How to Pay Less for Birth Control

Most of my patients are spending way too much money on their hormonal birth control. At close to $50 a month, contraception can eat up as much as $600 a year. Sure, compared to the cost of raising a child, $600 is peanuts. But what if I told you that you could get the same protection against pregnancy for less than $100 a year? That’s a savings of $500 that you can put in the bank, or use to pay off your student loans or credit card bills.

So get smart and start saving money on birth control!

1. Go mail order.

Stop refilling every month at the local Duane Reade or CVS, and go mail order. Did you know that if you use your insurer’s mail order pharmacy, you can get a 90 days supply of birth control pills for a single co-pay? Not only do you save money, but you don’t have to worry about finding a 24 hour pharmacy on a Sunday night when you run out of pills, because you’ll have a 90 day supply in stock all the time.

You’ll need to think ahead, since it can takes up to a week to get your pills in the mail. Solve this problem by asking your doc to write you two prescriptions – a one month supply with 12 refills to keep at the local pharmacy for emergency refills, and a 90 day supply with 3 refills for mail order.

If you don’t know what mail order pharmacy your insurer uses, check you insurance card – it’s usually there. If not, ask Human Resources at your job.

2. Go generic.

Most pills are available in cheaper generic forms that are just as effective and available at much lower cost. If your current pill does not come in generic, ask your doctor if changing to pill that comes generic would be a problem for you. In my experience, a significant proportion of patients can find a generic pill that they will be just as happy with as their brand name.

Check your insurer’s website for a list of preferred generics. Print it out and bring it to your next appointment. Ask your Doctor to see if changing to a pill from that list would be appropriate for you.

3. Get your pills at Walmart, Target or Kroger.

That would mean changing to generic Sprintec (Ortho-Cyclen) or Tri-Sprintec (Ortho-Tricyclen), but at a low cost of $9 a month, it may be worth a try. Ask your doctor if it makes sense for you. (more info here)

4. Get your pills from Planned Parenthood

Even though recent legislation has limited their ability to purchase pills cheaply, Planned Parenthood’s prices may still be cheaper than the pharmacy.

5. Ask your partner to share the cost.

It takes two to tango, so let’s go, gentlemen – Ante up!

6. Take your pills the same time every day, and don’t miss a pill.

After all, if you’re spending money on birth control, don’t take it properly and end up with an unplanned pregnancy, then you’ve wasted your money, right?

7. Use pre-tax dollars for birth control.

If you know you’ll be spending a given amount every year on your pills, put that amount aside in a health savings account with your employer and save on taxes while preventing unplanned pregnancy.

8. Join Planned Parenthood’s Birth Control Now Campaign.

Keep birth control prices low for college students and low income women.

9. Remember birth control pills are used for more than just birth control.

If your insurance won’t cover family planning (and shame on them if they don’t), ask your doctor to submit a letter of medical necessity to your insurer for your use of your pills for treatment of menstrual cramps, acne, or menstrual irrregularities if that’s another reason why you use them.

10. Your turn

Got any other ideas on how to save money on contraception? Share it in the comments section.

Media Blather Interviews TBTAM

I was interviewed this week by David Strom, tech journalist and host of Media Blather.

We “blathed” about blogging, technology in medicine, Michael Moore and Eva Peron. (When’s the last time you read those two names together in the same sentence?)

Listening to the interview, I was struck at what a nice voice and manner David has. It was really a fun interview for me, and I hope he had a good time too.

Thanks, David!

Menopause Defined

A reader commented in my recent post that she was just a tad insulted when her doc implied that she was “in menopause”.

“Menopause! I had the period from HELL last week!”

She then goes on to wonder just what the difference is between menopause and peri-menopause, and asked that I address these definitions for her and her friends, because they are all a bit confused.

Happy to oblige, Sea Spray. The reason you’re confused is that it’s, well, confusing. Not to mention the fact that the terminology around menopause has recently changed.

But let’s see if I can make it simple.

Menopause

By definition, menopause is the date of the final menses. But you don’t get to call it your final menses until 12 months have passed with no intervening bleeding. Then, you get to look back and say “That was the date of my menopause!”. Of course, it’s a bit anti-climactic at that point…

If you have what you think is going to be your last period, and then you bleed again in the subsequent 12 months, then the clock resets at that new bleeding episode and we start the 12 month countdown all over again.

As to what to call yourself, you are not “menopausal”. You are either in your reproductive years, peri-menopausal or post-menopausal. The chart below may help you understand these terms.

Postmenopausal

Once it has been 12 months since your last menses, you are officially post-menopausal.

So what are you in that year while you are waiting to find out if that was your last period? You are peri-menopausal.

Perimenopausal

You are perimenopausal from the time from when you first start having variation in your menstrual cycle length to one year after the last menses. Other terms for the perimenopause are “menopause transition” or “climacteric”.

For some women, perimenopause is very short. For others, it encompasses a good deal of their forties and early fifties.

Hormonally, the perimenopause is characterized by fluctuating hormone levels and rising FSH levels. Cycles can range from textbook normal to skipping months at a time to occurring every few weeks. PMS can worsen. Periods can become very heavy and erratic. Mood swings can be problematic. Breast tenderness can be a bitch. And you can have hot flashes even while you are still having menses.

A simple way to remember the perimenopause is this – “Perimenopause is hell”.

Reproductive years

This one’s easy. It’s the years from menarche to the onset of the perimenopause.

The problem with this term is that it implies that the perimenopausal years are not reproductive. Tell that to the woman who gets pregnant in her perimenopause. Which definitely happens, by the way, so use birth control till you are post menopauseal.

What about the word Premenopausal ?

By definition, you are premenopausal for your whole reproductive life, until your final period.

Premenopausal is not really a helpful word, because it not distinguish the perimenopausal years. But it can occasionally be used to describe all those women out there who are still menstruating.

What about the word Menopausal?

When docs use that, they usually mean perimenopausal.

What does Menopause really mean?

The use of the last menstrual period as a defining moment in a women’s life is really an artificial construct based on the only outwardly measurable event we have marking the decline in ovarian function – the last episode of bleeding.

But it’s not like the ovaries give up the ghost at the final period. Many women’s ovaries keep chugging along for quite some time after the last menses, but in general cycling in an increasingly erratic fashion that is characterized by a lack of ovulation, absence of bleeding and lower and lower estrogen levels over time.

But this continuing ovarian function can make the perimenopause and early post-menopausal years a bit less predictable than some think. Not infrequently, my post-menopausal patients will complain of episodes of breast tenderness or PMS, and swear they are going to get a menses, but then nothing comes. And some women, even after 12months of amenorrhea, will occasionally have a full blown normal menses.

Take me, for example.

My Post-Menopausal Period

Just last month, a full 14 months since my last period, I had a miserable 3-4 weeks of bloating, breast tenderness, crankiness and a 5 pound weight gain, along with a pleasant little blip in libido, followed by a whopping migraine the likes of which I had not had for months, followed by a week long episode of vaginal bleeding.

Officially, this was an episode of post-menopausal bleeding. Not something to be ignored, since post-menopausal bleeding can be an early sign of uterine cancer. So I had a sonogram, which was normal. I didn’t have uterine cancer. It was, simply, a period. Just my ovaries popping up to say “We’re not dead yet!”

It’s all normal, because menopause is really a period of time, not a magic day. An episode of transition that can last for days, weeks, months and even years.

Which Reminds me of a Joke

A woman goes to her gynecologist for a check up. “Doctor”, she complains, “There are pennies coming out of my vagina.”

“Take this medicine”, says the doctor, “It should stop the problem.”

Two weeks later, the woman is back. “Well, the pennies stopped, but today I found a nickel.”

“Let’s increase the dose”, says the doctor, and writes her a new prescription.

Two weeks later, she’s back. “Now it’s dimes”, she complains.

The doctor reaches for his prescription pad.

“But doctor,” cries the woman. “What is wrong with me?”

“Nothing,” he says. “In fact, it’s completely natural. You’re just going through your change.”
_____________________________________________________
For information on Menopause, see

 

Cartoon copyrighted and used with permission from cartoonstock.com.

Chart from Straw (Stagng of reproductive aging workshop). J Clin Endocrinol Metab. 2007 Aug;92(8):3060-7. Epub 2007 Jun 5.

A Quartet of Salads for a Choral Gathering

For the past few years, Mr TBTAM and I have hosted my Choral group’s annual end-of-season party. It’s one of my favorite days of the year. I take off work and spend the day cooking, with NPR and the dog for company, and the sun streaming in my kitchen window.

This year, I made Irene’s chicken with Pauls’ barbecue sauce and a quartet of salads. The group supplemented with wine, appetizers, desserts and more side dishes. Usually we eat on the roof, but the weather was cooler than we expected, so we only did drinks and appetizers upstairs, then dinner downstairs. After dinner, we listened to a recording of our recent concert at Lincoln Center. Was that beautiful singing really us?

Thanks to Martin Rutishauser, our choral director, for an amazing season and for what was for most of us, the opportunity of a lifetime – a chance to sing at Lincoln Center. And thanks to all my friends in the chorus for another great year of music and friendship.

A Quartet of Salads

All four of these salads can be made ahead, and make a great addition to any party plate.

Creamy Potato Salad with Lemon and Fresh Herbs

This recipe is straight from Epicurious, and one of the best potato salads I’ve ever had. There are so many flavorful herbs that I think one could get away with non-fat mayo in this recipe and no one would be able to tell.

3 pounds baby red potatoes
3 tablespoons unseasoned rice vinegar
3/4 cup mayonnaise
3 medium green onions, thinly sliced
1 celery stalk, cut into 1/3-inch cubes
1/4 cup chopped fresh parsley
1/4 cup chopped fresh basil
2 tablespoons chopped fresh dill
11/2 teaspoons finely grated lemon peel

Bring potatoes to boil in large pot of water. Reduce heat to medium-low and simmer until potatoes are tender, about 17 minutes. Drain; let stand until cool enough to handle, about 20 minutes.

Cut potatoes into 3/4-inch pieces. Place 1 layer of potatoes in large bowl; sprinkle with some of vinegar and salt and pepper. Continue layering potatoes with vinegar, salt, and pepper. Add all remaining ingredients; toss. Season with salt and pepper.

Cucumber Salad (Sorry, no photo)

This is a family standard that Mr TBTAM usually makes, but I did it myself this time.

6 large cucumbers
1/2 medium sweet onion
1 cup white vinegar
1 cup water
1/2 cup sugar
1 tsp salt
1/2 tsp pepper
Fresh dill (optional)

Peel cucumbers, slice lengthwise and using a teaspoon, scrape out the seeds. Then slice crosswise into thin slices using a knife or, if you have it, a mandolin. Slice the onion into think slices and then in half across so they are not too long. Mix together in a large Pyrex bowl.

Meanwhile, mix vinegar and water in a medium saucepan, add sugar and bring to a boil. Cool slightly and then pour over cucumbers and onions and mix gently. Salt and pepper. Cover and place in fridge overnight.

Best made a day ahead.

Rice and Lentil Salad ala’ Ottolenghi

This is a slight modification of a Wild Rice Salad from the website of Yotam Ottolenghi, the UK’s vegetarian sensation. (Hat tip to 101 Cookbooks for introducing me to this amazing chef.)

I substituted an Indian rice and lentil blend called Delhi Durhbar for the wild rice. You could use really any lentil or rice mixturein this salad. The original recipe also calls for fresh rocket, an herb that I could not find. So I used an herbal salad green mix from Gourmet Garage instead.

1 cup Delhi Dunbar mix
2-3 ounces by weight peeled dry roasted pistachios
5 ounces by weight soft dried apricot, soaked in hot water for 5 minutes
1 small bunch of mint, leaves picked
2 cos, loosely packed mixed mesclun salad herbs
3 spring onions, roughly chopped
Zest and juice of 1 lemon
2 tbsp olive oil
1 large clove of garlic
Kosher or sea salt and freshly ground pepper

Cook the rice and lentils according to directions. Coarsely chop the pistachios with a large knife. Drain the apricot and coarsely chop them too.

In a bowl mix the rice, apricots and pistachios. Add the rest of the ingredients, toss well and season with salt and pepper to taste.

Green Bean Salad with Mustard Vinaigrette

Another recipe modified from Ottolenghi. I increased the proportion of beans to onions, substituted basil for chervil and plated it on a bed of baby spinach.

1 lb trimmed French beans
1 small red onion, chopped
2 tablespoon capers
2 tablespoon tarragon leaves, chopped
2 tbsp basil (or parsely or chervil or dill)
1/2 bag cleaned baby spinach leaves

Vinaigrette
1 small garlic clove, crushed
2 tablespoons Dijon mustard
1 tablespoon cider vinegar
¼ cup olive oil
Salt and pepper

To make the vinaigrette, put the mustard, garlic and vinegar in a mixing bowl. Slowly add the olive oil while whisking until you get a thick dressing. Taste and season.

Blanch the beans in boiling salted water for 4 minutes. Refresh and drain.

Arrange the spinach leaves on a large platter or flat bowl. Mix the beans with the rest of the ingredients in a large bowl. Toss with vinaigrette and pile onto spinach. Serve.

Eva Peron, Cervical Cancer and the Pap Smear

Eva and Juan Peron, October 1951 (Image from Wikipedia)
Fat Doctor writes that she can never think of Argentina without thinking of the music from Evita, the musical that was inspired by the life of Eva Peron.

When I think of Argentina, I too, think of Eva Peron. But there’s no musical accompaniment. Just sorrow.

Because I can never think about Eva Peron without thinking about cervical cancer, Pap smears and HPV. And the tragedy that was Eva’s death, and the deaths of so many women from cervical cancer.

Eva died from cervical cancer in 1952 at the young age of 33 years. Although George Papanicolaou invented the Pap smear in 1942, this life-saving test was not widely used in Argentina until the 1960’s. Thus, Eva’s cancer was at an advanced stage when it was diagnosed after she began having vaginal hemorrhage.  She received radiation treatment to control the bleeding, probably right around the time of that photo up there, and then a radical hysterectomy in November 1951. Despite treatment, the cancer progressed rapidly and she succumbed to it just 8 months later.

Don’t be surprised if you did not know that Eva had cervical cancer

She herself never knew. Her diagnosis was kept from her at her family’s request, and the public never told, even after her death. The subterfuge was so extensive that when they brought in an oncologic surgeon from Memorial Sloan Kettering to perform a radical hysterectomy, he never met his famous patient until she was asleep under anesthesia, and Eva never knew that her surgeon was anyone other than her own doctor.  It’s an amazing story of paternalism and politics.

Eva’s husband, dictator Juan Peron, also lost his first wife to cervical cancer at 28 years.

Did Peron carry a particularly aggressive strain of HPV, the virus that we now know causes cervical cancer, and unknowingly transmit the infection to both his wives?  Or did Evita contract HPV elsewhere, having been sexually active with multiple partners from the young age of 15?  We will never know for sure.

What we do know today is that Evita’s death due to cervical cancer would likely never have happened if she had had a Pap smear. This simple test, in which cells from the cervix are collected with a brush and examined microscopically for abnormalities, can detect precancerous changes up to 10 years before cervical cancer develops. Ten years during which developing lesions can be treated before they become cancerous.

This week is the 125th anniversary of the birthday of George Papanicolaou, the inventor of the Pap smear.

Happy Birthday, George. If there is a heaven, you are surely in it. And thank you for your wonderful Pap smear – one of the most effective cancer screening tests ever created

If only Evita had had one.

_________________________________________________________

For more reading about Evita see –

For more information about cervical cancer, pap smears and HPV see these sites –

 

Mark Gungor on the Male and Female Brain

Very, very funny. I’m not so sure one can generalize this to all men and women, but I have to say it rings true for Mr TBTAM and myself.

I’d love to have a nothing box to go to once in awhile. Must be a nice place to be.

(Thanks to Annette for pointing me to this video.)

Grand Rounds (and a new blog addiction)

Grand rounds is up this week at Health Business Blog. It’s very well done, and exceedingly readable. Thanks, Dave!

No thanks, though, for pointing me to a post at Medical Pastiche, which has a link to a real estate blog called”Don’t cry for me, just get me my principle reduction“, which then led me to dozens of real estate blogs chronicaling the bursting housing bubble all across America. Reading these blogs is addicting, as one after another tells the story of housing speculation gone bad. Tales of “Super Flippers“, bad real estate agents, tricks being used to fool buyers into thinking a house has just been put on the market when it’s been there for months, entire blocks in Southern Califronia where every other house is in forclosure. These bloggers have the benefit of public records and google earth photos, and have a “take no prisoners” approach to blogging. No one is spared their critical eye as they chronicle the death of the housing market at the hands of greedy speculators.

Reading these blogs is positively addicting. Consider yourself forwarned.

Chef Mentor

Shuna Lydon has written the most amazing post about teaching and learning in the restaurant kitchen. It’s a must read for anyone who has ever had a mentor. And for anyone, who like me, is enamored of the culinary world. It’s the kind of behind the scenes look that we front-of-the-restaurant types are rarely given. I read it, and all I want to do is read more.

No.” Eric said to calm them a bit, “Stand over here, I’m going to show you how to put out this table, I’m going to show you how to cook, how to work like a team, how to put out just one ticket.”

And then he did. He cooked every single course, by himself, with not another soul on the line touching sauce pots or spatulas or garnishes. He jumped this way and that, gracefully, using every part of his body, talking, admonishing, telling, teaching, showing, explaining as he went. It was the most amazing thing I ever saw in a kitchen…

When the line resumed their positions, every single cook knew just who
they were. Cooks.

As I’ve written before, so much about the culinary world reminds me of medicine. Shuna has given me yet another example of that – how our mentors influence us throughout our career. Her description brought to mind the great teachers I had who helped me become the doc I am today.

Happy Mother’s Day

The Bath. Mary Cassat 1893.
Wishing all you moms out there a wonderful Mother’s Day. And to my Mom, all my love.

Paul Levy – You Are Not the Boss of Me. Well, Okay, Maybe You Are.

So, the other night, I’m listening to The archive of Dr A’s radio interview with Paul Levy, the CEO of Beth Israel Deaconess Hospital in Boston and author of the Blog “Running a Hospital“. And I’m really enjoying it.

“This guy’s great!” I yell to Mr TBTAM, who is reading in the living room. “Did you know he used to run Boston’s sewer system before he took over Harvard?”

Levy talked about how he had brought a new transparency to the Boston health care marketplace when he began to post Deaconess’s outcomes on his blog. I liked that. A lot.

Then he took on the technology must-haves, asking what data existed that robotic prostatectomies were better than good old fashioned procedures.

“Those machines cost a million two or a million five..When you consider that the margin on a prostastectomy… is $10,000 how long does it take to get a million and a half back?…Well, you never get it back… Those hospitals that have bought them have picked up market share from other hospitals in the field, and there’s just no clinical reason for this.”

And I’m thinking – this guy reminds me of Dr Wes. Looking for the evidence before jumping on the bandwagon and spending our healthcare dollars just to get market share. Great!

When Levy started to get on Dr A and his colleagues for not washing their hands, I was right there with him. After all, I’m an obsessive hand washer – always have been. I even began washing my hands in front of the patient years ago when a colleague of mine did a survey of adolescents, and discovered that the most important factor in their choice of doctor was whether or not she washed her hands before examining them.

So Levy and I, we’re simpatico, right? And I’m thinking – I’d like to work with this guy. Wouldn’t you, if you heard him say this?

“I never pretend to to practice medicine. They tell me what they need done in order to do their job and we do out best on the administrative side to get it done.”

Yes! Paul Levy! You are THE MAN! I begin imagining what it would be like to live in Boston…

And then he says it.

What He Said

It was a discussion he and Dr A were having about negotiation. About how docs don’t know how to do it very well, because it’s not a skill that mixes well with the quickfire decisions needed in the OR and in emergencies. I’m thinking “He really gets us…”

Dr A, who’s got an administrative position himself, joins in about how hard it can be to get consensus and change old ways. He asks Levy for his advice on what to do when a physician says “Do it this way or I’m leaving your staff and going to the competition.”

And Levy says this –

“My usual response to that is “Great. We need the office space anyway. And when will you be leaving?”

You could almost feel Dr A pull back from the mike. In fact, there was a massive shift in the universe as every one if us docs listening to the interview pulled back from our computers and began readjusting our position on Levy. (Okay, I’m willing to admit maybe this was just my own reaction.)

And I knew it, right then and there. He was not one of us. He was one of them. An administrator, not a doctor. Not getting that if a doc is threatening to leave, then maybe what you want him/her to do might be just a tad unreasonable. Maybe that EMR you are insisting he use isn’t quite ready for prime time. Maybe one can’t see a patient every 15 minutes without extra support staff that could have been paid for with just a minuscule portion of the ad budget. Maybe you’re not giving him the support he needs to make the change you want him to make. A change that may be good for the administration, but bad for the doc.

Easier and cheaper to let that guy go, rather than take the time to figure out just why he is so upset. Replace him with someone who is willing to play along without a fuss.

And it hits me. Again. The way its been hitting me for the past 20 years since I left residency.

We docs are really not in charge. The administrators are. Administrators who have never practiced medicine.

Why this is so hard for me

I have a confession to make. I became a doctor because I wanted to be in charge.

It was the summer of my junior year in college, and I was working full time in a nursing home, trying to find out a bit about this field of medicine that I was considering as a career. Trying to decide if I should become a nurse or a doctor.

I was doing private duty for a little old lady who had just moved into the home, spending the majority of her waking hours with her on the day shift.

She had Alzheimer’s disease. She figured that I was granddaughter, and that we were in a hotel. But she remembered that her son lived down the road (he did), and saw no reason why she shouldn’t be walking there whenever she wanted. And she couldn’t understand why, if I had a car, she and I couldn’t head over to the mall for some shopping. This made her mad.

As the days progressed, this little old lady got madder and madder, and it was becoming harder and harder to rein her in when she started to walk off down the driveway.

So they called in a shrink. A doc who she had never met. He came into her room and spoke with her for, maybe, 15 minutes. Never asked me a single question about her. Wrote a prescription for Haldol (an anti-psychotic) and walked out.

That Haldol dose was too much for her. She became lethargic, somnolent. Wouldn’t get out of bed. Began soiling herself. Lost all touch with reality. After a week, her brother, a retired doc, came to visit, assessed the situation and went ballistic. The Haldol was stopped. But she was never the same.

And I think – Wow. A doctor can come in, change a woman’s life in a really bad way. Another doc can come in and save it. And no one stops to ask me, the nurse who has been with her more than any of them, who knows her now better than anyone, what I think.

I want to be the doctor. I want to be the one in charge. No one is going to be the boss of me.

But I am not the boss of me

I know, I should just quit academic medicine and head out into private practice, where at least I will have some semblance of control.

But not really.

Because somewhere between the administrators, Big Pharma and the insurers, we gave away medicine. Gave it away because we were too busy taking care of patients to step up and fight. Gave it away because the battles were fought on such a large scale, and we were a bunch of unorganized small shops.

Some docs got smart and went back for their MBAs so they could talk the language and play the game with the suits. Some just became the suits.

But most of us didn’t go into medicine as a business. So as we were taking care of patients, those around us built up this huge business of health care around us. A business that is now turning non-profit medical centers into profit making enterprises. A business that is making insurance company CEO’s some of the highest paid CEO’s in America.

A business where the doctor, the one who is actually responsible for the patient, the guy who gets sued if anything goes wrong, the guy who that patient is coming to see in the first place, the guy who may not have taken Paul Levy’s negotiating class because he was too busy taking care of patients, that guy…that guy is as replaceable as a worker on an assembly line.

I get it.

I really do. I’ve been living it for 20 years, and I accept it. I know the rules and my place in the game, and I think I play it fairly well.

As for Paul Levy, CEO, well, you don’t just play the game fairly well. You play it really well. You’ve turned around a major medical center, which is no small feat. You know that. I know that. As good a doctor as I think I am, I could never accomplish something like that. I don’t have the skills you’ve got in this arena. Probably never will. And the truth is, I greatly admire you and what you have done. Heck, I even love your blog.

But I will ask you this.

The next time a doc threatens to leave, don’t be so quick to show him the door.

Stop and consider who he is and how he got to be in a place where he is willing to leave over whatever the issue is you are arguing about. Grant him the respect for what he does all day (and night). Remember what you said up there about never pretending to practice medicine, and how negotiating skills are not something we docs inherently have. Put yourself in his shoes. Go the extra yard to figure out why he’s so upset. Odds are, it’s because it’s going to effect how he practices medicine.

In the end, that’s really what this business is all about, right? Medicine.

And he is still, after all, the doctor.
___________________________________________
Levy responds in the comments below.

Soupe au Pistou


Once again, vegetarian dinner guests have challenged my culinary creativity. This time, rather than turning to the Moosewood or other veggie tome, I decided to cull a meatless dinner from a more classic source – Julia Child’s Mastering the Art of French Cooking. This Provencal vegetable bean soup has everything one could ask for in a meal. Add a sourdough baguette and a salad and it’s more than enough for dinner for eight.

Soupe au Pistou

3 quarts water
2 cups diced carrots
2 cups diced leeks
2 cups diced potatoes
(I also added about 1/2 bulb fennel, diced )
1 tbsp salt
2 cups canned white cannelloni beans, rinsed and drained.
1/3 cup broken spaghetti or vermicelli
2 cups diced green beans
1 slice stale white bread, processed in the food processor to make crumbs (I used a stale pita)
pepper
pinch of saffron (I used turmeric)
1/4 cup chopped parsley (my addition)

For the Pistou
4 cloves mashed garlic
1/4 cup chopped fresh basil
1/2 cup grated Parmesan cheese
1/4 t 1/2 cup fruit olive oil
4 tbsp tomato paste or 6 tbsp fresh tomato puree

I used 3/4 cup prepared pesto (without pine nuts) instead of the first 4 ingredients and just blended in the tomato paste by hand.

Add potatoes, leeks, and carrots to 3 qt cold water with 1 tbsp salt in a large soup pot. Bring to a boil and simmer for 40 minutes.

Twenty minutes before serving, so the green vegetables retain their freshness, add the beans, spaghetti or vermicelli, bread and seasoning to the simmering soup. Simmer another 15 minutes or until the green beans are just cooked. Correct seasonings.

Prepare the pistou while the soup is cooking. Blend garlic, tomato puree or paste, basil and cheese either by hand or in the food processor till smooth. Add the olive oil gradually. (If using prepared pesto, just blend in the tomato paste to the pesto). Place in the bottom of the soup tureen. When the soup is ready for serving, beat a cup gradually into the pistou. Pour in the rest of the soup. Serve with hot french bread or with hard-toasted bread rounds basted with olive oil

Makes 6-8 servings.

Nose Mohs Update – 8 Weeks Post Op

Several readers have requested an updated photo, so here it is. Eight weeks post-op from a bilobed flap reconstruction after a Mohs procedure for superficial basal cell carcinoma. (See the whole story here. Posts are in reverse chronlogical order – start from the bottom. Photos are here.)

My plastic surgeon is not thrilled with the lower part of the incision, as the scar ended up a bit wider than he’d like. He is expecting we will do a revision sometime in the future. The top part of the incision is a bit bumpy, as you can see, so I spend a lot of time massaging it really hard to break up the collagen fibers. It periodically itches, which is an odd feeling because it is also somewhat numb.

Truth is, it was really hard to get a photo that shows the incision, since in real life, it’s actually barely noticable, especially when I wear makeup (which I am not wearing in the photo.)

Grand Rounds from Little Rock

Head on over to Suture for a Living for this week’s best of the medical blogs. Plastic surgeon and quilt maker RL Bates has done a fabulous job compiling this week’s posts, not to mention giving us a little photo tour of her home state, Arkansas.

Not only is this week’s grand rounds is a treasure trove of posts, but but this blogger has also discovered a few new blogs to add to her blogroll.

Marianas Eye – An American Opthomologist living and practicing on a tropical island of Saipan. Think South Pacific meets MASH. (He even has a book!)

Denialism Blog – The Hoofnagel brothers and PalMD take on those who would deny scientific and medical fact. PalMDs post in today’s grand rounds is wonderful, but I was most impressed by an old post in their blog called “The Denialists Deck of Cards. This is a blog that’s going to keep me busy reading back posts.

DocGurley – How I missed this blog till now I’ll never know. She’s smart, she’s funny and she calls a mean fight, as shown in her last week’s Grand Rrounds Smack Down.

Tales from the ER and Beyond – A Canadian blog by Dr Couz, ER resident and new mom. For such a youngun’ she speaks with the authority and wisdom of one beyond her years.

Thanks, RL!