I was so happy that my first child was a beautiful daughter. Since I had two brothers growing up and more uncles that I can count, I though it was unlikely that I would produce a daughter. Even the ultrasound technician informed us that she was a he. My next (biological) child was a son, and tomorrow, my son's wife will deliver my grandson. When I remarried, my new wife had three sons, so we raised a total of four boys and a one girl. In my own microcosm, there was no shortage of boys.

There are two more new babies on the way among our friends, and both are boys. Knowing that the world may only be able to handle so many penises, I was wondering why there are so many boys being born, so I did a little research. Guess what? There are fewer boys being born than ever before - a troubling statistic that is puzzling researchers. No one really has the answer.

According to some authorities, like the Environmental Health Perspectives, there has been a 28-30% drop in male births since the 1970's. From 1970 to 2002, there were 135,000 fewer boys born in the U.S. than expected, or 17 fewer males per 10,000 births. Similar drops in male births rates have also been found in other industrialized nations, including Japan and several European countries.

It's not good to question Mother Nature, but an explanation would be nice. Since boys are indeed the "weaker sex" since we die sooner and are more likely to be killed in accidents (or wars), why has Mother Nature decided that we need more girls and less boys now? Apparently after World War II, there was an increase in male births, thought by some to be replacement males for the millions lost during the war.

There are lots of theories on the table. Maybe the drop in male sperm counts and semen volume is related to global warming? Since spermatogenesis requires cooler testicles, maybe the rising temperatures are cooking the gonads, or perhaps it is the heat created by laptop computers? One study said that the more we have sex, the more likely we will produce a male offspring. Apparently, we are not having sex as much since the hippie days.

The economy sucks and kids are expensive, so having smaller families (perhaps with fewer boys) is an economic decision of the times. My grandmother had 13 children (mostly boys), long before there was public assistance. They lived on a farm and were well-fed. When my grandmother passed away in the 1970's, she had about sixty-some grandchildren and great-grandchildren. My grandfather must have been quite active in the sack - not bad for a chain-smoking, heavy-drinking, coal miner. Of course, kudos to Grandma, too.

Smoking has been linked to a decrease in male births in both the U.S. and Japan. Cigarettes are loaded with a frightening array of cancer-causing chemicals, pesticides, and other substances of unknown risk. Maybe if my grandfather had not smoked, he would have even more kids. My father was a smoker who died at age 39 of lung cancer. He produced two boys; my older brother and me. Are the cigarettes different now, or is it something else?

Diet has been linked to lower male birth rates. Our diets are certainly different since the 1970's. Fast-food establishments were fewer and we all seemed to eat at home. We ate tuna that may or may not have had mercury, and we drove cars with lead additives. We all ate peanut butter. We may have bought houses on land contaminated by dioxin or asbestos, perhaps even under power lines. There were pesticides like DDT on our store-bought foods and we had more hidden radiation exposure than we really knew. Maybe the drop in sperm quality and the drop in male births are due to our underwear? Fertility experts have recommended boxers (or going commando) instead of briefs for years. I am not having any more kids, so I think I will keep my tightie-whities.

There is a link with stress and the number of male births. Apparently, the more stressed we become, the more girls that are born. The more girls that are born, the more stressed men become. Of course, this is just my theory, but some studies have shown that after major stress-causing catastrophes, there are more girls being born than boys.

Today, the news stories were filled with salmonella outbreaks from peanut butter this time, not eggs and pet turtles. Apparently, we are either dirtier or less-caring about the quality of our food products, since this is not the only contaminants in our food that we are facing. Last year, it was E.coli in everything from salsa to spinach. Could some super-bug be causing havoc in the reproductive department?

The 1970's was the height of the drug scene, or at least we thought it was the height. It is worse now, in my opinion. Perhaps all of the marijuana, laced with pesticides, or the LSD, or the mushrooms did something to the reproductive system? Now, we have "designer" recreational drugs, and even prescription drugs that keep getting recalled due to newly-discovered side effects, like diarrhea or death...or even worse, death FROM diarrhea.

For some reason, we did not have autistic children when I was young. Perhaps they were there and we called them something else, like "special", but something has triggered this frightening epidemic. No, and it isn't the MMR vaccine either! I am absolutely sure the vaccine is safe, but I am suspicious about everything else. I don't know what causes autism. Some thing(s), perhaps some undiscovered genetic aberration, is causing or triggering autism. Please don't post comments with your vaccine and autism stories. You will not convince me with anecdotal stories. Until ONE scientific study (and there have been HUNDREDS) establishes a link between the MMR and autism, I am going to keep recommending it. I KNOW what causes measles and I KNOW what measles can do. If we stop vaccinating, there will be a definite drop in our population, since both boys and girls will die again from this preventable (and terrible) illness. The MMR also contains the mumps vaccine. Mumps can cause sterility in males and females, by the way. Rubella is German measles (blamed on the Germans, of course) which caused more innumerable birth defects in past years.

If there is a shortage of boys, I haven't really experienced it. Based on the growing number of little boys that I see in my practice (and family), the number of circumcisions done in our office (I don't do them - I am not a proponent of this cosmetic procedure), I am doubtful. In my personal and clinical world, there seems to be plenty of penises. I don't really expect a serious shortage in the near future, but who knows?

Related Topics:

• Is Mom's Diet a Key to Her Baby's Sex?
• Deciding Baby's Sex

Labels: boys, gender selection

After over three decades of medical practice, I have seen quite a few interesting cases. Today, someone sent me the new Darwin Awards - a dubious award where the "winner" was either killed or seriously injured doing something really, really stupid. The medical profession really doesn't have awards like this, so I thought I would share some of my own - my top ten medical "Darwins":

1. Laying an Egg
A home-schooled young man was bored one day and decided to see what it would be like to lay an egg. So, in a moment of discovery, he inserted one of those plastic Easter eggs up his curious butt. In spite of his efforts to lay this egg, it became permanently stuck. After a few days of "constipation", he was seen. A laxative was recommended. It did not work. I saw him and examined his rectum, only to feel a smooth plastic object. Initially, he denied inserting anything, but after several attempts to remove this mysterious object, he finally ended up in the operating room where both halves of this plastic egg were removed. He had to undergo a colostomy for several months after having a large section of his colon removed.

2. The Baby Jesus
He was only four years old. He informed his mother that he put a "toy" in his nose. On examination, I noted the bottom of two tiny feet in his left nostril. Using a foreign body forceps, I grasp those little feet and gave birth to a tiny figure of a baby. "That's the Baby Jesus from my miniature manager!" cried the mother. No one really knows what motivates a child to insert objects into various body orifices.

3. Homemade Pole Saw
Pole saws are expensive, so this enterprising man decided to duct tape a regular chain saw to a large stick so he could cut some of the limbs higher in the tree. He started the chain saw, locking it into high gear. He was proud of his new invention, but the vibrating chain saw came loose from the duct tape. He attempted to catch it, but realizing this was not a good idea, landed on the ground. The running chain saw landed in his lap. Fearing the worst, he presented to my clinic in a panic. After cutting off his partially-shredded pants, I informed him that the vital organ of his concern was still there, but maybe a bit smaller. He looked down and told me that it was always that size. He was happy.

4. Bees for Arthritis
His hand was huge; nearly twice the size of a normal hand. He read an article that many people were using bee venom to treat arthritis. Since he had arthritis in his shoulder, he attempted to catch a bee in his hands and holding it to his shoulder. The bees, unaware of the location of his arthritis, repeatedly chose to just sting him on the hand.

5. The Growing Skin Lesion
Skin cancer was prevalent in his family, so Dad was very concerned when he noticed a growing, brown skin lesion on his 8 year old son's neck for the last month. Upon examination, it did not appear as a cancer. Taking a wet and soapy gauze pad, I simply removed this mysterious lesion. It was dirt. Patient cured. Dad embarrassed.

6. Dangers of Smoking
Children see parents smoking, so they naturally want to see what it is like. After being caught stealing a cigarette, two enterprising young kids decided that they would make their own tobacco. The boys picked an impressive number of leaves from the wooded area behind their home, including some bright-colored red ones. They carefully selected and dried the leaves, and rolled a big doobie using a piece of typing paper. Coughing and hacking away at this noxious homemade cigarette, the real danger came a few days later when they were covered head to toe in poison oak. Two boys learned a valuable lesson about plant identification and the dangers of smoking. I have to admit, that I was one of those boys. I have never smoked (anything) since that fateful day when I was ten.

7. What Do You Say to the New Grandmother?
She was 16 year old and overweight. My PA wife was seeing her in the clinic because of abdominal pain and vaginal discharge. Upon examination, it was quickly determined that the discharge was amniotic fluid - this teen was delivering a baby and didn't even know she was pregnant. While waiting for the paramedics to transfer her to the hospital, my wife had to inform the puzzled mother that she was also going to be a grandmother today.

8. Home Vasectomy
He was a physician (and his own patient). Why pay someone else for a vasectomy when you could simply do it yourself? So, while sitting on the toilet at home, this misguided medical professional attempted to inject lidocaine into his scrotal area in preparation for the "first cut". It was unbelievably painful to do this on yourself. After the first cut, the wound started to bleed profusely. He felt a little woozy and passed out. He woke up a few minutes later, on the bathroom floor, in a pool of his own blood. Several years later, he had the job finished by another physician, who questioned the one-sided scar. A half vasectomy is really worthless.

9. Fart Attack
She was eight years old and doubled-over in abdominal pain. Her anxious mother felt she had appendicitis. Upon examination, it was discovered that she did not have signs of appendicitis, but rather had a large amount of intestinal gas. "I cannot believe that this is just gas," said the mother. No sooner than those words left her lips, that the longest, loudest fart erupted from this little girl. At one point, I thought she lifted a bit from the examining table and hovered. "I feel so much better, Mom". Case closed.

10. Never Show a Mother How to Insert a Rectal Suppository
When a child is vomiting, anti-nausea medications are often administered rectally - by suppository - to help control those symptoms. A young mother expressed that she had no clue how to insert them in her two-year old. In one of my teaching moments, I decided that I should show her how to do. Taking a suppository from our office stock, I told her to place the child across her lap and pull down his diaper. "All you need to do is pull apart those little butt cheeks, and gently insert the suppository into the rectum." No sooner that I said "pull those little butt cheeks apart", a geyser of diarrhea shot into the air; hitting me in the face, beard, and dripping down my glasses. The mother was covered, too. When a medical provider is covered in crap, you get little sympathy from your nursing staff. You do receive a lot of inappropriate laughter. I was offered a change of clothes (OR scrubs) from another physician in our office - a size that would have fit a ten-year old. I am sure I received my share of stares when I went home to shower, wearing one of our paper examining gowns. In the world of primary care medicine, "[You Know what] Happens."

Related Topics:

• WebMD Video: Physician Assistants - Filling a Void in Healthcare
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Labels: health and wellness, humor

If you have been reading my Blog, you know how much I love dogs. I have two Shelties now and would love to have one more. With this brief preface, I would like to share an incident in my office last night.

By choice, I work 12-13 hour shifts, three days per week. I know that people do not just get sick from 8 to 5, and that working people and those in school during the day need options. I, on the other hand, like to have some days off during the week; hence, this is my schedule.

I walked into the examining room to see a 15 year old girl with ear pain. She was accompanied by an entourage of three siblings (all girls), a mother, and a puppy. The puppy was actively peeing on my floor; on two of my examining gowns placed on the floor to be exact. As I stood their in awe as the yellow stain leeched onto the floor below, the mother proudly announced that this puppy paper-trained himself. She picked up the dog urine-soaked gowns and attempted to put them on the top of the waste receptacle under the sink. That is, before I stopped her.

"You allowed your dog to pee on my floor, on my examination gowns?" She paused with that comment.

"Babies crawl on that floor. People often walk in their bare feet on that floor. While I admit that examining room floors are not the cleanest places for those activities, dog urine is really not wanted. I would respectfully ask you NEVER to do that again. I will have my nurse provide you with some supplies so you can properly clean up that mess."

I am usually easy-going and tolerate a great deal of (human) body fluids in those rooms. It is not unusual to see a geyser of urine stream from a little boy arching through the air toward a startled (new) parent. Those things are expected to happen. I find those amusing and we all help clean it up…properly, followed by some sanitation procedures that go on after the patient vacates the room. Had I not walked in on an actively peeing dog (!), I am sure that nothing would have been said. Microbiologically, I suspect dog urine (like most human urine) is pathogen-free, but it still has a significant "yuck" quality.

We have patients with service dogs all of the time. These canine companions are well-trained, usually better than the toddlers I see. The law permits service dogs in virtually any area, as it should be. This puppy was cute (all puppies are cute), but this was not a service dog. The dog made it past our front desk receptionist contained in a pet carrier. If it were 105 degrees outside, I would not have had an issue (other than the fact that a responsible dog owner should not even take a dog out in the car under those conditions), but it was raining and it was cool, and there were plenty of kids that could have watched that dog…in the carrier…in an isolated corner of the waiting room away from children that may have a dog dander allergy. If our office starts allowing or not actively prohibiting animals in the exam rooms, it will definitely get out of hand, I can assure you.

I stopped referring patients to a local podiatrist when more than one person told me that he had a free-range cat in the waiting room. Most patients (apparently) did not mind - perhaps cat-lovers and owners themselves, but I had a problem. Cats can carry all types of germs on their feet as they walk around in their litter boxes. Some of the worst infections I have treated involved cats in some way. Some cats also carry ringworm – a fungus that is actively treated by podiatrists when it is on the feet and between the toes. I guess this would be convenient.

My first Sheltie was highly-socialized, even before she joined our family. The breeder would take the adult dogs (and puppies) to nursing homes to be petted and handled. It was good for the residents and definitely good for the dogs. I suspect that the breeder has a pee-policy. Nursing home residents are mostly adults and the facilities are a bit different than a medical waiting room used by persnickety new parents.

Puppies also poop. Dog poop, unlike urine, is teaming with microorganisms and even worms. Granted, one of my kids (sorry, Alex) happily ate a dog turd when he was little. He did not get sick and is now an engineer. I step on a lot of dog poop in my yard, but I am not going to start stepping on it at work.

If you really love your dogs, please don't force them into places they do not belong. I don't want to see them sitting in shopping carts when I am at the grocery store, or poking their heads out of bags/purses at the mall. I definitely do not want to see them panting in hot cars with a window cracked one-half an inch. I don't want to see big dogs in the back of a pick-up truck barking at startled people walking by, or even tied to the back of a pick-up truck flying down the freeway. I don't like my neighbor's unrestrained dogs chasing my car; and I don't want other dogs using my self-manicured lawn as public toilet. My little dogs are okay but not the neighbor's behemoth and his impressive mega-piles. And, I don' really want dogs in my waiting room peeing on the floor. I don't really want "extra", uncontrollable kids in the examination room, but I don't want parents leaving kids in the car with the windows cracked either.

I have told my wife that if I were dying in a hospital bed, I would want my dog, Herman, lying next to me. Unfortunately, that role was tragically reversed. Two years ago, I had to lie next to Herman when he was dying. Friends do that for each other.

Related Topics:

• WebMD Video: Maggie the Hospice Dog
• Pet Symptoms: 6 Signs of Illness in Your Dog or Cat

Labels: dogs, medical practice

All of our medical records, from chart notes to sending prescriptions directly to the pharmacy are electronic now. In the old days (a few years ago), we would simply write out our prescriptions and write our chart notes on paper (assuming medical records could find the chart). Both prescriptions and chart notes were notoriously and sometimes, dangerously, illegible. Electronic medical records, although time-consuming and cumbersome, have nearly eliminated these issues...unless you are distracted.

Charting in the room, while the patient is still there, can be problematic. When you are trying to transmit a prescription to the pharmacy, or write a note, the patient may create a distraction by talking or remembering that they have another issue. Charting at your desk can be problematic because other people will see you. A medical assistant will ask you a question, or there will be someone just walking by and wants to say hello. These are distractions that cause me to either forget to transmit the prescription, or send prescriptions to the wrong pharmacy...a different state, or close a record before I have finished my progress notes.

Phones are always a distraction, so I try to limit making or taking non-essential calls until lunch or after work, when the patient visits are completed. Unless it is an emergency, I don't want the staff knocking on the exam room door to tell me someone is on the phone. Patients are getting slick. They tell the receptionist that they are returning my call. One of my friends tends to use different, made-up doctor names when he calls so that I will be interrupted. I was distracted by one of "Dr. Singh's" calls yesterday.

In California and other states, it is now illegal to talk on a cell phone that is not hands-free. Of course, I still see dozens of people talking or texting on cell phones as I drive to work. There is even a flashing sign near my exit that says, "Please do not text-message while driving." According to some authorities, talking on cell phones results in nearly 3,000 deaths per year, and not all of those deaths were people who were on the phone. There is some movement in this country to prohibit ALL cell phone use, hands-free or not, simply due to the distraction level. This is kind of silly since there are certainly more distractions for drivers than just using a hands-free phone.

When my youngest son earned his drivers license (age 16), we gave him permission to drive the family car to school a few days later. On the way to school (two miles), he rear-ended a State Farm insurance agent whose boyfriend is a lawyer! He was distracted by his teenager passengers fighting over the radio. California now has a "no passenger" law for new teen drivers. This is a good law.

Several years ago, I was following a car. The driver seemed to be very distracted by a disruptive child in the back seat. He kept turning around, yelling at him, and trying to grab him as he slid from side to side successfully avoiding a one-arm capture. A few minutes later, I see a belt being randomly whipped at the kid; the driver (assumed to be the father) running off of the road and nearly killing both of them. Disruptive kids are always a distraction when you drive, but it is always best to pull off of the road before attempting any corporal punishment.

Studies have shown that even music in the car can affect driving, with classical music having a calming effect (hopefully not to the point of falling asleep) to hard rock music having an opposite effect - speeding. I have even seen people arm dancing in cars and a few air guitars. Should we ban radios and stereos? I would be first to vote against those eardrum-bursting bass speakers!

I enjoy music, but not at work. I absolutely hate music on-hold. One medical assistant likes to program the speaker phones at the nursing station so music is playing. If I can hear it, it is terribly distracting. After repeated attempts to have her turn if off, she would do it over and over again. She told me that it was "her right" to listen to music. To make a long story short, I made sure she exercised her right to work somewhere else. I am not going to even talk about over-hearing "girl talk" - the conversations that are constantly going on at the nurse's station. I close my door.

What about distracting eating? There is nothing more distracting about plopping a juicy burrito on your clean shirt to affect driving. Safe foods might include chicken nuggets (without the sauce), or drinks (with a straw). If you don't have to take your eyes off of the road or worry about spillage, it is certainly safer. Accident-waiting-to-happen foods include anything scalding hot that you might hold between your legs. Ouch. Parents always bring food to doctor's visits so their kids can eat while they wait. I find the smell of McDonald french fries distracting, especially when I am hungry.

"Would you mind putting away those fries? Gimme a few first..."

I tend to eat at my desk so I can make phone calls or finish up charts, even though I have to shake the crumbs out of my keyboard periodically. Unless I close my door, I will experience distracting interruptions, perhaps starting with, "I know you are eating lunch, but a patient just walked in the door..." I have started leaving work for 15 minutes so I can find a quiet place to eat my lunch; a task that is becoming more and more impossible.

Another medical provider created a kitchen of sorts in his office - microwave, refrigerator, coffee-maker, etc. One day, he dropped a hot bowl of soup on his CRT computer monitor and keyboard. I am sure the smoke and sparks were a bit distracting, as well as cleaning up all of those noodles. He deserved it. I was getting damn tired of smelling his burnt popcorn wafting through the halls.

Other medical provider distractions include patients taking cell phone calls during a visit, kids playing loud video games, and unsupervised kids digging around in the drawers or pounding on my work computer. I even had a mother this week text-messaging WHILE I was talking to her! Unintentional (and expected) distractions include babies who decide that this would be a great time to take a steamy, eye-watering bowel movement. Our examination rooms have the worst ventilation, too. Medical providers always have to watch those crafty Dads. They are the most likely ones to hide a poopy diaper in the trash receptacle and not say anything. I am pretty tolerant of most human smells, like bad breath, B.O, and adolescent feet, but those smells can definitely be distracting. I am also not a big fan of over-perfumed people.

Maybe it's me? I seemed to be distracted by all kinds of sights, sounds, actions, and smells. Maybe I need a different line of work?

Related Topics:

• Fix Your Focus
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Labels: distractions, focus

There are only so many things that I can discuss regarding the ears, but as you may have guessed, the All Ears blog is more than just ears. At first, I decided on the name, since a good listener should be "all ears." I think I am a good listener, although my wife would probably dispute that statement. I hear her, but I must admit, I do "tune her out" from time to time. I love her dearly, but her stories go on...an on...and on. Even when I say, "Cut to the chase..." or "Get to the point...", she continues on her complicated and convoluted stories. I have to take notes and reminder her that I am not her hairdresser. I guess I am not "all ears" all of the time.

For some reason, medical visits are timed - usually fifteen minutes or less. There are few things in life, other than sex, that we can accomplish in fifteen minutes or less, yet the medical establishment feels that all issues can be properly addressed in this time period.

In order for me to be "all ears" in the examining room, I do have to get the patient to cut to the chase, especially when I am running behind. I would love to listen to life stories and talk about peripheral issues, but sometimes we just have to talk about why I am seeing them today. I hate when my medical assistant says there is a sore throat in room #1. I have to remind her that it is a PERSON who happens to have a sore throat in room #1. Of course, sometimes, they are in room #2, not #1 - a different, albeit, annoying issue we often encounter in busy medical offices.

A seasoned clinician should be able to address a sore throat in fifteen minutes, right? Well, that depends on the person attached to the throat. If the person is a smoker, or elderly, or a teenager, or appears to be seriously ill, this may not a garden-variety sore throat. A prostitute with a sore throat is a different ball game. The sore throat can be a cancer, mononucleosis, herpes, or any number of diagnostic possibilities. The sore throat can even be a smoke screen. Many times, a person will make the appointment for a sore throat, when they really have other, more important issues they would like to discuss. I'm all ears at this point.

People are both fascinating and complicated. The more you learn about a person, the more you know what makes them tick. Good listeners have to ask good questions, and one of the most important questions to ask a patient is, "What do YOU think it is?" What are the underlying concerns? If a medical provider whisks through an office visit, only to take a quick look in the mouth, pronounces that you just have a virus, take two aspirin, and don't call me in the morning, they are not going to get to the true issue. This patient may be a long-time smoker who just lost a good friend from cancer. Unless you ask...unless you are all ears and listen, you will not discover the true reason for the visit. This "treat ‘em and street ‘em" approach has absolutely no place in medicine.

On WebMD's Ear, Nose & Throat message board, I encounter many people who walk away from a medical visit with a prescription for amoxicillin without really knowing why. The medical provider did not tell them their diagnosis or reason for the antibiotics. They do not know their prognosis, or when they should expect to feel better. They were told nothing. This is NOT a good medical visit and the fault lies with BOTH the patient and the provider. The patient was not assertive enough to get their needs met, and the provider was not caring enough to spend a few extra minutes to listen. If the practice of medicine was this easy and quick, we would have drive up windows like a fast-food restaurant.

"Would you like fries with your amoxicillin?"

"Pay at the first window; pick up your amoxicillin at the second window. Have a nice day."

When you are all ears, you have lots of stories to share. When time permits, I love to talk with my patients. I found out recently that one of my patients raises buffalo. A week ago, I was surprised by a bag of ground buffalo meat, some steaks, and ribs. Now, if that wasn't worth a few minutes of friendly talk, nothing is. A few years back, I had a fisherman as a patient that brought me in a thirty pound albacore tuna (frozen). Why? Because I listened to his stories.

Several years ago, I was given a huge box of home-grown vegetables and a LIVE TURKEY when I made a house call to a homebound patient. When I listened to her plight, I felt that a rare house-call was the most appropriate utilization of my time. I don't do them often, but if people keep feeding me, I think I will re-evaluate my practice - low overhead, work out of my car. It pays to listen.

The All Ears blog is really my stories. All of the stories are all true; perhaps the names have been changed to protect the innocent (or not). They are stories from behind the examining room door and stories of interesting lives. They are stories that are a window to my soul and a backdoor to my often-bizarre sense of humor. They are the random vignettes of my life so far. They are stories about kids, old people, boogers, turkeys, circumcisions, Chinese, bad drivers, laxatives, coal miners, a dozen dirty places, dolphins, births, deaths, onion sandwiches, sex, Santa Claus, vaccines, dogs we love, and wiener dances. There are over 300 of them in the archives if you would like to read them. Sometime, they are even stories about ears.

Related Topics:

• Ask-the-Doctor Checklist
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Labels: ears, health and wellness, humor

America is truly a melting pot of cultures, and this is even more apparent in a medical setting. Not only can language be an issue, but cultural beliefs are equally as important - even if they tend to clash with Western philosophy.

If I throw one of my pharmaceutical ink pens out of my office door, I take the chance of hitting a medical assistant from Ethiopia, Mexico, China, Vietnam, or Russia. Of course, I wouldn't do that (unless they ignored me). It is nice to have some in-house interpreters from time to time, but I often encounter language barriers beyond the rich resources of our immediate office. Last week, I noticed that our group is installing a special speaker phone for interpreter services that will cover dozens and dozens of other languages. Being about to communicate effectively in the language of a patient is only half the battle. A medical provider needs to understand culture.

Cultures can be very complex. There are ethnic issues, religious issues, and even family belief systems that come into play when dealing with a medical issue - even one as simple as a sore throat or headache; or one as complex as the birth of a baby.

The daughter-in-law of our very good friends is due to have her second baby - the first one born in the U.S. She is from a rural island community in the Philippines where birthing is done in the homes, usually by an experienced, but informally-trained midwife. One of most important rituals of the delivery is the disposition of the placenta. In her culture, the placenta must be buried near the house so the spirit will always be able to find its way home. Her four-year old, a delightful little boy named Conner, has his placenta buried at the family home in Palawan. She has been very worried about what will happen when her new baby is born here - in a hospital.

She was told that the placenta will be kept by the hospital and subsequently destroyed after the delivery. When we informed her that she has a right to take her placenta, to be buried near her home in the U.S., she was delighted. She was also frightened since this is not the common practice here. Fortunately, her father-in-law is a university professor of cultural anthropology, and her mother-in-law is both assertive and opinionated. I have no doubt she will be bringing the placenta home; for a proper burial. Someday, the spirit of baby #2 will not have to wander aimlessly looking for home.

Not all cultures believe in germs as the cause of illness. They strongly believe that illnesses are caused by spirits (bad spirits, of course). Bad spirits are always hanging around, especially in hospitals and doctor's offices. I think I have seen or felt those bad spirits myself, especially on Mondays. Hmong patients are unbelievably stoic and quiet during medical encounters. Why? They do not want to draw the unwanted attention from these bad spirits. If the child cries from an injection, they are quickly quieted, lest the spirits spot them. When dealing with Hmong patients, I talk very quietly and try not to ask very many questions. If there are spirits in that room, I don't want them gettin' me either.

California has a huge Mexican population, perhaps since California was once Mexico until we took it. With our state budget crisis, it would be good to give it back now. Mexico doesn't want it now. Mexican patients tend to have strong cultural and religious beliefs associated with illness and medical care. In many area of Mexico, there are not doctors, just Curanderos - spiritual healers. Curanderos are often a part of modern medicine, too. Why not have a shot of penicillin AND a bit of spiritual healing, too? It certainly can't hurt.

Several years ago, I was with one of my medical students near Lake Tahoe. She was seeing a Mexican woman who was in a catatonic state; staring blankly and not speaking. The hospital felt she was in a coma of sorts and ordered a CT scan (normal). We were doing the follow up in the office. She was surrounded by dozens of concerned and worried family members, some of which flew in that day and others who drove all night to be with their critically-ill mother.

"When did this all start?" asked the concerned medical student. The answer was one that I didn't expect.

"It started when she heard the news that her son was getting married in Mexico and she would not be able to attend the wedding." Prior to that, she was perfectly fine. Interesting.

As the student asked more medical questions, I just watched her eyes. They would quickly, but purposely, glance at the student - not an action you would expect from a person in a coma. They were the eyes of a person following the conversation. I caught her looking at me, too. She was faking it! So, after a few minutes, I decided to try something a bit unorthodox.

I asked all of the family members to hold hands and close their eyes. I put my hand on her forehead and told her that God wants her to wake up now. I asked everyone to pray that she will come out of her coma. Within a few seconds, Mrs. Garcia (not her real name) started to react.

"Where am I?" she said. It was just like the movies. It was a fine performance; one that would have earned her an Academy Award. Family members screamed and cried as she sat up. After a few minutes, the startled student watched her coma patient, get down from the gurney, and simply, walk out.

Mrs. Garcia needed an "out". She had played her little game a bit too long, so I just gave her permission to stop. No, I am not a faith healer, but faith did heal this woman. For that brief moment, I was a Curandero, sort of. Incidentally, the wedding of her son, postponed because of her sudden illnesses, was rescheduled and Mrs. Garcia was able to attend.

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Labels: cultural issues

Well, Christmas is over, but certainly not winter. I grew up in southwestern Pennsylvania, an area not a stranger to snow. As a child, snow was seen as a blessing. We would listen intently to the radio, while simultaneously getting our sleds ready, waiting for the list of school closures to be announced. As soon as our school was mentioned, we were out the door, heading for the nearest hill. Dozens of our friends would be quick to follow. There were snow forts to be built and snowballs to make in preparation for the inevitable siege. The girls were busy making snowmen as we laughed and secretly planned the transformation of those "men" into snow-women. Our older siblings would be assigned the arduous task of shoveling the driveway and walkways, so working parents could get to work.

We had a sled-riding hill at our school, but of course, we were not allowed to have sleds. During recess, we would use the next best thing - our shoes or our bottoms. One day our favorite snow hill was defiled with a fresh, steaming pile of dog crap. When the bell rang, I vividly remember piling lots of fresh white snow on this fetid mound, before returning to class. A mischievous sneer could be seen on my face as I watched children from the second recess heading for the snow hill. After school, I proudly admired the long, yellow streak that indicated the overall success of my IFD (improvised fecal device).

My favorite aunt lived directly across the street. As an independent six-year old, I had safely crossed this quiet road thousands of times in my young life, rarely looking out for cars. Today, there was one coming, but it was at a sufficient distance that I could make it - if I ran. It is not that easy to run on packed snow, and of course, it is not that easy for a car to stop on it either. A miscalculation, mostly on my part, ended up with a vehicle heading for me in a wild spin. I stood their like a deer frozen in the headlights, as the car struck me broadside, sending me sailing through the air. I landed in a snow-bank in my aunt's front lawn.

Quickly, I sprang to my feet and headed to my aunt's front door, oblivious to the shouts, "Are you okay?" coming from the terrified driver. I rang the doorbell and entered like nothing had happened. A few minutes later, the doorbell rang again. It was the sweaty driver of the car. The jig was up. The driver identified me as the one he just hit. Fortunately, I wasn't injured.

Four years later, I was a front-seat passenger in my mother's car, sitting beside my newly-purchased Christmas present - a blue parakeet with cage. The snow was really coming down, but most rural drivers are not intimidated by this white stuff. Suddenly, there was a man standing in the road waving his arms for us to stop - he wanted a ride into town. My mother did not have time to stop. The thud of his body still echoes in my mind, as well as the vision of him hitting my side of the windshield before flying over the car. Stunned, my mother continued to drive about a block or so. At my insistence, she stopped and turned around. The old man was still lying in a pool of blood in the middle of the road. He wasn't moving. I went to the nearest house to get some help - the home of a friend, nicknamed Dog. Dog called the police and ambulance, but by the time they arrived, the man had died. He was a recluse that lived in the rambling shack next to Dog. He had no family. This was not a particularly good Christmas for a ten year old.

As the years progressed, I had many more encounters with snow. There was the time that my friend, Rick, decided to dive head first into a fresh snow drift. He did not know the snow drift covered a snow wall. There was the time in high school that I threw a snowball at my typing teacher, only to strike her in the back of the head, knocking off her knitted cap. I only speak about this now, knowing that she passed away years ago (for unrelated reasons). I passed typing that year, but I could not look at her the same way.

While in college in West Virginia, I nearly killed my best friend when I slid a full sheet of plywood down a snowy hill for him to catch. The plywood caught some air, rose up, and struck him square in the head. It knocked him out instantly. We carried him to the campus emergency room where he his concussion was treated. After this incident, we remained friends, although he did seem to act a bit odd thereafter.

I had never seen snow as deep as I did in Michigan. Michiganders love snow. They love to hunt and track deer. They love snowmobiles and four-wheel drive trucks. They love those wool hats with the fur on the ears. I remember losing my car in the parking lot when a sudden snow storm made all cars look the same. I remember shoveling off the sidewalk so children could get to the house for Halloween, and a recall moving boxes in the snow at the end of April, when most of the country is picking spring flowers. As a non-Michigander, I did not share the enthusiasm. When I moved back to California, I left my trusty snow-shovel behind, vowing to never use it again. Last week, I needed it in California.

Since I live about an hour or so away from Lake Tahoe, the freeways are unbelievably crowded with folks heading for the snow. The skiers and snowboarders have been waiting for this season all year. There is plenty of snow on the slopes to accommodate them. As I see those cars passing by, filled with smiling faces and weighted down by ski equipment, I start to worry. Statistically, some of the people will not make it home. They may hit a patch of black ice, or like my barber, slide off the side of the road and end up at the bottom of a steep embankment. If an alert trucker had not witnessed this early morning accident, I would be cutting my own hair. He made it out just fine, but unfortunately, others do not survive the road chaos of the Holiday season. So far today, three people have been killed in the Sierras on the snowy roads. I think I will stay home.

Even now, when I see snow, these and hundreds of other stories flood my memory. Snow is beautiful to look it, but not so beautiful when the weight breaks tree limbs across your driveway or takes away a loved one. I love watching the grandchildren sled-riding down a hill or learning to ski, but from the warmth of the lodge. My own futile attempts at skiing were not unlike the "Agony of Defeat" film footage that aired for years on the Wide World of Sports.

I do not want to insult or miff the snow-lovers, but personally, I could live just fine without ever dealing with snow. I would be content just to watch the Weather Channel and call friends in relatives that are completely socked-in, claiming that I am outside, wearing shorts, and firing up the barbecue.

Please drive safely. You may arrive at your destination a few minutes later, but you will arrive. Think of other drivers and the families and friends that are at home. Be prepared. Have full tank of gas and some emergency equipment, including some sleeping bags and snacks. You don't want another Donner Party. Watch the weather and traffic reports. Have a fully-charged cell phone, but don't talk on it - stay focused on the road, and of course, your valuable passengers.

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Labels: snow, winter