Pep talk

A long time ago I knew a gentleman who "bathed all decisions in prayer". I don't think he would get out of bed until he perceived the divine mandate to do so.

I always felt like less of a believer around him. I would read the Bible, maybe mutter a few incoherent requests to God, and then go my way and hope for the best. This fellow had a direct line to the Almighty. Life was going to be much easier for him. What a lucky guy.

One day he wanted to buy a new car. He fasted. He prayed. He meditated on the Divine Will, and the Divine Will made His car-buying preferences clear to him. "Go and buyeth this car, for it will go well, for you and your family. Listen to the word of the Lord".

My friend went right out, in full obedience, and bought this car. It was an AMC Gremlin.

For those of you who are too young to know about the Gremlin, or were too deeply traumatized by it, this thing routinely makes everyone's "Ten Worst Cars of All Time". It was butt-ugly, unreliable, and dangerous, like a Ford Pinto without any of its endearing qualities.

This brought about a theological crisis for me, the Crisis of the Sacred Gremlin. "Does God favor butt-ugly cars? Did He want to punish this guy for his spiritual presumption? Does He have a weird sense of humor? Was He turning to Michael and Gabriel and saying 'Get a load of this. Watch what happens when he tries to start this car up. He's only had it for two weeks.'"

After careful deliberation this is what I concluded: my friend was full of crap. He vainly interpreted every one of his whims and fancies as being Divinely Inspired. He probably didn't even take advantage of those God-given safety valves know as friends to advise him when he was in unchartered territory. He was a fool.

To this day whenever someone says he is doing the will of God, I always wonder if it is true or if he is following the will of the Sacred Gremlin.

"So," says the Very Wise Professor, "you are sentenced to live your life with detached irony, then? Never willing to step out in faith? Never willing to take the chance that what you believe actually might be God's will for you?"

The timing of this conversation was interesting. It was about 12 hours before I shared with him our plans for adoption.

It was pretty discouraging this week. We had thought we might realistically make the trip to the Ukraine by June. Now we are told, because of Federal footdragging, that September is more likely. Bummer.

I needed a pep talk, so I went to our church's internet portal and found the video blurb on adoption. It is linked above. I thought it was well done. It rings very true. And that is assurance enough for me. For now.

Reality check

So folks are insane if they adopt a child, especially an older Eastern European child?

Well, maybe.

Our local adoption agency stresses the need for appraising attachment issues realistically. They've told us about the good adoptions, the bad adoptions, and the ugly adoptions.

I've been reading my way through "Attaching in Adoption" by Deborah Gray. She covers about everything that could go wrong in her book, along with coping skills to overcome them.

My wife stopped reading the book. "It's like being pregnant and reading about every possible birth defect there is. I can't take it." I'll be doing the reading for now.

The interesting thing is that even in high risk situations, eg. adoption out of a marginal background, poorly run orphanages, etc, that only about 30% of the children go on to develop Reactive Attachment Disorder. That means that 70% don't. You see where I'm going with this?

As we check around our town, that seems to be a rough approximation for the local experience. We hear about the "nightmares", and for every nightmare there are two where the families/children couldn't be happier.

Love is not enough. Let's see, we've had experiences in our family with severe learning disabilities, severe childhood trauma, marital discord, mid-life crisis issues, poverty, etc. Things have worked out in spite of all of that. I like languages (although I'm not sure about Russian), and we know lots of Ukrainians for support. I get a quick language lesson at least three times a week, and I know how to get hold of the Russian cartoon network, though I probably won't let her watch it unless she gets severely homesick.

I only speak for myself. I've gone about the last 8 years (the beginning of the first lawsuit) until now feeling sorry for my sad plight and wanting to avoid all psychic pain, maybe pain altogether (an exception made for biking). I've also felt a little less than totally alive during that time. This is something I'm called to do, and not just for the adopted. My whole family will need more of me. I think that's a good thing.

One of my favorite quotes if from Mother Theresa: "We cannot do great things, only small things with great love". I modify it for me: "I can't even do small things with great love. I can do small things with just a tiny bit of love, and the Lord, who feed the five thousand with a few fish and a couple of loaves of bread, can do the rest."

And if it ends up being a disaster, at least we will have tried.

Dear congressperson

I'll be up front with you. I neither like nor respect you at all. You beat out one of hardest working, most competent congresspersonages this last election, based on you personal wealth and name recognition. Too bad for the district, I say.

Nonetheless I'm sucking up to you to give us doctors a break. I don't know how I distrust more, the Republicans with their glib talk of improving health care access while they cut the budget for Medicare and the VA hospitals, or the Democrats with their glib talk of improving health care access while they do their best to criminalize the practice of medicine.

Anyway, I appreciate all the lip service everyone is making for colorectal cancer screening. I think folks get a little carried away with it - I was recently referred a 91 year old gentleman for screening - but generally speaking the yield is high enough to make it worthwhile.

However, in order to balance the books, the reimbursement for colonoscopy has been in a free-fall over the past 15 years. I'm now getting 25-30% of what I received for this procedure in 1991, and this is not adjusting for inflation. The reimbursements for 2007 look even worse. The private carriers base our reimbursements on Medicare, so every time you folks lower the reimbursements, they do too. Except for (would I get in trouble for mentioning the company's name?), who now is reimbursing me for less than Medicare does.

A recent article in the NEJM demonstrated that when colonoscopists are in a hurry, they miss stuff. A lot. It has always been a temptation for docs to turn their practice into an assembly-line. Now I think it will be inevitable.

This is not an issue of me not being able to afford that beach house or making my Porsche payments. I'm having trouble making payroll right now, between taxes (I appreciate your pledge to raise taxes as one of your campaign promises. The voters in this district must have lost their minds on Election Day), health insurance which paradoxically has become almost prohibitively expensive, malpractice insurance, and employees who expect merit and longevity raises right on schedule in spite of the fact that it's getting tougher for me to make a living. Plus, I had to update my phones, my computer software, my computer memory, and replace my fax machine that died a violent and painful death about two weeks ago.

I'm reexamining the way I practice medicine right now. I've prided myself in taking time with my patients right up to the present. If I can make a living, or if I could do better selling Amway or something, I'll have to do what's necessary. Right now I'm working for the health insurance.

By the way, if you and/or Hillary and/or Obama want to nationalize health care, now would be a pretty good time to do it. I feel less than no sympathy or loyalty for the health insurance industry. They can all go to blazes.

Anyway, I worked in the military during the 80's and have a good idea how health care rationing works. I can get used to it again if I have to. Just let me make a living at it. I'm getting too old to be retrained.

Yours truly,

Orphan role models

Here are the roles models that I think all orphans should follow:

1. Anne of Green Gables. Bright, beautiful and personable, Anne is a wonderful model for orphans everywhere. Orphaned as a result of the tragic deaths of her missionary parents, she is adopted by good-hearted but basically clueless spinsters, who raise her as if she were their own flesh and blood. In gratitude for their sacrifice, she leads an exemplary live and lives happily ever after.
2. Jane Eyre. She might be the greatest orphan ever. Orphaned because of the sad deaths of poor but noble parents, she is taken in by an aunt who despises her. She is abandoned to an evil church orphanage, where, in spite of harsh conditions, she becomes fluent in French and learns how to paint. She becomes a governess for a wealthy but troubled Master, who falls in love with her. She becomes the means of his redemption.
3. And of course, Little Orphan Annie. No matter how bleak today is, she always has "Tomorrow" on her lips.

We are reading a book about RAD, or reactive attachment disorder. It seems likely that orphans in reality are more like this:

1. George, age 5. He hugs and kisses everyone he meets, but when he is taken home by his parents, becomes sullen and distant. "We feel like he is always interviewing other families for our job", one of the parents said.
2. Nicole, age 8. She'll enjoy cuddling with one her parents for twenty minutes, and then, as the parent is kissing her good night, says "I wish Aunt Mary would have adopted me instead of you".
3. Harry, age 10. He views his adopted home as a "very well-stocked orphanage" and says that his adoptive parents are fine, but if he really loved them he would be disloyal to his biological mother, who he really never knew.

I must say that as we progress through this book, we wonder if we're spending a lot of time, effort, and money to import a psychopath. If only I could be guaranteed of Jane or Anne.

A good stoker is hard to find

A few months ago my wife and I bought a tandem bicycle. As we work together (she's my office nurse) and live together, I figured we could spend every waking hour together, riding our bike off to marital bliss.

For married couples, tandems either are wonderful or evil, depending on skill of riders, temperment, control issues, and so forth. We happen to get along great together, I as the captain and my wife as the stoker, the person who sits on the back seat, peddles obediently, and, other than yelling at or cajoling the captain, has absolutely no control over where the bike is going.

It's a good arrangement if you ask me. I love doing it. And it means at least one person on the road is not going to pass me.

It's been an emotional weekend, to say the least. We went to a major fund-raiser for Ukrainian orphanages last night, of some interest to us as we are attempting to adopt out of one of the orphanages this group ministers to.

Have I mentioned yet that the Russian language is a pain in the patoosh? I'm working through Rosetta Stone. It's not their fault that Russian is so inscrutable.

Anyway we chatted with folks who have seen our adoptee and it was encouraging. "She is just the sweetest girl. We gave her extra hugs for you."

We also watched a video of what happens to these kids when they reach 17. It's on the streets for them. Girls are often involved in sex-trafficking in one form or another.

We can't save the world, but we can give one of these kids a chance. Yana (it's either that or Anya. We haven't figured out how she spells it. I hope to find out soon) will get a chance, if heartless bureaucracies don't tank the effort.

We received a digital photo album of the orphanages last night, and we poured through them looking to see if we could identify this little girl. We did. The kids get access to hot water once or twice a week, in the winter no one washes their hair, so everyone looked a bit disheveled, and most of the girls' hair was dirty looking. Yana/Anya had also hit a growth spurt and had shot up about half a head. She looked quite a bit older than pictures of her just three months ago had looked.

My wife was a bit shocked, as she was hoping to have bonding time before the onset of puberty. It also occurred to her that this undertaking was no longer some cool abstraction. It is now our responsibility to take a street urchin and raise her as our own.

Times like these, I'm glad I have a Y chromosome, along with all the rights and privileges that come along with it. While my wife is mourning a bit about losing some of this girl's growth, I'm rejoicing on how, now that she is getting bigger, I won't have to worry about converting the stoker seat on the tandem for a child.

I can't think of a better way to show off our great country, plus get a little exercise in the process. I'll worry about harsh reality, including my Russian studies, later.

On the cutting edge

We passed one of the major hurdles in the international adoption process last Thursday: the home study visit. Keeping details to a minimum for now (office starts in 5 minutes), the home study people, who have gotten to know you extremely well from all the paperwork and interviews that they have done up to that point, spends a minimum of three hours in your home. Their mission is to make sure that you are a suitable family, that you have the means and resources to take care of a new child, and that you're not a pedophile or some other low life. We think it's a very good program. We also think that if we had to provide the documentation for one of your "natural" children, the human race would die off after two generations.

There are some "hot buttons" in the home study process. One of the biggest is the question of firearm ownership. The home study agency doesn't want little kids getting into the family armory and raising havoc with themselves and others. Ideally, you should not own a gun, but if you do, it should be kept under lock and key, preferably in a safe, preferably at the gun club. We were questioned about it several times, and, no, we don't own guns. I get nervous with my son's paintball gun in the garage.

We take the home studier around our house. We show her my son's house, which is astonishingly clean. She nods in approval as she leaves the room. My son is turning very pale.

He had layed out, very neatly, on his dresser, his knife collection, some ten or twelve knives, ranging anywhere from a scrimshaw pocket knife to this huge machete that his brother-in-law had brought back from Guatemala. There was enough cutlery to slice and dice everyone in the neighborhood without having to use the same knife twice.

Only guns kill people, I guess. It certainly didn't bother the home study people.

Our paperwork now goes to the CIS/INS. We hope to hear from them in six weeks.

Brushing off the cobwebs

I realized a bit back that whining abut the evil tort system (and it IS evil) or writing about my modest biking exploits was not a good enough reason to generate blog entries. Maybe you'd like to join me for my latest adventure. It might be fun.

In September my wife journeyed to the Ukraine to help clean up orphanages: give them new paint jobs, take over new beds and matresses, stuff like that. She'd been to Eastern European orphanages before and was familiar with them, knew about the heartbreaking stories behind so many of the children, and our seeming inability to make even the slightest impact upon the kids' plights.

At one of the orphanges she instantly bonded with a child who's name we think is Anya, a cute little 11 year old girl who wanted to be loved in the worst way. Karin got a few pictures of her, and on her return showed them to me and explained about what she had seen.

"She's a sweet little thing. Sometimes I wish we could have brought her back." She knows that you can't get attached to those little ones else you'd bring them all back, which you can't do.

"Well, why don't we?" I said. "It works for me. We can't save the world, but we can help one child".

We thought of all the reasons we shouldn't do it:
--we're getting old.
--I could lose my job over one nuissance lawsuit (thank you, evil American tort system, almost the only one in the civilized world that has not adopted a "loser pays" approach so as to discourage stupid lawsuits).
--I might just decide to keel over from The Big One.
--There's no way I could retire until I get really, really old.
--And a lot of other reasons, like disrupting the family ecosystem, having another mouth to feed, child to educate (she doesn't speak any English), and woman to marry off.

Someone asked me why I'd even consider it, and I replied a bit flippantly: "We have three perfect children (well, we do), so we figured we needed one more chance to have an offspring break our hearts".

I think that's a good enough reason. So did my wife.

We contacted the local international adoption agency. "It'll cost you somewhere between $10 and $15 thousand, but it could all happen by June".

Cool. So, off we go.

Here's what we done so far:
--sent off for three personal non-family references.
--two family references.
--every single financial account we have, anywhere.
--last year's 1040.
--complete medical histories.
--proof of health insurance.
--proof of life insurance.
--family photo.
--birth certificates.
--autobiographies. This was kinda fun. I didn't realize I'd lived such a fascinating life.

This is just the first round of stuff. The hard part is coming up. I'll keep you posted.

All the fashionable people

(I admire "fake but accurate" journalism and seek to emulate it as often as possible. However, while I've changed all the names in this post, the details of the story are true.)

We deal with death and its apparent injustice all the time, yet the death of a medical colleague in the prime of his career always presents itself as a gross anomaly, like waking up one morning and seeing the sun come up in the west. Some would say that physicians believe themselves immune to the laws of physics and biology, and perhaps they are right. Doctors aren't supposed to die until they've retired and moved away to the golf course-side condo where they play every day until they become too senile to keep score and everyone has forgotten about them and then we read an obituary about an elderly gent with an M.D. after his name who sounds vaguely familiar but that's about it.

That's what's supposed to happen, so it was a shock when one of the endoscopy nurses asked me what I knew about Dr. Tom Wandzilak, an ER physician my age who died this past week.

I knew nothing. I spend as little time in the doctor's lounge as I possibly can, and although that spares me from all the incessant whining that goes on, it also leaves me outside the loop when it comes to news and gossip.

I entered "Dr. Tom Wandzilak" into the very same search engine that markets freedom-surpressing software to the Chinese, in hopes of learning what happened to the poor man. There was nothing about his death, but there were many other citations, several of which had to do with malpractice suits.

I came across this doozy:

Med-Mal Defense Verdict in Failure to Diagnose, p. 1
Several doctors failed to diagnose 38 year old housewife's cancer of the lymph nodes; ER doctors and internist chalked it up to psychological problems. After 10 months of being told she was crazy, she found out the real diagnosis and that it had spread - she died 13 months later leaving husband and children. A variety of defendants were targeted who treated a healthy housewife with no history of mental problems as if she had mental problems. Prior to trial, plaintiff/estate (including consortium claims for husband and children) had settled with three defendants (Dr. Sam Fredericks(ER), Dr. Susan Underwood and Dr. Jack Niles (post misdiagnosis psychiatrists). Two other doctors were in for apportionment purposes (Dr. Tom Wandzilak (ER) and Dr. Raymond Smithers(ER). Which doctors were left? Dr. Abdul Nafty (internist); Dr. Jim George(internist) and Dr. Louis Goldstein (psychiatrist). Psychiatrists were faulted for failure to pursue an organic component of the problems and therefore did an incomplete exam of the patient. The settlement was unknown to the jury. Dr. Benedict Arnold, Internist, testified for the Plaintiff criticizing Nafty and George for their incomplete exams. Mr. Andy Roberts did a vocational analysis since the decedent was college educated.

Plaintiff experts: Dr. Benedict Arnold (Internist); Dr. Huey Greenburg (Internist); Dr. Charles Zadok (psychiatrist); Dr. Dwight Davis (oncologist for causation); Dr. Eugene Eubanks (cardiologist and internist); Mary Margaret and Beth Sue McAllister (psychology for children's claims); Andy Roberts (vocational expert)

Defendant experts: Dr. Hiram Hildebrand (oncologist); Dr. Jack Louis (internist); Dr. Karl Jung (oncologist); Dr. Peter Rogers (psychiatrist); Dr. Elizabeth Reardon (psychiatry).

Prior to suit - Dr. Fredericks, Underwood, and Niles had settled.

Damages? Estate - $5 million; children- $2.5 mill each; husband - $500,000.

Settlement negotiations were spurred at trial after talking to the alternate juror - she had opinions regarding apportionment, fault and damages (millions). Nafty and George settled for an undisclosed amount.

It's a good bet that none of the physicians used the term "crazy" in their description of the patient. We're trained to use no subjective word in our descriptions. For example, instead of describing a patient as "hostile and threatening" we would document that he "looked me in the eye and said 'I'm going to beat your head in, sue your ass off, and feed your entrails to the buzzards.' " Direct quotes are not subject to misinterpretation.

What really struck me about this case is that all of the fashionable people were involved. I know, or know of, all the defendants. Not only are they NOT threats to the public welfare, but they are all excellent. I never dreamed that these folks would be dragged into a massive lawsuit. That kind of thing only happens to wretches like me.

There are times when The System fails. In complex cases involving multiple specialists, especially in academic centers, there can be horrible miscommunication which cause a patient to suffer. Sometimes the patient can be caught in a struggle between two (or more) towering egos, egos which refuse to acknowledge the possibility of making a bad judgment.

But what about cases where everyone gathers all the information and comes to a conclusion which is perfectly reasonable (or else they wouldn't have all reached it together) but is just flat dead wrong? Physicians are not, in theory, expected to be perfect in all things. They are supposed to be diligent and make reasonable judgments. We're not supposed to have our asses sued off just because our judgment is wrong. Can physicians be found to be below the standard of the community when the community itself is wrong?

Let's review the case:

Prior to suit - Dr. Fredericks, Underwood, and Niles had settled.

Damages? Estate - $5 million; children- $2.5 mill each; husband - $500,000.

Settlement negotiations were spurred at trial after talking to the alternate juror - she had opinions regarding apportionment, fault and damages (millions). Nafty and George settled for an undisclosed amount.

I can't blame them there. Being faced with a $5 million judgment will give you pause.

Verdict - zero - defense verdict. Jury came back - all three (including Nafty and George) had prevailed.

And I suppose justice was done.

Dr. Tom Wandzilak, rest in peace.

The lawsuit graveyard

One of my favorite movies of all time is Saving Private Ryan, partly because of the cool blood and gore war scenes, but mainly because of the tribute it paid to the American soldier and everything he did to preserve our freedom. One the most poignant scenes in turn is the one in which the elder Ryan wanders about the military graveyard in Normandy: rows upon rows of bleached white marble crosses, with an occasional Star of David, each cross or star bearing silent testimony of the life that was given during that awful campaign.

Wandering about military graveyards will make you ponder. You ponder the ultimate sacrifice of the soldier. You ponder that the sacrifice was surely made over the objection of the individual. You ponder how death represents the ultimate reality unless the eternal existence of the human soul is a greater reality. It provokes a terrible melancholy, and I deal with it the same way I deal with most of the great issues of our time.

I try not to think about them at all.

I'd rather think about biking, or my son's lacrosse games, or rooting for my daughter when she runs the minimarathon this weekend. I have such a melancholy personality that I fear if I ponder weighty issues too much, I'd withdraw from the pain of existence, living my days curled up in the proverbial fetal position under my bed.

One web site I visit from time to time is www.MalpracticeWeb.com. Looking for a good plaintiff's attorney? This site might just be for you. Not sure if you really want to sue your doctor? Want to get worked up about all the malpractice injustice of the world? Help yourself to the summaries of the lawsuits (I believe in the greater Chicago area) that have either been settled or have had a judgment for the plaintiff.

Pulling up these capsule summaries to me is the web equivalent of wandering about the graveyard, with each little summary representing what was a titanic clash between an aggrieved patient or his estate and his attorney and all of his expert witnesses versus the doctor and his family and his defense counsel and all the expert witnesses that they marshaled. Each represents a family in anguish, a patient in pain that won't go away, an anger that can only be quenched with a generous monetary judgment. Each represents a doctor who for three or four years looks at himself in the mirror each morning and wonders if the world wouldn't be better off if he just retired, the doctor who wishes he had made a better judgment in the middle of the night, or wasn't distracted by eighty thousand things demanding his attention causing him to miss the one detail which might have made a difference in the patient's course.

In this pediatric surgery malpractice lawsuit, the husband and wife plaintiff's claim that during bilateral inguinal hernia surgery (hernias where intestines bulge through a canal to where the testes descend) the above defendant doctors also removed E. B's left testicle and then didn't tell them about it. Dr. X settled for $75,000. This sounds like a bargain when you consider the fact that men consider testicles to be priceless. Dr. Y and Mt. St. Elsewhere Hospital were dismissed.

I suppose that this represents a bit of levity on the part of the authors, the equivalent of learning that a fallen soldier died because he mistook a claymore antipersonel device for a can of beer and tried to open it. Oops.

In her podiatry malpractice lawsuit filed in 1997, this plaintiff alleged, among other things, that on October 26, 1995, Dr. Evil performed unnecessary bunionectomies with osteotomies on both feet in spite of pre-operative x-rays that were clearly within normal limits. She claims that since the surgery she has not been able to play racquetball anymore, as she had played 3 to 4 times a month, cannot do step aerobics, cannot walk more than 1/2 mile without pain, and cannot walk around the house barefoot due to swelling and burning pain in the balls of her feet. On August 31, 2000, Dr. Evil was dismissed and his corporate entity, Dr. Evil, Ltd. made an undisclosed settlement.

I'd love to know what really happened in this one. Did the patient hound him and badger him into performing a surgery of dubious merits? Was he falling behind in alimony payments and churned a bit? Did he give up just enough money to make her go away? Once the case was dismissed, did the plaintiff use the settlement money to renew her membership at the local racquetball club? This information never shows up in this kind of capsule summary. Never will.

In his dental implant malpractice lawsuit filed on March 5, 1999, Mr. P., born in 1929, claimed that after having an allegedly negligently placed subperiosteal implant implanted into his lower jaw in 1991, dentist Dr. Nasty allegedly failed to provide proper care over the course of several years which allegedly resulted in an infection, nerve damage and bone loss that necessitated implant removal and hospitalization, and medical bills totaling over $94,000.
Dr. Nasty claimed that Mr. P., among other things, failed to maintain proper oral hygiene, used a metal pick to clean the implant when he was told not to, and delayed having the implant removed in March of 1997 when he was told to have it removed. This suit was settled for an undisclosed amount on January 9, 2003.

Let's see: the event in question happened in 1991, the lawsuit was filed in 1999 (that's a heck of a statute of limitations) and settled in 2003. Inmates on death row get a more merciful and swift execution than that. Any chance the plaintiff's attorney came up with delay after delay, leaving the dentist to twist in the wind until he was willing to give up some insurance money to make the whole mess go away?

Maybe I'll email the webmaster and suggest that they chronicle the methods the attorneys use to ply their trade. It's just a thought.

Questions

I have quite a few, actually.

Since I enjoy quality time with my daughters so much, why don't I schedule more of it?

Why is reading the Tao Te Ching relaxing and reading the Koran not? Why do I see the image of an angry Pharisee flash by whenever I read the Koran?

Since I don't see myself thriving in private practice, and as one malpractice suit would render me unemployed and unemployable, why don't I cut and run now?

Why has gastroenterology seemed more like a hobby to me for the past few years, in spite of the fact that I'm keeping up with things and that I'm pretty decent at it?

How can anyone in their right mind believe in the eternal existence of the human soul?

I know lots of Jewish folk that are better people than I. Is it fair for me to go to Heaven (assuming that it exists) and not them just because I'm a mediocre Christian?

Why do I keep trying to get mountain biking down in spite of the fact that I'm probably going to get really hurt doing it? After all, a broken finger is no biggie, but a trashed rotator cuff would be pretty darned inconvenient.

Why do I, when faced with these weighty issues, find myself wanting to blog about some mindless aspect of biking instead?

And why ask why?

Hammerheads and Nails

(The following is my latest attempt to gain acceptance with the local mountain biking community).

To hammer—(vi) to pedal as hard as you can for as long as you can.

Hammerhead—(n) one who hammers. Likes to vomit during or after riding.

“There are two types of people in this world: those who like to divide everyone in the world into two types, and those that don’t”. --ancient Jebusite saying.

The biking community likes to divide the world into two types of bikers; either you’re a serious biker who some day hopes to qualify for the national championships, or you ride a junker with coaster brakes and a little basket attached to your handlebars in which to carry your groceries on your jaunts to the local Save-a-Step.

This is too bad. There are a lot of bikers who would never be caught dead on a Huffy but just don’t think that riding until you puke is any fun.

I work everyday with lots of these riders. They decline my invitations to go biking with this universal response: “I was once invited on a ride and all the riders said they were going to ‘take it easy’, and then they sped off and left me all alone. It was humiliating, and I’ll never do it again.”

These folks have obviously never ridden with me, but I digress.

We need a group of riders who occupy the middle ground, who like to ride adventurously but don’t care if they finish in front of anyone else in the world. I’ve taken it upon myself to form such a group: the NAILS, a group of riders who are almost the exact opposite of the hammerheads. We are Non-Athletic Intelligent Lazy Slugs, and proud of it.

Not anyone can become a NAILS. The selection criteria are very strict. Below is a partial list of qualifications:

You might be a NAILS if:

--all your bike stuff, including the bike, costs less than $500.
--nothing you own is made of titanium.
--people talk to you about splines and gear ratios, and you stare blankly at them.
--someone asks you what kind of bike you own, and you reply “a red one”.
--the only race you’ve ever been in was to see who could get to the park bathroom first.
--you like to ride last so you can copy everyone else’s line.
--you approach a large hill and you look to see if there is a bike friendly bus-stop nearby.
--bike shoes strike you as being a huge waste of money.
--you have no idea what ‘periodization’ means.
--you’ve never used the terms ‘gnarly’, ‘shred’ or ‘rail’ in proper biking context.
--you use ‘Hammergel’ to lube your chain.
--you’ve owned clipless pedals for over six months and stopping your bike still fills your heart with terror.
--you wake up one Saturday morning, it is 68 degrees and sunny outside, the ground is dry and firm, the Wild calls to you by name, and… you brew some coffee, settle into your favorite chair, and read a book all morning.

It had to happen

I broke my first bone this week, mountain biking.

It was worth it. I'd do it again.

I ventured out on a trail that is a bit demanding. As I got on it, a freezing rain hit. This didn't make things too slick, but it made me slow down, thus causing my front tire to wash out when I hit a root. Flying over the bars, I almost made a graceful tucked-in landing, except I didn''t get my little finger pulled in.

I began to suspect that I hadn't merely jammed it when I noted that the finger was bent in a peculiar angle. I rode about four miles back to my car and was going to blow the whole thing off as I casually mentioned to my wife that the finger hurt a bit.

Next thing I knew, I was seeing my friend the hand surgeon. "Looks like you might need to get the finger pinned". Yikes.

One xray later, it was decided that I had "broke it good" but that I would be OK with the finger splinted for the next 6 weeks. I pondered this as I strolled about today in 75 degree weather, bright and clear throughout the Ohio Valley.

I was just getting good at it, too.

It doesn't interfere with my scoping ability, but when called to do household chores the pain becomes unbearable. It might stay that way for months, maybe even years. Time will tell.

Ideology

These days I've had so many ideas for blogging topics that I've not been able to focus on any one thought, a sort of analysis paralysis. That, and I've been lazy, preoccupied, and content to follow the easier path of "drive-by" commentary on other folks' blogs.

The toxic atmosphere of American politics probably has something to do with it. On my local mountain biking forum one thread was hijacked by posters spewing the most hateful, crassest forms of Bush-bashing left-wing hyperventalation. I typed out carefully nuanced commentary of the revolutionary pre-emptive doctrine of Bush and cronies, along with thoughts about Wahabism and Sufi Islam, appealing to all sides to put aside petty partisanship and calling for everyone to assume a greater historical perspective on the War on Terror.

My efforts were rewarded with what has sadly become a standard response from the New Left: "You SUCK, you dumbass psychofascist!" If you think my judgment of the New Left is a little harsh, then prove me wrong. I haven't seen any evidence to the contrary.

Well, I don't suck. I aspirate. I'm a doctor.

The irony of it is that I'm a lousy ideologue. I think my favorite political joke is one that was popular in Eastern Europe in the early '80's: "Capitalism is man's exploitation of man. Communism is the other way around."

If there was one aphorism that summed up my political philosophy, such as it is, it would be this: "Power corrupts; absolute power corrupts absolutely". Free market capitalist, socialist, communist, fascist, it makes no difference what the label is. Put enough power in the hands of a Few and the rest of us will suffer mightily for it.

I think many physicians are more open to the concept of Universal Healthcare than ever before. I'd love to assert that we physicians are becoming more altruist in our maturity, but this would be incorrect. As the health insurance companies are consolidating into economic oligarchic, and as we have less and less ability to influence issues such as reimbursements and expenditures, it's occurring to more and more of us that perhaps the companies should just go to blazes and divert the money being used for enormous bonuses for the CEO's and use it instead to provide at least a modicum of coverage for the nation's poor.

I'm open to it. I'd also like some assurance that if I have the Big One while typing this out, that as a self-employed practitioner I'd be able to afford coverage. If I had the Big One I'd be in a world of economic hurt.

A few years ago I took a trip to Romania where the question of what the local church, as supported by kindly American do-gooders and their money, could do to improve the delivery of healthcare. The quick answer was "I dunno". We met with local healthcare officials to understand the Romanian system better.

On paper it looks good. Anyone who works has 7% of their pay withheld to finance their medical care. They don't make much in Romania, but then again healthcare isn't very expensive, so there should be enough money to take care of basics. There might not be enough in the system for the citizens to get PET scans, but they should be able to obtain ibuprofen and lisinopril without any trouble.

But they can't. No one has enough money to purchase them.

The healthcare officials are all ex-communists, and in the best communist tradition, they siphon off huge amounts of money into Lord knows where, anywhere but into the hands of the people who desperately need it.

We assured the Romanian church folk that in America this kind of thing would never happen. The money wouldn't disappear, it would simply show up as a $100 million yearly bonus for the CEO of National Red Star/Red Sword, and all would be well.

March is Colon Cancer Awareness Month

(The following is an article being published in our local health and fitness magazine, with the tacit approval of my editor.)

Why should I care?
The risk of colon cancer goes steadily up once you hit fifty. Unless you've figured out how not to age at all as you get older, you better be aware of this disease's potential threat to you health. The disease does not care whether you are male or female, black or white. For it is the third most common type of cancer for both sexes, and altogether causes more deaths than either breast cancer or prostate cancer.

But hasn't everyone heard of Katie Couric, colon cancer, and colonoscopy?
Evidently not in Kentucky, We have the second lowest rate of colon cancer screening in the country. Sadly, Louisville/Jefferson County is bringing up the rear, having one of the highest rates of colon cancer deaths in Kentucky and the nation.

OK, I'm aware. Now what?
"Ask for IT!" as in Information and Testing. Our screening guidelines have changed dramatically over the last ten years, and they are not seared into our medical consciousness the way Pap smears and mammography are. Even conscientious physicians may overlook colorectal cancer screening in all their patients. As in all health-related issues, a knowledgeable patient is her own best advocate.

Give IT to me, then.
Because 90% of cases are diagnosed in patients over 50, we recommend that screening begin at that age. Studies have shown that ANY form of screening is better than no screening at all. The forms of screening include the following:
True colonoscopy.
Barium enema, preferably air-contrast.
Flexible sigmoidoscopy
Fecal occult blood testing
Less common forms include the following:
CT colography ("virtual colonoscopy")
Chromosome analysis of cells shed in the stool.
There are patients who should undergo testing at an earlier age. Patients with family histories of colon polyps or cancer should start their testing at the age of 40, or possibly even earlier. Patients with inflammatory bowel disease are often advised to begin screening earlier, too.

You make your living performing colonoscopy. Which test, by chance, do you recommend?
Colonoscopy, of course. It has major advantages over the other forms of screening. It is more accurate, in most hands, at detecting polyps and cancer than barium enema. It allows us to see the entire colon, instead just the third that is seen with sigmoidoscopy. It is more accurate than stool testing and, at least for now, virtual colonoscopy. It allows us to sedate patients, which is not routinely done for virtual colonoscopy. Most importantly, it allows us to spot and remove precancerous growths called polyps. In these cases we are actually preventing, not just detecting, colon cancer.

Sounds like a big hassle to me. And the clean-out for it doesn't seem inviting, either.
It is a hassle, but most folks only have to go through it only every ten years. It's not like getting yearly prostate checks or Pap smears, thank goodness! Every year we get cleverer with administering the clean-out. There are several different preparations you can take for colonoscopy. Discuss them with your doctor. Who knows, maybe some day we'llhave a prep that people actually enjoy.
The hassle is well worth it. Since 1985, coincident with the growth of colonoscopy, we have seen a 2% drop in colon cancer deaths each year, and nationally deaths from cancer are actually falling! Not all colon cancer deaths are preventable, but we think the vast majority of them are in patients who undergo proper testing.

Colonoscopy is expensive, isn't it?
The up-front costs can be a little daunting, but it is a whole lot cheaper than the costs of treating advanced colon cancer. It is so much cheaper that the Federal government is underwriting colonoscopy screening in Medicare beneficiaries.
In the long run it also saves the health insurance companies money. Recently I received a card from my health insurer reminding me that I was over 50 (thanks for the reminder!) and that I should be thinking about undergoing colonoscopy. This is proactive behavior on the part of the health insurer at its best.
By comparison, it is actually less expensive to save a life from colon cancer than it is to save a life from breast cancer.

You promise you'll sedate me for this?
We got more sedation than you have anxiety. I didn't feel a thing when I had mine, and I was glad I could check off colon cancer from my list of worries!

About that death wish

Yesterday was a fine day, of a sort: 20 degrees F, 3 inches of snow on the ground, and gray, overcast skies. After struggling to get my morning rounds performed, I took my son's bike out to the local trail for my first ever snow ride. My wife had lobbied vigorously against this endeavor: "You'll kill yourself out there", she said matter of factly, and reminded me that the Fate of Western Civilization rested on whether I was able to emerge from the trails unscathed.

Taking my son's bike was a good idea. His has disc brakes, and besides looking cooler than V brakes, they work well regardless of how much ice and grunge builds up on the wheel rims. Yesterday there was a lot of ice and grunge, and salt, and even mud, I'm embarrassed to say. More about that soon.

Riding at noontime in overcast skies, I was surprised at the abrupt changes of trail conditions I would encounter. I loved the "frozen tundra", where the snow was hard-packed and made crunchy Rice Krispy sounds as you rode over it. The grip was firm and reliable, except for one spot were there was some mud just below the surface. Down I went, but it wasn't painful; it just left a huge mess on my clothes.

The trail would then change into the "snow-mosquito infested swamplands" which are the bane of all responsible mountain bikers. Riding in mud is irresponsible because it tears up the trails and accelerates erosion, and everytime someone does it, God kills a kitten out of frustration. I'd find my way to the nearest road as quickly as possible. I was not going to have some innocent kitten's death on my conscience.

Riding on a snowy trail is a rush. Riding on an icy road is not. Losing control on a mountain trail and plummeting hundreds of feet to my demise would be cool in it's own way. Falling on icy pavement and breaking a hip would only be very painful and very stupid. I'm riding the icy road trying to save the life of a kitten and I'm fearful of my own life the entire time. My fear is accentuated as I hear a sickening metallic crunch behind me. A van has skidded out of control on the icy road and taken out a road sign. Was it the sign that said "Road freezes because of global warming, and its Bush's fault"? I was too frightened to go back and check it out. That metallic crunch could have been my bike.

I got back on the trail and spent more time alternating between frozen tundra and swampland. I was able to work my way back to my starting place without rutting up the trail in too many places, although my bike (or rather, my son's) is now covered with multiple layers of snow, mud, and salt. It looks nasty. Did a kitten die at the hands of an Angry God on my account? I don't know. I do know that I felt great for the rest of the day, and fell into an Ambien-less sleep in a matter of minutes. I felt more alive this day than I had in a long time.

I will feel even more alive when my son sees what a mess I've left his bike in. At that moment I will face death, especially if I by chance messed up the rotors to his disc brakes. Pray for me, now and at the hour of my death.

Death's not my first choice but...

This is one of my favorite doctor jokes:

Q: Why do doctors go into psychiatry?

A: To get free advise.

Psychiatrists didn't find that joke very amusing 25 years ago, but now they're having the last laugh. Stress disorders, depression, ADD, ADHD, and general gloominess are so rampant in our culture that knowledge of psychopharmacology comes in handy. I know how to treat Crohns disease. I don't really know how to treat Hashimoto's thyroiditis anymore, and that doesn't bother me much. But I really wish I were a bit sharper on the treatment of lawyer-induced chronic depression (a recognized medical entity, by the way).

When I was younger I wanted to go into psychiatry, until I was seduced by the dark side of the Force, that aspect of medicine dominated by Pathways and Mechanisms, by Techniques and Procedures.

I enjoyed "fixing things" or at least sharing the illusion of it. Surgery and cardiology were a bit too intense so I opted for the more laid-back field of gastroenterology. It's been a good fit, and I'm glad I chose it. These days I've been ready for a change, and for a specialty that I never would have dreamed of being drawn to.

When I turned 40 I was chunky and sluggish and determined that I wouldn't be that way for much longer. Fueled with the energy that comes with Mid-Life Hypomania, I lost forty pounds, built up muscle, took up skiing and horseback riding, and subtracted 15 years from my physiology. I felt great.

When I turned 50 I was chunky and sluggish and determined that I wouldn't be that way for much longer. At 50 I had no more mid-life energy; I had "matured", which meant that I was just tired. What excited me the most was the prospect of catching a cat-nap. I'm 53 now, but I won't be for long, and the leaves that are green turn to brown, and I'm still chunky and sluggish and have reason to believe that I'll stay that way until I get chunkier and sluggishier and so on and so on until I die some day.

I'm not being morbid. That's just the way it is.

So I could use some free advise facing these end-of-life issues. For the first time in my life I wish I had gone into Oncology, because in facing death we face life. When we face total loss we realize which things we are carrying that are worth the weight, and which ones are not. If I knew as a fact that I had pancreatic cancer with metastasis to the liver, I would not be wondering if it were worth upgrading my TV to high-def and getting TiVo installed in my cable box. I would want to tell my wife and my daughters and my son how much I love them and how I wish I'd bother to tell them that a lot more that I ever had when I thought that I would live forever. I'd tell my friends that I consider them friends. I just assume they know that. I never come out and tell them.

Last week I was discussing with a family the outlook for a man with pancreatic cancer that had spread to the liver, and almost surely by sound of things to a few other places as well. On a physiological basis there is not a lot of good news to share; there is no good news to share, other than to discuss the advances that we've made lately in palliative care.

"But Doctor, is it right to take all hope away from him?"

Baring divine intervention, do we take away all hope by sharing with families that the 5 year survival rate for advanced pancreatic cancer is essentially 0?

What survival rate do any of us have? 40%? 80%? Last I checked the same fate awaits every single one of us. Our collective survival rate is 0. Have we no hope? Shall we delude ourselves and tell ourselves something different? Would we really want it to be different?

What hope does my patient have? He knows he's going to die, like all of us, but he knows that his time will come very soon. Does he have relationships that need to be mended? Does he have people that need to hear about his love for them? Does he need to reconcile himself to whatever his belief is concerning Eternity? Does he find comfort in the fact that his thirty year mortgage and his 1040 and his zero coupon bonds are no longer of any importance to him? Is there no hope in this?

"There's something to be said about having 'the big one' and getting it over with in a hurry", I hear people say all the time. I don't think so. I think I'd have too many regrets dying suddenly, if I were capable of having any regrets at all.

My career is being prolonged because I have the priviledge of telling the vast majority of the patients that I see that they do not have colon cancer, and that has become a great source of joy to me. I hope to be able to continue to deliver this good news to people for years to come. But it is with the unfortunate ones, the ones that I must share the unthinkable, the unhearable and the unimaginable, that I am learning the most about myself and my life.

Free advise and worth every penny

It was a mistake to drink that third cup of Starbucks.

I knew it as soon as the vile brown teeth-staining fluid sullied my lips. This week I have hovered in the nether-region between illness and good health, too tired and sullen to exercise but too healthy to have anyone or anything to blame for it. When I'm in that mood, a third cup of coffee is not in my best interest. Now I feel like I have two hundred rabid parakeets clawing and fluttering in my brain, threatening to explode out my sinuses at any moment.

The parakeet simile is overwrought, of course, but it is not soothing at all to walk into my office after a pleasant and tranquil morning at the endoscopy center and be faced with lots and lots of the usual: "Mr. Jones is furious that you said he drank too much", "Mr. Smith wants you to say its OK for him to skip his colonoscopy because he hasn't seen anymore bleeding for a while", "the Blessed Fields of Dreams insurance wants you to rewrite all your prescriptions to some other drug that they get for less this month", "a patient is suing somebody who hit her with a car and wants you to say that her irritable bowel syndrome is all the plaintiff's fault" and so on and so on.

As I said, that third cup was not wise. I drank it anyway because I have an addictive personality and I just couldn't help it, but I knew it was a mistake.

"Hey Doc, I know of a blogger you would really enjoy. She's brilliant, writes well, and has read every book in the English literature. She's a little to the left of center but I'm sure you'll enjoy her anyway", says a nurse at the endoscopy department. Fine then, I'll check it out. I need something to relax me a little.

The website is nothing more than tired recycled unimaginative Bush-bashing liberal tripe. There are two things that this world just doesn't need anymore of, yes, even three things: No more pseudo-elitist producing liberal tripe, no more pseudo-rednecks producing more conservative tripe, and no more foul cranky doctors kvetching to the world because he's tired, a little peevish, and overdosing on caffeine.

Now that I've cleared the air, let me offer some suggestions on what I think an enjoyable blog would include:

1) Straight party lines are BORING!!! Try to mix it up a little. That was what was so endearing about Hunter Thompson: he was a liberal who enjoyed a huge armory of weapons and loved to shoot animals and blow things up. Imagine, a liberal who is a gun nut, or a conservative who is terrified of them (such as myself). Good stuff.

2) Open yourself to the possibility that people who think or feel differently on things than you might actually have good reasons for doing so. Well-reasoned political writers of any stripe are in short supply, but they are out there. If you're a liberal, for example, make yourself read one David Brooks column a week. It won't hurt that much. Honest.

3) If you rant about how much you hate the hatemongers, it makes you look like a total idiot. Rethink your strategy.

4) Try poking some fun at yourself for a change. Never rag on someone with criticism that you couldn't possibly think would ever apply to you. Admit that you can be hypocritical, self-serving, mean-spirited, or just plain wrong. You'll feel better about yourself, and everyone else knows it anyway.

5) Never post when you are caffeine-toxic.

The principle of paradoxical risk

One of our "throw-away" journals recently ran an article with this startling conclusion: 'defensive medicine' is a huge problem in America, resulting in an enormous economic drain on our healthcare system.

Practicing physicians have known this for years. Out of narrow self-interest, the trial lawyers have been misrepresenting the magnitude of this problem. If they gave two hoots and a holler about the welfare of patients, they would at least acknowledge that this problem exists and perhaps come up with some constructive suggestions on how to fix it. But they don't, and they won't.

There are many thoughtful reviews about this problem, and I won't burden the Thinking Public with yet another one. I will suggest that among the forces behind the Defensive Medicine Crisis is the Principle of Paradoxical Risk. I have no idea whether anyone else has described this. I've never read it, so I'm happy to take full credit for the concept.

If I see an 80 year old who is complaining about passing blood in the stool, there is a reasonable chance that the patient has colon cancer based on their age alone. If I blow the diagnosis, then Ill be liable for economic damages which are going to be limited to the extend that the patient's "earning potential" is likely limited. If I live in a state with some sort of limitation on "pain and suffering" damages, then my liability will be further limited unless the court can prove that I was willful and malicious in my malpractice, and I get nailed with punitive damages.

Will the threat of malpractice influence my behavior in this case? Of course not. I get paid to make the diagnosis of colon cancer, and, knowing the odds, I'm not about to pat a patient on the back and tell him to take some Preparation H. I'll schedule the colonoscopy.

How about a 60 year old with the some complaint? The patient is less likely to have colon cancer, but the economic damages will be higher, assuming that the patient is still working. The "cost" of blowing the diagnosis of colon cancer will be higher, although the risk of the patient having colon cancer is lower. Again, this isn't going to influence my decision-making. The right thing to do is to proceed with colonoscopy, and I get paid for doing the right thing.

But what about the 20 year old who presents with the same complaint? If I blow the diagnosis of colon cancer I'll have the Devil to pay. The plaintiff will claim 45 years of high economic productivity that I'll be denying him. Unless I live in a tort-reform state, the plaintiff will also parade a steady stream of friends and family who point out how a beautiful young life was snuffed out because of my negligence. I'd be thrilled to settle within the limits of my malpractice insurance. No one would be happy about this.

What are the odds of a 20 year old having colon cancer (I'm assuming the patient has no risk factors such as chronic colitis or a family history syndrome)? What are the odds of complications from colonoscopy vis-a-vis the risk of colon cancer? What is the cost-effectiveness of putting 20 year olds with rectal bleeding through the mill over what is almost always hemorrhoidal bleeding?

The Principle of Paradoxical Risk states that "the less likely a serious medical condition is, the more likely you are to get your butt sued off if you don't diagnosis it".

The Principle of Paradoxical Risk states that these questions have no relevance to the discussion. If you miss the diagnosis of colon cancer in a 20 year old, you will be savaged in every conceivable way. You'll have to look at yourself in the mirror every day realizing that you could have saved the life of a person younger than your own children. You'll be financially ruined. The ordeal of a malpractice suit would drag on for at least 4 to 5 years (plaintiff attorneys do this because it is in their financial best interest).

Fifteen years ago, a gastroenterologist who performed colonoscopy routinely on 20 year olds with rectal bleeding would have been accused of churning. Do you think they would be accused of it now? What would you do? Saying you would just retire from medicine because operating in such an evil atmosphere would take too high an emotional toll is an acceptable answer.

Taking stock

Truth be told, I've always taken pride in having an addictive personality.

Don't expect to read the diagnostic criteria on this website. Like the mainstream media journalists I emulate, I'm too lazy to look stuff like that up, and when it comes to blogging I'm no stickler for details. Trust me, addictive personality is like love itself: difficult to define, but we all think we know what it is.

Inconveniently for my self-assessment, I've not suffered from a major addiction: booze gives me a headache and flares my GERD; I'm too law-abiding to get illicit stuff; even legal addictive drugs would take too many fake complaints and doctors visits to obtain, and I'm too pig-headed to acknowledge that I could get some malady that I couldn't diagnosis and treat on my own. I have struggled with workaholism, but after suffering from massive burn-out I've been cured of that for the most part.

My addictive personality has been a peculiar comfort to me. It's reassuring in some weird way to know that there are dark forces that compel me to do stuff I may not want to admit to. It would definitely come in handy if I were accused of extra-marital relationships, for example. We're indebted to Bill Clinton for educating us all on that one.

One addiction that I've always been fearful of is gambling. I've never had any doubt that once I took my first bet that I would succumb to some primal blood-lust and take wild chances with my children's education and my pension.

So I decided to do some research on a cruise this past week (you've never heard me whine about poverty, and I'm grateful to have the means to spoil myself and my wife every now and then). One of my traveling friends invited me to join him at the blackjack table, and, against my better judgment, I joined him.

Within an hour I had tripled my initial amount. The other players at the table viewed me with admiration. The floor manager eyed me with suspicion. I started to mutter "Wopner, Wopner", under my breath, seeing if I could convince anyone I was an idiot-savant like the Rainman as portrayed by Dustin Hoffman.

If you're going to experiment with "drugs", why not just mainline them and go for the maximum effect? After awhile I started planning on how I'd be able to pay for shore excursions. Who knows, maybe if my luck held I could pay for the whole trip.

I went back to the tables several times, playing wisely and following the odds as best I knew how. My traveling companion is a "card-counter", so I would watch his bets carefully and would up my own if the "counts are favorable", an act that would have gotten us tossed out if they had caught us.

After diligent hours at the gaming table I decided I'd had enough, and that I'd retire on my winnings: $12.50. On a per hour basis I was making considerably less than minimum wage.

I quit not out of discouragement but out of boredom. I got tired of the smokers blowing their poison in my face. I got tired of counting the little numbers on the cards to see if they exceeded 21. I got tired of sitting in one spot for hours on end when I could have been off reading a book (even so I was able to read The Curious Incident of the Dog in the Nighttime and almost finished The Life of Pi, good books both).

I had to face the cold brutal truth: I felt no addictive calling to gambling.

I then had to face a colder, more brutal truth: I don't really have an addictive personality.

All these years I'd been doing more or less whatever I'd wanted to, and if challenged I would invoke dark forces over which I had no control. Work 80 hours a week for ten years? I'm a workaholic. Read every biking book and magazine in the English language? Sorry, just can't help it. Watch reruns of "Whose Line is it anyway?" every night at ten, come hell or highwater? No sane person would do that.

None of it was true. I'm just an undisciplined twit.

There are no local chapters of "Twits Anonymous" around that I know of. I'll never enjoy the camaraderie of announcing to the world, "Hello. I'm Jus and I'm a twit." I'm on my own on this one.

And that, I'm afraid, is the truth.

Time

For the hardcore introvert there are three words that strike terror into the heart: "You are invited". I hate parties. They are like Death itself, except Death seems to be finite and some parties drag on for Eternity. I'd rather have a root canal.

My mission at any party is to make as clean a get-away as possible without destroying what little social standing I have. Properly done, I can condense a wedding reception into one long graceful movement: walk in the door, extend my congratulations to the bride and groom, grab a bite to eat, and thank the parents, all done without ever touching a chair or talking to anyone I don't know or would like to avoid.

I'm not anti-social, it's just that I got better things to do with my God-given time.

Maybe I have a poor attitude. Maybe I should change.

Yesterday my younger daughter was married. When it comes to wedding planning I try to be a non-combatant, either mediating between warring parties, or just ducking out of the whole thing until the fallout settles. When the big event comes, visitors graciously give me credit for all the planning and I explain that I only sign the checks, even though I didn't even do that much (my wife did).

This was my second and last daughter to be married. Our first daughter's wedding had an ad hoc quality about it. It was our first wedding and lots of things went wrong. Everyone laughed it off, relaxed, and had a great time. There was dancing into the night. Levity was the order of the evening.

This time around our (my wife and younger daughter's) planning was seamless. Everything was perfect. Instead of a DJ we had a live swing band. Instead of a buffet we had a formal sit-down dinner. Even the bride's dances were choreographed. We came prepared to dance the night away.

Contrary to my nature, I wandered about greeting folks that I knew and saying hello to folks I didn't. It occurred to me that we were not likely to ever have this crowd under the same roof again until my fourteen year-old son gets married, or until I die and they gather for my funeral.

As I was getting ready to walk my daughter down the aisle, she said "Daddy, walk slowly. I want to enjoy this moment for as long as I can". We walked very slowly, my daughter appearing as beautiful as she ever has, with me trying to look invisible as to not detract from her moment.

I wanted the reception to go on all night. This was my baby getting married. We had planned for this over the last year. Everything was perfect. This day is one to be enjoyed, savored, lingered over.

But this is America, a nation of very busy people with Lots of Things To Do.

Just as I was settling in for the evening, guests started to pay their respects on the way out the door. I'm glad you could join us, I tell them. The reception is lovely but the moms did all the work. Thank you for coming.

But that's not what I'm thinking. What's the rush? Look at my daughter, how happy and beautiful she is! Listen to the band. They're just getting warmed up. Don't go quite yet.

"Dad, it's almost time for us to go", my daughter says. That is my cue to line folks up outside and give them the matches and sparklers. The reception hall does not allow for flower petals or rice to be thrown, but doesn't mind if guests wave sparklers for the bride and groom as they make their getaway. It's an idea I've been opposed to. I have visions of some guest's hair or jacket catching fire and having our friends and Defenders of the Public Trust, the lawyers, sue my butt off. We have 750 sparklers and, to my dismay, it's not raining, so we have to use them.

To my relief no one catches fire. The only injury I know of was my older daughter who had a slight burn on one of her fingers. She told me later that she thought about calling a personal injury lawyer but didn't want to sue herself out of her inheritance.

My new son-in-law, romantic to a fault, has a horse-drawn carriage awaiting the newlyweds as they work their way through the gauntlet of fire. They give us a quick wave and then they are gone.

"How lovely!" say our guests. They thank us once again, and then they are gone, too.

And it is over so quickly.

Milestones

In this quiet year of my life I've passed several milestones. This year marks my twentieth anniversary as a gastroenterologist. I'm thankful that the field still provides me with challenges and is a source of fascination, no less now than in the first year of training.

This month I picked up my younger daughter for the last time at college. She went through on an accelerated program, cramming four full years of school into three and a half. I'll miss her school's beautiful campus. I won't miss her school's tuition payments.

Part of my daughter's final studies involved taking a personal finance course, or "Getting ready for Harsh Reality 101". Part of her assignment was to review our car insurance, including deductibles, limits of coverage, etc. I either wish I'd done the review three years earlier, or not at all. I had no idea I have a $100 deductible on an old junker I own. I had forgotten about a fender-bender my wife had been in 5 years ago. And they said it was all her fault. Bummer.

Just then I realized I had passed yet another milestone: it has been five years since anyone has sued me for anything.

The lawsuits are ever with me, so it came as a shock that it has been that long since I received that frightening letter:

We are reviewing these circumstances to see if there is any merit to the suit that the plaintiff is now pursuing. We are definitely suing some other doctors involved in this case. Could you be next?

I suspected that the function of this letter was to see if it could prompt me to call the attorney and offer to turn "state's evidence" and give inside information/dirt on the other doctors in order to save my own hide. My own attorney agreed.

"These guys do that all the time, and some doctors fall for it. I'm glad you didn't. It would have voided your own coverage, you know".

I knew.

It's been five years since then. I wish I could say that I'm such a better risk because I'm better as a physician, but I'm not. I'm certainly more cautious. I avoid high risk patients like the plague; I dismiss any patient I catch lying about anything. I'm just better at avoiding lawsuits, I suppose.

If I've learned anything, it's that no one is going to give me a good citizenship award for working 16 hours a day as a matter of habit. The wisest thing I've done is to see myself as a retired physician, one who is no longer able to work because of unavailability of liability coverage. So what do I do with myself now? Who knows, but life will surely go on.

Until then I will enjoy my practice but will keep taking Wednesdays off to go mountain biking. I won't come in on Saturdays for out-patient procedures so that the patients don't have to burn a sick day. I'm going biking with my son then.

And I will, as always, keep up with the literature. The field is just too interesting to go along as a bystander.

Happy festive occasion!

This isn't original - I'm not even sure where it came from - but it is very funny.

FROM: Patty Lewis, Human Resources Director

TO: All Employees
DATE: 1 October 2005
RE: Christmas Party

I'm happy to inform you that the company Christmas Party will take place on December 23, starting at noon, in the private function room at the Grill House.

There will be a cash bar and plenty of drinks! We'll have a small band playing traditional carols. Feel free to sing along!

And don't be surprised if our CEO shows up dressed as Santa Claus!

A Christmas tree will be lit at 1.00pm.

Exchange of gifts among employees can be done at that time; however, no gift should be over $10 to make the giving of gifts easy for everyone's pockets.

This gathering is only for employees! Our CEO will make a special announcement at that time! Merry Christmas to you and your family!
Patty

*****************************************

FROM: Patty Lewis, Human Resources Director
TO: All Employees
DATE: 2 October 2005

RE: Holiday Party

In no way was yesterday's memo intended to exclude our Jewish employees.

We recognize that Chanukah is an important holiday, which often coincides with Christmas,, though unfortunately not this year. However, from now on we are calling it our "Holiday Party". The same policy applies to any other employees who are not Christians or those still celebrating Reconciliation Day.

There will be no Christmas gift exchange, it is now called just a gift exchange. No Christmas carols will be sung. We will have other types of music for your enjoyment.

Happy now?

Happy Holidays to you and your family.
Patty

***************************************

FROM: Patty Lewis, Human Resources Director
TO: All Employees
DATE: 3 October 2005

RE:Holiday Party

Regarding the note I received from a member of Alcoholics Anonymous requesting a non-drinking table....................... you didn't sign your name.

I'm happy to accommodate this request but if I put a sign on a table that reads, "AA Only", you wouldn't be anonymous anymore. How am I supposed to handle this?

Forget about the gifts exchange, no gifts exchange are allowed since the union members feel that $10 is too much money and executives believe $10 is a little chintzy.

NO GIFTS EXCHANGE WILL BE ALLOWED.
Patty

***************************************

FROM: Patty Lewis, Human Resources Director
TO: All employees
DATE: 4 October 2005

RE: Holiday Party

What a diverse group we are! I had no idea that December 20 begins the Muslim holy month of Ramadan, which forbids eating and drinking during daylight hours. There goes the party!

Seriously, we can appreciate how a luncheon at this time of the year does not accommodate our Muslim employees' beliefs. Perhaps the Grill House can hold off on serving your meal until the end of the party - or else package everything for you to take it home in little foil doggy bags.
Will that work?

Meanwhile, I've arranged for member of Weight Watchers to sit farthest from the dessert buffet and pregnant women will get the table closest to the restrooms.

Gays are allowed to sit with each other. Lesbians do not have to sit with gay men, each will have their own table. Yes, there will be a flower arrangement for the gay men's table.

To the person asking permission to cross dress, no cross-dressing is allowed.

We will have booster seats for short people. Low-fat food will be available for those on a diet. We cannot control the salt use in the food, we suggest those people with high blood pressure to taste the stuff first.

There will be fresh fruits for diabetics, but the restaurant cannot supply "no sugar" desserts. Sorry!

Did I miss anything?!?!?
Patty

******************************************

FROM: Patty Lewis, Human Resources Director
TO: All effing employees
DATE:5 October 2005

RE: The effing Holiday Party

Vegetarian effers, I've had it with you people!!! We're going to keep this at the Grill House whether you like it or not, so you can sit quietly at the table furthest from the "grill of death", as you so quaintly put it, and you'll get your effing salad bar, including organic tomatoes. But you know, tomatoes have feelings too. They scream when you slice them.
I've heard them scream. I'm hearing them scream RIGHT NOW!

I hope you all have a rotten holiday! Drive drunk and die.

***********************************************

FROM: Joan Bishop, Acting Human Resource Director
TO: All employees
DATE: 6 October 2005

RE: Patty Lewis and Holiday Party

I'm sure I speak for all of us in wishing Patty Lewis a speedy recovery and I'll continue to forward your cards to her.

In the meantime, Management has decided to cancel our Holiday Party and give everyone the afternoon of the 23rd off with full pay.

Happy Holidays

Nothing but the finest

I must receive twenty head hunter mailings a week, each promising obscenely large sums of money if you relocate to an out-of-the-way town and work 80 hours a week until you retire from burnout or repetitive stress injury on your hands from pushing scopes all day long.

Every now and then I receive a mailing that looks interesting, and this past week I got one that was so appealing that I promptly send the recruiter my CV:

Take care of military personnel and their families! No weekends, no night call! (No malpractice because you can't sue government workers!) Nice city! Teaching available!

What more could I want? Right after I sent the recruiters my CV, I composed a letter to my patients:

Dear patient,

I have lived in this area for almost twenty years and regard many of you as friends, even members of my family, so I am sorry to announce that I am closing my practice in six months in order to take a cushy government job where none of you can sue me for my house, kids' college educations, or pension. When a physician was elected governor of this state we all hoped that meaningful malpractice reform was right around the corner. Instead, the opposition party, which relies on the State Bar Association for sizable campaign contributions, not only has blocked his every move but is forcing him to waste his time defending himself from persecution from the State Attorney's Office (who is a member of the opposition party) from charges that would have made the Salem puritan magistrates blush.

Well screw it, people. When you wake up and find that no one with more than three years experience is available to take care of you, you'll have all the rich ambulance chasers to thank.

A tad harsh, to be sure, but I figured by the time the letter actually went out, calmer heads would prevail and the letter would lose some of the edge. I can always dream.

The sad thing is that when the recruiters call me back, I always feel like I'm applying for the position of cashier at the local convenience store because I'd be a little overqualified. "I must say that your CV looks great! Any chance you can start work next week?"

"Um, next week? I'd love to, but I'm a solo doc in a very busy practice and it would take me about six months to close the practice down (a very optimistic estimate, by the way)."

"Oh, darn. This is a contract position that would last one year. It might be renewed at the end of the year, maybe not."

"Let me be sure I understand. You're looking for a competent gastroenterologist who is prepared to pull up stakes in a moment's notice and relocate to a new city with no more than one year's guarantee that he'll be employed?"

"Well, no one said that our job was easy."

Good luck. I'm just an average Joe who can whip a scope around, but I cannot imagine them finding a decent doc who is in such a position. Maybe they exist. I hope so. I'd hate to think that the government was only looking for warm bodies to take care of Our Finest.

How to tell if you've joined the vast right-wing conspiracy

1) You hear someone talking about "morality" and you no longer instantly assume he must be a sexually repressed religious nut.

2) You're actually relieved that your daughter plays with dolls and your son plays with guns.

3) You sit all the way through Dead Man Walking and at the end still want the guy to be executed.

4) Christmas season rolls around and it hits you there may be a religious connection.

5) At your kids' back-to-school night, you are shocked to discover the only dead white male on your tenth-grader's reading list is Oscar Wilde.

6) And by the end of the night you realize the only teacher who shares your values teaches phys ed.

7) Much as you'd like to, you can't get yourself to believe that screwing around on one's wife is an addiction.

Taken from "How I accidentally joined the vast right-wing conspiracy and found inner peace" by Harry Stein

Freak snowstorm closes Paris subway system

One of the most obnoxious bumper stickers I've seen lately said something to this effect: "If you want to be patriotic, you'll have to do more than slap a yellow sticker on your car. You'll have to get informed." I was tempted to leave a note on the windshield that said, "Thank you for encouraging open and honest political discussion in this country by announcing that anyone who disagrees with you is an ignorant fool. BTW, you're a stinking traitor."

That might have been a little harsh. I really came away wondering, "OK, I've had it with the unwashed red state masses. Just where do I go to get educated properly? CNN? CBS? The New York Times? The Daily Kos?"

I'm afraid I'd have to overcome some major distrust issues, like being asked back to a marriage with a habitual philanderer. Which brings me back to what I thought was a weird headline from my local paper in 1982 or so: Freak snowstorm closes Paris subway system

In 1980 our country suffered a horrible epidemic the likes of which had never been seen in any civilized culture. This epidemic vanished in the 1990's, only to make a resurgence over the last five years. This was the epidemic of the homeless: millions of perfectly normal people who, because of the viciousness of the Ronald Reagan Tax Cuts Only For The Rich, were tossed out of their comfortable middle-class homes and were forced to sleep over grates and live by looking for half-empty dog food containers in the trash of those few people (mostly Republicans) who were able to hang on to their own homes.

I was a registered Democrat and a loyal ABC Nightly News viewer back then. It bothered me a little that the few homeless people I ever personally saw were schizophrenic drunkards, but ABC and all the other Major News Outlets surely knew what they were talking about. And they made sure that I understood that mass homelessness had never occurred in any other culture or country. It was strictly a modern American phenomenon directly related to Ronald Reagan's Tax Cuts Only For The Rich.

So the headline I saw one day, on A8 of the local paper was very perplexing. A subway is underground, so how on earth would a snowstorm close it down? I read on. When the snowstorm hit Paris, everyone was caught by surprise. All the homeless of Paris, some 50,000 strong, fled the streets to the relative comfort of the Parisian subway system.

It was not the snowstorm that closed the subway system after all, but all the French homeless that jammed up the underground so that paying customers could not get access to the trains.

50,000 homeless in the most urbane capitol of the most enlightened nation on earth, one not only untouched by Ronald Reagan's Tax Cuts Only For The Rich but in a system that prides itself on its compassionate socialism? I felt as if I had wandered into my bedroom to find my spouse in the arms of a significant other.

Many women, when victimized by a philandering husband, obtain a divorce and remarry yet another philanderer. In 1982 (or thereabouts) I swore that I would never watch ABC Nightly News again. Instead I relied on PBS/NPR to provide me all the information about the world I would ever want to know. This changed in 1991, when NPR campaigned actively on behalf of Bill Clinton. I still like NPR, but when I listen my mind's eye shows someone continually giving me the "wink wink, nudge nudge". I don't trust them, or ABC, or CBS, or the New York Times. They have to earn back my trust if they want me to take them as anything other than a mouthpiece for the Democratic Party.

They haven't been trying to win my trust back very hard. Consider these two fairly recent headlines, seen in the A4 or A6 pages of the local newspaper:

Polar icecaps on Mars receding.

The "Great Red Spot" on Jupiter slowly vanishing

Both of these changes are occurring because of global warming issues on these planets, yet they have no SUV's, defoliated Amazon rainforests, ignored Kyoto treaties, or drilling in the Alaskan wilderness.

What I know about America's greatness I learned from immigrants

Like many places, my city plays host to many different groups of immigrants: primarily Ukrainian, Bosnian, and Hispanic. I appreciate the last group because I'm trying to learn Spanish, and nothing helps to build the vocabulary better than walking through the local Home Depot.There's a smattering of other nationalities here from Eastern Europe, primarily Romanians. Romanians don't get no respect; our local drug stores provide free translation services for Poles, Vietnamese, and Filipinos, but not for Romanians. I think that's unfair. Any nation that has lost virtually every war they've ever fought in, yet thrives as an independent state (another country that comes to mind is Finland) deserves some respect, for resilience if nothing else.

An immigrant once told me, "No one knows exactly what the American Dream is, but what all Americans share is that we all believe that there is such a thing." Just as few defend the faith with the vigor and clarity of enthused converts, new Americans often see our country with the respect that we jaded old-timers lose after just a few generations.

I was proud of the unity that our country initially displayed after 9-11. In many ways I hope never to see the most touching scenes ever again: walking by a visitor's lounge at the hospital and seeing a dyed-in-the-wool "redneck", with his long hair braided into a pony-tail, openly weeping as the camera panned over the rubble of the twin towers. I didn't ask him if he were a registered Republican or a registered Democrat. That kind of thing didn't seem very important at the time.

One of the most passionate and outraged Americans I encountered was a Ukrainian who had recently just received her American citizenship and works as our hospital's librarian.

"How can zey do zees to my country!?!" she exclaimed in her heavily accented English. She'd been in this country for ten years, and she was every bit as American as my family that can trace it's descendants to the 1700's. Maybe even more so, given that members of my family couldn't tell you what the three branches of American government are to save their souls.

Back then one of my patients was an 95 year old woman from Poland. She showed up for appointment wearing a beautiful embroidered tiny American flag on the label of her jacket (like most folks her age, she would never have gone to the doctors wearing jeans and a sweater). She had had classic irritable bowel syndrome for sixty years, and nothing I prescribed ever affected her symptoms one way or another. She could remember the exact day her symptoms began.

"My father owned an apartment building in Poland. I remember one night the Nazis came and dragged off all the Jews. I remember the sound of their heavy boots coming up the stairs like it was yesterday. I've been nervous ever since. Then after the war one night the Communists came to my father's apartment building. This time they were looking for my father because he was a land owner. We left very quickly. I've had bad diarrhea ever since."

I've traveled to Romania three times and came away with two things. I'm told I have an excellent Romanian accent, probably because I naturally speak in a monotone and I can roll my "R's". I also have an enduring hatred of totalitarianism, regardless of ideological stripe. Nicolae Ceausescu was a "liberal" of sorts who routinely thumbed his nose at the "conservative" Kremlin hard-liners. He was also a vicious lunatic who damaged the Romanian psyche so deeply that it will take a generation or two for his ugly scar to heal.

Because I at least try to speak a little Romanian, I get to see what few Romanians live in my area. One of my patients is an older woman who was educated as, of all things, a lawyer.

"My education was a total waste of time under the Communists," she said. "The judges didn't care about the law. Most of them didn't even know it. You couldn't bribe them because they were rich compared to the rest of us, who had nothing. All the opposing lawyers could do is to convince the judge which one of them was the biggest Communist. I didn't care for the Communists, so I never won any cases."

I never knew what she thought about our Supreme Court and the conduct of the Senate Judicial Committee. I don't know what she thinks about our political climate in which our first question to any statement of "fact" is not "Is it true?" but "What is the party affiliation of the claimant?" Next time I see her I'll have to ask.

From what I can tell (perhaps there is some irony in this statement), the only just war we have fought since WWII was the Serbian campaign, in which we dislodged a murderous tyrant who, although he was a constant menace to his neighbors, posed no security threat whatsoever to our country. During the campaign our home shower door broke and needed replacement.

Two Bosnians came over to replace our shower door. One was a Muslim, the other an Orthodox. This struck me as a bit curious, given the enmity between the two groups that we were all seeing on CNN.

"Of course we would probably be trying to kill each other if we were back in Bosnia," the Muslim said, "but this is America, and here we all can voice our own views without any threats".

I think that moment was the proudest I've ever been of my American citizenship.

Crisis of the uninsured

The enormous number of Americans without health insurance constitutes a moral and economic crisis. Perhaps we could extend coverage to these folks if only doctors, hospitals, health insurance companies, pharmaceutical companies, medical supply companies, and malpractice lawyers all decide that for the Public Good we'll do with less money.

As I ponder that last sentence, I think of which groups willingly and cheerfully work for less money than what they could be earning in the "free market". Those in the ministry (including the occasional secular do-gooder) and those teachers who shun the public school system and work for peanuts in private schools are about the only people who are willing to make that sacrifice.

For everyone else, to expect us to surrender income obligingly is to indulge in Utopianism/Totalitarianism. I say this not from any ideological perspective, but from simple observation. If you are thinking, "Well, I'd take a big pay hit for the good of mankind!", I would conclude that you are in the ministry, or teach in a private school, or are unemployed, or are less than honest with yourself.

The rest of us take pay cuts either when we're forced to, or when we make trade-offs for lifestyle considerations. We're just not wired to surrender our earning potential "for the Public Good".

The boiler-plate media portrayal of the uninsured is that of a 50 year old middle class male who gets laid off by his profit-seeking company, loses his health benefits, has a heart attack over the stress of it all, and incurs hundreds of thousands of dollars of medical bills which he cannot hope to ever pay. I'm sure this really does happen from time to time.

I'm on ER call this week so I kept track of all the uninsured folks I was asked to see. I've never met a "boiler-plate uninsured" and I thought this would be a good opportunity to look for one.

Here is my list of the uninsured:

• middle aged male with alcoholic pancreatitis. He actually was laid off and lost his benefits for his erratic behavior which I suspect was due to his alcoholism. He was a very nice fellow who thought that his three sisters were unfairly ragging on him for his drinking.
• middle aged male with alcoholic pancreatitis, in and out of the chemical dependency center. Not really interested in stopping because it was his ex-wife who drove him to drink.
• young gangsta with alcoholic pancreatitis. He is a good-looking charismatic gentleman who could amount to being a lot more than a gangsta under the right circumstances.
• middle aged male with GI bleeding. He owns his own business but chooses to save money by not covering himself. He's not worried about his bills because he was rear-ended by someone two years ago and he's going to sue the driver and all the physicians who saw him six months afterwards. "You don't have a thing to worry about, Doc". Thank goodness.
• young male with belly pain due to anxiety, and probably from karmic retribution for being such a sociopath. He also owns his own business.
• middle aged male with bad esophagitis. I'm not sure why he doesn't carry any insurance, but his responsible next of kin was his mom. That always raises a red flag for me when the patient is a middle aged male. Could it be that no one other than his mother wants to put up with the guy?

This is a random unscientific survey, of course, but I would conclude from this list that if we were to eradicate alcoholism and figure out a way to integrate sociopaths into our society better, that just maybe the problem of the uninsured would get a whole lot better very quickly.

A first

Yesterday was planned out well. I'd go in early in the morning (never my first choice on a Wednesday, my "day off"), do a quick colonoscopy for a friend, go to the office and do "admin work", go home at noon and be available for the heating people to give my furnace an overhaul, then spend the rest of the afternoon on a local bike trail.

I would never complain about anybody being late for anything, so I simply note that the furnace person didn't show up until around 3, and took for ever doing whatever it is that those folks do. By the time he was done, it was clear that there would not be time enough to hit the trail.

I begged my son to give me some remedial wheelie instruction in our backyard. No sooner did we start to ride around than we were joined by six kids ranging from 8 to 12 years old, all on their cute little BMX bikes. I sensed a Lord of The Flies moment.

"Little dudes and future malchicks", I announced, "Let us form a bicycle gang and ride around the neighborhood. We shall threaten to beat people up unless they give us money or Gummi Bears or whatever floats your little boats."

"Cool!" they said.

"And I shall be your leader."

Next thing I was on my back, looking up at six hostile little kids. "How much is worth to you, Pops, for us not to leave tread marks on your face?"

After settling my account I had the further indignity of watching these kids fly off the backyard ramp we had constructed, even as I was unable to lift my front tire more than one inch off the ground.

Of course these kids have been riding for years and I've only been riding for four months, I reasoned. Maybe I should just do real basic stuff like they might do and see what happens. I started bouncing up and down on my bike in as exaggerated a motion as I could muster.

And then it happened. My entire bike left the ground and both wheels were at least a foot off the ground. Well, at least six inches. I had definitely completely left the ground. I had performed my very first bunny hop.

One of the little kids saw it. "Cool!" he said. "How did you do that?"

"Give me my Gummi Bears back and I might just show you," I said. The rest of the evening was spend in a state of pure bliss.

I just wish my knees didn't hurt so badly today.

Sometime nice guys finish first

Welcome to you stray readers from the Fat Cyclist's blog.

If you've read a few posts from this site, you may have come across a story in which I deal with a patient dying from a bleeding ulcer. Things go well, I'm able to stop the bleeding, and the patient survives, only to die of something else ten or twenty years from now. And I swear it won't be my fault.

In retrospect it would have been a better post had I not whined about not getting paid for my services; after all, the poor man was uninsured and had had tough financial circumstances. I really did not expect any reimbursement.

My patient accounts coordinator, AKA billings and insurance lady, was surprised to receive a call from said patient. "You know," he said, "I've gotten a bill from everyone involved in my care but good old kindly Dr. Juspasenthru. I'm going to get mad if he doesn't tell me how much I owe him."

My insurance lady told me this and, after she had revived me with smelling salts, submitted my bill which the patient has paid. In full.

To be honest, after that phone call I would have been perfectly content if he had sent me some chickens and some homemade marmalade, like they used to do in the old days.

Cash works well, too.

Survey

Dear Beautiful Fields of Happiness Healthcare Insurance Company,

Thank you for thoughtfully sending me a "participating provider survey" two days after you refused to authorize nutritional counseling for a patient with recently diagnosed celiac disease. Please excuse the writing on the back of the survey, but as all your questions were designed to get a favorable response from your "providers" and you left no space for comments, the back was the only place I was free to write.

I really appreciated your thoughtful response to my letter of appeals (a copy of which is included in my last post). Don't you think you are being a bit too generous for giving me a whole five days to provide you with PROOF that my patient really has celiac disease? After all, I'm only a board-certified gastroenterologist who has signed thousands of documents reminding me that if I misrepresent a patient's illness in order to facilitate obtaining benefits, I've committed fraud and could go to jail. I see hundreds of patients who BEG me to put them on a highly-restrictive diet that they have to follow for the rest of their lives. I'll be damned if I give in to any of them. Let them eat cake, I say.

Once you give in and authorize nutritional counseling for celiac disease, just where would it stop? Counseling for patients with dumping syndrome from prior stomach surgery? Counseling for patients with weight gain before they become diabetics? Crap, can you imagine a more outrageous deal than to try to PREVENT diet-related health problems? What a waste of the CEO's year-end bonus, er I meant to say our precious financial resources.

By the way, your reimbursements suck and certainly don't cover the aggravation your company gives me. Don't come whining to me when you guys tank.

Have a good day.