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The great unveiling

A psychiatric nurse once relayed an observation to me that I
have been pondering for the last decade.
We were working together in an inner city “dementia unit,” populated
with patients with end stage Alzheimer’s, vascular dementias, and brain
disorders of unclear etiology.
Individuals were parked in geri-chairs in institutional hallways, others
were in bed in 4 point restraints for their own protection, still others were
muttering to themselves in wheelchairs.

We were discussing the case of a particularly unpleasant
– he would swing at people as they got near him, trying to hurt them –
scratching, punching, even biting if you got close enough.  His favorite thing was to grab nurses’, or
other female staff’s, breasts or crotches.  He rarely succeeded at this, since most staff
were aware of his tactics, though he sat in his chair nearly motionless, like a
Moray eel in a reef cave, small eyes and snaggle teeth, mouth open slightly at
all times, taking slow deliberate breaths as he waited for an unsuspecting ocean
dweller to wander inadvertently into his reach.

I asked the nurse how she thought he had gotten to be so
rotten.  She replied simply, “When people
get older they become more like themselves.”

That one sentence has fascinated me ever since.  Could it be that as we age (and our minds
lose their ability to maintain the social graces we were taught), we slip into saying
things in an uncensored manner, and behaving the way we truly want to?  Or is the difference between “sweet little
old ladies
” and “mean old biddies” a matter of how much damage there has been
to their frontal lobes?

The scientist in me would like to explain away all agitation
as an organic brain disorder.  But I just
don’t think we can reduce human behavior to neuroanatomy.  The complexity of a lifetime of circumstances
and individual choices – and their interaction with personality – are soul-defining.

Perhaps age brings wisdom and life experience… or maybe it
unveils the truth about who we’ve been all along.  Either way I have a feeling that when the time
draws near for our bodies to give up our souls, we can catch a glimpse of what people
are “made of” in their final words and deeds.This post originally appeared on Dr. Val’s blog at

Nutrition standards for foods in schools

Congress recently directed the Centers for Disease Control
(CDC) to undertake a study in partnership with the Institute of Medicine (IOM).  The goal was to establish nutrition guidelines
for government-subsidized nutrition programs in schools nation-wide.  These guidelines are meant to help combat the
growing rates of overweight and obesity in US children.

The standards may surprise you in their restrictiveness – no
beverages with more than 5 calories/serving are permitted (excluding milk or
soy milk) unless the child is involved in rigorous physical activity for more
than 1 hour in duration (then they can have a sports drink such as Gatorade).  No items with more than 35% of calories from
total sugars are permitted, and all bread and cereal items must be whole grain.  There are also restrictions on fat and salt
levels in the food.  Artificially
sweetened drinks and caffeinated beverages are not recommended.  The IOM also calls for removal of all junk
food and soda machines, and replacement with fruit, milk, and healthy snack options.

Reading these guidelines I thought, “Wow, if kids really ate
this way we probably would make a big difference in obesity rates.”

And then I wondered… “But will these kids just go home and
eat a box of oreos and a liter of coke at the end of the school day?  Is it enough to have a healthy food
environment at school, but not at home?
What is the role of parents in this?”

What do you think?
Are the IOM’s recommendations likely to 1) be followed by all schools 2)
make a difference in childrens’ weights?
Is there anything else you’d recommend?This post originally appeared on Dr. Val’s blog at

Dr. Val & The Gluten-Free Cooking Spree

What do you get when you confess on your blog to having a
love affair with food and a history of a GI disorder?  You get invited to attend a really cool event,
a sort of Iron Chef meets Scrubs, right here in Washington DC!

Yes my friends, I’ve been invited to participate in a
gluten-free cook off hosted by the National Foundation for Celiac Awareness and
moderated by CNN’s news anchor Heidi Collins.
I’m going to be teamed up with a chef in a gluten-free cooking
contest.  I’m not sure how the chef will
want me to participate – but I’m hoping that I get to do a little more than pot
stirring and taste testing.  There will
be three teams, and 9 healthcare professionals – including 4 docs, 3
pharmacists, 1 nurse, and 1 dietician.
Given hospitals’ reputation for culinary mediocrity, I’m not sure that
we bring any credibility to the contest – but if anyone chokes, we’ll
resuscitate promptly.

The contest is on May 4th in the evening… maybe
you can catch us on a cable channel with a high number?  All proceeds go to Celiac disease research
and awareness programs.This post originally appeared on Dr. Val’s blog at

The cardinal sin of medicine?

An Emergency Medicine physician blogger calls laziness the “cardinal sin of

How did this quality achieve such status?
TrenchDoc explains:

Simple. It is the ONE thing that we as
physicians can control. We cannot prevent patients from smoking and driving
their minivans into light poles. We cannot help that patients have myocardial
infarctions without any symptoms whatsoever. We certainly can not force them to
take medicine or have routine checkups. We CAN however be careful,
double-checking and unassuming diagnosticians. I don’t mean by this that we
should order a whole boatload of tests on each patient… quite the contrary… I
mean we should SPEND THE TIME with the patient to find that one unlikely detail
that is the key to solving the problem.

Honestly though, being lazy, quick and
cheap are the easiest of sins to commit in our vaunted system. We pay
physicians in this country basically upon the number of procedures or the
amount of patients they care for per hour. Eventually, poorly directed
efficiency gives way to poor quality of care and to be honest, I am as guilty
as anyone when it comes to missing important clues from a patient.

In his blog post, TrenchDoc goes on to describe a terrible
case of a mentally disabled woman who fell out of an electric shopping cart at
a Value Mart.  She complained of severe back
pain and got every imaging study under the sun (which showed a normal
spine).  She was discharged from the
Emergency Department, only to be readmitted to another ED weeks later when her
pain was still too great to bear.  This
time she said it was her leg that hurt… take a look at the horrible fracture
she had that was missed at the first ED.

I have argued that one of the major causes of decreased
quality of care is reduced patient-physician interaction time.  We are so pressured to rush through our
history and physical that we often miss the diagnosis, furiously documenting
everything without mentally processing what we’re doing.

I agree with TrenchDoc’s call to spend more time with
patients, though time doesn’t come easily.
How do you think we can help physicians find more time to be with their

This post originally appeared on Dr. Val’s blog at

Hanging in the calorie balance

Alright so now you know I love cookies. But this is just a small part of my culinary
weakness – I actually like all food, and the less healthy it is, the better it
tastes (in my opinion). Of course I try
to eat lots of green leafy veggies, lean meats, and citrus fruits… but how can
one resist hazelnut gelato or Camembert cheese?
Or who would turn up his nose at Kobe
beef with truffle oil-drizzled mashed potatoes and butter? Or what about hot scones and clotted cream
with strawberry jam?

Sigh. I must admit
that my extreme enjoyment of all things gastronomical has landed me in quite a
position on the exercise side of the calorie balance equation. I’ve never been a natural athlete though I do
like getting out into nature.

In fact, I’ve been jogging (one could not describe my
efforts as running) since I was a pre-teen.
I like the minimal hand-eye coordination required for the sport, the
virtual inability to let teammates down (running by yourself has a low risk of
disappointing others), and the freedom of being able to go wherever you like –
breathing in the fresh air, taking in the landscape, and letting the mind

And so I’ve been trying to get back into jogging as this
winter has been the most sedentary of my life.
I am now experiencing what my profession calls “deconditioning” and have
been in near awe at my body’s ability to lose its capacity to perform something
it’s been doing for decades – all within the span of <6 months.

I was recently amazed by how difficult jogging had
become. My legs felt heavy, my heart was
pounding, everyone was passing me on the trail… I was becoming quite
discouraged, when I suddenly happened upon a brilliant idea: rope someone else
into my suffering!

I approached an unsuspecting friend of mine with a proposal:
“would you like to jog with me 3 times a week in the early mornings?” I tried to make that sound as appealing as
possible, putting on my best hopeful grin while sizing her up and wondering if
she could tolerate my slow pace. Much to
my surprise, she responded with an enthusiastic “yes!” She said that she was “not any good at
running” but was trying to get back in shape and would welcome some

And so the two of us have been trundling along a running
trail each Tuesday, Wednesday, and Thursday morning for the past month. We’ve had a lot of fun catching up on each
other’s lives, and somehow the exercise has become less arduous and more

So what’s the moral of this rambling post? Exercise is hard – it’s not always fun, and
if you haven’t done it in a while, you’re guaranteed to feel fairly embarrassed
by your inabilities at first. But don’t
give up! Find a nice exercise buddy and make
time to do it regularly. That way you’ll
be healthier, happier, and able to eat occasional rich food with less guilt!  Anyone out there been struggling to get more active?

This post originally appeared on Dr. Val’s blog at

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