The Lost Art of Thank You Notes

There was a time that thank you notes were commonplace. A few days after you invited a couple for dinner, a nice note would arrive. You send a gift to a grandchild and an amusing, child-written note would shortly follow - obviously encouraged by the parent. Thank you notes now seem to be rare. Why?

There are many ways to express gratitude. Saying thank you at the time of the act is the most common, perhaps followed by a phone call. E-mail thank you notes or Internet-cards are other ways. However, nothing is as special as receiving a hand-written, taken-to-the-post office, stamped, good 'ol thank you note.

Our friends have four children. Over the years, we have received hundreds of thank you notes from them. Every birthday, Christmas, or graduation gift was followed by a prompt thank you note. We were told that the parents do not let the kids use the gift or spend a cent of a gift of money until the note is written and sent. The kids are now adults. They still send thank you notes.

Recently, my 13-year-old granddaughter's other grandparents paid for an $800 plane ticket to Texas for a visit. While in Texas for the week, they showered her with gifts, including a new iPod. I am sure she said thank you at the time the gift was presented, but did she send a thank you note for the gift and the trip? No. Did that hurt the feelings of her grandparents? Yes.

Granted, she is 13 years old and a typical teenager; a bit self-centered, and yes, a bit entitled. Perhaps her parents should have insisted, but they did not. As a matter of fact, they were surprised that a thank you note was even appropriate. As kids, we ALWAYS made our children write thank you notes. Why didn't it stick? Why wasn't this simple act of common courtesy continued? I don't have that answer.

In my clinic, I go out of my way to accommodate patients that are seriously late for their appointment, even showing up a day late. I am one of the few medical providers in our large office that will see walk-ins - patients that do not have an appointment, but are sick. I stay late to see sick children just to keep them out of the ER. While I do not expect thank you notes for each and every one of these extra acts, when I do get them, it warms my heart. I save them in a drawer.

I don't want you to get the impression that I am some kind of Saint. Sometimes, for whatever reason, I piss someone off. I tend to "tell it like it is", and some people do not like my bluntness. I thwart efforts from drug-seekers, be it requests for narcotics or antibiotics. If they don't need 'em, they ain't gonna get 'em. These people write notes, too. Over the years, I have received my share of nasty-grams. Many of these unhappy folks spend hours carefully wording a letter of complaint, threatening me with all kinds of horrible consequences. Why would someone spend hours writing a letter of complaint, but won't spend five minutes on an act of kindness?

The older I get, the more I appreciate the kindness that has been bestowed to me. There are days when I get a bit morose about events in the past, that cause me to write a few letters. Yes, I would rather call, or send an email, but I write that thank you letter. I should be writing more.

There are little acts of kindness happening to you every day. People hold the door open for you. Let you go first at a four-way stop. Let you go in front of them in the grocery store, even if you have more items. I would love to send them a thank you note, but these are strangers; kind strangers.

For those bigger acts of kindness, such as gifts, letters of recommendation, and others, thank you notes are mandatory. My neighbor is a Jack-of-All-Trades and goes out of his way to help me with my various plumbing, electrical, or automotive needs. Sometimes, he will accept payment for big jobs (with a substantial neighbor discount), but other times, he only wants a cold beer. I don't drink beer, but I keep an ample supply of cold Coors in the fridge just for him. And, he does get a thank you note, taped to a six-pack from time to time. The only thing I can offer him in trade is medical services, which he rarely needs. I did help out his brother a few times for an anxiety attack! I won't go into those details.

As you read this Blog, think of the many acts of kindness that you have received. Did you send a note? If not, get to it. And, don't wait for Thanksgiving. Thank a relative for loaning or giving you money when you were a starving student. Thank your parents for the million things they have done for you. Thank your neighbors for being good neighbors. Thank your doctor or medical provider for helping you get better.

To all of you, I would like to thank you for reading my Blogs and tolerating my random, often-controversial ramblings over the years. Your comments encourage me to keep writing. They help me be a better clinician, a better grandparent, and a better person.

Related Topics:

• Make a Gratitude Adjustments
• A Little Gratitude

Technorati Tags: thank you, gratitude, health and wellness

Reducing Worthless Medical Visits

An increasing number of medical visits are for, literally, nothing. People are paying good money for self-limiting illnesses, like a "one day history of a runny nose," or "had abdominal pain last week," or my favorite, "going out of town - would like to know if he is getting an ear infection." True, people are paying for my time...my medical skills...my opinion, but I really hate charging people over and over for the same advice. A visit is often longer when someone doesn't have an ear infection, than for one that does. I have to exhaustively explain why a child may be pulling on their ears when they don't have an ear infection.

It is a fact that many people do not have the self-care skills or confidence to make simple health decisions. Many young parents, especially the well-insured, are afraid or unwilling to make medical decisions for themselves or their families. Their dependence on the health care system can be overburdening. I bet that your mother or grandmother didn't rush you to see the doctor with a sniffle.

People can, and should, take more responsibility for their own health care. While I realize that part of my responsibility to help patients make responsible decisions, some people keep coming in, over and over, for minor illnesses. Every medical visit must have an educational component, otherwise the cycle of worthless visits will continue. When the out-of-pocket expense may be only five to ten dollars for their insurance co-pay, many people relinquish all health decisions to the health care provider. In the old, fee-for-service days where people had to pay cash for each visit, there was a bit more home, decision-making going on.

An example would be the Common Cold. Colds last a week if you aggressively treat them; seven days if you leave them alone. Colds are worse for the first 3-4 days; then they gradually get better. Unless there is a strong suspicion that a secondary bacterial infection (high fever, chest pain, persistent earache, increasing sore throat, etc.) has developed, there is really nothing the medical establishment can really do to shorten the course of a self-limiting, viral infection. We can prescribe decongestants if you are stuffy, antihistamines if the mucous is dripping down your face, cough expectorants if your chest is tight, or a cough suppressant if it is interfering with your sleep or daily life. We can recommend acetaminophen or ibuprofen for the aches and pains, or the discomfort associated with fever. We cannot cure colds, but we can alleviate people's anxiety that the cold is "just a cold."

For some people, this is worth the medical visit. For others, they leave feeling cheated that I didn't give them an antibiotic. For the people that were refused antibiotics, most will get better and a few will not get better as fast as they wanted. They will go somewhere else, attribute the persistence of their illness to my refusal to give them amoxicillin, and some gutless, medical wonder will give them an antibiotic. A few days later, they get better, thanks to the last medical provider that saw them. Of course, none of them realize that they would have gotten better anyway.

I get the magazine, Budget Traveler. Each issue has a list of suggestions made by readers to make traveling easier. One of those suggestions this month said "Ask your doctor for an antibiotic prescription before you leave on a trip, just in case you get sick." Antibiotics are not miracle cures for all that ails you. As a matter of fact, the use of antibiotics in a viral illness is counter-productive and is very poor medicine. Getting ill on vacation happens. Why? First, your biological clock may be stressed. Second, you may be in an area where you have little immunity to local germs, or flew on an airplane more contaminated than a dumpster. And, third, you get sick because you are worried and expecting to get sick. Antibiotics will not change these facts, nor will they protect you once you arrive at your destination.

It is not easy, but people need to trust their immune systems more than they do. Illnesses happen, so why be surprised? Spend a little time educating yourself about common health issues, like colds, sore throat, earaches, diarrhea, and headaches. The vast majority do NOT turn into pneumonia, strep, ear infections, dysentery, or brain tumors. In most cases, it is okay to allow your body time to heal. And, it is okay to treat misery. It is not okay to rush to your doctor's office two hours after waking up with a sore throat, or when your two year old pulls on his ear. Watch. Wait. Save your money. Save your time.

For each illness that you overcome without the intervention of the medical establishment, the more experience and confidence you will achieve. Yes, you will second-guess yourself. Yes, you will still make an occasional "worthless visit." But, in the end, you will gain the knowledge and skills needed to take care of some of these minor, medical annoyances at home - safer, faster, and often, better than if you sought professional care.

Related Topics:

• WebMD Video: Kids and Cold Medicines
• WebMD Video: Surviving Kids' Cold Germs

Technorati Tags: health and wellness, antibiotics, colds, ear ache, medicine

AAARGH! Childhood Vaccines Do NOT Cause Autism!

The Internet can educate and inform. The Internet can also confuse and complicate many controversial health issues. Once an article or comment enters the Internet, regardless of its accuracy, it develops a life of its own. Just the way bad rumors used to spread in a community, bad information on the Internet travels at the speed of light.

While I realize that this topic is going to get a lot of comments, both pro and con, I think it is important to discuss. I do not shy away from controversy, especially when I do not feel the subject is controversial in the first place.

When I was a child, the Public Health Department apparently had the right to give us vaccines at school without our parent's permission. I think the parents had to send in a note if they did NOT want their child to get vaccinated; otherwise they lined us up like cattle and just did it. Of course, that was when we had polio, measles, whooping cough, chicken pox, German measles, and other kid-killers in our communities. It only takes one child with polio in a small town to get people lining up for their sugar cubes (the oral vaccine used to be given on a sugar cube). Not any more.

Perhaps, this is because this new generation of parents has never experienced these terrible childhood diseases, or perhaps because the Internet is just scaring people. Nothing in life is 100% safe; but vaccines are pretty darn close, and in my opinion, they are the best defense we have to keep these diseases from making a comeback.

Some of my patients decided that it was the "combination" of vaccines that caused autism, so they wanted the measles, mumps, and rubella vaccines given separately. While they are available separately, our group does not have them, nor do we have any intention of buying them just to appease this unsubstantiated belief. Some parents were so convinced that they bought their OWN separate vaccines. Separate measles vaccine comes in ten dose packages and costs about $1500. The child needs just one dose; the other nine will go to waste. The vaccine can deactivate unless it is kept at very precise temperatures. Unfortunately, medical offices have no idea how this vaccine was stored after the parents obtained it. If stored improperly, the vaccine may be ineffective. Legally, medical offices would be a risk to administer any vaccine to a child if we did not have knowledge of its validity. A few years ago, one of our storage refrigerators went on the blink and was actually too cold. The result? Our medical group had to scrap about $20,000 worth of immunizations; and spend ump-teen more bucks re-vaccinating children that may have received improperly stored vaccine. We now have some higher-tech, computer monitored refrigerators so this never happens again. Basically, if parents choose to buy their own vaccine, they are going to have to administer it themselves. Not a good idea, folks.

Now, a comment about the mercury preservative: Mercury can be deadly and cause brain damage. Of course, when I was a kid, we played with it. Maybe this is why I had problems with math or memory? We used mercury to our pennies and we rolled it around like some mysterious silver liquid. We used mercury thermometers. If the broke, we just salvaged the mercury to play with it. There was mercury in our medicines, and there was mercury in the creek we swam in. Did I tell you that I had problems with math?

In vaccines, thimerosal - a mercury derivative - was used in very trace amounts as a preservative. Currently, the vast majority of vaccines (just the flu vaccine) do NOT have thimerosal, but there is a public perception that they do, and that thimerosal and the MMR vaccine (measles, mumps, and rubella) is directly linked to autism. Even though there is ABSOLUTELY NO EVIDENCE that thimerosal or the MMR causes autism, there are thousands of Internet sites that dispute it. The Institute of Medicine published a review of data on autism and vaccines, and no casual relationship was found. Another study by the Centers for Disease Control and Prevention showed that thimerosal had NO EFFECT on development. The study also found that there was no evidence of the measles virus in the blood of children with autism. The rates of autism are even increasing in countries that do not use thimerosal.

So, what gives? Are we just getting better at diagnosing autism, or is there another cause yet to be discovered. Personally, I think there are other factors, but as of today, no one has been able to find them. This week, I had about six children in my office that had autism. If there is a discoverable cause, I hope someone finds it...soon. My heart goes out to those families caring for a challenging child with various degrees of autism. If parental love could cure this disease, there would be no autism.

People do not trust their government to tell them the truth. Maybe it is because we keep catching our government in lies. People do not trust their doctors as much anymore, either. But, is it a good idea to trust the people at the health food stores or your chiropractor's office on this important public health issue? People should trust our educational institutions, however. When you research information on the Internet, make sure of the quality of the information. Who actually is "Concerned Doctors Against Immunizations" or "Autism and Measles Vaccine Conclusively Linked"? (Incidentally, I made those up. Hopefully, they aren't real sites.) Some anti-immunization sites can certainly appear to be legitimate; quoting scientific studies, etc. Try looking up those studies and try digging deeper into who is sponsoring those sites and you will get an eye-opener.

In the end, people believe what they are going to believe. Even in the face of overwhelming evidence that the trace mercury preservative, the vaccine, or even the measles virus itself is NOT the smoking gun for autism, people still have the right to choose what diseases they would like to risk in their children. Did I vaccinate my own children and grandchildren? You bet. Do I recommend vaccines for my patients? Definitely.

Related Topics:

• WebMD Video: Rubella's Lasting Impact
• WebMD Video: Managing Immunizations

Technorati Tags: autism, vaccines, thimerosal, health and wellness

Doctors DO get sick!

A week ago, I published a blog post about medical providers getting ill. I casually mentioned that I had been coughing for a few weeks, proving once again, that exposure to sick people often gets the provider sick, too.

Our valley was filled with smoke from forest fires in the Sierras. The air quality sucked. Initially, I though my cough was due to breathing in all of this pollution. Besides, I didn't have a fever. With the exception of the annoying, persistent cough, I was still able to work...sort of. Not wanting to expose any of my little patients to my own germs, I decided to see my own family practitioner yesterday. Yes, my PA wife insisted on it. Like most men, even men in the medical profession, I need a swift kick in my stubborn butt once in a while. I just hate to inconvenience my patients by re-scheduling or missing work entirely.

So, there I was...sitting in the Waiting Room of a doctor's office reading some old magazine. Medical people can be the worst patients, but I was trying to be nice by cooperating. I paid my co-pay and was waiting patient-ly with the rest of the sick people. I like to glance around; trying to imagine why people were being seen. A few other people were coughing, too, so it kept others from looking at me. My cough made it quite obvious why I was there. There were children running around. Either they were not that sick or they were just tag-alongs. There was an elderly woman in a wheelchair, an obese man looking at his watch, a shy woman sitting in the corner (probably had some sort of "personal problem"), and a teenager listening to an iPod (I could hear his music, too). They were probably secretly checking me out, too, but periodically peeking over their magazines. We were all acting suspicious.

Finally, my name was called. "Rodney?" Don't you just love the kind of respect that happens in a doctor's office? No one calls me Rodney; not even my wife when she is ticked at me. My friends call me Rod. People that have never met me, and are 30 years younger than myself should really refer to me as "Mr. Moser". If she would have said "Dr. Moser", a dozen set of eyes would have lifted and stared at me. Anyway, the people looked at me anyway. Perhaps they were jealous that I was my turn, or perhaps they were trying to figure out why I was there. In retrospect, I should have limped on my leg to throw them off base.

"Hop up on the scale." As much as I wanted to "hop" like she asked, I restrained myself. I grimaced a bit when she proudly announced my weight for all to hear. Apparently, I was wearing about thirty pounds of heavy shoes and clothing.

"Let's take your blood pressure." I wish she would take my blood pressure; I don't want it. It was a little high, which I attributed to some anxiety of being a patient today. I just said, "Yes, let's do it."

"And, why are we being seen?"

"I am here because of my cough." As much as I wanted to say, "I am here for my cough; I am not sure why you are being seen", I bit my lower lip and restrained from my usual medical sarcasm.

She didn't make me undress, perhaps because I was not overtly sarcastic. I am sure if I would have given her a real hard time, I would be sitting in a paper gown with my bare butt exposed. It is best not to mess with those medical assistants.

My doctor came in, shook my hand (didn't wash his!), and took a brief history while typing my responses in the computer. He then listened to my lungs for a few seconds. That's all. He sent me off for an x-ray in the next building.

After waiting about thirty minutes, I was ushered to the back, told to take off my shirt, and get into a gown. The radiological assistant then asked me if I was allergic to anything. Allergic? I thought I was just getting a chest x-ray. Were they planning on medicating me for this? Not understanding the relevance of this odd question, I said, "Yes, I am allergic to fluoroquinolones and hymenoptera." She hesitated. I knew she couldn't spell 'em. Confused, she slinked away to her lead-line booth. This was my last chance to be little nasty, so I just had to do it. I did have a little remorse, but not much.

A few hours later, my doctor called to inform me that I had significant right, upper lobe pneumonia. That's just great. I coughed and headed off to the pharmacy to get my prescription...one that I didn't have samples of at home.

I took today off from work, inconveniencing any number of people. I am home, dogs at my feet, catching up on my blog and going through several boxes of tissues. I don't feel that bad, but my cough would be frightening to others. A few days of R&R (and some antibiotics, of course) will do me good.

Related Topics:

• Pneumonia Vaccine Cuts Hospital Visits
• Keeping Catchy Infections Contained

Technorati Tags: health, wellness, pneumonia, doctor visit

Why Don't Doctors Get Sick?

Doctors, PAs, and other medical professionals DO get sick. As a matter of fact, I am fighting an upper respiratory infection right now, and it has been hanging on for about two weeks. If illnesses were dependent solely on the amount of exposure that one gets, I should have been dead years ago.

Medical providers, depending on the type of practice, are exposed to sick people nearly every day. Working in primary care; working in pediatrics; and having an "open schedule" that allows sick people immediate access, puts me in the forefront of germs. For viral infections, people are most contagious early in their disease, when I get to see them.

Exposure comes in many forms, but typically hand-to-hand (direct contact during an examination), indirect contact (fresh germs on surfaces, like door knobs, sinks, etc.), or airborne (coughing, sneezing, flying snot, etc.). On some visits, I get 'em all.

Fall is the season for upper respiratory infections, from simple colds to influenza, and their complications (sinus infection, pneumonia, and bronchitis). It is also the the season for gastrointestinal infections (vomiting and diarrhea), often wrongly called the "stomach flu". Flu shots should be arriving soon, but keep in mind the influenza vaccines ONLY helps protect a person from influenza, not colds, and certainly not gastrointestinal viruses.

There have been some lengthy discussions on the ALL EARS BLOG regarding sanitation, especially in the schools, including the lack of disinfection by the janitorial staff. Last year, on the Blog, I did a series on the Dirty Dozen - Twelve of the dirtiest, germiest, places. Of course, schools AND medical offices were prominent on that list.

I typically work in my clinic until 9 PM three days a week, taking care of acutely ill children. Working late, I have the unique opportunity of watching our janitors at work. Janitorial service is provided by the landlord of our building, and is not a crew that the medical group hires. Unlike the janitor in my old grade school, who held the same job for generations, this crew changes like the weather. Some are good; some are unbelievably bad. Nearly all of them, just pick up the trash, mop the floors, and wipe off counter tops. I observed one janitorial crew (no longer there) actually using a feather duster instead of a disinfectant. The vast majority of our after-hour cleaning crew are Hispanic; some have been Russian. Our geographic area is a rich cornucopia of ethnic groups. Many do not speak English, but they are friendly and smile at me when I try to tell them what area needs "extra cleaning".

In a medical office, it is EVERYONE'S responsibility to keep things cleaned and sanitized. Basically, if you witness the breach, you need to see that it gets cleaned properly. If I see a child chewing on a chair, or wiping something or other on the wall, then it is really up to me to decontaminate it. However, I do not know what goes on behind those closed doors.

I think our office has one of the worst ventilation systems ever. I never feel air coming out of vents. You would think that in an office where a large percentage of the patients still poop in their pants, a better ventilation system would be present. No windows open, either. If germs were visible in the air, some exam rooms would look like Los Angeles in the summer.

Mothers are pretty good at cleaning up messes made by their children. I see them wiping up things, washing their hands, and picking up the Cheerios on the floor (so the next child will not find and eat them). I have to say that I do not trust the Dads. They don't wipe up anything and they are notorious for hiding poopy diapers (a big no-no) in the bottom of the trash can. Coupled with our poor ventilation system, a few, hidden poopy diapers can shut us down. When you walk in a stinky room, it is really not politically correct to comment about it. You never know WHO created the stink. My PA wife once apologized for a stinky room, thinking that the prior patient put a poopy diaper in the trash. While gloved-up and fishing around in the trash can for the offending diaper, her adult patient sheepishly admitted to farting. If you are ever impatient about waiting for your medical provider to come into the examining room, just fart and I can guarantee they will come right in.

Speaking of bad days, in a past Blog, I did share that terrible day (February 16, 2006 - a day that will live in infamy) that I tried to teach a young mother how to insert a rectal suppository. During my hands-on demonstration using her child, his little butt literally exploded, covering both of us with feces. Hey, poop happens! Surprisingly, I did not get sick. I suspect it is because of all of the crap I dealt with in the past. Apparently, I am immune.

Yes, Virginia, doctors and other medical professionals do get sick; more often than we would like to admit. Medicine is not for sissies.

Related Topics:

• WebMD Video: The Truth About Flu Shots
• WebMD Video: How and When to Wash Your Hands

Technorati Tags: medicine, colds, flu, health and wellness

Onion Sandwiches

Men and sandwiches have always had an intimate relationship. From the early toddler days of PB&J to now, I estimate that I have eaten about 15,000 sandwiches (based on 5 or so sandwiches per week for 2932 weeks). If there is still an Earl of Sandwich, I am the Duke.

My earliest childhood memories of any substance are from age five - kindergarten. In 1956, Mrs. Hickle was my kindergarten teacher; Eisenhower was in the White House. My father was dying of cancer, being cared for at home, and I spent most of my time with relatives.

My Aunt Norine, now 92 and living in a nursing home, loved to feed me. One day, when she asked what I wanted for lunch, I said, "An onion sandwich." Puzzled, she sliced some thick slabs of homemade bread, buttered it, and put on a huge slice of white onion. Thinking that I wouldn't really eat it, she sat amused as I wolfed it down, tears streaming down my red cheeks. Onion sandwiches became my mainstay until I went to stay with my Uncle Joe and Aunt Emily.

They were also farmers, but didn't have the type and quality of onion that I preferred. They were dairy farmers. My Aunt Emily introduced me to brown sugar sandwiches, made with hot, homemade bread, freshly-churned butter, and of course, a thick layer of moist, brown sugar. It was good.

The summer that I turned six, my father passed away. My mother was a waitress who worked odd hours, so I was back with Aunt Norine and onion sandwiches again. Being in first grade now, we had to bring our lunches. After a few days of school, I quickly discovered that onion sandwiches did not have universal appeal. Miss Rider asked me not to bring them to school anymore. Hence began my sandwich experimental days. I was allowed to make my own lunches.

Several shelves of the coat closet (called a cloak room, although none of us knew what a "cloak" was) sported a cornucopia of lunch boxes - The Lone Ranger and Tonto, Superman, Mighty Mouse, and others. Most of the boys just carried our lunches in brown paper bags so we wouldn't have to drag home an empty, smelly lunch box.

The cloak room was also used as a detention cell for the unruly. I was incarcerated a few times, but not as often as Tom Myers (his real name). At least two or three times a week, Tom was marched into the cloak room for a variety of serious first-grade rule infractions, like talking or looking out the window. Miss Rider was very strict. We soon realized that Tom's timely exile to the cloak room just before lunch was problematic. Tom had a particular fondness for Snow Balls, those pink, breast-like snacks that had a marshmallow coating over chocolate cake. Fortunately, I didn't like Snow Balls because they also had a subtle sprinkling of coconut. I would eat them from time to time, if I was hungry, but I would need to scrape off the coconut, or give the entire marshmallow shell to my friend, Terry, who would eat just about anything but corn chips.

Tom would systematically rifle through the brown bags, or perhaps he had x-ray vision. Either way, food would be missing. Since I packed my own lunch, I absolutely knew the contents of my bag. Others may have thought their Mom forgot that candy bar or whatever. Tom did eat sandwiches, too, but he was very particular.

He liked my chipped ham and pickle sandwiches (My Aunt Norine made her own pickles that I now make myself). He did not like my sardine sandwiches. Neither did Miss Rider. I had yet another sandwich barred from school. In retrospect, if I had poured off all of that sardine oil, it may not have leaked through the bags on to the other lunches.

A few minutes ago, I had a veggie sandwich. It was a recipe that I had stolen by reverse-engineering a delicious sandwich that I bought near the UC Davis Medical Center. I will share this recipe with my Blog readers:

The bread should be whole grain and very fresh. Start with a thick layer of Ricotta cheese. Next, put a nice layer of pesto (basil, olive oil, Parmesan cheese, pine nuts) and a sprinkling of Tabasco sauce. Then, layer by layer, add fresh sliced tomatoes, sliced cucumber, red onion, and a big pile of fresh baby spinach.

Yes, a bit more complicated than my original onion sandwich, but believe me, it is worth the extra effort. Enjoy.

Related Topics:

• The Sandwich Goes Upscale
• 6-Pack Sandwiches

Technorati Tags: sandwiches, healthy lunches, school days