Are you serious? One bowl of Total?

Terry is my favorite character on Reno 911, having admitted a clone about 8000 times in residency. Whenever he's on the show I start laughing as soon as I get a glimpse of his little bandana. On last week's episode Terry ran for president. To begin his day of campaigning ("Vote for me or I'll pee on you") he had 17 bowls of cereal for breakfast, which has cracked me up all week. Deputy Junior notes that if Terry had Total he could have eaten just one bowl, because one bowl of Total is like 17 bowls of regular cereal. Then Terry sees a dragon. So silly. Enjoy.

RENO 911!	Wednesdays 10:30pm / 9:30c
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Joe Lo Truglio Funny Cop Videos error

Michael Jackson-Free Zone

Oh, Lordie. The world is on a lard-lubed, roller coaster ride into the Dupont-chemical laden toilet, and Twitter is brought to its knees by a 50 year old broken, sad man with a clay nose. Dudes et dudettes, come on. Priorities, please. If nothing else, put Twitter aside and do your homework. MJ was a crazy firecracker of talent, the likes of which you probably don't have. Hard work and fortitude with limited access to iPhone apps are going to get your job done.

You're slowing down the internet which is impairing my ability to shop.

The Myth of Prevention/Abraham Verghese

Astounding. Resounding applause due. Take this:

I recently came on a phrase in an article in the journal “Annals of Internal Medicine” about an axiom of medical economics: a dollar spent on medical care is a dollar of income for someone. I have been reciting this as a mantra ever since. It may be the single most important fact about health care in America that you or I need to know. It means that all of us—doctors, hospitals, pharmacists, drug companies, nurses, home health agencies, and so many others—are drinking at the same trough which happens to hold $2.1 trillion, or 16% of our GDP.

Or this:

But if your preventive strategy is medical, if it involves us, if it consists of screening, finding medical conditions early, shaking the bushes for high cholesterols, or abnormal EKGs, markers for prostate cancer such as PSA, then more often than not you don’t save anything and you might generate more medical costs. Prevention is a good thing to do, but why equate it with saving money when it won’t? Think about this: discovering high cholesterol in a person who is feeling well, is really just discovering a risk factor and not a disease; it predicts that you have a greater chance of having a heart attack than someone with a normal cholesterol. Now you can reduce the probability of a heart attack by swallowing a statin, and it will make good sense for you personally, especially if you have other risk factors (male sex, smoking etc).. But if you are treating a population, keep in mind that you may have to treat several hundred people to prevent one heart attack. Using a statin costs about $150,000 for every year of life it saves in men, and even more in women (since their heart-attack risk is lower)—I don’t see the savings there.

Go on, please, Dr. Veghese:

Contrary to what we might think, comparative studies show us that the US when compared to other advanced countries, does not have a sicker population: we actually use fewer prescription drugs and we have shorter hospital stays (though we manage to do a lot more imaging in those short stays—got to feed the MRI machines). The bottom line is that our health care is costly because it is costly, not because we deliver more care, better care or special care. Alas, a solution that does not address the cost of care, and negotiate new prices for the services offered will not work; a solution that does not put caps on spending and that instead projects cost-savings here and there also won’t cut it. Leaders have to make tough and unpopular decisions, and if he is to be the first President to successfully accomplish reform there does not seem to be much choice: cut costs.

Pesky EMRs again:

.....an electronic medical record (EMR) may or may not save money (it won’t be anywhere as much as is projected) but what it will do is ensure that we doctors, nurses, therapists, particularly in hospitals will be spending more and more time focused on the computer, communicating with each other, ordering and getting tests, buffing and caring for our virtual patient—the iPatient is my term for this phenomenon—while the patient in the bed wonders where everybody is. Having worked exclusively for the last seven years or so in hospitals that have electronic medical records (EMR), I have felt for some time that the patient in the bed has become an icon for the real focus of our attention, the iPatient. Yes, electronic medical records help prevent medication errors and are a blessing in so many ways, but they won’t hold the patient’s hand for you, they won’t explain to the family what is going on.

But how do all these vaunted projected health care savings work in English?

My wife tried to tell me the other day that she had just ‘saved’ us money by buying on sale a couple of things for which we have no earthly use. She then proceeded to tote up all our ‘savings’ from said purchases and gave me a figure that represented the money we had generated, which we could now spend . . .she had me going for a minute.

My husband is very familiar with this kind of savings reasoning, as I've used it on him more than once.

Read the whole thing at the Wall Street Journal:

The Myth of Prevention

Jerk Faced Butt Weasel

Charles Nemeroff MD, you are on my shit list. If my children need medication some day for depression or anxiety and somebody quotes me a study you had anything to do with, I'm driving over to your house and spraypainting the windows red.

TWO MILLION DOLLARS (and substantial change) FROM DRUG COMPANIES. Jesus.

Reprimanded Psychiatrist? Bad Advice?

The article, from the Columbus Journalism Review, is actually a critique of the research (or lack thereof) which went into a PBS documentary that won a Peabody, but it's damning of Charles Nemeroff MD, who completely, utterly deserves it. May you never be able to lift your flabby ass from the soft cushion of your Arundian Kid Goat-Skin Couch resting on your silk moth Orobesian carpets to show your face outside the walls of your palatial mansion clad in real Tunuskian diamond stucco ever again. I hope you have to have cheap scotch delivered in which to wallow in self-pity for the next 25 years because you can't even get to the liquor store.

Me and thousands of hard-working, honest physicians who give a damn while earning SIGNFICANTLY LESS THAN 2.8 MILLION DOLLARS as we attend every day to mundane and profane problems of real people want YOUR damn money back.

Not that he'd stoop to reading anything by the likes of me, a sad little medical school graduate who hasn't even paid off her loans yet. He's out on the golf course, I'm sure, or having his feet pumiced at a spa. Oh, to not have a conscience.

Safe Sex

Everything I know about sex and sexuality that I pass along to patients I learned from Reno 911. If you come to see me, prepare to play Trudy Weigel to my Jim Dangle.

But if you're interested in a more substantive approach to some questions you might have, check out a rather well-done little ditty I came upon through beloved Doc Gurley:

Top Myths about Safe Sex and Sexual Health

Oh, Dr. Wes.

Image via Wikipedia

I'm his biggest fan. I read him and weep.

Now, in the unfortunate circumstance where you might become sick, you will need to develop symptoms that follow a few simple rules. Do not, under any circumstances, develop symptoms that fall outside federal protocols developed based on comparative effectiveness research data. If you do, your doctors will face pay cuts, litigation, limited resources due to lack of funding for cost-ineffective technologies, and the scourge of discharge planners . . .

Unfortunately, after years of clinical practice I have observed several clever patient stunts, like failure to respond to medications, unusual unforeseen infections, having an rare disease, and the like. I strongly recommend against these shenanigans as we move forward. It is in your best interest to not require long hospital stays, dear patient, or else.

I wish you the best as we move forward in this exciting time. Please feel free to contact my automated pool of nurse coordinators if you have questions. They'll each open your message, play a little "hot potato" with each other, and then contact you as our information technology system streamlines communication.

For the rest:

An Open Letter to Patients Regarding Health Reform

If you're all like, "Oh, Dr. Latte, whatever. Ha Ha, that's so Orwellian 1984." No, it's not. I'm both a deliverer and a user, and it's not.

Ah, Dr. Wes. He doesn't like his EHR.

I'm one entire week into an EHR, and I can tell you this. I'm faster, much faster, on paper. I think on paper. I'm more succinct on paper. I'm far more organized on paper. The notes I leave behind elucidate exactly what I was thinking about each problem in a nice little set of lists.

They're also illegible (to some) and the rest of the paper chart is, well, a bit of a crap shoot sometimes. Flip, flip, flip. Why is the xray report in correspondence and the CBC in prescriptions? Hmmm....When it was only me using my charts it worked out mostly, and who cared if the power was out or the internet down?

Now, of course, thanks to my illustrious former employer, who the hell knows where the paper charts are?

But I'm sure I'll work out a system on the computer which is faster at some things than paper. It's handy to be able to flip through and plot labs, vitals, etc. One place for vaccines, charges, xray reports, etc. is cool. I'll learn that writing "6/25/09 Spoke to patient on phone re: recheck potassium 2 weeks" is horribly inefficient and it's MUCH better to receive an electronic notification, click on the icon that takes me to the notification page, click on the notification I need to read, read the notification, click to open the EHR, click on the "addendum" icon and click "yes" when asked if I want to amend an encounter which already happened, click to the addendum screen and type in what I want to do, call the patient, discuss it with her, close the note, close the notification, go back to the practice management screen, and repeat for the next 30 notifications. I'm sure I'll eventually learn to pay some attention to the actual patient in the room while I'm tap-tap-tapping on the keyboard about said actual patient.

But I'll be part of the problem. I'll have those two page, single-spaced typed notes for upper respiratory infections with neat, legible type about how I assessed the patient's pain (or lack thereof) and verified what the nurse said the patient was there for AND wrote down what the patient told me he or she was there for. There will be long, long lists of vital signs and CPT codes displayed prominently near procedures ordered, and notations about offering to print the patient a medication reconciliation list. About two inches will actually be useful to the next physician reviewing the chart. There will be oh, 15 inches for the lawyers, coders, insurance companies, accredation compliance people, and everybody else who doesn't have anything to do with the care of the patient but who gets a slice of the pie. But that's progress!

For more, far more eloquently expressed, turn to Dr. Wes:

Killing me Softly

For a patient's perspective (and the patient is a physician who uses EMR):

How not to use an EMR--tweenager daughter visits the pediatrician

Cool, brief list of decent patient websites

Remember, dear reader, that you get what you pay for. There's a lot of good out there on Google, but you can't get a degree from the Google University of Medicine or do a residency at Google Hospital and seriously expect to do open heart surgery on your sister. Some information out there, oh my God. It's just awful. On the other hand, where's the first place I go when I'm starting to research cars, shoes, hummus, hyperaldosteronism in menopause, or potty training? Google!

Here are some decent sites to browse if you need to do some research about something you or somebody you know has something you're interested in knowing more about. Via the always excellent, always informative, always clinical nerd nirvana, Clinical Correlations, I give you:

Hot Spots: Evidence Based Patient Websites

Colbert and the Sweet Smell of Zicam Mockery

Saw this last night on the DVR:

"I cannot for the life of me understand why the FDA would crack down on an unregulated heavy metal that you spray in your nose that can cause permanent damage." Classic.

The Colbert Report	Mon - Thurs 11:30pm / 10:30c
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Colbert Report Full Episodes Political Humor Mark Sanford

On being a patient

Image via Wikipedia

From the my eyes as a physician, as, gentle reader, my eyes iz why u iz reading.

From Medical News @ medpage today:

Six Patient Behaviors That Drive Doctors Nuts

My first thought was, geesh, am I limited to six? But really, there are things that make me giggle and there are things which make my head explode. Here's my take on the article.

1. Meddling families in the exam room

Not always bad. I understand why families want to come sometimes. Sometimes, especially when giving bad news, I like to have families in the room. I like for everybody to be on the same page and hear the same things at the same time. I want everybody to be able to ask questions. After something big it's cool to have family around, say, after a heart attack. There are always a lot of questions: What happened? Why? What on earth did the cardiologist mean? What's this pill for?

It makes me nervous sometimes, though. New patient appointments with two people are tricky. It's hard to get a fix on the dynamic of two new people AND figure out what the hell is going on with the patient. It's absolutely unpleasant to be caught in the middle of some family drama. I hate being used as a pawn, like, "See, I told you she'd say that!" or "Doctor! Tell Dick that he needs to lose 20 pounds. Say it!" There's the ever popular lump in the corner. Sometimes patients bring their partner and the partner just glares from the extra chair. That's lovely. There's also the partner who hijacks the appointment, or asks for advice about themselves. After I know people it's pretty easy to manage but at that first appointment it's often unsettling.

It's also a SERIOUS problem to beg for a work-in appointment and show up with your entire family to talk about "what we're going to do with mom".

2. Keeping mum about the herbs

Or anything else I need to know about. 'Nuff said.

3. Quitting medication without notice

I've learned to let this one go. Good Lord, if I had a dime for every time it happens? I'd be writing this from my giant beach house.

4. Give me the pill. I'm not going to exercise/stop smoking/eat right.

Well, I'm guilty of this myself, so I can't really get too worked up about it. I'm there to advise, cajole, beg, plead, laugh, mock, ridicule, convince, or anything else I think I can do to win the patient over to my side, even if my side is eating a donut and drinking coffee in a Lazyboy. It's important to do as I say, not as I do.

I did have a patient once--have I mentioned her?--she had a terrible heart, out of control high blood pressure, and diabetes, blah blah blah, all at the ripe old age of 38. Before her appointment she'd eat two pounds of bologna, a few bags of Twizzlers, a dozen donuts, and a Big Gulp of Coke. Guess what her blood pressure and blood sugars were? That got to me. I'm sure she's dead. That's if she's lucky and not trapped at a nursing home from the ginormous stroke which almost, but not quite killed her.

5. Hey, Doc, give me a prescription for ....

Fill in the blank. "That purple pill", "The 'Get it on' drug", "the pill my wife takes for her moods", or whatever the latest advertisement is on television. How about you tell me about the problem and I'll tell you about some solutions?

6. Test everything!

Again, you tell me about the problem and you and I will work on a solution.

Here's my own list of pet peeves:

1. "I need refills on all my prescriptions but I forgot what they are and I need them all today because it's the last day of my insurance."
2. "I know you told me that I couldn't have any more pain medication unless I brought in my old records from my awful back injury, but could I have more pain medication?"
3. "I know you're behind because you've just talked to me about 10 problems, but could I trouble you to look at this mole and check my hemorrhoids, and I probably should have mentioned that I've been having chest pain when I exercise?"
4. "I know that it's just a cold, but mine ALWAYS turn into a sinus infection. I need for you to give me an antibiotic to ward it off."
5. "I know you told me to go to the hospital but I didn't have time and now I can't move my right arm."

Homage to my father

My dad. To know him is to not understand him for a while. He tends to get distracted mid-sentence and shift to something else, usually related, although sometimes not. Unless you've been listening for a few decades it can be confusing. Even if you have been listening for a few decades it can be confusing, as if he shifted language a few times. Your brain has to be light on its feet to follow along. You keep Dad's landscape in your head while he's talking and move around with him trying to follow along with the effortless jumps he makes. It doesn't help that he, like me, is bad with names. There might be three "Jiggers" in a sentence, like, "I talked to ah, Jigger, about replacing the ah, jigger, oh, you know, I need that guy, ah, Jigger, to meet me after my appointment over at ....Linda? Did you call to reschedule the furnace guy? What's his name? Jigger?"

My dad is shy, although you'd never know it to meet him. Like many inherently shy people, he is relentlessly socially gracious, grateful that you made the first move. If you speak to him you will be rewarded by hours of warm, interested conversation. Once you've met him you have a friend for life. He might not remember your name or where you're from but he'll know about your family, job, struggles, successes, and probably your surgeries. And you'll know a lot about him, although you might not know how to put it all together until you've met a member of the family who can piece together the patchwork of details for you.

My dad is relentless in general. Slowed a bit now by a multitude of medical problems, his mind still moves non-stop. When my siblings and I were younger he moved non-stop. Cleaning, writing, gardening, talking, helping with homework (not math), cooking, and making lesson plans for the next day, this retired teacher moved through life at the speed of sound, leaving clean windows, vacuumed floors, loved children, home-grown tomatoes, and roasted chickens in his wake. Now he calls at random times to say how much he loves you and your children, or to ask about this or that. He stops by with candy for his beloved grandchildren who fly to his pockets to see what BopBop has wrought. He kisses, tickles, and loves his grandchildren, who he says have made him fall in love with his own children all over again.

He still works full-time as a clergyman. His faith and unshaken belief in God and people is a shiny, hammered, vibrant, living thing which enlivens his every move. Love and belief in the goodness of one and all flow from my dad like heat radiates from the sun. Goodwill bubbles over this charming, eccentric man.

When my father has been sick, almost as sick as I've ever seen almost anybody, he is still gracious. He thanks nurses for poking his finger for the 100th time. He smiles despite horrible pain. He calls me from the hospital to tell me to bring things for the staff. Sweat pouring from his brow from a first walk after having his chest ripped open, gasping for breath, he doesn't say, "I can't do it" to a therapist, he says, "I wonder if perhaps you'd be kind enough to help me back to my chair." He makes his daughter clean up the floor after an accident so he doesn't have to bother an aide, then he gives his daughter some money to go by a candy reward for helping him. He hates to call his doctors after hours because he knows they have families, like his daughter. He doesn't want to be a bother. He calls his physician daughter in emergencies to be sure he won't be bothering his physician by calling, say for a heart rate of 180 a month after open heart surgery. I sigh and head for the hospital knowing what will be coming, stopping for a good decaf coffee for Dad, heading off the request I know will be coming.

My father loves his family and his family loves him back. It's a big noisy, happy, wet, strong, loud, messy, palpable love. It grows and blossoms in a big organic kind of way. My mother's love is more reserved and tidy, but also unshakable, no less steely. You can't shake either. I grew up enveloped in a family which moved often and was demanding it its membership requirements. We all cooked, did laundry, saved money for vacations, cleaned, and participated fully in the life of our little experiment (thanks, JIB). I might have questioned the decisions at the time, struggling against perceived unfairness as I separated slowly from the fold. That my parents can sit back now with a drink and watch me and my husband struggle with my own children and their long walk towards independence is a source of enormous pleasure, I think.

To my father I offer up my thanks. Thanks for making me learn to roast a chicken. Thanks for giving me the "swimming like a shark" gene. Thank you for making me believe I could do anything. Thanks for teaching me to worry about people in the middle of the night. Thanks for teaching me to dig in and participate, to love my children absolutely, unconditionally, and relentlessly. Thanks for teaching me to try to love everybody like family, but to always make family first. Thanks for the hot dogs, the pancakes, English muffins, ham & biscuit casserole, mashed potatoes, and sandwich spread. Thanks for the walks, the hikes in the woods, the games of "kick the stick". Thanks for helping me with my Russian homework and my social studies. Thanks for being goofy and silly. Thanks for teaching me to always say "thank you" even if it's for somebody to chop something out of you, when the chips are down. Thanks for dropping everything to come over for a drink. Thanks for being alive after so many assaults to your person. Stay alive, please. I love you.

And while I'm being idealistic

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I started my new job this week. I'm still licking my wounds a little about the old one. I saw my old MA last week and growled at her when she said, "Nice to see you" because that implies that I don't see her every day, which I don't, but I really can't face that yet, so rather than cry immediately I yelled at her, THEN cried. Imagine how magic it must be to work for me!

Anyhoo, I've gone from being around 3 people every day to being around 120. Wow. Talk about culture shock. I'm also smack dab in the middle of academia, which is, wow, different from private practice, like ice is different from a bonfire. I find myself happily surrounded by smart physicians and mid-levels and am already enjoying very much chatting with smarty pants such as myself, kicking around patient issues, AND miraculously having a minute to chat and kick around patient issues.

But even more than that, I tell you, it warms my little cockles that all over the world there are doctors and nurses and janitors and phlebotomists and everything in between who put up with a whole lotta shit to help. Sure, it's a living, but there are other ways to make the money with much less stress, paperwork, crap (literally and metophorically), trauma, sorrow, and hard slog.

I must now go burn my rose colored glasses and don again my suit of cynicism.

The hospital you don't see

Image via Wikipedia

From Rural Doctoring today, a most lovely post:

A Sick, Unruly Kind of Love

I too have a love affair with hospitals, although am in remission in honor of raising children while being married to a workaholic in denial. As recently as this past January, post-surgery, walking the halls late at night, I found myself happily immersed in the little unique world of a hospital. Nowhere do you find such an eclectic collection of competent people, united in a single purpose with attention divided in a multitude of ways, over many problems with many patients. Quiet. Funky. Funny. Hidden little pockets of pudding. Unlimited ice. Fresh coffee at 3:30am. A world of uncrowded codes; desperately ill crashing patients followed by onion rings and Dove Bars, then a plunge into the always frenetic crashing world of the ER, black humor, drunks, gangrene, gunshots, more coffee, and when you least expect it, a moment of grace. A pretty, dainty ring on the finger of a wife, stroking her dying husband's hand. A new baby. The first human it sees is you. You! The sadness, the despair, and the competent, caring people who offer up antibiotics, time, shoulders, normal saline, muscle, and tissues far too small for any human being to use to actually wipe more than a fractionated tear.

Once you've been bitten you never recover. You may move on with your life, but you know it's under your skin.

Greetings, dear readers, from my first week of new gainful employment. So far, so good, although my heart remains too wrecked over the loss of my last practice to explore fully. I miss my staff so terribly. I miss my patients. But terrifically nice, welcoming new colleagues, lots of coffee, denial, compartmentalization, and a CRAPLOAD of laundry sure can make a transition boogie!

Thank you Starbucks and Tide Total Care.

He's Alive, Alive!

This is freaking amazing. Pardon me if you've seen it everywhere, but it really is cool. A soccer player edges towards the edge of the field and falls. At 7 seconds or so, if you look towards the upper middle of the screen, you'll see him falls DEAD (okay probably not quite) to the ground; at 15 seconds he gets blasted by his implanted defibrillator. His legs twitch a bit. THEN HE GETS UP! Holy crap. Serve me up a big helping of science like that, please.

Exercise, lookin' good, and dementia

The NYTimes does it again with some stunning photos, this time from an dementia night care unit (what a devilishly clever idea) . The photos are interesting, gorgeous, and moving. This could be you, me (in 50 years, thank you very much), your parents. Take a peak.

I love this particular photo because of the splashy slashes and dots of primary colors juxtaposed on the more institutional drab colors of real life; the wide angle and sense of standing in the room and surveying the scene; and because instead of stretching, one lovely lady is doing her hair with the exercise band!

NOT only the subject of the plague...

Raccoon eyes today from Consultant Live, a nifty daily little picture and narrative about some visual medical goodie. I love it. I pick up the feed on Twitter and it's like eating a little Tootsie Roll, only instead of calories I learn something. Sadly, unlike calories which stay with me forever ("a moment on the lips, forever on the hips") the learning instantly leaves my head.

I was actually studying today for my boards (yay for me!), reading the chapter in my review book called "Special Topics in Rheumatology", and as I looked at this image I was frantically running through the differential in my head:

Dermatomyositis? Not exactly a heliotrope rash....Definitely not a malar rash like lupus and what up with the subconjunctival hemmorhage? Crap! I am so, so infinitely stupid. This must be a gimme and I should know because I have read half that damn book. Twice. But maybe it's tricky! Maybe the diabetes caused him to have a hypoglycemic episode and he fell and has been walking around with a head injury. Where is he from? Could it be cellulitis from Hflu that he got from NOT BEING VACCINATED because he is an immigrant?

I came up with nothing, so I scanned the narrative. I was increasingly confused until I read that he couldn't pee and saw his BUN & Cre (very, very, very high). His prostate had locked the gate! Clearly a post-obstructive uropathy, which caused the poor guy to strain so hard that the pressure in his poor little capillary beds around the eye was too high and he oozed bilaterally. Oh my. Thank heavens arteries in his head didn't pop open.

On a completely random note, well, not completely as it's kinda related to prostates, I learned the hard way to warn Viagra-users about getting up to pee at night. Curled up under a nice warm blanket, one night after successfully using Viagra, one of my patients got up to go to the potty, something he did rather frequently at night as those of us over 40 are wont to do, especially those of us who are male and have prostates that are larger than they used to be. So, this guy is all vasodilated from being comfy and cozy in his bed AND he's vasodilated from the glow of Viagra and don't you know he stood up and passed out cold? Ouch. Thank heavens it didn't happen in the bathroom with a nice soft head striking nice hard porcelain causing a nasty evil nasal fracture, which could cause raccoon eyes.

There. I brought it all home.

Around the World with School Lunches

Via Slashfood, this:

School Lunches from Around the World

Oh, yes please to Japan, Sweden, maybe not China, Malawi, Korea please for at least six weeks, India, ah, France sort of, and maybe some tater tots from the US meal. And a corn dog. After all, I live in the Midwest.

Can you see a US kid--MY kid--sitting down at lunch to a whole fried fish? And not only not screaming and running out of the cafeteria in tears, but actually knowing how to eat it?

MY BABY IS FOUR!!!!

Thanks for the cake, Auntie C! And for the balloons, Uncle S.

Good food in a recession: Food you throw away is the most expensive food of all

Image via Wikipedia

Another great post from Cheap Health Good today. It's been a while since I expounded upon my dietary guidelines for patients. CHG's sensible advice spurred me on today, however:

How to Tell if a Recipe is Cheap and Healthy Just by Looking at it.

Cheap and healthy is good, of course, but if it tastes like, ahem, poo who cares? It's going to be wasted. Let's say you make quinoa kumquat ketchup burgers on whole wheat miso toast and you take two bites and immediately your colon blows and you want to sandpaper the taste from your tongue then set yourself on fire. Sure it was cheap and wow, are you regular, but you'll never take bite #2 and the recipe made 50 burgers.

As always, I find myself unable not to comment on other's advice:

Choose your source wisely: I'm not a huge fan of the Cooking Light/Eating Well brand. I'd rather just modify a recipe that I know tastes really good, or eat less of something combined with something less calorically dense. Flank steak, for example. I'd rather have a little of that over a lot of salad. Chicken tenders dipped in egg white wash breaded in whole grain bread crumbs doesn't turn me on. Tasteless poultry with tasteless wash with cardboard glue-like bread crumbs doesn't flip my switch. If it flips yours, great. See my cookbook post for some of my favorite sources. There's always the interweb for ideas, too

Do check the number of servings: Portion control, plain and simple. Again, though, if it looks yummy and you've got the stuff, how can you stretch it? Move veges in your pasta? More pasta in your salad? Whole grains in your rice? Think about food like silly putty, and add safe foods (whole grain stuff, starches, vegetables, vegetables, vegetables) liberally. There's no reason not to investigate exactly what the nutritional content is, too. There are only about 8000 programs online into which you enter ingredients and bingo, out pops nutritional information.

While you're stretching that meal, what can you do with leftovers? My family isn't big on sitting down to the same dinner again, even frozen one year later (assuming I could spare whatever it is horrible freezer burn). Chili we have as nachos or tacos later. Chicken turns into salad, salad, salad, and sandwiches. I can make almost anything into a soup or filling for an omlette.

Do read the ingredient list carefully/Do consider out of the box ingredients: And if something seems too expensive or exotic, wait. Save the recipe. See if you find the magic on sale later, or find another recipe to share. And broaden those horizons. If I've said it once, I've said it a million times, a trip to your local Asian/Indian/Hispanic grocery is not only fascinating, but it's like a little vacation. Like all good travel, you walk out smarter and with a good story to tell about something cool you found. Don't be Sam I Am, Green Eggs and Ham. Try it. Expand your dinner table horizons.

Don't dismiss recipes with long ingredients lists outright: Unless you're trying to get dinner on the table in 15 minutes flat. Then stick to short lists. Or prep before work.

Consider what you have in-house: Obviously, using up any leftovers, be they pantry items or not, is cheap. The more experience you get the better you'll get at substituting (or judiciously omitting) ingredients that you don't have or things which cost to much.

Do opt for whole food ingredients/Avoid processed: I like Rick Bayless' advice to shop the outside of the grocery. Produce, dairy, bulk, fresh stuff is usually on the perimeter of a grocery store. Make forays at will into frozen for veges & fruit and down the canned island cautiously. Skip the snack aisle (and tell me what that's like....I'm drawn to it like a moth to the flame).

Watch out for meat and cheese: One chicken breast feeds my family. One pound of flank steak turns easily into two meals. Yes, occasionally have a thick burger or small filet. Or a brined pork chop. Or brat from the grill. With a giant salad. GIANT salad.

But don't take my cheese. Seriously. Stinky cheese and I are inseparable and I won't give it up. I'd kill a guy for cheese.

Calculate oil grams: Seriously? Not for me. I don't care. I just make sure I'm not deep-frying and I use only olive oil when I'm cooking. Occasionally canola. I have little kids. They need fat. Counting anything is tedious and dull for me. (Can you tell? I don't budget, either.)

Don't rule out fatty ingredients: Oh, Lawsie no! Nuts, avocados, olives, eggs, please. Please. More.

Safe techniques (beware boring): Baked, grilled, roasted, steamed, sauteed. Put me down for braise, please, and grill. Bake and steam tend to bore me and sautee is usually an intermediate step with butter.

Beware fried, au gratin, creamed, bisque, lard, etc. You know the drill. I refuse to rule out small quantities of bacon, however. Refuse. So little bacon can do so much to a meal.

Bon appetit!

PS: If you're bored, here are some of my oldies but goodies:

Food Glorious Food: Bourdain vs. Waters
Budget Food Ideas for the Dietarily Challenged
My Mini-take on Diet, Part I
Le Teeny Budget et Le Healthy Dinner
Mindfulness and Conscious Eating: Bah, Humbug
Also on the Menu: The River Cottage Family Cookbook

Hey, and while I'm thanking science deniers...

You know who you are. Put down you iPhones. They're loaded with chemicals which will render you stupider. Gaze upon the images in this video (before you throw out your computer since it too is loaded with scientific things and is a portal for smart and sensible thoughts to invade your brain) and THANK YOURSELVES that polio isn't gone! It can make a comeback. DO NOT VACCINATE your children, unless, that is, you'd like for them not to be paralyzed or dead. I'm selfish. I prefer my children breathing and moving around, even if it means I have to cook them the odd meal and wipe a few noses now and then, okay, every day about 50 times.

Book Report: Heaving Bosoms and the Plague

Image via Wikipedia

I just finished my lastest romp through history. I left the Middle Ages, briefly, for a jaunt in Restoration England with Charles II. The book was Forever Amber. I was expecting extravagant gowns, heaving decolletage, and secret assignations. I was not disappointed. I was pleasantly surprised at the fabulous and detailed historical and political landscape during the Restoration. I was also quite pleasantly surprised by the complexity of the characters (when they weren't heaving or gaping or mooning at each other).

But what I was MOST intrigued by was the plague. I'm endlessly fascinated by the plague. FOUR DOLLARS at Kroger cures it (Doxycycline). Millions of people have died! I'm sure the vaccine denialists would curse those damn dreary SCIENTISTS who sat for boring hours in their dreadful little labs trying the hurt us all by getting in the way of a natural death. I, on the other hand, am grateful. I don't want the plague or polio, or tetanus, or Hepatitis B thanks very much. Sign me up for antibiotics and vaccines.

Back to literature. This from emedicine about the plague:

• Bubonic plague
  • Patients most commonly present with this form of plague.
  • The incubation period varies but usually lasts 2-6 days.
  • Patients have a sudden onset of high fever, chills, and headache.
  • Patients also experience body aches, extreme exhaustion, weakness, abdominal pain, and/or diarrhea.
  • Painful, swollen lymph glands (buboes) arise, usually in the groin, axilla, or neck.

Yawn. This from Forever Amber:

Once or twice Bruce began to retch and each time she ran to hold the basin and help him sit up, covering his chest with a clean white linen towel, and at last he vomited again. When he tried to get out of bed she forced him back and brought him the urinal, and now she saw that there was a tender-looking red swelling in his right groin--the beginning of the plague boil. The last of her hopes died quickly.

Wow! Our heroine (Amber) cares for her beloved, Bruce, without the benefit of doxy but with the benefit of superstition. Recipe from the book to science denialists for plague treatment:

The room stank, for all the windows were closed. She was not afraid of the night air herself but she shared the common belief that it was fatal to a sick man. And she clung superstitiously to the country belief that if there was a serious illness in the house death would not come if all the doors and windows were kept tight shut and bolted.

Good luck with that, science denialists. Remember to bleed your bile to restore your humors! But back to science, in this case, emedicine:

Pharyngeal plague causes pharyngeal erythema and painful and tender anterior cervical nodes.

Bruce's pharyngeal symptoms:

His tongue had swollen now until it almost filled his mouth, and it was covered with a thick white fur, though the edges were red and shiny.

Ouch. Can somebody phone me in some doxy just in case?

Emedicine on the buboe:

• Buboes are unilateral, oval, extremely tender lymph nodes and can vary from 2-10 cm in size. Femoral lymph nodes are most commonly involved. Patients with an inguinal bubo walk with a limp, and the affected limb may be in a position of flexion, abduction, and external rotation. Patients resist any attempt to examine the involved lymph nodes. Enlargement of the buboes leads to rupture and discharge of malodorous pus.

With all due respect to emedicine, I love you, but this sticks with me more than your rather dry description:

"Well?" demanded Amber. "How is he?"

The doctor gave a faint shrug. "Madame, you ask me to answer the impossible. I do not know. Is there a bubo?"

"Yes. It started to rise last night."

She turned back to the quilts so that he could see the lump in Bruce's groin, enlarged now to the size of a half-submerged tennis-ball; the skin over it looked stretched and red and shining.

"Does it seem to cause him much pain?"

"I touched it once, by accident, and he gave a terrible yell."

Later, when it bursts:

She dragged herself to her feet then and saw that the great swollen mass of the carbuncle had burst, as though the top at been blown off a crater. There was a hole deep enough and large enough to thrust a finger into, and the blood poured out in a dark scarlet stream that ran into a spreading pool on the bed and clotted thickly. A watery gland-fluid came with it, and yellow pus was beginning to work its way upward.

Later, Amber of course contracts the plague, which has the disadvantage of being so infectious despite amulets of unicorn and tinctures of cow pee. Bruce, recovering, needs the nurse's help to open Amber's buboe:

With sudden resolution Sykes jammed the razor into the lump, but as she did so Amber moaned and the moan slid in crescendo to a quaivering scream. Sykes let go of the razor and stepped back to stand staring at Amber who was struggling now to free herself, twisting frantically in an effort to escape the pain, shrieking again and again.

A clearer description of incision and drainage of an abscess I could not give. There's much more graphic, juicy detail in this book, harrowingly rendered. London during the plague is devastated, of course, and the author (Kathleen Winsor) renders the devastation in most remarkable detail, including the godawful nursing care, the helplessness of medical providers, the pest-houses where the afflicted were sent to die, the death carts which collected the bodies from homes and streets, and the mass graves for victims.

This book gets an IcedLatte A+ for summer (or winter) reading, historical fiction, and fascinating, accurate medical interludes. It's an excellent primer for the denialist camp for what to expect when you've got a dread disease that could easily be treated with SCIENCE. If not the plague, substitute a different constellation of symptoms and an iron lung for polio. THANK HEAVENS you skipped IPV. Render your child sterile by contracting the mumps. You'll never have grandchildren to take to the zoo, but maybe you'll get lucky and die of the meningitis your unvaccinated friend's unvaccinated kid brought home from college anyway. Or the flu! There's always the flu to kill you. You won't know what you missed at the zoo with grandchildren you never had! Want to see your child choke to death with epiglottitis? It'll be a gas. You'll be so glad you skipped the Hflu vaccine.

Kids: Is it quantity or quality?

Tolstoy with his granddaughter via Wikipedia

I read an interesting post a week or two ago on White Coat Underground:

The absent parent

If you read the post and the comments you'll see that I contributed.

The last comment has been bugging me. "Quality time is a myth".

Really? I've been home for a couple of weeks now, and I find that my kids don't want to spend every second with me. That's good, I assume, because the idea is for them to grow up and want to spend time with their friends, spouses, children, etc. Hopefully, occasionally with me and Monsieur Latte, but not exclusively with Monsieur and I.

What I find here, home between jobs, is that my kids aren't that interested in me doing the laundry; me on the couch doing my board review; me weeding the garden. They'll help for a little while but they are far more interested in playing Batman and "I'm a baby". They construct elaborate games with rules made up as they go, barking orders at each other. The games move from one room to another. Am I spending quality time with them?

They do the same thing when they're at their childcare center, only they're challenged by other kids, other's rules, other's implements, other's superheros. They interact with other kids and other adults. They're encouraged to explore other things, other activities, other things toys to play with and books to read. More things that I could ever have at home. That's not necessarily better than being at home, but I refuse to believe it's inherently bad.

On the other hand, I get restless at home and we wander off. Yesterday we went for a hike at a park; drove around the southern part of the county, and stopped to buy flowers which we planted later. That's different from school. Today is boring, though. Laundry and straightening up. I think they'd be happier at school. Happy isn't always better, though. Being bored is okay too.

If I didn't work at all, I'd spend a lot of time clipping coupons, making clothes last longer, searching for deals, finding kids for my kids to socialize with, making giant cheap casseroles, cleaning my house, and making ends meet. Or my husband would work more to make up for our lost income and he'd have less time with the kids. As it is, I don't spend any time clipping coupons. I buy mostly what I want, mostly when it's on sale. I don't clean my house, and we eat pretty well. We go on vacation together and when I'm not at work we do fun, sparkly things together since I don't have to clean the house and we have the funds to play, play, play. I'm not talking about extravagance. We just don't have to count every penny. Daddy and Mommy are happy because we're not worried about a roof over our heads. My kids are pretty happy, I think, and relatively carefree.

It seems to me this working mom/stay-at-home mom thing is a bit of a luxury, anyway. Waaaaaay back when, children worked as soon as they could walk and start mashing grain into powder or hunt with the big, strong males. They raised crops, tended to the home, practiced the family trade, or went off to work in factories and got married at 13 and started having babies of their own shortly after. With the rise of the middle class, women started to have the luxury of selecting what to do and when to do it. If childcare proved tedious there was always a nurse, or even a WET nurse. It's nice that I can even consider staying home, but hasn't been the rule for a lot of history and it's certainly a luxury for a lot of families. "Luxury," though, kind of implies "desirable" which being at home with your kids might or might not be.

My way, I think, works pretty well for my family right now. It might not later and we'll adapt. I would never presume to draw conclusions for anybody else's family however. What works for you might not work for me. What works for your family now might not work for your children later. What does work for me now keeps my kids feeling safe, loved, interested, occasionally bored, well-fed, well-reasted, and giggling. What more could I want for them?

Why kind of statement is "Quality time is a myth"? It's perjorative and just plain wrong I think. Everything, everything in life involves trade-off and compromise. One size does not fit all. Back off, dude, mind your own store. I've seen hundreds, THOUSANDS of families in action now, and I can tell you, Tolstoy was only half right. Happy families and unhappy family are happy and unhappy in their own unique ways.

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• Sofia Tolstoy's diaries paint bleak portrait of marriage to Leo (guardian.co.uk)

Read with Caution: E-prescribing for Idiots

Image via Wikipedia

Courtesy of The Angry Pharmacist, who always makes me laugh and cringe in the same post. Read the original if you dare. He's (he?) is quite angry and his language can be, ah, rather ah, colorful.

Before giant, nation-wide mandates for electronic records and e-prescriptions are implemented, however end-user input interesting to me. Take this:

Next time you are at work, tally up how many refill requests you send to doctors a day. Now multiply that by $0.30 (ed: the present cost of via a middleman like SureScripts to transmit an Rx to a pharmacy) and figure out how much a month that surcharge will cost you. You think that the doctors are paying thousands of dollars a month for this “service?” No! The brunt of the cost is placed firmly on the backs of the pharmacies who get forced into this service by the doctors. Wait, it gets better. You know that idiot in the doctors office who points-and-clicks their way to that eRx? Well if they screw up and make any changes (and resubmit it to you), its another $0.30! Oh, but this time you’ve already filled the Rx and now have to RTS and redo everything.

TAP maintains that "eRx provides absolutely no cost or time savings for pharmacies or pharmacists."

1. We have to retype /everything/ due to a lack of a standard sig code table between the 1000’s of pharmacy software vendors out there. Not to mention that every pharmacy system has the drugs entered in differently as well.
2. It costs us $0.30 for the “privilege” of receiving an eRx, $0.25 for the NCPDP transmission, another $0.50 for the vial and label, another $2 for the labor, and when you’re dealing with horrible PBM’s (mostly MedImpact, MedImpact, MedImpact again, MedImpact and BlueShield), you only make $drugcost + $2. You lose money with every eRx you get!
3. If the person typing in the eRx makes a mistake, its another $0.30. If you fax it back for something that’s not covered and they respond via eRx, another $0.30.

Interesting. He goes on:

You see, the “old fashioned way” doctors had to sign each Rx they gave out to the patient. However those days are long gone thanks to ePrescribing. Now all some idiot has to know is the doctors password and ANYONE IN THE OFFICE CAN SEND OFF PRESCRIPTIONS. That’s right, this bullshit doesn’t save the pharmacies any time, but it saves the doctor a bunch because its pretty much giving anyone who works in the office the power to sign and give patients legit prescriptions (even for controlled substances!) Before, you had to steal the doctors pad and write out phonies, now anyone in the office with access to the eRx terminal can splatter out narcotics to every pharmacy that takes eRx’s and nobody would be the wiser. Oh wait, SureScripts is all about safety and quality.

Dr. Grumpy responded:

Regardless of what your government or insurance company tells you, e-prescribing is a pain in the ass. It is free for me to do it, but your unfortunate pharmacy is paying around 30 cents a script each time your doctor sends this crap over the internet.

It takes me, literally, 3-5 minutes PER DRUG to send this over the internet, with a decent high-speed DSL internet connection. As opposed to the 1 minute or less for me to neatly write it out, call in, or fax in.

I don't have any personal experience with e-prescribing, but I do have CRAPLOADS of experience real-life prescribing. While it causes my left hand to have a rather permanent claw-shape given the volume of Rx's I have been known to write in a day, I think while I'm writing. It's a few seconds to contemplate what I'm doing, the cocktail I'm handing out. Having 16 interaction and warning screens fly up at me I suspect would just be irritating and wouldn't cause me to think about the patient AND the drugs at the same time. When I'm concerned about interactions or side effects I look 'em up the old fashioned way. When I'm confused I call the pharmacist. We chat and I learn something inevitably.

Hmmmm.....Must think about this. More coffee.

Vaccines Cause Autism

Thomas Crapper, Courtesy of Wikipedia

Good LORD why won't this die?

I keep hoping the vaccine nuttiness will go the way of a few other oldies but goodies:

• The earth is flat
• Blood-letting is good for all manner of diseases, including but not limited to anemia
• Eclipses are because giants have taken a bite out of the sun
• It takes seven years to digest gum

It's a problem for me to accept some science, rejecting what is convenient for what sells your books and gets you on Oprah or Larry King.

But listen, I'm going to help anti-vaccinationists. You look like fools driving around in cars, talking on the phone, getting cold drinks out of the fridge. If you wanna have ice in your drink, you really have to get vaccinated. All those marvels are from the same wonderful world of science, and to reject one and not seem like a dribbling idiot, you really need to reject them all.

So I threw off my mantle of scientist last night and had a seance last night with my Ouija board, after I threw salt over my shoulder and sacrified a goat using aromatherapy. I obtained a list of messages from the great beyond for science denialists of all ilk:

• Willis Carrier wants your central air conditioning back.
• Henry Ford wants his car back.
• The Wright Brothers ask that you stop flying through the air in jets.
• The Romans want central heat back.
• Stop going to the grocery store, for heaven's sake because they use refrigeration.
• Stop flushing the toilet! Thomas Crapper wants it back.
• Alexander Fleming wants his antibiotics back. He hopes that you enjoy your UTI, and hope you survive pneumonia without medication.
• Alexander Graham Bell wants your phone back. Yes, your iPhone, too.
• A WHOLE BUNCH of people want your computer back. Geesh, that's LOADED with evil electrodes and wires and stuff.
• Ben Franklin requests that you unplug everything in your house because he wants electricity back.
  

Listen, denialists, I'm doing you a favor. Give back make-up, hairspray, razors, nails, anything commercially manufactured. I'm trying to save you from hypocrisy. Too badski if your appendix gets hot and you need surgery. We use science in the operating room! Sorry. Also sorry about how stinky you are, but it's hot outside and a cooling fan would use too many parts developed in labs everywhere. Deodorant might give you Alzheimer's anyway. God FORBID you should use toothpaste or mouthwash. Sure, your teeth will probably fall out, but you're probably not going to have much in the way of tasty food to eat. At least you'll get a lot of sleep, what with not having any electricity to keep the lights on, but no blankets please! Unless you make them from leaves and whatnot. You wouldn't want anything made on a loom in a factory. Why somebody had to invent that! The printing press, the cotton gin, tools! It's all so evil.

Find a nice cave; bury your heads under ground; and leave the rest of us to get on with our nice wine, air travel, and computers. We're all going to probably live a lot longer to enjoy it, what with aspirin, statins, antibiotics, and anti-hypertensives. I myself am going to enjoy no reflux today courtesy of a nice proton-pump inhibitor, and a good Zytec. That pesky all 100% natural pollen leaves me quite itchy and snotty. My kids will probably live longer than yours, too, since they won't be dealing with tetanus and polio and epiglottitis and all.

Anyway, leave it all and we'll talk. Only I won't be getting too close. Don't be offended, but you're naked and smelly....

Grumpily yours in search of a chemical-laced Diet Coke--Iced

PS Appropos of the above, a few nuggets of knowledge:

After all this time, Dr. Bob Sears finally tips his hand on vaccines, via Respectful Insolence
Should vaccines be compulsory, via Science-Based Medicine
Why health advice on Oprah can make you sick via Newsweek