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.

Friday, February 26, 2010

Responding to the Challenge

I received the following email from the NinjaBaker:
I had a really odd dream last night. It included Glenn Beck. One of the first things he said to me was "I got your Mom's haiku". I then wondered how he recognized me as your son (especially cause I imagine you might have emailed it to him), and he said something about how I breathed or spoke.

Anyway, upon waking and remembering this, I was wondering what kind of haiku you would write to Glenn Beck. I imagine it would have something to do with firmly disagreeing with his beliefs, including a few choice words, but I couldn't picture fitting it all into merely 17 syllables.

Consider this a challenge from my subconscious.
One way to cheat trick to getting around the strict 17 syllable limit is to use a series of haikus:

Dreaming of Glenn Beck,
the idiots' idiot:
subconscious challenge.

Word: "Conservative."
I do not think that it means
what you think it means.

Too stupid for words;
So wrong he's not even wrong.
Not worth the effort.


Saturday, February 20, 2010

Ice Rorschach

What do you see?

Best answer so far:
A curling match gone horribly awry.

Enough with Curling Already

Curling: the most ridiculous "sport" *ever*. And now it's in the Olympics?? For crying out loud, it's just shuffleboard on ice!

Since when has MSNBC become the all-curling, all the time station?? Enough!

It's just fucking shuffleboard. On ice. With big stones instead of little disks. And people running down the ice next to them sweeping the ice trying to make the stone go j-u-s-t where they want it to.

There are people watching this stuff. Live. And cheering! Chanting U-S-A, as if it were a hockey game or an actual athletic competition. Watch; next thing you know, someone will be petitioning to add tiddlywinks to the summer games. Or jacks! Now there's a sport! I excelled in it at summer camp. Maybe I can try out for the team!

But no. Instead, we have Curling.



Thursday, February 18, 2010

Bus Stop Diagnosis

Sometimes patients present with diagnoses that are so obvious, you know what the problem the moment you see them. Some call these "bus stop diagnoses," because, um, you can diagnose them standing at the bus stop*. Hyperthyroidism with exophthalmos is one; acromegaly and achondroplastic dwarfism are others. Obviously, many skin conditions can also be readily diagnosed from cursory inspection at a distance.

Now and then, though, a diagnosis and a cliche come together like soap and water.

I saw a lovely young lady today with what was probably one of the worst cases of rosacea I have ever seen. Her cheeks were bright red, as was her nose, and sections of her forehead and chin that had also broken out. Even my staff was able to diagnose it, telling me afterward that they, too, had never seen such a severe case.

Surprisingly, though, that was not why she had come to see me. In fact when I asked about it, she claimed that she had never actually been diagnosed with rosacea before.

I slammed my hand over my mouth as the response jumped into my head, but eventually, I couldn't resist, and this is what slipped out:
You've never been diagnosed with rosacea?
Why, it's as plain as the nose on your face.

* (Thank you, Mr. Frank.)

Wednesday, February 17, 2010

Fake, but Funny

For anyone who missed it, back in January a Jewish teen's tefillin set off a bomb scare on a commercial flight.

h/t to SG, but according to the comments on this source, it's fake. Still funny, though.

Tuesday, February 16, 2010

What's the Difference?

I have a friend with widely metastatic cancer. He's been in and out of the hospital recently, along with a stay at "rehab," after which he became strong enough to return home. I've tried calling him, but the word he has put out is that he doesn't want to see anyone right now. He's reserving his strength to "fight this disease!" He did leave me a voice mail a few weeks back, thanking me for my message of love and support, closing with the assurance that, "I will beat this thing."

His oncologist is totally on board with this. My friend is continuing to receive chemotherapy and radiation, complete with their devastating side effects. Recently, he became so weak he had to leave his beloved wife and home to back to the "rehab" facility again, to make up "all the gains he'd made" during his first stay. He's had multiple conversations with his family about his wishes. Nothing has changed. He doesn't want to see friends yet, because he's still fighting. He is adamant that he will win this battle.

But he won't.

My fear is that his refusal to acknowledge this undeniable fact will end up robbing him of the last part of his life, as he spends it "fighting," rather than living. There are many people who love him dearly, and while I understand his loathing of the idea of people coming to visit to "say goodbye," I'm terribly afraid that the next time they gather will be for the funeral. That's the way he wants it, though.

Armed with the insight from OncRN that "patients don't want treatment, they want outcomes," I realized that what my friend really wants is for the disease to be gone and to go back to life as it was. Back to his home and his work; back to his family and his garden; back to watch his grandchildren grow up and dance at their weddings. The oncologist knows (or ought to know) that none of the treatment he has to offer is going to result in that outcome. So he has the choice between trying to help the patient re-align his expectations to make the best use of the rest of his life, or continue to offer "treatment," tacitly agreeing that the patient's desired outcome is possible; anything not to undermine the patient's "hope." But isn't it far more important at times like these to redefine "hope" for the patient, as has been so eloquently expressed elsewhere?

This was the context in which this thought occurred to me:

What is the difference between oncologists who never stop treatment, and the alternative/biomed/quacks who push endless, dangerous, uncomfortable (and expensive) treatments on children with autism spectrum disorders?

  • Both of them have patients (or families) who are desperate.
  • Both of them have patients/families who desperately want/want them to get better.
  • None of these patients ever will.
  • Both feed into their patients'/families' false expectations in the name of "don't give up hope."
  • Both believe they are doing the right thing.
  • Many other people have dealt differently with the same situation, finding satisfaction and fulfillment in dealing more realistically with their circumstances.
Some may say that the difference is that autistic children aren't choosing to undergo useless "biomed" treatments, whereas competent adult cancer patients are, supposedly, fully aware of the pros and cons of the treatments to which they consent. Still, it isn't really treatment they want; they want a specific outcome. And when no treatment can provide the outcome the patient wants, what good is it doing?

My friend remains fully convinced that the treatments he struggles to tolerate will indeed eliminate his disease and return him to his previous state of health. He clings to that, and refuses to discuss any other outcome of his condition. Not really much different from parents who insist that they can "recover" their autistic child, if only they believe hard enough and pay enough money for scientifically useless treatments. What's the difference between their doctors?

Maybe not so much.

Sunday, February 14, 2010

What Patients Really Want

Once again, the incomparable OncRN nails it:
nurse - 'wait, why are we offering this super difficult treatment to this super old person with super crappy disease?'
doctor - 'because she wants treatment'

i so desperately need a game show buzzer for my pocket....because we're sorry - that is incorrect
i have yet to meet a patient who wants treatment.
patients want an outcome.
big difference.
Seldom have I ever seen the point made so cogently. By and large, patients have little to no idea what "treatment" really entails. From chemotherapy, to breast reconstruction, right down the line to the nasty side effects of antibiotics; no one really wants to undergo any of these treatments. They just want their disease to go away, and never come back. They want to feel better, though they may settle just for feeling a little less crappy than they feel now. Rarely will any of our treatments make anyone feel better while they are undergoing them. Patients are taking us at our word that once they recover from the treatment, they will feel better than before. That is why it is so important that we as physicians make pretty damn sure that they will, before we undertake the surgery; the chemo; the radiation; the medications. And we'd better be damned sure to do everything in our power to mitigate the discomfort of the treatment, which starts with recognizing it. Because OncRN has it right: No patient wants treatment.

Thursday, February 11, 2010

We Don't Miss You...

...except when we do.

Dear Jock, DinoDaughter, DenverDaughter and NinjaBaker,

Most of the time, DS and I have no problem with the fact that you're all out of the house, away at school and off on your own. We don't miss you at all. Really; we don't. Most of the time.

Then there are times like these:

We still have five shovels. Come home anytime.

Later that day:

(Let it be known that when DS went out for milk, he crashed the right side of that carefully carved snow cavern out to the street -- despite there being PLENTY of room on both sides of his car. Furthermore, upon his return, he crashed the left side.)

Just to give you a better idea:

I'm told that the terminology for this stuff is as follows: First there was Snowpocalypse, followed by Snowmageddon. This was "Snowverkill".

Wednesday, February 10, 2010

Snow Idiocy

It's snowing here. Not just a couple of flakes here and there, enough to heap scorn on those wimps who batten down the hatches and refuse to emerge until Spring. Rather, it's a nasty nor'easter that's got the entire northeast part of the country pretty much shut down. Not only have all the schools, businesses and government folk canceled out for the day -- and probably tomorrow as well, in order to shovel out, as this isn't supposed to stop until late tonight -- but several local highways have officially "closed," meaning fines for anyone venturing out onto them. In short, it's a mess.

DS and I went out this morning at 6:00 (we wake up early even without an alarm) and shoveled the first six inches off the driveway during a break in the precipitation. Now we're snuggled stuck here at home, waiting it out. In between cooking, eating, cleaning up, deciding what to have for the next meal and when to have it, plus reading, blogging, and other time wasting computer activities working on the new novel, we're watching television. The problem is that the weather is such a mess, it's preempted all the local network television affiliates' regular programming for "all weather, all the time."

The main message these and other news outlets are trying to convey is, "It's a mess out there; stay home if you possibly can." Of course, in addition to the talking heads and perfectly coiffed meteorologists in the studios, each station has people out in the community (usually at a Wawa), bundled up in parkas monogrammed with their station's logo, standing out there in the blowing snow, bringing us up to the minute news that basically consists of, "It's a mess out there; stay home if you possibly can."

Given that there's so little on TV, I must confess that we've been watching some of this coverage. One reporter at a super-Wawa (one that sells gas) was interviewing idiots drivers who pulled up, because hey, who wouldn't want to be on TV! Naturally, the first question the reporter asked was, "Why are you out in this mess?"

Here's the response that blew out my idiot meter:
I went to the gym.
You went to the gym? You went to the GYM?!? You needed to work out; fine, I get that. Exercise is important; possible even addictive. But why the hell don't you stay home and shovel your damn snow?!?!!

Idiots. They're everywhere.

Tuesday, February 09, 2010

Master of the Analogy

I have a patient in his 60s who is riddled with metastatic lung cancer. He isn't on hospice (oncology refuses to let him out of their clutches just yet; actually, the problem is that around here Hospice won't accept patients still on palliative chemo or radiation) but is aware of what they have to offer. He and his wife have assured me that they will let me know when they feel they need their help.

In the meantime, he comes to me for a visit because he is worried about his blood pressure.

Up until his cancer spread, I had been treating him (successfully) for high blood pressure. Pretty routine; good control; no big deal. The problem of course is that now he is extremely unlikely to live long enough to have a heart attack or stroke. I have already told him to stop his BP meds, and he has. At this point, his blood pressure isn't even all that bad, but he occasionally gets readings at home in the 150s over 90s. This has him concerned.

My gut reaction was a combination of, "Why?" and "It doesn't matter."

Although I have explained this to him and his wife several times before, either the chemo-brain or the whole brain radiation for metastatic disease has left him a little foggy. I need to find another way to explain this without coming right out and saying, "You're going to die of cancer before your blood pressure has any chance of hurting you."

So I said this instead:

Imagine there's a house with a leaky faucet. You know that it's important to fix leaky faucets, because they can cause big problems with the plumbing down the road.

He nodded his understanding.

Now imagine that the house is scheduled to be demolished next month.

"Ah," he said, smiling with comprehension. "It doesn't matter."

Exactly so.

One of the greatest pleasures I have in my job is watching things click. That "Got it!" moment when a vaguely abstract concept is presented in terms just different enough to trigger comprehension instead of confusion is exhilarating for both of us. Nothing beats the effectiveness of a great analogy.

Sunday, February 07, 2010

Best Part of the Day

It is well known that there are a number of other events held annually in conjunction with this evening's football game. Here in Philadelphia, for example, the Friday before the Super Bowl has become known for Wing Bowl, an event the likes of whose masculine debauchery is seldom equaled.

But our favorite here in DinoLand -- especially beloved by the Rolling Peke -- is, of course, Puppy Bowl:

complete with aerial views from a hamster-driven blimp, bunnies as cheerleaders, and a halftime show starring kittens. Cuteness abounds.

Yes, she really is entranced by it; and yes, I really got a shot of the screen with the logo. No photoshopping here.

There Might be Some Football on Tonight

Today's email from this crotchety old guy I've known for years:
I've been reliably informed that today is Superbowl Day, and CNN is trumpeting the news that nearly a billion people worldwide are expected to watch it. To your amazement and surprise, we will have the TV turned on for that event, too, so when people talk about it tomorrow, I will know what went on. After all, I love water polo -- what else would one play in a bowl? -- and will be glued to the set for every chukka. (I know there are no innings in that game.)
His ignorance of sports is exceeded only by his lack of interest in them. Still, I want to help him make sure he doesn't miss the parts everyone is really going to be talking about. Hence my response:
The real reason my friends and I will be watching is for the commercials. Of course we never turn our noses up at a chance to get together and gorge on scrumptious pot-luck food while enjoying each others' company either. Still, the rhythm of the event is very much talk-eat-talk-drink-talk-here-have-some-more while the football part is on, then "Shush everyone, here's a commercial!" -- resulting in everyone's rapt attention -- at appropriate intervals. So if you want to be in the know, all you need for the football game is the final score, but scrutinize the commercials carefully. (ie Time your bathroom breaks counterintuitively.)
That's what everyone's really going to be talking about.

Friday, February 05, 2010

HIPAA be Damned

We can be pretty informal in my office. Sometimes patients would rather sit by the front desk and chitchat with the office staff instead of going back to the waiting room, lovely though it is, and read magazines.

One of those regulars was in the other day. As she sat there filling us in on the latest goings-on with her grandchildren, the next patient walked in. As it happened, she was another lovely lady who preferred the company of the staff to the more comfortable chairs in the waiting room, so she also perched next to the check-in counter and joined the conversation.

After a few minutes of this informal give-and-take among us all, I found myself feeling ever so slightly rude. I realized it was my home training asserting itself, as I heard my mother's voice in my ear saying, "Introduce them."

So I did: "Mary, Jane; Jane, Mary."

First names only, of course. Including their last names would make them uniquely identifiable. This would constitute "Protected Health Information," which needs to be zealously guarded from inadvertent disclosure. That's what HIPAA says.

The first lady had been looking carefully at the second, but now she said, "What's your last name?"

I had to bite my tongue not to scream, "NOOOOOOOO!! HIPAA says you can't tell her that. It's Protected Health Information!"

But of course there's nothing in HIPAA that says a patient can't tell another patient her last name. They ended up exchanging not just current last names, but also maiden names -- and discovered they had gone to high school together fifty years ago. They caught each other up on their families: one was widowed; both had grandchildren. They laughed and had a lovely visit, foreshortened by me, party pooper that I had to be, to actually provide, yanno, medical care to them.

The take-home message is that privacy is the patient's. They are the ones who can choose what to do with it, including breaching it to reconnect with an old friend. It was a lovely encounter to witness, and the hell with HIPAA.

Wednesday, February 03, 2010

New Look

Some people change their blog templates like their underwear. Unlike underwear, though, blog templates are not subject to staining with bodily secretions containing aromatic compounds causing people to whine, "OMG, haven't you ever heard of SOAP?"

For the record, I love my old template. I think maroon and gray go together wonderfully. The look was classic. So why the switch?

Hat tip to the oxymoronically well-known Dr. Anonymous for this bit about branding. Reading it, I realized that my brand is, of course, the Dinosaur. For better or worse, whatever else I end up publishing (and yes indeed, there are plenty of other non-Dino works in the pipeline), I am Sparta Dino.

Hence the switch to a more saurian-appearing (ie, green) template. Rest assured, this portends no change in content, which is good news for all three of you regular readers, and bad news for this crotchety old guy in his 80s I've known for years. (Which is to say that yes, four-letter words will continue to appear on occasion.)

Monday, February 01, 2010

A Gentle Reminder

Many thanks to dzineprof: