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.

Sunday, December 30, 2007

Everything I Need to Know, Someone Emailed to Me

Yet another of those collections of heartfelt sentiments that look like they're going to be sappy, but have some delicious twists:

As I've Matured...
  • I've learned that you cannot make someone love you. All you can do is stalk them and hope they panic and give in...
  • I've learned that one good turn gets most of the blankets.
  • I've learned that no matter how much I care, some people are just jackasses.
  • I've learned that whatever hits the fan will not be evenly distributed.
  • I've learned that you shouldn't compare yourself to others - they are more screwed up than you think.
  • I've learned that depression is merely anger without enthusiasm.
  • I've learned that it is not what you wear; it is how you take it off.
  • I've learned that you can keep vomiting long after you think you're finished.
  • I've learned to not sweat the petty things, and not pet the sweaty things.
  • I've learned that I don't suffer from insanity, I enjoy it.
  • I've learned that we are responsible for what we do, unless we are celebrities.
  • I've learned that artificial intelligence is no match for natural stupidity.
  • I've learned that there is a fine line between genius and insanity.
  • I've learned age is a very high price to pay for maturity.
  • I've learned that the people you care most about in life are taken from you too soon and all the less important ones just never go away. And the real pains in the ass are permanent.

Tuesday, December 25, 2007

Season's Greetings

Very belated edit:

And an addendum to last year's "What Jews Do on Christmas": a music video by the same kid to his very own song:

Friday, December 21, 2007

Rad Rage: Part Two

(Part One is here, in which I coin the term "Rad Rage.")

One of the latest developments in "Patient Oriented Services" is the replacement of the "Mammography Department" with the "Breast Health Center." I suppose the principle of offering mammography, ultrasound and the various other radiological interventions in the management of breast abnormalities under one roof (or at least in close proximity) makes sense. But one local group of radiologists has gone too far.

A word of explanation: mammography is a breast x-ray that is currently our best screening test for breast cancer. ("Best" in terms of value; MRI is reported to be more specific, but at such a higher cost as to make it a poor value in women with no breast complaints or abnormal history.) When an abnormality is seen on a mammogram, the appropriate next step is to perform an ultrasound to determine if the mass is cystic (hollow/fluid filled) or solid. Solid masses often (not quite always, but close) require a tissue diagnosis. This means there needs to be some sort of biopsy, which is defined as "getting tissue for diagnosis." There are several different approaches to biopsy: the whole mass can be taken out, which also might need a needle placed into the breast tissue to guide the surgeon to the abnormal area if it can't be felt. Or a larger needle can be used to poke directly into the mass to get tissue or sometimes just cells for pathological examination. This is a clinical decision which takes many things into account: the patient's age, personal and family history, the size and location of the mass, and the patient's preferences, among other things.

The determination that an abnormal mass on breast imaging requires a tissue diagnosis is properly the radiologist's call. The most appropriate way to obtain that tissue is not; that is the job of the surgeon. And it's my job to explain to a patient that she has an abnormality in her breast that needs biopsy, and to refer her to the surgeon. Contrary to what you surgeons probably think, I do more than just give her your number. I try to prepare her for the kinds of things you're going to be saying to her; talk about some of the available options, but impressing upon her that the surgeon is better equipped than I to help her choose among them. I give her an idea about whether or not the radiologist is seriously concerned about cancer, not to scare her, but to prepare her. (I'm not telling her anything she hasn't already thought about and dreaded.) Besides, most of the reports stress the benign features of a mass while still advising biopsy; information that can be quite reassuring.

I received a mammogram report the other day that described a new nodule in a breast. The conclusion read, "Biopsy recommended." I called the patient and asked her to come in for a breast exam to see if the abnormality could be felt, to which she readily agreed. But when we got into the exam room and I began telling her about the report, she said, "Oh, I already have the biopsy scheduled."


I looked at the report again. Right above the "Conclusion" it said, "Recommend mammotome ultrasound-guided biopsy."


"Did they tell you to call me?"

"No. They said they'd send you the report."

"Did they tell you there was a chance they wouldn't get enough tissue and you'd have to have another procedure?"

"NO! I hate needles, but they kept saying it was so small and non-invasive. I asked for more information about it and the next thing I knew, they were scheduling it."

So not only was the radiology department recommending a specific biopsy procedure (with a specific proprietary device, no less) but they were doing a pretty shitty job of obtaining informed consent.

I did the breast exam, couldn't convince myself I could feel the nodule (which didn't change its management at all) and referred her to a breast surgeon -- at a different hospital, needless to say.

I was livid. I called over and ended up talking to the nice lady with the spiffy title of Breast Health Liaison, or something like that, about radiologists doing their own biopsies. "Oh, no," she told me, "We tell the patients to call their doctor. We just schedule the test right away for their peace of mind."

"What exactly did you say to my patient?"

"I told her to confer with you, to get a script for the procedure and any referrals that might be needed."

Sure doesn't sound like, "See your doctor to discuss this." More like, "You need to get paperwork from your doctor for this procedure."

"Did you tell her about the possibility of a non-diagnostic biopsy and the need for an open procedure?"

"The radiologist spoke to her and discussed all the options. She chose to schedule the procedure. She can always cancel it if you or she decide otherwise."

"How often do you get non-diagnostic results with the Mammotome device?"



"Well, since I've been here I don't remember any."

Oy f#%&ing vey. Sounds like they've got a new toy they can't wait to use to make money.

Look, I understand perfectly well that the words, "You have a lump in your breast" is among the leading causes of cardiac arrest in women, and that waiting around to find out whether or not you have cancer is its own special circle of hell. But how much peace of mind is there, really, from having a suboptimal test scheduled quickly? What's scarier still is the impression they left with my patient, who had no way of knowing just what kind of shenanigans they were trying to pull. I'm still so mad I can barely type straight.

The patient thanked me, though. She was glad I had seen the report and called her, setting her straight about what she really needed to do.

"No problem," I answered. "That's what I'm here for. I've got your back."

I waited a beat, then added, "And your front."

Tuesday, December 18, 2007

Coolest Phone Call Ever

I got a call today from the wife of a man who used to be my patient.

Five years ago he had come to me peeing blood. Gross hematuria, as we docs call this condition so you know we're special, in this context is cancer (either kidney or bladder) until proven otherwise, so I got started on the workup. In this case I started with a CT scan to look at his kidneys and a urology referral for a cystoscopy to look into his bladder.

Everyone over at CT started getting jumping up and down, though, when they couldn't visualize his left kidney. Was its blood flow completely occluded? His right kidney was quite large, so after lots of excitement and everyone staring at the CT, the diagnosis of a solitary right kidney with compensatory hypertrophy was made. I remember specifically asking the radiologists, "But how does his right kidney look?" "Oh," came the uninterested response, "It's fine."

Urology checked out his bladder and to my surprise, found nothing abnormal. No tumor anywhere; no explanation for all the blood in his urine. The urologist suggested repeating the scans in three months and sent him on his way.

I was not happy. I just wasn't.

Two weeks later he showed up in my office again with abdominal pain and diarrhea. Even though it was likely a viral gastroenteritis, I wanted to rule out hepatitis or gall bladder disease and make sure he wasn't too dehydrated, so I sent off some blood work. Imagine my shock at finding a creatinine of 3.2 (normal 0.7 - 1.4) and a BUN of 32 (normal 7-25), when both had been normal less than three months earlier! This time I sent him for a renal ultrasound, and got this call from the radiologist:
Positive for right renal vein thrombosis extending into the inferior vena cava, possible ["overwhelmingly likely" were the words used by Urology, Nephrology and Surgery] tumor thrombosis.
I started to ask about further imaging, but she said, "This was present on the CT scan two weeks ago." She was looking at the film; I was looking at the report that said no such thing. My breath caught in my chest. It didn't matter too much that the diagnosis had been delayed two weeks, but now the unimaginable worst case scenario was about to play out: the man had only one kidney, and there was cancer in it. It was going to have to come out.

Everyone knows that renal dialysis is a procedure where machines are used to clear the blood of toxins that are usually excreted by the kidneys. So they take out his kidney and start him on dialysis; no big deal. Turns out it's a hugely big deal.

The vast majority of dialysis patients suffer from end stage renal disease, the final result of years of progressive kidney damage, usually from diabetes and/or hypertension. As such, the nephrologists usually have a chance to prepare them for dialysis both mentally (dietary restrictions and such) and physically (surgical creation of a connection between an artery and a vein in an arm, called a fistula, into which needles can be inserted to allow the machine access to the blood stream.)

Not this guy. He went from being basically healthy, able to walk around, travel, eat and drink what he pleased one minute, to -- wham! -- anephric (no kidneys); a dialysis patient, completely dependent on three-to-four hour sessions tethered to a dialysis machine three times a week, just to stay alive. It turns out the kidneys do lots of other things too, and even when they're not working well enough, they still perform many of their other functions. Not having any kidneys at all was a very big deal. Then there was the cancer; thank goodness his metastatic workup was negative. Still, it was a helluva thing to bear. Needless to say, he was miserable.

Here's the thing: I never liked this guy. He was arrogant and condescending, and he refused to work. He had somehow finagled a full Social Security Disability pension for a minor leg injury, and told me point-blank that even though he *could* work, he wasn't going to. I never said anything to him about it, but he always rubbed me the wrong way. I just didn't care for him.

But when the cancer was discovered in his solitary kidney, my distaste for him abruptly vanished. The phrase "I wouldn't wish this on anybody" took on the ring of purest truth. Nowhere in my soul was there even the barest hint of schadenfreude; of cosmic karma; of "he deserved it." And believe me, when I explore my heart of hearts, I am ruthless. I grilled myself: wasn't there even the least little bit of "so there!" to be found? There was not. I confess that I was relieved to find my character was of that caliber.

Over the next year or so he landed in the hospital several times, and eventually switched his primary care over to the main group there that included his pulmonologist (of course his 100 pack/year smoking history had left him with COPD), oncologist and nephrologist. I was sorry to see him go, but I understood.

He continued to have a very tough time with dialysis, its restrictions and its side effects. I kept in touch through his wife, who is still my patient. She always tells me that he continues to sing my praises, telling everyone he meets how he wouldn't be alive if it weren't for me. I don't necessarily agree, but it feels good to hear it, and it makes me smile.

She called again today: he got a kidney transplant last week.

Very cool.

Sunday, December 16, 2007

A Work of Art

The Jock's Ultimate Frisbee team, in addition to having way too much time on their hands, has a true artist in their midst (alas, not the Jock.) Check out this re-staging of The Last Supper*:

Apparently, this required several photos to be digitally combined, as no one had a sufficiently panoramic camera; hence the artistry. The only flaw is that the Christ dude is looking the wrong way.

*The link is to a really cool high-resolution internet version of the painting. You can zoom in ridiculously close to see an unbelievable level of detail.

Saturday, December 15, 2007

The Wiseass on the Elevator

That would be me.

Our local mall has two levels. Darling Spouse and I headed over there this afternoon to get a few gifts and enjoy some great people-watching. At one point, we were on the bottom level and needed to go to the upper one; the most direct route was the elevator.

We didn't have to wait long (since there are only two floors) before it emptied out and we piled on along with about half a dozen other holiday shoppers. I made a point of standing in the far corner away from the control panel. A very nice woman came in and stood next to the buttons. The door closed and we began moving up.

I called out to the lady near the door, "Three, please."

I don't know if she was visiting from somewhere else, but she probably wasn't a regular mall patron, because she stared at the panel, trying to find the button for the third floor. When she finally figured out I was pulling her leg, she -- and everyone else in the elevator -- burst out laughing.

As we got off, I wished them all Happy Holidays; they all thanked me for the laugh.

Friday, December 14, 2007

Please Tell Me This is a Joke



Pretty pretty please:

Testicular Implantation For Pets
(US Patent #58-68140)
From the home page:
Neuticles allowing your pet to retain his natural look, self esteem and aids in the trauma associated with neutering. (emphasis added)
Talk about poor copy editing; by all means, let's traumatize the poor thing more.

More, from the FAQ page:

My vet said my dog wont know that he's missing anything. Is that true?

People know their beloved pet. Their pet can tell them when they are hungry, want to play, don't feel well, hide when approaching the vet's office or will get excited when driving by or going to the park- why wouldn't the pet know a familiar body part is missing? Would he know if his foot was cut off? Of course he would- its only common sense.

Right. Feet; balls; all familiar body parts. Dogs understand exactly what testicles are and what they're for, and they treasure them just as much as their masters. Hell, they scratch them together in unison. Thank goodness. Now poor Fido will be able to get out there with his buddies around the fire hydrant without being embarrassed by his little snippy-poo.

Ho. Ly. Shit! Is there no limit to what you can sell to anthropomorphizing idiots?

Now if this thing is nothing but a fantastic farce, my hat's off to you; I'm not worthy. But I'm afraid -- really afraid -- that it's on the level. Words escape me.

UPDATE: Apparently it's not. Here's the patent.

Don't You Just Love New Drugs

Aha! I beat you to it this time, Medblog Addict:

Same folks who brought you this.

Their blog (one of them, at any rate) is pretty funny too.

Thursday, December 13, 2007

Balance in All Things

I love this so much, I've put it on the bottom of my sidebar.

Reading and Ranting

I've seen this little toy on other blogs, and although I've played with it, I haven't publicized my results before now. But here it is:

I'm proud of this, and of the fact that according to this calculator, my office web site comes out at the elementary school reading level. Here's why: it means that I have successfully avoided the use of excessive amounts of medical and other scientific jargon, meaning that my blog is accessible (and therefore -- hopefully -- interesting and informative) to individuals without a great deal of formal advanced education. At the same time, I would hope that physicians, scientists and other professionals recognize that I am indeed "one of them." While I am perfectly able to write (and read, obviously) at a much "higher" reading level, I choose not to -- and presumably am still able to make myself understood; both on this blog and in talking with patients.

I learned in a college linguistics course that the anthropological purpose of jargon is a means of group identity; not just, as Wikipedia and "common knowledge" would have it, as a convenient shorthand. It's a "secret handshake" whose use is meant to show others in the group that you are one of them, while intentionally excluding outsiders.

Therefore physicians who use medical jargon when talking to patients are not demonstrating their superior knowledge. They aren't even just being lazy. They are flaunting the fact that they are physicians -- members of a privileged group -- and that the patient is inferior because he is not.

Jargon is not only counterproductive to effective communication, but disrespectful and rude.

Wednesday, December 12, 2007

Don't They Call This "Incest"?

From the hospitalist-dictated H & P of a guy in his 30's :
He is married with 2 children in a monogamous heterosexual relationship.
Alternate post title: "A Comma! A Comma! My Kingdom for a Comma!"

Tuesday, December 11, 2007

Eighth Night of Hanukkah

Here it is; the magnificent new centerpiece of my menorah collection: "The Wall," a work of art in fused glass, representing the Western Wall of the Temple in Jerusalem, by Israeli artist Tamara Baskin:

It's ten inches high by twelve inches long, and pictures just don't do it justice. I trust you can see why Darling Spouse and I were so taken with it.

I hope you've all enjoyed this little romp through my menorah collection. Thanks so much for sharing the holiday with me, especially all those who were kind enough to leave such nice comments (though all you lurkers were just as welcome.) I wish you all a very Happy Hanukkah!

Edited to add:

Darling Spouse, whose interest in this blog I had always believed was limited to "When are you going to get your ass off that damn computer?" insisted that it would be only appropriate to add this picture of the boring old ordinary menorah that we actually used this year fully alight on the last night of Hanukkah:

Actually, I think this menorah was one of the Jock's Bar Mitzvah gifts, but I'm holding onto it for him until he sets up housekeeping on his own. The foil-covered metal tray is my nod to safety. If you look carefully you can see the eight days of accumulated wax drippings, as well as the matches behind the candles on the right. Not nearly as elegant and amazing as the other eight, but a menorah full of lit candles always gives me a thrill. Happy Hanukkah, everyone!

Monday, December 10, 2007

Seventh Night of Hanukkah

This is easily the quirkiest, the wildest, the most "Do I really have the nerve to buy this thing?" menorah in my collection, but I adore it (ever since I got up the nerve to buy it.) I think of it as "The Joy of Love":

It's about ten inches long and six inches high, made of metal, by an artist named Jeffrey Manpearl. It looks kind of like me and Darling Spouse in profile.

(Sorry for that visual.)

Sunday, December 09, 2007

Sixth Night of Hanukkah

This was also a fairly early purchase. It's big and heavy, twelve inches long and seven inches tall at its highest point and feels like it's carved of stone. It's "Jerusalem":

I have it displayed on the bottom shelf of my hall tree, but it would also make a good door stop.

Friday, December 07, 2007

Fourth Night of Hanukkah

This was a Christmas gift (mixed family; told you I was easy to buy for) from my parents last year:

The illustration is from an Italian tapestry, circa 1700, and shows the Temple Menorah in the center. On the left is Moses holding the commandments, with his brother Aaron on the right.

Thursday, December 06, 2007

Third Night of Hanukkah

Mahjong tiles rendered in lucite. Sorry for the glare; hard to photograph with flash. The tiles are approximately actual size, making the whole thing about twelve inches long and three inches high at the shammas.

This one definitely qualifies as "cool." There was actually another version of this made of actual mahjong tile material (solid white; probably plastic. I think real tiles can be made of ivory) but it was recalled because it turned out the material was a fire hazard! Apparently more than one of them caught fire when filled with candles and lit.

Wednesday, December 05, 2007

Second Night of Hanukkah

"The Family Dinner", made of ceramic. The candle holders are the eight bowls lined up in a row at the front of the table; the shammas holder is the larger one all the way to the right. It's about ten inches long and four inches high.

I also have a set of Shabbat candlesticks by the same artist, shaped like a house with a fiddler on the roof.

Tuesday, December 04, 2007

First Night of Hanukkah

This was the first really nice menorah I bought myself. It's about six inches high, nine inches wide and over an inch thick, made of heavy glass. I call it "The Shofar" because of the shape of the blue glass.

The candle holders are little pewter cones stuck into the top, with the shammas in the mouth of the shofar. Doesn't the clear part look like water flowing in a bowl? It's all solid glass, though.

Monday, December 03, 2007

My Menorahs

About ten years ago I began collecting Hanukkah menorahs.

A word to the technical: the Hebrew "menorah" just means candle holder. Many menorot (plural) are seven-branched candelabras, representing the days of the week. The special nine-branched menorah used for the holiday of Hanukkah is technically known as a Hanukiah.

Hanukiot are certainly available in a wide variety of candelabra-type designs, but also in an infinite variety of non-traditional forms and materials. Many are magnificent works of art. Once my family became aware of my hobby, they began giving me menorahs as gifts, which made me easy to buy for and helped my collection grow.

One day not long ago, Darling Spouse and I were walking through the mall when both of us caught sight of one of, if not *the* most magnificent hanukiah either of us had ever seen. We decided we couldn't resist it, and so it is not only this year's addition to the collection, but all my Hanukkah presents for the year. (Probably my birthday too, just on the basis of price.)

Of course the first thing I wanted to do was post a picture of it on my blog to share with all of you. But then I realized what I really ought to do was save it for the last night of Hanukkah. For anyone who doesn't know, Hanukkah lasts for eight days and begins tomorrow night. (Jewish holidays always begin at sundown the night before.) Then I had another idea.

On each of the eight nights of Hanukkah this year, I shall post a picture of one of the menorahs from my collection. (I have over two dozen.) Some are cute; some are whimsical; some are cool; all are gorgeous, in my humble opinion, of course. The culmination -- the eighth night -- will be this year's fantastic work of art. So please come back and check them out; I'm looking forward to having you spend Hanukkah with me.

Sunday, December 02, 2007

Coolest Picture Ever