Sunday, December 30, 2012

The End of an Eponym

It's interesting when medicine and history intersect (at least I think it's interesting).  Here's a quick history lesson that I recently encountered.

An eponym is a medical term named after a person.  Some of these are familiar to just about everyone.  For example, most people are familiar with Alzheimer's disease and Down Syndrome.  Others are much less familiar, such as Castleman's disease.  Eponyms are the bane of existence for many first year anatomy students- trying to remember where Hesselbach's Triangle is, for example.

One fairly common eponymous disease is Reiter's Syndrome.  I've seen it several times.  It is an arthritis that occurs in reaction to a bacterial infections, usually food poisoning or a sexually transmitted infection such as chlamydia.  As I've mentioned a few times recently, I'm in the process of studying for my internal medicine board recertification.  I recently completed the Rheumatology module.  When reading the section about Reiter's Syndrome, I saw that it was always mentioned as "reactive seronegative arthritis, formerly known as Reiter's Syndrome."

I thought that was a bit weird.  Eponyms are annoying in that they are yet another term to memorize, but I've never seen one apparently being retracted.  About two seconds of Googling told me why.

Hans Conrad Reiter was a German physician born in 1881.  During his time in the army in World War I, he described a case of arthritis in a gentleman with a sexually transmitted infection.  This classic triad of arthritis, uveitis and non-gonococcal urethritis eventually became know as Reiter's Syndrome.  Following the war, he became a professor in Berlin and was, by all accounts, quite a popular teacher.

However, there is a much darker side.  Reiter was a eugenicist.  He believed that certain people and races carried "inferior" genes, and the removal of these genes from society would create a stronger human race.  It's not surprising that he became a vocal supporter of Adolf Hitler.  His support of Hitler led to a nice career trajectory.  Eventually, he became a member of the SS.

It gets worse.  He planned and carried out hideous experiments at Buchenwald, leading to the deaths of hundreds.  He sanctioned forced sterilization and euthanasia.  His own testimony at Nuremberg is damning, but he was not imprisoned, possibly in exchange for supplying the Allies with intelligence.  He died at the ripe old age of 88, living out the long, peaceful life that he had denied to so many others.

His war crimes started to come to light in 1977, and a campaign started to change the name from Reiter's  Syndrome to reactive arthritis.  The wheels of the medical community turn at a glacial speed, however, and it took until 2009 for the name change to become official.

So, it's the end of an eponym.  Eponyms are meant to honor- we need to make sure that those they honor are deserving of the accolades.

Saturday, December 22, 2012

Enough.


I've had a hard time watching the news about the Sandy Hook tragedy. I suspect many people have.  I have a son who is almost six, and it is literally sickening to think about losing him.  So, while on some level I am heartbroken about the loss of those innocent lives, on another level it's just been too much to even contemplate.

Until yesterday.

Yesterday I got angry.

What finally did it?  It was this.


It's the press conference given by the NRA executive vice president.  According to him, guns have nothing to do with the massacre at Sandy Hook.  Nothing.  It was video games.  And media glorification of violence.  And lazy law enforcement.  The solution?  More guns.  Got that?  More guns.  Guns for teachers.  Guns for "volunteer guards."  Guns for the "good guys."

I'm sorry.  That is sheer insanity.  It boggles my mind.  When a madman goes on a shooting rampage, the response should be, "How do we stop someone like this from ever getting a gun again?"  The response of the NRA was, "How do we get a gun for EVERYONE?"  

It ignores the fact that there was an armed guard at Columbine.  Virginia Tech had an armed security force.  Ft. Hood is a military base, for God's sake.  Everyone is armed there.

Enough.

We should have said "enough" after Columbine.  After Virginia Tech.  Ft. Hood.  Aurora.  We didn't.

Now it's time.

Enough.

This is not the Wild, Wild West.  This is America in 2012.  There is no place, outside of the military and law enforcement, for assault rifles, automatic weapons, and extended ammunition clips.  There is no place for the lax, farcical "restrictions" placed on gun ownership.  And the day there are armed guards patrolling outside my kids' school is the day I pull them out and start homeschooling them.  That is not the free country that I want my children to experience.  That's a country under siege.

Will it be easy to make a change?  Of course not.  I've heard the statistics, just like everyone else.  There are 200 million guns in America.  It will take years, maybe decades to make a difference.  So why wait?  That just means that the time to start is now.  It's not time to throw up your hands and say, "It's impossible, so why even try?"

So, please, join me in saying, "Enough."  Write to the President and your senators.  Write to your state reps and governors.  Don't let a lobbying organization of 4.3 million gun owners speak for the needs and wants of 300 million people.  

Enough.






Wednesday, November 14, 2012

Another Project: Entryway Cubbies


I know. I'm supposed to be studying. And I am, really. Today I learned about anti-NMDA-receptor encephalitis, a disorder that I had never, ever heard of before. Ever. So much so that when I was taking a practice test and saw this as one of the answers, I thought it was a made-up disease. Turns out it is an exceedingly rare autoimmune disorder that wasn't identified until 2007. Learn something new every day.

However, I decided that our entry way closet needed a serious makeover. We have a large double closet right where you enter the house, from the garage (where we SHOULD have a mud room, but don't). Apparently, it is too difficult for some people to hang up their jacket on a hanger when entering the house. Therefore, my first solution was to put a bench and some hooks in the closet. That didn't work. The hooks were too close together, jackets fell off of them, and the closet was still a mess. I'm a bit ashamed to show you what the closet looks like...but hey, people tell me their embarrassing problems all day. I should return the favor.


I told you it was bad. I wanted to take care of this problem before winter truly sets in. My answer- storage cubbies- one for each member of the family. Plans from Ana White, again.

Setting up to cut the plywood:
 Cutting plywood is a big pain in the butt.  Make sure you set up a good straight edge and clamp it down so that you can get accurate cuts with a circular saw.

Finished bases:


Finished hutch:




Putting it all together:


Painted and DONE!!



Alex likes his cubby so much that he wants it to be his "house."



Roll your mouse over for the amazing before and after picture!




I'd consider that a success!  Total cost for everything- $320 and about 10 hours of labor.  Cost at Pottery Barn- $1400 plus shipping.  Not bad for a day's work.

Monday, November 5, 2012

Watch an Insurance Company Try to Drive Me Insane



It's been a while since I posted one of these. Here's another ridiculous prior approval form. It's for zolpidem- the generic version of Ambien. Of course, this begs the question of why I need an approval form for a generic drug in the first place.

At the top of the form it says: Drug Name- Zolpidem.

The rest of the form goes on to ask the following questions:

1.  Is the drug Cialis, Levitra or Viagra?

     No, dumbass. The drug is Zolpidem, as written just a few lines above.

2.  Is the requested therapy Zyban?

     No, dumbass. The drug is Zolpidem, as written just a few lines above.

3.  Is the request for Aloxi, ondansentron, zofran, or Kytril?

     No, dumbass. The drug is Zolpidem, as written just a few lines above.

4.  Does the patient have hyperemesis gravidarum?

      What??? Where did that even come from? I write a prescription for a sleeping pill for a 65 year old woman and you ask me if she has uncontrolled vomiting from pregnancy????




And that's it.  Those are the questions asked. Nothing actually related to the medication I had prescribed.  It was basically like playing a long game of 20 Questions, except I don't think we ever got to the answer.

Monday, October 22, 2012

Hitting the books.




It's time to hit the books.

My American Board of Internal Medicine certification is up at the end of 2013. Hard to believe that 10 years have gone by since I last enjoyed this experience.

Back then, I was still in residency. All I had to do was complete my residency (no mean feat, that), get certified in a bunch of procedures, and take a 2 day exam (back then, still with paper and pencil). Now I get to experience the joy that is "Maintenance of Certification." This is comprised of earning 100 points in the MOC program. Some of the points have to be from clinical reading, and the rest have to be from "Practice Improvement Modules." These are, to put it kindly, a pain in the ass. They involve extensive chart audits.  Then surveys have to be sent to a bunch of patients. Then more and more have to be sent, since apparently people don't like to fill out surveys. Then you have to come up with all these improvement plans. Then you get to send out even more surveys.

You get the point.  It took about 9 months for me to complete my module.  All of that work had to be done in my "free" time, of which I have approximately none.

Now that I have my 100 points I can register to take the certification exam in April, so I've started my studying. Part of me finds this to be just another tiresome chore to do during an already busy day, but another part (the NERD part) finds it to be oddly comforting. Taking out the highlighters, making a study schedule... it's like slipping on a well-worn pair of pajamas and slippers. 

I know. I'm nuts...but it got me this far!

Wednesday, October 17, 2012

May the Force be with you!



It's a happy day in the Nicholas household. My kids are finally moving out of their Cars phase and into the Star Wars phase. Apparently, this is a required phase of life for all American males. They boys watched Stars Wars for the first time a few weeks ago. The obsession now has a stronghold on my family.

They are being aided and abetted by Patrick, who is only too happy to support the Star Wars habit. As a matter of fact, he saved all of his old 70's and 80's toys in anticipation of this very day. They are all now living in the basement.


Yes, that's a real, live, complete Ewok Village that you see down at the bottom. Of course, some of those toys from the 70's can't compete with 2012 technology. Check out these lightsabers!



As you can see, they are fun for both the under- 6 and over- 40 crowd.  Admit it.  All of you.  You would have LOVED those lightsabers as a kid. Anyway, this Star Wars phase has led to me saying a whole lot of sentences that I never thought would come out of my mouth. For example, "No using the Choke Force at the table!" and "Your brother is NOT a Tauntaun!"

So, anyone in the market for about 50 Lightning McQueen cars?  

Monday, September 17, 2012

My New Kitchen Table- Another Woodworking Project

This will probably be the last project for a while.  It's getting colder out and the garage isn't heated...
I also have to re-certify for my internal medicine boards this spring.  Time to hit the books!

I hated our old kitchen table.  And by old, I mean old.  It was left in the house by the previous owners.  It was really wobbly. Its chairs kept breaking, and we were down to two.  Here it is:



Hmmm.  That's an old picture.  I don't typically have a cat walking on my table.  Especially that cat.  He died last year.  Anyway, when we took the table to the dump, we saw that the previous owners had nailed plywood to the bottom of the table to hold it together.  Apparently, at some point, I had also shimmed it with my business cards (I KNEW they'd come in handy!!!).  Clearly, the table was on its way out.

I wanted a large table.  I also wanted benches for two reasons: 

1) When not in use, we could slide them out of the way under the table so that there would be more free space, and 2) The table is near the garage entrance (the entrance that we use).  Jackets get slung over the backs of the chairs.  Bags get thrown on the seats of the chairs.  Before long, they are so covered in crap that they look like a big mound of junk.

Soooo, here we go!  My new Farmhouse Table with Matching "Nesting" Benches!

Plans again from Ana White.




I'm totally happy with how this came out.  I used kiln-dried pine.  The finish was 2 coats of Minwax Red Oak stain and 4 coats of polyurethane.  It's really sturdy and I think it will stand up well to the abuse from the kids.  It's also incredibly heavy.  Really, really heavy. If you make this, don't drop it on your foot.

So that's it for now.  Like I said, this is the last project, at least until after I take the boards!  Oh, by the way, I SWEAR that it's just coincidence that the same bulb is blown out in the picture from a few years ago and the current pictures.  Really.  I swear, I've changed that bulb.  You believe me, right???

Saturday, September 15, 2012

Without saying a word, she taught a generation of physicians.



I first read The Spirit Catches You and You Fall Down while in medical school.  If you've never read this incredible book, go out and get it RIGHT NOW.

It is the story of Lia Lee, the child of Hmong immigrants living in the Sacramento area.  Lia had her first seizure as an infant.  Her parents spoke no English.  Their view of illness and disease was unlike anything Lia's doctors had ever seen before- leading to a culture clash that eventually culminated in a massive seizure in 1987, when Lia was four years old.  That seizure caused permanent brain damage, and Lia lived for the next 26 years in a persistent vegetative state.

She died on August 31.  Her death was first widely reported today, via an obituary in the New York Times.

This book is required reading in many medical schools, as it well should be.  It provides amazing insight for dealing with patients from different cultures who have different views of health, sickness, and disease.  Its lessons came in handy many, many times while I was working in the melting pot of New York City.  I continue to use those skills in my practice today.

RIP, Lia.  The sacrifice of you and your family will not be forgotten.


Monday, September 10, 2012

Balance

I apologize for the recent lack of blog content.  Things have been busy.  Work's been busy, family life has been busy, and I even managed to slip in a quick vacation down to NYC.

Matthew turned 3.



We got in lots of beach time.


Lots of ice cream was eaten. 





I remember back when I was a new parent, I naively thought that it would get easier as the kids got older.  Well, in some ways it does.  We get more sleep now.  There are no more diaper changes.  However, in many ways, it gets harder.  All of the sudden, Alex has after school activities.  He has homework.  I mean, I can't believe that I have a kid in kindergarten!  

It does sometimes get hard to balance work and motherhood.  It's especially difficult when work tends to run into evenings and weekends.  That's how I ended up with this scene in my office this past Saturday:


Alex had soccer.  Patrick is one of his team's coaches.  And I had to work.  That left Matthew to hang out in my office while I saw patients.  A donut and an iPad work well to bribe a child to stay quiet!

Thursday, August 2, 2012

More Woodworking- Toddler Bed

So, this past Friday night I was sitting and watching the Opening Ceremonies.  The kids were in tucked in and asleep (or so I thought).  All the sudden, I hear, "Mommy....Mommy," said in that sing-song way that only kids can say it.  I went upstairs, just in time to catch Matthew as he attempted to climb out of his crib.  So, I figured it was time to ditch the crib and get a toddler bed.  Not being one to want to spend money on something that will only be used to a year or two, I decided to DIY.  These plans are from Ana White (again).  I didn't make the fancy headboard, since I wanted this to be quick, cheap, and easy.


Total cost of lumber was about $40



Attaching the side rails


All done- ready for staining!



Hmmm...I guess they really mean it when they say to wear gloves while applying stain.



All stained and ready to go!




Taking apart the old crib- *sigh*- the end of an era!



All that's left is to add the kid!


So, now it's 9:15 PM.  Matthew is adjusting to his new bed...but I don't think we'll be getting a ton of sleep tonight!

Friday, July 27, 2012

Too Much Medical Care?

More from the NY Times- I'm on a kick this week, I guess.

In this column, Tara Parker-Pope, the medical reporter/blogger who writes the "Well" Blog in the Times, critiques her daughter's medical care.  She describes how her daughter sprained her ankle dancing.  She took her to the pediatrician, who recommended the usual care (rest, ice, compression) and waiting it out.  It was not better after a month, so she took her to a sports medicine specialist.  That specialist ordered an MRI and sent her to an orthopedist.  THAT specialist took a lot of blood and did another MRI, and sent her to a rheumatologist.  THAT specialist did a bunch more tests...but the ankle still hurt.  At this point, Ms.  Parker-Pope called a halt to the merry-go-round, went back to the original sports medicine person, had her daughter get a steroid shot, and she was better in a few days.

She says, "I canceled all her appointments with the various specialists, and went back to the sports doctor. We discussed a new approach that focused solely on pain relief. He consulted with my daughter’s pediatrician, and they agreed on a treatment. Within days, my daughter’s ankle had stopped throbbing, and soon she was back to sports and dancing. The cost of this ankle injury had reached well into the thousands of dollars — I had lost track because it was all covered by my insurance."


I agree, her daughter was a victim of over testing.  However, I feel that the blame lays primarily on the shoulders of the author.  Her daughter's pediatrician suggested waiting it out- Ms. Parker-Pope initiated seeing a specialist after only a month.  That specialist then participated in my least-favorite specialist behavior- he referred the patient to another specialist.  This is rarely a good idea.  Why?  Because specialists often seem to not know what the scope of practice of a primary care doctor is.  A good primary care doctor can treat many conditions, including initiating a workup for juvenile rheumatoid arthritis, which is what I think the sports medicine doc was concerned about.  

I feel lucky that the vast majority of specialists that I work with respect my opinion enough to send patients back to me for continued workup.  This keeps care from getting too fragmented and allows me to put a stop to the endless merry-go-round of overtesting.


Tuesday, July 24, 2012

Breast is Best, Right?

The NY Times ran a piece yesterday about breastfeeding.  Not surprisingly, it has elicited a ton of comments.  The piece can be read in its entirety here.  I thought it made a lot of good points.

As any pregnant woman or new mom knows, the breast vs. bottle wars are alive and well.  Moms feeding their babies in public often are in a no-win situation- they either get the stink-eye for breastfeeding in public, or they get sneered at by the "lactivist" crowd for bottle feeding.  Yes, there are really people who describe themselves as lactivists.

The AAP recommends breastfeeding for the first 6 months of life, and then for as long after that as is comfortable for mom and baby.  There is plenty of research that shows the benefits of breastfeeding, both for the mom and the baby.  Some of the reasons are pretty founded in good, solid research, such as the decreased risk of breast cancer in mom and decreased risk of diarrheal disease in baby.  However, other benefits are more nebulous- claims such as higher IQ and lower rates of obesity are less clear-cut. Other benefits, such as more "bonding" between mom and baby are even harder to measure.  A very good article regarding the conflicting research results can be read here.

What it comes down to is this:  every woman has to decide for herself how to feed her baby.  It's no one's business but hers what she is doing and why she is doing it.  There is not an official list of acceptable reasons not to breast feed.  I've created a list of breastfeeding myths that I wish I knew about before I had kids:

Myth 1:  Breastfeeding Is Easy.

  • It's not easy.  People think that because it's "natural," it's easy.  There's a learning curve for both mom and baby.  I tell new moms that if they want to breastfeed, give it at least six weeks before giving up.  It does get much easier.  It truly does.  However, those first few weeks are tough.  Very tough.  I remember with my first that when I would finally get him to latch on, I would freeze, afraid to move a single muscle lest he pop off.  
Myth 2:  Breastfeeding Should Never Be Painful.
  • It hurts at first.  It really does.  It almost always gets better after a few weeks.  However, it is normal to have soreness and cracked nipples and all sorts of other pleasant ailments.
Myth 3:  Breastfeeding is Free.
  • Yes, technically, it's free.  However, unless you are staying at home and are available for every feeding for the first six months of your baby's life, there are hidden costs.  The majority of women go back to work six to twelve weeks after delivery.  If you're doing that, you need a breast pump.  A decent one will run you over $300.  And, you'd better get a decent one if you have any prayer of pumping enough milk.  You might have lost productivity from work from time taken out for pumping breaks.  You still need bottles and milk storage bags. 
Myth 4:  All women can produce enough milk.
  • Not true.  It's just not.  I'll tell you my personal experience.  I breastfed my first son for one year.  I went back to work after 12 weeks and pumped for 9 months after that.  It was a pain, but really not that bad.  I had no supply problems.  I never had to supplement with formula.  With my second son, for whatever reason, my supply was terrible.  Pumping became torture, as I would spend 20 minutes pumping and have an ounce or two to show for it.  I saw a lactation consultant.  I rented a hospital-grade pump.  I drank the stinkiest teas imaginable.  Nothing helped.  After about 6 months, I just gave up.  It seemed pointless.  At least 7/8 of each bottle was supplemented formula.  Once I gave up, it was such a relief.  I was finally able to concentrate on enjoying my baby, rather than obsessing about how to feed him.  Now, think about it.  If I, a mother with breastfeeding experience, a job that allowed me ample time to pump, sufficient funds for a lactation consultant, fancy pumps, and stinky herbal teas couldn't make it work- don't tell me that all women can if they just "try hard enough."
Myth 5:  Breastfeeding is crucial for the "bonding experience."
  • I'm bonded to both my kids.  Adoptive parents are bonded to their kids.  There are so many factor in the bonding process.  It really doesn't always come down to what your kid is eating.

Anyway, that's my opinion.  I encourage breastfeeding, but if someone is having a lot of trouble, or hates it, or just doesn't want to do it- well, that's fine too.  I firmly believe that a more important factor in a healthy, happy baby is a healthy, happy mom.  Let's face it- we'll have countless opportunities to feel guilty about how we raise our kids.  This shouldn't be one of them.

Thursday, July 12, 2012

Common Issues in Primary Care: It's more than just runny noses and strep throat

I've decided to start a series about common issues that a primary care doctor encounters.  As I browse the internet, I frequently see comments that reflect misconceptions about what primary care docs can do and manage.  These frequently run along the lines of, "If there's anything really wrong with me, I'm going to see a specialist anyway!"  Never mind that just about every public health study has shown that countries with more primary care docs and fewer specialists have better outcomes.  There are also numerous studies that show that the more specialists a patient has, the more fractured their care is and the worse their outcome.  See here, here, and here, for example.

I'm going to start this series by outlining a typical day in my life, during which I see an average of 30 patients.  Details have been changed to protect the innocent! Keep in mind- we have a "walk-in" hours from 8AM to 10AM, when people can drop in for quick visits without an appointment.

7:30 AM- Arrive at office, after dropping kids off at daycare.  Review upcoming schedule, making sure people are scheduled in appropriate spots for the right amount of time.  Review labs, phone messages, refill prescriptions, drink first cup of coffee.

8:00- Patients start arriving.

Patient 1: Here for a routine followup of his hypertension and high cholesterol.  Did his labs 2 days ago- I've already reviewed results.   He looks great.  No changes made, see him in 6 months!  Good start to the day...

Patient 2:  Walks in without an appointment.  Been coughing and has had sinus pain for 2 days.  Wants an antibiotic for sinusitis.  Exam is normal- she just has the cold that's going around.  Spend 5 minutes explaining to her why an antibiotic is not needed.  Sample of a sinus irrigation system given to her.

Patient 3:  Here for a followup of her diabetes, high blood pressure and high cholesterol.  Forgot to do her lab work.  Has not been checking her blood sugars at home.  Blood pressure not controlled.  Blood pressure medications changed.  Discussion about the importance of managing disease, checking sugars, doing lab work.  Follow up in 2 weeks to recheck blood pressure and review lab work.

Patient 4:  Walks in without appointment.  States has a UTI.  Urinalysis done in office is negative.  Patient is having severe pain with urination.  Gynecologic exam done- very consistent with herpes. Cultures taken, but I'm 99.9999% sure she has herpes.  Tears ensue.  Education regarding herpes and STDs given.  Medication started.  Discussed with her how to talk about this with her boyfriend.  Make a mental note to call her later to see how she's doing.

Patient 5:  Routine physical with a Pap smear.

Patient 6:  Here for a blood pressure check, looks good.  Follow up in 6 months!

Patient 7:  New patient.  Has not seen a doctor in 15 years.  Only here because his wife forced him to come in.  Feels fine.  Overweight.  Family history of diabetes in both parents.  I do a random finger stick blood sugar- it's 347.  He has diabetes.  Lots of education given.  Medication started.  Given a glucometer and taught how to use it.  Referred to a nutritionist.  Follow up appointment made for next week.

Patient 8:  Itchy rash.  Bad, bad case of poison ivy.  Steroids started.

I'm now about 2 hours into my day.  In between seeing these patients, don't forget that I have to dictate notes on each of them.  I'm keeping a constant eye on my "pile".

Patient 9: Can't hear anything.  Ears are totally blocked with wax.  Wax flushed out- patient can hear.

Patient 10: Reason for visit given as "insomnia."  Patient starts crying while I'm taking her history.  Finally admits that she is being varbally abused by her boyfriend.  Counseling referral set up.  Domestic violence resource information given.

Patient 11:  Knee pain.  Has been hurting for a few months.  Has completed 6 weeks of physical therapy and is no better.  MRI ordered.

I get interrupted by a phone call from another doc.  It's a local endocrinologist.  He's seeing one of my diabetic patients and has noticed that their heart rate is irregular.  Should he send her to the ER?  I tell him to send her over here.  She becomes...

Patient 12:  Exam and ECG reveal that she is in new-onset atrial fibrillation.  Her vital signs are stable but her heart rate is a bit rapid.  Started on a blood thinner and a rate control medication.   Referred to a cardiologist for follow up and potential cardioversion. Follow up with me in 2 days to see how she's doing.

Patient 13:  Here for a follow up of depression and anxiety.  Medication started 6 months ago.  Things are going great, but would like to stay on the medication.  Follow up in 6 months.

Patient 14:  Here to review labs.  Cholesterol is high.  Diet reviewed, suggestions for changes made.  Follow labs planned for 3 months from now.

Patient 16:  Here for follow up of her hypothyroidism, which I diagnosed 3 months ago.  Doing much better on medication.  Energy improved.  No changes made in medication, follow up in 6 months.

Lunch time.  Spent eating at my desk, reviewing results, returning phone calls.

You know, I was going to write out the whole day, but you get the picture.  I don't sit around all day seeing sore throats and colds.  I don't sit around just referring people to specialists.  If it's something I am qualified to take care of on my own, I'll do it.  If it's out of my league, I refer.  However, I love the fact that I'm the one that gets to make the diagnosis.  People walk into my office with a group of symptoms- I get to put them together and make the diagnosis.  That's what's awesome about primary care.  Do we make less money than many (most) other specialties?  Sure.  However, that's not because what we do is less valuable.  It's because the payment system is screwed up and rewards procedures more than thinking.

So, little by little, I'm going to write about common issues I encounter.  This is meant to be educational and perhaps help you to spark a discussion with your own doctor.

Don't worry, I'll still blog about running, my kids, and the ridiculous things I encounter behind the scenes at my office.

Friday, July 6, 2012

The slippery slope of "Providers."

I'm a physician. I'm not a "health care provider."  I hate that term. The insurance companies call me a "provider."  In a sense, it's true.  I provide health care services.  However, over the past few years I've noticed that the lines between different types of "providers" are getting more and more blurred.  Sometimes they're blurred to the point that patients don't even know what kind of "provider" they are seeing.  I often have patients tell me about their previous doctors, only to review old records and find that their "doctor" was a nurse practitioner or a PA.  I'll be reviewing lab tests that look kind of unusual, only to find that they were ordered by a naturopath.  And so on.  I'm not saying that there's not a place for everyone in health care.  I'm not saying that physicians are at the top of the hierarchy (trust me, most days I feel like I'm in the basement).  I'm just saying that patients deserve to know who is providing their health care and what their training is.

Here's an example- something that I've been reading about as a result of my interest in running.

On February 5, 2011, the annual Kaiser Permanente Half Marathon took place.  As is typical of large races, Kaiser was the main sponsor but outsourced the race management to a company called RhodyCo Productions.  It was an unusually hot day for February.  About 2 hours into the race, a 36 year old man named Peter Hass neared the finish line.  As he approached it, he collapsed.  Apparently, it took more than 20 minutes for an ambulence to arrive.  Other racers performed CPR.  Sadly, Mr. Hass died, apparently of a cardiac event. 

The City of San Francisco has now released a report regarding the events of the day.  You can link to the full document and read it.  There were obvious problems in communication and there did not appear to be enough ambulances present.  However- this stood out to me:


"There were several items listed in the EMS Plan for this event that were not adhered to by the permit holder for the event, RhodyCo Productions. For example, the number of EMTs at the starting and finish lines was insufficient, pursuant to EMSA Policy 7010. Additionally, chiropractic students were used as medical staff rather than EMTs or emergency medical personnel. The EMS Plan also stated that one MD would be stationed at the Medical Tent or at the event, which did not occur. Rather, a chiropractor from PCCW was provided. "

Whoa.  Double take.  Triple take.  There were no MDs present.  The production company was using students from a chiropractic college as "medical personnel."  What?  This can't be true, can it?  So, using the powers of Google, I investigated futher.  I found this.  For those of you who don't want to click, it's the RhodyCo Productions Emergency Procedures for the 2011 San Francisco/Kaiser Permanent Half Marathon. It states:

 "There will be Medical Personnel onsite at the START line till the last runner/walker passes.  There will be medical personnel at the Finish Line for both the 5K and Half Marathon till last walker/runner crosses the finish line.  There will be a minimum of 3 Medical Personnel mobile on the course during the race."

Sounds good, right?  Sounds like "medical personnel" will be ready and available.  Until you read a bit further, that is.

"Medical Personnel:  Palmer College of Chiropractic West Sports Council will provide event trained medical teams for the event (students are all CPR certified and have taken emergency response class).  The head clinician event day, Dr. Hal Rosenberg, (phone number redacted) will be onsite at the post-race Medical Tent."

Yup.  It's true.  They had "health care providers" present.  Except they were chiropractic students.  Even if they were real, live, actual chiropractors, they STILL wouldn't have been qualified to provide emergency medical services at a half marathon, unless they were also EMTs or paramedics.  But wait, what about Dr. Hal Rosenberg?  He's a doctor, right?  At least he would be overseeing the medical response team.  Right?  Right?  Except...not.  Yeah.  He's a chiropractor, too. 

It's true that running a half marathon is an inherently dangerous activity.  A distance runner is pushing his or her body to its limits.  Even elite athletes die during endurance events.  That's why all these events make you sign a liability waiver prior to participating.  However, this is what the half marathon website says about available medical support (from the 2012 race page- I'm not sure what the 2011 page said, but this is fairly typical):


Medical Support

  • Medical Support will be overseen by a Medical Director experienced in event medical response.
  • There will be a Medical Tent staffed with trained emergency personnel at the start line, at the finish line and in the expo area of the event.
  • Ambulances will be located at the start line, on the course, at the finish line and in the expo area.
  • There will be mobile Medical Teams at each of the 5 water stations and roaming the course throughout the race.
  • Medical personnel will be clearly visible, wearing a medical response uniform.
  • Race monitors on the course will be in constant communication with the Event's Medical Director. If there is a medical need on the course, please let one of the course monitors know as soon as possible and they will call for medical assistance.

Reading that, wouldn't a reasonable person assume that there will be physicians present?

Would having physicians present at this race have changed the outcome for Peter Hass?  I have no idea.  There's no way to know.  However, don't you think racers deserved to know that the "health care providers" at their endurance sporting event weren't physicians, but chiropractors and chiropractic students?  All health care providers are not created equally.

Wednesday, July 4, 2012

What to wear while running in hot weather

Happy 4th everyone!  The heat is on.  We've had temperatures well into the upper 80s and 90s for the past few weeks.  It's tempting to skip your run on hot days, but with the right clothes and gear, you can still keep moving.

Proper clothing is key.  Cotton, while soft and natural, is the devil when it comes to running in hot weather.  When you sweat in cotton, it gets sopping wet and stays that way.  This leads to chafing.  OUCH.  Look for synthetic fabrics.  Coolmax is one of my favorites.  It is soft and light.  As you sweat, it wicks the moisture away from your skin to evaporate rapidly.  Awesome.  Dri-Fit is another one.  However, most lightweight rayon or polyester will do fine.

Socks.  SO, SO important.  If you've ever run with a blister you know this. Again, cotton is evil.  Look for synthetic socks made of a wicking fabric.  My favorite are socks that are in a double layer- these are my favorite.  True, you can't pick them up at the dollar store,  but they won't break the bank, either.  Investing in a couple of pairs of these is well worth it.  I have 2 pairs and just rotate them.  Obviously, with 2 kids I'm doing lots of laundry anyway.

A hat.  Here are some good choices.  Look for a hat made out of a lightweight synthetic material.  These will wick sweat away from your head and hopefully keep it from running into your eyes.  If you get really hot, a neat trick is to dump water onto your hat and put it back on your head.  As it evaporates, it will cool you off nicely.

Sunglasses.  Look for a lightweight pair.  Now, you can spend a lot of money on a fancy pair, but it's really not necessary.  Just look for a light pair that has UV protection and fits decently.  I usually pick up a couple of cheap pairs at the drugstore.  I have a habit of constantly losing sunglasses, so I don't invest in anything expensive.

Sunscreen.  Need I say more?  High SPF, waterproof version.  Re-apply partway through your run if you are doing a lot of sweating.  Get something like this- a little travel size sunscreen with a carabiner so you can hook it onto your belt.

Finally- water.  Lots of it.  I'll do another post about hydration belts, but for now, just make sure you are carrying water!

Now it's time to get out for your run. Enjoy, because before you know it snow will be flying.

Saturday, June 30, 2012

More DIY

This is an awesome website.  It's full of great ideas and plans for easy DIY projects.  I fell in love with her plans for a sling chair.  I had a chair similar to this while in med school.  I bought it at a craft fair and it stayed in Rochester when I left, since a tiny apartment in Manhattan was no place to bring lawn furniture.  Anyway, now that I'm a grown-up, I have a lawn.  Time to break out those tools again!

I will start by telling you this- the plan is deceptively simple.  It's not as easy as it looks.  I went through 3 failed attempts before hitting on a good method to make this chair.

You Can't Make an Omelet without Breaking Some Eggs, Right?


The plans call for using 1x2's for the side rails.  I made version number one with that.  It felt WAY too flimsy, so instead I used 2x2's.  Don't be an idiot like me.  Realize that if you switch the dimensions of SOME of the wood, it will necessitate changing the dimensions of ALL of the cuts.  Ahem.  As Handy Manny says, "Measure twice, cut once."

Without a doubt, the most difficult and most important part of this chair is making sure that the headers at the top and bottom where the sling attaches are square and tight.  This is a lot harder than it looks.  I tried many ways to get it just right, and finally settled on using a Kreg Jig and making pocket holes.  For those of you not familiar with a Kreg Jig, it is very cool and easy, once you get the hang of it.  You start by clamping the wood in the jig:

The drill goes in the hole and makes an oval hole:



Then it's very easy to screw that piece to the side rail.


You are left with a joint that looks like this- nice, square and flush.



USE GLUE.  It's important.  Don't be lazy and skip that step.  Ask me how I know.  Ahem.

ALSO-  DO NOT SPLIT YOUR WOOD LIKE THIS:


If your wood does split, remove the split piece and replace it, this time being more careful.  Don't think that it really won't matter.  It will.  Ask me how I know.


At any rate, I did eventually get it right.  Finished and ready to stain!  Another life lesson- take your time sanding, staining and finishing your furniture.  It's really tempting to go too fast and get careless here in your eagerness to be done.  It's not worth it.  If the furniture isn't finished well, you might as well not finish it at all.  I used stain and 2 coats of varnish.



Now for the really hard part- sewing the slings.  Confession- I've never used a sewing machine before.  Never.  However, I did have access to one- my father-in-law was happy to give me my late mother-in-law's machine.  Luckily, he also still had the manual.  Turns out, it wasn't all that hard and was actually kind of fun.


And, finally, success!!!




Overall, I'm really happy with how these came out.  They're incredibly comfortable.  I've weight tested them up to 220 lbs.  They look great around the pool.  Now it's time for a beer and a swim!

Thursday, June 28, 2012

Because everyone is asking me what I think...

...here it is.

Unless you live under a rock, you know that today the Supreme Court ruled on the constitutionality of the individual mandate of the Affordable Care Act.  They upheld that the federal government does have a right to require citizens to purchase health insurance.

The question everyone has been asking me today is "What do I think of ObamaCare?"

My answer is, "I don't know."  Sorry to disappoint you.  That's my answer.  Not because I'm uninformed on the subject, because I'm not.  Here is the reason why- I am interested in health care reform that will bring quality health care to my patients at an affordable cost.  Will the ACA allow that?  I don't know.  No one knows.  We won't know for several years.

Today's decision only ruled on the individual mandate to purchase insurance.  Overall, I think this decision was the right one.  I'll trust the SCOTUS on the specifics- they're the experts on constitutional law.  From a health care provider point of view, I think everyone should have health insurance.  The only way there's a prayer of that being affordable for everyone is for all people to have to purchase it.  The individual mandate has the ability to potentially lower costs, by spreading out the risk and bringing down premiums.  The ACA, in theory, does provide a way for all Americans to have health insurance, which is a good thing.  Will it work in real life?  Only time will tell.

 I will tell you one thing, in no uncertain terms.  Things have to change.  One way or another, the health care system needs to change.  It is no longer sustainable.  Will the ACA be the way to do it?  We'll know in about 5 years.  Until then, I'm reserving judgment.


Tuesday, June 26, 2012

How many ways can the same thing be repackaged?

I hate "me-too drugs."

What is a "me-too drug,", anyway?  It's a new drug that is very structurally similar to already existing drugs.  For example: Prilosec, Protonix, Nexium, Aciphex, Prevacid, and Dexilant.  All of these are proton-pump inhibitors and work basically exactly the same way.  One is not superior to the other.  And yet, pharmaceutical companies keep coming out with new ones.  Why?  I can give you 12 billion reasons.  They all have to do with dollars.

Anyway, here is another one that sticks in my craw, and has for a while.

Sleeping pills are big business in the USA.  In 2008, 56 million prescriptions for sleep medications were written.  According to the National Sleep Foundation, Americans pay $14 billion a year for sleep aids.  Ambien (zolpidem) is the most widely prescribed sleep aid.  I'm not really going to discuss the safety issues associated with sleep aids- that's a post for another day.  This is a different rant.

One of the big selling points of zolpidem is that it, in general, does not leave people with a hung-over feeling the next day.  This is due to its short half-life (the amount of time it takes for half the drug to leave your system).  In a few hours, the drug has all but cleared out of your bloodstream.  Of course, for many people this means that they take the pill around 10 PM, fall asleep, and then are wide awake at 2:30 AM.

Ambien went generic in 2007.  Coincidentally (yeah, right), Sanofi-Aventis released Ambien CR a couple of months before Ambien went off patent.  Ambien CR is the same drug as plain old Ambien.  It's in a special formulation that supposedly releases more slowly into your stomach, and this supposedly gets around that little problem of waking up after a few hours of sleep.  The data presented by drug reps showed that there were slightly higher levels of the drug in the blood for longer in patients who took the CR versions.  However, higher blood levels doesn't necessarily correspond to any clinical difference.  I have not been able to find one single head-to-head study of the clinical effectiveness of Ambien vs. Ambien CR.  Not one.  If any reader out there can point me towards one, I'd appreciate it.  Until then, I'll continue to suspect that Ambien CR is nothing but a patent-extender, designed to keep people on a more expensive version of a now generic drug.  Which is why I never prescribe it.

Now Purdue has joined the party by releasing Intermezzo.  In addition to having a ridiculous name, it's a ridiculous drug.  It is plain old zolpidem once again, this time repackaged in a teeny-tiny dose (1.75 mg).  It is meant to be taken in the middle of the night- when your Ambien or Ambien CR wears off and you're up at 2:30 in the morning, take one of these and get back to sleep.  An intermezzo is a musical interlude in between two other pieces, usually in an opera.   And you take this drug in the interlude that you are awake.  Get it???

I have no idea what the price of this wonder drug will be.  However, I can virtually guarantee that it will be far, far more expensive than what people have already been doing for years- taking half of a 5 mg zolpidem in the middle of the night- with exactly the same effect.  Voila!  A perfect example of a me-too drug.

I can guarantee two more things. First- an advertising onslaught.  I'm guessing opera will feature heavily in the ad campaign.  Second- people actually will ask me to prescribe this drug.  Yes, the advertising actually works.  Sad, but true.  I'll spend lots of time explaining why this new drug is no better than what's already out there, but some people can't be persuaded.  And health care costs continue to rise...

Wednesday, June 20, 2012

50 Shades of Hilarity



What is it about this book?  Seriously, if one more patient tells me about it...

I guess I should feel flattered that my patients feel comfortable enough with me to joke about their more...unusual...reading habits.  And yes, it can lead into a helpful discussion about sexual health, I guess.  Given that so many people have been talking about the book, I decided that maybe I should take the plunge and read it.  Purely for the educational value, you see.

Well, I wasn't about to walk into Barnes and Noble to buy it.  If I did, I would be virtually guaranteed to run into a patient while purchasing this fine selection of erotica.  In fact, I really didn't feel like spending money on it at all.  Therefore, the next logical step would be to hit the library.  Again, several of my patients work there, and I didn't want to get put on the wait list and have to get the phone call from a patient telling me that it was my turn to read Fifty Shades.  I therefore decided to utilize the wonderful NH Overdrive system, which allows you to take out books in E-book form.  This system rocks, by the way.    So, after logging in, I put myself on the wait list.  I was promptly informed that there were 734 people ahead of me.



Eh, no big deal.  I could be patient.

Last week, my number came up!  I quickly downloaded a copy to my Kindle, ready to delve into the mystery of what made this book so special.

And the answer is...nothing.  I'm sad to say, I only got about 3 chapters into it.  The writing was...bad.  Just bad.  The plot line (such as it was) was irritating.  And hey, I'm certainly no literary snob.  I love a good romance novel.  The problem is, I just wasn't seeing much in the way of romance.  So, I returned the e-book so it could be passed on to number 733.  I hope they like it more than I did.

I do want to share something funny.  I recently saw an elderly woman in the office.  She had shown up about 20 minutes late for her appointment and apologized profusely for running behind.  She explained that she had been reading and had lost track of time.  You'll never guess what book it was!  Yup.  You got it.  Her description of it was priceless: "I'm not sure what's going on, but I think that guy is up to no good!"

And there you have it, folks.

Monday, June 18, 2012

DIY

I haven't posted much in the past couple of weeks.  I've been busy playing with power tools.

What am I talking about?  I'm talking about my new hobby- woodworking.  It's something I've been wanting to try out for a while.  My last attempt at building something was in 8th grade shop class.  It was a VHS cassette storage rack (God, does that ever date me! Yes, Virginia, there really was a time when there were no DVDs).  It was terrible.  It was so lopsided that I had to glue the whole thing together and hope my shop teacher didn't notice (I think he did, but I got pity points because I had a broken finger at the time).   At any rate, I figured it was time to give it another try.

The true instigator of this was that mice ate through our backyard lounge chairs over the winter, and we had nothing left to sit upon.  I love Adirondack chairs, but when I started looking online for them, I was a bit taken aback at the price.  I mean, $200 for a chair that's going to sit outside?  No thanks!  So, I headed over to Woodcraft and picked up some plans for an Adirondack chair.  I then dusted off my Dad's old table saw, which I believe is older than I am.  I made sure my tetanus shot was up to date.  I  took out my jig saw (also a gift from my Dad), which I believe has been used approximately zero times since we got it.

Well, about 7 hours and multiple trips to Home Depot later...I had this:



And I was pretty darned proud of it, if I do say so myself.

Well, I tend to get a bit...obsessed about things. So, I figured, if one chair is good, four chairs are better!  Eventually, about 2 weeks later, I ended up with this:


Some came out better than others, but overall, I'm pretty pleased with them.  It's a vast improvement over a VHS cassette holder, at any rate.

Stay tuned for the next project.

Oh, and for anyone out there thinking of taking up this hobby...remember, safety first!  Eye protection, ear protection, and keep all body parts away from moving blades!

Tuesday, June 5, 2012

Congrats to Marni's Army

Thanks for another great season!  We had lots of runners complete the Red Hook/Runner's Alley 5K Race on Memorial Day weekend.  I'm so proud of everyone's hard work!


Wednesday, May 30, 2012

If you're trying to contact me by using the "contact me" button...

Make sure you include your email or phone number.  Kontactr doesn't provide that information.  Kathleen who emailed me recently- if you're reading this, email me again with your contact info- I'd love to talk with you.

Sunday, May 27, 2012

Tick PSA

It's a beautiful holiday weekend.  I'm sure many of you are outside, getting the yard ready for summer.  I'm also sure that several of you will be calling me on Tuesday morning because you got bitten by a tick.

Here's how to deal with a tick bite.  First of all- prevention is key.  Wearing long pants with the cuffs tucked into socks (I know, I know. Not very attractive.) is the best way to prevent a bite.  Check for ticks every night.

If you find a tick, remove it with a pair of pointy tweezers.  Grasp the head of the tick as close to the skin as possible and pull the tick off in one smooth motion.  Here is a good video.


Occasionally, the head will break off and remain embedded.  In this case, it is best to see your doctor to have it removed.  I don't recommend digging around to get it out, as this can increase the chance of infection.

If a tick is attached for less than 24 hours, there is very little chance of contracting Lyme disease.  If it is on longer, there is a chance of transmission (about 60% of deer ticks in my area carry Lyme disease), so see your doctor if you have concerns.  A prophylactic dose of antibiotics given within 72 hours of the bite can basically negate the chance of transmission.

Here's how NOT to remove a tick.  I have seen all of these methods tried.  They are...unwise, to say the least, and generally lead to more damage than if nothing had been done at all.  Don't burn a tick off with a lit match.  It's an awesome way to get a nice burn.  Don't take a really sharp knife and start hacking at your skin.  Don't "smother" the tick with petroleum jelly, nail polish remover, mineral spirits, or whatever caustic substance is lurking in your garage.  Please, people, just use common sense!  If your tick removal method might lead to a referral to a plastic surgeon, re-think your actions.

Tuesday, May 15, 2012

You Better Shop Around


Everybody knows that some medications can cost a lot of money.  I always try to take the cost to my patients into account when prescribing a medication- after all, if someone can't afford it, they are not going to take it.  When it's appropriate (and 9 times out of 10 it is), I try to prescribe a generic medication.  They are much cheaper and work just as well as the brand name (almost always).

Imagine my surprise when a patient recently presented me with this receipt, along with a request to change medication because the one I gave her was too expensive.


The medication was diltiazem ER, the generic form of Cardizem CD.  The patient pay portion was $0.  However, this patient is on Medicare, and the cost of every drug inches her closer to the "donut hole."  Basically, when the cost of drugs gets up to a certain amount (around $2700), the patient enters a coverage gap and must pay 100% of medication costs.  If you look in the upper right hand corner of the receipt, you will see that the cost of this drug was $536.84.

To say I was stunned is putting it mildly.  So much so that I was convinced it was a mistake.  After, the cost of brand name Cardizem CD is $288.99.  How could a generic be more expensive?  Cardizem went generic in 2010- that's plenty of time for the price to come down.

I called Walmart to see what the story was.  I spoke to the pharmacy tech and asked her how much diltizem ER costs.  Her answer was that there was one that was $54 and another that was $84.   I then gave her my patient's information and asked her why she was charged $536.84.  After a lot of hemming and hawing, she said that that was the cost for one particular pill made by one particular manufacturer.  I then asked her why my patient was given this one, instead of the one that was 10x cheaper.  She couldn't answer the question, so I got the pharmacist on the phone.  

I wish I could say I got a good, reasonable explanation.  I did not.  She told me that there are several versions of generic diltiazem ER.  They are all basically the same, but range in price from $53 to $536, depending on the manufacturer.  She had no idea why my patient was given the most expensive one.  I have some ideas, but I'm not going to speculate here, since I was always taught that if you can't say anything nice, then don't say anything at all.   I clarified to her that my patient was to only get the cheap one.  However, the damage is already done and she has edged an extra $500 closer to the donut hole.

So, what's the moral of the story?  Don't just accept that the price of a drug is what it is.  If something seems much more expensive than it should be, talk to the pharmacist or your doctor.  Shop around and bring your business elsewhere if a pharmacy is not willing to assist you.