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Ask Dr- Rob

Dr. Rob's Inbox

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Dr. Rob's Inbox

I was excited.  Finally I could get my questions answered by America's doctor darling.  Since I know he's a busy guy, I thought I'd need to get his attention. No, I wasn't interested in the miracle antioxidant pill that detoxes my carotid arteries, reprograms my neuronal circuitry, melts away belly fat, and enhances me in the bedroom.  I know about that already.  I've seen his show.

No, my questions were far more important

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Ask Dr. Rob: Medical Wreckords

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Ask Dr. Rob: Medical Wreckords

Dr. Rob:  

Long-time reader, first time writer!  I want to know why it is that my doctor makes me pay to get my own medical records.  It seems like since they are my records, they should be free to me!  Can you explain this to me?

- Lucy in Texas


Thanks, Lucy, for asking such an astute question that is near and dear to my heart.

There is, in fact, a simple answer as to why doctors don't want you to lay hands on their medical records, Lucy.  It's the same reason you don't want your son's underwear after his first semester in college (known to have broken autoclaves):  they stink.

Why do they stink?  It's complicated.  The best way to see this answer is to look into the past.  Way back.

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Ask Dr. Rob: Ring of Fire

People ask me lots of questions, some good and some not so good.

  • Is this illness I caught contagious? (How would you have gotten it otherwise?)
  • Is this medicine going to destroy my liver? (Yes, your wife paid me lots of money to bump you off)
  • What do you think about the odd pattern on my toenail? (I think it is a prophecy written in ancient runes).

There are times that I handle these questions skillfully;  I feel like I am an athlete "in the zone," where everything I do comes out right.  Other times I feel like the skinny boy in PE class facing the dodgeball firing squad.  There is no way to handle questions fired at me with unexpected speed or from unseen angles, and so I am left to plunge to the floor hoping to sustain minimal brain damage.  It can be terrifying.

But these aren't the only questions I face; some questions I ask myself.  They are questions that are usually deep, like:

  • Why am I here?
  • What can be done to save our health care system?
  • What if Peter Parker was bitten by a radioactive slug?
  • If Pluto is a dog, what is Goofy?

There are no good answers to these questions, I know that.  But still I foolishly try, and I end up with a really bad headache and a strong desire for lots of beer.

So is there such thing as a good question?  There is, in my opinion, only one good kind of question: ones that nobody asks.  Here's why these are the best:

  1. They put absolutely no pressure on me because nobody is waiting for the answer.
  2. I have minimal risk of concussion, brain damage, or future alcoholism.
  3. There is no awkward pause while I consider whether to laugh out loud, cry out in pain, or stay silent.
  4. I can dream up a question that nobody cares about and then devote a blog post to answering it.

This last reason spawned a whole series of posts in my previous blog, a series I called Ask Dr. Rob.  Some of these posts were actual responses to actual questions from actual people, but my need for questions was far more than my readers' supply.  Or maybe they just wanted me to stop.  In these posts I answered questions like:

And many more.

It's time to take the cover off of the car, put the key in the ignition, and give the old baby a whirl around the block.  Here is today's incredible question:

What's the deal with the the ring of fire thingy?

Before I answer this fantastic question, let me first explain what it isn't asking.

This question is not about that ring I discovered last summer after I got lost in a cave.  Since finding it I've been stalked by tall men with beards and creepy slimy guys with bad reflux.  It' quite prec...uh.. it's a really nice ring.  Don't even think about it.

I am sure that the thing that actually came to mind for most of my readers was the Ring of Fire Handbell Choir, that played at the presidential inauguration in 2005. They do a pretty hip rendition of "The March of the Baby Elephants."

But they seem to have disbanded, so that's not what the question is about either.

So what about "Ring of Fire Chicken" made famous by Alton Brown on the show "Good Eats?"

 While it is a culinary masterpiece with full-bodied flavor and an acidity that nicely balances the sweetness, it's not the "Ring of Fire" referenced in this question.

Surely then, the reference is to the famous Johnny Cash song entitled "Ring of Fire."

Love is a burnin' thing, And it makes a fiery ring Bound by wild desire I fell into a ring of fire.

I fell into a burnin' ring of fire I went down, down, down And the flames went higher, And it burns, burn, burns, The ring of fire, the ring of fire.

It's kind of interesting to note that he co-wrote this song with his wife.  If I wrote a song with my wife it wouldn't go over well to suggest that our love is a burning ring of fire.  I think things would actually get quite cold if I did that.

No, the "ring of fire" in the question refers to the recent annular eclipse, a type of solar eclipse also known as a "ring of fire" eclipse.  Please don't confuse the word annular with another word that has to do with people on commercials sitting uncomfortably in movie theaters only to be called out in front of everyone by a friend talking about an ointment to sooth the burning and itching (although "ring of fire" would be an accurate description for that problem).  The word actually means "circular, or ring-like."  An annular eclipse happens when the moon gets in front of the sun, but because the moon is further from the earth, it doesn't block the entire sun.  This creates the appearance of a "ring of fire."

 We have recently had an annular eclipse, which is a very rare event indeed.  Some say it is so rare that it is an omen, or a in from the heavens to warn us.

Warn us about what?  What is the significance of the "ring of fire" eclipse?  Ancient Mesopotamian prophesies (found mummified toenails) talk about the "ring in the sky" that tells of the coming of the "being of pure evil," or the "droopy eared Satan."

Dante', in his tale of the circles of hell (rings of fire), tell of the demons that come to torture lost souls.  Some scholars believe that Dante' wrote this book after he saw an annular eclipse and caught a glimpse of  "a horror of wrapped in a shroud of cuteness."  Some feel this idea was captured in the famous painting depicting Dante's hell:

Others have noted a secret code hidden in the words of the Magna Carta, which was signed a mere week after an annular eclipse.

The message hidden in this celebrated document, seen by many as one of the greatest documents in the history of civilization is this:

Beware of the beagle.  Beware of the cursed beagle.  Ring of fire brings the puppy of the apocalypse.  Flee from certain death.

Unfortunately, I have no idea what that means.  It's probably just fables and fairy tales.

Puppy of the apocalypse?  Who would believe that?

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Ask Dr. Rob: The Hand that Freezes

OK, so I've done this thing called Ask Dr. Rob, in which I answer questions that my readers have regarding health, tacos, webkins, fetuses driving speed boats, the end times, baby spit, the dangers of kumquats, and other crucial issues.  But there is a big problem: nobody ever asks me questions anymore. So I asked myself: why is this? Why don't people ask me questions?

Then I answered myself: well, you just asked me a question!

Then I said back: Yeah... but I am me, and that shouldn't count, should it?

To which I answered (in a very snarky tone): There you go again!  You keep asking questions!  Aren't you good enough for you (or me)?

I pounced on this: Hah!  Now you are asking me questions!  Caught you!

Then I stormed out and left myself alone.  I still haven't seen me, but it did start me pondering the fact that I could ask myself questions.  I did this without asking a direct question (so as to not raise a ruckus), but wondered this:

I think a question I would ask myself (If I would do such a thing) would be about the coldness of doctors hands and if there was a reason for it.  I think that this would, hypothetically, be a good question to answer (as it were) on the "Ask Dr. Rob" segment.

Then my doctor increased my dose of medication and everything got better.

But hey, why not answer the mystery of doctor's cold hands?  These hands of mine cause babies to cry when touched; they take away my patients' ability to breathe for several minutes, and cause asystole at least once a week.  My hands get so cold at times that I was contacted by Al Gore to see if they could be used to combat global warming.

I am considering it.

The Science

In the mean time, let me explain to you (and me, if I ever come back) the science behind cold hands.  Yes, it is science,not magic.  It does not involve he-who-must-not-be-named or horacruxes (though my patients may disagree with that).  It is science because it relies on the basic laws of nature, namely: the laws of thermodynamics, which include the following:

  1. If you have no energy, you won't get it; and if you have energy, it will changed from one kind to another (probably making you feel like you have none).
  2. Heat will move from the hotter thingy to the colder one until they are both the same temperature.  The colder one won't make the hotter one even hotter, which is too bad because my air conditioning bills would be a lot less if it could.
  3. The colder things get, the less they move, and if things get really, really cold, they give up even trying to move.

Now, some idiot scientist got all smarty-pants and said "Well, actually there has to be another law before the first one", and so instead of shifting everyone back in line, they made it the zeroth law.  I think they did this to insult that scientist.  This law states:

  • If two thingies (let's say they are gerbils) are just as cold as another thing (let's say it's a wrench), then the gerbils are just as cold as each other (although one will invariably complain more).

They didn't talk about gerbils and wrenches in the law when they made it, but it does make it more interesting.

Much more interesting.

In truth, these laws are pretty obvious, and many people don't understand why they were made in the first place.  The laws were actually voted on during the presidency of Millard Fillmore, who wanted to make the youths think he was a cool dude.  He figured that kids liked physics, as Albert Einstein was all the rage at the parties, he wanted to jump on the "hip physicist" bandwagon.  Nobody was fooled, though, and he was never invited to the cool parties.

Despite this, the laws still stand, even the one before the first law.

Crazy.

The Application of the Science

So, you may ask (because I wouldn't dare), what does this have to do with doctors' cold hands?

1. The Conservation of Energy

Certain patients come to the office constantly complaining that they have "no energy."  These patients are wrong about this, they actually have energy and consume huge quantities of it.  They actually are energy magnets, drawing all energy from their environment and storing it in their thymus gland.  You may have met this kind of person before; they often attend office parties.

This is what is known as the conservation of energy, which is the first law of thermodynamics.  Why does it conserve energy?  The reason is that these patients never use the energy they store in their thymus gland.  The heat energy in the hands of the doctors is removed by these patients, and not wasted on the comfort of the other patients.

Some scientists are looking into ways to tap this abundant store of energy in the thymus glands of these patients.  Unfortunately the scientists themselves don't have the energy to complete these experiments.

2. Entropy

The second law states the obvious fact that cold things don't make warm things warmer,  If someone sticks an ice cube in your pants, it doesn't feel warm.

At first glance, this doesn't seem to have to do much with doctors' cold hands (unless they are the ones who put an ice cube in your pants), but a central concept to this law is the principle of entropy. Entropy is the tendency of things to get disordered over time, the mortal enemy of people with Obsessive Compulsive Disorder.  It turns out that things that are cold are less disorderly than warm things, or conversely, warm things have higher entropy.

There are many examples of entropy in the day-to-day world of a doctor:

  • The state of the insurance industry - creates chaos and disorder in the lives of medical professionals.
  • The medical record - disorganized and incomplete.  Attempting to keep order in this realm is a battle against chaos.
  • Doctors' handwriting - nothing more need be said.

So you see, each of these chaotic things in the day of a doctor requires heat to cause such disorder.  This heat is sucked out of the hands.  If enough heat is removed, it will cause permanent freezing to the heart.

3. Absolutely Freezing

The third law states that cold things don't move as much as hot things, and really, really cold things stop moving altogether.  While this law does not explain the coldness of a doctor's hands, it does explain a troublesome phenomenon.  Why do doctors run late?  Simple: their hands are cold, which causes them to slow down progressively more throughout the day.

In response to this, doctors have turned the temperature of the exam rooms, attempting to accomplish two things:

  1. Slow the patients down so that the relative perspective of the patient is that the doctor is operating at normal speed.
  2. Some theorize that lowering the temperature enough will even cause time to slow down, creating a eddy in the time/space continuum where the patient sees less time pass relative to normal time.

This theory explains why doctors are slow to adopt computerized records, as the extremely low temperatures in doctors' offices has caused the slower passage of time.  One office in our city is actually still in 1964.

-----------------

So there you have it.  As you see, an understanding of  science allows complex problems to be simplified.  It's not magic, it's science!

Me: Wait!  You forgot to explain the application of the zeroth law!

Myself: So you've finally decided to come back, have you?

Me: I was over at Kevin MD's blog, but I could hear through the walls.  It sounds like decent science, but what about the Zeroth law?

Myself: The one with the gerbils and the wrench?

Me: Yeah, that one.

Myself: It actually has no place in medicine.  The law is restricted to the plumbing industry.

Me: And the Gerbils?

Myself: They turned out to be horacruxes and had to be destroyed.

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AskDrRob (ADR): LOL, EHR, Oprah

It's been a very long time since I did an Ask Dr. Rob post.  It's also been a long time since I shot a spitball out of a straw and hit someone behind the ear during social studies class.  I realize that just because it's been a long time since I've done something, it doesn't mean the world is better off with me doing it again.

Credit

Still, there have been some interesting questions that have come up and I think it's time they should be answered.  They are both along the same line:

Question 1: What is the difference between health care and healthcare? I see that you contribute to the Health Care Blog, but you write about healthcare all of the time.  What's the deal?

Question 2: What is the difference between EMR and EHR?  It seems that some people feel that it is vile and uncouth to call it "EMR", only accepting people who call it "EHR" into their secret societies of people who are smarter than everyone else.  What's the deal?

To Space or notto Space

These two questions focus on a very important issue in our society: the place of grammatical elitism in modern society.  You see, the folks who write "health care" are very suspicious of those who write "healthcare," as they feel that they wantonly leave out spaces betweenwords and endanger the very fabric of the spacetime continuum by doingso.  The "healthcare" camp, on the other hand, thinks that the "health care" crew is just dealing with pent-up frustration from being pottytrained (potty trained) too late and becoming the laughingstock (laughing stock) of the daycare (day care) center.

Back and forth the sides go, the one saying that the misuse of spaces between (be tween) words will open up a wormhole (worm hole) in the Internet (inter net) causing Twitter messages to be reduced to 30 characters (soyouwouldhavetoleaveoutspaces), and for every common expression to be reduced to abbreviations like LOL, ROFL, and ROTC.  Doing so would kill all human life, leaving only cats to LOL away their days in blissful laughter.  But there would be nobody there to laugh.

This makes them very FATFOH (fearful about the fate of humanity).

The "healthcare" crew takes exception to this portrayal of their space usage as being the same malignant disease that created BFF's, the CIA, and LSD.  They cite the frequent shortening of words in the medical field as their precedent for the omission of the space, such as PMR (polymyalgia rheumatica), "A Fib" for atrial fibrillation, and the original LOL (Little Old Lady).  They also argue the importance of conservation in these days of global warming (GW), oil spills (BP), and Dancing With the Stars (DWTS).  All of these are portents of darker days ahead, and so we should be conserving all of the space on the Internet possible to deal with these terrible threats.  Clearly the medical field needs to lead the battle against this, not a bunch of cats getting sucked into vacuum cleaners.

Who is right in this battle?  I have put myself into the "healthcare" camp, but with reservations.  I do wonder about worm holes eating up the inter net.  I do fear the final domination of the world by cats getting sucked into vacuum cleaners and the disappearance of my BFF's.  But being proactive I comedown on the sideof the ones who wantto take action.  I don't think weshould just sitthere and donithing except argue about the useofspaces.

ThatswhereIstand.

Evolution of Electronic Records

So what about the whole EMR/EHR debate?

You can see that these folks are in the "healthcare" camp, with the use of the abbreviation.  But within the camp of those who would shorten things there has formed a rift that may bring down any constructive work the leavingout of spaces accomplishes.  Unlike the "health care" vs "healthcare" debate, the fighting hasn't spilled out to violence on the streets, but it has caused some nominees for CMS to get OTD PDQ before they ended up MIA.

As many of you know, the term "EMR" stands for "Electronic Medical Record," while "EHR" stands for "Electronic Health Record."  The difference is not in the E or the R, it is in what lies between.

The original computerized records were called "CPR," which stands for "Computerized Patient Record."  This was all fine and good, and there was little dissent among the three doctors who used it at that time.  But an astute medical student noted that CPR also stands for "Cardiopulmonary Resuscitation," as well as for "Colorado Public Radio."  The confusion over these abbreviation caused dying patients to have "All Things Considered" given STAT, caused Ira Glass to be stalked by people wearing scrubs, and caused doctors to pause for 30 minutes of every hour to beg patients for money.

So with the urging of the patients not wanting to buy a copy of the musical "CATS" for $50, the families of resuscitated patients lamenting the now liberal bent of their saved loved-ones, and Ira Glass doing a "This American Life" episode on the fact that he was alive and his heart was beating just fine, the convention of "EMR" was adopted.

All things were quiet in the world of EMR, and, despite the fact that EMR also stands for "Emotionally Mentally Retarded," "Electromagnetic Radiation," and "Enormously Magnificent Radishes," the adoption rate skyrocketed to a whopping 20 doctors.

The Power of Oprah

But this all changed with the advent of the PC movement, which originated in the bastion of evil liberals, Madison, Wisconsin.  By "PC," I am not referring to the "Personal Computer," which originated in the bastion of blue screens of death, Redmond, Washington.  I am also not referring to "Processed Cheese," which was an attempt by the AARP to slow down "all of those young whipper-snappers" by making all children severely constipated.

I am referring to the "Politically Correct" movement that exists with a single purpose in mind: to make us feel guilty for calling anyone by their race, sex, physical defect, or occupation.  They made it impossible to classify people at all, instead preferring that everyone be called sexually non-specific names, such as "Pat," "Jean," "Taylor," and "Hillary."  The inevitable infiltration by this movement into the medical field occurred after the failure of the Clinton Health Reform bill (hardly a coincidence).  Their damage includes:

  • The use of the word "provider" instead of "doctor."
  • The use of the word "inadequacy" instead of "disease."
  • The use of the phrase "conspiracy to poison us all" instead of the word "medication."
  • The use of the phrase, "the one who really runs the show" instead of the word "nurse."

They also felt that the word "medicine" might cause people to believe that the pharmaceutical industry actually did something good, rather than their known practice of stealing money out of our pockets while they poison us.  They convened a summit, which included such luminaries as Oprah Winfrey, Donald Trump, and Sanjay Gupta, ending with the substitution of the word "medicine" with the word "health."  Oprah suggested that use of the word "health" would result in people having a more positive attitude and perhaps encourage them to get a makeover (make over).  Trump and Gupta were just bent on world domination (unlike Oprah, who is just so darn nice).

Feeling the pressure, the Health Information Management Systems Society (HIMSS) suggested changing the abbreviation of EMR to EHR.  They did this because their abbreviation clearly was shaky from a PC standpoint.  They had already changed their letterhead (letter head) from MIMSS to HIMSS, and didn't want to cave to the pressure from Oprah once more.  So now the battle rages among those who feel it's OK for the pharmaceutical industry to poison us all while taking our money, and those who think we should listen to Dr. Oz and take better gosh-darn care of ourselves.

Where do I stand on this issue?  I was trained to call it EMR, but feel guilty at times and call it EHR.  The problem is that when I type EHR on any Microsoft product, it changes it automatically to HER, which makes me wonder if Oprah has more influence than I ever knew.

Final Questions

Before closing, there are a couple of questions I want answered:

  1. Why do Emergency Physicians insist on calling their workplace (work place) an ED, instead of an ER.  Is this pressure from the pharmaceutical industry to increase the use of Viagra in an emergency setting?
  2. Why is PMS being changed to PMDD?  Clearly there is an additional letter in that abbreviation, so it is not in the wordshortening camp.  Is it because PMS can be confused with the phrase "Pass My Shotgun?"

Thanks for reading thisedition of ADR on MOADM.

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Ask Dr. Rob: Using the Force

So you wanted more "Ask Dr. Rob."  Next you are going to be asking for a colonoscopy. Well, I guess I can do it.  It has been a long time since I have done one of these.  I thought I was being merciful.  Whatever.

Here's a question from a moderately fictional person named Mike:

Dr. Rob:

What's the deal with physics?  I heard that you have to take physics class to get into medical school.  As a doctor, do you ever use physics?

Sincerely,

Moderately Fictional Mike.

Wow, what a coincidence!  That's the question I would have chosen had I written it myself!  What's the chance of that?

To answer your question: yes, I do use physics quite a bit.  It's a good thing, because my dad is a physicist.  This is a physical world we live in, with irresistible forces impersonally shoving us around without getting permission.  My father never told me about this dark side of the forces.

Force #1: Gravity

The first example of these forces at work is the ingrown toenail.  Toenails ingrow for one reason: they can't grow out.  Instead of sticking out the front of the toe like any self-respecting toenail would do, they grow into the toe.  Why do they do this?  What causes some toenails to grow in while the others behave respectably?

Gravity.

Ever since Sir Isaac Newton suffered a head injury, gravity was felt to be related to the mass of an object.  The bigger the object, the bigger the gravity.  But then came Albert Einstein, and the trouble began.  Einstein's theory of general relativity put forth the idea that gravity wasn't even a force, but instead a curvature of the spacetime continuum.  Wikipedia explains:

Einstein discovered the field equations of general relativity, which relate the presence of matter and the curvature of spacetime and are named after him. The Einstein field equations are a set of 10 simultaneousnon-lineardifferential equations. The solutions of the field equations are the components of the metric tensor of spacetime. A metric tensor describes a geometry of spacetime. The geodesic paths for a spacetime are calculated from the metric tensor.

Confused?  Yeah, well so is everyone else including the toes. What started out with a simple equation in Newtonian Physics:

became 10 simultaneous, nonlinear, differential equations! Yuck!!

Despite his lifelong battle with fruit, Newton remained a gentle soul.

To get back at Einstein, the toes decided to take advantage of these changes.  Using a loophole in this new law, they increased the local gravity in his big toes, pulling the nail down into the flesh part, giving Albert the first ingrown nail in recorded history.  In foot-wracking pain, Einstein tried to recant his theory, but the damage was done.  This is why the presence of an ingrown toenail, which is evidence of a hyper-gravitational podiatric state, is invariably accompanied by the following:

  • People step on them - scientists have proven that a foot with an ingrown nail is 10 times more likely to be stepped on than those without.
  • Heavy objects are kicked - careful analysis has shown that objects such as coffee tables, lamps, and even large appliances move into the path of a person with an ingrown nail.

Why do these things happen?  Gravity.  Thanks a lot, Albert!

Einstein, on the other hand, was left embittered by his chronic foot pain

Force #2: Opposing Forces

Following his head injury, Sir Isaac Newton (yeah, him again) decided to take the law into his own hands.   The result of this was the creation of Newton's Laws of Motion.  His design was to prevent future fruit-related head injuries, and he was largely successful (except for one unfortunate Kumquat encounter).

Kumquats can be dangerous

Newton clearly had a lot more sense than Einstein, and he kept his toenails happier as well.  Take it from me: always keep your toenails happy.  The three laws that Newton made were about moving objects, the most famous of which was the 2nd law, with the formula:

Translated: Force = Mass x Acceleration.  This is a great formula because it is so simple (as opposed to Einstein's ten differential equations), but sadly, it doesn't apply in the doctor's office.  The third law (the law of reciprocal actions) however, applies very nicely:

Which translates: "any force that is applied to object 1 due to the action of object 2 is automatically accompanied by a force applied to object 2 due to the action of object 1." (1)

The application in medicine is not in the clinical realm, but in the interaction between doctors and nurses.  Since both doctors and nurses are important cogs in the machine of medicine, they commonly have significant effects on each other.  Believe it or not, they don't always agree.  I am sorry if I shattered anyone's image of a blissful cooperation and camaraderie.  That is true most of the time (if by "most" you mean "almost never").   The Law of Medical Opposing Forces goes like this:

Any force that is applied on a nurse by a doctor is automatically accompanied by an opposing force applied by the nurse on the doctor.

The best example goes something like this:

Nurse: Doctor, Mr. Tucker's wife wants to talk to you about the side effects of all of the 29 medications you prescribed.  I told her you were on the floor, so she's expecting you

Doctor: Fine, nurse, I'll do that.  Let me first write these three orders for enemas and the order to discontinue the sedative for the screaming lady in room 244.

Nurse: That's nice.  Did I tell you that the Mr. Wafter has a large abscess that started draining?  I left it alone after explaining to him that you are an expert at wounds like that.  His roommate had to be moved, though, because he couldn't take the smell.

Doctor: Wonderful.  I forgot to mention that I can't discharge Mr. Whiner or Mrs. Screamer today.  I just want to wait another day to make sure they are stable.

Nurse: I'll be sure to have the night shift nurses call you hourly through the night to give you updates.

These two children are in training. This picture was taken before the hand-to-hand combat

This is a very important law to understand, especially for doctors in their residency.  Most residents assume that they are in charge since they have those letters after their name, but what they don't realize is that they are weak forces.  Nearly all forces exerted by a resident on a nurse are met with much stronger opposing forces.

There are other opposing forces in healthcare, including surgical vs medical doctors, doctors and nurses vs hospital administrators, members of congress vs. people who don't get money from drug companies, and insurance companies against anyone trying to get money from them.  Anyone dealing with healthcare needs to understand this very important law of physics.

Conclusion

I am just scratching the surface (which, of course, involves the force of friction), but the spacetime continuum is putting force on me.  But the bottom line (x-axis) is that physics is at the center of the medical universe.

Here's to you, Dad.  May the force be with you.

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Ask Dr. Rob: Frozen to Health

Hey gang.  It has been a long time since I have done an "Ask Dr. Rob" post.  That is kind of like saying: "It's been a long time since I have had hemorrhoids."

rectal

Well, get out our Preparation H, sit down, and brace yourself for the next installment of this infamous series.

Today's question comes from Luke, who asks:

Dear Dr. Rob:

What's with the temperature of the exam room?  Why is it that every time I go to the doctor I leave with a case of frostbite?  Don't you docs realize that people are taking off their clothes in those rooms??

I was wondering when this question would come up.  Many patients have chattered this question to me, and I relish the chance to set things straight.  There is a good reason for it - a scientific reason.

It's the Law

Physicians aren't keeping the rooms cold out of whim or nastiness, we are following the law.  To be precise, we are following the laws. Yes, the laws that I am talking about are none other than the Laws of Thermodynamics.

einstein_laughingMost people think that there are only three laws of thermodynamics, but there are actually four.  This is because chemists felt that three laws were just not enough for them to relevant to today's kids, so they made a fourth law.  But some chemists were really ticked off at this, and took it to court.  They felt that having a fourth law would make the physicists snicker at them, as physicists are perfectly content having three laws to guide them: Newton's Laws.  The courts upheld their complaint (siting the law of unintended consequences) so instead of having a fourth law, they made the zeroth law. This made the physicists laugh out loud.

Here are the laws of thermodynamics:

  • The Zeroth Law (he he) - If two thermodynamic systems are separately in thermal equilibrium with a third, they are also in thermal equilibrium with each other.
  • The First Law - The change in the internal energy of a closed thermodynamic system is equal to the sum of the amount of heat energy supplied to the system and the work done on the system.
  • The Second Law - The total entropy of any isolated thermodynamic system tends to increase over time, approaching a maximum value.
  • The Third Law - As a system asymptotically approaches absolute zero of temperature all processes virtually cease and the entropy of the system asymptotically approaches a minimum value; also stated as: "the entropy of all systems and of all states of a system is zero at absolute zero" or equivalently "it is impossible to reach the absolute zero of temperature by any finite number of processes".

Does that explain things, Luke?  I thought it wouldn't.  So let me show you how it applies to you when you are wearing that little paper gown that is open in the back.

Zeroth Law: All things being equal...

This law refers to different systems being in equilibrium.  The obvious application for this in medicine is the need for the digestive, cardiovascular, and neurological systems to be in equilibrium.  If these are out of kilter, many bad things can follow.  Here's how:

  • If a person's eyes are bigger than their stomach, the neurological system is in greater power than the gastrointestinal system.  This is a real problem.  It causes the GI tract to seek food in large amounts to stretch the stomach out.  Cooling the eyes to below 40 degrees F makes them shrink - fixing the imbalance and reducing the obesity rate.
  • nm_heartburn_080602_mnIf someone has a warm heart, it puts the cardiovascular system into equilibrium with the gastrointestinal tract.  A cold heart causes the stomach to try to put things back in order by heating the heart.  But the stomach isn't made to warm things, and so usually just causes heartburn.  So doctors are utilizing the physiological phenomenon: "cold hands, warm heart" to prevent this from happening.
  • If someone has a lot of nerve, it means they are not nice to be with.  This is diametrically opposed to someone being all heart. It is important for someone to get up their nerve and also for them to have a heart. To prevent people from having a lot of nerve, it is important to give them cold feet. This makes them lose their nerve - causing the system to get back into equilibrium.  It's really quite obvious.

The First Law: Energy Crisis

0108081342_m_ces08_blackberry_poseThe next law is the first (stop laughing, physicists).  This law is about the internal energy in a closed system. Internal energy is the energy something has inside of itself.  This energy results in work. Patients are not supposed to be doing work while at the doctor's office.  It really annoys me when they are typing on their laptop or staring at their Blackberry.

To prevent this, doctors lower the internal energy in the patient by cooling down the exam room and closing the door (thus making a closed system).  This prevents the patient from working.

Yea.

The Second Law: Disorderly Conduct

The second law has always been one of my favorites.  Entropy and me are pals.  It means that my desk being messy is simply a natural phenomenon.  It's not ADD, it's entropy!

So what does that have to do with cold exam rooms?  Entropy is a process that is driven by the energy in the system.  Increased heat causes particles to move faster, and hence for disorder to occur faster.  Despite my love of entropy as an excuse, it isn't good in the exam room.  I don't want my tongue depressors in the place where the cotton balls go.  People don't want me putting cotton in their mouths.  I don't want the scalpels to end up where the latex gloves go.  People wouldn't want me to use a scalpel to examine their....uh, never mind.

The gist of it is that it is clearly in the best interest of my patients to decrease the entropy in the exam room.  So, the colder the exam room, the less the entropy.  The less the entropy, the less the disorder.  The less the disorder, the less scalpels get mixed up with latex gloves.

You don't want that scalpel to end up....uh....well...you know.  Trust me: you don't.

The Third Law: The Absolute Truth

Probably the most significant thing about the third law (aside from the fact that it is really the fourth) is that it uses the word asymptotically. This word refers to the idea of an asymptote, which is "a line that continually approaches a given curve but does not meet it at any finite distance" (from the dictionary on my nifty-keen MacBook).  It is kind of like when you are packing to leave for a vacation, and are "almost" packed.  The closer you get to being done, the more time it takes to do any given task; and in the end, it takes two weeks to find your toothbrush.  It happens every time we try to go on vacation.  It is asymptotic.

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The point that is being approached in the Third Law is called absolute zero.

Absolut Vodka is made in Russia.  Absolute Zero was discovered in Minnesota.  The people of this fair state discovered that if they got cold enough, then all entropy would be stopped completely.  Reaching absolute zero would make all of their children's rooms be always clean and chaos from a contested election be non-existent.  They keep trying to reach absolute zero, but it gets harder and harder the closer they get.  So, despite their best efforts, their kids still leave the socks on the floor.

The reaction of the Minnesotans is predictable: they run for the Absolut Vodka.  It is my hope, however, that they will one day reach absolute zero.  I think they will find my toothbrush there.

So what does this have to do with exam rooms?  I am not quite sure.  I actually missed that class in medical school.

I was looking for my toothbrush.

The Cold, Hard Facts

So there you have it, Luke.  That's the science behind the arctic blast down the back of that paper gown.  We really have no choice in the matter.  We wouldn't want the thermodynamic police after us.

Before I close, I have to mention one more reason we doctors like to keep the rooms cold.  How else could we keep the stethoscopes cold enough to stick to your skin?  It just wouldn't be right to have a warm stethoscope!

Thanks for the question.

Don't forget to submit your questions to dr.rob.questions(at)gmail(dot)com.

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Ask Dr. Val: Why Can't I Lose Weight?

Dr. Rob has done a wonderful job of answering many difficult questions right here on his blog (such as “Why does my husband think that putting ketchup on tacos is a normal thing to do?”) with many profound insights. Today I’d like to follow in his great footsteps with an “Ask Dr. Rob Val” question. As some of you may know, I am leading an online weight loss group (called “Lose 20 Pounds”). I have been trying my best to “lead by example” by actually following the 3 recommendations of my own program and commiserating with the members about the process.

The most frequently asked question in my group is: Why can’t I lose weight? I’d like to answer that question here with more candor than I’ve been able to muster elsewhere: The Law Of Conservation of Mass

Students of physics, and doctors who were not asleep during all of their pre-med classes, will recall their professor’s lecture on the “law of conservation of mass.” This law of physics states that: “matter cannot be created or destroyed, although it may be rearranged.” This is the primary reason why no one can truly lose weight. The law of conservation of mass means that even if you do lose weight, someone else has to gain it, because matter (fat) cannot be destroyed, only rearranged.

So to begin this discussion, you should realize that no one’s going to truly lose any weight – weight is never lost, it’s just transferred elsewhere. The name of the game is how to give that fat to someone else.

Ways To Transfer Fat To Others

1. Friendship

First of all, you probably have friends or relatives who have figured this out a long time ago. You’ll recognize them by their “gifts” of cheesecake, cookies, or any chocolate product. They regularly shower these on you, describing them as “caring gestures” and occasionally wearing clown outfits to distract or disarm you. But make no mistake, this is nothing more than a fat transfer ruse. You must resist those gifts and tell those sneaky friends that you simply will not buy a new wardrobe of clothes to accommodate their “generosity.”

2. Food

Secondly, there is a little known food industry conspiracy – yes, that’s right, a conspiracy – designed to transfer fat on a national scale. This strategy began with a team of physicists who recognized that the only way to remain thin (Have you ever seen a fat physicist? Did you know Ramona Bates was a physicist? I rest my case.) was to keep the fat transfer going through an organized approach.

Back in the 1950s a small, renegade group of physicists broke away from the search for advanced nuclear weaponry and turned their attention to applying the law of conservation of mass to maintaining thinness for themselves and their future families. This was the group that first conceived of the “super size” movement, best embodied by the American muffin. In the 1950s, muffins were the size of a “donut hole” and now they’re the size of a 9-month- old’s head. Just check them out in your nearest Starbucks if you think I’m exaggerating. If you’re lucky, you can find a 9-month-old and a muffin in there at the same time.

3. Sloth

Thirdly, fat transfer may be achieved by assisting people towards inactivity. The Association of Escalator Manufacturers hosts a secret conference each year to plan a strategy for fat transfer in subways, airports, and large buildings – especially malls in the Midwest and New Jersey. Occasionally they invite splinter groups like the Segway Association of America and the Jet Ski Manufacturers Guild. Keeping people from walking, taking stairs, or swimming are great ways to ensure a constant pipeline for fat transfer. When this pipeline dries up, the inactivity militants know that there will be no further recourse but to enter the fast food business.

So there you have it my friends, the cold, hard truth about why you can’t lose weight: it's a matter of physics. The best you can do is give your fat to someone else. As for me, I’ve been baking cookies… would you like one?

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Ask Dr Rob: Briefs

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I got a lot of questions when I begged asked my readers for the third time.  So many questions, in fact, that I have decided to make my answers shorter.  This will allow me to not have to plagiarize so much answer more questions.

I don't know if that is bad or good.

Olympic Dreams

Charity asked the following:

If you could combine two (or more) Olympic sports to create a better hybrid version, what would you combine?

Wow.  Lots of choices here.  I feel like I have been served a hanging curve right over the plate.  In addition to hybrid sports, there are some sports I think need serious consideration for future inclusion.

Here are some of my choices:

  • gymnastics Equestrian Bobsledding - I would make the horses wear those skin-tight suits and a helmet (for safety).
  • I would make those rhythmic gymnasts use shot puts and javelins instead of ribbons and hoops.  I would probably enforce the "over 16" rule rigidly.
  • Spud - This is the greatest game ever invented.  If I was elected president, I would make this the national sport.  Mother may I is a close second.
  • Llama gymnastics - few people realize the grace and finesse of these wonderful animals.  I would not, however, take the job of spotter for the uneven parallel bars.
  • Synchronized pole vault
  • I would use the Olympic mascots as targets for archery
  • Greco-Roman Badminton - Players would have to wear togas and they would play to a score of XXI

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I wait with baited breath as to what my readers might add to this list.

Twitterific

Purplesque (I suppose that is a vague sort of purple) asks:

I recently joined twitter and regularly update my tweets, but nobody seems to follow me, including people I follow. Do I have the twitter equivalent of b.o.? How can I become more twitterific?

Twits-1

First let's take care of business:  everyone who reads this must follow Purplesque on Twitter.  Click HERE.

Now some of you may be wondering: Dr Rob, what in Odin's beard is Twitter?

Twitter is a social network.  The term social network is what is called a euphemism.  Euphemisms are nice ways to say mean things.  For instance:

  • "cosmetically challenged" is a euphemism for ugly
  • "television" is a euphemism for: the best explanation for society's collapse
  • "dermatologist" is a euphemism for doctor who doesn't like to work
  • "insurance company" is a euphemism for insane group of money-hungry morons.

In this way, the term "social network" is a euphemism for a group of people who can't make real friends.

1538621223_c8738bf6d4 Twitter is one of the largest of these groups of "pretend I have pals" people.  To talk to their "friends" people on Twitter "tweet" at one-another.  Just how you tweet depends on the tweeting modality.  You can tweet via the web, via an add-on program like twhirl, or on the phone.  That way you can access your make-believe chums in many ways.

So what should Purplesque do?  Nothing.  I have already supplied her with a glut of pseudo-buddies, as the millions of my readers have clicked on the above link.

As to becoming "Twitterific," just think about it: she is a person named for a sort-of color who writes to a looney doctor about the ins and outs of social networking.  I could think of no better word to describe her that twitterific.

Cornucopia

A reader who wishes to remain anonymous (I don't know why) asks the following:

"Where does the corn come from, you know, when you haven't eaten any?"

Most of my astute readers know the obvious answer here: Iowa.  But I must assume this anonymous reader is not asking about agriculture, but instead about biology.  I think the real question being asked (and the reason for anonymity) is about the ol' "corn in the toilet when you haven't eaten any" phenomenon.

A certain percent of the population have the habit of regularly inspecting their product of defecation after production.  Psychologists have long speculated as to the reason for this.  Are these people worried that they were just imagining their experience?  In my experience there are six reasons people look at their poop:

  1. x_files2_narrowweb__300x446,0 They get a sense of "a job well-done" when looking at their brown creation.
  2. They are obsessed with the "Will it Float?" segment on the David Letterman show.
  3. They desperately want to be in the Guinness Book of World's Records (or at least the Farmer's Almanac) but don't have any unusual talents.
  4. They are haunted by the "toilet alien" episode of the X-Files television show.
  5. They hope they could strike it rich if they find evidence of oil production.
  6. They are keeping a detailed diary of every body fluid/solid coming out of their body so that they can spend twenty minutes of their next doctor's appointment enlightening their doctor with the evidence that they are probably dying of a heretofore unknown disease.

I am not sure which of these is the malady of our anonymous reader.

So what about the mysterious corn?  To be honest, the research on the subject of physiologic corn production is scant at best, but I would suggest several possibilities.

Illu_pancrease

When you look at the above picture of the digestive tract, you see that the pancreas looks like a cob of corn.  Perhaps it is not actually corn you see in the toilet, but instead pieces of your pancreas.  If so, then you probably should start keeping a detailed diary of this and tell your doctor, as you may just have a new disease named after you.  It must also be noted that you may find other things in the toilet along with the corn:

  • Broccoli - from the pancreatic duct
  • Green Beans - from the common bile duct
  • Green water balloons - from the gall bladder
  • Words with arrows near them (which I did not realize were part of the GI tract).

340x Another possibility explanation for covert corn production is that you are one of the genetic experiments of the 1950's where humans were cross-bred with farm produce.  You would know this to be the case if you are named "Nibblet" and have a mortal fear of the Nebraska Cornhusker mascot.

My guess is that someone in your home bought one of those gag corn toilets from Spencer's Gifts in the mall.

Thanks for all of your questions.  Keep them coming!

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Ask Dr. Rob: South Beach Puffy - Second Try

To those who are confused, my hosting company changed servers and so this post was stuck on the old server.  That is why I am reposting it.  I have not gone nuts....well....I guess that is hard to say at the top of this post.... *************

Hey there gang.  Hold on to your hats/hairpieces as we do another installment of "Ask Dr. Rob."

Let me just say before I get started that the well is starting to run dry of questions for me to answer.  Some folks have sent some real medical questions to me (which means they obviously don't read the blog), but I haven't gotten any good questions.  PLEASE, if you would like me to entertain your question about whatever you like to know about, send it to dr.rob.questions(at)gmail(dot)com.

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So I went back and rummaged through my mailbag (in a cyber-sort of way) and came upon this previously unanswered question from G. Xavier:

I'm eating a South Beach Diet meal replacement bar. The trouble is... I'm not on the south beach diet. What's going to happen to me?

I would first like to comment your name, G. Xavier.  Why the G?  Did you have seven choices for names, the seventh of which was Xavier?

What name do you want:

A. Puffy B. George W. C. Retractable landing gear D. Zoinks E.  Bob F.  Llama Breath G. Xavier

Landing Gear Personally, I would have chosen C.

Regardless of how you came upon your name, typing G. Xavier is a pain in the gluteus maximus, so I will instead call you Puffy.

So what about Puffy's question?  What does science tell us about diet meal replacement bars?  What does science tell us about this important subject?

A Brief History of the Diet Meal Replacement Bar

Ancient Times

To really understand the question, we must first delve back into the historical phenomenon known as DMRB (which is the scientific notation for the Diet Meal Replacement Bar).

tcharc111900On the left is what scientists believe to be the first known reference to a DMRB.  It is a cave drawing found in southern Turkey and believed to be over 5,000 years old.  The pictures around it show an overweight man running after an antelope and a thin man looking at this object.  Archeologists believe that the little things coming up on the top are box tops and the scribble in the middle is a UPC symbol.

alexander_coin_250 Jump ahead a few thousand years to ancient Greece, where the DMRB became a widespread phenomenon.  It is said that Alexander the Great had a real problem keeping off the pounds, and became obsessed with finding the ultimate DMRB.  He scoured the known world in search of a way to lose weight and keep the pounds off, but was unable to ever regain his boyish figure.  He died in 323 BC from either malaria, typhoid, encephalitis, or a dangerously high LDL cholesterol level.

This is tragic, because a few years after Alexander's death, Demosthenes discovered a way to mix olive oil, dates, and wheat flax in a way that not only tasted terrific, but also was low in trans-fat.  He is known to many as the father of DMRB, and is pictured below carrying a DMRB in his right hand.

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The Middle-Ages and Renaissance

Like many classical inventions, much of the knowledge of DMRB's was lost after the fall of the Roman Empire.  Not only did the barbarians' sacking of Rome cause many scientific and cultural advances of the classical period to be lost for over a thousand years, but it also doomed people to an endless struggle with bulging love-handles.

703monk The biggest tragedy of the middle ages was the loss of a huge segment of the population to the plague, or black death.  This horrible disease is caused by a bacteria infesting the flea that lives on rats.  Many have theorized as to why the plague spread so rapidly during this period, but not at other times.  The latest research points to the fact that the high BMI that predominated made it difficult for people to run from rats and easy for fleas to hide in fat folds.

Despite repeated attempts by alchemists to turn goat livers into DMRB's, the Davidmiddle ages is felt to be a truly dark time for dietary supplements.

During the renaissance there was a veritable explosion of scientific discovery.  The Medici family of Florence sponsored much of that work.  But did they have influence on the development of weight-loss bars?  The evidence is unclear, but some art historians believe that Michelangelo's famous statue of David is holding a DMRB in his left hand.  This would explain is amazing physique, but is still a subject of debate.

Modern Times

Even though the years between the Renaissance and today are filled with references to DMRB's (the most famous of which was the one Napoleon Bonaparte hid under his lapel), very little progress was made until the birth of Dr. Robert Atkins, the founder of the famous Atkins Diet.

Dr. Atkins' beliefs regarding diet flew in the face of the scientific thoughts of his day.  At that time scientists felt that to lose weight, a diet of predominantly low-fat foods should be consumed.  The low-fat diet works like this: the person consumes as much food tasting like cardboard that the very idea of food is repulsive and the person loses weight.  This is a diet popular with goats (as pictured below), which is why you don't see many fat goats.

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Dr. Atkins, however, thought that food should taste better than cardboard, and so invented the low-carbohydrate diet.  The foundation of this diet is the breakfast favorite, bacon.  This diet works like this: the dieter eats so much food containing bacon that the idea of eating becomes repulsive and the person loses weight.  This diet is very popular at hospital cafeterias.

A strong anti-bacon sentiment developed, and a new diet was invented: the South Beach Diet, with it's revolutionary use of the DMRB.  The idea is to eat only DMRB's so that the very idea of food is repulsive and the person loses weight.

To Answer Your Question...

So, Puffy, what if you eat a DMRB and are not on the South Beach diet?

First off, doing this on a regular basis will cause weight loss.  It has been shown scientifically that a person's wallet gets significantly thinner when a person regularly eats DMRB's.

images_teamlogo Second, if you happen to live in the town of North Beach, this food will change your personal polarity.  This is very dangerous.  Your personal polarity is determined in your DNA, which gets really annoyed when the polarity reverses.  Your polarity determines all sorts of personality traits, such as: sense of humor, compassion, favorite color, and whether or not you put ketchup on your Taco.  Personal polarity is not to be toyed with.

Third, occasional consumption of the South Beach DMRB will have some benefits: your skin will become a nicely-tanned hue, you will become much better at dancing to salsa music, and you will start hanging out with hot chicks in bathing suits.  This has been my experience.

But despite the improvement to your social life, Puffy, I would not recommend eating South Beach DMRB's when not on the diet.

Why?

I think you should do the Dr. Rob Diet.

The Dr. Rob Diet has absolutely no restrictions to what and how much you eat.  You can have steak, cookies, jelly beans, and Little Debbie's as much as you want.  But, you have to read this blog every day.

The nausea-inducing effect of this blog is guaranteed to make you lose weight.

Thanks for the question, Puff-daddy.

PLEASE send me more material questions at dr.rob.questions(at)gmail(dot)com.

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