Wednesday, December 16, 2015
Well, I was never really gone...just on a little blogging hiatus as the new office gets up and running.
It appears than many of my new and prospective patients are Googling me, and many seem to have questions about who, exactly, I am. Therefore, I figured I'd make a little Frequently Asked Questions list.
Q: How old am I?
A: Old enough. Seriously, though, I think people are really asking one of two questions: "Is she some wet-behind-the-ears-fresh-out-of-school newbie?" or "Is she as old as the hills and 6 months away from retirement?" This answer is that I'm neither. I'm firmly in the middle-aged category. I graduated from medical school in 2000. I finished residency and chief residency in 2004, and I practiced in New Hampshire for 11 years before moving here.
Q: Where did I come from? Why did I move here?
A: I grew up in New Jersey. I lived in New Hampshire for 11 years before moving to Florida. I moved here to be closer to family and to get away from the endless snow and cold of New England.
Q:Where did I go to school? Where did I do my residency? Am I board-certified?
A: I went to medical school at the University of Rochester. I did my residency (and stayed for an additional year as Chief Resident) at St. Vincent's Hospital in Manhattan. I am board-certified in Internal Medicine.
Q: Why is my schedule so open?
A: People say this like it's a bad thing! Don't you want to be able to get into see your doctor? We just opened about 2 1/2 months ago. If you want to get in quickly to see me, now's the time! However, even once I get really busy, I always leave openings in my schedule to see people the same day. If you can't get in to see your doctor when you're sick, what's the point?
Q: Will I have to wait forever in the waiting room?
A: No. I like to run a tight ship and stay on schedule. Patients can help me do this by making sure they arrive for their appointment on time.
Q: Will I listen to you? Or will I rush you out of the room and just push prescriptions at you?
A: I will listen to you. I am definitely not one to push prescriptions. When they're needed that's fine, but I like to emphasize lifestyle changes and healthy living.
Q: What hospital am I affiliated with?
A: I have privileges at Jupiter Medical Center.
Q: Can you call me Marni?
A: Sure. Call me whatever you want.
Q: What is "Marni" short for, anyway?
A: Nothing. That's my full name.
Q: What happens if you get sick when the office is closed?
A: Call my office and you'll get my answering service. I take my own calls, so they will patch you through to me, and we'll talk about what to do.
Q: You have a doctor up north. Do you need to see me, also?
A: If you're here for more than a couple of months, it's a good idea to have a local primary care doctor. You never know when you might need someone, and it's a good idea to have an existing relationship. I send copies of my office notes to your other primary care doctor.
Hopefully this answers your questions! If there's anything I haven't answered, feel free to write questions in the comments section!
Tuesday, September 29, 2015
Change is scary. When you're leaving behind a busy, successful medical practice, terrific friends, a nice house, and beautiful scenery, it's even more frightening.
Sometimes, though, you've just got to take the plunge, because change can also be a really, really good thing.
I'm happy to announce the opening of Primary Care Services of Jupiter Medical Specialists.
If anyone is in the Jupiter, FL area, stop on by to say hi!
Sunday, April 12, 2015
The Fitbit app also integrates seamlessly with MyFitnessPal, which is a terrific calorie tracker. Using the two apps together is a really powerful tool to help lose or maintain weight.
Wednesday, April 8, 2015
Case in point:
I saw a patient recently who is on methotrexate. It's a wonderful drug used for autoimmune conditions, such as rheumatoid arthritis. It works by inhibiting an enzyme that allows cells to metabolize folic acid, which is necessary for the growth of certain cells. Because of its mechanism of action, it's completely contraindicated in pregnancy since it will stop the growth of a fetus. Obviously, you need to be careful when prescribing it to a woman who may become pregnant.
Anyway, back to my patient. I got a copy of the note from the specialist who prescribed the patient methotrexate. It includes a very comprehensive accounting of the extensive counseling of the risks and benefits of prescribing the drug, including the risk to pregnancy.
Wednesday, April 1, 2015
Approved? Unable to approve? Which is it???
On a side note...the best thing someone can do for their health is quit smoking. Forget about losing weight, exercising, getting a Pap smear. If you want to get the best bang for your buck, quit smoking. With this in mind, why is it that Medicaid will cover Buproprion and nicotine replacement like the patch or gum, but won't cover Chantix? After all, the results for Chantix are superior to those for nicotine replacement. In the long term, it's even cheaper than trying and failing other therapies. So, what gives, Medicaid? I don't like requirements that my patients "try and fail" medications. I aim for success the first time out.
Monday, March 16, 2015
When I moved to New Hampshire 11 years ago, I was in for a bit of a medical culture shock. One of the biggest surprises was my first realization that there are "Doctors of Naturopathy," or "NDs" in New Hampshire who are licensed to practice medicine. In New York, I had had no experience with this. This is not to say that people there didn't see people who practiced "alternative medicine." What I'm talking about are practitioners who had attended a school of naturopathy and held themselves out to be primary care physicians with equivalent education and training to mine.
My first encounter with this was a patient who came to me because she had been diagnosed by her ND with "heavy metal poisoning." She actually was my partner's patient, but had been squeezed onto my schedule as an emergency appointment because she wanted to be admitted to the hospital immediately to begin treatment. My curiosity was piqued when I saw the chief complaint on my schedule. How does an adult in Portsmouth, NH end up with heavy metal poisoning? Had she had some kind of toxic exposure at work? What kind of neurological problems was she manifesting? Imagine my surprise when I walked into the room and saw a well-dressed, healthy looking woman in her late 40s. She told me that she had seen a local ND for fatigue and difficulty losing weight (her weight was perfectly normal, by the way). The ND had tested her for heavy metal poisoning. She told me she was given some sort of pill, and then had her urine tested for heavy metals. She handed me a lab report that looked something like this:
I never heard from her again. She transferred out of the practice.
That was my first experience. I've had many others through the years...and most of them have been similar. In my experience, most patients that see NDs around here end up being diagnosed with one of several diagnoses- heavy metal toxicity, chronic Lyme disease, adrenal fatigue, or systemic candidiasis. I'm not going to go into each of these issues, save to say that all of those diagnoses are controversial, so say the least. Perhaps in another post.
I was also quite surprised that in addition to NDs being licensed to practice medicine in the state of New Hampshire, they are able to prescribe pretty much anything I can. Here's a link to their formulary. Then, I found out that licensed naturopaths are considered primary care doctors here. Just like me. So, silly me, I figured that their education and licensing process must be just like mine, right? Well, here's a link to the requirements to get a naturopathic license in NH. Here's a link to what's required to get a license to practice medicine in NH. Keep in mind, in order to get a medical license in NH, you also have to submit an application to the Federal Credentialing Verification Service (FCVS). Here's a link to the FCVS requirements.
Equivalent? You be the judge.
Clearly the licensing requirements for MDs are much more stringent than for NDs. But what about the education? NDs claim that their education is actually more complete than traditional medical school, with more classroom hours. Since I've only gone to medical school and not naturopathic school, I've had to take their word for it.
There's a new blogger in town, and her name is Britt Hermes. She attended Bastyr University, which is really the premier naturopathic school in the US. She then practiced as a naturopath, and gradually became disillusioned with naturopathy and the practice thereof. She's blogging about her experiences and her move away from naturopathy, and in doing so has truly exposed the deficiencies in the education given at Bastyr.
Head on over to ScienceBasedMedicine for the full post. It's long, but definitely worth your time to read. Some highlights:
I recently scrutinized my transcript, course syllabi, and student clinician handbook. (Here is a table detailing my coursework into more readable categories based on my transcript; credits were translated to hours based on all of my courses syllabi.) I graduated with 1,224.5 hours of clinical training, of which 1,100 hours were in what Bastyr considers “direct patient contact.”.....More on what Bastyr considers "direct patient contact"...
On a clinic shift, one faculty member (a licensed naturopath) supervised several naturopathic students. ...Each clinic shift had a specific structure that included three elements: shift preview, patient appointments, and shift review.Let me tell you about direct patient care in medical school. Let's take my internal medicine third-year clerkship. It was 12 weeks long. The first 6 weeks were all on the inpatient side. We were part of a medical team on the wards, consisting of an attending physician, a resident, an intern (first-year resident) and the medical student. We would typically arrive around 5 AM to start pre-rounds on our patients, and there were usually between 15 and 20 patients to a team. Pre-rounding is where you check up on how your patient did overnight, examine them, check labs, etc. After pre-rounding is morning report, which would be a didactic presentation of an interesting case. Then comes formal ward rounds. This is where the team rounds with the attending. Presentations of the patient are made at the bedside. A care plan is made for the day. Interesting physical exam findings are shared among the team. This usually takes at least 2 or 3 hours. Then it's time for "lunch." Lunch is always eaten in the lecture hall, because there's a didactic lecture during lunch. After lunch, it's time to start doing any new admissions that have come in during the day so far. If you're the lucky team on call, this will last until 11 PM. If it's just a normal day, it'll last until about 6PM. At 6 PM, you do a final quick round on your patients, make sure they're figuratively tucked in for the evening, and then sign out their care to the night float team who will cover them until you come in at 5AM the next morning.
Shift preview and review took place in the first 30 minutes and final 30 minutes of shift. During these periods, primary students roundtabled their patients. The patient’s medical history, previous visits to the clinic, and previous naturopathic assessments were discussed. Patient cases were presented in a standardized S.O.A.P. (subjective, objective, assessment, and plan) format. The supervisor usually asked students about differential diagnoses and treatment protocols. Medical standards of care were almost never discussed on my clinic shifts, with notable exceptions for one or two of my supervisors who insisted on it, to the dismay of many students. I often heard statements such as, “the patient has a strong vital force and it is expected that the patient will heal in 3 to 4 weeks’ time with proper self-care and home hydrotherapy treatments.” Sometimes, the preview and review was attended by first-year students completing their Clinic Entry 1 requirements. These students generally did not contribute to the discussions but their time was considered “direct patient contact.”
Actual patient care accounted for three hours of a clinic shift. Patient care visits were typically attended by two students, a secondary and a primary. Appointments lasted anywhere from one to two hours. During an appointment, the primary student charted the patient’s current medical complaint and relevant history. This charting included a typical medical intake, such as the seven attributes of the medical complaint, a review of systems, past medical history, medications and supplements taken, family history, social history, dietary patterns, and so on. Vital signs, like blood pressure and temperature, were usually taken by a student. The patient intake also included information thought relevant to naturopathic diagnoses, like toxin and heavy metal exposure, use of plasticware in cooking and eating, birth history, pesticide exposure through eating non-organic foods, food intolerances, religious affiliations, and a host of subjective assessments relevant for energy therapies (homeopathy, flower essences, UNDA numbers, etc.).
And you do this six days a week. One day off for good behavior.
The next six weeks are luxurious in comparison, because they're outpatient. You work alongside a primary care physician in his or her office. So, it's much better hours. We'd start around 7AM with hospital rounds on their patients, then see patients in the office until 5 PM, and then go back to the hospital to check on any inpatients or do any admissions. But we got both Saturday and Sunday off!
By the way...the internal medicine rotation is considered to be one of the "easy" rotations, schedule-wise. During my surgery and OB/GYN rotations, for example, there were days where I didn't even bother going home for 2 or 3 days at a time, because it just wasn't worth it.
And check this out:
They were considered to be competent in treating all cardiovascular diseases by seeing two patients with any type of cardiovascular disease? This is incredible. Also, please take note of what Britt says about the dearth of patients with serious disease. This is incredibly important to note. You can't be a good primary care doctor unless you've seen a lot of serious disease. Here's the thing. Any idiot can diagnose and treat 90% of what we see on a daily basis in a primary care office. The problem is with the other 10%. Those are the patients with strange presentations of either common or rare illnesses. You need to have seen a ton of stuff to be able to accurately diagnose a patient who is presenting in this way.
Now, I posted above about patient contact during my third year medicine rotation. In the fourth year, I did a medicine sub-internship. This is basically where as a fourth-year student, you pretty much function as an intern. So it was more of the crazy rounding schedule above, plus some.
Once I graduated, the training wasn't finished. Internal medicine is a 3 year residency. You're not supposed to work more than 80 hours a week (what a luxury!) but in truth, we often did. By my calculations, going off of 80 hour weeks, I had more than 11,000 hours of patient care in my 3 years of residency.
Naturopaths don't do a residency.
Tell me again how they're qualified to call themselves primary care physicians?
Do you want to see the doctor who is considered competent to treat all cardiovascular disease after seeing two patients with hypertension? Or do you want the doctor who has completed over 12,000 hours of training in internal medicine alone, not to mention several thousand hours of surgery, OB/GYN, psychiatry, pediatrics, family medicine, and neurology?
Your choice. Your decision. After all, it's your life. Literally.
Monday, February 23, 2015
Some lawmakers in Idaho are trying to pass a bill to prevent doctors from prescribing medical abortions (the abortion pill) via telemedicine. Medically speaking, a medical abortion, if done early, is safe and effective. This is also an important option, as there are only four abortion providers in the whole state of Idaho. 95% of the counties in Idaho have no abortion provider. Of course, certain lawmakers can't but help to stick their nose into women's reproductive rights.
Well, get this:
An Idaho lawmaker received a brief lesson on female anatomy after asking if a woman can swallow a small camera for doctors to conduct a remote gynecological exam. The question Monday from Republican state Rep. Vito Barbieri came as the House State Affairs Committee heard nearly three hours of testimony on a bill that would ban doctors from prescribing abortion-inducing medication through telemedicine. Dr. Julie Madsen was testifying in opposition to the bill when Barbieri asked the question. Madsen replied that would be impossible because swallowed pills do not end up in the vagina.Yes. you read that right. This male lawmaker actually thought that if a woman swallowed a "small camera" a doctor could conduct a remote gynecologic exam. Look, I understand that not everyone is a doctor. I understand that not everyone is going to have knowledge of anatomy, although, really, this is pretty basic stuff we're talking about here. But is it too much to ask that people who are stupid enough to think that the vagina is connected somehow to the GI tract try to refrain from passing laws affecting said vaginas?
I've got news for you, Rep. Barbieri. You also can't get pregnant from oral sex. Surprise!
Anyway, I'm just appalled by this and really have nothing else to say. So, Captain Picard and Commander Riker, you have the bridge.
Sunday, January 18, 2015
I've watched the emergence of anti-vaccination sentiment over the past few years with a mixture of fascination and horror. While in med school and residency, the idea of people willingly turning their nose up at vaccination never crossed my mind. I mean, vaccines! No brainer! The biggest success story of modern medicine! Eradication of smallpox! Polio eliminated from the developed nations of the world! How in the world could anyone be opposed to such a thing?
Then, in 1998, Andrew Wakefield published a small case study in the Lancet that hypothesized a link between the MMR vaccine (the combination vaccine for measles, mumps and rubella) and autism. At first, this didn't get too much press in the US. However, in England it became a Big Deal. Even though his paper did not explicitly state that the MMR caused autism, Wakefield held a press conference before the article was even published calling for suspension of the use of the MMR vaccine. This led to a rather spectacular fall in MMR vaccination rates in the UK over the next decade.
Then, in 2005, the proverbial you-know-what hit the fan in the US. Robert F. Kennedy Jr. wrote an article called "Deadly Immunity" which was published in Rolling Stone Magazine. This article claimed that there were excessive amounts of thimerosal, a mercury-based preservative, in childhood vaccinations, basically leading to mercury poisoning and causing autism. You can still read the full article on RFK Jr's site. You're not going to find it anymore on Rolling Stone or Salon.com. Both magazines retracted the article and wiped it from their sites after it was shown to be riddled with inaccuracies and downright falsehoods.
Now, interestingly, the MMR vaccine has never contained thimerosal. In addition to this, out of an abundance of caution, thimerosal was removed from US childhood vaccines in 1999. Today, in 2014, autism rates continue to rise. It's not thimerosal causing it.
It's also not the MMR. The studies have been done, and the science is in. As if that wasn't enough, The Lancet retracted Wakefield's paper after overwhelming evidence showed that he was paid by plaintiff's lawyers to find a link between the MMR and autism. In addition to this, Wakefield himself was trying to develop a alternative vaccine that would be "safer." He performed unethical, invasive tests on children, leading to potentially deadly complications in one of them. Other scientists were unable to replicate his original findings. In 2010, the British General Medical Council pulled his license to practice medicine.
You'd think this would be enough to put the fears about the MMR to rest.
It's not. Not even close.
I followed these issues only very peripherally until 2007, when I gave birth to my first child. That's when I fell down the true rabbit hole. Like any new parent, I wanted to do my best for my little one. And, like any new parent, I turned to the internet to lead me to what, exactly, "the best" was. That's when my eyes were opened to a whole world of woo. I was stunned to find that there were entire forums dedicated to not vaccinating, among other things. Forums where if you dared to correct someone or even share a dissenting opinion, you were shouted down, accused of being paid by Big Pharma, or just flat-out banned. And it wasn't just autism that vaccines were supposed to cause. They also caused SIDS, autoimmune disease, encephalopathy, allergies...the list goes on and on. How were they causing all of this? Well, sometime it was the thimerosal. Sometimes it was the MMR. Sometimes it was "too many too soon." Sometimes it was aluminum. The goalposts were constantly moving.
These issues are complex and I could probably write forever on it. However, other bloggers have been at this for much longer than me. I suggest starting with Respectful Insolence, which is written by a cancer surgeon who has been at this for more than a decade. Science-Based Medicine is also an excellent site. The Panic Virus, by Seth Mnookian is an excellent book and a quick, fascinating read.
The upshot of the entire vaccination controversy is that rates of vaccination are falling. They are the lowest in areas where parents are the wealthiest and best educated. This may seem counter-intuitive at first, but it really makes perfect sense. It's the Dunning-Kruger effect in action. A minimal amount of knowledge leads to an immense overestimation of expertise. Therefore, educated people truly believe that they can research some things on Google and gain the same level of expertise as scientists who have been studying this stuff for years. These are also a group of people who are used to nothing but success in life. They labor under the assertion that being able to afford the best in organic food, healthy lifestyle and alternative medicine will protect them from infectious disease.
Anyway, refusing vaccines is leading to the inevitable outcome- we are starting to see the resurgence of once-eliminated diseases. During Christmas week, someone visited Disneyland in California who was becoming ill with the measles. Measles is one of the most communicable viruses known- up to 90% of people exposed will become infected if they are not already immune. The vaccine is highly effective- between 95-98% effective. Just check out this graph.
But it only works when you use it. And when immunization drops below a certain threshold, outbreaks will occur, which is exactly what happened at Disney. The outbreak seems to have been traced to an unvaccinated woman in her 20's. From this one index case, there are now 51 active cases in four states. The exposures continue- a clinic in San Diego had to be shut down after six siblings visited with measles. Since the measles virus is airborne, the virus can linger in the air for hours after an infected person had been in the vicinity.
As quickly as things seem to be spreading, this story is also a testament to the effectiveness of the measles vaccine. During Christmas week at Disneyland, there are an estimated 80,000 visitors a day. Even estimating that only 80% of those visitors were vaccinated, that is 64,000 potential exposures. It's hard to find out exact numbers of how many of the 31 directly infected at Disney were vaccinated, although reports state that "most" were unvaccinated. However, let's say, for argument's sake, that they were all vaccinated. That still represents an incredible effectiveness rate of greater than 99%.
Despite what many anti-vaccine websites will have you believe, measles is not benign. In developed countries, the mortality rate is 3/1000. Other complications include pneumonia, ear infections, deafness, and SSPE, which is fatal. I have no doubt that if vaccination rates continue to drop, we will start to see some of these complications occurring. Just look at what happened in France:
Although few measles cases were reported in France during 2006 and 2007, suggesting the country might have been close to eliminating the disease, a dramatic outbreak of >20,000 cases occurred during 2008–2011. Adolescents and young adults accounted for more than half of cases; median patient age increased from 12 to 16 years during the outbreak. The highest incidence rate was observed in children <1 year of age, reaching 135 cases/100,000 infants during the last epidemic wave. Almost 5,000 patients were hospitalized, including 1,023 for severe pneumonia and 27 for encephalitis/myelitis; 10 patients died. More than 80% of the cases during this period occurred in unvaccinated persons, reflecting heterogeneous vaccination coverage, where pockets of susceptible persons still remain. Although vaccine coverage among children improved, convincing susceptible young adults to get vaccinated remains a critical issue if the target to eliminate the disease by 2015 is to be met.Scary. Not the future I want to envision here.
One more issue. Another story made the news- a young woman, unvaccinated by choice, was refusing to be quarantined after being exposed to her sister while she was infectious with measles contracted at Disneyland. The selfishness exhibited by her is breathtaking. She doesn't think it's fair that she should be quarantined when she's not even sick. Her mom think's it's "not nice" that her daughter is being "threatened." Well, I think it's "not nice" that someone who is potentially infectious sees nothing wrong with wandering about the community, infecting those too young to get vaccinated or who are immunocompromised by illness or chemotherapy.
Here's my take: if you want to practice 19th century medicine and turn your nose up at vaccination, be prepared to suffer the 19th century consequence- quarantine.
Get your vaccines, people. Make sure your boosters are up to date. Vaccinate your children. Remember, the good old days often weren't that good. Let's move forward, not backwards.