Jill of All Trades, MD

Obsessed with Oz

2011-03-01T16:09:00.000-08:00

What is it about the media obsession with doctors and the medical field? It seems like everywhere I turn I hear about yet one more medical show popping up on television. Seriously, are our lives really that interesting? It’s really not nearly as glorious as they make it seem, believe me. In fact, it’s sometimes downright monotonous and anticlimactic. I have spent many nights in the E.R, and never have I seen situations like those that pop up on these shows before…not even close.

And I hate to say this, but not many doctors look like George Clooney or James Franco. Don’t get me wrong, there are some good looking docs out there, but for the most part, we didn’t exactly give up a booming modeling career for a life filled with books and a stethoscope, Dr. Oz included (sorry, Dr. Oz). So why this strange obsession with all things medical?

As a physician I just simply can’t engage and find myself “hooked” on any of these shows for some reason – is it just me? Perhaps because the very LAST thing I want to do is to go home and feel as though I am back at work. I’d rather watch completely mindless television, where I no longer have to THINK when I come home.

Plus, I don’t know about other docs, but for some reason I lose interest quite rapidly when I see situations that I know would never realistically happen. I mean, what are the odds of having a pole stuck through two individuals who are awake, coherent, and having a full on conversation for hours in the ER, while the surgeons decide which of the two they should ethically (and I use the term loosely) save; because they can save only one, but of course. Just can't get into it, crazy me. I'm sure lawyers feel the same way when they watch law shows, mafia members when they watch mob shows, etc...no?

Here’s my running list of medical shows thus far (some old, some new):

MASH

Doogie Howser, MD

House

Grey’s Anatomy

E.R.

Scrubs

Dr. Quinn Medicine Woman

Nip/Tuck

Chicago Hope

Third Watch

Dr. 90210

Private Practice

Dr. Oz

The Doctors

St. Elsewhere

Mercy

Boston Medical

General Hospital (I have to admit, my personal favorite)

Have any more to add? Please share!

Mr. Noodles

2011-02-21T21:06:00.000-08:00

Me: “Mr. Noodles, your last blood test shows that your sugars are about 200 on average. Are you taking your metformin twice a day as prescribed?”

Mr. Noodles: “I have to admit, Doc, that I have been skipping a few doses here and there.”

Me: “A ‘few doses’? How many days a week do you forget to take it?”

Mr. Noodles: “Ummmm….about five times a week.”

Me: “Five times?! How about the cholesterol medicine I prescribed? Your electronic chart reports that you never picked it up?”

Mr. Noodles: “Yeah, I haven’t started taking it yet, either.”

Me: “How about the baby aspirin? Did you start taking that at least?”

Mr. Noodles: “Ummm…no. No, I haven’t, Doc.”

Me: “Well, gosh, Mr. Noodles, then what made you come in here today?”

Mr. Noodles: “Well, I’m here because I’m having some issues with…well…performing.”

Me: “You’re having problems with maintaining your erections, Mr. Noodles?”

Mr. Noodles: “Yes, exactly. Why do you think this could possibly be happening, Doc?! I can’t figure it out!”

About 50% of men over the age of fifty report experiencing erectile dysfunction, and only about 10% regain the functioning that they lost. Poor diabetes control results in damage to the nerves and blood vessels that feed the male genital system, and eventually cause problems with normal male sexual functioning.

What is the best way to improve male sexual dysfunction in those with diabetes? Prevention! Work closely with your doctor to control your blood sugars in order to prevent this damage in the very first place!

Body & Soul Cleansing

2011-01-24T21:55:00.000-08:00

It never ceases to surprise me what some of my patients are willing to put themselves through all in the name of health:

“That stuff I had to prepare me for the colonoscopy – can you give that to me again, Doc? I need an entire body & soul cleansing, and I want to start with my bowels.”

The colonoscopy is a screen for colon cancer, one of the top cancers found in men and women. Some people actually rather enjoy the preparation process, which is the most challenging part of the colonoscopy (not the actual procedure itself), like my patient above. And yet some people rather dread the procedure itself (and not the preparation process), which is really the easy part!

But to be honest, the entire process is really not that bad. My patients who refuse the procedure either tell me they are too "embarrassed" to have the doctor place a foreign object through their rectum, or are just plain terrified of any discomfort or pain they may possibly face. But you must remember that the doctor who performs these procedures does them for a living -- one rectum is really not any different than any other rectum to the gasteroenterologist (as special as you may think yours may be). Please do not be embarrassed. And as far as pain, it is quite rare.

5 Colonoscopy Expectations:

To combat some of your potential fears, here is what you can really expect from a colonoscopy:

1. A colonoscopy is a screen for colon cancer, that is recommended either:

a. starting at age 50

b. or 10 years prior to a first degree relative's (parent, sibling, or child) diagnosis of colon cancer

2. The day prior to the colonoscopy, you can only drink clear fluids -- broth, black coffee or tea, Jello, etc. NO solids. Perhaps the toughest part of the entire process to endure. But you can do it!

3. You will be given a special 4 L container of a solution that you will need to chug, and chug quickly (about 8 oz every 10-15 minutes) the night before the procedure. It will taste better if this solution is chilled. This will give you the runs -- meaning, you will be literally running to use the bathroom constantly for about two hours after you start drinking the solution. The goal is to run until it literally runs clear!

4. If the preparation is not sufficient, then the doctor will be unable to catch a clear view of the colon walls, and this will decrease the validity of the test. That means that polyps and abnormal spots on the wall of the colon will be potentially missed. And you may need to go through the entire process once again!

5. On the day of the procedure, you will be given a medication that will make you very sleepy. Most people do not remember the procedure and are asleep for the entire thing. As you can see, there is no need to be afraid!

Have YOU had your colon cancer screen?!

5 Tips to Keep in Mind When Reading Medical Websites

2011-01-18T17:38:00.000-08:00

During my transition from public to private health, I have indeed noticed some interesting differences that have forced me to practice medicine a perhaps a tad differently. One big surprise: in private health, I have to admit that I have been pretty astounded to see that my patients quite heavily rely on the internet before they even come to see me for their given ailments.

In public health, some of my patients were not even able to read, let alone surf the internet. Many were not even able to afford a computer in their home. My challenges there were not generally to find myself having to defend my practice of evidence-based medicine and to explain my medical reasoning on a step-by-step process, as I am doing now; all thanks to the internet. The internet has truly made it seem as though it is a daily battle, to wrestle and knock out each erroneous pseudo-factoid out there. No doubt about it, it has made my job harder in many ways.

But perhaps it’s not necessarily a public vs. private health difference, but more of an advancing-in-technology-with-time issue. More and more patients seek the internet for health information and advice as time goes by – that is just the reality of medicine today.

But unfortunately, most of the websites my patients are reading are unreliable, I have come to learn. That is what scares me, not that they are actually yearning to learn more about their health conditions. Sometimes, a little bit of knowledge can actually be a scary thing:

“Doc, I have this tingling in my hand for the last four days, and I am convinced it’s Lupus!”

“No way am I getting the flu shot – I saw that cheerleader video on YouTube!”

“I’ve had this back pain for two weeks now, and this websites says I need an MRI. Can you order me one, Doc?”

“I am so afraid -- I keep gaining weight and I read online that it could be a growing tumor!”

So I have started to adapt how I practice now, and am actually enjoying and embracing this new challenge that advanced technology has thrown at me. I love the fact that my patients want to educate themselves on their health conditions. The more knowledge they have, the better they will take care of themselves I have learned (in general). But I do encourage my patients to refer to some more reliable sources of health information online. Here’s the list I give to my patients:

www.familydoctor.org

www.cdc.gov

http://www.nlm.nih.gov/medlineplus/

http://www.who.int/en/

5 Tips to Keep in Mind When Reading Medical Websites

And when they are reading, I ask them to PLEASE keep these few tips in mind:

1. In general, please be wary of any website with the ending “.com”, and opt for those websites with “.gov” or “.org”.

2. If you are reading info online that is starting to become frightening to you, that is your signal to turn the computer OFF and make an appointment to see your doctor instead. Please do not continue to terrorize yourself, because most of the time, what you are reading is not what is really going on. Nothing good can come from that.

3. Always ask yourself, “Who is writing this article?” Is it written by a physician? Most of the time, it’s not. Many online health articles are written by journalists with “special focus” on medical information – and what does that mean, ask yourself. Whatever that means, it’s NOT typically sufficient enough to be giving patients medical advice. They are primarily writers, designed to catch headlines and grab your attention, not medically trained professionals who have enough knowledge to give accurate advice. The scarier and more controversial their writings, the more money they make.

4. Find out who sponsors the article, and if the writer is affiliated with any entity that wants to sell you a product. Does the author work for a drug company? What are they trying to sell you? Be wary…very wary. Where is this article written? I mean, is Vogue magazine a reliable source of medical information?

5. Anything you read is one dimensional. The computer cannot solve complex medical problems that require a background of experience and human reasoning. The computer cannot perform a physical exam, or feel your level of pain, anxiety, or whatever it may be with one look. Medicine is complex, that’s why it takes a minimum of eleven years of school to become a doctor. Otherwise, doctors would be out of a career. Trust your doctor.

"Technology is just a tool. In terms of getting the kids working together and motivating them, the teacher is the most important."

-- Bill Gates

Doctors Are Human, Too

2010-11-16T19:18:00.000-08:00

Since starting my new job, because I don’t have a full panel of patients yet, I have naturally been seeing more patients belonging to other docs in my clinic when they can’t get an appointment with them. Most of the time, they are grateful to be seen by me, even though their doc is not available. But sometimes they come in so angry with their doc for whatever reason it may be, ready to chew my head off:

“He doesn’t listen to me.”

“She made me come in today just to get my refill.”

“He gave me a bogas medicine that doesn’t work.”

“She couldn’t help me, and I doubt you can do anything, too. I don’t know why I even came in.”

“I hate doctors.”

Ok, I get it. You are mad at your doctor. Sometimes it’s a legitimate concern, and sometimes it’s a misunderstanding; and ok, so sometimes it’s completely warranted. But why are you angry with me before you even meet me? I am a nice person, gosh darn-it. And I am eager and willing to help you.

I don’t walk into the exam room mad at my second patient just because the first one gave me a hard time. I don’t carry that emotion into that next visit with me. I don’t generalize and think that “all” patients are mean and nasty just because a few are a tad less than courteous. In the same way, not “all” doctors are mean and nasty just because you had a few who were a tad less than courteous. We are all people – patients and doctors alike. We all deserve common courtesy.

We have feelings, too. It makes our jobs so much harder when we meet patients who are very angry. It can really make or break our day. We become doctors because we like taking care of patients, and generally have big hearts. We care. Really, we do. I can’t say we are perfect, because nobody is perfect, but we do care and want to help.

So before you walk into your next doctor’s appointment (especially if it’s a doc you’ve never met before) please remember that doctors are human, too.

Google vs Docs

2010-11-02T00:18:00.000-07:00

Ms. Gullible: "Yes, XYZ celebrity says that these pills really will make me look 10 years younger if I keep taking them."

Me: "How much do they cost?"

Ms. Gullible: "Only $120 a month, which is way less than what I've been spending on fillers lately."

Me: "Be careful, there is no good evidence to support XYZ's claims."

Ms. Gullible: "That's absolutely not true! I have read all about it on Google!"

"If you trust Google more than your doctor then maybe it's time to switch doctors."

-- Jadelr and Cristina Cordova

New Beginnings: Tips on Meeting Your New Doc

2010-10-28T20:38:00.000-07:00

Starting a new job can be exciting, a new challenge, while embarking on a new journey. I have the opportunity to meet many new fellow docs, staff, and kind patients. However, I have to admit that it is a tad more challenging in the beginning when starting a new practice from scratch. I do miss the familiar patient faces that knew me and trusted my medical abilities without question. But I also realize that it will take some time before feeling that same comfort level again with my new patients, as I build my new patient-physician relationships over time.

I sure do wish my patients knew a few tips that would make our first visit more efficient and eventful, before they come to see me for the very first time. This is especially helpful in my rather complicated patients with more complex and/or numerous health conditions. Oh, how I wish I could communicate with my patients prior to that very first visit with me to share these tidbits of info:

Bring your list of diagnoses: Every patient should have a running list of their diagnoses, and should be adding to this list as time goes by in life. It’s important to ask your current doc for a list of your health conditions, because if you were to ever change doctors or clinics, there will be a lag time in which your records may be transferred. Or if you were to ever have to visit an Emergency Room (hopefully never), the doctor there won’t know anything about your history and may not have access to any of your records. They may have to “guess” everything. Your health is too important for any “guesses.” Imagine if you would just “whip out” that diagnosis list! Boy, would they be so impressed! As patients, we all really need to take ownership of our health.

Bring all of your medication bottles: Even if there is an electronic medical record system that keeps track of your medications, I still want to see what you are actually taking, not just what is listed on a silly computer screen. I’ve talked about the importance of bringing your bottles to every appointment in my blog previously. This keeps us both in check – less risk for mistakes (which I catch ALL the time by checking my patients’ bottles)! Plus, I learn a lot by looking at the bottle – what your diagnosis may be, who prescribed it to you, how many refills you have, etc. Bring everything – even your vitamins and herbals.

Make an appointment just to “establish” with your new doc: That first visit is going to take a good deal of time since it’s your first one. EVERYTHING will need to be reviewed. Yes, even if it’s “already in your chart,” your doctor is going to go through your entire history from scratch. This is because most doctors like to be thorough. And the information, even if “written” in the chart already, was written by somebody else. It needs to be verified with the patient at this first visit to make sure that it is error-free. Why? Because your health is too important to take a risk! What if your new doc wrote you a prescription for a medication that you were actually allergic to, and that you had forgotten to tell your old doctor about it? Or, what if your brain completely repressed the fact that you were hospitalized for two weeks after a horrible fight with your gallbladder, which was subsequently taken out, and you just simply “forgot” to mention that to your last doc (these things really happen, I’m not kidding).

Oh, how I would love to just meet all of my patients for an “establishment” visit, this would make for a much smoother transition, before they actually suffer from that nasty low back injury, urinary tract infection, or goodness forbid, that debilitating diabetic foot ulcer. EVERY patient should have a visit to simply “establish,” without waiting for a symptom to arise first.

I may not be able to catch all my patients to share these tips with them before we meet for the very first time, but maybe it will help you in your new-doc transition one day.

Pressing Breast Facts

2010-10-20T20:21:00.000-07:00

(Cartoon Credit: By BellaGreetings.com)

Fact: Breast Cancer is the number one cancer found in women.
Fact: If found early enough, chance for cure is excellent.
Fact: Mammograms are the best screening tests to detect early breast cancer.
Fact: If you do not have health insurance coverage, the National Breast and Cervical Cancer Early Detection Program provides them for free.

It's Breast Cancer Awareness Month -- Did YOU get your mammogram?!

Nurse Circus List

2010-10-14T12:42:00.000-07:00

One of my kind readers, Carrie, recently posted the following comment in response to my prior post, Three-Ring Circus:

"Hi, Jill!

I'm a CMA and would love to know the"list" you give your new MAs. I am always searching for ways to maximize efficiency for our staff and this sounds like it would be a great addition. "

So I thought I'd share with you the following one-paged "pocket table" that I dispense to all of my new medical assistants who room my patients, which truly saves me a lot of time and allows for a more efficient patient flow. But you may want to tweak it here and there to suit your own clinic needs, or even add to it:

VISIT TYPE	SUPPLIES NEEDED	PATIENT PREPARATION	TESTS TO PERFORM
Breast Complaints		Undress from waist up w/ gown
Chest Pain or Palpitations			EKG
Eye Complaints	Eye Tray: flouresceine strips, flouresceine lamp, normal saline		Visual acuity
Shortness of Breath			Pulse Oximetry
Urine Symptoms			Urine dip
Vaginal Discharge	Wet mount supplies (slides, slide covers, KOH, saline), speculum, jelly, a working pap light	Undress from waist down w/ gown
Pelvic Pain	Speculum, jelly, a working pap light	Undress from waist down w/ gown
Warts (body or genital)	Liquid Nitrogen
Pap Smear	Speculum, jelly, a working pap light, pap slide/container w/ label on it, 2 pap swabs	Undress completely w/ gown	· If less than age 26: urine GC/Chl · If new contraception requested: U preg test
IUD Insertions	Speculum, jelly, a working pap light, IUD, betadine, large cotton swab, sounding instrument, tenaculum, sterile gloves	· IUD consent signed by pt & nurse as witness. · Confirm neg pap & GC/Chl in past 1 yr. · Complete IUD wallet-card for patient.	U preg test
Endometrial Biopsy (EMB)	Speculum, jelly, a working pap light, betadine, large cotton swabs, tenaculum, EMB pipelle, specimen cup w/ label, sterile gloves.	· Consent signed by pt & nurse as witness. · Undress from waist down w/ gown.	U preg test
Obstetrics/Prenatal Care	Doppler, measuring tape.		U dip
Toenail Removals	Betadine swabs, 10 mL syringe, lidocaine w/o epi, 18 G needle, 25 G 1.5 inch needle, one alcohol pad, tourniquet, nail elevator, nail splitter, hemostat, many sterile gauze, phenol swabs, antibiotic oint, curlex gauze, tape.	· Consent signed by patient & nurse as witness. · Patient’s shoes/socks off. · Chux underneath foot.
Pediatric Physicals		· Patient’s immunization card. · Growth chart plotted. · BMI recorded. · Pt undressed completely w/ gown.	Hgb level required? Lead level required? Visual acuity required? Hearing test required? Urine dip required?

If you have anything to add to this list, please do share!

Club Soda

2010-09-29T12:09:00.000-07:00

Me: Your blood sugars of 300’s are very elevated. We need to add a medicine, or else you may have a heart attack or stroke one of these days. Let’s add metformin.

Mr. Adamant: No, I cannot take that because it makes me feel “weird.”

Me: What do you mean “weird”?

Mr. Adamant: I don’t know, I just can’t explain it. I just don’t like it.

Me: Ok, then we can add pioglitazone. It’s more expensive, but we don’t have too many choices at this point.

Mr. Adamant: No, I tried that before and it makes me gain weight.

Me: Did you lose the weight after you stopped it?

Mr. Adamant (while attempting to conceal the soda can clutched in hand): No.

Me: Ok, then the only other choice we have left is insulin.

Mr. Adamant: Oh, no -- I definitely won’t take that! Over my dead body!

Me: There are no other choices. Why won’t you consider insulin?

Mr. Adamant: I tried that before and it didn’t work. In fact, nothing the doctors have given me works to lower my sugars.

Me (while pointing to soda can): But perhaps it’s because you refuse everything we give you!

Sigh…

Three-Ring Circus Clinic

2010-09-23T19:48:00.000-07:00

When I was a little girl, attending the circus was the highlight event of the year. I remember looking forward to it each year – perhaps because it was something fun, and each year something new. Never the same show twice. Very busy behind the scenes, yet at the same time, quite organized and appearing smooth on the surface.

In the same way, the clinic can be a truly hectic scene. But with me as Ring Master, I was able to magically eventually learn to conduct my three rings of fire for a much smoother overall show, with spotlight on the dedicated patients, meticulous staff, and me with my super chic top hat.

I have to admit that there have been days in which I have magically seen up to nineteen patients in one half day. However, I wouldn’t say that I am proud of that, or that it went smoothly. That is how many patients the average physician sees in one full day. But, I did learn greatly from the experience. I was forced to learn how to become very efficient. It’s survival of the fittest. If you aren’t efficient, you can easily become prey to your tigers and lions when seeing this many patients a day.

It was a gradual learning process, one that included some trial and error. But I have learned a few magic tricks to make my days run smoother. Here is what I learned as the clinic Ring Master, which may perhaps be helpful for others who put on a similar show:

• Practice Your Magic Tricks: Review the patient chart thoroughly before you walk into the exam room. First of all, it’s too distracting to review the chart when the patient is talking to me. Second, I may be construed as “rude” by the patient while doing so. I need to refresh my memory and review pertinent details of the patient’s case. I write all over the progress note and come up with their diagnosis list and my plan for them before I even walk in. For instance, if I have a diabetic that comes in for headaches, I come up with a plan for their diabetes – retinal photo, diabetic foot exam, and a pneumonia vaccine that they are overdue for. I write this in the chart. Then I walk in and address the patient’s concerns about the headache, and at the end take care of their diabetes. Reviewing and writing in the chart before I walk in saves me a lot of time, and gives an idea of how I want to manage my time with the patient knowing that they need other items addressed besides their headache. In this way, I am prepared to show off my magic tricks before I perform for my audience.

• Aim for the Cirque De Soleil: I train my medical assistants (MA) and aim for the best show. We have an occasional shifting of MA’s in my clinic. That means that every once in a while, there’s a new MA that needs to be trained on how I expect them to room my patients. Therefore, I have made a list of how I would like the patients to be roomed based on their symptoms. For instance, every patient with chest pain gets an EKG. Every patient with burning with urination gets a “urine dip” test. Every patient with a breast complaint needs to be dressed in a special gown for examination. This saves me time since I have these items completed before I even see the patient. I may even make a “pocket version” of this list and dispense one to each new medical assistant. My MA’s are then the elite of all performers.

• Construct the Stage and Props Meticulously: Take Photos of Rooms. When I have to leave the exam room to look for a band-aid, or goodness forbid a pap smear speculum in the middle of performing a gynecological exam, this wastes a lot of time (not to mention is also quite a disturbing experience for my patients). Rooms should be stocked frequently, and with items that I personally use frequently. Simply telling the staff to “stock the room” is not sufficient. Stock the room with what? One trick I learned is to create the ideal exam room myself, and then take photos of each cabinet, drawer, and tray. I then printed those photos and labeled each item in the photos. These photos were placed in a central location that the staff grabbed to take with them when stocking the rooms. And the stage is ready for show!

• Print Your Show Itineraries: Keep a stack of commonly used forms and handouts in the exam rooms. This saves me time; I no longer have to walk out of the exam room to fetch the handout from my office and return to dispense it to my patients. Every seat is prepared with an itinerary.

• The Ring Leader Calls the Shots: Delegate. Seeing this many patients a day, I am not able to respond to every patient message or request. I am not able to call every patient with their normal lab results. I delegate a lot to my very-efficient staff. This delegation has truly been key to running a successfully busy clinic. As Ring Leader, I call the shots and put on the show.

Now, let the show begin! Lights!

Shifting Speculum Gears

2010-09-16T22:01:00.000-07:00

New national Pap Smear guidelines have been revised by the American College of Obstetricians and Gynecologists Committee (ACOG) to commence at age 21, regardless of the first age of intercourse. Prior, we were screening for cervical cancer within three years of first intercourse, or sooner depending on patient risk factors.

This has caused some confusion amongst patients and the staff. Patients often still come in asking for a pap earlier than age 21 (because that is what they are used to doing), and the staff is continuing to room these rather confused patients. Like with everything else, when shifting gears, it takes a period of transition and acclimation to new guidelines every time they are revised.

Why the delay in screening age, my patients often ask? For several reasons:

1. Studies show that screening prior to age 21 does not prevent enough cases of cervical cancer to warrant screening. Let’s face it, the pap is not a pleasant visit. We all dread it. Why place these helpless youngsters into an uncomfortable position year after year when it may not even prevent cervical cancer?

2. Cervical cancer is rare in this age group, and accounts for one to two cases per million women per year.

3. The risks of having procedures performed on the cervix in those less than age 21 may place them at risk of preterm labor later in life in pregnancy.

4. Most Human Papilloma Virus (HPV) infections, the main cause of cervical cancer, in women of this age group are transient and self-resolving.

5. Cervical cancer is a slow-growing cancer that takes years to develop, allowing ample time to be discovered after age 21.

There are a few exceptions, however, that may require screening prior to age 21 (which you should discuss with your personal physician):
• Those with a diagnosis of HIV.
• Those with a prior organ transplant.
• Those with a history of long-term steroid treatment.
• Those deemed higher risk by their personal physicians for any other reason.

Knowing all of this, I personally wouldn’t want a pap before I was 21 years old. Would you?

Stray Cat

2010-09-07T20:57:00.000-07:00

Moving sure is no fun; not in the least bit. A seemingly endless to-do list has kept me busy and feeling quite like an anxious cat. This just goes to show that even positive changes in our lives can be stressful, something I always find myself saying to my patients. I feel like an anxious stray cat searching for a home.

This experience reminds me of a favorite patient handout of mine that I ran across while cleaning house, depicting the CATastrophic signs of anxiety and what you can do to combat it (I don't know who designed it, but it's brilliant):

Life isn't always “purrrfect” (or perhaps even close)…

Gross Emotions

2010-09-04T12:44:00.000-07:00

Here’s a true story from the Operating Room:

Surgeon: “Intern, what is the story behind this patient?”

Resident Intern: “Patient is a 51 year old female with breast lump on the left side, and 17 out of 20 lymph nodes positive for cancer.”

Surgeon (speaking in a rather ‘as a matter of fact’ tone): “Oh, she’s F_ _ _’d.”

Resident Intern: shocked, frozen and unable to respond.

'How do some physicians become so stoic?' I was once asked by a frustrated student. In one of my recent posts, Breaking Up is Hard to Do, I wrote about feeling sad in regards to saying goodbye to my patients, despite this unsettling feeling that somehow I was not “supposed to” allow myself to feel.

It wasn’t until one of my favorite physician bloggers, Dr. Synonymous, wrote a comment in response that made me think about why I felt that I was not supposed to get attached to my patients. This is what he said:

“Dr JAT, You KNOW you don't believe the above comment about "refrain from getting attached". In family medicine, We are SUPPOSED TO GET ATTACHED to our patients. That is the definition of compassion. That is what separates our specialty from many others."

Family physicians are stereotyped for being a rather pleasant, friendly, and compassionate bunch (in general). But there is still this underlying unspoken culture amongst some physicians (not all) across all specialties, including primary care, that perhaps frown upon the notion of allowing yourself to express emotions in your practice.

However, it is often necessary for physicians to build this rather concrete wall around their true feelings as a coping mechanism, in order to be able to function optimally in their careers. Because truly, after seeing patient after patient, if you allow yourself to feel too much it can wear you down in a big way.

Imagine this: you are a physician with approximately twenty patient encounters a day. Several of those twenty are very ill or dying. A couple of others are with major depression entrenched in helplessness, and perhaps contemplating suicide. And then another one or two who get angry at you for not prescribing them the medication that is driving their addiction. Several may be frustratingly non-compliant, and don’t take their medications like you prescribed, and now their health is deteriorating irreversibly as a result. Then, there are a few more that really make your heart sink, because frankly, they are the nicest people you have ever met, and there is something very serious going on with their health, and it is so unfair.

Now multiply that by a minimum of 5 days a week, 52 weeks a year, which comes to 260 days a year. This gives perspective as to why some physicians may appear to be stoic on the outside. It’s about survival of the fittest in this profession. Because how else can we function otherwise?

When were we all first taught of this unspoken ideology encouraging us not to feel? Is it passed down from generation to generation as a culture while in training? While contemplating Dr. Synonymous’ remarks, I can recall as far back as my Gross Anatomy class. I remember in the very beginning of the course, my small group was forced to confront our first real deceased human being lying before us. He was so real. He had a tattoo on his arm, with presumably his significant others’ name on it, and many surgical scars. Who was he? How did he pass and leave this world? Who did he leave behind? We all contemplated the answers to these mysterious questions while we respectfully dissected our cadaver as a team.

When the course commenced, we had a sort of a required "support group," in which all medical students were randomly assigned to a small group with an instructor, in order to discuss how we are dealing with actually knifing through deceased human flesh.

I remember the instructor asking, “What are your thoughts on dealing with this issue?” I was relieved to hear this question, because I had heard some students discuss their struggles (whether it was spiritual, religious, or personal) with the challenge of a face-to-face encounter with a body that was once alive. However, when we went around the room, no one voiced their thoughts. No one spoke. I knew that even though several had shared those difficulties with me in private, they were perhaps afraid to voice their emotions in an atmosphere where “sharing your feelings” is not encouraged. How can you blame them?

Finally, there was one student whose words I will never forget. He expressed that he personally tried to view the cadaver as an “object” and that it was only when he looked at his cadaver’s hands that it seemed so “real” to him. “You do a lot with your hands,” he stated. He too was struggling to feel.

But there is something about going through the medical school and residency training process that begins to harden your soul, in preparation for protection against the potentially emotion-draining life as a physician. Is it a bad thing? I don’t think so. Perhaps it is a necessary, hardening process to experience in order to survive mentally.

At the same time, however, I think it is very important to maintain compassion. There has to be some balance. It’s a primal instinct to want to be loved and cared for, and physicians who are able to feel and convey this compassion may have much more influence over their patients’ health. And it ultimately makes us much better physicians if we just allow ourselves to feel once in a while.

LMAO

2010-08-24T22:22:00.000-07:00

(This is what I looked like while waiting in line at Costco)

I received a funny series of jokes about husband and wife relationships in my email inbox today, with the heading “How to Start a Fight,” sent by a close relative of mine. I don’t know who the original author is, but I was laughing so loud while reading it on my cell phone that everyone in Costco started to stare.

Here’s one of my favorites:

After retiring, I went to the Social Security office to apply for Social Security. The woman behind the counter asked me for my driver's License to verify my age. I looked in my pockets and realized I had left my wallet at home. I told the woman that I was very sorry, but I would have to go home and come back later. The woman said, 'Unbutton your shirt'. So I opened my shirt revealing my curly silver hair. She said, 'That silver hair on your chest is proof enough for me' and she processed my Social Security application.
When I got home, I excitedly told my wife about my experience at the Social Security office. She said, 'You should have dropped your pants. You might have gotten disability, too!'
And then the fight started...

LMAO :)

Breaking Up is Hard to Do

2010-08-19T23:29:00.000-07:00

When I realized that I would be moving to a different county within Southern California and would have to change jobs, I knew it would be inevitable that I would have to say goodbye to my patients. I was dreading this. I mean, really dreading it. I don’t like goodbyes. I feel as though I am breaking up, and in a way I am. Like any other relationship, my patient-physician relationships are coming to an end. And breaking up is always hard to do.

I know as a doctor I am supposed to refrain from getting attached to my patients. But how is that possible, I mean really? I am human after all. I have been taking care of these patients for three years now. I have seen them routinely, perhaps more than some of my own family members. I have been taking care of them, their kids, their spouses, and their grandparents. I have gotten to know what their hobbies are, what they are afraid of, and perhaps their deepest darkest secrets. I have laughed with them. And yes, I have even on occasion cried with them.

I broke the news to one of my patients today. And she started to sob. I mean really sob, with a fountain of tears. I didn’t know what to say or what to do, except to hug her and tell her I am so sorry. I felt as though I was abandoning her. It was difficult, I tell you. I reassured her that she will surely find another physician that she will connect well with.

In the end, I didn’t regret telling her, however. I knew that she needed to know, no matter how difficult it would be. I have heard of physicians leaving without saying goodbye. And I do understand why. It is because it's not easy to say goodbye, whether we admit it or not. It’s awkward, unsettling, and emotional. Physicians aren’t 'supposed to' get emotional. It would certainly be much easier to sneak away without having to face my own and my patients’ emotions.

But no matter how difficult, I have to say my farewells. It is just the right thing to do, and for several reasons:

Insurance Lead: Many insurance programs require you to select a primary care doctor. If I don’t tell them that I am leaving, they will fall behind in this process and may even be randomly assigned. In saying goodbye, I can give them the heads-up so that they can start looking for a new PCP, instead of being randomly assigned to a physician that they may not connect well with.

Sign-Out: I know them well, I know their health issues, and I know their personality. In this way, I also know who they may “match-up” well with. I can give them a few names of physicians that I think they would connect well with, so that they are not left out in the dark. I care about my patients and I want them to be well-taken care of after I leave.

Closure: Some of my patients may feel as though I have “abandoned” them after I leave if I don’t give them a heads-up. I would feel very uncomfortable if they were to feel this way. They need closure, and so do I. Like any other relationship, I have to tell them so that we can both move on in a healthy mature manner.

Pre-Preparation: When they meet their new doctor for the first time they need to be prepared. They need to bring all their medication bottles, a list of their health problems, and mentally they need to be ready to re-establish from scratch in case their new doctor has questions. If I don’t say goodbye, I will have robbed them of this pre-preparation period. They need to be ready.

Ethics: Like any other relationship, it deserves an exchange of communication from the two sides. Physicians are professionals, and providing this closure for our patients is the ethical way to handle it. It’s just the right thing to do.

And with that, I sadly say farewell…

(Until my next blog entry, of course)

Ice Age Evolution

2010-08-14T12:18:00.000-07:00

I have made a big life-changing, evolutionary decision: I am leaving my job with public health. It was not an easy one. It isn’t because I don’t love my job greatly; because I do. In fact, I feel like the queen of the jungle, leaving her subjects. It’s not easy to let go.

My reasons for leaving have nothing to do with the job itself, but have everything to do with my own personal life situation which requires me to migrate from one county to another in Southern California, in order to follow my primal instincts to be closer to family. It is an ice age era, and in order for my family to survive I need to migrate. I have decided long ago that I never want to live with any regrets in life. And taking care of my family is number one priority, as it should be perhaps for all of us mammals. After all, that’s what life is really about – protecting your own, isn’t it?

But I still cannot help but think about how much I will miss my patients whom I’ve been taking care of for the past three years. My experience in public health has been truly irreplaceable, and probably one of the best in my mammalian career. One that I will never forget.

For this reason, I thought it may be a good idea to take this opportunity to reflect on my previous three years here in the public health territory, and chronicle the reasons why I am so grateful that I chose a career in public health:

Survival of the Fittest. You’ll never lose your skills. It’s an ideal job to move into, especially straight out of residency. Why? Because I was able to practice every facet of family medicine – from taking care of numerous children, practicing low-risk prenatal care, serving very sick patients with chronic disease, performing minor surgeries, and everything else in between. You will be taking care of patients with diminished access to care, and you are truly “it” for many of them. In other systems, you may be able to refer out for many conditions; in public health referring out is not often so easy. Therefore, you learn to really tease out those wonderful skills you learned in residency, and develop them even further. You will become a better diagnostician, with less reliability on tests and technology. In public health, you are the epitome of the family physician; there are no specialists in the territory. It’s just you. That’s it.

My Encounters with Rare Species in Danger of Extinction: What I have seen in my public health clinic, I have never came across prior in my life as a physician. I never know what will appear behind that exam room door: an ill patient knocking on death’s door with no prior medical care or health insurance, full-blown syphilis in pregnancy, large breast lump the size of a grapefruit that you can literally spot across the room, patients seizing in the lobby, end-stage rheumatoid arthritis in a patient without prior care, numerous involuntary psychiatric hospitalizations, child-abuse cases you would cringe at the mere thought of, and infectious diseases I’ve had the unfortunate job of diagnosing. All those rare cases we read about in the books but never really see in reality, well I actually got to see some of them. Every day was an interesting one. You just don’t get to see such cases in other settings very often.

I Am the Queen of Jungle. You may be working as the only physician, or with a select few others or mid-levels. No one will be telling you how to practice. You are your own boss on a day-to-day basis. You are typically at the top of the hierarchy in your clinic. The staff will be coming to you for guidance because you are the decision-maker. You rule the kingdom. But the truly best part: you won’t have to worry about the financial details of running your own practice.

My Subjects Worship the Lioness Ground I Walk on: This is perhaps the best reason to join public health. These humble patients are generally so very grateful for the care you provide them, and thank you on a daily basis. Some end up waiting for the providers for up to two or even three hours, and they do not get angry or complain. They are just grateful to be seen. They may not have health insurance, and they cannot afford to be seen anywhere else. You are often all they have in this big jungle of a world. You’ll love these patients, and they will love you back.

Community medicine is one of the most rewarding experiences in my life. I know that I will never have this experience anywhere else. And I have truly become a better physician because of it.

But, like in any ice age era, we all need to thaw out, migrate and evolve sometime I suppose.

Now, if it were only as easy and affordable to settle into a new home in Southern California as it was in those days...

Practice Perks

2010-08-07T23:35:00.000-07:00

Dr. McDreamy

I have to be honest, I get a little down on occasion when I read about some of the recent depressing prospects of healthcare: the new healthcare reform bill, the new Medicare pay-cuts for physicians, the challenges of practicing in primary care, being overworked, accruing a large medical school debt, etc. If you become a doctor thinking that it will be as glamorous as the recent episode of Grey's Anatomy, you have quite a surprise coming your way.

I recently came across a rather refreshingly positive article from an issue of the Physicians Practice magazine regarding the “Top 10 Reasons to Be Happy you’re a Doctor.” I need a little break from all the madness sometimes in order to remind myself of all the reasons I chose this great and rewarding profession every time I start to feel overwhelmed.

Here is what the article lists as their “Top 10 Reasons” to be super stoked you became a doctor:

10. You get to do cool things most people will never have the chance to do: …no matter what your specialty, you are critical to furthering the life spans of your patients.
9. Your medical training prepared you for a successful life: ...You’re also likely to be a good decision maker simply because you must do it constantly in situations where the stakes can be high.
8. You relieve more than just physical pain: …never doubt the effect you’ve had on people who survive and thrive simply because you bothered to listen.
7. You have influence: …Just by virtue of your profession, you earn respect in your community…
6. You have actual job security: …the recession has hit every sector, including healthcare. But even employed docs who lose a job don’t stay out of work for long…
5. You’re free to move about the country: …you can decide to work virtually anywhere you want.
4. You can diagnose yourself. (Ok, but this could be good or bad as you can imagine)
3. You’re never bored: …Physicians have great stories.
2. You’re always in vogue: No matter how the fashions may change, lab coats and scrubs never go out of style…the coat still carries the cache of being the uniform of the folks people trust with their health… (A bit of a stretch, but still rather humorous)
1. You make a difference: …you still have a job that provides a genuine service to the public…

And I decided to throw in a few of my own:

• There are always others yearning to tap into your brain and extract your knowledge: The residents on Grey’s Anatomy don’t have much time to study in between their sexual flings and high drama, but in reality, there are numerous eager beavers willing to learn what you can teach them. You can help mold these future doctors who will be taking care of you and your family some day if you so choose.

• You can look out for your own family and friends: Your breadth of knowledge is a gift you can freely give to your loved ones when they are in need (whether you want to or not). It’s great to know that I can relieve some of Aunt Agnes’ anxiety when she shows me that lipoma on her left flank at our next family reunion (If you’ve ever seen the movie “My Big Fat Greek Wedding,” that is exactly what my family is like).

• You get to be center of attention at all Grey’s Anatomy parties: Somehow all my medical-show-obsessed friends think I have extra knowledge on how two patients can survive, let alone be conversing with each other, with a five feet pole invading their respective abdomens. The answer: they can’t -- It’s a TV show! But it’s still fun to see the world obsessed with so many shows centered on what you do for a living, albeit it far from the daily truths.

• Rare Perks: Did you know there’s a “Doctors Loan” for home mortgages? 10% down payment, rather than the 20%. No joke. Ok, this is off topic…and no, I have no ties whatsoever to the loan industry.

Now, if there only truly was a real Dr. McDreamy… sigh (Since we are on the topic of perks).

What would you like to add to the list? C’mon, you know this profession totally rocks! (Just nod, yes...)

Mission Impossible

2010-08-04T13:43:00.000-07:00

Here is an unfortunate, but almost daily not-so-secret occurrence in my practice:

I am in the midst of an intricate follow-up visit with a rather complicated patient with diabetes, high cholesterol, and high blood pressure. I am feeling as though I am a CIA agent in a rather mission impossible assignment: she is here for lab results, is complaining of low back pain, and presents with an elevated blood pressure of 168/90. I have already spent ten minutes with this patient addressing her low back pain, and am starting to review her top-secret lab results with her. I have two patients, aka U.S. government agents, eagerly waiting to meet with me while they pace the lobby.

Me: "Your recent lab test shows that your diabetes is currently not sufficiently controlled with the current regimen. Your hemoglobin A1C, which is a lab test that tells me what your sugar level has been at home for the past three months, is 8.1. We need to add a medication at this point because..."

“Riiinnnggg!!,” a quite startling sound lifts me off my seat, as if signaling a new secret-agent assignment.

Patient: “Oh, Doctor, hold on one minute please.”

Is this a conspiracy? Before I can even respond, she picks up the cell phone and starts talking to this rather shady intruder.

Patient: “Hi, honey. I'm at the doctor's office. What do you need? ...”

I wait about thirty seconds, with what seems like an eternity in the secret agent world, and she is still on the phone with this suspicious invader. At this point, I decide to exit the premises. Many of my fellow CIA colleagues say they do not even wait one second, let alone thirty. They dissipate as soon as the patient picks up that cell phone, with the onset of the betrayal.

On my way to see the next patient, I pass by one of our many subliminal "No Cell Phone" signs in the hallway. How thoroughly it must have brainwashed our traitors, no? It is perhaps time for some newer and bigger signs with more deeply penetrating messages.

I see my next patient and then return to check up on this likely double-agent-of-a-patient. She ends up waiting twenty minutes before I walk back into the room; fortunate for her, it was not any longer (as it often is).

This undercover agent gives me a look of frustration as she exclaims: "Doctor, why did you leave the room? I have another appointment in half an hour!" Does she have a meeting with the enemy camp, I wonder? Hmmm…

What's the big secret deal, you may ask? Here's why answering your cell phone in the midst of the office visit is a grand problem of high security:

The cell phone call...

1. Interferes with the flow of the detective work. I spend a good deal of time looking over that chart in detail before I walk into that room to see this patient. I have a secret plan in my mind regarding what needs to be executed, and I've already begun discussing this detailed scheme to my patient. This phone call just interrupted my train of thought in a rather complicated patient. That means that when I return, I need to restart from the beginning of my conversation with this patient and re-explain my train of thought to her so that she fully understands why I am initiating a new medication for her diabetes. I cannot just simply pick up from where I left off, because this is an intricate issue of high importance that we are discussing and I have to make sure she understands the details of this intricate plan. Recovering this highly sensitive information is not an easy mission.

2. Intercepts the entire secret agent list. This mission compromises the patient schedule. I have patients pacing the premises, and this phone call is causing an even longer wait for my patients. My patients have jobs of high-importance to return to, child spies to pick up from spy-school, and other top-secret appointments to catch. The cell phone interruption is not just taking time away from the doctor, but it's imposing on all my secret-agent-patients for the rest of the entire day, as well.

3. Makes a mission really impossible. It interferes with the time I am given with this patient. My appointment slots are fifteen minutes. This patient’s history is already of sensitive and intricate matter. But she's also expecting me to address her low back pain, and I certainly cannot simply ignore her elevated blood pressure. If we add a cell phone call to the mix, it is really just a huge mission-impossible.

4. Interferes with other CIA gadgets. Most hospitals and clinics ban the use of cell phones in their buildings, just as airplanes do. This is not because we fear that these cellular waves penetrate our brains and take over our thoughts, contrary to popular belief. This is because the cell phone waves may cause interference with other electronic devices. In the case of a patient, it can potentially cause medical harm if, for instance, a patient's pacemaker starts malfunctioning. No one wants to be responsible for causing such catastrophe that botches the entire mission.

5. Disrupts proper agency etiquette. It is simply inappropriate agent-behavior. I do not carry my cell phone into my exam room with my patients, and in fact, don't even turn it on during my work hours. I expect this same common courtesy from my patients. Anything otherwise may be considered espionage.

Let’s make this a successful mission, Bond, by working on the same team – let’s all turn off our electronic secret-agent gadgets while at the doctor’s office!

Just don’t forget your bullet-proof vest, though…

Bad to the Bone

2010-07-30T13:51:00.000-07:00

Here’s a neat medical tool that I think could be useful for both physicians and patients: the osteoporosis "FRAX tool."

When diagnosing a patient with osteoporosis, a DXA scan (a special x-ray) is a diagnostic test in most cases. Just because you have a “low bone density” result on your DXA does not mean you should be taking prescription medications for osteoporosis, however. Diagnosis of osteoporosis is based on multiple factors that determine a patient’s risk for developing a fracture, and low bone mass diagnosed through the DXA is a part of the entire picture. These bad-to-the-bone risks include: personal history of fracture, family history of osteoporosis or fracture, alcohol intake, smoking, glucocorticoids (a type of steroid) or other medications causing bone loss, rheumatoid arthritis, and low bone density. It’s important to get a complete picture that includes all of your risk factors.

Treatment of osteoporosis with prescription medication is not without risk. Therefore, it’s important to determine how these risk factors, including the DXA scan, combine to figure out a patient’s risk for fracture. The World Health Organization (WHO) has developed a super handy “FRAX” tool to do exactly that. Many doctors use this FRAX tool on a daily basis to assess a patient’s need for medication. If you’ve had a DXA scan, you can go to this website:

http://www.sheffield.ac.uk/FRAX/index.jsp

Plug in your numbers, answer a few simple questions about your risk factors, and get cracking at figuring out your risk of developing a fracture within the next ten years. Print it out and discuss it with your doctor to see if your risks outweigh the benefits of taking a medication.

And don’t forget about the importance of smoking and alcohol cessation for bone health – no ifs, ands, or bones about it!

Why Are We Risking It: Gulf War Exposure to Depleted Uranium

2010-07-25T16:40:00.000-07:00

Have you heard about the health effects of Depleted Uranium (DU) used in weapons by the U.S. military? I have learned that not enough physicians or general public have heard much about it, as it has not been covered in great detail by the media. But in order to bring change, we need to bring knowledge first.

Working in Southern California near a Marine Corps base, I have had the opportunity to take care of a few Gulf War veterans who fought in the Middle East in 1991. I encountered a case of leukemia in a thirty-something year-old gentleman with radiation/toxic exposure only while in the Gulf War which sparked my interest in veteran’s health. I started to research this topic and learned some of the various Gulf War exposures, including that of DU, which has been a hot topic of controversy both in the U.S. and United Kingdom. These two countries have been incorporating DU into their weapons and arms, and are amongst the very few countries worldwide in doing so. Roughly 340 tons of DU was used in the Gulf War.

DU’s controversy is due to the question of whether or not it is the culprit in causing some Gulf War illnesses. The Gulf War Syndrome is a rather new illness, and DU is proposed as a possible causative agent since it was first introduced to the U.S. military during the Gulf War. Many human rights organizations worldwide have been fighting to eradicate the use of DU by the U.S. and U.K. in their weapons, which are still being used today in troops abroad.

What Is Depleted Uranium?
Uranium is defined by the World Health Organization (WHO) as a “silvery-white, lustrous, dense, weakly radioactive element” that is “ubiquitous throughout the natural environment” but is used in greater concentrations in nuclear power plants. Depleted Uranium, on the other hand, is uranium after removal of the enriched fraction, with three times less of the 235U component.

DU is weakly radioactive, but may be harmful with exposure in greater amounts. It emits alpha radiation, which is harmful only if exposure is within close range. Therefore, inhalation or ingestion poses the greatest risk. Even though it is weakly radioactive, it is still radioactive.

Its density is two times that of lead. Because of this high density and the fact that it can “ignite on impact if the temperatures exceeds 600 degrees Celsius,” it is a powerful tool to incorporate into military weapons.

Potential Harmful Effects of DU:
• Kidneys: Urinary excretion of DU is detected more than twenty years after inhalation post-war. Because it is filtered through the kidney, it has potential to damage the proximal tubules. There are reports of minor changes in renal functions, although no significant overall kidney damage, in Gulf War veterans with embedded DU fragments who demonstrate DU urine excretion. This indicates that almost twenty years after the war, there is a subset of veterans with chronic systemic exposure to DU.
• Central Nervous System (CNS): DU dust particles cross the blood-brain barrier and accumulate in the CNS. This accumulation occurs (in order of increasing concentration) within the olfactory bulb, hippocampus, cortex, and cerebellum. High dose uranium has shown to cause tremors in rats, in addition to effecting rat behavior.
• Development: Rodents exposed to DU during development exhibit behavioral changes, memory changes, and had smaller brains.
• Cancer: Animal studies have shown altered gene expression in vitro, and increased incidence of sarcomas in rats.

Unanswered Questions
In summary, there are currently no good human studies to show DU’s potentially harmful effects, for several reasons. First, it is difficult to measure the amount of exposure to veterans years after the fact. We can only “guesstimate” this exposure.

Second, the harmful effects of DU may take years to develop. There are some cases of leukemia and cancers gradually being reported in these young men who developed their illnesses years after the war. But these are too few and far in between. It’s possible that we need to wait longer to see if there really is a link between DU and cancer.

Third, DU is not well-studied. According to a recent article by Wayne Briner in the International Journal of Environmental Research and Public Health, unlike lead exposure “where long term exposure to small amounts [of lead] can produce subtle neurodevelopmental defects, hypertension and increased rates of carcinogenesis,” studies on DU are only beginning to arise secondary to its newly proposed effects on Gulf War veterans. We currently test all children for lead levels circulating in their blood stream because we are aware of the results of these studies. Studies on DU are too few and limited to the small sample sizes of veterans from the Gulf War. Most studies are currently on animals, and direct conclusions cannot be transferred to humans. Also, doses used on animals are often much higher than the chronic subtle doses typically found in veterans post-war.

We need more well-designed research on DU to draw further conclusions. Unfortunately, the military is still incorporating DU in their weapons in the meantime and we are taking a risk by sending in our troops by the thousands and exposing these brave men and women who may continue to risk their lives even years after they fight for our country. Is it worth it? I personally think not. If there is even a small chance, I think we need to stop using DU in our weapons.

What do you think?

The VA sends the “Gulf War Review” newsletter to all its veterans, and encourages all to obtain a free “Gulf War Registry Health Examination” and a “DU Evaluation” to all those with potential exposure. If you take care of any Gulf War veterans, please make sure to refer them to VA Health at: 800-827-1000.

References:
1. Briner, W. The Toxicity of Depleted Uranium. Int. J. Environ. Res. Public Health (2010), 7: 303-313.
2. Parrish, R. et al. Depleted Uranium Contamination by Inhalation Exposure and its Detection After ~20 Years: Implications for Human Health Assessment. Science of the Total Environment (2008), 390: 58-68.
3. McDiarmid, M. et al. Biological Monitoring and Surveillance Results of Gulf War I Veterans Exposed to Depleted Uranium. Int Arch Occup Environ Health (2006), 79: 11-21.
4. Squibb, K.; McDiarmid, M. Depleted Uranium Exposure and Health Affects in Gulf War Veterans. Phil Trans R Soc B (2006) 361: 639-648.
5. Bertell, R. Depleted Uranium: All the Questions About DU and Gulf War Syndrome Are Not Yet Answered. Int J of Health Services (2006), Vol 36, No. 3: 503-520.

A Doctor in Disguise

2010-07-21T00:12:00.000-07:00

While visiting the beautiful city of Cancun, Mexico, I experienced a rather interesting yet unfortunate incident while waiting for the elevator lobby to take me back up to my room. A middle-aged female arrived in the lobby and subsequently passed out. She had been drinking one too many margaritas and bathing in the hot Mexican summer sun without proper hydration. Immediately, several of the kind American tourist bystanders ran to her rescue. She fortunately did not experience any head trauma during her fall, and lost consciousness for less than five seconds.

A brave gentleman with good intentions started to take charge. As I headed towards the patient, before I was even able to introduce myself, this gentleman took one brief look at me and decided that I cannot possibly have any useful function at this scene, and ordered “You! Go get some towels and a bucket of water.”

Ok, so perhaps I appear as though I could still pass for a freshman in college (and I hope it stays that way). But looks can be very deceiving.

Today, I came across this joke published on my “Doctors” desk calendar which reminded me of this rather humorous incident in Mexico and gave me a chuckle or two:

After an accident, a woman stepped forward and prepared to help the victim. She was asked to step aside by a man who announced, “Step back please! I’ve had a course in first aid and I’m trained in CPR.”

The woman watched his procedures for a few moments then tapped him on the shoulder, “When you get to the part about calling a doctor,” she said, “I’m already here.”

It's good to know that I am not the only doctor with a similar experience.

Later, I found out that this kind gentleman I ran into that day had no medical training. He was just trying to be a Good Samaritan. There really are some very kind souls in this world, I have to give him that.

However, it reminded me of an important medical career lesson: never make any assumptions about a patient’s background, age, nationality, sexuality, education, career, or relationships to other members who accompany them to their visits. And this advice should really extend to all life encounters, in general. Yes, even in regards to your personal physicians.

Looks can be very deceiving…

Risky Business

2010-07-18T16:26:00.000-07:00

(Remember the 1983 teen movie, Risky Business, where Tom Cruise's teenaged character invites a call girl into his life while his parents leave on a trip?)

A very typical clinic scenario:

I knock and enter to see my next patient, only to find a 13 year old young girl sitting alone on the chair in the exam room.

Me: Why, hello there! I’m Dr. Jill. How may I help you today?

Ms. Teen: Your nurse made me this appointment and told me to come in.

Me: And why did she ask you to come in?

Ms. Teen: I don’t know. I just came to get the morning-after-pill yesterday, and she told me to come in to talk to you so that I can get birth control, I guess.

Me: Are you interested in birth control?

Ms. Teen: Yeah, I guess.

Me: How long have you been sexually active?

Ms. Teen: One month.

Me: Did you use protection?

Ms. Teen: No.

Me: Please be very careful. I have seen 12 year old girls pregnant in this clinic after having sex once.

Ms. Teen (appearing genuinely appalled): Really?!

Me: Yes. All it takes is once.

I am no longer shocked at the fact that there is a 13 year old girl sitting in front of me who is having sex. I’ve seen it time and time again in my clinic, but it still never fails to sadden me a little. I worry about these young girls who take such great risks with their lives and allow peer pressure to take over. It is a reality, no doubt about it – children are having sex, whether we like it or not. Here are the statistics:

• 2% of women are sexually active before the age of 11
• 7% by age 13
• 28% by age 15
• 70% by the 12th grade

As parents, it’s important to talk to your kids about sex, get to know their friends, and take an interest in their lives in order to give them guidance and prevent risky behaviors. You can start talking to them about sex early; in fact, the earlier the better. But provide only age-appropriate information. For instance, for your toddlers, you can teach the “vagina” or “penis” when reviewing body parts. For your older kids, you can ask them if they know how Cousin Betty’s baby will be born. For the pre-teens, you can discuss how hormone changes affect the way their bodies will change (for example, deeper voices, body odor, etc). For the teens, review common myths. One common myth amongst the teens, for instance, is that pregnancy is impossible with the “first time.” If you don’t talk to your kids, they will hear misinformation from other unreliable sources, either through their friends or the media. Most ninth graders have a mandatory Sex Education class, however, that is too late. Studies show that kids who feel comfortable talking to their parents about sex have less risky behaviors.

I then have a very long conversation with the patient that includes the topics of abstinence, peer pressure, how to say “no,” sexually transmitted infections, pregnancy prevention, and all birth control options. Unfortunately, she passes on the option of abstinence and decides on the pill with condoms for her choice of birth control prevention.

Me: Do you have any other questions for me?

Ms. Teen: Yeah, I think so. Will it be a problem to, like, take the pill if I drink alcohol?

Teaching Residents is Like a Box of Sweet Chocolates

2010-07-11T12:40:00.000-07:00

Can the field of family medicine truly become monotonous? I never thought I’d ever find myself in a repetitive routine when selecting family medicine as my specialty. I spent eleven years after high school studying what I know. How can eleven years of material really become mundane? Going through the stages of becoming a doctor was so exciting: finishing four years of college, then applying to four years of medical school, then to three years of residency, and then finding a “real job” (where you finally get paid instead of paying others for almost enslaving you). One great challenge after another. After graduating from residency, it becomes a tad anti-climactic, don’t you think?

In a way, it’s a great thing – it means I am comfortable and confident in my job. And I am fortunate enough to be able to do anything and everything: pediatrics, prenatal care, minor surgeries, women’s health, geriatrics, chronic disease, you name it. I am the Jill of All Trades. After all, you really can’t find any more variety in any other field of medicine than in family medicine. Like Forrest’s box of chocolates, “you never know what you are going to get” -- on the other side of the exam room door that is. But it’s only a matter of time that eating the same box of chocolates daily becomes predictable and mundane, just like any other job. How can you sweeten up the experience?

Then, an opportunity came knocking on my door to teach family medicine residents. Teaching takes me back to the excitement of that academic setting. I use that same eleven years of material and make it more interesting again by teaching it to others. I look forward to those several days a week I get to teach. It’s like a new sweet treat in the midst of my work week. How come all other physicians don’t do this?

Teaching my residents is now one of the most delicious parts of my daily routine. Here is why teaching residents has brought back the sweetness to my daily grind:

1. Adding New Flavors: It will break up the monotony of your day. Instead of doing the same repetitive job every day of the week, it gives you something new to look forward to again. It’s like an upgrade from eating See’s Candies to a box of Godiva chocolates. It will never replace my special one-on-one interactions with my great patients, but it does bring an element of excitement to my daily grind. I still get to practice medicine and do what I love to do on most days of the week, but for several half-days a week it adds a new flavor to my box and brings variety to my job.

2. Learning the Ingredients: Just like reading the ingredient list, it’s important to learn what components are combined to produce your sweet treats. What branches of the cranial nerves feed the tongue? What structure in the brain is responsible for the pleasure I experience when devouring my box of chocolates? Teaching my residents keep me on my toes. In order to teach, I have to remember and review all the minute details that we all may lose sight of after our training and our exams are over.

3. It’s All in the Wrapping: It is so rewarding to see the residents come through the clinic not knowing how to insert a speculum during a pap smear, but watching them graduate able to place an intrauterine device all on their own. It may be partly selfish, but it feels good to know that I helped shape that person’s learning, and thereby indirectly helping their future patients in turn. It’s all about the end product, and how wonderful of a physician you help produce in the end.

4. Molding & Sampling: It depends on where you work, but if you are in a large group, HMO, or even a small private practice that is growing, you may need to recruit for a position one day. What better way to “sample” your sweet candidates than to work with them closely as their teacher? Also, you can shape and mold them into how you would want them to practice, by teaching them great work ethics and skills from the very beginning of their training.

5. Relocating the Chocolate Business: It’s a very noble profession, to be involved in academics in any way. And if you were to ever move on from your current position, it’s a great addition to your resume.

6. Your Chocolate Sales Proceeds: Did you know you can claim CME (Continued Medical Education) points for teaching residents? In fact, you can claim these points as a member of your medical organization directly through most of their websites. For family medicine, you can claim your CME directly on the AAFP (American Academy of Family Physicians) website.

For these reasons, and so much more, I cannot recommend teaching enough. You will get the chance to meet and mold these future doctors, many whom will be taking care of you or your family members one day. You will get the opportunity to form new friendships with your future colleagues. You will get the opportunity to meet some super interesting people with very intriguing backgrounds and futures. And you will truly liven up your practice by adding some variety to your daily routine.

To take the opportunity to teach, you can contact your local residency, medical school, or nurse practitioner schools. Make a difference. You have a lot to give.

Bon appétit!

Not Tonight, Honey...I Got a Headache.

2010-07-03T19:59:00.000-07:00

Migraine headaches are one of the top causes of missed days at work and missed nocturnal activities in adults, especially among my female patients. If you suffer from migraines, you know that it can be quite disabling and often interrupts your daily functioning and routines.

What’s interesting about acute migraines is that halting the headache in its tracks often requires a medication to be taken as soon as the headache begins. The longer you wait to treat it, the less likely that it will abort the headache.

Many patients with health coverage may have access to a group of medicines called triptans, such as sumatriptan, that have been FDA approved for the treatment of migraine headaches specifically. They often work well if taken properly. But I often feel somewhat “stuck” with my migraine patients for two reasons:
1. Most insurance plans allow only a maximum of nine tablets a month of these triptans.
2. If you don’t have insurance, these triptans are very expensive medications that most of my patients are unable to afford out of pocket.

I found a recent interesting study that researched the simple use of aspirin, which is one of the cheapest over-the-counter medications out there, for the use of migraines. This was a Cochrane review that combined data from 13 studies (4,222 patients total) that compared aspirin 900mg or 1000mg alone, or in combination with an anti-nausea medication called metoclopramide 10mg (inexpensive with prescription) with:
1. sumatriptan 50mg or 100mg, or
2. placebo (a sugar pill)

What did they find?
• All medication groups were superior to the placebo group.
• Sumatriptan 50mg did not differ from aspirin alone in relieving the headache and also in remaining pain-free for 2 hours.
• Sumatriptan 100mg was better than the combination of aspirin + metoclopramide for remaining pain-free for 2 hours, but not for achieving headache relief.
• Associated symptoms of migraines, like nausea, vomiting, light and sound sensitivity, were all improved with aspirin when compared to placebo. The addition of metoclopramide to aspirin significantly reduced nausea and vomiting even further when compared with aspirin alone.

So what does this all mean for migraine sufferers?
• Aspirin at a dose of 1000mg is an effective treatment for an acute migraine, similar to sumatriptan.
• Adding metoclopramide improves nausea and vomiting of migraines.

However, if you are suffering from more than two migraines a month, you really should talk to your doctor about possibly taking a prophylactic medication, a pill that can help prevent the onset of migraines in the first place.

Of course, you can only take aspirin if you don’t have any contraindications to it (like bleeding, or history of stomach ulcers). But it’s definitely something to consider talking to your doctor about if you are a migraine sufferer who doesn’t have health insurance, and even if you do.

Just goes to show, expensive doesn’t mean better.

Unfortunately, gals, now there’s no longer an excuse to say “Not tonight, honey. I got a headache.” Hmmm, I haven't read any studies on aspirin for low back pain, however...

Reference:
Kirthi V, Derry S, Moore RA, et al. Aspirin With or Without an Antiemetic for Acute Migraine Headaches in Adults. Cochrane Database Syst Rev. 2010 Apr 14;4:CD008041. (Review) PMID: 20393863.

5 “Bueno” Tips on How to Learn Medical Spanish

2010-06-27T18:58:00.000-07:00

I work in a clinic located in a primarily Spanish-speaking-only community in Southern California. When I started working in this clinic approximately three years ago, I knew perhaps at the most a total of five Spanish words (no joke):

“Hola!” = Hello!
“Como esta?” = How are you?
“Gracias” = Thank you
“Adios” = Goodbye

And truly, that’s about it. No kidding. I did not take Spanish in high school, I took French. Mais, oui. I grew up on the East coast; no one speaks Spanish there, do they?! And my entire family spoke French and I wanted to use them to help me with my homework in school. Plus, I had a great French teacher in high school who I still keep in touch with today. How should I have known that I would move within hours of the U.S./Mexico border and would one day be unable to function without Spanish later in life?!

When I first started working there, almost every single patient encounter required an interpreter. Thankfully, every member of our super talented staff is also gifted with the Spanish language. I was so envious. Granted, it was their native tongue. But I was still envious at how easy they made it seem.

My typical day was as such: I would knock on the exam room door, enter and introduce myself. I very quickly learned the phrase “Habla ingles?” (Do you speak English?), and was almost always given a head-shake “no” in response. Then, with a “Con permiso” (which I later learned is “excuse me”), I would leave the exam room and search all over the clinic for a staff member looking not-busy-enough to help me interpret. That was truly a pain in the “nalgas” (behind), and caused me to waste a lot of “tiempo” (time).

This made me very motivated – I wanted to learn Spanish just so I can avoid having to search for an interpreter. And it was a challenge that really got my juices flowing. I was done with college, done with medical school, done with residency, and now I needed a “nuevo” (new) challenge to keep me going. I love a challenge. So I set my sights on learning Spanish. I was determined.

Thankfully, and perhaps somewhat miraculously, I now very rarely need an interpreter. Seriously, I think the last time I used one was “meses” (months) ago. I cannot even remember when.

So “como” (how) did I do it? Here’s my advice:

1. Find a good medical Spanish book: There are not that many. Buy the best one. And read the entire thing, word-for-word. Underline as you go. Then, re-read the underlined items from the first round. If you want to know which book I used, you can email me: jillalltradesmd@gmail.com.

2. Make note cards: I bought some large index cards, and made one for each “tipo” (type) of visit. For instance, since I see a lot of women, I made one for the “Papanicolau” (the Pap Smear). I would then literally whip it out of my pocket each time I had a pap.

“Que metodo usa para evitar el embarazo?” = What contraceptive method do you use?
“Por favor, acuestese y muevese hacia mi – mucho mas.” = Please lie back and move towards the bottom of the exam table – much more.
"Muy bien. Es todo. Por favor, levantase.” = Very good. That’s all. Please sit up.

As another example, I made one for “gripas” (head colds), and I’d whip that one out each time I had a patient who complained of a sniffle.

“Tiene tos? Nariz tapada? Dolor de garganta?” = Do you have a cough? Stuffy nose? Sore throat?”

You get the idea.

Soon, I realized, I don’t even need the note card because I whipped it out so many times that it was all bent around the edges (you may want to laminate yours).

3. Ask “mucho” (a lot) of questions: I was shameless. Seriously, shameless. I did not care if I sounded like an idiot. I pronounced everything wrong in the beginning. But I made sure to ask my patients to repeat everything “otra vez, por favor” (one more time please), and asked them to repeat it “mas dispacio” (more slowly). And the poor things, they did “todos” (everything) I asked. If they used a word or phrase I did not understand, I made sure to ask them what it meant. My patients became my teachers. I also learned to ask the following three important phrases:

“Como se dice ____, en Espanol?“ = How do you say ___, in Spanish?
“Que quiere decir ____?” = What does it mean ____?
“Disculpe, no entiendo” = I’m sorry, I don’t understand.

4. Learn the culture: There are many cultural beliefs and values when it comes to my Mexican patients, and many may pertain to their health. I tried to learn as much as I can about why they believe what they believe so that I can better educate my patients. For instance, I learned that many Latinos believe that insulin causes blindness. Not uncontrolled sugars, but insulin. I learned this while I was trying to understand why my patients were so reluctant to start the insulin I prescribed. Now, every time I want to start insulin, before they even say anything, I tell them from the get-go that there is a “mito” (a myth) out there about insulin causing blindness, but that it’s the opposite; it’s the uncontrolled sugars that may cause this to happen (they all nod their heads when I say this). I’m on to them, and they know it! Submerge yourselves in their culture. Go to Mexico. Visit Barcelona. Listen to the Gypsy Kings. Wear a sombrero. Eat tamales (no, eating at Taco Bell does not count). Ask questions. Learn the culture. It will help you to understand and appreciate the language even more.

5. Work on the accent: If they can’t understand what you are saying, even if you are saying the right words, it’s not going to work. So I bought myself some Spanish CD’s for every day conversational phrases. I bought the ones that designed different real-life scenarios all in “song.” It was totally cheesy, but it worked! I played it in my car every day. And I repeated and repeated, while singing along out loud (thankfully I drove alone to work and back every day).

And there you go – 5 "bueno" (good) tips to learn medical Spanish. Ok, so I have been mostly living in the present tense when I speak to my patients. But they understand me. And most importantly, I don’t need to waste so much time looking for an interpreter. And, I have built a closer connection to my patients because I have made such an effort to learn their language. They never made fun of me, not even once (at least to my face). In fact, they have been so supportive. They know I understand them, and they understand me. It’s a priceless connection.

My next step: I bought a verb tense book, and now I’m learning the past and future tenses.

“Hasta luego, Amigos!” (Until later, friends).

And “bon chance!” (good luck) – oh, wait, no...that’s French.

Second Chance at Life Rejected

2010-06-20T17:18:00.000-07:00

One of the very saddest, yet at the same time horrifying, patient stories I have heard:

Me: “So how may I help you this morning?” I asked, meeting my new patient.

Patient: “My kidney doctor told me to see you.”

Me: “Why did he ask you to see me?”

Patient: “Because he thinks I’m depressed.”

Me: “Why would he think that?”

Patient: “Because I didn’t take my anti-rejection medication for a couple of months, and I lost the kidney my twin sister donated to me 3 years ago as a result.”

My heart sank so low that I’m sure there was a loud thump as it hit the floor. After a period of what seemed like forever, I was able to move on from the shock of what I thought I had initially heard wrong.

Me: “Are you depressed?”

Patient: “I don’t feel depressed. But he kept insisting, so now I’m here.”

Surely this cannot be. It seemed so surreal. How can he let this happen? His sister gave up her kidney, risked her life, and underwent surgery so that he can live a better life. In fact, his sister’s health will never be the same – she’ll always have to be careful with her one remaining kidney. So that he can live. And that kidney was working so well for him. And now he just gave it up, so nonchalantly. As if he just merely gave away a pair of old, used shoes.

Me: “I can see why he would want you to be evaluated.”

He then went on to tell me that finances were tight, and he chose to pay other bills rather than the co-pays for his medications. I can understand that the economy has truly hit most of my patients hard, but the kidney that his sister donated wasn’t just a nice pair of shoes gift-wrapped in a box for his birthday. This was an organ. Those are not easy to come by. The wait time to receive one is years to a lifetime.

I was disappointed that he did not discuss his financial situation with his doctors to let them know he was having difficulty affording his medications. Was it because he couldn’t afford his co-pays, or was it because he just didn’t make an effort to find a way?

He was so lucky that his sister was a match. He was so lucky that she agreed to donate it. He was so lucky that the surgery went well. He was so lucky that the medications kept his kidney alive and thriving in his body.

If you are having difficulty making your co-pays, please communicate this with your family and with your doctor. You can find a way as a team when you know it can save your life. There are patient assisted programs that help patients with their medications when they can’t afford it.

This is a perfect example of why as a physician I believe that your health has to be priority in life. Sure I’m a little biased in that it’s my job to take care of my patients’ health. But if you don’t have your health, you don’t have life – quite literally, in this case.

Now he’s trying to get back on the waiting list for an organ, while he is back on dialysis three times a week. There are no other family matches.

Should he get another chance at an organ? Or should he be forced to continue with dialysis for the rest of his life instead?What do you think?

Dancing With the Doctors: Learn 5 Steps to Tango Effortlessly at Your Doctor’s Office

2010-06-13T21:22:00.000-07:00

A friend recently asked me in great frustration after her visit to her doctor why doctors “always run late.” Why do doctors make their patients “dance around” the office, getting moved around to different spots in the clinic, but still having to wait and wait at each location. Instead of explaining what really goes on at the doctor’s office, I ended up emailing her a couple of links to some of my favorite blogs that have quite eloquently addressed this issue already:
1. Lockup Doc
2. Common Sense Family Doctor

Dr. Rob Lamberts also designed a very concise list of both patient and doctor “rules,” important for every patient and physician to read:
1. Patient Rules
2. Doctor Rules

I believe it worked, having her read these illuminating posts on why doctors’ offices do what they do. Then it dawned on me, if only I can convince all patients to not only read these eloquent posts, but to go one step further – to learn what they can actively do during their office visit, as well. If patients simply learned “how to dance” while they are in my clinic, perhaps I wouldn’t be running as late, I’d be able to provide thorough and more focused care, and I’d be able to perhaps get all my extra work done on time, and maybe even have time to eat lunch. But every patient would have to be on the same page, learning the same dance moves. The clinic would run so efficiently if every patient learned these basic “dance steps,” and we’d all be doing the tango effortlessly. Here are the 5 basic dance steps each patient should learn in order to dance like the stars at the doctor’s office:

Step 1. Arrive on Time to Dance Class: In fact, try to arrive 10 minutes earlier than your appointment slot. This will give you enough time to park, check in at the front desk, and compensate for the unpredictable. Like a domino effect, one late patient causes everyone else for that day to run late, including the doctor. And that may just cause the judges to deduct points during a poor dance performance – and we want that trophy now, don’t we?

Step 2. Don’t Try to Learn More Than One Dance at a Time: This is perhaps the most important lesson of all to learn. It will become much too confusing to learn the Samba, the Salsa, and the Merengue at the same time, wouldn’t it? The doctor will have 15 minutes to spend with you at the most (some doctors even less). Therefore, your expectations need to be realistic. The doctor will not be able to address every single issue you may have on your list. Select 1, or at the very most 2 problems per visit. Why? Because each problem requires the proper line of questioning (called the history), the physical exam, and a possible work-up of tests. If you come in with a longer list, your visit will not allow the greatest focus and proper attention that each problem deserves, and something’s got to give. I would assume you would want your doctor to be very thorough, no? You don’t want the doctor to gloss over something important in this very detailed and meticulous process by becoming distracted, and your health is too important for that. Don’t risk it. If you need to be seen once a week every week until all your problems have been addressed, then so be it. Then, you will have learned each dance thoroughly well, ready to earn a perfect score in the end.

Step 3. Make Sure You Sign Up for the Correct Dance Class: Tell the nurse who takes your vital signs and places you in the exam room exactly what you are there for. If you have 1 or 2 problems, make sure you tell the nurse BOTH problems. If you need refills on your medications, make sure to tell the nurse that, too. Why is this? Several reasons. First, the room will need to be set up a certain way depending on your symptoms. For instance, if you are there for a pap smear, the nurse will need to give you a gown to have you change into it and set up the proper supplies. If you are there for chest pain, they may need an electrocardiogram (EKG) before they see you. If you do this after you are already with the doctor, the doctor will need to leave the room (which may cause you to wait while the next patient is seen), ask the nurse return to set up the room, and then return again. This is very inefficient, and it causes a big delay in the patient schedule. Second, the doctor really needs to know why you are there so that they can plan your 15 minute slot appropriately from the get-go. If you are there for headaches and a diabetes follow-up, and you also need your medications refilled, the doctor needs to know all of this before they see you so that they can come up with a timeline of how your short visit time will flow. Whatever you do, do not bring up a new problem after the visit has already begun. So when you sign up to dance, make sure your instructor knows which class you signed up for beforehand – you don’t want to show up for a tap class when you signed up for the tango!

Step 4. Don’t Forget Your Dancing Shoes: As important as those dancing shoes are to learn how to dance, so are your medication bottles when you visit your doctor. A simple “list” is not sufficient. Why? First of all, the amount of information you get from looking at the bottle is invaluable. When I look at the bottle, I can tell when the patient filled it, how many refills they have, when it expires, and how many pills are left in the bottle. Just because a medication is on the patient’s electronic pharmacy records doesn’t mean that they are actually taking it. Also, I occasionally catch mistakes that the pharmacy has made on patient prescriptions in this way. Whatever you do, don’t tell your doctor that you don’t know the name of your medication, only that it’s a “little white pill.” Almost every pill is a “little white pill”!

Step 5. Don’t Forget to Practice Your Moves at Home: If you have diabetes, bring your blood sugar log with you. If you have high blood pressure, bring your blood pressure log with you. This information is very important. Although your doctor may check your blood sugar level or blood pressure while you are in the office, this is just one number for one day. What your numbers look like over time are so much more important, and are significant chunks of information for the doctor. No one wins the competition without practicing the moves at home!

Now that you have learned the 5 basic dancing steps to make the most of your visit with your doctor, go ahead and show off your dance moves! Go on, shake it!

Defensive Medicine

2010-06-09T19:50:00.000-07:00

True story from this morning:

Nurse: “Oh, Dr. Jill – I’ve been looking for you everywhere!” my seemingly frustrated nurse exclaims, panting, after finally catching me running in between two exam rooms.

Me: “What happened, Nurse? Is everything ok?”

Nurse: “The pharmacy has been calling me all morning about a patient prescription.”

Me: “What did they want that is so urgent? Did I make an error on a prescription? Do they need an urgent refill on a patient’s super important medication?”

Nurse: “No. You wrote for #30 insulin syringes, and they have a box that contains #31. They want to know if that’s ok?”

I started to laugh really hard. 'Surely you’ve got to be kidding,' I was thinking to myself. Isn’t this a silly reason to call the doctor’s office? Then it dawned on me -- the pharmacists practice “defensive medicine,” too. And some just take it an extra step further. They don’t want to be liable for anything. Even for something so miniscule. I do empathize with them, but to some extent, for goodness sakes. These are the types of daily events that interrupt good patient flow, and take time away from my efficient staff that could be handling something much more useful instead of answering the phone and searching for the physician all over the building. It’s all in a day’s work as a physician, though. It is part of the job, and I know that. In fact, it brings some humor to my day on occasion, like today.

But really, one syringe?

Just another one of those things that make me say "hmmmmm"…

Advancing Birth Control Options: Evolving Quickly Since the 80's

2010-06-04T17:31:00.000-07:00

I see a lot of women in my office. Perhaps because female patients tend to seek out female physicians -- especially when it comes to pap smears and birth control. It never ceases to amaze me how advanced birth control has become throughout the years, and how many options women truly have nowadays to prevent pregnancies. After the creation of the birth control pill 50 years ago, it has truly evolved into so much more -- most especially and most rapidly since the 1980's, with the creation of more advanced methods such as the intrauterine device, the rod implant, and newer sterilization techniques. Whether you are a woman or a man, you should know your options. Here are the options I discuss and offer my patients in the office:

Abstinence: This is the only option that is 100% effective. The only one. Never allow anyone to pressure you into having sex.

(White Wedding, by Bill Idol)

Condoms: 85-98% effective. One of the oldest methods, it can be traced back to ancient civilizations, but first patented in 1930. Still one of the most popular methods today. And it’s the only one that provides protection against the transmission of sexually transmitted infections, except for abstinence of course. It’s best to combine one of the below options with the condom as a back-up.

(The Safety Dance, by Men Without Hats)

The Good Ol' Pill: 92-99% effective. It celebrated its 50th birthday this past May! There are so many -- just because you couldn’t tolerate side effects of one, doesn’t mean you are out of luck. Some people need to try a few before they find one that they like. Side effects of nausea and mild headaches are transient, and resolve after the first pack if you can hang in there. But if you just can’t remember to take one pill around the same time every day, this is not for you.

(Freedom, by George Michael)

The Patch (Ortho Evra): 92-99% effective. Introduced in 2002, it is a small thin patch placed on the body that releases hormones into the skin, and then into the bloodstream. You don’t need to remember to take a pill every day, but you need to remember to change it once a week for 3 weeks in a row, and then skip the fourth week (when you will typically have your period). Studies show that those using the patch may have a higher risk of blood clots in the legs (a potentially life threatening problem) compared to other methods, but the risk is still very low, and is higher in women over age 35 who smoke.

(Stuck On You, by Lionel Richie)

The Ring (Nuvaring): 92-99% effective. Released in 2001, it is a plastic circular vaginal ring that you insert into the vagina yourself (similar to inserting a tampon) and leave in for three weeks. Then you take it out for one week, and replace it with a new ring again for three weeks, etc. The hormones are released from the plastic ring into the vaginal tissue. If you’ve never used a tampon or you are not comfortable inserting an object into the vaginal area, then this may not be the best option for ya.

(Ring My Bell, by Anita Ward)

The Injection (Depo-Provera): 97-99% effective. Approved in 1966, it is one of the oldest and most effective forms of birth control, a progesterone-only hormone is injected in the clinic once every three months. The two most common side effects I hear from my patients is weight gain and irregular periods. However, most women have lighter periods or stop having periods altogether after 6 months. It is not recommended for more than 2 years at a time because it has been associated with a decrease in bone density if used longer than that; however, the bone loss is usually reversible once you stop using the shot, and is more severe the longer it is used. It’s a great option for young women or teens who find it difficult to remember to take their birth control in a timely manner and who want a more discrete birth control option.

(Hit Me With Your Best Shot, by Pat Benatar)

The Implant (Implanon): 99% effective. FDA approved in 2006, it is one of the newer more advanced methods: a 4cm x 2mm single-rod implant that releases a progesterone-only hormone, and is placed 8-10 cm above the elbow into the skin of the upper/inner aspect of the arm. It lasts 3 years and is highly effective, comparable to the effectiveness of the Depo injection. During the first year, however, 50% of women report more bleeding (either more frequent or heavier periods) and 50% report less bleeding. After the first year, most women report less bleeding overall. And it's very discrete, almost "invisible," but you can feel it if you gently rub your hand over it.

(Invisible Touch, by Genesis)

Intrauterine Device (IUD): 99% effective. It is a T-shaped device that's been around since the 1980's and is inserted into the uterus in the office. There are two types – one that lasts up to 5 years (Mirena) and releases a progesterone-only hormone, and one that lasts up to 10 years (yes, years) without any hormones (Paraguard). The Mirena may cause irregular bleeding the first 6 months, but then after most women report less bleeding or cessation of periods altogether. It is more ideal for those with heavier periods in order to lighten it. The Paraguard may cause heavier periods, and therefore may not be ideal for someone with already heavy periods. However, less risk of side effects in general since it does not contain hormone products. Make sure your provider leaves the strings long so that you can feel it, and so that it does not “rise up” into the uterus – because if that were to happen, you’d need to have surgery under general anesthesia to remove that IUD (not fun).

(Holding Back the Years, by Simply Red)

Tubal Ligation: 99.5% effective. The traditional method of sterilization for the female is under general anesthesia laparascopically by a gynecologist. But women have been tying their tubes as early as 1880's. You do need to be absolutely certain that you no longer desire children, because the chances of reversal are slim to none. There now is a newer method of sterilization for women, called “Essure,” since 2002. It is an office procedure under local anesthesia, with less complications and discomfort.

(Point of No Return, by Expose)

Vasectomy: 99.9% effective. Being performed since the 1950's, it is definitely the fastest, most effective, and less complicated method on this list. It is a quick 15 minute procedure under local anesthesia, with a quick recovery time. There is now even a newer “no-needle no-scalpel” technique with minimal discomfort, developed in China and brought to the U.S. in 1988. No need to be afraid any longer, men! Yes, you can go for that!

(I Can't Go For That (No Can Do), by Hall & Oates)

Times are changing. Even though the music of the 80's is still arguably one of the best of any decades', it's a good thing that birth control is evolving so rapidly, bringing so many options for both men and women. Now there’s an option for almost everyone. Not one method is right for every person. Each individual is different, and the choice is really dependent on multiple factors such as your personal medical history, your age, your menstrual periods, medications you are taking, whether you are breastfeeding, the length of time you desire to prevent pregnancy, etc. So make sure you learn about your choices, and then discuss them with your doctor. And most of all, be safe!

Top 10 Stress Reduction Tips

2010-05-28T21:42:00.000-07:00

(From my walk on the beach this sunny, rather stress-free day)

Everyone experience stress – whether it’s problems you may be experiencing at work, financial struggles at home, interpersonal issues with your spouse or family members, or a recent move. Even positive life changes can be stressful. That’s why it’s important to find a way to cope with stress, so that you can learn to cope with daily life. Here are my Top 10 Stress Reduction Tips that I like to share with my patients:

1. Exercise: Regular cardiovascular exercise lasting 30 minutes on most days of the week gets the blood flowing to your muscles, reduces muscle tension, decreases blood pressure and heart rate over time, and improves self-esteem.

2. Take a walk: Remove yourself from all stressors, leave the situation, and take a 30 minute walk.

3. Read a book: Go visit your local bookstore, library, or coffee shop and lose yourself in a good novel, book, or magazine.

4. Find a hobby: Whether it is beading, boating, or blogging – do it regularly. Well-rounded individuals have better stress-coping skills. Let this be your outlet.

5. Do Yoga: Take a class or buy a DVD and do it yourself at home. Yoga improves the mind, body, and soul. Can’t go wrong with Yoga.

6. Meditate: Take a meditation class, or invest in a meditation CD/DVD. Do this at least 5-10 minutes every day.

7. Listen to relaxing music: Classical or jazz works well. Don't do anything else but listen to the sounds.

8. Pamper yourself: Schedule a day each week to do something for yourself, away from daily stressors – whether it is shopping, getting a pedicure (which is becoming quite popular with the men these days as well), a massage, or just doing something you enjoy.

9. Relaxation Techniques: Here’s a link to a great relaxation technique called “Progressive Muscle Relaxation” that I find works pretty well for my patients: http://www.wikihow.com/Perform-Progressive-Muscle-Relaxation

10. Go to the beach (if you are lucky enough to live near one)! If you aren't as fortunate, a CD with ocean sounds may do the trick. This is why I choose to live in Southern California:

How do you like to deal with stress? Share your ideas with us!

A Perilous Pertussis Peak

2010-05-24T21:30:00.000-07:00

Microscopic Image of Bordetella Pertussis bacteria

Pertussis is a highly contagious disease caused by the bacteria named “Bordetella Pertussis,” and is associated with a high mortality rate. Its activity seems to be cyclical, with a peak about every three to five years. The last peak was 5 years ago in 2005, where 8 infants died from this disease in the State of California alone. Ominously, Pertussis is expected to peak again this year, and so far has caused 4 infant deaths in California since January 2010. Twice as many cases are being reported this year compared to the prior year thus far, and the year is only half over.

Fortunately, it is a vaccine preventable disease. However, those kids who have not completed their vaccination series and those kids too young to be fully vaccinated whom are less than 3 months of age are at greatest risk. It often begins with a rather mild onset of a runny nose without a fever, and its diagnosis is often delayed because of its mild appearing beginning stages. There may also be a mild cough initially, but it rapidly progresses to pneumonia, respiratory distress, cessation of breathing, or even seizures.

In young infants, a blood test reveals an elevated white blood cell count greater than 20,000 cells with a greater than 50% shift towards lymphocytes (a specific type of white blood cells). In addition, a nasopharyngeal swab (a swab placed in the back of the nose) is the diagnostic test of choice.

The department of public health is asking to keep a closer eye on young infants, especially those less than age 3 months presenting initially with mild symptoms, and to treat suspected cases promptly with Azithromycin. Treatment should not be delayed in suspected cases pending test results. Infants should be monitored very closely and considered for hospitalization in a facility with an Intensive Care Unit (ICU).

Pertussis is prevented with the vaccine, and all infants and healthcare workers should be immunized.

Please report all suspected and confirmed cases to your local public health department.

Top 8 Insomnia Tips to Help Catch Your Z's

2010-05-23T20:33:00.000-07:00

Difficulty with sleep is one of the most common patient complaints presenting to the primary care office. Chances are, you will suffer from difficulty with sleep at some point in your lifetime. It can be distressing, and cause difficulty with functioning during your wake hours. The first thing you may want to do is to run to the doctor for a prescription for a medication to help you sleep. However, you don’t always need to rely on medications to sleep. In fact, insomnia can usually be cured on your own by simply changing your lifestyle and routines. Resist the temptation to run to the doctor right away, and instead take some steps to treat your insomnia naturally before you seek your physician:

1. Adopt a routine schedule: Try to maintain a regular, routine sleep/wake schedule. That is, sleep at the same time every night and awaken at the same time each morning no matter how sleepy you are. This may cause some difficulties the first few nights, but eventually your body will get used to maintaining the same schedule. Do not vary your weekend schedule by more than one hour from your weekday schedule.

2. Avoid taking daytime naps: People who nap have more difficulty falling asleep at nighttime. If you can skip your nap, you will find that you will be able to not only fall asleep faster, but will be able to better maintain your sleep during the nighttime.

3. Avoid caffeine and alcohol: Caffeine is a brain stimulant that interferes with good sleep. Alcohol may seem to initially help you fall asleep more rapidly, however it causes early morning awakenings and difficulty returning to sleep. They are also both diuretics that may cause an urge to urinate in the middle of the night.

4. Use the bedroom for what it’s meant to be used for: Don’t get into the habit of watching TV, eating, or performing any other activities in your bed. You want to train your brain into thinking that once you are in bed it is time to go to sleep. If you routinely engage in other activities in bed, your brain will be more difficult to shut down at bedtime as well. Do not use your bed for anything other than sleep and sexual intimacy.

5. Avoid bedtime high carb snacking: Avoid sugar or carbohydrates within two hours of sleep. If you are hungry, eat small portions of foods that promote sleep such as one glass of warm milk, turkey, or nuts.

6. Avoid nighttime fluids: Drinking fluids three hours prior to sleep causes an urge to urinate in the middle of the night. Try to drink fluids in the first half of the day, instead of at nighttime.

7. Get regular exercise: Routine exercise releases endorphins that decrease stress. This in turn increases deep sleep. Get at least thirty minutes of cardiovascular exercise daily, such as walking, running, or biking. Try to avoid doing this in the evenings, however, as the endorphins can cause brain stimulation if performed within three hours of sleep.

8. If you can’t fall asleep: If you are unable to fall asleep within thirty minutes, get up and do something relaxing, such as light reading or taking a warm bath. Then go back to bed once you feel sleepy.

If taking the above steps doesn't cure your insomnia, then it’s time to see your physician to see if there are any underlying health conditions that may be causing your insomnia. Getting a good night’s sleep is so important to your overall health. If you are unable to obtain adequate sleep, it can manifest itself physically and emotionally and interfere with your functioning and quality of life. Although taking the above steps takes some effort, it’s important to realize that it’s a process and may take a little bit of time to conquer. However, a good night’s sleep is well worth the battle.

Injection Rejection

2010-05-20T23:24:00.000-07:00

Specialists accepting Medicaid insurance during these tough economic times are scarce, due to Medicaid's low reimbursement rates to physicians. And who can blame them? After all, medical offices struggle to keep their businesses operating and running, too. Just like all other businesses. Because that's what our current healthcare system really is set up to be -- a business. Therefore, as a public health primary care physician taking care of patients with Medicaid, it is often quite a ~~pain in the butt~~ challenge to get referrals and treatments for my patients approved, and I ~~every single frickin' day~~ occasionally feel as though I am battling to meet my patients' needs.

My orthopedic surgery referral reads:

“42 year old female with chronic heel pain secondary to bilateral plantar fasciitis with decrease in functioning and quality of life, refractory to conservative measures. Patient would like to try injections please.”

The referral was denied and returned back with the following response:

“Try injections first.”

Now, if I performed plantar fasciitis injections myself, do you think I would have sent the referral in the first place?!

(Another one of those things that make me say “hmmmmm”…)

Plantar Fasciitis:

• One of the top causes of heel pain.
• Due to a tightened “band” of tissue that attaches the heel to the bottom of the foot.
• Considered a rather benign condition.
• Pain is usually worse after a period of rest, or upon awakening in the mornings. Resolves or improves with activity.
• Contributing factors: obesity, runners, sudden weight gain, and flat feet.
• X-Ray is not diagnostic and not useful to diagnose.
• Having a “heel spur” is not significant, and is not a cause of the problem, contrary to belief.
• Treatment:
     1. Half-inch heel support with a heel pad, and comfortable shoes with a good arch support at all hours of the day – even while inside the home
     2. Shoe orthotics or arch supports: can try over the counter inserts prior to custom made orthotics
     3. Night splints: keep the foot stretched during sleep/rest hours
     4. Weight loss
     5. Pain relievers, including anti-inflammatories
     6. Stretching the bottom of the foot upon awakening or prior to taking first few steps
     7. Exercise: Rolling a frozen bottle of water under the bottom of the foot
     8. Steroid Injections to the foot
     9. Most pain resolves in months to less than one year.

Don't Forget Your Travel Health Kit!

2010-05-16T15:32:00.000-07:00

My Trip to Cancun, Mexico

So you want to see the world? Perhaps you are planning on joining the Peace Corps and country hopping? Or, you may just want to take a quick trip to the Bahamas for your honeymoon? Either way, with summer around the corner, it’s important to consider your health while you are in the midst of packing your suitcase. When consulting with my patients, I realize how ill-prepared (pun intended) many are prior to getting on that airplane. Most come to see me because of their fear of flying in hopes of acquiring a prescription for an anti-anxiety aid, but they forget about what happens after they land. What about that local E.Coli outbreak? Or, the 100 degree sun-scalding temperatures? Make sure to travel smart and prepared – make your own personal Travel Health Kit to take with you before you go. You may want to select a separate bag or container for the following items to travel with:

• Prescription medications: resist the temptation to place them in smaller non-labeled containers, as airport security may require you to carry all medications in the originally labeled containers.
• Over the counter medications: you may want to include such items for the following emergencies --
     1. Fever reducers/Pain relievers
     2. Anti-Diarrhea aids
     3. Antacids
     4. Cough/Cold aids
     5. Throat lozenges
     6. Anti-motion sickness aids
• First Aid Kit:
     1. Adhesive bandages
     2. Gauze
     3. Antibiotic ointment
     4. Antiseptics
     5. Alcohol wipes
     6. Ace wrap
     7. Scissors
     8. Anti-fungal cream
     9. 1% Hydrocortisone cream
    10. Saline eye drops
• Sunscreen: with SPF of 30 or more, preferably with ingredients containing zinc oxide or titanium. Apply every 2 hours or more. Stay in the shade. Drink lots of fluids (that doesn't include alcohol!).
• Insect Repellent: If you are traveling to an insect-borne endemic area, make sure to take an insect repellent with at least 20-50% DEET as active ingredient.
• Bottled Water: perhaps bring a few, otherwise, may be able to purchase this abroad as well.
• Anti-bacterial Hand Sanitizer: always a good idea to carry with you, no matter where you are going – out to your own garage, or traveling out of the country.
• Vision Care: extra pair of contacts/glasses and contacts solution. After all, that is why you are there – to “see” the world!
• Medical Records: make sure to bring a copy of your important medical documents in case of an emergency.
• Vaccination Records: Did you seek a pre-travel consultation from your physician and get your vaccinations up to date? Bring a copy of your immunization records with you on your trip.
• Health Insurance Coverage: Before you leave the country, contact your health insurance carrier and inquire as to whether or not you have extended coverage outside of the United States. If not, inquire as to how you can go about purchasing an extension for emergencies. Please make sure you understand the details of this coverage before you make your purchase. Make sure to take a copy of your proof of coverage, important insurance carrier phone numbers, and a phone number for all of your physicians.

Please note that many liquids and sharp items may need to be checked-in, and cannot be carried onto the plane. Refer to the Transportation Security Administration for more detailed information: http://www.tsa.gov/ .

No matter where you are traveling to, also make sure to visit the Center for Disease Control (CDC) website and research your particular destination’s risks and travel warnings at: www.cdc.gov/travel .

And most of all, have fun and be safe!

My Top 15 Resource List for the Uninsured

2010-05-13T15:33:00.000-07:00

Working in Public Health, I see patients without insurance on a daily basis. I often find myself struggling with this population the most, because I am very limited as to what I can do with them. To illustrate my challenges, here are some typical examples of some uninsured patients I encounter:

a postmenopausal woman with a large 6 cm growing “peau d’orange” breast lump that she had neglected for the prior two years
women without a cervical cancer screening or mammogram in the last 30 years
young 20-something year olds with new-onset seizure disorders
diabetics without their medications or even a glucometer for over a decade, now coming in for an diabetic ulcer on their toe
a well-educated couple living in their car for the previous one year after they lost their jobs and now unable to afford their medications
middle-aged male with what looks like possible leukemia on his lab values
hardworking, eager male with a brain aneurysm that was operated on less than one year ago, without follow-up since, urging me to release him to go back to work because of his financial debt

The list can really go on and on. All of these patients were uninsured. How do I get them the care they need, with the proper follow-up, referrals, and imaging?

I had a young man recently ask me to compile a list of resources for those without insurance for my blog, and I thought it was a great idea to share my personal resource list with my readers. Whether you are a patient or a physician looking to help your patients, I think it’s important to know what is available for those without insurance. Here are my top 15 personal tips for my uninsured patients, which I hope you find useful:

1. Find a County Public Health clinic in your area: You can probably Google “county public health clinics” and add the name of your county to it, in order to find your local public health clinic website. County public health clinics offer lower-cost care for its patients, and co-payments are typically based on an income sliding scale. As an example, in my particular clinic, if your income is below 200% of the poverty level, visits are $50 for the first visit, and $35 for visits thereafter. You do need to provide proof of income, however. And you may be asked to provide proof that you live in that particular county, as well.

2. Medicaid: A state-run program with strict income requirements. Rules and eligibility may vary from state to state. In California, it’s currently geared more for those with children less than or equal to age 18, for pregnant women, and those with disabilities. Depending on the income, it may be extended to certain adults with children, as well. Check out their website for more information: http://www.cms.gov/home/medicaid.asp .

3. Medicare: A program for those aged 65 and above who have worked and contributed towards Medicare in their lifetime, for some people with disability, and for those with End Stage Renal Failure requiring dialysis. Part A is for inpatient hospital coverage, and Part B is for outpatient/clinic services. It does not cover everything. There may be a monthly premium and deductible. Please refer to the Medicare website for more information and an online application: http://www.medicare.gov/default.aspx .

4. Emergency Medicaid: It only covers potentially “life-threatening” conditions presenting to the emergency department. Some examples possibly include a catastrophic motor vehicle accident, acute stroke, and seizures. Chronic or non-emergency issues, such as most fractures or lacerations are not typically covered. Immigration status is not a factor in determining eligibility. Please refer to the Medicaid website listed above.

5. Disability: If the patient is considered disabled, such as those with Autism, mental delay, or paraplegia, an application may be placed with the social security office. They typically have a list of their own physicians they contract with who will meet and examine you, and then send their documentation to the social security office who then determines whether or not you qualify for disability. Physicians do not determine whether you qualify or not, they only submit their documentation of the history, exam, and reports of any imaging performed. They may also obtain records from your own personal physician office in order to help make their decision. If you are deemed disabled, then you may qualify for Medicaid or Medicare. The social security office can be reached online via http://www.ssa.gov/ .

6. California Children’s Services (CCS): A state program that covers children up to age less than or equal to 21 meeting income criteria and in need of coverage for a specific disease or health problem. Even illegal residents may qualify. Other states besides California may have similar programs for children. However, coverage is typically for only one diagnosis and must be on their “approval list,” such as Cystic Fibrosis, Hemophilia, Cerebral Palsy, etc. It covers all visits and treatments for the specified diagnosis only. Refer to their website for more information: http://www.dhcs.ca.gov/services/ccs/Pages/default.aspx .

7. Prenatal Care/Pregnancy Services: Whether you are a legal or illegal resident of the United States, you are covered by Medicaid for your prenatal care once you become pregnant and are living in the United States. Please refer to the Medicaid website listed above.

8. California Healthy Families Program: Covers only children, no adults, who do not qualify for Medicaid services. There may be a small monthly premium. This is a California program, however similar programs may exist in other states. For more information and to download an application, please refer to: http://www.healthyfamilies.ca.gov/Home/default.aspx .

9. County Indigent Health Programs: Some counties may institute a “program,” yet not a comprehensive insurance plan, for those without health insurance and in need of urgent health coverage whom are unable to afford this care. Contact your local County Hospital to inquire about an existence of such a program in your area.

10. Breast & Cervical Cancer Detection Programs: Uninsured, underserved women may be eligible for free or low-cost breast cancer screenings and pap smears for cervical cancer detection through a program sponsored by the Center for Disease Control (CDC) for women living in all 50 states. To find your local program, go to the CDC website at: http://www.cdc.gov/cancer/nbccedp/ . For those living in the state of California, this program is paid for by federal grant and state tobacco revenue, and is called the “Cancer Detection Program: Every Woman Counts” (CDP) through the California Department of Public Health, and may be found at: http://www.cdph.ca.gov/programs/cancerdetection/pages/cancerdetectionprogramseverywomancounts.aspx .

11. Contraception & Family Planning Services: Title X Family Planning Program is the only federally funded program designed to provide access to contraception and family planning services, such as pap smears, sexual transmitted infection testing and treatment, patient education and counseling, breast examinations and mammograms, and pregnancy testing. Services are free or low-cost for those without insurance coverage. To learn more about this program, go to: http://www.hhs.gov/opa/familyplanning/index.html . To find your local clinic providing these services, go to: http://www.opaclearinghouse.org/db_search.asp .

12. Women, Infant, Children (WIC) program: This is a federal program that provides grant funding to states for nutrition and food for kids less than or equal to age 5 and pregnant women with low income. Eligibility is regardless of immigration status. You can learn more at: http://www.fns.usda.gov/wic/default.htm .

13. Optometry Services: For patients without insurance, or for those with Medicaid (which no longer covers adult dental or optometry), I refer to the local Costco, Walmart, or Target optometry departments for an exam which costs about $50 currently. Also, glasses tend to be less expensive for purchase at these locations.

14. Medications: Walmart and Target pharmacies have a super long list of medications for approximately $4 a month, or $9 for 3 month supply. Many medications are on this list, including those for diabetes, hypertension, hyperlipidemia, thyroid disease, antibiotics, and much more. The cost for these medications is often even less than most insurance co-pays. For more information, please visit the corresponding store websites.

15. Glucometers: Target currently has a glucometer dispensed for only $9, and its corresponding lancets and testrips for $20 for 50 of each, in those with a diagnosis of diabetes. I have found that a glucometer and its corresponding lancets and testrips can be quite costly, otherwise.

Please Note: I am not employed by and am in no way affiliated with any above entity, and it is simply the information I have gathered on my own as a family physician working in public health. Please either call or refer to each website to obtain more accurate and current information.

Do you have anything to add or change to this list? If so, please let me know!

First Do No Harm

2010-05-06T19:54:00.000-07:00

Another yet common daily clinic scenario:

Me: "So, how can I help you today, Mr. Fiction?"

Mr. Fiction: "Well, I'm here for my diabetes and blood pressure follow-up. But I was also wondering if you can fill out this form for me?"

Me: "Let's take a look -- you want me to fill out a DMV Placard form? Why do you think you need a handicap parking permit?"

Mr. Fiction: "Well, Doc, my knees hurt when I walk across the parking lot."

Me: "But Mr. Fiction, we talk about why you need to lose the weight at every single visit. I need you to walk MORE, not less!"

-- No matter how much my patients may "beg," my oath is to "first do no harm," and sometimes I have to just say "no," no matter how badly I feel about it. As a physician, I think it's really important to empower the patient. If I was to fill out this DMV placard form, I'd be doing him a disservice. In fact, I would be harming him. I would be encouraging him to continue with his inactive lifestyle, thereby gaining more weight, and contributing to his diabetes, hypertension, and heart disease. When I explain my reasononing, thankfully, my patients do understand. It's tough love.

Dali Distortions

2010-05-05T18:42:00.000-07:00

A quote from one of my favorite artists, which I occasionally have to repeat and remind myself of as a practicing physician and human:

"Mistakes are almost always of a sacred nature. Never try to correct them - On the contrary: rationalize them, understand them thoroughly - After that, it will be possible for you to sublimate them"

-- Salvador Dali

The Endless Enigma, 1938

(One of my favorite Dali paintings that I was lucky enough to view in person at Madrid's Reina Sofia Museum)

A Doctor's Trip: Rosarito's Mexican Pharmaceuticals

2010-05-02T14:20:00.000-07:00

Photo: Mexico/San Diego Border

I just had the opportunity to visit the beautiful city of Rosarito, Mexico a couple of weeks ago, 20 scenic miles south of the U.S. border from San Diego. Over one million visitors come to Rosarito each year, mostly for its beautiful beaches, delicious food, and rich culture. It is one of the most popular “Spring Break” destinations for Southern Californians. It is also the location of one of Fox’s studios, and where the famous movie “Titanic” was filmed off the coast (in the photo above, to the far right).

It is also the location of the legendary Rosarito Beach Hotel, one of Baja’s most famous landmarks. Prior guests include Gregory Peck, Spencer Tracy, Anthony Quinn, Rita Hayworth, and Marilyn Monroe. There is a sign above the foyer entrance that reads “Through this door pass the most beautiful women in the world.” Breakfasts here are a must, and I highly recommend the “Chilaquiles De La Casa” – yum!

Somewhere during my rich Mexican adventure, I met a super neat lady by the name of Raquel, who makes exquisite authentic Mexican hand-painted pillows. She showcases her pillows at a gallery called “Polo’s Gallery” in Rosarito, and her work has been illustrated in local Rosarito magazines. This American entrepreneur also has a pretty neat website at: http://raquelferrerart.com/ . I could not help but bring back a couple of these unforgettable yet affordable souvenirs:

While in Rosarito, I decided to mix a little business with pleasure. Many of my uninsured patients tell me that they go to Mexico to purchase their medications. And many walk into my clinic with medicine containers from Mexico, and I find myself searching the internet to find its equivalent in the Unites States. So, since I was in Mexico myself, I decided to take the opportunity to visit a couple of local pharmacies to see what the hype is all about, and seek answers as to why my patients without insurance who report having trouble affording their medication decide to head to Mexico to purchase their medications. Here is what I found out:

MEDICATION NAME	NUMBER TABLETS	PRICE IN MEXICO (in U.S. Dollars)	PRICE IN UNITED STATES (in U.S. Dollars)
sildenafil (Viagra) 100mg	1 tab, 4 tabs	13.18, 52.75	16.79 per tab
“Maxifort” 50mcg (generic for Viagra in Mexico)	10 tabs, 1 tab, 4 tabs	50.92, 9.73, 27.18	None Available
tadalafil (Cialis) 20mg	1 tab, 4 tabs, 8 tabs	14.00, 53.68, 98.69	17.19
vardenafil (Levitra)	10mg: 1 tab, 4 tabs 20mg: 1 tab, 4 tabs	10.87, 46.44 11.73, 45.79	15.49
tretinoin (Retina-A) Cream	0.05% 40g tube 0.1% 40g tube	16.08 23.84	0.05% 45g tube: 162.17 0.1% 45 g tube: 188.18
“Tocoderm” 0.05% (generic for Retin-A in Mexico)	30g tube	5.91	None Available
“Nograine” 50mg (generic for Imitrex in Mexico)	8 tabs	31.18	Imitrex Brand, 9 tabs: 253.34
finasteride (Propecia) 1mg	28 tabs	63.92	57.55
finasteride (Proscar) 5mg	30 tabs	86.96	106.88
“Filuxa” 5mg (generic for Proscar in Mexico)	30 tabs	50.04	None Available
glargine insulin (Lantus)	100 Units/ml (10ml)	49.04	111.88
fluticasone/salmeterol inhaler (Advair Diskus) 50/500mcg	One Inhaler	48.80	274.97
fluticasone inhaler 250mcg	One Inhaler	24.18	224.97
nicotine patch 21mcg	7 patches	16.59	39.43
nicotine gum 2mg	30 pieces of gum	10.30	14.80

Note: 1 Mexican Peso = 8 U.S. Cents (as of today)

Of note, all controlled substances require a prescription from a federally registered Mexican physician, and those from a U.S. physician are considered illegal. Sentence for possession of an illegally controlled substance runs anywhere from 10 months to 15 years in a Mexican prison. However, a prescription is not required for non-controlled substances.

I realize that the lure of Mexico for many of my patients is for the lower cost of these medications. However, most medications in Mexico are obtained without a prescription. That worries me. Some patients taking these medications go unregulated, without the proper follow-up by a physician. That means that my patients may self-treat their diabetes and hypertension. That is a pretty scary thought. Also, it’s important to remember that the drug formulations in Mexico go essentially unregulated. There have been cases in which the medications sold in Mexican pharmacies have been substandard, and possibly even counterfeit -- studies report one in five medications being as such. That means that the drugs my patients are purchasing there may be completely ineffective. That is too great of a risk to take, in my opinion.

Thankfully, most of the medications I prescribe in the U.S. are on the Wal-Mart and Target “$4 prescription list.” I am still surprised to find that many patients and even physicians still do not know about these lists, which contain medications that are often even cheaper than the equivalents found in Mexico. They are often even cheaper than patient co-pays under many insurance plans. It’s truly unbelievable how extensive this list is; check out the one from Wal-Mart, for instance, at http://i.walmartimages.com/i/if/hmp/fusion/customer_list.pdf . Like oral terbinafine (Lamisil), which is considered a cosmetic treatment of toenail fungus and is not covered by many insurance plans, is only $4 a month. So is carvedilol (Coreg), used in those with heart failure.

To be honest, I find myself prescribing from these lists about 90% of the time. It’s that extra 10% that I struggle with; for instance, steroid inhalers for asthmatics, triptans for migraine headaches, and erectile dysfunction treatment (although most patients don’t seem to mind paying $10 a pill for Viagra for some reason) do not have generics available in the United States currently. However, some of these pharmaceutical companies that produce these drugs offer “patient assistance programs” that provides the medications for free, if the patient meets income requirements. It’s a little extra work for the physician who needs to complete a form that the pharmaceutical companies send them, and they’ll need to make a phone call every so often to refill the medications for the patients. But if the patient really needs it, it may be an available option to them. The patient can find the application forms for these programs on the individual pharmaceutical company websites.

In general, if my patients’ medications are not FDA approved, I personally do not recommend it as a physician and would rather that my patients obtain the medications from the United States. How do you feel, as a patient or as a prescribing physician?

One of Those Things That Makes Me Say "Hmmmm...": Indirect Work -- Before & After

2010-04-29T14:42:00.000-07:00

I was so very excited to have finally finished ALL of my indirect work during my lunchbreak -- it was the very first time in months that I was able to empty out my 3-tiered cart.I was so ecstatic that I just had to take a photo of it, beaming like a proud parent. I felt so relieved, like I had really accomplished the impossible, filled with pride.

Then, as I am taking my hard-earned photo, my dedicated, efficient nurse walks in with a new huge batch of charts. Here is what my cart looked like just 35 minutes later:

As family physicians, we are not reimbursed for the great amount of time we spend doing this indirect work: answering phone messages, calling specialists, reviewing labs and imaging reports, replying to emails, refilling prescription requests, calling patients, etc.. Check out this study published by the New England Journal of Medicine regarding the average "invisible" workload on the primary care physician at: http://content.nejm.org/cgi/content/full/362/17/1632

With the new healthcare reform bill, our patient panels sizes will undoubtedly increase, as the demand for primary care increases -- which is exciting in a way. But we currently get paid about half of what specialists make, and only about 10% of U.S. medical school grads choose family medicine as a career choice. What's going to happen to this "invisible" burden on primary care docs and their indirect workloads? Just another one of those things that makes me say "hmmmm"...

U.S. Dengue Fever Outbreak in Returning Haiti Relief Workers

2010-04-28T21:28:00.000-07:00

The U.S. Department of State issued a travel warning on 3/15/10, “strongly urging” U.S. citizens to avoid travel to Haiti. The CDC also released a Health Advisory on Tuesday, April 27, 2010 regarding reports of Dengue Fever found in Haiti relief workers returning to the United States. Why all the hoopla about this “Dengue Fever”? Here are details of the Health Advisory report -- If you don’t know what “Dengue Fever” is, make sure to read on…

Transmission:
• Transmitted via the Aedes mosquito. The mosquito is initially infected after biting a human that is infected with one of the 4 subtypes of the Dengue virus. After the mosquito is infected, it can transmit the virus to another human via another bite.
• Symptoms begin 3 to 14 days after being bitten by the mosquito.

Epidimiology:
• Dengue is the leading cause of illness and death in the tropics and subtropics, where 40% of the world’s population currently resides and is at risk.
• More than 100 million people per year are affected by Dengue, yet mortality is less than 1%.
• Endemic areas include Puerto Rico, Latin America, Southeast Asia, Samoa, and Guam.
• United States: Florida, Texas, and Hawaii have had outbreaks in the last 10 years as a result of travelers infected with the virus abroad.

Signs & Symptoms:
• Dengue Fever: high Fever, plus 2 or more of the following symptoms:
     1. headache
     2. pain behind the eye
     3. joint pain
     4. muscle pain
     5. rash
     6. mild bleeding symptoms: for example, nose bleeds, bleeding from gums, subconjunctival hemorrhages (bleeding in the eye), petechiae (a rash with red spots), or easy bruising.
     7. low white blood cell count
• Dengue Hemorrhagic Fever: high fever lasting 2-7days, and the following symptoms begin within 24 to 48 hrs after the fever resolves:
     1. any bleeding symptoms (see above)
     2. persistent vomiting
     3. severe abdominal pain
     4. thrombocytopenia: platelets below 100,000
     5. low albumin
     6. abdominal or pleural effusions
It can result in shock, circulatory failure, and death if patient is not hospitalized.

Diagnosis:
• The CDC advises clinicians seeing patients returning from Haiti with symptoms consistent with Dengue should “seriously consider laboratory testing.”
• The CDC will provide free Dengue diagnostic testing for physicians. Physicians should order the following labs tests:
     1. Acute sample: if patient presents within the first 5 days of symptoms, obtain an “RT-PCR for Dengue Virus”
     2. Convalescent sample: if patient presents between day 6 to 30 of symptom onset, obtain an “ELISA for Dengue IgM”
     3. Send 2 mL of centrifuged serum for the above tests, along with a completed CDC “Dengue Case Investigation Form” from this link: http://www.cdc.gov/Dengue/resources/caseformhaiti.pdf, and send it to:
Centers for Disease Control and Prevention
Dengue Branch
1324 Canada Street
San Juan, Puerto Rico 00920
Phone: 787-706-2399

Treatment:
• There is no specific medication to combat this disease.
• It is treated with supportive measures: fluids, acetaminophen to reduce fevers, and rest.
• Consult your physician.
• If you feel worse 24 to 48 hours after your fever subsides, go straight to the hospital.

Prevention:
• There is no vaccine to prevent this disease.
• Cover or discard containers containing any water, as this attracts mosquitos.
• Empty and clean pet water containers and flower vases with water in order to remove eggs at least once weekly.
• Turn on the air conditioner.
• Use window and door screens to prevent mosquitos from entering your home.
• Apply a mosquito repellent with 20-30% DEET as the active ingredient when you are outside at all times.

Treating Female Sexual Dysfunction

2010-04-25T21:42:00.000-07:00

Female sexual dysfunction has been reported in up to 40% of women, and described as causing actual distress in approximately 12% of women. Therefore, it is an important topic to familiarize with and screen for as a primary care physician, as many patients may not report these symptoms unless they are elicited during the history taking process of the patient encounter. Female sexual dysfunction is often multifactorial and complex; it is affected by such factors as depression and anxiety disorders, life stressors, interpersonal conflict between the couple, medication side effects, age, religious concerns, personal health, privacy issues, personal body image, substance and alcohol abuse, and hormonal influences.

In order to understand the necessary treatment options, it is important to understand the normal female sexual cycle. There are four phases:

1. Libido: the desire for sexual intimacy, through images or thoughts.

2. Arousal: the increase in heart rate, blood pressure, and respiratory rate, along with increased genital blood flow.

3. Orgasm: the peak of sexual pleasure, with rhythmic contractions of the pelvic muscles.

4. Resolution: the return to baseline with pelvic muscle relaxation.

However, there may be overlap, they may be out of sequence, absent, or a phase may even be repeated in the normal female sexual cycle. Also, many women with dysfunction are impacted in more than one phase of the cycle. Therefore, the main categories producing female sexual dysfunction consist of the lack of desire, impaired arousal, the inability to achieve orgasm, and sexual pain disorders. However, it is considered a medical disorder only when it is perceived as distressing to the patient.

Treatment is often initiated with non-pharmacologic modalities first. Medications are reserved in those who fail the following:

• Discontinuation of offending medications: Medications such as beta blockers used to treat high blood pressure, or those with depression or anxiety disorders being treated with Selective Serotonin Reuptake Inhibitors (SSRI’s) are two of the most prescribed groups of medications that may contribute to sexual dysfunction. It is important to review and discuss all medications being taken by the patient.

• Lifestyle Changes: Lack of privacy, life stressors, or personal body image may contribute to sexual dysfunction in many women. This can be alleviated by the introduction of regular exercise, relaxation techniques, support groups, yoga, or establishing scheduled “alone time” for the couple away from family and daytime responsibilities.

• Counseling: Consider in those with interpersonal conflict within the relationship, or for those with underlying depression or anxiety disorders.

• Sex Therapy: Many insurance plans cover the visit to the sex therapist, who may be a physician, psychologist, or highly trained social worker. You can find a certified sex therapist through the American Association of Sex Educators, Counselors, and Therapists at: www.aasect.org.

• Lubrication: For those experiencing vaginal dryness or pain with intercourse, over the counter lubrication jelly may be of benefit if used during intercourse.

• Devices: There is also a clitoral suction vacuum device, EROS CTDT, that is FDA approved for those with female sexual dysfunction. This is similar to the device designed for males, and allows better genital blood flow. However, it may be no more effective than other less costly devices, such as the vibrator.

If the above treatments do not yield results, and if the dysfunction is found to cause personal distress for the patient, the next step is to consider pharmacologic therapy. However, it is important that patients understand that the data on many of the hormonal treatments are limited, that there is a lack of long-term studies on hormonal methods, and that many are not approved by the United States Food and Drug Administration (FDA):

• Androgens:

DHEA: is found over the counter without a prescription. It is found to improve sexual satisfaction in women with adrenal insufficiency, however, no change was found in other women without this diagnosis.
Testosterone: Most data is on postmenopausal women, and has not been found effective in pre-menopausal women. There are two preparations that are currently the most affective: one is the topical compounded 1% cream applied at about 0.5 grams daily to the skin of the arms, legs, or abdomen. Then, there is a 300mcg patch that is applied twice a week, yet is only available in Europe at this time.
Potential Risks: Oral testosterone is currently limited in use due to its adverse effects on the liver and cholesterol levels. However, topical and transdermal preparations should be used with caution in those with cardiovascular disease, liver disease, a history of endometrial hyperplasia or cancer, and those with breast cancer. Also, the issue of pregnancy prevention should be addressed, as there is a risk to the developing fetus in those with androgen exposure. In addition, androgens may cause hirsutism and acne, yet these effects are mild and usually reversible.

• Estrogen:

Vaginal Creams: for those with vaginal dryness or pain with intercourse. However, it is contraindicated in those same patients with contraindications to oral estrogens as well, such as those with a history of breast cancer.
Oral Estrogen: The Women’s Health Initiative (WHI) study found that oral estrogen does not improve sexual functioning in postmenopausal women, and may even be harmful.

• Non-Hormonal:

Sildenafil (Viagra): For those requiring SSRI’s for depression or anxiety disorders, phosphodiesterase inhibitors (PDE-5) such as Sildenafil have shown to be effective in limited studies. However, they have not been shown to be successful in women not being treated with SSRI’s. Studies are currently limited.
Buproprion (Wellbutrin): Has been shown to effectively treat women with sexual dysfunction even without depression.
Zestra T Oil: This is an herbal feminine massage oil that may be applied to the female genitals, and reported to improve sexual functioning in a small study.

Please make sure you consult your personal physician prior to initiating any kind of treatment for female sexual dysfunction.

References:

Shifren, JL. Sexual Problems and Distress in United States Women Prevalence and Correlates. Obstet Gynecol 2008; 112:970.
Davis, SR, Moreau, M, Kroll, R, et al. Testosterone for low libido in postmenopausal women not taking estrogen. N Engl J Med 2008; 359:2005.
Morales A, Nolan J, Nelson J, Yen S. Effects of replacement dose of dehydroepiandrosterone in men and women of advancing age. J Clin Endocrinol Metab 1994; 78:1360.
Braunstein G. Safety of testosterone treatment in postmenopausal women. Fertil Steril 2007; 88:1.
Segraves, RT, Clayton, A, Croft, H, et al. Bupropion sustained release for the treatment of hypoactive sexual desire disorder in premenopausal women. J Clin Psychopharmacol 2004; 24:339.
Ferguson, DM, Steidle, CP, Singh, GS, et al. Randomized, placebo-controlled, double blind, crossover design trial of the efficacy and safety of Zestra for Women in women with and without female sexual arousal disorder. J Sex Marital Ther 2003; 29 Suppl 1:33.

Polycystic Ovarian Syndrome (PCOS)

2010-04-18T14:38:00.000-07:00

Case Scenario:

27 year old female presents to the office with a complaint of irregular periods. Menarche was at age 15, and periods occur about 1-2 times a year. Breast development began at age 9, followed shortly by axillary & pubic hair. Growth spurt was at age 13. She’s been trying to get pregnant for the last one year now, and has never been seen before for her irregular periods.

On physical exam, she is overweight with a Body Mass Index (BMI) of 26, exhibits mild facial hair (hirsutism), and shows brown thickening of the skin behind her neck (Acanthosis Nigracans).

This patient exhibits classic signs and symptoms of someone with Polycystic Ovarian Syndrome (PCOS), a common disorder which affects up to 10% of women. It is one of the most common causes of dysfunctional uterine bleeding, with a complaint of irregular periods being the most common presenting complaint to the doctor. The PCOS diagnostic criteria were developed by the National Institute of Health (NIH) in 1990, and include the following:

1. Hyperandrogenism: These women tend to have more androgen (the classic male sex hormones) levels floating around in their system, causing hirsutism, acne, male pattern hair loss (alopecia), and elevated blood testostosterone levels.

2. Chronic Anovulation: These women tend to ovulate less, and therefore exhibit more difficulty with their periods. They may lack periods all together (Amenorrhea), have cycles that last greater than 35 days (Oligomenorrhea), have unpredictable periods (Dysfunctional Uterine Bleeding), or report of infertility with difficulty reaching pregnancy.

3. All secondary causes of the above must be ruled out: Pregnancy, Thyroid Disease, Eating Disorders, Exercise Related Amenorrhea, Hypothalamic-Pituitary Disorder, Premature Ovarian Failure, Pituitary Adenoma, Congenital Adrenal Hyperplasia, and Cushings Disease.

The name is a misnomer, since having cysts on the ovaries is not a criterion of this disorder. Up to 20% of healthy women may exhibit cysts on the ovaries, and do not have PCOS. Obtaining a pelvic ultrasound to search for ovarian cysts is not diagnostic, and should not be ordered. The pathophysiology includes two pathways. First, there is a specific chemical released from the hypothalamus in the brain, called Gonadotropin Releasing Hormone (GnRH). When the hypothalamus releases GnRH in a high pulse frequency, as it does in PCOS, it signals to the pituitary gland to preferentially release another chemical called “Lutenizing Hormone,” or LH. This LH stimulates the ovarian cells to produce more androgens, thereby causing PCOS. The second important pathway of this syndrome is caused by insulin resistance. Insulin resistance occurs in women with a predisposition to diabetes or pre-diabetes, and they often have a family history of this. Insulin is released by your body in response to glucose when you consume sugar. Certain cells have a “doorway” that require insulin to open it in order to allow glucose to enter its cells and become metabolized. When this doorway is malfunctioning, your body continues to release more and more insulin in order to open these malfunctioning doorways. This rise in insulin levels attack your ovaries and directly stimulates them to increase androgen production, thus causing PCOS.

The reason PCOS is important to learn about is not only because of its high incidence, but also its potential complications if left undiagnosed or untreated. Here are some of the more important complications in those with PCOS:

Decreased Fertility: Although, with good treatment, most women are able to ovulate and become pregnant.
Endometrial hyperplasia: There is a higher endometrial cancer risk if non-menstruating women do not shed their endometrium, with a three times higher risk of cancer in women who have a period less than four times a year.
Obesity: 30-40% of PCOS women are also obese.
Dyslipidemia: Many PCOS women show high triglycerides and LDL levels (your “bad” cholesterols), and low HDL (your “good “cholesterol).
Insulin Resistance: There is a ten times higher risk of developing Type II Diabetes in PCOS patients. Thirty to forty percent have impaired glucose tolerance. Ten percent have Type II Diabetes by age 40.
Hyperandrogenism: Many fight a long battle with excess body and facial hair, adult acne, and even male pattern hair loss. Cosmetically, this is a great cause of concern and frustration for many of these women.
Coronary Artery Disease (CAD): There is also an increased coronary artery calcification in PCOS women. Yet an increase in morbidity or mortality from CAD not yet established.
Pregnancy Risks: There is a higher rate of reported gestational diabetes, hypertension-related disorders in pregnancy, multiple births, and a 30-50% risk of first trimester miscarriage in those with PCOS.
Hypertension: Many with obesity also show an increase in blood pressure levels, and require treatment.
Sleep Apnea: Those with an obesity co-morbidity may also suffer from sleep apnea, and require screening.

There are several treatment options for those with PCOS. The most studied oral medication is Metformin, which is a medication given to those with diabetes in order to decrease insulin resistance. It works on the liver to decrease production of glucose, which in turn decreases insulin levels. And if there is less insulin, there is less androgen production by the ovaries. When combined with exercise, it can facilitate weight loss. It also increases fertility, as 40-90% taking metformin report more regular periods and ovulation. It may also help prevent the onset of diabetes in those with PCOS. Side effects occur in 30%, and include diarrhea and bloating, yet this resolves with time and is minimized if the medication is taken with meals. The extended release formulation of metformin may also help minimize side effects. There is a decrease in the rate of miscarriage to 8.8% compared to 41.9% on placebo, & a decrease in gestational diabetes if conceive while on metformin. Metformin is normally continued during the first trimester of pregnancy, and then stopped when reaching second trimester.

Oral contraceptive pills are also used to treat PCOS women with irregular periods. Several different brands offer a progesterone component that acts as a weak anti-testosterone component, which may add a greater benefit to those with PCOS and elevated androgen levels. This may be of benefit in those with excess hair, male pattern hair loss, or acne. If not considering pregnancy, oral contraceptives will allow the endometrium to shed in order to decrease the risk of hyperplasia and cancer.

Mainstay of treatment, however, is weight loss. With a 5% or greater weight loss, 82% have improved menses over a six to seven month period of time. Like in diabetics, a lower carbohydrate diet is recommended in order to increase insulin sensitivity. Weight loss decreases insulin resistance and improves hirsutism. And with a 5% weight loss, 40% have reported a pregnancy outcome.

In those who desire pregnancy, there are good treatment options available. Clomiphene is the mainstay, and induces ovulation in 75%, and 50% of those who ovulate on Clomiphene will conceive. Most pregnancies occur within the first six ovulatory cycles while on Clomiphene.

Patients with PCOS should consult their physician regarding their individual treatment options.

References:
• Ehrmann, David A. Medical Progress: Polycystic Ovary Syndrome. NEJM 2005; 352: 1223-1236.
• Lane, Danielle E. Polycystic Ovary Syndrome and Its Differential Diagnosis. Obstetrical and Gynecological Survey 2006; vol 61, no. 2: 125-135.
• Sheehan, Michael T. Polycystic Ovarian Syndrome: Diagnosis and Management. Clinical Medicine & Research 2004; vol 2, no. 1: 13-27.
• Pasquall, R. and Gambineri, A. Insulin-Sensitizing Agents in Polycystic Ovary Syndrome. European Journal of Endocrinology 2006; 154: 763-775.
• ACOG Practice Bulletin, No. 108, October 2009.

A Doctor's Trip: Barcelona's Spanish Healthcare System

2010-04-15T22:36:00.000-07:00

Doctors have the right to take vacations too, right? After all, I am Jill of All "Trades" -- that means I get to mix it up once in a while and get to write about my personal hobbies too, no? I always said that if there was one job I would consider giving up medicine for, it may very well be Rick Steve’s job. That guy is truly the luckiest guy in the world; he gets to travel all over the world, write about it, and get paid for it, too! Well, I've been traveling, and I am now going to write about it, but I just am not getting paid for it. There’s something to be said about plopping yourself down into a foreign country with only a map and your curious sense of adventure, having to learn your way around the city maze with minimal comprehension of the language. It’s intriguing to experience how other people live, without our luxuries of living in the United States. I recommend not taking a tour, and finding your own way around -- that's half the fun!

We are rather spoiled in America. There’s no other country with a store like Home Depot, where you can walk in and find every possible sized nail, screw, and wing-nuts you can ever dream about finding. And where else but in America can you walk into a store like Target and find anything from a flat screen TV to a gallon of milk. Life may not be as easy in other parts of the world, and we need to remember how lucky we are. In this blog, I hope to give my reader’s some sporadic insight about my travels to various cities and countries. Besides, it gives me the chance to show off my photographs of the city, taken with my super old 7 megapixel digital camera.

My first travel post describes one of my greatest cities ever – Barcelona, Spain. This is a famous fishing port with beautiful sea views, and everything from rich gothic to contrasting super modernized segments of the city. There’s something for everyone here, whether you are a family with children, or visiting for a romantic couple getaway.

4 Travel Tips I learned:

1. No need to EVER take a Taxi in Barcelona. Once you arrive at the airport:

• Go to the Tourist Info (TI) desk & ask for: a metro map + city map, & you are set!

• Just make sure you travel LIGHT, otherwise you will have to carry all of your luggage everywhere while traveling up and down the stairs in the underground metro system.

• The T10 metro card is not necessary if you stay somewhere central near Placa De Catalunya (I stayed at the Hotel Regina) you only need the metro on rare occasions.

2. The Barcelona Card is also not worth it, and I didn't purchase one.

3. Also, the Articket is only worth it if you attend at least three sites listed on their website. It does include the Picasso & the Casa Mila (La Pedrera), but the others are all museums & not among the greatest Barcelona attractions.

4. If there is one guidebook I would recommend, it's the Rick Steves Spain book -- he's so on target about everything. He does a great job of "guiding" you throughout all of it.

Top 10 Sites I saw & recommend:

• La Ramblas: the famous stroll through this pedestrian boulevard full of performers and pick-pocketers is a must-see. But see it once, and that's enough. And keep your wallets close!

• The Columbus Monument: this 200 foot tall tower sits at the end of La Ramblas. This is where King Ferdinand and Queen Isabel welcomed Columbus home after his first trip to the Americas. Go to the top for beautiful sea views, and then walk onto the pier there for a beautiful stroll afterwards.

• The Cathedral (make sure to go before 12:45 or after 5:15pm when it's free): this traditional Catalan Gothic church was built in 14th century and is super rich in history and beauty. Make sure to visit the cloisters and its 13 resident geese.

• Picasso Museum (they don’t allow photos though): get ready to see some of Picasso's earlier works, including more than 50 interpretations of Velazquez's "Las Meninas." Doctors aren't the only ones with obsessive compulsive disorder -- and if you've seen this museum, you'll know what I am talking about.

• Church of Santa Maria Del Mar (it's free): Another traditional Catalan Gothic church built in dedication to the town's famous shippers, hence the name "Del Mar," which means "of the sea." Muy bonita!

• Casa Mila: This beyond-its-time, and rather eerie Modernista apartment building designed by famous architect Antoni Gaudi in 1906 is now turned into a work of art and museum. Go to either this or Casa Batllo, as both is not necessary. I chose this one over Batllo because of its breathtaking rooftop "ice cream" style views. Que linda!

• Block of Discord (view only from outside): this is a block of competing 19th century Modernista facades, each one in striking contrast to the next as if in competing "discord." One facade is Gaudi's Casa Batllo (on the right in the photo below).

• Sagrada Familia: a little disappointing on the inside, but still worth seeing; no need for the audioguide. This is yet another of Gaudi's Modernista work of art, which he left unfinished with his passing in 1926. It's not expected to be completed for another 25 years! Si, es verdad!

• Palau Guell (free): Another one of Gaudi's work, is located off of Las Ramblas, and was being renovated and, therefore open with limited rooms for viewing at the time.

• Parc Guell: Gaudi had intended for this 30 acres of space to be an exclusive 60 residence luxurious housing project that flopped as a project. Now it has been converted into a park. You can skip Gaudi's House there, though -- it is not so interesting if you have already seen Casa Mila.

Now, it wouldn't be a true medical blog unless I added a few pointers about Barcelona’s healthcare system, would it? Their healthcare system is universal, and according to the world health organization, it provides one of the best healthcare in the world; it is ranked number seven in the world (much higher than the Unites States), even though it spends much less on healthcare in comparison to the United States.

It’s a two-tiered system – public and private. About 10% of its people purchase private health insurance, even though its public health system is considered to be excellent. This is often the non-working segment of the population that is not contributing to social security. Those who are working contribute to the Spanish social security system and are entitled to "free" healthcare through the network of Centros De Salud. Your employer is obligated to pay part of your contribution, and the other part is deducted from your salary. They believe that the right to healthcare is a basic human right.

There are no out-of-pocket expenses, except for prescription medications. Dental care and optometry are also not covered under this system, yet is not considered costly. Common complaints from patients are regarding long waits to undergo procedures or to see their specialists. Most report only a one or two day wait to see their primary care physician, however. They can also select their own primary care physician, and are not assigned. However, they must attend the hospital that is serving the district that they live in. If an ambulance picks them up from their home, it will also return them to home, even if nothing is found to be “wrong.” Of note, life expectancy in Spain is one of Europe’s highest.

I hope my travel tips have inspired you to visit vicariously or in person to this beautiful city full of life, love, and good health! Hasta luego!

One of Those Things That Make Me Say Hmmmm....

2010-04-12T20:47:00.000-07:00

An all too common scenario in my clinic:

I walk into the patient exam room, and greet my new patient whom I’m meeting for the first time, “Good morning, Ms. Fiction. What can I do for you today, today?”

Ms. Fiction: “I am here for my diabetes and blood pressure medication refills.”

Me: “Oh, good – did you bring your medication bottles?”

Ms. Fiction: “Oh no, I forgot to bring them.”

Me: “That’s ok – just tell me the names and doses of your medications.”

Ms. Fiction: “Oh, Darn! I don’t remember the names, either.”

Autism Awareness Month: The What, Who, When, Where of Recent Rise in Measles

2010-04-09T19:26:00.000-07:00

It’s Autism Awareness Month! There’s a lot of hype in the media regarding a pretty shady link between the MMR vaccine and the development of autism. This is some good information to share with your patients when you are discussing the lack of evidence behind this link, and the harmful consequences of not vaccinating children. I thought it would be a good time to share the following What/Who/When/Where information regarding a recent rise in Measles cases in California -- here is the gist of the advisory report:

1. WHAT: There have been a total of nine cases of measles reported in the state of California since January 2010 -- there were only a total of nine cases in all of 2009! The California Department of Public Health just released this health advisory report, stating that many of the cases were in those with recent travel to Europe or Asia, however, some were in those children who were not vaccinated with the MMR. Last outbreak was in the early 1990’s with 17,000 reported cases that caused 70 deaths. However, with the widespread vaccination program that was initiated, the endemic transmission was essentially eliminated by the year 2000.

2. WHO: As a physician, this means that I will be considering measles in anyone coming in with a rash and fever. Symptoms may begin with a cough, runny nose, conjunctivitis, and a fever up to 105 degrees. Then, a rash may develop -- a red, diffuse, maculopapular rash that begins on the face and travels down the body. You may also see “Koplik Spots,” which are white/blue spots on the buccal mucosa.

3. WHEN: It is important to elicit a recent travel history, or any exposure to those with recent travel within the previous three weeks. Also, it is important to know if the patient has been vaccinated with two doses of the MMR, which in kids are given at age 1 and 4 years.

4. WHERE: If you suspect a patient may have measles, place them in an isolation room immediately, preferably with negative pressure. Implement airborne precautions – masks for both the patient and everyone entering the exam room. Then call the local department of public health to help guide you through your next steps. Do not use the room for more than two hours after the patient has left the room.

As a physician, we can help control the spread of measles greatly – be on the lookout, and let’s continue to educate our patients regarding the MMR vaccine and safe travel.

Be Prepared for Disasters: Learn How to Create Your Emergency Supply Kit

2010-04-07T23:27:00.000-07:00

Having experienced a piece of this 7.2 earthquake in San Diego this past week, it made me revisit my special emergency supply kit that I created when I first started working for the department of public health. Emergency preparedness is a big issue for us in southern California, with whispers of the very frightening “big one” coming our way in our future. The problem is that we’ll never know when. Disasters often don't give a warning, unfortunately. No matter where you live, you need to be prepared for disasters, whether it’s for a flood, hurricane, Tsunami, tornado, fire, winter snow, or earthquake.

The first thing you should do is sit with your entire family and devise an “Emergency Plan,” and preferably put it in writing and place it somewhere visible where it is easily accessible in case of an emergency. You may want to also make a copy of this for each family member to have. In this plan, make a list of emergency contacts with phone numbers and addresses. Then select a contact that lives out of town that your family members can reach to check on each other; this would be someone that lives far enough away that would not be affected by the same disaster. Your family should devise a home escape plan in the event of a fire or other emergency from every floor of your home in case of an evacuation. Come up with at least two escape routes from the home and designate a meeting place outside the home. In your disaster plan, also make the following lists:

• Household Members: names/cell phone numbers of everyone living in your home

• Service Providers: name/phone numbers for electricity, gas, water, cable, telephone companies

• Health Care Providers: name/phone numbers for all your family’s doctors, providers, caretakers

• Medication Lists: name, dose, prescriber name/phone, and reason why you are taking it (example: for high blood pressure)

Review with your family how to turn off the water, gas, and electricity. Turn off utilities only if you suspect lines are damaged or if you are instructed to do so. If the gas line is turned off, it needs to be turned back on by a professional and you should not attempt it yourself. Your family may also want to consider taking a first aid and/or CPR course to familiarize yourselves with the process in case of an emergency.

It is very important to create an Emergency Supply Kit, preferably in a large sturdy duffle bag or a new covered trash can with wheels and a lid. Keep the heavier items and the clothing/bedding on the bottom, the food in the middle, and the lighter items on the top. Here is a good checklist:

• Bottled water: at least a 3 day supply, which is 1-2 gallons of water per person per day

• Nonperishable food: 3 day supply, which is 1-3 lbs per person per day. Good examples: canned foods (don’t forget the non-electric can opener), dry milk, nuts, crackers, dried fruit, peanut butter, granola, etc.

• Plastic cooking utensils

• Battery or crank powered radio (some even come with a flashlight as a dual functioning bonus): to listen for news/messages

• Extra batteries

• Flashlight

• Blankets

• Poncho/Rain Gear

• Sturdy shoes

• Warm Clothing, Gloves, Jacket

• Prescription Medications: at least a 7 day supply.

• Non-Prescription Medications: ibuprofen, acetaminophen, antacids

• First Aid Kit: gauze, bandages, tape, scissors, disinfectants, latex gloves, antibiotic ointment

• Personal Hygiene Products: toothpaste, toothbrush, deodorant, toilet paper, feminine hygiene products, soap.

• Special Items: for infants, pets, or people with disabilities.

• Extra pair of eye glasses

• Credit Card & Cash (preferably small bills or quarter rolls)

• Extra plastic trash bags

• A whistle: to use if trapped or threatened

• Matches (in a waterproof container)

• Swiss Army Knife/Multipurpose Knife

• A small fire extinguisher (ABC type)

• A wrench: for gas valve 10-inche (25 cm)

• Duct Tape

• List of important phone numbers: family/friends/neighbors, credit cards, banks, licenses

• Important Documents: wills, insurance, investments, birth certificates, household inventory/photos. Place these in a water and fire-proof container.

• Photos of your high-value belongings: this would be for insurance purposes.

• A copy of your family emergency plan

Make sure to note expiration dates on foods, water, and medications and replace them accordingly. Non-perishable foods often need to be replaced every 6 months. In general, it’s a good idea to review your emergency plan with your family every 6 months, and revisit your emergency supply kit at the same time.

Be prepared, don’t have regrets. And most importantly, stay calm.

The Donut Room

2010-04-05T17:12:00.000-07:00

Donuts -- almost every day of the week, we have someone bringing in a batch at work. Creme filled, chocolate covered, rainbow sprinkled, honey glazed, you name it. Why donuts, I always wondered. Why not fruit or something more healthy? I always tried to convince the staff to bring healthier alternatives, but no one would go for it. So every day, the staff would take turns bringing a box of donuts and placing it in our small break room. I would avoid the donut room like the plague, for fear of the extra calories and high fat content. However, for our staff, this is by far the most popular room in the clinic -- where people can gather to take a break, chat with their co-workers about their lives outside of work, and enjoy a sip of their coffee and a bite of their donut.

Then I realized that this break room is situated exactly in the center of the clinic. And much like the center of a donut, this is the “untouchable” region of the workplace. This is where the staff gets the chance to relax from the hustle and bustle of the busy and often stressful clinic atmosphere. Here, in the donut hole, there are no patients allowed. There are no supervisors hanging out in the donut hole. This is where there is a moment of peace for our very hard-working staff.

I have to admit, I am so very lucky to have some of the very best and hardworking medical assistants and nurses. Since the economy took a fall, there have been layoffs, pay-cuts, and furloughs. We are seeing more patients, with up to 18 per half day, and with less staff. We are very short-staffed, and that means that with those remaining, the workload for each employee has about doubled. However, I am so proud to say that there is not ONE employee slacker in my clinic. Everyone gives a hundred percent, and everyone is on task.

So, if all it takes is a few moments of indulgence in the donut room to keep the staff sane, I think they completely deserve it and more. Because after all, I learned that it’s not just about the donuts, it’s what they represent.

The Paper Chart Diaries: Back to the Days of the Flinestones

2010-04-04T18:39:00.000-07:00

Am I working in the only clinic in America still using paper charts? We are a modern stone-age family medicine clinic, in the same way that the Flintstones were a modern stone-age family in their city of Bedrock. However, Fred was working in the stone-age era, yet was considered quite modernized for his time. But for us in my clinic, it often feels the opposite: it is the year 2010 and we are living in modern times, and I am lucky enough to be working in a brand new “state-of-the-art” facility that opened in 2007, but I still feel like I am working in the stone ages when it comes to our paper chart system. If you don’t have an EMR system, you can probably relate and may want to consider joining the modern world. Here's a list of the top nine ways in which an EMR can change your life – my yabba-dabba-doo personal experiences with this quite inefficient paper chart system:

1. The Flintstone Family Car’s Wasted Manpower: Like the famous Flintstone car, Fred may be driving, but he’s wasting his energy pedaling profusely before he even arrives to work. Time is money, and for our wonderful, hard-working staff, the time spent locating charts must amount to at least several hours of pedaling each day. Anytime the following events occur, the staff needs to enter the clinic abyss and search:

• with every patient checking in

• when patients come up to front desk with questions for the physician, prescription or form requests

• when patients call to leave a message for the physician

• any specialists, hospitalists, pharmacies, lab, radiology technician calling to speak to the physician about a patient or to clarify an order

• when the pharmacy refill requests are faxed to the office

• when the labs or radiology reports are faxed to the office

Any time spent searching for these charts is precious time taken away from doing something else more valuable.

2. A Waste of a Bird Pen: Of course, it’s only natural that when we are dealing with this high volume of charts in a busy clinic, there are going to be times when the staff just simply can’t locate the chart they are searching for. What does this mean for the physician? Well, if a patient is there for “diabetes follow-up”, I have no idea what I did with them at the last visit. Did I start them on a new medication? Did I tweak their insulin? What were their last lab values? I don’t know unless I read my hand-written documentation from the previous visit. So I walk in to the patient exam room and pretty much just practice on the fly. And if you knew me, you would know that I am not a fly-by-the-seat-of-my-pants-kind-of-gal. Not to mention that it opens up the potential for error and hence malpractice. But we can’t simply tell the patients to reschedule because we can’t find their chart. So I end up feeling foolish and need to ask the patient a number of questions, and pray they remember and understood what I did with them at their last visit.

3. Dinopeptidis: Wilma and the Rubbles (their neighbors) try to keep Fred awake for seventy-two hours when he is incorrectly diagnosed with “Dinopeptidis” after Dino’s x-ray is mistaken for Fred’s. In the same way, when you are dealing with paper charts, there is a certain rate of human error involved when the chart is compiled by humans. You will no doubt find misfilings and errors on occasion. I may find a chart with a misfiled lab report belonging to a different patient. I may run across a chart with my last progress note missing, even though I know I saw that patient last month because I remember the visit. If they came in and we couldn’t locate their chart at the last visit, they have two charts roaming about that may not have been combined. The x-ray report may be filed in a different section of the chart, instead of under the “radiology” tab. Or, a patient may leave me a message, and the message slip written by the staff will fall off from under the paperclip used to attach it to the charts. Do these events occur frequently? No, but they do occur. Even once is too many, again opening the door for liability. But how can you blame the staff? The problem is this ancient Flintstone system, not the hard-working staff.

4. No Writings In Stone: When working with paper charts, every communication with outside offices is also performed using paper, including referrals sent to the specialist. That means that on the other end of the fax, the specialist’s staff must pull the fax sent to them as well. I may send a referral to cardiology for an abnormal stress test and will receive the “ok” confirmation from my own fax machine, but it’s still not written in stone. I may find out several weeks or even months later when the patient calls me that the referral was not obtained on the other side, for whatever reason. They too can lose loose paper, have fax malfunctioning, misplace the faxes, etc. This greatly delays patient care. With an EMR system, we would ideally be able to send referrals electronically.

5. The Pelican Garbage Cans: When Wilma steps on the pelican’s foot, his beak opens and accepts the trash. But where does all that waste go? The city of Bedrock must have had landfills, too. When I first started working in the public health clinic three years ago, I was absolutely horrified to find that there was no paper recycling bins in the clinic on my first day of work. We were thankfully able to purchase and install recycling bins all around the clinic within the next two months, and then install them in our entire public health clinic system in the county within the following month. Yet, I still cringe when I occasionally find paper in the regular trash – it’s going to happen no matter how many recycling bins we install. Imagine all the trees we could all save by avoiding all the wasted paper used in these clinics if we only had an EMR system.

6. Our Rock Carvings: we have designed special lists and logs for important tests, such as pap smears and mammograms, so that we can keep a closer eye on these values for proper follow-up. This takes a lot of effort and time for a member of the staff to sit down and log each one of these tests performed. If we had an EMR system, this could be performed automatically and we could simply print a list.

7. Bedrock Mishaps: depending on the EMR system, there are features that allow you to connect with the pharmacy network. There is a great deal of time wasted by writing out each and every prescription for the patients, and for patient to take the prescription to the pharmacy and wait for it to be filled. The patients occasionally return to the clinic after their visit, reporting that they lost the prescription on the way to the pharmacy: they spilled soda on it while dining at McDonald’s, they flushed it down the public toilet by accident, their dog ate it, whatever it may be… So the staff needs to interrupt my precious flow to ask me to rewrite it once again. That wouldn’t happen with an EMR system – it would be electronically sent.

8. Expanding the Cave: I can only imagine what the extra space we currently use for the chart room could be used for. Perhaps we can turn it into a minor procedure room, or possibly 3 or 4 extra patient exam rooms? We could use it to set up extra offices for the staff. We currently have a large facility, yet one can never have enough cave space.

9. The Stone Vessel: When I initially began working there three years ago, I was assigned a bucket to keep my charts that needed to be reviewed by me, and the staff would simply carry over this bucket to my office every morning. The clinic grew so fast, we now remember the bucket as the “good old days.” I now need a large three level cart to hold my charts. And now we are even outgrowing this large three level vessel. What do we use next? I cannot imagine wheeling in and out anything larger than this cart -- we can barely pull and push this one as it is. With an EMR, there would be no need to herniate our discs carrying charts around.

So what is holding us all back from switching to an EMR system? The answer is financial. The public health department is really suffering in this economic crisis. Yes, an EMR system can be quite expensive. But the time and inefficiencies currently are also costing us, and increasing our risk of liability as well. But I am confident that it is coming our way – it has to. It’s a natural progression. One day when we are living like the Jetsons, we’ll be wondering how we ever worked like the Flintstones; and we too will be a page right out of history. One can dream of that day.

Or just turn on the Cartoon Network…

How to Gracefully Sing “Beat It” to Your Narcotic Seekers

2010-04-01T19:57:00.000-07:00

When conversing with my fellow provider colleagues in public health, one of the hottest topics of frustration at our monthly meetings is often the one on how to handle the narcotic seeker. With the media coverage of Michael Jackson’s death, and with the death of celebrities overdosing and mixing harmful medications, the DEA is really starting to “crack down” (no pun intended) on physicians who overprescribe and prescribe inappropriately.

When I first began working at the public health clinic three years ago, our clinic was inundated with these requests for extra strength Norco’s, morphine, Oxycontin’s, and such. I was shocked to see almost a quarter to fifty percent of my appointment slots filled with patients seeking a prescription for controlled substances. Nowadays, thankfully, it is a rare event. This was not a coincidence, however, and no easy task to accomplish. It also took a great deal of patience, persistence, and effort spent on dispersing these patients, literally one-by-one. How did I tell my narcotic seekers to “Beat It,” Michael Jackson style? It may not work for everyone, but here are some of the details of my personal plan:

1. Meet with Your Backup Singers: I met with the other providers I work with to make sure that we all agreed on a “chronic pain policy” for the entire clinic. This really needs to be the first step, otherwise you may be able to deter these patients from your own personal panel, yet they will still return to your clinic to seek your partners. Ideally, you should all be on the same page, unless you don’t mind being blacklisted, or goodness forbid, deleted from your colleagues’ Facebook accounts.

2. Design Your Music Contract: It’s important to distinguish your patients with real pain, however. I do have a very small group of patients whom I do prescribe chronic narcotics for. However, if I do so, I have made it a policy to have all of my chronic pain patients agree to either a verbal or written “Pain Contract.” This contract includes the following key elements:

• They cannot be working for more than one music label at a time: The patient sees me and only me for any controlled substances. I make sure they understand that this means no emergency room or urgent care visits for these prescriptions, as well.

• They cannot perform gigs outside the network: The patient must select one pharmacy and fill all their prescriptions at this same pharmacy, whether it is a controlled or uncontrolled substance.

• No illicit drug use is allowed by my performers: I include a clause that I may unpredictably throw in a random urine drug screen on occasion, like a “pop quiz.” And if there are any surprises on that quiz, they will be fired from the choir. I will be terminating our music contract, and thereby no longer prescribing these meds.

• They must sing within range: They also understand that I will only prescribe a certain number of pills per month that I believe is medically appropriate for their pain. If I don’t think that taking 240 tablets of Norco a month is appropriate for their hangnail, then I simply say “no.” That simple. They must agree to stay within those set limits and not to take more than what is prescribed, both on a monthly and daily basis.

I find that in general, those who sign my contract are legitimate pain sufferers. After all, why would they endure all of these annoying rules when they can get their medications elsewhere with much less hassle?

3. Practice Your Gig Often: What they forgot to teach me in residency is that you can actually request a Patient Activity Report (PAR) from the DEA for any patient – the juiciest piece paper you will read in your clinic, like a clinic version of the tabloids (except that it’s very accurate). They send you a list of every controlled substance the patient has filled within a given span of time, along with the dose prescribed, date filled, pharmacy name, the number of tablets filled, and the name of the prescriber. I check up on my patients both at baseline, and periodically to make sure that they have followed the rules above. And I do this for every single patient that I form a pain contract with, no matter how legitimate they may seem. I have been fooled once or twice in the past, and I know now that narcotic seekers are very good storytellers and can sing to any tune. I am honest with my patients and let them know that I do obtain a PAR on all my patients routinely, and that this is not selective to any specific patient, but to everyone we write a controlled substance for in the clinic.

We all need to come up with our own plan as physicians, and practice within our personal comfort zones. My personal reasons for being rather stingy with the narcotics have nothing to do with the media. In fact, it existed way before M.J.’s death. It is so much easier and faster to simply write that prescription and tell them to “Beat It,” than to spend the extra time it takes to explain my reasons or to form a contract. It is tempting, especially given the time constraints on us physicians to see the most number of patients in as little time as possible in today’s economy. However, I took an oath to “do no harm.” I am not ethically ok with writing any prescription that may potentially hurt my patients, no matter how much they beg – whether they’re asking for Tylenol or Tylenol #3.

Healthcare Reform Part I: Digging Our Way Out the Trenches With More Affordable Shovels

2010-03-28T23:45:00.000-07:00

Working in the deparment of public health, i come across the inadequacies of our current healthcare system on a daily basis. It is very frustrating, and occasionally freightening from a family medicine physician's perspective. One of the reasons that i am so excited about this new healthcare reform bill is because of its improved affordability -- that means more of my patients can afford care, and in turn, it allows me to give them the care they really need and do what i need to do with them:

1. My patients without health insurance cannot be denied based on
pre-existing conditions: Not many of my patients can afford health insurance. But the few that may be able to have tried and have been denied. I just saw a patient last week with newly-diagnosed, diet-controlled diabetes with an A1C of 5.9. She got flat-out denied for health insurance entirely. Not even given the chance to pay a higher premium. The insurance companies headed for the door as soon as the word "diabetes" was uttered.

For the first time in history, slimy insurance companies can no longer say "no" based on your pre-existing health conditions. They can no longer increase your premiums just because you caught pneumonia, or drop you from your plan because you got sick.

How did we Americans allow this inhumane practice by insurance companies to continue for so long? What about the patient with newly diagnosed leukemia or cancer? Insurance companies are denying them coverage right now. How is that fair? We as a society cannot punish these patients for a diagnosis that is out of their control and which requires some sensitivity. What if this was your sister, child, or father? They need care. We have been denying them this care under our current healthcare system.

2. My patients that desperately need specialist care can have coverage: Now 32 million more Americans without health coverage today will be able to receive it. The patients i see pay $35 per visit to see me if they meet income requirements. But what if i need to do further testing, or need to send them to the specialist? i am stuck.

I just recently saw a young female with a history of brain tumor with a resection two years ago, with clear recurrent signs and symptoms. She needs imaging and specialist follow-up urgently. Well, she lost her insurance last year when she lost her job. She hasn't seen a doctor in over a year. She cannot afford private health insurance (and if she could, let's be honest, she'll be denied). She has no children, making her ineligible for medicaid. She is under age 65, and will not qualify for medicare. What can i do with her? She will have to wait until her situation is an "emergency," go to the ER, and contribute to our current health care crisis by increasing costs to the taxpayer.

These are stories of real patients deep in the trenches of our current system. We may be able to see a dim ray of light above, but we still need to keep digging for a long time to come.

Into the Medical Blogosphere

2010-03-27T13:44:00.000-07:00

Do we really need another medical blogger, you may ask? I have been reading other excellent and quite experienced medical bloggers for a while now, contemplating the thought of starting one myself. I often come home from work with a flight of ideas and experiences to share, and search for an outlet for my thoughts. So I hope that this blog will not only be a therapeutic diary of my trials and tribulations as a physician, but also something useful for my readers as well.

I am a family medicine physician practicing in the department of public health in southern california. I often feel like the "Jill of All Trades" in my practice, seeing everything from pediatrics to geriatrics. I am lucky enough to still be practicing everything i learned in residency: low-risk prenatal care, minor surgeries/procedures, lots of women's health, and have a large chronic disease population with diabetes, heart disease, COPD, and everything in between.

I have seen up to 19 patients in a half day -- yes, half day. On average, however, I see between 12-15 a half day, which is still no easy task. But it is amazing how efficient I have learned to become, at the same time, still able to deliver quality care while keeping my patients happy. But this didn't happen overnight -- which can perhaps be a topic for a future post.

Forget the number of patients I am pressured to see on a daily basis for a moment -- that is the "easy" part. But the acuity of the illnesses is what makes my job in public health so demanding. My patient population is one without great access to care -- they are the ones with Medicaid, Medicare, and often no insurance. Many of them come in only when they absolutely have to, because they are unable to afford medical care and maybe haven't seen a physician in years. So I am often all they have and all they can afford.

I have prescribed and managed diseases that i never thought would be in my scope of practice. I am often the PCP and their specialist. For instance, I have patients with severe rheumatoid arthritis whom I have had no choice but to initiate Methotrexate on, and continue to take care of alone without a specialist input. I am their rheumatologist. I have young men with new-onset seizures that I have placed on anti-epileptics, and am acting as their neurologist. I have hyperthyroid patients taking PTU whom I monitor by myself, and act as their endocrinologist. I have seen patients with Bipolar Disorder & Schizophrenia whom i've prescribed antipsychotics for, practicing as their psychiatrist. I am the Jill of All Trades, MD.

Now, I am not encouraging other primary care physicians to do what I do -- I don't think it's right for primary care to act as the specialist in any way. But what can i do? I have nowhere to send these people. It is either watching these patients suffer, or treating them by myself. They cannot afford the $285 dollar visit to the county hospital specialist. Their visit to see me is $35 out of pocket. Some are not be even legal residents, and they do not qualify for Medicaid or Medicare. For those that are legal, many have been denied repeatedly by Medicaid/Medicare, or don't qualify because they don't have children or are not above age 65.

In this age of great health care reform discussions, I can try to give you my personal perspective in my blog. I am deep in the trenches, seeing these people without health insurance or with poor access to care suffer first-hand. I can describe my personal experiences and challenges of treating these patients on a daily basis. My ideas are my own, and I have absolutely no affiliations.