Dueling Medical Studies - Who to Believe?

People who primarily get their health information from the evening news, the local newspaper, or non-medical Internet sites are in big trouble. The amount of conflicting information about the risks or benefits of just about anything is staggering. I guess I am particularly troubled by television news. I use coffee as an example:

"New Study Shows that Coffee Consumption Linked to Breast Cancer"

This was a story that I heard over 30 years ago (before the Internet!). It was so shocking at the time, that women stopped drinking coffee all over the country. In one, highly-publicized study, coffee was blamed for fibrocystic breast disease and tentatively linked to breast cancer. This alarming coffee/breast cancer link was later disproven, but that news never seemed to make it to the media. This is really like having your neighbor hauled off by police as a possible child molester. The evening news shows him being put into a police car. The police quickly realize that they got the wrong man, apologize, and release him. All your neighbors really remember is that there is a child molester that lives in that house. The news that this was a mistaken identity doesn't really filter down. The accusation of being a child molester, even after being vindicated, is reason enough to move away. Capturing a child molester is a big story. The man not being a child molester is boring news.

A doctor in a nearby community was accused of fondling his patient's breasts. He was arrested in his office and put in jail. It made the evening news top story and the front page of the newspaper for weeks. After spending tens of thousands of dollars to defend his medical license and good name, he was finally exonerated after the victim admitted to lying. She had made up the entire story. What was once front-page news, complete with pictures, was now a tiny write-up on page seven. Most of his patients never saw that he had been exonerated. His practice and reputation was ruined by the news media jumping to sensationalism. People are supposed to be considered innocent until proven guilty, but the media can prematurely imply guilt.

Coffee has been vindicated, too. As a matter of fact, coffee has completely recovered from that story that it causes breast cancer. Coffee is now considered medically beneficial, assuming of course, that those recent studies were not funded by Maxwell House or Starbucks. People spend billions of dollars every year on this valuable commodity, so having a safe reputation is essential. According to WebMD there have been 19,000 studies that have examined coffee's impact on health. It appears that the benefits of coffee greatly outweigh any hazards.

Coffee contains a significant amount of caffeine, about 85 mg. - a potent stimulant. It can zip you up when you are tired, boost your concentration, but it can also raise your pulse and blood pressure, and make you a bit jittery, at least until it wears off. If you are not used to drinking strong coffee, those effects can be frightening.

When my daughter was in high school, she worked part-time at a neighborhood coffee shop. I worked for a university at the time, with a remote campus about ninety miles away. At the time, I was not a coffee drinker. I was a coffee virgin. Since I had to leave very early, I thought that I would try drinking coffee to keep me awake on the long, boring drive, so I ordered mocha. I assumed this was primarily chocolate. The guy behind the counter asked me if I wanted a "single or double". I figured this referred to the size of the cup. It was a long drive, so I said "double". I had absolutely no idea that he was referring to two shots of espresso. In about twenty minutes, the palpitations of my heart were so severe that I had to pull off of the highway. Now, my entire coffee consumption is just one cup in the morning - no double shots of anything. When driving non-stop back from Mexico, I did drink one of those new "energy drinks" heavy in caffeine. I definitely felt those effects and remained alert while driving the last six hours of an 18 hour journey.

As parents, we typically don't let children drink coffee, perhaps because we feel that kids are zippy enough without it. Believe it or not, no studies have shown that coffee is harmful to kids. Even if it is safe, I am not going to ever suggest that parents give their kids a cup of joe before heading off to school. With teenagers dozing off in math and social studies on a regular basis, perhaps coffee would not be a bad idea for them. Of course, we all worry about "complimentary behaviors" in coffee drinkers. I just can't picture a five-year sipping on a cup of coffee in one hand, a cigarette in the other, and looking for the newspaper. Okay, I know this is a bad stereotype, but you get the idea. Maybe coffee is a gateway drug? Perhaps we need a study.

Studies have now concluded the coffee is good for us; or most of us, at least. Coffee drinkers are less likely to develop Parkinsonism, decreased the risk of colon cancer, less chance of gallstones, and even less dental cavities. There is even evidence that asthmatics who are also coffee drinkers, have less asthma attacks. Coffee appears to be a good diuretic, too. There are just some of the positive health benefits that have been linked to coffee, if we are to believe those studies.

People are more likely to believe the last thing that they read in the newspaper, magazine, or on television news. We tend to quickly forget that a conflicting story may have been highlighted a few weeks prior, or even a rebuttal or disclaimer announced later. Once we glom on to a story, it becomes part of our belief system - one that we will freely share with others.

Every day in my clinic, I am defending vaccinations and dispelling junk-science about their presumed hazards. Once a parent is convinced that vaccinations may be harmful to their child, perhaps causing autism, it is very difficult for a medical provider to convince them otherwise. For some, holding on to those beliefs are like a religion - they are deep and personal.

I watched an anti-smoking documentary the other day that effectively used the Scared Straight technique. The anti-smoking lecture was given by a surgically-deformed cancer survivor who had most of his face removed. Those kids were listening. I think it would be a good idea to get a group of survivors of vaccine-preventable diseases, like polio, meningitis, or mumps, to have a talk with some of these parents.

Until I hear otherwise, from a well-designed, scientifically-controlled medical study, I am going to continue to promote vaccines, and of course, drink my one cup of coffee in the morning. Let the fools continue to smoke, avoid seat belts, drink booze, drive crazy, take drugs, have unsafe sex, and believe that vaccines are a government plot to control and harm us. Nature has some unique ways of dealing with them.

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Masks and Dark Glasses

As a seasoned medical provider, I can't tell you the importance of actually "seeing" the patient. I have always had issues when people come in wearing dark glasses. Since the eyes are the window to the soul, I find it very difficult to have an effective medical encounter with someone wearing dark glasses. When you address a particular medical question, you instinctually look at the eyes for response. Is the person making direct eye contact? If your patient is a teenager, are they "rolling their eyes" at you? Are they gazing downward? Before I start any medical encounter, I ask the person to please remove their dark glasses so I can see them, and not my own reflection.

Morgan / CC BY 2.0

H1N1 flu pandemic has hit our area big time. We set up a "flu station" in the lobby where people can use hand-sanitizers and pick up a surgical mask to wear. When I enter the examining room now, it is not uncommon for everyone to be wearing masks - except me.

Just like the eyes, I also like to see a person's entire face. I want to see if they are smiling, grimacing in pain, or frowning at me. If a person had both a mask and dark glasses, I would just assume they had a big paper bag on their heads. Just like the dark glasses, I ask them to remove their masks once they are in the examination room. I don't know how Westerners can practice medicine in the Middle East. If I saw a person wearing an Islamic burqa, I am not sure how I would react. But at least, could see her eyes.

The Lone Ranger wore a mask, like no one would really recognize a well-spoken man in clean white clothes, riding a white horse along with this companion, an Indian that speaks like Tarzan. Bank robbers and train bandits wear a scarf or bandana over their mouth and nose. Spiderman wears a full face mask apparently so you won't recognize him as Peter Parker. Superman doesn't wear a mask, but uses a pair of dark-rimmed glasses when he changes into Clark Kent - another clever disguise designed to fool idiots. A guy in a ski mask coming to my front door would definitely get a rise out of me.

Josh Westbrook / CC BY-ND 2.0

If someone walked into a bank today, wearing a surgical mask and dark glasses, they would definitely get the attention of the security guards. Halloween is just around the corner, so our pediatric practice allows the staff to dress up, without masks, of course. Masks typically scare kids, even surgical masks. We don't get the Trick or Treat crowd in our rural neighborhood anymore. I sort of miss them.

The first time that I saw people in public wearing surgical masks was in Japan many years ago. Japan is a crowded, but highly-organized and respectful society. When I inquired about the masks, I assumed that people were protecting themselves from the germs of others. To my surprise, it was the people in the masks who were trying to keep their germs to themselves. They had colds or influenza and did not want to infect others. This is a very respectful hygienic practice that we rarely see in the U.S. People on the subways in the U.S. will just about sneeze in your face; or sneeze in their hands just before the grab the hand rails.

I have been exposed to so many cases of H1N1, that I expect that I have some residual immunity. I have been endured numerous sneezes and coughing in my direction. I have held contaminated hands. I have wiped noses of children. If and when the H1N1 vaccine arrives, I am not really sure I need it. I will take it for my patients, of course, but I suspect that I am either immune from prior infections, or darn lucky.

One provider was complaining this week that he had to wear to complete biohazard suit, complete with a battery-powered air filtration system and full spaceman helmet when he was examining a baby in the ICU. The baby was in protective isolation. He said it was impossible to listen to heart or lung sounds using a stethoscope while wearing a space helmet and noisy respirator.

Until this pandemic is over, we must all learn to tolerate people in surgical masks - even when they are surgeons. It could be worse. We could all be wearing those space suits.

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Salt of the Earth

I recently read a New York Times article, that according to the Rand Corporation, the US could save $18 billion dollars per year in health care costs if Americans would cut their current amount of salt intake (about 3400 mg) to the recommended 2300 mg. They estimate that there would be 11 million fewer cases of hypertension. Hypertension costs about $55 billion a year to treat. Of course, there are other contributing factors to hypertension as well, including obesity, sedentary lifestyle, and a diet too low in potassium-rich vegetables and fruit. Untreated or poorly-managed, hypertension leads to heart disease, kidney failure, and strokes. Human beings are basically bags of salt water, so the "Salt of the Earth" will always be an important part of our diet, but too much of a good thing results in a lot of bad things.

Historically, salt has had a significant impact on human history. Wars have been fought over it. Salt has been actively traded as a commodity, and has been used for money. Salt has been traded ounce per ounce with gold. Roman soldiers were often partially paid with salt. The word "salary" has its derivation from salarium (salt). Gandhi lead a non-violent protest in India to assert people's right to make salt from the sea without being taxed.

TheGiantVermin / CC BY-SA 2.0

Most of the salt that we consume is not coming from the shaker, but rather in processed foods. People, especially Americans, love (and expect) the taste of salt, so it is added to most dishes and most prepared foods. Just like growing up eating chili peppers, salt is an acquired taste. You can "un-acquire" it, however.

Growing up, we always had a big salt shaker on the table, even though my mother actively salted the food during cooking. There was a significant amount of salt in processed baby food. Why? Mothers would taste the food, usually for proper temperature, before feeding the baby. If it was unsalted, it would taste terrible to the mother, who would not buy this baby food again. Babies are not born with a taste for salt. As a matter of fact, they have a very undiscriminating palate and will eat many things that we find objectionable. My kids were caught eating dried flies in the window sills, cat food, leaves, lint, dirt, and one of our kids even happily ate a dog turd! He is a successful engineer now, so it didn't seem to hurt him.

My old boss and mentor once mentioned that a person who salts their food before tasting it first is a sign that he/she is untrustworthy. When I get tempted to reach for the shaker, I always think about this. I really should trust the chef not to under-salt the food. A lot of consumer pressure got rid of a lot of salt poured over those fast-food fries.

A kid's diet is high in salt, from the more obvious potato chips, peanuts, beef jerky, and French fries to the hidden salt in ketchup and pickles. If you read the labels, you will see the word "sodium" in many forms, including preservatives and sweeteners. Sodium chloride, of course, is plain 'ol table salt.

There are literally thousands of uses for salt, not just for improving the taste of foods. My mother and grandmother used salt as some sort of cleanser. My mother brushed her teeth with salt, until she got dentures, and then used salt to clean the dentures. Salt and vinegar can be used to polish brass. We gargle with salt water when we have a sore throat, and we spray salt water into our congested noses when we have a cold. In Pennsylvania, we used tons of salt on our icy roads. You can pay big bucks at a spa for a salt rub and massage. I never had one of those, but I can imagine how it would feel if you had some open scratches on your skin.

I personally love the taste of salt, except when it is dripping down my face in the form of perspiration. When I am feverishly working outside, I tend to sweat like a sprinkler. It drips on my glasses, obscures my vision, and burns my eyes. I tend to get some painful leg cramps on those days, most likely due to electrolyte imbalances. Since I am one of those millions of Americans with hypertension, I do my best not to use the salt shaker. I must admit that this can be difficult. Old habits are very hard to break.

I recommend saline nose drops to just every patient with an upper respiratory infection, especially children. Since the FDA took away all of those cold medications for kids, saline is all that we have left to recommend. Since tears are saline, and tears drip into the nose through the naso-lacrimal duct, then spraying salt water in the nose is really just augmenting tears. When you watch a sad movie, you start to sniff as your nose runs. This is really not snot, but merely your tears (mixed with a little snot, of course). Most home and work environments are dry, so saline sprays can work for all ages. Or, you can just arrange to randomly cry.

Here are some simple steps to help break the salt habit:

1. Get rid of the salt shaker, on the table and near the cooking areas. You can still have salt, but don't make it so easy to grab.


2. Use less and less salt in your cooking, even if the recipe calls for it. Gradually, you may be able to reduce your family's salt habit.


3. If your food seems tasteless, then substitute other spices, like onion or garlic powder, chili flakes, or whatever your tastes dictate. Experiment with non-sodium based spices. There are even commercially-available, sodium-free spices to use.


4. Pay particular attention to processed meats, like ham or bologna, and canned vegetables. Ketchup and pickles are particularly high sources of sodium, so read those labels. Don't buy high-sodium snacks, like potato


5. Drink lots of water. One teaspoonful of salt will hold one quart of water in the body. By drinking water, you can actually flush out some of your excess sodium through your kidneys. Don't over-drink water, however, since too much water can leech excess sodium and other essential electrolytes as well. About six to eight, 8-ounce glasses of water is about right for most people. (Remember that a typical water glass is considerably more than 8 ounces).

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Puppies Off to New Homes

Photo: Rod Moser

I think it was easier to send the kids off to college than it was to send two of the puppies to a new home today. My wife was sobbing, until she realized, of course, that we have reduced our puppy poop by 33% now! We still have four of them left - one will go to the neighbor's in about a week; one will go all the way to Maryland's Eastern Shore to live with my brother and sister-in-law. The other two will live with us. We are keeping Ellie, a hyper little girl who is teaching the others to bark; and Zac, a quiet little boy that has totally bonded with my wife. I guess I get Ellie....

The new owner is a retired, widowed man who lost his dog about 9 months ago. He initially wanted one puppy, but quickly jumped at the chance of getting two when another person changed her mind. He has been actively preparing for their arrival, including getting them a dedicated room in his house (I don't even have that), and has read up on caring for Shelties. Although it was sad to see him drive away with two of our puppies, they will be going to an excellent home. We know, we drove by and checked it out. My wife prepared a nice puppy pack that included the recipe for the food we are giving them now, one of my old socks filled with their mother's hair, a new collar/leash, and some of those smelly stuffed animals they have been sleeping with since they were born.

We also have an older Sheltie, soon to be fifteen. She is deaf, arthritic, and has teeth like a British methamphetamine user. She is unbelievably sweet, but sleeps about 22 hours a day now. Yesterday, when we decided to give her a bath and brush out her heavy coat, we discovered a mass. She has a walnut-sized tumor on one of her front legs. I took her immediately to the veterinarian that afternoon. The vet said it was cancer. The good news is that it is not painful for her; the bad news is that it would be too risky and painful to have it removed. Excising this malignancy will not change the inevitable, unfortunately, and surgery is a bit risky at her age. Sadly, after experiencing the utter joy of having six new little Shelties, we are going to lose our oldest one. I know that euthanasia is compassionate, but it still sucks. We hope we will not have to do this anytime soon.

Dogs have relatively short life-expectancies, unlike humans. Fortunately for many of us, we may live well into our eighties or beyond if we take care of ourselves, and are spared from life-threatening disease or accidents. Assuming dogs live about 15 years (some live longer); our life span is about six dogs, assuming you get one at a time.

My good friend drove up yesterday to see the puppies. He, too, has a very old dog. He stated that he has no intention of being without a dog, so like many people, he is looking for a back-up dog now. We have been friends for so long, that I remember at least six of his dogs. He told me that he can't imagine his life without having a dog. This time, he wants an Australian Shepherd. In the past, he has had English Bulldogs, two West Highland Terriers, a German Shepherd, and now, a pit bull (although he calls it something else less-menacing).

My brother procrastinated and pondered this decision since the puppies were born. He wanted one desperately, but did not want to sacrifice his freedom and mobility. It took repeated conversations with his friends, both pro-puppy and con-puppy, before he made the decision to get one. Logistically, this is going to be a difficult move. The puppy has reservations on Pet Airways to fly (first-class) from Los Angeles to Chicago, and then from Chicago to Baltimore. Pet Airways has a flight-attendant for the pets in transit; checking on them every 15 minutes. They fly in roomy cages in the cabin of the plane. It ain't cheap - about $250 for the one-way fare, not including the fact that we have to drive seven hours to Los Angeles to drop off the puppy. My brother is flying out for a few days prior. He will accompany the puppy to the flight, and then hop on another flight to Baltimore so he can get the puppy at the other end. Now, that is dedication. We both decided that having this little puppy in a cramped cage under the seat of the plane for eight hours was a bit cruel. This really is the best way, and a hellava lot cheaper than our other solution: having me drive the puppy to Nebraska (about three days), and him driving to Nebraska to make the switch. Of course, when you add up six days on the road, just for me, including fuel costs, hotels, meals, and wear and tear on the vehicle for 3000 or so miles, it would have cost each one of us about a thousand dollars or more!

Pets are good medicine, folks. I call it Petication! People with pets are usually less stressed (although I see a new pile of puppy poop on the floor) and happier. Pets are great listeners and relatively-good psychiatrists. They are non-judgmental, loyal, fun, and loving. Yes, you have to spend money on veterinarian bills, buy special food, and other pet necessities, but you don't have to send them to college. Pets will not steal your car, borrow money, or have parties when you are away. Pets do not smoke, drink booze, or take drugs. They will, however, chew your shoes, crap and pee on the carpet (at first), and wake you up at all hours of the night. The good things definitely outweigh the bad.

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Mentoring: Jump-Starting a Life

My good friend, Robert, reminded me this weekend that "The greatest gift a man can give is to stoop down and help a child." For the last year, he has developed a relationship with a young man who lives in his neighborhood. Chad is 18 years old and will be graduating high school soon. In addition to having straight-A's for the last three years, he is also concurrently taking college classes.

Chad's drug-dependent parents are not in the picture, so he has been cared for by one of his former teachers who now has guardianship. This dynamic woman (and her mother) helped transform this endangered young man into the polite and humble scholar that he is today. Chad wants to go into the medical profession.

Robert e-mailed me a few months ago and asked me if I would be a resource for him. I quickly agreed. Robert is currently is under treatment for prostate cancer. Chad recently accompanied him on a nearly 50-mile bike ride that he wanted to do before starting before starting brachytherapy and external radiation.

Knowing that I was going to be speaking at a medical conference about an hour from his home, I invited Robert and Chad as my guests for the day. The night before, we had a wonderful Italian meal at Robert's home. I was also able to meet Chad's guardians - his "mother" and "grandmother"-the two women that have taking him under their wings.

Adolescents tend to fall in two major categories: the unmotivated group, and the academic over-achievers. Of course, there are many teens that sit on the fence between the two. Chad falls well into the second group. He was well-mannered and poised. He participated in conversations like an adult, unlike some of the teens I see in my practice that would happily text-message while pretending to listen. He wore a tie.

The next day, Robert brought Chad to the Palm Springs Convention Center. The organization provided him with a special guest pass and invitation to lunch. He attended several medical lectures, and was even allowed to cruise the exhibit floor. I introduced him to the president of the American Academy of Physician Assistants, and the author of a new book, Becoming a Physician Assistant, and acquired a signed a copy for him. Since it was about 110 degrees outside, he spent the entire day interacting with several hundred PAs.

I don't know if he will pursue the PA profession or not, but I thought we at least should try to recruit him before someone else gets him. You can teach medical skills to just about anyone, given enough time, but you cannot teach someone to be a kind and compassionate healer. Robert saw something special in this young man, and I agree. I know that he will make a wonderful clinician someday, whatever medical path he travels.

Every person who has achieved personal success has others who have paved the path before them and people that have held their hands. Some people like to think that they did it alone, but this is rarely the case. Chad has some true angels to watch over and guide him, and his journey has already started.

Is there someone out there that you can help? Can you show a little girl how to knit or make a dress? Or, teach a little boy how to fish? Can you teach a teenager how to change the oil in a car? Can you bring a young student to your office and allow them to shadow you for a day? Maybe you can help a struggling college student to pay rising tuition costs? What can you do to guide or jump-start someone else in need?

I am reading a book by one of my favorite authors, Paul Theroux, called Ghost Train to the Eastern Star. He tells of meeting an Alaskan fisherman vacationing in tropical Cambodia. The fisherman had met a young man, making a few dollars a day, operating a rented, motorcycle taxi. The man wanted to be an accountant, but since he had to rent his motorcycle, it would take him many, many years to save enough money to achieve this goal. After three days as his personal driver, the fisherman had him stop by a motorcycle dealership. The fisherman plopped down $8000 - just about all the money that he had - and bought this Cambodian stranger a motorcycle so he could earn a living and reach his goal sooner. He gave the taxi driver his e-mail and only asked that he write from time to time and let him know how things turned out.

My friend, George, has brain cancer. He and his wife allowed an immigrating Vietnamese family to live with them for nearly a year so they could get a jump-start. More recently, they paid the tuition for a Filipino woman, the sister of their daughter-in-law, so she could attend school. My friend, Randy, who now lives in Loreto, Mexico, along with other American ex-patriots, buys school uniforms and pays the Catholic school tuition for dozens of children in their little community. My own mentor, the late Dr. Robert Haskell, once wrote me a check so I could have a down payment for my first house.

It was my pleasure to be invited to help Chad - to participate in his jump-start at a career. I really didn't have to stoop down and help him. Chad was already standing tall.

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CTAs as WEDs - Weapons of Ear Destruction

willc2 / CC BY-SA 2.0

In the early days of the Iraq War, Special Forces were scouring the area around Baghdad, looking for WMDs, like poison gas, missiles, or Saddam's nuclear arsenal. Although puzzling at the time, our dedicated troops found tons of cotton-tipped applicators (Q-tips) earmarked and destined for the U.S. The goal was to flood the market and encourage Americans to clean their ears. A large number of people would be rupturing their eardrums, causing damage to their hearing, and setting themselves up for infections in the ear canal. This was a dastardly and evil plan, striking at the closed doors of our bathrooms. Had it been successful, people all over the Western World could become seriously addicted, cleaning and scratching at the inside of their ears at every opportunity. Soon, pencils, paperclips, and bobby pins would be substituted. The productivity of workers, with one hand dedicated to ear-cleaning, and the other free hand attempting to type, would drop. Eventually, our economy would suffer, the stock market would plummet, with only a few companies thriving, perhaps those companies that make these Weapons of Ear Destruction.

Little did Saddam know is that Americans and other countries are already hooked. Along with toilet paper and tissues, our medicine cabinets were well-stocked. Made of tightly-packed cotton and paper, Americans were not going to be taking any unnecessary chances should these commodities suffer.

Q-tips do not damage ears or rupture eardrums. PEOPLE damage ears and rupture eardrums. Perhaps due to social consciousness or even litigation, the makers of Q-tips have tried to warn the ear-cleaning addicted masses not to stick these things inside the ears. I am using the term "Q-tip" in the generic sense, and in no way am I pointing fingers at a particular company or their finely-made product. Anyone can make cotton-tipped applicators (CTAs) in a free-market, and there are imitations galore - imitations with wooden sticks long enough to protrude through the other ear, or tips that fall off inside your ears. A significant portion of an ENTs practice is diagnosing and repairing damage due from these CTAs - The Weapons of Ear Destruction.

Unlike the requirements for cigarette makers putting scary warning labels on the packages, CTA manufacturers can still package them like they did in the past. In some countries, smokers will see gross pictures of cancerous lungs and blackened /missing teeth on cigarette packages - perhaps aimed at those who cannot read the warning labels. I am proposing now that CTA manufactures put two pictures on their packages: One with a big circle with a line through it, showing a CTA inside an ear, and another showing the face of a puzzled person in pain, blood pouring down the side of their neck, holding a bloody CTA.

I have done my very best to discourage the use of CTAs and ear-cleaning on the WebMD Ear, Nose and Throat message board, and the All Ears Blog, but the message has apparently met deaf ears (as you might expect!). I have been anxiously waiting for some celebrity to take up the cause. When a celebrity gets a type of cancer or Parkinsonism, they become important spokespersons for the cause - raising awareness and raising money for education and research. Everyday, I watch the news hoping to hear about some ear-prominent person has been permanently injured. Prince Charles has prominent ears. So, does Ross Perot, Dumbo, and my favorite, Bugs Bunny. Now that I think about it, maybe this is why Bugs Bunny says, "What's up, Doc?" Elmer Fudd aways seems to be sneaking up on him, so maybe he doesn't hear very well? Perhaps he tried to clean out his ears with a carrot!

If Valerie Bertinelli can lose a ton of weight and thus promote Jenny Craig, maybe someone will surface for my "Ban the CTAs" campaign. I was going to write a letter to Jerry Lewis, but I think he is contractually tied up with another worthwhile project.

I could write some pseudo-science studies and publish them on the Internet. People believe what they read on the Internet, no matter how ridiculous or medically-unsupported. I suspect someone will be quoting my Saddam Hussein Q-tip Plot Revealed! When I read this story to my wife a few minutes ago, she said, "Is that true?" I rest my case.

I can try and link the use of CTAs to erectile dysfunction or obesity. For instance, "Researchers found that obese people clean their ears on a regular basis. Is there a link?" "Men with erectile dysfunction admit to regular Q-tip use." Once you get an article on the Internet, it will be quoted forever. People will then say that they lost 37 pounds in three weeks after giving up Q-tips. Actually, you CAN lose weight by using Q-tips to eat, instead of a knife, fork, or spoon. I will write a book and promote the Q-Tip Diet! Oprah, here I come.

The Federal Government is handling out a lot of cash lately, to auto companies, banks, and failed brokerages. The "Cash for Clunkers" campaign gave a few billion dollars so that people could upgrade their cars. Maybe I will write to President Obama (he has some pretty big ears that seem suspiciously clean on those close-ups) and ask for some money. As soon at this Mexican/Swine/H1N1 global influenza pandemic thing is history, maybe there will be some money left.

I already have some possible slogans and t-shirt ideas: "Skip the Tip." "Avoid the Wax Pack." "Here's to Ears!" "Don't Clean Children's Ears - They Don't Listen to You Anyway." "Don't be a Rear, Stop Cleaning Your Ear." Or my personal favorite: "Cleaning Cerumen - Not Part of Groomin'."

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Do Kids Need Pack Animals?

Photo: M.Lubinski / CC BY-SA 2.0

Now that school has started again, I expect to be seeing my share of backpack-related back pain again. Obviously, the weights of those packs vary from child to child, but I have weighed many backpacks in my office and found some to top twenty pounds. That is two, ten-pound sacks of potatoes! Another observation has been - the smaller the child, the heavier the backpack. I don't really understand this.

Why are packs so heavy? First, books are heavy and kids often have to lug around ALL of their books to every class. Unlike my school days, many schools have completely eliminated lockers. Why? Apparently kids were hiding contraband in those lockers, such as illegal drugs or weapons. The only things we would find in our lockers two generations ago were ancient lunches, snacks, smelly gym clothes, and of course, the occasional Nerd. In those days, schools had the right to open our lockers anytime that they wanted without fear of the ACLU coming down on the school for violating civil rights or privacy laws. I didn't think we were entitled to any privacy in public schools.

If kids wanted to hide contraband, they can hide a lot of scary stuff into those huge backpacks they are carrying around every day.

Why don't they have wheeled backpacks? They do, but none of the kids will use them because wheeled backpacks are not cool... not cool at all. If they tried using them, they would most likely be stuffed into one of those unused, empty lockers, and permanently labeled as a nerd. It is also not cool to use both straps, like a camping backpack. Kids are expected to use just one strap, hanging on one shoulder. Backs do not like this type of imbalance.

Adolescents get injured in sports all of the time, injuring limbs and backs. Unless they are paralyzed, they want to continue to play football or do cheerleading anyway. Regardless of their injuries, they always ask for a note (see my blog post about notes) for PE. Teen rationale dictates that it is okay to play football with an injury, but not square dance in PE.

I have a solution to bring this on-going back problem to light. Since service animals, such as Seeing Eye Dogs, are protected by the Americans with Disabilities Act, I think I am going to start recommending pack animals to kids with recurrent back pain who must carry heavy loads all day long. I can just see it now; kids walking the halls with miniature donkeys, mules, llamas, or St. Bernard dogs. They can tie up outside the classrooms, or to their desks. They will be novelties at first, but soon, the schools will get used to seeing of animal poop on the floor, llama spit on the walls, and of course, the omnipresent barking and braying. I am really, really tempted to start writing prescriptions for service (pack) animals. Schools won't give our kids some lockers, so let's see if they build some stables.

Heavy backpacks are not the only things responsible for adolescent back pain. Teens tend to have the worst posture ever - the slouch in their chairs, and sit with their backs humped over like Quasimodo. The kids in sports tend to be very active, but a large percentage of teens just come home, raid the fridge, and then plop onto the couch, or more likely, slouch in a chair to play hours of computer games. Inactive, after-school, latchkey kids tend to get fat, and of course, get into mischief.

Several of my patients with back pain have bed issues. For some, there are still sleeping on swayed mattress, handed down from older siblings. Many of the six-foot plus adolescents sleep with their legs hanging over the end of their toddler beds.

I have back problems myself, but mine was not due to lugging around a back pack. I do carry a brief case that could be lighter. My briefcase weighs considerably less than my wife's purse, which incidentally, looks a lot like a backpack without the sleeping bag. I would love to dump out a woman's purse someday, just as an experiment. Once a year, I do make my wife dump out her purse so I can get the hundred or so receipts jammed in there so I can do the taxes. I once found a receipt that was four years old!

I was always told to never look inside a woman's purse. When I was older, I just assumed it was so that curious boys would not find a tampon and think it was dynamite. When my wife goes into a dressing room on those (very) rare occasions that I am with her when she shops, I usually have to sit in the man chair with the other guys and hold her purse. The men sort of nod at each other, but none of us are digging around trying to see what is so heavy in there, perhaps expecting an anvil.

Women with children get very adept at carrying heavy loads - a heavy purse and a diaper bag hanging on one shoulder, balanced out with a huge, squirming toddler on the other arm. I am often amazed in my clinic, when I lift up one of those "big ones" onto the exam table, how deceptive their weight can be. Even some of the "little ones" are dense as lead. Maybe I am just getting weaker. At the end of the day, my back is starting to hurt. I don't know how these Moms do it. I have a hidden rule: if I see a baby with more than two chins and no neck, I let the Mom pick them up.

My old college roomate, Robert, was planning a six-month long backpacking trip to Tahiti, Fiji, New Zealand, and Australia (must be nice). I had to watch him everyday, packing and unpacking his backpack, trying to make room for both summer and winter clothes and balance his load. He actually used my postage scale to actually weigh socks! After about a hundred packings and unpackings, he finally was satisfied. He was in the shower the morning of his departure; his carefully weighed and balanced backpack sat by the door. As I went out to get the morning newspaper, my evil eye spotted a loose brick sitting next to a garden wall. Smiling, I picked up the brick, and rushed into the house. I quickly unpacked his backpack, pulled out his down jacket in the bottom (for the winter in New Zealand), and carefully hid this five pound red brick. I finished repacking his bag as I heard the shower stop.

Over the next several months, I anxiously awaited those postcards from exotic places; and pictures of his lazy butt sitting on the beach in Fiji. I would smile when I would see that backpack sitting under a swaying palm tree. Then one day, my long-awaited postcard arrived.

"You SOB! I found that brick!" I had attached a note asking that he please deliver this brick to New Zealand for me.

So, somewhere in the South Island of New Zealand, perhaps along a rural road, sits a lonely, red brick. I should have put two bricks in there. Maybe next time.

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Doing Your Part

Your Responsibilities as Member of a Community and of the Human Race

In the last two weeks, we are starting to administer the seasonal flu vaccine. You would be surprised how many people are refusing it because they do not think they need it. But, what about the rest of us?

We all share this small planet; a planet with limited natural resources, and a planet that is progressively becoming more polluted and damaged. Globally, steps are being made to limit greenhouse gases, preserving the protective ozone layer, finding cleaner fuel sources, and replacing some what has been exploited and raped over the centuries.

I grew up in a strip coal mining area, where beautiful topsoil was moved aside in order to get at a narrow layer of soft coal. Thanks to the efforts of environmentalists, much of that land has been restored. The air and our streams are no longer stinky and yellow. It was commonplace to run sewer lines directly into a pristine creek. A generation ago, people mindlessly dumped their trash along the side of rural roads, or simply threw out their fast-food bags from a moving car. Thanks to Lady Bird Johnson's efforts, our roadsides are no longer piles of discarded junk and rubbish. Little by little, America became more beautiful when people started caring.

A week ago, we were given evacuation orders when a wild fire threatened our neighborhood. Over eighty homes were burned to the ground. Had the wind changed directions, our home would have been lost, too. The cause of this fire is yet undetermined, but arson is a possibility. A few minutes ago, the Department of Forestry spotter plane buzzed and circled my house. There was another fire; this time only a mile away and the wind was blowing in our direction. The quick efforts of our local fire department quickly got this fire under control. According the Highway Patrol, a motorist threw a cigarette out of the window, starting a roadside brush fire. Throwing a burning cigarette out of a moving car deserves jail time, in my opinion. Of course, they will never catch the culprit.

Are we all doing our share? Do you turn out the lights in rooms that are unoccupied? Do you use energy-efficient bulbs? During the summer months, do you set that thermostat a little higher? Do you drive the speed limit and wear your seat belts? Do you recycle your aluminum cans, glass, and plastic? Are you immunized against vaccine-preventable illnesses? Do you wash your hands? Do you smoke? All of these seemingly little things help our planet and your community. As members of the human race, these are your responsibilities.

As a child, we did not have seat belts in our vehicles. Children were not restrained in infant car seats; they could freely jump from the back seat to the front if they chose. Motorcyclists were not required to wear helmets. So, how does wearing seat belts impact our role in the community or the human race? A non-seat-belted person is more likely to sustain serious head and neck injuries, assuming they are not killed. If they have health insurance, the bills could be astronomical for their care. This will raise rates for all of the other insured people who do wear seat belts. If the person does not have health insurance, the state and federal government will end up footing the bills, and of course, guess who pays the state and federal government through taxes?

Smokers feel that they have a right to smoke. Apparently, "Freedom to Smoke" is protected by our Constitution somewhere. Smokers pay the same insurance premiums as you and I, but of course, smokers tend to get more respiratory illness, such as pneumonia, asthma, or emphysema, use the emergency room more often, and have a higher rate of cancer, requiring expensive surgeries and cancer treatments. Smokers have higher absenteeism at work and lower productivity. Again, the insurance companies (and we non-smokers) foot the bill, as well as the government. When smokers flick their cigarettes out of a moving car and start a fire, someone else still has to pay for those damages. When a person chooses to smoke, they impact more than just their own lungs. They seriously impact ALL of us, directly and indirectly, in so many ways.

If people defend their right to smoke, do they also defend their right not to wash their hands? Is personal hygiene (or the lack of) protected by the Bill of Rights? Someone comes out of a public restroom and doesn't wash their hands. They put their contaminated (poopy) hands on the door handles. A little child touches that handle and becomes seriously ill. The simple act of washing your hands can have a major impact on the community.

There was a major public health effort in the 1950's. If people had the right to refuse vaccinations, no one really exercised those rights. Everyone felt that it was our community responsibility - our duty - to be vaccinated, so that people would not get polio, or measles, or whooping cough. In less than a decade, the incidence of these vaccine-preventable diseases plummeted. Everyone, by getting vaccinated, did their part. These public health efforts have saved millions of lives and billions of dollars, yet now, people feel they have the right to refuse vaccinations for personal reasons...stupid reasons. They don't care if they, or their children get the diseases, and they certainly don't care if they spread it to others in the community. You cannot achieve "herd immunity" unless all or most of the herd has been inoculated. Just like one bad apple making the others rotten, if there is an unimmunized person in a community, the disease will survive. An epidemic starts with one.

There are people in the community that count on "herd immunity". Our efforts to vaccinate ourselves and our children is their only protection. They want others to take any risks, but then expect the insurance companies and society to take care of them if they get one of these serious, preventable diseases. Medical care is God-awful expensive, not just in dollars but in emotional toll. Are their calculable risks to taking vaccines? Sure, very small ones. The risks of serious vaccine reactions are considerably less risky than the chance of getting struck by lightening, but yet people are afraid. Some of these fears are created and nurtured by the Internet, backed up by pseudo-science and charlatans.

Perhaps the real barrier is trust. Since the 1950's, Americans seem to have lost faith in their government, perhaps for good reasons. Remembering thalidomide and other recalled drugs, they do not trust the pharmaceutical companies. They do not trust the FDA that approved these drugs. Often, they do not even trust their medical providers - the people that they chose to participate in their health care. People do not trust banks, the post office, the military leaders, or our President. What happened? Right now, President Obama is trying to make a complacent and mistrusting population aware of the serious health threat that influenza can cause. Millions of Americans died in 1918 and it can happen again. Why don't people listen?

In order for people to share responsibility, we have to have trust. We have to trust that everyone will do their part and not opt out or make excuses. We have to trust our elected leaders and our scientists, and we need to come down hard on those who betray basic, human trust. It has been said that we can trust, but verify. It is perfectly normal to question recommendations, but at some point, it will come down to trust. Do you trust your government? Do you trust your medical providers? Do you trust your own judgments?

As a medical provider, I am on the front line. I had to take four nasal swabs for a pertussis test this week on a 15-month old. The mother does not "believe" in vaccines, so none of her children are immune. I can take care of her because I am immune to pertussis. I took my vaccine. Otherwise, I would be putting my own life at risk. I can take care of people with influenza and other life-threatening illness because I am vaccinated, and this is my job. Vaccines are not perfect; few things in life are perfect, but vaccines are and will remain one of our best defenses. It is much easier to prevent an illness than treat one, I can assure you.

Please do your part. Don't throw trash out of the window. Turn off unnecessary lights and use energy-efficient bulbs. Wear your seat belts or helmets, and secure your children in car seats. Don't smoke, and if you do, stop. Wash your hands. Unless you have a true contraindication, take the recommended vaccines. Be honest and learn to develop trust (again). We live in the same community; on the same planet. We are all in this together.

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Worms!

We attended a birthday party for my grandson, Tynan, who turned four years old this weekend. All of the children were happily playing in the front yard, when one of the boys came in asked to use the bathroom. He said he needed to wash his worm. At first, I thought what you are probably thinking right now, but no. He actually had a dirty earthworm in his hands and wanted to rinse it off. Tynan came in next with a handful of his worms, also needing a bath apparently. By the end of the party, they had managed to dig up quite a few worms that were (happily?) living in a box of dirt.

We have six new puppies at home. Even though our puppies have never been outside, there is a very good chance they have could have intestinal worms. So, we have been giving them worm medication, even though I am skeptical that they need it. Because of these puppies, I had been thinking a lot about worms lately....all kinds of worms.

I was petting our friend's scrawny cat the other day, running my hand down his backbone. This cat, known for his bird and mouse-catching (and eating) skill, has been eating a lot, but seems to be losing weight.

"Have you thought about worming him?" I told my friend. It would not surprise me that this cat had worms.

My oldest son decided it would be a good idea to have two huge Rottweilers in his small Texas home. They were eating him out of house and home, yet had the physiques of emaciated Greyhounds. I told him to worm those two dogs, and guess what? They put on an incredible amount of weight. The next time that I saw them, their coats were shiny and healthy, and they weighed about 80 pound each. The worms, of course, were not pleased with the outcome.

In the classic movie, Christmas Story, the father was attempting to eat a piece of uncooked turkey.

"You leave that turkey alone. You'll get worms!"

I find it interesting that we dig up worms for bait in order to catch fish, but if we eat those fish, sushi-style, we could end up getting worms. Different worms, of course, but I like the irony.

You wouldn't know by looking at me now, but I was once a very skinny child. My grandmother, a doctor in her own mind with the experience of raising 13 children, was convinced that I had worms. I vividly remember being held down by my two uncles while they attempted to get me to swallow some sort of foul liquid worm medicine. I maintained my svelte shape until age 35 or so. After that time, I put on weight, hoping many times, that I would get worms.

Around the turn of the century, capsules containing live tapeworm larvae were sold as a weight control method. Apparently, you would let the tapeworms happily feast on your overindulgence until you achieve an ideal weight, and then simply take worm medicine to rid yourself of this infestation.

As a student, I was doing a pediatric rotation at the University of West Virginia. During this particular week, I had seen an unusual number of children with pinworms, a common human infestation. I have always been a dedicated hand-washer, but after seeing so many cases, I started to doubt myself. My butt started to itch and I was convinced that I had contracted pinworms. Not wanted to reveal this to my physician supervisors, I decided that I would just treat myself. Why not? I diagnosed myself. At this time, the worm medicine was a noxious, foul-tasting liquid that apparently attacked the worm's neurological system. The dosage was based on body weight, of course. Little children were given just a few milliliters. I had carefully calculated that I would need considerably more. After getting up my nerve, I downed the medicine. The taste was unbelievably bad, not unlike the stuff Grandma was trying to force down my throat nearly two decades ago. The taste seemed to evoke those repressed memories.

One of the side-effects of this medication was neurological effects, namely profound dizziness, nausea, and vomiting. Needless to say, I got them all. To this day, I really don't know if I really had pinworms or it was just my mind creating those symptoms. My butt did stop itching, so all's well that END's well, so to speak.

Perhaps because of this experience as a student, I have always had my eye out for pinworms. Anytime I would have a patient complaining of pruritis ani (the more pleasant Latin term for "itchy butt"), I would immediately consider pinworms as a potential cause. Of course, not all itchy butts are pinworms. It could be yeast, an allergic reaction, or just plain, poor hygiene.

One day, I got a call from a patient who thought her son had pinworms. He seemed to be scratching his bottom quite a bit, and this conscientious mother thought of worms.

"I am sure that my son has pinworms. How do I find out for sure?"

My sick sense of humor wanted to ask her if he was scooting around, dragging his but on the carpet, but I didn't.

"After he goes to sleep, creep into his dark room with a flashlight. Carefully, as to not waken him, pull down his underwear, spread his butt cheeks, and shine that flashlight. If he has pinworms, you will see these little, thread-like creatures moving around. If you see them, give me a call and I will prescribe the proper medication."

An uncomfortable silence ensued.

"He's 17 years old!" She replied.

I had learned an important lesson about asking the age of the child before recommending this action next time. The recommended treatment is now just one simple pill (Vermox), no matter how much you weigh. This teenager had not idea how lucky he was, although I suspect he would have spent years in therapy had he discovered his mother peering at his bare butt with a flashlight.

Once again in medicine, fate prevailed and a minor tragedy was avoided - just another case where I was able to worm out of an embarrassing situation.

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Work Notes, School Notes, PE Notes - Aaaargh!

When did we become a society that requires doctor's notes for everything? I spend a great deal of my precious day writing note after note to coaches, teachers, day-care providers, and bosses. Is this really necessary?

I have always felt that people are basically honest until proven otherwise. When a responsible employee is required to submit a note to his/her boss just to confirm an illness, I find this very problematic. If I have seen the patient for a particular illness, I will write the note, although I think it is ridiculous that adults have to do this. In generations past, if you were too sick to go to work, but not sick enough to pay for a medical visit, then you just stayed home. Now, people have to pay for a medical visit just to get a work note sometimes.

Yesterday, I had one of the "no show" appointments. Someone made an appointment, but didn't have the courtesy to call and cancel it. When I reviewed the records, I discovered that this person has no showed for eleven visits! I am surprised that the PCP (primary care provider) has not discharged them from our practice, since they are costing us a considerable amount of money. When someone no shows, they prevent someone else from using that appointment slot. I find this rude and inexcusable. Sure, we all forget and miss an occasional appointment. We are human. But, eleven appointments... this person has a problem. I suspect this is the same person that will call me in a few days asking for a note for her employer because she was "sick"... apparently too sick to come in, and too sick to pick up the phone and cancel her appointment.

Someone with chronic work absenteeism, someone that tends to be sick only on Mondays or Fridays, or someone who becomes too ill to work the day before a long holiday weekend, would certainly raise my eyebrows as a boss. For these yahoos, I would require a note, too, or better yet, provide them with a note - an official DCM (Don't Come Monday, you're fired).

State and federal employees always ask for notes. Teenagers who work for fast-food places ask for notes. People who are on probation for chronic absenteeism ask for notes.

This is football season for the high schools. Coaches are scrambling to get their players ready for competition, so many have practices twice per day now. If a player misses a practice, the coaches require a note to prove they were ill. A note from the parents is apparently not good enough. They want a "doctor's note". I get so tired of doing these that I have become passive-aggressive, often writing "Jim was sick today" and sign my name. I don't feel that the coach has any business knowing the nature of the illness if it does not affect the player's performance or put others at risk for a contagious illness. There are days that I would like to write, "Jim has gonorrhea and cannot play today."

Schools are probably the biggest abusers of notes. It took me a while to realize that these notes are worth big bucks to the school, since an excused absence due to illness still qualifies them for federal matching funds. For instance, a school may get $35 per student per day from the government. If just ten kids fail to show up, the school will lose $350 - perhaps the salary of one teacher (including benefits). When a hundred kids stay home during a flu epidemic; that can add up to a lot of money... and, a lot of notes for me to write.

For some reasons, teens try to get out of PE. I know, our kids were always asking us for notes. Our oldest son, Josh, wanted a note to get out of PE because of "back pain". Apparently not realizing what we do for a living, we examined him and determined that he was a malingerer - nothing wrong with his back. We gave him a note for "remedial PE" that did not include running, so he was fine. He was fine, until the PE teacher decided that if he couldn't run or play basketball, then he would be reassigned to the special needs class. For two days, our son was in a class with kids in wheelchairs, leg braces, crutches, or with mobility issues because of cerebral palsy. He quickly discovered that his bogus back pain wasn't really that significant. On day three, his disabling back pain miraculously resolved and he returned to his regular PE class. Some time later, we discovered that he had PE during first period, and it messed up his carefully styled hair!

Kids with the True Flu (medically-diagnosed Type A Influenza) MUST stay home. As a matter of fact, if they are doing okay, I would prefer that they not come in to our office, either. A doctor's office, no matter how we try to keep things clean and sanitized, is a great place to spread illness, and a great place to come in with one illness, and leave with another. Here is the Catch 22. If they need a doctor's note, I have to see them. If I have to see them, I have to have an open appointment or work them in. I often have a dozen more requests for appointments per day than I have open slots. If they can't get an appointment (to get the note), they go to urgent care or the ER, over-crowding the waiting rooms and over-exposing everyone they meet. I suspect the quest for notes costs our economy billions of dollars per year.

Daycare providers often think they are medical providers. If I had a nickel for every rash that was supposed to be measles or chicken pox, only to be hives or mosquito bites, I could have retired years ago. My wife and I used to teach a class called "Pediatrics for Child Care Providers" that was required for licensing in our county. We taught thousands of eager child care providers how to properly recognize certain infectious diseases, and how to establish reasonable exclusionary polices. When child care providers exclude your child for suspected pink eye or the plague, the parent has to leave work to pick them up, make a timely appointment for my office (usually the next day, so they miss TWO days of work), and require a doctor's note before the child can return, then I have to write TWO notes - one for the child care provider since they don't trust the parent, and one for the boss, also because they don't trust the parent.

One study showed that over 80% of all missed days for working women are for the illnesses of their children. It doesn't take very long for a responsible working parent to quickly run out of sick days just to take their kids to the doctor. If the employed parent becomes ill, they have to go to work sick, where they will expose their fellow workers, who will become sick, inadvertently infecting the kids going to day-care, thus starting an epidemic. They will then show up at my office asking for notes.

If I were the dishonest, entrepreneurial type, I would have a note vending machine in my waiting room. People could insert a five-dollar bill, type in the days they missed work or school, and out pops a signed note. That is a good idea. The Doctor Note-O-Matic! This would be a noteworthy and lucrative venture. Sorry about that...

I do have a confession to make. In my teen years, I became quite skilled at forging notes so we could go to the library instead of French class, or a teacher's signature as proof that we had completed a chemistry experiment. One of my proudest days as a forger occurred when a teacher turned down his actual signature since it did not look like the other (forged) signatures that I had done!

Actually, I attempted to write my own note in first grade when Gregory and I decided to play hooky and hide in the woods all day. In my youthful naivety, I did not know I would need a note to get back to school the next day. When mean old Miss Rider told me that I had to have a note from my mother for missing school yesterday, I truly became sick. After dozens of attempts to replicate my mother's handwriting, I knew it was not very good. Fessing up and hoping for a one-time only reprieve, my mother was not sympathetic. She actually wrote "hooky" on my note! This would not do.

I went across the street to my kindly Aunt Norine (now, 95 years old), to see if I could con a note out of her.

"Why didn't your mother write this note?" she inquired.

"She didn't know how to spell "sick", I replied.

My aunt wrote the note and I was ever so grateful. She also made me go to church the next Sunday hoping that I would confess my sins before it was too late. I found that you could pray for forgiveness. Unlike Miss Rider, God didn't require a note.

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Brain Tumors

I remember the scene in Kindergarten Cop with Arnold Schwarzenegger where a little boy tells Arnold that he probably has a tumor.

"It's NOT a Toom- A!" Well, sometimes it is.

Senator Ted Kennedy passed away yesterday from brain cancer - a glioblastoma, considered one of the most difficult tumors to treat. One of my best friends, George, was diagnosed with this same tumor about five months ago. He calls it "The Big Kahuna - The Mother of All Tumors". As you might imagine, George has been following Ted Kennedy's cancer fight closely. Kennedy seemed to be doing so good in the beginning, that his progress was an inspiration to my friend. He would tell his doctors, "I want the same treatment that Ted Kennedy is getting."

Like Senator Kennedy, he has been fighting his HMO for the best care. When he woke up one day, his only sign of his occult mass was his inability to remember words. All that came out of his mouth was a meaningless word - "Perkis". Thinking this was a sign of a stroke; his wife gave him some aspirin and called us. Obviously, we had her call 911 to get him to the hospital - STAT. A CT scan was ordered and the mass was quickly spotted. A day or so later, he had brain surgery to remove as much of the tumor as they could. Of course, this is not the full story. George had another tumor, a smaller one that was initially missed. This second tumor is the real trouble-maker right now.

It took nearly a month before he was finally started on radiation and chemotherapy. The radiation course has been completed, and he is now on this second, even stronger, round of chemotherapy. Sadly, this second tumor disqualified him for some promising experimental drugs, and more recently, the location of this second tumor, disqualified him for gamma knife treatment. His oncologists are hitting his brain cancer with round after round of potent chemotherapy agents. His most recent MRI showed that the second tumor has not increased in size - a somewhat promising sign if there really can be such a thing with this diagnosis.

When I heard the news about Senator Kennedy's death last night, my heart went out the Kennedy family, but more so, my heart went out to George and his family. Cancer victims are inspired by survivors, so I know this news will be devastating to more than just the Kennedys and our country.

George is a recently-retired university professor - a brilliant man in all respects. He can converse on just about any subject, including the medical management of glioblastomas. I am sure that he never anticipated doing research in this fringe area five months ago.

George has lost some (not all) of his Sasquatch hair. He is now wearing a hat that he found at the local hardware store that has a large crop of fake hair on the top. Like me; he has a full beard. For some reason, the chemotherapy has not affected his facial hair. The chemo is kicking his butt most of the time, so he is sleeping more, and tends to be rummy after those long naps. However, he is still the same 'ol George with a great sense of humor and a love of life. Of course, as an intellectual and realist, he knows that his life is threatened.

George is spending as much time as he can with his four (adult) children and his four grandchildren. There are get-togethers of some sort nearly every weekend - 4th of July parties, Mexican fiestas, birthday bashes, etc. You name it. George planted his annual vegetable garden with his grandson, Connor, this year. Connor eats most of the tomatoes, as soon as they are ripe.

George loves good food and fine wine. He is a member of a wine co-op and has done his share of grape-stomping over the years. His wine collection is now sitting idle. Wine is not on his "cancer diet". Also banned is red meat, with the exception of lamb (his favorite). A few weeks ago at a dinner at our house, I gave him his fill of New Zealand lamb chops, marinated and grilled to perfection, I might add.

As I write this blog post, I look out at a 12-foot high, hand-carved wooden giraffe standing in my yard. A few years ago, while we were on vacation, George drove a few hundred miles to buy it, and then installed it in my yard. We came home at night, so we didn't see it. The next morning, while I was drinking my coffee, I was startled to see a giraffe staring at me. George and his wife, Claudia, always considered our place to be "in the jungle", and you really can't have jungle without a giraffe.

If I ever have to face a serious health crisis, I hope that I do it with George's attitude and conviction. Ever since I received a letter from John F. Kennedy at age 12 (I wrote him a letter and he responded), I have been a Kennedy watcher and admirer. Our country is blessed with some extraordinary leaders, but sometimes, seemingly ordinary people do extraordinary things. George is, and will always be, my personal inspiration. Life is so precious that not one moment should be wasted. When your life is threatened by a serious health crisis, each and every day becomes even more golden.

We are but a dash in life. We are born on a certain date and some day we will all die. A little dash (-) will appear between those dates indicating the entire span of our short time on Earth. So, while we are alive, we need to do our best to make our precious dash really count.

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Airing Some Dirt

Photo: √oхέƒx™ / CC BY 2.0

Airplane cleanliness was one of my twelve Dirty Dozen that I discussed on a past Blog. My experience on my most recent cross-country flight has not changed my views. Like most businesses, the airline industry has to cut corners. I guess if I had to sacrifice cleanliness for safety, I would chose safety, hands down.

Hurry Up and Wait
We have to get to the airport now about two hours early due to safety inspections, and I did just that. However, I had to wait in line while only a few people checked us in. I had no bags to check. Now that I have my Rick Steve's travel bags, I can haul a weeks worth of clothes and several books, including a suit, into a backpack. My briefcase has my camera (I always carry it) and my essentials - toothbrush, comb, medications, and busy paperwork. Since 9/11, I have been more anxious about flying, so I try to remain busy. As a non-drinker, I do not have alcohol as an anti-anxiety crutch.

I stood (patiently) in line for over an hour. Once I checked in (I should have printed out my boarding pass the night before, but I worked too late and forgot), I was directed to my gate, about a mile away. That heavy backpack wasn't so convenient at this point. As you might expect, there was another line at security.

People were standing around in bare feet and all I could think about was foot fungus. I saw some pretty funky feet in that line. I was wearing sandals, but I had to take them off, too. I didn't think the space between my toes was much of a security risk, but I guess the soles of my sandals could have been an issue. I had gone to great detail making sure all of my liquids - shampoo, cologne - were in tiny bottles. I had nothing sharp, except my wit, of course. For some reason, my bags were set aside for the sniff-test, checking for explosive residue. I do not deal with explosive, so I had no worries, except that maybe I fit the profile of a mad bomber.

Frequent Flyer Seats
I was able to use my frequent flyer miles to upgrade to first class, although there are several degrees of first class. Every time that I do this, I get into seat 6A - the last row of first class. This is really much better than the first row, of course, since this row is the waiting area for the toilet. Not only do occupants in these seats get frequent whiffs from those open doors, but a few whiffs of those anxiously waiting for that one door to open.

I apparently have a huge bladder, since I can hold it for many hours. I don't like to use public restrooms, especially on an airplane. Turbulence tends to start about the time you try and pee anyway.

The last row of seats gets the meals that are not chosen first. On this breakfast leg of the flight, I just knew I would get cold cereal. So, as I ate my corn flakes, I thought about the cleanliness of my tray table that I forgot to wipe off. Was there a pile of used Kleenex sitting there from the previous passenger, recently diagnosed with H1N1 flu? How many sneezes did that tray get? I made sure not to touch it, or sit down my microwave-heated muffin. Between flights, airline personnel will empty the trash, but they do NOT sanitize the trays or arms of the seats. Since germs can remain on hard surfaces for hours, this concerns me.

Announcements
We live in an age of electronic marvels, so why do announcements on a plane hiss and echo like a New York subway. Granted, my hearing isn't what it used to be, but I had absolutely no idea what the pilot or flight attendants were talking about. They could be announcing a water landing, but I would not have a clue. In the event of a water landing, your seat cushion can be used as a floatation device. I can tell you right now, if we were making a water landing, my own seat cushion would not be suitable. I always listen to those safety briefings and notice where the emergency doors are located.

Pull Back and Wait
Airlines treasure their on-time statistics. This is why they pull back from the gate on-time, only to wait another 30 to 45 minutes on the tarmac. We had a 30 minute delay in Dallas, sitting there in the 100 degree heat, and a 45 minute "weather" delay in Washington, DC, on the way home. I don't mind weather delays, since I absolutely hate the storm cloud roller coaster. Once, while flying into Detroit, our plane hit some unexpected turbulence, the kind that will field test those seat cushions. The look on my face must have concerned my elderly female seat mate, because she took my hand and said, "It's okay, honey, I have been in worse than this. You'll be fine."

Seat Mates
On the first leg of my flight, I was entertained, non-stop, by an embittered newly divorced man. He was ragging about his ex-wife, her attorney, and his child support/alimony responsibilities. I picked up a new seat mate in Dallas, a cowboy (naturally). He was pleasantly quiet, drank a lot of free booze, and was miffed that he had to eat a salad for lunch. I sort of aced him out by choosing the last pasta dish.

A seasoned soldier, home from Iraq, shared one of the travel legs. He was Cuban, having immigrated in the late 1960's, after the Bay of Pigs. He still had a Spanish accent.

My seat mate on the way home was a young woman armed with an array of antibacterial hand lotions, wipes, and other forms of disinfectants. I did admire her recognition that planes are not the most sanitary modes of transportation, I think she overdid it a bit. I don't know why these sanitizers have to smell so much like perfume. It reminds me of those old ladies in church who use gallons of cologne to mask unwashed body odor. I coughed a few times from the fumes, which concerned her a great deal. If she had a mask, I am sure she would have worn it, or at least handed it to me. Incidentally, our clinic now has a "flu table" set up, complete with hand sanitizers, masks, gloves, and even gowns for people to use if they want. The airline industry should take a hint.

Idle Time
I had several books and bought a few magazines at the airport. Just likely eating all of your popcorn before the movie starts, I read nearly all of my magazines before the plane took off. My book is a bit boring, so I did nod off a few times. I am so concerned that I will loudly snore that I tend to avoid sleeping on the plane. My last seat mate had loaded a lot of movies on her laptop and was listening to them on some nice Bose headphones. I would glance at the movie from time to time, and wished that I would have brought my own laptop this time. Knowing that my brother, a Born-Again Apple user again, has one, I decided not to bring mine. I was thinking that I was sparing the extra weight, but your own in-flight movies on a laptop are sure a nice distraction for idle time.

Window seats give you the ability to spot clouds that may cause some unexpected bumps. Over California, I spotted several active forest fires - a seasonal threat to many of us who live in wooded areas. When I saw the deep, blue waters of Lake Tahoe, I knew I was nearly home. Soon, I spotted the rice fields adjacent to the airport. It is always nice to travel, but it is even better to be safely home.

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Interesting Tidbits from the Medical Literature

More on Losing Health Insurance
It is worse than I thought. Up to 14,000 Americans per day may be losing their health benefits during this economic downturn (a nice term for "crisis") according to a report by the Center for American Progress and Health Care for America Now.

"Approximately 2.4 million workers and their families have lost the health insurance their jobs provided since the current recession started in December of 2007, according to an analysis by Nayla Kazzi at the Center for American Progress. "

"More than 51 million Americans under age 65 do not have health insurance as of January 2009, and millions more drift in and out of coverage as their employment and financial situation changes. According to a March 2009 study from Families USA, approximately 87 million Americans under 65 - nearly one in three - went without health insurance for some period in 2007 or 2008."

(See "When You Have No Health Insurance or Money" blog post). More and more people are being qualified for the government's Medicaid program - millions of people are already enrolled and the number is growing. If families try to purchase private insurance, they need to expect rising costs there as well (assuming they are healthy enough to qualify and do not have any pre-existing health problems).

And More on COBRA... It Strikes Employers, Too
The economic stimulus package will subsidize 65% of the COBRA health insurance costs for up to 18 months. Some companies feel that this will be an additional (and costly) burden to companies who have to pay the administrative costs to manage this program for laid-off workers. Personally, I think the minor administrative costs are the least a company can do for these disadvantaged workers. In a way, it was nice for our government to help out.

Get Ready for the Upcoming Epidemics
Most young families have never seen measles or Hib-related diseases, but that may change soon. There have been pockets of Hib and measles cases popping up across the country. There were about 400 cases in the U.S. last year. Unimmunized families may see them first-hand, unfortunately. As more and more families opt not to vaccinate their children due to unfounded fears that they cause autism and other developmental disorders, those diseases will surely return - perhaps with a vengeance. Measles has never left and continues to be among the leading causes of death in children worldwide. I suspect that families without health insurance will also be skipping these important vaccines.

According to the CDC, there were 131 cases of measles in 2008, the most since 1996. Most experts feel that this resurgence of measles is due to the highly vocal anti-vaccine movement.

Swine flu may be less serious than we expected, but expect an unprecedented vaccine campaign in the fall. Not only should a swine flu vaccine be available, but we will still have our usual and customary annual strains that take about 35,000 lives each year. Anticipating the circulating strains is becoming more and more difficult as these ancient viruses mutate and change. The World Health Organization fears that up to two BILLION people could be infected by swine flu if the current outbreak turns into a true, global pandemic

Speaking of Vaccines
The pneumococcal conjugate vaccine, Prevnar, which has been protecting infants and children against seven of the more common streptococcal strains is now going to be even better. A newer, improved vaccine called Prevnar 13 will be adding protection against six additional strains, offering even more protection against pneumonia, meningitis, and yes, even the dreaded middle ear infection.

In the last decade, the insertion of tympanostomy tubes for recurrent ear infections has increased 35%; a whopping 85% increase since 1996. Although there has been an active campaign to reduce the astronomical amounts of antibiotics used in the management of pediatric ear infections, the overall usage has not drastically improved. Many parents feel that tubes are a less-risky alternative to frequent antibiotic use.

Cell Phones May be Contributing to Hospital-Acquired Infections
First they blamed dirty hands, then stethoscopes (rightfully, so). A few years ago, a study proved that our neckties (I stopped wearing them and I have a great collection of medical ones) may be spreading dangerous pathogens. Now, cell phones are being blamed for the spread of MRSA (Methicillin-Resistant Staphyloccoccus auerus) - the superbug in a study of Turkish hospitals. It doesn't surprise me at all. Since I do not carry a cell phone with me during clinic hours, this does not pertain to me. Computer keyboards and other hospital equipment may also be contaminated. Personally, I consider EVERYTHING in the hospital potentially contaminated. I hate touching elevator buttons ("Can you push three from me, please?) and I never touch stairway banisters.

Electronic Medical Records (EMR) "Depersonalize" Medicine
I read a New York Times story about how EMRs are going to transform medicine into a highly-efficient machine, saving billions in healthcare costs. This is not without a big price, however, in the social arena. Not only do medical providers have to spend additional time documenting their medical records (not all medical providers are good typists!), but computers have created yet another depersonalized barrier in the medical relationship.

We have used EMRs for several years in our office, but I rarely use the computers in the exam room during the encounter unless I am just briefly checking lab results, etc. I just do not want a flat screen between me and making eye contact with the patient, I am sorry. I find it terribly disruptive to have a medical provider typing away as a patient is talking. I experienced this as a patient with my own medical provider. As in the past, I still jot down my notes, only to type the later, in the comfort and quiet of my own office.

We get less than 15 minutes allotted for each patient visit. I am not going to waste 12 minutes of that precious time by typing notes.

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Nuclear and Other Fears

Photo: quinn.anya

The siren made a different sound; it was constant, striking fear in all of us. The teachers knew it was a drill; we did not. As a 6th grader and a big fan of my hero, John F. Kennedy, I knew what to do. I quickly crawled under my wooden desk near the window, a piece of old chewing gum (Black Jack, I think) stuck to my flat top. Our desks, we were told, would act as our individual bomb shelters.

Anxiously, I glanced in the direction of Pittsburgh, a more likely nuclear target than Fairchance, population 1,200. As the siren wailed, I half expected to see the flash, followed by that mushroom cloud. It would give me a few seconds to overt my eyes before being blinded, or cut by the inevitable breaking of the windows. The old building would rock and sway; the heat would be unbearable. If I was lucky enough to survive a few seconds longer than my classmates, I might see them melt or burst into flames. Mrs. Gretchen with her heavily-lacquered hair would surely be one of the first to ignite. Then, it would be over. Perhaps, Cleet the Janitor, hunkering down in his furnace room, would survive, only to die later of a painful death from radiation poisoning.

As far as we knew, no one in Fairchance, Pennsylvania had a bomb shelter. Many had root cellars and cinder block coal bins, but there were no places to ride out the nuclear war. The coal miners, deep in the mines, would survive if there were not cave-ins. They would emerge at the end of their shifts to see a bleak, scorched landscape, not unlike the normal appearance of our heavily, strip-mined community. They may not even notice, except that their pickup trucks had vaporized.

My stepfather, Joe, always talked about building a bomb shelter. He even started stockpiling things that we would need. Thus far, he had a dozen cakes of Ivory soap, some cans of Spam, and a case of beer. The soap was important since the temporary location of our bomb shelter was the coal bin. If the nuclear war started in the winter, there would be little room for us, hiding in the shifting coal. In the summers, we would at least have space to lie down. He had not stockpiled water, so I wasn't sure how useful the soap would be, unless we rinsed with a precious bottle of Iron City. We didn't have any guns, so I was not sure how we would fend off hungry neighbors, now mutants, trying to get in our coal bin.

Photo Credit: Thomas Williams

Nuclear bombs concerned us the most. We were not particularly worried about the flu, although three decades before I was born, an influenza pandemic killed millions in the U.S. The parents were worried about polio. My cousin Danny got it from playing in the creek (aka, "crick") and was now crippled. We had measles, mumps, scarlet fever, whooping cough, chicken pox, rheumatic fever....you name it. We received smallpox vaccinations along with a stern warning never to touch or pick off the scab; otherwise we would have to get another one. I am sure that people died or had other serious complications from those diseases, but we didn't know of any.

In kindergarten, the school doctor (we had one of those) and the two school nurses (twins) lined us up and gave us some of the newer vaccines, even if we already had the disease it prevented. There were no excuses. Everyone had to get them. It was the law. No one developed autism, even though the vaccines (and our creek) were loaded with thimerisol (mercury). If any child was mentally-challenged, it happened before those vaccines and we knew who they were already. In the late 1950's and the early years of the 1960's, it seemed that everything was out to get us, from that cigar-smoking Fidel Castro and his pal, that shoe-pounding Commie, Nikita Kruschev to this endless list of diseases that required us to get shots.

For some reason, we rarely got sick. It was rare to miss school due to an illness. In my family, if you had a heartbeat, you went to school. Rain or snow, we walked. To shave off a few minutes, I would often walk through the woods along the sewer and mine run-off polluted, orange creek. That is, until I seemed to scare up an unusual number of snakes. I am not a big fan of sudden snake appearances, nor was I convinced that snakes do not chase you. I had what I believed to be snake magnetism.

Later, I selected a safer route to school; walking the railroad tracks. Several times a day, heavily-laden coal trains would come through town. They were not particularly fast and did blow their whistles, so you would have ample time to get out of the way. Perhaps one of the most dangerous acts that we frequently committed was crawling under a train that had temporarily stopped. Not knowing how long our route would be blocked, we would wait, listen for any sounds of movement, and then dash under the train to the other side. Of all of the children, only one was injured by a train, He ran into it on his bike, breaking his leg.

The nuclear war never came and we didn't have to live in the coal bin eating Spam and washing up afterwards. President Kennedy was killed in Dallas. No one we knew died of vaccine-preventable diseases. I was never bitten by a snake or hit by a train. I was hit by a car crossing an icy road, but that is another story...another blog.

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A Bad Week for Health, My Friends

The older you become, the more likely you will have to deal with health problems, not only your own, but those of your close friends and relatives.

Last year, it was a friend's wife with lymphoma and my sister-in-law with breast cancer. This week, one of my best friends was diagnosed with a particularly aggressive form of prostate cancer. And, yesterday, one of our closest friends was rushed to the hospital when he could no longer speak. Later in the ER, a CT revealed the cause. He had a brain tumor.

Prostate Cancer
Bob has been my friend since college. We met in line since our school felt it necessary that everyone stand in alphabetical order for various functions. Both of our last names began with "M". We were even assigned dorm rooms in alphabetical order, so he lived two doors down the hall. His major was music, and he could really blow the saxophone, plus play the piano and sing. It didn't take us long to join forces with his roommate Danny (now a Baptist minister in the Midwest) before we had a singing trio - the "A-Courtians". The name originated from the fact that we lived in a dorm called A-Court. For the next several years, the A-Courtians would sing for assemblies and a few gigs for the Office of Admissions.

We were both from Pennsylvania and now, over thirty years later, we both live in California. Of course, I pursued a medical career; Bob used his music background to prepare him for a very successful career owning a pump company. After years of losing touch living our separate lives, we found each other's friendship again. We only get together one or two times per year. That is about all my splitting sides can take, since it is a non-stop laugh fest.

Bob's doctor has been monitoring his PSA levels - an indicator of troublesome prostate activity - for a few years. Sometimes the level was elevated; other times, it would go back in the normal range. It was never at the point where his doctor felt further investigation was needed; until recently, that is. His doctor decided it would be a good idea to do a prostate biopsy, in the office, without any anesthesia. This, of course, would never be something that I would agree to. I am personally at the point where I want anesthesia for a hair cut. Bob agreed to this transrectal procedure, telling me it was the most painful thing he has ever experienced - even worse than the time I hit him in the head with an entire sheet of plywood. A complication quickly developed when the surgeon hit a bleeder - an artery. Bob was rushed from his urologist's office to the hospital, losing about three pints of blood in the process. Having cheated death, Bob felt that he deserved to have the biopsy be negative for cancer. Unfortunately, it was not. Although I do not know the details of my friend's case, Bob tells me that it is a particularly aggressive type.

Aggressive types of cancer require aggressive treatments in my opinion. I insisted that he contact the best oncologist in the area. He was particularly fond of the oncologist that took care of his life-partner's lung cancer several years ago. I told him to make that call. Cancer treatment has made leaps and bounds over the years, and newer, more effective therapies orchestrate actual cures, not just palliative treatments. In the experienced hands of a good oncologist, I expect to be laughing and singing with my friend for decades to come.

Brain Tumor
It started with a phone call from George's wife.

"I think George had a stroke. I gave him three baby aspirins. Should I take him to the hospital?"

"Get off of the phone NOW. Call 911."

The paramedics arrived promptly and the stroke team at the ER was waiting for him. Prompt anti-clot treatment is critical; minutes or even seconds can determine outcome. However, George was not having a stroke.

George is a retired professor of anthropology. He speaks about four languages and has traveled and lived and lectured in many parts of the world, from Iceland to Pakistan. As a connoisseur of all foods ethnic, he was preparing a chicken dish for a lunch. He came up to his wife and started to talk. Instead of the usual rhetoric of a learned scholar, what came out of his mouth was gibberish. George thought he was communicating, but the words were not words at all - they were not words in any of his four languages either. They were aphasic words from a damaged brain.

A CT scan revealed the source of George's sudden loss of speech, and subsequent seizures. Silently, a tumor had been growing in the left side of his brain. Was it a cancer? Was it a metastatic tumor from a cancer somewhere else in his body? At this point, we do not have those critical answers.

Throughout the day, George was having periods of normal communication, followed by odd periods where he was speaking in tongues unknown. The hospital's only neurosurgeon met with him this morning and he is scheduled for surgery in two days. We will keep you posted.

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A Ton of Prevention - The Big FIVE

It used to be an "ounce of prevention is worth a pound of cure", but everything has gone up. The cost of medical care is astronomical, but preventive efforts can be relatively cheap. Not only will you save money, you will live longer (so you can earn the money you lost in this economic crisis). I know you have heard these things over and over in your life, but hearing them...and doing something about it is an entirely different issue. I am no different that millions of other people. I have health issues and I struggle with them, too.

I have health problems that I cannot change, like my tinnitus. I can't even remember what it was like to experience quiet - not hearing that constant, high-pitched whine. I have basically learned to ignore it (sometimes). I have arthritis, both degenerative (due to age) and acquired (from injuries). I have high blood pressure - a family legacy. And, my weight has been silently creeping up on me over the last two decades, to the point where it has been affecting my overall health. I could have over a thousand dollars a year if I didn't have to take blood pressure medications.

1. STOP SMOKING. Not only are cigarettes expensive, cigarette smoking results in billions of dollars of health related costs, from respiratory diseases (bronchitis, pneumonia) to even more life-threatening problems such as emphysema and cancer. All smokers know people who have smoked all of their lives without problems, but all smokers also know people that have died as a result of this habit.

I met a fellow in my clinic the other day from Ireland - one of my favorite countries. I read that Ireland has now banned smoking in the pubs and I wanted to know his perspective. He told me that every person in Ireland knows someone who has died of lung cancer, or has emphysema, so this ban on smoking was to honor their shortened lives and to keep from attending more funerals/wakes.

I never smoked, but I do know how difficult it is to break bad habits, or in this case, nicotine addiction. At an average of $5.00 a pack, a one-pack a day person would be spending well over $1,500 per year. Since you buy things with after-tax money, you are going to need to earn more than $2,000 to support this habit. If you have missed days of work due to respiratory illnesses, then the costs are even higher. My father was a smoker. He died of lung cancer at age 39.

2. EAT BETTER AND WISER. This is my biggest nemesis, since I love to eat and I hate dieting. I track my families spending on Quicken so it is easy to see how much we spend on food per month. It saddens me to see how much we waste by throwing it away - we either made too much and no one wants to eat leftovers, or we bought too much (like fresh vegetables) and they went bad before we got around to eating them. We used to cook for five kids, so our food bill was unbelievable. I know we prepare larger meals than we need, still thinking we are cooking for a small army.

I think we eat relatively well, but perhaps too much. Both my wife and I work long hours (12-13 hour shifts, not including commute times), and we just do not plan well enough. We only have an hour of awake-time after we get home. We tend to eat lunch at our desks completing patient charts, and we do not have time to have dinner at work before our evening shift.

As I was writing this Blog, my wife came in trying to make a three-day meal plan. We are trying to do better; one step at a time. She is on a mission right now after getting weighed at her doctor's office last week, so I expect to be suffering along with her for a while. I need to lose weight, too. Not only would my blood pressure and arthritis improve, but I would not have to spend money on bigger pants.

I suspect we could trim our expenses hundreds of dollar per month by preparing less food, pre-planning meals, and shopping wiser. We do try not to eat out, especially a fast-food lunch, but sometimes we wake up too late to make lunches. I am a big sushi fan, a healthy but expensive alternative to a packed lunch. Grocery store sushi is cheaper, but not very good, so I tend to buy it anyway. I eat less when it doesn't taste very good.

I have a stressful profession and good food was always a reward. I don't drink alcohol - never did - and I don't take sedatives. There are times when I would risk prison time to get a good chocolate chip cookie. For people who do drink (excessively), you know you have a problem.
And, for you vitamin-takers - vitamins do not really correct poor nutrition or prevent the kind of illnesses that are likely to kill you. Don't fool yourself that taking vitamins, herbs, or other concoctions will assure you longevity.

3. EXERCISE. I absolutely hate to exercise. I permanently injured my ankle several years ago trying to stand on my kid's skateboard (Don't laugh. It looked easy.) My neck and back were injured in a car accident and if I overdo it, I will feel it for days. I work very hard all day, probably putting on several miles between exam rooms, and my days-off are active with gardening, stacking firewood, and mowing the lawns. I do not sit on my butt, but you wouldn't know that by looking at my butt. I just can't get beyond the fact that I find walking boring and a waste of time. I hate to go to a gym and deal with that eclectic crowd. My wife joins a woman's gym at least every year and doesn't go, so that is a waste of money, too. She insisted on buying a treadmill, and as you know, it quickly becomes a dust-collector and a place to hang up your clothes. I can effectively justify a hundred reasons for not exercising except one. If I don't overcome my own personal block and devote a reasonable amount of time doing purposeful, organized exercise, I will be paying a big price. Because of my long working days, I do have four days off per week, so I will have to start by walking the dogs. Maybe I can get them to pull me on a skateboard? No, tried that once. Bad outcome. All of us need to find a physical outlet that is both enjoyable and safe.

4. PHYSICAL EXAMS. If you have lost your insurance, you may be avoiding the doctor's office at any cost. Men, in particular, avoid medical offices like the IRS. Men tend to wait until things are really bad and their spouse drags them in. Even though I am in the profession, it has been a while since I saw my own medical provider. I guess I am avoiding the lectures about all the things that I am not doing - the same lectures that I give to other people every day. I can dish it out, but I hate hearing it from the patient-end of things. I am a believer in self-care; the concept that people can and should take responsibility for their own health. However, believing in it and doing it are two different things. I know my health risks, but like many people, I have a reluctance to do something about it.

Ignoring preventative care is a dangerous practice. No one want to have a gloved finger up their butt or worse yet, a colonoscopy, but ignoring efforts to detect colon cancer won't prevent it from happening.

Something as simple as an annual flu vaccine can save your life. Although it doesn't make the evening news, thousands of people die every year as a result of influenza. Adults need tetanus vaccine (the disease is 100% fatal), too, with diphtheria and now, whooping cough vaccine again (its back!). Pneumonia vaccines are helpful for older people and those with asthma and other respiratory illnesses.

Women need periodic pap smears and mammograms, and most of them are pretty diligent about getting them. Men need to take a lesson from this dedication.

Work closely with your medical provider and make sure that you openly disclose any financial problems you may be having. Less-expensive, generic medications, less-expensive diagnostic tests, etc. are usually available IF your provider is aware of your situation.

5. SAFETY AND ACCIDENT PREVENTION. You can save a lot of health care dollars by not being stupid and getting hurt. If you do not wear seat belts, talk on the cell phone, eat (fast food) in the car, and drive too fast or aggressively, or God-forbid, drive while impaired, then you going to be seriously hurt or killed...eventually. If you climb up a rickety ladder to hang Christmas lights, or try to do your own electrical work, you may be asking for an injury. Loose throw rugs at the top of stairs, slippery bathtubs, poor lighting, etc., all take their annual toll. People are killed or seriously disabled from some of the more obvious home hazards - hazards that are preventable.

These are just FIVE of the many preventative health measures that we all can do. The longer we live, the more we have the opportunity to enjoy life. Like the immortal words of Spock to "Live Long and Prosper", we need to prosper by remaining healthy.

We all need to tighten our belts - financially and physically. I am going to do it and I strongly suggest you do it as well.

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When You Don't Have Health Insurance (or Money)

Millions of people in the U.S. do not have health insurance, and more and more are losing their insurance when they lose or change jobs. When you have limited financial resources, priorities rapidly shift to the essentials, like food and shelter. Getting medical care tend to be low on the list. Nearly every day, someone will tell me that this will be their last visit due to insurance or financial constraints.

I tend to be highly sympathetic and do the best that I can to hold down costs, often by putting down a lower billing code and making sure to order only tests that are absolutely essential. When prescribing medications, I will look for samples (becoming increasingly scarce) or only use the less-expensive generics. I am often embarrassed by the costs of medical care. As a salaried employee of a large, health organization, there is little that I can do to

I am definitely less sympathetic when I know my patient has not changed expensive habits, like smoking, drinking expensive coffee, and eating out instead of packing a lunch. When someone asks me to bill them for their small, insurance co-payment and I notice they have a pack of cigarettes sticking out of their purses, I tell them how I feel. I am getting too old to let these "teaching moments" slide.

Setting reasonable priorities is not something that all people know how to do. And not all people are proactive and resourceful when it comes to trimming their personal budgets or finding affordable care.

Things you CAN do

1. Unless you have a true emergency (life-threatening) condition, stay out of the emergency room. If you have a primary care problem, like a sore throat or earache, this would be the most expensive way to get treatment. Call a few urgent care facilities (aka "Doc in the Boxes") for prices. They are certainly less-expensive than the ER.


2. Check your area for free clinics, or clinics that charge a sliding scale. There are fewer and fewer of these around, but sometimes you will be lucky.


3. Many counties have Public Health Departments that offer free or discounted medical services, especially immunizations.


4. Many uninsured and non-working people qualify for state-run insurances like Medicaid but never bother to check their eligibility. Children, especially, will benefit from this.


5. Find a good primary care provider or solo practitioner. Medical professionals who work for themselves set their own charges and have the ability to charge less or nothing at all. You will be surprised how many dedicated professionals will find a way to help you out during these tough economic times.


6. Ask for samples. Although pharmaceutical samples are also becoming increasingly scarce, even a few days of medication to get you started will reduce your overall health costs.


7. Ask for a generic prescription or for an alternative choice of medications known to be less expensive. Although medical providers often do not know what prescriptions cost at the various pharmacies, most will have a good idea if they are giving you an expensive one or a reasonably-priced alternative. Generics are just as good for a fraction of the cost. If your doctor wrote for a brand name, your pharmacist can substitute a generic equivalent in most instances.


8. Don't be shy about shopping around for a better price on your prescriptions. Call the pharmacy, read your prescription to them (if the writing is legible!), and ask how much it will be. Many large, chain pharmacies have huge medication discounts for certain commonly-used prescriptions. A prescription that costs $60 in one pharmacy may only be $18 at another.


9. Ask for a discount. A $75 office visit may only be reimbursed by insurance companies for a fraction of that cost. So, why should you pay more simply because you do not have health insurance? Even fees vary among private medical practitioners, so call around.


10. Be creative in your available resources. I am often surprised that people can afford to buy beer or cigarettes, but they don't seem to have money left for their own medical care. A one pack per day person would save over $150 in a month - a savings less-costly than of an average office visit.


11. If you have a credit card, most medical offices will charge your visit to the card, giving you up to a month to come up with the cash.


12. If feels good when you help someone, so if you are in serious need, it is okay to ask family or friends to help you out. Remember, you are asking for help to get medical care, not to buy a new toy. By helping you, they will feel better.


13. If you are a member of a church or synagogue, many will help the less-fortunate with reasonable, but unexpected medical costs. It doesn't hurt to ask for help. I have seen local churches buy glasses for children, or provide medical appliances for the elderly. Don't forget to thank others who help you, including God.


14. Practice medical self-care. The first-step in staying healthy is taking care of your self and practice healthy habits. Don't smoke. Don't take recreational drugs. Don't drink and drive. Always wear seat belts. Exercise and maintain a healthy weight. These things do not cost a dime.


15. If you have lost your job and are looking for a new one, try and find employment that will offer health benefits for you and your family.

Ten Things you should NEVER do

1. You should never ignore potentially-serious symptoms simply because you do not have the resources. Not only can your condition become worse (and more expensive to treat), you are potentially putting your life in jeopardy. If you feel you need medical care, find a way. You really can't die now and pay later.


2. Don't ignore preventative care, like mammograms and pap smears for women or prostate exams and PSA tests for men. And, keep up with your preventative dental visits.


3. You should never take someone else's medication. Every person and every disease is different.


4. You should never take expired or suboptimal (sub-therapeutic) dosages of leftover medications from prior prescriptions unless specifically instructed to do so by your medical provider. For instance, by not having a complete course of antibiotics - about ten days worth - it may not be possible to eradicate an infection. You may also create a resistant bacterial strain that is more difficult to treat.


5. Many people resort solely on alternative medicines, such as homeopathic remedies, vitamins, or herbs. Most are not scientifically proven by clinical trial, and any response may be merely anecdotal. It is okay to try them, but if you are not improving, you may need traditional medical intervention.


6. You should never smoke. Smokers have considerably more cancer-fears than other people. People who smoke worry that sore throats, lymph node enlargement, or chronic cough may be something serious. Sometimes, they are right - all the more reason NOT to ignore long-standing symptoms.


7. Don't rely solely on online health information sites (including WebMD) in an attempt to diagnose (and treat) yourself. Online health experts have no way of examining you, reviewing your medical history, or treating you based solely on your posting.


8. The same goes for being diagnosed (or treated) by your non-medical friends and relatives...don't do it. Just because people have similar symptoms or experiences, in no way implies that it is applicable to your case.


9. Don't rely solely on phone advice by your doctor or advice nurses. They can only make medical decisions based on what you have told them. Most advice will most likely be conservative. Don't expect to be definitively diagnosed and treated on the phone.


10. Never use the ER as your primary care medical facility. The ER is for life-threatening situations or medical conditions that cannot wait until your regular medical office is available. ER medicine is the most expensive care you can receive. Find a good family practitioner.

As an optimist, I know things will get better. We need to take care of ourselves...our families...and find time to help others. Together, we will get through this economic crisis.

Related Topics:

• Better Health Care at Lower Costs
• Laid Off? 10 Health Care Tips
• Living Better Newsletter - free wellness tips to keep you healthy & strong

The MEDICAL Darwin Awards

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."

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"ALL EARS"

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.

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Cyberchondria

Finally, someone gave it a word: Cyberchondria. The number of people who research or attempt to self-diagnose their medical problems over the Internet is exploding. Could it be because over 40 million Americans do not have health insurance? Could it be that the cost of providing even the most basic medical care is astronomical? Could it be that doctors are often too busy to listen? Yes.

A few minutes ago, I got a call from my automobile mechanic. It is not going to be good news when they ask you if you are sitting down first. I should have been a little suspicious when three of them jumped on my car this morning; one under the hood, one with a computer, and another checking my tires, as part of my "free" 48 point inspection. Needless to say, they found a few things that they would like to fix. Please keep in mind that I dropped off my car because the gas gauge was not working. I am not comfortable just guessing how far I can drive without running out.

Humm...maybe medicine should have a 48 point inspection. A person comes in with a sore throat, we can check them out head to toe, tell them what we found, recommend some expensive tests, refer them to specialists, remove a few suspicious moles, etc. Let's use up that expensive insurance!

The friendly mechanic said that they will not have my car ready by 1 PM like they promised. They will need to keep it overnight - the automobile equivalent of being admitted to the hospital. They wanted me to bring the car in with a near-empty gas tank so they would not need to drain it to fix the fuel sensor. Again, when your gas gauge does not work, this is not always possible. They found a transmission leak, so it will need a new seal/gasket. They would like to flush my transmission fluid, too. This is an expensive procedure that the mechanic described as "similar to a kidney dialysis". I didn't want to share with him what I did for a living.

Apparently my transmission fluid (urine) is too dark (not drinking enough?) and needs to be replaced for about $375. Now, I am not an auto mechanic, but I think I will shop around for a better price. I have no idea if there is a car equivalent of WebMD that I could have diagnosed my mechanical problems and perhaps, fixed this myself. The "check tires" light on my dash has also been bugging me. Apparently, the car's computer was not aware that I bought some new tires two months ago. The mechanic said that my tires were fine and did not recommend that I replace the air in them. Oops, there I go on a tangent again.

Hypochondriacs are a part of any medical practice. We also call them the "worried-well" - people who are basically well, but feel they are sick; usually with cancer or some sort of rare disease they read about or heard on ER. People with good insurance tend to abuse it sometimes by coming in with very trivial, quasi-medical complaints.

"I woke up this morning, and my hair does not seem to be a shiny. Do you think I have a scalp cancer?"

"No, I think you just need to wash your hair."

Of course, I say this on the "inside". On the outside, I try to be respectful of their concerns and offer them as much reassurance as I can, short of doing an MRI on their hair.

It is not unusual for modern hypochondriacs to bring in some articles that they found on the Internet. One mother brought me some information that she found on WebMD's ENT board regarding her teenager's on-going vertigo and asked me what I thought about it. She was convinced that her vertigo was due to the power lines near the home; or perhaps from some toxic mold hiding in the walls.

"It seems accurate to me," I said. "I wrote it."

At first, she thought I was kidding. Then she compared my picture on the web site to the guy sitting in front of her. She was both embarrassed and thrilled at the same time to meet me. Unlike the usual people who post on the advice boards, at least I had the opportunity to examine and treat her daughter first-hand. By the way, her daughter had labyrinthitis, a common, self-limiting viral infection that involves the inner ear.

Cyberchondriacs are particularly worried and fearful of cancer (carcinophobia). The Internet has made leaps and bounds over the last 15 years or so, but the Internet will never replace a hands-on medical examination. Until I can literally "reach out and touch someone" through cyberspace, the Internet will always have its medical limitations. Perhaps, the future will tie in computer robotics that will prod and probe areas at our command, but what about those important senses of touch and even smell that cannot be simulated? I doubt that a robot will ever be able to recognize the smell of strep throat or give a therapeutic hug.

Perhaps because I practice a little cyber-medicine, I am not turned off by worried patients who present with Internet-based references. I am turned off, of course, if those Internet references are not from legitimate, mainstream medical sites. Web sites are becoming quite clever in disguising themselves as legitimate, so people must always be on guard for against cyber-charlatans. There are more snake oil salesmen on the Internet than there ever were traveling from town to town in medicine shows. Hypochondriacs are magnets for quacks selling unproven, bogus cures.

In defense of people's rights to participate in their own medical care, the Internet has indeed saved lives. When people, for whatever reason, cannot seek medical care, the Internet can be an invaluable source of life-saving information. I have had people come in with a picture of a melanoma that they found on-line, and then point out a similar lesion on their leg.

Busy physicians often tune-out people who bring in print-outs and medical reports, but I love this type of participatory patient. Often, the patient themselves will give me some valuable clues as to their elusive diagnosis by their independent research. However, I have to admit that sometimes the information that is collected is not that helpful; even dangerously wrong.

Medical providers have to remember that even hypochondriacs get sick, and like it or not, sometimes the patient is RIGHT!

It's like the epitaph on the hypochondriac's grave: "I told you I was sick!"

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• Digital Medicine
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"I Do Not Have Health Insurance"

Several times per week, I have a posting on the Ear, Nose, and Throat message board that mentions that the person posting does not have insurance, or does not have the financial resources to pay for a medical visit. With the economic crisis we are all facing at this time in history, I suspect we will see more and more uninsured Americans. One physician in our office stated just today that three of his patients lost their jobs, along with their insurance, and would not be returning for on-going care. This is just the tip of the financial iceberg.

For the most part, medical care in the United States is embarrassingly expensive. Since I am on the inside, I am often in a position to justify many of those charges to my patients. Insurance is equally as expensive and not all people have insurance benefits with their jobs. In most states, automobile insurance is required - it is the law. Health insurance is optional. I find that inconsistent with common sense since a liver transplant is considerably more expensive than fixing your bent bumper. Unless you have unlimited resources, going without health insurance will devastate your family in the event of a medical crisis. The government will end up paying the costs for the uninsured only after your resources have been depleted. The U.S. does not have universal health insurance, so those people without insurance must pay for their medical care.

When I was a child back in the 1950's, we had one general practitioner in our town. I don't believe my parents had any insurance. An office visit was $3.00 (this included medications in most cases), and a house call was $5.00. Even at those prices, adjusted for the 1950's, this was still a pretty good deal. We were a lower income family; so fortunately, I did not have to utilize medical care very often. At age 18, I had appendicitis, but my mother must have had health insurance by that time, otherwise she would have told me how much it cost.

The cost of a routine office visit in my practice is $141.00, or at least this is what is billed to the insurance companies. Insurance companies typically negotiate these fees and will reimburse considerably less. A cash-paying patient will pay about $98. There are some quick-clinics at the local pharmacy that charges about $65. An urgent care clinic will charge about $75. People who have insurance will typically pay a co-payment of $10 - $30 for their entire out-of-pocket expenses.

Like medical care itself, insurance premiums are astronomical. I have many infants and children in my practice, some who were born with special needs. A parent of a 2-year-old child last week told me that her medical bills are over three million dollars (so far). It only takes a few of those for insurance companies to raise their rates on healthy people to make up for it. In Ancient China, doctors were paid a fee to keep people well. If you became sick, the doctor had to pay you!

I have always been very sensitive about charges, but in my current practice, I have no control over fees that are charged by the medical foundation. I am on salary. If I were in private practice, I would have been bankrupt from giving away free or discounted care. The cost of routine medical care has skyrocketed to the point of embarrassment. The cost of using liquid nitrogen to freeze off ONE common wart is about a $150, and one treatment may not do the job.

When I see a patient or perform a procedure, I put down a billing code that represents what I have done, the complexity of the visit, and the time spent. This code is translated into a bill, either sent to the patient or the insurance carrier. I am basically out of the loop.

Medical providers can "down-code". In other words, they can put down a lesser billing code than what was done. Providers can also not charge for certain "simple and quick" procedures, like removing ear wax. The cost of removing earwax in my office is well over a hundred dollars for the procedure alone. If it only takes me a minute or so to clear out that ear canal so that I can properly see the eardrum, then I do not charge extra. However, if I spend a half hour digging out an impacted amount of earwax from some obsessive Q-tip user, I am going to charge extra - about the cost of 30 boxes of Q-tips.

When I know that a patient is private-pay (paying with cash or credit card), I tend to down-code or cut them a break if I can. If I have samples, I tend to give it to them. There is nothing like paying for an expensive office visit, only to be dinged again at the pharmacy. Medication costs have skyrocketed, too.

When the antibiotic Augmentin first came out, it was expensive compared to plain 'ol amoxicillin. A full-course to treat a middle ear infection in a child could be $65 to $80 or more; amoxicillin was only about $10 or $15. My wife and I were traveling in New Zealand years ago, so I compared some of those prices with a Kiwi pharmacist (chemist). Augmentin in New Zealand only cost about $8.00 and was from the same pharmaceutical company. Why? According to the chemist, the entire country of New Zealand negotiated a lower price - and the cost is not increased to the consumer. In the U.S., we pay top dollar for the same medication. Of course, Augmentin is generic now, and the price has dropped (sort of).

The Veterans Administration and some large HMOs do negotiate for cheaper medications for their patients. When I worked for the VA years ago, it would drive me crazy. I would get someone controlled on one blood pressure medication, only to discover that it was now not available. I would have to change it to another one. Six months later, I would be told that that medication is not available, and I would have to go back to the original one that is now suddenly available again, now at a cheaper cost the government, of course.

The cost of medications has driven many Americans across the border to Canada or Mexico looking for deals. This practice is highly discouraged by our government, and is really illegal in some respects. People on fixed incomes who are paying more than half of their monthly income for medications for cholesterol, blood pressure, or diabetes are desperately looking for ways to reduce their costs. Smuggling medications across the border happens every day. I have personally witnessed people being hassled over a bottle of blood pressure medications they bought in Mexico, while tons of cocaine and marijuana seem to make it across okay.

Our government sites safety as their primary concern. Fake medications made in China are showing up everywhere, even in the U.S. Look-alike medications are being sold by the ton in Mexico to tourists. When someone shells out some cold hard cash for a bottle of Viagra before the cruise ship leaves, there is little recourse when those little blue pills fail to work. Maybe you get the real Viagra, but maybe your little blue pill is just that - a little blue placebo from China. Personally, I would not have any problem buying medication in Canada, but I would be a bit leery of some of those Mexican pharmacies along the border.

When it comes to buying food or buying gasoline, someone without health insurance tends to set priorities. Food comes first, followed by rent or mortgage. Then comes automobile costs. The lowest on the list tends to be routine medical and preventative health care. Emergency medical care tends to get attention, even in the worst of economies. When you have an arrow sticking out of your head, you don't typically wait a few days to see if it goes away on its own. A guy in a neighboring community was shooting arrows into the air. Not understanding gravity, he inadvertently hit himself in the head with one of those falling arrows. He hesitated going to the ER because he did not have insurance. I am surprised that the arrow didn't go all the way through since there appeared to be nothing inside his skull.

If you don't have auto insurance, you are screwed if you wreck your car. If you blow your engine because you can't afford routine maintenance and oil changes, you are screwed because auto insurance does not pay for repairs. If you do not have health insurance, and choose to ignore your crushing chest pain, you may not need health insurance anymore - you so need life insurance for your family. If you do not go to the doctor because you have a cold, you will probably be fine. Colds are self-limiting and you don't really need a doctor to tell you that again and again. Of course, if your cold seems to be turning into pneumonia, you are going to have to make a big decision. Should I take the chance of dying, or use my credit card or hard-earned cash to get some medical care? Get the care. Borrow some money or worry about paying the credit card later.

My auto mechanic charges $90 per hour (even if he fixes my car in five minutes). He is a high school graduate and makes more than my own hourly rate in my clinic. Is it fair? Probably; he can fix my car - I cannot. Of course, when he cuts open his head when he slips on some grease, I am not going to reduce his cost by down-coding him. I am going to get even.

Related Topics:

• 45.7 Million in U.S. Lack Health Insurance
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Life is an Open Blog

For a busy clinician, I have done my share of writing. I have published more than a few hundred medical articles in lay and medical periodicals. I have written, edited, and published six books, including four medical textbooks. I edited a professional association newsletter for many years, was "Children's Health Editor" for a magazine, and still serve as an editorial advisor for a few more. As an educator, I have written hundreds of classes, lectures, and presentations, as well as many grant proposals. I have written poignant letters to the editor and a smattering of other rants and rages that still surface from time to time. I have written love letters and, of course, letters of apology to my wife. As a 12-year-old, I was a junior reporter for our local newspaper. Basically, I have written things since I learned to write.

When WebMD first approached me about doing a blog, I was not even sure what a blog was. Then, I was not sure I would have the time to do it, along with my busy clinic schedule and, of course, the ENT Board. I agreed to try it. Now, I am hooked.

I don't advertise my blog to my patients, but many have found it. Some will ask, "How's your daughter?" Or, "Did you kill those turkeys yet?" At first, I am amazed that they know these things. Then, I quickly realize they are reading my blog. It is a rare patient interaction when a patient knows that much about their medical provider.

I have shared personal stories with my patients for my entire career. They know I once smoked poison oak. Many know my father died of lung cancer at an early age. Many know about my klutzy son that broke his arm dancing at a wedding, and many will know that I nicknamed my new grandson, Elmo, and why.

There are few secrets when you grow up in a small town. Everyone knows everything about you. My life has always been an open book. Now, my life is an Open Blog. No difference.

Openly talking about your family or patients in a public blog can be tricky. You cannot disclose any confidential information about patients, although I do disclose a lot of family secrets. If I was running for Vice President, there would be little they could uncover. If I had written a personal diary for my entire life, there would be little left to uncover should someone find and read it.

Do I have secrets that I have not disclosed? You bet. We all have embarrassing secrets. We all have past events in our lives that we regret. Knowing that you cannot change the past, requires that we exercise a high degree of forgiveness - for others and for ourselves. We only have the ability to change the present, and the motivation to change certain aspects of our future.
Allowing people to know who you are as a person is more important than having your professional credentials on your office wall. Yes, people are interested in your educational background, but as humans - curious humans - people like to know your character. I am not afraid to share what makes me happy, or what makes me cry. I am still reluctant to discuss the two taboo subjects - politics and religion- with people I do not know. I feel that I know my blog readers well enough to give it a try.

My political beliefs are deeply personal. I cherish honesty and commitment. I will accept a President who exhibits both. I like to see things "get done", not just talked about. I would love to have a President that listens, and one who is articulate when he speaks on my behalf in front of the world. All Presidents have speech-writers, but some truly touch your heart. I grew up listening to John F. Kennedy. He was no angel, for sure, but people loved to hear him speak and he was trusted. I remember many wonderful speeches by Reagan. When I listen to Bush, I just listen for mistakes or errors. As a charismatic speaker, Obama is better than McCain, but I question his ability to lead a very troubled and damaged nation. If McCain is to be our next President, he needs to start working on his speaking ability. You are not supposed to judge a book by its cover, but crappy covers do not sell books. As a people, we often judge a leader by their ability to speak, and of course, their actions. Actions do speak louder than words, but I still like to her the words - the correct words; the reassuring words; the heart-felt words. I am proud of my imperfect country, and just want to love (and trust) a President again.

A physician colleague of mine (Jewish), moved to rural Ohio to practice. When the first words uttered by a patient are "Where do you go to church?" you know you are not in California anymore. People would not see this fine, wonderful man because he was Jewish. Disillusioned by the intolerance of the townsfolk, he eventually moved his family to a more ethnically and religiously-diverse college town in North Carolina. He and his family are so much happier. Ohio lost a good doctor.

I grew up Baptist in a tiny town with a dozen or more different churches. I went to a Baptist college (because they gave me a scholarship, not because of religion). My first wife was strict Catholic (Shi'ite Catholic!). My mentor was Jewish. I absorbed gifts from all of them. My Aunt Norine (now, 95) was my religious teacher. She took me to Church, taught me enough of the bible that I can still answer all of the Jeopardy questions when this category comes up. I took the required religion courses in college and got A's. My Catholic ex-wife introduced me to a community of people who are committed to their ancient faith. Many go to Mass every day, refuse to eat meat on Friday, and send their kids to Catholic schools. My children were raised Catholic. We used to say that the streets are empty in my town on Sunday because the Catholics are at Mass, and the Protestants are in bed sleeping. We didn't have any Jewish people in our town.

My first boss and dearest friend/mentor was Jewish. He invited me to Seder and shared with me the significance of the many Jewish holidays. I sat with his family at Passover. Until his death a few years ago, he was among the most important and influential people in my life. I would have converted to Judaism if he would have invited me.

One of my best friends is a Buddhist. My exchange student's family are Shinto. We had neighbors who were Muslim (and held services in their home) and many friends who are Mormon. I had one aunt who was Adventist. I have colleagues who are Hindu and patients who probably represent every religion on earth. They are all good people, but not because of their chosen religious. They are good people because they are... good people.

I consider myself deeply religious, but I am not a Baptist, a Catholic, or a Jew. I guess I am a combination of all that I have learned and all that I have experienced in my life so far - maybe I am a congregation of one. I do not attend an organized church anymore (I haven't really found one that "fits"), but I feel that I live a good life with the same morals and ideals that encompass all religions. I believe that this is really what a spiritual God intended.

Now, you know even more about me. I feel naked.

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Names and Nicknames

Growing up, we all had nicknames. There was Bird, Thumpus, Special, Getchaoutside, just to name a few. In college, nicknames were mandatory, like Alf, Hally, Charlie Trombone, Quickdraw, and Irwin. Of course, I had a nickname, too. It was a legacy, since my brother (Larry) had it first. Our nickname is Moe. My brother has a son that took over the nickname, but my son, Ryan, never fully adopted it. I even gave him my gold ring with the raised letters, MOE, on it. A few people refer to him "Mo" (without the "e").

I grew up with the Three Stooges and my favorite Stooge (if you had to pick) was Moe, the self-appointed leader. My brother's real name was Larry (Well, Rupert actually), so that seemed to be a good fit for a nickname. We didn't have a Curly, but my step-father was a spitting image of him.

In Japanese, Moe is pronounced "Moe-eh" which means "love of characters". One of our Japanese exchange students has a niece (Yes, a girl) name Moe. I was honored.

I have a grandson named Dylan, which is a nickname cornucopia. From time to time, he gets Dilly, Dill Pickle, Dilbert, or simply, Dill. The guys on his Little League team call him Dee. When he starts Junior High, I am sure there will be other names less cute or flattering.

I am pretty good at creating nicknames. I have taken my share of punches during my formative years when the nicknamed person was not as enthusiastic. I recently won the "Name the Skeleton" contest at our new Medical Museum. It immediately came to me. Her (a female skeleton) is Anna Rexia. I have such a gift.

Yesterday, I was informed that my youngest son and his wife will be having a little boy. We knew she was pregnant for several weeks now, but yesterday was the ultrasound, or as I like to call it, "The Wiener Hunt". My daughter-in-law desperately wanted a little girl, but Nature has a way of serving up surprises. They are going to have a little boy; my first biological grandson. I have three other grandchildren from my wife's lineage. My son is elated, of course. They had picked out a name well in advance of the ultrasound. Regardless of the sex, the baby will be named, Ellis. Ellis Moser.

Ellis? A very nice name; somewhat atypical, but that is what makes names unique. My son, an avid Oakland A's baseball fan, said this is the name of the second baseman, Mark Ellis. Ellis is also the name of a famous island, perhaps an entry point of some of the ancestors. The grandmother's family - intensely Catholic - emigrated from Czechoslovakia in the early 1900's, so perhaps they came through Ellis Island. My family emigrated from Germany in 1790, so we were already here; way before Ellis Island. We probably co-mingled with the Native Americans (No, not the Mo-hicans!) I do not know anything about my daughter-in-law's family ancestors, except that they are Jewish. Perhaps, they came through Ellis Island. My grandson, Ellis, of course, will be Jewish through this proud, matriarchal line.

So, it is either Mark Ellis, Ellis Island, or they just liked the name, Ellis. Either way, we are going to welcome Ellis Moser with loving arms. Is he going to have a nickname? I have no doubt whatsoever.

It can't be Elly - much too feminine. It might be Moe, but Moe is a very unusual nickname for a baby. Moe Howard of the Three Stooges was Jewish (so was Larry and Shemp), but no, that isn't going to fly. There is Moe Szyslak from the Simpson's, but he is not really a good role model for my grandson, even though he invented the Flaming Moe. There is the Pep Boys - Manny, Moe, and Jack. There is Moe-hammad? (Oops, sorry about that. Please don't issue a fatwa; it was joke.) Maybe, he can be nicknamed Elton? (Great singer and composer, but flamboyant lifestyle) Or, Elwood? (One of the Blue's Boys) How about El-beau? No, too anatomical; perhaps, too Middle Eastern. Then, it hit me! His nickname will be Elmo. In Spanish, it would be El-Moe! The Moe. I ran nickname scenarios with some of my new parents of little boys. The fathers immediately guessed "Elmo" as the most logical nickname. I would like to know what YOU think, too.

In my pediatric practice, many babies, even the unborn ones, get nicknames. An excited four-year old once told me that she was going to Scooter's doctor's visit tomorrow. Scooter was what she called the tummy-baby. That has been several years ago now. Scooter (real name, Scott) is now one my patients. The nickname stuck. Maybe that is how Scooter Libby got his name?

Elmo. Why not? My daughter-in-law is an elementary school teacher with a special education masters. Elmo the Muppet from Sesame Street is an educational icon (good dancer, too, if you tickle him). Elmo was the only Muppet to testify before the U.S. Congress, urging support for increased funding for music education.

I work in pediatrics, and we have Elmo stuff all over the place. One of the other pediatricians actually wears Elmo clothes. There was a St. Elmo (aka, St. Elmo's Fire), so this may please the Catholic side of the family. And, most of all, Elmo is a damn, cute nickname. I love it. I suspect my son will think it is funny (he shares some of my warped sense of humor) but Elmo's mother may not immediately embrace it. Every child needs a cute nickname, so I am getting my dibs in first. If I have to secretly call him Elmo, so as to not offend anyone, I will.

As I write this Blog, my nickname campaign has begun. My wife is heading for Toys R Us to get a talking Elmo doll. I asked her to make a Sesame Street quilt, with Elmo in the center, of course. I have no idea if the nickname, Elmo, is going to stick. My son hopes it will be just "E". Borrrring!

I just can't wait until February so I can tickle me a REAL Elmo.

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Spoiled Rotten Kids - Part Two

Children that are from financially-privileged families, those that seem to have all of the best toys and the best opportunities were discussed in Part 1. I would now like to comment on the "other" spoiled rotten kids - the ones that lack discipline, respect for parents and other adults, and the one's that seem to get away with murder (hopefully, figuratively).

We all see them. They are the one's screaming in the cereal aisle at the grocery store; or the one's having a fit at the kid-height candy stand at the checkout. We see spoiled rotten kids in restaurants, school functions, and at the sports fields. Day-care and preschool providers live with them every day.

A pediatric office is a place to do an anthropological study and child-parent interactions. When children come for medical care; either when ill or for preventative services, they do not come alone. One or both parents are usually accompanying them. More often than never, a cadre of siblings will also be there - as interested observers or annoying distracters. Grandparents also tag along from time to time - a true family reunion. The smaller the examination room; the more people there are; trying to find places to sit among the automobile-sized strollers.

At least one child will be on my roller stool, spinning around or trying to stand on it. I took the liberty of posting some basic exam room etiquette "rules" such as don't play on the stool, don't take out all of the gloves from the drawers, don' t take out the pelvic exam stirrups, or play with the expensive instruments. We like to give out stickers and sugar-free lollipops to the little ones, but I have to remind parents every day not to do this until AFTER the visit. They may be sugar-free, but they are not sticky-free. And, there is nothing like seeing a child with a sore throat who has been eating a red lollipop or drinking red Hawaiian punch before I had a chance to examine him.

One day, while sitting in my office typing some notes, I heard one my rolling stools flying from one end of the exam room to the other. Clearly, some oblivious parent was allowing the child to play on it. Since I had one child that kick-launched himself into the corner of a cabinet a few weeks prior, cutting a big gash in his head (I had to put in 5 sutures), I knew I needed to intervene. When I opened the exam room door, I did not find a child on the stool, but rather a Dad happily lying on his abdomen; darting from side to side, using his legs to kick off. He was embarrassed. Good.

When you open the exam room door to enter, you are rarely surprised what you will find. It could be a mother happily talking on the cell phone ("Gotta go. Doctor just came in.") while the child has taken all the exam gloves out of the box and put them on the floor. Or, they are tearing the pages out of the children's books that I brought from home. Those books survived five of our kids, only to be destroyed by an unsupervised child.

I encourage them draw on the exam table paper to occupy their time while waiting. The older kids can play Hang Man or Tic-Tac-Toe; the younger one's can scribble or draw pictures (often very cute). Unsupervised, the younger ones go beyond the table and try to decorate the walls. I completely gave up on putting up anatomical and educational posters because they just get ripped up. My PA wife was smarter, she had hers laminated.

All of these breaches in common etiquette reflect directly on the parent's ability or inability to supervise or appropriately discipline their children. Parents who do not let their kids jump on their living room furniture will allow their children to jump on mine; even with muddy shoes. Parents who do not permit their children to eat crackers in the living room, will allow children to drop them all over the floor, only to leave without offering to clean it up. There are so many cheese goldfish on my floor some days that I could survive a famine.

It is good that parents do not hit their children anymore, but that does not mean a parent should allow a child to hit them (or me). I see toddlers punching their mothers in the face, and I have had several toddlers try to take a bit out of my leg. Granted, toddlers are not a good example, because most are inherently mean. The Terrible Twos tend to start at age 15 months with stranger anxiety, and supposed to end before age three. Some children will carry whining and tantrums well into their teen years and beyond.

Thankfully, undisciplined children are not the majority. Most of my little patients are delightful and respectful - this is why I love pediatrics. Most parents are wonderful; especially the Moms (Some Dads are clueless, I have to say). I am heartened when I find a sulking child sitting in the corner in "time out", or the peripheral entourage of kids quietly reading, listening to music (with headphones), or doing their homework. I am delighted when I see a parent reading to a child, instead of talking on the phone while their child destroys the books.

I love it when I see a parent stick to their guns. No means no. It is not negotiable. If you don't behave, you will not get a lollipop. Twenty minutes later, I will see that same child decompensating down the hall, screaming that he wants a lollipop. I told you. You wouldn't listen. Maybe next time you will get one.

I think I can handle undisciplined children (and their parents) quite well. After thirty plus years in this medical business, I don't hold my tongue anymore. I will intervene if I see a parent being abused by a toddler, or a teenager being verbally disrespectful to parent. I will also proudly comment on excellent behavior when I see it; both to the child and the excellent parent.

Positive discipline goes a long way. Children need boundaries and limits. They need to experience disappointment and logical consequences; as well as receive rewards and accolades for positive acts. They need to see examples of acceptable public behavior from their parents. The "Don't do as I do, do as I tell you" approach to parenting just doesn't work.

Lastly, children need attention and they need love. When they seek out parental approval, they should get it. When they try to please, it should be noticed and acknowledged. And, when their behavior is inappropriate, regardless of the setting, they should not get away with it.

All children are good. Good children occasionally do bad things. Bad things have consequences. Good parents have the ability to discipline with love.

Spoiled Rotten Kids - Part One

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Spoiled Rotten Kids - Part One

There is nothing like a pediatric practice to demonstrate a wide variety of parenting (or lack of) styles. I see 'em all. Can you really have children who are considered spoiled rotten?

A well-cared for and loved child may be viewed as spoiled rotten, but these are not the kids I am talking about. I am talking about the kids that have the best of toys, the finest designer clothes, and devoted parents who make sure the get the best of everything. I see kids with expensive iPods, their own, high-tech cell phones, and some pretty impressive toys. I have teenage patients who drive better cars than I drive (I actually have issues with that one). If people have the financial ability to provide their children with those things, then who are we to judge?
We helped all of our kids (all five of them) buy used cars when circumstances dictated that they needed them, such as sports practices, college, or after-school jobs. Most of our kids were grateful; some were miffed that we didn't lease them a BMW, like Kim's dad.

I said, "Why don't you call Kim's dad and see if he will get you one, too."

Some of my older patients are heading off to the universities - Stanford, UC Berkeley, Cal Poly, Yale, and Harvard. Their parents are forking out a King's Ransom in tuition. Of course, I had to work my way through school by dumping bedpans and feeding old geezers, but I am not jealous. I am not jealous because I couldn't have been ACCEPTED to those schools, let alone afford to go there. I am justifiably humbled by their accomplishments and tell them so. From a financial point of view, I am glad that my kids attended state schools. It was hard enough with four of them in college at the same time. Thank God for student loans to postpone some of those costs. We only have one more left in college, which is good since I would like to retire some day.

I have one father who built an Olympic-class pole vaulting run in his backyard so that his son could train. Parents travel the country with their kids who are in competitive soccer leagues. We have several friends who sent their kids to Europe (for fun), and one who sent their son to Japan to study the violin (he does not play the violin anymore). My heart goes out to the families that support their children in sports or other pursuits. Special kudos to Michael Phelps's mother and all those like her. I was not a promising athlete or musician, so my parents didn't have to shell out squat. My parents chose not pay a dime toward my college education, either.

A large number of my little patients attend preschool - some of the more prestigious (and expensive ones). My kids went to Montessori School - about thirty years ago now - and I was shocked by the costs then. I was amazed that it cost more for my daughter to go to Montessori for one year than it did for me to get a graduate degree at UC Davis. She even had more fun that I did. Nowadays, I have no idea how parents can afford to send their kids to private preschools and schools. I guess you can't put a price on good education. Wait! Yes, you can.



My wife did attend a snooty private school outside of Boston when she was in high school. It was the same school that her mother attended, so it was sort of expected that she would go there some day as well. She even had classmates named Muffy and Winky (I am not kidding!). In Appalachia, I had classmates named Cletus and Buck. She went to school with crowned African princes, movie star and politician's kids. Many of my classmates went to jail, or quit school in junior high to work in the coal mines. My wife and I both work in the same clinic and get the same salary. We are equal in every respect. She just has better class reunions that I do. I tease her about her private, finishing school, but I would have given my right arm to go there. Her tuition was a subsidized $6,000 a year in the mid-1960s - a lot of money in those days. It is $43,600 a year now. Even adjusted for inflation, that is still a huge tuition.

Do children appreciate things more if they have to work for them? Perhaps, but if they have a choice, they would prefer that you gave it to them Scott-free. The first car that we gave our kids was a very used Olds Vista Cruiser station wagon with faded wood grain on the sides; like the one Chevy Chase drove to Wally World - not what you would call a Babe Mobile. We found out that they parked it a few blocks from school so that the other kids would not see them in it. Very few of our kids dated seriously while in high school; perhaps, due in part to this car - our BCV (Birth Control Vehicle).

We didn't pamper (actually we did use Pampers) our children; and they seemed to turn out just fine - an attorney, two engineers, a registered nurse, and hopefully, an MBA in marketing. They don't drive fancy cars; they go to work everyday, pay their mortgages, and the ones who have children do not pamper them. Our grandchildren go to public school (those that are old enough). If anyone spoils them with toys and gifts, it is us; my wife, actually - 'Ol Giftin' Grammy.

Spoiled Rotten Kids - Part Two

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