On July 14, 2008 you received my Gateway FX 7026 serial #CSX84K1002958 at your service facility. Thank you for promptly responding to my problem of the misaligned USB ports and for quickly sending me a box with a prepaid shipping label. Since that time I have had several conversations with your friendly support staff who tell me that my computer was mistakenly shipped to Never-Never-Land. Normally, this would not be a problem but, as I understand it, the Never-Never-Land facility is now closed. I understand that strikes by the recently unionized Darling children were unexpected and largely beyond your control and that Peter Pan's contract was up (I hope he is enjoying retirement at his Malibu beach house). Captain Hook, I am not surprised to hear, continues to turn in substandard work and so I thank you for rerouting my computer to your other repair facility in Texas where it was received on July 21. But now, I need it back.

I understand that you are very busy with the large influx of computers coming in from the Never-Never-Land facility so, while I am on hold with customer service, I am writing this post using my Compaq Presario which I bought in 2001. This thing has 128 MB of RAM and there has never been any space on the hard drive in recent memory. I can't take it anymore. I can live without USB ports but, if I have to wait 5 minutes for another web page to load, I may have to shoot myself. Therefore, I propose the following.

Please send me proof that my FX 7026 is unharmed. A photo of my computer holding a newspaper with today's date will suffice. Upon receipt of said photo, I accept whatever you demand in exchange for 7026. And, please hurry. You have my contact information. My service request number is 1-3OYUV6. As my letters have gone unanswered and as I continue to hold for "the next available representative" I can only hope that you happen upon this post so that I may have his matter promptly resolved.

Sincerely yours,
James Logan, M.D.

There are a number of problems with making performance-enhancing substances illegal - the most significant, to my mind, being that there is no clear boundary between what is medically indicated and what is indicated only for performance-enhancing purposes. For example, in weight lifting it is prohibited to use furosemide in order to pee off some fluid and make your weight class. Perhaps HCTZ is also banned. Should it be? What if an athlete has hypertension? Should he be consigned to suboptimal blood pressure control while in active competition? Or perhaps the athlete will only be allowed to choose from a pre-approved list of medications that are sufficient to control his illness but, at the same time, will not offer him a competitive advantage. Caffeine also acts as a diuretic, as does alcohol. Should we test for these substances as well? Surely, if a patient has asthma, we can't ban his steroid inhaler. His inhaler does not represent an exogenous, performance-enhancing substance but rather we prescribe it in order to correct an underlying pathology; although, if the athlete happens to be a distance runner, his inhaler will undoubtedly have the side-effect (intended or otherwise) of improving his performance. Stimulants like pseudoephedrine can help correct the symptoms of an underlying pathology (like a cold). If the athlete has a cold, can he take a Sudafed®? What if he's just a little bit congested? What if he's not really congested, but he just needs that extra little boost? Should a female-to-male transsexual be denied her hormone therapy? Should she/he be barred from competing altogether? Endocrinologists have even proposed the use of human growth hormone for use in children who "fall off the growth curve." How does one determine who has normal shortness versus pathological short stature? My point is that I believe it doesn't matter what you or I think about these questions but that they are questions which the patient-athlete must approach jointly with his or her doctor.

Now, you may object, citing that some doctors are clearly more liberal than others. If you have chronic pain, some doctors will give you enough pain medication to sedate an elephant for a month (trusting you to take it only as prescribed), others only enough to get a very small rodent sleepy for a few days. The same will naturally be true of drugs that have the ability to enhance an athlete's performance. If you have iron deficiency anemia with an hemoglobin of 11.2, some docs may just give you iron supplements. Maybe a female athlete with this condition can start to cycle her oral contraceptives with the provision that she go back to having regular periods once her hemoglobin returns to an acceptable level. But, then again, there may be one or two female athletes who have had their uterus removed for one reason or another, or who have congenital absence of uterus, putting them at a possible relative advantage. Does taking erythropoietin give you an unfair advantage if it only brings your hemoglobin up to the level of your competitor who trains at high altitude, or your other competitor who happens to have hereditary polycythemia?

As you can see, any attempt to create a set of uniform standards of practice when it comes to using medical therapy in professional athletes descends quickly into absurdity. This is why, in order to level the playing field, all athletes must be given complete access to whatever substances are available. We need to stop the testing of athletes and the banning of substances altogether. Yes, by taking advantage of this, professional athletes would potentially be taking on some serious additional health risks. But they are already taking on a number of additional health risks that the rest of us don't face just by making the decision to be an athlete in the first place! It's not for you or I to decide how much additional risk to one's health is tolerable in order to improve athletic performance. It is a personal decision to be made by the individual patient-athlete in conjunction with his or her doctor.

"So, tell me, what were you doing before you came into the hospital?"
"I was at my boyfriend's house. We were watching a movie about this guy, who takes out your eyeballs and eats them!"
"Oh, wow. Ok. Then what happened?"
"Then, it turned out that he was really an alien from outerspace. But he was just disguised as a human. And he wasn't really eating the eyeballs, but just collecting them for experiments!"
"I see. But what was it that brought you to the hospital?"
"An ambulance."
"And the ambulance came because..?"
"Oh, my boyfriend knew something was wrong, so he called 911."

"Dr. Pulous, how many days of treatment would you give for a patient with this type of pneumonia?"
"Why don't you look it up and tell me?"

"Dr. Song, in what situations do you give bicarb to an acidotic patient?"
"That's a great question. What do you think?"

Yes, I am an adult learner and I am perfectly capable of looking up the information myself. But, since I happen to be in the presence of someone who knows the answer and whose job it is - at least on paper - to teach me thing about medicine, I just thought maybe you might be gracious enough to share some of that information with me.

One attending's reasoning behind not giving us the answers was, "If I tell you the answer, you won't remember." Well, Jesus Christ! That may be true. But, if you don't tell me the answer, I'm sure as hell not going to remember!

Where did this warped concept of what it means to teach come from? In any other teaching situation, information is supposed to flow downhill - from the people who are more knowledgeable to those who are less knowledgeable. Many readers of this blog will be familiar with the adage - If an attending asks you a question and you don't know the answer, a great response is "I don't know, but I'll look it up. To all learners in the medical community, I now propose a coup. If someone in a teaching position asks you a question and you don't know the answer, do NOT offer to look it up. Stand firm at the gates. There is knowledge is that brain; he can only hold onto it for so long. Hold your patients hostage, if you have to. You're the one writing orders, after all. Make your teachers understand that they can either tell you how to properly take care of your patients, or allow your patients to be subject to your guesses at how to take care of them. Medical learners unite, and we shall overcome!

The aftermath has played out in the fashion of a Shakespearean farce. Rather than ignoring this proposed nonregulation, the democrats have seized on it as an opportunity to lash back - calling it "...A dangerous assault on women's health."

Nobody is more in favor of providing contraception and family planning services than I am. But please, let's make sure the battles we fight are meaningful ones. A federal ban on partial birth abortion, for example, could potentially have the effect of seriously limiting the medical options available to a woman for managing complications during the second trimester of her pregnancy. This current proposal does not mess with the legality of abortion, or birth control or with the laws that are currently in place in 14 states guaranteeing women who are in need access to emergency contraception. It may keep one or two reactionary pharmacists from losing their jobs and will certainly generate extra paperwork but, in the grand scheme of things, I think us progressives can live with that.

I have to wonder, do they really understand what they've done? A perfectly analogous situation would be if the justice department were to apologize for the disparity between the number of blacks and whites on death row. Can you imagine the public outcry if that happened? I mean, we already knew that there way more blacks were convicted of murder but we didn't realize that you guys were preferentially convicting them on purpose! Why were you doing that? And if that's what you're doing, don't apologize, just stop doing it!

Likewise, the AMA's apology amounts to an admission of racism. They have apparently been intentionally giving inferior care to their African American patients. Again, rather than apologize, why not simply stop doing it? The answer, of course, is that they really aren't responsible. With rare exceptions (the Tuskegee experiment, comes to mind) you won't find any doctor who makes it part of his practice to provide one level of care to members of one race and another level of care to another race. Nor are any such health care policies in place, nor has the AMA issued any such guidelines. Are there disparities in the levels of care that blacks and whites receive in this country? Absolutely, there are! Just as there are huge disparities in income, level of education, crime etc. But for the AMA to say, "Yeah, sorry. These disparities exist because we fucked up. We've been giving shitty care to blacks while giving excellent care to whites, " is obviously ludicrous. If this were the case then the solution, as I have said, would be simple - STOP DOING IT! But, even though the AMA has apologized for these disparities, I'm pretty confident they will persist - at least for the short term. Which means that either a) the AMA was never responsible for these disparities in health care to begin with or b) they were responsible, but are going to choose to go on providing disparate care based on their patient's race.

We need to put aside this issue once and for all. The simple existence of racial disparity would not be a problem if race made no more difference to people than hair or eye color. Can you imagine anyone studying whether blue-eyed people received the same level of health care as brown-eyed people? If there are systematic ways in which our society is treating whites differently from blacks the solution is to seek out these injustices and to fight them. But the simple existence of these disparities does not necessarily point to any such injustice. And, if we are serious about achieving a color-blind society, the question of racial disparity is one that we need to stop asking.

While on call last week, I received the following page: "Mr. Gephardt has pulled out his foley; there's blood everywhere. You should probably come see." The nurse's words were calm and measured - as if she'd seen this a thousand times before. She seemed almost apologetic at having to wake me for something so trivial. I walked over to Mr. Gephardt's room. There was, indeed, blood everywere. The nurse didn't need to say another word as the blood splashes on the floor told whole story. The story began with Mr. Gephardt pulling out his foley while still in bed, walking over to the bathroom to urinate blood, walking from the bathroom to the nursing station (with no clothes on, mind you, and still dripping blood) and back to his bed after being chased there by the nurse from whom I had received the page. And the most relaxed person in the room was Mr. Gephardt himself.

"Mr. Gephardt, you pulled out your foley." I tried to sound as matter-of-fact as possible.
"No, it just sort of fell out."
"Did it hurt?"
"Yeah, it hurt!"
"Does it hurt now?"
"No."
He wasn't actively bleeding anymore. So, I went back to the call room, arriving just as my vision was about to turn completely black and just in time to pass out on the bed rather than on the hard tiled floor.

When there is blood coming from the female genital tract, I've never had an issue. During my former life as an OBGYN, I used to handle buckets of it! When it's coming from the male genital tract, I need to put my head between my knees and take some smelling salts. I could never have been a urologist.

For those of you unfamiliar with the concept of a foley catheter, this illustration should help you understand what I'm talking about.

Before today, I hadn't seen a pediatric patient since my first medical school rotation - now going on four years ago! It kind of throws you. If someone had brought in their cockatiel into the clinic for an evaluation, I'd have been just about equally flustered. To be fair, I actually had seen one or two pediatric patients during my tenure as an OB resident, mostly either for injury related to sexual abuse or to remove a foreign body. Those cases are kind of different though. OB's don't have to medically manage the patient. To us, she's just a minature vagina that has some strange creature attached to it.

Clem Bronson, a 70 year old army vet from Oklahoma who wears cowboy boots, gray hair down to the shoulders, a thick bushy mustache and a face that appears to have been left out in the sun too long had been admitted two days earlier with a COPD exaccerbation. On the way to his room this morning, I was confronted by the respiratory therapist. "Mr. Bronson really made upset Rachel this morning." Tall, blond, 25 year-old Rachel was his nurse today.
"How so?"
"He was making comments about her legs and her butt. Rachel told him to stop, but he didn't. She was really upset."
And, the fact that I went to medical school and wear a white coat makes me qualified to deal with this situation how?

That morning on rounds, we decided to have a little chat with Mr. Bronson about his behavior. His response, "Yeah, I know she's upset. She'll git over it." Great. And in regal fashion, the men in white coats come charging forth in order to...have virtually no impact on the situation. If it happens again, plan B is to recruit the second large category of professionals one goes to when there's nobody else who is specifically qualified to deal with their problem - the police.

The FX7026? He's fine - thanks for asking. His motherboard was just slightly misaligned. This, unfortunately, was making 5 of the 7 USB ports unusable. Otherwise, he's running great! I'll keep you updated on his condition. He should be getting discharged very soon!