The Hot Dog Mensch

This is second in a series called I Get It On the Streets. Click on the link at the end for the next post in the series.

Like the Handbag Guy, the Hot Dog Man has been on the hospital corner ever since I started working here, and I suspect, for a few years before. Great dogs and sausages, and unlike the push cart vendors in Central Park who are milking the poor tourists, this guy’s got great prices.

During my first year here, when I was commuting from Philadelphia 3 days a week and totally stressed, I lost my laptop computer. About a week into the loss, I stopped for a hot dog on my way to the train. And there, sitting on the wheel hub chained to the Hot Dog Man’s cart, was my laptop case. Turns out I had set it down there while paying for a soda the previous week.

“I didn’t know whose it was,” the Hot Dog Man told me, “but I figured they would probably pass by or stop again and see that they had left it.” So he schlepped that laptop back and forth with his cart to Queens every night, got a chain to lock it down to the cart so he wouldn’t have to worry about it getting stolen, and waited for its rightful owner (me) to claim it.

I love this guy (and this city).

Next Up: Coffee Guy.

Category: Considerations

The Handbag Guy

This is the first in a special TBTAM Post Series. A link to the next post is at the end of each post.

If you are a city dweller like me, you probably have a cadre of vendors whom you frequent regularly, whether it be for coffee, lunch, fruit or the occasional umbrella or scarf on an inclement day. Here in New York, my vendors are as much a part of my daily life as the corner grocer is to the residents of any small town. Allow me to introduce you one of my favorites –

The Handbag Guy

No Saks 5th avenue or Bloomies for me – I get my bags from this guy. He requested that I not take his photo or tell you his name, but did let me snap a shot of his perch across the street from the hospital. Great selection, nothing too fancy, and most importantly, lots of bags actually big enough to hold all my stuff.

My Handbag Guy and I actually started working this territory at the same time – me in the GYN clinic, him across the street, in 1993. That’s right, he’s been at this corner, and no where else, for 13 years.

Handbag Guy is from Senegal. He came to the US in 1981, served in the Army for a few years, then opened a business up on 125th Street, selling bags and sundries. He did pretty well for a few years, until the neighborhood began to gentrify, and the big chain stores moved in. When his landlord raised the rent to $10K a month, Handbag Guy took his wares to the street and has never looked back. He works alone, and buys his goods from wholesalers, mostly in New Jersey.

Like my bag? I got it from the Handbag Guy last fall. I’ve lost count of the number of complements I’ve gotten on it, and how many women think it’s a designer bag that I spent hundreds on. Nah, it was just $35.

It turns out this is not the first orange bag I got from Handbag Guy. I bought another one exactly like it a week before I bought this one. But the strap broke about 3 days later, probably because I had crammed it so full.

“No problem”, said Handbag guy, when I showed the broken strap to him the next day on my way to the office. “Give me a few days. I’m expecting another shipment, and I’ll replace it for you.”

I gave him my business card, and sure enough, he called me at the office a few days later to report that he had my replacement bag. I sent my daughters over with my old bag, and he made the switch, no questions asked. And since then, whenever I pass and say hi, he asks me how my daughters are doing. I don’t think you can get more personalized service at the finest department stores.

Handbag guy is a licensed vendor, having secured a merchandising vendor license that is all but impossible for anyone but military veterans to obtain. (As opposed to food vendor permits, which are easier to get.) According to The Street Vendor Project Website, the New York City Council passed an ordinance in the 70’s restricting the number of vendor licenses to 853. Since then, the wait list for a vendor licence is so long that they stopped adding names to it in 1992. But there is an exception for vets who can prove an honorable discharge. So when you buy anything other than food from a vendor, if he’s not one of the old timers, odds are he’s a vet, and you should probably thank him for more than just giving you a great price.

Well, now that spring is here, it’s time for me to check out Handbag Guy’s selection for the season. Maybe a pink bag this time?

Next Up: The Hot Dog Man

Category: Considerations

Disease Mongering and Medical Education

This week, PLoS Medicine, a Journal of the Public Library of Science, has published a collection of articles on the topic of Disease Mongering. (Thanks to my friend Annette, who sent me the table of contents today via e-mail.)

Disease Mongering, a term coined by the late journalist Lynn Payer, former health editor at the NY Times, refers to the creation or expansion of disease definitions by the pharmaceutical industry in an attempt to create a market to match the drugs that they manufacture.

The topic has been getting a lot of discussion lately, spurred by the recent publication of Ray Moynihan and Alan Cassels’ book Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning Us All Into Patients. (Here’s a Newsweek interview with author Moynihan.)


No one argues that the pharmaceutical industry creates medications that save lives and cure disease. It’s the medicalizing of things like sexual dysfunction and menopause that are the problem. Or the pushing of drugs like Fosamax for low bone mass in patients without risk factors for osteoporosis other than age. (Trust me, the reps are in here once a week pushing that.)

What I find fascinating is that those who are fighting against disease mongering have taken a lesson from the big pharma playbook, and are using Big Pharma’s own marketing tactics against them. They are “creating buzz” with the media campaign around Moynihan’s book, legitimizing their argument further by publishing it in a scientific journal (PLoS), and now, just as the Pfizer did in the 1990’s to create a market for Viagra, they are convening a conference to teach others about the issue. Brilliant!


The Role of the Physician in Disease Mongering

We physicians must become cognizant of the role we play, often unwittingly, in disease mongering. They get us involved by ploying us with medical education, written and delivered by “thought leaders” in the field, who themselves have a research or clinical interest in the topic at hand, and sometimes are paid consultants to the companies whose drugs they discuss. This sort of education need not be drug specific to be effective, so the MD’s feel as if we are not being bought or used, but are participating in legitimate medical education.

What we don’t see is that we are being used. Big Pharma has learned that if they spend their advertising dollars on disease creation and awareness, they sell more drugs. Rather than fighting over their share in a stable market, they simply grow the market. And, if they “partner” together on disease awareness, they all win.

The problem for me as a physician is that it is becoming almost impossible to distinguish between real medical education and industry- sponsored marketing. Especially when there is so much overlap. And there really is overlap. Industry-sponsored medical education has lots of real knowledge within it. If not, we would never had gotten into this situation in the first place, trust me.

So I try. I really try to distinguish when I’m being marketed to and when I’m being taught. Problem is, I sometimes can’t. Because it is getting harder and harder to identify who’s benefitting from the “medical education” I receive.

Prime example – today, I received a “Newsletter” about menopause and hormone replacement. “Okay”, I thought. “Let’s see which HRT manufacturer sponsored this one.” I looked on the back. Noticeably absent were pharmaceutical sponsorships or disclosures from the panel of experts whose photos appeared on the cover of the newsletter. Just a logo for the Foundation for Better Healthcare.

I went to FBHC website, which describes the organization as a non-profit group whose mission is “Moving clinicians from Knowledge to action”. Action – what action? A prescription, perhaps?

The FBHC has patented a tool they call ROEI – Return on Educational Investment. This term usually refers to educational returns. But look at this statement from the group’s mission: The Foundation for Better Health Care consults with organizations interested in supporting medical education and who want to measure return on investment. What kind of return on investment? Well, according to the conflicts information published at various CME’s sponsored by the FBHC, its executive director owns stock in practically every major pharmaceutical company known to man. Is that the kind of return on investment they mean?

The FBHC seems to be a legitimate non-profit group whose goal is to educate my patients and me. They certainly seem to be holding lots of conferences and CME activities, and they are advertising for CME monitors to assure the objectivity of their educational activities. And to be honest, the activities they sponsor seem just fine to me. But each one is industry sponsored, from what I can tell. And when I see that its director is playing big in the Big Pharma stock market, it has to make me question what this organization’s objectives really are. And toss the Newsletter they sent me into the trashcan.

I’m not trying to point fingers at this foundation as the bad guys – I just happened to get their newsletter today, so I’m picking on them. But let’s be honest – my own professional organization uses industry funds for every single meeting, and I can’t recall a medical conference or meeting in recent memory that I have attended that was not in some was sponsored by an “unrestricted grant from Company X.” I myself have beem paid honoraria to present at meetings.

But I think it’s gone too far. I worry that these non-profit educational consortiums are really fronts for industry sponsored education. And if they are not, it doesn’t matter, because I really don’t trust medical education anymore.

Breaking Up Is Gonna’ Be Hard To Do

Iona Heath, a GP in the UK, writes in the PLoS journal that the first step in combating disease mongering has to be a genuine disentanglement of the medical profession from the pharmaceutical industry. And I agree – the time has come to disengage. But I expect it’s not going to be an easy process. Because the ties between us are so deep and so long, and are getting harder and harder to identify.

It reminds me of when I was trying to dissect out a nerve from the sacral plexus in anatomy class. I couldn’t do it without bisecting the nerve, and came away both frustrated and as usual, stinking like formaldehyde.

Category: Second Opinions

A Tart Pretty Enough for a Song

This asparagus tart is just so pretty, I don’t know what else to say, except to tell you that it is a combo of several recipes I found, with a dash of champagne vinegar that I thought of all by myself.

I have no idea if it tastes any good, because I am freezing it and reheating it on Sunday for Easter dinner. But you know what? I really don’t care how it tastes, I am so in love with how it looks.(Addendum 4/17/06 – It was delicious. But next time I’ll try freezing it uncooked.)

My daughter thought it was so beautiful that she sang it a song with her guitar. You see, Friday nights are chick-flick night, since Mr. TBTAM has a regular Friday night tennis game, so my daughters and I were watching The Wedding Singer while I was making the tart. We fell in love with the movie even though it is Adam Sandler and corny. After the movie was over, my daughter wanted to learn the chords and words to the song Adam sings to Drew about growing old together. So she went on the web and found them and was teaching herself the song when I called her in to the kitchen to see the tart. When she saw the tart, she decided it was so pretty that we had to sing to it, so she brought her guitar into the kitchen and we all sang the song to the tart. I think it will make it taste even better on Sunday.

Hey, if people can talk to their plants, we can sing to our food, okay?

Colorful Spring Asparagus Tart

Make a Pate Brise pie crust in a tart pan with a removable bottom, and bake it till just set and barely golden. (See instructions for pie crust here.)

Peel and trim 1 lb young asparagus. Further tirm the ends of 16 spears to make 3-4 inch spears for arranging on the top of the pie. Cut the remainder of those spears, and the rest of the asparagus into 1 inch lengths. Cut 15 cherry tomatoes in half and set aside.

Heat 1 tbsp olive oil in a 12 inch saute pan. Slice 1 onion thin and saute over medium low heat till soft, about 7 minutes. Add asparagus and saute for an additional 8-10 minutes, until the asparagus are just tender. Sprinkle with 1 tbsp champagne vinegar about halfway through the saute, and just a dash of salt and pepper. Remove from heat to cool enough to handle.

Mix 3 eggs with 1 cup half and half, 1 tbsp chopped fresh tarragon, 1 tbsp chopped fresh parsely, 1 cup coarsely grated gruyere cheese, and a little salt and pepper.

Remove the 1 spears and set aside. Spread remainder of asparagus and onion mixture into tart pan. Pour egg mixture over top. Arrange 16 spears on top like spokes on a wheel, pushing them ever so slightly into the egg mixture. Scatter the cherry tomatoes on top. Brush the edges of the crust with an egg wash.

Bake on a cookie sheet for 30-35 mintes, until golden and just set. You may want to cover the edges with foil for the last 15 minutes of baking time. Let cool slightly before serving. Can be made ahead and frozen, then reheated before serving.

Sing to Your Tart

If you want to sing to your tart too, here’s the music and words!

Grow Old With You

I wanna make you smile whenever you’re sad
Carry you around when your arthritis is bad
All I wann’a do is grow old with you.

I’ll get your medicine when your tummy aches
Build you a fire if the furnace breaks
Oh it could be so nice, growing old with you

I’ll miss you
I’ll kiss you
Give you my coat when you are cold

I’ll need you
I’ll feed you
Even let ya hold the remote control

(Music solo break)

So let me do the dishes in our kitchen sink
Put you to bed if you’ve had too much to drink
I could be the man who grows old with you
I wanna grow old with you

The Shiksa Does Brisket (and Another Prune Recipe)

When I was in med school, all my Jewish friends thought I was Jewish. It may have been because I was funny and smart-alecky and fresh from 3 years of grad school in New York City. Or because somewhere on my mother’s Irish face I reflect my father’s Czech heritage. Or maybe I subconsciously channel the spirit of my dad’s mother’s grandfather, who, we are told, was Jewish.

All of which may explain why, even though I was raised Catholic, attended Catholic grade school, Catholic high school and yes, a Catholic college, I make a mean brisket. Every year in recent memory I have brought the brisket to my friend Linda and Andy’s seder, and every year it gets rave reviews.

Of course, it may just be simply that I have always used my Jewish mother-in-law’s recipe.

Well, this year, the shiksa is branching out. It’s time to stand on my own two Irish-Czech feet, and stop basking in Irene’s reflected glow. I got a new brisket recipe, which I made and brought to Seder last night. Now my brisket reputation with my friends was made on Irene’s recipe, so I was a little worried about shaking that by doing something different this year. But I came across this recipe at Epicurious, and just had to try it. And guess what? It even has prunes in it.

Well, I am ever-so-pleased to report that the new brisket recipe is a winner. It was absolutely delicious. My husband likes it better than the traditional recipe. My friends went back for seconds and even third helpings. (That’s what was left up there in the photo.) And I survived, reputation intact. (Whew!)

Maybe it’s time to flex my Irish cooking muscles and try corned beef and cabbage…

Brisket with Dried Apricots, Prunes and Aromatic Spices
Note: Quantities shown are total used, but amounts are split for use. Read the recipe carefully. I modified the recipe by dusting the brisket with a litte flour before browning, and increased the fruit slightly. I also added tomato paste to the sauce to make it even richer and fuller flavor. Some of the Epicurious reviewers recommended longer cooking times at a lower temperature of 275 instead of 300 fahrenheit. I didn’t have time for that, but think I’ll try it that way next time to see if it makes the meat even more tender than it already was. Finally, the apricot mixture can burn while you are browning the meat, so be careful.

3/4 cup quartered dried apricots (about 4 ounces)
9 large garlic cloves
31/2 teaspoons ground cumin
1 teaspoon kosher salt
1/4 teaspoon ground cinnamon
1/4 teaspoon ground black pepper
1 4 1/2- to 5-pound flat-cut beef brisket
2-3 tbsp flour mixed with 1-2 tsp kosher salt and 1/2 tsp pepper
3 tablespoons olive oil
4 cups chopped onions
2 medium carrots, coarsely chopped
3 tablespoons tomato paste
1 tablespoon minced peeled fresh ginger
1 teaspoon ground coriander
1/8 teaspoon cayenne pepper
1 cup dry red wine
3 cups homemade beef stock or canned low-salt beef broth
3/4 cup pitted prunes, quartered
Chopped fresh cilantro.

Combine 1/3 cup apricots, 3 garlic cloves, 1 teaspoon cumin, salt, cinnamon, and 1/4 teaspoon pepper in processor. Using on/off turns, chop to coarse puree. Using small sharp knife, make 1/2-inch-deep slits all over brisket. Set aside 1 tablespoon apricot mixture. Press remaining apricot mixture into slits.

Position rack in bottom third of oven and preheat to 300°F. Heat oil in heavy large oven-proof pot over medium-high heat. Gently rub brisket all over with flour mixed with salt and pepper to taste. Add brisket to pot and sauté until brown, about 5 minutes per side. Transfer to plate, fat side up; spread with reserved 1 tablespoon apricot mixture.

Add onions to same pot. Sauté over medium-high heat 5 minutes. Add carrots, tomato paste, ginger, coriander, cayenne pepper, remaining 6 garlic cloves and 2 1/2 teaspoons cumin; sauté 3 minutes. Add wine and boil until reduced almost to glaze, stirring up any browned bits, about 5 minutes. Return brisket to pot. Add stock and bring to simmer. Spoon some of vegetable mixture over brisket.

Cover pot and place in oven. Roast brisket 2 1/2 hours, basting every 30 minutes with pan juices. Add prunes and remaining apricots. Cover; roast until brisket is tender, about 30 minutes longer. Cool brisket uncovered 1 hour. Chill uncovered until cold, then cover and keep chilled overnight.

Spoon off any solid fat from top of gravy; discard fat. Scrape gravy off brisket into pot. Place brisket on work surface. Slice brisket thinly across grain. Bring gravy in pot to boil over medium-high heat. Boil to thicken slightly, if desired. (I found that I didn’t need to thicken the sauce.) Season gravy with salt and pepper (also not necessary.). Arrange sliced brisket in large ovenproof dish. Spoon gravy over. Reheat either on the stovetop or in a 350 degree oven for about 20-30 minutes.

Sprinkle with cilantro and serve.

Iene’s Pot Roased Brisket

Haverchuck has requested that I post Irene’s recipe for comparison, and here it is. You’ll see it’s really not that different from the one I made. I think it’s pretty funny that her first ingredient is pancetta (optional, of course). I use olive oil, but I’ll bet the bacon adds great flavor.

4 oz. pancetta or bacon, cut in half inch cubes or 3 tbsps. olive oil
3 tbsps. Flour, optional
Salt and freshly ground black pepper
3 ½ lbs brisket or boneless beef rump roast, in one piece
2 medium onions, chopped
3 medium carrots, peeled and chopped
1 stalk celery, chopped
4 cloves garlic, peeled and minced
1 cup fruity red wine, like Beaujolais
3 tbsps. Tomato paste
2 tbsps. Fresh thyme leaves
1 bay leaf
2 ½ cups veal or beef stock

1. Preheat oven to 300 degrees
2. Place pancetta or bacon in a 5 or 6 quart oven-proof casserole dish, and saute over medium heat until it is browned. Remove pancetta, leaving fat in pan. Set pancetta aside. If you don’t want to use bacon fat substitute 3 tbsps. of olive oil.
3. Season flour with salt and pepper, dust beef roast with flour and brown it in casserole over medium high heat. Remove it from casserole, and set aside. Drain all but a film of fat from pan. (You can brown the meat without the dusting of flour)
4. Add onion, carrots, celery and garlic, and cook, stirring, over medium heat until they have softened. Add red wine, and cook over medium-high heat for several minutes. Stir in the tomato paste. Return beef to pan, and add thyme, bay leaf and stock. Bring to a simmer, cover and place in oven for 3 hours, or until meat is tender.
5. Remove meat from casserole, cool and wrap in aluminum foil. Refrigerate overnight before slicing. Store gravy separately, overnight also, and remove fat when it solidifies.
6. Slice meat and reheat in gravy.

Category: Food

If There’s a Heaven…

Then this is it (at least for me).

It’s 10:30 am on a weekday, and I’m in my kitchen cooking. The rain has cleared, the sun is streaming in my kitchen window, the ceiling fans are on and blowing warm spring air, I’m listening to Brian Lehrer on WNYC, the kids are downstairs in the courtyard playing, and my babysitter is here.

I’ll blog tomorow about exactly what I’m making. Just wanted to share my joy.

Category: Food

City Garden Update

My anonymous commenter was right. Those bulbs forcing themselves in mid Februry were hyacinths. Our building management has also pulled up the horific winter cabbages (which should be banned as a horticultural abomination) and put in pansies.

Meanwhile, up on my rooftop, the lilac has begun to bloom, and soon will fill my bedroom with its aroma, lulling me to sleep at night, and wakening me in the morning. (Well, maybe. If the wind is just right…)

The day lilies are early this year,
and the flowering plum fulfills the promise its name makes.

On the terrace herb garden, things are also coming alive. The tarragon is vigorous, the thyme, rosemary, basil and sage survived, and the lemon balm has returned. Come the first of May, to the Union Square Green Market I’ll go, to get new basil and tomato plants. This year I’m gonna’ increase my basil crop size to four plants, two were not enough last year.

Time to get in and pull out all the dead twigs and leaves to give room for the new growth, and start feeding, mulching and spraying. There’s much to do, and I can’t wait to get started…

Category: Gardening

Sor Juana Ines de la Cruz: My Contribution to the Really Dead Woman Writers Meme

Bardiac has challenged us to come up with names of female writers who lived and wrote before 1800. Apparently Bardiac gets a lot of disbelief that a feminist like herself could teach and study the literature of the Shakespearean and early English era, as if no female writers existed before 1800. She’s created this meme as a way of generating both a list and interest in pre-1800 female writers.

Of course, I wanted to participate in Bardiac’s meme because I like to think of myself as a feminist. But being no literary expert, I could not come up with five names off the top of my head, especially since the only one I could think of, Sappho, was already listed. So I did a little internet searching, and in doing so, learned the fascinating story of Juana Ines de la Cruz (1651 – 1695).

De la Cruz was a nun who wrote and ran a literary salon from her convent library in Mexico City in the mid 1600’s. De la Cruz’s literary output was prolific. She wrote poetry, plays, prose, historical vignetes and mythological tales, poems and plays.

Sor Juana, as she is called, was a feminist. According to Wickipedia: By her own account, life in the convent indeed gave her freedoms that she would never have had if she had married, as was expected of respectable women.

In1690 De la Cruz was silenced by the archbishop when criticism she wrote of a famous Jesuit sermon was published without her knowledge. After that time, she wrote no more, and died not long after during an epidemic of the plague.

Here is one of her poems, from an English translation by Michael Smith, from his website.

You Foolish Men
by Juan Inez de la Cruz (translation by Michael Smith)

You foolish men who lay
the guilt on women,
not seeing you’re the cause
of the very thing you blame;

if you invite their disdain
with measureless desire
why wish they well behave
if you incite to ill.

You fight their stubbornness,
then, weightily,
you say it was their lightness
when it was your guile.

In all your crazy shows
you act just like a child
who plays the bogeyman
of which he’s then afraid.

With foolish arrogance
you hope to find a Thais
in her you court, but a Lucretia
when you’ve possessed her.

What kind of mind is odder
than his who mists
a mirror and then complains
that it’s not clear.

Their favour and disdain
you hold in equal state,
if they mistreat, you complain,
you mock if they treat you well.

No woman wins esteem of you:
the most modest is ungrateful
if she refuses to admit you;
yet if she does, she’s loose.

You always are so foolish
your censure is unfair;
one you blame for cruelty
the other for being easy.

What must be her temper
who offends when she’s
ungrateful and wearies
when compliant?

But with the anger and the grief
that your pleasure tells
good luck to her who doesn’t love you
and you go on and complain.

Your lover’s moans give wings
to women’s liberty:
and having made them bad,
you want to find them good.

Who has embraced
the greater blame in passion?
She who, solicited, falls,
or he who, fallen, pleads?

Who is more to blame,
though either should do wrong?
She who sins for pay
or he who pays to sin?

Why be outraged at the guilt
that is of your own doing?
Have them as you make them
or make them what you will.

Leave off your wooing
and then, with greater cause,
you can blame the passion
of her who comes to court?

Patent is your arrogance
that fights with many weapons
since in promise and insistence
you join world, flesh and devil.

All my male blog readers, don’t get your drawers all in a huff. This poem does not necessarily reflect the views of this blog author about men (although I can think of a man or two to whom it does apply. You know who you are…) Having been raised Catholic, and taught by nuns for much of my early life, I just find it fascinating that this came from the pen of a 17th century nun. She’s almost a feminine counterpart to Shakespeare, the way she writes about the conflicts between the sexes.

Here’s another poem by Sor Juana, apparently written in response to a man who questioned the legitimacy of her birth:

Tonic for a Pompous Ass
by Sor Juana Inés de la Cruz

Not to have an honest father
would be shameful, I’d agree,
if I had made my father rather
than my father making me.

Your mother, so compassionate,
saw to it that you’d succeed
a host of father candidates
so you could claim the one you need.

Sor Juan was not only smart, she was funny!

Here’s a website with lots of information about Sor Juana. Encyclopedia Brittanica also has a nice entry on her life.

Thanks, Bardiac, for posting your meme. I learned something.

Sor Juana Inés de la Cruz, painting by Miguel Cabrera, c. 18th century; in the National Archivo Iconografico, S.A./Corbis. Category: Considerations.

Prune and Almond Tart with Armangnac

Well, I promised a prune recipe, and here it is.

I found lots of recipes using Armagnac with prunes. Armagnac-soaked prunes are a classic of southwest France, where, not-so-coincidentally, both Armagnac and the highly touted Agen prunes are produced.I had no Armagnac, so I used good French Brandy that we had in the closet.

This recipe is modified from Rick Stein at the BBC food website. Because it it from the UK, quantities are in weights, not volume (sorry).

The original recipe called for a shortcrust pastry that was made without sugar. I used a slightly different pie crust recipe fom the Joy of Baking website that uses both sugar and an egg. I didn’t roll it out, just pressed it into the pan and it worked out just fine. The crust started to brown so I covered the edges with foil for the last 10 minutes, but I should have put the foil on about 5 minutes earlier, as should you. I really need to get one of those crust protectors.

This tart is not too sweet, we like it that way. But if you want something a little sweeter, you could add some sugar to the armagnac, cook it over the stove a bit to melt the sugar, and then add the prunes.

Next time I make this, I will prick the prunes with a toothpick so they can absorb more of the brandy. Although if I did that I supect that I might need to add a little more of the liquer (hic!).

If you want more prune recipes, David Lebovitz had a one time blogging event last October that he called Prune Blogging Thursday, and got some great recipe submissions. Of these, I found a recipe for Armagnac and tea soaked prunes at TooManyChefs the most intruiging…

Prune and Almond Tart with Armangnac

10½oz pitted prunes
4 tbsp Armagnac (or other good French brandy)
1 recipe sweet shortcrust pastry, and butter for greasing
35g/1oz ground almonds
1 large egg, lightly beaten
55g/2oz sugar
1 7¼fl oz/200ml tub crème fraîche
Confectioner’s sugar, for dusting
Extra crème fraîche (or vanilla ice cream) to serve alongside

Put the prunes into a small bowl, pour over the Armagnac and leave for one hour, turning them over every now and then to help them soak up the alcohol.

Preheat the oven to 400F

Butter the tart pan. Make the pastry and press into the pan. Line the pastry with a foil or parchment paper add a layer of dried beans or pie weights and bake for 15 minutes. Remove the paper and beans and return to the oven for 4-5 minutes. Remove, brush the inside of the pie crust with a little of the beaten egg and return to the oven once more for two minutes. Set aside and lower the oven temperature to 375F.

Drain the prunes over a bowl to reserve the Armagnac. Add the ground almonds, egg, sugar and crème fraîche to the Armagnac, and beat together until smooth.

Scatter the prunes over the base of the pastry case, pour over the almond mixture and bake for 45 minutes until golden brown and a skewer pushed into the centre of the tart comes away clean. (Cover tart pie crust edges with foil for the last 15 minutes of baking to prevent over-browning.)

Carefully remove the tart from the tin and leave to cool slightly on a wire rack. Dust with a little Confectioner’s sugar and serve warm or at room temperature, cut into wedges, with some more crème fraîche or some vanilla ice cream. We, unfortunately, had no ice cream, since I was unable to talk Mr. TBTM into going to the store for it. That’s all right, we’ll get some for tomorrow’s leftovers…

Sweet Pastry Crust
1 1/2 cups (210 grams) all purpose flour
1/8 teaspoon salt
1/2 cup (113 grams) unsalted butter
1/4 cup (50 grams) granulated white sugar
1 large egg, lightly beaten

In a separate bowl, sift or whisk together the flour and salt. Set aside. Place the butter in your mixer and beat until softened. Add sugar and beat until light and fluffy. Gradually add the beaten egg, beating just until incorporated. Don’t over mix or the butter will separate and lighten in color. Add flour mixture all at once and mix just until it forms a ball. Don’t overwork or pastry will be hard when baked.

Category: Food

Dyspareunia: A Funny Word for Something Not so Funny

“Dyspareunia” is the medical term for painful intercourse.

I always liked the word, although it does sound a little whacky. Today I saw a patient who has dyspareunia, and decided to once and for all figure out the origin of the word. Turns out it derives from the Greek word “dyspareunos”, which means “badly mated”. To go even further into the Greek origins, “par” or “para” means beside or side by side, and “eun” means bed, so “pareunia” means to be side by side in bed, and is the ancient Greek term for sexual intercourse. Adding the prefix “dys-” means that what’s going on in bed is not so good.

Of course, outside of medicine, we no longer use the Greek terms, because it leads to too much confusion. “Hey, honey, do you wanna’ pareun?” makes it sound like you are offering up a serving of dried fruit. (Well, depending upon how old you are, maybe you are…) But if you like prunes as much as I do, either a pareun or a prune will do nicely, thank you very much.

Since I brought it up, let’s talk about what causes dyspareunia and how we treat it. In decreasing order of frequency of occurance in my practice, the causes of dyspareunia are:

Menopausal dryness
That’s easy to treat. Lubricants, vaginal estrogens, and keep having sex. The old adage “Use it or lose it” really does apply here. Sexual activity (even masturbation) increases blood flow to the vaginal tissues, helping lubrication. So, let’s go ladies, you’ve got some work to do…

Yeast infections.
Most women don’t know that vaginal dryness can be a symptom of a yeast infection. Well, it can be, and in my experience, is frequently the only symptom. When it is the only symptom, I often find yeast called Candida Glabrata, a strain resistant to standard over-the-counter remedies. But whatever strain of yeast you have, I can easily treat it, and that should solve the problem of dyspareunia.

Desquamative vaginitis
An inflammatory condition of the vagina that we treat with steroids and antibiotics. If you have dyspareunia, make sure your doctor looks at your vaginal secretions under the microscope right there in the office, otherwise this condition will be missed. Desquamative vaginitis can be chronic in nature. It is similar to, but not as bad as lichen planus (described below.)

Post partum dryness
Due to low estrogen levels while breastfeeding. Treat it with vaginal estrogens. Use a good lubricant. And have sex, if you can manage to stay awake for more than 2 seconds after hitting the sack.

Vestibulitis/Vulvadynia
These are non-infectious conditions that cause vulvar pain, sometimes with inflammation of the entrance to the vagina. Technically, vestibulitis and vulvadynia are separate entities, but since there is a lot of overlap, we often treat them the same. Vestibulitis may be associated with genetic variations in the proteins that mediate inflammation. Both vestibulitis and vulvadynia can be difficult to treat. We use low dose antidepressants, topical anesthetics, anti-inflammatory meds, interferon injections and, as a last resort, resection of the involved tissues. Changes in diet can be helpful in some patients. There are lots of other things you can do yourself to help the symptoms, see the resource list below.

Lichen planus
An uncommon chronic inflammatory condition of the mucous membranes of the vagina and mouth. We treat Lichen Planus with steroids and antibiotics, although it can be very difficult to treat. A new drug called tacrolimus shows promise in patients who don’t respond to typical treatment. If your partner has Lichen Planus of the vagina, be very, very nice to her because it is no fun to have lichen planus.

Something structural
A cyst, an abscess, a stricture, a hymeneal remnant, a vaginal septum, endometriosis, a fibroid – anything that’s getting bumped or pulled can hurt. Fix it, remove it, treat it, whatever, the pain goes away. Endometriosis treatment can be a little more complicated than some of the others, but it’s rare that we can’t control the symptoms enough to keep sex pleasurable.

Vaginismus
Another fancy word, this one means an involuntary contraction of the vaginal muscles and vaginal opening. You can’t get in if the door is closed, so don’t try to force it, because it only hurts more. Make sure there’s nothing else wrong (see above). Then use biofeedback, relaxation, masturbation techniques, couple’s therapy, topical anesthetics, and sometimes dilators. Botox is being used for this condition with some success.

Whether or not you have dyspareunia, you should eat some prunes. They are very good for you. Now that I’m thinking about it, maybe I will post a prune recipe, would you like that?

Dyspareunia: Resource List
National Vulvadynia Association
AAFP Article on Vulvadynia
Vulvar Pain Foundation
University of Michigan Center for Vulvar Diseases
Diagnosis and Treatment of Atrophic Vaginitis
Yeast Infection Resource Center
Pamphlet on Dyspareunia

Photo: “Plums in a Tree”, used with permission from stockphoto.com. Category: Second Opionions, Food

The National Honor Roll Scam

UPDATE: Since this article was posted,new information about the NHR has come to light. To read this information, click here.
These happy students are smiling because they have been inducted into the National Honor Roll. The National Honor Roll is NOT the same as the National Honor Society, a legitimate organization that recognizes academic excellence.

The National Honor Roll is a marketing scam.

THE SCAM

Today, we received a letter from the National Honor Roll, offering my oldest daughter the opportunity to be inducted into the Roll. My daughter’s school’s name was featured prominently on the letter, lending it an air of legitimacy, and at first making us think the letter had come from her school.

Of course, in order to be inducted into the National Honor Roll, my daughter must complete a detailed survey about her interests. If we want, we can buy the book that will list her name and bio. We can give the Honor Roll addresses of her grandparents who may want to buy the book. We can add a picture to your profile, but that will cost extra.

“Please”, I hear you thinking. “Don’t tell me you fell for that!”

Of course, I didn’t fall for it. As Jean Hagan said in Singing in the Rain: “Wadda’ think I am? Dumb or somethin’?”

But that’s not the real scam, you see. It’s just the tip of the iceburg. Because the National Honor Roll is a front for a nationwide mailing list of young high school students. A mailing list that the Honor Roll and its partner organizations then sell for profit to whoever will buy.

Each year, thousands of unsuspecting high school students are offered induction into the National Honor Roll. What is the qualification for this prestigious award for academic excellence? Not too stringent – a B average or above.

Here’s a link to the privacy policy of the National Honor Roll, and here’s what it says: From time to time, National Honor Roll may combine the information we receive online with outside records to enhance our ability to offer you products or services that may be of interest to you.

THE SCAM BEGINS IN YOUR CHILD’S CLASSROOM

How does the National Honor Roll find out your child’s name, address and personal information? Your child’s school provides it. That’s right. The school provides it, along with data mined from your child as part of in-class surveys handed out and collected by your child’s teacher. In my daughter’s case, she now remembers being asked to complete a survey in her Math class earlier this year. She was told it was for college.

I can’t entirely blame my daughter’s teacher (Well, I do blame him a bit). Most likely he thought that the survey results were being used to offer his students scholarships and college information. The surveys are sent to teachers from a “non-profit” organization called the Educational Reseach Center of America. ERCA is associated with something called the Student Marketing Group.

SMG is a direct marketing company that targets the youth market. ERCA does the dirty work for SMG, sneaking into our schools to mine our children’s personal data, all in the name of harmless surveys. To keep up their front, ERCA does publish the results of these surveys on their web site, and claims to send them to colleges, who probably file them in the wastebasket.

Here’s a link to ERCA’s privacy policy, and here’s some of what it says: Personally identifiable information also will be made available to certain other entities nationwide that wish to contact high school students or to help others do so. .. these include businesses that market interesting products and services to students and student achievement recognition organizations.

THE LEGAL RESPONSE

Elliot Spitzer filed for judgement against ERCA and SMG in 2003 for fraudulent and deceptive business practices. The Federal Trade Commission issued a judgement and a consumer alert against ERCA in 2003.Depite these rulings, it looks to me as if the ERCA and National Honor Roll are still up to their dirty tricks in 2006.

IT’S ALREADY TOO LATE FOR US

Even though I didn’t get caught in the National Honor Roll scam, it doesn’t matter. My daughter’s personal information is already on ERCA’s database, collected by her math teacher, and now being sent out who knows where. I have no idea if my daughter signed something on that survey that permitted her information to be used, and neither does she.

What upsets me is that we parents trust our children’s teachers and schools to protect them. And they are failing in that duty. I know it is not just my daughter’s school that has failed in this regard. These companies are thriving because they have found inroads into our schools nationwide, using the educational system as a marketing goldmine.

WHAT YOU CAN DO

Feel free to link or email this post, or to pass this information on to anyone you know who has a child in school. And not just if they are in high school. The ERCA has collected personal information from children as young as 10 years old.

Tell your PTA and your school principal. Tell your child’s teachers. Work with your child’s school to develop policies that protect your child’s and your family’s privacy. Help develop curricula that teach kids (and their teachers) how to know when their privacy is being threatened or their personal information mined for profit. And simply, tell your kids not to fill out any surveys at school without them being sent home first.

Stop your child’s school from unwittingly mining your children’s personal information for profit-making entities.

UPDATE: Click here for new information about the National Honor Roll.

______________________________

I just realized that this the second time this week that someone has tried to involve me in a scheme that invades personal privacy. (See April 3 post) Okay, who wants to be third?

Category: Considerations

Big Pharma and Your Protected Health Care Information: Together at Last

This nice family has no prescription drug coverage. You can tell this not only because they have rather grim smiles, but also because they can’t afford to update their 1970’s panelled kitchen. The photo is tinted in sepia, and it reminds us of the old black and white photos taken of poor Appalachian families during the depression. See?

But now this nice family has help. It’s called the Together Rx Access Card. According to the its website, “The Together Rx Access™ Card has been created to help qualified individuals and families without prescription drug coverage to save on brand-name prescription drugs and other prescription products, as well as save on a wide range of generic drugs.”

How do I know about the Together Rx Program? Well, today a drug rep came to my office asking me to give enrollment cards to my patients who had no prescription drug coverage, so that they could afford her medication. It sounded like a good idea, but being a skeptic, I decided to google the Together Rx Program.

HSS Secretary Tommy Thompson, the man who brought us the HIPAA Health Care Privacy Act, likes the Together RX Program. He even sent out a press release to announce his support for the Together Rx Program. Here’s what Tommy said: “This program will complement President Bush’s ongoing work to expand access to care for those who are uninsured or underinsured.

Web MD has an article about the Together Rx Program. Here’s what it says: “There is no cost to use the Together Rx Access™ card, which is accepted at many pharmacies nationwide and in Puerto Rico. Once you’ve enrolled, simply bring the card to your pharmacist along with your prescription, and receive your savings right at the pharmacy counter.”

Let’s enroll, shall we? The enrollment form is easy to use, just a single side of a paper with a place for your signature at the bottom. Hmm…That was easy. Okay, let’s print it out.

Oh, wait. There’s something on the back. I almost missed it, I was so excited to see such a short and easy form. On the back of the form, after the place for your signature on the bottom of the first side, is something called “Program Information” Here’s what it says:

So what companies are associated with the Program? According to the website, Together Rx is a joint effort of the following companies:


There is no information sharing opt out option on the application. I’ll say it again, in case you missed it, and because I think it’s important. There is no information sharing opt-out option on the application. So if Pfizer is the one discounting your meds, they can share information about you with Novartis, who can share that info with Ortho. Then they can all use that information to market drugs specifically to you based on the information they’ve shared with each other. Don’t want to share your information? Too bad, you’ll have to pay full price for your medications.

So, what is Together Rx? It’s a Drug Savings Program and a marketing solution, all rolled up into one. How else could pharmaceuticals sell medications to consumers who otherwise would not buy their products because they can’t afford them? Like any good retailer who has outpriced their market, they’ve lowered their prices. And in return, they are getting free market research, consumer-specific health profiling, AND your personal health information.

As Tommy says in his press release: Together Rx “is a great example of private sector leaders coming together with an innovative solution to a complex problem.”

Photo Credit: Walker Evans. “Bud Fields and His Family, Hale County, Alabama,” 1936–37. From the Encyclopedia Brittanica. Category: Second Opinions

Skylight

You know what’s special about this photo?

I took it at 7 PM!

I love daylight savings time.

Categories: Considerations

Still Searching for Perfect Scone

INASCONES

Hi, I am Natalie, the daughter of the author of this blog. My mother has talked about me, I am the one who is always helping her find the best recipe for scones. Today I went out at 11:00 to our local supermarket to buy all the ingrediants for our new “kitchen adventure”. My mother was getting familar with the recipe. My father is usually the one to go out and buy all of our things but at that moment he wasn’t available to.

We got the recipe from the cookbook The Barefoot Contessa by Ina Garten. We don’t mean to upset the master but the final outcome of the goods were not as good as we would have hoped. They were the lightest ones we made so far. But they were a bit dry. This may have not been Ina’s fault as we put in a bit too much salt by accident, but our question is, how could salt make something dry? But don’t go swearing Ms. Garten because we also cut the recipe in half and that doesn’t always work when you’re baking compared to cooking. I doubt that Ina would ever read this but if you googled yourself or something, hi. We are trying to find a way to write to you asking for a recommendation of what we could do in order to make this recipe work for less scones or less dry scones.

This has been blogging with Natalie on The Blog That Ate Manhatten. I may be back. Here are some pictures of the final turnout. Talk to ya later!

Next: The Perfect Scone? Sorry Delia, not quite…

Category: Food

More Thoughts on Chinese Medicine

I was just re-reading my last post (I know, I know – I’m gazing at myself again). And I realized that, in that post, I appear to be fairly open to Chinese medicine. But being open to it does not necessarily mean that I embrace it completely. I’m pretty much a doubting Thomas when it comes to alternative medicine. You gotta’ show me before I’ll believe. And by show me, I mean the usual peer reviewed controlled clinical trial.

Sure, I can tell you anecdotes about how I’ve seen Chinese medicine work. I once had a patient who failed to conceive with modern infertility treatment but became pregnant after only one treatment with acupuncture. Another whose baby was overdue and who actually broke her membranes and went into labor while at her first acupuncture treatment (I remember asking her just where the doc put the needle.) I saw the video made in China by one of my medical school professors, showing a man undergoing major abdominal surgery with acupuncture as the only anesthetic. And I even had a patient cure her migraines with Chinese herbs.

I do believe that acupuncture taps into some very real physical phenomena. The latest thinking is that accupuncture affects the release of neurotransmitters and neurohormones that mediate pain, blood pressure, and other bodily functions. It doesn’t work for everything, though, and needs verfication in clinical trials. But I’ll admit that I’ve toyed around with the thought of getting formal training in acupuncture and trialing it in my menopausal patients.

But you know what? I don’t think I could stand take sitting for hours in a classroom with a straight face listening to someone talk about the flow of Qi (pronounced Chi). I’m sorry, but the way Chinese medicine explains itself is still too steeped in non-scientific silliness for me to completely embrace its teachings. Don’t tell me my Qi is blocked – Talk to me in real biologic terms. It’s not meridians, and it’s not Yin and Yang. It’s neurotransmitters and antibodies and cytokines and calcium channels and renal tubule function and LH and FSH and estrogen receptors. And if you dont know how it works, that’s okay. I can handle that.

I always say that the human body is the car we’re being asked to repair without ever having a manufacturer’s manual. But Chinese medicine teaches like they have the manual, and the manual says that the engine runs on Chi. ‘Cmon, guys. It’s the 21st Century. Can you at least try to make it relevent to what we’ve learned about the human body since you came up with this stuff in the 5th century?

Now, Chinese medicine uses herbs a lot. And it’s no suprise that they have found, as has Western medicine, that certain plants have medicinal properties. This is good. But they still have to prove that they work. Of course I have no way of knowing if they’ve proven anything, because we really don’t have access to the Chinese medical literature. And if I did, who knows if it would be filled with well done clinical trials, or just lots of articles about Qi.

I do know that some of the plants and compounds we use in the West are actually quite similar to those in Eastern medicine. For example, some Chinese herbal remedies used to treat menopausal symptoms, when analyzed, are found to have estrogen in them. Black Cohosh, an herb used in China as well as in the West, probably helps hot flashes. But just try to find out what’s really in the mixtures the Chinese practitioners hand out.

It’s not that I distrust Chinese practitioners themselves. I believe that, for the most part, traditional Chinese practitioners are sincere and ethical in their practice. And I don’t think they’re in it for the money. They don’t overcharge their patients for saliva hormone levels and hair metal screens, or try to sell them thousands of dollars worth of vitamins and powders. And they don’t do infomercials.

But their way of practicing is based on traditional mixtures, mixtures that vary from province to province. You can never really know what you are getting, even if they tell you the name, because every area has it’s own recipe for that name. (Sort of like Gumbo in Louisiana.) And honestly, I’m not sure that the Chinese docs themselves know what’s in their mixtures. And that’s a little scary.

It makes no sense to me that here in America, where every food manufacturer is required to list ingredients on the package, Chinese practioners are allowed to hand out medicinal herbs without regulation. And Americans are more than willing to take them. Usually the very same Americans that are screaming at the FDA about Vioxx. (Not that I’m defending Merck. No, no. One of these days I’ll post on what I really think about Big Pharma.)

It’s the complete blind faith that some of my patients have in Chinese remedies, when it is accompanied by complete distrust of anything Western medicine has to offer, that irks me. Nothing drives me crazier than to sit and have a patient grill me for a half hour about the potential side effects of anything I prescribe, then tell me she’s taking Chinese herbs whose name she doesn’t even know.

Let me warn you. Chinese herbs have been found to be tainted with poisonous heavy metals. One Chinese herb, Aristolochia, has been found to cause kidney failure, kidney cancer and death. If you are going to use Chinese medicine, please, please ask your practitioner for a detailed list of what he’s giving you. If he can’t do it, don’t take it. And unless you can tell me exactly what you are taking, don’t ask me to support you in using it. If I don’t know what’s in the bottle, I can’t recommend it. Sorry.

The NIH now has an office of complementary medicine, and clinical trials using chinese herbs and acupuncture are being published everyday. I have no doubt that some treatments will prove to be as, or more, effective than Westen medicine for some conditions. I’m just going to wait for a little more objective data before I climb on board.

Look, you want to try acupuncture? Go ahead, knock yourself out. It won’t hurt, and it may even help. And one day, who knows? It might even be me who’s sticking the needles in you. Just don’t let it keep you from getting the health care you need.

As for cupping, another traditional Chinese Medicine practice, well, it’s just plain wierd. Even if Gwyneth is doing it…

Picture Credits: Li Shih-Chen, 1518-1593. From the National Library of Medicine, Classics of Traditional Chinese Medicine, an Online Version of an Exhibit held at the NLM , NIH , October 19,1999-May 30, 2000. Gwyneth courtesy BBC. Category: Second Opinions