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Showing posts from November, 2008

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…

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

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’r…

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…

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.

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.

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…

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!

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 mouthGood diagnostic work, readers.

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.

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.


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 workplaceDon't call the President Elect "Evil Incarnate" in writingDon't threaten your staff and colleaguesDon't insult your staff by calling them names like "lazy" or "slacker."
Don't act like a victimDon't be a total jerkGreat 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…

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 popula…

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 Thaila…

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 we…

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 symptom…

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 …

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…

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…

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 …

Only 24 hours to Go

Halloween Costume Winner

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…