The Music of The Children Act

Music features prominently in Ian McEwan’s new book The Children Act. The book’s protagonist Fiona Mayes, a family court judge, is also an accomplished pianist, and both she and her husband Jack are lovers of jazz.  Almost every important moment in the book, aside from the first scene and Fiona’s time in the courtroom, occurs while music is being played or listened to.

I love how McEwan weaves the musical themes seamlessly throughout the story, informing character, time and place. I listened to the Audible book (a fabulous performance by Linsday Duncan), and found myself wishing that someone had thought to add a score to the recording.

For those of you reading the Children Act and also wondering what it might sound like, here are some recordings and a little context from the novel.

Bach’s Second Partita in C Minor for Keyboard

I loved this passage, as Fiona walks to work, trying to distract her thoughts from her failing marriage by recalling the Bach Partita, a distraction that of course, fails.

Children.

The inevitable thought recurred as she moved on to the demanding fugue she had mastered, for love of her husband, and played at full tilt, without fumbling, without failing to separate the voices. Yes, her childlessness was a fugue it itself. A flight. This was the habitual theme she was trying now to resist. A flight from her proper destiny. A failure to become a woman, as her mother understood the term.

How she arrived at her state was a slow patterned counterpoint, played out with Jack over two decades, dissonances appearing then retreating, always reintroduced by her in moments of alarm, even horror, as the fertile years slipped by, until they were gone, and she was almost too busy to notice.

Down by the Sally Gardens

Fiona visits a young man with leukemia in the hospital as she tries to decide if the court will force him, a Jehovah Witness, to take blood products that will save his life.  In a very non-judicial moment, as he plays Down by the Sully Gardens on his violin, she sings along. That moment and that song decide the case for her, sealing his fate and binding them together in a way she had never anticipated.

Keith Jarret – Facing You – (First track) In Front

Jarrett ‘s Facing You was “one of three or four albums that formed the soundtrack” of Fiona and Jack’s early relationship. Jack now uses the album to begin to bring them back together.

..the technical facility, the effortless outpouring of lyrical invention as copious as Mozart’s, and here it was again after so many years, still holding her to the spot, reminding her of who she and Jack once playfully were.

Hector Berlioz: Les Nuitsd’ete – Villanelle  / Gustav Mahler Ich bin der Welt abhanden gekommen (I Am Lost to the World)

The book culminates in a live performance by Fiona and a tenor colleague, a performance that coincides with her learning of the fate of the young boy. The combination of such beauty and such sadness in the two pieces they perform mirror the young man perfectly.

I have become lost to the world, where I used to waste so much time;
It has been so long since it heard from me, that it may well think that I have died!
I don’t care if it thinks me dead, for I really have died to the world.
I have died to all the world’s turmoil, and I rest in a silent realm.
I live in solitude in my heaven, In my love, in my song.

Patient Identifiers, Hospitals & the EHR

FIngerprintCurrent Joint Commission standards call for the use of two patient identifiers to avoid mixing up patients with the same or similar names. For inpatients, these identifiers are usually the name and the medical record number (MRN).

Which is fine if the only place you need to identify the patient is your own hospital.

But your hospital’s MRN is meaningless to me and my EHR.

So if you send me a copy of my patient’s chart (or her lab result or mammogram report) and all that’s listed on the top of the page is her very common name and your MRN, I have no clue who this patient is.

(My EHR gives me a box to check to confine the search to my own patients, but that button only works about 10% of the time.)

So please, hospitals, start adding the patient’s date of birth to your printed reports and records.  And EHR vendors, you could make it easier for all of us by defaulting to a header that includes the date of birth as an identifier.

Thank you.

 

The Not So Scary Truth About HPV

http://www.dreamstime.com/stock-images-emotion-2-image597604There’s a downside, I think, to educating the public about the link between HPV infection and cervical cancer.  And that’s scaring the bejesus out of every woman who happens to find out she has HPV.

It’s not surprising that you’re scared.

You see, we want you to know that HPV infection is linked to cervical cancer, and that we have a vaccine against HPV that can prevent cervical cancer. So we’ve been doing our best to get the word out. (With no small bit of help from the HPV test and vaccine manufacturers.)

But in our zeal to get you screened and vaccinated, we sort of forgot to tell you something equally important. And that something is this –

Pretty much everyone – 80% of US adults- will get HPV at least once, if not more than once, in their lifetime. At any given time, 20-30% of US women ages 14-59 have HPV. That’s right – a third of the female population. If you include men, there are about 20 million persons at any given time in the US who have HPV.

The overwhelming majority of HPV infections do NOT lead to cervical cancer. Around 95% of the time, the infection clears, usually within 1-2 years, without you, or anyone, doing anything

Yes, the problem with HPV disease awareness is that it ultimately makes every woman feel like she have a bull’s eye on her cervix. Which may a good way to get her in for HPV testing and vaccination, but is actually misleading women about an infection that basically everyone gets at some point in their lives.

The Not So Scary Truth About HPV

The truth is that while having HPV is a necessary precondition for getting cervical cancer, it’s also true that almost all HPV infections DO NOT lead to cancer

Think of it this way. Getting in a car is a necessary condition for having an automobile accident, but in fact, most of us will make it to our destination alive. Same thing with HPV. The chain of events that ultimately leads to cervical cancer starts with HPV infection, but almost all the time something intervenes to prevent cancer. That something is called your immune system.

If for some reason, your immune systems doesn’t do the job, and you’re in the 5% of women with HPV who don’t clear the infection, we have ways to monitor you closely so that if a precancerous lesion arises, we can treat it. Years before it becomes cancer.

But I have “High Risk” HPV 

So does everyone else with a positive HPV test.

“High risk” HPV subtypes are called that simply to distinguish them from the “low risk” types that cause genital warts.  Current HPV tests only screen for the “high-risk” types. So by definition, if you’re HPV positive, you have a “high risk” strain. (Someone really needs to change the name of that test…)

But if everyone has HPV, and most infections clear without treatment, then why do we test for it? 

HPV testing is better at finding precancerous lesions that Pap smear alone, so what the Pap misses, the HPV test will find. It’s so good that it’s being considered as a replacement for the pap smear as the first line test for cervical cancer screening.

The HPV test is also good for weeding out the false positive Pap smears. A mildly abnormal pap (ASCUS) can be safely ignored and repeated in a year if the HPV test is negative. This saves a lot of women unnecessary testing.

The other good thing about HPV testing is that if it’s negative, you’re really in the clear. So much so that if both the Pap and HPV test are normal, the risk for cervical cancer plummets, and you can safely wait up to 5 years between pap smears.

The problem with HPV Testing

The problem with HPV testing is that it has a very high false positive rate. Most of the women with HPV  actually do not have precancerous lesions. They just have HPV.

That’s what happened to NYC Councilwoman Melissa Mark-Viverito, who then went public with her HPV diagnosis on Twitter. Ultimately, when she had additional testing after her HPV diagnosis, she found out that she was fine.

Of course, you don’t want to ignore the fact that you have HPV.

You should take it as a sign that you, of all people, need to get your pap smears regularly. Or , if your doctor recommends it, have a simple office procedure called a colposcopy – a magnifying lens that looks for tiny abnormalities on the cervix that are too small to be seen by the naked eye, but if found, can be treated so that you never get cervical cancer.

But know that it would be exceedingly unusual for you to actually have cervical cancer just because your HPV test is positive. This is about finding precancerous lesions, and ultimately, preventing cancer.

So if you have HPV, don’t be scared. But be smart.

If you have HPV, odds are overwhelming that you’re going to be fine.  Between the HPV test and the pap smear, if you have anything precancerous, we’ll find it and we’ll treat it. Years before it becomes cervical cancer.

In the meantime, there are things you can do to help your immune system along. Things like not smoking, using condoms, getting enough sleep and getting 4-6 servings of fruits and veggies each day. Women who do these things clear the virus faster, although ultimately most will clear it anyway.

So do be smart and get screened. And follow through on whatever testing is recommended based on that result.

But please. Don’t be scared.

_____________________________________________________________________

More good info on HPV and cervical cancer.

A slightly modified version of this post first appeared on WebMD.

Corn, Zucchini and Chickpea Fritters

Fritters corn zucchini chickpea
Our first dinner in the empty nest.

We dropped our youngest off at college, which to our delight is a mere two hours drive north along the lovely Taconic Parkway. To say the campus is bucolic is an understatement, with the Catskill mountains on the horizon, and a lovely little town just a short ride away.  This was a happy day for us all, the culmination of an amazing summer for the entire family. She’s launched and we’re so happy for her. (And can’t wait to come back up to visit on parent’s weekend…)

After settling her in, we explore the area, following dead end roads like fingers that end at the Hudson River. We stop at an amazing little farm stand, where we find fresh corn and heirloom tomatoes.

Heirloom tomatoes

A little further down the road, the guy who owns the pastry store is selling huge zucchini from his garden at a little table out front of his shop. Of course we have to buy one.

At home later that evening, we find a recipe to combine our farm finds, and eat delicious vegetable fritters al fresco on one of the warmer days of this unseasonably cool summer, sitting on the terrace at the table which until now was too small for a family dinner. Now with just the two of us, it’s just the right size.

We share a beer and talk about the future.  Yes we miss the kids, but then we think of each of them – one settling in at her new college, the other launching a theater career (and a play opening!) in our hometown -and we are just so happy for them that we would not have it any other way.

_____________________________________________________________________________________________________________________________

CORN, CHICKPEA AND ZUCCHINI FRITTERSfritters cooking

This is my own modification of a recipe from The Wednesday Chef, who herself modified a recipe from Taste.com/Au. Feel free to change up the herbs you use. Makes 12 fritters. If that’s too many fritters for one meal, the leftovers heat up nicely for lunch the following day. My mother in law Irene, who made these a few days after we did, instead froze the extra batter to make another day.

  • 1 15-oz can of chickpeas, drained & rinsed
  • 1/2 cup milk
  • 2 eggs
  • 3/4 cup flour
  • 1/2 tsp baking powder
  • 1 tsp salt
  • 1 large zucchini, grate
  • 2 large ears of corn kernels (about 2 cups)
  • 2 tablespoons chopped fresh mint leaves
  • 3 scallions, thinly sliced
  • Zest of one lemon
  • Canola Oil
  • Plain sheep’s yogurt and hot sauce for serving

Process chickpeas until roughly chopped.

Whisk milk and eggs in a measuring cup. Mix flour, baking powder and salt in a bowl. Gradually add milk mixture to flour, whisking until smooth. Stir in chickpeas, zucchini, corn, mint, scallions and lemon zest.

Heat a shallow layer of canola oil in a large skillet over moderately high heat. Add 1/4 cup mixture to pan. Spread slightly with a spatula. Repeat to make 3 more fritters. Cook for 2 to 3 minutes each side or until golden and cooked through. Transfer to a plate and cover or keep warm in a 200 degree oven. Repeat with remaining mixture to make 12 fritters. Serve with freshly sliced heirloom tomatoes, a dollop of sheep’s milk yogurt and a splash of hot sauce.

I’m Writing for WebMD

http://www.dreamstime.com/stock-photography-typewriter-keys-image14524512

I’m now writing for WebMD. Just one to two blog posts a month.

Here’s my first post.

It’s kind of exciting to actually be paid to write, although I don’t think I’ll be quitting my day job anytime soon.

I’ll be cross posting the Web MD posts here a week later, so you can read me here or there, and nothing will be lost from this blog.  (It is, after all, my baby.)

Let’s see where this thing goes…

Appetizers for Summer Book Club

Book Club appetizers

As much as I love book club, I love hosting it even more. Because hosting means I get to leave work early and do my favorite thing in the whole world – spend the late afternoon in my kitchen. I’m rarely at home at that time of day, when something wonderful happens to the light in our apartment as the sun begins to peek out from behind the tall apartment towers just south of us, and pours into my kitchen.  Add in NPR or a good book on tape and I’m in heaven.

The evening promised good weather, so we planned to meet on the roof.  I took my cue for the menu from the book we were discussing – “My Brilliant Friend”, set in Naples – and went for a Mediterranean theme. (Plus I had a whole mess of amazing, pitted Castelvetanos olives and a jar of fig preserves.)

In an amazing feat of pre-planning, something highly unusual for me, I actually decided on the menu and bought all my ingredients the day before, so I was able to head straight home and got to work around 4 pm. Luckily, Mr TBTAM was home early as well, and I put him to work weeding the rooftop garden, which we had ignored for most of the summer.  Somehow I managed to pull it all together by the time the group arrived at 6:30, with a little help from my friends who arrived first.

The discussion was as always, interesting and spirited, and we went till dark. This is one great bunch of women, and I’m thrilled to be a part of the group.

___________________________________________________________________________________________

Book Club Appetizer Menu

  • Fig & Blue Cheese Savories
  • Olive all’Ascolana
  • Manchego cheese with Firehook Za’Atar flatbreads
  • Nectarine segments and dried apricots
  • Wine; Mint lemonade
  • Cappucino almonds (Thanks, Amy!)
  • Sunflowers for the table (Thanks Stacy!)

Fig and Blue Cheese Savories

FIG AND BLUE CHEESE SAVORIES

These delicious babies come from The Runaway Spoon, found via Food 52.  I used a wonderfully pungent Roquefort style sheep cheese (Ewe’s Blue) from Nancy & Tom Clark’s Old Chatham Sheepherding Company.  I did not have a one inch round cookie cutter, so I used a floured 1 inch soda bottle cap. You may be tempted to make these bigger, but do not. The small size is perfect. They can be made ahead and kept in layers separated by waxed paper. They freeze beautifully.

  • 1 cup flour
  • 1/2 cup butter, room temperature, cut into four pieces
  • 4 ounces blue cheese, cut into several chunks
  • Ground black pepper
  • Fig preserves (about 1/4 cup total)

Preheat the oven to 350 degrees. Line a baking sheet with parchment paper. Process the butter, blue cheese, flour and a few grinds of black pepper in the food processor until the dough starts to form a ball. Dump onto a lightly floured surface, knead a few times to pull the dough together and roll out to 1/8 inch thick with a floured rolling pin. Cut rounds out of the dough with a floured 1-inch cutter and transfer to the parchment-lined baking sheet. Using the back of a round half-teaspoon measure or your knuckle, make an indentation in the top of each dough round. Spoon about ¼ teaspoon of fig preserves into each indentation. Bake the savories for 10 – 14 minutes, until the preserves are bubbling and the pastry is light golden on the bottom. Let cool on the baking sheet for at least 10 minutes, the remove to a wire rack to cool.

Can be made ahead or frozen in an airtight container in layers separated by waxed paper.

Olive all'Ascolana

OLIVE ALL’ASCOLANA  – Vegetarian Version

This recipe comes from Arielle Clementine via Food 52. It’s inspired by the classic Italian stuffed olives, which have a spicy meat stuffing and use olives from the Ascoli region of Italy. (Here’s a wonderful video on how to make the real thing, which I must try one of these days.)  I made some fresh breadcrumbs for this recipe, but did not toast the crumbs as I usually do, since they would get crisped as they fried. I had no mustard seeds, so used a pinch of dried mustard instead.  I fried them in my electric fryer, a kitchen appliance I only use otherwise for latkes, and it worked beautifully.

  • 24 large green olives, pitted
  • 1/2 cup goat cheese
  • 1 teaspoon whole mustard seeds
  • 1 teaspoon fresh rosemary, chopped fine
  • 1/4 teaspoon crushed red pepper flakes
  • 1 garlic clove, minced
  • 1 cup all purpose flour
  • 1 egg, beaten
  • 1 cup breadcrumbs (fresh or panko)
  • 1/3 cup freshly grated Parmesan cheese
  • 1 cup vegetable oil (I used canola oil)
  • parmigiano reggiano, for sprinkling
  • zest and juice from one lemon, for sprinkling

Mix the goat cheese, mustard seed, rosemary, chile flakes, and garlic in a small bowl. Stuff the olives with the cheese mixture (I used my fingers, rolling the filling like a small cigar and sliding it into the pitted olive.) Put the stuffed olives on a plate and refrigerate for 20 minutes. While the olives are chilling, heat the oil in a heavy-bottomed frying pan to 375 degrees. Set up three plates for your breading station (Flour, beaten egg, breadcrumbs+grated Parmesan) When the olives have chilled, roll half of them in the flour, then in the egg, then in the bread crumb/Parmesan and carefully drop them into the heated oil. Fry until golden brown, about one minute per side. Transfer to a plate lined with paper towels to drain, and repeat with the remaining olives. Pile on a plate and finish with a shower of freshly grated cheese and lemon zest and a spritz of lemon.

The Hobby Lobby Solution to Teen Pregnancy

Via Paul Rudnick at the New Yorker –

When it comes to the Court’s decision on contraception, I think I can be of service. For my five beautiful daughters, and the other one, I have used a cheerful heavy-gauge yarn, mixing strands of cashmere, alpaca, and barbed wire, to knit what I call a Crotch Cozy. When my girls wear their Crotch Cozies, they not only receive endless compliments in the locker room but sexual intercourse becomes impossible. Any additional form of birth control is unnecessary. Case closed!

A very funny read.

Unfortunately, there’s not much else funny about the Hobby Lobby. Read Jan Gunter, MD if you have any questions as to why its a bad ruling, not just for women, and not just for contraception.

The Berlin Wall in New York City

Berlin Wall in NYC
Meeting friends for dinner last evening at Valbella, I was surprised to discover that the strikingly painted concrete slab on display in the tiny plaza outside the restaurant is actually a section of the Berlin Wall.

That’s right. The Berlin Wall. Tucked away in a lovely little plaza on the north side of E 53rd between 5th and Madison. How could I have lived in NYC for over 20 years and not known it was there?

Berlin Wall in NYC
This section of the wall was illegally painted in the 1980’s by Berlin street artists Therry Noire and Kiddy Citny. Noire, who lived a mere 5 meters from the west side of the Wall, was the first street artist to paint on the wall, a risky act of political rebellion that he and the other street artists he inspired continued until the Wall came down in 1989.

To paint the Berlin wall, to transform it, to make it ridiculous, to help to destroy it.

– Therry Noire

Amazingly, the sections of wall on display at 520 Madison are the very ones Noire is painting in the  1987 Wem Wenders Film “Wings of Desire”.


After the wall came down in 1989, the East German Government, seeing the value in the art Noire and his fellow artists had created, ultimately auctioned off huge sections of the wall in Monaco, which is probably where Jerry Speyer of Tishman and Speyer, the owners of the plaza at 520 Madison, purchased this piece of history in 1990.

The artists who painted the Wall have seen very little of the income from the sale of the sections that bear their paintings, and it is not known where the profits from their sale, supposedly slated for humanitarian causes by the East German government, ultimatley ended up.

Kudos to Speyer for sharing his piece of the Wall with the public in this lovely little respite in midtown.

I encourage you to visit the Wall. If you choose to eat al fresco at Valbella, as we did on this warm summer evening, you’ll have plenty of time to  consider this infamous piece of history and the spirit of courage and freedom that both its demolition and the remarkable artwork painted on it represent.

__________________________________________

MORE READING

Berlinermauer The Berlin Wall (from Wikipedia)

Dense Breasts on Mammogram – No Need to Be Afraid

Mammogram Fatty and Dense

Only in America can we find a way to scare the bejesus out of a woman with normal breasts and a normal mammogram. But that’s exactly what happened when NY Times reporter Roni Caryn Rabin read her normal mammogram results letter –

A sentence in the fourth paragraph grabbed me by the throat. “Your breast tissue is dense.”

I can’t really blame Rabin for being afraid. The information about breast density in her mammo letter was mandatory verbiage crafted by legislators as part of a law that all women be told if they have dense breasts on mammogram.

“Your mammogram shows that your breast tissue is dense. Dense breast tissue is very common and is not abnormal. However, dense breast tissue can make it harder to find cancer on a mammogram and may also be associated with an increased risk of breast cancer. This information about the result of your mammogram is given to you to raise your awareness. Use this information to talk to your doctor about your own risks for breast cancer. At that time, ask your doctor if more screening tests might be useful, based on your risk. A report of your results was sent to your physician.”

Raise awareness? More like raise the alarm. The information mandated by the law is just enough to scare any women who happens to have dense breasts, but not enough to help her understand what this really means.

If you’ve gotten a letter telling you your breasts are dense, don’t be afraid. Having dense breasts is entirely normal, especially if you are under age 60.  Here’s what you need to know –

What is Breast Density? 

Breast density is a radiologic assessment of how well x-rays pass through the breast tissue. It is a surrogate for how much of the breast is composed of glandular tissue and how much is fat. The radiologist reading the mammogram classifies the breast composition as one of the following –

  • Almost entirely fat (<25% glandular)
  • Scattered fibroglandular densities (25-50%)
  • Heterogeneously dense breast tissue (51-75% glandular)
  • Extremely dense (> 75% glandular)

Breast density is subjective.

Different radiologists may give the same mammogram different ratings. Use of computerized density measurement could alleviate inter-observer variability, but there is not yet a standardized computer rating system. For the purposes of the law, dense breasts are defined as those that are heterogeneously dense or extremely dense.

Breast density can vary across a woman’s menstrual cycle and over her lifetime.  

The same women being scanned at a different time of month or at a later year can land into a higher or lower breast density category, and may or may not get that extra statement in her mammogram letter. Recent research suggests that a single breast density reading may not be the best way to predict breast cancer risk, and that the risk may be confined to those women whose breast density does not decrease with age.

Dense breasts are extremely common, especially in younger women. 

According to a recent report of mammograms here in New York City, 74% of women in their 40s, 57% of women in their 50′s, 44% of women in their 60′s and 36% of women in their 70′s have dense breasts.

Increased breast density may be a risk factor for getting breast cancer. 

The mechanism is unknown, but it may be that breast density is just the end result of other factors that increase breast cell proliferation and activity – factors like genetics and postmenopausal hormone use.

How much of a risk? Well, it depends on what study you read and who you compare to whom. If you compare the two extremes of breast density in older women, those with extremely dense breasts have a three to five-fold higher cancer risk than those with mostly fatty breast. The risk is lower than that in those in the middle category of breast density and in younger women, though not well-defined.

The truth is, we really have no way to translate individual breast density into individual risk. Researchers are trying to see if breast density can be incorporated into current risks assessments such as the Gail Model, but at this point, breast density has not been shown to add much more than we already know about a woman’s risk from using these models.

The problem with breast density as a risk factor is that most women at some point in their lives have dense breasts. Should we really consider 75% of women in their 40’s to be at increased risk for breast cancer?

I don’t think so.

Dense breasts can obscure a cancer on mammogram.

This makes mammogram less reliable in women with dense breasts. Digital mammograms may be better at finding breast cancers in women with dense breasts who are also perimenopausal or < age 50, but it is not known if this translates into better outcomes. Additional testing with ultrasound and MRI can find cancers that mammograms miss in women with dense breasts. Unfortunately, breast ultrasound and MRI screening tests are less specific than mammograms – three times as many biopsies will be done, most of which will not be cancer.

Breast cancer patients with dense breasts are not at increased risk of death.

In a study of over 9,000 women with breast cancer, no association between increased density and death from cancer was found. In fact, it was obese women with lower breast density who had the higher risk of death, possibly because their fatty breasts may be a more favorable environment for tumor growth.

We do not know if additional breast cancer screening beyond mammograms saves lives.

Sonogram and/or MRI for breast cancer screening is currently not recommended based on breast density alone. Additional screening beyond mammography is only used in women at highest risk for breast cancer – those with cancer in a first degree relative with a high risk gene mutation, a family history suggesting one of these mutations, a Gail model or other combined lifetime breast cancer risk assessment >25% or a history of chest irradiation. Even in this group, declines in morality with the additional screening have not yet been shown, and the false positive rate of this additional testing is extremely high – only 20% of abnormals are cancer when biopsied.

There are no recommendations to use sonogram and MRI in otherwise low risk women, and none that have shown that using it based on breast density alone saves lives.

Additional screening beyond mammograms adds significant costs to breast cancer screening.

For some women, this additional cost may not be covered by insurance. While Connecticut has passed a law mandating that insurers cover additional sonograms, New York State has not.

What should you do if you’ve been told your breasts are dense on mammography? 

If you are at increased risk for breast cancer due to personal or family history, you may want to consider adding ultrasound or MRI screening.

Otherwise, at the point there is no recommendation that you do anything other than continue screening at whatever interval you and your doctor have decided is right for you. If you decide you want a sonogram, understand that you will need to accept the additional false positives and biopsies that may result and that the additional screening has not been shown to decrease deaths from breast cancer in women at average risk.

_________________________________________________

More info on mammograms and breast density

Lemon-Fennel Chicken with Mushrooms & Scallions

Fennel lemon chicken and spinach

For years, my friend Susan (of the famed Chicken Salad Susan) has been making her Italian grandmother’s sautéed chicken breasts with breadcrumbs, parmesan and fennel.  Not too long ago, she was also on a diet program that included an amazing recipe for pan fried lemon chicken. I decided to combine both her recipes, and now have a killer entree that I’ve made almost weekly since she first shared it with me.

LEMON FENNEL CHICKEN WITH MUSHROOMS & SCALLIONS

You can just make the chicken breasts, and you’ll have an amazing entree. Or just cut up the chicken breasts, skipping the breading, and have another amazing entree. But together? OMG.

Ingredients

  • 1 pound boneless, skinless chicken breasts,  pounded thin
  • 1 egg, lightly beaten
  • 1/4 cup flour
  • 1/4 cup homemade breadcrumbs
  • 1/4 cup Parmesan cheese
  • 3  tbsp fennel seeds
  • 1 tsp lemon zest
  • Juice of 1 lemon
  • 1/2 cup reduced-sodium chicken broth
  • 3 tablespoons reduced-sodium soy sauce
  • 2 tablespoon canola oil
  • 10 ounces mushrooms, quartered
  • 1 bunch scallions, cut into 1-inch pieces, white and green parts divided
  • 1 tablespoon chopped garlic

Preparation

Whisk 3 tablespoons lemon juice with chicken broth and soy sauce in a small bowl and set aside.

Rinse chicken breasts and pat dry. Place flour on a dinner plate. Lay a 12 inch long piece of wax paper down on the counter. Mix the bread crumbs and Parmesan and spread out onto the wax paper. Sprinkle some fennel seeds atop the crumb/cheese mixture in such a density that every bite of the breast you are about to coat will have a fennel seed on it. Lightly coat a breast by dipping in the flour and shaking off, then dip into the egg, then into with the breadcrumb, cheese and fennel mixture, coating the second side in a different spot on the wax paper so that it too gets the fennels seeds on it in the right distribution. Set aside on a plate. Scatter some more fennel seeds if you need to and continue dipping and coating and scattering more fennel seeds as needed to be sure that each breast has enough fennel seeds on each side. Toss any unused breadcrumbs and flour. (Of course, you could just mix the fennel seeds in with the breadcrumbs, but this is how Susan does it, and I assume how her grandmother did it, so that’s how I do it.  There is power in tradition, and I respect it when I can.)

Heat oil in a large skillet over medium-high heat. Add chicken and sauté 2-3 minutes each side, until just cooked through. Transfer to a plate with tongs and cover with tented foil.

Add mushrooms to the pan and cook for about 5 minutes – enough to cook but not to dry them out. You want them plump and juicy.  Add scallion whites, garlic and lemon zest. Cook, stirring, until fragrant, about 30 seconds. Add the broth mixture to the pan; cook, stirring, until thickened, 2 to 3 minutes. Add scallion greens and the chicken and any accumulated juices; cook, stirring, until heated through, 1 to 2 minutes. Serve.

Baba Ganoush, Lebanese Style

Babaganoush, Lebanese Style

My friend Paula and I threw a Middle Eastern dinner party on my rooftop last Saturday evening.

It was really all Paula’s idea. You see,  her dad once ran a Lebanese market in Worcester, Mass. Paula inherited not only her father’s butcher block kitchen table and meat grinder, but a real love for the foods of her ancestors. I can tell you that enthusiasm is highly infectious, having caught it from her last year while sitting at the table at our cottage rolling grape leaves under her tutelage. So when Paula proposed a joint party – she’d provide the food and I, the venue and sous chef duty – I jumped at the idea.

The menu was perfect for the warm summer evening – Appetizers of fresh feta, olives, baba ganoush and pita served with red Lebanese wine, followed by a dinner of grilled lamb kabobs, rice pilaf, stuffed grapes leaves and green salad.

The lamb for the grape leaves? Paula ground it herself that morning.The mint? Dried on her dining room table just a few weeks ago.  And the recipes? Handed down from her father’s generation to her – via the parish cookbook of the St George’s in Worcester. With a few gems culled from May Bsisu’s wonderful cookbook The Arab Table.

We culled the guest list from the ranks of our friends we knew would appreciate the lemony pepper bite of the baba, the saltiness of the feta and the earthy flavors of the lamb, but would also be open to sampling my first attempt at homemade pita bread (a valiant but mistimed effort), and most importantly, open to getting to know one another. We also asked the guests to bring a reading to share that would be appropriate for the gathering.

And so it was that we dozen found ourselves at a picnic table drinking wine under the waxing moon and twinkling lights on one of the most beautiful nights of the year, eating a most delicious meal and afterwards, listening to the words of Kahil Gebran, EB White and Maya Angelou, along with readings about Lebanese and Irish immigrants to America,  capped off with the words of a modern young Jew and the intimate details of the days before the music died.

Our only regret was that the late hour at that point limited our chance to discuss the readings we had shared – a  lesson we will keep in mind as we plan our next Mediterranean salon.

Oh yes, there will be another. Because we’ve barely sampled the mezze or ventured into the kibbe.

And I’ve got pita to perfect.

BABAGANOUSH

Baba Ganoush (Eggplant bi Tahini), Lebanese Style

This recipe is originally from the famed El Morocco Restaurant in Worcester, where Paula’s aunt once worked in the kitchen.  This is a much more lemony baba ganoush than you may have tasted before, and is the first baba I’ve ever really loved. The trick is getting the texture just right – too much smoothness and its just a other puree. Not enough and the odd texture of the eggplant dominates the flavors. When Paula told me she makes hers by cutting it over and over again between two knives, I took that as my cue to bring out the wooden bowl and chopper, and the result was a perfectly textured baba.  You can use less lemon if you like – start with one and only add more if you think you’d like it that lemony. (I have a feeling lemons may have been smaller when this recipe was first written.)  Don’t skimp on the pepper and use a coarsely ground sea salt or large grind kosher salt for flavor. Serve with homemade pita chips.

Ingredients

  • 1 large eggplant, skin on, cut in half lengthwise
  • 3 tbsp sesame tahini
  • Juice of 2 lemons
  • 2 cloves garlic, finely minced
  • 2 tbsp water
  • Salt and pepper to taste

Instructions

Brush the eggplant with a little olive oil and broil, turning it frequently, until the meat softens, about 15 minutes total.  (f you want to grill it, that would be even better…)

Scoop out the softened eggplant meat into a large wooden bowl, discarding the skins. Add the tahini, lemon, garlic and chop until the eggplant is blended, but still recognizable as eggplant. (Alternatively you can use a pastry blender or two knives. If you must use a blender or food processor, be very careful not to pulverize it into an unrecognizable puree.) Avoid long stringy pieces – its a relatively fine chop.  Add water and salt and pepper to taste. Garnish with parsley, lemon or a scallion.  If you want to drizzle a bit of extra virgin olive oil on top, go ahead. No one will complain.

My Wooden bowl and chopper

 

Seven Things You Can Do to Help Reduce Prescription Errors

Pill BottleI just got off the phone with a very upset patient who discovered that her pharmacy has been giving her the wrong medication for the past 5 months, substituting a similarly spelled antibiotic for her rheumatoid arthritis med. She was tipped off when she realized how bad she had been feeling of late and decided to check the expiration date of her med, only to find it was the wrong drug. I won’t get into the unethical behavior of the pharmacist when she pointed out the error, something I’ll be reporting on her behalf to both the head of the pharmacy chain and the state Pharmacy board.

But that’s not the point of this post. The point is that, despite all our fancy technology and advances in healthcare, medication errors can and will occur.

So what can you do, as a patient, to be sure that your prescriptions are correct?

1. Keep a list of your current meds with you at all times. Include brand or generic name, dose and frequency. Paper, online, or on your phone – wherever its easiest and most accessible. But a paper list in your wallet will cover you in emergencies, so consider that even if you use your phone routinely.

2. Cross check and update your med list with your provider at every visit. In quality parlance we call it medication reconciliation, and it’s one of the most important things we docs do at a patient visit.  You’d be shocked how many patient come to a visit without knowing the names of the drugs they are taking. Now, if I go to prescribe a new medication, how can I be sure it doesn’t interact badly with something you are already taking? Or even if you may already be taking the very med I am prescribing? If I’m lucky, your pharmacist will pick it up, but only if you’ve filled a prescription in his system before. Don’t leave it to chance. Take charge.

3. Ask for an updated list of your medications and prescriptions before leaving your doctor’s office. Most EMR’s can create a current med list, so ask your doc or his/her staff for a copy. If you use it as your med list to carry with you, we’ll all be on the same page.  Alternatively, if your practice gives out an AVS (after visit summary) at check out, that usually will have your med list on it.

4. If you’re tech savvy, use the practice portal. Your providers practice portal has a med list. Take it upon yourself to check the portal between visits to be sure your med list is up to date and correct. You can usually print your med list yourself from the patient portal.

5. Cross check every med after you pick it up against the prescription your provider wrote. This includes refills. Use your printed med list, the portal or your AVS to check what your provider wants you to be taking. If you don’t have that, you can ask the pharmacist for a copy of your prescription. Don’t wait till side effects occur, as my patient did, to double check. Your health is too important for that.

6. Don’t hesitate to speak up if you think a prescription is wrong. You take it once a week, and now it says twice a week? Say something. And it’s not just the pharmacist who can make a mistake. Your doc isn’t perfect either. In fact, we’re less perfect in some ways since we started using the EMR to write prescriptions. More than once, I’ve caught myself typing in a prescription in the wrong patient’s chart – with up to 4 charts open on the computer screen at a time, it happens, trust me. Recently, my EMR made every part of a prescription a discrete field or check off box from a drop down, so that writing a single prescription is more like completing an online tax return than ordering a med. I hate it. It used to be so much faster (and safer) for me to just write or type out the frequency and dose. So please, stop me if you think I got it wrong. 

7. Finally, don’t forget that so called “natural” supplements are meds too. Don’t  get me started on the over use of these unregulated products. (And yes, overuse of prescription drugs as well, but at least we know whose making them and what’s in them.) But do know that many, many interactions can occur between so called “natural” products and prescription meds. So if you’re taking any kind of supplement, vitamin, herb or natural product, be sure to add it to your med list.

Any more suggestions or ideas? Tell us in the comments section.

Understanding Women’s Choice for Mastectomy

It’s a bit of a conundrum.

Despite advances in breast cancer treatment, and ongoing proof that survival is just as good after breast conserving surgery as it is with mastectomy, more and more women are opting for mastectomy for earlier and earlier stage cancers, especially DCIS.

In a well written, insightful post, Dr Deanna Attai, president-elect of the American Society of Breast Surgeons, outlines both the arguments against mastectomy and why women might make a reasonable choice to have a mastectomy anyway.

What we see in our offices is a rational fear: Many women understand that the type of surgery does not determine their survival.  While of utmost importance, survival is not the only thing that is important to women being treated for breast cancer. Women worry about having to repeat the whole process in another year or so if something new shows up on a mammogram or if a lump is felt. Women question the value of annual mammography for surveillance when their initial tumor was not picked up by a mammogram. Women have seen their family members and friends develop complications from radiation therapy and from attempts to perform additional surgery after radiation therapy. While women understand that a mastectomy is no guarantee that they will remain cancer-free, to many it is such a significant decrease in the rate of recurrence or new primary cancer that they feel it is an acceptable trade off for the complication rates that have been reported in patients who undergo a CPM with reconstruction.

I encourage you to read Dr Attai’s post – it goes a long way to informing both patients and their physicians about this agonizingly difficult decision that so many women face.

____________________________________

Mastectomy image from Wikipedia

Vinod Khosla – Still Stirring Things Up

Vinod Khosla (Image from Wikipedia)
Vinod Khosla (Wikipedia)

Vinod Khosla’s still at it. This time its the Stanford Big Data in Biomedicine Conference. 

I don’t really blame him – he’s got quite a thing going on the speaker circuit.  As long as he keeps getting invited to give keynote addresses at healthcare summits, he’ll keep cranking through his slide set and stirring up the hornet’s nest by saying that 80% of docs will be replaced by digital devices. Which coincidentally, his venture capital firm finances. Except now he’s calling it big data, since that’s what the most recent summit he spoke at was about. (Like any paid speaker with a slide set, he’s good at mixing it up for his audience.)

Here’s the response I wrote when Khosla started his act a few years ago. Since he’s still saying the same old thing, I didn’t see much need to rewrite it. (Although like any writer given the chance, I did edit it a tad.)

Will Doctors Be Needed in the Future?

There’s a big discussion going on in the health tech community about a controversial keynote speech given by Vinod Khosla at the Health Innovation Summit (HIS), in which he stated that 80% of what doctors do could be replaced by machines.

If you’re a doc like me who has no idea who the heck Vinod Khosisa is (he’s a venture capitalist and co-founder of Sun Microsystems), why he’d be a keynote speaker at a healthcare event, well, that’s the point of this post.

You see, there are a whole lot of folks like Khosia out there – investors, entrepreneurs, tech types – who are attempting to redefine healthcare according to their own personal vision.  Where we see a healthcare system in crisis, they see opportunity – just another problem with a technological solution.  Computer-driven algorithms are the answer to mis-diagnosis and medical error, IPhone apps can replace physician visits, video connectivity can increase access.

Where we see illness and distress, they see a market.

And what business folks like to call disruption in the marketplace. Think about what happened to downtown small town USA after the first shopping mall opened. Or what happened to movie houses when Netflix started offering DVD rentals online. Or where all the independent bookstores went when the first Borders opened up, and what happened to Borders when the Kindle hit the market.

If  Khosla is right, the we docs in our offices and hospitals are the old downtown department stores, the bookstores and the bricks and mortar businesses in an online revolution.

We’re replaceable. At least most of us.

Is Khosla right?

Maybe.

The therapeutic relationship between a doctor and a patient can never be replicated by an IPhone app. Not when so many of my patients leave my office on a daily basis telling me how much better they feel just having spoken to me. It’s a powerful and sacred relationship that is irreplaceable.

These days, however, almost all of my patients have googled their symptoms, and many have done a over the counter diagnostic test or treatment  before coming in to see me. I’ll never see the ones who got their questions answered online or their symptoms cured by that over the counter med – I see what’s left after self-diagnosis and self-treatment has failed, or google told them to see me.

That’s disruption, isn’t it?

One day very soon, women will be able to screen themselves for cervical cancer and std’s using a self-administered vaginal swab. No need to see me unless the test is abnormal, or there are symptoms.

Disruption.

Of course, computer driven diagnostic algorithms, apps and programs can create a whole new set of problems in over-diagnosis, since “there’s nothing seriously wrong with you” is rarely an output.  In my office, that’s a very frequent clinical assessment. Functional ovarian pain.  The occasional errant menstrual cycle or missed period. Anxiety. Stress. Depression. Lack of sleep. Over-eating, over-drinking, over-medicating.  What computer is going to pick that up?

Not to mention trauma care, surgery, childbirth, respiratory distress and any one of thousands of health emergencies that you can’t treat with an IPad.  I don’t see any of that work going away for docs anytime soon, do you? Some of it, of course, is being shared with trained non-physicians, and even robots. But docs are still an indispensable part of the healthcare mix.

So while the mix is changing, we docs are still in it. And I don’t see that changing. At least for here and for now. But the future?

I don’t know.

Docs need to be part of the digital revolution

I do know that if this is the new revolution in healthcare, we docs better get in on it.

Take the EMR as an example of what happens when docs let non-docs innovate in healthcare without significant physician input. We become typists, not physicians. Clerical work that used to be done by lower paid staff – entering lab and radiology orders – becomes ours to do. We spend the majority of a patient visit looking at a computer screen and not the patient. Retrieving relevant clinical information is like searching for a needle in the haystack of required fields of entry, most of which are not necessary to provide care.

Indeed, we have not yet shown definitively that EMR’s improve outcomes.

And yet we’re all using them, aren’t we?

If we are not part of the digital revolution and leave it to the venture capitalists and entrepreneurs, they will develop products that may sell, but if they don’t improve outcomes, all that will have been accomplished is a disruption in a marketplace.

Wouldn’t it be so much better if we could disrupt disease?

The real opportunity in healthcare innovation

There are millions upon millions of folks – some in American, but most in the undeveloped world – who have never had, and will never have the opportunity for a patient-physician therapeutic relationship such as that I’ve described above. They have no one to call when Google tells them to “talk to your doctor”.

But the overwhelming majority of the do have cell phones. Amazing, really. We can’t get indoor plumbing, modern contraception or malaria tents to all those in need, but 80% of folks in the developing word have cellphones. If that’s not an opportunity and a potential market for healthcare innovation, then nothing is. If we can get any healthcare into the hands of these folks, even if it’s healthcare delivered by a mobile app, we have the potential to improve their lives.

Now, imagine that we docs were able to free ourselves from the 80% of our work that can be replaced by technology, and then redistributed ourselves (virtually and personally) across the globe where we were truly needed, so that we could provide needed healthcare to the entire planet?

Now that’s disprution.

When it’s Your Wife…

In a painfully honest and moving essay entitled “The Day I started Lying to Ruth“, physician Peter Bach chronicles his gradual evolution from the oncologist who couldn’t understand why his patients would continue to seek treatment for a disease that was inevitably fatal

Each successive change [of treatment] brings more side effects with less chance of benefit… the cancer gets smarter, the treatments get dumber. Somewhere in this progression the trade-off no longer makes sense … I’ve often thought that cancer doctors go well past that point.

to the husband who, along with his wife, grasped at any options made available to them, whether or not they provided a chance for cure.

None of that mattered to me, the medical professional to whom all these nuances and trade-offs should. All I could think about was the blood test telling us the tumor marker was too high. With that, any dreamy conceit—that patients should be given enough knowledge that they can weigh the risks and benefits for themselves, then come to the choice that best suits them—flew out the window. Our choice wasn’t a choice. Take the chemo…. I will never again be mystified, as I had been with many patients, by why someone who is at the precipice of death seeks out yet another shot at treatment, even with something harmful that has a near-zero chance of helping. “Why not?” was suddenly a winning argument.

Bach’s story will be all too familiar to those of us who have had a loved one succumb to cancer. For me, it was my sister Fran – a nurse who, like Bach and his wife, was forced to negotiate the frightening choice between the rock and the hard place, always holding out hope for another round of chemo that her doctors said would “treat but not cure” her cancer. We all lied to ourselves, me especially, by not saying the truth. Until it was too late, and then it was over.  (God, I miss her …)

What makes Bach’s essay even more powerful for me is knowing that he is one of our county’s foremost experts in health care effectiveness and yes, cost.  What his essay is telling me is that he understands what cancer patients and their families have known all along – that reining in health care costs will mean more than just raising copays and lowering drug costs and funding more effective interventions. It will also mean quashing hope. And learning to tell ourselves the truth.

Curtailing the growing cost of end of life care is probably one of the most difficult challenges lying ahead of us. How we face that challenge will define us, both as a profession and as a nation.

Knowing Bach is at the table, I have a feeling we’re going to do it right.