Monday, December 31, 2018

Friday, December 28, 2018

To the Dermatologist

For several years I have watched a pigmented lesion at my left zygomatic arch.  Initial concern occurred maybe ten years ago.  Dermatologist in the building next to my office too a look at it, declaring it benign.  I did not intend the comprehensive skin inspection recommended for cancer screening for people my age and I had to get back to work so I declined the more extensive look-over and returned to my office reassured.  About two or three years ago, my doctor thought the skin exam was a good idea, recommending it without any prompting from me just based on age.  I have seen my share of malignant melanoma over the years, sometimes from patients who have had this in their histories when they come to me for something else, too often as hospital patients with metastatic disease.  Got it done, reassured the facial pigmentation was benign.

Time has proven that correct, though it is larger, and my wife found something that concerned her on my ear so it's time for another opinion, including whether it might be better just to have it excised.  The last dermatologist made a very good impression but she had moved on from her satellite university position, so it's back to the original office with a different doctor.  I waited quite a few months for the appointment.  They offered a sooner one with the Nurse Practitioner, but since the question of elective removal can require an intricate thought process and I was in no hurry, I waited to see what the fellow who does the surgery thinks.

It turns out that the lesion in question had started to get raised from the surface.  It is still benign.  Removal is possible but trades one discoloration for another and costs money.   It would be a hard sell to call this something other than cosmetic for Medicare to pay for.  We concurred, leave well enough a lone, take a photo with his good camera, and compare in a year.  The area on the ear is an hemangioma, which is what I suspected.  Totally harmless.  He noted scratch marks elsewhere.  I have some itching, usually in exposed areas and I scratch them but it never really bothers me and I never sought attention for this.  Leave well enough alone. 

I had been to that office some ten years ago.  It looked like a medical office.  There is now a presence of cosmetic dermatology everywhere, in-office presentations of topical everything and options for removing everything from freckles to tattoos.  But the doctor who tended to me yesterday seemed more energized by skin diseases than appearance, which probably subsidized the more serious elements of medical care.  He did professional examining, leaving the scribe work to his Physicians Assistant.  And on the walls, he had a warning to patients who needed modern biologics for their psoriasis, medicines that work well but pose a significant risk.  Diversion of medical attention from diseases to appearance would probably make me feel like less of a doctor.  We don't have that so much in endocrinology, though our diseases can have an adverse effect on appearance.  We do send women for hair removal.  Weight reduction surgery is an investment in health, in my mind, but sometimes the recipient seems more concerned about clothing size.  And we got into quite a lot of trouble prescribing Redux or Acomplia to make people look slimmer when the weight excess threatened their health less than the pills did.  Eye care for Graves seems entirely focused on protecting vision and the eye surface.

Since dermatology can be very lucrative and with a better personal lifestyle than may other specialties, with limited training slots, the best and most promising from each American medical graduating class in recent years seem to secure those slots.  Skin cancer, disabling pruritis, psoriasis, eczema, and cutaneous infections can be quite a challenge worthy of medical graduates of that caliber.  I'm less convinced that wrinkle stretching or botox injections should divert some of our best medical talent.  Give the public what they want and they'll come out in droves the Hollywood moguls accurately predicted.  And so we have professional dermatology teetering at the edge of vital medicine and patient vanity.

Tuesday, December 25, 2018

Merry Christmas

As the Jewish physician in the group, Christmas was my assigned holiday on call for most of my career.  More recently as the hospital's only endocrinologist, I let it lapse to a legal holiday, took the day off unless it was part of an extended weekend, then saw in-patients that day.  Now retired, it's movies and Chinese as is our ethnic tradition.

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Monday, December 24, 2018

NSAID Holiday

Our regional blood bank always solicits CMV negative platelet donors.  I've been giving quarterly until I retired, but now with greater flexibility of schedule I've tried to double the frequency.  It's a slight ordeal to get there and be tethered to a lounge chair for two hours, as the two arm donation has been far more reliable than a few attempts with single arm.  But for two hours I have the cell phone off, no pager anymore, and nothing to do but watch whatever wretched show stands out on daytime cable TV, as I am not sufficiently attentive to the movies they offer.

There are some upsides, in addition to doing somebody who I don't know considerable good, which justify the effort by itself.  Donors must eat within three hours prior to donation, so I treat myself to a diner or breakfast buffet.  The process finishes by late morning, so I will typically head off someplace other than home for the afternoon, often Lancaster when my donations were limited to Saturday morning, now a wider range of places.

As my 60-something years advance, various aches and pains have emerged, none serious, rarely but sometimes sufficient to limit my activity.  Naproxen seems to give more reliable relief than ibuprofen, and it has a longer duration of action, so once I know that musculoskeletal symptoms need suppression, I just include naproxen in my daily medicine case along with the prescription stuff.  More often than not, I will also swallow one at the breakfast table or the car.  When the lumbar and pelvic areas feel better, I will try to discontinue this, successfully for a while, then resume treatment the next time I think symptoms need suppression.

NSAIDs, the category of pills that includes naproxen and ibuprofen, need to be stopped a few days before platelet donation as they impair platelet function.  Typically this is a good excuse for my drug holiday.  While only two days off are needed to maintain donation eligibility, I will typically stop about five days in advance, which enables me to assess the orthopedic benefits.  I'm off and I can tell but I am also not disabled, just achy.  I've been able to progress my treadmill time if not its speed.  My lower back feels OK, right hip a little sore with some radiation downward along the ilio-tibial band.  Should be able to complete the donation in a couple of days, then decide whether to extend the time off.

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Sunday, December 23, 2018

My Deteriorating Wallet

With a few days to go before Christmas, and my Hanukkah and birthday shopping completed nearly a month ago,  I could casually keep my eye out for sales to get things mainly for me.  Boscov's generally has the most suitable stuff at the optimal price so I pay special attention to their brochures.  I've gotten a likely non-licensed Penn long sleeve T-shirt and a new shaving brush for half price.  I really don't need anything, having stocked up either last year or in anticipation of my cruise last fall on clothing and spent my accumulated $5 bills on an electric shiatsu massager which I have used less than I expected.  But one thing I actually need is a new wallet.  Wallets don't last more than a few years.  I buy them on sale when I need them.  I do not know if an expensive Coach wallet would make the replacement every five years or so unnecessary but I don't want to put up a large sum to get disappointed anyway.  The best selection is easily the leather shop at the New Castle Farmers market.  Some stuff like my passport case remains sturdy, some like my coin cases soon have zippers that separate from the leather.  Last time I paid a little more than usual for a light tan model, softer than usual leather and able to hold as much as I could cram in.  It lasted less than five years as enough stitching has separated to make the contents insecure. 

My wallet has important stuff, some hard to replace.  My lifetime passes to the Delaware State Parks and the National Parks would cost a considerable fee if lost.  My drivers license identifies me for all sorts of useful purposes.  It could be replaced but would be quite an ordeal if a police officer asked for it on the way to the motor vehicle department to do that and I didn't have it.  I keep copies of my medical licenses, voter registration, some shopping cards that get me discounts, two credit cards and the debit card that allows me access to cash from my checking account at any time.  I carry my Medicare and other medical insurance cards. My eyeglass prescription could be important some day. Relatively little cash, though.  My old wallets had clear film inserts suitable to remind me of my wife and kids, but recent ones lacked this feature, as the need to store plastic cards overwhelmed the need to remember what your family members looked like.

Since the Farmers Market wallet turned out shabbier than expected despite the small premium in price, I opted for a more conventional replacement source.  Shopping with two days before Christmas has its own challenges, but you can never go wrong with TJ Maxx or Boscov's, especially when Boscov's advertised them for $10.

First, the models have become more standardized.  There are bifolds, trifolds and passcases, each with a set number of card slots, a clear window for drivers license and one or two pockets for currency.  The passcase being most suitable, I priced those.  TJ Maxx only had a few, $12-$16, mostly with names I recognized.  Moved on to Boscov's.  For $10 you could get a very flimsy looking wisp of thin leather, forgot the brand.  Wallets looking more sturdy, which is what I want, sold for $16-20.  It can wait.

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Friday, December 21, 2018

Shabbos Approaches

Image result for shabbat tableShabbos which begins at sundown on Friday and concludes about 25 hours later has some activity restrictions that need preparation.  The main one for most observers is preparation of a hot dinner, elaborate enough to elevate it above usual supper fare.  We start with challah, an egg bread whose leftovers find their way to fancy Sunday brunches in the form of challah French toast, which can be quite good but never as good as the loaf that starts shabbos dinner.  I usually buy mini challot but last night I had pretentions of making a large loaf myself, which is a fair effort even with a modern stand mixer and its dough hook.  My enthusiasm was not the same as determination, so even though I still can, I think I'll go to Trader Joe's later and get more mini-challahs as theirs are the best and we don't seem to have any left in our freezer.

Usually I make chicken in some form, occasionally beef though kosher beef has gotten rather expensive, and occasionally a half turkey breast, which is on tonight's menu.  Lasts two or three meals and needs little preparation to get it into the oven.  Rather forgiving on roasting time as well.  Made shlishka's a few weeks ago.  Ate half, froze half, so that's tonight's starch.  Out of fresh vegetables.  Stop at supermarket or Farmers Market and get some.  And I bought blackberries which should make for a special dessert. 

This may be the earliest start time of the year for shabbos.  Keep my eye on the clock.

Thursday, December 20, 2018

Medicare Coverage

As an employee or the spouse of one I had to do next to nothing other than choose my plan.  If DuPont, my wife's employer covered me, my wife chose the plan and DuPont paid part and deducted the rest from the paycheck.  No checks or credit cards needed.  As I became eligible for coverage as a medical network physician, if my share was available for less that $100 a month of my contribution, which it technically was but not a plan I would want, DuPont required spouses to purchase their coverage from their own.  I signed up for a pretty decent plan, one notch from the most expensive and maintained it through retirement.  No money changed hands, no bills came my way.  The employer paid most, my share came off my pay stub, which I rarely looked at.  While I became eligible for Medicare while still working, the company plan was much more suitable but once I retired, I joined most seniors in the Medicare whirl.  There is a base premium, not excessive, a surcharge assigned to my earnings history.  Doctors get paid well so this came to real money.  I needed a supplement plan, opting for a Plan F which also comes to real money.  And a Part D for medicines.  While my current potions are all generic, generating no bill beyond the monthly premium, I spent decades prescribing needed but financially ruinous stuff so without insurance beyond what Medicare offers, an uncovered Donut Hole would far exceed an annual premium in very little time.

As a result, my out of pocket costs, which had remained hidden for most of my working years and paid for by organizations whose revenues would amount to billions, became my responsibility, partly defrayed by the Medicare deductions from each of he last 40 years of paychecks, but with a check writing dollar amount far in excess of what I've had in the past.  Good health into my Medicare years being my good fortune, I've not used any benefits since retiring other than my prescription refills.  For now, the G-Men and their insurance company delegates are coming out ahead.  But for the first time I can see how all that medical care that I generated directly and indirectly adds up, and it's a lot.  Not that I want to become ill to get my moneysworth.

A system that size can also become unwieldy.  My Medicare statement arrived in the mail four days before the due date.  My supplement and prescription statements for the coming year still have not arrived with only ten days to go.  I called everyone, authorized credit card payment as the path of least resistance, even though the supplement carrier's records show my statement mailed a week ago.

Considering the massive nature of this enterprise, it works rather well but monumentally complex and therefore prone to snafu.  I wouldn't be surprised if each Member of Congress had to hire a staffer just to resolve Medicare inquiries from baffled voters.  And the more complex it is, the more you have to pay the maybe 10,000 people in America who actually understand it at a professional level, be they government employees, financial mavens, or attorneys.  And that's before any provider has even asked to be paid for what he or she did.

Premiums now up to date once my credit authorization gets picked up by the Postal Service tomorrow and somebody at the receiving end processes my credit card authorization.  Much too cumbersome though.

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Wednesday, December 19, 2018

Different Route

Among my favorite outings has been Pennsylvania Dutch country, less than an hour away.  Lancaster, Pennsylvania also has the shopping outlets, once a much bigger lure than now, as seen by the ease of parking these past few years.  They have farmers markets, restaurants based on the pig, along with the department store chains and franchise restaurants on the main drag.  But it has always been the rural sections with buggies, kids and women coasting on bicycles that they push along with their left foot as pedals are prohibited by their sects, real farms, some grown quite large, and other out of the way places that keep me coming back as a brief escape from home.

I have two routes there, my usual path from home, Route 41 to 30, the Lincoln Highway, or Route 896 that connects the University of Delaware to the Rockvale Outlets.  Each main route has a number of places where roads less travelled can be accessed.  One takes people to Strasburg, built around the Pennsylvania Railroad Museum and steam engine ride, with most of the town having a rail theme.  One road takes people to Oxford, a larger place than I expected that seems to rise from nowhere.  Whatever cross road you take, it will eventually connect to Route 41 or 896 so getting to Lancaster is pretty much a sure thing, but just in case I can set the GPS.  So yesterday I hit Pizza/Atglen, got off Route 41 where I always wanted to but never did and stayed on Route 372, not quite following the GPS to the pizza destination.  Virtually entirely farms with perhaps and occasional small factory with a bunch of cars in the lot.  A few modern houses that could pass as suburban tract housing.  I always wondered how people in these places make a living when business are few and do not need a lot of workers, and certainly not a lot of highly paid workers, other than the utility companies, hospitals and school districts.  Amish buggies and bicycles but hardly any cars other than mine.  Not even a lot of churches.  Eventually this road found its way to 896, which I followed to the Rockvale outlets, stopped briefly at two stores, and returned in the direction of Strasburg, which advertised itself on the billboards as an historical destination.  GPS indicated a nearby winery just outside my route home, but on arrival it was defunct.  Just headed home.  Pleasant outing as it always is.

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Tuesday, December 18, 2018


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Indulged one of my favorites yesterday, Oatmeal Walnut Chocolate Chip Cookies in the manner of Frog/Commissary that was often a destination when I went to Center City Philadelphia.  I substituted Crisco instead of my more customary half butter/ half Crisco.  It's better with the butter but easier to mix the sugars into the fat using Crisco and I did not have endless patience last evening.  They came out fine, and if I had used pareve chocolate chips, the cookies would also have pareve ingredients though prepare with dairy equipment.  Not hard to make, mix sugars, crisco, egg, vanilla, salt, baking powder, baking soda, flour with a mixer.  Add by hand oatmeal, chocolate chips, walnuts.  Drop a tablespoonful onto a baking sheet.  Bake for 14 minutes, turning the tray about halfway through.  Leaves a lot of dishes, though.  I put each of the ingredients in a cup or small plastic container.  The beaters get pretty sticky,  Measuring cups, including one with residual Crisco, and spoons. The mixing bowl.  Washing the baking tray takes some effort too.  Got started with the intent of finishing in time to use up our over ripe bananas as banana bread later today.  Dishes from dinner too.  One of the better efforts though.