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.

Thursday, July 31, 2008

Managed Care

Here is everything you need to know about Managed Care in 167 words (yes, they are mine):
Managing medical care consists of deciding what tests are needed to diagnose a particular patient's ailment, and then making sure they get them. Managing medical care involves referring patients to other doctors when a family doctor can't handle the problem alone. Managing medical care means reviewing letters from consultant physicians, noting when they recommend tests or procedures that have already been done or might be dangerous for that particular patient, or when they prescribe medications that either duplicate or conflict with those the patient is already taking. Managing medical care includes preventive care; keeping up to date with the latest recommendations for screening tests for asymptomatic patients, educating patients about the advantages of early detection and treatment afforded by the results of those screening tests, performing them or arranging for them to be performed and explaining the results to the patient. Managing medical care certainly includes encouraging patients to adopt healthy behaviors and habits while avoiding those that are harmful. Managing medical care is called "practicing medicine."
I'm just saying.

Saturday, July 26, 2008


I took Boards for the fourth time today; my third re-certification of Family Medicine Boards.

Our Board certification is good for seven years, although most people take the exam after six years in order to be safe. This was the first time I let it go for the full seven years, which means I first certified 19 years ago, when my baby was two months old. He is now about to start his second year of college.

What I remember most fondly about the initial certification exam was the pencils. They were lovely, sturdy white #2 pencils with the words "AMERICAN BOARD OF FAMILY MEDICINE" emblazoned in a gorgeous shade of green. We received two of them for the full-day exam, and we got to keep them; my $350 pencils ($175 each, of course.)

Six years later, I again reported to a downtown hotel ballroom with several hundred other FPs to take my first re-certification exam. This time, though, the pencils they gave out were the regular, grungy old yellow ones -- sharpened to a tiny little point, like a golf pencil! No way these were going to make it through an entire day of testing! Except that close on the heels of the lady checking IDs and handing out pencils was another person carrying a large plastic bag. As he stepped in front of me, he reached into it and extracted -- I kid you not! -- a small, white, plastic, birthday-party-favor-style pencil sharpener (that actually worked pretty well.) The best part of the day came when the head proctor was reading us the instructions and came to this line:
No test materials may be taken from the room.
At this point she stopped, looked up and added sheepishly:
You can keep the pencil sharpeners.
And that is the story of my $500 pencil sharpener.

Fast forward another six years, and it was time to do it again. I found myself wondering what the pencil situation was going to be. I wasn't disappointed: this time we were each handed a spiffy pink mechanical pencil, complete with extra leads and erasers tucked away in its little hidden storage compartment. The more memorable thing about that day, though, was the occupants of the ballroom on the other side of the foyer from ours, where there was an official Ballroom Dancing Competition. Watching the dancers warm up and practice in the foyer, the women resembling life-size Barbie dolls and the men in their stylized tuxedos as they glided and spun around the room at full speed, was amazing. Several of us taking the re-certification exam agreed we would far rather be in the other ballroom. But I did get to keep my $850 mechanical pencil.

That was seven years ago. Times have changed. Prices have gone up. More importantly, the ABFM has moved away not only from the paper-and-pencil format, but also from the hundreds-of-docs-gathered-in-a-ballroom venue. Instead, the exam is administered on a computer (of all things!) at multiple contracted testing sites on multiple dates. Amazing! You register online, pay $1,150 by credit card, and show up at a suburban office building on a Saturday morning where you are surrounded by people taking all kinds of other tests.

I'd been warned in advance that no pens, pencils or papers were allowed in the testing room. We were told that we'd be given white boards which we could use for any calculations or notes we wanted to make during the exam, but that all materials would have to be returned at the end of the test.

The exam followed along the lines of my recollections of the others pretty well. Questions ranged in difficulty from, "Are you kidding me?" (ie, I learned that in high school) to "Not a f***ing clue!" I've always been fortunate enough to test well, so although I went through each question as slowly and deliberately as I could, I was still done with the entire exam (scheduled to last eight hours) in five hours. That included scheduled breaks. Of course the other nice feature of the individualized computer experience was that the breaks were optional. Instead of having to sit around for over an hour waiting until the lunch break was over and the afternoon session could start, I just went out and stretched my legs, then plunged back into it.

And here's the best part: I told the above pencil stories to the folks monitoring the exam, and they were so amused that they let me keep the dry-erase pens (2 of them!) they'd given me for the white board (which was actually a yellow sheet of laminated paper with the facility's name on it.)

So I am now the proud owner of a pair of dry-erase markers that only cost $575 apiece. I'll find out in 6-8 weeks whether I will also be the recipient of a nifty engraved certificate that doesn't expire until 2015. I wonder what the exam will be like by then.

Friday, July 25, 2008

Water Doggie

The Rolling Peke had a play date last week. We finally got together with some old friends and their Big Doggies: a 150 lb. Bernese Mountain Dog and a 180 lb. rescued Great Dane. The Rolling Peke, who by now can actually walk quite well (though the wheelchair still comes in handy for long walks and certain excretory functions) quickly put them in their place, as they then proceeded to have a wonderful time together. The Dane kept sniffing her as if to say, "You smell like a dog, but you're so small!"

The other new addition to our friends' household since our last visit two summers ago was a swimming pool; and what a gorgeous pool it was. A large, shallow "sun deck" area at one end to enter gradually, a "swim-up bar" seating area with a table in the middle, and two other bump-out areas at the far end for seating, complete with steps (instead of ladders) for climbing out. (For those familiar with pool shapes, there's your basic kidney-shaped pool, as well as something called a "ruptured kidney," referring to a pool with a single bump-out seat on the convex edge. I looked at my friend's pool with all its assorted bump-outs and said, "Holy cow! A polycystic kidney pool!")

But it felt great to get in it on a really hot afternoon.

The Rolling Peke began running around the edge as Darling Spouse and I went swimming, trying to stay as close to us as she could, and getting a little frantic when we got too far away. I was afraid she might fall in, though she never did.

But our hostess and Darling Spouse suggested to me that she might like to come into the water. Why not? I thought. So I climbed out and picked her up, then slowly re-entered the pool, holding her close so I could instantly feel (and soothe) any trembling or other sign of fear. Much to my surprise, she was fine!

I held her a little away from me, and lo and behold, she started making doggie-paddling motions with her front legs. I held her out to DS and she began swimming over. I didn't have the nerve to let go of her completely at first, but we quickly realized that she really could swim! All by herself!! She swam 4-5 feet back and forth between us, perfectly content. I'm sure it was fabulous physical therapy for her weakened back legs. Never in our wildest dreams would we have thought the Rolling Peke would enjoy swimming. We stopped after awhile; probably sooner than she needed to -- and I just sat in the pool holding her in my arms, her body nice and cool but with her head comfortably supported above the water.

When we finally got out, she did bear more than a passing resemblance to a drowned rat, but a brisk towelling-off and lying around for awhile, plus a few shakes, and she was dry and fluffy again in about an hour.

Who'd have thought our little puppy was such a water doggie!

Thursday, July 24, 2008

I'm Waiting

I'm absolutely certain that someday -- probably soon -- I will have the following exchange with a patient:

Me: What can I do for you today, Mr. 400lb Man?

400lb patient: Well, Doc, I heard on TV that if you write down everything you eat, you'll lose weight. So I've been writing down every last thing I've eaten for the last month, and I haven't lost any weight at all!

Me: (perusing diet diary) Um, when you add all this up, you're eating like 6000 calories a day.

400lb P: So?

Me: The idea is that by being more aware of what you eat by writing it down, you can reduce your food intake. That's how you lose weight.

400lb P: Charlie Gibson didn't say anything about eating less. He just said if you write it down, you'll lose weight.

Me: The only way that can happen is if you eat less.

400lb P: But I wrote it all down. That's all they said you had to do. Damn media! Getting my hopes like that for nothing!

Wednesday, July 23, 2008

Purple Isn't Green

My sample closet is down to a cabinet, thanks to my increasingly restrictive policies about seeing reps and only accepting samples for drugs I already prescribe. Still, I'm remain amazed and appalled by some of the excessive packaging of the samples.

The other day when I was handing out some Nexium samples to a new GERD patient. (Yes, I know it's the same as omeprazole/Prilosec OTC. But I had them, and this way he could at least try them. If they work, I'll tell him to get it OTC.) I apologetically counted out six little plastic bottles as I pointed out to him that each contained only five capsules. We winced together at the environmental unfriendliness of the packaging (not to mention that each little plastic bottle had come in its own 2 x 2 x 3 inch cardboard box) and this is what popped out of my mouth:

"It's purple, not green."

Friday, July 18, 2008

A Tale of Two Titties*

(*Title credit to Darling Spouse)

Two patients with similar mammograms: a vague finding appreciated by only a single radiologist. Extra views are done; ultrasounds are done; MRIs are done; all are negative. Neither patient has any palpable abnormality within the affected breast. Here’s where they part company: one patient receives a recommendation for a 6 month repeat; the other an appointment to a breast surgeon, who, although unimpressed, bows to the suggestion of the original radiologist and orders a core biopsy of a poorly defined area near the chest wall, that is not seen on MRI or ultrasound.

Suffice it to say, neither woman was happy with the recommended course of action. Here’s why:

The first patient had had a delayed diagnosis of cancer in the other breast, and although now more than five years out from treatment with no evidence of disease, was emphatically NOT willing to wait 6 months with a possible abnormality in her remaining breast. Interestingly, the original radiologist, a part-timer, was out the day I called back to confer on the initial mammogram. The doctor I talked with couldn’t even see what the first doctor had, and said, “I’d have let her go for a year.” When the part-timer got back, though, he stood by his guns and said he definitely saw an area of "asymmetry." Although he was comfortable with a 6 month follow-up, he offered the MRI now to appease the patient.

Worried less about his comfort than that of my patient, I managed to locate a surgeon (with a great deal of kicking and screaming emphatic persuasion and numerous phone calls on my part) who agreed that the best course of action for this patient was in fact a prophylactic mastectomy on the second side, all so that she “wouldn’t have to keep going through this.” (the patient’s words) She has had her surgery (with completely benign pathology) and all is well.

The second patient is actually a physician, albeit one who has left clinical practice to become a pharma shill (a term of great affection and endearment, L; great affection and endearment!) with negligible risk factors for breast cancer, who knows damn well this is nothing. Yet because this isn't technically her area of medical expertise, she is as much at the mercy of of the goddamn specialists as the least edumacated of our patients. She is willing to accept the uncertainty and settle for a 6 month (or even 3 month) follow-up, but no; everyone is playing on her emotions, guilting her into a biopsy with a bolus of "just in case," followed by a continuous drip of "better safe than sorry." All because one radiologist -- just one -- isn't comfortable with something he saw on her mammogram.

So she hems and haws, and panics (and blogs) and goes for her MRI biopsy. One might wonder how you go about biopsying something on MRI that doesn't actually show up on MRI; well, I did, at any rate. It turns out that you don't. So what we have here is a wasted morning by a respected physician who could otherwise be churning out perfectly good pharma propaganda (feel the love, L; feel the love!) Not to mention all that adrenaline that could have been used to fight a tiger or wax indignant about an anti-Gardasil post. Frankly, this strikes me as a case of Someone Asleep at the Switch. Why the hell didn't *someone* (primary doc? surgeon? patient?) put 2 and 2 together and ASK why an MRI biopsy of an MRI negative lesion was being ordered!! And the upshot is (her words):
...a repeat mammogram in 6 months as follow up. Now who was it who suggested that course of action last week? Oh right. That would have been me.
Here's my point:

A radiologist notes a subtle finding but is comfortable with interval follow-up, a course of action that is completely inappropriate and unacceptable to the cancer survivor.

Another radiologist is uncomfortable with a mammogram, so patients undergo invasive procedures to assuage the concern of their doctors.

Excuse me, but isn't this just about the most ass-backwards thing you ever saw? Since when is it the patient's job to make the doctors comfortable? Luckily (?) someone was silly enough to schedule a useless appointment (though I'm certain her insurance company will still pay for the second MRI) so my new friend wasn't actually punctured, but still; how far should she -- or any patient -- be forced to go essentially to placate the single radiologist who read the initial mammogram? Although she's not my patient, if she were, I would have supported her in her acceptance of the (minimal) risk entailed in settling for short interval follow-up mammography.

Two patients; similar findings. Different recommendations from two different radiologists based on their different comfort levels (which are -- admit it! -- fundamentally related to their fears of malpractice litigation.) Different patient preferences based on very different clinical contexts. All other things being equal, I think we should be more concerned with our patients' comfort than with our own -- or even that of our consultants.

Thursday, July 17, 2008

It's That Time Again

It's JibJab, skewing everyone with equal opportunity verve:

Wednesday, July 16, 2008

I Love xkcd

Thanks to the Nestling for turning me onto This one still cracks me up whenever I think about it:

Tuesday, July 15, 2008

Is 70% Good Enough?

This is a patient conversation that I have had on many occasions:

Patient: I hear there’s this new vaccine available. Can you tell me about it?

Me: Sure. After a primary series of three shots, it provides 70% protection.

P: That’s it? I have a 70% less chance of getting the disease?

M: That’s right.

P: Does it mean I don’t have to worry as much about watching for it?

M: No. It doesn’t change the recommendations for surveillance at all. You still have to do the same things to screen for the disease.

P: Is the disease dangerous?

M: Well, if you let it go for a long time without doing anything about it, yes, it can be very dangerous. But if you catch it early, as it almost always is, it’s quite easy to treat. Treatment isn’t a picnic, of course; there are side effects with all treatments. But it’s completely curable if caught early.

P: Are there any other things I can do -- besides getting the shots -- to decrease my chances of getting the disease?

M: Absolutely! There are several recommendations.

P: So let me get this straight: after three expensive, painful shots, I still have to do regular screenings for the disease, which can be completely cured if treated early, and there are other ways to lessen my chances of getting it in the first place?

M: Yep.

P: Hm.

I’ll bet you all thought this was the discussion about the pros and cons of the new HPV vaccine Gardasil. Well, it is, but it’s also the EXACT same conversation about a vaccine few people remember anymore: LymeRx, the vaccine for Lyme disease sold by (then) SmithKlineBeecham. From April of 1999 through the end of 2001, I gave out 40 doses of it. Here’s my timeline:

4/99 - 12/99: 25
All of 2000: 12
All of 2001: 3

I live in an endemic area for Lyme disease. I see it and diagnose it frequently, before, during and after the time I was vaccinating against it. So what happened? SmithKline couldn't make any money on it, because whenever I had the above conversation with my patients, it usually ended with the patient saying this:

“Given what you’ve just told me about the shot and the disease, I don’t think it’s worth it.”
Despite the abuse we usually heap on patients’ intelligence by complaining about how stupid they are, I think many of them are remarkably resistant to the marketing efforts of the vaccine manufacturers. They read, watch and listen, but then they come in and ask us doctors for our opinion. When couched in the terms above, it turns out -- historically -- that 70% wasn’t good enough for them; at least not for Lyme disease.

The calculation for Gardasil and HPV is remarkably similar. Once you sit down and explain the relationship between HPV infection and cervical cancer, much of the Gardasil marketing loses its punch; not because cervical cancer isn’t scary enough, but because its actual prevalence in this country doesn’t justify the hype. (Using global HPV incidence and prevalence figures to scare American consumers is like trying to get a kid to finish his dinner by telling him there are starving children in Africa. They’re very quick to pick up on the absence of logic in that one.) It's so much less sexy to try to sell HPV immunization as "Reduces your chance of an abnormal pap by 70%." My experience with the Lyme vaccine leads me to believe that Gardasil will probably suffer a similar fate eventually.

So there you have my take on Gardasil. Present patients with the options and let them decide for themselves if 70% is good enough.

Saturday, July 12, 2008

Yo, CrankyProf!

This made me think of you; or of your baby, at any rate:

more cat pictures

Friday, July 11, 2008

You Want Evidence Based?

From the New York Times:
The pens, pads, mugs and other gifts that drug makers have long showered on doctors will be banned from pharmaceutical marketing campaigns under a voluntary guideline that the industry is expected to announce Thursday.
Medicine may still be struggling with the whole idea that one should be able to show that one's proposed interventions actually work, but there is another industry in this country that has evidence down to a science (if you'll pardon the expression.) This other group has extensive research to buttress every move it makes and every cent it spends. Missteps are rare. Of whom am I speaking? Advertising, of course; unless you want to call it Marketing.

I have no doubt in the world that the recent withdrawal of pens and mugs from the drug reps' goodie bags is nothing more than the result of a consultant's report that the return on that investment is not worth it. That same consultant probably then suggested that the announcement be couched in such a way as to present Pharma as the good guys. "See? We're not trying to buy prescriptions with cheap dreck like that anymore."

Cut me a break. They're still dishing out cash left and right: directly to doctors via "consultant fees," "speakers bureaus" and executive vacations disguised as educational meetings, not to mention direct-to-consumer advertising. That's where the ROI is.

Thursday, July 10, 2008

From the Washington Post:

Medicare has paid as much as $92 million since 2000 to medical suppliers who billed the government for wheelchairs and other home equipment purportedly prescribed by physicians who, according to records, were dead at the time, congressional investigators said yesterday.

The Centers for Medicare and Medicaid Services (CMS) honored about 500,000 such claims despite pledging six years ago to correct the problem, which was identified by the Health and Human Services Department's inspector general in 2001.

In more than half the cases studied, the doctor listed as having ordered the equipment had died more than five years earlier, said a report by the Senate Homeland Security and Governmental Affairs Committee's permanent subcommittee on investigations.

"We discovered that some medical equipment suppliers have scammed the Medicare system -- and the American taxpayers -- out of massive amounts of money," Sen. Norm Coleman (Minn.), the panel's top Republican, said in a statement.
What do you want to bet CMS responds like this:
The Centers for Medicare and Medicaid Services (CMS) announced today that they are launching a thorough investigation into the recent allegations of fraud by dead doctors by pursuing their heirs.

"Doctors are responsible for the use and abuse of their Medicare identification numbers. Nothing in the statute absolves them of that responsibility at death," said a CMS spokesman. "Physicians should have made provisions for the deactivation of the number as part of their estate planning, and their failure to do so has cost the American public millions of dollars. We intend to recoup those funds from their heirs and assigns."

As with other types of Medicare fraud, CMS acknowledged that they would be seeking triple damages from the doctors' heirs. The possibility of fraud prosecutions had also not been ruled out.

Too Much History

Many people will claim that there's no such thing as "too much medical history" when trying to diagnose a patient. Technically I agree with that statement, but there are times when too many clues make things harder instead of easier:

Saw a 20-something lady the other day with a three-day history of watery diarrhea; 10-12 stools per day; no blood; no nausea, no vomiting, no abdominal cramping; slight fever (100.2 in the office); otherwise unremarkable physical exam; stool frequency decreasing.

More history:

Symptom onset was about 4 hours after consuming a meal at a fast food restaurant, which included tomato products. Note: source of a national tomato/salmonella scare not yet figured out.

Some more history:

Said fast-food meal was consumed approximately 12 hours after returning from a 10 day business trip to India.

Even more history:

Having misunderstood the instructions given to her about the ciprofloxacin pills she was given to take IF SHE HAD SYMPTOMS while in India, she had in fact taken them twice a day for 10 days on the trip despite feeling perfectly fine. (She thought they were to prevent diarrhea.)

So which is it?
  • bacterial colitis, possibly salmonella, from the fast food restaurant
  • bacterial or viral gastroenteritis acquired in India (cholera? vibrio? campylobacter? other weird parasite?)
  • antibiotic-associated colitis, possibly C. diff, from the cipro
  • none of the above (garden variety everyday viral gastroenteritis)
Really though, how often do you see an HPI with all those possible etiologies for acute diarrhea?

Wednesday, July 09, 2008

So True

From one of my new favorite websites:
song chart memes
more graph humor and song chart memes

Tuesday, July 08, 2008

Statins for Kids? No F-ing Way!

The nation’s pediatricians are recommending wider cholesterol screening for children and more aggressive use of cholesterol-lowering drugs starting as early as the age of 8 in hopes of preventing adult heart problems.

The new guidelines were to be issued by the American Academy of Pediatrics on Monday.

When I'm presented with a patient whose med list is as long as my arm, one of my favorite things to do is go through it and take people OFF meds. Duplicative therapy; unnecessary poly-pharmacy; relieving medication side effects by stopping the drug -- and perhaps one or two more begun to combat those side effects. I love it!

Before I start any 8-year-old on a statin drug for his cholesterol, I'm going to first suggest stopping all video games and discontinuing all TV. Then I would prescribe 3-4 hours/day of running around outside in the sunshine (with sunscreen, of course) possibly supplemented by 1-2 hours in a swimming pool or ocean. Other things I'd like to see on that kid's med list -- before statins! -- would include:
  • biking (with helmet, please)
  • stickball
  • hide & seek
  • daydreaming in a hammock
  • catching frogs
  • etc.

Statins for kids. Sheesh!!

Monday, July 07, 2008

Giving Bad News Over the Phone

How do you avoid giving a patient bad news over the phone?

This is a trick question, because the real answer is, "You can't."

I know how they say you're supposed to do it: have the patient make an appointment and give her the news face to face.

Oh yeah? Let's see exactly how that works:

Patient: Do you have my results?

Receptionist: Let me check. (finds pathology results; notices that it says "highly suspicious* for carcinoma"; hems, haws) Let me check with the nurse. (finds RN; shows results; gets told to schedule patient for MD appointment right away.) Um, yes. The doctor would like to see you to go over them. Can you come in first thing tomorrow?

Cut me a break! How much more clearly can you say "BAD NEWS!" but in the worst possible way. Now she's left terrified -- still having to wait until tomorrow.

I know, I know. Schedule all patients for return visits after all tests; no exceptions. The only problem is that makes for piss-poor customer service the 95+% of the time the results are completely negative. I sometimes fudge that by having them make the appointment, then calling them with the normal result and canceling the return visit. Still, that does nothing for the inevitable quandry of having bad results in hand with the patient on the phone.

Those waiting for me to hand down some masterful stroke of saurian wisdom are out of luck. However you cut it, this situation completely sucks, especially when the call above was to the specialist's office and the next call was to me. The specialist's office then faxed me the path report with a note, "Patient unaware of results; has appointment tomorrow to discuss."

What was I going to say to her? There was no way I was going to make her feel better and the risk of making her feel worse was considerable. She was seeing the other doctor in the morning. I weighed the pros and cons and made a unique decision: I intentionally did not return the call. I don't know if this was the right thing or the wrong thing to do, but it's what I did; didn't do, that is.

BY THE WAY: This is NOT how I handle these things in my own practice. I *always* call patients back with *all* results (therefore when a patient calls to see if the results are in, my staff can always say, "No; you will get a call when they are.") When things are abnormal, I do come out and say so over the phone, giving enough information to assuage their fears until I can see them in the office and go over the everything in greater detail. But in this case, I was stuck.

Any ideas?

*In Pathology-speak, "highly suspicious for" = "is"

Saturday, July 05, 2008

Schizophrenia is Painful

To whoever posted the 27,881 word comment on one of my previous posts, I have only one thing to say:

Dude, please take your meds.

For anyone else, either medical students on or preparing for a psychiatry rotation or confirmed insomniacs looking for a sure-fire sleep aid, email me if you want to read it. Although I deleted it from the blog, I saved a copy, much as ER docs keep collections of bizarre objects removed from assorted orifices. Bear in mind that nearly 28,000 words comes out to 35 single-spaced pages. That's one blog comment. I've actually had this happen before, but that one was only about 14,000 words. I have no idea how long it took to write this one, but it's clear to me that the writer is in pain.

Friday, July 04, 2008

Immunization Primer

It's a slow time for blogging between holidays, vacations and needing to devote time to (PAID!!!) writing, yet I wanted to respond to some of the commenters on my previous post who asked about what immunizations are recommended for "perfectly healthy adults." Here's the thing about official vaccine recommendations. They are:
  1. Easily accessible
  2. Changing at an accelerated pace, and
  3. Developed with applicability to populations as opposed to individuals.
This last point is often lost in the translation of "recommendations" to actual patient care. I have a confession: much as I respect the work of the Advisory Committee on Immunization Practices, I find some of their more recent recommendations harder to sell to patients -- on medical, epidemiologic and financial grounds -- than many of their previous ones. I take care of one patient at a time, so I need to be able to explain to a patient (or parent) what the specific advantages of a given recommendation are to them specifically.

Given that the original triumph of vaccination was the vanquishing of vaccine-preventable childhood diseases, any immunization recommendation regarding diseases that are specifically a hazard to infants and young children are easy to sell. Likewise, the prevention of catastrophic diseases -- even if rare (meningococcal disease) -- are accepted more easily than preventing illnesses that may be uncomfortable and inconvenient but do not have lasting sequelae (hepatitis A.) Questioning the ACIP is difficult for me, like discovering the views of a cherished professor shifting away from what I can comfortably agree with; but I do find myself coming to different conclusions than they when faced with individual patients instead of patient populations.

All that as a disclaimer that the following applies specifically to healthy adults with no special medical issues, no chronic diseases, no specific travel or occupational issues; people not under medical care, living in the United States with reasonable standards of sanitation and hygiene; not in intimate contact with large groups of people (ie, not living in dorms, military barracks, etc.) Also taken into account are my personal opinions based on my clinical knowledge of the applicable vaccine-preventable diseases involved. (Note: explicitly reviewing each of those diseases would render this post ridiculously unwieldy. That information is easily and quickly found at the CDC website linked above.)

Every year: Flu shot

Should be obvious.

Every 10 years: Tdap (tetanus, diphtheria, pertussis)

At the moment, the official recommendation is only one lifetime Tdap dose with plain Td given every 10 years, but given the waning of pertussis immunity, I'd bet that before the decade is up, plain Td will be history.

At age 60: Zostavax (shingles)

Often devastatingly painful disease, with the pain being permanent up to 10% of the time. The shot is still extremely expensive, therefore difficult for us dinosaurs to stock, and a PITA to obtain at a pharmacy and bring to the office for injection, since it has to remain frozen, but overall probably a good idea.

At age 65: Pneumovax (pneumococcal disease, the #1 cause of pneumonia in the elderly)

Once per lifetime; previous recommendations for boosters have been rescinded.

For those few adults who have had neither chickenpox disease nor vaccination: Varivax, two doses 4-8 weeks apart

Chickenpox is no big deal in kids, despite the ACIP scare tactics of including immunosuppressed kids undergoing cancer chemotherapy or suffering from HIV in their morbidity and mortality statistics, but vaccination has become such a juggernaut I can't really do anything about it anymore. Still, adults are more likely to suffer complications from chickenpox; and varicella pneumonia carries a 10% mortality. Nothing to sneeze at.

That's basically it. Don't get me started on the Hep A and Hep B (covered in the disclaimer by the travel, sanitation and occupational clauses) or the HPV vaccine Gardasil. As I've said previously, I've softened my virulent stance against it somewhat, but that's a post for another day.