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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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Adventures in Medicine, Part 3

New Book 16 (1)

So, Dr. Ron wants to play for Simon Powell on "Doctor Idol," and Chuck ("Chuck," I mean) wants to play for the Mud hens. What's wrong with that?  Nothing, actually, aside from their total lack of athletic and musical talent.  What's wrong is the part of the stories preceding these winsome wishes of our dear compadres.

1.  The Interaction

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Both doctor and patient imagined a simple interaction between doctor and patient, as they are the only two humans physically in the exam room.  Unfortunately, there are many other in the doctor's office and exam room in a non-physical, but very real, sort of way.

New Book 16

The outer circle is comprised of the entities or tasks that are taking Dr. Ron's mind out of the exam room.  These include:

  • Insurance companies, with their complex rules (more to follow on this) of payment and ever shrinking payments.
  • The government, with it's growing involvement in the office in areas of measurement, regulations, and (above all else) bureaucracy.  Ron feels their ever-growing presence in the office each day.
  • The huge amount of paperwork generated by both of these entities (and others).
  • The media, with it's hype machine built to sell advertising, not truth.
  • Denials of claims (and decreasing reimbursement), which lead to...
  • The need for higher patient volume, putting Ron further behind and giving Chuck more time to enjoy his waiting room adventures.
  • The Internet with its double-edged sword of information/misinformation, leading to patient confusion and decreased patient trust.
  • Specialists, who Ron uses to help him manage problems on his patients, but who often don't send him any information about those visits, do procedures that Ron doesn't always agree with, and are paid 3-4 times more than him (mostly through contracts negotiated by physician groups led by specialists).
  • Hospitals, who alternately treat Ron as royalty (to get his referrals and ancillary orders) or dog poo (because he doesn't generate direct revenue for them like the specialists do).

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Sitting in the exam room between Chuck and Dr. Ron are things which are immediately on Ron's mind, distracting his attention away from Chuck and his back:

  • The threat of malpractice - while this is not high for Ron, as a PCP, he knows he's always one exam room away from potential catastrophe.  The presence of these distractions make it harder to give the focus needed to avoid missing something important.
  • Financial pressures - either running the business itself (like Ron does) or cowing to the demands of the hospital overlords (as many other docs do) put finances at the center of the universe in the exam room.  Are all the possible charges being entered on each patient?  Is he spending too much time with them and therefore decreasing his overall volume?
  • CPT/ICD codes - Ron sees this as a trap, with it's incredible complicatedness, always seeming to give payers an "out clause."  Patients try to convince him to leave off a diagnosis, while billers want him to include the second digit after the decimal on every one.  Ron wonders how digits after decimals became such an important thing in his life.
  • E/M coding compliance - Like most doctors, Ron realizes two things:
    • That he is paid for documentation, not care.  Having a specific number of bullet points in the history, review of systems, exams, and documenting certain thought processes are the things auditors look for when evaluating the records.  Ron is forced to either put in a huge amount of information to justify the visit, or to "down code," charging less for the visit than he deserves to avoid documenting diarrhea.
    • That no matter how hard he tries, he is never 100% compliant with documentation requirements.  This is the ticking time bomb PCP's face, as they realize that non-compliance with the impossibly complex documentation rules, in the eyes of hungry auditors has another name: fraud.  Ron prays that no auditor with an agenda looks at his charts, as he knows that any doctor could be used as a public whipping-boy.
  • HIPAA - While Ron likes the fact that HIPAA keeps prying relatives out of the chart, he worries that he will mistakenly talk to someone who is not authorized  and get into trouble.  More worrisome is the fear of electronic communication or patient records getting out of the office, giving authorities another chance to take him down in public for something he has little control of, let alone understanding of.
  • thQuality measures - while these seem to be a positive thing, to reward good doctors, Ron always feels that the real agenda is to go after the "bad" doctors.  He's worried that because he doesn't get rid of complicated or non-compliant patients, he will be labeled as an "underperforming" doctor, and get on someone's "doctors to avoid" list.  He also thinks it will be used as a reason to lower his payment.
  • Meaningful Use - It seems like a classic "bait and switch," where doctors are lured into using computers with money, only to use the information gathered on him with those computers to increase his chance of being labelled as an "underperforming" doctor, or making the job easier for auditors to hit him with the charge of "fraud."

All of this surrounds Dr. Ron with a series of barriers that Chuck must unknowingly cross to do the seemingly simple task of telling the doctor what's wrong.  All Chuck knows is that his back hurts and that perhaps buying the Roomba wasn't such a good idea.  He just wants to make sure there's nothing serious going on, and he wants to feel better.

We'll address those issues in our next post...

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Adventures in Medicine, Part 2

IMG_0481 In case you missed my last post (some may consider it a blessing, like missing the season premiere of "Jenny McCarthy, the science Gal"), this is the star of the show.  His name is "Chuck."

Why, many may ask do I use "quotes" when I use the name "Chuck."  To this, I respond, that it's a "secret."  Maybe you should get a "life."

IMG_0480So when last we left Chuck, he was in the office of his "Primary Care Provider," Dr. Ron.  Chuck fell over his cat and injured his back.  He didn't think he had a problem that needed a doctor's attention, but when he went to the Internet for answers (which everyone does, in case you didn't know), he only got more confused (and a little scared).  He needed advice from someone he trusts, and, despite the wait times and co-pays, he likes and trusts Dr. Ron.

So, being the good soldier within the patient brigade, Chuck takes the whole afternoon off and sets his mind toward the exciting prospect of the hours of excitement at Dr. Ron's office.

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Despite the seeming reality TV scene in the waiting room, Chuck is happy to be in a place where he can get concrete answers to his questions and an end to his pain.  For Chuck, as with most patients, the visit to the doctor should go like this:

Step 1:  Chuck tells the doctor his problem.  Doctor Ron listens and knows what is wrong.

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Step 2: Doctor tells Chuck what is causes his problem and comes up with a solution.

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Step 3: Problem gone, Chuck can once again pursue his dream of being center fielder for the Toledo Mud Hens, and Dr. Ron is thrilled to be part of his success.

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Not to be outdone in the expectations department, Dr. Ron expects the visit to happen like this:

1. Patient has questions and problems which Dr. Ron answers and solves (respectively).

IMG_06392.  Patient happily pays for the encounter, as do all his satisfied customers.

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3. Successful in medicine, Ron turns to his hidden fantasy: to compete on (and win) the popular "Doctor Idol" TV show.  His patients are proud of him.

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So what's wrong with these pictures (besides obvious anatomical inconsistencies, such as the regular disappearance of noses)?

Stay tuned....

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Adventures in Medicine, Part 1

While hard at work at building a new practice and (in the eyes of some) on my insanely misguided effort to build a medical record, I've been thinking.  Dangerous thing to do, you know.  It can lead to scary things like ideas, creativity, and change.  I know, I should be satisfied with the usual mental vacuum state, but I've found it a very hard habit to kick.  Perhaps there's a 12-step group for folks with ideas they can't suppress. Anyway, my thoughts have centered around explaining what I am doing with all of the my time and energy, and, more importantly, why I am doing all that stuff that keeps me from writing about important things like body odor, accordions, and toddlers with flame-throwers.  I've really strayed from the good ol' days, haven't I?  The problem is, I've grown so accustomed to my nerd persona that I end up giving explanations that are harder to understand.  To combat this, I've decided to employ a technique I learned from my formative years: stories with pictures.  My hope is that, through the use of my incredible drawing talent I will not only explain things faster (saving 1000 words per picture), but prevent my readers from falling, as they often do, into a confused slumber.

So, here goes.

Adventures in Health Care: Part 1 - The Participants

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This is a patient.  Let's call him "Chuck."  Chuck is not really a "patient," he's a person.  Many doctors believe that people like Chuck don't exist outside of their role as "patients," but this has been proven false (thanks to the tireless work of Oprah and ePatient Dave). But since this story is about Chuck's wacky adventures in health care, we will mainly think of Chuck in his role of "patient."

Why are people like Chuck called "patients?"  Some people think it's to put them in their necessary subservient place in the system.  I think it's just to be ironic.

Chuck is a generally healthy guy, but occasionally he does get sick.  He also worries about getting sick in the future, and want's to keep himself as healthy as possible.  This is when he uses the health care system, and when he is forced to be "patient."

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This is Chuck's Family.  It's the main reason he wants to stay healthy and avoid being a "patient."  He has a lovely wife, two adorable children, and a cat that likes to ride around the house on a Roomba.  I suspect you've heard about the cat; he's gotten pretty famous.  Chuck's family wants him to stay around for a long time so he can pay bills, share his expert opinion on whether an outfit makes his wife's butt look fat, lecture the kids about the dangers of drugs and Cartoon Network, and answer his cat's voluminous fan mail.  He would also like to live to be able to see his grandchildren (although he's not sure his kids will survive that long).

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This is Chuck's doctor, Dr. Ron.  Dr. Ron is a "primary care provider," or PCP.  Ron never particularly liked being called a "provider," but the peer pressure from the insurance companies and the other "cooler" doctors (specialists) have made Ron accept this name without thinking any more.  Primary care doctors are also called "generalists," but are known to hospital administrators, insurance company barons, and the "cool" specialists as:

  1. Referral sources
  2. The ones to blame
  3. Cannon fodder for insurance contracts
  4. The guys who can't afford the cars we drive.

Like most primary care doctors, Ron is very, very busy.  He doesn't feel like he's got much of a choice, as it's the only way he can make enough to pay his student loans and still have enough for his loan on his Kia. This causes the following deadly consequences:

  • Spending all day seeing patients in the office gives him little time for anything else.
  • He doesn't answer questions over the phone, instead making patients come in for anything that takes more than three words to answer.
  • This makes his office visit workload even heavier, and makes the average visit be about less "exciting" problems.
  • Ron then wonders why his patients come to him for such small problems.

Last week, Chuck hurt his back (while trying to avoid his cat) and wasn't sure what to do about it.  He didn't initially go to the doctor, but did what most people do when they have a question: checked the Internet.  He doesn't like doing this, though, as it usually confuses him more.  Besides, he's heard that doctors get mad if you look things up on the Internet.

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He gave up trying to find answers on his own, called Dr. Ron's office, and was set-up with an appointment.  This meant that he had to take time off of work, wait in the office for a long time, and then fit all of his questions into the brief time Dr. Ron is in the exam room and not focused on documentation. This usually is about 30 seconds.  But this is what Chuck, and everyone else in the country is used to, so Chuck puts up with the inconvenience this causes, dutifully paying his copay for those precious 30 seconds of attention.

In truth, Dr. Ron is not too happy with this arrangement. He went into medicine because he thought it would be cool to help people, have awesome knowledge nobody else knew, and to make his mom proud. He likes taking care of people, but is finding less and less of what he went into medicine for. Each year it seems like he spends less time with his patients, and more time with his computer.

This got much worse in the past few years as the government decided all doctors should be using computers in a “meaningful and useful” way. Unfortunately, “meaningful” and “useful are defined by the government, not doctors and patients, and Ron is not quite sure if the government wasn't just being ironic when they decided on these definitions.

Despite the difficulties, Chuck likes Dr. Ron, who seems to spend more time with him and listen to his problems more than other doctors he’s had. A few times Dr. Ron spent a whopping 5 minutes talking with Chuck and answering his questions. This made Chuck feel a bit guilty, as Dr. Ron seemed pretty tired and stressed out.

(To Be Continued....)

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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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The Physical Exam: Thighs Matters

One of my favorite series of posts I did on my old blog was a run-down of the physical exam.  Some might say I ran down the physical exam as one might run down a pedestrian, I suppose, but it was a fun series to write.  If you didn't get the chance to read it (or don't remember the trauma of first reading them) go here.  If you do, please make sure to do the following:

  • Have bucket handy
  • Buy a bottle of strong liquor
  • Stay away from sharp objects.

Trust me on this.

So, I have decided, I will once again inflict share this series with the readers of this blog.  Feel free to flee in terror.

My last writing on this subject was on the exam of the hip joint, which is, as I pointed out, a very confusing topic.  What most people call "hips" are not actually hips, but the outside portion of the thigh.  To clear this up, I now turn to the subject of the thigh.  The thigh, which is just south of the hip (but is not the hip), is that portion of the leg the spreads out when you sit down, causing many to go on diets and compulsively buy strange products when watching late night TV shows.

 

Underneath the spreading tissue is the largest bone in the body, known as the femur.  The femur connects the knee to the groin. Now, my use of the phrase, knee to the groin has probably brought out one of two responses in my readers:

  1. A dull moan accompanied by cold sweats from male readers who had PTSD flashbacks to middle school
  2. A desire to watch the popular TV show, America's Funniest Videos, which has built an empire on traumatic groin injuries.
It is interesting that two totally-opposite reactions would happen from the use of one phrase: "knee to the groin."  I would speculate that it was a male traumatized in middle school who chose the name "femur" was chosen instead of "humerus" or "funny bone."  Clearly the people who make the show America's Funniest Videos are the ones in middle school who were associated with kneeing, not groining.  Either that, or they have exceptionally good therapists.
Double-entendres aside, there is one thing about the femur none can deny: it's big.  Orthopedists, who definitely were the doctors doing the kneeing and not the groining during medical school, go one step further, calling the femur a big honking bone.  Paleontologists (who were more likely on the receiving end of the knee/groin transaction) also are prone to use the word "honking" (or it's language equivalent) in reference to the femurs found as dinosaur fossils.
This is a paleontologist next to the femur of a dinosaur. I think the sign he's holding says "this is a huge honking bone."
There is some controversy, however, as to the nature of one specimen discovered that dates back to the yabba-dabba-dithic period:

Some scientists believe that the bone in the hair of this child (nicknamed "Pebbles" for unknown reasons) is a femur, noting the similarity to the big honking bone the paleontologist with the sign is standing next to.  Others eschew this theory, pointing the lack of the ball-shaped portion of the bone (acetabulum) that inserts into the hip. The first scientists call the second group a bunch of smart-acetabulums, leading to some more knee/groin interactions.  Despite the acrimony of this debate, all scientists agree on one thing: that's one darling little girl.

(Note, astute reader Ngsurgery corrected me on this one, as the ball portion is actually the head of the femur, while the acetabulum is the socket the head goes into.  I won't change it, as it would make the smart-acetabulum pun drop in its funniness quotient.  I appreciate sharp readers pointing out my brain farts).

The femur isn't the only part of the thigh with size as it's claim to fame.  The sartorius muscle, in its circuitous course from outer pelvis to inner knee, is the longest muscle in the body.

The sartorius muscle gets its name from the Latin word sartor, which means "tailor," and hence it gets the nickname, "the tailor's muscle."  Just why someone chose to name this muscle after a profession not quite known for its physicality is cause for discussion.
There are four hypotheses as to the genesis of the name: One is that this name was chosen in reference to the cross-legged position in which tailors once sat. Another is that it refers to the location of the inferior portion of the muscle being the "inseam" or area of the inner thigh tailors commonly measure when fitting a pant. A third is that the muscle closely resembles a tailor's ribbon. Additionally, antique sewing machines required continuous cross body pedalling. This combination of lateral rotation and flexion of the hip and flexion of the knee gave tailors particularly enlarged sartorius muscles. (from Wikipedia)
I personally think these people have too much time on their hands.
So what's the use of the sartorius muscle?  Again, from Wikipedia:
Assists in flexing, abduction and lateral rotation of hip, and flexion of knee.  Looking at the bottom of one's foot, as if checking to see if one had stepped in gum, demonstrates all four actions of sartorius.
Stepping on gum, a fact of modern life, is not something others have experienced through history. I've uncovered a new possibility for the word origin of sartorius, coming from an Indo-European expression shouted out when people stepped in dog feces.  This sculpture, found in the Metropolitan Museum of Art, depicts such a misadventure.So what about the exam of the thigh?  How did this post devolve to a discussion of people stepping in dog poop?  What about the quadriceps muscles?  What about the hamstrings?  What about Suzanne Summers?I gave you the chance to flee in terror.  Now look what you've stepped in: a bunch of yabba-dabba-doo.

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The Origin of Feces

I got this in my email today from "Living Social."

Colon

When I first read it, I thought it said, "Your mother always reminded you to wash your behind…", which makes sense, given the advertising subject material.  I haven't read the remainder of the deal, so we can only guess what the last sentence reads: "Pay $39 to get one colon hydrotherapy treatment that will safely and comfortably remove excess wast from your…" well, I guess from behind your ears, if you use enough hydrotherapy.  This woman, however, seems to have not washed behind her ears because she's sprouting flowers from that spot.  Either that, or the hydrotherapy is successful enough to allow growth of hydroponic plants.

I do wonder about two things in this advertisement: first, I wonder at the serene expression on her face.  Surely, this isn't the face of someone having colonic hydrotherapy.  I would expect that face to look a little more like this:

Expression Fig 20 Terror 253x300

Or this:

 Expression Fig 21 Horror 270x300

Which are both pictures taken by Benjamin Amond Duchenne during an experiment using electrodes.  

Duchenne had set out to find the muscles responsible for creating particular expressions using an electrical device he had originally developed to investigate the muscles that control the hand. He applied galvanic probes to the facial muscles of a number of different test subjects. He also took what today could be thought of as control photographs of the same people with blank expressions, and others where they were attempting to simulate expressions without the aid of the probes.

Source

These photos fascinated Charles Darwin enough to include them in his book on emotional expressions.

Which brings me back to the second observation about the advertisement: the inclusion of a beautiful woman with flowers around her is not necessarily what comes to mind when I think about "colon hydrotherapy."  The below pictures (also from Darwin's book) express to me a more realistic response to the turning of one's colon into a water balloon.

1872 Expression F1142 figplate5

After all, what is inflated must then deflate.  We all know what the end product of hydrotherapy is: Galapagos.

Which brings up the final irony of this offer to put water in my colon for a fraction of the expected cost: it comes from a website called "Living Social."  Do people really believe that colonic somehow gives them an advantage while "living social?"  Perhaps, however, this will work for the benefit of natural selection, as they will have less of a chance to have children.

I think I'll stick with Groupon.

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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.

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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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Thank Goat it's Friday

So I thought I would bring you joy on this Friday in one of the best ways I can think of: goats.  Nothing brings more joy to the heart of man than goats.  Well, maybe cheese puffs bring more joy, but goats are second only to cheese puffs.  It's a close call, really. But before I cheer you up, I need to make you miserably sad, because the first goat tale is a sad tale.  It is a tale of intrigue and tragedy.  It is the story of the evils of gang violence and the sadness of love lost.  This actually came from the Toronto Sun, and naturally, it is a story that takes place New Mexico.

A dwarf goat was killed in a drive-by shooting in Santa Fe, N.M., Sunday evening.

Neighbours said they heard three shots after a minivan pulled up in front of the house. Afterwards they discovered Maria the Nigerian dwarf goat had been shot in the abdomen and face, the Santa Fe New Mexican newspaper reported. It was an hour before the animal died in the arms of its owner as neighbours gathered around.

Maria's owners have two other goats that survived the shooting, as well as 12 chickens, four cats, a dog and a duck, most of which are rescue animals.

Sad.  I don't know if the folks in Toronto found this of interest because of the poignant image of a goat baaing it's last baa in the arms of a weeping owner, or because there is also a rise in gang/goat violence in Canada.  Perhaps they have a soft-spot for Nigerian dwarf goats; I know I do.  We can only speculate about this, as can we wonder what exactly Maria knew that someone wanted to cover up.  Why spare the other animals?  Were the other goats dwarf goats?  Were they from Nigeria?  Or were they Hungarian giant goats?  There just isn't enough information and it is quite suspicious.

This wasn't lost, obviously, on a goat in Madison county, Georgia:

Authorities won't press charges against the owner of a goat that attacked an 88-year-old Colbert man last month, though city leaders plan to bolster animal control as a result.

The sheriff's office planned to press charges against the goat's 69-year-old owner for of allowing livestock to roam free, but decided against it, Madison County Sheriff Kip Thomas said.

"The (Davis) family didn't want to, so we didn't," Thomas said.

The goat escaped when a tree branch fell and broke the fence around its pen.

Tree branch?  Right.  Don't people realize the connection between these two stories?  Why haven't the Canadians shown interest?  This really smells of a cover-up.

My third story was picked up by the Wall Street Journal, and it also (suspiciously) involves my home state of Georgia. It appears there is a restaurant in Wisconsin that is famous for having goats on the roof. People call it: "That restaurant with the goats on the roof."  I am not quite sure they call it this, but the owner of this establishment decided to capitalize on the goat notoriety (goatoriety?), trademarking the "goat on the roof" motif.  He then caught wind of some trouble in the state of Georgia:

Last year, he discovered that Tiger Mountain Market in Rabun County, Ga., had been grazing goats on its grass roof since 2007. Putting goats on the roof wasn't illegal. The violation, Al Johnson's alleged in a lawsuit in the U.S. District Court for the Northern District of Georgia, was that Tiger Mountain used the animals to woo business.

The suit declared: "Notwithstanding Al Johnson's Restaurant's prior, continuous and extensive use of the Goats on the Roof Trade Dress"—a type of trademark—"defendant Tiger Mountain Market opened a grocery store and gift shop in buildings with grass on the roofs and allows goats to climb on the roofs of its buildings."

Al Johnson's "demanded that Defendant cease and desist such conduct, but Defendant has willfully continued to offer food services from buildings with goats on the roof," the suit continued.

The article makes no mention if the goats are Nigerian, nor if their size is of note.  But you must see the whole connection here; the goats are at the eye of a storm of gang-related violence perpetrated by Swedish restauranteurs.  Was Maria the Nigerian dwarf goat about to snitch?  Was the killer goat of Madison County sent as an "enforcer" to give a "little reminder" that infringement on the "goat on the roof" idea will be "dealt with swiftly and savagely?"  Where are the Canadians when you need them??

Here is, in fact, a video showing a masked goat terrifying other goats in an attempt to keep them quiet:

Terrifying. Utterly terrifying. You see the terror unleashed by this heartless goat wearing a mask. What is the world coming to??

My final story is about goat intimidation going wild:

Just why are these goats fainting?  Do we really believe the story of so-called "myoclonus?"    Are these people really kind owners who like to laugh at the expense of a genetic defect, or are they in the clutches of the Swedish restauranteur gang that has these goats terrorized to the point of syncope?

I think only the Canadians can give us the answer to that.

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What's a Duck Got To Do With It??

Dear American Academy of Pediatrics: I think there is a mistake.  Kids started coming into the office recently with forms for sports physicals, and the form is different.  See Below:

Someone added stuff to the form!  Not only do we have to continue the inexplicable obsession with the hernia check (for maximum humiliation of boys, we try to use only female examiners for this), there's a bunch of new stuff.  I do understand why we need to check for heart problems, with the risk of hypertrophic cardiomyopathy that can kill previously healthy kids.  But what's this with the femoral and radial pulses?  Yes, I know it is a screening test for coarctation of the aorta, but so is a simple pedal pulse check.  Plus, checking a femoral pulse on kids is almost as bad as a hernia check.

Then there's the "functional" part of the exam.  The kids all think this is hilarious, but we were quite confused.  I never was taught in medical school or residency what a "Duck-walk" was.  I did a Google search and found that it is a brand of wine, but I don't think that's appropriate for a sports physical (you know, with underage drinking being such a problem).

Google also had lots of pictures of Chuck Berry.  I assume his walk in a squat position is referred to as a "duck walk."  So are we supposed to have them do air guitar and pretend to be Chuck Berry?

Would the Chicken Dance be OK?  Most of the kids these days have never heard of Chuck Berry.

Then finally, there's the hopping on one leg thing.  Why would hopping on one leg include or exclude a child from sports participation?  Wouldn't a child who couldn't hop on one leg have a low likelihood of making the team in the first place?  What exactly are we looking for?  I guess if we gave them some of that Duck Walk merlot, they pretty much would do anything.  Come to think of it, I wonder if they were drinking merlot when they made this form.

I wanted to bring this to your attention because it's caused quite a stir among the teens.  They apparently are swapping stories about doing duck walks and are very disappointed with having to do the Chicken Dance.  Somebody thought that hernia checks were not humiliating enough and wanted to share the love with girls as well.

I hope you fix this problem as soon as possible.

Sincerely,

Dr. Rob

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