Paper Rainbow Memories

I've mentioned before that I don't use an electronic medical record. My paper charts serve my needs adequately. I've designed my own system with colored folders, based on the second letter of the patient's last name, that's kind of nice to look at as well as being quite functional. Still, paper charts do require some annual maintenance.

In addition to labels identifying the patient (and sometimes the insurance) there is a sticker on the end of each chart showing what year the patient was last seen. Patients seen within the last three years are considered "active," so we keep their charts on the most easily accessible shelving. Charts of patients not seen for seven years are considered inactive, but we keep them nearby in case they call and want to be seen again. After seven years, we move the charts to "cold storage." Technically this is allowed to be off-site, though I have plenty of storage space in the basement of my office, so that's where they go.

What this means is that once a year someone (me, in this case) goes through all the active charts and pulls those of patients who haven't been seen since 2005. This task is made easier by the fact that the end-tab stickers for each year are a different color. They repeat over a cycle of 10 years: black, yellow, blue, pink, brown, orange, olive, green, gray and red. I'll be starting on my third round of them in 2009. Before I do that, though, I have to make room by moving the charts of people who haven't been seen since 2000 down to the basement. Then I can move the 2005's over to the inactive shelves, and enjoy the relative increase in the amount of space available for regular filing...at least until they get packed in again with new patients and more records on old patients in the New Year.

So as the year draws to a close, I find myself hanging out alone at the office finishing up these annual chores. Hardly anyone wants to be seen, so the staff is out. I find that being here to answer the phones cuts back on messages and frantic calls later on; besides, there's work to do.

It's great exercise running up and down the steps a dozen or more times lugging armfuls of charts and rearranging them on the shelves. In the process, of course, my eye scans over the names and, cursed blessed with an elephantine memory, thoughts of the people behind the paper come back to me. I remember them; their illnesses and their medical histories, but also what they were like as people. Some I liked; others not so much. We are all only human after all. But over the years, many of those patients and I truly became friends.

Wow, I think; has so-and-so really been dead for eight years now? His grandchildren are getting so big; they miss him, and so do I.

Oh yeah, that family moved away. I wonder how the kids are doing. My goodness; the "baby" must be in school by now!

On and on, twice through the alphabet plus whatever it takes to shuffle them around evenly on the shelves. The tips of my fingers split and bleed from dozens of paper cuts and the muscles in my hands begin to ache from moving handfuls of charts at a time. As I work, I find myself looking back, remembering not just the year gone by, but all my years in practice.

When my task is done, I stand and regard a wall of color. Narrow stripes of it superimposed on larger blocks, together representing so much: sickness and health, life and death, all arrayed before me in rainbows of memory. Even though I saw the patients one at a time, generated the pages in those folders before me word by word, visit by visit, day by day over each of all those years, now I stand and gaze upon them in aggregate. So much more than just words on pages, each of those folders is a record of a person whose life touched mine and whose life I was privileged to be a part of, hopefully influencing it for the better. And I find myself profoundly grateful to each of them for that opportunity.

I smile to myself as I turn out the lights and head for home, wondering how long the charts will stay so nice and neat on the shelves like that.

Happy New Year!

Another Reason to Keep Your Socks On

Here's the latest salvo in the NP vs. MD wars:

Patient sees a GYN nurse practitioner for her annual GYN exam. Got that? A gynecological checkup which, last time I checked, involved a problem focused history and a physical exam limited to the thyroid, breasts, abdomen and a pelvic exam. This is actually one of the narrowly defined areas where I happen to believe physician extenders can be useful; but not in this case.

What this NP noticed was something on the patient's little toe that she "didn't like the looks of." Okay; I guess that's not unreasonable. I'm not saying that an NP should ignore a blatant abnormality that she may happen to notice. It was her response that is leading me to iatrogenic alopecia areata [jargon translation: physician-caused patchy baldness, as in tearing my hair out.]

Which of the following do you think this idiot "provider" said:

1. You should see a real your family doctor about that.
2. You should see a dermatologist about that.
   
3. You should see a foot doctor about that.
4. Here's a slip for some blood work to see if you're diabetic.
   

Numbers 1, 2 and 3 are all acceptable, presented in order of desirability. But no. This highly educated, trained professional that so many people seem to feel is capable of handling Primary Care medicine unsupervised actually sent the patient to rule out diabetes with a fasting blood sugar.

Luckily, the patient called me first and readily agreed to come in to let me see THE CORN ON HER TOE. That's right, boys and girls: a nasty, abraded, excoriated corn that I shaved for her, curing her on the spot. Oh, and her fasting blood sugar three months earlier had been 87, with an A1c of 5.5, ordered for her annual screening for her family history of diabetes.

I hardly know where to start:

• Wrong diagnosis
• Unnecessary test
• Would not have helped the problem, whatever the result

About the only utility for a universally accessible personal health record (as opposed to a physician office based electronic medical record, which is what everyone is talking about) would be to allow morons like this to access the patient's recent blood work. But no; Americans are far too worried about strangers being able to find out what their last back MRI showed to ever allow implementation of something as useful as that. Never mind that they have perfect confidence -- mostly deserved, mind you -- in the security of electronic systems to do their banking online.

But I digress.

What was she thinking? That's what I want to know. "Diabetics have problems with their feet. This patient had something funky on her foot, therefore she might have diabetes." Semi-logical, so how about finding out what kinds of foot lesions are characteristic for diabetes and what they look like so you have a prayer of diagnosing them semi-accurately. What, exactly, did she think was going to be accomplished by obtaining a fasting blood sugar? If it was terribly high, then yes, the patient has diabetes, but how does that help her foot?

I frequently see specialists (not just NPs) ordering inappropriate tests to rule out conditions not supported by history or physical -- but out of their specialty. Gynecologists ordering coagulation studies to rule out congenital clotting defects on patients with no family history of bleeding problems who report that their gums bleed when they brush their teeth (but have delivered babies and had multiple surgeries with no problems); orthopedists ordering echocardiograms on patients who report that "someone once heard a heart murmur on me"; pulmonologists ordering lung function testing on everyone who walks in the door before ever being seen -- including the guy with a pre-employment positive PPD with no lung complaints at all. They may be experts in their own little fields of expertise, but they don't have to step very far outside those boundaries to look (and act) like flaming idiots.

How on earth can we keep people from causing mischief -- and wasting piles of money while they're at it -- by failing to recognize their limitations? I, for one, am not holding my breath.

Chief Complaint FAIL

My throat is sore, but I don't think I have a sore throat.

Helen's Stuffing

I don't know what's better, the recipe or the presentation:

[Helen's Perfect Stuffing]: Bacon. Forget about sausage, nuts or god forbid fruit for your stuffing. That’s all just a bunch of crap. The surefire way to have the perfect holiday meal is bacon. Unless, of course, you are Jewish or vegetarian. Then I can’t help you. A little day-old, plain, white bread, some butter, onions, seasoning, a little celery and a pound of bacon - fried crisp. Mix it all up complete with the bacon grease from the pan. You can’t go wrong. It’s the perfect stuffing every time.

News flash, Helen: not all Jews keep kosher. This sounds unbearably yummy, and you'd better believe I'm going to be using it in the very next turkey to which I have access.

(Actual recipe at the end of the post.)

Giving New Meaning to the Phrase, "Putting the Cat Out"

As long time readers may know, this is a cat house. There are four of them at current count. One of them, previously blog-named The Mighty Hunter, has the unfortunate habit of spraying when he doesn't get his way. The result of this is that he has us very well trained to give him his way; usually letting him out of the house to patrol the neighborhood. We have also gotten into the habit of putting him out at night, having grown weary of being awakened by a characteristic noise -- followed by a distinct, also characteristic odor -- in the bedroom as he expresses his desire to go outside RIGHT THEN. That it usually happens around 2:00 am does not appear to have any significance to him whatsoever. Therefore, an important part of our bedroom routine is to make sure that the cat has been put out.

As long, medium and short-term readers of this blog, and perhaps some others, may know, tonight is the second night of Hanukkah, a minor Jewish holiday celebrated with the lighting of candles. To the surprise of no one (I hope) we lit our Hanukkah candles again tonight. We sang the blessings and exchanged gifts as we waited for the latkes to finish frying.

This particular evening, the cat jumped up on the table. This is not new; he does it all the time. After all, he has to help us read the newspaper, check out what is on our plates and stuff his snout into the glass to lick out the last remnants of chocolate milk. (Not to worry; he doesn't do this during actual meals, usually just during what passes for breakfast as we struggle to read the paper and snarf something down before speeding out to work.)

At any rate, tonight he hopped up onto the table and began exploring. He approached the menorah (which held three lit candles) and began to sniff one of the flames. His curiosity temporarily sated, he proceeded to pass around the menorah (which still held three lit candles.) The NinjaBaker watched as TMH passed perilously close to the flames. In fact, as I was told later, NB actually thought, "Hm, I wonder if he's going to be dumb enough to catch on fire."

Well, he was, and he did.

Luckily, NB immediately blew him out -- along with the candles, which were quickly re-lit (before I even realized what had happened.) Fur was slightly singed, but no lasting damage ensued to cat, candles, menorah, table or gifts. And the phrase, "Did you put the cat out?" has now gained entirely new meaning in our little household.

Next night addendum: Same event; different cat. It's the only way an indoor cat will ever legitimately get put out.

An Apology

Deep apologies for reneging on a promise:

Because of the timing of assorted holidays this year, life is just too busy this week (actually, this previous weekend) for me to get around to selecting, photographing, annotating and posting more pictures from my collection of hanukiot. Apologies to both of you who were looking forward to it, and a very happy Hanukkah to all.

If you wish, here are links to last year's pictures:

1. First night
2. Second night
3. Third night
4. Fourth night
5. Fifth night
6. Sixth night
7. Seventh night
8. Eighth night
   

The Unbearable Lowness of Brass

This was a day of Philadelphia holiday adventuring by Darling Spouse, the NinjaBaker and your humble Dinosaur narrator. The three of us went a-traipsing into Center City Philadelphia this morning, where our initial stated goal was to attend a free event at the Kimmel Center known (for real) as Tuba Christmas, but was then followed by several other season- and city-specific activities

We have a warm spot in our hearts for low brass; Darling Spouse because DenverDaughter played bari horn in her younger days, NinjaBaker ever since he branched out from trumpet onto horn, mellophone and trombone, and I because I love the way the sound pounds its way in through my chest instead of just making its way through my ears like ordinary music. We were not to be disappointed. We got there a good half hour before show time, but the rows of chairs set up for the audience were already so full that we ended up sitting behind a free-standing staircase in the general vicinity of what was functionally "stage left." Listeners eventually filled the atrium area of the Kimmel and lined all the balconies as well.

There were so many performers that some of
them had to go upstairs to the balcony,
a few of whom are visible in this picture.

Obviously our location was irrelevant to the sounds we experienced, but we had a cool view of the conductor:

This year's Philadelphia version of Tuba Christmas featured 132 participants, ranging in age from a 6th grader to a Civil War veteran (ok; a costumed re-enacter, but the instrument he played was a functioning period antique.) There were all varieties of all members of the tuba family, and when they let loose, let's just say this wasn't John Philip Sousa's oom pah pah band. Here's a picture NB snapped of the two oldest instruments in the group, the 1860 Civil War era baritone saxhorn and an old fashioned upright Sousaphone*, aka "raincatcher" from 1889:

Darling Spouse noted that one doesn't usually think of this family of instruments as particularly melodic, so this event is their opportunity to show that they can, indeed carry a tune. For about an hour, they proceeded to carry over a dozen Christmas tunes that defied superlatives. Some were paced a bit slower than might have been expected, because as NinjaBaker pointed out, (tongue only partly in cheek) tubas don't do eighth notes. Audience participation included the jangling of keys during Jingle Bells, as well as song sheets handed around to allow us to sing along with two other carols.

In the spirit of inclusiveness, there was also mention of Tuba Hannukah and Tuba Kwanzaa. To honor the latter, an arrangement of Go Tell it on the Mountain was included. The Jewish contribution, of course, was tubas belting out the old familiar strains of the Dreidl Song. The real problem, of course, is that as soon as they started to play, the following quatrain jumped into my head fully formed :

I have a little tuba,
I made it out of brass,
And when it gets too heavy,
It knocks me on my...
Oh tuba, tuba, tuba...

(Digital Cuttlefish, eat your heart out.)

'Twas a truly amazing experience, and one that I look forward to repeating again in years to come. After it was over (and once the NinjaBaker was through gawking at the sight of a group of sousaphones getting onto an elevator, contemplating the amazing experience of listening to them play in that confined space) we turned our footsies to the north and mosied up Broad Street. The weather was cold but not yet biting, and it warmed me to realize we were at the very site of rather a happy event just a few months back. We turned right onto Market street and one block later found ourselves at Macy's.

Who the hell cares about Macy's in Philadelphia at Christmas? you may ask. And well you might. I may have mentioned one or two (hundred) times that I didn't actually grow up in Philadelphia (which is to say, the Philadelphia metropolitan area) but I have been here since 1981. What that means is that even I know that a now-defunct store called Wanamakers used to have this really cool pipe organ at its flagship store downtown, and a reportedly spectacular light show at Christmas time. What has happened in the fullness of time is that Wannies is now Macy's, but they still have the organ and the Christmas light show, which was our next destination:

Darling Spouse admitted to some disappointment in the experience, probably the result of over-hyped expectations. I did point out to NB how much more impressive the concept was if one considered what was involved in essentially the same production before the invention of the computer. My sense is that the event would probably have been more fun in the company of those aged in single digits. However it was something to check off the bucket list.

At that point, we were ready for a meal. Another three blocks north and one block east and we were at our favorite mecca of Philadelphia food, the Reading Terminal Market. Darling Spouse went for a hot pastrami sandwich while I got a few hand rolls of sushi, but not until after I followed NinjaBaker around the entire place mopping up his drool as he checked out every single stand. He finally settled on chicken parmigiana. Of course the process was then repeated for dessert.

Finally, tired but unbowed, we retired to the car park where we ransomed Old Redder for a mere $9.00 and made our way home. What a day. As NinjaBaker put it, "Oh, the Tubanity!"



*Do click on the link for some chuckles. It includes lines such as:

Few things are more continually irritating to a genuine sousaphone man than to have his instrument constantly called a "tuba". A tuba is a weak, puny thing fit only for mewling, puking babes and Guy Lombardo -- the better to harass balding, middle-aged dancers. An upright instrument of startling ugliness and mooing, flatulent tone, the tuba has none of the grandeur, the scope or sweep of its massive, gentle, distant relation.

and:

[The sousaphone] is an instrument a man can literally get his teeth into, and often does. A sudden collision with another bell has, in many instances, produced interesting dental malformations which have provided oral surgeons with some of their happier moments.

Also, there are already plenty of Tuba Christmas clips up on YouTube from various locales this year. Check them out to get more of a sense of the whole thing, and/or consider checking out your local performance. It really is great fun.

Why Do I Even Bother?

So I saw this patient ten months ago.

Ten months ago. Got that? In March.

I found a lump in one of her breasts. Oh, that, she says. I'm sure that's just a cyst. I had it once before and it must have come back. That's all it is. I'm not worried. That's what she says.

Well, says I, you're probably right. But you never know for sure. I'd really like you to have a mammogram and an ultrasound, because it's been a couple of years since you've had those studies, and you can never be sure about these things just from feeling them. So it's really important that you go and have these studies done. Understand? Ok?

It's not like I just threw a mammogram requisition at her and walked out of the room. I spent a fair amount of time trying to explain to her why it was important to investigate this breast lump. She said that she understood what I was saying and that she would go ahead and schedule the studies.

I put her chart in a section of my file shelving where I store charts with pending studies. After a month, when I noted that the results hadn't come back yet, I called her. She hadn't scheduled them yet, but said that she would. The next month, I called her again. Same thing. This went on, month after month. Each time I called her, my urgings escalated. Each time I called, I documented it in her chart. Finally finally finally she got the tests. I'm sure everyone reading this is shocked -- SHOCKED -- to discover that the mass was not a cyst, but was in fact an invasive breast cancer now requiring treatment TEN MONTHS AFTER I FIRST DETECTED IT ON CLINICAL EXAM.

I'm not particularly worried about the liability issue, because of my pristine documentation, but jeez! It's times like these that I wonder why I even bother doing what I do at all.

Rant Time in the ER

An ER nurse who just doesn't get it:

I was sitting at work a couple of days ago and one of the other nurses commented that staff nurses could really handle a lot of what comes into the ER without doctors. It got me to thinking, why do we pay doctors big salaries to do what a nurse practitioner could easily do? Honestly I think that a nurse practitioner could easily handle what comes into an ER if they specialized in emergency medicine. My co-worker pointed out that they couldn't do emergency procedures. Why couldn't they? They could intubate, place central lines, etc. if they were trained. Nurses are already doing this in some places.

The thing about changing medicine and making it less costly is that there are so many interest groups that would fight it. Among the first would be the AMA which will fight it tooth and nail. I guess that is their purpose to stand up for doctors.

As I see it the future of medicine in primary care, family practice, is the nurse practitioner. Doctors will be the specialists. Will nurse practitioners change the face of medicine? Perhaps. Nurses are taught to look at the whole person. Doctors, for the most part, are taught to treat the physical. Nurses learn more about preventive care. Doctors, for the most part, learn to deal with problems that have already happened.

If you are a young nurse, consider being a nurse practitioner.

Oy. Here's my comment:

Why stop there? I've seen what nurses do in triage. They just ask a bunch of questions off a sheet of paper and do whatever the protocols say. It seems like the unit clerks could really handle a lot of what the nurses do. Why pay nurses big salaries to do what a clerk could easily do? Honestly, I think a clerk could do what a triage nurse did if they were given specialized training.

The thing about changing ER nursing and making it less costly is that there are so many interest groups that would fight it tooth and nail, like the ANA. I guess that is their purpose to stand up for nurses.

As I see it, the future of nursing is the clerks. Nurses will take care of people already in the hospital. Will clerks change the face of the ER? Perhaps. Clerks are taught to do paperwork.

If you are considering a medical career, become a clerk instead of a nurse or a doctor.

(Oh, wait: I guess we already are.)

When are people going to realize that watching someone do something does not make you qualified to do it, even if you think it looks easy? So much of what doctors do (and many other professions as well) is infinitely more complicated than it looks, especially when someone is very good at it. Just because an extremely skilled physician makes medicine or surgery look easy does not mean that anyone else "could easily do it," regardless of "specialized training" (short of medical school and residency training.)

This is as true for Primary Care medicine disrespected by Partialist physicians as it now appears to be for Emergency Medicine disrespected by ER nurses. I, for one, am getting really sick of it; so cut it out already!


(h/t to Scalpel)

(Note to all you ER folks: not talking about fast track or misuse of ERs for minor shit here, because hell, a clerk really could triage that crap. The question is, would you want them to?)

Overheard

At last night's holiday party:

What they should really do is let the Oil industry bail out the Auto industry. Hell, they could do it out of petty cash and never miss it.

Truer words were never spoken.

My Kind of Reindeer

Thanks again, SG. Do you ever work?

Introducing Shlomo, Rudolph's first cousin on his mother's side:

(source uncertain; citation welcome)

Radiology Isn't Rocket Science

From the Health Business Blog: Image Gently for Teens too.

There has been some recent awareness about the dangers of radiation to young children (theoretically understood for only the last hundred years or so) resulting in initiatives like Image Gently, urging adjustment of radiation doses for CT scans (necessary ones only, please) in kids. Apparently, there's a cutoff at age 12, so that once that magic birth date arrives, teens are subjected to the full pre-set adult radiation dose.

Cut me a break! Pediatric medications are dosed by weight. There are cutoffs too, but more often by weight than purely by age. I refuse to believe that a highly techno-savvy radiology department is incapable of adjusting the radiation settings based on a patient's weight as well, whatever their age. Good heavens! It's probably even possible to incorporate a scale into a CT table and program the computer to make the adjustment automatically, letting the tech override the setting if desired, instead of making the poor thing remember one more detail.

It's not brain surgery, after all.

Euphemisms

So...Darling Spouse comes home yesterday having been listening to a particular song ("Why Don't We Get Drunk and Screw" by Jimmy Buffett) on the way home, and suggests that we try using "having a Jimmy Buffett" as a new euphemism for one of our favorite activities. (Please ignore for the moment why an empty nester couple needs to resort to euphemisms for that, or any other activity, for that matter.) Since one of our other favorite joint activities happens to be eating, I pointed out that the main problem with using "having a Jimmy Buffett" as a euphemism runs the risk of being met at the door not hot and naked, but holding a cheeseburger and a margarita.

Another New Favorite Blog

Thanks to Janet from Cape Cod for this one:

Margaret and Helen

A pair of 80-somethings who have been friends for 60+ years, one of whose grandson's set them up with a blog. Every freakin' entry is a beverage alert, so be warned! (Watch out, Lynn; they're radical lefties.) Go check them out. I mean it. Really.

When Newer is Not Better

Latest correspondence from a large health insurance company that shall remain nameless (except that it's named for a color and a shape):

To achieve a more consistent look for member identification cards nationwide, the Color/Shape Association is requiring all plans to follow new graphic standards for ID cards that will take effect January 1, 2009.

As it happens, we've already begun seeing some of these new cards, and there are definite differences:

1. The print is smaller.
2. The numbers are much more difficult to read, because they're printed closer together.
3. The background is a duller, more matte finish that produces hard-to-read, darker photocopies.
   

So much for quality improvement.

Report of Pastry Comparison

TITLE

Blinded Comparison of Butter vs. Butter-Flavored Shortening in Baked and Unbaked Cinnamon Pasty Swirls

AUTHORS

#1 Dinosaur MD, NinjaBaker HSD*

ABSTRACT

We performed the experiment outlined here and evaluated blinded taste comparisons of both uncooked dough and final baked cinnamon pastry swirls. Neither researcher was able to tell the difference between pastry made with butter and butter-flavored shortening when small test aliquots were used. Larger, unblinded sample mouthfuls were judged different both in taste and texture, although neither of us could reliably identify which fat was which when blinded. From this we conclude that pastry is delicious whatever it's made of, and that both of us have way too much time on our hands.

INTRODUCTION

Because our family enjoys the taste of pastry, one of us (#1D) invented a recipe several years ago that basically allows the eating of almost-unadulterated plain pastry. By rolling out a slab of dough, slathering it with cinnamon sugar, jelly-rolling and slicing it, we have been able to enjoy this treat without worrying about incidentals such as nutrition, as would be included with something as inherently healthy as apples in a pie. One of us (NB) has begun the process of learning to bake, and it was felt that learning the technique of pastry baking would be a valuable addition to his knowledge base. Thus our experiment had several purposes aside from exploring the initial hypothesis.

MATERIALS & METHODS

We performed the experiment as outlined here. The butter used was unsalted Costco brand generic butter, removed from the freezer approximately four hours prior to the experiment. The shortening was butter-flavored Crisco brand. We used Safeway store brand flour, water from the tap (aka "Schyulkill Swill") and Morton's brand iodized salt (kosher.) Each pastry batch contained the following ingredients:

1.5 cups plus 2 tbsp. flour
8 oz. butter or shortening
0.5 tsp. salt
3 tbsp. cold water

Pastry was prepared according to standard procedure and rolled out into an approximately 9 x 11 inch rectangle. One stick of butter was melted in a glass measuring cup; approximately 1/4 of this volume was sufficient to cover each dough slab. Cinnamon and sugar were combined to an agreed-upon level of brown-ness (sufficient so that the scent of cinnamon was clearly perceptible throughout the experiment.) Approximately 1/3 cup of cinnamon-sugar mixture was spread over each slab, which was then rolled up, sliced into 1/2 inch slices and baked on an ungreased cookie sheet for 10 minutes in a preheated 450 degree oven. Unbaked dough aliquots (the ends of the rolls, where the dough was less even) were set aside for tasting.

Formal tasting comparisons were performed as follows: each of us in turn closed our eyes and held out our hands. The other investigator then placed approximately 1 cc samples of either dough or baked product in each outstretched hand. The samples were consumed in any order and the blinded participant rendered an opinion on whether the two samples were the same (both butter or both shortening) or different. In each case, an estimate was also provided about what each sample was made with.

RESULTS

Much to the surprise of the senior investigator, neither participant was able to reliably determine whether a given sample was made with butter or butter-flavored shortening when tasted blindly in small volumes. This observation held both for unbaked dough samples and pieces baked pastry at room temperature. When tasted in an unblinded fashion and in larger quantities (ie, shoving the whole thing into one's mouth) one of us (#1D) believed there was a difference in "mouth feel," with the butter dough giving a greater sense of smoothness, for lack of a better adjective. The other investigator (NB) wasn't as certain, but made a valiant effort by continuing to stuff whole cinnamon swirls into his mouth.

The experiment was also attended by ancillary personnel including Darling Spouse, the Jock, DinoDaughter and DenverDaughter, each of whom also sampled unbaked dough aliquots and baked cinnamon swirls. Their consensus opinion correctly identified which plate was made with butter and which with shortening, but further trials should be conducted to control for luck.

DISCUSSION

There were several differences noted between the butter batch and the shortening batch during the pastry preparation process. The butter batch tended to be somewhat more elastic and easy to handle, both while flattening it with the rolling pin and while rolling it up after the butter and cinnamon sugar were applied. Both operators noted that the shortening dough seemed drier and tended to crack more, rendering the final product somewhat less visually appealing.

The senior investigator was actually somewhat surprised that the entire experiment ever came off at all, as the process did not begin until 7:30 pm, after the junior investigator had spent the entire day playing an Ultimate Frisbee tournament. The fear was that the experiment would run too late and that the junior investigator was too tired to participate. Fortunately this turned out not to be the case. In fact, because the junior investigator took longer to complete each preparation phase (as would be expected, given his lack of familiarity with the process) the senior investigator was able to complete most of the clean-up procedure during the baking phase of the experiment. The entire process was accomplished quite smoothly, and was considered very enjoyable by all participants.

FINAL CONCLUSIONS

As above, we conclude that pastry is delicious, however we do feel that butter produces a dough that is easier to handle than shortening. Further, as also stated above, it is quite clear that all investigators, participants and readers of this paper have far too much time on their hands. We recommend that they immediately begin attempting to get a life (and/or a job at the Food Network.)


*High School Diploma

A New Record

(Posted with explicit patient permission.)

Ah, forms! The bane of our existence. Far too much of our time is devoted to the filling out of various and sundry forms: camp forms, driver forms, handicapped parking placard forms; physical exam forms; adoption forms. The list is literally endless.

One of the greatest inventions in human history was that of the photocopy machine. This way patients can easily receive a copy of a given form for their records. Similarly, if some camp or school or government agency needs multiple copies of something, they are easily produced.

Once in a while you run into a situation where someone needs multiple originals of a given form. I first ran into this when my mother-in-law passed away and we were told we should order at least a dozen original death certificates. Apparently many agencies insisted on originals instead of photocopies for documenting that the dear lady was no longer among us. As it turned out, we went ahead and sent some folks copies instead of originals; no one ever blinked. We never did use up all the ones we ordered.

On rare occasions I have been asked to sign a form more than once, so that whoever it is who requires multiple originals will be mollified. Today, however, I set a new personal record:

I had a patient come in who needed to submit an application to join the Turkish military, where service is required. (So why does he have to "apply"? Don't ask; he's just as puzzled.) This nice man needed me to complete and sign the same original document (each of which had an original color passport-size picture attached) five times. You read that right; here it is numerically: 5.

Why? Beats the holy hell out of me! This is the Turkish government we were dealing with. I've seen Midnight Express. I know better than to mess with the Turkish government. I completed the paperwork and wrote in my chart:

Forms completed in quintuplicate.