The Marcellus Shale – Your Shi Poo Pi!

Turns out that our summer house in the Endless Mountains of Pennsylvania is sitting on top of a large vein of Marcellus Shale, which in turn is housing one of the largest natural gas fields in the United States. No one cared about the Marcellus Formation until recently, when new drilling techniques first used in Texas were applied to the Marcellus and lo and behold, there was gas in them thar hills!

Most of the drilling in the Marcellus Formation will be horizontal and underground, with large quantities of water used to create fractures in the rock to release the gas. It’s a process that allows a single visible well to extract gas from a very large underground acreage, making the entire process financially feasible and quite profitable. The Marcellus could potentially yield enough natural gas to supply the entire country for 2 years, with an estimated market value of trillions of dollars.

The Gas Rush is On

Land lease negotiations with the locals in our area are in full swing as gas companies compete for rights to drill wells on their land. The first to sign contracts got fairly low rates, but land owners have since learned to negotiate in groups, and the lease price has gone up considerably in the past year. Land leases in our county are currently going for $2000 an acre, with 15% royalties.

Part of me is really happy for the locals living in the sparsely populated rural areas being targeted for drilling. These folks deserve a break. And, if they play their cards right, they will surely get one. Why, farmers formerly earning a sustenance living could become millionaires if their wells produce as expected!

The Environmental Questions

Of course, there are many concerns about the environmental impact of the drilling. Although the underground nature of the process means a relatively small visible footprint, the huge quantities of water that must be used could threaten local water supplies. The trucks needed to carry that water from areas outside the drill zone can create noise and pollution and damage roads. There are also concerns about quality of the water in the area, since most of us get out water from wells. The Gas Companies tell us that the wells are drilled well below the water supply and with casings to protect the aquifers. But who ever trusted an energy company with the environment?

Last night was one of the first meetings on the environmental impact of what will likely be decades of natural gas development in the area. Some good advice came from the meeting, the most important of which was to test your water both before and after drilling starts and not to allow drilling within 200 yards of the water source. Given that most of the drilling is underground, I don’t see how the latter can be reliably enforced.

The DEP is getting involved, and advises landowners to be proactive in monitoring drilling going on on or near their properties, and to report any potential violations to the DEP.

I wonder if any of the folks over at The Pump Handle can comment on the potential health impact of natural gas drilling…

More Information

  • Penn State Extension is doing a marvelous job of educating the public about the issues. Their Natural Gas Wiki has everything you need to know, from how the gas is mined to how to negotiate a land lease contract.
  • Geology.com is another great source of information on the Marcellus Formation mining.
  • Catskill Mountainkeeper does a nice job of summarizing the environmental issues.
  • OGAP, the Oil and Gas Accountability Project, has a free downloadable 220 page booklet called Oil and Gas at Your Door, written specifically for landowners and others affected by oil and gas development.

Shi Poo Pi?

Of course, whenever I hear the name Marcellus, all I can think of is Marcellus Washburn, the Music Man’s lovable sidekick, played by the late Buddy Hackett. Hackett started his show biz career in the Catskills, another area on the Marcellus Slate Belt that is being targeted for natural gas mining. So I know that, were Hackett alive today, he’d be singing this song…

Shi-Poo-Pi!

Well, the well you dig on the very first try
Is usually a shy one
And the well you dig on the second time out
Is sure to be a dry one
But the well you drill on the third time around,
Slate on the top, gas in the ground!
That’s the well you’re glad you’ve found–that’s your
Shi-Poo-Pi!

Shi-Poo-Pi! Shi-Poo-Pi! Shi-Poo-Pi!
The gas that’s hard to get!

Shi-Poo-Pi!Shi-Poo-Pi!Shi-Poo-Pi
But you can mine her yet!

Summer’s First Corn

On the way home yesterday from dropping our younger daughter off at camp in the Pine Barrens of New Jersey, we stopped at a farm stand for our first corn of the summer. Sweet white Jersey corn, fresh from the fields.

Paired with fresh Jersey tomatoes, it’s one of our favorite meals on a hot summer night. That’s the whole meal. Just tomatoes and corn. Washed down with a cold beer, of course.

Where do you get your favorite summer corn?

What is the Role for Breast Sonogram?

The WSJ has an article this week discussing MRI and breast sonogram as adjuncts to mammogram, and the debate going on in the medical community as to how these modalities should be used. The article does a nice job framing the debate that is occurring among physicians regarding when to use these modalities.

Medical practitioners are divided about the proper role of ultrasound in breast-cancer screening. Wendie Berg, a radiologist at a clinic in Lutherville, Md., who was the lead author of the study published in JAMA, says she recommends ultrasound screening to some women who don’t have evidence of very high risk that would justify an MRI. “It is a judgment call. The denser the breast, the more difficult the mammogram is to read, the more likely I am to recommend an ultrasound,” she says.

But Constance Lehman, a University of Washington professor of radiology who led a study published last year in the New England Journal on MRI screening, says she never advises ultrasound for patients. “We find it ineffective as a screening tool,” she says. “It’s not even in the same ballpark” as an MRI.

I’ve been actively debating the songram issue with an internal medicine colleague. She’s anti-sono, I tend to favor the screening method, but with caveats. She and I decided the issue is pervasive enough to discuss publicly, and are setting up a debate forum this fall with a panel of respected breast specialists and radiologists to see if we can come to some resolution on the matter.

Will let y’all know how that turns out.

Does a Brief Cessation of Hormone Therapy Lead to a Better Mammogram?

Since we know hormone replacement therapy (HRT) increases breast density, it seems logical that a short break from hormones prior to a mammogram might improve mammographic sensitivity. In fact, some doctors would recommend that women on HRT stop their hormones for as long as several weeks prior to a scheduled routine mammogram.

However, a recent study in Maturitas suggests that stopping HRT for as long as a month before having a mammogram makes no difference in mammographic breast density.

Researchers in the UK enrolled HRT users who were willing to have a mammogram, then stop their hormones for 4 weeks and repeat the mammogram. The mammograms were read by two experienced radiologists and scored for breast density using two different visual methods and two different computer methods.

All told, 44 women completed the study. The researchers found that stopping HRT for 4 weeks made no difference in mammographic density measured either visually or by the computer. In addition, there was no significant effect on breast tenderness during mammography.

The study’s findings stand in contrast to other studies that suggested stopping hormones might be helpful prior to mammography. But these studies were either confined to women with abnormal mammograms or compared groups of women to each other (case controls).

What makes this study especially compelling was that it used women as their own controls, included women who had used HRT for longer than one year, and was in the setting of routine mammograms. In addition, the researchers used several different techniques for measuring breast density, and found agreement among them in their results.

Weaknesses of the study are that it was relatively small, and that duration of HRT use varied within the population studied.

If supported by other studies, these findings are not so good news for women on hormone replacement hoping to mitigate some of the adverse breast effects of their hormones, at least as it relates to mammographic sensitivity and specificity. However, it is good news in that women should not be asked to suffer without their hormones without a proven benefit.

What is Mammographic Breast Density?

Mammographic density is a measure of permeability of x-ray, and an indirect measure of the density of breast tissue. Increased breast density is an independent risk factor for breast cancer, but is more likely a marker for underlying biologic differences in breast composition rather than a pathologic process in itself.

HRT can increase breast density, though not in all users. Intermittent progestin HRT regimens cause less of an increase in breast density than continuous regimens, and new low dose regimens may not increase breast density at all.

I tell my patients that reading a mammogram of a dense breast can be like looking through fog. If there’s an abnormality there, it may be harder to see. By contrast, a mammogram of a fatty breast is like a clear blue sky. Dense breasts are also harder to examine, and I am less confident in my ability to detect small masses in a woman with dense breast tissue on exam.

There’s a lot of active discussion these days as to how to improve breast cancer screening in women with dense breasts. Use of digital mammography, sonogram and MRI may improve detection of breast cancer in women with dense breasts, but the latter two come at a price of increase in false positives and biopsies.

What Should You Do?

Here comes the usual answer – Talk to your doctor. When data in the literature conflict, and there is not a clear recommendation as to which is the best way to go, then it’s really up to you to bat it around with your doctor before making any change in your hormone regimen before a routine mammogram. There is certainly no serious downside to stopping HRT for a short time, and if you’re willing to do so in order to have a better mammogram, then I say go for it.

To be honest, though, I do not routinely advise my patients to stop their hormones before having a routine mammogram. Stopping HRT for as little as a few days for some women can mean re-emergence of bothersome symptoms, including vaginal bleeding.

My experience is that a woman willing to stop her hormones for 4 weeks because she was worried about mammographic density would be a woman who would probably not ever take HRT in the first place. Most of my patients these days who choose to use HRT are truly miserable without it, and living the kind of high functioning lives that would be adversely impacted by a month off HRT. Without proven benefit, I see no reason to ask these women to stop hormones before a routine mammogram.

However, this reasoning on my part is very likely influenced by the fact that I don’t hesitate to order breast sonogram for women with dense breasts on mammography, especially if the radiologist hedges their reading by stating that the breast density “may lower the sensitivity of mammography in this patient.”

But that’s another controversial topic for another day, so stay tuned.
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– Weaver K et al. Does a short cessation of HRT decrease mammographic density? Maturitas. 2008 Apr 20;59(4):315-22.
–Mammogram information from the NCI.
–Improving Breast Cancer Screening– Info from the NCI

Grand Rounds at Shrink Rap

This week’s grand rounds can be accessed from two slick I Phones over at Shrink Rap – Click the buttons to read the posts! An amazing little piece of geekwork. I’m totally impressed.

Just disappointed my post didn’t make it. (I guess that’ll teach me to submit it on time next time…)

Head on over for the best of this week’s medical blogosphere.

Healthcare 3G

Twice as fast. Half the price.

Sounds good, right? It should – it’s the slogan for the new Iphone 3G. Everyone wants one, including me.

Ironically, this is also the slogan for modern medical care.

Because as the reimbursement goes down, docs are seeing more and more patients. Half the price, twice as fast.

You get 15 minutes, tops, talking to a back of a person typing madly away at a computer while you talk. We can take some additional history while we examine you. Write that script even as we’re telling you what we’ve found. Print out that script or referral faster than you can get dressed, and have it all ready for you by the time your check out. No need to ask questions – here’s a print out with the answers to ones you didn’t even think of. Now on to the next room!

Want it even cheaper and faster? Head over to your nearest in-store clinic and see a nurse practitioner instead of a doc. Heck, we’ll even start making nurses doctors – that’ll really lower the price.

Now, we all know that as electronics get cheaper, the quality starts to suffer a bit. Laptops konk out after 3 years. DVD players last just long enough for us to catch the last season of the Sopranos. That new fancy cell phone’s battery won’t hold a charge longer than an hour.

Same thing in health care.

Because fast works for things like sore throats, vaginal infections and vaccinations. But better not have a complicated problem, or need coordination of care between specialists, or god forbid, need to talk to someone because you’re anxious or depressed. We can’t handle that. Not at these prices. Sorry.

Of course, when that cheap DVD player breaks, you can just head out to Best Buy and get another.

Unfortunately, that option won’t work in health care.

Not to worry. That’s why we have lawyers.
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This post was written in response to a call for submissions to Grand Rounds at Shrinkrap 6/24/08.

Butternut Squash Risotto with Sage and Gorgonzolo

We haven’t been to the Endless Mountains since November. Our cottage there is not winterized, and spring weekends are filled with activities that keep us in New York City. But 7 months is much too long, and I’m starting to wonder if we’ll ever get away. Then, finally, it happens – a free weekend.

We arrive after 10 pm on Friday night. A stop for groceries and dinner and a pelting rainfall on back roads has turned a normally 3 1/2 hour trip into an almost endless 6 hour ride, and we are exhausted. We find the house still standing, and rush inside to see how things have fared this winter. Good news – no mice nests. Bad news – No water. We just this month had the well pump replaced and the filter system fixed, but looks like the plumber never came to turn things on inside the house. No problem – we lived without water in this house last summer when the well went dry. We can tough this out till morning.

Which would have been fine if we hadn’t opened the fridge to put away our supplies and discovered the shelves to be spattered with black mold. Lesson learned – Unplug and dry out the fridge before closing up next time. Now, we set to work with Clorox, some bottled water and a rag.

Next morning, we figure out how to get the water back on (simple valve in the shed) but there is no hot water. Turns out we had turned on the power to the hot water heater before it filled up, and burnt out the heating element. Luckily, the plumber comes and fixes things. Soon, we have fresh, delicious running water supplied from our well by the new pump. Good enough, I declare, to forgo bottled water for drinking and cooking, a first for us here.

A gorgeous sunny day ensues. Armed with fresh coffee and the radio, I clean the kitchen and arrange the larder while Mr TBTAM mows the lawn using his trusty hand mower and the girls sleep in. We all head into town for lunch at the Sweet Shoppe, and discover it is under new management, which worries us when we find out that the mac and cheese is coming off the menu and there are no more onions for Mr TBTAM’s burger. We reserve judgement, though, and promise to give the new management the rest of the season to learn just how to keep us happy.

Then it’s off to the local winery for a bottle of dry white wine for tonight’s dinner. Along the way, we detour to a flea market a a local campground. An airshow is underway at a nearby airfield, and antique biplanes loop overhead as we poke through out of style clothes, old suitcases and Tupperware. Next, the hardware store for a new garden hose.

After we get back, Mr TBTAM takes a long nap while I bike the loop around the lake, pleased that my rides in Central Park this spring have toughened my legs such that I can do the hills without stopping. It’s still too cold to swim as far as I’m concerned, but the girls go in for a dip while I’m gone. I stop at the lake at the end of my ride – thankfully, nothing there seems to have changed. Promising to come back tomorrow and attempt a swim, I head back to the house for a hot shower.

Now comes the best part of the day. Cooking. This is really why I come here. The lake and the bike riding and the mountains and the fresh air – its all just a gorgeous backdrop of an excuse just so I can get away and cook.

It’s still a challenge cooking in this kitchen. We really should replace the oven, but are waiting till we are ready to redo the kitchen. The altitude (2100 feet) makes baking feel like a science experiment, and slows down everything on the stove top. But there’s decent enough counter space and a large pantry, and I can get NPR in on the radio with just a little static, so I am just fine, thank you.

Tonight’s dinner is a wonderful risotto I modified from a recipe by Marc Murphy, chef at Landmarc Restaurant in Tribeca. The recipe uses Gorgonzola cheese, and Mr TBTAM is hesitant. He hates blue cheese. Can’t I leave it out? But I’ve been planning this meal since Thursday, and am convinced he’ll love it. (I was right, of course…)

As I am stirring the risotto, obligatory glass of white wine in hand, my thoughts turn to fungi. It is mold, after all, that marbleizes through and gives the Gorgonzola its distinct flavor. And, ironically, it was also mold that kept me up till midnight last night, scrubbing the fridge with Clorox. In the right place, with just the right set of circumstances, fungi can do wonderful things. But in the wrong place with no control, they are nothing more than trouble.

Which, not surprisingly, gets me to thinking about the current administration, politics and the upcoming election…

But that’s not what this post is about. It’s about food, and summer, and country houses. The need to get away, and the work that can bring. Tomorrow, I need to scrub the pantry floor and try to get up the rust the old metal cabinet has left there. Dust the cobwebs from the mantle and hang the pictures we’ve brought up. Hose down the porch. Hang the hammock. Lay the rug we brought up with us. Think about planting some herbs for summer cooking.

Which gets me thinking that opening up a country house is a lot like making risotto. It’s takes patience and a bit of work. But in the end, it’s a delicious meal.


Butternut Squash Risotto with Sage and Gorgonzola

The original recipe was actually a pumpkin risotto with no instructions on how to roast the pumpkin, called for a bit less onion, sage and cheese than I used, and use toasted walnuts for garnish. I tried it with the walnuts, and decided it was gilding the lily. Maybe if you wanted nuts your could add some toasted pine nuts. But I think this is fine as is.

Don’t be afraid of the Gorgonzola in this recipe. It adds wonderfully complex flavor without dominating the dish. Mr TBTAM hates blue cheese, and he loved this risotto. We served it with a salad of fresh greens tossed with a homemade lemon vinaigrette.

1 large butternut squash
2 tbsp olive oil
1 tsp Kosher salt
1/2 tsp Fresh ground pepper
2 tbsp chopped fresh sage leaves

1 tbsp butter
1 tbsp olive oil
1 large Vidalia onion
2 large cloves garlic
2 tbsp chopped fresh sage
1 tsp salt
Fresh ground pepper
2 cups Arborio rice
1 cup dry white wine
chicken stock (3-5 cups, depending on how you like your risotto)

3 tbsp crumbled Gorgonzola cheese
3 tbsp grated Parmesan
2 tbsp butter

Preheat oven to 400 degrees Fahrenheit. Peel the squash, cut lengthwise and remove seeds and pulp. Cut into 1 inch dice. Toss with 2 tbsp olive oil, 2 tbsp chopped fresh sage leaves, salt and pepper in a medium size bowl. Spread out evenly on a cookie sheet and roast for about 20 -30 mins, tossing once or twice while cooking, but being sure to leave them long enough to develop a nice brown color on at least one side. (See the little squash pieces in the photo up there for an idea of what it should look like when it is done)

Meanwhile, heat the chicken broth on a back burner and keep warm.

In a large pot, melt butter with olive oil over medium high heat. Add onion, garlic, sage, salt and pepper and cook till onion is translucent. Add rice and cook, stirring, for about 3-5 minutes. Add wine and cook until it is absorbed, stirring constantly. Add a large ladleful of chicken stock and cook till almost absorbed. Keep adding chicken stock, 1 ladleful at a time, cooking each time till absorbed before adding more stock, until rice is cooked but not too mushy.

Remove from heat. Stir in roasted squash, 2 tbsp butter and cheeses. If you want, garnish with a little more chopped fresh sage and some fresh ground pepper.

Birth Control Savings Calculator

Virtually 100% of young women in my practice who use birth control pills are filling their prescriptions monthly at a local chain pharmacy, paying anywhere from $25-$50 a month (depending on their copay) for contraception.

In a recent post, I proposed that by changing to mail-order, among other things, these young women could save a lot of cash.

Today, I tried to convince such a woman in my practice to do so herself. She was paying a $25 copay every month for her pills, but was reluctant to change to mail order because she liked the convenience of the corner chain pharmacy. (Here in Manhattan, we have a chain pharmacy on practically every corner. Sometimes, the same chain will have 2 stores within a block of each other…)

To convince her, I suggested that if she put her annual pill savings into a retirement account, it might be worth quite a bit by the time she retired. She didn’t believe me.

So we went into my office, pulled up an online savings calculator and calculated it. And here’s what we found –

If this young lady, who is 22, were to use the pill till her late 40’s (say 46), taking 5 years off to have kids (generous by modern standards), and depost the annual savings (for her, $200) into her retirement account with an annual estimated return of 9%, then at retirement at, say, age 66, she will have (are you ready?)

$68,762!

That’s the magic of compounding.

How much could you save by going mail order?
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To calcuate, I assumed she was adding $200 a year into a tax free account till age 30, stopping contributing for 5 years, then contributing again for another 11 years, then leaving that money in the same account till age 66.

The Brits on DTC Drug Marketing

Thanks to Kathy A. for pointing me to this opinion piece in BBC news re direct -to-consumer marketing of drugs here in the good old US of A.

America is, I think, the only country in the world which permits
advertising of drugs which are available only through your doctor. The insidious mssage is simple; if your doctor is not offering you this drug, maybe you should be asking for it…

Advertising subtly changes that relationship by sending us in to see the doctor filled with nameless dreads about the symptoms of diseases we might have, and a detailed knowledge of the drugs that might help us.

Spot on, old chap!

You can listen to the entire piece here.

CVS/Caremark – Detailing for Bayer?

Today I received a “Dear Doctor” letter from CVS/Caremark under the auspices of Prescriber Services Clinical Information, and something called “RX Viewpoints”.

CVS was taking the opportunity to inform me that Yaz birth control pills are FDA approved for both acne and PMDD treatment, and that Yaz is on the preferred drug list for Caremark. The packet included prescribing info for Yaz and a little article about Yaz. There’s nothing about other treatment options for PMDD or acne. Just a monograph summarizing the studies that got Yaz FDA approved for PMDD and Acne treatment.

There’s also a pad of tear-off sheets for my patients about Yaz, PMDD and Acne. The PMDD info doesn’t really tell patients that they need to have a really lot of severe symptoms to be diagnosed with PMDD. It just lists “some common symptoms of PMDD”, like breast tenderness and food cravings. Reading that list, most women are sure to assume they have PMDD and that Yaz will help them.

The copyright statement at the back of these materials tells me that “this publication is written and distributed by Caremark for the benefit of its clients, the health plan sponsors,” with funding provided by Bayer Pharmaceuticals.

Now I prescribe Yaz, both for birth control and for PMDD, and off label for PMS. I even wrote a review article recently in which I suggested that if a woman has PMS and needs hormonal contraception, Yaz would be a good option for her. So I have nothing against the drug itself.

But this sort of marketing by a drugstore chain for a big pharmaceutical company, under the guise of physician education took me quite by surprise. And, though we docs do a lot of drug talks, most of those are careful to include information about all treatment options for a condition. This article was just about Yaz. Nothing more, nothing less. Drug detailing, pure and simple.

C’mon, why don’t we all just stop playing around? Enough with the smoke and mirrors. Let’s just tell it like it is.

An Honest Dear Doctor Letter

Dear Doctor –

Bayer is trying to corner the market on oral contraceptives. Problem is, their best selling pill Yasmin, just went generic. So they need to get you to stop prescribing that baby and start thinking of their new pill Yaz, instead.

The truth is, we really don’t care what you prescribe. Our main goal here is to increase share price. Coincidentally, that’s also Bayer’s goal. So they figured if they offer us Yaz at a discounted price, we’d help them sell it. Of course, we all know the sweetheart deal won’t last forever. Just long enough for Bayer to get enough new prescriptions for Yaz to corner market share. But that’s okay. Short term profits is what we’re all about. Plus, this year’s Yaz will be next year’s antidepressant, and so on.

To sweeten the deal for your patients, we’re going to put Yaz on our “preferred pill” list. That means your patients will pay less than if you prescribed some other birth control pill thats not on that list. Of course, generic Yasmin would be even cheaper, but we’re not pushing that right now.

Hey! Did you know that Yaz is FDA-approved to treat PMDD? Well it is! Of course, PMDD is the really, really severe form of PMS that hardly anyone has. But Bayer figures, what the heck? Docs don’t know the difference between PMS and PMDD, so you’ll just prescribe the Yaz off label for PMS, right? Not to mention, we’re gonna’ give you this patient handout that will convince every woman reading it that she already has PMDD, which will make the whole thing go much faster for you. By the way, do you know why they call it PMS? The term “mad cow” was already taken. Ha, ha…

Seriously, though, did you also know that Yaz treats acne? Well, it does! We know, we know, so does almost every other birth control pill. But those manufacturers are not the ones giving us a deal right now. Bayer is.

In case you’re not getting enough pressure, Bayer is doing a really nice DTC campaign. So don’t be surprised if your patients come in and ask for Yaz by name. It’ll be your job to figure out “if Yaz is right for her”. But that’s why you’re the doctor, not us! 🙂

So, anyway, long story short. Can you prescribe the hell out of Yaz?

Thanks!

Sincerely yours,

CVS/Caremark and their good friends, Bayer Health

What it’s like

Thanks to Joan for pointing me to this post by her friend David about what it’s like to sing in a choir.

Finally the Dona nobis movement arrived. The end was in sight. Damn it. How could it be over? Why can’t peak experiences last forever? I was high as a kite, tired from standing for 2 hours and smelled like a sheep in the rain, yet I was blissed-out. I was in love…in love with the human voice and the beauty of communal singing. And the absolute drive we humans have for perfection…even the woman who sang in the rests.

Head over and read the whole post – there’s lots more. Not to mention a great blog title – “And Your Little Blog Too.” And a really nice poem.

Close Encounters

What happens when the doctor and the patient run into each other outside the office, in the real world?

For RL Bates, a plastic surgeon, the encounters can range from “Hey, there’s the lady who did my boob job!” to desperate glances from patients who pray she won’t out them (or their new boobs).

Doctor Rob’s reactions vary depending on the patient – happiness and concern for those patients he knows and loves vs. the old “duck and cover”, reserved for those few patients whose over-familiarity breaches the boundaries of the doctor-patient relationship.

Rural Doc’s small town practice gives her ample opportunity to run into her patients, who she hopes will stick to conversation about food and gardening, and leave the medical questions for the office.

Though New York isn’t exactly a small town, you’d be surpised how often I run into my patients outside the office. The nature of my business means that most of my patients feel rather intimate with me, even if, in truth, we don’t know each other very well. So, no matter where I am, conversations with my patients (and, come to think of it, even with strangers at parties) tend to get pretty personal pretty quickly.

For some reason, I don’t mind. Maybe it’s because I hate small talk.

And though as a rule, I really do prefer the office, I have to admit that I’ve done more than one breast exam for a worried woman at a dinner party (in an empty bedroom of course), and even diagnosed preterm labor once at a baby shower.

One problem I do have is names. I’m horrible at remembering them. I can recite almost eveything about someone and still not be able to tell you a name. I’ve tried to train my husband to introduce himeslf and ask “And you are?…”, but more often than not I find myself searching for a name when I encounter a patient outside the office setting. And I am ever so grateful to those patients who anticipate this and re-introduce themselves when we meet on the street.

My Favorite Out-of Office Patient Encounter

A few years back, I happened to take my daughter to a kid’s musical where one of my patients, an actor, was playing a lead role. It had been a fun show, and my patient had been hilarious. After the show, we all lined up for autographs from the performers, who were sitting behind a long table outside the auditorium. The audience was mostly women and their toddlers, a very casual crowd.

My patient, still in costume, saw me and gave me a big “Hey doc!” Then she said, “Wait a minute. You probably don’t recognize me. Here, I’ll make it easier for you”, swept her feet up onto the table in front of her and spread out her legs.

“She’s my gynecologist”, she explained to her fellow performers, all of whom nodded in complete understanding.

Sunny with a Chance of Meatballs

So there I was, minding my own business, sitting in my car in front of a high rise apartment building across from Asphalt Green, waiting to pick up my daughter and her friend from softball practice.

It was a warm, beautiful summer afternoon with an amazingly blue, cloudless sky and a strong but warm breeze blowing in from the East River. Jonathan Schwartz was playing something by Nancy Lamott on WHYY, and I was trying to think of a 9 letter word meaning “commonplace”.

I don’t know what made me look up from my Sunday Times crossword. Maybe I was hungry.

All I know is that, at that moment, a large uncooked hamburger patty fell from the sky and splattered onto my windshield. Come to think of it, it didn’t really splatter much. It just sort of spread itself out there on the wipers in front of me.

No cheese. No bun. No fries. Just fresh, raw ground beef.

Now that’s what I call a heavenly burger.
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Apologies to Judy and Ron Barrett for mutilating the cover of their wonderful children’s book.

Asian-Marinated Salmon


Irene’s recipe. Simple. Delicious.

Asian Marinated Salmon

salmon filets
Equal parts each soy sauce, rice wine vinegar, sesame oil and Asian fish sauce (1tbsp each per fillet, adjust accordingly)

Marinate salmon for 20 minutes. Broil (not too close, on 2nd shelf down from the broiler in our oven)10-12 mins till done. (Irene uses Mark Bittman’s broiling method, we just broiled ours up there.) Baste halfway through. Serve.