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!