A Moment

Every now and then, I'm blessed with a moment; an aliquot of time apart from the usual hustle and bustle, the endless rushing here and there between appointments and obligations to just stop and be, quietly at one with the universe.

It was one of the those glorious days last week when the spring sun was warm but not prematurely stifling. I stopped at the post office on the way home to pick up the mail. There wasn't much money in the deposit that day, so I didn't feel compelled to get it to the bank. I was meeting the NinjaBaker and NinjaCutie for dinner later, but didn't have to be anywhere for a good half hour. So I took the Rolling Peke out of the car and went for a walk.

The post office is a quaint little stone building just outside Valley Forge Park, surrounded on three sides by occasionally tended greenery. Its next door neighbor on the fourth side is a tiny church, complete with a graveyard in back. Separating them is a falling-down fence consisting of low concrete posts connected by metal pipes.

Although the Rolling Peke still uses a wheelchair for her daily toileting walks, she can actually walk quite well on her own now, four years after her back surgery, so it didn't matter that I didn't have the cart with me. She wobbled off into the pasture, fervently inhaling the grass like Bill Clinton never did. I walked ahead a little, doubling back after her as she veered toward the cemetery. The lower of the two pipes that made up the fence was maybe twelve inches off the ground; the dog doesn't clear nine, so it was no barrier to her at all. The other pipe wasn't more than two feet up; not much of a barrier to me either, as we moseyed into the cemetery and wandered among the headstones.

RP galumphed along gaily until she reached the shade of a small tree, where she planted herself and waited patiently for me. I have no idea how long it was -- not long, but long enough -- that I meandered up and down the rows of headstones, taking in names and dates. I didn't calculate actual ages; rather I got a sense of who had been really old and who had succumbed earlier in life. From names and dates, I extrapolated families. Several graves were clearly those of servicemen. There were few epitaphs, all the more memorable for their paucity. One said simply, "He was a nice guy."

As I meandered, I noticed that there were no specific emotions flowing through me. I noticed that it was neither too hot nor too cold, that the breeze felt good, and that the RP was smiling as she panted in the shade under her tree. The grass was freshly cut, and very green from the preceding week of rain. I noticed everything, yet as soon as anything came into my conscious mind, I let it go. Almost like the description of meditation, when they tell you to stop thinking. It's impossible to do that, but it is possible not to pay attention to your thoughts. That's what I did. For a few minutes, I wasn't thinking about the office, that day's patients, or the next day's. I wasn't thinking about what I was going to make for dinner, or whether or not the dishwasher had been run, or the last time the cat boxes had been emptied. I wasn't even thinking about life and death, even as I wandered through the very essence of its distal terminus. I just was. On a gorgeous spring day, with my dog lying in the shade smiling at me.

Eventually the moment passed. I picked up the Rolling Peke and nuzzled her in my arms as we returned to the car, back to our regularly scheduled lives; grateful for the moment.

Ahead of the Curve

Physicians are often castigated for not keeping up with and following the latest recommendations for clinical care. The reality of innumerable "guidelines" issued by countless specialty societies and other entities (cough*federal government*cough) that feel empowered to do so is that just keeping track of all of them can be a full time job. Still, there have been some major sea changes over the years as good science comes up with some pretty definitive findings. I'm referring specifically to broad brush guidelines about the treatment of that ubiquitous triad of high blood pressure, diabetes and LDL cholesterol.

Those of us who have been practicing for a few decades now recall that recommended goals for blood pressure, blood glucose, and lipid levels have tended to shift ever downwards over the years. When I was in training, the threshold definition for hypertension was a BP measurement of 140/90. Anything below that was fine; above it required treatment. Some of the older attendings even scoffed at that, recalling when an acceptable systolic blood pressure was "100 + age", a nod to the fact that blood pressure tends to increase with age, making isolated systolic hypertension common in the elderly. Diabetes outcomes seem to improve with lower blood glucose levels, and the advent of statin medications for lowering cholesterol has truly revolutionized lipid management. Further, growing evidence seems to support the lowering of all three parameters to decrease cardiovascular risk.

Now it seems that among patients with stroke and LDL levels already under 100 -- with or without statins -- those ON the statin lipid-lowering meds had better oucomes. Current guidelines for use of these drugs takes into account how many cardiovascular risk factors a patient has aside from the cholesterol reading. The greater the number of risk factors, the lower the threshold for starting cholesterol meds. Here's the thing: those numbers have also been trending downwards as the accumulating research points towards better outcomes for patients who take statins.

Here's where I'm going with this: whether or not to offer statins to non-diabetic non-smoking patients with controlled hypertension and moderately elevated LDL cholesterol levels.

According to current formal recommendations, a patient like that would not qualify for statins unless the LDL was over 160. At this time, that is. Every time those guidelines have been revised, it's been in the direction of starting statins at lower and lower levels of LDL. What if 10 years from now we have the data to support lowering LDL cholesterol to at least 130 in everyone? What if it turns out that taking a statin confers added protection against macrovascular events (stroke and heart attack) whatever level of LDL reduction is achieved (ie, goal or no goal)?

It sure looks like this is the way things are headed to me, and I would like my patients to have the benefit of an extra 10 years -- or however long it is until the jury returns -- of cardiovascular protection. Statins are now cheap ($40.00 a year) and extremely well-tolerated, with very rare adverse reactions that are easily reversed with stopping the drug. There just doesn't seem to be much of a downside to wider statin use, and the distinct possibility of a significant advantage.

Believe me, I am not a pill pusher. The more favorable evidence that accumulates for the damn statins, the more pissed off I get. The last thing I want is to be writing more drugs. Still, it's getting harder to deny my patients the benefits implied by the old "better living through chemistry" line.

The bottom line is that I have gingerly begun offering cholesterol-lowering meds to more of my patients, complete with extensive counseling and discussion (much like that above.) I'm curious about what other clinicians are doing, and how they feel about trying to get ahead of the curve a bit with primary prevention of cardiovascular disease.

Bass-ackwards

I received an envelope in the mail today containing a thick sheaf of papers. It turned out to be from a management company, an intermediary specializing in worker's compensation and auto insurance, that was trying to get us to join their network. Actually, you had to read the first paragraph pretty carefully to figure that out. Here's how it began:

As our network expands, we continue to seek facilities that can provide quality care for our claimants. Kindly review the enclosed information and return it to us so that you can be included in our growing network. In order to expedite this process, we are enclosing and application and contract for your convenience and review. If you choose to complete these documents, we would be pleased to count you among the providers already servicing our clients! [emphasis decidedly not theirs]

Here's the problem. Following the next page, which lists the documents that need to be returned (signed service agreement; completed application; license; DEA; current malpractice insurance; board certification; CV; W-9), comes a blank "network application" and a 19 page contract labeled PARTICIPATING PROVIDER AGREEMENT. At least this one actually includes all the appendices it refers to; not all of the contracts I receive do. But the cover letter concludes:

...Once credentialing has occurred...you will also receive our manual that describes [our] policies and procedures.

Ahem. Why would anyone in their right mind sign a contract before reviewing the company's policy and procedure manual? Hell, right there in the contract, it states that I'm agreeing to:

Comply with the rules, regulations, policies and procedures as...summarized in the Provider Manual.

Hell, there are two full pages devoted to "Obligations of Provider" without ever mentioning any obligations on their part (like prompt payment of clean claims, for example.)

Interestingly, they have a website. After perusing it for 10 minutes, I can say this is 15 minutes of my life I'll never get back. It's so incredibly generic, I could probably co-opt several sections of it for myself! Here's what they say about their "commitment":

Our organization understands that our clients have a variety of needs and expectations. We also recognize they share common goals, for outcome based solutions that address their needs, while also enhancing their performance. We deliver services how, where, and when requested and make a difference where it counts: by achieving measurable results.

How do they do this? With these "Strategies":

[We] prides [ourselves] on our basic structure of client service teams. We first understand and evaluate each client's specific needs and then tailor an organized program, with individual or combined services, that will make a difference. Our strategy is to formulate innovative, visionary and technology enhanced solutions that meet our common delivery of excellence, exclusively to our clients.

Wow. That could just as easily be a motorcycle repair shop! I also love their all-purpose Mission Statement:

Our mission is to understand and respond proactively to our client's needs, to exceed all expectations, and to devote ourselves to quality, innovation and service.

We will continue to strive towards excellence and to ensure a consistently high level of service to all involved parties.

Our goal is to initiate and develop a total customer-centered program by providing uncompromising professionalism and responsiveness.

We vow to maintain our competitive edge and adjust to the ever-changing health care environment without relinquishing the integrity we've achieved and maintained throughout the years.

WTF? Talk about meaningless gibberish.

The worst part is that deep in the fine print, it turns out that the rate they're offering to pay me is 20% below my usual charge. Er, given that my two largest payers are currently compensating me at only 95% and 88% of Medicare, all I can say is take this contract and shove it where not even the colonoscope shines.

Atheist Hypocrisy

Once more, PZ Myers has his diapers in a bunch. It's perfectly legitimate: an illiterate columnist, after calling atheists to task for being boring (never a good way to begin a column, as PZ points out), proceeds to babble on about the usual nonsense that passes for "religion" in the media, and that PZ has such fun deconstructing. As usual, of course, he limits himself to shooting fish in a barrel, which is why he can brag about such a great kill ratio.

This line made me sit up and take notice, though:

My usual theme instead is to show what a botch theists have made of the country, and how hypocritical they are, and how absurd their beliefs are.

Holy shit, PZ; are you really that naive?

Of course politicians are hypocrites, and of course many of them use religion as an excuse for their hypocrisy. But if you really think that it is the sincerity of their beliefs in God that are the root cause of the mess they've made, think again. News flash: atheism offers no protection from corruption. Look at communist Russia. Surely those "godless commies" did just as good a job, if not better, at fucking up a country.

Corruption/integrity and theism/atheism are completely separate axes, with all four quadrants very well populated indeed, with hypocrisy liberally sprinkled throughout.

Atheism is no talisman against corruption, nor does it preclude hypocrisy. Exhibit A, of course, is PZ Myers' cry for tolerance of atheist beliefs while mercilessly ridiculing the beliefs of others who dare to find strength and solace in difficult times from a social support system grounded in what they call "religion." This, by the way, is the only proper function of religion, and I agree wholeheartedly that billions of people mis-use it every day. I also share PZ's contempt for them.

As I've said before, though, ridicule is a most pernicious form of intolerance. The hypocrisy of disrespectfully blasting all religion as "superstitious nonsense" while demanding respect for atheist views is mind-bendingly hypocritical, with PZ Myers the Hypocrite-in-Chief.

In Case You Were Wondering

For anyone following major league baseball who might have thought Manny Ramirez's explanation of his recently disclosed use of human chorionic gonadotrophin ("a medication, not a steroid, prescribed by a physician for a personal health issue") was legitimate, allow me to point out that there is no medical indication for prescribing hCG to a male that cannot be more safely and effectively treated with other agents.

Luckily, not many people seem to be buying it.

When More is Less (or Vice Versa?)

A lady comes in on the day she takes her last blood pressure pill for a checkup and a refill.

Her blood pressure is well controlled, the rest of her exam is normal, she's all caught up on her preventive care, so I go to write her refill.

Would she prefer a 30-day or a 90-day supply of her medication, I ask.

30 days, please. She can get them for $4.00 at her supermarket's pharmacy.

Ah, I respond. Did she know they would also give her 90 pills for $10.00?

Yes, as it happened; she was aware of this fact. But it turns out that for every four prescriptions she fills at the pharmacy, they give her a coupon good for 10% off her next grocery order, so she makes sure it's a big one; $250.00 at least.

Hmm:

12 x $4.00 = $48.00 per year for pills.
3 x $25.00 (10% of her $250 grocery bill) = $75.00 off on food ---> up $27.00 on the year.

vs:

4 x $10.00 = $40.00 for pills
1 x $25.00 = $25.00 off on food ---> down $15.00 per annum.

Can you tell she used to work as an accountant before she had kids?

I Don't Get This

Can someone help me with this? I mean, really; I just don't get it.

Patient calls and schedules an appointment.

(No, no; that, I get.)

Then they call back and say,

I have to talk to the doctor.

Er, you have an appointment tomorrow.

Yes, but I have to talk to the doctor first.

Why, in the name of the great and powerful FSM, do you have to talk to the doctor today if you have an appointment tomorrow?

If you're having crushing chest pain or something like that and that's why you think you're coming in (not having bothered to tell my Wonderful Staffer who asked you, "Are you having a particular problem?" anything other than, "It's personal,") then it will serve you right to wake up dead from the massive heart attack you're trying to ignore. It doesn't work that way. God made 911 for a reason, you know.

Granted, there are occasions where family members will call ahead to let me know things like, "his leg has really been bothering him for three months instead of the three weeks he's going to tell you about." But the whole point of making the appointment was to, um, TALK TO THE DOCTOR!!

If I'm going to see you tomorrow, there is absolutely no way you need to talk to me today. Think about it: what the hell are you going to say to me on the phone that you couldn't be saying to me tomorrow, in private, face-to-face, when I have a prayer of a chance of actually doing something about it; ie, something other than saying, "Why don't you make an appointment so we can talk about this in the office?"

In the words of the lovely and talented CrankyProf: Whiskey, Tango, Foxtrot?

Everything is Relative

Two different responses to the same exchange:

Kid: Daddy, could I have some money?

Dad: What do you want it for?

Kid: To be rich.

Household A, an upper middle class family living in a suburban neighborhood of a large east coast city: [hilarity]

Household B, the Bush family: Sure. Would $50,000,000 be enough to start? You can get a nice baseball team with that.

Geek Heaven

It brings a tear to my eye (and a rumble to my stomach) to share this:

Original recipe here (with the nifty title, "Periodic Table of the Aliments")

In the words of the NinjaBaker (and his faithful companion, the NinjaCutie):

According to the Ninja code of scientific baking, we must detail all changes to the procedure:

1. We only chilled the dough 1-2 hours while we made lunch because we only had so much time.
2. We used a smaller cookie size, so we only doubled the basic sugar cookie recipe.
3. All the frostings (except the chocolate non-metal one) were home/dorm-made from powdered sugar, milk, and food coloring (at a ratio of 1 cup : 1.5Tbsp : 6 drops : however much we felt like changing it so it would look right)
4. We reduced the rare earth metals (the 2 row insert) to 2 long cookies because we underestimated the amount needed.

Entire cooking time: ~6 hours.

The Obligatory Flu Post

Many other people have posted all kinds of useful information about this little Spring hiccup of a swine flu pandemic we seem to be experiencing on our planet this year. But I've still been getting I'm-not-really-worried-but-should-I-be? emails and calls from assorted patients, friends and others, so I suppose the most efficient way to address the topic is by posting on it.

Actually, most of this is re-posting. Good information is available here and here. Here is my bottom line answer to the question, "Is this whole swine flu thing a just lot of hype?"

Yes.

Here's why. I heard Governor Corzine of New Jersey put it rather well on TV the other night. To paraphrase, we have to keep in mind that "pandemic" refers to geography, not to severity. Its anomalous timing is also part of what's keeping it in the news. Flu is usually a winter thing. Did anyone bother monitoring the spread of flu 24/7 online over the winter? (Actually, yes, some people did. They were widely felt to have had no life.) As far as news coverage, flu in winter is too "Dog bites man" to warrant much excitement. Flu in spring is so much sexier.

I think the main reason the word "pandemic" engenders so much visceral fear is that it is (INCORRECTLY) used as a shorthand reference to the 1918 Spanish flu pandemic that was, in fact, unusually virulent and lethal to populations who do not ordinarily succumb to the flu, ie, healthy young adults aged 20-40. The very old, the very young, and the already-sick are always susceptible to complications from any kind of flu, be it human, bird or pig. There is no evidence that the current swine flu strain is especially virulent. Most cases have been mild; few hospitalizations have been required; the single US death was a toddler with a pre-existing illness.

So yes, closing schools and canceling events is definitely overkill. The real question we should be asking is why wasn't everyone worried over the winter, when the "regular" seasonal flu killed 36,000 people in this country alone? As of today, there have been a whopping 141 cases and 1 death. This is not something rational people should be losing sleep over.

Of course, "rational" and "American" do seem to be mutually exclusive much of the time.

Proof That Some People Have Way Too Much Time on Their Hands

For the realists:

Do I have swine flu?

For the pessimists:

Do I have swine flu?

Thanks to Kensington, MD, who, as some have long suspected, probably has way too much time on her hands. Although this line was pretty good:

"Blog fodder" always sounds to me like someone with a cold addressing Don Corleone.

Now I Get It

It's been said that the only way you can understand your parents is to have children. Having had both parents and children, I agree with this statement. Yet even raising your kids lets you come to know your parents better, there are things about them you still don't get. And every now and then, new moments of insight present themselves.

When I was a younger physician, the following interaction with my parents used to annoy the hell out of me:

Parent: Hello, Doctor Child, I just got the following prescription filled. [starts to spell name of common medication]

Me: [cutting to the chase] Oh, yes, that's such-and-such; it's used for (this condition), and its side effects include (this, this, and this.) Anything else you need to know about it?

Parent: You're right!

Me: Why are you so surprised?! I do this for a living. Of course I know about medications, diagnoses, and all kinds of treatments and stuff. Hell, you paid for my education; I'd hope you would expect me to know this stuff.

I thought they were idiots to get so excited over something so obvious.

Then I had kids. The start out as blobs and progress to rug rats. Finally they become bipedal and learn how to talk. But as a parent, in the beginning, you already know everything your child knows. His world is a subset of yours. You already know the answer to every question you ask him. And just think about how much of your conversation with an infant or toddler consists of questions. ("Where's that baby?"; "What color is the kitty?"; "What's this?" pointing to common object like a cup)

As he begins to go out into the world -- even if it's just daycare -- his experience expands beyond yours. I was kind of surprised at how incredibly cool I found this to be.

I'll never forget the first time I asked one of my kids a question I didn't know the answer to:

"Where's your baby brother?"

"Upstairs getting his diaper changed."

For the first time, I had an exchange with my three-year-old wherein he provided me with information I did not already have. I was amazed and thrilled! This was so cool!! And I'm sure he thought I was an idiot for getting so excited over something so obvious.

As time went on, my kids knew more and more stuff I didn't already know. And every time they did it, I was amazed and thrilled. And I suddenly realized that this was how my parents felt whenever I told them something they didn't already know.

Still, I didn't get what the big deal was about birthdays to my parents.

My father was 30 when I was born, which means that each time he turns the corner on a new decade, so do I. Each time he had one of those milestone birthdays, he'd recite the same old litany:

I don't mind turning 60/70/80, but I can't believe you're turning 30/40/50.

Geez, Dad; what's the big deal? I certainly don't mind any of those "zero" milestones any more than you do. Hell, you're the one who spawned me. Why is this such a significant event for you?

Now I know.

Today, my youngest son is 20. No more teenagers. He's 20. How did this happen? He's 20. I didn't mind turning 50. I loved it! It doesn't feel any different at all. No big deal. But this, my baby turning 20, has caught me unawares.

And all of a sudden, I understand my father a lot better.

Happy birthday, NinjaBaker; my little one, little no more, but always a baby in my heart.

(Gee, now I know why my father says that about me, too.)