Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Wednesday, February 28, 2007

The Customary Interview Link

Thanks to all for the kind accolades regarding my Grand Rounds hosting.

As is his practice, Nick Genes has posted my "pre-rounds" interview (ok, so it appeared the same day, but hey; so what?) at Medscape. As usual, I think he did a bang-up job with it.

Although thanks have been emailed, I'd like once more to publicly thank Nick for all his hard work, and for the opportunity to host GR. It was fun; which is to say, it satisfied the requirement of Part A of the 9th Law of the Dinosaur (see sidebar.)

Steroids

Corticosteroids, or glucocorticoids, are synthetic versions of the body's naturally occuring stress hormone, cortisol. When used for medical therapeutics, they are the ultimate two-edged sword.

When I was in residency (20 years ago) we had a patient who was a textbook case of just about every steroid-induced complication there is. His underlying disease was pemphigus vulgaris, a nasty autoimmune blistering disease of the skin. In those early days of immunomodulation, the only medication that worked for him was prednisone. But the many years he had been on it (at varying but usually fairly high doses) had left him diabetic, hypertensive, osteoporotic, buffalo-humped, weak, and with purple striae, central obesity and peripheral muscle wasting, acne and cataracts. He was a mess.

On the other hand, the classic steroid-responsive disease is something called polymylagia rheumatica, which I actually diagnosed and treated a few months back. Literally overnight, an elderly gentleman with debillitating pain and weakness in his thighs and upper arms felt almost 100% better. I'll be carefully weaning him down off his prednisone over the next year or so. Hopefully he won't end up like my patient in residency.

Steroids are basically the most powerful anti-inflammatories we have. (Hence the general term for all the lesser ones as "non-steroidal.") They don't work instantly, in a matter of minutes or hours, because the drug has to be taken up by the body's cells and then transported into the cell nucleus, where it does its anti-inflammatory magic at the nucleic acid level.

All this by way of introduction:

Still so hoarse as to be essentially incapacitated after 5 days, I -- gasp -- went to a doctor. An ENT friend who scoped my throat (NOT fun; nostrils are my least favorite orifice to have messed with) and was underwhelmed. But he did suggest that a short steroid course would help me feel better faster. At that point, I was sufficiently miserable that I decided what the hell, why not do something totally out of character and try compliance with medical advice. So that night I took 60 mg of prednisone, as directed.

Prednisone pills are bitter and kind of hard to swallow, and I have trouble swallowing pills in the first place. I took them after dinner, as one of the side effects -- GI upset -- can be mediated that way. I've been told by my endocrine consultants that the best way to avoid problems with the body cutting back on its own production of cortisol ("why bother when there's plenty of prednisone around" is how the adrenal gland sees it; the problem is when the prednisone is stopped and the adrenal can't pick up the sudden slack fast enough) is to take steroids as a single daily dose in the morning. Because of the delay in action, I usually tell my patients to go ahead and take the first dose with their next meal, and begin the morning dosing the following day; that's what I did.

I am thrilled to report that I am at least 95% better. I was probably on the mend anyway, as my voice might have been marginally better yesterday, but I think the steroids were probably the difference between what I would have guessed about a 50% improvement (my guesstimate if I hadn't taken anything) and how I feel. I'm sure the good night's sleep I finally got played a huge role. But I am virtually certain that I am reaping the benefits of my steroid "blast" (what I call a three day course of 60 mg of prednisone.)

Thank goodness for modern medicine. I'm just glad I'm on the right edge of that sword.

Tuesday, February 27, 2007

My Blood is Boiling

NBC Nightly News with Brian Williams is trumpeting the HPV epidemic with the statistic, "1 in 4 American women is infected with the virus that causes cervical cancer." And guess what: there's now something that can be done to prevent it. Gardasil to the rescue!

About that opening statistic of "1 in 4": technically, no. Although 1 in 4 women may have HPV, only about a dozen of over a hundred types have actually been assiciated with genital warts or cervical cancer, so the number of women infected with those high risk types is correspondingly lower. The Associated Press piece from which the story is reported quickly backs off, but I heard those exact words quoted above. Myself. On TV. Less than half an hour ago.

I also heard these words spoken by Nancy Snyderman, MD: "Almost four thousand women die of cervical cancer in this country every year." That's playing with the numbers a bit. The projected figure for 2006 was 3700 deaths. I know, because I looked it up for my first post on this subject. The Associated Press piece used by NBC quotes 3670 as a projection for 2007. Projections. I haven't seen any data on actual numbers yet. Even so, anyone notice that the projection for 2007 is for FEWER deaths than 2006? HPV vaccination will have nothing to do with that, as the first possible benefits from vaccination today won't be seen for at least a decade, given the natural history of the disease.

The Blog That Ate Manhattan put it best (paraphrased; sorry I deleted your email):
A huge part of Merck's marketing strategy in the wake of the Vioxx debacle consists of selling this expensive vaccine to frightened first world women and their daughters.
If all the money that's going to be spent on Gardasil and other HPV vaccines were instead used to enhance basic gynecological services (paps and HPV treatment) and outreach to women who currently either don't have access or to help overcome the barriers to screening, those cervical cancer death rates -- already ridiculously low; the lowest numbers for all GYN cancers -- can be slashed even further, and in far less than the 10-12 years it will take for Gardasil to "prevent" its very first case.

Thanks, Mr. Williams. Now I'm going to be fielding calls for weeks from adolescents and their mothers whom you have scared shitless. Nothing new here. Stick to the stock market crash. Please!

(Yes yes yes: I know all about the supposed reduction in abnormal paps and treatment for HPV induced dysplasias and all. But it still makes my blood boil.)

Grand Rounds 3.23

In the beginning, there was the Big Bang; followed in short order by the dinosaurs, polyester, HMOs and the internet. Although the crowning achievement of creation -- Grand Rounds -- has already been accomplished, the only thing we can be certain about is that things change. The more they change the more they may stay the same, but they still change. So welcome to Grand Rounds, the weekly round-up of the best of the medical blogosphere, where we'll expore what's old, what's new, what's changed, what hasn't, and whatever else happens to strike our fancy.

The oldest of the old, of course, is the juxtaposition of life and death. MedStudentGod at Creating the God Complex describes his introduction to that emotional seesaw when the two careen out of control. Wyatt of Foggy Bottom Lantern provides a provocative post about dying on schedule. Kim of Emergiblog offers a harrowing description of a near miss, and reminds us of the life and death nature of addiction.

Birth doesn't always go wrong, of course. In fact, the opposite is true the vast majority of the time and so PixelRN is changing over to a midwife practice, a move I personally approve of heartily.

Nurses, it seems, have been around forever. Or nearly so, to hear Nurse Ratched tell it.

Once upon a time, children were children, and the words "Sexy" and "Girl" were understood not to go together. Nancy Brown decries the sexualization of children at Teen Health.

Does anyone else remember a time when Pre-Med was an actual undergraduate major? Welcome Vitum Medicinus to the blogosphere with his neo-Latin terminology and reminiscences of simpler times.

Speaking of which, when did "health" become thinking outside the box? The Fitness Fixer discusses this nicely.

Some things that are gone are not missed; least of all because of what they have left behind. Pearls and Dreams convincingly describes how the 1950s aren't necessary anymore.

Some procedures have virtually disappeared as our understanding of the diseases they treated were revolutionized, as Dr. Bob Centor points out about ulcers.

Some things are still here but shouldn't be (or at least shouldn't be used nearly as much as they are.) Xanax is one of them, according to Shrink Rap (and I agree.)

But enough of the old days, because the newest of the new is pretty exciting. The discussion of a new insulin delivery system ("don't say pump") at Diabetes Mine is nothing short of amazing. However marvelous the technology is, though, Sandra Miller at Shot in the Dark reminds us of the toll it still takes on the youngest diabetics.

Some of the new things still need some tweaking, of course. Manu Varma at Transplant Headquarters discusses the pros and cons of changes in the criteria for kidney transplant allocation. While surgical staplers are great gadgets, Sid Schwab still finds glory in sewing guts the old fashioned way.

Chronic Babe points out that the only way to really change is to let go of the old. Sometimes all you have to do is change your colors, according to Mom MD. Sue Palwick of Rickety Contrivances of Doing Good (what a great name for a blog) discusses a fascinating new way to look at the medical history.

Computers, while certainly in the "new" category, are also changing continually, as Dr. RW describes his first twenty years with them. The internet in general and blogging in particular are also relatively new, and Rita Schwab of MSSPNexus Blog points out that until a few years ago, she never could have imagined what she's doing now.

The old and the new aren't always so easily distinguished. There are times when old conditions garner new understanding, as both Difficult Patient and Moof point out in their discussions of Asperger Syndrome. Rare diseases, while also not new, need to be brought back to our attention from time to time, as Science Roll does with Pompe Disease. And sadly, some things never seem to change, as Sandy Szwarc of Junkfood Science tells us yet again that medical care of the obese is so much more than "just losing weight."

Whether we like it or not, alternative medicine has become enough a part of our patients' lives that it behooves us to at least address it, as Liana of Med Valley High puts so elegantly.

The business side of medicine is also changing, and David Williams at the Health Business Blog discusses the new phenomenon of Retail Clinics purely from an economic perspective. A newer blogger, poeMD, presents the most eloquent (and poetic) descriptions of how medical practice has changed -- and not for the better -- in recent years, with Prayer Pills.

Sadly, it seems that big business will never change. PreMedPilot certainly calls it like it is, without mincing words like "parasite." And just when you thought Big Tobacco couldn't stoop any lower, Anxiety, Addiction and Depression Treatments lets us know that they do.

As February changes into March, Dr. Deb Serani reminds us that March 1st is Self-Injury Awareness Day.

Finally, apropos of nothing much, a story heard before but given a fresh spin with wit, panache and peanut butter M&Ms by Sowing Mild Oats: the not uncommon tale of needle localization breast biopsy marvelously titled Mammosity.

And in closing, we offer the last random word to the venerable Dr. Dork: to dream, perchance to sleep.

Thanks for tuning in to this week's edition of Grand Rounds. Don't forget to join us next week at GruntDoc for a special treat: Grand Rounds without a theme -- for a change.

Saturday, February 24, 2007

It's That Time Again

Tuesday rolls around so quickly each week, and now it is finally my turn to formally request submissions for the coming edition of Grand Rounds. For those with a right-sided hemianopsia (inability to see to the right, where my sidebar topped by the words "Grand Rounds" is located) let me re-hash the following:
In keeping with the theme of "I'm not dead yet", what do you remember from long ago that has disappeared, even though you thought it would last forever? Or, conversely, what's new in your world that you never in your wildest dreams could ever have imagined? Or: what did you expect to be temporary or fleeting that has, to your surprise, stood the test of time? (Basically anything about change, or lack thereof.)
On the topic of GR themes: although I present myself as an opinionated curmudgeon, I am in reality more of a pandering wuss. Therefore themed submissions are OPTIONAL.

Submissions should be sent here, preferably with the words "Grand Rounds" included somewhere in the Subject line so that I can more easily sort them out from offers to enlarge my mortgage payments and shrink my penis by purchasing Xanax, Vicodin, and other non-prescription substances.

Friday, February 23, 2007

Primary Care and General Internal Medicine

Dr. Bob and Dr. RW, among others, are in the midst of a discussion about the identity crisis of the General Internist: who they are, what they do, and whether or not they are becoming obsolete.

Let me see if I understand what they're trying to say. Here's DB:
I personally reject the primary care label to describe general internal medicine. Internists are specialists, OK? Internists are not just “doctors for adults” as the ACP defines them. Not even “general” internists.
Ok. They're specialists:
I view general internal medicine as the specialty of complex care of adults. Our patients span inpatient, outpatient and nursing home. While we can do some primary care, we tend to attract patients who have multiple diseases. Our skills are diagnosis and juggling multiple diseases.
So how would you like to get your patients? Not under the fragmented, laughable free-market melee currently mislabeled the "healthcare system," but if things worked the way they should.

Primary care is defined as the first doctor you go to when there's something wrong with you and, theoretically, you don't know what it is. You may think that if you have chest pain you should just go straight to a cardiologist, but because many other things can cause chest pain you're often better off going to a primary first, so that if you do need a specialist, it's more likely to be the right one (cardiology, pulmonary, GI, etc.) Family Practice is the specialty that provides specific training in primary care. Not just triage, either: we can treat about 90% of the problems we see. Referral is not a failure; it's just not always necessary.

People aren't born with multiple complex conditions. Of course there are exceptions, but I think most internists would run screaming from the care of an 18-year-old former micro-preemie with all the sequelae of a NICU graduate -- an adult with multiple, complex diseases -- preferring to leave them for the family docs or the noble pediatricians who got them this far.

I see young healthy people who, rumor has it, grow older and develop diseases. I can diagnose and manage hypertension. I can diagnose and manage diabetes and hyperlipidemia and metabolic syndrome, along with arthritis and GERD, and so on across the board. Describe to me when, who and why I should refer to you? I am more than just a referring gatekeeper. If I have a diagnostic challenge, I am just as capable as you of researching it and, if specialty care is required, determining which specialist's bailiwick is appropriate.

Do you expect me to say something like this: "Well, Mrs. Smith, now that you have multiple complex diseases, I think you should be under the care of a specialist. I'd like you to go see an Internist. They won't provide your primary care [what exactly is that in this context? Immunizations?] but because they enjoy the complexity and diagnostic challenge, I think you will benefit from their style of training and deeper understanding of complex diseases."

Huh?

Patients don't walk in the door with neat little labels on their foreheads saying "Straightforward Problem," "Multiple co-morbidities," or "Atypical presentation of common problem." Sorting that out is the purview of Primary Care, defined as the doctor who gets "first crack" at a patient. Perhaps that's why your colleagues are trying to enhance the primary care aspects of Internal Medicine.

One of the most important things specialists must do is recognize their scope of care, and realize that outside that scope, other specialists are better qualified to render care than they are, even if they could. A cardiologist who has determined that his patient's chest pain is not cardiac, and strongly suspects it is gastrointestinal in origin, is perfectly capable of ordering an upper GI study, but out of respect for his GI specialty colleagues he defers that decision to them [especially since an upper endoscopy is often a better first test.] As an Internal Medicine Specialist renouncing primary care, what are you conceding that Primaries do that you don't (or, what do we do better than you?)

That said, I agree there are settings where your special expertise in complexity is useful. I speak primarily, of course, of the hospital and the nursing home. Because Americans today are more mobile than ever before, I can also see a role for you taking care of Mama, brought up from Florida who's having problems with her sugars along with her valvular heart disease, borderline renal function, hypertension, CAD, etc. If you want an ambulatory practice, consider limiting it to patients referred by other docs. I wouldn't mind having someone I could send a puzzling patient to once in a while, to help me figure out what's going on, but the respect needs to go both ways.

Once you present yourself as willing to take care of anyone who walks in the door, you are by definition offering Primary Care, whatever you call yourself. If you see yourself as a specialist -- and want to be treated like one -- it's probably best to start by acting like one.

Thursday, February 22, 2007

Handicapped

I have a cold.

No big deal. Not really.

It began a few days ago with a sore throat; little cough; some sneezing. Headachy; nothing that couldn't be controlled with a little tylenol (when I'd remember to take it.) Not sleeping well at all, so I've been running on empty at the office. It's been ok, though. I was able to get out an hour early today and go home for a nap.

Starting last night, though, the cough changed. It moved from the "deep in the chest" kind of cough back up to a back-of-the-throat kind of cough. You know; that annoying "trying to clear your throat" combined with post-nasal drip kind of cough. Annoying, because the cough doesn't "scratch the itch."

Somehow or other, I have wound up with what feels like a sprained larynx.

As it happens, I am no stranger to laryngitis. I often finish up a cold by losing my voice, which of course takes longer to come back than it would if I were physically able to follow the advice I give my patients with laryngitis: voice rest.

But as today has progressed, what started out feeling like a simple upper respiratory infection has left me virtually mute. In typical laryngitis, speaking in a normal tone of voice takes the effort of shouting. I cannot even do that. I can barely whisper. It doesn't hurt in the way a sore throat hurts (sharp mucosal pain, worse with swallowing) but more in a muscular aching kind of way. I can almost feel how swollen my vocal folds must be. It's even more difficult to cough up the scant sputum that still rattles around my lower trachea, and I get the sense that I'm making things worse with every cough. I've got tylenol and guifenesin in me to control the headache and thin the mucus, and I've had three big mugs of tea since I got home. The problem is the sudden impossibility of something I've always taken for granted: speech.

My spouse can't hear me, and I'm just at the other end of the couch. I have to repeat myself three times, often eventually croaking out the words. I paged someone earlier today, and when he finally called back I could barely make myself understood. Today at the office I already found myself asking my staff to make calls I would usually have made. If the phone rings tonight, there's no way I'm going to be able to answer it. Each day this week has been worse than the day before. I don't know what tomorrow's going to be like.

I'm reminded of when I broke a bone in my foot about six years ago. Things previously taken for granted because they were so easily accomplished became much more of a project. Little things, like getting up to go to the bathroom. Find the crutches; hoist up off the couch; hobble over; etc. I find the same emotional reactions coming into play now. Is what I have to say really that important, given how much effort it now takes? More times than one might imagine, the answer is no.

What about work tomorrow? I'm going to have to talk and it's not going to be easy. (It'll be better if I get a good night's sleep, which remains to be seen.) But perhaps it'll be easier to listen more. I won't be so quick to interrupt my patients' stories (though I usually don't.) I'll have to ask my staff for more help, which is never easy for me to do. Most of all, the fact that something so natural, so easy, something that doesn't usually require a second thought has suddenly become such a struggle, is exhausting.

I hate being sick.

Tuesday, February 20, 2007

Do You Write Like a Man or a Woman?

Found via a post at Forward Motion, my online writing community (where I've been merely lurking for way too long now:)


Copy and paste a block of text into the box. Indicate whether it's fiction, non-fiction or a blog entry (although commenters at FM have experimented and found no difference in scoring depending on which is chosen) and then click "submit." There's a note that it works best on selections greater than 500 words.

You end up with numeric male and female scores based on what they consider masculine and feminine key words (different in different languages) along with a color coded version of your text with the key words highlighted. The Genie makes its male/female guess on whichever score is higher, but it's also interesting to compare passages with larger or smaller spreads between the two scores.

Evaluating its accuracy (ie, the rate at which it correctly identifies the gender of a particular piece's author) I leave as an exercise for the amusement of others. For what it's worth, I think writing in such a way as to equalize the M/F scores would be an interesting goal.

Saturday, February 17, 2007

Another Find (Kid's suggested title: Something to Read After Lunch on a Tuesday)

Once again, an amazing new web site discovered via Miss Snark:


Not only is it utterly hilarious, but it garnered the adjective of ultimate praise from my son, the geek: "That is so random." Here's the first paragraph from their "Answers to Questions & Accusations" page:
Johnny America (ISSN 1553-9177) is a little magazine of fiction, humor, and other miscellany. It is published about twice a year by the Moon Rabbit Drinking Club & Benevolence Society. It’s also this web site, updated frequently and with much affection. ‘Johnny America’ is the name of the journal, of the web site, and of the svelte rabbit who lives in a bungalow on the Moon between two rivers of wine (one red, one white), from who both literary endeavors take their names. It is not the moniker of any human individual likely to answer correspondence.
Another sample, labeled "Other Miscellany":
People truly ask, so we’ll answer: the typeface we use for the magazine is ‘Perpetua,’ designed by Eric Gill in 1928. It’s named in honor of Vibia Perpetua, the patron saint of cattle. A Roman Christian, Emperor Severus sentenced her to death by stampede when she refused to deny her main man J.C. After a mad heifer trampling through an arena failed to do her in, she helped guide a nervous gladiator’s sword to her throat and her martyrdom was cinched. You were a strange girl, Perpetua, but you inspired a lovely typeface.
Regarding the issue of payment:
Payment, if there is any, will come in the form of peculiar or amusing objects of negilible monetary value; a doodle of a mongoose on a coffee-stained napkin, for example.
And finally, there's the article titled (I kid you not) Ingredients in Many Brand Name Toothpastes that could be Trendy Baby Names.

They even ask for your blood type when you sign up for the mailing list.

Do you have any idea how hard it is to get a teenager to laugh at something you, the parent, find funny? As I sit here enjoying the absurdity of this site, my kid is cracking up over and over as he goes through it.

Now that is random.

Friday, February 16, 2007

Dinosaur with the Red Face

I swear I came up with Salmonella as a random example of a readily treatable, generally non-fatal disease to use as an analogy for my feelings about the HPV vaccine. Then yesterday I hear about the multi-state Salmonella outbreak attributed to peanut butter! And today I see a family with diarrhea and vomiting who've all eaten peanut butter from the affected lot.

I'd better not ever mention Bubonic plague.

Wednesday, February 14, 2007

An Oasis in Time

Due to the ice storm here in the northeast, I'm taking a Snow Day.

School was canceled for my kid, and I decided it was the better part of valor not to risk life and limb (not to mention fenders and side panels) trying to get in to the office just to be there to receive a return call from a medical director who received word that I was now an (illegal) boutique practice ("charging a sliding scale from $20 to $100"), a ridiculous misinterpretation of the letter I sent out regarding my new Administrative Fee. But that headache will still be there tomorrow.

So here I sit: laptop charged up (because the kid has commandeered the main computer) with the manuscript of my latest work in progress open; hours of long-canceled, beloved series showing on cable (JAG; Judging Amy; all the Star Treks -- original, DS9, TNG and Voyager); heater at my feet and surrounded by cats and dog on the comfy couch; and a book (The Kite Runner) to savor during commercials (when I'm not writing.) Thanks to the marvels of technology, I remotely forwarded the office phone to my home. Other than having answered calls from my spouse twice with the "office" greeting, it's fine. The phone has rung less than a dozen times, and virtually all calls were to cancel appointments today.

It's a lovely thing, this oasis in time. Due to circumstances entirely beyond my control, I have been granted a day off.

My son took the opportunity to talk with me. Really talk. "Important conversations" (his words.) About his summer job: he's been invited to apply as a camp counselor for four weeks. Should he do it, or should he get a job around home and hang with his friends for his last summer before college? What did I think? What did *I* think? It's entirely up to him. But he really wanted my opinion. So I gave it to him, and was rewarded with the comment, "That's probably one of the more useful conversations we've ever had."

This has been an intense year for him. Once in a while, he's asked me for a "mental health" day off of school. He works hard, is very conscientious, and has superb grades, so I have no problem with it.

But today is a mental health day for me. It feels good.

Tuesday, February 13, 2007

Grand Rounds: Give Me Some Sugar

Just in time for all the Valentine's Day hoopla (anyone know when it became Valentine's "Week"?) Grand Rounds is up over at Chronic Babe. (picture is the link)

Go.
Read.
Enjoy.

Then give your dentist a call.

Monday, February 12, 2007

A Gardasil Analogy: Killer Salmonella

Comments on my anti-Gardasil post have continued to trickle in. The general sense is that of disagreement with my position, and I must admit that my economic analysis was somewhat off-the-cuff. But I remain opposed to the vaccine on a pragmatic basis, which I hope to explain a little further here by way of an analogy:

Did you know that you can die from Salmonella? Really. Severe abdominal pain, nausea, vomiting and copious bloody stools can lead to dehydration and vascular collapse, which can be fatal!

Now what if I told you that for about $400 you could buy a special cutting board that could reduce (not eliminate) your chances of getting Salmonella? (And remember, you can DIE from Salmonella.) Wouldn't that be wonderful? [Note: the expensive cutting board piece is fictitious; everything else is real.]

Hopefully, you would say that's ridiculous. Salmonella can usually be avoided by commonsense precautions like avoiding the consumption of raw or undercooked eggs, poultry and shellfish. Even if you do contract Salmonella, it is eminently treatable with antibiotics and supportive measures to prevent dehydration. Although technically one can die from it, as a practical matter the only way to do so is if you don't get any medical care at all. Why spend such a ridiculous amount of money against a disease that isn't all that hard to avoid in the first place, and is essentially never fatal with relatively modest levels of medical care. And yet nothing I said above about Salmonella is wrong -- technically. The only difference is that it doesn't cause "cancer," which is a scary word.

That's my argument against HPV vaccination. I'm not disputing that HPV -- left untreated for many years (10-12) -- can cause cervical cancer. I'm not disputing that Gardasil can reduce (but not eliminate) the chances of contracting high risk strains of HPV. But early stage HPV disease is eminently treatable, and completely avoidable via abstinence (of which I am an advocate in principle, although not a "Just Say No" fanatic.) Finally, it is virtually impossible to die of cervical cancer unless you never see a doctor.

The vaccine costs $120 per dose, with a recommended 3-dose schedule. The jury is still out on booster doses at this time. That's a pretty hefty sum spent to reduce -- not prevent -- a disease that, with usual medical care, will never occur. Yes, it may cut down the number of abnormal paps, but it still seems to me to be too little benefit for too great a cost. The appeals made by advertising are to the emotions provoked by the word "cancer."

That said, in answer to the question about who should get it: anyone with enough money to spare, to whom "peace of mind" is worth it.

Don't even get me started on a certain Governor who signed an executive order -- never mind bothering with the legislature to, yanno, pass a law -- mandating this vaccine for all 11 and 12 year old girls in his state. However much Merck spent to buy him, you know they stand to make it back big time.

Saturday, February 10, 2007

The Ozone is Falling, the Ozone is Falling!

Global warming is real. Also, I understand the critical role of the ozone layer in protecting life on earth from harmful ultraviolet radiation. Both of these important issues are the direct result of human activities, primarily the byproducts of the combustion of fossil fuels, although chlorinated fluorocarbons (CFCs) from refrigeration units are also implicated. I have no problem with these scientific assertions.

Here's the thing, though: the generic albuterol inhaler -- an effective, cheap, useful medication for which I write dozens of prescriptions a month -- is being discontinued because the propellant contains CFCs!

CUT ME A BREAK!!

Are they trying to tell us that all those little itty bitty inhalers with their few grams of propellant apiece are somehow so dangerous to the environment that they need to be banned, while the SUVs and Hummers -- you know, the ones with the giant internal combustion engines burning fossil fuels -- our patients are driving to the drugstores to pick up their replacement prescriptions for brand name inhalers that use environmentally friendly CFC-free propellants (but don't seem to work as well, even after patients become accustomed to the lesser "whoosh") are NO BIG DEAL?

Oh; did I mention that because the CFC-free inhalers aren't generics, they're much more expensive? Gee. What a lucky break for the companies that happen to manufacture them. Just another example of the haves further increasing their lead over the have-nots on the backs of all of us.

Please excuse me while I go plotz.

Friday, February 09, 2007

Update: Administrative Fee

It's been just a few weeks since the fateful letters went out informing my patients of my new administrative fee, and things have been hopping:
  • Bad addresses: not unexpectedly, each day we get a couple of the letters back.
  • "Please transfer my records": two families so far.
  • Phone calls: some.
  • Checks: plenty.
The phone calls are easily handled. People are reassured that they don't have to send the money before scheduling an appointment. We've also been emphasizing that it's optional. I plan to gradually become more hard-assed about not providing phone services and refills to non-payers over the next 6-12 months. It would be too abrupt to go from our present, extremely laid-back style to the opposite extreme of pay-now-or-pay-as-you-go without at least an informal transition period.

If I had it to do over, I would have included the "Rules" sheet that's posted in my office along with the letter in the mailing. That's where it's spelled out that you don't have to pay until you come in and that it can be waived for financial hardship. I think that's why folks have been sending in the checks, which of course has been very heartening. Even more so have been the little notes some people include. Things like:
  1. "Thank you for all you do."
  2. "Well worth it."
  3. "Just having the phone answered by a person is worth the $20.00"
Bottom line for this interim report is "so far, so good."

Thursday, February 08, 2007

New Definition of "Chutzpah"

From a discussion among FPs about undercoding:

Granted that we should all be accurately coding all of our services all of the time, nevertheless the question came up about Medicare fining us for undercoding. Was this possible, in that undercoding would seem to cost Medicare less?

Never underestimate Medicare:
A physician coded the wrong joint for injection (minor joint instead of major) and Medicare came along two years later and wanted a refund of their incorrect (lower) payment. It was then too late for [the physician] to bill the correct code/service.
I have now officially seen it all.

The Best Fractured Fairy Tale Ever

Well done, Angry Professor!

I love this: The Anti-Princess.

UPDATE: Apparently this blog has been changed to invitation only. I can't even get there because Blogger won't let me log in (even when I'm already logged in) to check and see if I'm invited. It's probably miffed at me for not having switched to new blogger.

I feel bad for the Angry Professor for whatever must have happened to make this step necessary. AP, on the minutest of chances that you're reading this, email me. I have several loyal readers who want to keep reading you.

Wednesday, February 07, 2007

The Envelope Please

And so we come to the end of a week of oh-so-elegant missives; letters that say "Fuck Off and Die" without garnering so much as a PG rating (for the most part.) I want to thank all who submitted their letters, whether created for the occasion or pulled from a file cabinet somewhere. Each was indeed unique and wonderful. I think you all should give yourselves a big hand ... and then pitch in to replace the keyboards you made me ruin with nasal emissions of coffee, cocoa and other assorted beverages.

So without further ado, the winners (links included):

Honorable mentions:
  • For pulling no punches: #1 and #26
  • For Romance: #10 and #16
  • Didactic: #8 (for big words) and #33 (for big sentences)
  • Medical: #13, #27 and #32
  • Literary: #19, followed closely by #21
  • Caffeinated Sinus Lavage (snorted with the first sentence): #20
The Runners Up (in NO particular order):
And finally.......

The First Place, Grand Prize Winner, the FOAD to truly end any and all other FOADs:

You have a rare talent. If you are not otherwise employed, may I suggest contacting Medblog Addict for a job at her firm, where I have no doubt your amazing skills would be put to excellent use. Congratulations.

Again, many thanks to all who entered, read and enjoyed.

We now return to our regular blogging schedule already in progress.

FOAD #34

Hey, at least you found a parking space:

Dear Ms. Ombudsman person,

I really appreciate that you took 4.5 minutes from your schedule to see me, while I was visiting your hospital on Tues. Without our visit (mine and yours) my trip would have truly been in vain.

Remember how I had to arrange to be off work for 3 days of testing at your facility? Also, how my husband had to miss work for the same period of time. How I had to PRE-PAY (non-refundable) to get the patient discount on the motel rooms your facility so graciously offer to their patients? Spending $249.00 per night, as opposed to the original quoted price of $269.00 per night for 3 nights, was really quite the bargain. Imagine how delighted I would be, if instead of being something we had no need for, we had actually gotten something for those 3 nights. Why, I wouldn't be able to stand myself.

After we had been informed that all my tests had been cancelled, due to my Doc needing to vacation during this week, I felt elated to be the recipient of the (4) free parking passes you insisted I take to make up for the terrible confusion. I can't possibly imagine how you could have been more giving. Well, maybe a simple phone call from his staff informing me that my tests had been cancelled would have been nice. Not to have made a 5 hour driving trip (one way) needlessly would have been a joy beyond words. But hey, we can't, nor should we, expect everything.

Now, when you again receive those same tickets back, once they have been used, please don't be confused if it is at a time that your computer tells you I did not have an appointment. One good turn always deserves another. Since I will no longer be visiting your facility, I did not want your kindness to go unappreciated. I handed those tickets out to (4) strangers in the parking garage, as we were leaving. I'm certain they also appreciated your kindness. I thought it only proper that I take the few minutes this letter has taken to write, to inform you of these changes.

Sincerely,

FOAD #33

Hey, it could work. (CMS? We don't listen to no stinkin' CMS!)

Dear Dr. Raoyhroduttatio:

I am writing in response to your letter dated 3/15/06, (copy attached), in which you purport to represent 14 “like-minded” physicians on the solution to no-doctor Emergency Department patients requiring admission to Our Lady of Perpetual Deficits, “Our Lady”.

As I understand your solicitation, you and your like-minded colleagues are willing to accept the aforementioned no-doctor hospital admissions in exchange for a daily stipend of $2500.00 payable to an account you will be opening at your brother’s bank in New Delhi. Your proposal adds that absent an agreement on the part of Our Lady of Perpetual Deficits to accept your proposal, you and your like-minded colleagues will cease admitting patients to Our Lady of Perpetual Deficits effective October 1, 2006.

I understand from a review of your Medical Staff file that you are relatively new to America; this might explain why you do not understand the implications of your solicitation. The Federal government, acting through the Centers for Medi-Care and Medi-Caid Services “CMS” has very clear guidelines for defining an appropriate relationship between a hospital and a physician. Please be advised that all of the elements of your solicitation are prohibited and open you and your like-minded colleagues to sanction by CMS.

In my role as the Chief Executive Officer of Our Lady of Perpetual Deficits I am subject to several of the CMS guidelines relative to physician business relationships. Were I to accept your solicitation I would be opening myself up to sanctions similar to you with one exception- I do not have Medical License to lose.

Being mindful of the potential personal, professional and business implications of your solicitation, I have sought advice from our attorney, Ms. Helen Waite, J.D., of the firm Waite, Dewey, Cheatum and Howe. Ms. Waite has advised that I limit my communication with you to this letter and that I advise you that you can expect to hear more about this matter after he has had a chance to review your solicitation with Ms. I.M. Amartyr, J.D., the Federal Prosecutor for the Great Lake States.

I wish to underscore the fact that I have been instructed to cease communication with you beyond this letter. Should you have concerns about this matter I suggest you go to Helen Waite.

Yours in Christ,
Sr. Mary Richard Attila, D.C.

FOAD #32

Eh? What was that?

Dear Elderly Deaf Pensioner,

Thank you for stopping by unexpectedly to see me this afternoon. Nothing pleases me more than to be torn away from the stack of work on my desk to give someone the oral version of a form letter. So while I've got your full attention, there are a few things I think I should make clear.

First of all, this is a research laboratory, not an audiology clinic. I can see how you might think otherwise - we have audiologists, Captain Hearing Aid colouring books, and cushy waiting room chairs - but believe me, they're not the same thing. So when you tell me that you've returned four different models of hearing aid to four different hearing aid providers in the past year and have now come to the end of your tether, don't mistake the look of benign sympathy on my face for interest. Again, like the laboratory/clinic dichotomy, they're not the same thing.

At an audiology clinic, you've got the starring role. You can natter away for hours on end about your hearing difficulties and it's perfectly okay, because they exist to serve you. But at a research facility, we recruit clients to meet our needs. If we're conducting a study on the effect of wide dynamic range compression on chinchillas with severe conductive hearing loss, and you're not a chinchilla with a severe conductive hearing loss, the simple fact is this: we can't help you.

Plenty of our research subjects get personal benefit out of volunteering with us, it's true. But ultimately, all you're really doing this for is a cup of government-subsidized coffee and the good of all the hearing-impaired people who will come after you. So as much as I'd like to, I can't wave my magic hearing wand and fit you with that elusive fifth set of hearing aids that will make all your problems vanish.

I mean, honestly, if I could do that, would I be settling for a researcher's salary?

Love,
Your Friendly Neighbourhood Research Audiologist

FOAD #31

I'm pretty sure I had this guy in college:

Dear Professor:

If academia were subject to consumer protection laws, I would be requesting a refund on grounds of fraud. I enrolled and paid tuition with the impression that I would be taught a college-level course by a person with a PhD. Instead I was often taught by an undergraduate teaching assistant, a heinousness rivaled only by the fact that he often did better than you. You also failed to return our papers, even the final project, and did not show up for either the final review or the final exam.

Since you sent me a strangely nasty and defensive e-mail in response to a reasonable request to learn the grades on my last two papers, I'm pretty sure you already know you have attained a level of irredeemable incompetence. I also know that you have some medical issues (because you whine about them in every class period), but unfortunately the university exists to educate students and not to employ disabled professors.

What really confuses me is why, a month after final grades were posted, you have sent me insulting and even more defensive e-mails apropos of nothing. It is obvious that I owe you a heartfelt apology: I must have given you the impression that it is acceptable to address me in that fashion, whereas it certainly is not. I do apologize for giving you that idea, and now I beg of you on bended knee to please fuck off.

Sincerely,

FOAD #30

That was my favorite store:

Dear Mr. Customer:

Thank you for taking the time to contact us regarding a policy change that you were not made aware of. This change was made January 14, 2002. In the months prior to this change, we posted signage in our stores and mailed out 10,000 flyers to our regular customers. As you have assured us that you’ve been a long-time loyal customer, the flyer we mailed to your home must have gone astray. We apologize for the inconvenience this has caused.

We made this policy change to help decrease profit losses. We understand you are not concerned with our profit margins; however, profit directly impacts our ability to serve our customers, buy quality merchandise, pay employees and maintain our stores.

We regret that this policy change has made it impossible for you to do business with us in the future and we are sorry to lose you as a customer. You are certainly within your constitutional rights to take your business elsewhere; we would however like to alert you that the company you specifically mentioned, Competition Industries, went out of business January 2001.

Again, we apologize for any inconvenience this has caused.

Thank you,
Fictitious Industries

Tuesday, February 06, 2007

FOAD #29

Anything for the kids!

Thank you for contacting our company regarding our exclusive line of futuristic toys and games. I can certainly understand how welfare checks alone would not provide enough hard-earned cash to be able to purchase luxury items such as high-tech gadgets and computer games.

Please be assured that we have carefully read and considered your letter outlining the unfair day-to-day responsibilities you are required to perform as a parent of six children from three separate marriages. As much as we are saddened to hear of the disappointment your children face during the holidays, having been promised that Santa would deliver the voice-activated computerized robots they saw while watching television--and yes, I imagine the robots do look especially impressive on your big-screen TV--we regret that we are unable to grant requests for free products.

There are many great toys out on the market. The classics, such as board games and sporting goods, continue to provide entertainment the whole family can enjoy. Also, you may be able to find quality second-hand toys offered at reduced prices by checking the classified section (where the employment ads are printed) of your local paper.

On behalf of the company, I wish your children a warm and loving family holiday.

FOAD #28

(The writer informs me that this letter was inspired by an actual case of identity theft and her perpetual fear of this really happening.)

Dear Mr. Police Chief:

I had the occasion to tour the new city jail last month and see how well my tax dollars have been spent. Unfortunately, my tour was from behind bars after I was falsely arrested for aggravated assault.

Two of your fine officers pulled me over the evening of December 10th, 2006 for speeding. My two year-old son was in the back of the car. He and I were both quite surprised when the officer suddenly pulled out his gun and ordered me out of the car so he could slam me against it and slap the cuffs on. When I inquired as to the nature of my rough treatment, he informed me I was wanted for aggravated assault. I told him it was a mistake as I had recently been the victim of identity theft and that items verifying my identity were located in my purse on the front seat. He then proceeded to call me lascivious names as he pawed at me, checking for weapons. There was a brief moment of panic before he verified the item in my pants pocket was actually a pacifier.

After spending a night in your lovely jail, I am disinclined to return and tarnish the memories of my visit. Instead, I will send my lawyer, Mr. Stewart Crumbottom, for all future communication.

Cordially Yours,
Penelope Dicgrabber

FOAD #27

How about an Ambien prescription?

Dear Madam (and I use the word advisedly),

Some weeks ago I ordered an eye mask from you to permit me the common luxury of sleep. I paid for express delivery and waited in anticipation.

That expectancy has since turned to anxiety. I fear the wheels may have fallen off your van and your delivery man been kidnapped by unscrupulous persons. Because of your many awards for customer care and employment excellence, I am sure you have already posted him as a missing person and have your minions scouring the city for news of him.

Knowing this neighbourhood as I do, I have sent out boy scouts armed with catapults and homing pigeons to locate and succour your undoubtedly acned messenger, who has, I suspect, been lured into a den serving potent drinks and fevered women who have taken his mind off his job and transferred it to his own gratification.

Perhaps selfishly, I feel that my own pleasure is more important than that of a thousand messengers, however pimply. I beg you to raise your eyes above your profit margins, retrieve your employee from the impure solicitations of the objects of his desire, fulfil your contract, and allow me the luxury of shielding my eyes from the blinding light of your incompetence in the sleep mask I have paid for. Otherwise I shall be forced to expend the little insomniac energy that remains to me in consulting my own solicitor.

Yours,

One Who Never Sleeps (thanks to you)

FOAD #26

Now that's what I call hardball:

Dear scurrilous bastards,

Your happy horseshit grows tedious. Produce the contract, or Ginger dies.

I regret that our business relationship has fallen upon such hard times. Our firm has tried to work with you in good faith, and we cannot begin to express the disappointment we feel in our hearts as we make this ultimatum.

Tender the contract and let the girl live.

Appalled as I am by your conduct during these contentious negotiations, I trust that cooler heads within your organization will prevail, and that you will ultimately make the right decision, for your business, and for your entire family.

Her deadline is noon tomorrow.

We trust that the potential loss of a loved one will not in any way affect our standing with regards to the Fuergeson contract, nor our ongoing relationships and future business ventures over the up-coming years.

Warmest regards to you and your family during this blessed, Holiday Season!

FOAD #25

Merry Christmas to you too:

Dear Mr. Claus,

Mentioned in the body of this letter is the gift I received from you this year. I gratefully acknowledge the "fishnet with something sweet in a stocking" as the card read, and would kindly like to wish you the same "joy" I received from you in the coming new year, one befitting the spirit and love you have shown me with this unusual prize.

As you may not know, I am presently residing at the BelFair Hospital in my home town, suffering from a rather nasty bacterial attack. It seems that the fishing net you placed in my stocking was covered with small microbes from the third world cess pool where you purchased the net. It is not hard to understand how wrapping the fishnet around the chocolate bars might transfer these pesky little critters to the candy. A more judicious Santa might have sent the chocolate under separate cover.

As a token of my esteem for this little adventure, I have decided to set out some special cookies for you this year. Bon Appetit!

In closing, I would suggest that you take a moment to have your dyslexia checked and corrected as needed. What I asked for was "something sweet in fishnet stockings." Both your gift and my request are useful items, but hardly interchangeable.

Guess Who.

Monday, February 05, 2007

FOAD #24

I didn't realize this writer lived in my neighborhood:

Hey, Kelly,

It's your neighbor yet again. I like your dog as much as the next person, and I understand that it's really difficult to count food stamps, watch your six kids, and vie for your spot on Maury's show (too bad you didn't find your baby's daddy...I thought for sure it was one of those four) but I have a favor to ask. Since you're still not employed, do you think it's possible to maybe pick up after your dog? Surely you could use some of that dog crap to fertilize all of those beautiful hemp plants you have growing in the basement.

Thanks for understanding!

FOAD #23

The PS is the kicker:

McGriff Pools and Fountains
1220 Wewatta Street
Denver, CO

Dear Mr. McGriff,

Amazed. Dumbfounded. Incredulous. These are three of the happier adjectives to describe my feelings about the "pool" you've built us. Being a big fan of the movie Spinal Tap, I suppose I should appreciate the humor in having a twenty-inch by fifteen-inch swimming pool in my backyard, but the situation is far from humorous. At six inches deep, the pool gives new meaning to the words "watering hole."

I realize that you're a very busy man. In fact, before I left that morning, you spent over two hours on your cellphone trying to convince someone named "Lucinda" that you didn't give her "the nasties." What's more, the rest of your crew didn't seem to have time to step around our flower garden or to use the facilities when urinating. Still, I would have imagined that you would have taken a moment to study the details of the job, particularly the difference between the symbols for inches (") and feet (').

Now, I'm not sure from which evolution-free pocket you and your staff arose, but as a whole you seem to have been spared the burdens of common sense, intelligence and, as my children pointed out, hygiene. Even my cocker spaniel could have figured out that nobody wants a twenty-inch swimming pool. I am therefore returning your bill for $3,500 unpaid.

Sincerely,

ps. From the way you were scratching, I'd bet you DID give Lucinda the nasties.

FOAD #22

I think that's my bank:

ReallyBigBank
Automobile Leasing/Financing Department
Big City, Not Your State, USA

Dear Sirs:

I wish to express my concern regarding the recent lack of calls I’ve received from ReallyBigBank. I was accustomed to at least weekly calls from your representatives and this subsequent absence of calls has been disquieting.

Nonetheless, I was pleased to learn that the car that I returned to your company at the end of my lease was finally located. I have additionally learned that my last payment has finally been credited to my account, five weeks after my check was cashed by ReallyBigBank.

Given the numerous departments in your establishment, it could be difficult to keep the information regarding each client in order – but to circumvent this problem every division calls the customer directly. There’s no need to worry about lost files or files traveling between branches with this system! Some companies would be troubled by perceived inefficiency and redundant communication with this arrangement, but your employees have none of these concerns.

This degree of individual attention given to me by ReallyBigBank has caused me to rethink my dealings with financial institutions. I know I cannot realistically anticipate this level of personal interaction in future transactions. To ensure that I am not disappointed because of any retained expectations, I will remain acutely aware of all parameters of future business interactions and will cease negotiations if ReallyBigBank is involved in any way.

Thank you for your attention.

Sincerely,

FOAD #21

Do they all keep copies?

Dear Ms. Ivonna Wright,

I read with great interest your submission to my literary agency, titled "A Brutal Eunuch's Guide to Scrubbing." I must admit, you had me hooked the moment I saw that it was written in crayon. Your thirty-three page manuscript combines the brilliance of a young Marcus Paulk with the creative writing of Pierre Deligne, and will surely be devoured by archaean readers everywhere you send it.

Unfortunately, it suffers from one significant drawback: it's just too good. Merely looking at it enervated me to the point that I couldn't leave my seat. I daresay that should this book be published, you'll have trucks barrelling through the thick snows of Gehenna just to make deliveries on time. We'll have a single-book industry, and then what? I'll have to leave my job to be a menial hand in the new peccary feather trade.

No, it's best that you give me time to get the world ready for your work. For now, get a nice lead box and put all copies of your novel in it. Add some lye to protect it from insects, and bury it in the woods to keep it safe. Deep, deep underground.

Sincerely,

FOAD #20

But that's my favorite restaurant. (Also a beverage alert)

To Whom It May Concern:

I don’t find goat nipples an appetizing dish. I cringe while watching that scene in The Temple of Doom where Indiana Jones is a guest at an Indian banquet that serves live snakes and chilled monkey brains. Hey, some people might like goat nipples and chimpanzee gallbladder juice on ice, that’s their prerogative. I, on the other hand, do not.

So when I order a cheeseburger, plain and dry, no lettuce, ketchup, pickles, tomatoes, I think that the item in the bag that comes my way a minute later should have nothing on it other than a slab of greasy meat smothered with melted cheese. Do you see how goat nipples shouldn’t factor into this? I don’t even want to know how one managed to infiltrate my burger in the first place. The important thing is that it did.

Now I tried to explain my predicament to the manager, in small, gentle words, but he couldn’t quite grasp the concept of giving people exactly what they order. Goat nipples on cheeseburgers? Perfectly acceptable in his enlightened analysis of the situation. Arguing with one of your highly gifted managers over whether or not there is a diseased goat nipple button on the register is a very surreal experience, and a potentially damaging one. It was like The Twilight Zone’s wet dream of The Twilight Zone.

As such, please return $6.04 in included SASE. And hold the goat nipples; I’ll hold the lawsuit.

Sunday, February 04, 2007

FOAD Interlude

Thanks to s9 for providing this:
This fictional letter from the Smithsonian goes well beyond your 250 word limit, but it's a classic of the genre.
I agree. Here it is:

Paleoanthropology Division
Smithsonian Institute
207 Pennsylvania Avenue
Washington, DC 20078

Dear Sir:

Thank you for your latest submission to the Institute, labeled "211-D, layer seven, next to the clothesline post. Hominid skull." We have given this specimen a careful and detailed examination, and regret to inform you that we disagree with your theory that it represents "conclusive proof of the presence of Early Man in Charleston County two million years ago." Rather, it appears that what you have found is the head of a Barbie doll, of the variety one of our staff, who has small children, believes to be the "Malibu Barbie". It is evident that you have given a great deal of thought to the analysis of this specimen, and you may be quite certain that those of us who are familiar with your prior work in the field were loathe to come to contradiction with your findings. However, we do feel that there are a number of physical attributes of the specimen which might have tipped you off to it's modern origin:

  • 1. The material is molded plastic. Ancient hominid remains are typically fossilized bone.

  • 2. The cranial capacity of the specimen is approximately 9 cubic centimeters, well below the threshold of even the earliest identified proto-hominids.

  • 3. The dentition pattern evident on the "skull" is more consistent with the common domesticated dog than it is with the "ravenous man-eating Pliocene clams" you speculate roamed the wetlands during that time. This latter finding is certainly one of the most intriguing hypotheses you have submitted in your history with this institution, but the evidence seems to weigh rather heavily against it. Without going into too much detail, let us say that:

  • A. The specimen looks like the head of a Barbie doll that a dog has chewed on.

  • B. Clams don't have teeth.

    It is with feelings tinged with melancholy that we must deny your request to have the specimen carbon dated. This is partially due to the heavy load our lab must bear in it's normal operation, and partly due to carbon dating's notorious inaccuracy in fossils of recent geologic record. To the best of our knowledge, no Barbie dolls were produced prior to 1956 AD, and carbon dating is likely to produce wildly inaccurate results. Sadly, we must also deny your request that we approach the National Science Foundation's Phylogeny Department with the concept of assigning your specimen the scientific name "Australopithecus spiff-arino." Speaking personally, I, for one, fought tenaciously for the acceptance of your proposed taxonomy, but was ultimately voted down because the species name you selected was hyphenated, and didn't really sound like it might be Latin.

    However, we gladly accept your generous donation of this fascinating specimen to the museum. While it is undoubtedly not a hominid fossil, it is, nonetheless, yet another riveting example of the great body of work you seem to accumulate here so effortlessly. You should know that our Director has reserved a special shelf in his own office for the display of the specimens you have previously submitted to the Institution, and the entire staff speculates daily on what you will happen upon next in your digs at the site you have discovered in your back yard. We eagerly anticipate your trip to our nation's capital that you proposed in your last letter, and several of us are pressing the Director to pay for it. We are particularly interested in hearing you expand on your theories surrounding the "trans-positating fillifitation of ferrous ions in a structural matrix" that makes the excellent juvenile Tyrannosaurus rex femur you recently discovered take on the deceptive appearance of a rusty 9-mm Sears Craftsman automotive crescent wrench.

    Yours in Science,

    Harvey Rowe
    Curator, Antiquities

  • FOAD #19

    Hey! I didn't realize she saved a copy of the letter she sent me!

    Right way:


    Dear Author:

    Thank you very much for your recent cover letter, novel and synopsis. I regret I must write you to say no because of the visceral response your work engendered. Sadly, my agency has forsaken the thoughtful, line-by-line, comma-by-comma reading your project so clearly has earned. The days of back and forth with writers about the joys of the subjunctive, the charm of the passive voice, and quirkiness of homonyms are gone forever I fear. A sadder, speedier world indeed, and progress a cruel taskmaster, much likes punctuation and grammar, those devilish details.

    Many labors of love fall victim to this cold, cruel business practice. As you surely will discover there are many fine companies who have stepped in to fill this shocking void. Many of them advertise in Writers Digest, a publication I hope you can read in your library.

    I wish you the all the success you deserve,

    Miss Snark (who else?)
    Literary Agent

    PS I am returning all 300 pages, the remaining glitter, the chocolate bar, the photos of your shar-pei Harry and your spouse Mo (those tattoos are defy description indeed-who knew “mom” could look so provocative on a flexed bicep) under separate cover, via media mail. Please note our address has changed since you sent this. Our new address will be posted promptly on our new website www


    Wrong way:

    WTF????

    FOAD #18

    Where can I get a subscription?

    To the Editors of El Journo Elitio Quarterly:

    As of the first of December, it had been fourteen months since I submitted my short story, "Eastern European Immigrant Tale #11,376," to your publication. I knew that EJEQ was merely rebelling againstthe non-artistic world's currently-accepted soulless standards of punctuality, or, perhaps, my manuscript was simply lost among all the other treasures that you are so privileged to read, and you have grown blind due to the accumulated effects of gazing upon brilliance, so I did not question your delayed response.

    However, in mid-December I was presented with the opportunity to submit my work to Pomp and Posterity, your rival publication. P&P responded to my submission within a week, purchasing the rights for a sum greater than what your publication claims to offer on your submission guidelines on your website. (Of course, your submissions page has not been updated since 2002, and I did not adjust for inflation.)

    Therefore I wish to withdraw this story from your consideration. I am sure this comes as a relief -- it is a thankless burden to champion the excellence of others from manuscript to publication without the reassurance of sales or readership. If you are interested in my future work, please use Google to search for my name as well as the name of your publication; my work should appear above you in the search results. I look forward to seeing your sixth issue on the newsstands this spring.

    FOAD #17

    This guy must use the same phone company I do:

    Wrong: Your f-d up telephone answering system doesn’t work. Every number pressed brings back the damned menu until the line goes dead.

    Right: Naturally, one cannot expect to speak directly to a customer service representative to discuss discrepancies in a telephone bill when your state of the art, automated telephone answering system offers a broad range of options designed to cover every contingency, including billing related issues, except unfortunately, the one in which your system is persistently down and disconnects all incoming calls.

    FOAD #16

    I think I stayed in that hotel too:

    To Whom It May Concern:

    We would love to share with you our unique honeymoon experience at your Sandals Resort.

    We wanted a honeymoon that we could eat breakfast on the balcony, watch the ocean with drinks on the balcony, and have romantic candlelight dinners on the balcony. See the pattern?

    When we entered our room we were excited to go out to the balcony. We were surprised to see a massive construction project with bulldozer, dump truck, and a dozen workers digging and working on the grounds, (this wasn’t in the brochure). Our balcony experience was going to be shared with the locals—a bonus I had not considered in my honeymoon fantasy.

    We immediately requested another room. We were shown two rooms that you must market to those who have an aversion to sunlight; we opted to keep the room where we were the view.

    That night I was awoken at 2 am by Chinese water-torture. I got out of bed and found myself standing in water. This is an island, rain happens. I would expect that the rooms would be built to keep the water out; I guess you wanted us to have the FULL island experience.

    We want to thank you for showing us that we do not have to ever spend $5K again with any of your resorts, as we can stay at home and have the same experiences, just need to walk past construction workers in a rainstorm, what fun.

    Saturday, February 03, 2007

    FOAD #15

    It's the same all over the world:

    Situation: We have to have official rules for everything (except breathing, but they are working on that) in Germany. So in order that we can choose our students at university, we have to have rules stating how we choose. These have to be fair and equal and non-discriminatory and and and and. My colleagues and I spent two wonderful summer days locked into a room making up rules for this and other stuff. We submitted them at the beginning of September. And there they lay. We inquired occasionally as to their status and got gruff: we'll get to it when we get to it.

    Finally, in January of the next year, it is our rules' time to be checked before getting passed up the chain to the next official.

    And we get hit with the nasty whip: Bad boys and girls. You just copied the rules from your Master's program for your Bachelor's program. We passed new rules on how to do such rules (meta-rules, if you will) in November of last year, you should have been aware of this.

    My FOAD:

    Dear Ma'am. Interesting. We developed the rules in August. We sent them to your office in September, where they have been waiting for confirmation ever since. No, we were not able to incorporate the new rules about rules passed in November into our rules written in August, for obvious reasons.

    (Unfortunately, she did not understand, and went on about how the rules about the rules are published somewhere on the Intranet. I rejoinded that I can't guess that someone has passed rules and published them somewhere - it would be really, really nice if someone would tell me about this. Perhaps the office who has been sitting on my rules since September? This is a rather large indication that we are concerning ourselves with rules, if we have already handed in a version......

    This did not compute. Sigh. Will the good doctor prescribe a nice aquavit to calm my nerves?)

    FOAD #14

    It's called "cephalo-rectal intussusception":

    I have been a platinum flier with {Airline} for 5 years now and have flown with many great flight attendants. Not this time, though.

    On November 12th I flew on {Airline} from Boston to Detroit, departing at 6 a.m. For a variety of reasons, none important to this complaint, by the time I got to my seat in first class on the plane I was in a terrible mood and wanted a drink.

    I politely ordered a screw driver from the lead flight attendant, Bobby.

    He brought it. I thanked him. And then he spent 10 to 15 minutes standing at the front of the plane commenting loudly and repeatedly to the other flight attendants about how revolting and disgusting it was that anyone would drink that that hour.

    He also insulted another passenger who boarded the plane and wanted help finding his seat. After directing him, he commented to another attendant "Why take the bus when you can fly us?"--clearly implying that the passenger wasn't "classy" enough to be on Bobby's plane.

    I was horrified by his rude and unprofessional behavior. I am shocked that, with so many flight
    attendants out of work, this is the caliber of flight attendant still working at {Major Airline}. I am angry at having been treated this way, and embarrassed that it was done so publicly and with such spite. And I am embarrassed for the other passenger who was also publicly insulted.

    I just thought {Airline} would like to know.

    FOAD #13

    I love the salutation; I think I'll take it as a new nickname:

    Dear Dr. Band-Aid:

    Thank you for you kind and supportive care. You were always there for me when I needed a shoulder to cry on.

    Although you missed my Hashimoto's Thyroiditis, and the gall bladder disease, not to mention the hernia, the Hydradenitis Suppurativa, the Crohns, the high blood pressure, and the other unspecified autoimmune disease, I did feel much better over those ten years because of the Zoloft. I can't tell you how good it made me feel about being miserably sick. And to think that I could have been horribly ill AND depressed!

    I also want to thank you for failing to diagnose and refusing to test my daughter for Hashimoto's. No, it wasn't stress that caused her hair to fall out. Thanks to you, she no longer has that incredibly thick mane of hair. It is now nice and thin and much easier to manage.

    You may have noticed that we don't consult with you anymore. That's because when I nearly died in the emergency room, the physician there insisted that I see several specialists. I told him that wasn't really necessary "and that you'd said so" but he wouldn't hear it. I am now in the care of very expensive doctors and I just wanted to let you know how much I miss you. I will call you to say hi when I recover from all my surgeries.

    Sincerely,

    FOAD #12

    More love:

    Dear FK

    My crying as if you'd died, that I've been doing so frequently these days, seems to me to be just and intuitive. My life feels sere without your craziness to listen to each day. Why did I believe you? The simple answer, and the honest one, is love. But love doesn't make me blind. This moment is like a present death to me. I'm ready, I've been ready for months, to have you go. You've rehearsed your leaving before. Now you should be ready, too. Don't take my words as bitterness or hurt. My love's too big for that. Go and live, don't waste your time on me.

    And now I'll close, but not in my usual way. No "love you, past the end of time," though love it is, and past the end of time is true. Don't use me as a fill-in love when other loves are far away. My love for you means more than that to me.

    Best wishes always,

    FOAD #11

    Beverage alert:

    Dear Customer Service:

    First, I want to thank you for sending me a toner cartridge when I ordered one from your site. It means your employees are capable of such activities as "putting object in box" and "putting box on truck." Those homes that help find jobs for mentally challenged adults really are a great idea.

    But, and this is only a suggestion, you might want to make sure the toner cartridge you send your customer is the one that actually works with the printer in question, especially after the customer has already contacted you once regarding the mistake. I know it can be difficult to look at the model number on the side of the packaging (1710589) and compare it to the model number I told you I needed (1710587), so here's a hint: The number seven (7) is different from the number nine (9). There are similarities. I sympathize, trust me. When I was learning to count, I got them confused, too. Fortunately, I had a really good kindergarten teacher.

    I thought I should let you know that after you ignored my requests via your online form to call me that I contacted my credit card company and disputed the charge. If one digit on a model number is too complicated to deal with, I didn't want to think what you guys would go through trying to handle money.

    I hope you don't mind receiving this letter via email. I would mail it, but my printer doesn't work.

    Friday, February 02, 2007

    FOAD #10

    Very classy:

    Dear Mr and Mrs Smith,

    Thank you for inviting us to your wedding. It was an unparalleled experience.

    The cashier at the church was a very innovative way to finance the event. I am certain I would be unable to equal such an ingenious move. In fact my fiancee told me so in no uncertain terms, and she made a point adding how awestruck she was at seeing him again at the reception later.

    It was most thoughtful of you to inform us where we could buy the food to bring -- otherwise we would have been late to the party itself.

    All of this has made us understand how insufficient in comparison our wedding would be. We don't wish to inflict such a paltry experience on the two of you. I apologize for sending you the invitation earlier and hope you are gracious enough to forgive us for not retracting it sooner than we did.

    Yours humbly

    John Doe

    FOAD #9

    Not sent certified, return receipt requested? How about a 30 day window for emergencies? I should be a vet. (PLEASE read the PS before flaming me about vets)

    Dear Ms. X,

    While we do sympathize with the escalating costs of medications, we are unable to sell expensive medications at a discount. As you can see from the enclosed print-out, our price is lower than what 1800petmeds.com charges. Once a medication leaves our facility, we are unable to take returns, as federal law prohibits the resale of previously dispensed items, and considers them misbranded, adulterated, and unfit for use, even if unopened. Surely you would not like returned medications prescribed for your own pets.

    I’m sorry we are unable to meet your expectations for veterinary care for your pets. As of today, we will no longer provide any veterinary services to you or your pets, nor will we sell you any products or medications. Please let us know where you would like us to fax your pets’ medical records.

    Sincerely,

    Note: This letter was actually sent to a client.

    PS Yes yes yes; I know it's much harder to be a vet than a doctor; fewer schools, therefore fewer training slots; multiple species; and you still have to deal with crazy people.

    FOAD #8

    I'll settle for an apple, thanks:

    Letter to my daughter’s 5th grade teacher:

    Overall I think you work at an outstanding school. You are the prime nefarious part of it. I think I will bake you some equally miasmic homemade cookies to thank you for your part in my child’s education.

    FOAD #7

    Ah, love:

    Dear George,

    I hear you have lately met up with my old roommate, Lauren. I'm so happy for you both.

    Wow, it's been a long time. But it must seem like an instant to you! Lauren confides that you recall me saying she was "bad." Goodness, that must have been nearly six years ago, yet you remember it so clearly! I had no idea I occupied such a prominent place in your memory. And, lest you believe I could fail to remember *you* with corresponding detail, I wracked my brain for amendments to my initial recommendation of your character (for I'm sure you will agree that simply saying someone is nice and smart and possessed of a wry sense of humor is not at all the same as having something *specific* to say.) So I was very glad to hear that you described your total relationship experience as "one girlfriend for six years...off and on." Well, I thought of several ways to expand upon this modest recital. Unfortunately, I am slightly incommunicado just now, and I was never as attentive to rumor as I might have been. I was able, however, to give Lauren a general idea of what (or who) "off and on" might have entailed on your part.

    Anyway, I beg your pardon for my earlier recommendation. It must have seemed to you insultingly brief. Perhaps if you'd like to reminisce over any more of my old hijinks, you might contact me directly. I always love to hear about myself.

    Sincerely,

    FOAD #6

    Maybe I can pick up a science lab and a dorm or two:

    While I admire the quality liberal arts education you have been providing to students for approximately 160 years, I have found that, in my own collegiate experience, some of the administrative staff has lost sight of what is really important at a college. That is, the education of the students. As a result, I would like to announce my resignation as Active Alumna, and inform you I will no longer be contributing to the development of this institution. I wish you all the best, and when the doors close, I'll be at the yard sale.

    Thursday, February 01, 2007

    FOAD #5

    Don't you wish people would just say what they mean, instead of beating around the bush like this:

    Sir, (Previously, I had typed “Dear Sir,” but I found I could not stomach it.)

    Your placement of letters on a page, though strewn together in lengths of words, I cannot bring myself to admit as being any kind of known form of writing—not even terribly wrought gibberish, which would be considered intellectual stimulus in comparison to whatever it is you thought to send me on sheets of 8x11 typing paper. In fact, the reason only two sheets of that mauled assortment of 700 plus pages you claimed to be a manuscript have been returned to you, is that out of the graciousness of my heart, I have found better uses for it: Origami (swans and frogs are my forte), sailor hats, coffee coasters, absorbents for oil spills, birdcage lining, puppy pee pee pads, etc.—though I did find it quite abrasive for use as toilet paper, and I blame you for any paper cuts that resulted from the use of it.

    And now, because I relish saying it: I must wholeheartedly decline accepting your pile of typed fecal discharge for representation. In fact, you might have heard my declaration of NON-acceptance all the way in the cesspool of your dwelling as I yelled it from my rooftop—and my neighbor’s rooftop, his neighbor’s rooftop, my favorite restaurant’s rooftop, my banker’s rooftop, and assorted other rooftops. Of course, that was done in between all the laughter.

    Sincerely Most Aggravated to Have Read Your…Oh, I Still Can’t Say It,

    Agent

    FOAD #4

    The PS is what does it!

    Dick:

    As you know, I have always been a truthful person and have always appreciated the truth in return. Your recent actions, which caused only minor disruptions to the lives of my mother, sister, stepsister, brother, and stepbrother; their dog; my girlfriend, real dad, and stepmother; and me (also to those of your own parents, three sisters, and two brothers; also, five neices, four nephews, and several cousins; finally, those of hundreds of your past and current business associates), would have been quite an aberration for someone who is normally reliable; for you, though, who was previously established to be a moderately less-than-truthful person, the several hundred of us perhaps should have been more privy to your real dispositions. If I had to equate you as a person to a primitive life form, which I don't but will anyway, I would most likely assign you to one of the genus of bottom-dwelling aquatic organisms, such as the small-headed sole (A. microcephala).

    Thanks for everything!

    PS: Your given name doesn't quite wholly convey how I feel about you, but considering its brevity, it will have to do for now.

    FOAD #3

    An erudite alternative to banging one's head on the steering wheel:

    Dear Johnny Roadster,

    You may recall me from our recent spat(s); I'm the gentleman who raised my voice at you ever so briefly. For that, I would like to apologize, for I hadn't yet fully come to grips with your complete incapability of remaining intact for longer than a few weeks at a time. You might additionally recall the large sums of money I paid in order to fix you for the eleventh, twelfth, and thirteenth times.

    I write you now to inform you that it would be highly appreciated if, in the future, you would alert me as to your impending ineptitude more than a few seconds ahead of time. That way, I would have a more acceptable amount of time in which to prepare to spend the remainder of my savings in compensation for your ubiquitous and increasingly frequent shortcomings. If you cannot comply with my request, I'm more than happy to refer you to my associates at LT Auto Wreckers & Junkyard, Inc., who may be able to more demonstratively clarify the importance of this proposal than I am able in this medium.

    Sincerely yours,


    FOAD #2

    I'll thank this writer to stop eavesdropping on me and my spouse!

    Right Way:


    Dear Love,

    I, like you, regret that the last two days have been so rough. We are different in so many ways, and the rational, considerate part of me loves that about you. That you think I am pulling away for someone better saddens me (because it isn't true) and that is why I asked you to match apology for accusation two long days ago.

    It seems we are at an impasse. The pragmatic, thoughtful side of me should have seen this coming. I guess I've lost some of those qualities since we became "like one." Oh, Love! Can we repair the damage of these two horrible days?

    I think we can. Please, Dear, look on the bright side for it is not as bad as it seems. You say that you have no idea why you should apologize, but "sorry." That's appropriate, I think, since I have no idea why I would forgive you. We are still the same! I hope, from this common ground, we can rebuild.

    Wrong way:

    You harpy. Our marriage is sucking the good out of me. I should be so lucky to have better options, but I would never act on them because of THIS RING (points dramatically to ring). My faithfulness to you is that last thing remaining after all you've stripped, and you insult it?! You're right: how dare I ask for an apology after the way you feel. Nevermind the way you act and the things you say!

    (Winded from the activity of dramatic protest, sighs) What's the use. I'll take your half-assed "apology." Just leave me alone so I can forget how unhappy I am. Yes, in the garage. Fine, I'll get the garbage (loathing escapes in mumbles).


    FOAD #1

    What it lacks in subtlety you must admit it makes up for with enthusiasm.

    Seriously, though, I'm worried about this writer. Keeping all your emotions bundled up inside like that can be very bad for you. She should learn to express what she really feels:


    (This is an actual conversation I had with a mail-order drug company when they continued to screw up a patient‘s RX's, despite my best efforts to correctly follow all their procedures.)

    Me, politely: You know, it’s been 3 weeks without their prescriptions--when you promised 10 days. The patient is getting frustrated with your company…

    Sarcastic drug company rep: I don’t talk to road nurses. I talk to doctors. Get HIM to call me. And if your patient doesn’t like our services, they are more than welcome to get their meds at the local pharmacy.

    Me (less polite): Oh really? Let me talk to your supervisor, please...

    Me to Supervisor (and I'm not polite anymore): I am a road nurse. And about your guy's crack that the patient is “welcome to use the local pharmacy.” Listen, we are the road nurses who actually FILL OUT your damn forms for half-blind, confused, forgetful elderly patients who can’t do it for themselves. Theyrely on ME--yes, ME-- to help them buy zillions of dollars of drugs from your stupid company per year. Guess what will happen if I get mad at you? I will advise every last one of those patients to switch their Rx's to another one of the MYRIAD of mail-order drug companies---you get the picture, bud? In fact, how about if I tell every fucking patient within a 100-mile radius NOT TO USE YOU for whatever reason? Because, believe me, baby, I'll fucking do it. Not only that, but I will tell all my other road nurse buddies to do the same damn thing with their patients in this city, Austin, Dallas, and Houston--do you get the picture, baby? Hell, I'm having PMS--I'll put it on my fucking BLOG! Because believe me, baby--I’ve got BETTER FUCKING THINGS TO DO WITH MY FRIDAY AFTERNOON THAN LISTEN TO ONE OF YOUR DUMB ASS REPS advise me to “use a local pharmacy“---because that can be arranged!!! Have I made myself perfectly crystal clear?

    Supervisor: What was the name of the rep who said that to you?...