Wednesday, January 28, 2015

The Finger Pointing Begins. The Joan Rivers Malpractice Lawsuit

You knew it would come to this. For all the talk about medical staff teamwork in the operating room, when the sh** hits the fan, each person is on his own, trying to save his own butt from the wrathful vengeance of the malpractice attorney. In the medical malpractice lawsuit filed by the late Joan Rivers's daughter, each doctor is now essentially blaming each other for the comedienne's untimely death last September 4th during a simple endoscopy.

During the official investigation following her demise, a note was found in the chart that was handwritten by the anesthesiologist, Dr. Renuka Bankulla, that said she tried to find the ENT surgeon who had performed the laryngoscopy and possible vocal cord biopsy, Dr. Gwen Korovin, when Ms. Rivers went into cardiac and respiratory arrest. However Dr. Bakulla couldn't find Dr. Korovin in the room to perform a cricothyrotomy to open up the patient's airway even though she was there only minutes prior to the arrest. The suit speculates the Dr. Korovin fled the room at the first sign of trouble because she was not credentialed to perform procedures at the Yorkville Endoscopy center.

The attorney for Dr. Korovin counters that she was in the room all along. In fact, the faithful doctor was the last person to leave the room when the patient was taken away by ambulance. Just because the anesthesiologist didn't see her doesn't mean she had left the room. However, Ms. Rivers's lawyer wonders why, when Joan wasn't able to get any air into her lungs, the surgeon didn't take over the airway and performed the emergency operation. Said Jeffrey Bloom, the attorney, "She's an airway specialist. Why isn't she stepping forward and saying 'I'll do it' or 'You do it'. Instead she obviously did nothing."

Naturally much more will come out as the lawsuit proceeds. More witnesses will be testifying as to the whereabouts of Dr. Korovin, including the testimonials from the GI doctor and two other anesthesiologists and nurses that were in the room when disaster struck.

This is an important lesson for all anesthesiologists. You may think you are good buddies with your favorite surgeon, going out and playing golf or fishing together. Maybe you send each other Christmas cards or your children play soccer on the same junior high team. But when trouble hits, that friendship will quickly dissolve into acrimony.

A few years ago, one of our anesthesiologists was working with a highly likeable orthopedic surgeon. The surgeon was always friendly and loved to tell corny jokes in the operating room. Everybody wanted to work him. Then one day, after a simple joint procedure on an elderly female patient, the surgeon wrote a narcotics order after she had already been transferred out of recovery and to the floor. The patient consequently had an unwitnessed respiratory arrest and died. The inevitable malpractice suit was filed and now the surgeon was blaming the anesthesiologist for oversedating the patient while in recovery leading to the arrest from a routine narcotics order when she went to her room. That happy face mask quickly disappeared when facing a multimillion dollar lawsuit. A tough education no anesthesiologist should forget.

Thursday, January 22, 2015

The ASA's New Sexist Home Page

ASA's new home page
With the start of a new calendar year, the American Society of Anesthesiologists has unveiled a brand new home page on their website. They are quite proud of it and hope you like it too. They even provide a convenient link to their web editor so you can express your amazement at the good use of your annual dues to keep their home page fresh and engaging. You know of course that dripping sarcasm is difficult to express on a written page.

So here is my problem with the new site. There is nothing wrong with the new design. It is less cluttered and more prominently offers links to pages that you are most likely to use, like the current news or log in page. But the contents on this particular page are beyond sexist. Their first feature of the year is a discussion on pain in women. I object to the society pandering to females when pain is a universal ailment. Everybody feels pain. Why is the ASA focusing on predominantly female problems like fibromyalgia? And now the ASA claims they have expertise in treating PMS?

What happened to the other half of the world's population that also experiences pain? When I get back from the gym after benching 250 pounds, I get a soreness in my chest and shoulders. What's the ASA's answer to that? After a long weekend trip in the Santa Monica mountains mountain biking, my knees and thighs are screaming for relief. Will the ASA also offer a rose oil rubdown as treatment? Men suffer pain too. We just don't bring as much attention to it as we probably should because, well, we're men. And we can take it.

The other part of the new home page that I find extremely objectionable is the lack of diversity being shown. The slide show that scrolls across the top of the page currently only features one kind of anesthesiologist. I'll give you a hint: none of them are men. All the anesthesiologists pictured are women, even though they make up a minority of the ASA membership. Is this the ASA's idea of membership diversification? Did I miss the memo that January is Women Anesthesiologists Month? The links associated with those pictures aren't even gender specific. They involve subjects like Practice Management and paying your membership dues, neither of which are gender related. Yet every single image is of a female anesthesiologist. Has the ASA been hijacked by the National Organization for Women?

Exclusion of men does not make the ASA more inclusive. The ASA should be embracing all anesthesiologists, not just the politically correct ones. I've never heard anyone complain that there are too many male anesthesiologists. Don't stir up a gender controversy when there is none to begin with.

The Ultimate Sacrifice

Dr. Michael Davidson
We like to think doctors are kind, selfless people, working tirelessly to help the sickest and neediest human beings with little regards for our own well being. Unfortunately, not everybody feels the same way. The shocking murder two days ago of Dr. Michael Davidson, a cardiothoracic surgeon at Brigham and Women's Hospital in Boston, once again underscores the precarious situation physicians face every day when dealing with people who may not be thinking rationally when confronted with severe illness, either in themselves or in a family member.

Dr. Davidson was shot in his own medical office by the son of a deceased former patient, Stephen Pasceri. He then turned the gun on himself and died of self inflected gun shot wounds. Police investigations have not yet revealed the reasons why Mr. Pasceri decided to shoot the surgeon. His family is equally baffled by the violence, stating they felt their mother received good care while under Dr. Davidson's watch.

Dr. Davidson was only 44 years old. He was essentially just getting started with what was supposed to be a long and brilliant career. When you take into consideration the extremely long road that's required to become a cardiac surgeon--medical school, surgical residency, cardiothoracic fellowship--it's clear that he had only been in practice a few years. It's tragic that so much sacrifice he took to become a surgeon could be so easily extinguished by a crazed individual with no regard for human life. He leaves behind three children and a wife who is seven month pregnant.

This isn't the first time a surgeon, was murdered by a disgruntled individual in his own office. Back in 2013, a urologist, Dr. Ronald Gilbert in Orange County, was shot and killed by a patient unhappy with his prostate surgery performed 21 years prior to the shooting. He was not the patient's surgeon but was unlucky enough to have been chosen by the gunman for retribution.

More commonly, doctors and nurses have to deal with verbal and sometimes physical abuse from our patients regularly. Any healthcare professional can easily rattle off instances where patients have swung at them with fists, or tried to kick them while lying on a gurney. We've been yelled at, spit upon, threatened with legal action, all while we're doing the best we can to heal the patient. Sometimes we wonder if facing these confrontations is worth the sacrifice to our own dignity and well being. The answer of course is yes, because taking care of patients is our ultimate goal, no matter how much we too have to suffer before they understand that.

Tuesday, January 20, 2015

My Easiest Cancellation Ever

Every anesthesiologist has been through this. A surgeon books a case for a procedure and we go evaluate the patient. We examine her and think, "Hmm, this patient probably shouldn't go to the OR. She needs more workup to evaluate and resolve some important issues." We then gird ourselves for the inevitable argument with the surgeon for why the case needs to be postponed. Inevitably we win the argument but they still fight anyway. Or they decide to find another anesthesiologist with looser standards for administering anesthesia.

However that was not the case the other day. The surgeon scheduled a case later in the afternoon. I dutifully went to the ICU, where the patient was located, to preop her. Most anesthesiologists have had the "Holy shit! They want to operate on this patient?" moment. And this was one of them. I could only shake my head at the audacity of the surgeon to even book this case. Did he even examine her?

A quick perusal of the labs revealed the patient had a hemoglobin of 2.9. Platelets were 6K. Not 600,000, or even 60,000. SIX THOUSAND. The patient was highly coagulopathic with an INR of greater than 4. How will the surgeon possibly stop any surgical bleed during the case? And worst of all, on her blood gas her pH was 6.9. And the patient is on dialysis. WTF?!

I called up the surgeon and calmly relayed my concerns. The surgeon replied that the ICU team was giving the patient more blood, though I didn't see any hanging at the moment. Well, they didn't want to give the blood too quickly because of the renal failure. Uh huh. Then I asked, if the patient is on dialysis, why is she so acidotic? Why hasn't the dialysis machine corrected the pH? Well, the patient is on a very expensive experimental drug that costs $20,000 per dose. The team didn't want to dialyze out the drug. Haha. That excuse was too funny to hold back my snort. So the primary team didn't want to waste $20,000 on a patient even though a pH of 6.9 is not compatible with life? This is so not happening. Case cancelled.

P.S. Subsequently the team tanked up the patient with blood to a more sane hemoglobin of 7. They also started a bicarb drip to bring the pH up to 7.3. They found an anethesiologist to do the case the next day after all these corrections were made. The patient then expired less than 24 hours after that. Don't we just love American medicine?

NIMBY And The Measles Epidemic

Huntington Beach High School in Orange County is doing the right thing. A student with measles was on the campus last week. Consequently the school has told all students who have not been given the measles vaccine to stay home until the end of the month. That is when presumably measles will present itself by then in these unprotected kids. Bravo.

Finally we are seeing some sanity in dealing with these parents who withhold essential vaccines from their children. What started out with an infected international traveler visiting Disneyland last month has now spread to four states and Mexico. This is the worst outbreak of measles in the United States since it was thought to have been eradicated in this country back in the year 2000. Most of these measles victims were not vaccinated by their selfish guardians.

Why selfish? Because not only are they irrationally paranoid about the link between vaccines and a host of other problems like mercury poisoning and autism, all of which have been debunked, they are counting on other people to vaccinate their kids so that they don't have to do the same for their own. The ugly mentality of Not In My Backyard is one of the main excuses these parents fall back on to justify their actions. You know how environmentalists love solar power and windmills to generate renewable energy until it is located near their own homes? The vaccine deniers think vaccines are great, but for other people's children. They are counting on the kindness of strangers to continue herd immunity and prevent the spread of any outbreak of communicable diseases.

Unfortunately so many parents in California, particularly in the affluent and so called educated neighborhoods, that this herd immunity has broken down. We've now seen measles and whooping cough epidemics where there should never have been one in the first place if all the children were properly immunized. Instead of pampering these parents, the state education board must enforce its own rules for childhood vaccinations. There should be no leeway with religious or personal exemptions to vaccinating school age children. If parents feel that strongly about not giving their kids the proper, and medically tested, vaccines, then they can just home school their own children. This madness has to stop before one child becomes permanently disabled, or even dies, from a totally preventable disease because of the ignorance of his parents.

Friday, January 16, 2015

A Desperate Cry For Attention--Physician Anesthesiologists Week

Which person is the anesthesiologist? You can't tell either?
I've been trying to avoid bringing this up because I think the concept is so insipid. But the ASA has been bombarding its members with daily emails to spread the word for their latest idea on promoting the virtues of anesthesiologists, the first annual Physician Anesthesiologists Week. Therefore as a dutiful member of the society I am going to publicize this event even though I think it reflects badly on anesthesiologists as a whole.

Why do I think this is a bad idea? It has all the hallmarks of a desperate cry for attention from an organization with an inferiority complex. It says, "Look at me! I'm relevant! I am a REAL doctor!" Is that the message we want to be sending out? Have anesthesiologists become so insignificant and replaceable that we need to promote ourselves as a brand, like laundry detergent? Perhaps.

When our group's leadership asked our hospital to place a Physician Anesthesiologists Week banner as a screen saver on all the computers in the place, the response we received was less than enthusiastic, "As a rule, we don't use our communications channels/publications to promote organizational weeks or months. For one thing, there are far too many of those. More importantly, our strategic purpose is to promote the work under way at [the hospital] for our patients. So I'm afraid that we cannot assist with promotion of the Physician Anesthesiologists Week."

In other words, they use their screen saver to emphasize events like OR Nurses Week or Radiology Tech Week, but they don't see the need to promote anesthesiologists. And I don't blame them. You don't see the surgeons or internists clamoring for a Physician Surgeon Week or Physician Internist Week. For one thing, the title is redundant. Everybody knows surgeons and internists are physicians. They don't need to repeat it before their profession. Unfortunately the ASA thinks anesthesiologists have become so anonymous that we can't afford to do that, "Hey people, I'm a doctor too!"

Then, there's the awkwardness of celebrating ourselves. We're supposed to be leaders in patient care yet this campaign gives off an image of desperation, like we don't really believe our own legitimacy. Surgeons know they are leaders in patient care and the patients know it too. There's no need to have a special week to celebrate their work. It's innate. You know how despots in totalitarian countries conduct parades to themselves to imply to their own people how powerful they are and we laugh at their insecurity? Yeah it's kind of like that.

To see how embarrassing and debasing this Physician Anesthesiologists Week is, guess who else wants recognition for their work? And it takes place almost immediately after ours. Coincidence?
I bet everybody here is a CRNA.

Thursday, January 15, 2015

Does The Flu Vaccine Work? Depends.

Public health departments have been preaching the virtues of getting the flu vaccine for years. Many workplaces, including medical offices and hospitals have been mandating that their employees receive the flu shot or risk getting terminated. This despite evidence that the vaccine's effectiveness may be little more than the flip of a coin.

Now comes another study that details how ineffective this particular year's flu vaccine really are. The Centers for Disease Control has calculated the vaccine effectiveness (VE) of the vaccine. In most years, the VE ranges from 10% to 60%. This year they have reported it is only 23%. That means that getting it will lead the receiver to have a 23% less likelihood of needing to visit a doctor for the flu compared to the unvaccinated person. Sounds pretty good, right?

But take a closer look at the numbers. The VE is highest in children ages six months to 17 years with 26%. For adults ages 18 to 49, the VE is 12%. Adults greater than 50 have VE of 14%. But here's the kicker. The VE in adults was considered to be too small to be statistically significant. In other words, the vaccine's ability to prevent a person from going to see a doctor for the flu was no greater than somebody who never got the shot.

Once again, why are we forcing medical workers to get a shot with dubious medical efficacy with loss of employment? I'm not against vaccinations for the population that has been demonstrated to be helped by it. I am on my tirade because of losing my loss of self determination. My body. My choice.

Sunday, January 11, 2015

Medicine's Gravy Train Has Left The Station. And You Weren't On It.

Ferrari F40. A Doctor's Car?
Despite all the handwringing among doctors about their dwindling reimbursements due to the changes taking place in the healthcare industry, there is still a widespread perception in the public that physicians are fatcats who are raking in the dough hand over fist. Though most doctors today will tell you that they can hardly be considered rich, this illusion is hard to shake off. Why is that? How did this all get started? Were doctors really as fabulously wealthy back in the day as people think they were?

There is an illuminating column in the February 2015 issue of Car and Driver that furthers this belief. Written by Ezra Dyer, he recounts his days back in college when he was invited by his roommate to spring break in south Florida to stay with his uncle. As he recalls, the first thing he saw when his uncle opened the garage door was a Lamborghini LM002. And next to that exotic were a Lamborghini Countach and Diablo. Other cars he found in that garage were a Bentley Turbo R, a Porsche 911 Turbo, a BMW 850 CSi, a Ferrari Testarossa, a Ferrari 348, and a Ferrari F40.

This uncle had a million dollar car collection parked inside his ten car garage. What kind of person had the means to purchase all these supercars? Was he the CEO of a Fortune 500 company? Maybe he struck it rich as a real estate tycoon or a trial lawyer? Mr. Dyer answers that question when he says, "My career choice was decided: I'd be a neurologist, just like the F40's owner. Med school, here I come!"

I was flabbergasted when I read that. A neurologist? Are you kidding me? According to Medscape's 2014 Physician Compensation report, neurologists on average earned $219,000 per year. While certainly high by a layperson's standards, it is hardly enough to buy a Ferrari, much less a fleet of them. Mr. Dyer looks like he is in his late 30's. So the uncle probably practiced medicine in the 1970's and 80's. They must have paid doctors a lot more money back then if he could purchase so many rare cars with such ease.

If they didn't pay doctors that much money back then, there must be some other explanation. Maybe he was a physician who ran the business side of medicine, like a hospital administrator. That could easily raise his salary into the millions. Or he made wise investments in the stock market and real estate. Because short of running an illegal drug mill, it is nearly impossible today for doctors to make enough money to buy a Ferrari.

It's a good thing Mr. Dyer didn't go into med school thinking he would be able to cruise into the doctor's parking lot in a Ferrari LaFerrari. He would have been sorely disappointed and rued the day he didn't go into computer science and applied to Google.

Wednesday, January 7, 2015

Measles Outbreak In Disneyland. Ignorance Has Consequences.

Well that didn't take long. Just the other day I wrote about how flu vaccines were being forced on everybody even though this year's batch has been found to be ineffective in greater than half the flu viruses circulating this season. Yet parents, mainly in the supposedly well educated and affluent communities, are allowed to withhold vaccinations for the usual childhood diseases like measles and whooping cough for religious or personal reasons.

Now there has been a reported mini epidemic of measles right here in our beloved Disneyland. Twelve people were found to have, or suspected of having, measles after they visited the theme park between Dec. 15th to the 20th. So far the California Department of Public Health has confirmed that six of the patients were unvaccinated, with two that were too young to get the shots. Only one person was vaccinated for measles.

Thanks to all the ignorant parents out there who refuse to vaccinate their children because of some idiotic paranoia linking vaccines to autism, more epidemics of childhood diseases are likely to occur. These people so easily forget that correlation does not imply causation. Though I don't wish anybody to get sick, I hope these fools will get first hand experience on how devastating it can be to get sick from a disease that is so easily preventable.

Monday, January 5, 2015

Look Who's Stupid Now.

Ha ha ha!. The irony is just too rich and delicious. The New York Times features an article about the uproar taking place at Harvard University over the rising health insurance premiums facing their faculty. These are the some of the same people who advised the Obama administration and the Democratic party on how to design the Affordable Care Act, aka Obamacare.

The university now says that the faculty have to pay more for their own healthcare and that is partly a direct result of the ACA's many new rules. Some of these expensive mandates include keeping adult children on a parent's plan until the age of 26 and free preventive care like mammograms and colonoscopies. The new health plans now have deductibles of $250 for individuals and $750 for families. They also have to contribute $20 as copay for a doctor's visit. Though these numbers sound ridiculously cheap to many of us who now can only afford high deductible and catastrophic health plans, the Harvard professors have their panties all twisted over it.

Jerry Green, an economics professor and former provost, declares the new expenses, "equivalent to taxing the sick." He fears the higher deductibles will cause people to avoid seeking medical care until they are sicker, increasing the cost of the care. Mary Waters, a professor of sociology, worries "It seems that Harvard is trying to save money by shifting costs to sick people."

While insurance companies have tried to trim premium increases by offering extremely narrow physician networks, that plan is anathema to this crowd. "Harvard employees want access to everything. They don't want to be restricted in what institutions they can get care from," says Dr. Barbara McNeil, head of the health care policy department at Harvard Medical School. Presumably some of these institutions that would be excluded would include the world class but high cost centers like Mass General and Brigham and Women's hospitals.

It looks like the faculty at Harvard University isn't so smart after all no matter how many laurels they wear. As Jonathan Gruber, a professor of economics from MIT and one of the principle architects of Obamacare, infamously noted, the ACA was designed to be so complicated that it will receive the endorsements and votes of the "stupid" public. Now I guess we know which campus has the more stupid professors.

The Flu Vaccine Hegemony

The flu vaccine industry hegemony rolls on. In New York City, preschool children are now required to receive the flu vaccine before they are allowed to attend classes. The schools can either exclude the unvaccinated kids from their premises or pay a fine of $200 to $2,000. This follows on the heels of forced vaccinations of healthcare workers like doctors and nurses. In some places, including my hospital, the staff can be fired for refusing to get a flu shot.

Ironically, this year's flu vaccine may be protecting against the wrong strain of viruses. Vaccines are formulated months in advance in anticipation of the most likely type of viruses that may affect a particular season. Therefore it is total guesswork on the part of scientists as to which strains the shots should protect against. This year's guess was particularly bad. The vaccines that are being used in the U.S. have been found to be protective against only 48% of the H3N2 virsuses that are in wide circulation. Therefore it is a coin toss as to whether the flu shot will work at all. Yet the recipient of the vaccine still has to risk all the potentially deadly complications of the injection.

While the government seems to be terrified of the flu virus, it seems to hedge when it comes to the usual vaccinations of childhood diseases like whooping cough and mumps. Though supposedly required before children can attend classes, parents can, and are, raising personal and religious exemptions to giving their kids these shots. This has caused new epidemics of whooping cough and measles to appear in California after decades of quiescence. Sadly the resistance to vaccinations is coming mainly from the rich and so called well educated sectors of society. These parents have googled flu vaccines too many times and become terrified by discredited horror stories of associations with autism, some perpetrated by physicians who should know better.

So let's get this straight. People can get kicked out of school or their jobs because they refuse to receive a vaccine that has a less than fifty percent likelihood of being effective. Yet the government is allowing parents to forgo vaccinations that have, over the last several decades, been proven to be effective and causing a resurgence in epidemics that were thought to be nearly eradicated. Who have the flu vaccine industry been in bed with to receive such priority?

Sunday, January 4, 2015

When I Grow Up I Want To Be A Drug Rep

We all know how difficult it is to become a doctor. It's a long journey filled with mental stress, lack of sleep, and social isolation. But in the end one becomes an MD and starts reaping the riches of American medicine, right? Maybe not. While it's true that most of the occupations that earn the top incomes in the U.S. are related to healthcare, the statistics don't take into account how much capital it takes to get there.

One website has done some calculations and it is quite sobering. The average medical student debt at graduation is $166,750. If it takes the doctor thirty years to pay off the student loan at an interest rate of 6%, then the total cost of the loan works out to over $350,000. Now we need to add in the years of missed income while studying in medical school while all our college buddies have already joined the work force after getting their undergrad degree. If one takes the median U.S. income of $57,000 per year, then the total loss of potential income is nearly $600,000. The amortized cost over a thirty year career is $20,000 per year. That's like buying two first class plane tickets to Australia every single year for thirty years. Or purchasing a good used car annually for three decades. This doesn't even take into account interest that could have been earned on that money or potential retirement fund appreciation.

The AMA and federal government are all encouraging more medical students to become primary care physicians when they graduate. Yet these are the lowest paying fields in medicine, with median salaries of $176,000 for a family practitioner. Take out the annual student loan repayment and that drops to $156,000. This figure doesn't factor in the stress of running a medical business with its constant threats of medical malpractice, myriad government and insurance compliance rules before receiving payment, and staffing headaches.

By comparison, a drug rep for a major pharmaceutical company generally only needs a bachelor's degree to qualify for the job. The average salary of a sales manager is $123,000. With that income, the rep probably also gets benefits like health insurance, matching 401K, travel expenses, sales meetings in places like Hawaii, and various other goodies as part of his pay package that a doctor can only dream about. Or what about an air traffic controller. They only need an associate's degree but make an average of $118,000. Though stressful, I doubt being an air traffic controller is any more difficult than a physician trying to run a medical practice while getting called from anxious patients and nurses every ten minutes. The controller also gets the perks of being in a steady government job, with generous health and retirement benefits and civil service job guarantees.

So next time the drug rep knocks on the office door looking to sell his latest wares, don't treat him with condescension. He may very well be making more money than you while taking every weekend off.

Saturday, January 3, 2015

The Most Selfish Patient In The World

It has been one crazy December. We have been super busy the whole month. Every day we've been working from sunrise to well past sunset. I've neglected my own health by skipping my usual gym workouts. I missed several social gatherings because I was still at the hospital. And I have totally neglected this blog for weeks. Of course this is nothing new and follows a well established seasonal pattern of operating room bookings. Hopefully all this hard work will pay off in the coming weeks. Ka ching!

So it was during this December madness that we had an unexpected cancellation. You have to remember that patients have been trying for weeks to get an operating time before the calendar rolls over to 2015. Surgeons and hospital staff have all been working overtime to help their patients get their procedures done before their insurance deductibles reset on January 1. But one morning, the first case of the day, we waited and waited for the patient to come to the hospital. When he hadn't shown up at the registration desk by the appointed time, we finally called him at home.

As it turned out, the patient was still in bed. He said he didn't feel like having his operation today. It was Christmas break and he didn't want to get up early, instead preferring to sleep in for once now that school is out. And that was his whole excuse. WTF?

This incredibly selfish patient had secured himself a coveted first case time slot for a procedure then backed out because he didn't want to wake up early? He had known for weeks the procedure would be done during his holiday break and he didn't think he might not be able to drag himself out of bed? Dozens of patients have been trying to get their cases squeezed into the schedule and this jerk just decides to blow off his allotted time because he was too freaking lazy? And all the hospital staff are left standing around and costing facility money because suddenly there is no case to foot the bill? What an incredibly lame piece this person is.

Nothing left to do but go to the break room and eat more holiday cookies. The skinny jeans will just have to wait until I get back on the treadmill in January.