Grand Rounds

Grand Rounds:

“Are you ready to ruum-ble? This week here at Doc Gurley is the Grand Rounds Smack Down edition, where the best contenders of the health care blogosphere wrestle down and dirty with tough, scary topics."

Read. Enjoy.

You'll Never Think of a Comb-Over the Same Way Again

(Blogged with permission)

I saw a woman today who'd had a mastectomy last week for multi-focal breast carcinoma. She's doing fantastically well! She was home from the hospital in two days and was out walking around the block two days after that. I saw her today for some blood work before she starts chemo. Her incision looks great and she's feeling wonderful. She seems to understand what she's up against and has a solid support system among her family, friends and church.

One thing she shared with us was just hilarious. She said it cracked up the nurses in the hospital too:

She didn't yet have a temporary prosthesis, so she was stuffing her bra with kleenex. But here's what she said she ought to do:

This other breast is so big and droopy, I should just pull it across to the other side; sort of like a comb-over.

Grand Rounds

This week Dr. Val has a real feel-good edition of Grand Rounds. And she even included a post I meant to submit but never got around to. Enjoy!

The Four Best Things About Today

ONE: It's going to be bright, clear and sunny with a high of 77 degrees.

TWO: The Phillies won last night, completing a 2-game sweep over the Colorado Rockies, putting them just over .500 for the season so far.

THREE: The Flyers won the first round of the Stanley Cup playoffs with a thrilling seventh game overtime goal by Joffrey Lupul to win the game 3-2 and the series 4-3. They may very well fall to the Montreal Canadiens in four straight, but today is still a good day,

FOURTH, and MOST IMPORTANT: Today marks the end of the incessant phones calls from Bill, Michelle, Hillary, Barack and dozens of their friends, as well as the endless commercials, radio ads and traffic snarls from their local campaigning. It was fun to have them here but GAWD I'm glad to see them go.

Warning Sign

The radio station I listen to in the morning has a weekly feature called "Love Court." People can send in letters about sticky situations, usually some aspect of their relationships, and listeners call in with their opinions. Topics range from, "My husband wants to go on a vacation with the guys; should I let him?" to "My 11-year-old wants a cell phone. I don't have a problem with it but my wife disagrees." Last week's dilemma sounded fairly minor:

"My husband and I have been married for five months and now he's decided he doesn't like my dog. I've had the dog for nine years, but he wants me to get rid of it. What should I do?"

I don't know how surprising it is, but most of the comments were along the line of "lose the husband; keep the dog." I actually called in with my opinion, though I didn't get on the radio (I was amazed I actually got through in the first place) but the more I thought about it, the more important I think it is to share my take on the situation.

I agree that the letter writer needs to get out of the marriage, but I didn't hear anyone else articulate the reason that occurred to me:

This man is an abuser.

Trying to get her to get rid of a dog he knew all about during their courtship is just the first step. If she gives in and gets rid of the dog, the next thing he'll do is start picking on her friends, telling her he doesn't want her spending time with them. Finally, he'll isolate her from her family, forbidding her to see them and eventually even talk to them. All along the way, he'll be telling her that it's because he loves her so much, and that she'll do what he wants if she loves him too. Once he has her all alone, isolated from all the people she cares about (and her support systems) there's no way to tell what he'll do next. But by then it will be too late.

The key is his lack of respect for things that are important to her, like her dog. That, in my opinion, is a giant red flag that no woman should ignore.

So Just Do It

From the mouth of the Panda:

"If we just got aggressive with triage..."

I've never quite understood why EMTALA, the legislation referred to as an "unfunded mandate" by all the ER docs who bitch and moan about having to see everyone who walks through the door whether or not they can pay, is such a big deal. Here's the text:

In the case of a hospital that has a hospital emergency department, if any individual (whether or not eligible for benefits under this subchapter) comes to the emergency department and a request is made on the individual’s behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists.

Here's how they define "Emergency medical condition," by the way:

(i) A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in-

(A) Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;

(B) Serious impairment to bodily functions; or

(C) Serious dysfunction of any bodily organ or part.

I've gone on to read all the rest of the regulations and amendments and commentary and so on. At no point is there any mention of the obligation of a facility or provider to an individual WITHOUT AN EMERGENCY MEDICAL CONDITION. In fact, they say so over and over again in the 44 page document containing the 2003 EMTALA amendments:

The statute plainly states that the objective of the appropriate medical screening examination is to determine whether or not an emergency medical condition exists. Therefore, hospitals are not obligated to provide screening services beyond those needed to determine that there is no emergency medical condition.

There is no way a rash for three months constitutes an "emergency medical condition", yet somehow Scalpel still interprets EMTALA as a mandate to treat. What's to stop you from booting someone once you've ascertained that no "emergency medical condition" exists?

I know what you're going to say, all you ER folks: there's no way to be 100% certain that no emergency condition exists, so not going ahead and treating everyone would put you at unreasonable risk of liability. Yeah; right. In theory; perhaps. But still! Just reading your blogs, it sure seems like plenty of folks come around offering pretty clear histories in triage (stubbed toes, for crying out loud!) that they aren't dealing with an emergency. Grow some testicles and street them.

Oh, wait: do some of them have insurance? Might they be a source of easy revenue? Is it your hospital's policy to treat all comers (as opposed to the dreaded "EMTALA")? Then quitcherbellyachin'. Or, as Panda says: "If we just got aggressive with triage..."

Passover Fun

So last Friday night I'm sitting around minding my own business when my daughter calls to ask for the recipe for Passover Fudgies*. She's at college out in the middle of NoJewsVille, Pennsylvania, unable to find things like matzah, much less matzah meal or matzah cake meal, but she was planning a seder for two (non-Jewish) friends and really wanted to make Passover Fudgies. One conversational thing led to another, and I eventually went upstairs to cajole Darling Spouse into a spur-of-the-moment road trip.

The next morning we headed out to western PA, trunk loaded with pesadech (stuff that's kosher for Passover), dog in lap, last-minute hotel reservation made with difficulty. I could not for the life of me figure out why everyone in the world needed to be in this little corner of western PA this weekend, but nearly every place I tried was full.

As it happened, the Jock's Ultimate team was having their home tournament this weekend, so we looked forward to some time with him and his friends as well. He's living in an off-campus apartment that I'd never seen, so I wanted to check out his place. It was nice enough, given that it was the abode of three college males. Luckily he was willing to keep the doggie for us overnight, as she was forbidden in both the apartment where my daughter was making seder and the hotel. (He also tortured his girlfriend later while IMing with her: "I'm having a houseguest; she'll probably spend the night in my room with me; she was sitting on my lap earlier; she nuzzles as well as you do." The girl huffed offline for dinner, so it wasn't until later that he was able to add the piece that let her figure it out, "You've met her; she's like a member of the family." Her reaction: "You dick.")

The seder was lovely. Not overly traditional; not overly rigid; but we said prayers, drank wine, dipped parsley, told the stories, explained the symbols, and ate: matzah, charoset, eggs, matzah ball soup, gefilte fish, and Passover Fudgies for dessert. There was nothing missing; I was so proud of my daughter, I could burst. She made her first seder: today, she is a woman!

There were some unique moments, of course. Because the apartment wasn't occupied by Jews, it wasn't really scrubbed of all sources of leavening, grain and so on, as (an observant) Jewish home would be. After dinner, it was time to search for the afikomen. It was one of her friends who finally found it, but I found her selection of a hiding place somewhere between ingenious and pure evil: BEHIND THE BOX OF BISQUICK.

There was also the conversation about chocolate animals; bunnies, chickens, etc. in the context of Easter candy, which gave rise to the question about Kashrut (one of the tenets of which is the forbidden mixing of meat and dairy products): Can a chocolate cow be kosher if it's made of MILK chocolate?

And so a lovely weekend was had by all. Upon our arrival home, it turned out that the Nestling had also returned. Rather than attending college in NoJewsVille, the Nestling is instead attending a university that specifically schedules spring break to coincide with Passover. He was waiting for me when I got home from work today. I greeted him and then invited him to come along while I walked the dog; an invitation he agreed to. The moment I saw him in daylight, I did a double take:
Yes, his hair was blue. Ah well, I thought; as rebellions go, it could have been much worse.


*Passover Fudgies

• 4 eggs
• 2 cups sugar
• 1/2 lb melted butter
• 1 cup unsweetened cocoa
• 6 tbsp. cake meal
• Optional: 1 cup chopped nuts or coconut

Beat eggs and sugar together; gradually add melted butter and beat well. Sift dry ingredients together and add to mixture. Stir in nuts and coconut if desired. Pour into greased 9" x 13" pan and bake at 375 degrees for 20-25 minutes.

A Different Spring

Ah, Spring: the grass and trees start to turn green and the flowers start poking their little buds up through the earth. The sun gets warmer, and for the first time in months you don't have to put on a coat when you leave for work in the mornings.

But elsewhere in the world, you have friends experiencing something very different: an expedition to the Arctic.

• Part 1
• Part 2
• Part 3

All illustrated with the Tundra PA's captivating photography. Go and read. It will take you to another world, and then give you a whole new perspective on that gentle Spring breeze blowing against your face.

Disturbingly Apt

Hat tip to Pharyngula:

A portrait of George W. Bush composed entirely of clippings of pictures from porno magazines.

"End of Life" Care Costs: A Logical Fallacy

A joke:

Man gets on a bus in a strange town and asks the kid sitting next to him, "Which stop is Main Street?" Kid answers, "It's three stops before I get off."

An assertion:

More money is spent on medical care in the last year of life than at any other time (implying wasted resources on futile care.)

This statement may be true, but those who would then try to discuss means of decreasing this amount are losing sight of a critical distinction: the "last year of life" is a retrospectively defined time frame. And as the vast majority of oncologists will affirm, it is devilishly difficult -- if not impossible by definition -- to pin down that designation reliably in a prospective fashion.

I don't disagree that futile care is a huge problem in this country. Perhaps measures such as default DNR status for nursing home patients, or even more proactively, a prohibition on admitting them to an acute care facility might put a dent in the sum expended. Even if we were better able to address the unreasonable expectations of the families of clearly terminal dementia patients (thus eliminating all those "senile grannies" that seem to be the bane of existence for Panda, White Coat and the Happy Hospitalist) I don't think we'd see much of a dent in those dollars; at least not nearly as much as many professionals in the acute care setting seem to think we would.

However you look at it, most people get sick before they die. (Though I'm reminded at this juncture of Health Business Blog's David Williams' pithy comment, "For all its disadvantages, sudden death is cheap to treat.") When they get sick, they go to doctors (NOT always to emergency rooms, believe it or not.) Doctors then try to figure out what's wrong; this often involves testing, imaging and consulting with other doctors. When a diagnosis is made, especially a serious one, treatment is then undertaken. Costs for treatments like surgery, prescription medication, various therapies and so on add up quickly. By the time it becomes clear (perhaps) to some or all involved that the patient is not going to recover from the condition, the expenses have already been incurred.

Not only that, but patients often get well. Treatments sometimes work. Most of the time it is not possible to tell at the beginning of treatment how the patient is going to respond. Yet when they don't and the patient succumbs, some government accountant looks back and complains about "all that money spent in the last month of life," an example of perfect hindsight.

Obviously one key is to improve our prognostic skills while remaining ever vigilant about limiting truly futile care. But how to go about it? How about this: At the time of each hospitalization, the admitting physician makes a guess -- say on a scale of 1 to 100% -- about what he thinks the patient's chances are of living to be discharged from the hospital. Routine elective surgeries would probably garner a rating of 99% (to account for the ultimate unpredictability of everything.) Senile septic ancients might rate a 5% or lower. Don't formally publicize these guesses, but if everyone did it, over time we might very well find our predictive capacities improving. Eventually, physicians might feel empowered to limit aggressive care to those with very low likelihoods of survival. I know this sort of thing may be happening now on an informal basis, but if it were more systematized if might become easier to incorporate into policy.

How about the world of outpatients? Try this: At each patient visit, I generate my 1-100% guess that the patient will be alive after given time, whatever it is. A year; six months; three months; one month; doesn't matter. Formally determining a prognosis for every patient encounter; think about it. It doesn't seem appropriate for well baby care, but for COPD, CHF, CAD patients? Oncologists do this all the time (or at least they should;) why can't the rest of us? What about patients who are healthier, but with risk factors: hypertension; diabetes; sedentary lifestyles?

It's totally unfair -- not to mention illogical -- to bemoan money "wasted in the last year of life" without recognizing that they're talking about a bus that passed our street three stops ago. It's time to be more specific in our conversations about futile care; and a little more honesty and efforts to elevate our prognostic skills to try and approach the level of our diagnostic skills would be a better use of our time and efforts.

Definition Please

Can animals engage in bestiality?

There are four cats who roam my abode; all male; all neutered. One of them, the one to whom I have previously referred as Botox Cat (because his total lack of facial expression makes him appear to have had Botox injections) has recently revealed himself to be either:

1. Really stupid,
2. Blind (doubt it; he's not that old)
3. Anosmic (ditto), or
4. Perverted.

He's been frequently observed in compromising positions (as if the balance of humping and being humped somehow denotes a compromise) with one of his feline fellows. Now I have no problem with that. I'm a tolerant Dinosaur; however they get their jollies is fine by me.

But this morning I caught BC trying to get it on with the dog. Ok, so the dog is the same size and shape as most of the cats, but geez -- it's a dog! Ew. Gross. Stop that!! Besides, the poor little doggie looked so confused. I couldn't blame her. I whisked her up and we headed in to work, leaving Botox Cat to ponder his perversity -- though frankly I don't think he has enough synapses for any meaningful pondering.

Yet the question remains: does interspecies coitus constitute "bestiality"?

A Manner of Speaking

Scalpel said this:

Is billing for questionably-indicated procedures really any different than adding an unnecessary family or social history to increase one's charges? I say no.

The Happy Hospitalist disagrees with him, and he is right (HH, that is.) Here is why:

Scalpel is correct in only the most technical manner of speaking. In the sense that anything you do (or document) that is not strictly necessary for diagnosing or managing the patient is "fraud" then yes, documenting a family history in a geriatric pneumonia patient is the same as a colonoscopy for bright red rectal bleeding in a teenager with visible hemorrhoids.

The case begins to fall apart when you explore the concept of risk/benefit analysis. The risk of taking a history is zero. No one's colon was ever perforated by asking what their parents died of. No one ever suffered a pneumothorax from being asked if bleeding runs in the family. No matter how small the potential benefit of "history" vs. any procedure, you can't beat zero. Therefore unnecessary (sorry -- marginally useful) procedures can never be truly comparable to elements of a history.

HH and Scalpel agree that the central issue is that counting the elements of documentation to determine levels of payment is nonsense. It would be much more logical to simply pay for evaluation and management services on a straight time scale (like lawyers) rather than the ridiculous system in place today. Given the system that we are stuck with have, though, it goes without saying (sadly) than all players will take whatever steps they need to maximize income.

But for those padding their pockets with procedures to claim that we're doing the same thing by recording "unnecessary" elements of a history is like the school bully pointing at the Chess Club president and saying, "You beat people every day too, you know!"

Only in a manner of speaking, Dude; only in a manner of speaking.

Six Word Memoir Meme

I watched as this one began and spread across the 'sphere, and actually looked forward to catching it; many thanks to the Happy Hospitalist.

The Rules:

1. Be a creature unlike any other.
2. Don't talk to a man first (and don't ask him to dance.)
3. Don't stare at men or talk too much.
4. Don't meet him halfway, and don't go Dutch on a date.
5. Don't call him, and rarely return his calls.
   

Oops; wrong Rules.

Ok, here are the Rules for the Six Word Memoir Meme:

1. Write your own six word memoir.
2. Post it on your blog and include a visual illustration if you’d like.
3. Link to the person that tagged you in your post.
4. Tag five more blogs, with links.
5. Leave a comment on the tagged blogs with an invitation to play.

For my blog persona, it writes itself:

Solo family practice: not dead yet.

Although I'm breaking my usual rule by participating, I'll continue my personal tradition of not tagging anyone else; partly because most of the other bloggers I read have lives, and partly because virtually everyone else has already been tagged.

A "Stupid" Rant

(I wrote this the other day when I was too hopping mad to see straight. Today, GruntDoc's post about waste rekindled my ire; hence the profanity:)

Who the fuck does an MRI on a 14-year-old gymnast with two months of low back pain, no history of injury, no neuro findings and a normal physical exam? A suburban orthopedist, of course. Believe it or not, the study showed "mild degenerative disk disease," but it had no impact whatsoever on management: wear a lumbosacral support; activity to comfort.

Cut me a fucking break! Talk all you want about how much money the "healthcare system" wastes each year/month/week/hour on futile care, defensive medicine, unnecessary medications and bullshit hospital admissions, but this is the bread and butter that pads specialists' incomes to the half-mil mark.

Build it and they will scan! An MRI on every street corner, and they won't go begging for business either. Shit; how long until someone starts to push screening MRIs for brain tumors? Catch them early, you know. Not that you could do anything about them, but at least the patient might live for six months instead of six weeks. Can anyone say "lead time bias"?

This isn't defensive medicine; this isn't zebra hunting; this is intellectual laziness plain and simple. Just because someone got into and out of medical school and an orthopedic residency does not mean they can't be STUPID! And that's what this is: stupid, wasteful and well, stupid.

As of today, I'm changing the Fourth Law of the Dinosaur from "No good deed goes unpunished" (a generalized truism that was suggested originally by Flea and included because I didn't have many Laws at the time) to:

There is no cure for Stupid.

An Open Request to Everyone Who Works in an Emergency Room

I hereby call upon all ER physicians, nurses, clerks, aids, receptionists, security and housekeeping staff, along with anyone else who talks to patients to BANISH the following words from your vocabulary:

Why didn't you come in sooner?

For starters, it isn't even really a question; it's a poorly disguised way of saying, "You should have come in sooner." Next, it doesn't matter. Science has yet to perfect a working prototype of a time machine, so whatever would have been different if the patient had presented at some time in the past is completely irrelevant. The patient is here now. Not two weeks ago; not two hours ago, but now. This is what you have to deal with, so deal with it.

It just so happens that a great many patients are in fact themselves wondering why they didn't come in sooner. At the same instant you are asking the (non-)question, they are feeling stupid/anxious/upset/other distressing emotions about that very issue. It does no good to intensify those negative feelings when the patient is already struggling with them.

For another thing, there may be a perfectly valid reason for the patient to come in when he or she did. I saw a woman today in follow up who had been to the ER for a pyelonephritis (and told, "Why didn't you come in sooner?") who'd had a respiratory infection preceding the UTI. She was achy; she didn't think anything of it until the pain changed and increased. Then she came in. Other people may have needed a ride (and felt that calling 911 was not appropriate.) Not only might patients have valid reasons for presenting when they did, it might even have been appropriate given the entire clinical picture -- which may not yet be clear to ER personnel.

The appropriate time and way to address the issue is at disposition. Under the guise of "education" it is permissible to say, "You know, if something like this happens again, it would be better to come in sooner."

So cut it out!

Sigh.

I guess I should have said something sooner.

Rad Rage Redux

(I must sound like I have a huge hate-on for my local radiologists. I don't. Really. They just get to me sometimes.)

Why is it that radiologists assume they're the first ones to see the patient? Do they think I just order studies over the phone (like the specialists; Ortho won't see them without X-rays, and you can't even get an appointment with a neurosurgeon without an MRI.) Guess what, guys: I really do EXAMINE THEM FIRST!!

Excited phone call from radiologist (on a Saturday, since he's not in during the week, and this can't wait):

OMG, Dino, this lady has the biggest abdominal mass I've ever seen!

Uh, yeah; I know. I palpated it. She's been menopausal for 20 years and bleeding for the last 10, so my working diagnosis is endometrial cancer. It says so on the request I sent you. Is there anything else there? Liver mets? Retroperitoneal nodes? Omental implants?

Oh; wait, let me look. Yes, the mass is consistent with that. No; everything else looks fine. I'll get the report dictated right away.

Um, thanks.

Connecting by Analogy

I had an extremely satisfying patient encounter several weeks ago, during which I was able to translate my medical recommendations into an analogous situation that the patient was able to grasp quickly and completely. By finding just the right approach to explain the concept of optimizing control of cardiovascular risk factors, the patient emerged with an "Aha!" moment and I with the warm fuzzies of a job well done.

The patient was a computer guy in his early 40's with controlled blood pressure, non-smoker, non-diabetic but with a positive family history of premature coronary artery disease and an LDL cholesterol in the 140's despite ideal body weight and optimal diet and exercise regimen. He didn't mind the meds he was taking for his BP but was leery of side effects that he feared from adding a cholesterol-lowering drug. My first reaction upon seeing his lipid panel and hearing his reticence was to let it go. His HDL was decent (over 40) and his BP was well controlled; but something made me pursue the conversation.

"Look," I began, "If you really don't want to take another pill, that's ok. Your cholesterol isn't that terrible, so I don't feel that strongly about it either way; but hear me out.

"I'm talking about optimizing your health by fine-tuning all your risk factors, so instead of just being 'ok' they're the best they can be.

"Say I have a computer here, and you notice it could use some updates; maybe some security or other maintenance stuff that -- even though it's working well enough for my needs right now -- would fine-tune it, enhance its performance even if I don't notice anything actually wrong with it; perhaps head off some trouble up the road. I'm sure you see machines like that every day."

He nodded.

"Now, what if my response to your offer was, 'No way! Every time someone screws with my computer they mess it up. It's working fine; just leave it alone!' I'm sure you meet people like that all the time."

He looked like a man in a V8 commercial who had just slapped himself upside the head.

"You're right! I completely get it," he said. "I'm just being stupid."

I hastened to reassure him there was no stupidity involved. Just as he had a greater understanding of the capability of a computer and the advantages of preventive maintenance -- along with the experience of dealing with stubborn people who didn't have that knowledge yet refused to trust in his -- he realized that I knew more about the body and how it worked, and that he could trust my recommendations. The suggestion of a low-dose statin took on the same significance as loading anti-viral software; in the event of a problem, the drug can be stopped, just as the program can be uninstalled.

He left with a prescription for a small dose of a generic statin, a follow-up appointment for blood work in 2-3 months, and the same warm glow as I over the connection we had made.

Rad Rage Reciprocated

Do not piss off a radiologist.

I learned this the hard way today.

Earlier this week I had another case of a radiologist ordering a breast biopsy: a call came asking me to fax over a note for a patient already sitting there. I had seen the abnormal mammogram, but apparently the report for the extra views and the ultrasound never made it to me. They faxed it over; I made the patient come over for an exam and then sent her back for the biopsy. Actually, she had more than one lesion: a cluster of little cysts that were aspirated uneventfully, and a "worrisome" lesion that they tried to needle but said that if the pathology came back negative, I should assume it was because of faulty sampling, because they really thought it looked like cancer on both mammogram and ultrasound. (So why needle it? Because they can.)

Anyway, the next day I had called the radiologist back and threw a major hissy fit; really chewed him a new one. All he agreed to was that I should have gotten a phone call instead of just the report (that never came.) And he made certain I got the report of the aspiration/biopsy. Along with a later addendum with the path results (which I had gotten under separate cover anyway.)

Actually, I got the report twice: the original, then the addendum faxed under separate cover after a call from the Breast Center Liaison confirming my fax number (because they wanted to be *sure* I got it.) Then I got the whole thing sent over again, labeled "Superceded Report." Actually, it came over twice.

Then today it came over again. And again. And again. And again. And again. And again. And again. And again. And again. And again. That's right: 10 more times. Four pages each.

After the eighth time, I called over to the hospital and promised never to yell at them again; just please, make it stop! They claimed it was an IS gremlin, but I found it a bit too coincidental that it just *happened* to be the same patient I'd chewed them out over. They had the IS guy call me; he asked me to fax the first page back over to him. I asked why. So they could tell where it was coming from. Good luck; there was NO indication of what phone number was sending the runaway faxes. By then, though, I thought it had stopped.

No such luck. About half an hour later it came over again; and then again. Another call to radiology and another transfer to IS; more groveling on my part; promises never to complain to any radiologist ever again; happy to write notes allowing them to do ultrasound guided mastectomies if they would please please please stop faxing me the same goddamnable report over and over and over. Eventually it stopped.

Ever feel someone sneering at you from two miles away?

Uncle.

Put the Beverage Down

This lady notices that her skin is sagging badly, making her look really old. So she decides it's time to go to the plastic surgeon.

The doctor comes in and listens to her tale of wrinkles and woe, examines her and says, "I have just the thing. It's a brand new operation called "The Knob." We implant the Knob under your scalp; once a year you give it a twist and it pulls everything up, tightening it beautifully. It lasts about 10 years."

"Great," she says, and has the surgery.

Sure enough, each year she twists the Knob under her scalp and all the wrinkles get pulled up; she looks great. But after about 11 years, she notices that now she's got these big bags and dark circles under her eyes. So she goes back to the plastic surgeon, who recognizes her immediately and says, "How's the Knob working for you?"

"Well," she answers, "It was great for about 10 years, but now I've got these bags and circles under my eyes."

The surgeon looks closely and says, "I'm sorry to tell you this, but those are your breasts."

"Ah," says the woman. "That explains the beard."

Ni!

I routinely laugh out loud (literally) at LOLCats without posting them, but this I couldn't resist.

Grand Rounds

Wow! I'm honored to have been given top billing at Grand Rounds over at GruntDoc. Go check out the best of the medical blog-o-sphere.