Monthly Archives: February 2009

The Tragedy of Jade Goody

Jade Goody, the controversial star of British reality TV, is dying of cervical cancer at age 27. This young woman, who has lived her life in front of the camera for the last 7 years, will die for the camera as well, having sold the rights to film her last days in an ongoing reality show.

Whatever you think of Jade, the publicity generated by her illness has led to a 20% upswing in the number of women getting Pap smears in Britain.

And this is a good thing. Because if Jade’s story causes even one young woman to get the smear that saves her life, it will mean Jade’s death will not have been in vain.

The Irony

Unlike Eva Peron, whose death from cervical cancer occurred in the years before we had access to screening, Jade did get pap smears.

Jade had more than one pap smear, starting in her teens. At one point, she was even treated for precancerous changes of the cervix. And went on to have more follow up smears after that.

But when those follow up smears showed a recurrence of abnormal cells, Jade ignored letters that were sent to her advising her to come in for follow up and treatment.

Why? Because she was scared..

“They had sent a letter to me ages ago, telling that I needed to go in for an operation, but I had been too scared to do anything about it,” Goody confessed.

So Jade put the whole thing out of her mind and pretended it never happened. Until repeated episodes of pain and hemorrhage became symptoms she could no longer ignore. But by then, the tumor had spread beyond the cervix to her uterus. And while a radical hysterectomy and chemotherapy staved the cancer off for awhile, it returned this past month with a vengeance.

And now Jane Goody is going to die.

Let me stop beating around the bush

What has been on my mind all week since I first read about Jade’s story, and what I want to ask is simply this –

Did any health professional ever actually call Jade and try to get her in for treatment in all that time after her Paps came back abnormal? A nurse? A doctor? Anyone?

Please don’t tell me the only contact ever made with this frightened young woman was a series of letters, each one scarier than the next. Please tell me someone called her personally and tried to get her in.

Look, I know Jade was stupid.

No one, even Jade, I suspect, would say otherwise. Ignoring multiple abnormal Pap smear letters was not the first or the last stupid thing Jade Goody ever did. This is a kid who, in front of millions, stripped nude during a game of poker, made an ass of herself shouting racial slurs to an Indian housemate and then gave a blow job under the covers to another housemate. We’re not talking rocket scientist here.

But I’ve seen Jade in interviews that I’ve watched over the past few days, trying to wrap my head around this tragedy. This kid doesn’t hold anything back. She is completely genuine, self-effacing and ready to admit her shortcomings. She’s an idiot, but she knows it. And she is anything but unreachable emotionally. I just can’t believe that someone couldn’t have convinced her to come in sooner if they’d just talked to her.

Please tell me someone tried to reach her.

Jade seems to have had multiple interactions with the health care system during those years between the abnormal smears and her ultimate diagnosis. Times when she visited doctors for pain or gastrointestinal symptoms that were probably related to her growing cancer.

Did these doctors know about her abnormal smears? Did Jade think to tell them? (Probably not…) Were the letters being sent from the NHS cervical cancer screening program separate from Jade’s actual ongoing medical care?

Heck, did Jade even have a source of ongoing care, or, god forbid, a primary physician? I doubt it. This is, after all, a lower class girl from a very rough upbringing – someone, I suspect, whose only contact with the health care system was in public clinics and ERs. She probably bounced around ER’s and hospitals during those years, failing follow up appointments, checking out AMA so she could appear in one or another publicity venue, denying that there was really anything wrong. (Update – Dr Crippen corrects my misperceptions of the British system…)

She even tried to delay her surgery after her diagnosis so she could stay on TV, till they told her she’d be dead in 3 weeks unless she went into the hospital right away.

So maybe I’m completely off base.

Maybe, just maybe, there were docs and nurses who tried to help Jade. Folks who personally called, warned, cajoled and hollered at her countless times, until finally, as a last ditch effort, they sent her a certified letter. Health professional who really cared about Jade and wanted to help her, although ultimately she refused their help.

Maybe Jade was just really that stupid.

I hope so. Because otherwise, the tragedy is not just Jade’s, but all of ours.
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Update –
Dr Crippen reponds to my post with a very thoughtful post of his own regarding Jade.
I respond to Dr Crippen.

For more information about cervical cancer, see these sites –

Jade Goody Photo from Wikimedia

Healthcare Hedging

I saw a patient this morning for an emergency appointment.

The emergency? Her husband is suddenly losing his job due to downsizing at his firm, which is losing contracts in the bad economy. She wanted to get her annual appointment in before March 1, when his insurance coverage ends. (She is a self-employed minister and they have no other insurance.)

Her exam was fine. We got her squeezed in for a mammogram and a bone density tomorrow. (She has had osteopenia and has been on a bisphosphonate for a number of years.)

But here was my dilemma – If her bone density is not improved, I would want to check a vitamin D level and urine NTX. If it is improving, I probably would not do these tests this year.

But by the time I get the results of her bone density, her insurance will have run out and she won’t be able to afford the tests.

So I did the tests today, even though I don’t know yet if I will need the results to manage her condition. She is also refilling her bisphosphonate for another 90 day supply, even though there is a chance I will discontinue it if her bone density is improved significantly.

Of course, their COBRA could end up coming through, in which case we could have waited and potentially saved the system the cost of those test and her meds. But she won’t hear about that coverage till next week.

She also asked if, while I was at it, I could send off “a panel of tests” that she might need in the upcoming year, but that I refused to do. She just saw her rheumatologist 6 months ago, after all.

And I can only potentially waste so much of the American healthcare dollar.

Grand Rounds

Welcome to Grand Rounds Vol 5, no 23! We’ve got a wonderful pot luck menu of great posts from around the medical blogosphere, so sit right down and dig in!

Daily Specials

  • In post worthy of the science section of the New York Times, Sandy Szwarc at Junkfood Science shows us just how misguided NYC’s Health commissioner is in proposing a nationwide low-salt initiative.
  • In his fabulous post Measuring Process, Not Belief, Daniel Lende shows us how Shane Battier’s approach to the game of basketball can be a lesson in managing stress, and how, like the NBA’s stats, we may be measuring the wrong thing.
Appetizers

  • Fat Barbie? Maybe that’s not such a good idea, says Dr Deb. I agree.
  • Peanut allergy sufferers are worried now that peanuts are back as airplane snacks. Allergy notes covers the issue from all sides.
Salads

  • Laika gives us some context for interpreting recent studies sowing a lack of effect of nutrients on cancer risk. Or as she puts it “You are what you eat” depends on who you are.
  • From Insureblog – An update on what Big Pharma’s commitment to transparency in their relationships with docs. I’d say too little, too late, but that’s just me…
Main Course

  • David Harlow wonders if mandated nurse-patient ratios will ensue in Massachusetts now that nurses unions are joining forces, and references a recent California study showing no improvement in patient outcomes with higher nurse-patient ratios in that state. That study contradicts previous research I’ve read on the topic, and I think it’s safe to say the jury is still out on this one…Stay tuned. This is a very important issue, with much to be said on both sides of the argument.
  • Sullydog at Receiving, a group blog from docs at a Detroit ER, asks “Are patients customers of the Emergency Department?”, then gives us 10 reasons why they are not. I like reason #10 the best –
  • If you’re heading out for a seafood dinner tonight, you might want to hold off reading this post by Paul S Auerbach, MD on toxins in fish and shellfish. Then again, forewarned is forearmed…
Sides

  • Toni Brayer, MD has a simple yet elegant recipe for braised cabbage, a food rich in vitamins and minerals.
  • Nancy Brown, PhD teaches adolescents about vaginal discharge. And, since she mentions cottage cheese, it’s on topic!
  • Dr AmAng Zhang bestows a little Chinese wisdom about food and medicine.
  • Couples therapy for treatment of anorexia? That’s what the UNC wants to know, as they recruit for a clinical trial. Via Barbara Mivowitz at Sickness and Health.
Beverages

  • Ramona Bates, MD is pouring herself another cuppa’ after new findings from the Nurse’s Health Study showed that coffee drinkers have lower risks of stroke.
Lunch Menu

  • The Samurai Radiologist has a comic about radiology conference, which, as he points out, occurred at lunchtime, so technically he is on topic. Also, one of the sounds made was a “Snicker”, so he gets in on two counts!
  • David Rabiner at Sharp Brains highlights recent research on working memory and brain chemistry.
Desserts

  • Rita Schwab has a wonderful post at Supporting Safe healthcare summarizing what she learned at conflict management skills training. I learned a lot just from reading her post. Thanks, Rita!
  • Diabetes Mine announces the winners of the Diabetes Makover, a three month intensive diet and exercise coaching program. Sounds great, although the cynic in me was a little bit disturbed to see the large self-branded vitamin component of the program. Amy has wisely made that part of the program optional for the prize winners.
Take Out Menu

  • One Big Health Nuts guest posts on How to Cope with Pain about how diet and exercise can alleviate chronic pain.
  • From Jolie Bookspan the Fitness Fixer – If you’re going to kick someone, don’t hyperextend!
Reviews

  • Cases Blog tells us that Wellsphere is using Zagat to allow their members to rate doctors. What’s next? Frank Bruni in my waiting room?
  • Duncan Cross, a patient who blogs about illness from the other side of the exam table, wonders how the widespread use of medical imagery desexualizes our view of the human body. If Dr A is an example of what years of exposure to medical imagery can do, Duncan, I wouldn’t worry.

Thanks for coming, and have a great day!

Next week’s Grand Rounds will be hosted at Health Business Blog. Thanks to Dr Val, who coordinates Grand Rounds and Colin Son for his pre-rounds article about me.

High Protein Carrot Muffins

I’m still searching, baking and tweaking, looking for that perfect Zone diet muffin recipe. Along the way, I’m having fun making and eating some delicious muffins.

While this muffin isn’t quite in the Zone (40% CHO, 30% Protein and 30% Fat), it is very high in protein and made with healthy fat. If you have it with a bit of low fat protein on the side, you’re getting pretty darned close to a perfect Zone breakfast.

These muffins are a variation on a recipe I found at a great little blog called The Food I Cook. I encourage you to read Chris’s original recipe for a great discussion of the ingredients and, if you prefer to use Splenda and can take the higher flax content, you can try his recipe instead.

This recipe makes a nice big batch o’ muffins. They freeze well, and I have been taking one to work every morning for breakfast for the past 2 weeks. With a cup of coffee and a slice of non fat cheese or a half cup of yogurt, they hold me quite nicely till late lunchtime.

High Protein Carrot Muffins

I’ve listed specific brands in this recipe, not because I am endorsing them, but because my calorie count and nutritional analysis are specific for these brands. Protein powder brands vary a lot in protein and fat content, so read the label before you buy. The one I used has no fat.

As I’ve posted before, the key to great muffins is not over-mixing, so get your wet and dry ingredients all ready before incorporating them in as few strokes as possible before adding the carrots and such.

If you are going for an even lower fat content, use skim milk instead of low fat buttermilk and cut out half the oil and the nuts. If you use skim milk, change the leavening to 4 tsp baking powder and 2 tsp baking soda.

Dry Ingredients
1 cup Stone Ground Whole Wheat Flour
1 cup Spelt flour
1/2 cup Arrowhead Mill Soy Flour
1/2 cup Bob’s Mills Flax Seed Meal
1/2 cup Quaker Old fashioned rolled oats, dry
1/4 cup Brown Sugar
2 tsp vanilla extract
1/2 tsp ground cloves
1 tsp nutmeg
2 tbsp finely chopped crystallized ginger
2 tsp cinnamon
1 tsp salt
5 tsp baking soda

The Good Stuff
2 large granny smith apples
2 cups (just under 1 pound) Shredded Carrots
1/4 cup raisins

1/3 cup ground almonds

Wet Ingredients
2 cups low fat buttermilk
1 cup Jay Robb Whey Protein
4 large Egg Whites (1/2 cup)
2 tbsp olive oil
¼ cup orange juice

Preheat oven to 350 degrees Fahrenheit. Very lightly grease non-stick muffin tins using a very little olive oil.

Whisk dry ingredients together is a large bowl. Set aside.

Peel and core apples and shred using food processor. Set aside in a medium size bowl. Peel carrots and shred using food processor. Add to apples in bowl along with the raisins and ground almonds. Combine them well so they are all distributed evenly in the mix.

Pour buttermilk into a medium size bowl. Whisk in protein powder until well dissolved. Add egg whites, olive oil and orange juice and whisk till foamy.

Add wet ingredients to dry, stirring just enough to incorporate the dry ingredients. DO NOT OVER MIX. Fold in the apple/carrot/raisin/nut mix in as few folds as possible.

Fill muffin tins almost to the top. Bake for 20-25 minutes till done. Let cool a bit in the muffin tin, loosen edges gently and turn out onto a plate to finish cooling.

Flash freeze muffins as soon as they are cool. Pop into the microwave for about 30 seconds to thaw before eating.

Nutrition analysis provided by CalorieCountAbout.com

The nutritional analysis above is for the entire recipe – divide it by the number of muffins you make for the per muffin data. You’ll get between 18-24 muffins with this recipe, depending on how full you make the muffin cups. That’s 130 -170 calories per muffin, with 7.5-10 grams of protein in each. (For you folks on weight watchers, it’s about 3 points for a muffin.)

Think You Hate Brussels Sprouts? Try this Recipe.

As a former brussels sprouts hater, I continue to be surprised at just how delicious this vegetable can be when prepared correctly. This recipe is hands down the best preparation I’ve eaten yet of this much-maligned vegetable.

If you think you hate brussels sprouts, it’s most likely because the ones you’ve eaten have been overcooked. Overcooking brussels sprouts releases Sinigren, a sulfur tasting glucosinate. Sinigren is also found in brocolli, another veggie that tastes best when cooked less.

The best way to prepare Brussels Sprouts is to roast or saute them. Prolonged boiling is a no-no, although a quick blanch will bring out their lovely green color without drawing forth nasty humors.

So now you know. You don’t hate brussels sprouts – just badly cooked brussels sprouts.

Brussels Sprout and Shallot Saute with Golden Raisins and Pine Nuts

This recipe is based on one from Jill Silverman Hough that can be found on Epicurious. I’ve modified it by cutting it in half (sort of), adding golden raisins and cutting back on the butter. It’s still too much fat, but it sure tastes wonderful. I think I could cut the fat and nuts even further and it would still taste great. (Let us know how it turns out if you decide to try that.)

1 pound brussels sprouts, rinsed, outer leaves removed and bases trimmed.
1 tablespoons olive oil
1 tbsp butter
6 medium shallots, thinly sliced (About 1 cup)
3 garlic cloves, thinly sliced
2 tbsp golden raisins
2 tablespoons pine nuts, toasted
1 tablespoon fresh lemon juice

Slice brussels sprouts using thin slicing disc of the food processor.

Heat olive oil in large skillet over medium high heat. Add shallots; sauté until almost translucent, about 3 minutes. Add garlic; stir 1 minute. Add brussels sprouts and sauté until tender, about 8 minutes, adding raisins during the last 2-3 minutes. Stir in 1 tablespoon pine nuts and lemon juice. Season with salt and pepper. Transfer to bowl. Sprinkle with remaining 1 tablespoon pine nuts and serve.
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I’m not the only one cooking Brussels Sprouts!

Yaz Makers to Women – “We Screwed Up”

The Misleading Yaz Ad

In a rare move, the FDA has mandated Bayer Pharmaceuticals to run ads correcting misperceptions they’ve created with their ad campaign for Yaz Birth control pills. (via NY Times)

Yaz is FDA-approved as contraception and for treatment of PMDD, a very severe form of PMS that occurs in only about 3% of women. Yaz is also FDA-approved to treat acne. But the Yaz ad targets the common premenstrual symptoms such as irritability, breast pain and bloating – symptoms most women have at one time or another – and implies that Yaz will maintain clear skin. Basically, Bayer is targeting healthy women with typical premenstrual symptoms and no acne.

Think of it as if the makers of Prozac started to target their adertisements to folks having a bad day.

Bayer has taken the same approach in pushing their pill to doctors, assuming we’ll prescribe off label for PMS instead of reserving their pill just for women with PMDD. And in this, they are right. We docs love to find a reason to pick one pill, any pill really, over another. It makes us feel like we’re using our brains and not just blindly throwing a dart at a formulary list. Of course, we have no clinical trial data to support our choice, just a bit of logic that if you want birth cntorol pills and this pill is good for PMDD (and believe me, it does work, though not for everyone), why not try this one? For these patients, the primary indication for treament is contraception, not PMS. The problem with the Yaz ad is that it promotes the non-contraceptive effects of Yaz over the contraceptive effects, and targets them to healthy women.

Unfortunately, we will never know if Yaz treats the milder forms of PMS, because the FDA will not allow clinical trials for PMS – just PMDD. So it’s a bit of a catch-22 for Bayer. I don’t feel sorry for them, though. It’s not like they don’t already have 3 indications for their pill – contracetpion, acne and PMD. They just got greedy for market share. The FDA has very clear guidelines, and Bayer has been flaunting these for a long time now. They deserve this unusual mandate.

What will be interesting is seeing how the new ads affect sales of Yaz. Or how many phone calls I get from worried patients already taking Yaz. Because I’m sure the ad will end with the usual “talk to your doctor” disclaimer.

It will also be interesting to see what the lawyers do with this one. This ad is basically a “Come and get us!” from Bayer to the plaintiffs attorneys. Look for lawyers ads soon.

Wyeth and University of Wisconsin sitting in a tree…

…..selling us their CME!

Wyeth is coming under increasing scrutiny for its incestuous relationship to academic medicine. First, it was discovered that the company contracted for ghost written articles that appeared in mainstream medical journals under big name academic authors.

Now the Milwaukee-Wisconsin Journal Sentinal reports that in the year following the Women’s Health Initiative, Wyeth invested 12 million dollars in a CME program targeting docs who prescribe HRT – a program that the Journal Sentinal reporters claim downplayed the risks and highlighted the benefits of the treatment. Administered through the University of Wisconsin and written almost entirely by Wyeth’s ghost writers at Design Write, the course netted over a million dollars to the university, not including money paid to consultants involved with the course.

The Council on Hormone Education – A Wyeth front group

Wyeth delivered it’s message under the guise of a group they created called The Council on Hormone Education – a consortium whose members were Wyeth, Design Write, the University of Wisconsin, Wyeth’s paid consultants and a smattering of unpaid academics whose point of view on HRT coincided with the group’s agenda. Together the group produced and distributed over 16 newsletters and maintained a website that only recently came down the day after the Sentinal published it’s investigative report. A quick google search finds position statements on HRT from the group sprinkled throughout the web.

As a member of Wyeth’s target audience, I’ve received pretty much all of the material from this program either via mail or online at various venues since 2002. I recall checking into the Council early on and figuring their were a Wyeth front group, and learned to take anything from them with a grain of healthy skepticism.

Is Wyeth the Bad Guy?

The information Wyeth disseminated was technically correct. It just tended to highlight the benefits of HRT, which are real, as opposed to the risks, which are also real. They made sure everyone heard the latest theories that HRT started early on was safer than HRT started later, giving a legitimacy to a theory that, while plausible, has yet to be supported by any randomized clinical trials. They publicized the results of the estrogen-only arm of the WHI, data the media pretty much ignored compared to their reporting on the Prempro combination data.

Wyeth will argue that their message was scientifically-based and necessary to balance out the anti-HRT hysteria perpetrated by the release of the WHI results. That someone needed to point out the flaws of that trial, which failed to enroll women with menopausal symptoms and whose population was a good decade older than the typical new start HRT patient. They will say that their message is much more scientifically based than the mythology perpetrated by the anti-aging crowd, who seem to be getting away with saying anything they want to the American Public without any scrutiny from Congress. That they are being singled out among the field of Big Pharma, whose members all play from the same playbook.

Some of these arguments, if they make them, may even seem defensible. But none of that justifies the use of a front group to take Wyeth’s message to physicians for them. None of it justifies the kind of stealth marketing disguised as CME that has taken over graduate medical education. Or the gostwriting.And none of it justifies playing down the risks of a therapy they are selling.

But truth be told, it’s not Wyeth that I’m upset with. I’ve come to expect this kind of behavior from Big Pharma. After all, they have a product to sell. I should expect a sales pitch from them.

In fact, Wyeth isn’t the only pharmaceutical company using the University of Wisconsin to get CME. Pfizer, Bayer and others have joined forces to create and market CME related to their products as well.

Or are we physicians to blame?

No, it’s academic medicine that so disappoints me. The bed we are sharing with Big Pharma is king sized, and big enough for all of us. The University of Wisconsin may be the biggest player, but we’ve all played our part in creating this monster called Pharma-sponsored CME.

We’ve taken their money for paid consultancies. We’ve given and listened to their canned slide show CME lectures because it’s easier than creating them ourselves in the shrinkingly small blocks of protected time academic medicine allows these days. We eat their lunches and go to their sponsored dinners and attend their lectures at medical meetings. We visit the Hall of Wonders at our meetings and stash our cloth satchels with free pens, power bars, flashlights and other trinkets to take home to our kids. We read the throwaways instead of the scientific journals because they’re glossy and faster to read. We have their TV’s and their magazines in our waiting rooms. We visit the internet sites for pharma sponsored CME to fulfill our increasingly CME-laden licensing requirements (and I’m starting to wonder how CME got all mixed up with licensing, now there’s something to investigate…)

Now what do we do?

It’s really time to start to sever the ties. How?

If you’re giving a talk, skip the prepackaged slide sets and make your own. (I have to admit I’ve taken more than a few slides over the years from the free teaching sets offered by some of my medical organizations that were clearly Pharma sponsored CME.)

Look for CME sources in the peer reviewed journals, like the NEJM or see what’s being offered for Pharma Free CME at Pharmed Out. If you see a “sponsored by an unrestricted grant” at the bottom of CME, go find something else to read. If you’re at a medical meeting, skip the box lunch seminars and the Hall of Wonders – go instead for a work out or tour the town you’re visiting. Or read a textbook.

Some of our smaller medical groups are starting to experiment with Pharma free CME. What I can’t understand is why our medical organizations aren’t setting the example by setting up Pharma-free meetings. I don’t expect anything anytime soon from the AMA , but c’mon NAMS or ACOG, how ’bout it?
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Pharma-Free CME at Pharmed Out

Our own Dr Rob on Pharma-sponsored CME
The British Medical Journal on severing the ties (via Schwitzer Health Blog)

Seven Things To Know About Hormones – My Take

The Wall Street Journal gives a nice response to Oprah’s recent HRT hype with an article entitled “Seven Things You Should Know about Hormones. This, of course, is not to be confused with George Carlin’s Seven Words You Can’t Say on TV, which is really funny but won’t help you decide whether or not to take estrogen…

Here’s my take on the seven things –

1. ‘Bio-identical’ hormones are available in FDA-approved forms
I agree. The stuff Suzanne Somers and Oprah are getting compounded is exactly the same chemical ( probably purchased from the same supplier) as Big Pharma uses to make their estradiol patches and creams and progesterone pills.

2. Hormones from compounding pharmacies aren’t safer than conventional HRT.
I completely agree. Any compounding pharmacist or doctor who sells HRT without warning patients about the risks should be put out of business. We don’t stand for this behavior from Big Pharma, and we shouldn’t accept it from these folks. They are couching their sales pitch around women’s wellness and selling women a purported fountain of youth, while trashing Wyeth for doing the same thing with Prempro. FDA – Get on it. And if you don’t have the authority, Congress needs to give it to you. Women’s Rights Groups should be all over this one, but they are unfortunately being duped by these shysters into thinking they are all on the same side.

3. Don’t trust saliva tests.
Ditto. Most of the folks doing saliva testing make money on the testing. Be wary of any doc who has a financial interest in what test he/she orders. Or what vitamins you take.

4. There’s a critical window of time for starting HRT.
Not so fast. It’s a hopeful hypothesis, but it’s just not proven yet. A lot of the docs pushing the hypothesis are also consultants and speakers for pharmaceutical companies who sell HRT. In my heart of hearts I think and hope that they are right, but I’m not willing to tell a patient to count on it. We need studies to prove it.

5. The increased risk of breast cancer appears related to progesterone rather than estrogen.
The key words here are “appears to be”. It’s not written in stone yet, so don’t count on it. And don’t go taking estrogen without progesterone if you still have your uterus – that’s a recipe for uterine cancer. I’m not about to trade one risk for another with my patients.

6. Estrogen applied to the skin, in patch, cream or gel form, may have a lower risk of blood clots and strokes than in pill form.
Agree. This is the one piece of new data that makes the most sense to me and that I am willing to put out there. I prescribe transdermal estrogen preferentially over oral whenever I can. We know clot risk is related to dose and there are well-done studies showing the lesser impact of transdermals on serum clotting factors. There’s no reason to think this won’t translate this to lower incidence of blood clots. Stroke incidence is a little more tricky, since strokes are multifactoral, but if clotting times are closer to normal, that’s one less factor to worry about.

7. Stay tuned.
This, of course, is the hardest part about HRT. It’s not like your menopause is going to wait for the next big randomized, placebo controlled trial. You have to make a decision with imperfect information and uncertainty. And that’s difficult for some women to understand and accept.

Easier to do what Oprah and Suzanne have done and latch onto the compounding pharmacy crowd, who sell certainty and security along with their drugs. But it’s a false security and very dangerous. I find it so sad that these two intelligent women are letting themselves be taken in this way. And even sadder that they are bringing other women along with them into their fantasy of hormonal certainty.

If you’re interested
Here are TBTAM’s Ten Rules for Prescribing HRT.

Now if you’ll excuse me, I have to get back to You Tube…

Happy Groundhog Day

Not the Day. The movie.

Groundhog Day, released in 1993 and starring Bill Murray and Andie Macdowell, is one of the best movies of all time. It appears to be a comedy, but it’s much, much more than that. It’s really a mythical tale of transcendance, a lesson in how to live a life making every day count. Even if that day looks supiciously like the day before. And the day before that. And the day before that…

What do you do to given meaning to your days? That string of little events that repeat themselves day after day? What keeps you going when you’ve gotten there and nothing looks new to you anymore? (If you’re reading this BS, you know what I’m talking about.) How do you live a day and “get it right”?

Watch this movie and learn.

I require myself to watch it at least once a year, and should make myself do it even more often.

Think I’ll watch it tonight.

A Visit to Salzburg – Part 2. A Revisit Tour

This was my third trip to Salzburg, a wonderful place to visit any time of year, though early January would not have been my first choice.  I had some work and sleep to catch up on, and they kept us busy with concerts and dinners, so this won’t be the grand tour. We won’t be taking the Sound of Music Bus Tour, visiting the museums or Fortress, or taking any day trips to visit the salt mines or Hitler’s Eagles Nest, as I did on prior trips.We’re just going to take a few hours to visit my fave spots in this wonderful little city.

Mozartplatz and Mozart Geburtshaus

Mozart was born in Salzburg, and was court musician to the Archbishop here in his early career. The city celebrates him with festivals twice a year, one in late January and a bigger one in the summer. A visit to his birth house is a must.

If you miss the festivals, catch his music at the Mozart Dinner theater- it sounds hoaky, but it really is a nice experience – they serve a menu from Mozart’s era and serenade you with his music. ( Definitely beats the Sound of Music Dinner Theater, which is to be avoided at all costs.)

Chess at Kapitel Platz

St Peter’s Cemetery


Where Maria and the Von Trapp family hid from the Nazis in The Sound of Music.

Michaelskirche


The oldest church in Salzburg. I was treated to an organ solo last time I visited. It was quiet this time, and I was sorry to miss yet again the wonderful concert series held here.

Salzburg Markets

The weekday Green Market is located near Collegiate Church. It was small in this weather, but there were still beautiful breads and meats.  Even better is the Thursday Schrannen Market at Mirabellplatz, and the Christmas markets in December. Maybe next time.

Shopping in Salzburg

Shopping in Salzburg is a cultural experience, as you wander through the old streets and narrow alleyways. There are literally hundreds of shops, and prices are not always so cheap. I mostly window shoppe, but always stop at Furst Condiserie for chocolate and visit the tiny Kaslochl Kaserei near the river just down from the Mozart Geburtzhaus.

I recall my first visit to this tiny family-owned cheese shop 9 years ago. The owner’s two -year old daughter was sitting beside her on the counter. Of course, she’s a big girl now and was in school the morning of my visit, but I had a nice talk with Mom about the cheese business, and bought some local goat cheese for lunch.

My favorite place to shop in Salzburg is Interio. It’s sort of like a slightly upscale IKEA. I got some gorgeous placemats.

Near Interio is Ma Lai a wonderful woman’s clothing shop that mixes new and used clothing.

The Supermarket

One of my favorite things to do in a foreign country is to go food shopping. It makes me feel like a local, and I love exploring the local foods. Here in Austria, it’s the meats that are unusual – many varieties of smokes bacon and pork, with Speck being the local favorite. (My colleague Amos tells me that Speck is amazing, so I buy some to bring home – I’ll tell you how it is once I use it.)

I pick up some teeny sausages for my lunch and head down the aisles. I note that every kind of sugar imaginable is available, including beet sugar.

Entire aisles of chocolate, and I notice mostly locals buying it.

I pick up some tiny noodles for soup and mayonnaise. Why the mayo? It was in a tube!

Biking in Salzburg

On my last trip, I enjoyed biking the path along the river, which runs for miles from Salzburg into neighboring towns. Although I decided to forgo the pedals this trip, winter’s cold and snow doesn’t stop the natives.

My Lunch

Having spent a good 5 hours wandering the city, I headed back to my rooms at the Schloss to enjoy a late afternoon lunch with the provisions I had purchased. I fell in love with the tiny sausages – so delicious!

TBTAM PSA : Is Double Click Slowing you Down?

My internet has been increasingly slow lately. As I was waiting for pages to load, I kept seeing “Waiting for http://www.doubleclick.net.”.

Double Click belongs to Google. It’s major product is the DART cookie – a device that lets advertisers track how many users saw their ad, how many clicked through, and which ads users went to. The cookie stays with your browser and gets updated every time you visit a webpage that uses the cookies (like Google).

Can Ad-Double Click be disabled?

The answer is yes!

Simply go to the Adclick website and download a privacy cookie. That’s it!

Really? It’s that easy?

Yep. But there are a few things to know to keep things in place once you’ve opted out of double click –

1. Opting out is a cookie, not a program. So if you remove or diable cookies, doubleclick will come right back as soon as you visit Google and you’ll need to go and opt out again.

2. If you have both IE and Firefox, you’ll need to upload the privacy opt-out cookie to both browsers.

3. It’s not as if you won’t keep getting ads. They’ll just be generic and not targeted to you. (Sorry.)

4. Doubleclick will still be able to track you by your IP address (just like I know the IP addresses of everyone who visits this blog), unless you use an IP blocker or route your visits through another site like AOL.

So, does it really work?

I am ZOOMING!!! (Mouse, don’t fail me now…)