Lemon Grass and Rice Noodle Fish Soup

This soup from David Tanis City Kitchen column in the  NY Times is a revelation.  The noodles, mussels and squid are perfectly cooked and tender, providing contrasting textures with the raw vegetable and herb garnishes. The broth will warm the cockles of your heart, and the flavors will lighten your soul.

Mr TBTAM made this soup for dinner last Thursday, despite my objections that it was too much work for a weeknight on which I had a lot of work to do.  I was so glad he didn’t listen and went ahead and made it without me, even cleaning up the kitchen afterwards himself.

My friend Allen was glad too – he downed a bowl of the soup at 10 pm when he and Jane arrived from Minneapolis for a visit.

And I was even gladder two days later, when Mr TBTAM and I shared what was left of the soup for a quick lunch before heading to a Sunday matinee (The Anarchist – Patti Lupone was  fabulous, unfortunately the script was not.).

So go ahead – Make this soup.

You’ll be glad you did.

(Recipe here. We used chicken rather than fish broth. I left the chiles out of my garnish – it was spicy enough without it.)

A House Call From Hell

Open Culture points us to Koji Yamamura‘s powerful animation of Kafka’s nightmare short story “A Country Doctor”.

I was in great difficulty

So says the doctor as he tells us of how he was called in the middle of a nighttime blizzard to attend a dying boy, a house call that will ultimately force him to face his own shameful and tormented soul.

His own horse dead from overexertion in the severe winter, the doctor is forced against his will to leave his maid in the arms of a mysterious groomsman, the only person who will lend him a horse on this terrible night.

Arriving at the sick house, the doctor at first dismisses the boy’s illness as a short-term coffee overdose, ranting on about patients who torment his unnecessary emergency calls, his low pay from the district and the uselessness of his calling. Despite this, he gives the family a prescription for the boy because

it is easy to write prescriptions, but difficult to come to an understanding with people.

When it appears this is not enough to satisfy them, the doctor heads back to the sick bed only to discover that the boy is actually dying from a maggot infested wound that will become a flower, and for which there is no cure. At that point, he is surrounded by the villagers and his employers, exposed, literally, as the useless failure that he is, stripped of his clothes and laid in the bed with the dying boy.

Take off his clothes and he will heal.
And if he doesn’t cure, then kill him.
It’s only a doctor, only a doctor.

After convincing the boy that his wounds are actually not as bad as those of many others, which actually comforts him, the doctor escapes, naked on horseback through the storm, past the villagers and back into his home, accompanied by the chanting of children, who sing –

Enjoy yourselves, you patients. The doctor has lain in bed with you.

Wow.

In this short tale written almost a century ago in 1916, Kafka has embodied the inherent conflict between the humanly imperfect doctor and the society which both respects and ultimately despises him for his inability to save them all from death – for in modern society, the doctor has replaced the priest as the road to salvation.

Always demanding the impossible from the doctor. They have lost the old faith. The priest sits at home and tears his religious robes to pieces, one after the other. But the doctor is supposed to achieve everything with his delicate surgeon’s hand.

He also shows us the toll this conflict can take on the individual doctor, who has clearly become burnt out and as a result, useless to his patients.

I’ll never come home at this rate. My flourishing practice is lost. A successor is robbing me, but to no avail, for he cannot replace me. … Betrayed! Betrayed! Once one responds to a false alarm on the night bell, there’s no making it good again—not ever.

In some ways, the story portends the decline, not just of an individual doctor, but of the medical profession itself.

Called to society’s side, we fail to see the real problems in front of us, and even when we do, we are ill-equipped to cure them. But with the rise of the internet, we are being stripped bare of our robes of power, and sent on our way, while others who represent the gods of technology step into our place as the beacons of hope and immortality. If Kafka’s truths are indeed as timeless as they seem, these new gods will ultimately fail as well.

Then again, I may just be having a bad day.

Latkes 2012

It’s Hanukkah, and in our family that means latkes.

This year, our market seemed to be having a bit of a potato shortage, so I ended up using mostly Russets instead of my usual favorite Yukon Golds. What I did not realize was the the Russets have very little water in them,  so when I did my usual potatoes-in-the-dish-towel-squeeze I ended up with a very dry potato mixture that required 4 eggs to stick together!

Lesson learned  – If you use Russets, don’t drain the potatoes or onions after shredding them. Bittman says the Russets make better latkes than the more waxy varieties, but I still like the Yukon golds the best.

Despite my love of old traditions, I also think the food processor makes better shreds than the hand grater.

This years latkes were still delicious, despite (?because of) the extra eggs. Then again, there’s not much one can do to ruin a latke.

Here’s my recipe.

Penne with Brussels Sprouts, Chili and Panchetta

I take full credit for this dinner, because when my husband called me at work to ask “Shall I make that brussels sprouts pasta recipe from Melissa Clark’s column in the Times?”, I immediately said “Yes!”.

I thought it was delicious served with grated Parmesan, although, given the bite this dish packs,  it was even better the next night with a dollop of sheep’s milk yogurt. (Yes, I am addicted to the stuff.)

Recipe here.

Time-Based Billing – It Won’t Waste Your Time

In a NYTimes Op-Ed piece entitled “A Shortcut to Wasted Time“, internist Leora Horowitz bemoans the erosion of the medical record, once a means to communicate about a patient’s health, now merely an electronic repository for the minutiae of a medical encounter required for docs to get paid for the work they do. Because, as she simply puts it –

Doctors are paid not by how much time they spend with patients, how well they listen or how hard they think about what could be wrong, but by how much they write down.

In her editorial Horowitz tells us that she spent 40 minutes counseling an anxious patient who was neither sleeping nor eating, and how she was unable in the current payment system to bill for that visit –

Last week, I spent 40 minutes with a patient who had just placed her mother into hospice care. My patient was distraught, not sleeping, not eating. I gave her some advice, but mostly I just listened. By the end of our visit, she was feeling much better. But I wouldn’t be able to bill much for that visit based on my documentation: I didn’t review her medical or family history, conduct a review of organ systems or perform a physical exam.

What the payment system tells me to do is to cut her off after 10 minutes, listen to her heart and lungs and give her a sleeping pill. Which doctor visit would you prefer?

There are many of us who agree with Dr Horowitz about the erosion of the medical record in the era of the EMR.

But I have to disagree with her when she says she would not be able to bill much for that patient’s visit.

Because there is a simple and ethical way within the current system to easily document and get paid for medically necessary encounters such as the one Dr Horowitz describes that does not involve check off boxes, cutting and pasting, or even a physical exam.

It’s called time-based billing.

When you spend >50% of the encounter in counseling and/or coordination of care, time is the key factor in deciding the level of service. Not history, exam or medical decision making. Just time.

How do I know this?

Because I’ve been the billing compliance leader in my department for almost a decade, reviewed hundreds of my colleagues’ charts for coding accuracy, and sat through more lectures on coding than anatomy classes. If there was a GME approved fellowship in medical coding, I’d be running the damned thing.  That’s how I know.

Plus, I asked a certified medical coding expert.

Time based billing is like the WAYBAC Machine for the Medical Record

You simply document the chief complaint of the patient and the extent to which history and exam may have been done, what you talked about, including advice given and management plan, how much time you spent doing it, and indicate the diagnosis to support the medical necessity for your work.

Here’s when and how you do it, straight from the CMS Manual –

C – Selection Of Level Of Evaluation and Management Service Based On Duration Of Coordination Of Care and/or Counseling

Advise physicians that when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the type/level of service provided. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.

EXAMPLE
A cancer patient has had all preliminary studies completed and a medical decision to implement chemotherapy. At an office visit the physician discusses the treatment options and subsequent lifestyle effects of treatment the patient may encounter or is experiencing. The physician need not complete a history and physical examination in order to select the level of service. The time spent in counseling/coordination of care and medical decision-making will determine the level of service billed.

The code selection is based on the total time of the face-to-face encounter or floor time, not just the counseling time. The medical record must be documented in sufficient detail to justify the selection of the specific code if time is the basis for selection of the code.

In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided.

In an inpatient setting, the counseling and/or coordination of care must be provided at the bedside or on the patient’s hospital floor or unit that is associated with an individual patient. Time spent counseling the patient or coordinating the patient’s care after the patient has left the office or the physician has left the patient’s floor or begun to care for another patient on the floor is not considered when selecting the level of service to be reported.

The duration of counseling or coordination of care that is provided face-to-face or on the floor may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling.

How Dr Horowitz could have billed that encounter

For Dr Horowitz’s patient, there were real complaints that the patient presented with and she probably did review (and update) family history.  There were also some elements of exam – Constitutional (general appearance) and certainly Psychiatric (mood). She could document all of that, the total time she spent with the patient and the fact that more than 50% was spent (listening and) counseling, as well as a summary of the discussion points and plan.

Per CPT guidelines, the average time allotted to CPT 99215 is 40 minutes. So, I’d suggest she bill 99215 with a diagnosis of depression/anxiety, insomnia and weight loss.

Which brings up another problem

Of course, using a high level code like 99215, Dr Horowitz should be prepared for her chart to be audited, since insurers increasingly don’t want to pay for high level visits.

Which is whole ‘nuther post for whole ‘nuther day…

_______________________________________________________

WAYBAC machine image from Wikipedia

More on Mammogram Over-Diagnosis

Surgeon/scientist Orac has written a wonderful in-depth analysis of Bayer and Welch’s recent NEJM article on 30 years of mammography screening. I strongly recommend you read Orac’s post, entitled “Cracks  Spin vs Science on Mammography”,  if you are interested in exploring this topic further.

The post, like most of what Orac writes, is incredibly informative but very long (I thought I was verbose, but he beats me every time), so allow me to summarize the points I took home from reading it –

  • The NEJM study’s finding of over-diagnosis is in line with prior studies, strengthening it as a real possibility, but does not excluding the possibility that both studies have as yet unidentified biases that lead to the finding of over-diagnosis.

After reading this study, my first thought was: Here we go again. My second thought was: Wow. The result that one in three mammographically detected breast cancers might be overdiagnosed is eerily consistent with a study published three years ago that looked at mammography screening programs from locations as varied as the United Kingdom, Canada, Australia, Sweden, and Norway, which I discussed at the time it was released. The consistency could mean either convergence on a “true” estimate of overdiagnosis, or it might mean that both studies shared a bias, incorrect assumption, or methodological flaw. If they do, I couldn’t find it, but it’s still an intriguing similarity.

  • The study used SEER data, which is not perfect, and made some assumptions that could have over-estimated the rate of over-diagnosis, again not perfect and possibly over-estimating, but not eliminating, mammogram’s rate of over-diagnosis.
  • Using the rates of breast cancer in women under 40 as a surrogate for breast cancer mortality rates in un-screened women over age 40 may not be appropriate, as the biology of breast cancers in younger women is likely to be very different than those in women over 40. Unfortunately, there is not a better comparison group that could have been used instead.
  • The study ignores the possibility that stage creep could account for the lack of decline in later stage breast cancers of time. This is a phenomenon  in which previously so-called early cancers are more likely now to be classified as later stage due to better detection of tumor cells in axillary nodes using sentinal node biopsy. This is a concept of which I had not been aware.

One study suggested that the stage migration rate was as high as one in four; i.e., 40% of patients having “positive” axillary lymph nodes with SLN biopsy compared to 30% having positive nodes using axillary dissection. Another studyreported similar results. How this would affect Welch’s analysis is hard to tell, and correcting for it is probably not possible using the SEER database, particularly given that the extent of “up-staging” is not fully known yet. Be that as it may, an increase in the apparent incidence of patients with positive lymph nodes would increase the apparent incidence of advanced disease and decrease any decline in the incidence of advanced disease. How large this effect is, I don’t know, but it would suggest that the rate of over-diagnosis is lower than what Welch estimates. How much lower, or whether stage migration is even a significant factor, I don’t know, but I wish that Welch had at least mentioned it.

  • Could mammogram be victim of the so-called  “the decline effect”?

Basically, this is a term for a phenomenon in which initial results from experiments or studies of a scientific question are highly impressive, but, over time, become less so as the same investigators and other investigators try to replicate the results, usually as a means of building on them.

Orac also takes on the extremists on both sides of the issue – those that would use the study as fodder to paint mammograms as evil – or as he puts it,  “The cranks have had a chance to discover the study” – as well as those in the medical profession who refuse to accept any criticism of mammography – one actually calling it “malicious nonsense”.

…the Bleyer and Welch study is simply more evidence that the balance of risks and harms from mammography is far more complex than perhaps we have appreciated before. It’s very hard for people, even physicians, to accept that not all cancers need to be treated, and the simplicity of messaging needed to promote a public health initiative like mammography can sometimes lead advocacy groups astray from a strictly scientific standpoint.

It has weaknesses and might well overestimate the rate of overdiagnosis, but overdiagnosis is a real phenomenon….As I said, it’s hard for many physicians to accept that not all cancer necessarily needs treatment. Certainly this is likely to be true for ductal carcinoma in situ (DCIS), which consists of cancerous cells that have not yet invaded through the basement membrane of the ducts. Unfortunately, this is the predominant form of breast cancer that is detected by mammography.  Indeed, the authors even point out that their method didn’t allow them to disentangle the incidence of DCIS from that of invasive breast cancer, thanks to the way that the SEER database is setup. The problem, of course, is that we don’t know how to predict which cancers will progress and which cancers will not.

Finally, for all the confusion this study causes, there is one spot of good news, and that’s the observation that much of the decline in breast cancer mortality over the last 20 years—yes, contrary to what you might have heard, breast cancer mortality has actually been steadily decreasing—is likely due to improvements in treatment.

Finally, he reminds us that, for all its limitations, mammograms are not going anywhere anytime soon.

…right now reports of the death of mammography are very premature. To me, what is most important in breast cancer screening right now is to develop reliable predictive tests that tell us which mammographically detected breast cancers an be safely observed and which ones are likely to threaten women’s lives. We are currently at a point where imaging technology has outpaced our understanding of breast cancer biology, or, as Dr. Welch put it, “Our ability to detect things is far ahead of our wisdom of knowing what they really mean.” Until our understanding of biology catches up, the dilemma of overdiagnosis will continue to complicate decisions based on breast cancer screening.

Thanks, Orac. I always learn from reading your posts.

Inspirational – Morten Lauridsen’s Lux Aeterna

Morten Lauridsen’s amazingly beautiful Lux Aeterna. I first heard this choral music in a cathedral in Florence, and am thrilled to be singing it this weekend with The Collegiate Singers here in New York.

I’ve been singing The Lux for 5 days straight now and I swear, such a sense of incredible peace has invaded me. The only thing I can think is that it is this music – it is so calming, yet lush and expansive. (Thanks Elena for those adjectives…)

You can hear the entire piece on You Tube (there are three parts).

Remove Restrictions on Emergency Contraception

The Reproductive Health Technologies Project is sponsoring a petition to remove the current restrictions on emergency contraception and allow it to be placed on pharmacy shelves next to the condoms.

In December of 2011, the FDA was prepared to make emergency contraception accessible to consumers without restriction, based on more than a decade of medical research and policy debates. Instead, HHS Secretary Kathleen Sebelius overruled the FDA, putting politics ahead of women’s health. Her decision created unnecessary confusion for women and couples at a moment when clarity and timing matter most.

Despite Secretary Sebelius’ December 2011 decision, no evidence suggests that making emergency contraception accessible leads to risky behavior among teens. What it does do is give teens a second chance to prevent and unintended pregnancy so they can stay in school…

Emergency contraception is a safe, effective back-up method of birth control that can prevent pregnancy after unprotected sex or contraceptive failure. A woman is healthiest when she can decide the timing and spacing of her pregnancies. Let’s ensure that any woman who needs EC can get it safely and quickly.

Both the American College of Ob-Gyn and the American Academy of Pediatrics have released opinions supporting over the counter EC Access.

And as I’ve written before, emergency contraception is safer than Tylenol.

‘nuf said. Go sign the petition. (I did)

Understanding Mammogram Over-Diagnosis

This video from H. Gilbert Welsh, the author of the recent controversial NEJM paper on mammogram screening, should be required viewing for every woman and her doctor. (HT to Gary Schwitzer for bringing it to my attention.)

 

Bottom line – three decades of mammogram screening has had only a modest impact on the incidence of late stage breast cancer, and leads to over-diagnosis and over-treatment of early stage cancers in return. Declines in mortality are modest, and can be attributed in large part to advances in breast cancer treatment.

Overall, mammograms are thought to lower breast cancer mortality by about 15-20%. Which ain’t nothing. But it’s a lot less than most people think.

If you want to see what a highly effective cancer screening intervention looks like –

Let’s look at pap smears and cervical cancer screening – in this case in the UK, where a nationwide cervical cancer screening program was introduced in the late 80’s. Note the dramatic decline in the incidence of cervical cancer resulting from screening and subsequent treatment of pre-cancerous lesions-

With a concomittent large decline in cancer mortality that has not been disputed (note how the angle of the decline drops significantly in the late 80’s when screening is introduced) .

What is not shown in these graphs is the sharp increase in precancerous cervical disease that went along with the decline in invasive cancer and later stage disease – exactly what you’d expect from a highly effective cancer screening intervention. Pap smear screening works because cervical cancer has a relatively long precancerous phase during which screening and treatment can be done to prevent progression to cancer. (Colon cancer screening works the same way).

Mammograms are just not working as well as pap smears and colon cancer screening works. Either they don’t find the treatable early or pre-cancerous lesion in enough cases to make the kind of impact we were expecting, or more likely, not all so-called “early” breast cancers are destined to progress or cause death if diagnosed later or left untreated. This is supported by the fact that increases in the diagnosis and treatment of DCIS (Ductal carcinoma in situ) has not led to much of a decline in later stage breast cancers in the same way that treating cervical carcinoma in situ prevents invasive cervical cancer and cervical cancer deaths.

We are beginning to think that there are different types of breast cancers – those that are slower growing and less likely to metastasize and kill, and those that are aggressive from the get-go. Screening tends to pick up the former (hence the term “over-diagnosis”) and miss the latter, since they grow and spread so quickly.

This does NOT mean that no woman should get a screening mammogram.

It is saying that we need to have a more realistic understanding of what mammograms can and can’t do, and supports the recommendation that we make make decisions about mammogram screening that are based on that reality.

It also will hopefully help to dispel the prevailing myth that if every woman just got a mammogram every year, there would be no deaths from breast cancer.  Sadly, that is just not true.  Mammograms do prevent some deaths from breast cancer.  But not all of them. And the price we pay for preventing the deaths we do prevent is over-diagnosis and over-treatment of some women who may never have died from their cancer in the first place.

The problem, of course, is that at  present we have no way of knowing which women we are over-treating and which women we are saving.

Until we can do so, we must and will continue to offer screening mammograms.

When to start that screening, and how often to have it, is the question each woman must ask and decide with her doctor.  Hopefully, videos such as this one will help in making those screening decisions informed and reality-based.
__________________________________________________________

Recommended Reads

Tarragon-Cream Turkey Pot Pie

I awoke late today, feeling a bit melancholy. Eldest daughter left very early to go back to school, younger daughter is heading off with a friend to a museum, and the hubbub of the Thanksgiving holiday is over. As one who thrives on hubbub, I am a bit thrown by the quiet.  Although I had been counting on this free day to get quite a few things done, I find myself uninterested in doing anything, and since it is too cold for a bike ride, I instead waste the morning in front of the computer, allegedly handling email but in reality accomplishing nothing.

My husband, the math teacher, appears unfazed and is preparing math contest problems for his class. He brings a particular difficult one to me for help in solving, and though I remember little about geometry I do find his error – a simple math mistake. I decide that he too must be having trouble today as our little family once again rearranges itself from a quadrilateral to a triangle.

This realization reassures me somehow, and I am jolted back into activity. In short order, I shower, make the bed, eat breakfast, finish last week’s open encounters and lab result reviews online, write a few checks and finish a few odds and ends I’d been putting off doing. I then head out for a much needed mani-pedi, during which I start on my book club’s monthly selection (Age of Miracles, OMG you have to read it) and then come home to tackle dinner, which of course means the turkey leftovers.

Inspired by this recipe from Ina Garten, and remembering this delicious preparation for chicken breasts, I decide to make a pot pie using plenty of tarragon. This will also allow me to finish up that herb’s harvest before frost takes what’s left. (It did not survive last winter…)

Unfortunately, my younger daughter arrives home too hungry to wait for me to make the pies, so instead we compromise and serve half the filling over penne tonight (delicious), with the rest in small individual pies that cook while we eat dinner.  They finish baking just as we finish the dishes, and they are gorgeous. We’ll serve them tomorrow night, but of course I take a small taste – yep, this recipe is a keeper.

And so was this day.

Tarragon-Cream Turkey Pot Pie

The tarragon gives a light feel to what could otherwise be a heavy dish. (Much the same way adding lemon can lighten a dish). I made individual pies, but you can make one large pie if you prefer. If you don’t have time for a pie, make the filling and toss it with some penne pasta (pass the Parmesan when serving it).

  • 1 double recipe Pate Brisee
  • 2 tbsp butter
  • 1 tbsp olive oil
  • 3 large leeks, rinsed and into large dice
  • 3 large stalks celery, cut into large dice
  • 3 large carrots, peeled and cut into large dice
  • 10 ounces Crimini mushrooms,stemmed and cut into quarters
  • 2 cloves garlic, minced
  • 3-4 tbsp chopped fresh tarragon leaves
  • 1 tbsp fresh thyme leaves
  • 4-5 cups leftover turkey, shredded or cut into bite size pieces
  • 1 cup chicken broth
  • 1 cup cream or half and half
  • 1/2 cup white wine
  • salt and pepper to taste
  • Beurre manie  -1 tbsp flour mixed with 1 tbsp soft butter in a small bowl (optional)
  • Egg wash – 1 egg whisked with 1 tsp water

Prepare pastry and roll out half to line individual tart pans. Preheat oven to 375 degrees fahrenheit.

Heat olive oil and butter is a large skillet. Saute leeks, celery and carrots till they start to soften. Add mushrooms and cook till they just give off their liquid Add garlic and saute another minute. Add turkey, tarragon, thyme, chicken broth, cream and wine and heat to boiling, then turn down heat to low and thicken with flour-butter mixture (if necessary). Cool slightly and pour into tart pans. Roll out top pastry and cover tarts, crimping the edges to close the pastry. Cut three small slites in the top of each tart. Brush with an egg wash. Place on baking sheet and bake for 45-50 minutes, till crust is brown and sauce is bubbling.

Makes 8 individual or one large pie.

 

Of Haircuts and Vaginas

So I’m at my friend Wendy’s salon in Philadelphia today, getting one of the wonderful haircuts that only she can give me (plus color and eyebrow and upper lip waxing), on a day that she came in special because I was in from New York, even though the salon was closed, when she tells me she’s really worried about a little something she felt on the outside “down there”.

The thing about hair salons? They have plenty of gloves.

So we traipse down to the basement, and armed with my IPhone flashlight, amidst the boxes of product and with Wendy propped up on a stepping stool, I take a look and render my diagnosis – basically, nothing to worry about.

Wendy is exceedingly grateful and I’m happy to have been able to do her a favor in return for her coming in on her day off to cut my hair.

Later, as I hand her a credit card to pay the bill, Wendy says “Aren’t you even going to look at what I charged you?” and I’m thinking “Honey, you can charge me anything you want for this haircut – I absolutely love it!” but I take a look at the bill and holy cow! she’s practically given the whole thing away. I look at her, shocked.

Wendy smiles and says  – “I gave you the vagina discount.”

I love my job.

And my friend Wendy.

Candied Sweet Potatoes

Just a quick post to share this wonderful family Thanksgiving favorite.

And to remind myself not to let the fabulous food distract from what this day is really about – giving thanks.

It’s hard to do sometimes, when those we love are taken from us, when the forces of nature (and man) lead to death and destruction, and when it seems that the insanity of war will never end.

And yet here I sit, with the sun shining down on me from a clear indigo sky, in a home that has heat, electricity, water and plenty to eat, in the city I love more than any place else on this earth, surrounded by my husband and children, preparing to travel to the city in which I was born to share not one, but two delicious meals with my brothers and sisters, nieces and nephews, father and in laws.

What else can I be but grateful?

Candied Sweet Potatoes

Modified from a recipe in Gourmet, Nov 1991. I double this recipe that serves 8. Although I cut the potatoes crosswise, lengthwise, as described below, is better for the shape of the pan.

3 pounds sweet potatoes, peeled
3/4 cup firmly packed light brown sugar
2 tablespoons water
3 tablespoons unsalted butter, cut into pieces
1 teaspoon salt
1/2 tsp freshly ground pepper (optional)

Peel the potatoes. Cut them lengthwise in half. Place cut side down on counter and cut lengthwise into 1/2 inch slices.

In a steamer set over boiling water (I use a pasta inset w/ my 8 quart calphalon boiler) steam the potatoes, covered, for 10 to 15 minutes, or until they are just tender. Let them cool, uncovered. Arrange the potato slices in one layer, overlapping them slightly, in a buttered shallow baking dish. Combine the remaining ingredients in a small pot and bring the mixture to a boil and cook it over moderate heat for 5 minutes, stirring while cooking. Drizzle the syrup evenly over the potatoes, and bake the potatoes in the middle of a preheated 350°F. oven, basting them with the syrup mixture every 15 minutes, for 1 1/2 hours, or until the syrup is thickened and the sweet potatoes have deepened in color.

May be made 1 day in advance, kept covered and chilled, and reheated.

Cranberry Apple Pie – Doing Double Duty at Thanksgiving

Once again, since neither I nor my husband has ever been willing to give up Thanksgiving dinner with our respective families, we are gearing up for our annual schizophrenic Philadelphia holiday celebration, in which we join my family for an early afternoon dinner, followed by another meal at my in-law Irene’s home  later that evening.

Like us, this particular dessert will be found  at both family’s celebrations this year. It is a true harvest pie, with apples, cranberries, raisins and nuts,and quite delicious. Irene makes it every year for her dinner. I made it once a few years back for my sister’s dinner, and she requested I bring it again this year.

SInce we save dessert for the evening meal, I won’t get to taste the one I made. That’s okay – I’ll just eat a piece of Irene’s instead.

Happy Thanksgiving!

Cranberry Apple Pie

This recipe hails from the November 1985 issue of Gourmet Magazine. Irene modified it by reducing the sugar.
  • 5 cups thin apple slices (Red delicious or other )
  • 1/2 cup golden raisins
  • 1/2 cup fresh cranberries
  • 1/2 cup chopped pecans
  • 1 tsp cinammon
  • 2 tbsp corn starch
  • 1/2 cup granulated sugar
  • 2 Pate Brisee pie crust recipes (top and bottom) – see below 
  • 3 tbsp butter, cut into small pieces
  • Egg wash – 1 egg + 1 tbsp cold water
  • 1 tbsp sugar

Combine first 7 ingredients in a large bowl. Roll out bottom crust and line an 11 inch deep dish pie or tart pan. Pour apple/cranberry/nut mixture into pan. Dot with butter pieces. Roll out the top crust and place atop the filled pie, sealing and crimping the edges. Cut 5 slits in a circular pattern around the middle. whisk egg and water together in a small bowl.Brush egg wash onto crust and sprinkle with 1 tbsp sugar.

Bake atop a baking sheet on the middle rack of preheated oven at 400 degrees fahrenheit for 20 minutes, then lower heat to 350 and bake another 50 minutes or until the juices start to bubble. Remove from oven and cool.

Can be made ahead and frozen. On Thanksgiving morning, remove pie from freezer and let thaw at room temp. Pop into a 350 degree oven to warm if you like.

Pate Brisee Pie Crust made with shortening and butter

This recipe makes one crust. For this pie, you will need to make this recipe twice for both a top and bottom crust . Alternatively, if your food processor bowl is large enough, you can simply  double the recipe and make it in one batch, then splitting the dough into two crusts.

If you want a butter-only Pate Brisee that is even easier to work with than this one, try this recipe instead.

  • 1 1/4 cups flour
  • 1/4 tsp salt
  • 3/4 stick cold butter, cut into equal size 1 inch pieces
  • 2 tbsp Crisco
  • 3 tbsp ice water

Pulse flour and salt once in food processor. Add butter and pulse till consistency of corn meal, about 15 secs. Add water through feed tube and pulse till dough comes together, about 10 secs. Remove dough from bowl, pat into a round and press flat. Wrap with plastic wrap and keep cold in fridge till ready to roll.