Monday, September 29, 2008


I know, I know, again with the sports metaphors.

Henry is doing so well that he had his Hickman (central venous catheter) removed today. The surgery went smoothly, and he's excited.

I'm equal parts exhilarated and terrified. The Hickman was convenient for blood draws and sedations, but he's down to blood only once a month and procedures once every three. So we didn't really need it anymore - it's an infection risk, and he can take a monthly venipuncture.

But pulling it says more than that.

Chemo and radiation delivered the punch, the knockout that landed Henry's cancer on it's ass. And now we've turned our backs and said, "I don't believe you'll be back."

I've said before that I'm not religious, but I'm a sucker for hubris. Are we tempting fate?

At the same time, I'm ecstatic. We haven't even hit his year anniversary of diagnosis yet. Treatment is done.

Treatment is done.

Friday, September 26, 2008

Love note

I got a love note today. An anonymous one.

I was having lunch with some of my coworkers in a small family restaurant near my office, when our waitress dropped off a handwritten note. She said, "I was asked to give this to you."
Dear Dr. Smak,
Thanks for everything you do. We really appreciate it.
We're praying for your son.
And when I asked for my check, the waitress told me the anonymous note-writer had paid for my lunch. I have a hard time expressing how touched I am.

Sometimes small town life seems dull. Sometimes I wonder if I could have done more in a bigger setting, a more "glamorous" doctor role.

Times like that make small towns look really good.

Sunday, September 21, 2008

Dr. Smak's Bucket List

I'm not getting any younger. Mortality dances in front of me on a routine basis, whether at home or at work. While I'd love to plan on doing fun and fabulous things in my retirement, I don't want to live waiting for that grand event. There sure aren't any guarantees I'm going to get there. So, without further ado, my bucket list. (I'm adding it as as new sidebar, and will add to it periodically as things come up. I'm deleting my nightstand, since knitting continues to gobble up the scarce free time I have. I'll read a book again in a few years.)

1. See the aurora borealis. Or, as a dear relative once coined, the areola borealis. In her defense, it was after a glass of wine.

2. Take a super fabulous grown-up vacation with Mr. Smak. We started marriage penniless, and pretty quickly started making Smaklings, so this one has eluded me thus far. I'm talking 2 weeks, no responsibilities, food, drinks, travel, sightseeing, foreign countries. Right now I'm thinking Mediterranean, but the details are unimportant and subject to change. (Fodder for another post, but after you have kids do you ever really have no responsibilities? Did we miss our chance?)

3. Become a certified Master Gardener.

4. Learn to speak another language. Not great, but at least passable.

5. Drive across this big and beautiful country in an RV with Mr. and Smaklings. I'm hoping to hit the right age, where everyone is in the range of pretty self-sufficient but before teenage attitude kicks in. I think this is the one that has the real time constraints on it. I've never seen the Grand Canyon, and I'd love to do it with my kids.

6. Learn to make a kick-ass pie crust. "Kick-ass" is per my own standards. If I never ate another piece of cake in my life I'd be fine, but a crisp, flaky, buttery pie crust is about as good as it gets.

In general, I don't make pies, as the crusts aren't up to my standards. But the whole point of a bucket list is that there is no time like the present to start, so tonight middle Smakling and I practiced on some apple dumplings. They look prettier in real life than the photo. I can't wait to taste them tonite!

Tuesday, September 16, 2008

"You keep using that word..."

"...I do not think it means what you think it means."
-Inigo Montoya, The Princess Bride

Quote of the day, during disability evaluation:

"Just because I'm working now doesn't mean that I'm not disabled."

Tuesday, September 9, 2008

Getting Worked

In primary care, you have to keep your wits about you. Often medicine is the easy part; identifying, understanding, and dealing with secondary motivations that patients have can be tough. You hope that your Spidey-Sense is about you, most of the time.

But sometimes it isn't.

Like when you are writing chronic narcotics for patients with well-documented and legitimate pain issues, but when you check a random drug screen it's negative for narcs and positive for cocaine.

Or when the patient you put on disability for oh-my-aching-back can't call you back since he's out hunting for the week.

I got worked today. The perpetrator: 3 years old.

He was nervous for his well child check. Cute kid, I don't really know him that well, and don't at all blame him for being nervous. But we had a good time, played a little, used my favorite trick of looking for the belly button on his foot (always gets a laugh from a 3 year old). The exam was over, he was roaming the room while I talked car seats and sunscreen with mom.

He approached me, tugging on my arm. "Dodder. Dodder. DODDER!"

"Yes, cutie."

"Dodder, I wub you."

So cute. So innocent. So sweet.

"May I have a kiss please, right on my cheek?"

He obliged.

But whilst he was planting a big wet one on my cheek, his hand was slipping into the pocket of my lab coat, and pilfering my prescription pad.

Smooth operator, that one.

Saturday, September 6, 2008

The Smak Family time warp

We're coming up on the year anniversary of Henry's diagnosis. Somewhere in the last 4-6 weeks, life is....well, I can't say it too loud....perhaps a whisper? back to normal.

The girls are in school. I'm back to my fulltime work schedule. Soccer season is in full swing, except now we've got three sets of practices and games to arrive late for. I'm doing things like fall clothes shopping, looking at plane tickets for the holidays, even considering taking an overnight, sans kids, with Hubby.

It's exhilarating. I love that I'm once again annoyed and complaining about the little stuff. What a luxury.

Something happened over the year, that I didn't anticipate. Though it may be more obvious to the rest of you, Henry is a year older than when we started. He was barely 3 at the time, still requiring help with toileting. He had the attention span of a fruitfly, and we were unable to sit down for a board game as a family. We needed blankets, binkies, diapers, strollers whenever we went anywhere. We had to work around the nap. Typical life with a younger child.

One of the forgiving things about parenthood is that you get eased into situations. The first time you get a terrible two tantrum handed to you, it's like being bitch-slapped by a former convict. Lucky for you, there are 4,552 more tantrums to come, and by the time you live through a hundred or so, you're got the upper hand. The eye rolls come before she really means it, before she's a full-fledged teen. You get to manage kindergarten homework before the middle school scheduling starts.

With Henry, it's like someone hit the developmental pause button, but now we're back to live TV. It's like he jumped a year.

All of the sudden, he's a delightful 4 year old. 4 years olds are great - they get humor, and love to make everyone laugh. They're proud of their independence, their accomplishments, and motivated to be a "big kid". They play games, they love to read, they begin to expand their palates. It's one of my favorite ages.

Over a very brief period of time, we've hit parenting Shangri La. After 10 years of having young children, we are now stroller, nap, and binky-free. I can cook without a crying child clinging to my leg. We sleep uninterrupted, at least most nights. The promised land.

And even better, everyone's happy. Healthy. Busy.

This has been a really nice surprise.


Diabetes is the ultimate lifestyle disease. A metabolic avalanche, poisoning the body organs. When I diagnose or meet an early diabetic, I tell them that they can reverse the whole thing with lifestyle changes. They can avoid pillboxes, insulin, blindness, kidney disease, heart attacks, without any help from me, if they can make the lifestyle changes needed.

How many have taken me up on it?

Two. Out of the hundreds of diabetics who's paths I have crossed.

The first was unintentional. A middle aged man, his wife died suddenly. He was lost without her. He stopped eating, lost large amounts of weight. Stopped coming to see me. Stopped taking his pills. After a year, his diabetes, high cholesterol, and high blood pressure were gone. He was so depressed, so distraught, his most fervent desire to be with her again. I couldn't tell him that his lifestyle changes (albeit depression-induced) had greatly extended his predicted lifespan.

The second was beaten into submission. His wife, so quiet I rarely hear her speak, listened carefully at our first visits. They started walking between 5 and 10 miles a day. Every day, for years now. It's clearly her idea. It's clear that he doesn't have an option to not walk. And it's worked great for him, his numbers are fabulous. He feels great too.

The rest don't do it. The vast majority know what it is that they are supposed to do. But they don't. Over and over I ask myself "Why?" Surely there is plenty of negative reinforcement.

What doctors require of diabetics isn't fun. Shots, blood sugar monitoring, daily medications, frequent office visits. I ask, "What is your worst eating habit?" and they know. It's not that they don't know. But they don't change their behavior.

Doctors aren't educated in behavior change. We don't really have time for it. Diabetics can get all of the diabetic education you can shake a stick at, but without behavior change it means little. These are deep-rooted behaviors, formed very early in life, cemented in by kids, work, family, society.

We need to understand better how to teach behavior change. It needs to become an integrated part of the medical field. There is only so much that advice can do.

Thursday, September 4, 2008


A cute, but hyper, patient was in for an ADHD checkup this week. He's already dreaming of Halloween, and was musing aloud about what he wanted to be this year.

His mother suggested a big Concerta pill.

That I would like to see.