operate on the basis of paying for services rendered?

Ah, he said. But with fee for service, there’s no accountability.

Whiskey, Tango, Foxtrot, I thought (because I was of course far too polite to come out and say it to someone I’d just met.)

Accountability. I do not think that means what you think it means.

Accountability, per Dictionary.com,  is “the state of being liable or answerable.” Being “answerable” presumably means that when something goes wrong, he who is accountable is the go-to guy for blame. The bit about “liable” would imply a monetary dimension to the exchange.

What does this mean in medical terms? “When something goes wrong, someone has to pay”? Sounds rather like a rallying cry for the plaintiff’s bar. The problem is that in medicine, the line between doing something wrong and something bad happening is far less straight than may be imagined.

Another issue is that bad things often happen to people which is no one’s fault. Tumors metastasize; organs fail; people even die. (Actually, all of them will eventually.) Where does “accountability” come into it?

The health care policy guru’s answer: chronic disease management. Diabetes, hypertension, chronic heart, lung, and kidney disease cost way too much; ostensibly way more than they should (according to whom, by they way?) When physicians are held accountable for the costs of the medical care they provide, so goes the theory, they will provide…what? Better care? More evidence-based based? More efficient?

We then run smack into the fact that so much of the response to treatment depends on the patient! What about people who keep smoking, refuse to exercise, eat whatever they want? To non-physicians, this is still our fault. “Education” is the perennial answer. Obviously if we had appropriately educated/persuaded/cajoled/etc, the patient would comply with our recommendations and get better. At what point are patients ever accountable for themselves?

Apparently the only kind of accountability that counts (at least to health care policy gurus) is for physicians to be associated with organizations that take financial responsibility (also known as “risk”) for the costs of medical care. And of course, the only reasonable way to take on that kind of risk is to be  part of a very large organization, and assume responsibility for a very large number of people (a population?) These Accountable Care Organizations nothing more than Managed Care 2.0, resurrecting the failed debacle of Managed Care from the 1990s, but with more money thrown at them this time around. I’m not holding my breath to see how many of those dollars trickle down to people actually providing medical care to people who are sick and hurt (known respectively as “doctors” and “patients”.)

When you stop to think about it, true fee for service makes me ultimately accountable to the only person who really matters: my patient. Once you take both government and insurance companies out of the middle (the so-called “direct pay” model, where the patients pay me directly for my services) and it’s just me and them, only then am I truly accountable.

Posted by: notdeaddinosaur | April 29, 2014

Words That Don’t Mean What You Think They Mean: “Quality”

Round and round and round we go yet again. The system is broken! Do something! Healthcare reform!

“Pay for performance” morphs into “measure (and pay) for quality.” The big problem is that no one has bothered to actually define the term, maybe because everyone assumes they know what it means — and that everyone else agrees with them. Wrong.

Quality is very much in the eye of the beholder, and can be surprisingly subjective. From my previous post:

Quality is like pornography; you know it when you experience it. But it cannot be measured; only assessed, and then only subjectively.

What does “quality” really mean in the context of medical care?

Some argue that when you have an operation, the surgeon shouldn’t leave anything inside you that shouldn’t be there. Others would say that everyone taking care of patients should wash their hands before and after every patient contact. Certainly all medical professionals should maintain proper licensure and credentials. I think of those things as basic expectations; more the difference between “acceptable” and “unacceptable”. “Quality” is different from “not unacceptable.”

Enter the idea of looking at “outcomes” (another meaningless word, also previously addressed by me here and here.) To reiterate: only certain kinds of illness and injuries have measurable outcomes. Fractures (should) heal. Surgically treated illnesses (should) resolve after operation. And so on. It’s generally accepted that there is a direct causal relationship between medical treatment provided and resolution of the condition, though this is not always so. Postoperative complications are not always preventable. Some fractures won’t heal. Cancers sometimes recur. So even the measurement of “outcomes” as a proxy for “quality” is fraught with hazard.

What about the relationship between “quality” and “Patient satisfaction”? Two words: Press Ganey. Short version is that there are times (lots of times) when what people think they want from doctors is not only not what they need, but can be dangerous, useless, and expensive. The patient is not the customer (and even so, the customer is not always right). When you actually look, it seems like the more satisfied people are, the worse their care.

So what does “quality” mean in the setting of primary care? Me again:

Quality in medical care has more to do with meeting the needs of individual patients and less to do with checking off boxes on a preventive care form. Some patients want detailed explanations of every facet of their medical care. Others prefer a more “Just the facts!” approach. 

What does it mean to be a high quality primary care physician? According to me:

[T]he ability to bring more than one style of communication to bear in meeting the needs of a varied patient base.

How do I and other skilled primary care physicians accomplish this? That’s simple (not the same as easy): time. Taking the time to listen, get to know what kind of communication the patient wants and needs from us, and then providing it. That’s quality. Find a way to pay for it (or at least find a way to not penalize it) and stand back while things fall into place.

How to measure it? No one has a clue.

Why not?

Because it can’t be done.

 

Posted by: notdeaddinosaur | April 28, 2014

There is No Such Thing as “Healthcare”

I do not provide “healthcare”. I don’t even provide “health care.” One word or two, what we physicians do is practice medicine, and what we do for patients is called “medical care.”

No one says, “I want some healthcare.” What they think is, “I don’t feel well. I want to see a doctor.”

People get sick and they get hurt. It’s true that many these conditions occur as a result of things they do (smoke, eat junk food, drink too much alcohol, go skiing) or don’t do (use seat belts in the car or helmets when riding motorcycles, exercise regularly.) But even if everyone in the whole country made perfect “choices” all the time, they would still need medical care for illnesses and accidents from time to time.

One of the wonderful things we can do these days is keep people from getting sick. This is called “preventive medicine” (or “preventative”, if you think it sounds more impressive with an extra syllable.) We have Primary prevention, such as vaccines to prevent certain infectious diseases, and Secondary prevention, such as taking aspirin and statins after a heart attack to prevent you from having another one.

We can also find some diseases before the patient has any symptoms of it. Sometimes (not always!) we can treat it then, preventing symptoms in the future and possibly (possibly!) prolonging life.  This is called Screening. It is still a form of medical care.

“Healthcare” is a made up term. It was invented by administrators, bureaucrats, and politicians (people who do not provide medical care) to insinuate themselves into the income stream process between people who are either sick or hurt, or who feel well and wish to avoid becoming sick or hurt, if possible, and the people whose care they seek. Their sole purpose is to siphon off as much of that revenue stream as they possibly can, leaving an ever shrinking pool of funds to pay the doctors and hospitals (meaning nurses, technicians, and housekeepers) who actually take care of people who are sick or hurt.

Sadly, they’ve done an awesome job of it. One of their strategies is recruiting doctors who are tired of fighting them to come join them…not coincidentally by greatly enriching them in the process. But every doctor seduced away from taking care of patients (our word for “people who are sick or hurt”) means one fewer available to make a real difference in the lives of real people.

What would I do to reform the “Health Care System”? Begin by abandoning the word (or words) “Healthcare” and going back to calling is what it is: Medicine.

 

Note: meme ca change…Already addressed this in March of 2012.

Posted by: notdeaddinosaur | April 23, 2014

Building a House (15)

Just for a change of pace, the back:

photo (5)

We have siding (though why they don’t call it “backing” when it’s on the back of the house…)

Plumbing and electrical rough-ins mostly complete. First (formal) walk through is tomorrow.

Moving along.

 

Posted by: notdeaddinosaur | April 20, 2014

Building a House (14)

photo (1)

Windows also now placed in the family room, only visible from the back of the house. Plumbing and electrical mostly done. Ready for “Pre-drywall walk through” next week.

Also coming up next week: see those boxes in the right side of the garage? That’s siding. They should also be delivering a pile of brick sometime soon, so the exterior should really start taking shape quickly.

Posted by: notdeaddinosaur | April 19, 2014

Not Quite There; Why the Paperless Office Still has Plenty of Paper

When last we visited the world of electronic medical records, Dino and Friend were happily puttering along with our freebie EMR and our freebie practice management system (including free electronic claim submissions.) We were hooked up electronically to the lab, so we entered orders and got results through the computer, though we still have to print out requisitions and labels for specimens. But we still had a fax machine.

Until about six months ago, when I splurged on a hideously complex and expensive piece of technology which we plugged into the fax phone line and one of the office computers, and Voila! Faxes on the computer. The fax machine still sits there, seldom utilized (except for outgoing faxes; we could do those electronically as well, but Friend has some techno-timidity), though it comes in handy when the power fails. (It comes back on automatically, whereas the computer does not.)

At last the office utilization of paper has shrunk. Dramatically! Checking faxes is now a matter of point and click instead of risking smeary-inked paper cuts. Best of all, they go directly into the EMR.

The next step — over a chasm still as yawningly huge as ever — is sharing all this information with other doctors. As mentioned above, lab results come directly into the computer as well. Luckily, the lab has this nifty feature allowing me to send duplicate copies to referring physicians. So whenever I draw a test for another doctor, I always make a point of asking the lab to send it along. (Yes, people come to me for blood draws. I have mad phlebotomy skillz).

There’s this one office, though, that always calls and asks us to fax patients’ labs over.

“Didn’t you get it from the lab?” I ask, over and over.

“No,” they claim.

I look at the lab report. Sure enough, it says right there, “DUPLICATE FAXED TO ABC SPECIALISTS.”

“But the lab report says they sent it to your office.”

“Oh, well Dr. A can’t access it through our EMR unless it comes directly to him.”

Only problem with that is that when I put Dr. A’s name into the lab, the program changes it to the practice information.

Deep sigh.

So I guess we’re not finished killing trees just yet.

 

Posted by: notdeaddinosaur | April 18, 2014

Artful Dodge

Saw a 56-year-old woman the other day.

“Have you had your colonoscopy?” I asked.

“No,” she said. “I know I was supposed to get that at 50, but I didn’t. You’re supposed to get them every ten years, right? I guess I’ll just wait until I’m 60.”

Nice try, honey.

Posted by: notdeaddinosaur | April 18, 2014

Building a House (13)

Lots has been happening inside (plumbing, wiring, etc.) but nothing much that shows up in a picture Today, though, there was action: cutout done for the window over the garage, of which DSS sent me a picture.

Here’s the thing, though: when I downloaded and opened the image, the way it showed up against my computer desktop cracked me up. So here’s a screenshot instead of just the picture:

Screen Shot 2014-04-18 at 8.53.10 AM

Looks like a scary neighborhood we’re moving to, doesn’t it.

Posted by: notdeaddinosaur | April 10, 2014

Flower Power

Look here, now. I’m as sick of winter as the next person. And I love flowers just as much as anyone else. Far be it from me to take on the role of Fashion Police (especially loving Vera Bradley as much as I do), but this is a little much:

photo (9)h/t MBS

 

Posted by: notdeaddinosaur | April 8, 2014

Forests and Trees, or: Why I Don’t Take Care of Populations

We lost a branch off a big old tree a few weeks ago.

“Call the tree guy,” said DSS.

“It’ll cost us a grand,” I muttered.

“No it won’t,” he said, dialing Dan, the tree guy.

$300 later and the branch was gone. Such a deal. But Dan the tree guy discovered that the tree was starting to rot out. Also, without the fallen branch, the tree was now dangerously unbalanced and really should be taken down, as it could present a safety hazard. $700 later and the “big stick” (as he called it) was history.

“Told you so,” I muttered to DSS.

But I had the chance to talk with Dan the tree guy.

“So I guess your dream job would be something in forestry, right?” I asked.

“No. I take care of trees.”

“But isn’t a forest just a whole bunch of trees?”

“Well, yeah. But there’s much more involved in taking care of a forest than just taking care of one tree at a time.”

Hm. Sounds familiar.

I take care of patients. Many patients. But, contrary to the impressions of the medically naive regulators who somehow consider themselves competent to pontificate on health care, a “population” is more than just a collection of “many patients.”

My job is to take the best possible care of the patient in front of me. Then the next, and the next, and the one after that. At the end of the day, however many patients I’ve seen, I still haven’t taken care of a “population.”

Caring for populations is called “Public Health.” It includes such things as access to potable water, food supplies, and schools as well as hospitals, doctors, and medical care. Physicians can be involved in public health, but it really doesn’t have anything to do with “practicing medicine.”

If the patient in front of me needs an MRI, I cannot in good conscience tell him that he can’t have it because someone else may need it more. That’s a population calculation, and it falls into the realm of public health. If you don’t need whatever it is you’re asking for, it’s my job to explain to you why you don’t need it. It has nothing to do with “good stewardship of scarce resources.” If you need an MRI, a consultation, or a procedure, my job is to do everything in my power to see that you get it. Period.

All these calls for Primary physicians (in Orwellianly named “Patient Centered Medical Homes“) to “manage populations” are disingenuous at best, and counterproductive at worst. We don’t manage populations. We take care of patients. One at a time. Each to the very best of our ability, with the help of the best possible evidence, but still one at a time.

And then the next.

 

 

Posted by: notdeaddinosaur | April 4, 2014

Building a House (12)

We are progressing: garage framed out and doors installed.House-12

Several more things have happened that aren’t visible from the outside. We now have cement floors on the front porch, patio, garage and basement, plus stairs down to the basement. The half-wall that will eventually be the larger of our two kitchen islands is in place.

Still a ways to go, but getting there.

Posted by: notdeaddinosaur | March 24, 2014

Building a House (11)

Now with windows (some, at least):

photo (3)

Posted by: notdeaddinosaur | March 18, 2014

Building a House (10)

We have shingles! (Roofing, which is good; not viral, which is not good):

photo (2)

Posted by: notdeaddinosaur | March 16, 2014

Building a House (9)

Wrapped in green:

photo 1 (2)

Posted by: notdeaddinosaur | March 13, 2014

Rotten Low-Hanging Fruit

The topic for today is In-Home Assessments by insurers masquerading as “useful.” I’ve previously discussed my observation that only patients with few or no actual medical problems seem to be chosen for these assessments. What happens when someone with multiple, complex, longstanding problems is selected?

This:

PAIN QUESTION/RESPONSE:

  • Location of pain: All over body
  • Quality of pain: Throbbing
  • What causes pain: Everything
  • What relieves pain: Seeing the chiropractor
  • How long has pain been going on: 42 years

Um, okay then.

PAIN TREATMENT PLAN: Follow up with doctor

Always a great default response. Since you home-assessment folks are right on top of things, what else do you suggest?

Member is recommended for reassessment of pain in: 6 weeks

Right. Because at that point it will have been there for 42 years and 6 weeks.

Good for a laugh, even though there’s nothing funny about it at all.

 

Posted by: notdeaddinosaur | March 12, 2014

Building a House (8)

And roofing on the roof:

0312141611a

Posted by: notdeaddinosaur | March 11, 2014

Building a House (7)

…And a roof!

photo (2)

Posted by: notdeaddinosaur | March 10, 2014

Building a House (6)

We have walls!

photo

Posted by: notdeaddinosaur | March 4, 2014

The All-Knowing Google

Did you know that Google will display a special birthday doodle for you on your birthday?

I didn’t. Until today, when I saw this:

Birthday doodle-page-001

Oh, I thought. That looks like a doodle for someone’s birthday. Let me mouse over and see who…turns out that the alt-text mouseover message says, “Happy Birthday, Dino.”

Cool.

 

Posted by: notdeaddinosaur | March 3, 2014

Dinner

Udon Noodles with Doctored Peanut Sauce.

Some assembly required:

photo 1

 

Assembly instructions:

  • Go to medical or other graduate school to attain “doctoring” credential (optional step)
  • Cook udon noodles according to package directions. (Notice that directions are all in Japanese. Go to internet and discover that they need to cook at a full rolling boil for 10 minutes.)
  • Thaw shrimp according to package directions (gratefully noticing they are in English)
  • Coarsely chop red onion; slice scallions on the diagonal. Cook until tender in a splash of peanut oil (not shown) over medium heat.
  • Add about 3/4 cup of peanut sauce, pinch of red pepper flakes, and a handful of peanuts, stirring until heated through.
  • Serve over drained udon noodles:

photo 2

Posted by: notdeaddinosaur | March 2, 2014

Saving Lives with Primary Care, Part 2

I just didn’t like the looks of him.

It was the way he was breathing. I counted for a full minute: 24 breaths. (The ER would later document 40.) No accessory muscle use. Not even much coughing. He didn’t look overly anxious or uncomfortable, though he said he couldn’t breathe. No fever. No wheezing or other abnormal lung sounds on exam. No leg swelling or tenderness. Pulse ox 95% on room air. (97% in the ER.) Not terrible for a non-smoker in his 60s. Not much to go on. 

I was afraid he had a blood clot in his lungs. Pulmonary embolism; PE, for short. Life-threatening if not caught. Fever, cough, chest pain, anxiety, and leg pain (clots in the leg can break off and go to the lungs) would have been suggestive signs. Then again, their absence didn’t rule it out by any means.

Here’s the kicker: He was already on coumadin, a blood thinner, and his INR was 2.9 the week before. He was therapeutically anticoagulated. Blood thinners are supposed to prevent blood clots. He couldn’t have a blood clot in his lungs if he was already on blood thinners, could he? What was going on?

Pneumonia? Possibly, but with no cough, fever, chest pain, or abnormal lung exam, it seemed less likely. Asthma? Even less likely with a normal exam.

I just didn’t like the looks of him.

So I called the ER and told them I was sending him over.

“Already on coumadin?” asked the nurse.

“Yep.”

“Therapeutic INR?”

“That’s right.”

“Hmph. Probably not a PE. But send him over; we’ll take care of him.”

Later that afternoon, the patient called me.

“I just wanted to say thank you,” he began.

He had been admitted to the ICU with numerous blood clots in both lungs. The only other thing they could find was a little non-occlusive deep vein thrombosis in one of his popliteal veins; the kind that don’t typically break off and to to the lungs (especially when already on blood thinners.) The hematologist was stumped.

But he was alive. Which he probably would not have been if he had continued sitting at home, hoping to feel better, as he had told me he was his original plan.

That was a save. Based primarily on that sixth sense of the experienced clinician: I just didn’t like the looks of him.

[By the way, if there are any coagulation gurus reading this with any ideas for taking care of this guy other than an IVC filter, please feel free to shoot me an email. We really are stumped.]

Posted by: notdeaddinosaur | March 1, 2014

Building a House (5)

The foundation has been backfilled:

photo 1 (1)

Also, we have wood!*

photo 2 (1)

Despite the fact that another 6-10 inches of snow are expected within 48 hours, we have a house; some assembly still required.

*No, that doesn’t mean the Viagra just kicked in.

Posted by: notdeaddinosaur | February 27, 2014

How Do You Know Your Cat is Planning to Kill You?

All hail “The Oatmeal,” the source of all truth in the universe.

So how do you know your cat is planning to kill you? Answers here, but not the fully correct one. The real answer to the question, “How do you know your cat is planning to kill you?” is this:

You have a cat.

I was reminded of this the other day by a comment on a post by Rob Lamberts on KevinMD which began:

As an incurable compulsive introspect, I tend to brood, ponder, contemplate, and (of course) muse on “big ideas,” such as:

  • What makes people choose things which cause themselves harm?
  • Are some people better people than others, or are they just more skilled at hiding their problems?
  • Is pain really a bad thing, or is our aversion to it a sign of human weakness?
  • Does God ever wear a hat?
  • Do dogs watch Oprah?
  • Why did I put “big ideas” in quotes?

I love Rob.

One of his commenters, Eqvet215, added this at the end of a thoughtful response:

By the way, most tasteful dogs watch Ellen; Pugs watch Maury or Jerry Springer Spaniel. Cats watch Dexter.

Of course cats would watch Dexter; makes perfect sense.

Which led me to think of my little Bootsie; my BooBoo Bear; my sweet little 14-year-old tabby with no front claws (rescued that way) who sleeps between me and DDS each and every night. Planning to kill us? Not my darling kitty.

But he is a cat. And suddenly I realized what was going on.

He’s paralyzed by indecision. Every night he jumps up on the bed and tries to decide which one of us to smother first. And every night he lies there, torn: her? Him? Her? Him? All night long. Poor thing just can’t make up his mind. Then before he knows it, the sun is up and we’re gone. Another day to plot and ponder (and poop and barf; he’s nothing if not versatile in his talents), until tonight…

Posted by: notdeaddinosaur | February 26, 2014

The Power of “Reply All”

The guy was a curmudgeon. That’s all you could say about him. His blood pressure and diabetes were dreadful, and he insisted there wasn’t anything he could do about it. The meds were too expensive; the diet was far too limiting; he had no pleasures in life other than food. He lived alone, hated his job, saw few people, had no friends; so he told me at every visit. His visits were unpleasant in other ways as well. He didn’t bathe often, nor did he appear to believe in doing laundry. 

He sent me emails from time to time. Funny pictures of cats; sentimental powerpoint presentations on the changing of the seasons; the usual. Sometimes I read them, sometimes not; depended on how busy I happened to be at the time. Mine was just one in a long list of names in the header.

Then one night, everything changed.

I got a call from the emergency room. My patient had had a heart attack, found slumped next to his car. They’d been able to get a rhythm back, but not before he’d sustained some mild anoxic brain injury. I’m not sure how they figured out he was mine, because he really wasn’t able to communicate at all. I got to show off my spiffy EMR, rattling off his meds to the ER doc. (“Are you in the office at this hour?” “Nope. I’m logged onto my EMR from home.”) but not much else.

There wasn’t much they could do for him. Just wait for his brain to improve to whatever degree it could, helped along with intensive physical and occupational therapy. Frankly, I didn’t think he had much chance for any meaningful recovery, and would likely be bed-bound and completely dependent for whatever remained of his life.

Later that night, I saw an email. The header indicated it had been sent to everyone on the curmudgeon’s contact list. It read:

Does anyone on this list have Mr. C’s daughter’s phone number? VERY IMPORTANT.

I know what that’s about, I thought, though of course I couldn’t say anything. Confidentiality and all that. Besides, I had no idea how to get ahold of his daughter.

The next day, there was another email from someone with the same last name as the curmudgeon. It relayed what had happened to him and his current condition in far more detail than any other correspondence I’d gotten from the hospital (ie, none). Followup emails from others on the list relayed thanks for the info, good wishes, and prayers. When he was ready for visitors, it was announced through the list. News of his transfer to a rehab facility was next (again, before I’d received any official notice from the hospital), followed by continued improvement and transfer to a stepdown rehab. Finally came word that he was going to live with his daughter to continue his recovery.

Around that time, the daughter also called the office to make an appointment for a followup visit. I was as thrilled as I was surprised to see him walk into my office, unassisted except for a walker.

He smiled when he saw me; a surprisingly symmetrical smile. His neurological recovery wasn’t complete, but it was remarkable. So was his attitude. I’m not sure if the brain injury had caused a change in his personality, or if it was as simple as having nearly died, but he was a different man. Smiling, friendly, pleasant, and optimistic. Everything he hadn’t been before. And with a very long list of people who cared very much about him, that he either never before admitted, or had never believed.

As with everything else in life, there is a time and a place for “Reply All.”

Posted by: notdeaddinosaur | February 25, 2014

Dinner

Pan-seared sea scallops with clam risotto:

photo 2

Posted by: notdeaddinosaur | February 23, 2014

Dinner

Thin sliced top round, dredged in pan-searing flour and very briefly pan-fried, with carmelized onions and served over polenta:

photo 1

Posted by: notdeaddinosaur | February 22, 2014

Saving Lives with Primary Care, Part 1

I’m going to let you in on a little secret: not all doctors “save lives” every time they see a patient. Emergency medicine physicians,  trauma surgeons, oncologists can all rightfully brag about “saving lives.” Hell, even paramedics probably save more lives than I do over the course of a year. I admit it: more of my time is spent either relieving suffering (diagnosing and treating acute but self-limiting illnesses) or trying to prevent it down the road. Trust me: it doesn’t feel the least bit heroic to discuss diabetic diets, recommend weight loss, prescribe blood pressure medicines, and advise people to quit smoking over and over again, day in and day out.

Also, because primary care is an ongoing endeavor, there will always come a time when “saving a life” is not the goal. Helping patients with terminal conditions to remain comfortable — physcially, emotionally, and spiritutally — through the last stages of their lives is an important facet of our job. It just doesn’t make for compelling cocktail party conversation or blog fodder.

But I still have my moments.

A patient* came in for followup after a protracted hospitalization for sepsis, weak but well on the road to recovery.

“You saved my life, Dr. Dino.”

Those were her exact words.

She said it again: “You saved my life.”

Do tell.

“I give you credit: all those times I came in asking for antibiotics that you wouldn’t give them to me. If you had, I would have died.”

She was quite sure of it.

Who was I to argue?

She was probably right. If I had given in and prescribed antibiotics for previous conditions when they were clearly not needed, I would have killed off the susceptible portion of her microbiome and allowed the smaller population of resistant organisms to prevail. Had those resistant bacteria been the ones to invade her blood stream, she very likely would have succumbed.

We doctors may have “The power of the prescription pad.” But there are still plenty of times when we just need the power of “No.”

*Blogged not just with permission, but by request. h/t TC

Posted by: notdeaddinosaur | February 17, 2014

What a Difference a Word Makes

In the news this morning, there’s the story of an Ethiopian co-pilot “hijacking” his plane to Switzerland.

I’ll bet that if this had been, say, a Russian plane, perhaps at the height of the cold war, and a white pilot, given exactly the same circumstances (asylum requested, no gun), the media reporting the event would have used the word “commandeered” instead of “hijacked”. But since it was a black man from Africa (albeit from a country with a history of violence in the air) the more emotion-laden term was used.

Sounds racist to me.

Posted by: notdeaddinosaur | February 14, 2014

Breakfast

Once again my trusty Ratio cookbook comes through on a cold, snowed-in morning: Popovers! Surprisingly simple; amazingly delicious with just honey:

photo (5)

In the oven, just starting to pop.

Just out of the oven.

Just out of the oven.

And voila: breakfast as elegant as it is yummy:

photo (3)

Apparently they would have popped even higher if I’d put them in smaller tins. But all I have in this hypoplastic kitchen of mine is this new large muffin tin. I can’t bear the thought of buying more of what I already have, even though it’s in storage and I won’t be able to use it until summer. The popovers turned out fine, though.

 

Posted by: notdeaddinosaur | February 8, 2014

Dinner

Rosemary crusted rack of lamb with balsamic reduction, served over mashed potatoes:

20140206-194517.jpg
Yum.

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