Monthly Archives: July 2008

Cancer Stats Deliberately Altered

Someone’s been messing around with the cancer statistics in Maryland. Apparently a private vendor, which had contracted to collect the statistics, was responsible.

Here are specifics from the FHA report itself.

..MCR data (for 2001 and 2002) had been deliberately altered between August
2004 and December 2004. Specifically, over 13 percent of all cases in diagnosis
year 2002 showed some sign of alteration, especially cervical, prostate, and melanoma cancer cases. The investigation disclosed that the changes were made
after the cases were initially entered into the MCR by the laboratory facility or provider (such as, changes to the codes from non-invasive cancer to invasive cancer and changes to the year that the diagnosis was made)…

The vendor concluded that these changes were methodical and were made by one or more persons with broad access to the system, and not a result of a random set of events.

As a result of the aforementioned changes, recipients of the MCR data (such as, federal Centers for Disease Control and Prevention, NAACCR, other states, and researchers) were obtaining and using incorrect data.

It’s unclear as to what the motivation was for over-reporting of cancer statistics.

Given all the politics around cervical cancer vacination at this point in time, this information is sure to cause concern, although I’m not sure to what use, if any, the 2002 data may have been put in this regard. Studies I’ve seen that examined the cost effectiveness of HPV screening and vaccination used much earlier cancer incidence data.

Two Weeks and Nine Pounds Down…

and I’m still going strong on this diet of mine.

I actually lost weight while on my own last weekend at our cottage, but could not wait to get back to my delivered food on Monday. When’s the last time you couldn’t wait to get back ON a diet?

This is not to say it has been entirely easy. I’ve had a few shaky afternoons, and the headaches were no fun. My kids have commented that I’ve had some pretty irritable moments with them, but I have to say that overall, I feel much more calm. I did finally add skim milk in the mornings (decaf cappuccino with a bit of Agave nectar) and before bed with my evening snack. With that, the early morning headaches are better.

Health pluses

1. I’m snoring much less already, according to Mr TBTAM.

2. My reflux is better.

3. Most importantly, I am feeling so good. The biking probably has something to do with this as well – three times a week at this point, though I’d like to increase that over time.

Psyching myself out

Tonight was a bit of a milestone for me. We were set to meet a family from Barcelona, in preparation for our kids doing a student exchange with one another next year. I had originally planned to have them all over for dinner, on a weeknight. Which would have meant my running home early from work, scrambling with Mr TBTAM to make something incredible, then worrying if everyone was happy and fed, then cleaning up after everyone had gone (and blogging it, of course…) In an amazing move (you have NO idea how significant this is) I suggested we meet downtown at their hotel instead and go out to a restaurant. It was a perfectly lovely evening, and I had a great time. And ordered a wonderful grilled shrimp on arugula that fit perfectly with my diet.

I realized that a lot of my cooking is me trying to get others to like me. Which doesn’t mean I don’t love to cook, because I really do. But if cooking becomes mostly about doing something I love more than about trying to impress, it just becomes that much more fun, right?

Oh, the things I am learning about myself…

I have just started reading Judith Beck’s book that offers Cognitive Therapy as an adjunct to dieting. Because if I am successful at getting the weight off with this diet, the last thing I want to do is regain it all. Will let you know what I think as that goes on.

What Diet am I on?

It’s probably not important which Diet Home Delivery Service I am using, but if you want to know, you can check out their web site. If you want to see exactly what they are serving daily, go here.

For me, it’s not whether it’s the Zone or Atkins or South Beach. I lose weight no matter what diet I am on. But what I haven’t been able to do for a very long time is stay on any diet. Having someone else take care of the food is what is making this one work for me right now.

More to come…

Who’s Your Mommy?

Apparently, more and more women are nursing each other’s babies, a practice called Cross-Nursing.

I think that it’s just not been our social norm,” said Morgan McFarland, who has been breast-feeding her friend Sarah Griffith’s son since he was just 3 months old. “In some cultures, it is, and you would think nothing of, you know, nursing your neighbor’s child if something happened, or nursing your sister’s baby if she has to go to work.”

While I can understand this practice in primitive societies where refrigeration and infant formula are not affordable or available, or for the rare woman who cannot breastfeed for medical reasons, I see no reason for such practices in the modern society, especially for the reasons cited in this article, namely “community and convenience”.

Breast feeding is an intimate, bonding act between Mother and Child. Why would anyone want to share that with another woman?

Are there Health Risks?

There is little to no data on long term outcomes for infants fed with breast milk from someone other than their own mother. One should not assume the benefits are the same as for infants fed with mom’s milk.

Breast milk contains antibodies unique to Mom and shared to some extent genetically with her child, not to mention growth factors and other proteins. What are the impacts of exposing a child to these proteins from an unrelated individual? No one knows.

More concerning for me is that infections such as TB, HIV and hepatitis can be transmitted via breast milk. In addition, medications taken by the nursing woman also find their way into breast milk.

So if you are going to share your child with another woman, you better be pretty darned sure she is free of infection and not taking any medications that could harm your child. I for one would not be willing to take that risk with my child.

Bottom Line

I see no reason why, in today’s society, a nursing mother needs to share nursing with anyone. There are potentially serious risks and no proven benefits.

If you want community and convenience, then join your neighborhood food coop.

(Okay, Commenters, let loose…)

Fresh Air Fund Asks Your Help

The Fresh Air Fund is looking for families willing to host a city kid on their farm or at their rural home this summer. The end of July is nearing, and they still have about 200 children who need placement.

Further information at http://freshair.smnr.us

Dr Bubbe

Oy! Such tsuris. All these nice, pretty, young patients of mine dating on the Internet. Such nice girls. Why can’t they find a young man to settle down with? Is it so wrong for me, their doctor, to want them to be happy?

Take my patient Rachel H. Such a shaina maidel!She’s 36 years old, and doesn’t look a day over 25! She comes to see me today for her annual check up, and we schmooze a little after her pap smear. You know, a biseleh girl talk…

Afterwards she sends me an email to tell me the visit has inspired a new chapter in her forthcoming book entitled – “Tequila Has No Carbs; and other things that are important to know when dating in New York City”.

I get a little verklempt just thinking about it! Me – in a Book! But I’m going on. Here, let Rachel tell you all about it…
______________________________________________________

So, worse than the scrutiny by my Jewish grandmother as to why I’m not married is the conversation I have yearly with my gynecologist as she looks at my date of birth on my chart and then immediately says, “So, seeing anyone special?”

I look down at the floor shaking my head in shame, because of course, I have also indeed checked the box that says “YES, I have had new sexual partners since my last visit.”

Have you tried “eHarmony? I have a patient who just got married…”

She actually listens with great interest as I explain to her my friend Jen’s marketing theory surrounding Internet dating – and how few men despite how good the date is, are going to commit easily when 7 blondes have e-mailed him between our last martini and the time he gets home and logs on…

I tell her that most men around 40 – fall into a number of categories. After dismissing the divorced with kids, we get to the classic 40 something guy that and all my friends and I have dated – We all know the type – he’s too independent at this point to easily integrate someone into his life – and if he’s attractive and successful – he can get sex whenever he needs it – so why should he settle down?

I mention an exception, a friend that I had dinner with recently whose wife died several years ago… But he’s still getting over it and while he’ll make some girl really happy someday – he’s just not there yet. She nearly jumps out of her seat and says:

“THAT’S THE [type of] GUY YOU WANT!!!”
(and she’s getting really excited and animated now…)

“OR – THE GUY WHOSE WIFE CHEATED ON HIM!”
(at this point she’s squealing so loud nurses are surely starting to detect the conversation behind the closed door…)

“HE’S CAPABLE OF LOVE!!! THAT’S A GUY YOU WANT TOO!”

So I left the gynecologist this morning, one pap smear down, another few years reprieve from my first mammogram, with the following advice:

Place an ad:
Wanted: Damaged Goods.
Has your wife died or left you? If so, call me…
________________________________________
Tsuris = Serious worry
Shaina Maidel = a pretty girl
Biseleh = just a little
Ken Ayina Hora = lit. = without the evil eye, “not to jinx it”
Verklempt = How you feel knowing you’re meeting Barbra Streisand. A voice like BUTTA!

Food Blogging at it’s Best

This post by Shuna Fish Lydon, a pastry chef in San Francisco with a blog called Eggbeater, is quinessential food blogging. It combines wonderfully enjoyable prose (in Shuna’s inimitable poetic fashion), judiciously placed links and photos to create the perfect blog post about the perfect cup of mocha, at a place called Blue Bottle Coffee.

Read and enjoy.

ps – Shuna also made the NY Times this weekend, in an article by Amanda Hesser.

Someone is Feeding Me

I signed on to one of those diet delivery services, with three fresh meals and 3 snacks delivered right to my door every morning in a little black cooler.

The food ranges anywhere from fabulous to just fine (that’s a particularly delicious lunch in the photo up there), and I’ve lost 5 lbs in four days. I’m giving up caffeine in the process (can’t drink coffee without half and half and sugar, so it had to go), so I can’t say I feel fabulous yet, but I expect that will follow.

What I’m finding is that this diet is NOT about the food. The food is taken care of, and it’s out of my control – except for restrictions I might put on it, such as no vinegar because it gives me headaches. The meals are good enough that I enjoy what I am eating, but can’t over eat. I just eat what they give me, and that’s that, on the schedule they suggest.

Which leaves me to deal with the emotions that come up when I can’t use food to stuff them down. It’s the closest thing to going cold-turkey that I can imagine.

I’ve probably cried more in the past 4 days than I have in months. Not about anything in particular, or anything serious – just raw emotion coming up. Seeing Mama Mia last night, for instance, was a real wellspring. (Fun movie, by the way. A bit silly, but hey, why not? It’s summer, and a chance to see Meryl Streep singing and doing air splits and catch a little Colin Firth eye candy.) Maybe it’s just the caffeine withdrawal, but I really think it’s more than that.

Because in the end, my weight is not about the food. It’s about what I use food for other than sustenance. Now, someone else is dealing with the food. Leaving me to deal with the rest some other way.

So stay tuned. This is going to be interesting…

Week 2 Update

Touched by the Dalai Lama

Okay, I realize I am outing myself here, but it’s only for one post and it’s only because my sister writes such a great newspaper column, and I just have to say that this was one of her best.

Go read it and see if he touches you, too.

Love ya’, sis.

Abortion on the Web

In countries where abortion is illegal, a group called Women on Web is offering medical abortion over the Internet. (via National Women’s Health Report)

Clients complete an online questionnaire and are then contacted by a doctor who prescribes the medications that are then taken at home to induce abortion. The medications are mifepristone (RU-486) and buccal Misoprostol. (Buccal is holding the medication in your cheek till it dissolves.) The vaginal route for misoprostol is avoided so that no evidence of pills is left to implicate a user.

The group has published outcomes on 484 women from 33 different countries who received their services in 2006-7. Follow up was obtained via e-mail or phone for 367 women.

About 8% of the women never took the medication. For those who did, outcomes were reasonable for the method used – Between 6 and 12% reported having to have a D&C for bleeding or incomplete abortion, which presents as an early miscarriage and can be treated safely in a medical setting. Continuing pregnancy rates were less than 2%.

These results are similar to those reported in the initial clinical trials of mifepristone here in the US.

The Royal College of Obstetricians & Gynecologists has released a statement saying that it “neither approves or disapproves” of the work provided by Women on the Web. More from that statement –

The results from the study demonstrate that Early Medical Abortion is safe and acceptable to women, confirming other studies including the recent pilot study conducted by the Department of Health in May. The study also shows that women are capable of safe self-administration of drugs provided they receive good and clear instructions, are aware of the possible side-effects and the nature of complications which indicate that further medical attention is required.

And more from the BBC on the UK reaction.

What are the legal issues?

Women on the Web claims its services are legal, even in those countries where abortion is not, since the receipt of medications for home use does not violate customs laws. They do not offer the service in countries where abortion is legal.

The Women on the Web Site

I went to the site, and have to say that I am quite impressed with the quality of the service.

Women are told to go have an ultrasound if it is available to confirm their gestational age before using the service. (Ultimately 80% do so, an impressive percentage) For women where ultrasound is not available, instructions are given to determine gestational age, which prior research has shown to be accurate in most cases.

All cases are reviewed by a doctor for contraindications before medication is released. (I wish they had reported how many women were refused medication for medical reasons or referred elsewhere so I could get a handle on this aspect of the care.) Women are told to seek care for complications in a medical setting. Warnings about undiagnosed ectopic pregnancy, probably the most serious risk of this procedure, are clear and frequent.

The site uses idealized data from other clinical trials in their information about complications. (Now that they have their own data on outcomes, I would urge the group to use that info to guide women in their decision as to whether or not they wish to use this service.)

The site also asks women to post a photo and /or their experience on the site, in an attempt to remove the shame surrounding the procedure. For women who don’t want to use their own photo, the generic photo up there is used. The photo is a sexy, braless blonde in a mini dress. …what’s that about?

How do I feel about this?

Uncomfortable is probably the operative word. I like to see medicine practiced face to face whenever possible. Plus, I’m a law abiding citizen, whether I like the law or not.

But I know that I feel this way because I practice medicine in a country where abortion is safe and legal (for now, at least). If I were practicing in one of the countries where abortion is illegal, and seeing the consequences of those laws in the lives and health of my patients, I might feel very differently. As a physician, I’d probably prefer to handle the miscarriages that result from an early Internet-based medical abortion over the complications from a botched curettage.

Mostly what I hope is that someday, contraception will be free and available to all women so that few women have to seek abortion, legal or illegal.

Doctors Dropping Medicare – The Domino Effect

When the docs in my area began dropping Medicare, their patients had no where to go but to the docs like me who still participate in the plan.

And so, over the past year or so, I began seeing more and more new older patients in my practice. The shift in my practice demographic was almost palpable as these new Medicare patients began filling my appointment book months in advance for routine annual visits. Add in a few retiring docs, and the influx of older women became too much to ignore.

On the day I saw seven new Medicare patients, all coming from the practices that had stopped taking Medicare, I knew that I had to do something.

The Practice Impact

Now I already see more Medicare than most of my colleagues in 0b-gyn. I’m known for managing menopause, and that tends to draw an older crowd to start with, who move into Medicare as they age. Plus, I like the older patients, and almost went into geriatrics at one point.

But this was getting to be too much. The Medicare patients were taking all my new patient appointments.

You see, unlike younger patients, Medicare patients usually call far in advance for their appointments, and fill up my new patient slots for weeks to months at a time. That leaves no room for the 25 year old who just moved to Manhattan and needs her pills refilled within the month, the 35 year old who thinks she is pregnant, the 45 year old with hot flashes who can’t wait till March, the Italian tourist with the UTI or the 16 year old whose mom just found out she was having sex. If I don’t have the slots to see these patients soon, they’ll find someone else who does.

These younger patients provide the variety that drew me to this field in the first place – the opportunity to care for women at all stages in their reproductive lives, with medical problems that change with each decade. My research arena is contraception and std’s, and that means younger patients. I especially love the teens, and ran the adolescent gyn and teen pregnancy clinics at my former jobs. I really missed seeing these patients in my practice as the older patients began taking all the new patient appointments.

What are the financial impacts? Well, if the visit is medically complicated, Medicare pays reasonably well for my time, although it’s still less than half of what I get from managed care for the same services. At current volume levels, it’s not that much of a problem. But if Medicare were to increase much beyond that, it could impact the bottom line significantly.

And finally, I have to be honest and admit that my temperament is not suited to seeing a large volume of elderly patients in one day. I can’t stand having patients waiting in my waiting room because I am behind. Older patients just take more time per visit, no matter what the reason. I can handle a few Medicare patients a day, no problem. But more than, and I am guaranteed to get behind on schedule. And that stresses me to no end.

My Response

In response to this rapid change in my practice demographic I advised my staff that if a non-Medicare patient called, for whatever reason, she got offered an appointment immediately, even if it meant adding her onto the beginning or end of an already full day.

I thought that would solve the problem.

But after a few months, it became clear that this was not working. New patient slots continued to be filled months in advance by the Medicare patients.

So I put a moratorium on new Medicare patients except those referred by colleagues for a problem. I am continuing to see my current Medicare patients, as well as my own patients who transition into Medicare.

I feel terribly guilty about all this, but it’s working. I’m seeing more and more new younger patients. The Medicare new visits are still coming, but on a more limited basis, and overall Medicare now comprises about 20% of my visits. Which is fine for now. This solution is working for me and for my current patients, as well as for my referring docs.

Of course, it’s not working for those women out there still looking for a new gynecologist.

Sorry, Doc

No more pens and mugs.

WASHINGTON — The pens, pads, mugs and other gifts that drug makers have long showered on doctors will be banned from pharmaceutical marketing campaigns under a voluntary guideline that the industry is expected to announce Thursday. (Via NYTimes)

Would cold, hard cash do instead?

I’m from Philly

So says the Accent Quiz. Amazingly correct. Try it yourself.

What American accent do you have?

Your Result: Philadelphia

Your accent is as Philadelphian as a cheesesteak! If you’re not from Philadelphia, then you’re from someplace near there like south Jersey, Baltimore, or Wilmington. if you’ve ever journeyed to some far off place where people don’t know that Philly has an accent, someone may have thought you talked a little weird even though they didn’t have a clue what accent it was they heard.
The Northeast
The Midland
The Inland North
The South
Boston
The West
North Central
What American accent do you have?
Quiz Created on GoToQuiz

Uh Corse, if yuz wanna’ rilly tawk ike a Fluffian, en yuz godda moove ‘ere, dgrive over the Wall Women Bridge to Sener Siddy or Sow Shreet and rute for dem Iggles. ‘En yuz are rilly tawkin ‘ike a Fluffian.
________________________________________

(Hat tip to Addicted to Medblogs, who also appears to be addicted to waste-of-time web things like this quiz, and feels it is her duty to get the rest of us addicted as well. Head on over for more Time Killers)

Summer Squash, Pea and Red Onion Salad with Feta

Mr TBTAM made this wonderful salad from Melissa Clark’s Recipe in today’s new York Times. In addition to getting the recipe, I encourage you to read the article on how she created the recipe – it’s a lovely story about how buying and eating locally can lead to a wonderful new dish.

The salad is delicious, and calls for blanched peas, and raw zucchini. I liked it, but could also see this salad with the zucchini blanched as well. We liked the zucchini slices halved as you see them in my photo up there, rather than whole as Melissa did them.

For the salad, Mr TBTAM used fresh sweet sugar snap peas, which normally we would eat whole, pod and all, raw and by hand – summer’s candy as far as we’re concerned. Now we are left with all the empty pea pods. Any ideas on what to do with them?