You want passion? Let's talk food!!!

I can't stand it anymore. I read my own blog, and I fall asleep... Health care, costs, access, blah blah blah. I like to write about things I'm passionate about. And I generally am passionate about my job, except for this time of year, when I feel like I'm drowning in boogers. Although some of my patients happily eat their little green boogers, I'd rather dine on other snacks!

I was raised in a family where we ate dinner together every night, we had a salad every night, and we had dessert usually when we had company. Dinner was a fun, chatty event, and we kids helped cook and clean up afterward. Our father cut the bread, and, I believe, that was it for him! But my mother was an excellent cook. I learned to taste unusual foods that my parents enjoyed, including pig brains, mountain oysters, and tripe. I didn't necessarily like them all, but I did acquire a taste for at least trying anything once. Some things, like avocados, I hated as a kid and learned to love as an adult; others, like tripe, I still don't like. Yet, my parents' love of food and dining with family and friends was definitely passed on to all of us kids.

These days, I travel to eat. I exercise to eat. I dream of food. When I go somewhere, I try to research where I can eat interesting food. Sometimes, the best restaurants are ones we find by accident. Ethnic food is my preference, although this past Sunday, I had one of the best hamburgers I've ever eaten in my life in Coronado, just across the water from San Diego, at The Burger Lounge, www.burgerlounge.com. I didn't think I was hungry when I entered the restaurant, but I didn't have any difficulty eating my burger and some outstanding fries. When it comes to eating ethnic food, Ethiopian is probably my favorite. I still remember the first time I ate at an Ethiopian restaurant - it was called The Blue Nile, as many are, and it was in Durham, NC. We ate at a traditional table with the woven basket, drank some delicious tej, and ate a wonderful variety of vegetarian dishes on the traditional bread, injera. From then on, I started to seek out such restaurants on my travels. One of my all time favorites is in Berkeley, called FinFine, www.finfine.com. The kitfo, an Ethiopian-style steak tartare, is outstanding, if you enjoy raw meat.

However, if we're talking passion, I need to talk about barbecue in North Carolina. Now, when my family moved there from New Jersey, I thought that the word barbecue was a verb or an adjective, but definitely not a noun. So, needless to say, when I was offered barbecue at our school cafeteria, I asked, in all innocence, "barbecued what?" The lunch lady looked at me strangely and answered, "barbecue." I politely repeated my question, and she politely repeated her answer. Just as an aside, there weren't many northerners in Winston-Salem at that time, and I think she thought I was as strange as I thought she was. Eventually, when I asked what kind of meat it was (remember, it was a school cafeteria, so color is meaningless, it's all the same shade of brown, even the chicken), she said pork, so I happily ate it. Not long after, our next door neighbor invited me to go with her to Lexington, NC, home of "western" barbecue and the famous Lexington Barbecue festival, www.barbecuefestival.com. This type of barbecue uses a ketchup-based sauce and only the pork shoulder; eastern barbecue uses the whole hog and a vinegar-based sauce. Both kinds are cooked over an open pit, traditionally with wood fires. Anyway, we ate at one of the famous old restaurants, and I liked the hush puppies, but I wasn't crazy about the barbecue. So, at this point in my young, naive life, I simply thought I didn't like barbecue much because I didn't like the tomatoey, sweetish sauce. Then, about four long years later, I saw the light, and it was in Goldsboro, North Carolina, home of Wilber's, www.wilbersbarbecue.com. The pulled pork was out of this world juicy, tasty, smokey, and had a wonderful zing from the vinegar-based sauce. That was it! I done been converted that very day, as some people around there might say. The restaurants along US 70, starting with Ken's in La Grange, going all the way to the coast, are all pretty safe bets, with some, like Ken's, being better than others. If you get a chance to go, remember to ask for "outside brown," which means the pieces of meat that are closest to the fire and have a crispy side. Better yet, try to get in on a real pig pickin' at someone's house. And ask if you can get there at 4am when they start the hog cooking. It is a slow, careful process, with lots of basting and stoking of the fire, and, as often happens when men stand around a fire for many hours, a fair bit of beer gets consumed! If I've managed to pique your interest in this delicacy and in the debate between the east and the west, check out this website: http://hkentcraig.com/BBQ.html. And please, as bumper stickers in eastern NC say, keep your maters off my pig!! I now have to wipe the drool off my keyboard and go and plan my next culinary adventure. Bon appetit!!!

Economics, job losses

Last week, I had the pleasure of watching the inauguration of our 44th president. I felt optimistic about our future, even though President Obama's speech was not full of the optimism he expressed during the campaign, rather full of realism. I know the economic disaster we have on our hands, as well as the diplomatic one, the wars we are fighting and some might say losing. Yet, I am basically a glass half-full kind of a person!

However, I am really starting to see the effects our economy. On the news this morning, there was more disturbing news about record job losses, record company closures, etc. In my community, there always seems to be a recession with few good-paying jobs, expensive gas and groceries, and a lot of elderly people with limited incomes. But now, we are seeing an influx of people from elsewhere in the country who have lost their jobs. They move here because housing is still inexpensive, and the weather is nice. I guess if you're going to be unemployed, at least it's nice to sit in the sunshine. But really, it's shocking to realize the numbers of people moving from industrial cities like Detroit, Minneapolis, Pittsburgh. The problem is that there are, like I said before, few good jobs.

I was speaking with a drug rep who survived large cuts at his company, only to be given a larger area of NM to cover. He is very grateful that he has a job, even if it means he doesn't see his family. I also now see several fathers in my clinic who are back home, having lost their jobs in the oil fields, suddenly becoming reacquainted with their wives and children, but jobless. I'm also seeing a rise in kids entering the military after high school because college is unaffordable.

It's just very different when you know people directly who are suffering from our economy, rather than only hearing about it on the news. I hope that our new president and congress can come together to create jobs, to improve education, and to improve our health care system. Sadly, I don't think there is a quick fix, even a great big economic stimulus package. I know that I'll just continue to take care of the families in the community; at least I can do that to a degree, whether they have health insurance or not!

Lab fees

As winter is progressing, I am getting busier, as are most pediatricians. It's amazing the difference between June and say, January or February, numbers. I appreciate my slower days in the summer, but I have to say that winter days in the office simply tend to fly by!

However, this winter is going to be a bit different. I've mentioned in a previous blog that our clinic now requires patients to pay for labs at the time they're done if they don't have any health insurance. This is awkward and annoying to me to have to explain that I want a particular test done, and, by the way, that will cost you ten bucks! I have the power to waive the fee if the family cannot pay, and I document exactly why the test is required. Yet, when I do this, there are many phone calls back and forth between our main office and my office to find out exactly why the fee was not paid. I could go on about this, but I've already complained about it in a previous blog.

Today, what brought this back to the forefront of my thoughts was that I had to ask a family to pay for a test, and I also happened to read another blog about lab fees: http://thecountrydocreport.wordpress.com/2009/01/15/the-price-is-right-country-doc-style/
I was shocked to see the prices he posted for labs. I had been told by the powers that be that we got a special rate for our labs and that we did not have to charge the administrative fees. So, just to show the stark differences, here is a list of some our fees, without the additional administrative fees: (admin charge is approx $10.)

1. CBC (complete blood count with differential): $2.70
2. BMP (basic metabolic panel): $2.70
3. CMP (comprehensive metabolic panel with BMP): $2.76
4. PSA (prostate specific antigen, a test for prostate cancer): $7.20
5. TSH (thyroid stimulating hormone, a test for monitoring thyroid disease): $ 3.60
6. Lipid panel: $2.58
7. Urine culture: $6.00

The most expensive test on our basic listing is a hepatitis C RNA PCR for $181.20. Now, you can see an enormous difference in the costs I've listed versus those listed by the Country Doc. Why is there this difference? Admittedly, one needs to add $10 to the fees I've listed, and the rates I've listed have been negotiated for a large group of 8 health centers. In addition, the lab company is willing to accept some loss with uninsured patients, but this cost gets passed on to those with insurance. On a side note, it would be interesting to see what that particular lab charges insured patients for the same labs. But why is there so much difference between the two labs? Again, it brings to mind the problems we have with our health care system. Imagine saving $12 on each CBC that is drawn throughout the US - if 1/3 of the US population of ~305 million received one CBC per year, that would add up to 1.2 billion! I'm sure it's the same with the pharmaceutical companies and saving $12 per script written in the US would also add up.

I'm just hoping, come January 20, that the debate on healthcare will start up with actual results this time. I do know that SCHIP is already being re-addressed and will not be vetoed by the new president, so I have hope.

New Year's Resolutions/Wishes

Happy New Year to everyone!! Now that the holidays are over and school is back in session, my life is returning to it's usual busy wintertime schedule. It's also the time of year when people discuss their resolutions for the new year, and I see a lot more people walking on the track after work! I've often been tempted to ask if they are there to lose weight in the new year, but instead I just see how many days they last...it seems that two weeks is about the maximum. All this aside, it's also a special January this year, as we will be inaugurating a new president in a few short weeks. I hope things will start to change quickly.

In light of the potential for change, I have come up with a list of my top 10 wishes for our health care system which I am hoping will be targeted for change early in this new administration. I know that some of these wishes are not free, and I don't know where the money will necessarily come from, but a wish is just that, a wish! I could also go on with many more wishes, but I think ten is a good start.

1. Renew and increase funding for SCHIP. Perhaps with more Democrats and more progressive Republicans in Congress, this will happen.

2. Increase reimbursement for pediatricians giving vaccines.

3. When considering universal health care, examine what other countries have done and perhaps create a system which combines the best from the different approaches being used world-wide. Having waited this long to do what most other first-world countries have already done, we might as well turn this to our advantage and learn from the mistakes of others.

4. We, as physicians, need to practice medicine responsibly. We need to accept that we are contributing to the skyrocketing costs of medical care in the US, and we need to do something about it.

5. Continue to encourage medical students to go into primary care with increased emphasis on programs that already exist, such as the National Health Service Corps. As costs for higher education continue to escalate and funding for student loans is cut, informing pre-med college students about the availability of scholarship programs may be more effective than in the past.

6. Continue to study pharmaceuticals specifically in the pediatric population.

7. Continue to promote the safety of vaccines. The American Academy of Pediatrics is working diligently on this effort.

8. Strive to continue research efforts with stem cells.

9. Provide adequate reimbursement for obesity counseling, nutrition education.

10. Let's get daily physical education back in schools!!

MRIs as screening tools

I have really come to enjoy the world of blogs! I was doing a little catch-up reading today of several that I enjoy, and I found a disturbing bit of news on one of my favorites, http://thecountrydocreport.wordpress.com/2008/11/23/today-show-plugs-mri-screening-for-brain-tumors/. This show was aired on 11/17. I don't watch the Today Show, as I tend to get my news online and on NPR, and somehow I missed this story.

Briefly, it appears that there is a push to use MRIs as a screening tool for brain tumors. As the Country Doc points out in his excellent discussion, there are no data supporting this type of use of MRIs. I'm just appalled at the Today Show for airing such a piece! I realize that the mobile MRI traveling around NYC was only charging $169, but that is not a realistic price, just like no-money down house financing...

Our health care system is in shambles; we outspend every other country in the world, yet we have worse outcomes than most 1st-world nations. It seems that finally we may get universal health care, but if it is going to work, we need to make some difficult choices. Fortunately, we have established a few evidence-based guidelines we can use to help make decisions, but we need to use them. There are also studies from foreign countries we can use to help guide us. Please don't get me wrong, I am grateful to live in one of the most scientifically innovative and creative societies! And I do worry that if/when we cut health care spending, some of it will come out of research funding. However, we need to take responsibility and use our limited funds wisely. Perhaps if we place more emphasis on preventive care, we'll avoid some of the huge costs of preventable diseases. I know I'm not saying anything remotely new, but I feel strongly that our American mindset needs to change; in other words, we may not be able to save every life regardless of cost, we may not be able to give every single citizen access to the newest, most expensive, and not necessarily the best drugs! As a medical provider, I share in this responsibility, and it is a heavy burden. I went into the medical field because I like to fix things, make people better, but I too need to accept that there are limits.

The Desert

I grew up on the East Coast, and I always loved all the trees, all the green, the lush green lawns. I also remember driving from Flagstaff down to Tucson for the first time, thinking how brown and dreary the desert was. Shortly after arriving in Tucson, I visited the botanical gardens and started my education about the desert. Slowly, I began to learn the names of desert plants, such as creosote, mesquite, and ocotillo. The more I learned, the more variety I started to see in the landscape. Where I'm going with this is that I have come to love the desert and see more colors in it than in the green landscapes of the east.

Last year, on Christmas Eve, we camped out on the dunes of White Sands National Monument, under a full moon. We were the only ones camped in the park and were utterly alone in the vast expanse of the stunning gypsum sand dunes. The silence was deafening, the light was breathtaking, and the air was sharp. Although we were quite cold, it was one of the most incredible camping experiences I have ever had!

I decided to look up some poetry about the desert to share with my readers, hopefully conveying some of it's beauty and loneliness and power. Enjoy!

The desert has many teachings

In the desert,
Turn toward emptiness,
Fleeing the self.

Stand alone,
Ask no one's help,
And your being will be quiet,
Free from the bondage of things.

This is an excerpt from a poem is by Mechthild of Magdeburg, a German mystic from the 13th century. Although she did not live in a desert, and the desert in this poem is likely not a physical desert, I feel that these first two stanzas of this poem captures the spirit of being in a desert.

The following is a poem by Lord Byron which appealed to me as well!

Oh that the desert were my dwelling place,

With only one fair spirit for my minster.

That I might forget the human race,

And hating no one, love her only.

This next poem is by Bernard Howe, a poet who lives in Tucson, which is part of the Sonoran desert, quite different from the Chihuahuan desert where I live. It is lighthearted and quite descriptive of the terrain.

Way out west where the prickly pear grows,

lived an old man who only had 9 toes.

Seems a javelina wanted one for lunch,

when it got the chance it took it with a munch.

Life in the desert is different from the city,

for out in the sonoran no one gives you pity.

With the hot sun beating down upon your head

if you run out of water the next thing is your dead.

The snakes are hiding quietly amongst the desert rocks,

if your not to careful one may bite you through your socks.

And if that ain't enough there's scorpions that will sting,

then there's monsoon storms that always come in spring.

Yes that old sonoran desert that runs through the southwest,

is home for me old sam the old man thats possessed.

The desert cactus that flowers are pretty to your view,

but if you step on one, the thorn goes through your shoe.

It seems everything grows wild within this here desert,

along with the critters that make sure you stay alert.

But there is still beauty in all of this here land,

like the setting of the sun which is always grand.

Many colored wild flowers cover everything in spring,

the splendor of a sunset which makes your heart just sing.

Yes mother nature protects all that she has made,

and all that lives out here knows where to find the shade.

Yes the desert sage may dry up and become a tumbleweed,

and with a dust devil they can pick up lots of speed.

The road runner runs along like the quail with her young,

and our Native American brothers speak another tongue.

All these things live in harmony along with mother earth,

I hope nothing destroys this for it is beyond any worth.

God made this desert land with all its natural beauty

and we must protect its balance because it is our duty.

The final poem is one that I wrote. Now I put it at the end, with the hopes that my readers don't actually get to it...Poetry is not a strength of mine, and I've probably broken every rule/convention in writing it. It is about White Sands National Monument.

Vast and undulating
Glistening and rippled
Interrupted by lone yucca

The power is overwhelming
The silence roars

I am alone in the vastness
My footsteps are my only past
Adjacent dunes are my only future

Connections

I've been a bit slack with blogging through the holiday, enjoying a break from work, then coming back to a flood of phlegm!! You know how it is when you take off of work, you end up paying for it in spades.

I live in a fairly small town in a state that is not known for it's good schools. I myself was fortunate enough to grow up in areas with excellent public schools, and this was primarily due to my parents' choices of where to live; they sacrificed a lot for us to be able to go to good schools. I also enjoyed school and did pretty well.

Sadly, it seems that a lot of the high school teenagers here are not particularly ambitious and don't work very hard. For example, the first year we lived here, there was no valedictorian in the graduating class because no one had fulfilled the requirement of taking at least three honors classes in four years of school. This was stunning to hear. However, this week I had the pleasure of interacting with a junior who I could identify with a little better. She loves school, is taking the hardest classes she can possible take, and wants to go to college. She hates to miss school, and she feels stressed when she gets behind. It was just such a pleasure to chat with her about school and AP classes! When I saw her a couple of days ago, I felt like we really connected. Today, she came in to see me for some mental health issues, and she was really able to articulate her feelings, and so I felt like I could help her in a way that I can't the teens who simply grunt!

Seeing her reminded me that I do enjoy working with teenagers, I love the conversations, I like listening to their thought processes, I like hearing about their plans for the future. Sometimes I lose sight of this when I have less meaningful interactions, but I was pleasantly reminded today with my last patient of the day.