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General Practice

Family Medicine in the 21st Century

Updated: 2018-03-05T19:39:07.946-05:00


Not that Nascar will accept help from the federal gubmint...



    (a) In General- Subparagraph (D) of section 168(i)(15) is amended by striking `December 31, 2011' and inserting `December 31, 2013'.
    (b) Effective Date- The amendment made by this section shall apply to property placed in service after December 31, 2011.


Geek Cruising


So we’re back from a great trip, and I’m struggling with how I’ll to respond to the “how was it” questions on returning to work. Elaine has already spoken to two of her siblings at length and seems more sure than I. In fact there’s enough surety that she’s composing an email about our trip. I hope she sends it to me!But I want to get a little of this down so I’ll remember what a great time we had and, more importantly, why it was such a great time.So the questions. Where did you go? Why there? What did you do? Was it what you thought it would be? Isn’t that a long way? And from my family – what did you eat?Oosterdam at Circular QuayWe went on a cruise. We sailed on Holland America’s Oosterdam from Sydney up the east coast of Australia to the Barrier Reef, then through the coral sea during a solar eclipse, weekended in New Caledonia, then back to Sydney. No sea sickness, though the catamaran trip to the barrier reef and back certainly came close. We’ve never been on a cruise before, unless you count the overnight ferry ride from Piraeus to Chania we took on our honeymoon, or the subsequent Heraklion to Santorini jaunt that taught me the dangers of mixing ouzo with high seas, which is one reason we’ve avoided cruises this long.The other reason is our resistance to demography. Isn’t a cruise for the newlywed and nearly dead? Sure, we’re old(er), but not that old. We want to explore on our own! We would rather travel alone than go with the crowd. Explore the byways not the highways. But in the course of resisting the typical sales pitch I was psychically roped into a cruise by an even stronger demographic pull – my geekness.Jaccaranda Tree outside Sydney Town HallAs the byline of my blog attests, I’m a husband, father, physician, geek. But those of you who know me well know that this isn’t always the order of priority. So when I became aware of Insight Cruises ( MacMania cruises via my favorite podcast network ( I longed to cruise China in the company of fellow geeks. That didn’t work out. Neither did South America and Cape Horn. Job, money, life got in the way. But I heard tales from those who went, saying things I wish I could say. Regret is a powerful teacher, and I’m a quick learner. Or at least susceptible to targeted marketing.So when MacMania 15’s itinerary was announced to be an Australian/New Caledonian/Solar Eclipse cruise I put down our deposit and for a year resisted every reason (and there have been a *lot* of reasons) to cancel. All the old reasons were there, and added to those were family. Without revealing what’s not mine to reveal, I’ll just say there has been serious illness in my family in the past year and many would put family first. Let’s just say many in my family have put family first, and if not for them I wouldn’t have had the opportunity to go.We visited Sydney in all it’s Fall (springtime) glory. We learned what a Jaccaranda tree is, that Ibises are Australia’s pigeon’s, bushy-tailed possums it’s squirrels, and the Melbourne Cup it’s Kentucky Derby. It’s a gorgeous city of neighborhoods that’s utterly walkable, with a great transit system too. We know because we used it a lot going back and forth to the airport to retrieve the bags we left there. The ferry system around the harbor is world class and cheap, even if little else in the city is. But you don’t have to pay to listen to birds you’ll not hear in the states, nor to see plants you’ve never seen before. It’s odd to walk among an utterly recognizable cityscape with an utterly foreign flora and fauna. Nov 13, 2012 Eclipse Collage as shot by Tom , our cruise mateEclipse stories are legend, and now I know why. Despite knowing exactly what’s coming, it’s startling to actually see it with your own eyes. If you want to see what we saw, view Steve Sheridan’s videos on youtube. The first is the eclipse as seen from our vantage point on deck. Steve was shooting right behind Elaine and I. He is also geek enough[...]

My new computer is a car


After seven good years my Mini Cooper is gone, replaced by a 2012 Ford Focus.

Good things about the Mini: fun to drive, easy to find parking.
Less than good things about the Mini: premium gas, 21 actual MPG city, run-flat tires (stiff harsh ride and expensive to replace), no spare tire, rear seating a suggestion more than a reality.

Good things about the Focus: regular gas, 28 actual MPG city, computer on wheels, nice ride, more space, parks itself, american made, very competitive pricing.
Less good things about the Focus: sync interface by Microsoft.

When my wife got her Prius in 2004 I was amazed at how easily she could walk up to a locked door, open it, get in and push-button start the car without taking a key out of her pocket. Not only that but her bluetooth phone automagically paired and worked with the handsfree system. At the time there were novel features. Now I can finally do the same and much more. Go Detroit!

Recipe for pain


Start by overeating. Blend in two glasses of wine. Elevate to 6200 feet above sea level. Put on an elliptical machine for 30 minutes or until done, whichever comes first.

I now have an inkling of what Jon Krakauer was talking about in Into Thin Air.

Back to sea level tomorrow.



So this is what bolted in the garden last week. How to cook it. That was the question.

So I checked my favorite recipe sources and the consistent recommendation was Kale with Cannellini in one variation or another. But most called for lacinato kale (also called tuscan, nero, dino or variations of all). But we have red russian kale, which I learned only by googling some images. Apparently we chose it for it's less bitter taste than the more common curly Kale, at least that's what Elaine suspects. It grows earlier in the season also. But I couldn't find specific recipes for russian kale so I did what I've learned to do. Don't look at the specific ingredients, look at them as placeholders for a class of ingredients.

All the recipes for kale with beans called for sautéing veggies in a fat, then adding spice, liquid, and then beans and greens. Most sautéed a few onions, carrots and garlic in olive oil, then added cannellinis, liquid and kale. Others substituted pancetta or sausage fat for olive oil, added some celery or tomatoes to the carrot, or used other beans (navy, great northern, lima, kidney, black) or other greens (spinach, collards, chard, cabbage). The variations are clearly endless, but the overall approach was the same.

(image) And so this is my recipe, based on what I had on hand and in our garden. One chopped carrot, onion and celery stalk sautéed in a little olive and sesame oil until softened. Then 3-4 finely chopped garlic cloves and 1/4 teaspoon of salt for another minute. I then added 3 cups of chicken stock to the mirepoix, bringing it all to a boil before adding 7 cups of washed, de-stemmed and chopped kale. I then simmered for 3 minutes and added a 1/2 can of cannellini that had been puréed with 1 cup stock and then the remaining  1/2 can of cannellini and 1 can of black beans (it was all we had). A little more salt, some pepper, a bit of chopped thyme, rosemary and sage from our garden and the juice of one lemon to add some taste. Served it with some shaved parmesan cheese and olive oil drizzled on top. Would have been better yesterday when it was raining and 58 degrees rather than sunny and 78. But it'll do. It'll definitely do.

Refusing to cry, refusing to laugh


"My dear Kepler, what would you say of the learned here, who, replete with the pertinacity of the asp, have steadfastly refused to cast a glance through the telescope?  What shall we make of this?  Shall we laugh, or shall we cry?" --Letter from Galileo Galilei to Johannes KeplerSomalis in Minnesota have experienced a higher than predicted rate of measles and resultant excess of preventable deaths in the past year. A similar measles outbreak occurred in 1996-97 in Minnesota in children who were members of a religious group who eschewed immunizations. It also happened in 1977. Same place, same disease, same issue.California and elsewhere have seen outbreaks of Pertussis (whooping cough) in recent years.And last but not least Polio continues to win skirmishes in a war thought won 60 years ago.I personally participated in immunization drives to combat a measles outbreak in Philadelphia in the late 1980's. I've also had the "privilege" of performing a lumbar puncture on a three month old infant with Hemophilus Influenza Type B. All of which leads me to struggle with how to respond to those who continue to warn of the risks of immunization. Autism! Seizures! ADHD! Asthma! Diabetes! Death! And worst of all Peanut Allergies! OMG!Are you as non-plussed by the sensationalism, hucksterism, and general snake oil feel to the anti-immunization fringe as I am? Puh-lease save me your "What your doctor doesn't want you to know...", "We have real qualifications too...", "Just buy this..." and especially your "God doesn't want you to vaccinate...".Yes, Immunizations are risky. We no longer use oral polio vaccine because of the risk of vaccine associated polio. We use inactivated polio instead.Yes, Immunizations are not perfectly effective. But perfection is the enemy of the good, and immunizations are much more than good enough, measuring higher even than chocolate or Cliff Lee on the goodness scale.Immunizations are not a choice between disease and no disease; they are a choice between less vaccine preventable disease and complications (with all the costs that come with vaccination) and more vaccine preventable disease and complications (and all the costs that come with no vaccines.) If you wish to save money, vaccinate. If you wish to reduce overall morbidity and mortality, vaccinate. These choices are not imaginary; they are written in the history of those who've made them before us, and those who forget the past...Lastly, immunization is a social act. The risks of vaccination are borne by those who vaccinate, while the benefits of immunity are received not only by the vaccinated but also by those who aren't, whether they ask for it or not. The least the un-immunized could do is gracefully and thankfully accept that saner, braver folk are not only willing to tolerate their fear but also work to ensure that it doesn't kill the rest of us. But history also tells me that this expectation is too great. Sigh.Sometimes my patients ask me "Do I have to take this medicine for the rest of my life?" or, in another version "Should I get this immunization?", and my answer to both remains the same. Yes, until we know  better, or until something better comes along. Knowing better or identifying something better is often hard, except in the case of immunizations. That one is easy. For most of us anyway. So long as we wear head protection.[...]

We love you Bruiser


Bruiser died today. Suddenly if not unexpectedly. He's been on medications for his heart for years, and could barely make it around the park without getting short of breath, but he still wagged his tail and pranced for joy until the last, like all good dogs do.

He was 11 years and one month old today. Here's a picture of him with his siblings. You can tell why he was called Bruiser. He's the one with the blue collar.


Like all Scotties he thought he was bigger. Here he's playing (and winning) at Frisbee with his cousin Scout.

But this is how I'll remember him - tail wagging and wanting to play.

Good dog.

Good dog.

Travel and Karma


I'm waiting for my flight back to PHL from SeaTac after a week in Seattle-Vancouver-Olympia and feel compelled to share the benefits of a week of good karma.As I learned during a forced layover in Rouen several years ago the travel gods kneecap your best laid plans for a reason. In this instance last minute changes resulted in my 'discovering' the Chucknaut Drive in northwest Washington, the Skagit Valley Tulip Festival, Mallard Ice Cream in Bellingham, the Sunset Inn in Vancouver's Davie Village, Milestones Restaurant in Kitsilano, the Cedarbrook Lodge, and the best meal of the trip - homemade (literally!) pasta with asparagus, fennel, and red onions by none other than Chef Daniel Lipson (husband of noneother than Penn's own Michelle Seelig) who moonlights daytimes as a Physician Assistant at Group Health Puget Sound. If there were ever an argument for slow travel, this trip was it. Get off the interstate peeps!I was in Vancouver for the Society of Teachers of Family Medicine. As is true of all good meetings I learned more than I thought possible and benefitted repeatedly from serendipity.For example I would never have planned 20 minutes in a private informal discussion with Jerome Kassirer, emeritus editor of the New England Journal of Medicine, but that's what happened when he chanced upon me in an out of the way spot we both discovered while waiting for his talk. Was he hoping to nap too? And what a talk! His slides aren't up yet but here's a podcast of his thoughts on industry-medicine relationships. Standing ovation from a full house. At 4:30 in the afternoon! Be still my heart.The mantra of business travelers is free (fast) wifi and breakfast, but Cedarbrook Lodge (right at SeaTac!) provides the fast free wifi, breakfast of charcuterie, hard boiled eggs, outstanding coffee, oatmeal, juices, bagel, croissant, cheese, yogurt, artisinal bread, in the room you see here. The view out the floor to ceiling windows is even better. Great rates through online booking sites. If you have an early flight out of SeaTac you *can't* stay anyplace else. Did I mention the free all you can eat malted chocolate balls in three different flavors (mint, chocolate, and butterscotch)? Inconceivable!I met some great new folk, caught up with old friends (Congratulations Mike R.), and remain impressed that our specialty is attracting some enthusiastic and energetic young talent like our own Mario DeMarco who talked about experiential learning in residency properwise. The man haz powerpoint skillz.And who could ask for more than a dropped ball in the 11th to seal a passable if not winning road trip for the Phillies?Glad to be coming home. The gate agent is calling...[...]

I have more than enough. Do you? Here's how to tell.


Kurt Vonnegut first got my attention as a freshman in college. I ran across this when he passed away a few years ago and thought I had lost it. Fortunately a friend's request got me looking again and reminded me how Yossarian and Billy Pilgrim are related.

Adobe Flash and the iPad


I'm a confirmed MacHead, so everyone who knows this about me has been asking whether (Ha!) or more appropriately when I'll get an iPad.

Watching the introduction this week I noted that the NY times webpage didn't render Flash, prompting instablogs to tout "I can't believe it's not going to use Flash!"

But as a long term MacHead I have the kool aid in my genes. I don't think I have any natural DNA left in fact. So it's natural to me that Apple is again saying "It doesn't work, we're moving on and suggest you do too."

They've said this before. I remember "I can't believe there's no 5 1/4 inch floppy drive!" only to be followed by the hit single "I can't believe there's no floppy drive!" among others.

If Apple's good at anything it's good at making the future.

As my maven John says: Flash sucks and deserves to die. And thanks for pointing out the Daring Fireball treatise that explains exactly how and why Adobe sucks the big one. Adobe installers routinely interrupt me when seeing patients, crash when browsing, and use stupid proprietary installers that were bad when they were state of the art in 1998. And NO I DON'T WANT TO INSTALL YOUR INSANELY ANNOYING AND BUGGY UPDATES NOW.

The Flash install and crash saga is Apple v Adobe, and I know where my money is. (Not really, I bought Apple at $19.50 many years and two splits ago and could probably have retired by now if I hadn't sold it at $24 - on it's way to today's $192 - which is why I don't put money into single stocks anymore. I'm clearly incompetent at the money making part.)

But the money is beside the point. Flash is the past. I'm moving on. If hulu wants me to watch then they're gonna have to get with the program and dump Flash like all right thinking webmasters.

Rob Centor speaks for me today


Sore throats are easy, right?

If it were easy anyone could do it.

Official Google Blog: A new approach to China


Official Google Blog: A new approach to China
In which Google says to China, "Not cool dude." And I thought the Google v. Apple saga was interesting.

Language matters


And in my final post of a trifecta today, and to reassure those of you who worry that I buy too much into the Two Cultures phenomenon, I give you a prime example of the intersection of humanities and science.

Take medicine as art and distill it into a coding language. Politics as sausage is sterile by comparison.

Coding taxonomies seem dry until you recognize the magnitude of their influence in our current f**ked up healthcare system. John refers to them as deadweight. I prefer to think of them as red matter. I don't have the patience or aptitude to distill our healthcare dreck into a better future state. Thanks to John, I don't have to.

Albert Crewe obit


From the NYT obit for Albert Crewe, U Chicago Physicist who pushed electron microscopes to show atoms for the first time:

In a public lecture shortly after becoming the director of Argonne, Dr. Crewe bemoaned the growing gulf between scientists and laymen.

“There are too many people behaving like the proverbial ostrich and hoping that science will go away if they bury their heads in the sand,” he said, “and this in spite of the fact that the last few decades have indicated strongly that science will not go away.”
Say hi to Galileo for me Albert. RIP.

That's what I'm talkin about


I can't believe I missed Robbie Aronowitz' NYT mammogram editorial on Thursday!

THE United States Preventive Services Task Force’s recommendation this week that women begin regular breast cancer screening at age 50 rather than 40 is really nothing new. It’s almost identical to the position the group held in the 1990s.

Nor is the controversy that has flared since the announcement something new. It’s the same debate that’s gone on in medicine since 1971, when the very first large-scale, randomized trial of screening mammography found that it saved the lives only of women aged 50 or older. Despite the evidence, doctors continued to screen women in their 40s...
...Even though [the screen at 40] consensus was more asserted than definitively proved by experimental evidence or clinical observation, it soon became dogma...
...You need to screen 1,900 women in their 40s for 10 years in order to prevent one death from breast cancer, and in the process you will have generated more than 1,000 false-positive screens and all the overtreatment they entail. This doesn’t make sense. We could do more research and hold more consensus conferences. I suspect it would confirm the data we already have. But history suggests it would never be enough to convince many people that we are screening too much.
You've heard the rabble and the science. How many times will Galileo be tried before we get it right? Robbie's piece has, sadly, been written before. Different names, same ending.

[disclosure: I'm a proud faculty mate of Robbie's in Penn's Department of Family Medicine and Community Health.]

Has hell frozen over?


I work with many wonderful orthopedists who continue to see patients without regard to payor. That isn't true for most private orthopedics groups in town who continue to refuse medical assistance patients. Still, I wasn't expecting this... – orthopedists asking for my pay to be raised.

I'm gonna have to send them some link love.

Road trips are underappreciated


Thanks for all the b-day wishes. I must say it's been a pretty perfect day. And how often can you say that when you start by waking up in a hotel in Poughkeepsie on a cold rainy October day?

Several months ago my oldest drove across country to return to college. On the old Lincoln Highway (US 30). All the way.

I was jealous, but not wanting to spoil his trip with my company (he had a friend to co-pilot) I instead convinced my wife to take a local road trip vacation with two rules: no interstates, no chains. We committed to only one fixed event in the week and have left the rest to whatever strikes our fancy. So last Sunday we packed a small suitcase with two changes of clothes, headed north via the backroads to Princeton where we walked the Delaware and Raritan Canal towpath with friends older than our marriage. I knew about the Erie Canal, but the Delaware and Raritan? Nice. After a Thai dinner we parted ways with our friends and meandered to Milford, PA and the Hotel Fauchére. Eat your heart out Four Seasons.
Monday we toured Grey Towers, the home of Gifford Pinchot, former PA governor and first head of the US Forestry Service. A gorgeous day and a chance for Elaine to talk to someone about American Chestnut blight, which in her book means fun. For my part the grounds were gorgeous, the house more so, and the stories entertaining.

Later we headed a few minutes north to pay our respects to the site of the Woodstock Festival. As we walked up to the roadside monument someone was playing a Janis Joplin tune. Fitting.

From there we wound our way past innumerable Jewish summer campgrounds, across the Shawangunk Mountains, into the Hudson Valley and across the mid-Hudson bridge to Poughkeepsie. And what's there to say about Poughkeepsie? We didn't have reservations anywhere and so settled for a generic local hotel last renovated in the 80's. Sad as it was however the staff was predominantly young can do New Yorkers who were aggressively good at their jobs. Good thing we checked in before the Yankees lose the series.

Today we toured the Hyde Park home of Franklin Roosevelt and just returned from a fantastic dinner at the Culinary Institute of America. We also found a great spot to stay in Rhinecliff; right on the water, impeccable service and decor, and half-price!

The best part however is that by taking the back roads and taking our time it feels like we've gone to the other side of the world and have been gone for a week, even though it's only been two days.

I don't think I'll drive an interstate highway again.

This American Life is My Life as a doctor this week


TAL is hit or miss, but they've hit close to home (work actually) with their episode Someone Else's Money. The sad part is that the examples of bureaucracy run amok are among the more routine and least outrageous.

What about the time my patient with AIDS was unable to receive his meds because his employer "forgot" to pay the insurer, leaving my patient at the pharmacy counter with a pharmacist saying "you don't have any coverage."? My patient (now dead) missed several weeks of therapy, a pause that is known to breed resistance, contributing to treatment failure and decline. The employer's penalty? Nothing.

I could go on, but I have patients to see.

The value of art


Art is essential.

When the Phillies are down and it's the bottom of the ninth inning the jumbotron doesn't light up with a math theorem, but with the Rocky theme. Myth and metaphor communicate in a flash what science can take years to deliver. Our brains, as predictive rather than computing organisms, make connections more quickly (if sometimes errantly) through art than computers can with logic. And our communities, as social organisms filled with social beings, grow stronger with art, especially shared art.

But don't listen to me, read this speech to incoming students at the Boston Conservatory of Music. (tx to Paul Levy's blog pointing it out.)

A Study in Contrasts


I'm a city boy. Noise and activity. Light and sparkle. But walking across the desert this morning I was struck by its absolute dark and soundless nature. Until, that is, I looked up. I've seen stars before, but this was heaven.

What a beautiful way to start a day of change.

Women's Calendars are from American Greetings; Men's Calendars are from Intel.


Here's my wife's calendar for the next two weeks. Written on the inside of a greeting card box lid. Graphics are hers. Nice tree.

Here's mine. Requires electricity. Performs better with internet access.

Not sure which is better, but they summarize pretty neatly our respective preferences for organizational activities.

1 down, 6 billion to go


Ellen Kim got a Mac.

Why I'm a Phillies Fan


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Two degrees


On reading my Kentucky alumni magazine today I ran across a book review of The Venus Week, written by the older sister of my first 'real' date (to a high school homecoming in the 7th grade - but that's a post for another day...) 

It turns out my one time date has made a name for herself by marrying Ted Olson (his fourth wedding, her first.) If you don't know him it's probably because you've blotted the memory from your mind - how he won Bush v Gore in the Supreme Court for Bush? Then was rewarded with an appointment as solicitor general for the US from 2001-2004. In her defense, she met and married him only after he stepped down from the SG post. His third wife (Barbara Olson) was killed on American Airlines Flight 77 when it crashed into the pentagon on 9/11 - his 61st birthday. I suppose that'll rearrange your priorities: his new wife is a registered democrat.

As SG he argued (and lost) an affirmative action case against the University of Michigan, whose president then and now– Mary Sue Coleman – taught me biochemistry and prodded my entry into UK's medical school many years ago. 

Which only goes to show, it's not six degrees, it' two. And Kevin Bacon has nothing to do with it.

And as for former dates; no offense Lady, but I'd have to say I've upgraded.

DrRich (the other one) sums it all up


And nicely, too. 

I'm meeting incredible applicants for our residency during this interviewing season which, along with DrRich's advice, gives me hope for the future. I wonder if they feel the same.