Dr Dork

The Dork Abides

2011-12-31T23:59:00.002+11:00

Both his followers will be surprised to discover that Dr Dork is stirring, occasionally spinning, restless in his unquiet tomb.

The medical 'blogosphere' (or however the current version is named) has changed much. The landscape has been remodelled, roads rerouted, and the forest has reclaimed some once-bustling towns.

Such is the nature of growth, and life cannot exist without change.

All manner of things have changed for Dr Dork since he reflected on the senescence of his blog in 2007.

Dr Dork has stepped away from clinical medicine at a relatively young age, a move which was necessary but nonetheless a little saddening for him. He is these days combining his professional and personal experiences of recovery from a ''mental illness triumvirate" in roles that he feels will benefit others stumbling along similar paths.

If it helps but one other, it is worth the effort.

Today Dr Dork reflects on his reflecting upon his reflections and gets dizzy.

Time for a sit down and a cup of tea.

Grand Rounds

2011-06-24T15:47:00.000+10:00

The prolific psych-blogging juggernaut that is Shrink Rap hosts the current edition of Grand Rounds.

Dr Dork recommends. He recalls the privilege (and dastardly amount of work) involved in hosting grand rounds with ambivalence, and offers an abundance of kudos to Dinah, ClinkShrink and Roy for an informative and entertaining summation of the week in health blogging.

Reanimation*

2010-07-11T12:56:00.001+10:00

Hello there. It has been a long while.

Hope you are well and happy.

This particular Dork is both.

More to come, in time.

Silence speaks of things unsaid.

The wheels are always turning.

*Do NOT read this story. Stay away from this disturbed film.

Just Checking In

2008-05-24T14:55:00.000+10:00

Dr Dork has been on an extended sojourn, but hasn't fallen off the face of the earth quite yet.

You have been warned, previously, that this blog is itinerant at best.

Kind regards to fellow travellers upon unsettled seas.

Dork

Not Drowning, Waving

2007-09-26T20:52:00.000+10:00

I haven't posted anything for a long time, so please bear with me.

I'm not even going to pretend any pertinence to clinical medicine, nor any forays into Dorksome jocularity. I shall refrain from the third person self-referencing for a change, as well.

Firstly, an apology to all my intertubes comrades, friends and acquaintances, who felt excluded by this blog 'going all private'. With my rudimentary understanding of Blogger, my decision to close the blog in May seemed to present only two options - make it "private", or delete it completely, which I wasn't quite prepared to do.

I have eschewed my dorkdr@gmail address until now, and regret any hurt feelings, as I wade through a great backlog of email tonight, to those who might take umbrage at any perceived exclusion from a "private blog". It was simply easier for me, at the time, to close the blog and avoid the brief flurry of kind email inquiries. The blog was not so much private, as in a state of pre-deletion.

I have started lurking about again of late, and note that many other health blogs, some of my favourites included, have shuffled off as well, pro tempore or otherwise. As others have discussed with far more perspicacity, perhaps this is simply the nature of the beast.

Why did I vanish ? Let me count the ways...

1. Ill health. Improving now.

2. Copyright concerns. I have developed further some of the nascent scribblings I occasionally posted, and as posting on Blogger legally counts as "publishing" in most regards. I have had to remove most of my creative work that I am compiling or submitting elsewhere, unfortunately.

3. Privacy. I don't write about my patients in any way that could be potentially identifiable. This is a Hippocratic fundamental, in my opinion. However, I have chosen to bare my personal foibles and failings in this blog. Others have suffered for similar disclosure, possessed of far greater altruism than I. Whilst hosting Grand Rounds was a privilege and a pleasure, the consequent huge surge in site visits was worrisome for me. I much prefer peeping out (and piping up occasionally), snug beneath my warm little rock, to the glare of the hot sun.

I am of the opinion that, particularly with my personal spectrum of illness, this fractured window may have been, and still could be, of use to someone, somewhere, sometime. When traversing one's own dark night of the soul, a single kindred spirit is of much value, wherever and however found.

So the blog archive is back, in part. Not that there is much of it, in retrospect. At least for now.

It is a pleasure to read the words of others, especially those who have lingered long. It is a pleasure to be read.

Yours occasionally,

Dork

In Absentia

2007-05-04T05:28:00.000+10:00

Waiting Room

Long story short: Dr Dork is on hiatus. For salubrious and salacious medical writing, please explore the blogroll.

Disgruntled patients

Grand Rounds Vol 3, No.30

2007-04-17T22:54:00.000+10:00

Grand Rounds now available at Fat Doctors.

Archives and upcoming schedule here.

Another nonsensical bout of self-absorbed whimsy

2007-04-16T19:42:00.000+10:00

Irrelevant and irreverent descent into mirth and whimsy has been just about the only output from Dr Dork of late.

Apart from Grand Rounds, of course - which was not as time-consuming as Dr Dork thought it might be. Dr Dork reads most of the blogs which submitted anyway - his Bloglines feed count stands at 205...and counting.

Dr Dork is perhaps showing his age by divulging his love of cheesy Creature Features. An excellent way to while away a few hours of insomnia.

So here we have a Godzilla dancing extravaganza, produced by Daniel, a 15 year old in San Jose.

Don't know the music, but the combination is much fun.

Dr Dork is thinking he will finally bestow a first name on himself, for a trial run.

Until next time,

Dr Tom F. Dork

The Magick of Iridology

2007-04-13T16:01:00.000+10:00

Mr Odd : My back feels completely fine. But I still see the chiropractor every 3 weeks, of course.

Dr Dork: Of course. Do the wrists give you much trouble after the operations ?

Mr O: None at all, doc.

Dr D: Great! Good for you. How has the drinking been going ?

Mr O : I drink a bottle and a half each night, but I took out the unhealthy stuff from the mix.

Dr D: Meaning...?

Mr O: I saw my iridologist just after the operations. He told me to cut down on the Coca-Cola.

Now I mix my bourbon with ice-water.

Only smoke light cigarettes as well.

Dr D: OK. *takes a sip from diet cola*

Mr O: The phosphates in that will kill you, you know...

Grand Rounds Vol 3, No.29

2007-04-10T07:13:00.000+10:00

G'day and welcome to this weeks edition of Grand Rounds. Dr Dork is pleased and honoured to host your journey through some highlights of this weeks medical blogging.

No time to shave today

Dr Dork has elected to follow the early tradition of Grand Rounds, as established and maintained by Nick Genes, venerable beyond his years in this regard. To elucidate, a few posts that have stood out, in this editor's opinion, have been selected for each category, to keep this edition of Grand Rounds to a readable size.

There were roughly quadruple the number of submissions for the (arbitrarily) designated size of this edition. Many quality submissions were regrettably left out this week, apologies to all. Dr Dork wouldn't have made the cut himself amongst the field of entries this week.

For those with particular preferences and predilections, the 30 selections for this week have been compiled into the following categories:

Rants
In Practice
Of Patients and for Patients
Education
Research and Advances
Healthcare Policy and Reform
Medicine in the Media
Miscellany and Mirth

Lastly, In Parting, we have a bittersweet farewell from the greatly admired Barbados Butterfly.

Rants

Fallen Angels rants on discourtesy in the healthcare blogosphere in Doctor Bloggers

Dr Dino berates the local lawmakers for the misguided enforcement of BMI Measurement in Schools.

Susan Palwick of Rickety Contrivances of Doing Good (perhaps the tongue-twistiest healthcare blog title) shares her anger at observing abusive behaviour towards an ED "frequent flyer".

In Practice

Dr Kenneth F. Trofatter discusses the evaluation of Recurrent Early Pregnancy Loss as part of an ongoing series on the topic. An increasing problem, one presumes, as many elect to become parents later and later, it seems.

Fat Doctor shares a moral dilemma as an overzealous schoolteacher almost berates her into support of developing SuperBugs.

Azygos shares a poignant tale of a patient's death from Multiple Sclerosis, and touches on the dangers of a fragmented care system in Paul

Signout, in the midst of a trying cardiology rotation, is touched by the power of a simple gesture of thanks in What we're supposed to do.

Dr Shazam of Mr Hassle's Long Underpants (still one of the best blog names, period) shares the electricity, and the enervation, of emergency room codes in Fallen Star.

Of Patients and For Patients

Dr Rima Bishara gives a comprehensive summary for parents, examining sports injuries in children.

Adam of Daylight Atheism gives a disturbing account of the situation faced by those in the Congo, where a single, lone psychiatrist, Dr Alain Mouanga, struggles to turn the tide of abuse inflicted upon the mentally ill.

The Bohemian Road Nurse shares her deeply personal experiences of battling alcoholism, a common affliction throughout the healthcare professions.

ChronicBabe shares some advice on time management for those struggling with their health...advice which we could all heed, irregardless.

Education

The inimitable Orac looks in detail at the subtleties of early cancer detection, particularly in regards to breast cancer in a highly informative two-part post.

Vitum medicinus shares a compendium of people he admires most in his class at medical school. Reminds one of the different paths many of us walk to the same destination.

Research and Advances

GrrlScientist identifies a major flaw in the much lauded "treatment" for ABO blood type incompatibility which has been bandied about in recent weeks.

Docinthemachine blogs on new developments in genetic pap smears which could lead us one step closer to eradicating some common STDs.

Dr Domenico Savatta looks at surgical options, including some recent research of his own, in treating prostate cancer. Very relevant to us old codgers.

Dr Charles revisits some of Kinseys ground-breaking and controversial work with a "Kinsey-style" sex survey of the health blogosphere. Go on. Be honest!

Healthcare Policy / Reform

Australian Parliamentary Debate

Dr Kevin takes a break from his frenetic link-blogging to give us a thoughtful and considered discussion of the growing problem of defensive medical practice.

Amy at Diabetes Mine previews Michael Moore's much anticipated "sicko" documentary. Even those of us on the other side of the globe will be interested in his take on the American system.

Medicine in the Media

N=1 from Universal Health berates the New York Times in Heart Disease, Treatment and Thrills for a recurring debasement of the nursing role.

Kerri at Six Until Me considers from the perspective of a diabetes sufferer the recent macing of a Mr Universe whilst hypoglycaemic in Doug Burns, Maced ?

Walter at HighlightHealth examines an inflammatory television "investigation" of pharmaceutical dispensing errors.

Jon Schnaars at Anxiety, Addiction and Depression Treatments comments on recent research looking at the questionable use of "check-list" questionnaires in psychiatric diagnosis and arbitrary exclusion criteria in Checklists Often Fail to Address Important Aspects of Depression Diagnosis. Dr Anonymous takes another look in is depression really depression ?

Miscellany and Mirth

Aaaaaah...Dr ? Are you Ok ?

Dancing Bare gives us a taste of Gilbert and Sullivan with an ode to Dr. Mom.

Roy of Shrink Rap gives an emotive, heartwarming view of the necessity of humour in preserving sanity in the face of tragedy in laughter is a drug. Dr Dork couldn't agree more. Ijeoma Eleazu reminds us that April is national humour month for American readers.

Dr Karen Little, a South African intern, of Just Up the Dose, shares with us some stomach churning experiences in a post succinctly titled ew.

Dr J of Northmed does some brain-twisting with medical acronymony

Nurse Ratched shares with us some outstanding additions to her vast collection of medical pulp fiction. Ah, those were the days....

What ? Time for my sponge bath already ?

In Parting

Charity Doc shares an ode dedicated to the much admired Barbados Butterfly whose wings have been sadly clipped.

It is common knowledge, after some dubious leakage to a major Australian newspaper, that Dr Barb was (in this Dork's, and many others opinions) inappropriately reprimanded by her hospital administration. Dr Dork recalls his many 100+ hour weeks from his hospital training days. Even back then many administrators preferred to deny the ridiculously unsafe hours many doctors worked. Unsafe for patients and doctors both. Dr Dork suspects this is what got Dr Barb in trouble...but we will, sadly, possibly never know.

Dr Dork has badgered Dr Barb into providing an "approved statement", which follows.

BARB BUTTERFLY STATEMENT APPROVED FOR RELEASE
=============================================
Dear Blogosphere,

Thanks to everyone for your well wishes, kind words, expressions of concern
and thoughtful tributes in recent weeks – I was amazed to realise the extent
to which the Barbados Butterfly blog had touched and inspired others since
its beginning in 2005. As the blogosphere has reported, the BB blog has been down since March 15th 2007.

The 2006 post “Tips For Surgical Intern #1” stated that in a bad situation
you can either leave it, reframe it, accept it or change it. In some
situations change is the only option. It may be daunting and difficult, but
that must not dissuade us from trying. Surgical training is necessarily
hard, but there are some paths that trainees should not have to walk. Long
term readers will recall my Darker Days series:

“I do know that as a profession we need to do better. We need to promote a
culture of safety. We need humane leaders - both clinicians and
administrators. We need to value our colleagues and create work environments
that we feel confident about and excited to be a part of.”

I am grateful that there are people who are both willing to accept the need
for change and willing to act. My blog is down and I shall miss sharing my
stories with you, but I sleep restfully (my pager notwithstanding!) and
continue to wield my scalpel with a smile. We live in exciting times.

“If nothing ever changed, there would be no butterflies.” – Anonymous.

Best wishes and much love to all,
Barbados Butterfly

That's all for this week. Next weeks edition of Grand Rounds will be hosted by The Fat Doctor.

Addendum: the pre-emptively curmudgeonly Dr Nick Genes interviewed Dr Dork for Medscape Pre-Rounds here.

Can I have some more, Sir ?

2007-04-07T05:54:00.000+10:00

Just a reminder.

Grand Rounds here this coming Tuesday. All are welcome.

Submissions to dorkdr@gmail.com

Low Expectations

2007-04-05T23:49:00.000+10:00

Pip and Miss Havisham

The key to enjoying modern cinema, perhaps.

Dr Dork is aware of the detriment that the culture of merit-free celebrity has upon civilised society. He tries to avoid TV...apart from Dorky things.

Dr Dork occasionally, for various and variable reasons, inflicts aspects of his musical or literary tastes upon his readers. He has only - indirectly - referenced contemporary cinema once before.

Tonight's Film at Château Dork: Little Miss Sunshine (LMS)

Dr Dork loathes formulaic film. Dr Dork enjoys films that break the mold. Or is that mould ? Unlike much of the current commercial cause célèbre, such can still, at times, be considered an art form.

Dr Dork had been recommended LMS by a few members of his desiccated gene pool, and had read a few rave reviews.

Rave reviews are usually the kiss of death at Château Dork. However...Dr Dork needed an extra movie to complete his VideoStoreCheapoDeal today. LMS effectively cost a dollar. Expectations were low.

Expectations were surpassed.

Conflict of interests should be identified:

1. Dr Dork has had a schoolboy crush on Toni Collette since Muriel's Wedding.

2. Dr Dork perhaps sees too much of himself in Steve Carrell's previous roles.

Dr Dork enjoys ice cream. French vanilla, preferably. Enough said.

Pageants debase and demean humanity. Enough said.

Urostream Grand Rounds, and holler for submissions

2007-04-03T20:38:00.000+10:00

Grand Rounds are up at UroStream.

Dr Dork thinks Dr Keagirl (seen here:)
has the most amusing and apt blogheader of all medical bloggers, but he can't work out how to display it...so you'll have to go see for yourself !

Dr Dork will have the pleasure of hosting Grand Rounds next week. Please make your submissions to dorkdr(AT)gmail(DOT)com.

Curfew will be lunchtime Monday your local time, after which the CHUDs will be released.

Grand Rounds will be following the traditional format as per Nick Genes guidelines from the early days of the tubal interweb, with a selection of highlights from the week.

Addendum: You can find Dr Keagirls Pre-Rounds Medscape interview with Dr Nick Genes* here.

*Grand Rounds founder/co-ordinator/eternal slave to the beast he has created

Centennial Rounds

2007-03-29T17:14:00.000+10:00

Dr Rosendo Ribeiro, and his trusty zebra, Kenya, 1907

Dr Dork, whilst briefly logging on the intertubes to upload his typically belated Grand Rounds notification, noticed that this is also his hundredth post.

Dr Dork can almost hear the tumultuous response from the medical blogosphere :

"Whoop-di-do."

"Tell someone who gives a rat's derrière."

Dr Dork has wrestled since beginning to blog with a multiplicity of goals to the endeavour. Overarching all of these, of course, is the primary reason why he came into existence.

Like many of his medical brethren, Dr Dork has a propensity towards perfectionism and distinct obsessive traits. "Best to do something well, or not at all," he recalls Dork Sr advising.

Dr Dork suspects his psychologically savvy colleagues might suggest this "everything or nothing" style of thinking is a recipe for disaster.

There are a lot of medical blogs out there. Dr Dork has lost count of the number he is now subscribed to. Many of the consistently productive ones seem to focus on a particular modality or two of blogging only:

Politics of healthcare. The particular speciality of the writer: Surgeons to shrinks. Emergency medicine to General Practice. Little people to even littler people. Tickers to tubing. Debunking quackery. Collating medical news. The history of nursing caps and dodgy romance novels. Medical literature. Doctor as patient.

Just to name a few.

Dr Dork is fragmented. He produces random output in at least 5 different modalities. Choosing to avoid his particular speciality field (which may or may not have been touched on at some point) is quite limiting.

Anyway.The loperamide appears to be kicking in, so enough verbal diarrhoea for now.

Suffice it to say Dr Dork is contemplating whether he might get more out (ie. put more in) if he chose a particular modality on which to focus. We'll see.

A trace of ennui intrudes at present, and output shall continue scarcely. This appears the eternal nature of the Dork, to spew forth at random intervals in random amounts. So be it - like it or lump it...Ha!

The main point of this post, before Dr Dork become absorbed in the wonders of navel gazing, is that Grand Rounds is up at Medviews.

Medviews is written by Dr Stuart Henochowicz, an Allergist/Immunologist at Georgetown with an impressive breadth of credentials.

Grand Rounds and Dorkish Humour

2007-03-24T18:12:00.000+11:00

Dr Dork is aware Grand Rounds was posted several days ago. Better late than never.

Dr Sam Blackman is a paediatric haematologist/oncologist from the US who is the host of Grand Rounds this week.

For any non-medical readers paed/haem/onc = little kiddies with cancer.

Tough gig.

Dr Blackman touches on the role of humour in grand rounds, and Dr Dork thinks this a salient point. In a similar vein, CodeBlog has made impressive use of limericks in this weeks
Change of Shift.

Humour is a useful tool in medical teaching, and in medical practice. From his psychiatry days, Dr Dork recalls it as a critical element of assessing a mental state properly.

Humour is, of course, a therapeutic tool in and of itself. Although Dr Hunter "Patch" Adams is a controversial figure, and Dr Dork disagrees to some extent with his extremely anti- “conventional” psychiatry stance, the message that humour does us good is beyond reproach.

In this spirit, Dr Dork would like to share some of his favourite humour sites. Please note, some are at times crude. In the tradition of FARK, the NSFW (not safe for work) tag will be applied for these, for those of you reading from a work computer.

Dork Humour

Dr McNinja – yes, it is a comic strip about a Ninja Doctor. Seriously. The premise : a kindly physician is infected with a virus which bestows ninja powers. The current story, with guest (ie. shoddy) artwork is average, but the archives are very entertaining.

Amateur Transplants – by Dr Suman who is a British anaesthetics trainee. The highlight is the section of mp3s, which are very funny.

Chaser – largely political Australian humour, possibly nonsensical to those outside Oz.

Comics curmudgeon – dissects humorously various daily comic strips

The Daily Show – you can’t get the show clips via Youtube anymore due to Viacom getting all "sue-y", but they are posted here at ifilm. The Chappelle Show archive is also recommended. Sometimes NSFW

Dilbert – probably the funniest comic around at present, given that Patterson and Larson
have effectively retired.

Dr Rob – arguably the funniest medical blogger around, at least to Dr Dork's mind, although there is some stiff competition about.

The Onion

The Overheard series. NSFW

Reasons you will hate me. A sometimes raunchy blog with much political humour, by a 30-something author/screenwriter/ex-child actress that is especially entertaining if familiar with Melbourne. Very NSFW

And last but not least, Red Meat, Medium Large and The Perry Bible Fellowship are three irreverently funny web comics. Often NSFW

Well, all that should keep some of you out of mischief for awhile.

Dr Dork is a bit tied up at present, hence Chateau Dork might be a tad quiet over the next week or two. He also apologises for being rather tardy in replying to comments - these will be addressed over the next few days.

Viraemia

2007-03-19T21:59:00.000+11:00

Dr Dork generally is wary of "memes", in the same way he doesn't forward chain mail.

Nonetheless, as two health bloggers he holds in high esteem, AngryDoc and JMB, have pointed the bone in regards to suggesting Dr Dork is a "thinking blog"...

Flattery will get you everywhere, Dr Dork thinks.

The requirements of this "meme"

1. Post with links to 5 blogs that make you think.

2. Link to (*original source blog*) which contains advertisements and solicits "donations" to its author. Maybe not.

3. Variation on 2. Definitely not.

Well, if anyone's interested, these are the 5 blogs that make Dr Dork think more than any other:

1. Stranger's Fever

2. NHS Blog Doc

3. Respectful Insolence

4. The Dilbert Blog

5. Intueri

These selections are entirely idiosyncratic, in random order, and Dr Dork also notes that thinking ain't always a good thing. Ha !

Chrysalis

2007-03-16T05:01:00.000+11:00

The Bloglines ~~post notifier~~ / ~~reader~~ / thingamajig, which Dr Dork opens even before his email nowadays when cranking up Old Rusty^TM, his venerable PC, is temperamental at best.

Oftentimes, little red exclamation points appear next to various blogs Dr Dork subscribes to. Usually, this is a transient software glitch. Going directly to a blog / site address bypasses such RSS or similar problems.

Today, Barbados Butterfly (link now inactive) was “flagged” in this manner.

Dr Dork had some trouble accessing the site, and presumed a glitch or gremlin was at play until just now reading this.

Dr Dork is very sad tonight.

As he has mentioned elsewhere, Dr Dork has been reading weblogs of non-medical nature for years, but only really began to appreciate the burgeoning of medical blogging in late 2005, not long before dipping his own toe sporadically into this great ocean of data.

Although the *cough* “honour” was never requested, this dork has long considered Dr Barb as one of his “blogparents”…whatever that means. If nothing else – it is a token of respect and admiration.

Dr Dork is hoping against hope this heralds a necessary pupation, and that Dr Barb will one day return.

Grand Rounds

2007-03-14T12:33:00.000+11:00

Grand Rounds are up at ScienceRoll which is a blog by an Hungarian medical student.

Interspersed this week with lots of Monty Python videos.

Ni !

Wordsmith of the Week

2007-03-11T19:35:00.000+11:00

Dr Dork (to waiting room):
Mr Simia ?

Mr Simia stands. They enter office.

Dr Dork:
Hello, Mr Simia. Have a seat.

How are you today ?

Mr Simia:
G’day doc. F***ing al’right. Not too f***ing bad. F***ing hot, ‘ay ?

Dr Dork:
Boiling, isn’t it ? So, tell me about…..

(later)

Dr Dork:
And what operations have you had before ?

Mr Simia:
Couple ‘a things. My knee was f***ed for years.

Dr Dork:
….

Mr Simia:
Then Dr Amazing fixed it. ACL. Better than ever. It was f***ing f***ed for years before. He is absolutely f***ing amazing. Best f***ing doctor ever. Does all the footy players. Really f***ing good.

Dr Dork:
…

Mr Simia:
F*** oath. Good job, mate.

Dr Dork:
…

Dr Dork:
…and the other operation ?

Mr Simia:
Opened up me f***ing guts and ripped me appendix out. F***ing ripped it out.

Dr Dork:
OK then…

Uh..by the way...you know your appendix didn’t do you any good, anyway ? So no harm in losing it.

Mr Simia:
Well, why the f*** is it there then ? What f***ing good ?

Dr Dork:
Some people would say it is a vestigial evolutionary remnant. Of something useful at an earlier stage..

Mr Simia:
F***ing evolution ? What about that s*** anyway ? What f***ing proof ? Eh ? Why’s it there then if there’s evolution. Why we f***ing evolve it if it's no f***ing good ?

Dr Dork:
Fair enough...now, back to.....

Dr Dork avoids imposing his religious or other world views on his patients. He believes it unethical to do so. This was an attempt to reassure gone horribly wrong. Mr S was raring to go for a philosophical debate. Which would have been interesting.

Dr Dork is trying to figure out how to write dialogue effectively. You have been warned.

Mateship and Rapport

2007-03-08T19:27:00.000+11:00

Old Slim

"Mate" is a non specific greeting used between Australians. Of both genders in certain regions. It is usually of a positive connotation.

As with much Australian vernacular, subtleties of inflection and context can produce a great variety of meanings.

"Maaaaaaaaaaaate", as a drawn out drawl, accompanied usually by a half-smile and a knuckle-crunching handshake, is the traditional greeting of the Australian male in the wild.

"G'day, mate!" is often used as a general, friendly greeting to an unknown person, especially of the male persuasion. The equivalent of "Good afternoon, sir", "Bonjour, monsieur".

"Mate" can also be used in a derogatory context just as easily and this is what led Dr Dork to consider the topic today.

Whilst sauntering down the street in the vague direction of his morning bus, Dr Dork was nearly cleaned up by a cyclist who barrelled past without warning. A near collision...and partially Dr Dorks fault, as he tends to meander along a circuitous path, especially when his mind is 90% elsewhere...as it often is. The words that leapt to Dr Dorks lips, albeit unspoken: "Use your *(edited)* bell, mate!".

Dr Dork sometimes refers to his male patients as "mate".

On his new patient registration forms the only option available is Mr for males.

Being of a certain age, Dr Dork still refers to new older male patients as "sir", unless or until they clearly indicate a preference otherwise. Younger males are usually "mate" or addressed by first name.

This seems to assist in rapport building with younger males, in particular. It is a gesture of camaraderie, of casual "blokiness" that makes the staid old Dr Dork seem less intimidating to a young 'un, perhaps.

Females may select Ms, Miss or Mrs, and are addressed according to their preference. No grey areas.

On the whole, Dr Dork finds it often takes longer to develop rapport with female patients. He is a dork, and thus the instinctive female repugnance to Homo Dorkus Sapiens (and his negative evolutionary corollaries) must be gradually overcome.

The greater flexibility he has in addressing his male patients seems to further facilitate rapport. More scope to tailor to the individual, less possibility of inadvertent offence.

Dr Dork works only in adult medicine. Kiddie rapport is a whole other kettle of fish. Ask Dr Flea.

Children are evil, and should stay off the lawn, anyway.

Grand Rounds

2007-03-07T00:00:00.000+11:00

Grand Rounds are now up at Grunt Doc.

Grand Rounds

2007-02-28T20:49:00.000+11:00

Grand Rounds for this week are up at one of Dr Dork's favourite reads, Musings of a Dinosaur.

Next week they will be hosted at GruntDoc.

Stasis

2007-02-26T16:59:00.000+11:00

This isn't a post of any substance, beyond self-indulgence, so feel free to skip over it.

The BritMeds are worth a read if seeking proper medical blogging.

Dr Dork is mildly concerned that he is violating a Dinosaur rule or two today.

Well, not that concerned, really.

He is going to talk about blogging, as a doctor, and any feedback, scathing or otherwise, is welcome.

Dr Dork has waffled on previously as to his personal motivations for blogging. He enjoys, most of all, blogs of those driven by similar motivations.

Yet once one has established a 'presence', however limited, however brief, one cannot help but feel an expectation to pander, to please an invisible audience. This is the kiss of death for a blogger such as Dr Dork. This explains his reticence about participating in certain annual events. Not to imply that there is anything wrong with these - far from it. Simply that Dr Dork considers such contrary to his personal blogging motivations, as he is one who blogs anonymously for his own edification, ventilation and amusement.

Dr Dork is new to medical weblogs, only having really discovered them in late 2005, but has been present, under a different pseudonym, in a couple of non-medical online forums, for several years. He was once asked to contribute, a few years ago, a regular 'column' to a popular non-medical Australian website, and did so for awhile, before finding that it was sapping his creative impetus, and found his interest and output soon waning.

It would be interesting to hear what Dr Dorks colleagues in supratentorial pathology think of this propensity. Conversely, Dr Dork in his "non-creative" life as a medico is driven to work harder by increased demand. In practical and technical matters, his output increases with increasing demand.

This has led Dr Dork to the conclusion....that Sloth is his muse.

Absent poetry

2007-02-25T02:31:00.000+11:00

In Dreams

2007-02-22T19:46:00.000+11:00

Dr Dork has been thinking about his own history of challenges with Hypnos in light of some recent discussions such as this.

Sleep difficulties are rarely not a major component of depression - indeed, of most if not all psychiatric illness, it could be argued. The classic problem in depression being early morning wakening, considered one of the core physiological shift symptoms.

In the hour before the dawn,
When darkest thought is often born.
It seems to me my head is shorn
And that I sleep on frigid steel.

It's not fun to await the day, when your mood, your perspective, your world... are all bottoming out together in the diurnal trough.

Dr Dork has previously suffered from what is nowadays termed PTSD, as well as wrestling with the Black Dog since a young whippersnapper. He has run the full gamut of sleep dysfunction at one time or another.

Dr Dork also often advises his patients on improving sleep.

If there is a physical cause, such as pain or obstructive sleep apnoea, it needs to be treated.

Sedatives - anxiolytics and hypnotics - are, to Dr Dorks mind, best avoided if possible. Used briefly if necessary. They are only ever a short-term bandaid solution, and can exacerbate the problem(s) in the longer term.

Benzodiazepines are addictive. They also have a depressant effect on the CNS. Even a 'pure hypnotic' like zolpidem is at the very least psychologically habit forming.

Persistent insomnia is enervating. Exhausting.

The first goal is to treat the cause, whatever it may be, if it is identifiable.

The second goal is to promote sleep hygiene. This is not referring to clean pyjamas. In summary, this entails several principles, which the Dork endeavours to practice as well as preach, including:

1. Get a routine and stick to it. Always get up at the same time. As much as possible turn in at the same time.

2. Maintain a comfortable sleep environment. Not too hot, not too cold. Quiet. Dark. Wear earplugs if you have to.

3. Your bed is for two things. One of these is sleep. The other is not eating, reading, or watching television.

4. Limit caffeine. The half-life of caffeine is at least a few hours. Dr Dork religiously avoids caffeine after 3pm. Or maybe 4pm.

5. Alcohol. Many think alcohol helps them sleep. This is bollocks. It can induce sleep initiation, but stops you entering the 4th/dreaming phase of sleep, and leads to less restful, poor quality sleep.

6. If you're a Nana-napper, limit to 20-40 minutes.

7. Exercise. Doing so in the mid-afternoon / early evening has been shown to promote improved sleep. If Dr Dork wasn't nodding off, he'd source a reference....*Yawn*.

Sweet Dreams.

Grand Rounds

2007-02-21T23:51:00.000+11:00

Grand Rounds for this week are now up at Pure Pedantry.

It is themed, the topic being 'The Oscars'.

Dr Dork is not sure, but thinks this is some type of Bollywood ceremony.

Political Banter

2007-02-20T08:54:00.000+11:00

Dr Dork is feeling a mite repetitious of late, what with returning yet again to the contentious theme of healthcare funding in his last post.

One last parting shot over the bow that Dr Dork especially recommends for any medicos or medical students out there : No Free Lunch.

As per usual, the BritMeds are up at NHSBlogDoc.

Dr Crippen continues to impress with his prolific yet thoughtful output.

A matter of considerable debate in the BritMeds this week. A link was originally included that went to a particular racist/xenophobic/extremist right wing political party in the UK. Albeit this appeared to be in a derisory, derogatory fashion there was nonetheless an outcry amongst NHSBlogDoc's copiously commenting community. Such that the link was withdrawn.

Dr Dork leans towards the justification Dr Crippen put forth in the comments on this post, to whit:

"Better to get them out in the open and put the case against. I fear that by advocating censorship as you appear to do, you achieve the opposite effect to the one you intend. If that guy is so wrong (and I think he is too) why not demolish his arguments rationally, rather than saying he should be suppressed? If you take the latter course, people will say you cannot demolish his arguments and that therefore he must be right."

To borrow a Respectfully Insolent^TM term, such Wingnuts are only a danger to the ignorant and iniquitous. It is better to expose such idiocy, stamp it out like a bug skittering from under a rock, than to allow it to fester and grow in a darkened corner.

Dr Dork disagrees not infrquently with some of the health bloggers he regularly reads, and holds in high regard...irregardless.

Debate and discussion amongst those with dissimilar viewpoints is one of the ways in which we grow as human beings.

"Ooh - an eclipse !"

Two Tiers Part III

2007-02-17T15:57:00.000+11:00

It is interesting to observe, from this sequestered shore, the seemingly perennial debate over the growth and evolution of further two-tiered systems akin to that found downunder.

In particular, the heated debates arising amongst and between the principle sources of health bloggers : the UK and the US.

Although at present they appear at extremes in their philosophy of healthcare delivery - and funding thereof - they appear, from afar, to be gravitating towards each other.

Dr Dork knows little of fiscal matters, but it seems that in the UK, in essence, there is fairly heavy taxation with the resultant expectation of (amongst other public services) quality, accessible public healthcare. In the US, there is perhaps less taxation, certainly less public funding for healthcare, and more of a “user-pays” or privatised system.

In Australia, we have been under the sway of a rightward leaning government for a decade, and whilst for many years prior healthcare has been an admixture of public and private, the pendulum has swung increasingly moreso towards the latter.

In theory, we have public hospitals and a fully government funded Medicare system to provide inpatient and outpatient care to all.

Australians, for the most part it seems, still subscribe to the ideology of providing healthcare to all – irrespective of income, employment status, or ability to pay.

Dr Dork disagrees profoundly with the viewpoint that access to basic healthcare is not a right, as some have suggested. Healthcare is a fundamental right common to all humanity. It is inhumane to deny treatment to those who cannot pay – directly or indirectly – just as it is inhumane to deny the starving food and water.

For many reasons healthcare costs will only continue to grow. As science advances, we live longer, and consume more health resources. We expect not just greater longevity, but greater quality of life.

What we gain in mortality, we lose in morbidity.

Our public healthcare system in Australia is increasingly struggling to keep up. The cracks are perhaps not as wide as in parts of the NHS, but one supposes this has much to do with such being papered over by a parallel private system which is inexorably growing. Many doctors choose to practice only within the private system. They are not necessarily better skilled or qualified than those remaining largely in the public sector, but it is almost inevitable that the overall standard of care is often better in the ‘private’ system.

Like 40% of Australians, Dr Dork has chosen to pay for private health cover. It is silly not to, with our current system, if one can afford it.

If one can afford it.

Housekeeping

2007-02-15T17:39:00.000+11:00

Dr Dork is finding his internet niche increasingly cluttered and cumbersome.

Some renovations are underway.

One thing that has been particularly time consuming is attempting to maintain a collection of medical links organised by specialty. It is increasingly hard to keep up with the growing number of such contributors, and occasionally superlative blogs are missed for a long time. Dr Dork suspects he inadvertently classified some bloggers into inappropriate categories, as well, at times. Apologies.

To allow more time for blogging, and reading other blogs, all are now combined into a Blogroll of sites Dr Dork peruses. This is recommended as an excellent, free, time-saving option for others struggling to keep links up to date. User friendly and no annoying advertisements.

Dr Dork recently discovered the wonders of RSS as well, and finds Bloglines an easy way to keep up to date with blogs, without having to keep checking constantly if sites are updated. In the spirit of this phenomenon, Dr Dork foisted links to several RSS/feed/thingamajig services upon his sidebar, but is worried they look a mite gaudy, so has recommended they take administrative leave of absence.

Dr Dork only views his site via his venerable PC at Chateau Dork, hence is rather ignorant of any display errors or similar gremlins on other systems. Any feedback on layout, links, archives, load time, doohickies, thingamajigs...positive or negative ...is appreciated.

Rounding Off

2007-02-13T19:05:00.000+11:00

Grand Rounds for the week are now up at Chronic Babe. There is a theme: 'give me some sugar', perhaps in honour of the Hallmark/Cadbury Annual Celebration of Commerce.

Paediatric grand rounds are up at Awesome Mom. Or Awesome Mum, in the local vernacular.

The Brit Meds are up at NHSBlogDoc also, and is quite an interesting collection yet again.

Image courtesy National Library of Medicine

Hyppocrates

2007-02-10T17:48:00.000+11:00

Dr Dork has found it highly disturbing in recent years to note an increasing trend whereby doctors are appearing in television advertisements. Often extolling the wondrous virtues of certain competing "over the counter" analgesics.

As reported here and supported by the AMA, the Federal government has acted to close a loophole in TGA regulations whereby a few shonky medicos had been rather lax in recalling the recommendations of this old Greek chap.

Dr Dork was frankly surprised, and disappointed, when these ads started appearing a couple of years back. He is uncomfortable enough with the marketing of pharmaceuticals as it is.

Thankfully direct to consumer advertising of prescription medication is not permitted here, as it is similarly banned in most of the developed world - the only exceptions being the US and our Kiwi neighbours.

Dr Dork is of the opinion that to nonspecifically promote one specific treatment, therapy or medication to the general public, when it is not always the best option, and there is furthermore a risk of harm, is a gross violation of rudimentary medical ethics. Especially when one is being paid to lie.

A lie of omission, rather than commission, perhaps, but a lie nonetheless.

Fortunately, at least one of the offenders listened to Mr Cricket after all.

This type of behaviour should never have been allowed in the first place. It indirectly violates primum non nocere. It harms the therapeutic nature of the doctor-patient relationship in general for all who see it, and demeans the profession as a whole in that the public observes the lack of any consequences for these unscrupulous bad apples.

Time for a cuppa and a lie down again.

Grand and Other Rounds

2007-02-07T11:12:00.000+11:00

Grand Rounds for this week are up at Tales of the Emergency Room and Beyond.

A themed collection (albeit fairly nonspecific) regarding "Medical Professionals as People".

nb: I think Dorks are higher order primates, but we don't get voting rights, and communicate via jumbled screechings. Dorkus Australopithecus, perhaps ?

Dr Dork did submit this week anyway, as the 'topic' correlated with an already planned proctological post. Rather than bemoan theming ad nauseam, Dr Dork has put his hand up to offer to host a future version to briefly appease the Dork and his fellow curmudgeons.

The BritMeds are also up at NHSBlogDoctor.

Updated: Nurse Ratched's Place is hosting Change of Shift this week.

Paging Miss Pollard

2007-02-06T19:51:00.000+11:00

Yes but, no but, Dr, what you see was...

Dr Dork: I notice in your file here you’ve had some heart trouble ?

Patient: No, never gave me any problems.

Dr Dork : Oh. It says here that you had a triple CABG 5 years ago ?

Patient: Oh. Yeah, that. I went to see my local doc about my indigestion. My indigestion was really giving me grief. And I was feeling dizzy.

Dr Dork: So…you had the operation on your heart and it fixed that ?

Patient: Yes. But I never had any angina, any heart pain, no.

Dr Dork: Okay. So, things were good until last year, then ?

Patient: Yep.

Dr Dork: When you had the stent…

Patient: Yep.

Dr Dork: Was it chest pain, angina , that lead to the stent being put in ?

Patient: No. Never had any chest pain.

Dr Dork: So what led to the stent being done ?

Patient: I was having this pain in my neck. I just wanted the pain in my neck to go away.

So they put the stent in to fix it. Which it did, it went away.

...

Dr Dork: Any angina after the new stent ?

Patient: No. Never had angina doc. Never had any problems with my heart.

Dr Dork:

Heart disease is no laughing matter. It is our biggest killer in the developed world. It seems to get a fraction of the press of more fashionable but rarer conditions. As our population ages demographically, and our adults and children balloon into obesity, it is unlikely to diminish in impact in coming decades.

Heart disease is often treatable. Even better - it is largely preventable.

Dr Dork recommends discussing how best to reduce your own risk of heart disease with your friendly local medico.

Heart Foundation of Australia
British Heart Foundation
American Heart Association

Blogger Bug

2007-02-04T15:26:00.000+11:00

Dr Dork has encountered a lot of problems over the latter part of this week with accessing many of the multitude of blogs he endeavours to keep up with.

Some sites would simply not load, others seemed mainly to have problems with the comments.

Dr Dork apologises for any inconvience to his readers. Whatever the problem, it seems to have been rectified now by the good people at Blogger.

Like many Dr Dork is appreciative of the Blogger service. It is free, it is not encumbered by garish advertising, and it is fairly easy to use, even for us technical dummkopfs.

It is a bit temperamental at times, but you get what you pay for.

Get well soon, Blogger.

Dork Unveiled

2007-02-03T16:22:00.000+11:00

As Dr Dork was afraid might happen, someone remembered his promise to post a picture as an incentive to encourage voting in one of the blog awards, prior to his defection from the Sith.

Well, one must be true to their word.

Click here, if you dare.

Dr Dork quite likes this new portrait. Perhaps he might even replace his old pic. Any thoughts ?

Auscultating Joy

2007-02-01T21:13:00.000+11:00

Dr Dork is excited.

He bought himself a new toy today. A new stethoscope. The first one in a decade.

When Dr Dork was a medical student, he spent the equivalent of many weeks wages at his part-time job on a swish stethoscope that would purportedly stop him from misdiagnosing things like death and dextrocardia.

He used this until fairly recently.

However - Dr Dork also received a free "cheapo" stethoscope as a medical student. A Rappaport-Sprague* (double lumen) type.

Dr Dork also made much use of this "cheapo" stethoscope. And found it much easier to use than his swish mucho dinero version, more sensitive in particular.

Today, Dr Dork compared the "cheapo" double lumen versions with the "swish" stethoscopes, the latter costing several times the former.

He still prefers the double lumens to the fancy ones.

Dr Dork is interested in the preferences of others, if anyone would care to share.

*Maurice Rappaport and Howard Sprague invented this type of stethoscope in the 1940's. It is a style of stethoscope, not a specific manufacturer or brand.

Nice summary of the history of stethoscopes here.

Doctor as Patient III - Topical Nitrates

2007-01-31T00:12:00.000+11:00

One of the reasons, amongst several, why Dr Dork endeavours to maintain anonymity, is to facilitate frank, unguarded disclosure and discussion of his myriad of medical maladies.

This is for Dr Dorks own benefit, of course, albeit he hopes that some of his readers find his perspective on being variously on both sides of the consultation of interest.

In the first of this series, Dr Dork broached some of his experiences as a cardiology patient. Dr Dork would like to apologise, particularly to his medical colleagues, who would likely have presumed further discourse of this nature, presumably on the use of transdermal patches in angina.

There are other uses for topical nitrates.

Dr Dork was once prescribed a medication called venlafaxine for depression. This is a type of antidepressant used fairly commonly by psychiatrists. As Dr Dork has mentioned before, however, he is a tad prone to adverse effects with many pharmaceuticals.

Venlafaxine gave Dr Dork two problems.

Firstly, it caused his blood pressure to rise. This is a fairly common event.

Secondly, there were some problems with peristaltic orificial output.

Many days of problems.

When service was resumed, due to the delay in ... egress ... there was, shall we say, some clamouring about the exit.

Someone broke the door on the way out.

As Dr Dork has demonstrated with the above oblique account, many people find it very difficult to broach these types of problems. Even when it is relatively easy to sit on the other side of the fence.

Especially for men, it could be argued. There are some challenges to the male ego that many find rather terrifying. We all know what comes next.

But it is no laughing matter. The causes of hematochezia can be benign, and can be very dire.

In case anyone is unsure, Dr Dork is talking about bleeding out the Rik Mayall. And about changes in bowel habits, to a lesser extent.

Dr Dork grew to love the taste of bran. Or, at least, to convince himself that bran is actually possessed of taste.

Compendiums

2007-01-30T09:51:00.000+11:00

Dr Dork has been a mite preoccupied the last week, hence the scarcity of output.

Rather belatedly, he would like to mention that Change of Shift, the nursing blog carnival, is up at Emergiblog...and has been for a few days. Apologies, Kim.

Jumping the gun, conversely, Grand Rounds will be up later today at Envisioning 2.0. It is early evening here in Oz, and where the author of Envisioning, Fard Johnmar, is based, it is probably not Tuesday for some time yet.

Another planned themed topic this week, unfortunately, regarding aspects of the confusing American insurance systems. Well, confusing to Dr Dork, at least. Which isn't a particularly unusual event.

There are a few regular Grand Round type collections akin to the seminal creation of Nick Genes that Dr Dork would like to bring to the attention of any readers unaware of them.

Most tend to focus on the relevant area of expertise, but promote those from other disciplines contributing as well.

Apart from the above two, Dr Dork has so far become particularly aware of:

The Pediatric Grand Rounds, which Clark Bartram of Unintelligent Design established, are hosted often at his site - as per this week - but also at various other locations, as per the archive. These are published every second Sunday.

The Radiology Grand Rounds are generally produced by Dr Sumer at Sumer's Radiology Site, although there are guest hosts, and he has set up a handy archive as well. These come out on the last Sunday of each month.

Dr John Crippen publishes The Brit Meds, a collection of British medically related writing, each Sunday at NHSBlogDoc.

Those of us in the penal colony feel unloved, John. As perhaps do our colleagues from the religious pilgrimage.

Dr Dork is just kidding. He is sure there will be an Australian version, once some critical mass is reached.

(insert own joke about slothful Australians here)

Grand Rounds is published at various locations, each Tuesday, and there is a handy archive and schedule at Blogborygmi.

Change of Shift is generally published at Emergiblog, each Thursday.

Dr Dork has spent an embarrassing length of time today trying to organise some form of Grand Round linking omnibus to tack up in his sidebar, to no avail, and much vexation.

Dr Dork recommends perhaps bookmarking some or all of the above compendiums.

He also recommends unplugging your monitor before attempting to throw it through a window.

Cujo

2007-01-26T17:37:00.000+11:00

Continuing an occasional series.

As someone who has lived only in Australia and the UK, it is fascinating, and frightening, to see the prevalence elsewhere of rabies, which those of us in Oz do not encounter. Apart from the odd bat lyssavirus in North Queensland, that is.

Dr Dork last exposed himself to the possibility of this nasty disease when in Indonesia a few months prior to the Bali Bombings.

Dr Dork strayed from the usual tourist path to a fair degree, and thus was taking appropriate malarial precautions. With associated amusing dermatological effects.

Dr and Mrs Dork visited a tourist site replete with a surfeit of semi-tame monkeys. These little guys were quite used to tourists, in no predatory danger, and would probably dance upon your outstretched palm if they thought there was a banana in it for them.

When you entered this park, you could purchase a bunch or two of (rather meagre) bananas, all the better to feed the unrestrained zoo within.

Dr Dork, like your stereotypical Western tourist, was wearing a shoulder bag containing photographic paraphernalia. Mrs Dork decided to store a few spare bananas in the shoulder bag.

Dr Dork was not aware of this at the time.

He was rather perturbed, in due course, to find himself surrounded by a collection of very demanding little simians. And their many, many teeth.

And a bite from such is rabies until proven otherwise.

Thus the benefit of vaccination, especially in one whom anything with teeth tends to find...teethable. Tasty. Worth a 'chomp' or two.

A bite, where rabies is prevalent, is rabies until proven otherwise, as far as Dr Dork is concerned.

Rabies is preventable. It is treatable.

If not treated, it is fatal.

More bl***y needles...

Iron Man

2007-01-25T19:30:00.000+11:00

Dork takes it like a man

Revisiting preparations for a distant future jaunt, Dr Dork is planning having various immunisations updated.

Like many others born in the latter half of last century, some diseases to which Dr Dork's parents and grandparents were exposed had become eradicated (or virtually unknown) by the time he started ~~playing with dolls~~ ~~setting fire to kittens~~ pottering dorkily about.

For his psychiatric friends, Dr Dork is aware of his tendency towards neologisms.

Polio is one such affliction. It exemplifies many of the diseases that we now vaccinate against, which in their relative absence many of us become complacent about. In essence – an uncommon disease, that has nonetheless devastating potential.

Dr Flea has gone into some detail on the ramifications of poliomyelitis as part of his excellent vaccination series.

Dr Dork is not one to gamble with the health of himself nor his family.

The oral Sabin vaccine, now less commonly used, was a live virus preparation with a 1 per million (at most) possibility of contracting a strain of polio from the vaccine itself. The incidence has fallen so low, thanks to a program of eradication, that even this miniscule risk is too great, and the injectable Salk preparation, with no such possibility of disease inception, is used.

The major obstacle to complete eradication of polio, and the reason for an extra perforation in many, has been ignorance and misinformation.

Religious fundamentalism, to be blunt, is to blame for the ongoing existence of this crippling illness, and for many completely unnecessary deaths.

Grand Rounds

2007-01-24T15:06:00.000+11:00

Grand Rounds for the week are now up at Signout.

Signout is an interesting blog from the Scienceblogs.com menagerie, written by a 1st year US medical resident.

A well thought out presentation this week, in the format of a scientific paper.

Unfortunately, at least in the opinion of the Dork and a few others, there continues this week the trend towards designated thematic content rather than non-specific editorial control by the host.

As an aside, Dr Dork apologises for the lack of normal posting of late, he has been a tad ~~lackadaisical~~ ~~lugubrious lazy~~ preoccupied.

The bloglines service is recommended as a way to keep track of sporadic posters such as Dr Dork, who has found it useful and fairly easy to use.

Earl Grey

2007-01-20T19:55:00.000+11:00

It is not the local cup of tea here at Chateau Dork. So to speak.

Nonetheless, Dr Dork nominated Dr Flea for best new medical blog, and Dr Crippen for best overall blog. Which he is pleased to see they have won.

Irregardless of Dr Dorks tendency towards introspective navel-gazing, it is nice to see such deserving docs showered with accolades. Dr Dork can highly recommend both blogs as entertaining and enlightening reads.

Dusk till Dawn

2007-01-19T16:02:00.000+11:00

Dr Dork is planning an overseas jaunt, hopefully in the not too distant future. He is re-acquainting himself with what little he vaguely recalls in the realm of tropical medicine and travel health. The below will likely be part of an ongoing series and is not intended to be definitive, comprehensive or suitable for personal medical advice. To reiterate...real, living patients with real health issues or concerns...should see real, living doctors.

Remember - Dr Dork is wholly a figment of your imagination...

Malaria

There are around 400 million infections worldwide, annually, as a ballpark estimate.

Between 1 and 2 million estimated deaths annually. That's 3 or so deaths per minute.

Most deaths are in young children.

There has been increasing resistance to antimalarial medications in recent times. Nonetheless, malaria is not only preventable, but eminently treatable.

Risk is greatest in Sub-Saharan Africa. 90% of malarial infections occur here. Mostly, deaths are in young children.

The risk of contracting malaria in SubSaharan Africa is around 1/50 per month of stay for a traveller, if no chemoprophylaxis is taken.

1 in 4000 travellers to high risk areas will die without prophylaxis.

In Australia, there are about 750 cases per year, with an incidence rate of 1.5/1000.

About 10,000 international travellers fall ill with malaria after returning home each year.

This is a drop in the ocean, in regards to the overall public health impact.

There are four different protozoan species causing malaria:

Plasmodium Falciparum (the nasty one that likes to eat your brain)
Plasmodium Malariae
Plasmodium Vivax
Plasmodium Ovale

The latter two like to set up camp in your liver but generally don't kill you.

P.Falciparum is most common on the African continent, P.Vivax in the Americas and Asia.

Transmission is, in essence, via infected blood.

Usually by the bite of an infected female Anopheles mosquito. Dr Dork has no idea why it is only females. This critter is found in most countries in the tropics and subtropics and loves to feed at night - hence "dusk to dawn".

The first step in malarial precautions is trying to stop the blighted little buzzing b*****s from biting you. Repellent with DEET (N,N-diethylmetatoluamide) is most effective, and at 35% strength gives around 10 hours protection. Clothing and bed linen/nets can be impregnated with a contact insecticide such as permethrin. A good spray of an aerosol insecticide before retiring is advisable, especially if rooms aren't adequately screened.

Longsleeved light clothing is preferable - mozzies are attracted to dark colours. Also to strong perfume and cologne. *What's the deal with safari suits, then ?

In summation -

1. Dress like Michael Bolton

2. Lather yourself with a neurotoxic chemical
3. Develop a noisome aroma

There is no vaccine. Not exactly a "Big Pharma" priority.

And, of course, the chemoprophylaxis - ie. preventative antibiotics. Dr Dork doesn't like taking antibiotics if he can avoid it - he tends to be rather prone to side effects, and recalls having a decidedly unpleasant anaphylactic reaction to penicillin when given it as a teenager.

No antibiotic provides 100 % cover.

Doxycycline

Taken from a couple of days before entering the malarious area, until 4 weeks after leaving. One 100mg tablet, once a day. Dr Dork likes that aspect - easy to remember. Not an option if up the duff (Dr Dork estimates his gut at 3 months gestation, oh dear) or prone to peptic ulceration or similar problems. About 1 in 25 get oesophagitis, and candidiasis is common. Interestingly, a small proportion develop an alarming propensity to photosensitivity and sunburn. Dr Dork is already ruling out this one for himself - he took doxycycline once before in the middle of summer. The result was amusing for all and sundry.

Mefloquine

This is the one that seems to have all the horror stories. The good news is that it is just one 250mg tablet, once a week, for a couple of weeks prior to entering the risk area and for a month after leaving. The bad news is the contraindication in psychiatric illness and cardiac conduction abnormalities. Pretty much rules that out - the Dork is well and truly bonkers, and has a questionable ticker to boot.

Apparently the risk of seizures/psychosis/major depression is generally low (1:10 000) but is potentially much higher in those of us with a history of psychiatric illness. Even those with their heads screwed on correctly have a 10% incidence of minor "neuropsychiatric" sequelae such as insomnia, mild agitation, and weird dreams.

That's two down for Dr Dork...

Malarone (atovaquone/proguanil)

Bit on the expensive side, but only one 25omg/100mg tablet once a day as with doxycycline. Also need to start only a day or two prior, but can stop just one week after leaving the malarious area. No good in the gestating, but after auscultating his gut throughout this posting Dr Dork is sure no fetal heartbeat is audible. That kicking must have just been last nights souvlaki...

This one needs good kidney function, and Dr Dork got such a good price for one he is pretty confident about the other. Generally pretty well tolerated, apparently, the odd headache or upset gastrointestinal tract. Dr Dork considers his persnickety bowel emotionally labile at the best of times so this won't be a new problem.

A quadruple dose of malarone also serves as emergency self-treatment for a few days if unable to obtain suitable medical care and one becomes unwell with suspected malaria. The Dorkbowel might be miffed if it comes to that, though.

The reason for the continuing antiobiotic use after leaving the area is referred to as terminal prophylaxis, as some malarial strains (especially P.Vivax, P.Ovale) tend to have dormant liver stages.

Furthermore, one needs to keep potential exposure in mind for a year or two after returning from a risk area, it seems - a pyrexia of unknown origin should generally be considered malaria until proven otherwise if you've recently been to a risk area.

What is it like if you actually have malaria? Dr Dork doesn't know. He has never seen a patient with acute malaria. Part of the reason for the death rate in travellers seems to be the vague nature of malarial presentation, and the tremendous potential for variability in incubation.

In extremis, especially with P. Falciparum, there is often anaemia, jaundice, neurological effects...but especially with milder strains it is described as generally a "flu-like" presentation.

Great. Dr Dork will be panicking over every sore throat for a year.

Risk assessment for the Dork itinerary has a lot to do with location and accomodation, it seems. This is to do with the distribution of various strains, which also varies with the time of year, and with regards to the expected degree of exposure to the mosquito culprit - such as whether you're sleeping in a plush hotel with screened windows or on the beach.

Dr Dork is one of those whom, for reasons unknown, seems especially tasty to mosquitos. There are all sorts of theories to do with blood type, various hormonal levels and whatnot - but no hard evidence as to why some have tastier blood according to mosquito connoisseurs.

Maybe Dr Dork should wear one of these.

More info:
CDC
WHO

Languorously Knackered

2007-01-18T20:29:00.000+11:00

Dr Dork is tired.

Good tired.

Busy week at work. More urban ranging than usual today, running some errands. Excuse the pun.

Yet, the mood is good. Pleasant. Euthymic.

Call it what you will, the Dork feels good for having galavanted about today.

Exercise alleviates depression. Lifts the mood.

The effect is evident even now, when the black dog is at bay.

If you're feeling a mite down in the dumps, Dr Dork heartily recommends a spot of exertion.

Go for a stroll. Pummel a punching bag. Whatever suits.

You'll feel better.

Guaranteed.

Grand Rounds

2007-01-17T08:39:00.000+11:00

Grand Rounds for this week are up at Six Until Me.

Six Until Me is one of many intriguing and perspicacious patient blogs Dr Dork has encountered. It is written by Kerri, an American journalist who has lived with type I diabetes for over 20 years.

Dr Dork is very impressed by the format of grand rounds this week - presented in the format of a lyric poem, and very well done at that.

Chauceresque !

The Clock Ticked One

2007-01-15T08:49:00.000+11:00

It is now one year to the day since Dr Dork first appeared.

As can be seen from the first post, Dr Dork was originally created to enable easier commenting on other's blogs. The disclaimer was added later.

Dr Dork discovered the world of medical and health blogging late in 2005. Some of his early favourites were Intueri, Barbados Butterfly, Orac and the now sadly departed Shrinkette.

Dr Dork was unsure why he began blogging in the first place, but made an early attempt to synopsize his reasons. His reasons haven't changed, albeit he strayed a little towards the dark side after returning from his extended sojourn.

It has been good to follow the development of other bloggers, in particular those who began around the time of Dr Dork:

Dr Crippen of NHSBlogDoc is an entertaining, prolific writer who has grown into a powerful voice advocating NHS reform in the UK.

Dr Flea has also been leaping and bounding to new heights regularly, in particular penning a series of posts rationally discussing immunisation in children - notably at the risk of enraging the misguided zealots who troll the internet with the intent of flaming away rational discourse opposing their blinkered worldview.

And Shiny Happy Person, of Trick Cycling For Beginners, with whom Dr Dork feels much empathy. TrickCycling has, like Dr Dork, waxed and waned at times as it's author struggles with psychiatric illness. Dr Dork, with only unipolar dysfunction, has it comparatively easy.

As Dr Dork blows out his solitary candle, his wish is for a speedy recovery for Shiny Happy Person.

Doctor as Patient II - Depression

2007-01-13T21:22:00.000+11:00

It is best to begin at the beginning.

The aetiology of depression is loosely described as biopsychosocial.

Biological

There is certainly an hereditary element to depression. A genetic predisposition. A biological component, independent of circumstances good or bad. Exactly where and how and to what extent is not well understood. Suffice it to say that the degree to which depression is biological varies from person to person.

Psychological
Much of the above paragraph can be reiterated with 'psychological' replacing 'biological'. the extent of causative contribution is quite variable. To simplify, one could say a pessimistic propensity is at play (Dr Dork never turns down an alliterative opportunity). Negative thinking patterns, whatever their genesis, are self-reinforcing.

Social
One way Dr Dork conceptualizes this impact is that, for a given degree of depression, the extent to which it is impairing can partially relate to one's social circumstances. For example, someone socially isolated is more prone to a greater degree of social withdrawal when depression develops than is someone with a close, supportive family and social network. Social factors such as excessive work demands, interpersonal conflicts, bereavements and the like can precipitate or exacerbate depression.

Alcohol and other psychoactive drugs, licit or illicit, could be classed as both a social contributor and a biological contributor, Dr Dork thinks. Alcohol, for example, can be alluring to the depressed and/or anxious for it's transient elevation of mood and anxiolysis, yet alcohol is a depressant of the central nervous system, and is known to accelerate, exacerbate and possibly initiate depression.

This triumvirate, the biopsychosocial model, is a fundamental element of medical school teaching. Although most salient in psychiatry, every doctor is taught to consider healthcare for each patient within the context of their individual biopsychosocial milieu. A patient is more than a broken machine, and doctors are more than technicians.

Depression, for Dr Dork, has been aetiologically related to all three elements.

Depression, for Dr Dork, has also had ramifications biological, psychological, and social.

In the extended Dork family, depression is not uncommon. There is something in his families neurochemical makeup that lends a certain predisposition to this particular ailment. When depressed, all sorts of 'physical' aspects manifest directly, what psychiatrists refer to as physiological shift symptoms.

Psychologically, Dr Dork shares many traits common amongst doctors. Perfectionism, fear of failure, unforgiving of one's foibles, with a record of placing one's own needs for sleep, nutrition, exercise and rest a distant second to his vocational demands. Furthermore, Dr Dork is in many ways the typical Australian male: poor at openly discussing his emotional needs, in denial of his own distress, maintaining a resolute facade to all, and attempting to drown his demons at times.

Socially, the tendency to overload himself has been a contributory factor at times. For Dr Dork, this has been another method of 'escape', at times, which is also doomed to fail. And in his dark times, the costs to relationships, family, career and finances have been steep.

For these many reasons has the black dog lingered long, in the shadow of Dr Dork.

That is enough for today. This is a long tale to tell, and not altogether pleasant in the telling.

More another day.

Change of Shift

2007-01-11T17:47:00.000+11:00

Change of Shift is a blog carnival written by nurses and/or about nursing, begun by the always entertaining Kim of Emergiblog, where it is hosted this week.

A different perspective, one suspects, than Grand Rounds which tends to be dominated by doctor blogs.

Submission guidelines and more info on Change of Shift here.

A Whimsical Interlude

2007-01-11T09:38:00.000+11:00

Maria of Intueri recently asked a group of medbloggers with delusions of literary grandeur to contribute to a creative writing project. The rules were simple: Each contributor would add one sentence at a time only, of any length, and never consecutively.

This is the result, presented for your amusement:

THE FIRST DRAFT

There was a lot of blood on the floor.

His foggy mind focused on the congealing pool closest to his head—-and the large shard of aquarium glass with green algae on one side—-and two thoughts circled each other: why doesn’t anything hurt, and where was his brand-new poisonous puffer fish? John’s first question was answered almost immediately as he tried to lift himself up off the floor.

Still leaking blood, which oozed slowly, as if afraid of what it would find, was another body, parallel to his own, head tilted away, neck twisted hard to the back.

He sighed with irritation; when he’d woken refreshed this morning between the Egyptian 700 thread count sateen sheets that Sadie had brought back from Paris he’d anticipated that today would proceed smoothly. Whenever Sadie was involved, though, nothing went smoothly: was it really that surprising that both she and John were vying for the exact same puffer fish that promised not only a financial reward of exactly 3.14159 million dollars, but also the guaranteed opportunity to work with the exacting Dr. Crust, who was internationally revered for his research in the use of pies as drug delivery systems?

He wiggled his fingers and toes and all seemed in working order, although there was tingling in his left ring and middle fingers and the left pinky was completely numb, leading him to wonder about possible nerve damage. His mind still on pies and puffer fish, John dragged himself towards the other body, afraid to look, though certain in his own mind of whose body it was.

He gasped in horror.

It was as if he were looking in a mirror: for years he’d had dreams—nightmares, really—of having a twin, but he’d dismissed them because they only occurred after Chinese take-out. Looking into his own glassy, lifeless eyes, he saw his own terror returning tenfold. He stumbled backwards and something fell from the pocket of his scrubs: the crumbled remnants of a pork pie.

“Damn!” John said to himself; not only had he lost the puffer fish he had intended to use to ingratiate himself to Dr. Crust, not only had he awoken to find his long lost twin brother lying dead beside him, but that traitor Sadie had incredibly eaten the last slice of pork pie and then stuffed the crust mockingly into his pocket before sneaking off.

But had she discovered the polonium-210?

John wasn’t sure what upset him more, the fact that Sadie may have discovered the secret to pies with wrinkle-defying moisturizer or the fact that his identical twin was the ugliest person he had ever seen in his entire life. But since there was no time to ponder such imponderables, he forced himself to his feet and headed toward the door, pausing, for old time’s sake, for the last time to lick the algae off the aquarium glass.

Mmm… tastes like pork pie, he mused to himself before his attention was drawn to the shifting, prickly sensation near his groin. The genetically modified puffer fish—the single, viable specimen—was poised in his lap, venomous teeth preparing to bite.

He was unaware that the puffer fish, intended for sushi, had been fed the stolen polonium-210. In its radioactive fury it had grown to immense proportions, puffing its chest in and out like a bull about to charge. John knew he was just seconds away from becoming a soprano unless he was able to dislodge this massive sea creature from his nether regions. His mind raced, faster and faster, sifting, sorting until it landed on the fire extinguisher hanging on the wall: could he use it as a puffer slougher?

When he saw his mind splattered on the fire extinguisher, he gingerly touched his head, felt the sticky blood oozing from the gaping hole near his ear, and wondered how he managed to launch his mind out of his skull at such a high velocity. Acting purely on innate survival instinct, John grabbed the tail of the fish, a split second before its jaws closed, and hurled it away towards the door, which opened to reveal someone he knew only too well.

“Dr. Crust… uh… how, uh… sir, sorry, I thought you were coming tomorrow,” John stammered, automatically reaching to straighten his tie. The enraged puffer fish dropped from where it had struck the wall above the door, and viciously latched itself to Dr. Crust’s nose!

“Aahhh, yes!” Dr. Crust screamed in simultaneous pain and rapture. “At last you have brought me my precious!”

Despite the preternatural grip that said fish had upon his facial protuberance, Dr. Crust smiled triumphantly and began to hum a tune: “The Dance of the Puffer Fish”. In disbelief, John stared as the puffer flopped to the floor and began, artlessly but in time to the music, to “dance”, while Dr. Crust laughed demonically and surreptitiously reached into his hip pocket. He pulled out a slender gold chain from which dangled a small, empty vial, an open locket that contained a sepia-tinted photograph of a smiling Sadie, and a flour-dusted hand mixer.

John spluttered in confusion: “I don’t understand this, Crust—what’s going on here?”

“Sadie left you this morning for dead, selfishly hoping to reach me first,” Dr. Crust explained, “she inexplicably forgot the puffer fish that promised a financial reward of exactly 3.14159 million dollars and the opportunity to work with me… perhaps it was the horror she felt after she killed your long lost twin who had coincindentally shown up that morning after his 30-year, worldwide search for you… sucks for him…” Dr. Crust shook his head.

“But,” he continued. “He really was the ugliest person I had ever seen and I still intend to open the biggest, the best and the only chain of fast-food sushi stores this side of Tokyo; how sad for Sadie that the only fish she’ll be working with will be a Filet-o-Fish sandwich from McDonalds.”

John was flabbergasted, and barely managed to blurt out: “We can’t let her get away with this, especially if she knows about the algae—and who taught the fish to dance?”

“As for her tenure at McDonalds,” replied Dr. Crust, “that may be a just reward for her maniacal egocentricity; however, as for the fish’s ability to do the merengue, that is another story altogether.”

“The merengue, Dr. Crust?” John asked angrily because the word on the street was that the pork pies would impart the ability to do the macarena!

“Won’t you join me?” Dr. Crust sweetly asked and, the anger melting from his heart and brains oozing from his skull, John, smitten, placed his arms around the good doctor and they began to dance along with the puffer fish, with smiles on all of their faces, before Dr. Crust remarked, “Now about that polonium puffer fish pie….”

FINIS.

Co-authored by:

Barbados Butterfly
Keith RN of Digital Doorway
Maria of Intueri
Kim of Emergiblog
Dr. Charles of The Examining Room of Dr Charles
Sid Schwab of Surgeonsblog
Shiny Happy Person of Trick-Cycling for Beginners
Tundra PA of Tundra Medicine Dreams
And Dr Dork

Grand Rounds

2007-01-09T19:46:00.000+11:00

Grand Rounds are up at Dr John La Puma's Healthy News. The theme is one of Diet and Food.

Dr La Puma is an American Internal Medicine Physician who has written several books on aspects of diet and health and who apparently even hosts a television show about preparing healthy meals.

Lunch at Chateau Dork

No more blog awards !

2007-01-08T16:46:00.000+11:00

There are now at least 4 different blog awards that Dr Dork is aware of being plugged via blogs he reads. Dr Dork hasn't been looking, this is just what has been seen via other health-related bloggers. There are probably many more.

Dr Dork was a little bit uncomfortable about this plethora of self-aggrandisement to begin with, and the squirming of his conscience has only increased as others, such as Dr Crippen and Dr Flea have voiced concerns similar to his own.

It's hard to avoid the allure of the 'ego-boost' of such a popularity contest... but Dr Dork is beginning to feel like he is whoring himself away bit by bit in service of, well, incorrigible narcissism.

Dr Dork can understand the appeal for non-anonymous sites. Arguably, such blogs, whether intended or not, have the potential to increase the professional prestige, or at least the visibility, of their writers. So there is professional gain, feasibly, from such accolades as the various blog awards. Free advertising, if naught else.

Sites that receive income from advertising links would also have a logical reason to seek such accolades as such will increase their traffic, and hence their income from said advertisements.

But for those of us who blog anonymously, for our own personal ventilation and expression, there doesn't seem much point to the whole exercise.

There is, furthermore, the argument that some of the sites hosting these awards are commercial sites. In otherwords, sites generating income for their owners, directly or indirectly. And some of these awards probably draw huge amounts of traffic to their host sites.

For some, to be blunt, traffic = dollars.

So Dr Dork has decided to step back from further participation in this orgy of blogging awards. He wonders if it is like this every year ?

Cervical Erythema

2007-01-06T19:22:00.025+11:00

DownUnder, our healthcare system has been struggling to meet adequate staffing levels for many years now.

This is most evident in general practice and in the public hospital system.

Both are, to be blunt, kept afloat by overseas trained doctors (OTDs) recruited into the Australian system. There has been a boost in medical school places in the last couple of years, but there will be a long delay before this has a positive impact. It takes at least 10 years to train a family G.P. in Australia, and even longer in many other specialties.

The OTDs are generally forced to work in "areas of need" for many years after entry. This entails usually one of two things - being forced to work in our struggling urban public hospitals, or (especially for GP's) to work in a remote and isolated rural or semi-rural area.

If Brits stopped coming here on extended "working holidays" and filling many of our junior grade hospital positions, the entire system would collapse.

What Dr Dork suspects is most challenging for OTDs, however, is that of ending up in the Australian bush for those of a different cultural origin.

Image source

Rural medicine in Australia is very different from city medicine. Australia is vast, our population relatively small. And most of that population is concentrated in our urban coastal enclaves. In the bush, there aren't many hospitals. Or many specialists. Ancillary services may be a thousand kilometres away. Our indigenous people, to our great shame as a nation, are plagued by Third W orld health concerns whilst in our cities there are Botox clinics and 5-star private hospitals.

Dr Dork has worked in the bush. He still does, not infrequently. Dr Dork's grandparents were farmers, yet he still finds it hard at times to connect with and adjust to bush life. He can only imagine how hard it is for those coming to Australia from extremely different cultures in places such as Europe, Africa or even our Asian neighbours.

Dr Dork had this illustrated today quite explicitly. A patient came to see Dr Dork for a second opinion. This patient lived in a rural area, and had been under the care of a doc local to his area for a few weeks. From the name on the documentation shown to Dr Dork, this doc was clearly of Middle Eastern extraction. The care he had provided, as far as Dr Dork could ascertain, was perfectly appropriate.

Yet the patient was rather disenfranchised. Very derogatory in regards to the other doc.

The problem was not clinical competence. Perhaps communication with the patient had not been ideal as there was some degree of language barrier. But mainly, it seemed about race.

Dr Dork treats all his paients the same, he likes to think. Be they saint or sociopath.

For some the mask is harder to wear.

Absent poetry

2007-01-05T02:35:00.000+11:00

Incorrigible Narcissism

2007-01-04T22:32:00.000+11:00

The Medical Blog Awards

Dr Dork is honoured and somewhat abashed to have been nominated in the 2006 Medical Blog Awards in the Literary Medical Weblog category.

Having a look at the polls so far, it appears that all 3 of Dr Dorks regular readers have already voted, nonetheless it is worth paying a visit to Medgadget to check out the various nominees if you're looking for some excellent medical and health blogging to read.

The voting closes on Jan 14th. Dr Dork will be leaving up a link in his sidebar in the hope a few readers might inadvertently click on it - Dr Dork is considering posting a picture for his exiguous readers if he gets over 10 votes...you have been warned!

The AntiVax Hordes

2007-01-04T21:24:00.000+11:00

In keeping with the recommendation of Dr Crippen, Dr Dork is adding his voice to the chorus of the reasonably minded and rational in regards to immunisation, as are many in support of the recent focus on this topic by Dr Flea.

In regards to the various childhood immunisations, and also for adults (especially when travelling), Dr Dork recommends you discuss your specific, individual situation with your specific, individual doctor.

If you haven't seen them yet, Dr Dork recommends having a gander at Fleas concise, coherent articles on:

Hepatitis B - Yellow Alert

Chickenpox - Dew Drops on Rose Petals

Whooping Cough - The Cough of One Hundred Days

Tetanus - Risus Sardonicus

Diphtheria - Strangling Angel

Haemophilus Influnzae Type B- Go Home and Die

Polio - The Can from Hell

Smallpox - On my Left Shoulder, A Very Great Fright

Urban Rangers and Egyptian Watercourses

2007-01-03T20:17:00.000+11:00

Dr Dork was lurking around intueri recently. Amongst, in essence, waxing lyrical upon her resolutions for the forthcoming year, Maria happened to make mention of something or someone called "urban rangers".

The Dork followed the link and found this interesting site which is the work of a gentleman called Reinhard Engels. It is a collection of what he refers to as everyday systems. The urban ranger is by far the best of the lot, Dr Dork thinks.

In apercu: "We've invented one class of machine to spare us physical exertion, and another class of machine to inflict it back on us again, but in an infinitely more boring, painful, and useless manner."

Dr Dork likes this kind of thinking.

As has been discussed before, obesity is a major problem in all Western societies. It is tantamount to a pandemic. We Docs don't really care what our patients look like in an aesthetic sense, within reason, we care about obesity as it complicates, exacerbates and causes such a vast array of health problems, costs our society billions and our individual patients many years of life.

Dr Dork has straddled both sides of this fence. Before he dropped 30 kg (65 lbs) a few years back, he was guilty of the same rationalisations, defences and methods of denial that he now sees in his patients.

The urban ranger approach is simple : incorporate walking into your day. Walk to the local deli or the video store, don't drive. Walk to work, or at least to/from public transport routes.

Dr Dork used to say to himself he was too busy, too tired, not enough time, other priorities, ~~too many restraining orders, too many complaints about his spandex bodysuit.~~

*Ahem*. Lets just say there is always an excuse if you want to find one.

Dr Dork found that the excuses tended to fade away when he ignored them. Kind of like a reverse Mr Stay Puft. Once he started exercising, he was less tired. He slept better, and woke up earlier, giving him more time. And so forth, for each apparent impediment.

Dr Dork now rarely drives. He walks or cycles to and from work, the local shops, nearby friends and family - whenever possible. Maybe hops a bus or train or tram part of the way.

Dr Dork doesn't bother spending many hours and dollars at the gym anymore - he gets all his exercise by simply incorporating it into his day.

Like a good urban ranger. Won't you join the Dork ?

Grand Rounds

2007-01-02T20:18:00.000+11:00

Musings of a Distractible Mind is a highly entertaining blog written by Dr Rob, a multi-talented US Internist and Pediatrician.

It is certainly one of the most amusing medical blogs Dr Dork has had the pleasure of discovering since his return from ~~holiday~~ ~~incarceration~~ ~~sabbatical~~ ~~exile~~ hiatus.

Dr Dork has already learnt something he didn’t know about emus by visiting there today.

Grand Rounds is up - including soundtrack and explosion theme (!) here.

The Placebo Effect

2006-12-31T14:23:00.000+11:00

In his private and personal life, Dr Dork is...a dork. A dweeb, a dolt, a dummkopf.

Yet in his interactions with his patients, he exudes confidence, charm and reassurance.

This is a conscious decision. This is an aspect of the mask.

This is, in essence, utilizing the Placebo Effect to help his patients.

Dr Dork does not think he is being misleading or deceptive. He gives bad news truthfully, but with some dorky aplomb, he hopes. He ensures his patients are aware of potential pitfalls of treatment options. If he thinks a particular medication might help a particular patient, for example, he uses words such as "could" and "might" as opposed to "will". He gives probability outcomes where there is good evidence for such.

But Dr Dork knows that his subtle, subvocal clues, his body's unspoken language, his demeanour and so forth...have themselves a potentially significant contribution to the healing process. Especially in regards to symptoms of pain, depression, nausea and other scenarios where there can sometimes be a large psychological element contributing.

As strange as it may feel in the hands of a Dork...like any tool at his disposal to help his patients, it is sharpened, oiled, and used to best effect.

The Mercy Seat

2006-12-30T00:59:00.000+11:00

Dr Dork, as any doctor, has a fundamental difficulty with the concept of 'capital punishment'.

Is Dr Dork ' a softie '.

Maybe.

The Mercy Seat - Lyrics

Dangers of Dial-A-Diagnosis

2006-12-29T19:02:00.000+11:00

Dr Dork was saddened to hear of this tale of unnecessary death in Queensland.

There have been pushes in various Australian states for such "telephone triage" services. At the very best, they are staffed by nurses. Often, by persons with little clinical background in any discipline.

This is very, very dangerous territory.

Any doctor or nurse of reasonable experience knows well that medicine is art, as well as science. That clinical judgement and acumen are acquired through experience. That, sometimes, one can tell that something is just not right at a glance, without being able to put our finger on any objective criterion on which to pinpoint our suspicion...that something is subtly awry.

Dr Dork feels uncomfortable providing telephone advice to a patient he has not seen, and cannot see. He feels this is Bad Medicine.

These "health hotlines" are about bureaucratic cost cutting. A layer of insulation to shield ambulance services and emergency departments. As Dr Crippen and others have discussed in regards to NHS Direct in the UK.

Dr Dork does not know the specifics of what actually occurred in the Queensland case. This is pending on autopsy results.

Dr Dork knows well, however, that an ill wind bodes no good.

Absent poetry

2006-12-27T02:37:00.000+11:00

Grand Rounds - 2006 Highlights

2006-12-27T00:55:00.000+11:00

Nick Genes, the founder of Grand Rounds, has engendered a summary of the most interesting posts of the year.

Well worth perusing.

Two Tiers (Part the Second of n)

2006-12-26T19:15:00.000+11:00

"In a country well governed poverty is something to be ashamed of. In a country badly governed wealth is something to be ashamed of."

Confucius

"And the King shall answer and say unto them, Verily I say unto you, Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me."

Matthew 25:40

"The degree of civilization in a society can be judged by entering its prisons."

Feodor Dostoyevsky

"The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped."

Hubert Humphrey

Dr Dork notes a quintessential contrast in what he perceives of the US and UK systems, and of those exponents and critics of their approaches to healthcare.

The NHS is disparaged as “socialised medicine”, as if that is a failing unto itself. Of course, private companies driven by shareholder profits would not exactly be more compassionate, one thinks, in attempting to distribute a limited resource unable to keep pace with demand.

The US provides well, but at great direct financial cost to its users. Dr Crippen, of interest, pointed out the frighteningly high correlation between medical costs and personal bankruptcies in the US. Yet, as far as Dr Dork can infer from his US colleagues, the system is underpinned by a “socialist” Medicaid network.

Australia is a mixture of these two approaches. Here in Oz, we have traditionally operated primarily as a public healthcare system for the most part. In recent years, there has also been increasing growth in a separate private healthcare system. Rather than funding by largely employer sponsored insurance, as in the US, ‘private’ healthcare is funded generally by paying insurance premiums oneself. The exception to this rule is occupational health problems, wherein the cost of treatment (whether via the public or private system) is funded by the employers insurance.

This system is inherently possessed of two tiers of care level – in many areas, but not all. The public system struggles to meet demand in many areas. Emergency departments get overcrowded. Waiting lists for elective surgery are sometimes ridiculously long, and numbers are politically obfuscated. Only in the private system can you choose your doctor, choose your hospital, and not spend several months on firstly a waiting to be seen list, then a waiting to be treated list.

However, for acute, devastating injuries and illnesses, public hospitals are, arguably, much better equipped. Larger and better staffed ICUs, for example. Medium level staff always onsite.

One important annotation to the ‘private’ system is that health insurers in Oz are not-for-profit. There is no CEO earning $30 million in bonuses. There are no shareholders demanding cuts in coverage to boost their stock portfolio.

As mentioned in his previous post, Dr Dork is cogitating out loud on the two-tiered system in which he operates. This is further groundwork.

There is more to the story than this précis. Arguments for and against each approach. Dr Dork would love to hear from others experienced in multiple healthcare systems, as health provider or patient.

To echo the sentiments of Dr Crippen, in large part, Dr Dork is open in his bias: he believes healthcare is a right, and not a privilege, in any civilised society. Tax-based support of the public system in Oz is positively biased to place costs moreso on the wealthy who do not self-insure than the poor (the Medicare Levy).

It becomes, one could say, essentially an argument of efficiency and management, of finite resources confronted with ballooning demand, as our knowledge of the health sciences grows, and our populations age demographically, and live longer lives. Neither approach seems sustainable in the long term.

More on this at a later date. Your opinion is welcomed.

Merry Christmas

2006-12-24T01:57:00.000+11:00

Dr Dork likes this picture so much, he has decided to share it again.

Dr Dork would also like to apologise for inflicting his musical tastes upon his audience.

Merry Christmas.

Peace, and goodwill, to all.

Annual Accolades

2006-12-23T15:49:00.000+11:00

As far as Dr Dork is aware, there are two ongoing "awards" for health bloggers decided each year by internet voting.

The venerable and highly respected Orac over at Respectful Insolence was voted the best Medical/Health Issues Blog in the Weblog awards.

Orac is particularly known for examining the evidence basis of dubious medical/health claims, and for often drawing the ire of the rabidly vocal anti-vax minority.

The Medical Weblog awards run via Medgadget are currently accepting nominations and voting starts early in the new year.

Voting is limited to one vote per IP address.

Dr Dork is pleasantly surprised to have been nominated for the Literary Medical Weblog category, and extends his thanks to the nominator, wherever you are!

Dr Dork considers himself seriously outclassed but it is nice to appear on the nomination list, especially having only actively blogged for a third of the year.

Well worth perusing the various nominees for both of the above awards in all categories - a great diversity of health blogging is but a click away.

As Shakespeare Said*

2006-12-22T16:56:00.000+11:00

Dr Dork is irate.

Livid, even.

This case from the UK is one of the most ridiculous examples of tort law he has ever seen.

The anaesthetist in question is penalised for providing the advice that quitting smoking would prolong this persons lifespan. This is true. This is an attempt to act in the patients best interest. This is trying to do good, when it is easier to say nothing - to the belligerent patient in comfortable denial, regarding the ramifications of their habits upon their health.

Perhaps if the baby in question were premature, it could sue its mother for smoking throughout the pregnancy?

*"The first thing we must do, is kill all the lawyers". Dick the Butcher; King Henry VI, Shakespeare.

Despite popular interpretation as the first derogatory lawyer joke, in the context of Henry VI it is rather complimentary. Perhaps.

Absent poetry

2006-12-21T00:00:00.000+11:00

It's Christmas Grand Rounds, Charlie Brown!

2006-12-19T18:45:00.000+11:00

Mother Jones from the always interesting Nurse Ratched’s Place is hosting this weeks Grand Rounds - with a Festive theme.

An varied collection of yuletide related ramblings from a menagerie of medical bloggers this week.

Enjoy.

Dr Dorks Holiday Survival Guide

2006-12-17T16:00:00.000+11:00

The christmas / holiday season has, to Dr Dorks mind, been so corrupted by commercial interests that any semblance of the true altruism of the season appears lost.

It is also a time of year that is especially hard for many. It is often thought that rates of suicide, for example, peak. However, this is in actuality not the case.

Why ?

There has been some suggestion that the temporary boosting of services at such times is perhaps a reason, at least in part. This makes some sense to Dr Dork.

People do reach out more to others, at this time of year. Which is a good thing. However, come the new year, these good intentions may be often forgotten. Which is sad.

Better transient compassion than none, you might say.

Dr Dork has been of late considering whether he should gift his nom de plume a first name. 'Ebeneezer' had been suggested by Cathy following Dr Dorks reluctant and rather dour response to the "Christmas Meme".

Dr Dork was not being facetious in his responses. Added to the fact that he is wrangling the black dog at present, he understands why many loathe the 'festive season'. For Northern Hemisphere readers, this is also the time when Seasonal Affective Disorder is rampant.

Dr Dork has a simple prescription for making it through this period - watch this movie. And go easy on the eggnog.

The 2006 Medical Weblog Awards

2006-12-15T20:30:00.000+11:00

Dr Dork understands there has been a tradition of Medical Weblog awards organised via Medgadget for the last few years.

The nomination process is apparently now open and actual voting begins early next year.

Dr Dork already has his favourites for a few categories and is willing to consider any informal email bets, usually involving some form of public humiliation of the 'loser'.

Or is this just an Oz thing ?

Here are the winners from 2005

Infected with a Christmas Meme

2006-12-14T23:04:00.000+11:00

Dr Dork has been tagged with a Christmas meme by Rob over at Musings of a Distractible Mind.

OK then:

1. Hot Chocolate or Egg Nog?

Eggnog. No-one drinks hot chocolate when it's 40 degrees Celcius.

2. Does Santa wrap presents or just sit them under the tree?

Santa places the coal directly into the stockings.

3. Colored lights on tree/house or white?

Coloured on the tree, when I have one. There are motion activated spotlights on the outside to deter small children. Just like Halloween.

4. Do you hang mistletoe?

Nope. Not sure if it grows in Oz even.

5. When do you put your decorations up?

Last-minute if at all.

6. What is your favorite holiday dish?

Meringues.

7. Favorite Holiday memory?

When a toddler, noticing my father jingling some bells behind his back whilst pointing at "Santa flying over the roof'. Dr Dork is a born cynic.

8. When and how did you learn the truth about Santa?

See 7.

9. Do you open a gift on Christmas Eve?

No.

10. How do you decorate your Christmas Tree?

Haphazardly, if at all.

11. Snow! Love it or Dread it?

Love it, but it's not too common in an Australian summer.

12. Can you ice skate?

Very badly but technically yes. I broke my coccyx in an ice-skating mishap as a teenager.

13. Do you remember your favorite gift?

Yes.

14. What’s the most important thing?

Reinforcing the need for compassion, for helping/giving to others. And meringues.

15. What is your favorite Holiday Dessert?

See 6. And 14.

16. What is your favorite holiday tradition?

The backyard post-lunch cricket match with the extended family that has been continuing for decades.

17. What tops your tree?

Is not to be repeated in a PG rated blog.

18. Which do you prefer giving or receiving?

Giving, of course.

19. What is your favorite Christmas Song?

Little Drummer Boy, Charley Pride rendition.

20. Candy canes, Yuck or Yum?

OK....but I tend to re-use them each year. So they get a little stale.

Dr Dork understands that he is now meant to 'tag' several others who may wish to participate. So will tag :
A fellow Antipodean Barbados Butterfly
A fellow anachronism #1 Dinosaur
A fellow traveller Shiny Happy Person
A fellow curmudgeon Dr John Crippen
And DB, for the stimulating debate that has been evolving in his blog on the topic of
"personal responsiblity". Even though our opinions appear irreconcilable.

PS- please don't feel obligated if tagged. Dr Dork is aware that this is almost encroaching on chain mail territory. You will not develop a suppurating pustulence throughout your nether regions by ignoring the meme.

Well, probably not.

Canine Obedience Training

2006-12-14T00:48:00.000+11:00

Dr Dork has spoken of the Black Dog in a previous post.

Dr Dork has been acquainted with the Dog for more years than he would care to remember.

This year, the Dog has been rather troublesome.

Rather troublesome indeed.

The reacquaintance, at close range, with this rabid rotty has had more than a little to do with the absence of the Dork in recent months.

The Dog isn’t very nice company. Shiny Happy Person describes it more eloquently than Dr Dork could.

It’s been years since the Dog misbehaved like this..

No tugging on the leash.

No chewing the couch.

No howling at the moon.

No mauling Dr Dork.

Though the Dog is a faithful companion, in his way, and has his own lessons to teach, he is not welcome company.

Breathe. Keep Breathing.
Don't lose your nerve.
Radiohead - Exit Music

Grand Rounds

2006-12-12T21:38:00.000+11:00

Grand Rounds are now up,
at Anxiety, Addiction and Depression Treatments.

Dr Dork recommends sauntering on over.

We are what we eat

2006-12-11T19:17:00.000+11:00

There has been much brouhaha in Oz and in the

in recent weeks regarding attempts to restrict trans fats.

This gives a nice précis of the problem.

The AMA has been calling recently for either a ban on their use as a surreptitious additive (they currently sneak through a food labelling loophole, it seems), or at the very least for labelling requirements…so that people are at the least aware of the trans-fat content.

In some parts of Europe, stringent restrictions have been in place for many years.

Dr Wes, a cardiologist in Illinois has blogged recently on the topic following a ban on trans fats being enacted in New York, and is one of many voices noting that substitution with saturated fats will often occur, which isn’t really an improvement.

Dr Dork is a bit ambivalent about banning such things outright. He thinks the biggest issue at stake is the lack of disclosure – the situation whereby manufacturers have not had to disclose often inordinate levels of trans-fats until now.

As a doctor, Dr Dork sometimes thinks it would be nice if the ground opened up and swallowed Ronald and cohorts.

Ischaemic heart disease is our biggest killer, after all.

At the very least, we deserve to know what we are eating.

Take the quiz on dietary fats from the ABC Health Matters site.

Responsibility, Choice and Compliance.

2006-12-09T19:45:00.000+11:00

Dr Dork has been following with interest some posting earlier in the week by DB over at medrants, here and here...and here. More recently, #1 Dinosaur has thrown in his two cents with a thoughtful post on the topic.

Some interesting discourse has ensued in the comments section of DB's postings.

Essentially this is a discussion on the concept of a "reward" system for demonstrating personal responsibility in healthcare. The debate was sparked by this story.

As far as Dr Dork can tell, there appears to be considerable support in the US for such an approach in terms of health economics.

"Cost effective distribution of finite resources"
"Helping those who help themselves"

And so forth.

Dr Dork finds such a proposal....disturbing. This is not a question of economic principles.

If we reward only those able to comply with recommended treatment and lifestyle regimens, we are in effect punishing those unwilling or unable to comply.

As Dr Dork commented on the original debate on DB's medrants:

"In otherwords…punish those who do not, or are not able to, comply with recommended medical treatment ?

What of the doctor or business executive who develops a stress related cardiovascular problem and refuses to reduce their working hours ? Should they be refused treatment ? What if someone is non-compliant because they are unable to afford the medication ? What of the impoverished who are only able to afford junk food to eat rather than a broad healthy diet ?

In terms of personal responsibility, what if you cause a car accident(eg from fatigue, inattention) and suffer serious injuries - should your insurance be entitled to refuse you treatment?

Where do you draw the line ?

By this line of reasoning, are the homeless and poor in dire straits purely due to laziness ??

Are not mental health disorders, including alcohol and drug addictions, by their very nature characterised by poor insight and hence difficulties with compliance ?

Wolves may cull the weak from the pack…but we are human beings."

Such an approach raises profound philosophical, political and moral questions. It also reeks of countertransference towards "difficult patients".

This was brought to mind by one of Dr Dorks recent patients, Stan. Though seen by Dr Dork for another matter, Stan has been plagued by severe hypertension for years.

Stan is in his late 50s. He works a physical job. Long hours. Work is a bit sporadic, and Stan walks a financial tightrope. He takes several medications, for his blood pressure amongst other things. Some of these are not cheap.

Stan earns just above the low-income pharmaceutical concession threshold. Not by much. With all his health problems...he could probably go on disability if he wanted to. This would greatly lower his medical costs, and he would probably be fiscally better off. His medical costs are, almost entirely, his medication costs.

Stan is bulk-billed by his GP and specialists all. He is not charged anything out of pocket to see Dr Dork.

This week, Stan was waiting for a new job to start. He had to choose between paying his mortgage, and buying his blood pressure medications.

He chose the former.

Whilst not as astronomical as before treatment began, Stan's blood pressure was again high. Quite high, really. Not good. He already has a dodgy ticker.

Should Stan be refused followup and treatment from his cardiologist as he is a 'noncompliant' patient ?

Dr Dork doesn't think so.

Vote Flea

2006-12-08T20:29:00.000+11:00

For Dr Dork, Dr Flea is a favourite regular read.

Flea is a US paediatrician with an entertaining, sagacious style of writing, who is clearly driven first and foremost by the needs of his diminutive patients.

Flea has been nominated as a finalist in the 2006 Weblog awards in the Medical/Health category.

Dr Dork is wearing his shortest skirt and waving his pompoms exuberantly.

Sorry about the mental image.

Update: Dr Dork acknowledges that there are many other superlative bloggers in the same category, and intends no disrespect...but Dr Dork definitely has a soft spot for the Flea. Looks like the venerable quackbuster and woo-whomper Orac is lapping the field though.

Two Tiers (Part the First)

2006-12-08T16:15:00.000+11:00

In considering the state of the Australian health system, it is probably useful to be able to compare it to those of other countries.

Dr Dork, however, has firsthand experience of only a few different Australian states, and a relatively brief period of working in the UK last century.

Australia

, in theory, has a comprehensive public healthcare system. Dr Dork believes this is important. As Dr Crippen puts succinctly in regards to the ideological goal of the NHS in Britain:

“the concept of a decent standard of health care for all, independent of means.”

Dr Dork comes from a similar perspective. He believes access to quality, timely, comprehensive healthcare is a fundamental right of all Australian citizens. Like the right to speak freely, to dress as one chooses (within reason), to hold a protest march, to worship one’s chosen deity, to vote as one pleases to.

Not a privilege for those who can afford it. We’re not talking about caviar. Life, and death, are often at stake.

As far as Dr Dork can tell, the UK and Canada, as other vassals of the Commonwealth, also aim towards the provision of universal healthcare. With limited success, at times. To say the least.

No system attempting to manage such a vast, unpredictable yawning abyss of expenditure can be perfect. Where much of the disdain is directed, it seems, is the gross inefficiency of current systems. The administrative bungling of the NHS and Oz’s public hospitals. The obscene corporate profits of the private US insurers.

Australia has been, at the Federal level, under the sway of the conservative, right-wing Liberal party for a decade. For US readers, we find the name ironic as well. At the State level however, the Labor party runs the show. They are relatively left-wing, and historically Labor draws its power from the unions, the Libs from business and corporate interests. There are also the Greens and the Democrats, but neither has come close to holding the balance of power.

So every single time there is another health crisis - and various aspects of the system are often overloaded, some constantly - the same dance occurs. The States blame the Federal government. The Federal blames the States. Nothing gets done. The media moves on to dead donkeys.

This is not a topic that is lightly broached. Dr Dork is very interested in hearing the perspectives of those who have experienced multiple disparate healthcare systems, as doctor, nurse, allied health staff and, especially, as patient.

Dr Dork is just laying some groundwork today.

To be continued.

The Mask

2006-12-07T18:07:00.000+11:00

Dr Dork is not a psychiatrist.

However, one skill he recalls well from his time as a psychiatry registrar is that of the mask. The façade.

This is a necessary thing, at times, in all of medicine. Particularly psychiatry.

A fundamental ethos of medical practice is the necessity to maintain an emotional distance from ones patients. The principal reason is to enable objective judgements to be made, without emotional bias. This protects patients.

Doctors in Oz are discouraged from treating family or close friends, for example. Our emotional attachments result in us usually either undertreating or overtreating. Both of which can be harmful.

Primum non nocere, after all.

A doctor allowing their emotional reaction to a patient to compromise their decision making is perhaps an example of countertransference. A good doctor provides the optimal care to each and every patient, be they saint or sociopath.

But doctors are subject to emotional reactions just like everyone else. Some of us get very desensitised, unfortunately, as a protective defence.

The key, at least to Dr Dorks mind, is not allowing our emotional reactions to affect our decision making. And, obviously, to not express our emotional reactions. Whatever they may be.

To maintain the facade. Protecting the doctor, perhaps, but principally protecting the patient.

Yet we still feel. We feel the lonely, lingering, untimely death that we cannot prevent. We flinch internally at the barrage of expletives. We seethe inside at the dozen old fracture lines on the malnourished childs Xray. Our pulse skips a beat at your drunken threat to our family.

We all learn to wear a mask.

Sometimes it’s hard to take it off.

Grand Rounds

2006-12-06T14:51:00.000+11:00

Grand Rounds
are now up at
The Antidote.

My, how this phenomenon is growing. Exponentially, it almost seems.

Dr Dork will need to pack a cut lunch and a thermos of tea to get through all these...but nonetheless anticipates reacquaintance and new discoveries both.

Happy reading.

Notifylist given notice

2006-12-05T20:23:00.000+11:00

Dr Dorks posting regimen has always been rather erratic.

Hence the decision to recommend his readers put an email address into the NotifyList thingamajig.

To use the technical parlance.

Unfortunately, notifylist continues to…well…not notify people on the list.

This was a problem prior to Dr Dorks sojourn and is rather irksome.

Thus the decision to terminate NotifyList.

All email addresses registered with the notifylist function have been sold to the Russian spamming mafia, for a tidy sum.

Just kidding. All have been destroyed.

Dr Dork has been noticing many seem to be using RSS and similar notification systems. Seems like a good idea. Any recommendations?

Bearing in mind that Dr Dork is not especially au fait with all these electrickery doohickies and whatnot.

Dr Dork would like to mention the cricket, but is averse to being flamed by his erudite British colleagues. So he won’t.

Back from beyond the back of beyond

2006-12-05T01:49:00.000+11:00

Dr Dork is pleased to confirm that the rumours of his demise are greatly exaggerated.

Each and every expression of concern is met with gratitude.

Dr Dork also notes that his unofficial hiatus far exceeded his official hiatus. Typically dorkish behaviour. Or perhaps doltish.

Dr Dork has been recently acclimatizing to the changes in the health blogosphere during his 7 month absence.

The cockles of his heart have been warmed by sentiments sweet, and by virtue of not being forgotten…despite his absence exceeding his presence.

Dr Dork is pleased to see many of his favourites still kicking against the...well, you know what.

Saddened to note the absence of some eminent colleagues.

Enamoured with the many new voices.

Time to update the blogroll.

Let us, then, be up and doing,
With a heart for any fate;
Still achieving, still pursuing,
Learn to labor and to wait.

A Psalm of Life

Henry Wadsworth Longfellow

Absent poetry

2006-12-04T18:25:00.000+11:00

Faire ses adieux, bon ami

2006-11-13T02:20:00.000+11:00

Dr Dork would very much like to thank his readers, commenters and well wishers.

He has not been well.

Apologies for not being able to reply to all comments and emails.

This blog is officially, now, in hiatus.

Dr Dork hopes to return to blogging in the future, particularly regarding the perspective of a doctor struggling with chronic health issues. Acute on Chronic of late, albeit.

Please join the notifylist if you would like to be informed if and when Dr Dork returns to the fray.

Warm regards to all fellow healthcare bloggers and all readers.

Dr Dork, signing off for now.

Grand Rounds

2006-04-12T14:51:00.000+10:00

Grand Rounds are up at Anxiety, Addiction and Depression Treatments.

Well worth perusing, a broad selection of healthcare blogging, with a spotlight on mental health.

Doctor as Patient I - Cardiology

2006-04-11T12:21:00.000+10:00

Before launching into this first of many sorties into the travails of a cantankerous, cynical doctor in his adventures as a cantankerous, cynical patient...Dr Dork would like to make one thing clear.

Dr Dork has been getting a bit "touchy-feely" in his last post and comments.

Dr Dork would like to reiterate that he is still definitely a grumpy old bastard. 'Nuff said.

Cardiology.

Dr Dork spent some time working as a junior doctor on cardiology wards and in Coronary Care Units. And in emergency departments. He finds this area of medicine a bit of a mystery still at times. The difficulty is not in diagnosing an acute cardiac event...rather in working out what the hell is going on if cardiac enzymes, ECGs et cetera are normal.

Even though it is not his area, his clinic is not particularly close to an emergency hospital, so Dr Dork not infrequently gets a patient presenting with chest pain as he is "the nearest doc" to quite a few.

Dr Dork knows all the protocols for managing the serious side of things; arrests, anaphylaxis and the like. These kind of things are drummed into us ad nauseaum, no matter what area we practice in. Even back when he was doing psychiatry, Dr Dork had to do "resuscitation training" every 6 months.

A growing problem is how the management has been affected by the increasingly litigious climate here in Oz. It is the most common reason general practitioners in Oz are sued. So, in response, pretty much every single patient with chest pain presenting anywhere except to a cardiologists practice is now referred immediately to hospital. With the attendant expense to both the patient and the beleaguered public hospitals.

Unless they just put on a new shirt without taking the pins out. Even then it's touch and go.

Nonetheless, as a patient...it is a frightening position to be in. Simply being male increases risk. As does the work of Chronos. Heart disease is the biggest killer in Western society, after all. Of both genders.

Dr Dork would like to share some of his experiences as a cardiology patient, that he was not quite so aware of when on the other side of the desk.

1. It is impossible to sleep when you are wearing an ambulatory blood pressure monitor. This is a machine that involves an inflatable cuff being worn around your upper arm, wired up to a small device worn at your waist. It inflates to a level sufficient to cut off arterial circulation in your arm. Every single hour. For at least 24 hours.

If your partner grabbed your upper arm and squeezed as hard as they could every single hour during the night, Dr Dork suspects this might qualify as grounds for justifiable homicide.

2. If you have symptoms of a cardiac arrhythmia and wear a 24 hour ECG (Holter) monitor, you are guaranteed to experience symptoms immediately before the monitor is connected...and soon after it is disconnected.

3.Fixomull is rather painful indeed when removed from the chest in large quantity. Especially if the patient is worried the ECG Holter Monitor leads it has been used to affix are a bit loose. And the patient then adds significantly larger quantities of Fixomull than had the ECG technician. Covering a nipple.

Dr Dork understands how Steve Carell felt.

Lazarus, arise !

2006-04-08T19:47:00.000+10:00

Dr Dork is back on the air.

Or the net. Or whatever the kids call it nowadays.

Many thanks to all well-wishers. Apologies for such a long absence. Dr Dork has been crook, to use the Oz vernacular.

Dr Dork considers himself still relatively young. His hair follicles might beg to differ.

Nonetheless, there has been a fair amount of illness in his life, especially in the last 5 years.

Some cardiological things. Some gastrointestinal things.

But most of all, the Black Dog

Depression.

Some readers will have inferred this already, perhaps, from some of Dr Dorks previous posts.

This will be elaborated upon later. As an ongoing theme. In much detail. You have been warned.

Dr Dork has spent many hours, whilst squirming uncomfortably in the patient role, pondering the reasons he began a blog in the first place. He thinks there are a few.

1. Dr Dork is opinionated.

He holds the view that the world should be a more just and fair place than it currently is. According to Cognitive Behavioural Therapy (CBT) principles, he now understands that this is classified as the "fallacy of fairness". Whilst Dr Dork accepts every other cognitive distortion that Ellis et al propose, he's stuck on this one. Blogging alleviates a sense of injustice. Like any half decent medico, Dr Dork gets pissed off at things that impact negatively upon the health of the society in which he lives, and on his own patients.

Ventilation, in a nutshell.

2. Education.

Dr Dork knows that a lot of patients seek information over the internet. This can be beneficial, or can be dangerous. As a general principle, Dr Dork thinks it is fantastic when patients take responsibility for their illness and want to be well informed. It bodes well for outcomes. But there is a lot of biased misinformation out there. Dr Dork believes that medicine is art as well as science. But the art is in the communication and interaction with a great diversity of individuals, and in the finer, subtle aspects of diagnosis and care. The provision of treatment is essentially based on scientific principles. Dr Dork may be a squeaky little voice in the forest, but that won't stop him squeaking. This is better explained here.

3. Doctor as Patient.

The world as viewed by someone struggling with depression. Who has straddled both sides of the fence.

Dr Dork suspects this is, perhaps, the principle reason that drove him to blog, in light of the problems in the treatment and prevention of psychiatric/psychological illness in Oz.

Which become more evident when you've seen them from multiple perspectives.

This is also the reason he has been careful about anonymity and location, and shies away from discussing his own practice. Sadly, even amongst the medical profession, depression and other psychiatric illnesses remain highly stigmatised.

Dr Dork has previously spent several years working as a psychiatry registrar. He went about halfway down the path to becoming a fully fledged psychiatrist before realising that he was sublimating his own illness, and changed to a different area of medicine.

However, Dr Dork has learnt more about mental health issues as a patient and a carer for a family member than he ever did as a doctor treating psychiatric illness.

He has learnt more about medicine than in all his years of study and clinical practice.

In otherwords, the experience of Doctor as Patient...with a chronic, common, complex illness, with much morbidity, significant mortality, and no ready cure.

Dr Dorks own illness is a mix of biological and psychological factors. He has experiencd both aspects of depression as a consumer, a carer, and a curer.

Dr Dork will return to this topic soon.

Grand rounds will be up on Monday at Anxiety, Addiction and Depression Treatments.

Dr Dork is recuperating with relatives whom are computer bereft and apologises, in that he might take a few days between posts, and a few days to reply to comments or emails. Akin to Intueri and Dr Crippen, both of whom are highly recommended, Dr Dork attempts to respond to all comments. If you've taken the time to read Dr Dorks blathering opinions, your own justly deserves a response.

In Hiatus

2006-02-20T02:01:00.000+11:00

Dr Dork has unfortunately not been well, and after various scans and whatnot tomorrow is chuffing off to hospital for probably some weeks.

Dr Dork is not au fait with bluetooth and wireless laptops and PDAs, so won't be able to post until he eventually gets back to his crusty old PC.

Dr Dork sends his regards to his readers. All three of you.

Polypill versus Polymeal

2006-02-18T20:33:00.000+11:00

A meta-analysis (basically a summary of all quality studies) was published in the British Medical Journal (BMJ) a couple of years back. It became known as the Polypill study.

In essence, it is a strategy to reduce the risk of cardiovascular disease, the biggest killer in Western society. Specifically, it aimed to reduce several risk factors clearly associated with cardiovascular disease, such as blood pressure, cholesterol, and clotting propensity. It provided some evidence that if everyone over 55 or with a history of cardiovascular disease starting popping this combination pill, the incidence of heart attacks and strokes would drop by 80-90%.

There has been considerable debate about this. Some question the methodology and statistical leaps of faith of the researchers. Some question cost effectiveness. A Dr Trewby, a Darlington physician, took the trouble to review the statistical claims in detail. He points out that, "if a typical 55 year old took the Polypill for the next 10 years the chance of benefit will be less than 1% per year and that of side effects 6% overall, some of which (such as aspirin related gastro-intestinal haemorrhage) may be life threating".

"There are three types of lies - lies, damn lies, and statistics." (Mark Twain)

A rather whimsical response to the Polypill proposition was published in the BMJ a year or so later: the Polymeal. By careful wording of statistical results adopting this particular dietary approach suggested a 76% reduction in cardiovascular events.

Ingredients of most benefit were red wine (1/2 a glass a day), fish four times per week, lots of fruit and vegetables, of course, almonds, garlic, and...100 grams per day of dark chocolate. The last one got a lot of lay press attention, that's for sure. Most didn't realise the whole exercise was a bit tongue in cheek, and the evidence tenuous.

Still...my dinner plans for tonight are garlic bread followed by a fish meal, accompanied by red wine, with a chocolate dessert.

Seriously.

RU 486, or against ?

2006-02-16T02:13:00.000+11:00

Dr Dork has been wary of even approaching this topic.

Abortion.

This is an ethical minefield.

Dr Dork is not an obstetrician. He is also not a woman.

He is not an expert on exactly what point a termination remains permissible. He doesn't agree with this, though.

There is an interesting medicopolitical debate raging in Australia at present.

It is about RU486.

RU486, or Mifepristone, is principally an antiprogesterone. A type of hormone. It is fundamentally used as a medical, as opposed to surgical, method of inducing first trimester abortion, and also as an alternative to postcoital contraception.

Post-coital contraception, also known as "the morning after pill" (Postinor-2), can be purchased over the counter from pharmacists in Australia. Dr Dork thinks this is a problem. For one thing, those engaging in unsafe sexual behaviour are at risk of various STDs. Including HIV. This warrants professional counselling and education of the risks involved, so that people can make informed choices.

A chemist, on a shop floor, is neither qualified to do this, nor in a situation to do this with any modicum of privacy.

Abortion law is very complicated in Australia. It varies greatly from state to state. In some states, 1st trimester abortion is permissible only if there is endangerment of the physical or mental health of the prospective mother. In other states, it is permissible if there is "social or family risk", with the proviso that "counselling" of some form is given in regards to risks of abortion, and the risks of continuing pregnancy.

It is all very confusing. To cut through all the 'bull'...women in Australia have been able to obtain surgical abortions, if they so desire, quite easily, for decades. It is not for Dr Dork to pass judgement on this.

The issue of late has been regarding an alternative method for an already accepted procedure in Australian society. Some women, if they decide to abort a pregancy early, are at less risk of harm if they choose RU486 over surgical abortion.

There is little evidence which option is generally better, from recent reviews of the research evidence, here and here.

The issue has become more than a matter of science. Generally, matters in regards to approval of medications for use in Australia are decided by the Therapeutic Goods Administration, or TGA. The TGA serves as a risk management review authority of any medication or medical device. It is staffed by scientists, epidemiologists, and other experts in the relevant fields.

The problem with RU486 is that, in 1996, legislation was introduced by our current highly conservative government, still in power, enabling the health minister to veto the TGA on certain matters. Such as RU486. Our health minister,Tony Abbott, is a lawyer with a previous background in economics. He has no training or experience in any scientific discipline whatsoever, let alone health matters.

He is also a staunch Catholic.

A private Members bill to return the decision making process on medical abortion to the TGA is in the process of passing through the various stages of approval in the Australian parliament, and appears likely to succeed. It has become what we refer to as a conscience vote. Even from Mr Abbotts own party, the majority of female politicians have voted in favour of removing his veto.

Dr Dork doesn't like politicians deciding national matters on the basis of their religion. This is a very dangerous and slippery slope to tread.

Church and State should remain separate. Theocracy is a form of dictatorship.

Note: Dr Dork apologies to his NotifyList members...the service seems to be misbehaving.

Grand Rounds

2006-02-14T18:44:00.000+11:00

Grand rounds are up at Intueri.

Maria, the author of intueri, is an American psychiatry resident who has blogged through much of her medical training.

Although young, she is thus one of the medical blogospheres more venerable figures.

Intueri mixes personal musings with compassionate and literary tales of psychiatry.

Heroism

2006-02-13T01:32:00.000+11:00

It was March, 2005. A balmy Saturday evening in Koondoola, Western Australia.

Terry Vo was 10 years old.

Terry attempted a "slam dunk" on a backyard basketball ring.

It went horribly wrong.

The backboard, basketball ring, and wall, collapsed, landing on Terry. He had one foot severed midcalf, and both arms completely severed below the elbows.

Thanks to heroic efforts by the surgical team that night, all three limbs were reattached.

Eventually, the reattached foot did not take, and is now prosthetic. But Terry still has both arms, and is apparently progressing well in rehabilitation.

This is the real heroism. This courageous young mans positive outlook has never faltered. He has progressed beyond medical expectation.

He was back at school by September. He wants to be a doctor when he grows up.

He is now advocating child safety on behalf of the WA police service.

That is Dr Dorks kind of hero.

Passive Smoking

2006-02-10T22:18:00.000+11:00

Dr Crippen of NHSBlogDoc posted earlier in the week on the topic of tobacco advertising that targets children in poisoning children again.

This led to a discussion on passive smoking, and Dr Dork has built upon the opinion he originally gave on NHSBlogDoc below.

Dr Dork doesn't like smoking, to be utterly frank. It is an addictive habit, and it kills many people. Dr Dork doesn't like things that kill people.

If one smokes in the privacy of ones own home, however detrimental to ones health it may be, this harm is limited to, well, oneself. When someone inflicts harm upon others as well, in Dr Dorks mind, it becomes a public health issue.

Passive smoking in confined spaces has been well estabilished to cause harm to innocent bystanders, and to employees working in those confined spaces. Some examples of research are provided Here and here and here and especially this below, which is the abstract from a 2001 meta-analysis (ie. statistical summation of all available evidence) from the Australian and New Zealand Journal of Public Health:

Aust N Z J Public Health. 2001 Jun;25(3):203-11.
Passive smoking and lung cancer: a cumulative meta-analysis.

Taylor R, Cumming R, Woodward A, Black M.

Department of Public Health and Community Medicine, Faculty of Medicine, The University of Sydney, New South Wales. richardt@health.usyd.edu.au

OBJECTIVE: To review the epidemiological evidence for the association between passive smoking and lung cancer. METHOD: Primary studies and meta-analyses examining the relationship between passive smoking and lung cancer were identified through a computerised literature search of Medline and Embase, secondary references, and experts in the field of passive smoking. Primary studies meeting the inclusion criteria were meta-analysed. RESULTS: From 1981 to the end of 1999 there have been 76 primary epidemiological studies of passive smoking and lung cancer, and 20 meta-analyses. There were 43 primary studies that met the inclusion criteria for this meta-analysis; more studies than previous assessments. The pooled relative risk (RR) for never-smoking women exposed to environmental tobacco smoke (ETS) from spouses, compared with unexposed never-smoking women was 1.29 (95% CI 1.17-1.43). Sequential cumulative meta-analysed results for each year from 1981 were calculated: since 1992 the RR has been greater than 1.25. For Western industrialised countries the RR for never-smoking women exposed to ETS compared with unexposed never-smoking women, was 1.21 (95% CI 1.10-1.33). Previously published international spousal meta-analyses have all produced statistically significant RRs greater than 1.17. CONCLUSIONS: The abundance of evidence in this paper, and the consistency of findings across domestic and workplace primary studies, dosimetric extrapolations and meta-analyses, clearly indicates that non-smokers exposed to ETS are at increased risk of lung cancer. IMPLICATIONS: The recommended public health policy is for a total ban on smoking in enclosed public places and work sites.

Note: The emphasis is Dr Dorks. "ETS"= environmental tobacco smoke

It is difficult to design a trial to accurately measure the degree of impact of passive smoking. This is due to logistical problems in measuring the extent of exposure, and also, given that evidence is already there that there is some level of harm, it is highly unethical to knowingly expose anyone to passive smoke.

The evidence is there, it is strong, you just need to know where to look. The evidence of harm is strongest in regards to harm to the health of children and pregnant women. Dr Dork also feels strongly that it is an occupational health issue - does ones "right to smoke" in a pub override the right of the hotel employees to not have their risk of lung cancer, asthma exacerbations, even heart disease be increased ?

Does ones civil liberties, which Dr Dork greatly values, entail the right to cause harm to others in the pursuit of ones personal pleasure ?

Dr Dork is interested in what his readers think. He provides some case scenarios for consideration :

1. A mother of a young child with severe asthma smokes in her car, and in her home. The child has frequent episodes of asthma requiring hospital admission, triggered by the mothers smoking. Is this a form of child abuse ?

2. A pub employee of many years develops lung cancer of a type clearly associated with smoking. She has worked in a crowded, smoky pub for 25 years, but has never smoked herself. Is her employer, the pub owner, liable for her illness for exposing her to passive smoking ?

3. There is evidence that secondhand smoke can trigger acute cardiovascular illness, such as heart attacks and strokes, in those at risk for other reasons. A smoker blows smoke in the face of an elderly gentleman after the gentleman requests he not smoke around him. The elderly gentleman immediately suffers a heart attack and dies. Is this manslaughter ?

This is a thorny issue. Dr Dork doesn't pretend to have all the answers.

If you are a smoker and are considering quitting, Dr Dork recommends you go here.

Absent poetry

2006-02-08T02:23:00.000+11:00

Photo courtesy Jerome Leronte, Openphoto

Grand Rounds

2006-02-07T18:29:00.000+11:00

Grand Rounds are up at the Science and Politics blog.

A suitably grand diversity of posting from throughout the medical blogosphere this week.

Stem Cell Research

2006-02-06T05:53:00.000+11:00

Dr Dork has strong personal views, when it comes to stem cell research.

Unfortunately, this seems to boil down to an issue of theology, as much as neurology.

Dr Dork remembers studying obstetrics and embryology.

The issue a lot of people have, it seems, is...when does a morula, embryo, or foetus become a human being ?

That is a profound philosophical question, not just a scientific one.

The philosophy ? Dr Dork pleads ignorance.

Catholics claim consciousness occurs at the moment of conception. Dr Dork thinks this viewpoint is well summarised here

The science ?

There is no easy answer. Dr Dork recalls from his embryology training that the complexity at 8 weeks is barely that of a fish. Not a dolphin, mind you. A goldfish. Maybe a snapper.

But, Dr Dork recalls, a large proportion of pregnancies, 40% perhaps, spontaneously abort. A lot of these occur due to maternal use of alcohol, tobacco, even caffeine. If Dr Dork was Catholic, would this then be murder?

Dr Dork means no offence to the Catholic religion. His grandmother was a devout Roman Catholic. He wishes to engage in debate, and wishes to air his opinions. He apologises for any inherent offence.

This site gives a reasonable summary of details involved in stem cell research. To an extent, these can even be taken from peripheral blood samples (ie. typical blood samples) in adult donors. Dr Dork knows this from personal experience as well - he has donated his own peripheral blood stem cells for a bone marrow transplant patient with a haematological (blood based) cancer. One is injected with a type of hormone to stimulate more stem cells then these are drained just like a normal blood donati0n.

Dr Dork has much hope for the potential of this avenue of scientific exploration.

In particular, there is a just beginning trend, it seems, wherein stem cells are stored from the umbilical cords of newborn babies. And this is where the real potential lies.

These stem cells have the potential to be developed into any organ. A heart, a liver, a pancreas, a spinal cord.

Dr Dork hopes our children, or perhaps our childrens children, will be free of the spectre of organ failure.

Heart disease is the obvious fear, It is our biggest killer. Imagine growing a new heart, when ones own fails, from ones own blood sample, given at birth.

That is worth fighting for.

Dr Dork would like to thank dragonflylili of Flamingos Hideaway for
emailing Dr Dork in regards to this topic and inspiring this post.

Backdoor Big Pharma

2006-02-06T00:02:00.000+11:00

Direct to consumer advertising of prescription drugs is banned in Australia.

"Current Affairs" television is a colloquialism for the evening tabloid news programs that reside between the "real" news and the gameshows.They are "journalism" of the lowest form.

Some recent examples from one called Today Tonight include:
Sex drive solution to be released and
Herbal therapy cures infertility

The last one is Dr Dorks favourite. It has a nice little retraction at the end where it acknowledges even the single case history, which they tout as evidence, is retracted due to obvious confounding bias.

These shows aren't all bad. But they are full of rubbish, fearmongering, false hope and shoddy journalism.

This article in the Australian Doctor magazine refers to a conviction recently against Roche. Roche had sent clearly positively biased material in relation to Xenical, a prescription weight loss drug, to these journalists, which they aired without any particular research or fact-checking. One suspects more was happening under the table. But this is speculation only.

Roche was fined $20,000. A small price to pay for such positively biased exposure. And free advertising.

UPDATE: Angry Doc has posted an eloquent discussion today exploring the relationship between doctors and the pharmaceutical industry. Worth a read.

UPDATE: This post originally vanished after posting. Thanks to AngryDoc who found a copy for him. Dr Dork suspects his computing inability is likely to blame. Apologies to readers.

There have also been some Blogger.com issues this week

All posts are now backed up more thoroughly.

Losing weight

2006-02-04T00:05:00.000+11:00

Dr Dork is interested in weight loss. He is not a dietitian.

But many of his patients have obesity as a comorbidity of the conditions for which they see him. It often complicates treatment. It puts them at risk of diabetes, heart disease, certain cancers, among other things.

He often gives dietary and exercise advice to his patients. As should any doctor with a patient who has health problems due to their weight. This involves some finesse and delicacy, to say the least.

It is really up to the patient, of course. There is no miracle cure for this one.

Dr Dork knows it is hard work. He was once 30kg (66 lbs) overweight. He was working very long hours - that was his excuse.

At this time he changed career path, and decided to lose the pork. Despite still working 60-80 hr weeks, plus doing a specialist training program, plus doing postgraduate university study, he lost the weight in 5 months.

He changed his diet, and exercised for an hour 3 out of 4 days.

Dr Dork knows he is going on a bit...but this is a common problem.

Most studies show about 25% prevalence in the UK and Australia...and about 35% in the US.

Dr Dork has complicated views about dietary adjustments. He recommends monitoring calories as the primary intervention.

He believes in "outsmarting your body". Our brains live in the 21st century. But our physiognomy thinks we are still hunting mammoths.

If you eat lots of calories before you go to bed, your body will store them. It is thinking "I don't know when I'll next catch a mammoth". If you eat lots of calories at breakfast, you will generally use them to a greater extent. Your body is in active mode, not storage mode, during the day. Even if you sit behind a desk much of the day.

Dr Dork changed his main meal from evening to breakfast. It was hard for a few weeks. Then he got used to it.

When he has breakfast with his friends nowadays, they accuse him of "feasting".

But it worked.

It boils down to two things.

Eat less.

Exercise more.

Update: Dr Dork originally made the above comment in a discussion engendered by Dr Crippen at NHS Blog Doc in this erudite discourse on obesity management, and the dangerous allure of the chocolate digestive.

A tale of Aussie Guts

2006-02-03T01:20:00.000+11:00

Australians are, like any nation, understandably proud of "their own".

Sometimes, creative interpretation of the truth occurs..
Blimey...I sound like an advertising executive.

Phar Lap was raised in New Zealand. As was Russell Crowe.
But we'll bend the rules for the national ego. They're Great Australians.

Sidenote: Dr Dork doesn't agree with beating up concierges. He did like A Beautiful Mind, though.

On the world stage, we are a small nation. Barely 20 million. About the size of Texas.

We take some pride in this. Per capita, we outperform the world at the summer olympics. Mind you, we suck at the Winter.

The story of Nobel Laureates Marshall and Warren is "Aussie" to the core.

They had a revolutionary idea.
It offended the establishment.
They fought. As unknown underdogs.

Barry Marshall ingested the bacteria in question. He gave himself an ulcer.
Risked his life, really.To prove his point.

Namely, that the Helicobacter Pylori bacteria caused most ulcers.

And could be cured.

Cervical cancer and Religion

2006-02-01T22:15:00.000+11:00

Dr Dork is pleasantly surprised.

Professor Ian Frazer, an immunologist, (pictured right) has been named as Australian of the Year for his development of a vaccine against the Human Papilloma viruses (HPV).

HPV is the main cause of cervical cancer. This vaccine will ultimately prevent virtually all cervical cancer.

But Dr Dork is also angry.

There has, for some time, been a groundswell of argument from Christian religious fundamentalists against the use of this vaccine. Their argument ?

It will increase promiscuity. What bollocks. It will save hundreds of thousands of lives...as a conservative estimate.

This reminds Dr Dork of the resurgence of polio in Africa in recent years. This is due to the Islamic religious fundamentalist control of northern Nigeria, who harbour strange beliefs about vaccines. Polio was, prior to this, close to going the way of smallpox....complete eradication.

Dr Dork is glad of the separation of Church and State where he lives, and in most of the world. He respects people who have strong religious convictions as much as those who don't. But not when they proselytize. And certainly not when unecessary deaths result.

Grand Rounds

2006-01-31T23:16:00.000+11:00

Grand Rounds are up at Barbados Butterfly, who provides a superlative snapshot of the weeks events in medical and health blogging.

Dr Dork is very pleased to rate a mention so early in his blogging career.

Dr Barbados is a surgical registrar with a penchant for interesting, thoughtful clinical tales, a literary flair, and some excellent advice for medical students and interns.

One of Dr Dorks favourites. Dr Dork highly recommends spending some time perusing her site.