Lichen planus

The answer to yesterdays medical quiz was #4- oral lichen planus.

It is an autoimmune condition that causes inflammation on the lining of the mouth. It can affect the gums, tongue and lips, but is usually seen on the inside of the cheeks.

We see oral lichen planus during midlife, but it can occur any time and can last for years. Lichen planus can be found on the skin, scalp, nails and genitals. Like other autoimmune conditions, the cause is unknown but something triggers the inflammatory process in the mucous membranes.

The lip lesion could also have been squamous cell carcinoma and a biopsy can cinch the diagnosis. High potency corticosteroid gels are used as treatment.

Lip Lesion - You Be The Doctor

This 76 year old woman had a long-standing sore on the border of her lower lip. It was not tender and she denied any trauma or known exposure. What is the diagnosis?

1. Leukoplakia
2. Squamous cell carcinoma
3. Contact dermatitis to oral hygiene products
4. Oral lichen planus
5. Apthous stomatitis

Make your diagnosis and the answer will be posted tomorrow.
(from Consultant)

Medical Grand Rounds

Head on over to Captain Atopic to read the best of the medical grand rounds on the blogosphere. Good random reading on a number of health related subjects.

Cancer Screening Tests

I sat with non-medical friends last night and the discussion turned to "health", as it often does. One guy related the terrible story of a woman who went to her doctor with a certain pain which turned out to be cancer that had spread and she died within a week. The inevitable question; "How do you detect early cancer, so you can catch it and cure it?"

The answer I gave was less than satisfactory for my friends. In fact, they were a bit incredulous with the answer.

All cancer is genetic, in that it is caused by genes that change. Only a few types are inherited. Most cancers come from random mutations that develop in body cells during one's lifetime - either as a mistake when cells are going through cell division or in response to injuries from environmental agents such as radiation or chemicals.

Different types of cancer show up differently in the body. We have screening tests for some types of cancer. We can detect early breast cancer with mammography. We detect early colon cancer with colonoscopy and hemocult stool tests. We do screening for cervical cancer with pap smears. Early prostate cancer can be detected with PSA, but it is not very specific. Skin cancers can be found early with visualization and biopsy.

What about brain cancer, testicular cancer, leukemia, sarcoma, lung cancer, ovarian cancer and a number of other less common malignancies? We have no screening tests for these diseases. Perhaps we will discover some gene test or imaging test or breath test in the future, but right now, a person would need to have symptoms that would point to the disease.

This is a scary thought for people...especially those who try to live healthy lives.

It is the randomness of life that has always made us feel vulnerable to things we cannot control.

Costs Skyrocket for Pharmaceuticals

I just heard from one of my patients that the cost of "Advair" (an inhaler commonly used for asthma) at the pharmacy was $160.00. That is the discounted price the patient pays WITH HEALTH INSURANCE.

I suspect the pharmaceutical companies are gouging as much as they can just in case health care reform comes along and changes things. How strong do you think the legislature will be against the Pharma lobby? Boston Tea party, anyone?

Medical Marijuana

In medicine, we say things come in "threes". Sure enough, I have written three prescriptions for medical cannabis within the past 2 weeks. One was for a patient to help manage chronic pain, one was for a patient who was losing weight with metastatic cancer and the third for a patient with multiple sclerosis and spasticity. Medical marijuana has been found to be effective in all three of these diagnosis.

In case you haven't been paying attention, much has changed in the marijuana world over the past few years. In the urban cities of California there are thought to be over 1000 dispensaries for medical cannabis. Patients with a prescription from an MD, can purchase marijuana to smoke, eat or in the form of lozenges and suckers. These public dispensaries usually get the product from small growers and have a selection of different types of marijuana to suit different problems.

In San Francisco there are 22 registered dispensaries of medical marijuana. There is no problem with law enforcement since regulations went into effect and there is oversight of the Department of Public Health and the City Planning Department. In Los Angeles there are over 300 facilities and only 186 are registered and the others are being closed down.

There is always the question about are these "pot clubs" being just a way for someone to legally get marijuana. Since it is easy to find a doctor (some advertise) that will write a prescription for just about any bogus condition for a $200 fee, there are probably lots of users who don't really need it as medicine.

On the other hand, these programs prevent access by minors under 18 without being accompanied by a parent (and a legal Rx). They pay taxes and keep marijuana from being controlled by drug lords. One club employs over 100 people. (I don't know if they provide health benefits.)

No matter if some of the users are charlatans, the clubs do serve an important purpose for patients who do benefit from natural marijuana for a number of medical conditions. Since marijuana (both legal and illegal) is the largest crop grown in California (estimates at $18 billion), I call this an opportunity for legalization and taxation.

In case you missed it: Here is a link to a complete transcript of President Obama's address to the Nation on Health Care Reform. Embrace change! Read it now!

Creative Stool Collection

When doctors instruct patients to do a "stool collection" for diagnosis, we usually assume they will use the small container to collect the stool and then transfer it to the "already provided" lab specimen jars.

Not wanting to miss a thing...this patient devised his own system.

Primary Care Provider

I am ashamed to admit that I actually felt annoyed tonight over being referred to as a "primary care provider." It is hard to explain that after 21 years of education and another 23 years of practice as a specialist in Internal Medicine, I would be bothered by this.

One of my patients that I have cared for for 20 years was admitted to the hospital after going to the ER with abdominal pain. I was not informed of his admission and the "hospitalist" became the attending physician. The patient called me today from his hospital bed to inform me. He actually had a previously scheduled appointment with me in the office today and, good patient that he is, was calling to say he couldn't make it. He assumed I already knew he was admitted to the hospital.

I asked him to have the attending doctor call me as soon as he/she made rounds. I got the call from a young sounding hospitalist physician who did not know my name and wondered if I was the "primary care provider". She then said "Oh I don't usually call the primary care provider."

That phrase just stopped me cold. It is so "insurance" sounding. So contrived and replaceable. Primary care provider...delivery man....vacuum cleaner salesman...roto-rooter man. It's the doctor you can dismiss if you are a hospitalist one or two years out of training.

"I don't usually call the primary care provider."

Guess I better get thicker skin.

Sexual Side Effects of SSRIs

The SSRI drugs used to treat depression and anxiety are known to cause sexual side effects in many users. SSRIs include Paxil, Zoloft Prozac, Effexor, Lexapro and others. It is fairly common for patients to complain of low libido, dampening sexual desire and even decreased ability to have orgasm with these medications. The cause of these reactions is not known and there is no way to predict which patients will have these side effects. In my experience it is a rare patient that maintains their usual sexuality on SSRIs.

Many physicians do not feel comfortable talking to patients about the possibility of sexual side effects of SSRIs and they worry that warning patients might even "trigger" the change in sexuality. They also worry that patients who need the medication might decide not to take it and the depression will worsen.

Researchers at the University of Texas at Austin looked at educating patients about the sexual side effects of SSRIs and found that patients who were educated in advance reported less sexual dysfunction at follow-up visits compared to controls. Patients who attributed their sexual problems to their medications rather than blaming themselves were less likely to report sexual dysfunction.

Since many patients with depression blame themselves for problems, perhaps knowing that the medications are the cause, helps them manage any side effects that do occur.

This study points to the fact that doctors should discuss this side effect with patients. There are ways to deal with it (adding Wellbutrin, taking drug holidays, switching medications) but certainly understanding the cause helps patients understand symptoms and where they arise.

Is There A doctor On This Plane?

I was on a flight to Alaska (for a medical meeting) and the flight attendant came on the intercom "Is there a doctor on the plane? We need assist for a passenger." If you read my blog on Doctors as Good Samaritans, you already know my hand went up. This is the first time I've done an airplane rescue.

The 82 year old gentlemen was in first class (Alaska Airline first class is like coach..not very roomy), traveling to a cruise with his wife. He had gotten up to go to the bathroom and almost collapsed.

Doctors can assess a situation very quickly by just LOOKING at the patient. He was sitting in a seat, conscious, but pale and clammy. Pulse not detectable. Able to speak but not able to really give me a good history. A quick look at his chest as I unbuttoned his shirt told me he had had major cardiac surgery (Chest zipper sign). That already told me a lot.

First questions; "Are you having chest pain?" "No". "Are you nauseated?" "No". Blood pressure was difficult due to plane noise but was low...95 systolic. For older people we want to see that pressure at least over 110.

We put some oxygen on him and he started looking a little better. Wife told me he was a diabetic and she had his test kit so we quickly got a finger stick glucose...280. That's high but not the cause of the problem. I would have been concerned if it were below 100 (hypoglycemia).

My assessment was helped tremendously by the fact that his wife had a MEDICATION LIST. I could quickly rule out certain diagnoses with a quick glance at his medications. Insulin, Coumadin (that ruled out a pulmonary embolus or blood clot), Blood pressure meds, high cholesterol meds, potassium, arthritis, gout. There were about 15 different medications and I was told he had taken them in the morning.

According to his wife, they had been traveling all day, had been going through airports in a wheelchair. He was fine until he tried to stand up.

The patient got his color and cognition back with the oxygen and a little orange juice. I spoke via phone to the captain and a ground EMT. I stayed with him to make sure all was well for over an hour and decided the plane did not need to do an emergency landing nor did we need an ambulance at the destination. I stayed with him getting off the plane (last) and made sure his wheelchair was ready, transport was there and that he would go directly to an Emergency department in Anchorage for an EKG and labs before setting off on the cruise the next day.

The whole event had a satisfactory outcome and I hope he just had a syncopal episode because he is a frail guy traveling. I advised him he probably needs oxygen all the time because when he exerted himself, he got a little pale again. A full blown assessment was indicated.

I went back to my cramped seat in coach and ate my pretzels. Just another day!

Airport Food

First it was the indignity of having to take off my shoes and walk on a dirty floor just to get through security at the airport. Add to that, the inability to pack a nice healthy meal to get you through a day and night of flying because you can't get it through security. As much as I would like to avoid airport food, even short flights require long stretches of time spent in the airport. There is no way to avoid eating airport food and that is bad for your health.

Some airports have a food court with some choices...if you are lucky enough to be in that terminal. Today I was not so lucky.

Hungry during a layover, I had only a few choices. I stopped in at the "bagel haven" and found a chicken sandwich (on a bagel of course). It actually had the calorie count at a whopping 1250! I don't even like chicken on bagels so that didn't seem like a good choice. I cruised down to the "deli" and found it was closed. The "pub" offered chili, pizza, hamburgers and beer. Pass!

What is a hungry traveler, who wants a decent, low cal, healthy meal to do? I ended up getting a burger king whopper (680 cal) much to my dismay. There were just no other choices.

It is no wonder we have an obesity epidemic. Our society is not conducive to healthy eating and cheap fast food is everywhere. Does anyone else agree with me that a great organic salad bar would be a huge hit at the airport?

Nurse Shortage or Nurse Glut?

For years we have heard there is a shortage of nurses and as recently as today, the California Senate Education Committee approved a bill (AB867)to "address a severe nursing shortage in California." The Health Resources and Services Administration (HRSA) projects that 90% more RNs must be produced in order to meet the predicted need for one million new nurses in the American healthcare system by 2020.

So if there is such a shortage...why can't new nurse graduates find a position? I was pleased to pass on the name of a new RN school graduate who had great references from previous allied health care work and was told by the hospital;

"Virtually no one is doing a new grad training program at this time. We have made the commitment to "trickle in" some new grads this fall and received over 1000 applications for 5 positions. I might suggest this individual get their foot in the door as a nurses aide, phlebotomist or some other non-nursing job. Unfortunately, the economy has turned our profound nursing shortage into a glut, virtually overnight."

Upon investigation I find that there is actually an overabundance of nurses in Canada, Philippines as well as across the United States. There may be openings for experienced critical care nurses, but medical-surgical nurses are pounding the pavement looking for work and finding few or no jobs available. There are hundreds of nurses vying for every opening. The jobs just aren't there.

The downturn in the economy means more older nurses are keeping their jobs and delaying retirement. Hospital census is down and staffing is lean. Is that enough to turn a shortage into a glut? Apparently it is, or the prior predictions just weren't true.

Experts are still saying there will be a shortage after the recession is over that will only get worse in coming years. But for now, it looks like nurses are not in demand and there are thousands of unemployed RNs looking for work.

Summer Reading and Summer Tipping

I just finished a great read that I would like to pass on. It is called "The Help" by Kathryn Stockett. It takes place in Jackson, Mississippi during those transformative years of the 1940's through the changing 1960's. It is written from the voice of various "negro" maids who stayed with families for years and raised the kids and ran the households for their white employers.

The "Jim Crow" years of extreme segregation were not much better than slavery. Everyone had their place and these wonderful maids were constantly shown where their place was. They held the homes of the white southerners together and then went home and toiled in their own shanty houses.

The southern women could employ a maid for 20 years (below minimum wage) and never really know who she was or about her life. After all, it was a "privilege" to be welcomed into the white home to be "part" of the family. But make sure you never use the same toilet.

Change came slowly and violently to Mississippi and "The Help" is the type of book that you wish would go on and on.

Talking about "The Help" gives me a chance to encourage every blog reader to please, please remember to tip the maid when you travel. Women hotel maids, unlike the bell captain or waiter, are invisible and they work about 10 times as hard as any other hotel help. Have you ever tried to pick up wet towels, push a heavy sweeper and make huge beds all day? These women are at the bottom of the financial food chain and I bet every one has carpal tunnel syndrome and a painful back.

Leave them some money each day. Don't wait until the end of your stay when cash is short and you are rushing to the airport. I love to tip the maid daily. It is one part of keeping green than I feel good about.

Read "The Help" for a glimpse into recent history and tip your hotel housekeeper. You're welcome.

Welcome World Blog Readers

I get a kick out of my tracking software and enjoy seeing the visits to EverythingHealth from around the world. I am amazed that the internet works to connect us. In the last 24 hours I welcome: Jakarta, Guam, Australia, Nigeria, London, Anchorage, Delhi, Manila, Edinburgh, U.K., Canada, Saudi Arabia, Poland, Japan, Spain, Chile, Mexico and Costa Rica. Come back soon and I'll be humming "We are the World".

Estrogen and Progesterone for Menopause

"If you wait long enough, the pendulum will swing back", is a statement I have made to women patients who had concerns about taking estrogen and progesterone for menopause symptoms. In 2002 the Women's Health Initiative study was all over the news and it implicated hormone replacement therapy (HRT) in causing breast cancer, heart attack, and strokes. No wonder women freaked out, stopped taking hormones and decided to go "Au natural" through the aging process.

A few years later, Oprah started having hot flashes and the subject has been open for more discussion. "Natural" (and unproven) treatments have sprung up and women are more confused than ever about what is safe to deal with hot flashes, sweats, foggy thinking and aching joints that accompany menopause in many women.

The North American Menopause Society (NAMS) has published a formal consensus opinion after extensive review of the current scientific knowledge and health management. They have stated "Recent data support the initiation of menopausal hormone therapy (HT) around the time of menopause to treat menopause-related symptoms; to treat or reduce the risk of certain disorders, such as osteoporosis or fractures in select postmenopausal women; or both. The benefit-risk ratio for menopausal HT is favorable close to menopause but decreases with aging and with time since menopause, in previously untreated women."

Let me interpret (and add more based on the published document):

• The data shows relieving the symptoms of menopause is worth the small health risk of taking hormones
• For women with osteoporosis, estrogen preserves bone
• The best time to take hormone therapy (HT) is when you are going through menopause and having symptoms. There is less evidence of its benefit in older women who have never taken it previously
• If the problem is mainly vaginal dryness, using topical estrogen is best
• HT is not recommended as the sole treatment of sexual libido decline
• HT doesn't seem to affect weight one way or the other
• Some studies show HT may slow the development of atherosclerotic plaque. The Women's Health Initiative showed women younger than age 70 who started HT had no increased risk of coronary heart disease
• Women with a uterus need to take progesterone along with estrogen, or there is an increased risk of endometrial cancer after 3 years of use
• Women who take estrogen and progesterone have a slight increased risk of breast cancer.
• HT is not a treatment for depression, but it may improve mood in some women
• HT does not prevent aging or dementia
• HT reduced total mortality by 30% when initiated in women younger than age 60
• "Bioidentical" hormones (custom-compounded) have not been tested for effectiveness or safety. There is no scientific basis for using saliva testing to adjust hormone levels.
• Lower doses of hormones are recommended to treat symptoms. Topical progesterone is NOT recommended as it does not protect the uterus.

So there you have it. The pendulum is swinging back and many women will be reassured that they can get relief from menopausal symptoms without compromising their health. If you want to read the full paper click here.

Bloggers Holiday

I'm taking a week off from EverythingHealth. Enjoy early July and click on my side links for great medical blog reading. Better yet, click on the "followers" and become a follower of EverythingHealth. I'd like to return and see lots more added. See you in a week with more health news, tidbits and opinions.

Should You Send a Bill after a Patient Dies?

I logged onto a physician forum website and came across the question; "Do you charge an uninsured man's family after he dies?" The patient was in the hospital for a month and the doctor cared for him daily. The man was not insured but the patient's finances are enough to pay cash for the entire hospitalization. The doctor questions if he should bill the family after the patient died?

My first though was "No, just absorb the losses. The situation is unfortunate and the family will have enough problems without receiving doctor bills." As I read the comments on the site however, I realized no one else thought that way, and in fact, I could see the wisdom of the replies.

Most comments were something like, "You provided service and you should be compensated". Or "We all have bills to pay and they sure seek me out when I owe them - the lawyer, the credit cards, even the grocery store." Or "If the plumbing stopped up at the man's house while he was in the hospital, would his family NOT be expected to pay it?" Or "Absolutely send a bill. You can be sure the funeral home, the car dealer, the mortgage company, the magazine subscription, the credit card companies are all sending bills every month." Or "When will physicians realize that medicine is a business? Bill the estate the entire amount due." Or "Beware of the doctor who does not charge. He knows the value of his services."

There were 116 comments and about 99% of them felt a bill should be sent. Some advised a sympathy note also and some said the bill would likely not be paid. Only 2 out of the 116 suggested he not bill the estate.

After reading the comments, I re-thought about my gut response. I think he should bill, but should not actively pursue collections if the family/estate does not pay. We all do charity work, and this may just need to be written off. Of course, that may be one reason why primary care doctors are going the way of the dinosaur.

FDA Recommends Ban on Vicodin/Percocett

I must admit my jaw dropped when I read the headline about the FDA recommending a ban on two popular painkillers...Percocet and Vicodin. Both of these drugs are combination drugs, which means they combine another ingredient with acetaminophen (AKA: Tylenol). Tylenol is available over the counter and Percocet and Vicodin both require special "secure" prescriptions, yet it is the acetaminophen component that the FDA is worried about.

In 2005, over 28 billion doses of these meds were bought by patients in the U.S. (Don't you wonder who counted?) Let me repeat...28 billion. The FDA expressed concern because of tylenol overdoses and liver damage from too much acetaminophen. They reported more than 400 people die and 42,000 are hospitalized every year from overdoses.

None of the policywonks asked, but I could tell them that pain control is a huge problem for physicians and patients. We try to use as little drug as possible but pain that does not respond to over the counter medication like ibuprofen, naprosyn (NSAIDS) or Tylenol require prescriptions. Oxycodone and hydrocodone (the ingredients in Percocet and Vicodin) are not available without combining with another pain reliever like aspirin, tylenol or ibuprofen, except as controlled release form (Oxycontin and Oxyir).

Doctors have had their hands tied by the regulations about pain relief. In California we are required to take courses in "pain management" and can have our license removed if we don't manage pain or if we manage pain too well (and over prescribe narcotics). Patients can sue us for being left in pain and they can sue for becoming addicted to pain medication. We are damned either way.

Many physicians just opt out completely and send patients to expensive "pain management clinics". I just paid $808 for renewal of my controlled substance prescribing license and the idea of opting out looks appealing if the FDA bans these drugs without offering a substitute for patient care.