Whatever Got You Into This Specialty, Anyway, Doc?

December 12, 2014 Leave a comment

Whenever I am asked this question, I can’t help but think of the punch line to a joke that was once supposed to be funny but would now be considered beyond the pale in all respects, so I won’t repeat it. The punch line is: “Just lucky, I guess.” That’s the short answer to why we gastroenterologists work in our field. Despite the distasteful aspect of human waste and the perverse nature of inserting rubber tubes where the Good Lord never intended, there are many reasons my colleagues and I work in a specialty where our slogan might be “Your business is my business”. And speaking of medical specialists, for the information of the jokesters among my 2 or 3 readers, we gastroenterologists are not referred to as proctologists. That’s a branch of surgery.

I myself find it surprising that anyone would wonder why I chose my specialty when most people themselves have such a keen interest in such matters . As a rule, people I encounter, upon learning what I do for a living, have questions. Even complete strangers in public places have on occasion immediately shared their digestive problems in embarrassing detail.  (One time when the GI professional convention was in town, a ticket-taker at the movies spotted my badge and inquired about his flatulence while my wife and the rest of the queue were kept waiting.)  I once thought to try to fend off potential requests for medical advice at cocktail parties by misrepresenting my specialty: if asked what I did for a living, I would reply in a somewhat ominous tone, “I’m in waste management.” I soon gave up that dodge when I discovered that the few people I fooled into thinking I operated a garbage hauling business were even more interested in that business’s – undeserved, of course – reputation as mobsters than they were in doctors.

Now, for a few answers…

Above all, I love to eat. Remember that the upper GI tract is half my bailiwick. There is something inherently fascinating about even the fact that we creatures are capable of ingesting and digesting food substances, not to mention what becomes of them. The whole process is nothing short of miraculous! Spinning flax into gold is the stuff of fairy tales, but turning a perfectly good meal into – well, you know what – is something only we living beings can do.

Moreover, eating is a particular interest for my fellow gastroenterologists in general, as best I can tell from our meetings. I would submit to you that our specialty has more and better quality dinner meetings than any other. The whole digestive process is so fascinating that I recently devoured with relish a book about the GI tract aimed at lay people, Gulp, by Mary Roach, and enjoyed every page, even though I knew most of the stories therein. I highly commend it; the digressions and the droll reportage are worth the trip.

As for the distasteful material I have to work with, remember that there are other specialties whose stock in trade I regard as far less delicate. Pulmonology, for example: I would rather deal with a bucket full of stool than a bucket full of phlegm any day. Granted, the urine that my friends the kidney specialists work with is fairly sterile, but so is nephrology as a specialty, in my opinion. And while pathologists nowadays spend the bulk of their time looking at slides with lots of pretty colors, they still have to slice up dead bodies or cut up smelly organs in buckets of formaldehyde. And anyway, for the most part, by the time I come to routinely examine  your colon, it is essentially as clean as the inside of your mouth.

But I don’t mean to be flip.  I will next offer some serious answers to what is a legitimate question, “Why do you enjoy practicing gastroenterology?”

Firstly, most of the people who come for me for help can truly be helped. While cure is only an occasional outcome in medicine, relief of symptoms is a common and attainable goal, and reassurance is almost always possible. (I am paraphrasing a mission statement that was proposed centuries ago by a great physician.) As I see it, of all the medical specialties, with the exception of infectious diseases, ours offers the greatest chance to achieve positive results and even cures. In my own professional lifetime, I have seen stomach ulcers practically vanishing from among the diseases we regularly encounter. We are on the path to wipe out colon cancer. And there is even reason to hope that we will some day find the cause and cure for the most common, least serious, but extremely distressing ailment among GI diagnoses, Irritable Bowel Syndrome!

Second, the converse of the previous claim is the following one: only in minority of cases do we have to deal with the weighty matters of life and death. Of course, it is painful to inform a patient that she has colon cancer or pancreatic cancer. But that task is fortunately infrequent, and when it must be done, it can at least be done in the most supportive possible manner. I am happy I don’t have the daily task of the trauma surgeon that comes after an exhausting marathon of trying to patch together a human being:  presenting the prognosis to one or more distraught loved ones. Nor do I relish the life of the obstetrician, whose practice usually leads to the joy of a healthy human being arriving in the world, but occasionally, tragically does not.

And third, speaking of OB-GYN and surgery, my hours are definitely more predictable than in those specialties I just mentioned. Of course the hours are long, but these days the number of patients in need of emergency procedures is diminishing. Gastrointestinal hemorrhages are rarely in need of middle-of-the-night endoscopy at my small community hospital. The biggest threat to my sleep is actually the seemingly innocuous piece of steak or sausage that becomes lodged in some poor soul’s esophagus, usually during dinner. That’s the call from the emergency room that I welcome least, because there is no putting off what we refer to as a “foreign body” stuck in the esophagus.

Fourth, we gastroenterologists get to treat the greatest number of different organs in the human body, although the endocrinologists come in a close second.  Of course, oncologists and infectious disease specialists might argue that their disciplines treat every organ in the body, since none are immune to malignancies or infection. But with all due respect, their acquaintance is only passing and superficial. After all, what does the oncologist really know about the life of the stomach that she has cured of cancer? No more than the firefighter knows of the life of the citizen carried from a burning building. In any case, we do manage to avoid boredom in our specialty by treating everything along the pipe that runs from mouth to anus as well as a few side branches such as the liver, gallbladder and pancreas. My first patient of an afternoon in the office might be complaining of trouble swallowing and the next one of difficulty defecating. I pity the poor pulmonologist or cardiologist, with only one organ to claim for their own.

Next comes the matter of how we gastroenterologists spend our workdays. We get to know our patients. I love meeting people and getting to know them as people in the course of diagnosing and treating them. As a gastro doc, I have learned things about people I would never have in any other profession. Of course, the price I pay is having to hear on a regular basis certain intimate descriptions of things that I would just as soon not discuss over dinner. Even in that, there can be some humor. But overall, the role of the gastroenterologist is as close to that of a psychiatrist as any other specialty. Addressing the “psychosocial” aspects of illness (as they are referred to) can be at times depressing but at times rewarding.  I have learned to put people at ease in a wide range of ages, social classes, nationalities and personalities, and they, in turn, have welcomed me into their worlds. (I will concede, though, that there is another specialty that demands an intimate relationship between doctor and patient, namely, oncology, and I suspect this accounts for some of the motivation that keeps my esteemed colleagues doing what they do.)

But sometimes I get weary of hearing about the woes of the world, the worries of the well and the suffering of the ill. That’s when it’s time to walk down the hall to a place where I don’t have to listen to people endlessly bemoan their problems, or act as though they can expect miracle cures, or return and inform me they have failed to do anything I have asked of them. It’s called the “endoscopy suite”. There, I can confine even the most tedious of such conversations to the few minutes before we sedate the patient and after they wake up when I brief them before they leave. Tough conversations can be postponed until the biopsy comes back, and even the neediest characters understand when I tell them that I have to see to my next patient who is already “on the table”. And while each patient is “under”, I get to play my favorite music and listen to the gossip of the nurses and assistants while I do what is – thankfully – a routine set of tasks. Lest you worry that as a patient, your doctor is distracted, it is quite the opposite. Sometimes it is routine enough to be “mindless” in the zen sort of way that driving in Manhattan traffic is for me; I can become so focussed on the task that I forget all else. At other times, it is challenge to decide what best to do and how best to do it. Either way, it’s a welcome change from the office.

Which brings me to a related attraction of doing GI, which I share to a great extent with surgeons: I get to work with my hands. There is something just plain satisfying about seeing the work of our hands. Even since I was a child, I enjoyed playing with tinker toys, then erector sets, then balsa wood airplanes and then ham radio equipment. Even recently, one of my greatest pastimes has been going to my workshop and putting together a tube guitar amplifier. As you can imagine, it is no small source of pride having cauterized a hemorrhaging ulcer or having removed without hemorrhage a large potentially cancer-causing polyp. And these are just a few of the procedures we general gastroenterologists do. Nowadays, the hotshots in my specialty are actually doing surgery in the abdomen by deliberately making a hole in the stomach with the scope and operating through it and then closing the hole! And all of this work we do is performed by working the controls of a scope and watching a video screen. It’s not as much fun as playing a video game, because you can’t just reset and start over if you “die”, but you get used to the high stakes involved early in your training, so it’s still a rewarding way to spend a morning.

And finally, the intellectual aspect of diagnosing and treating GI problems is an enduring challenge that will not depart from me even if colonoscopy becomes an obsolete test or my hands become too weak to hold an endoscope. The challenge of solving a puzzle, and one that has direct meaning for the person sitting in front of me, remains one of the things that brings me back to work each day. Other doctors do the same thing in their own branch of medicine, but I like to think that I am using my brain so that others can make the most satisfying use of some of their most treasured bodily functions – or at least, some of my favorites. I believe it was Mark Twain who said that of the human needs, one of the most overrated is sex, and one of the most underrated is… well, you know.

So now that you know how I chose my specialty, I plan to share with you in a future discussion, the not-so-secret ways in which I have been able to avoid – thus far – a doctor’s biggest professional hazard: “physician burn-out”. Stay tuned.

Categories: Doctors, None of the Above

How and Why I Became a Doctor

November 6, 2014 Leave a comment

Once in a great while, a patient asks me why I became a doctor. It surprises me that I am asked that question as infrequently as I am. Perhaps the average person assumes that doctors are born and not made, and that most of us “always wanted to be a doctor when we grew up”. I don’t know about my colleagues, but I certainly didn’t to start out with; neither to be a doctor nor to grow up. I’m still just wrapping my head around both.

The ingredients in making a doctor vary from individual and individual and even the same ingredients are mixed in varying degrees. The first assumption some people make is that doctors are motivated by a compassion to help our fellow human beings, while other more cynical patients assume we all went into it for the money. These are two ends of the spectrum, but few of us fall close to one side or another. And while there is probably a bell curve along this axis, there are many other axes. For example, it would be hard to find a pathologist whose lifelong dream to help others was by looking at microscope slides all day. Intellectual stimulation, curiosity, and the satisfaction of accomplishment all play a role.  And while there are certainly a few doctors I know who calculated how they could make the highest income and chose medicine as the means, the majority of us had more complex and for the most part commendable reasons.

The first clue to an observer that I might have had “doctor potential” was my brains. (No, I won’t assume a false modesty. )  This was apparent to family and friends even before I entered preschool. I was a precocious child and worked out how to do sums and multiplications up to past 100 even by the age of 3. My aunt, a teacher, enjoyed posing problems and I was delighted that I could solve them. This ability to come up with answers grew so that by the time I was in first grade, I was finishing class quizzes before my classmates had barely begun. At one point, my overtaxed teacher allowed me to help my classmates during quiz sessions. I distinctly remember one day a line formed at my “help” desk. I got a charge out of that because it made me feel important, respected, and in some measure,  helpful.

The next ingredient in my career choice was a developing need to “fix” things. At an emotional level, I suspect the foundation was a wish to fix my own nuclear family. Mind you, I did not come from a broken  home; far from it by conventional measures. But there was always a neediness in my parents’ relationship that was worsened when my younger sister was born with what were at the time called some ” adjustment problems” as a child.  This worsened the family dynamic and even by the age of  12 I had a sense of deficiency in my parenting. I was even pressed by my parents into the role of emotional caregiver by the time I was a young teenager, although that brief period ended with the advent of teenage rebellion. I think this background may have contributed to my perennial urge to “fix” everything, whether it be a door that sticks, a workflow process that doesn’t (work), or a shoulder joint that sticks. My wife keeps reminding me that it is not my role in life nor is it even my business to fix everything that seems to be functioning to less than what I think it should. But in a larger and more positive sense, the need to “repair the world” is one of the tenets of my religious (insert “lack of” here to be honest) faith. “Tikkun olam” is the Jewish phrase for repairing the world.

So far however, even by age 12, I regarded the medical profession only as a bunch of authority figures with needles. My interests were more technical. An inspiring science teacher saw my budding interest in electricity, which I was convinced was nothing less than magic. He lent me a box of telephone equipment and I was soon setting up an intercom for my parents to call me down for dinner. I took up an interest in modeling and  found I enjoyed working with my hands. Soon this evolved into an interest in amateur radio, and before long I was building ham radios and studying for a license. At that point, the design and construction of radios so fascinated me that I set my sights on electrical engineering as a career. By high school I was even allowed to play with a new invention: a computer. In those days it was a matter of programming IBM cards in BASIC. But it was a chance to solve technical problems.

Meanwhile, a humanistic side was blossoming in direct parallel with the technical. I took an interest in writing. I wrote for and then edited the school paper. Then the yearbook. Then I started writing short stories and poetry. Stories mainly about people. I found that even on my Ham Radio, my main interest was in the other people I met on the air and not on the number of countries I collected or the construction of ever more complex radios. I changed my mind about career. I decided I was going to be a writer. I became a member of the high school literati.

It was at that point in high school that one of those – I hate to use the word epiphany – shall we say, formative moments occurred.  You see, I had a crush on a classmate.  It was not mutual, but we hung out in the same crowd. One warm spring day, we were seated on the expansive lawn of her sprawling colonial house when her father, a doctor, pulled into the driveway. The family Scottie dog came running, my friend ran to greet her Dad, and her Mom came out from the kitchen to greet him with a fresh-baked apple pie in her hands. This last part I think I embellished in my memory. I stayed for dinner and was treated to a tableau of what can only be described as a Norman Rockwell family, with Dad, the doctor, as the center of it all. I concluded two  things from the experience: doctors make a good living and have adoring, happy families. Writers, I was coming to realize, live alone in garrets and eke out a living word by word. Maybe I could learn to be a doctor and write on the side.

By the time college loomed, I began brooding about the meaning of life. Somewhere, the quixotic notion of founding all ethics and science on a solid ground of a priori logic and factual construct entered my head. I started spending my study hall hours in the library reading all I could about philosophy. I went off to college and promptly signed up for a major in philosophy . But I was immediately asked by parents, relatives and friends how I proposed to make a living as a philosopher. Easy, I decided! Doctors make a lot of money, right? So why not be a doctor part time and philosophize in my leisure? I finally had an answer for the skeptics: I was going to be a meta-physician. Get it?

It was only at that point that I gradually took an interest in what medicine actually entailed. But what I learned was inspiring. First, I read a tell-all book entitled Intern! by Dr. X, which chronicled the first year of a doctor in training who had spent some time at Johns Hopkins, wherever that was. What adventure! Life and death! Saving lives! Now that’s what I call the meaning of life! By the time I was a college senior, I was had applied and was admitted to – guess where – Johns Hopkins Medical School. I waited for graduation day and  studied works of medical history such as Cushing’s Life of Osler. I found all kinds of medical historical reading to occupy the time that I was studiously devoting to not studying

I entered medical school in September 1974 and found it was a major adjustment after a life of liberal education. But that’s a tale for another post. By that time, even before donning a white coat, I was already becoming a doctor.


Categories: Doctors, None of the Above

A Taxonomy of Medical Humor

October 7, 2014 Leave a comment

Medical Humor is a time-honored category of humor that probably dates as far back as the first shaman to wield a stick.  But it occurred to me that it  might be amusing and enlightening if we  further categorized medical humor itself.  Why? Mainly because I am an inveterate and – as my wife would contend – pathologically compulsive organizer. And for some time now I have been thinking of organizing my ever-accumulating fund of medical humor. Hence this entry.

First, definitions: What is a taxonomy?  This term refers to any system of classification, usually applied to the world of living things, for example, such as evolutionary trees of life.

What is Medical Humor? Although the term may seem obvious, an answer to the question of “What is medical humor?” is not as simple as it sounds. It is not quite the same thing as “doctor jokes”, since there are many kinds of healers.  And some jokes feature doctors only incidentally; not all jokes which include doctors are truly about illness and healing.  So for my purposes, medical humor refers to jokes about human ailments and the people who minister to them. As a physician, I have heard so many that I could not fail to take an interest in them.  Over the years I have collected a large repertoire of jokes of all sorts, and like most collectors, I try to keep my collection in order.  Moreover, I suspect at this point if I don’t start keeping some order, I will begin to forget jokes as fast as I learn them.

You may not be aware of it, but the need to classify things, even humor,  seems to be an innate human urge. So much so, that some famous authors have even satirized those attempting to analyze humor. I recall reading somewhere a parody in which laughter itself is proposed as a sublimated urge to sneeze.  Even as a child without any inkling of my future career path, I recall eagerly opening Readers’ Digest Magazine to the column entitled “Laughter is the Best Medicine”, which included at lease two pages monthly. With so many people dedicating themselves to producing and disseminating medical humor, it seems to me worth an attempt to organize it. What follows is a proposed taxonomy.

In classifying humor, the most obvious but not necessarily the most fundamental scheme might be by topic. Categories come to mind such as: doctor jokes by specialty, medical jokes by ailment, greedy doctor jokes, stupid patient jokes, hospital jokes, medicine jokes, etc. While  this sort of system might serve as an outline for a book of medical jokes comprising multiple chapters, it doesn’t seem adequate to the conceptual approach I am aiming for here. A disadvantage to the simple list-of-topics approach is that it doesn’t readily lend itself to creation of a second and third order hierarchical structure, or in other words,  a system of categories, subcategories and sub-subcategories. It would be like trying to arrange a supermarket by placing only a few brands of each item to an aisle and having hundreds of aisles.

To some extent, any system of classification outside of biology or chemistry will be arbitrary, but I propose to base mine on the most fundamental of human experiences regarding health, illness, life and death, and those who confront them.  Some of you old enough to recall the famous TV series of the 1960’s, “Ben Casey” may recall the chief of surgery, Dr. Zorba, intoning these fundamentals as a hand sketched on a chalkboard the symbols for man, woman, birth, death and infinity. As with all drama, these are the elements of a good medical drama, and in my opinion, are just as apt for organizing medical humor.

So  if the reader has indulged me this far in this as yet anything but humorous endeavor, let me set out a proposed system of headers for the first order categories:

  1. Prognosis
  2. Patients
  3. Healing
  4. Healers
  5. Humor only Incidentally Medical in its Subject

I have arrived at this list partly a priori and partly having thought of a few of my favorite jokes and trying to find common elements. I plan to discuss a subcategory of each category and give a few examples. I note that some humor can only be classified as belonging under several headings, but we will come back to that. So let us discuss Category I, Prognosis. The following classification might run:

  • Category: I. Prognosis
  • Subcategory: A: Scary Diagnoses.(serious illness)
  • Sub-subcategory: 1. Breaking bad news.


  • Doctor: I’m afraid it’s terminal.
  • Patient: How long have I got, doc?
  • Doctor: I’d say 5 or 6 at best.
  • Patient: 5 or 6?! Is that weeks or months??
  • Doctor: (looking at watch) ” …4″


  • Doctor, phoning patient: Well, Sam, I got your lab tests back.
  • Patient: You don’t usually call me yourself with the results. Is there a problem?
  • Doctor: I’m sorry but I have bad news and  worse news.
  • Patient: (pauses to brace himself) OK, Doc, hit me with the bad news.
  • Doctor: Your blood tests say you have 24 hours to live.
  • Patient: That’s the BAD news?! What’s worse than THAT?!!
  • Doctor: I meant to call you yesterday.

What I find interesting about these jokes is that they tug at us at so many levels. We laugh as a defense against our awareness that we are not only mortal but that our demise may be much sooner than we expected. We also laugh at insensitivity with which the bad news is conveyed. But the second joke might also fall under a sub-sub-subcategory of breaking bad news jokes that I would entitle “good news – bad news” jokes. You must have heard at least a few. They all begin with the doctor walking into the hospital room or the exam room after a test of some sort and announcing that there is good news and bad news. They concern our need to temper the blow when we deliver bad news and make light of the lengths to which it might go if carried to its ridiculous logical extent.

Category II is Patients.

Patients come in all kinds and say all kinds of things. Subcategories might include: A. Patient Complaints, B. Crazy Patient, C. Doctor-Patient Interaction, 4. Patient Billing, or other doctor-patient relationships.

Let us say that II .A.1  is Patient Complaints. Under that is II.A.1.a, Patient Complaints by specific symptom or organ system. Consider under  II.A.1.a, sexual function:

Some are just plain silly.


  • Patient (to urologist): Doc,, I have a genital problem
  • Doc: What seems to be the trouble?
  • Patient: I have 5 penises!
  • Doc: (laughing) So  how does your underwear fit?
  • Patient: Like a glove, Doc!

Or perhaps in a more reality-based theme,  II.A.1.b, Patient Complaints by Ailment:

A man and his wife visit the doctor, who first conducts the wife into his exam room.  Shortly, the doctor emerges alone with a serious demeanor and informs the husband, “I’m afraid the blood tests and the neurological exam are somewhat conflicting. It appears your wife has either Alzheimer’s Disease or HIV-AIDS. I’m awaiting further tests.” The husband, dismayed, responds, “That’s awful Doc! What should we do meanwhile?”  The doctor responds, “Well for now, you both should just go home and get some rest.  But when you get to that Stop & Shop  5 blocks from your house, let your wife out of the car and have her pick up some ham and eggs and milk. As soon as she goes in the store, drive home. If she finds her way back, whatever you do, DON’T HAVE SEX!”  (This joke sounds much funnier if the term in the punch line is a bit coarser than the standards for this blog allow.)

The joke here carries some weight because it borders on the “scary diagnosis” realm that might place it in the Prognosis category. Clearly there are more jokes about AIDS and Alzheimer’s than there are about the common cold. The more we fear something, the more prone we are to cover our anxiety with humor. But this doesn’t always apply: jokes about leprosy can still be found even though it is rare in Western countries and curable with antibiotics.

But on to another subcategory: II.C , which would be Doctor-Patient Interaction.

Example (lifted from Vaudeville act as seen in the movie “The Sunshine Boys” :

  • Patient, demonstrating a motion with his arm: Doc, it hurts when I do this. What do you recommend?
  • Doctor: So don’t do this.

Some of the humor in this is aimed at the ridiculous response to a seemingly reasonable complaint. Perhaps this falls under II.C.1: Obtuse Doctor

But sometimes the complaint is unreasonable and the doctor’s response is appropriate. Consider II.C.2: Obtuse patient:

  • Patient : I have a terrible flatulence problem .  It is most embarrassing in Church because it’s the noise, not the odor that seems to bother people. Can you recommend a gastroenterologist?
  • Doctor: This could be serious. I want you to see an ENT doctor and a neurosurgeon.
  • Patient: How will that help my loud farts?
  • Doctor: You have lost your sense of smell. You may have a brain tumor!

Sometimes the patient outwits the doctor, or vice versa. Here’s an old one:

  • Patient: Doctor, how soon after the elbow injection will I be able to play a violin?
  • Doctor: It only a cortisone injection. You should  be playing in a day or two.
  • Patient: That’s great, Doc!  Because I don’t know how to play it now!

Category III is Healing. Jokes about healing include those referring to  physical exam, diagnostic tests, oddball treatments, surgical procedures, etc.

For III.A. , Examination, an example is III.A.1, rectal exams:

  • Doctor: I am concerned about your prostate blood test. It’s on the borderline. I need to repeat your rectal exam.
  • Patient: Ouch! Did you just use two fingers?
  • Doctor: Yes. I wanted to get a second opinion.

Say III.B is diagnostic testing. Example: (this is just one variation on an oldie-but-a-goody)

A patient comes to a doctor complaining of abdominal pain. After a thorough exam, doctor says “I have an idea but I need to run some tests first.” Patient agrees. Doctor places a cat on patient’s abdomen and after the cat paces up and down (no, that’s not the punch line), doctor leads in a dog that proceeds to sniff the patient’s ass. Doctor announces that the patient has (fill-in-the-blank) disease and hands patient a bill. Patient asks, puzzled,  “Doctor, I can understand your fee, and I can understand the charge for the CAT scan, but what’s this other charge for the dog? Doctor replies, “Oh, that’s for the lab test.”

III.C. Is “Oddball treatments”. Example:

A patient visits the doctor complaining of gas and abdominal pain. After a simple stool test, doctor announces you have a tapeworm. (tapeworms are rare in Western countries but ubiquitous in jokes) Doctor writes a prescription but patient returns from pharmacy and says, “Doctor, that anti-parasitic drug is $500! My insurance won’t cover that. Isn’t there anything cheaper?” Doctor says, sure, but it is a one-week course of therapy here in the office at only $25 per visit.” Patient says he can handle that and agrees. Doctor instructs him: “Come tomorrow with a hard-boiled egg and a cookie?” Patient: “How is that supposed to help?” Doc: “Just trust me. Works every time.” Patient returns the next day and doctor has him bend over. Doctor inserts hard-boiled egg in rectum. Looks at watch. A minute later he inserts the cookie. The patient complains he feels worse than before. Doctor says the treatment takes time, be patient.  This continues for the following 5 days. By that time the patient says he is feeling no better and he can’t take much more treatment. Doctor says, “Don’t worry. Tomorrow come back with an egg and a hammer.” The next day, patient bends over as usual and doctor inserts the egg. A minute goes by. Nothing happens. Another 30 seconds. Nothing. Finally, suddenly, a small head pops out of the man’s rectum and says “Where’s my cookie???”  WHAM goes the hammer. (Pound the table as you tell the punch line.)

Bet you didn’t expect that one! There are numerous others, some so corny I will only offer them condensed: Chinese herbalist explains his diagnosis of dental abscess to man complaining of flatus that sounds as loud as a Japanese automobile horn:  “Diagnosis simple. Abscess make the fart go ‘Honda’!”.

III.D. is surgery.  III.D.1 includes genital surgery.  This one might come under patient complaints, since penis complaints are legion. As a matter of fact, penis lesions are complaints. Size is the perennial theme. Example:

A patient goes to ENT specialist complaining of a stutter. After a thorough evaluation, the specialist informs  him he has an unusual condition caused by phallic hypertrophy, or in other words, excessive penis length, and offers to send him to a urologist to have his penis trimmed. Patient decides the cure is worse than the disease but after consideration of how his stutter has impaired him on the job and made him shy about meeting women, figures he still has enough to spare that he can afford to lose a couple of inches. At length, he calls the ENT doctor and is duly referred to a surgeon known for expertise in genital reconstruction and transplantation. The surgery and the two inches of excess come off without a  hitch. At follow-up, the surgeon inquires, “Well, how is that stutter?” The patient replies, “It’s completely cured, Doc! I got a promotion at work and I’m meeting a lot of women. You did a great job, and I don’t want to seem ungrateful but…”   The doctor responds, “You seem disappointed. What’s it it?” The patient replies that he is doing OK in bed but he is not satisfying his dates sexually the way he used to. He asks, “Doc, is there any way you can reverse this operation?”  Doctor replies with a smile, “S-s-sorry, b-b-buddy,  a   d-d-deal’s  a   d-d-deal!”

Some jokes don’t fit neatly into categories. The preceding might fall under doctor-patient relations, where doctor outwits patient, or even under patient complaints, but the theme of unusual surgical procedures seems to dominate over that of penis complaints. Transplant jokes are numerous, and not surprisingly, penises are popular, although brains, breasts, vaginas are mentioned.

Another example:     A single  man with a penis that is too short seeks help from another surgeon in the same specialty as above.  (Perhaps a woman surgeon this time? The male gender for the doctor  in the joke above was essential.)  The patient is desperate because he cannot maintain sexual relationships after the first few dates due to his deficiency in that department. This time, the surgeon explains that penis transplantation is untested, risky, and expensive and discourages the patient. The patient pleads with him. He is told “Well, yes, there is a new procedure that could help you but it is highly experimental. There is a transplant procedure in which an extension is fashioned from just the very tip of a newborn elephant trunk. The elephant barely misses it once he reaches maturity.” The patient agrees and of course, the operation is wildly successful.

The patient proceeds in short order to meet a girl, fall in love with a wealthy young woman, and is invited to dinner to meet the parents. Dinner is delicious and all is going as well as he could hope, until midway through the meal. Suddenly, to his dismay and deep embarrassment, his penis of its own accord reaches from his pants and takes hold of a baked  potato on his plate and retrieves it. The dinner table conversation abruptly stops as the girlfriend’s mother stares in shock and disbelief. After an extremely uncomfortable pause, she breaks the silence with, “I say, young man, would you kindly do that again?” The suitor, caught even more off guard, replies, “I would, Ma’m, but I don’t think my rectum has room for another one!”

One might argue that this joke is only tangentially medical in nature and belongs more under the category of sexual humor in which the medical aspect is only incidental. But there is no getting away from how the joke is set up. Both jokes make some reference to the commonly debated issue of whether length matters and by extension (bad pun intended), male anxiety about penis length and sexual success.

Category IV is Healers.

Some jokes make fun of the doctor. Maybe we can make the first sub-category jokes classified  by specialty.  Psychiatry, Gastroenterology, Urology and Gynecology are the most popular specialties for obvious reasons. You won’t hear too many hematology jokes. Although you may find oncology among the “life and death category. Psychiatry jokes sometimes fall under Category II.A, Crazy Patient, but how you draw the line depends perhaps on who is crazier, doctor or patient.

Under IV. A.1., which is Healers/Jokes-by-Specialty/Psychiatry we might find the following:

  • Patient to psychiatrist,  as patient frantically brushes at his clothing: Doc, you have to help me!
  • Psychiatrist: What seems to be the problem?
  • Patient: You have to get these spiders off me! They’re all over me all the time!
  • Psychiatrist: Well, to start with, stop brushing them off on me!

Example:  A psychiatrist meets another in hallway. The first says, “How am I?” The second replies, “Fine! How am I?”

Both refer in one way or another to the idea that psychiatrists all must be crazy themselves.

IV.B. might be about healers’ motivations. One of my favorites concerns a doctor’s sensitivity to his reputation in the community:

A nurse rushes into the doctor’s consulting room in alarm saying, “Dr. Jones, come quickly! Mr. Smith just dropped dead on his way out the door of the office! You just told him he was fit as a fiddle! ” The doctor responds, “Well turn him around, for God’s sake, so it looks like he was on his way in !”

Another favorite of mine is about empathy, although it might  appear at first to be about good news –  bad news. The patient sits down with the doctor in his consulting room to go  over his lab tests that just came back.

  • Doctor: I have good news and bad news.
  • Patient:  OK. Hit me with the bad news first.
  • Doctor: It’s leukemia. You have about 6 months to live.
  • Patient: “That’s really bad! What’s the good news?
  • Doctor: Did you speak with my receptionist on your way in?
  • Patient: Yes, why?
  • Doctor: The blonde with the big boobs?
  • Patient: Yes, yes. But what’s the good news?
  • Doctor: I’m screwing her!

Finally there is Category V, jokes in which the medical profession is only incidental. These really only need to be categorized along the same lines as non-medical jokes.

I will conclude with an old one about the elderly man and woman who stroll into the doctor’s office and explain that they are concerned that their ability to have sex is deteriorating in their old age and want to know if there is any treatment the doctor can offer. He offers to refer them but they insist on first explaining further. Over the doctor’s protests, they persuade him to observe them having sexual relations. They proceed to have obviously vigorous and mutually satisfying sex. The doctor tells them there is nothing wrong with them, they are lucky to still be able to be physical in their marriage at their age and asks what made them think they needed to see the doctor. They inform him that they are actually not married and are cheating on their spouses, and they are saving a bundle on motels since the doctor visit is covered under Medicare.

At this point, I have hardly exhausted my supply of doctor jokes but I have probably reached the limit of the reader’s patience.  Besides, this post has been in the draft stage for nearly nine months, and the last one was about a near-death experience, so I am beginning to worry that my 8 or 9 readers will get the idea that the last one was a farewell. Now that this opus has been delivered,  bad puns and non sequiturs and all, and my followers reassured,  I feel I can move on the other topics.  Leave ’em laughing when you go! (per Joni Mitchell)

Categories: Doctors, None of the Above

Reflections on a Near-Death Experience

December 27, 2013 Leave a comment

Now that it has been nearly two months since my cardiac arrest and resuscitation, I have finally found the leisure and the motivation to put fingers to the keyboard to gather some thoughts and feelings about it.  Of course these include at least in part the sort of changes in attitude and philosophy people are commonly supposed to experience, but for the most part, my own experience seems different.

In my particular case, the way it happened was not a bolt from the blue, but during a test specifically designed to provoke signs of cardiac ischemia. I knew I had mild coronary disease, but I was on lipid-lowering medication, had a good blood pressure, didn’t smoke, exercised regularly, wasn’t significantly overweight, and had passed two previous stress tests. On the other hand, I had just come to the emergency room with chest pain. But on the other hand, (I guess that’s the first hand), my EKG and cardiac enzymes had returned normal. So the event was a surprise, but not a huge surprise. Nonetheless, it’s a bit daunting to know that there but for fortune, the event could have occurred on the airplane I planned on boarding that evening.

First, lets attend to all the questions, truisms, and philosophic platitudes.

No, there is no white light. At least not in my case. Perhaps I wasn’t out long enough. (Although long enough to have a seizure and need CPR until the paddles were charged and shock administered. ) Or maybe I’m not headed in the “white light” direction anyway. On  hearing of my failure to see a white light, a friend asked, “Well, how about a red one?” . Or maybe I just don’t believe in a benevolent God who watches over me. In any case, there was no white light and I did not witness the scene from above. I would love to have had that opportunity to watch it though. However, the experience was that one minute I was walking and talking  on the treadmill and the next minute I was being rudely awakened from a sound sleep by a slap on the cheek and  a bustle of frenetic activity. Nothing spiritual about it.

Next, that thing about “no longer sweating the small stuff”, “stopping to smell the flowers”, appreciating “the big picture”, etc.  I wish I could say I have been changed by the experience but I really haven’t.  I’m still compulsive. I’m still what they call “Type A”.  I still sweat the details about patient care. I still worry about stupid stuff. The same minor irritations still annoy me; in fact, they annoy me even more sometimes because I feel I have less time to be bothered. Mind you, I do smell the flowers, but I don’t stop. Flowers are nice but I have other things I want to get done. And to illustrate how little I have changed, I will relate an incident that occurred walking our dog in a park where picking up after your pooch is the law. It took me only a minute to realize my foolishness, but I actually had the temerity to tell my wife she was going about picking up the dog poop the wrong way. (I won’t explain my logic, but I thought she should start with the small turds and work her way to the larger ones.) She reminded me that I was criticizing a woman with a bag of dog shit in her hand, standing within an easy hurling distance. So much for stopping to smell things.

Naturally, having turned 60 last year, I spent a lot of time contemplating my mortality for 6 months before and really ever since that birthday. I was even thinking, the day before my event as I was driving to work, how beautiful the nearly bare trees looked in a sunlit morning mist, and how I would miss that sort of beauty if I was told my life would be cut short.

But since the arrest, the notion of mortality has taken on a more immediate flavor. I have always had the sense that we spend our days skating on thin ice and not knowing it, never realizing how it all could fall apart without a moment’s warning. Lately, that sense is keener. I am reminded of a rented DVD that has skipped a few times, frozen, and been rescued by going back a scene. If you have had that happen, you know the feeling that it might freeze again and this time not allow you to finish it. So you watch every moment knowing it could be the last you see of the movie. I never really have been able to “live in the moment”, but I think I have gotten a bit better at it. The other observation I have come to is a firmer conviction that the thing we spend the most time worrying about is never the thing that gets us. It is always something from a completely unexpected angle.

The awareness that my span on this mortal coil is finite leaves me with less patience for people or things that waste my time. I am quicker to throw out some item on my desk that I would have previously contemplated making use of at a later date. I am less inclined to have my philanthropy dictated by letters with appeals from charities that happen to enter my mailbox or appeals to add a dollar that are made at the checkout counter; I am going to make my contribution how I want to, when I want to, and to whom I want to, of my own accord.

For better or worse, I am less inhibited about expressing my feelings, both benevolent or angry. On the streets of Manhattan, my wife and I were nearly struck by an aggressive driver in an SUV who was turning right onto a side street as we were crossing the same street with a walk sign in our favor. I turned and thrust an accusatory finger at him. He rolled down his window. I yelled,  “I had the green, buddy! ” He yelled back, “So did I!”  I responded, “Pedestrians have the right of way, Mister!” My wife, seeing he was half my age and fearing he might get out of the car to continue the discussion, tugged at me to continue walking (but only after she chimed in, “Yeah, read the book!”). As we walked on, I turned my head to look back and saw a crowd of pedestrians gathered around his vehicle scolding the man. I am not sure that before two months ago I would have confronted the guy. I guess I felt like, “I’ve been DEAD before, buddy, and you think YOU scare me?”

By the same token, I am much more liberal with my praise, generous with my smile, and generally more understanding of other people’s limitations and frustrations. I am nicer to everyone I encounter, even if they are dunderheads or nincompoops. After all, they are probably doing the best they can. I don’t hesitate any longer to say what I think, but I am quicker to forgive. (Exception: None of this applies to those jerks on the Merritt Parkway who think they will get there faster by first tailgating me in the left lane and then going around me on the right to cut in front when traffic is doing 65 in the passing lane, 60 in the right lane, and everyone is 3 car-lengths apart as far as the eye can see.)

I still think a lot about what it will be like when death does finally catch up with me. Will it be sudden, or will I be given a fatal diagnosis? Will I find that I have been obsessing about a healthy diet and exercise, only to learn I have pancreatic cancer next year? Or will something take me from completely out of left field? I know this much: I was looking back on my life this morning, waiting for some minor surgery with propofol sedation, wondering what I would choose to look back on. I found myself looking back on all the good times and not the bad ones. There have been many bad times, perhaps as many as good, but they seem to recede in my recollection. It is the joyful ones that stand out. Some people have criticized the effect that digital photography has had, allowing us to so easily edit out the bad images, unflattering takes, and blinked eyes. But memory does that too, and maybe that’s a good thing.

After my bypass surgery, and hospital discharge,  I had the most uncanny sensation as I was being wheeled through the hospital lobby out to the car. Traversing the lobby was a crowd of people there, walking in all directions, most of them not looking down at the man in the wheelchair, each seemingly preoccupied with his or her concerns or plans. I was overcome with an acute awareness of each of them as a thinking, feeling individual with all of these cares and concerns, each with a life that was infinitely complicated with circumstances I would never know. It was reminiscent of that movie where the protagonist hears everyone’s thoughts, but for me like a world where I now almost expected I might hear them but knew fully I was deaf. That sensation has faded with time, but I think it can only be described as a heightened sense of empathy.

I guess one of the most positive consequences of having survived my experience is the feeling of gratitude that I have for my return to life, health, work, family, and all the joys of living. I am grateful to everyone who worked so hard to bring me back to health, people who number in the hundreds in one way or another. I am grateful to my good fortune, if not to a God who I have serious doubts about. I find it easier to believe I am incredibly lucky than to think that a supreme being should concern him or herself with the fate of one person on a planet of 7 billion souls among a galaxy with hundreds or thousands of planets occupied by millions or billions of equally sentient beings.  It’s enough for me to thank my lucky stars.


December 3, 2013 Leave a comment

Yes, you read that right. I nearly died a month ago on a treadmill halfway through a stress test. The short story is this: I had just gone to bed and was about to go to sleep when I started to have some chest pain that I told myself was just my usual heartburn, only worse. As a gastroenterologist, I knew better.  It was bad enough that I couldn’t go to sleep. After two sleepless hours of denial and mounting pain, I conceded that it was time to get help.  I woke my wife and called 911 for ambulance to the ER.  I chose to go to my own community hospital even though I could have gone to an Ivy League “world-class” hospital that is equidistant; the staff at my own ER  know me and they are family.  One of my most trusted ER doctors saw me. But strangely, by the time I arrived, the pain was nearly gone. I proceeded to have a normal EKG. The cardiac enzyme levels in the blood returned negative. So, probably no heart attack. But was it angina? My cardiologist recommended a stress test immediately, since my wife and I had long-anticipated plans to get on a plane that afternoon and fly across the country to visit my kids.

Well, I failed my stress test. Big-time. Halfway through, just after I finished relating a humorous scene from a movie where a character drops dead, my heart stopped.  They laid me on a stretcher, pounded my chest and performed CPR. I was brought back from ventricular fibrillation with a defibrillator and a single shock of 200 Joules (=watts of electricity). I was rushed to a tertiary care center where I underwent emergency angiography showing a high-grade narrowing at the origin of my largest artery. (Narrowing to that degree in that location is sometimes called a widow-maker.)  I was placed on IV anti-platelet agents and other blood thinners while my doctors waited for me to decide between a bypass and having stents inserted. They recommended bypass surgery over stenting and I chose surgery. My operation was  performed through an incision between two ribs, with my heart beating, by a surgeon using what is known as a robot. My cardiologist friend up the street tells me they aren’t even doing heart surgery that way yet in the Ivy League hospital in New Haven.  Thanks to my surgeon’s talent and the efforts of everyone along my journey, I alive to write this entry, and I expect to write more on this topic.  I walked out of the hospital three days after my surgery. I am indeed a very, very lucky man.

But one of the reasons I am telling this tale is to share what it was like from my viewpoint to experience waking up from cardiac arrest. Now I have participated in a few “codes”, as cardiopulmonary resuscitations are called in hospitals, as a witness, particularly when I was in training, and I have watched a few people wake up promptly. It is unforgettable experience. One that stands out in my mind took place when I was an intern in the emergency room at Lenox Hill Hospital in New York City. A man had arrived in chest pain and we were doing the usual EKG and blood testing when he suddenly lost consciousness. The cardiac monitor above his head revealed why: his heart was in ventricular fibrillation, the abnormal heart rhythm that can result from a heart attack among other things, and end in death if not corrected. I was told to start pumping on the chest as I had done so many other patients before, futilely, as the usual crowd of nurses and supervisors and anesthesiologist arrived.  But this time the outcome was an exception. My resident charged the paddles, yelled, “Clear!” just the way you see do on TV, and administered the jolt. The man’s torso practically jumped 6 inches off the stretcher and he almost immediately sat up and asked, “Whats going on? What are all these people doing here? What happened?”  My resident and mentor, before even turning to  the patient with an explanation, announced to the assembled team, “See? Electricity is GOOD for you!” as if he did this stuff for fun. We, the house staff, celebrated the occasion in the retelling.

In my own case, in the role of patient, the experience was quite different altogether. I didn’t get to witness the event. One minute I was walking and asking the cardiologist what level of exercise I had achieved thus far. I was anxious to finish the test so my wife and I could make it to the airport in time. My main thoughts were on our trip to San Francisco for a wedding celebration with friends and a visit with our children. With my usual off-beat sense of humor I was asking him “How many mets, Mario?”. This puzzled him because his name is Bob. I explained, as the treadmill was gathering speed and I was already breathing hard, that there is an old movie called “Putney Swope” that features an opening scene of a corporate board meeting in which the chairman berates the members, gesticulates wildly, and abruptly clutches his chest, and the board members don’t get it that he is having a heart attack. One of them, clearly a bit senile, thinks he is playing Charades. He asks him repeatedly, “How many syllables, Mario?” until the man finally keels over dead. I had no idea how ironic I was being. The last thing I remember was the nurse saying,  “Are you getting tired?” or something like that.

An unknown number of minutes later, I was awakened from a sound sleep by a hand slapping my cheek and the cardiologist’s voice saying “WAKE UP, DAVE”. My annoyance vanished in a millisecond when I opened my eye to see a roomful of people in great activity, a red cart to the right of the bed and a large hard square object between my legs that was clearly a defibrillator. When you’re a doctor and you awake to this scenery, you figure out pretty quickly what has happened to you. As if I needed to told, my friend and colleague told me from his supervisory perch at the foot of the stretcher, “Dave, you are NOT going to San Francisco today.”

Now let me say what else didn’t happen. Perhaps I was not in arrest for long enough, but I did not see any white light or view myself as if from above. They tell me they caught me promptly and lifted me down off the treadmill. I am told I had my chest thumped and then compressed until the defibrillator could be charged and I came right back after the first shock. They tell me I seized during the arrest. I later had proof of that when I realized that my tongue was severely lacerated by my teeth and my jeans were wet.

But what did I experience immediately was an overwhelming sense of gratitude. Gratitude that I was still alive. Gratitude to all the people in the room. And along with it, an immense feeling of being completely cared for in a way I don’t remember since childhood. All my life I have been caring for others in one way or another, even when I was a child. For the first time in as long as I can remember, I completely relinquished the imperative to make decisions. I placed myself completely in the hands of my colleagues and co-workers. And they came through for me in a big way.

My cardiologist probably had a far more traumatic day then I. I have been told that the incidence of sudden death during a stress test is 1 in 10,000. To have that happen to a colleague, referring doctor and a friend, on your watch, even if though it is an inherent risk that could happen to anyone, must have been very difficult emotionally. He was trying to keep his cool when he called my wife, who was across the street picking up some necessities for our flight. But she says his attempts at reassuring words were belied by his white complexion and shaking hands. In fact, I think I had an easier time of it than he did.

The strangest thoughts go through your mind sometimes. In all the commotion, I noticed that a nursing supervisor I have known for 25 years had highlighted  her hair. And as they were wheeling me out of the room, I called out to her, “Nancy, I really like what you’ve done with your hair!” My journey from there to the Hartford Hospital cardiac cath lab  to surgery was a whirlwind and a blur. And the road to recovery has been slower, but still seems to have proceeded at amazing speed. But more on these topics another time.

Let’s Eat Right for Success and Popularity

This one is for all you perplexed nutrition-conscious readers!  You know who you are. You’ve had it with all that nutritional advice and  diet plans; where has it gotten you? Weight control is a bore as well as an elusive and vain pursuit;  just as all the studies attest, you’ve always gained back everything you lost after a year has elapsed. Are you any the better for it?  It’s time to rethink your goals : the real reason we want to lose weight isn’t to live longer, it’s to live better. So why not keep your eyes on the prize and aim for the real goal: success and popularity!

How can a diet help you win friends and influence people?  Over the past 30 years of intense research and testing, my partner (Mrs. Dr. Sack) and I have discovered the secrets of eating your way to success and popularity. In the next few paragraphs, we will share with you a synopsis of these valuable lessons. If you find them useful, you can send for the full text of our revolutionary new method at the ridiculously low price of only $15.99 plus postage.

Chapter 1. What not to eat at the cocktail party

Never mind what you should eat at the party. Just mind what you shouldn’t:

With your first drink: Avoid cheese and crackers. They always break and you will look foolish. Don’t eat the shrimp if it has tails you have to leave over. It looks bad on your plate. Stick to the hors d’oeuvres that pop in the mouth and leave little residue. And under no circumstances choose the pigs-in-blankets; it immediately marks you as low-class.

With your second drink, try to avoid things that will leave a stain when you spill them, or if you are wearing anything low-cut and pushed up, that might dribble in. Unless you are aiming to attract attention, in which case choose something creamy and not mustard or cocktail sauce.

With your third drink, be sure not to choose things that roll, such as olives.  By now your balance is off and so will your game be if you are more focused on the orb on your plate than on gazing into those gorgeous orbs in front of you.

With the fourth drink, STAY AWAY from anything with toothpicks in it! We are serious. Toothpicks are one of the most frequently swallowed foreign objects we are called to remove from stomachs or even colons, and most often this occurs as a result of distracted deglutition (i.e., masticating while drunk). No joke.

With your fifth drink, the only caveat is to choose foods that will taste just as good going down as they will coming back in the other direction, since at the very least you will be experiencing some repeat tastes and at worst a recap of  your evening’s alimentary activities.

Chapter 2. So-called “junk” food that will put a smile on your face and all those around you

We are constantly reminded that rapidly absorbed carbohydrates and fructose especially lead to fatty liver, obesity, diabetes, slovenliness, bad skin, sloth, torpor, flatulence and a propensity to gambling, as is well-known to anyone who has gone into the fast-mart for a Snickers while gassing up and then been tempted to buy a lottery ticket while at the counter. But why doesn’t anyone mention all the ways in which “junk” food can enhance your appearance and popularity? Here are some:

1. There is a reason people speak of a “sugar high”. It’s because sucrose lifts your mood. Any 5-year-old can tell you that.  And when you are happy, those around you sense it and are attracted by your charisma.  You will smile more and use far fewer of those horrid frown muscles everyone has cautioned you about exerting. Your good attitude will infuse your work. The alleged “low” that follows a burst of sugar is easily deferred by consuming more sugar, until you can safely remove your social persona for the evening.

2. Junk foods can improve your social acceptability. Got halitosis? Sure you can keep those nasty Listerine film strips on your person. But Thin Mints and Peppermint Patties are much more tasty and will give your breath the same freshness that you just can’t get from kale chips.

3. Payday Bars have peanuts. Nuts are good for you. The syllogism should be obvious. Ditto for peanut M&M’s, peanut clusters, and turtles (the chocolate kind, not the terrapins).

Chapter 3. Flatulence-free foods for small meeting rooms and intimate occasions

It should hardly need saying that nothing spoils a date like an unexpected announcement blaring from the hindquarters occurring in close quarters .  Many a ride back from a nice first date at a tony restaurant with that hot guy/gal you met on match.com has come to grief when the vehicle’s operator failed his or her emissions  test.  Sometimes the standard dietary don’ts and “no, really don’t!”s   are not enough. We all know about avoiding beans, onions, broccoli etc. You’ve already gone that route. And what can you do if you are already flatulent no matter what you eat? Here is where Dr. Mrs. and Dr. Sack can really help you avoid alienating those most important in your path to success and riches.

1.  Feed a cold but starve a colon!: In the board room (or at the sales pitch): Your colon can’t make much gas if you don’t eat anything with metabolic value. If the occasion does not call for food, such as a business meeting, be continent! (behaviorally, of course.) But if you must eat, simply don’t consume anything organic from the time you awaken to the time of the meeting. And you don’t have to go hungry, either. Our recipes chapter teaches you how to create mouth-watering dishes such as our no-calorie omelet made using only methylcellulose (an inert product made by chemically treating wood pulp or such), Splenda, sliced dried mushrooms, a few spices, yellow dye #5, and Bacon Bits. Some substances, even coliforms won’t eat.

2. And for you organic types out there who insist on all natural ingredients, try our kale and sprout shake with a touch of agave nectar and liberally laced with Jagermeister. You might not like the first sip, but after a few it truly grows on you.

3. OK, so diet isn’t everything. Sometimes drugs are called for to keep your microbiota stymied! A good burst of non-absorbed antibiotics the night before your social plans can drastically cut down on the fermentation that normally occurs in your lower GI tract. We recommend two tablespoons of Pepto-Bismol with a capful of Miralax.

Chapter 4. Foods that say, “Come hither” you can dispense from your cubicle

Everybody loves a winner. And nothing says “winner!” better than the sight of smiling — and occasionally laughing — co-workers gathered around your desk from time to time. Others may assume you are entertaining them with your wit or that they are seeking your advice. Everyone knows the office colleague who keeps a bowl of M&M’s or mints by the desk. But if you can go one better, you can enhance your position in the office social order. Why not go all out?

A microwave under your desk can easily be used to keep a bowl of popcorn ready at a moment’s notice. But why stop there? You can find microwave cookies and even brownies; the recipes are readily available nowadays on the web. There was even a piece about it on NPR recently! They’ll be flocking to your desk like pigeons in St. Mark’s square to a tourist covered with birdseed.

Beverages, too, can gain you points at work. A bit of vodka will never be noticed in the thermos of  coconut water you keep on your desk, but it will certainly improve your colleagues’ attitudes! Imagine the places you’ll go with a little creativity.

Chapter 5. Party-stimulating additives your guests will never guess

Whether it be a dinner party or a discussion group, your friends will leave with a positive attitude toward you if they leave having had a good time. While we heartily recommend alcohol as a social lubricant (see Chapter 4), not everyone wants or needs a drink to enjoy a party. Some people will enjoy themselves more if they feel charming, energetic, or less inhibited, and food can work the same magic:

1. Certain spices are known mental stimulants. Tea has long been popular in this regard. But if  you frequent the natural medicine web sites, including Web MD, you will find scores of assuredly safe herbal products purported to increase energy and well-being by the thousands of clearly objective reviewers. Given their safety, what’s the harm in adding them to your cooking?

2. Use caffeine as an ingredient. Your guests may opt for decaf when it’s time to leave, but why not keep them lively during the soiree? Dark chocolate, rich in caffeine, may be used in your mole sauce, and instead of root beer in your brisket recipe, try using Coca-Cola with a touch of Red Bull. Did you know that manufacturers are adding caffeine to everything from waffles to jelly beans? Caffeine is an ingredient in many products nowadays, even an oatmeal. Imagine the lively conversation you could stimulate by starting your Scottish Food night with haggis made from caffeine-laced oatmeal! (Yes, it is really available.)

3. Good old-fashioned Alice B. Toklas brownies are legal in many states and have no more calories than conventional ones. Your guests will go home raving about the wonderful meal they had, and if not,  at least raving in general. [BLACK BOX WARNING: Illegal in Many States and Unethical in All. Do NOT act on this advice. It is intended as SATIRE!]

Further chapters we have no room to summarize in this post that we will share in our book:

Chapter 6. Foods guaranteed to enlarge your male or female anatomy

In this chapter we will share nutritional strategies to spare you from replying to all those offers you get in your email for costly and artificial treatments. Here’s how to eat your way to success in bed (and not by reading fortune cookies!).

Chapter 7. When “empty” calories leave room for more

In this chapter, we expand on the notion that “there is always room for Jell-O”. We reveal the miracle foods with negative calories.

Chapter 8. Antidotes to food indiscretions

Who hasn’t committed a food mistake at one time or another? In this chapter we reveal our nutritional “morning-after pill”.

Chapter 9. Secrets we can’t even share in this post

You’ll just have to buy the book.

Categories: Health, Nutrition

How I Realized I Am a Senior (Doctor)

June 18, 2013 2 comments

It has been creeping up on me for the past year or so, but I think it really hit me today. I am a senior (doctor).

I don’t mean to say that I am old.  If anything, I feel younger than I did a year ago, having had a rejuvenating surgery for sciatica only this past April. What I mean to say is that I have achieved the status of venerable, sometimes crotchety, and even “old-fashioned”.

The evidence has been  accumulating but today was the tipping point.

It was a simple terms of address . We doctors often address each other as Doctor, especially if we are strangers,  out of respect. But after having worked with a colleague more than a few times, I usually say, “Please, call me David.” But lately, the new hospitalists are addressing me as “Dr. Sack”, and when it happened today, I found myself free of the urge to correct her. It has become apparent to me, astonishingly,  that the junior staff really respect my wisdom.

And speaking of wisdom, that’s another thing. I have started to dispense it. And doctors and nurses have been actually listening lately. I’m not used to that. (My wife sees to it that I don’t get accustomed to it at home.)

I am even noticing that I am dressing old-fashioned. When I started out as a medical student, doctors wore ties. Some eccentrics sported bowties, but everyone put on a tie. This dress code was fairly well observed when I was an intern and resident. Most everyone I worked with after I became an attending maintained this practice . There was the occasional out-and-out rebel/weirdo that wore a bolo tie.  (There was even for a time an ER director who wore a cowboy hat on the job.)  Naturally, surgeons were permitted scrubs in their offices. But over the past ten years, I have noticed that the necktie is becoming an endangered species among my colleagues. Most of my gastroenterologist colleagues are either wearing their shirts open or are wearing surgical scrubs. Same for the hospitalists. Some specialties at my hospital seem to be holding the line: our nephrologists, oncologists and cardiologists. (All serious specialties.) Perhaps dealing in serious illness demands dress standards as serious as one’s demeanor. Yet here I am, knotting a tie most mornings.  Lately, I must admit, I have been dispensing with the necktie on days that I will be doing procedures all morning. The patients are all too anxious beforehand or dopey afterwards to notice.

And recently I realized that my attitude about how a history and physical exam should be written, and how to interpret it, is utterly antiquated. I was taught in medical school to follow a certain order for recording the H&P. With the advent of the EMR (electronic medical record), I now note that the traditional order has been ceded to the province of computer programmers instead of doctors and is now completely and, for all appearances, arbitrarily scrambled. It has seemed to me an abomination but today I realized that the traditional order is really only arbitrary. Why should I be bothered if the chief complaint and present illness appear on page 5 after a listing of patient’s habits, prior surgeries, native language, and whether they wear seat belts? I’ll find the information I want sooner or later if I just keep looking. I’m just being a curmudgeon, right?

For that matter, the physical exam itself reveals itself as a telltale about my antediluvian attitude. And this particular item is really what originally inspired me to write this post.

Up until this month, I have been locked in combat with the “Physical Exam” section of the progress note in my EMR, which is so unwieldy to alter from the default normal that I end up swearing at times. I find myself spending precious time tailoring an organ system’s examination in the note, only to find all my free text gets erased when I try to amend it further. The menu tree is a shriveled excuse for a multiple choice device and takes more effort to enter the pitiful data that it does accept than it does to just free-text it.  My EMR doesn’t even allow me to copy the previous visit’s exam components that are unchanged. Even my primitive “non-qualified”, “non-meaningful” EMR I installed in 2002 had that feature! Don’t  I sound like an old curmudgeon complaining about these “new-fangled contraptions”.?

So I have sometimes taken to simply opening a text box at the bottom saying: “EXCEPTIONS”, by which I mean “ignore all the useless drivel above!”.  After all, it was only put there to satisfy the bullet points required to code for the visit at a level appropriate to my effort and time. No one reads these exams; not referring doctors, not doctors who I send patients to, not patients themselves, not, God forbid, insurance company auditors, who might count bullets.  The sole exception is me, doing my proofreading. So why bother? I have come to the realization that most of my colleagues have long since recognized that this is nothing but a charade. If I spend my time perfecting a note in an EMR, I will have no time left to treat the patient.  Anyway, most of the visit is always spent in counseling and coordination of care anyway, and I code it so. But it really would be easier to just click the box that says everything is normal. I know many doctors that rely on their memory for the real exam and do just that for the note. As Julia Child famously asked, “Who’s to know?”

Remember the movie Fail-Safe? The subtitle, as I recall, was “or how I learned to stop worrying and love the bomb.” It was about simply surrendering to the absurdity of the doctrine of “Mutual Assured Destruction”, or MAD, as it was referred to. Yes, I am old enough to remember the Cold War, and believe me, that notion was the foundation of our strategy for keeping the peace by nuclear deterrence.

At least I am trying to stay current in my medical knowledge and continuing education. So far at least this habit has not gone out of style.!


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