Friday, November 28, 2008

Sarah Palin's Turkey Bloodbath Causes a Stir

The election is over but, please make it stop.
Talk about poor judgment.

Hat Tip to Shadowfax at Movin Meat

Women's Self-Esteem

Stop with the retouched, perfect photos! This is why young girls develop self-esteem issues.
(Can we all agree that the unretouched was just fine the way she was?)

A Cute Baby Hippo

This photo just made me smile!
(Daniel Munoz/Reuters)


Probiotics are microorganisms with potential health benefits. I never heard about probiotics in medical school. Maybe they are teaching it now, but I've had to do my own research to find out what they are all about.

Probiotics are mainly used to treat GI conditions, including antibiotic-associated diarrhea, infectious diarrhea and irritable bowel syndrome where the microflora of the intestine has been disturbed. When the friendly microorganisms in the body have been disrupted or killed by antibiotics or stress, the homeostasis of the body is thrown off. Restoring the balance and proper immune function by placing new "friendly" organisms into the body is what probiotic therapy is all about.

The organisms we know the most about are in the Lactobacillus species that are naturally found in the human gut. Most probiotics are bacteria (Lactobacillus and Bifidobacterium) but some are yeasts such as Saccharomyces boulardii. The probiotic species must be resistant to acid and bile to survive transit through the upper GI tract and they must be taken regularly to work.

A number of studies have shown that probiotics may reduce the incidence of diarrhea in people who have taken antibiotics. The benefit is the greatest when they were taken within 72 hours of taking the first antibiotic. For adults, the greatest benefit came from doses of a least of 5-10 billion colony-forming units (CFUs).

There are no contraindications to probiotics comprised of Lactobacillus, Bifidobacterium, S. thermophilus or S. boulardii species. There are also no known interactions with medications or other supplements.

Scientific studies have shown benefits from probiotics in infections diarrhea, antibiotic induced diarrhea and irritable bowel syndrome and possibly atopic dermatitis (eczema) in infants and young children. Other allergies such as asthma, food allergy or allergic rhinitis showed no benefit.

Probiotcs are sold as capsules, powder, liquid or placed in foods. A recent study analyzed a range of brands of probiotics and found that of the 19 brands examined, five did not contain the number of live microorganisms stated on the label*. So really knowing the brand and making sure it contains enough CFUs is important.

Traditional yogurt does not usually contain enough probiotics to make a difference but therapeutic yogurts do. Look for Danactive, Activia, Yo-Plus, Stonyfield and Danimals for children.

Warning: Probiotics don't "cure" anything.

More information on probiotics can be found here. and at the National Center for Complementary and Alternative Medicine.

* product review: probiotic supplements.

Thursday, November 27, 2008

Happy Thanksgiving

"I know it is hard to be reconciled
not everything is exactly
the way it ought to be

but please turn around
and step into the future
leave memories behind
enter the land of hope"

Zbigniew Herbert, from A Life

Wednesday, November 26, 2008

Engage With Grace

Bloggers everywhere are posting this same message today in hopes our readers will come on board and start having meaningful conversations with each other and their loved ones. Here it is:

We make choices throughout our lives - where we want to live, what types
of activities will fill our days, with whom we spend our time. These choices are often a balance between our desires and our means, but at the end of the day, they are decisions made with intent. But when it comes to how we want to be treated at the end our lives, often we don't express our intent or tell our loved ones about it.

This has real consequences. 73% of Americans would prefer to die at home, but up to 50% die in a hospital. More than 80% of Californians say their loved ones“know exactly” or have a “good idea” of what their wishes would be if they were in a persistent coma, but only 50% say they've talked to them about their preferences.

But our end of life experiences are about a lot more than statistics. They’re about all of us. So the first thing we need to do is start talking.

Engage With Grace: The One Slide Project was designed with one simple goal: to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it. Five questions designed to help get us talking with each other, with our loved ones, about our preferences. And we’re asking people to
share this One Slide – wherever and whenever they can…at a presentation, at dinner, at their book club. Just One Slide, just five questions.

Lets start a global discussion that, until now, most of us haven’t had.

Here is what we are asking you: Download The One Slide and share it at any opportunity – with colleagues, family, friends. Think of the slide as currency and donate just two minutes whenever you can. Commit to being able to answer these five questions about end of life experience for yourself, and for your loved ones. Then commit to helping others do the same. Get this conversation started.

Let's start a viral movement driven by the change we as individuals can effect...and the incredibly positive impact we could have collectively. Help ensure that all of us - and the people we care for - can end our lives in the same purposeful way we live them.

Just One Slide, just one goal. Think of the enormous difference we can make together.

(To learn more please go to This post was written by Alexandra Drane and the Engage With Grace team)

Tuesday, November 25, 2008

Miraculous Facial Tumor Surgery

Lai Thi Dao , a 15 year old Vietnamese girl, endured a huge facial tumor called a Schwannoma for most of her life. It is obvious she had difficulty eating and breathing due to the terrible deformity and its rapid growth would have killed her.

Surgeons at the University of Miami/Jackson Memorial Medical Center performed a 14 hour procedure to remove the growth in April and little Lai had additional reconstructive surgery on October 10. She still has a tracheostomy tube in her throat but that will be removed in the next round of surgery and she will be able to speak normally for the first time in years.

The surgery was made possible by the International Kids Fund.

Isn't Medicine wonderful?

Health Care is Not Recession Proof

The economists and financial experts always say Health Care is recession proof. Traditionally, health care stocks have performed better in a down-turn and people still get sick and need care and services.

But we are seeing a big drop in hospital admissions, doctors visits and elective surgery as people lose their jobs, lose their insurance and can't afford even small co-pays for health care. A large consumer survey conducted in February (seems like long ago!) reported only 11% of people felt they could handle upcoming medical bills. Heck, the economy was practically thriving in February compared to now.

With California unemployment over 8% (and rising) and millions of others working part time or low wage jobs, the ability to see a doctor or seek medical care is just out of the question for many people. Even people with insurance will postpone medical treatment because they don't want to miss work or be laid up.

"Consumer driven health care" is a code word for "you pay more", so most folks co-pays are so excessive, when given a choice of the mortgage payment or doctor bill, the house wins.

Paul Keckley, executive director of the Deloitte Center for Health Solutions, sees three likely impacts from a recession: Primary and preventive care will be delayed, people with high deductibles will delay payments on care received, and there will be an increase in the number of bankruptcies from medical debt.

This recession is really going to put a strain on hospitals, care givers and patients in equal doses. It is a glaring example of how fragile our health infrastructure is.

Monday, November 24, 2008

Age is Just a Number

The Honolulu Marathon is just 3 weeks away. Gladys Burrill, a 90-year-old grandmother is training to set a world record for her age and this will be her fifth marathon.

The great-grandmother times 22 says, "Just forget about age and enjoy getting out there and exercising and walking or running or whatever they do. It will inspire them to do more."

Nicknamed, the "Glady-ator", this lady hopes to finish the race in 8 hours and 30 minutes. You go girl.

Sunday, November 23, 2008

Holiday Dinner, 1935

I've been putting my Thanksgiving Dinner list together. This photo is Earl Pauley and his children, preparing holiday dinner near Smithland, Iowa (Circa 1935).

May we continue to give thanks and have hope and optimism for President-elect, Obama and his new administration team. For more commentary, read what Thomas Friedman from the NY Times has to say, here.

Saturday, November 22, 2008

Vitamin Roundup

More and more well done studies are being published that evaluate the true benefit of vitamins. The best studies are random, double-blind trials that use enough subjects over a long time.

Here is the latest roundup:

Vitamin E - No benefit for preventing cancer, including colon, esophageal, gastric, pancreatic or liver. No benefit for preventing cardiovascular disease and people who took over 400IU's a day had a higher risk of dying from heart failure and other causes.

Vitamin E plus Selenium - No benefit for prostate cancer and maybe did more harm than good.

Beta Carotene/Vitamin A - Smokers and non smokers may had an even higher rate of lung cancer and heart disease.

Vitamin A - had a higher risk of hip fractures than women who did not take Vitamin A supplements.

Folic Acid - essential for pregnant women but did not prevent heart disease in others.

Vitamin C - didn't prevent colds but there was a reduction in colds among people who were extreme athletes or under physical stress (soldiers)

Beta carotene, Selenium, Vitamins A, C and E (Antioxidants alone or in combo)- users had a 6% higher death rate than placebo

Vitamin B - No help for heart attack or established vascular disease.

Multivitamins - No difference in infection rates or visits to doctors.

Vitamin D - numerous studies are emerging that show the "normal" ranges are too low and higher amounts of this vitamin are associated with decreases in cardiovascular, bone loss and cancer incidence.

Calcium - Improves bone health in women and men.

Gingko Biloba - doesn't prevent dementia or Alzheimer's disease.

Bottom line: Get your vitamins from food. Use your vitamin money to buy organic food. The 5-7 fruits and vegetables recommended a day have been proven in multiple excellent studies to prevent cancer, heart disease and promote longevity.

Many people argue that the vitamin studies are flawed and they keep wasting money on supplements. That is a choice, but at the very least eat real food!

Friday, November 21, 2008

Frustration Free Packaging

(click image to enlarge)

Finally, one of my pet peeves is being addressed by Amazon. They are introducing "Frustration Free packaging" in time for the holidays.

My cortisol levels start to surge when I receive a package with plastic form fitted around the object, metal twisty wires holding it together and plastic so tough my scissors can't even cut through it. None of it is recyclable and usually the packaging is bigger than the product inside.

Amazon is now beginning to work with the manufactures to eliminate this waste and ridiculous trend that seems to have sprung up everywhere. So far they only have 19 products that feature recyclable boxes that are easy to open. Jeff Bezos, CEO of Amazon, says the initiative will take many years, but the vision is to offer their entire catalog of products in Frustration-Free packaging.

To view the selection that will avoid wrap rage, go here. We need more of this!

Thursday, November 20, 2008

Women, know your place!

"kittens are so cute and furry."

Answer to Medical Challenge

The answer is #3 Diffuse esophageal spasm.

Here is another radiograph that shows barium contrast material that highlights the esophagus in a spiral formation. The esophagus is made of smooth muscle and it contracts to propel food down to the stomach. Esophageal spasm is an abnormal uncoordinated contraction and it can cause mid chest pain and slow the progression of food after swallowing.

Signs and symptoms of esophageal spasms include:

  • Pain in your chest, often intense, which you might mistake for heart pain (angina)
  • Difficulty swallowing (dysphagia)
  • The feeling that an object is stuck in your throat (globus)
  • Bringing food back up (regurgitation)
  • Heartburn, a burning sensation that may radiate from your upper abdomen to your neck, sometimes leaving a sour taste in your mouth
Good diagnostic work, readers.

Check it Out

Head on over to "Cranky Fitness" , a cool and fun website where "healthy living is a pain in the ass". I am the guest blogger on eating a healthy breakfast. Check it out.

Wednesday, November 19, 2008

This Weeks Medical Challenge

You be the doctor. This is a barium swallow and you are seeing the esophagus within the chest area with barium highlighting it. What is the diagnosis?

#1 Ingested foreign body
#2 Esophageal diverticula
#3 Diffuse esophageal spasm
#4 Gastric linitis plastica
#5 Esophageal carcinoma

Click on the image for a better view and the answer will be posted tomorrow.

Tuesday, November 18, 2008

A Doctors View of PBMs and Pharmacy Hassles

I was interviewed for a widely read publication in the Pharmacy world called Drug Benefit News. They kindly gave me permission to reprint it on my blog:

Volume 9, Number 21 October 31, 2008

The following interview is part of an occasional DBN series that examines hot-button pharmacy benefit issues though the words of the industry’s thought leaders. To suggest a topic and com- mentator, contact Neal Learner at Toni Brayer, M.D., has practiced internal medicine in San Francisco for more 20 years, and is regional chief medical officer of a large hospital/physician network in California. She is a fellow in the American College of Physicians and has served as president of the San Francisco Medical Society and chief of staff at California Pacific Medical Center. Brayer is a well-known speaker and author of the popular blog EverythingHealth (www. DBN caught up with Brayer to get her view of how well the pharmacy benefit works in the doctor’s office.

DBN: How would you assess the state of the pharmacy benefits industry from a physician’s perspective?

Brayer: The pharmacy benefit industry is confusing and overwhelming to physicians. There is a lack of understanding about how they operate and the difference between mail-order pharmacies and PBMs. Some are subsidiaries of health plans, some used to be owned by big pharma. There are perceived conflicts of interest. It is unclear if PBMs bring any value to health care, and if they do...who benefits? Pharmacy costs continue to increase by double digits, and PBMs are thought to be part of the problem, not the solution.

DBN: Do you see significant differences in the way that individual health plans and/or PBMs provide Rx drug coverage?

Brayer: Physicians deal with too many health plans and numerous PBMs, and from our view they have no consistency. We have no way of knowing the various protocols and regulations they operate with, and new product designs make it impossible to keep up. Formularies are cumbersome and change all the time, and it is unclear who controls the formulary. It appears that formularies are based on [achieving] optimal revenue, not evidence- based. The goal should be to reduce hassles for primary care physicians and lower costs to patients and purchasers of health care. Health plans and PBMs are seen as the problem, not the solution.

DBN: What are the biggest hassles that you face every day in getting patients the drugs that they need?

Brayer: Prior authorizations (PA) are exploding and require both staff and physician time to muddle through. A drug that is covered on one plan might need a PA on another. The protocols are different for each one, and some require the physician to list every drug the patient has previously tried and failed (with dates), which means an extensive chart review. It is unclear what is considered a generic, a brand or a preferred drug with each plan or PBM, and there is no transparency in pricing. Pharmacies do not automatically refill ongoing prescriptions and call or fax the doctor’s office for refills, even when it was clearly written on the Rx. Requiring tamper-proof prescriptions is a huge hassle, and it is unclear that they reduce drug abuse, but they certainly reduce physician efficiency. Pharmacies in 2008 are akin to the DMV [i.e., department of motor vehicles]. It is a nightmare to get a prescription filled. The cost of pharmaceuticals is obscene, and the waste we see within the pharmaceutical industry (which drives up cost) is infuriating.

DBN: To what extent do you consider the cost of a drug when writing a prescription?

Brayer: Always. But information is not clear, and I advise patients to use mail order or Costco or price shop. The variation in pricing is not rational, and the fact that patients can only get one month at a time for chronic medications is just plain gouging them for the dispensing fee and monthly copayments. Certain generic drugs should cost pennies a pill, but even generics have inflated pricing if the patient pays out of pocket. It is unusual for any medication to cost under $40, even if it is a generic that has been around for decades. That is a marketplace out of control.

DBN: What would you suggest to PBMs, health plans and others to improve the system?

Brayer: Initiate education for physicians and transparency for everyone. Who benefits from PBMs? Can you really be transparent about rebates, kickbacks and back-room deals? Make formularies evidence- based, and stop the onerous PA. Price non-generic drugs lower if there is no generic to offer as an alternative (example: transdermals, bisphosphenates, certain inhalers, certain antibiotics, once-daily dosing regimens).

DBN: What can or should physicians do to improve the operation of the pharmacy benefit?

Brayer: Physicians are at the bottom of the food chain and do not have the ability to improve this operation. As I see it, PBM customers are the health plans and the pharmaceutical industry. Health plan customers are the employers or purchasers. Employer customers are the stockholders or company owners. Physician customers are the patient. Physicians and patients are out of the loop except as the user of the services. Since we are no one’s customer, in a free market we are irrelevant.

Monday, November 17, 2008

Matrix 101: The Medical School

For my medical school colleagues. It can be a very surrealistic experience!

How NOT to Be a Medical Director

Dr. Karen Kim, director of Pooler Pediatric Clinic, in Pooler Georgia, wrote the above first letter (click on it for a better read) to her staff and colleagues.

After the backlash, she wrote a 2nd letter, which further inflamed the situation. A few days later a resignation letter said she would be leaving Pooler to devote more time to caring for her 7 children at home.

This is a good case study in how NOT to be a medical director (or any other manager of people).
  • Don't bring politics to the workplace
  • Don't call the President Elect "Evil Incarnate" in writing
  • Don't threaten your staff and colleagues
  • Don't insult your staff by calling them names like "lazy" or "slacker."
  • Don't act like a victim
  • Don't be a total jerk
Great advice I received at an early age from my mother was, "Don't ever put in writing anything you wouldn't want to be seen by everyone."

Now, with the internet it means it will be seen world wide. Sorry Dr. Kim. You never met my mom.

Sunday, November 16, 2008

America's Healthiest and Unhealthiest Cities - Its the Economy Stupid

Huntington, West Virginia has been named by the Centers for Disease Control (CDC) as the unhealthiest city in America. Nearly half of the adults in the five-county metropolitan area are obese and Huntington leads in heart disease, diabetes and elderly people who have lost their teeth. Contrast that with Burlington, Vermont, the nations healthiest city. What’s the difference? It all boils down to money and education.

First let’s look at Huntington. Its poverty rate is worse than the national average. It is a blue-collar white skinned community – people of English, Irish and German ancestry. Over the last few decades the manufacturing jobs have left the area and the remaining jobs are low paying. The largest employers are the hospitals and Marshall University.

Contrast that with Burlington. Only 8% live at the federal poverty level, compared to 19% in Huntington. Nearly 40% of residents have a college degree, compared with 15% in Huntington.

In Burlington, healthy eating is popular. Vegan options are plentiful and even low-income residents have the choice of bulk rice and grains and vegetables at local markets. In Huntington, donut shops abound and Pizza, KFC and fast food offer the best bargains to poor residents.

In Burlington people ride bikes, hike, ski and garden. Huntington has few parks and even on sunny days, residents are not out and about. The rural roads are busy and there are few sidewalks.

Huntington allows smoking in restaurants and local bars and even the hospitals have not been effective in forbidding smoking. Huntington’s culture is one of “you’re not going to tell me what I can or cannot eat” and the fact that poor eating, lack of exercise and smoking causes medical problems does not seem spur change.

Huntington officials are striking back and saying that the CDC report doesn’t exactly “mention” their area by name but includes a larger square mile area, of which they are just a portion. Despite the excuses by the city officials, a local physician, Dr. John Walden who is chair of family and community health at Marshall University says,
"I don't know that I've ever been in a place where I've seen so many overweight people.”

Colbert on Drugs

In case you missed this...Colbert Nails it. Watch to the end for his take on the Statin (Jupiter) Trials.

Thursday, November 13, 2008

Medical Tourism is Here

It was only a matter of time until health costs in the U.S. rose so high that we would outsource health care. That time is here.

WellPoint, the nation's largest health benefits company has announced a new product that allows its patients to travel to India to receive care. Starting in January, 2009, "members planning to undergo certain procedures can enjoy access to an extended network of respected hospitals and health care providers in India. By electing to use the international benefit, members can receive care at accredited facilities at lower out- of- pocket costs that could result in thousands of dollars of savings."

They go on to say a dedicated case manager will coordinate all medical arrangements, including scheduling and concierge travel services. All travel arrangements are booked and paid for, for both the member and a traveling companion. The case manager also arranges any post operative follow up care.

Certain medical tourism facilities in India and Thailand have quality outcomes that rival the United States. Their doctors are trained at fine institutions like Harvard and Johns Hopkins.
The facilities are accredited (without all of the unnecessary United States bureaucracy that drives up costs).

How do they do it? They have less government interference, practically no lawsuits, lower cost structures, no unions, low wages and better customer service.

You may not like it, but that is a fact.

How about a vacation and a knee replacement?

Tuesday, November 11, 2008

Health Care Costs - Whew!

My daughter purchases her own insurance. As a healthy young lady she spends $560/month (up from $375 in 2007) for a policy with $8000 deductible a year. She has already fulfilled her deductible this year (paid the first $8K) and had good coverage for her recent pregnancy and childbirth.

She understood the baby was covered for the first 30 days under the mom's policy. Well...yes the baby is covered but there is another $2500 deductible for the baby as well as $7500 annual co-pay before the baby is covered for hospitalization. That adds up to $10K for the baby to be covered for the first 30 days.

After 30 days, the premium will be $995/month for healthy mother and baby.

Enough said?

My Pet Peeve of the Day

Anyone who reads EverythingHealth or many other health blogs (Kevinmd, Maggie Maher, Dr. Rob, Dr. Val, Happy Hospitalist to name a few) knows that primary care physicians are a dying breed. Everyone talks about the money (painfully low reimbursement) as the cause, but equally annoying is the LACK OF RESPECT for the specialty.

Repeatedly I run across doctors who have no training in Family Medicine or Internal Medicine who say "Oh, I'll just be a primary care doctor." One doctor is an 86 year old surgeon who was denied operating privileges so he's going to "be a primary care doctor." He did surgery training in 1948.

Another doctor hasn't ever seen a live patient and he originally trained in Pathology and has done only laboratory work. He is moving to Hawaii to be a "primary care doctor."

Another has been a hospital administrator for years but want's to "see patients again" so he is going to do "primary care 1/2 day a week."

Give me a break! This is not a specialty you can drop in and out of as a hobby.

There is a severe lack of understanding about primary care medicine and the medical specialties of Family Medicine and General Internal Medicine. Each of these specialties requires years of residency after internship and continued medical education and exams for board certification status.

A tremendous body of knowledge is needed to be a primary care physician. One must have diagnostic acumen, know all treatment modalities, have skills in psychology, inherent common sense, knowledge of medical economics, a vast knowledge of pharmacology and hundreds of drug interactions. Primary care physicians must keep up with all of the medical literature and current evidence to be at the top of their game.

I've practiced non-stop for over 20 years and I am still challenged by patient care. Even though I could probably deliver a baby or remove an appendix or even amputate a limb if I were stranded on a desert island, I would never be so bold as to think I could drop in and out of those specialties and render good patient care.

Unfortunately the shortage of REAL primary care doctors means the field is wide open to anyone who wants to hang out a shingle and give it a try.

Monday, November 10, 2008

Britney Spears Son Has Allergic Reaction to Food

Britney Spears two-year-old son, Jayden, was rushed to the hospital with an allergic reaction yesterday. The tot was admitted for an overnight stay and observation after he developed hives, itchy skin and irritability. A rep for the family reported, “Doctors concluded he had a reaction to something he ingested”. He was released from the hospital in good condition today.

Most of the time, in food related allergic reactions, it is difficult to pinpoint the causative agent without further testing. The most common symptom is a flushed feeling, accompanied by a hive like rash (urticaria), tingling redness of the skin and palpitations and anxiety. Most reactions are self-limited and resolve by themselves or with the addition of anti-histamine medication.

Rarely a serious reaction can cause anaphylaxis and individuals who have asthma in addition to food allergies may be at increased risk for having a life-threatening anaphylactic reaction to food.

Signs of anaphylaxis include skin symptoms or swollen lips accompanied by difficulty breathing or reduced blood pressure. Abdominal cramps or vomiting, accompanied by difficulty breathing or wheezing can be signs of anaphylaxis and the patient should have immediate medical attention. Common causes of anaphylaxis include food, medication, insect stings or latex.

There are eight foods that account for 90% of all food allergy reactions. They are: milk, egg, peanut, tree nut (walnut, cashews etc), fish, shellfish, soy and wheat. True food allergies cause an immune response in the body, which is different than food intolerance. It is estimated that only 2-5% of the population have a food allergy.

Most food allergies begin in the first or second year of life, like in the case of little Jayden Federline. Many children outgrow their allergies (unlike adults), especially allergies to milk or soy formula. The most important diagnostic tool is a good history. What was eaten? What was the timing of the reaction? Did anyone else get sick and how much did the child eat? Skin testing can usually cinch the diagnosis.

Despite the problems Britney Spears has had in her young life, if her son has a food allergy it is not her fault. Getting him to the hospital for treatment and diagnosis was the right thing to do and avoiding the offending food is the treatment going forward.

Saturday, November 8, 2008

Obama's First Major Decision - a Hypoallergenic Dog

The world is dancing in the street at the election of Barack Obama. His every word is news and everyone wants to know what he will do next. During his victory speech he announced he will be getting a new family dog for the white house and animal lovers everywhere are weighing in on the best pet for the first family. The blogosphere is buzzing with names, breeds and advice for this major decision.

President Obama (I love those two words stung together) has now related that their new pet needs to be hypoallergenic and they would love to get a dog from a shelter. First of all, the fact that we have a leader that can say "hypoallergenic" is so amazing, I am just giddy.

And the fact that he understands the best dogs are rescue dogs is also to my liking. My pets have always come from the humane society or a rescue society and, I swear, these animals have a special sense about their place in the world.

Nothing is worse than being allergic to the family pet. I have had many sad family counseling sessions with patients to deal with this subject.

So, President Obama, may I present a few breeds for your consideration? This choice will outlast your presidency, and your ability to take your time and not rush into decisions will serve you well in this decision as well.

Best breeds for allergy sufferers:
  • Basenji (Came from Africa. Would make a nice statement)
  • Bedlington Terrier (I had one as a child. Fabulous dog and fur like a lamb)
  • Bichon Frise (Cute but I bet not found at a shelter. Too pricey)
  • Cairn Terrier (Good with children and small enough to take on world tours)
  • Chinese Crested (A status symbol..probably not right for the Obamas)
  • Coton de Tulear (Improve relations with France)
  • Fox Terrier (Improve relations with Fox News)
  • Havanese (Improve relations with Cuba. They have genetic health issues and you have enough problems with Health Care in the U.S.)
  • Irish Water Spaniel (Improve relations with Ireland)
  • Kerry blue Terrier (Impressive head, just like Obama)
  • Maltese (Improve relations with Malta)
  • Poodle (Tried and true success and very smart)
  • Portuguese Water Dog (Is there a pond at the white house?)
  • Schnauzer (Improve relations with Germany. My mom has this type. Very smart)
  • Shih Tzu (Improve relations with China. Doubt available in a shelter)
  • Soft coated Wheaten Terrier (They are so cute)
  • Yorkshire Terrier (Improve relations with the UK)
Good luck, Mr. President. If you need any advice on Health Care reform, you know where to find me.

Thursday, November 6, 2008

Extreme Steroids - Danger!

Prostate Cancer Screening - muddled and confusing

Prostate cancer is the most common nonskin cancer in men in the United States and 1 in 6 men will receive this diagnosis in their lifetime. The Prostate-specific antigen (PSA) test was approved by the FDA as a screening test for prostate cancer in 1986 and its use has increased since that time. Most male patients are aware of the test and ask for it at their annual exam.

What is little known by patients, is that the PSA test is not specific for prostate cancer. Men can have an elevated level for no disease reason, or it can be elevated for other common conditions like benign prostatic hypertrophy or prostatitis.

In 2002, the U.S. Preventive Services Task Force found insufficient evidence to recommend for or against routine screening for prostate cancer. They found inconclusive evidence that screening and early detection improved health outcomes.

A new study was conducted by the same task force this year and published in the Annals of Internal Medicine. The researchers looked at the PSA test and asked three new key questions that were not asked in 2002:

1. Does screening for prostate cancer with PSA as a single test, or multiple tests over time decrease morbidity or mortality?
2. What are the harms associated with PSA?
3. What is the natural history of PSA-detected, non palpable, localized prostate cancer?

Their recommendations remain the same as 2002. They do not recommend routine PSA testing in men as a screen for prostate cancer. They state it is associated with psychological harm, possibility of erectile dysfunction, urinary incontinence, bowel dysfunction even death if treated. And its potential benefit remains uncertain. They recommend against testing any man over age 75 years.

So, there you have it. Evidence based medicine. The major medical associations like the American Academy of Family Physicians, the American College of Preventive Medicine, The AMA and The American College of Physicians recommend discussing the "risks and benefits" with patients and consider the patients' preference.

It is no surprise that the American Urological Association recommends offering PSA and digital rectal examination to men annually beginning at age 50. The urologists benefit from elevated PSA levels.

I would bet that there are very few physicians who will take the time to try and explain this study to their male patients. Every patient I have ever had believes if a test is available that "might" detect cancer...they want it.

With the escalating cost of health care, out out of control malpractice lawsuits and the bankrupt Medicare system , we are going to need to tackle these thorny issues of everything for everyone. There are so many unproven tests and treatments in Medicine and we have not had the will or the leadership to say "no" when there is no proven benefit.

Wednesday, November 5, 2008

Tuesday, November 4, 2008

Barack Obama Elected President

"Change will not come if we wait for some other person or some other time. We are the ones we've been waiting for. We are the change that we seek."
Barack Obama

Focusing your life solely on making a buck shows a certain poverty of ambition. It asks too little of yourself. Because it's only when you hitch your wagon to something larger than yourself that you realize your true potential. "
Barack Obama

"If you're walking down the right path and you're willing to keep walking, eventually you'll make progress."
Barack Obama

"There is not a liberal America and a conservative America - there is the United States of America. There is not a black America and a white America and latino America and asian America - there's the United States of America. "
Barack Obama

Today we are engaged in a deadly global struggle for those who would intimidate, torture, and murder people for exercising the most basic freedoms. If we are to win this struggle and spread those freedoms, we must keep our own moral compass pointed in a true direction."
Barack Obama

"What Washington needs is adult supervision."
Barack Obama

Monday, November 3, 2008

Evidence Based Wound Care

It is always kind of a shock when I find out that the way we physicians "have always done things" is not supported by the evidence. When studies prove us wrong, we need to make changes. Here are some new evidence based ways to care for wounds and lacerations:

  • Tap water is as effective as sterile water for wound irrigation and does not cause more infection. (In my prior Emergency Department days, the mantra was "irrigate the wound copiously" and we always used liters of sterile water. We should save a lot of money by using tap water.)
  • White petroleum jelly is as effective as topical antibiotics in preventing infection. (Vaseline? My mom used to use it. Who knew?)
  • For scalp lacerations, hair twisted across the wound and fixed with tissue adhesive is as effective as sutures. (sutures are needed for wounds across joints or areas that flex)
  • Keep the wound dry for 12 hours. (We used to make patients keep it dry for 24 hours)
That's the most updated information we have for wound care. Remember, washing with soap and (tap) water is the most effective thing you can do to prevent infection.

Only 24 hours to Go

Saturday, November 1, 2008

Women Pay More For Health Insurance

With Sarah Palin running for the second highest office in the Country, you would think women have finally made it. Before we get too complacent and think there is equality between men and women, we must keep in mind that the full time working woman's average pay is still only 77% of her male counterpart.

Now I found out that women pay MUCH MORE than men of the same age for individual, identical insurance policies. At a time when our economy is in the tank and people are out there looking for individual health insurance because they have lost their job, it is shocking to find out that women are charged as much as 49% more than a man for the same policy. Even high deductible plans are a disadvantage for women and there is no actuarial explanation for it. Does being born with a uterus count as a preexisting condition?

Proponents (if there are any that are not in the insurance biz) of these inequities would say that women utilize more health care than men. Women go to the doctor more and use services in childbirth. So, as a society, we are penalizing women for preventive health care and for bearing the future citizens of the world. I guess we are rewarding men for dying sooner and getting the hell off the planet and off the insurance rolls. There's nothing like a dead policy holder to increase profits!!!

If the claim that women use more services in childbirth and should pay more is true...then why penalize women who never have children or who have had a hysterectomy? Why are they paying more when men are not? The entire scheme makes no sense and all you need to do is check the profit margins of the nations top insurers, as well as the executive compensation, and it is obvious that they charge women more BECAUSE THEY CAN!

And what a surprise to read in today's New York Times that women pay more for home mortgages too. Women are 32% more likely to carry mortgages at higher interest rates than men with similar incomes. The article points out that wealthier women were 50% more likely to carry expensive loans than their male counterparts.

I used to be pissed that I paid more for my shirts to be laundered than a man does. Boy is that the tip of the iceberg. Women need to learn the methods of negotiation and standing up for themselves and their pay rate. Kudos to the NYT for shining a light on these inequities and women also need to be aware that nothing will change by itself. It takes knowledge, activism and supporting each other in the workplace.

When to Use Urgent Care

We all know that Emergency Departments are over-crowded with long waits and exorbitant fees.  Free standing Urgent Care is a great solu...