Saturday, December 31, 2011

Some Like It Hot.

I went to my first Bikram Yoga class on Thursday.  In short, Bikram Yoga is a series of 26 yoga poses performed in a room that is heated to 105 degrees and 40% humidity (!).

I've done other types of yoga before (mostly Hatha Yoga).  To be honest, I never really enjoyed it that much.  I definitely feel it's beneficial- it promotes balance and flexibility.  What I had trouble with was the whole meditation/relaxation aspect of it.  I'm rather...Type A (to put it mildly), and always had a hard time just sitting and breathing.  My mind just starts running to the millions of other things I need to be doing, and I get all agitated...which probably means I really SHOULD be doing yoga on a regular basis, but oh, well.

I will say that I enjoyed the Bikram class, and I think I might start going on a regular basis.  Like many runners, I tend to get a bit lazy about stretching, and this class certainly will cure that problem.  The heat of the room does seem to make stretching easier.  What I found really interesting was that I didn't feel like I was working out that hard during the class, but boy was I sore the next day!

So, here's my overall opinion of the pros and cons of Bikram:

Pros:  The heat does promote muscle flexibility.
           The postures hit all the major muscle groups.
           There is an emphasis on balance and core strengthening.
           You get into an aerobic state just by virtue of your heart rate increasing from the heat and             dehydration.

Cons:  It's easy to overdo it- maybe too easy.  Forcing a stretch can definitely lead to injury.
            Dehydration is a definite risk.
           Anyone on blood pressure medications, diuretics, or medications that interfere with sweating (antihistamines, especially) should not do this.
            Anyone with a history of cardiac disease or lung disease should not do this.
            Anyone who is pregnant should not do this.
So, I'll be attending some more sessions- we'll see how it works out.

*A big shout out and thanks to Becky for getting me started!*


Friday, December 23, 2011

A Plague on My House

I haven't blogged in over a week.  That's because I've been dealing with sick kids.  Poor Matthew got the horrible cold that's been going around and has just been miserable...consequently everyone else in the house is also miserable and not sleeping.

Just as Matthew was starting to get better, Alex started vomiting.  First into the toilet, then on the couch, then on me, then in my bed.  Good times.

Now I have pinkeye.

My patients always ask me, "How do you avoid getting sick?" The answer is...I don't. 

TGIF, and looking forward to the long weekend.

Monday, December 12, 2011

Behind the Scenes- Watch an Insurance Company Try to Drive Me Insane

I've blogged before about prior authorization forms that insurance companies make me fill out all. the. time.  Here's another fun thing that I encounter on a regular basis.

Now, on the surface this looks like a run-of-the-mill form to approve Crestor.  There's a backstory here, however.  This patient had been on Lipitor, and her cholesterol was well-controlled on it.  At her last visit she gave me a notice from her insurance company saying that they will no longer be covering Lipitor but will cover Crestor.  So, I changed her to Crestor at their request. Now- wait for it- they want me to fill out an approval form for a medication change that was initiated by them in the first place!!!

This is why every day I discover more and more gray hairs...

Sunday, December 11, 2011

'Tis the Season...

The season for colds and flu, that is.

I'm just putting this out there in black and white, so that everyone can see it.  I'm even going to italicize it, so that you know I really, really mean it.  Here goes...

I can't cure your cold.  I can't even make it go away faster than it would on its own.  Even if you have a vacation in two days and you're flying to the Caribbean and don't want to be sick- I STILL can't make it better.

There.  Glad I got that off my chest.

Colds are caused by a virus, not a bacterium.  This means that antibiotics will not work for them.  Bronchitis typically does not need an antibiotic either- it gets better on its own.  Likewise sinusitis.

A cold typically lasts 10 to 14 days.  A cough from bronchitis can last for weeks, and sometime a few months.  Sinus pain and pressure can last for weeks.  A cough does not means that antibiotics are needed.  Green mucus is not a sign of a bacterial infection- that's just the color of mucus.  A fever doesn't mean an antibiotic is needed.  I highly recommend that everyone read this.  It's a link to the CDC Get Smart Homepage, and is chock-full of great information about antibiotics.

Certain over the counter cold medications can be helpful.  For those without high blood pressure, Sudafed is my top choice.  Nasal saline rinses are almost always helpful.

Now, I never mind people coming into my office to get their cold checked out.  I'd hate for someone to be worried that their cold might be something more than just a virus.  It's never a waste of my time- I'd rather someone get checked out than worry, and sometimes someone actually has an ear infection or pneumonia. Even if it's not something like that, I typically will be able to give individualized advice about dealing with the symptoms.   However, I do ask that people trust my judgement.  Don't get angry with me if I won't give antibiotics.  I never give them just to appease someone- I only give them if they're needed.  And please, don't get angry with me if you're still sick in a week- that's typical.  It stinks, I know.  It's just how it is.  If I find the cure for the common cold, I promise, my patients will be the first to know!

Sunday, December 4, 2011

Another Great Running App

The last app I reviewed was RunKeeper, which I still love.  However, if you want to spring for the $1.99, check out the Nike+GPS app.  I'm really enjoying this one.  It lets me sync my iTunes playlist with the app itself, so I can navigate through songs without exiting the program.

It also has a neat little feature called "PowerSongs".  At any point during the run, I can hit the PowerSong button and an "inspirational" song that I've chosen in advance starts playing.  It's pretty cool- I might be dragging towards the end of a run, and I all need to do is hit a button and Gloria Gaynor's singing "I Will Survive."  Perfect!

I can also run against friends (virtually, of course), and post my results for the world to see on Facebook or Twitter.  I can challenge myself by setting the app to prompt me to beat my best time or distance.  The best part- when I post a personal record, Lance Armstrong or Paula Radcliffe comes on to congratulate me!

All in all- I think this is my new favorite.

Sunday, November 27, 2011

Breaking up is hard to do...

When is it time to break up with your doctor?  It can be a tough decision to make.  After all, if you don't like your experience at a store, you shop somewhere else next time.  If you go for a haircut and hate it, you find someone else.

With your doctor, it's a bit different.  This is someone who might know some of your deepest, darkest secrets.  There is a history to that relationship.  Logistically, it is also a bit of a pain in the butt.  All of your records are with your doctor.  You might need to have a chat with your insurance company.  Then you actually have to go through the process of finding a new doctor you like.  So, when is it worth it to take the plunge?

First things first- try to articulate to yourself why you want a new doctor.  Did you have one really bad appointment, but otherwise have had good experiences?  If so, you should probably talk to your doctor about your concerns before you jump ship.  Your doctor might have just been having a bad day.  Not that that's an excuse, but it is an explanation.  Doctors are people, too.  We get sick.  We have worries about kids and family.  However, if you repeatedly have not been satisfied at your appointments, you might want to seek a new doctor.

Is it a personality issue?  Do you and your doctor just not "click?"  If that's the case, you probably are better off finding someone else.  You need to be able to completely trust your primary care doctor, and if you can't be comfortable with him/her, it's not going to work.

Is it the office staff?  Is someone at the front desk always rude?  Do you always get put on hold for 20 minutes when you call?  For these issue, I strongly suggest that you talk to your doctor.  Here's the truth- since we're not patients in our own offices, we often have no idea of what's going on up front.  Sad, but true.  However, we can easily remedy many of these issues if we know about them.  So, don't switch for these reasons.  Talk to your doc first, and give it a bit more time.  If there is no improvement in services, then it's time to make a move.

Now the harder stuff- care issues.  By this, I mean that you have concerns about the level of care that your doctor is giving you.  This is a very tough one, because unless you are in the health care field yourself, you might not be able to accurately assess this.  The internet is changing this, however, and more and more people are reading online and educating themselves about their health conditions.  This is a good thing.  However, just because your doctor is treating you one way, and you read about a different treatment online, doesn't mean that your doctor is wrong.  The practice of medicine is an art, and highly individualized.  If you have concerns, you must talk to your doctor.  You might even want to get a second opinion from another doctor.  A reasonable doc should never be angry about you getting another opinion. If your issues about the level of care you are getting are legitimate, you should definitely find another doctor.

Lastly, whenever you think of switching doctors, I ask you to look at yourself, too.  Have you been to doctor after doctor after doctor, never finding one who has satisfied you?  The problem might not be your doctor.  Nothing strikes dread into the heart of a primary care physician like having a patient say, "I've been to ten other doctors and no one has listened to me/been able to help me."  Are your expectations of your doctor unrealistic?  I have one patient who left my practice because she wanted a personal phone call from me with all of her lab results.  Now, I do send out letters for all results, but I can't make calls to everyone.  I review about 50 lab results a day.  If I called everyone personally, that's all I would be able to do.

So, it's a complicated subject.  However, I hope I've gotten across the one recurring to your doctor.  The worst that can happen is that you mutually decide to part ways.

Monday, November 21, 2011

Behind the scenes- thanks for the suggestion!

We have a suggestion box in the waiting room. We've gotten some very helpful comments in it. Some, though, well...judge for yourself.

Now, we actually do have a television in the waiting room. We play a DVD that shows nature scenes and has soothing background music. The box that the DVD came in claims that it is clinically proven to lower blood pressure, but clearly it did not work in the case of this particular person.

Tuesday, November 15, 2011

Cook for a day, eat for a month

It can be tough to get a healthy, well-balanced meal on the table every night.  We all have busy lives, and too often that gets in the way of us eating right.

That's why my family is trying this for the month.  I'll freely admit it- I love Rachael Ray.  I don't watch her show or anything, but I've tried out several of her 30-minute meals and they always turn out well.  The idea behind cooking for a day and eating for a month is this:  you make large quantities of five "building block recipes"- in this case, tomato sauce, pulled chicken, pulled pork, roasted veggies, and rice pilaf.  You use these starters in various combinations in all the recipes, with some additions.  Pretty cool concept.

We cooked the starters this past weekend- it was not particularly difficult or time consuming- and froze everything.  So far, we've made two meals from the starters, spanish rice with shrimp and fusilli pasta with chicken.  Both just took a few minutes of prep and cooking time.  They were pretty tasty, too.  Plus, there have been leftovers for lunch the next day.

I have to say, there's a lot to be said for not having to think about meal planning for the rest of the month.  If you're pressed for time and trying to feed your family a healthy dinner, I encourage you to check this out!

Tuesday, November 8, 2011

Marathon memories

Anyone else watch the NYC Marathon this past Sunday?  It was pretty incredible, with course records being smashed right and left.  It made me want to go out there and do it again...

Running the NYC Marathon was one of the most incredible experiences of my life.  Just to be clear with everyone, I wasn't always a runner.  Actually, up until residency, I basically despised running.  I remember moaning and complaining about having to do a one mile run in gym class in high school.

However, during my residency time was short and stress levels were high.  Running provided the best bang for my buck for fitness and stress relief.  I started running during my intern year, but I can't say I enjoyed it.

During my second year, 9/11 happened.  My experience with that is a post for another day.  I will tell you this, watching the NY marathon two months after that was amazing and powerful, and I vowed that I would run that marathon one day.  I stated running on a more regular basis and I joined the NY Road Runners.  I ran my first race (a 10K) that January, and racked up enough races over the next few months to guarantee an entry into the 2003 marathon.

Training for a marathon during residency is...interesting.  I was basically working seven days a week, with several overnights a month.  Marathon training requires a minimum of 40 miles of running a week.  I remember some days getting up at 3 AM so I could complete a 20 mile training run and make it to the hospital in time for 7:30 AM rounds.  And yes, Mom and Dad, I'll tell you now that I ran in the dark in NYC by myself!!!!  And lived to tell the tale.  Looking back, it sounds a bit...nuts.  However, I've always been pretty determined (my family has been known to call it stubborn).  It was all worth it on marathon day.  Running into Central Park, with the crowds cheering, knowing that I had just run 26.2 was amazing.  However, the real reward was knowing that I could truly do anything I set my mind to, and that I had found an activity that I loved.

I've continued to run since then, but I haven't done another marathon since the Disney Marathon in 2005.  Pregnancy and motherhood have gotten in the way a bit.  Right now, time with my boys is so precious that I don't want to spend four hours on a weekend running when I could be playing with them.  In the future, though...there are plenty of races left to do.  I look forward to getting out there again, sometime soon!

Wednesday, November 2, 2011

Why I won't just "call something in."

I often get calls from patients, either during office hours or while on call, requesting that I "call in a prescription." It is usually a request for antibiotics.  Usually, the message is something like this.  "Hi, this is So and So.  I've has a cold for a week and I'm coughing up green stuff.  Can Dr. Nicholas just call in a Z-pack for me? It always works.  I'm  too busy at work to come in for a visit/don't want to pay for an office visit/in Florida on vacation and can't come in."  Or it's "Hi, I think I have a bladder infection.  Can Dr. Nicholas just call in something for me?"

The answer to these questions, invariably, is no.  Here are the various reasons why.

1.  There's an almost 100% likelihood that your cold is viral.  That means that antibiotics will not do anything for it, other than give you a yeast infection or antibiotic-associated diarrhea.  The reason that the Z-Pack "always works" is because the cold would have gotten better on its own.

2.  If your upper respiratory infection is not viral, I need to figure out what it is.  Is it sinusitis (which usually doesn't need an antibiotic!)?  Is is pneumonia?  Different antibiotics treat different bugs.  It's not one size fits all.

3.  Maybe it's not an infection at all.  People mistake allergies and asthma all the time as a "cold" or "bronchitis."

4. More often than not, my patients who have self-diagnosed themselves with a UTI don't actually have one.  I've seen sexually transmitted infections, kidney stones, bladder cancer, and even acute liver failure in people who were convinced that all they had was a UTI.

5.  Antibiotics need to be treated with respect.  They are horribly overused and we are paying the price with antibiotic resistant infections. If you are sick enough to need an antibiotic, you are sick enough to need to see a doctor.

6.  It's just plain bad medicine to treat a patient without seeing and examining them.  So much is gained just by laying eyes on someone.  I can't tell you how many times I've "forced" a patient to come in for an evalution- only to know within about 10 seconds that they need to be in the hospital.

So, patients, I'm not trying to annoy you.  I'm not trying to waste your time.  I'm not trying to rake in the big bucks from an office visit.  All I am trying to do is provide top-notch care.  I want the best for all of my patients.

Saturday, October 29, 2011

Don't go looking for problems...

Interesting article in the NY Times about how MRIs, when not used judiciously, can lead to inappropriate and even harmful treatment.

One of the hardest parts of my job is trying to convince people that the appropriate treatment is...nothing.  People will often present to me with an acute complaint- knee pain, back pain, shoulder pain- and want an MRI.  Nine times out of ten, it is not necessary.  Everyone needs a good history and physical exam.  Based on that, I determine if imaging is needed.  Most often, it's not.  What's needed is rest and sometimes physical therapy.  And time.  Lots and lots of time.  It takes a lot more than a week or two for a muscle or ligament to heal.  It's frustrating, but true, and there is absolutely nothing that can be done to speed it up.  So, have patience.  Otherwise, you might be buying yourself an unnecessary surgery.

Tuesday, October 25, 2011

The Seven Habits of Highly Effective Patients

This is something that I give out to all new patients.  I wrote it because I feel that while I need to be a good doctor, my patients also have to do their job.  A physician-patient relationship is like any other relationship- you only get what you give.  One-sided relationships are usually doomed to failure, so I like my patients to be active, empowered participants in their healthcare.

 Seven Habits of the Informed Patient
Get the Most from Your Health Care!

1. Be Early For Your Appointment.
§  You may have paperwork to fill out, or phone calls may need to be made to your insurance company. 
§  You need to have your blood pressure and vital signs taken.  By arriving early to your appointment, you ensure that you get to spend as much time with your doctor as possible.

2.  Be Organized (Part 1).
§  Make a list of what you want to discuss with your doctor.  Prioritize it so that you cover the most important items first.  Check off your items as you cover them.  Don’t rely on your memory!

3.  Be Organized (Part 2).
§  Make a binder or folder of your health history. 
§  Get copies of lab work or tests from other doctors. 
This will help your primary doctor stay up to date on what is going on with your health.  This will also help you keep track of appointments and dates (like when your next physical should be).

4.  Know Your Medications
§  Bring a list of all of your medications, dosages and how often you take them to EVERY visit.  This is especially important if you receive medications from more than one doctor.
5.  Know Your Insurance Plan
§  Be familiar with what your insurance plan covers.  Call them if you have any questions.
§  Get a copy of your insurance plan’s Formulary (list of covered medications).  Bring it to all appointments.  This will help your doctor to make the best medication choices for you.
Remember, your doctor deals with dozens of insurance plans.  He can’t be expected to know exactly what your particular plan covers!

6.  Do Your Homework.
§  If your doctor orders tests, make sure you do them!  There was a reason for ordering it.  If you are not sure of that reason, ask.
Don’t assume that no news is good news.  If you do not hear from your doctor within 2 weeks of getting a test or labs done, call the office for the results. 

7.  Take Charge!
Your doctor will work with you to keep you as healthy as possible, but ultimately you are in charge of your health.  Eat right, exercise, don’t smoke and take your prescribed medications.

Wednesday, October 19, 2011

Now on Twitter!

And tumblr.  I'll still be blogging here, but now you can also follow me on Twitter and Tumblr- buttons are to the right.

Monday, October 17, 2011

Doctors really are technology dinosaurs.

So, here I am at my CME conference.  Like I said yesterday, it's been a while since I've attending a live conference.  They've gone high-tech.  There are no handouts at all- instead we were handed a flash drive, which contains all of the presentations.  I did bring my laptop, so I was all set to go.  I have to say, I'm loving it.  All of the presentations come up in Adobe Reader, and I can just type in notes and comments.  No more hauling around piles of handouts, which inevitably would just get shoved in some drawer in my office for years until I finally got fed up and threw them all out without ever looking at them again...

Everyone also got one of these handy little electronic response cards.  This way, the lecturer can ask questions, we respond, and there is immediate feedback presented.  It's kind of like the "Ask the Audience" option on Who Wants to be a Millionaire, except without Regis Philbin or the big bucks.

One thing that has surprised me is the general level of angst I've seen from the physicians here regarding the lack of a paper-and-pencil option.   Some people are really ticked that there are no handouts.  Keep in mind, we were warned in advance that this was a "green" conference and that all presentations would be electronic.  People just can't seem to grasp the concept.  There is also some confusion regarding the fact that all the evaluations of the course need to be done online.  One middle-aged woman that I was talking to yesterday seemed positively panic-stricken regarding this.

Come on, my fellow physicians!  Let's move into the 21st century!

Sunday, October 16, 2011

Laissez les bons temps rouler!

So, here I am in New Orleans.  I'm attending a medical conference.  In New Hampshire, all physicians are required to complete a minimum of 50 hours of continuing medical education yearly.  For the past several years, I've done most of mine online, as getting away for a conference was tough, what with pregnancy, childbirth, infants and breastfeeding, etc.  I do find that I get a lot more out of actually attending a conference, though.  It gets me into that learning mindset, and I just get to concentrate on doing nothing but absorbing new information.

I have to admit, it's also nice to have a change of scenery.  Thanks to my awesome parents, who are pulling babysitting duty, both Patrick and I were able to get away for a few days.

I always like to go for a run after I travel to a new place.  First of all, it's a great way to stretch out all the kinks after a long flight.  It's also a terrific way to see some of the sights and get the lay of the land.  Here are some pictures from my run yesterday.

This is where I will make up all the calories that I burn during the run (if you've never had a beignet, you're missing out).

More blogging from my conference tomorrow!

Wednesday, October 12, 2011

Behind the Scenes

This is a non-formulary approval form.  Junk like this takes up a good part of my day.

Basically, this says that the medication I prescribed is not on the patient's insurance formulary.  A "formulary" is the list of medications that an insurance plan will cover.  All insurance companies have different formularies, and different plans within the same company have different formularies.  There is virtually no way for me to know what medications are covered on what plan.  To make things even better, formularies change all the time, depending on which drug company is in bed with which insurance company.  So, that medication that you've been taking for a year that works well?  Sorry, it might not be covered next week.

This form says that I prescribed a patient Prevacid.  His plan only wants to cover Nexium or Prilosec.  So, in order to get the patient the medication he wants and has done well on, I have to review the whole chart, fill out the form, and hope I come up with a reason that's good enough to get him his medication.

Remember, this work was just for one patient.  I usually have to fill out at least 10 of these forms a day.

Medications are not always approved.  And it is NOT MY FAULT!  Patients, I am on your side.  I want you  to have the medications I prescribe.  When your insurance company will not approve a medication, it is as aggravating to me as it is to you.  But, no, I can't just "write a letter to someone" or "call someone" to get your medication approved.  If your company doesn't cover it, thems the breaks.  You can pay cash or take an alternative medication.  When you chose an insurance plan, you agreed to all of the stipulations and restrictions.  That includes the formulary.  I do my best by trying to write for generic medications as much as possible, but some companies do not even have generics on formulary.

So, I'll keep on tackling the paperwork.  I hope this helps explain why the prescription that I called into the pharmacy is not sitting there waiting for you.  It's caught up in a mess of red tape.

Sunday, October 9, 2011

Study of the Week

And controversy of the week.

This past week the US Preventative Services Task Force (USPSTF) release its latest recommendations regarding the PSA test.  The PSA (prostate-specific antigen) is an enzyme produced by the prostate.  It can be elevated in men with prostate cancer.  Many other things can elevate it- including infections, benign prostatic hypertrophy (the prostate getting larger as someone gets older) and certain drugs.  It is a test with very poor specificity, meaning that there are a high number of false positives.  Most people who have an elevated PSA do not have cancer.

Prostate cancer is most commonly a very slow growing cancer. It is very common- many older men will get prostate cancer and never have a problem with it- they will die with it, but not from it.  However, a subset of prostate cancers are very aggressive and metastasize quickly.  The problem is that it can be very difficult to tell which cancers are slow growing and which are aggressive.  Therefore, most men with a diagnosis of prostate cancer get some sort of therapy- they either have their prostate removed or have radiations.  The potential side effects are severe and very common- impotence and urinary incontinence.  Some men who are older at the time of their diagnosis and have a very small focus of cancer do chose "watchful waiting," and don't do any definitive treatment.

The USPSTF reviewed several high-quality studies and found that screening for PSA does not reduce the death rate from prostate cancer.  What it does seem to lead to is more interventions.  More prostate biopsies, which are quite painful.  More surgeries and more radiations.

So, what's the problem?  Why order (or request) the test at all?  Because everyone knows someone whose prostate cancer was found by an elevated PSA, received treatment, and is now fine.  It's really hard to look at that person and say "Well, you probably would have been fine anyway."  There is also the very real chance that that man was saved by the PSA test.  The USPSTF makes its recommendations for the population, not individuals.

So, should you have a PSA test?  I can't answer that, because the answer is different for everyone.  You need to talk to your doctor about it.  This is just another example of how medicine is as much an art as a science.

Thursday, October 6, 2011

Backyard Chickens Part 2- The Inevitable Outcome

Vegetarians, read no further.

It's a fact of life.  Whenever there's a new hatch of chickens, about 50% of them will be roosters.  And, for the most part, no one wants them.  They don't lay eggs.  They are extremely loud and tend to start waking the neighborhood around 4AM.  Worst of all, they can be aggressive.  So, for better or worse, most roosters meet an early demise.

In the egg industry, roosters are usually euthanized within a day of hatching.  In the meat industry, both roosters and hens are butchered around 6 weeks of age.  Let's not talk about the conditions they are kept in- for more information, you can read this.

When you raise backyard chickens, you can order either a straight run from a hatchery (a mix of hens and roosters) or a sexed run (all hens).  Many backyard chicken owners get a sexed run so that they don't have to deal with the roosters.  However, what do you think happens to all those unwanted roosters?  One guess.

We got a straight run of chickens and ended up with 14 roosters and 12 hens.  We obviously want to keep all the hens for their eggs.  We also want to keep 2 roosters, one for each coop, so that we can hatch fertile eggs in the spring.  However, that left us with a surplus of 12 roosters.  They are now 15 weeks old.  They are getting big, loud, and aggressive.  They're starting to fight among themselves and aggravate the hens, and that means that it's time to cull the flock.

So, that's what my husband and I did today.  Our freezer now has six fresh chickens in it- organically raised, free-range, antibiotic free chickens.  Six more will join them next week, and peace and quiet will return to the coops.

People have asked how can I do it?  How can take a chicken that I raised, kill it, pluck it, and butcher it?  I'll be honest- it's hard the first time.  It then becomes a lot easier.  The truth of the matter is, my roosters have had a wonderful life for the time they were with us- a veritable life of luxury compared to what most roosters face.  For those reading this who might be making a face or rolling their eyes- think about the last time you ate chicken breast from the supermarket.  Do you think that the chicken was sent down to Stop-n-Shop like manna from the heavens- complete with neat Saran-wrapping?  Nope.  It arrived onto your plate the same way all meat does.

So, I thank my roosters for their sacrifice.  I've honored them in life by treating them well, and I'll honor them in death by making sure that their life did not go to waste.

And with that, I'll say goodnight.

Monday, October 3, 2011

Can Nurses Also Be Doctors?

The debate over this question is raging over at the NY Times.  Be sure to check out the article and comments.

Here's the situation in a nutshell.  Nurse Practitioners (NPs) are nurses who have achieved a master's degree in nursing.  In New Hampshire, they can practice independently, meaning that they do not require supervision by a physician.

A DNP is a nurse practitioner with a doctorate.  It is an additional 4 semesters on top of the masters program, concentrating on statistics and epidemiology.  Apparently the American Association of Nurses will require that all NPs by 2015 have a DNP degree, basically making the current NP degree obsolete.

So, the answer to my question is yes, nurses can be doctors.  They have obtained the terminal degree in their field, so they are doctors.

The more important question, however, is what does it mean?  A DNP's training still does not compare to that obtained by an MD or DO.  A comparison of hours spent in education and clinical training prior to starting practice shows that a primary care physician right out of residency has between 15,000-19,000 more hours of training.  So, while they are doctors, they are not physicians.  

Personally, I don't really care what I'm called.  I introduce myself to new patients by first and last name, and leave it up to them what to call me.  Many call me Marni.  Many others call me Dr. Nicholas.  Some call me Dr. Marni. That's my least favorite, because it's kind of cutesy, and that's just not my personality.  But, hey, if that's what someone wants to call me- fine.  I'm more interested in a patient feeling comfortable with me than in a name.  Trust me, my ego is not so fragile that it's damaged by what a patient calls me (and, believe me, some patients have called me some pretty "colorful" things) or by nurses also being called doctors.  

There are plenty of patients to go around for everyone.

Saturday, October 1, 2011

To all my patients- Don't eat this!

This is a noodle kugel.  A "kugel" is basically a pudding or casserole.  It can be sweet, like the one below, or more savory, made with potatoes.  A sweet kugel is traditionally eaten on Rosh Hashana, to start a "sweet" new year.  It's delicious, and now that I've cooked one for the first time, I know why.

Here are the ingredients: 1 lb egg noodles, 2 cups of sour cream, 16 oz of cream cheese, 6 eggs, 1/2 stick of butter, 1/2 cup sugar, cinnamon, and raisins.  Basically, you mix it all together and throw it in the oven for 45 minutes.  My husband looked at the ingredients and asked if we should be serving it with a side of Lipitor.

At any rate, this will not win any awards for healthy side dish of the year.  However, is ok to have a treat once in a while, and as you can see from the picture the kugel was enjoyed by all.

So, L'shana Tovah to all of my friends, family, and patients.  May everyone have a happy, healthy, and sweet new year!

Thursday, September 29, 2011

"Test Me for Everything!"

There was an excellent article in the New York Times today entitled, "Why Doctors Order So Many Tests."  I encourage everyone to check it out, along with the comments.

Those of you that are my patients know that I try to take a pretty minimalist approach to testing and medications.  I encourage people to make lifestyle changes before taking medications, if appropriate.  I do not encourage so-called "screening" tests unless they are recommended by the USPTF.  For example, I've spent plenty of time trying to convince patients that they don't need a full body CT scan and that certain women don't need a Pap smear every year.  Some people take my advice, some don't.  And that's fine.  All I can do is make recommendations based on my expertise.  After that, it's up to the patient.  They are the steward of their own health, and I have no problem with that.

One of the toughest things I have to do is convince people that antibiotics are not needed for a self-limited infection.  This is one thing that I do not cave on- no one can force me to write a prescription that I don't feel is indicated.  However, I can't stop someone from heading over to the ER or urgent care center.  Nothing frustrates me like telling a patient that they don't need antibiotics for their bronchitis, and then having them go to the ER a day later and be given a Z-Pack.  This will typically be followed by a phone call from the patient saying, "You wouldn't give me an antibiotic and I had to go to the ER.  I took the Z-Pack and I was better in a week."  My response to this- you would have been better in a week anyway, with or without an antibiotic.

Please, I beg of everyone- try to think of antibiotics as a life-saving treatment that is reserved for a serious infection.  Our armamentarium is limited, and over-prescribing of antibiotics has the real potential to put us back in the pre-penicillin days.  That is a scary, scary thought.

Wednesday, September 28, 2011

Favorite Apps

I've already mentioned previously how in love I am with my iPhone.  I wanted to spotlight some of my favorite apps that people might find helpful.

This is my favorite running app- RunKeeper.  It has some great features.  First of all, it uses the GPS on your phone to track speed, distance, and pace.  With a flick of the screen, it will pull up Google Maps and trace your route.  It keeps a history of your runs, so your progress is tracked.  Turn on the "coaching" feature and the program will give voice prompts for what to do.  You can create your own workout, also.  Even better, you can program a playlist from your iPod so the workout is synced with music.  Once you're done, you can tweet about your workout or post your results to Facebook (not that I've ever done this, but it's easy to do).

Oh, by the way, if running's not your thing, you can set it for pretty much whatever activity you want- biking, hiking, skiing, snowboarding, even swimming.  Swimming???  How, exactly, does one swim with a smartphone?  At any rate, if you want to destroy your phone, apparently you can track your progress via GPS while doing it.

Stay tuned for more of my favorite apps!

Tuesday, September 27, 2011

Study of the Week!

Now, this is my kind of medical study!  These results were published in the Archives of Internal Medicine this week.  It looked at data from the Nurse's Health Study, an amazing study that has been going on since the mid '70 and has analyzed data from over 200,000 participants.

The most recent analysis looked at data from over 50,000 women.  It showed an association between higher intake of coffee and lower incidence of depression.  The more coffee, the lower the risk of depression.

So, what can we take from this study?  Mostly, that we need more studies.  While there is an association between the incidence of depression an caffeine consumption, we can't say yet that caffeine actually can prevent depression.

I will say this, though.  For most people, it's fine to have a cup or two a day of coffee.  Enjoy!

Sunday, September 25, 2011

Backyard Chickens

These are my chickens.  Well, some of them at any rate.  Right now I have 25.  Within the next few weeks I'll be down to about 14, as I will be sending most of the roosters to freezer camp.

Why do I have chickens?  Well, the eggs are incredible.  Really, if you've never tasted a farm-fresh egg, try to find some.  You'll never go back to supermarket eggs.  The chickens eat all sorts of yard pests, like grubs and ticks.  They are very low maintenance- we give them water and food once a day and clean out the coops every few weeks (takes under an hour). They also provide my kids with hours of amusement:

Alex hasn't caught a chicken yet, but that doesn't stop him from trying.  Not that he'd know what to do if he ever actually caught one...

Friday, September 23, 2011

Behind the scenes

This is my paperwork.  It takes up about 2 hours a day, every day.  This is in addition to the 8 hours I am seeing patients.  It consists of lab and x- ray results, prescription refills, consultation notes, and phone messages.  This is what the pile looks like at 8:30 AM.   It gets replenished throughout the day.  Every second that I'm not seeing patients, I'm either dictating notes or tackling the pile.  This is how I spend lunctime, too.  Every piece of paper has to be carefully read and reviewed.  Luckily, I have a fantastic PA (physician assistant- Hi Dorothy!).  If it wasn't for her, I'd be really in trouble.

So, if it takes me until the end of the day to return a call, this is why.  If you need a form filled out, don't expect me to do it instantly- drop it off in advance.  If you call the office and refuse to tell my nurse or medical assistant what you need to talk to me about and just say "I will only talk about it with the doctor"...well, you're going to have to wait to talk to me.  I will call you back, but the pile has to be tamed first.  So patients, please have patience.

Thursday, September 22, 2011

My Accessory Brain

"No, Mrs. Smith. I'm not texting on my iPhone during our appointment. I'm just using my accessory brain."

That's what I call the various medical references that I carry with me at all times. Most doctors have an accessory brain of some sort. For the most part, I need to use it to look up drug dosages or to do some calculations. However, my accessory brain has come a long way, baby! Here's my first one, dating back to my time as a third and fourth year medical student:

The book on the left is a house staff handbook, chock full of quick references and mnemonics.  Notice how well-worn it is- I got a lot of use out of it, and actually still occasionally look something up in it.  The one on the right is a Pharmacopoeia- a drug reference.  I also usually carried a Ferri Manual with me- this is a spiral bound book that's several hundred pages in length, but yet claims to be a "pocket manual".  I thank Dr. Ferri for my recurrent neck pain and poor posture.

After graduation, I went high tech.  At the time, high tech consisted of very primitive PDAs.  I had one called a Handspring Visor.  It had a whopping 2M of memory and was...large.  It also had this dumb little stylus that you had to use on the touchscreen.  I was always losing that stupid stylus.  However, it had the great advantage of being able to combine several medical references onto one device.

The handspring lasted a year or two, then I took my husband's Palm Pilot as a hand-me-down.  It was smaller and had more memory.

I then moved up to a PDA called a Sony Clie.  It had this neat swivel screen.  Most impressively, it was in COLOR!  Wow!  I got a lot of use out of my Clie- I'd say it lasted about 4 years, which is an eternity in the world of technology.

The problem is that the pockets of my white coat would still bulge.  I'd carry my Clie, cell phone, pager, and prescription pad all the time.  My posture remained stooped.  Therefore, as technology advanced, I moved with it.  First, I tried a Trio.  This combined my cell phone and PDA into one device.  I still carried a pager.  I hated my Trio.  Hated it.  To be honest, I don't even remember why I despised it so- I just did.  I probably had it for less than 6 months.  I then moved on to a BlackBerry.  That was better.  I used it for about 2 years.

And love affair began.  It's a love affair with my iPhone.  We started our relationship in 2009, and we're still going strong.  All of my medical apps, my running apps, my email, my phone, e-prescribing...all in one cute, tiny package.  I'm not sure if things can get better than this, we'll see.

In the meantime, I'll be making future posts about my favorite apps.

And I promise not to text during an office visit.

Tuesday, September 20, 2011

Man's best friend.

Let's face it. It can be tough to get motivated to exercise.  Really, many of us would prefer to do just about anything other than exercise.  That's why I suggest getting a workout buddy.  It's pretty easy to come up with excuses as to why you shouldn't exercise, but it's a lot harder to use those lame excuses on a friend.

So, meet Indy.  He's my workout buddy.  We've been running together since 2006.  He doesn't care what the weather is like.  He always runs at my speed.  He never, ever, passes a chance up for a run.  His only downside?  I have to pick up his poop.  He also gets a bit stinky if we run in the rain, but hey, so do I.

So, if you're just getting started with a running or walking program and you're having a bit of trouble getting motivated, find a friend.  How do you do this?  You can check out this forum.  Or you can join a local running group.  If you live in my area, you can join my running group in the spring. Or, you can get a dog (but a friend might be better, since you won't have to pick up their poop).  Enjoy the companionship and the exercise!

Monday, September 19, 2011

Edible Rorshach Blot

Mondays are a tough day to blog.  I have evening office hours on Mondays, so I see patients from 8AM to 7PM.  It makes for a long day, and I don't have much energy left to put into posting.  So, here's a quick one.  I pulled this potato out of my garden this weekend.  I thought it say the least.

So, what do you see when you look at this potato????

Sunday, September 18, 2011

Eat Your Veggies!

I remember when I was a perfect parent.  It was before I had kids.  Back then, I smugly thought about my perfect not-yet-even-conceived children.  They would never have tantrums.  They would never talk back. And, of course, they would eat whatever we put in front of them.  In fact, when Jessica Seinfeld published a book called "Deceptively Delicious"about how to sneak veggies into food, my husband Patrick and I rolled our eyes.  "Why not just teach your kids to eat vegetables?" we asked.  Our perfect children would not have to be tricked into eating healthy foods!

Well, not surprisingly, karma came and bit us in the butt.  Our older son, Alex, is 4 1/2 and is quite the picky eater- maybe even worse than I was at his age.  If he had it his way, he would subsist entirely on milk, mac and cheese, and Cheerios.  It's a constant struggle to get anything approximating a balanced diet into him.

Therefore, I was pretty excited when I heard about this magical vegetable called spaghetti squash.  Apparently, when cooked, it looks like noodles.  Your kid will never know the difference!  Well, I decided to put it to the test and make a Spaghetti Squash Casserole.

Here's the squash- for those of you not familiar with what it looks like (I actually grew these in my garden).

After cooking them in the oven and scraping them out, I have to admit it actually did look like pasta (or at least rice vermicelli).

After cooking it- here's how it looked (after some had already been taken out for the kids):

As for how it went over with its intended audience...well, let's just say the kids were not fooled for a minute.  They knew it wasn't spaghetti, despite my claims to the contrary.  Matthew ate it, but he eats everything.  Alex, with a lot of coaxing, actually ate about 2/3 of his portion- which is probably more vegetable than he's eaten in the past year.  I think, although he'll never admit it, he actually might have enjoyed it.  So, a success in my book!  I'll keep fighting the good fight...

Saturday, September 17, 2011

Why do you need a primary care doctor?

Why not see a specialist for everything?  After all, they're the experts, right?


It's vital for everyone to have a primary care physician.  Your PCP should always be your first point of contact with the medical world.  A good relationship with a good PCP can save you time and money, but most importantly, can save your health.  I'm going to tell you why...

An internist does more than diagnose your strep throat, take care of colds, and do your yearly physical.  Internists are specifically trained to take care of medically complex patients.  The most import skill an internist learns in medical school and residency is to create what is called a "differential diagnosis."  This is a list of all of the possible things that could be causing an illness.  It takes years of experience and practice to be able to develop a comprehensive differential diagnosis, but it's vital that your doctor be skilled in doing this.  Otherwise, important illnesses can be missed.

It's a bad idea to try to "self-diagnose" and then self-refer to a specialist.  Here's an example of a common scenario:

Let's say a patient, we'll call him Joe, starts to have some chest pain when he lifts things.  He doesn't have any problems that he knows of, but his father had heart disease, so he's worried.  His wife is also worried.  They go to see a cardiologist.  He has an ECG done, which is normal.  His cholesterol is also checked, and is normal.  Because he still has chest pain, the cardiologist does a stress test.  It's normal.  The cardiologist says, "Your heart's fine."  And that's it.  The cardiologist is done.  But Joe still has chest pain.

Now, let's say that Joe went to see his internist first.  The doctor gets a history and performs a physical exam.  The physical exam shows that Joe's chest pain is reproduced when certain areas of his chest are pressed.  The internist diagnoses Joe with costochondritis- an inflammation of the cartilage of the ribs.  He's treated with ibuprofen and the pain goes away.

What Joe needed in the first place was someone to look at the "big picture."  And that's what your internist does.  A good internist will be able to treat many, many things right away, but will be able to steer you to the appropriate specialist when necessary.

So, even if your insurance says you don't "need" a primary care physician, it's still important to have one!

Friday, September 16, 2011

Hey, I'm starting a blog!

If you're reading this, you're likely either my patient, a prospective patient, a friend, or my mom.  I've decided to start this blog to help my patients get to know me better.  Its secondary purpose is for people to find out more about primary care and the practice of medicine today.  Although I plan on posting a lot about medicine, I would also like to concentrate on other things that are important in my life.  My family, of course, has the top spot.  My hobbies, such as running, will be discussed, too.

Join me on this journey!  Feel free to comment, and I look forward to this adventure!

PS- Please excuse the current boring appearance of this blog.  I'm working on's a learning process...