Saturday, September 29, 2007

Hey Pfizer! This one's for you...

There rarely exists a pharmaceutical need that doesn't go filled by Big Pharma. Too hard to swallow that pill? Here, we'll make a dissolvable tablet...or a patch...or an inhaled form.

But they've missed a hole, a marketing void. And I'm about to give it to them.

Primary care doctors need a combination antifungal/low-potency steroid cream.

Lots of topical fungal/yeast infections, when in the angry and red stage, would really benefit from this. Sure, we've got Mycolog and Lotrisone, but the steroid components of those are stronger than I like to use excessively, especially on a baby bottom. The problem is that they work so well that once patients get a taste, plain nystatin ain't gonna cut it anymore. I have been begged in the past.

Why can't I just write two prescriptions, a steroid and an antifungal? Of course I can. But then there are two copays, and two creams to confuse.

Really, I think this is a good idea. I'll settle for a 10% cut.

If there already exists a cream such as I've described and I'm ignorant of it, please enlighten me. But please be gentle. I've had a rough week.

Pfizer. Call me.

Friday, September 28, 2007

Not a surgeon

RLBates of Suture for a Living has been asking politely to see my quilting. I'm happy to oblige. I love looking at others' quilts for inspiration - perhaps these will give someone else a new idea.

The first is one that I finished about a year ago. I really enjoy the handquilting part of a quilt (up to a point - I can't quilt a bed quilt, just my wall hangings). This one was fun because I got to do some handstitching prior to assembly. I still quilted it once it was together.

The second is pieces of the one that I'm working on now. It's essentially been a work in progress since the previous one was completed. It's a bit bigger than what I usually like, and I've found that I've been bored with the repetition at various stages. I'm currently in a stage of frustration rather than boredom...I'm a bit sloppy with my seams at times (yet another reason I never considered surgery) and my points aren't going together nicely. Maybe now that I'm baring my squares to the world I'll actually start working on them again?

Wednesday, September 26, 2007

Glad I could help, part 2

Actual phone message: (patient has missed 5 followup appointments)

Please phone in refills on (various psych) meds.

Patient doesn't want to waste her time and money coming in to see Dr. Smak.

Apparently I'm doing a stellar job this week.

Tuesday, September 25, 2007

Glad I could help...

Actual phone message from today:

Seen by Dr. Smak two days ago. Told she had bronchitis and prescribed albuterol, prednisone, and flonase nasal spray.

Didn't fill prednisone, doesn't like how it makes her feel.

Didn't fill flonase, didn't think it would help.

Already had albuterol but had lost it and didn't want to get it refilled.

Not any better. Thinks she needs an antibiotic.

Monday, September 24, 2007

8 Random Facts

I've been tagged by RLBates of Suture for a Living with the 8 Random Facts meme. I guess I'm officially no longer a newbie to the blogosphere. Here goes:

1. I lived and worked a summer in Oslo, Norway. It might be the best place in the world to spend a summer, since the sun is only down for 4 hours a night and the Norwegians groan about how unbearably hot it is when it hit 80 or so. I don't snakke Norske, so don't try to strike up a conversation.

2. I'm a total cheapskate. I come from two long lines of cheapskates, so it's not really my fault.

3. I'm the first doctor in my direct family line since my great-grandfather, whom I never met. He was a small-town doc in rural South Carolina and drove a horse and buggy on house calls for many years. His house calls were $2 - I charge a little more.

4. I cry uncontrollably whenever groups of small children sing together. They don't have to be mine. I don't even have to know them. This makes for great fun at school assemblies and birthday parties.

5. When I started medical school I hoped to either become a pathologist or a radiologist, so that I wouldn't have to talk to patients.

6. I quilt. I'm not prolific, and when I get frustrated I get stalled, so there's not much going on in my sewing room now. I suck at points, and in my infinite wisdom chose to sew a quilt full of points. Good thing I'm so self-aware.

7. I hate to exercise.

8. A genetic freakism - women in my family (including myself) are able to hyperextend our IP joints of our thumbs (essentially to make a right angle out of the first two bones of the thumb). I've not found it to be useful since I've gotten past the stage where it was fun to gross people out with it.

I'm going to forgo the tagging of others, not because I don't like to play, but I'm think I'm the end of the line. Ten out of Ten was quite sure he was the last to be tagged, so I'll have to bump him to second to last, but it ends here.

Friday, September 21, 2007


My mind has been spinning around the healthcare system in the US this week. I'd call it a crisis, but that might be a bit dramatic.

My general feeling is that we as Americans need to decide that it's worth spending taxpayer money to fund affordable health care for our countrymen. We have decided that regarding education, and it's doing well for us, for the most part. How exactly this needs to get worked out isn't settled in my head - when I come up with the perfect solution I'll let you all know.


The current medicaid system is not a functional piece of the puzzle. We need some BIG changes there. And I'd start with just a small co-pay.

Virtually all patients have co-pays, to see their PCP, a specialist, or to go to the ER. Except medicaid patients.

There needs to be a small barrier to entry, to help deter overuse. I never see private pay patients who bring in two extra kids "just to get them checked" with the one that was really sick, because it would cost them an extra $40 in co-pays. I don't know about you, but I can usually find a cute pair of shoes on Zappos for $40 (OK, they weren't $40, but they are cute). But medicaid patients pay nothing to be seen, so might as well pack 'em in.

I saw a medicaid patient this morning who said she'd felt drunk ever since she woke up. She literally still had pillow marks on her face. She had been in not 14 hours before for another self-limited complaint that had - don't be shocked - resolved.

If she had just a $2 copay, I bet she would have checked her own (normal) blood sugar at home instead of having me do it.

Affordable health care, yes. Free health care, no.

And I'm all for cheap shoes.

Wednesday, September 19, 2007

Plastic surgery

Had a little done today.

I had a nevus (mole) on the back of my head. It's been there for 20 years, at least. The only people who know about it are my hairdressers (stylists? Hairdresser sounds a bit 80s), who uniformly rake a comb across it when cutting my hair, sometimes to the point of bleeding.

I've been meaning to get it off for 10 years. Today I got around to it. This month we have a medical student I really like, and I've been waiting for the right one to choose to get her feet wet on my mole.

She did great. Numbed me up nicely, didn't pass out. What more could I ask?

It's funny - doctors are almost uniformly your classic overachievers. I think I'm still trying to get honors now that I'm the preceptor.

Monday, September 17, 2007

My, what long skinny fingers you have!

French surgeons piloted a transvaginal gallbladder removal.

Somehow that doesn't seem like it should be possible.

When doctors examine patients, especially those whom we don't know well, it can be very helpful to read the "roadmap" of scars on the chest and abdomen. A lot of patients amazingly forget to mention that they may have had an organ removed, even when asked explicity.

Begin dream sequence:

Future Dr. Smak: OK, Mrs. Jones, please try to relax your legs while I do your pap smear. Oh, what's this scar?

Mrs. Jones: The one on the right side was my transvaginal cholecystectomy, the left side was my splenectomy, and the big one in the middle my transvaginal hysterectomy.


Sunday, September 16, 2007

He weighs, she weighs

Who hasn't heard of the BMI these days?

It's all over the place: the evening news, magazines, actuarial tables, notes being sent home from schools.

BMI, or Body-Mass Index, is a number derived from height and weight. There are plenty of internet calculators to help you come up with yours. You are classified as being underweight, normal weight, overweight, or obese based on your BMI.

There are several reasons not to like the BMI, detailed in any number of places. My objection today is to it's gender-neutrality. There is no difference in BMI classification for men and women. Putting aside issues of muscle mass, or changes in body composition based on age, we're still left with the same chart for men and women. An average build, in-shape male always weighs more than an average build, in-shape female. Why should this not be reflected in the BMI charts?

This is where the BMI loses it's mainstream credibility, at least my experience. Mildly obese middle-aged males who look at their 'goal weight' on a chart are generally dumbfounded - they haven't seen a BMI of 25 since they were 17 years old. But when they ask me "I'm supposed to weigh the same as my wife is supposed to weigh?" it's hard to answer yes.

A woman with a BMI of 18-20 looks very trim. A man with a BMI of 18-20 looks sickly. I suppose one could claim that these perceptions are based on misogynistic ideas about what makes men and women attractive, but I don't think so. We have different growth charts for boys and girls; why the same weight chart for men and women?

Friday, September 14, 2007

Tassimo, take me away

Another shameless product plug. (I don't have any good medical stories today.)

I. Love. My. Tassimo.

It's the perfect cup of coffee. Every time.

If you're a big-pot-of-coffee kind of household, Tassimo might not be the best option. But at my house, I want my coffee an hour before my husband wants his. And then I might want one cup later in the day, depending.

So if you're a one-cup-at-a-time house, this will change your life.

Downsides: A cup of coffee costs 50 cents, a latte $1. And I feel a little bad about filling my local landfill with little plastic disks full of biodegradable coffee.

But I love my Tassimo.

PS Try the Chai Tea. - mmmmm.....

Thursday, September 13, 2007

Freebie of the week

Dr. Smak, I have a question.

This morning I sliced and ate a raw green pepper, then fried up some sweet sausage and put tabasco on it. About a half hour later my stomach really burned, and I had a tightness in my throat, and I kept coughing.

Do you know why?

Yeah. I got that one.

Wednesday, September 12, 2007

Bottom of the barrel

I have said before, and I'll say again, medicine is humbling if nothing else.

I take care of a lot of bottom of the barrel patients. No job, no money, no personality, no life skills, no motivation. Sometimes no hygiene. What I am realizing more and more is that a lot of these people have no one in the world that gives a $*&# about them.

It's really sad.

Some of these people are hard to like. Their kids don't like them, their spouse doesn't like them, their neighbors don't like them, their employer doesn't like them. Heck, I don't like them.

But sometimes, I'm the only person in their corner. The only person pulling for them in this great big world.

And so, tho I don't like them, I can still care about them, and what happens to them. I can't fix their odor (tho I try), poverty, or crappy home life. But I think they know that I care, and I think it makes a difference for them.

And I'm humbled by that.

Saturday, September 8, 2007

Told ya...

Shrink Rap has posted on the recent news regarding increased suicidality rates since the black box warning was added. I had previously posted on the warning, as it was clear that this was going to become an access issue for patients.

This was not a patient safety issue. This was a CYA issue.

Is there any evil in the world that at some level can't be traced to a lawyer?

The FDA, having made a few recent snafus, is trigger happy with the black box warning, when physician education would have been more appropriate. It's a lawyer thing.

Physicians, so as not to be sued, either avoid antidepressants in patients who would otherwise benefit, or "educate" the patients so thoroughly on the risks of treatment that zoloft looks like a death sentence, and many reasonable people won't touch it.

How about a class action lawsuit against lawyers for over-lawyering?

All kidding aside, there is a lot of talk about the huge expense in US medicine as a result of CYA test ordering and other activity. There is less talk about mortality as a direct result of CYA. For me, this clearly falls in to that category. Patients are dying because of lawyers.

Tort reform would be nice for doctors. We won't pay as much for malpractice.

But tort reform is needed for patient safety as well.

Friday, September 7, 2007

Eh hee

So I'm a big Dave Matthews fan.

He released a video of a new recording this week on iTunes. Blog-eyed fish has a link up to the video. It's not a song you know, and if you know Dave Matthews' music from what plays on the radio you probably won't like it. But the video is worth a watch.

What amazes me about it is the degree of creativity that is required to come up with something like this. I don't always appreciate art as much as I probably should, mostly because I don't understand it. But if you locked me in a room by myself for a year, promised me $10 million on completion and threatened me with death if I didn't succeed, I still couldn't come up with something nearly as creative. It's just not in me.

Which may be why I'm a doctor.

Wednesday, September 5, 2007


You learn a lot of medicine in medical school and residency. Not everything you'll every need to know, but it's a good start.

But they don't teach you much about dealing with difficult personalities. Even in a touchy-feely family practice residency. So you learn on the job.

In walks Ms. Prickly Porcupine. She can suck the beauty out of a warm spring day (and usually does.) She never smiles. She treats everyone as if their personal mission in life is to annoy her. I'm not excluded from this vast conspiracy. My last interaction with her got me this close (can you see my fingers?) to telling her to find a new doctor.

However, the doctor's best ally with difficult patients (as with all things medicine) is her nurse. And my nurse tells me the best way to handle Prickly is to prickle back.

PP: (whiny) I'm gaggy, snotty, pukey.

Dr. Smak: Pukey? How many times have you puked?

PP: (snapping now) Does it matter? You need a count?

Dr. Smak: (resignedly) Less than five?

PP: (on fire) Five? Is that the limit?

Dr. Smak: (snapping) Yes, five is the limit on Wednesdays.

PP: (surprised) How about Fridays?

As usual, my nurse was right. Prickly was quite settled for the rest of the visit. She only prickled me a little bit more. The tide had turned.

Then the winds changed. She started crying. And said all she wanted was some "love and sympathy." You could have pushed me over with a tongue depressor.

And to Prickly, love and sympathy today came in the form of an unnecessary antibiotic for her 3 days of cold symptoms with under five pukes a day.** And I learned another good patient care technique. Sometimes it pays to be prickly.

**I considered trying to explain to her why she didn't need one. I really try to avoid unnecessary antibiotics. But it's the only thing that would have made her feel cared about, and that, today, was more important.

Tuesday, September 4, 2007

Patience, grasshopper

I saw a patient today for a checkup. He's been coming to me for a variety of chronic conditions for a few years now. His chart is littered with conversations about weight loss, quitting smoking, and refused shots and colonoscopies. I send my medical student in to see him first.

Her report was that he'd lost 10 pounds in three months, and was requesting a tetanus shot and an appointment for his colonoscopy.

I was tickled. So I asked him "why the change of heart?"

"Because I trust you now."

Which was nice to hear. Then I asked, "Is there anything I could have done differently, to have helped you trust me sooner?"

"Nope. Just be patient."

Guess I'll have to trust him on that.

Saturday, September 1, 2007

Plastics for the pitty-pat

ACOG denounced the recent surge in cosmetic vaginal surgeries. The number of these procedures performed is on the rise, over a 1000 performed last year.

I'm with them. So is Richard D'Amico, president-elect of the American Society of Plastic Surgeons. He cites risks of unnecessary surgeries and the unproven benefits (improved self-esteem or relationships) as reasons why they are not supported.

Plastic surgeons performed 329,000 breast augmentations last year. I'm unaware of any clinical trials documenting relationship healing.

I don't blame the plastic surgeons for doing what they do. But I find it very troubling that so many women feel a need to enhance themselves surgically, specifically for sexual attractiveness. It is a sad commentary on where American women place a large portion of their self-worth. How is a boob job any different than a vaginoplasty?

And I'd recommend Dr. D'Amico get off his very high and galloping horse before he falls, sustains a nasal fracture, and needs an elective rhinoplasty.