Monthly Archives: November 2006

The HPV Test: A Piece of My Mind

peace of mindWhat’s the new mantra for marketing health care testing to American women? “Peace of mind”.

That’s right. Forget medical necessity. Forget that your doctor feels it is not needed. Or that your insurance may not cover it. Get the test “for your peace of mind”.

Digene is tapping into women’s inherent anxiety and fears about cancer by suggesting that they routinely get the HPV test, even if their pap is normal, so that they can sleep at night.

Digene’s web site for women is a cross between Women’s Day Magazine, 20/20 and a pharmacetical rep training manual. It’s absolutely brilliant marketing. Chock full of anectodal survivor stories to warm the heart and scare the bejesus out of the reader. If you weren’t worried about cervical cancer before you came to the site, you sure are now. Then, once they’ve got you good and scared, they sweep in on the white horse to offer you the cure – the HPV test.

But there’s one problem – Routine HPV testing, although FDA approved, is not the only strategy recommended for cervical cancer screening. And there’s the little problem of that darned doctor…

Not to worry. Digene is going to coach you so you can convince your doctor to give you the test. Here’s just a little bit of their advice:

Call your doctor’s or nurse’s office before your next exam to find out if the HPV test is offered as part of routine screening for cervical cancer, along with the Pap. Remember: Make sure the office understands that you want the HPV test no matter what the Pap test shows. Some doctors and nurses only order an HPV test when your Pap results are inconclusive (called an “ASC-US” Pap).

If your doctor or nurse says the office does not order HPV testing for all of its patients who are 30 and older, indicate you’d like them to make an exception for you.

If your doctor or nurse (or the office staff) responds by saying he/she doesn’t think routine HPV testing is necessary, the simplest way to respond is to say that you would still like to have the test “for my extra peace of mind.”

That didn’t work? No problem. Digene has a full page of strategies for women to use to convince their doctor to give them the test. I swear, it reads like a pharm rep training manual. Every possible response from the doctor is covered, and Digene has an answer for each one of them. And they all end with telling the doctor that you want the test for “extra peace of mind.”

“Talk to your doctor” has turned into “Sell our test to your doctor”.

And the survivor stories? Well, if you have ever read the cancer stories in Women’s Day or Glamour, you know how they read. Anectodal horror stories that will convince anyone reading them to run out and get the HPV test right away. All implying that if these women had gotten an HPV test, things would have been different. Maybe…

Digene can take the story of a woman whose HPV test added absolutely nothing to her health care and make it sound like a survivor story. This woman got not just one, but four HPV tests over three years for a transient HPV infection that never resulted in a single abnormal pap smear or any need for treatment. Here’s what she says about it:

This experience taught me the importance of not being afraid to ask questions and make decisions with my doctor, rather than letting him make all of the decisions for me. Demanding the HPV test may have saved my life.

She never had an abnormal pap. She did not develop cervical cancer or even cervical dysplasia. But the HPV test “may have saved her life”.

Now, I could give you a few anectodal stories about women whose HPV test was negative, but whose pap showed high grade dysplasia. (No test is perfect, not even the HPV.) Or women whose relationships were broken up by an HPV test that added nothing to their health care. Or physicians who do the HPV test on every patient, only to have patients get angry at them for finding a condition that basically has no cure and hasn’t changed anything except to creat anxiety. I could even make a website about it, and coach you into talking your doctor out of that routine HPV test.

But I won’t.

Because you should talk to your doctor about the HPV test, not me. Someone who hopefully knows you, knows about the test, and together with you can decide if having the test is right for you. Because routine HPV testing is not necessarily the best strategy for every patient and for every medical practice.

And for the record, do I ever order HPV testing on a woman with a normal pap smear? Sure I do. But that’s a decision I make on a case by case basis, one that the patient and I make together after discussing the reasons for and against the test, the cost implications, and what we will do about the results if they are abnormal.

It’s not a decision she has been talked (and coached) into by a company trying to market that test.
__________________________________________________________________

For patient information about the HPV test, see the American Cancer Society Website.

Clinician information from the Centers for Disease Control.

Financial disclosure: I used to own Digene’s stock, and even made a few bucks on it back before the test was being used in clinical practice. I knew HPV testing was going to become part of women’s health care. I didn’t know Digene was going to annoy me this much…

Category: Second Opinions

A Brazilian Thanksgiving Eve : Moqueca de camarão, Mango & Avocado Salad and Pudim de leite

I know, I know. It’s ridiculous. But every year, on the night before Thanksgiving, we have a dinner party.

You see, my friend Andy and his daughter are clowns in the Macy’s Thanksgiving Day Parade. So their family stays with us the night before in order to be able to get to the parade on time (5:30 am for the clowns), and we all have a nice dinner together. For the past two years, our friends in from Maine have also joined us. It’s a wonderful, low-key evening, and I look forward to it every year. I try (usually unsuccessfully) to keep the fare light, and we all try to end the evening early so the clowns can get to bed.

Of course, part of the reason I can enjoy Thanksgiving Eve is that I do not have to cook dinner the next day. We head to Philly on Thursday morning, and tag team two family back-to-back dinners. (Don’t ask… ) I usually bake a pie and bring some sides, but that’s the limit of my responsibility.

This year’s Thanksgiving Eve dinner was a challenge. Isabelle cannot have anything fermented or with cow’s milk, and one of the kids is now a vegetarian. It took awhile, but I finally hit on the perfect menu – Brazilian fish stew (most of which is made ahead), and mango and avocado salad with a lime vinaigrette. Dessert was flan with fruit. (Oops, Isabelle. I got so caught up with the Brazilian theme I forgot about the milk. Did you even have dessert?) We served a white pinot, but I don’t know if this was the best choice of wine. Suggestions are welcome…

The kids set the table with the fancy dishes, and we put up votive candles all around the apartment. Emily S. Arrived early and helped us set up the appetizers (Thanks, E.S.!), which were crostini topped with chopped liver or white bean and sage puree, olives, baby carrots, apple slices, roasted peppers in oil and a wonderful sheep’s milk cheese from Fairway.

I had a great time. This year, the clowns were in bed by 10:30 – not too bad – and the rest of us hit the sack by 11:30. Thanks, Linda for doing the dishes. We missed you Sam, but hope to see you at Christmas. Happy Thanksgiving!

Moqueca de camarao (Brazilian Fish Stew) (See original recipe at Epicurious.com)

This goes down in culinary history as one of the best dishes I have ever had. It’s a great dish to make to amaze your friends, and so easy.

The original recipe calls for pureeing the diced tomatoes, but I chose to keep them whole. I’ve also re-written the recipe to reflect how I prepared it ahead. If you are making it just for yourself, and not ahead of time, use the Epicurious version. I was not able to find dende oil (red palm oil) at my usual sources (Fairway and Gourmet Garage), but am determined to get it before I make this again. I cannot imagine this stew could taste any better than it already does, but from what I have read, that oil puts the flavors over the top.

Sauce
1 1/2 tablespoons olive oil
1 medium onion, finely chopped
1 green bell pepper, finely chopped
1/2 teaspoon cayenne
1 tsp salt
1 tablespoon coarsely chopped fresh cilantro
1 (14- to 15-oz) can diced tomatoes including juice

1 cup well-stirred canned unsweetened coconut milk (to be added just before adding shrimp)

Shrimp marinade
1 1/4 lb large shrimp in shell (21 to 25 per lb), peeled and deveined
1/4 teaspoon black pepper
1/2 teaspoons salt
2 garlic cloves, minced
1/4 cup fresh lemon juice

Last-Minute Additions
1 tablespoon dende (palm) oil
4 tbsp coarsely chopped cilantro

Accompaniment
Cooked white rice (I used Basmati)

Cook onion and bell pepper in olive oil in a 12-inch heavy skillet over moderately low heat, stirring, until softened, 8 to 10 minutes. Add cayenne, 1 tablespoon cilantro, and 1 teaspoon salt and cook, stirring, 1 minute. Add tomatoes and simmer briskly, stirring, until mixture is very thick, about 15-30 minutes.

Make marinade and keep, covered, in the fridge till you are ready to use it.

About 40 minutes before serving, start your rice cooking. Then toss shrimp with marinade in a large bowl, and let sit in fridge, covered, for about 20 minutes. (Not any longer, or you will have ceviche).

5-10 minutes before serving, stir coconut milk into sauce and bring to a boil. Add shrimp mixture and cook, stirring, until shrimp are just cooked through, about 3 to 5 minutes. Stir in dende oil and remaining 4 tablespoons cilantro and season with salt and pepper.

Plate individually, first putting rice into a small bowl, then inverting it onto the plate. Spoon the stew over the rice. Keep bowls of stew and rice on the table, though – everyone will want seconds!

Mango and avocado Salad with Lime and Honey Vinaigrette

salad greens (We mixed red lettuce with mesclun)
large ripe mango, halved, pitted, peeled, sliced
2 small avocados, halved, pitted, peeled, sliced
Juice of 1/2 lime
3 tbsp honey (Depends on how tart or sweet you like it.)
1 tbsp hot water
½ cup olive oil
Salt
Pepper

Whisk the honey and lime together with the hot water. Gradually whisk in the olive oil. Season with salt and pepper to taste. Toss greens with ¾ of the dressing. Arrange mango and avocado on top of greens and drizzle remaining dressing over them.

Pudim de Leite (Brazilian Flan)

There are many ways to make flan. Some recipes use eggs, others add corn starch or use cream instead of milk. All start with caramelized sugar, which forms the base (and later, the top) of the dish. This is the Brazilian version, from Maria Brazil web site, with a few modifications on my part. You can use a ring mold if you are being traditional. I used a Pyrex glass dish.

1 cup sugar (for the caramel)
1 12-oz cans sweetened condensed milk
Equal volume of regular milk (use the can to measure)
3 eggs
1 quart strawberries, washed and drained
Lovely cookies

Place 1 to 2 inches of water in a large roasting pan. Place the pan in the oven and preheat to 325°.

Put the sugar into a heavy saucepan. Heat over medium high heat, stirring almost constantly, until the sugar melts into a golden brown caramel. (Watch carefully, it goes slowly, then turns color quickly.)

Pour carefully into pyrex dish or mold. (Listen for cracking noises as the sugar cools and cracks!) and spoon it a bit up the sides of the dish. Be careful not to burn the sugar and yourself. Let it cool.

Whisk together the condensed milk, regular milk and eggs. Pour this mixture through a fine sieve into your prepared dish. (This gets any little egg lumps out).

Place the dish carefully into the center of the roasting pan with water. Bake for about 1 hour. (You will know it is done when you can insert a knife inserted into the center without the custard pooling into the defect you made.) Carefully remove the dish, Let it cool to room temperature and then place in refrigerator for at least 6 hours or overnight.

Just before serving, run the tip of a knife around the inside of the mold. Place a deep platter over the mold and invert: the flan should slide out easily. If not, give the mold a firm but careful shake. Cut into squares. Plate with a spoon of caramel sauce on top, two strawberries and a little cookie.

Serves about 10.

Category: Food

The Perfect Scone? Sorry Delia, not quite…

In our first attempt at making the perfect scone, my daughter Natalie and I made some pretty tasty scones, but the texture was not as light as we’d hoped. We tried Ina Garten’s scones next, and came up with a lighter scone that seemed a bit dry.

Thanks to my reader’s comments and a little research, I’ve figured out that the scone I am looking for must be an English scone, which it seems, is more akin what we Americans would call a biscuit. Given that the first scone I’d ever had was in Bath, England, that made sense to me.

So last weekend, at the suggestion of both Waynetta and Chairwoman, I finally tried Delia Smith’s Scone Recipe (complete with photos, here). Delia is sort of the Julia Child of Britian, a TV chef who made cooking seem simple, and whose recipes are known to be tried and true. (You can read her BBC bio here). I figured that if Delia didn’t have the right British scone recipe for me, no one would.

The first thing I noticed about Delia’s recipe was that she recommends the butter be at room temperature, which goes agains everything I’ve come to learn about making pastry, and is the exact opposite of the recommendation in my Professional Chef, namely, to put the butter back in the fridge after cutting it up to be sure it stays cold until the very last minute. This was my first inkling that perhaps Delia’s recipe would not be the best…

I decided to stick with the Professional Chef, and kept my butter cold. Otherwise I followed Delia’s recipe exactly, even using castor sugar and a round biscuit cutter (except I added chocolate chips).

The first batch was made with daughter and her friend. The kids took a little longer than I wanted working the dough, and it really became too cookie like. So I made a second batch myself, working like lightening to keep the dough light. Mine is on the left up there, and the kid’s scone is on the right.

They look great, and the flavor was great. But you know what? The scones were too dry. I know scones are meant to be eaten with clotted cream or jam, but still I was disappointed. I think the recipe I seek has a bit more liquid than Delia’s. In fact, when I look at biscuit recipes, they definitely have more liquid.

So it’s back to the drawing board. Next up, I think I will try the Cook’s Illustrated scone recipe. If anyone knows where I can find it, do let me know.

Of course, it may be that what I am looking for is not a scone, and perhaps doesn’t even exist. But I have this memory of a warm, light, not dry scone with clotted cream sometime in my culinary past (perhaps in Bath?), and I’m determined to make it…

Addendum: I Found it! The Pefect Scone.

Category: Food

Suzanne Somers on Larry King Live

Suzanne Somers appeard on Larry King last night, supposedly to take on her critics in the medical establishment who, like me, are concerned about the misleading medical information contained in her best selling books. (See my recent post on suzanne and the bio-identical hormone hype.)

What could have been an informative debate ended up being a cat fight that did nothing to inform American women about the real issue. That issue is the unfettered promotion of bio identical hormones as a risk-free cure-all for everything from depression to cancer to getting old.

Neither Suzie nor her critics got to say more than a few uninterrupted words at a time, and Larry seemed unable to control his guests or to frame the debate. When he did attempt to give some context, he focused on the personal battle between two of the guests, a physician and an unlicenced practitioner of anti-aging medicine. (You could read the transcript here, but don’t waste your time.)

Wolf Utian, the head of the North American Menopause Society, and probably the most objective of the guests, was unfortunately placed at a distinct disadvantage given his consultant work for Wyeth and his society’s Big Pharma support. (One more argument for disentangling the medical profession from Big Pharma.)

The fact that Wyeth appears to be leading the charge against Suzie and her anti-aging consituents is unfortunate. Wyeth’s involvement only serves as a lightening rod that distracts from the real issues and hurts the credibility of those in the medical establishment who want to see the FDA regulate the multi-billion dollar anti-aging and compounding pharmaceutical industries. These folks love to play themselves as the little guy against Big Pharma, and as long as Wyeth stays in the fight, that’s how they get to frame it.

This is not about protecting Big Pharma or defending Prempro. It is about informing women. Wyeth needs to step out of the fray.

Category: Second Opinions

The Seven Songs Music Meme

Okay, it’s been over a month since Tundra PA tagged me for this meme, and it’s about time I got around to answering it.

A meme is an idea that is passed from blog to blog, and doing a memes are a great way for bloggers to get to know one another and to share a bit of themselves that they otherwise might not think to do.

This meme asks that I list seven songs that I am currently listening to, and then to tag seven other bloggers. This meme is so old, everyone else has probably already done it by now. But if you haven’t done it yet, consider yourself tagged and do it already, it’s a lot of fun! (Linda and Main Mama, this means you..) Thanks, Tundra PA, I really enjoyed this one…

Click on the red links to hear the music or view the album…

1. Graceland – Paul Simon

I never tire of listening to this gem, truly one of the best albums ever released. The music is fantastic, a mix of American and African rythyms plus a little Ladysmith Black Mombasa, and the lyrics are sheer poetry. Not to mention alliteration – “the boy in the bubble and the baby with the baboon heart”.

I know every song on this album by heart, and have even invented some cool moves for the “whoop, whoop” parts of the song I Know What I Know. One time we were driving to Maine with our friends, two cars playing tag along Rt 95, all the kids somehow in our car. Our friends passed us at one point, and later told us they knew exactly what song we were listening to because everyone in the car was doing that “whoop – whoop” move.

My favorite memory of the Graceland album, though, is from my fourth year of ob-gyn residency, in the days when in vitro fertilization was in its infancy. On this particular day, we were implanting embryos from our very first batch of frozen embryos. The patient was special to all of us, having gotten to know everyone intimately over the course of her treatment. (These were also the days before IVF became a mill.). Both the patient and our chief loved music, and she used to bring in mix tapes for him whenever she came for her appointments.

On the day of the embryo implantation, our patient dressed herself in a beautiful cotton nightgown instead of the hospital gown. She insisted that we turn down the lights so that only the procedure light was on. Then, while her tape player played These are the Days of Miracles and Wonder from the Graceland album, my chief implanted the embryos. It was almost too intimate and beautiful a moment for words.

She conceived, of course, and went on to deliver healthy twins. A miracle and a wonder, truly.

2. Flower Duet from Delibe – Lakme (Natalie Dessay et al)

Remember that sweet little movie from the 1980’s “I Heard the Mermaids Singing“? In it, there is a gorgeous opera aria that plays while the heroine flies through the sky. For years I’ve wondered what that aria was, and thought that I would love to learn to sing it.

Now I am no opera buff. I think I can recognize Madame Butterfly, and I know the movie Rent is based on La Boehme, but that’s about it. So it took me awhile to find out that this lovely aria is actually the Flower Duet from the opera Lakme’ by Delibe. (Click here to view it performed by Dessay and Maurus. Wait through the intro, the best part comes just after it…)

I bought the CD last month and have been listening to the song ever since. It’s actually a lovely opera, and I am enjoying more than just the Flower Duet. (I now have this image of myself really getting to know opera, and listening to the Opera at Lincoln Center on the radio while I cook on Sunday afternoons…)

The next step, of course, is to get the music, and convince someone to sing the other part of the Flower Duet with me. Any takers?

3. I Just Don’t Think I’ll Ever Get Over You (Colin Hay)

One of the best things about having your kids get to the teen years is that they bring new music into your life. And the great news is that there is some incredible new music out there.

Take a listen to this clip from Colin Hays album Going Somewhere, and tell me it doesn’t give you goosebumps…

4. Live at Blues Alley / Over the Rainbow- Eva Cassidy

Eva is one of the founding member of my Favorite Female Singers Taken Too Soon Club. (The other two members are Laurie Beechman and Nancy Lamott). I discovered Eva’s music some years back, only to find out that she had recently died from melanoma. Cruel, cruel world…

This album is her best, showing her incredible versatility and soul, as she moves from the jazzy Cheek to Cheek through a bluesy and smoky Stormy Monday to a rockin’ version of Take Me to the River.

But my favorite Eva Cassidy song is her beautifully unique rendition of Over the Rainbow on her Songbird album. Everytime I hear that song, it breaks my heart to think that she is gone. Click here to view a video of her singing this song. and here for a two part ABC segment on her life.

5. Enya (But not on purpose…)

I actually am not an Enya fan, and have never bought an Enya CD or listened to her voluntarily. When you call my friend Lori’s office and get put on hold, you can hear Enya. So sometimes I hear her then. But mostly, Enya wakes me up in the mornings.

You see, my neighbor, whose roof garden ajoins ours, waters her garden every morning at 6:30 am while listening to music. She seems to be particularly fond of our friend Enya over there. And so most mornings, Mr TBTAM and I, who sleep in our upstairs bedroom with the door open to our garden, are awakened to the sound of Enya’s singing.

And do you know what? It’s not a bad way to wake up. Except that while you are in that state between sleeping and dreaming, you start to wonder if maybe you died in your sleep and that the angels are singing…

Of course, now that the cool weather has arrived, Enya has taken to the indoors. Too bad – Now I have to listen to the damned alarm…

6. Nancy Lamott – Live at Tavern on the Green

As I mentioned before, Nancy Lamott is another member of my Favorite Female Singers Taken Too Soon Club. Nancy is one of the greatest cabaret singers of our time, not because she brings the house down with her voice (although she does), but because she epitomizes the intimacy, warmth and spirit of cabaret.

I was introduced to Nancy though one of my favorite radio programs, The Saturday Show with Jonathan Schwartz. I ran out to buy this album, fell in love with it, and then headed to the web where I learned that, tragically, Nancy had died from uterine cancer shortly after recording it.

A loss, to be sure, but I am thankful that we had her for the time that we did. Best song one the album? Hands down, Listen to My Heart.

7. Hallelujah – Rufus Wainright or Jeff Buckley?

Leonard Cohen wrote the song, but the definitive version belongs to Buckley. However, I really like Rufus’s version, recorded on the soundtrack of Shrek. His voice, the ease with which he sings, the piano instead of the guitar.

Here’s an amazing video of Buckley singing Hallelujah. Then check out Rufus doing his version on the Shrek Soundtrack, or in concert. You decide, I can’t.

And more…
This was very difficult for me, choosing just seven. I feel like I left so much out. So here’s a sample of what’s in my CD case (I don’t have an ipod yet…) Click on the links for the album. Enjoy!

Keith Jarret – Tokyo ’96 [Live]

Lyle Lovett and His Large Band

I am Sam Soundtrack

The Divine Miss Sarah Vaughan

Gillian Welch – Revival

Profile – The Best of Emmylou Harris

Norah Jones – Come Away with Me

Category: Considerations

Not Snickers

It’s a week after Halloween, and we’re down to the bottom of my kid’s candy bags, sifting through the empty wrappers and stale Tootsie Rolls hoping to find that last Snickers, and coming up only with Milk Ways and Three Musketeers. (No one in our house ever eats those.)

After that, the only candies left are the Starbursts, Gummy Bears and other pure sugar treats that only a kid can love. As far as we grown-ups are concerned, once the good chocolate is gone, it’s all over. Now the kids can finally have the candy to themselves.

What’s left in your kid’s bags?

Category: Food

He Dispatches Smiles (and Lunches)

This is the fourth in a special TBTAM post series called “I Get It On the Streets“. Links to the next post in the series are at the end of each post. Enjoy!

Vinnie is the MTA bus dispatcher who works on the corner near my kid’s grade school. For years, every weekday from September through June, our girls walked past that corner to their school, usually in the company of our baby sitter, although I was occasionally along for the walk. And Vinnie was there, rain or shine, always with a hello and never, ever without a smile.

Vinnie is the quintessential New Yorker, with a Brooklyn attitude and the accent to match. He’s also a pretty cool guy – In addition to cutting a suave figure in his MTA uniform, he sports a little earring in one ear and has a trim pony tail. I’ve never gotten close enough to tell, but I’ll betcha’ he wears a nice after shave.

Vinnie knows my kids by name, and is great buddies with our baby sitter, but he just calls me “Mom”. And that’s just fine with me.

These days, the girls have moved on to new schools, but they still pass his corner almost daily, more often with friends instead of our sitter. When I pass, Vinnie comments to me how beautifully they are growing up, and how time flies…

You may wonder what that is under the tree there where Vinnie is standing. Glad you asked – It’s his Graveyard of Fame…

It started out as a funny little Rock n’ Roll Graveyard, a “tongue-in-cheek” tribute to Vinnie’s favorite dead rock and rollers – John Lennon, Freddy Fender, and Richie Valens, to name a few. They each had their own little tongue depressor tombstone, some fancier than others, all special in their own way.

Over the years, the graveyard has grown into a memorial to anyone famous who has died and who Vinnie decides is worthy of a special place in his cemetery. June Allyson, Billy Preston, Rosa Parks. (Who else can you spot?) Markers come and go, some are stolen at night, some are added by strangers, but all are ultimately vetted by Vinnie. The graveyard has made him a minor celebrity here in the Big Apple, and even garnered a recent photo op in the NY Daily News.

When I walked by the other day, Vinnie made sure I saw his most recent addition to the graveyard…

l’ll bet everyone in the neighborhood has a Vinnie story. But since this is my blog, you get to hear mine –

One morning about 3 years ago, my eldest daughter left her lunch in our building lobby on her way to school. Coming along just a few minutes behind her, I saw it on the table and decided to try to catch up to her. I did pretty well for the first few blocks, but gradually, weighed down with my laptop and wearing heels, I began to lose steam. She was in sight, a block away, but the wind was blowing towards me, so I got no response as I yelled her name at the top of my lungs.

As I approached Vinney’s corner, he saw me and immediately sized up the situation. “I’ll get her, Mom !” he cried, and like the winning runner in a relay race, grabbed the lunch bag from me and delivered it my daughter, making it back to his corner almost before I could finish crossing the street.

Now that’s a dispatcher!

Next up: The Knife Sharpening Guy

Category: Considerations