Monthly Archives: October 2012

Birth Control Pills Lower Uterine Cancer Risk

In a study of risk factors for uterine cancer,  prior use of the pill was associated with a marked reduction in risk among women having a prior endometrial sampling-

We observed that OCP use before the benign endometrial biopsy or D&C was associated with more than six times lower likelihood of endometrial cancer. Similar findings in the general population were reported by othe  investigators. Estimated protection with use of OCPs ranged from 20% with 1 year of use to 80% with 10 years of use.

This protective effect of OCPs against uterine cancer is not news to us docs, but bears repeating for the public. Between the recalls, the FDA rulings and the lawyers, women rarely hear anything good about the pill.

More good news about OCPs here.

Fracking and Drought – Bad Company

I recently heard a piece on the radio about farmers in the United States who are being forced to sell livestock because they cannot raise them in drought conditions that are plaguing America in the wake of one of the hottest summers in history.

It got me thinking about how fracking uses water. A lot of water – two to four million gallons per well. I found myself wondering how many areas of the country that are at risk for drought also have shale gas in play.

Notice how much overlap there is between the two maps?

Just sayin’….

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Maps from droughtmonitor.com and gasland.com. Here is another map from the Energy Information Administration showing the same thing as the gasland map. 

Sisters – An Election Day Parody

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My four sisters and I gathered a few weeks ago for a girls-only weekend – the first time we had done so since our Fran died a little over a year ago. Fueled by wine and laughter, and inspired by the spirit of our exuberant contest-loving sister, we decided at the last minute to enter the Prairie Home Companion Duet contest with this little parody we wrote of Sisters from the movie White Christmas – a Polaneczky girls collective favorite.

Unfortunately, our duet (well, it’s actually a trio but don’t tell Garrison…), although graciously accepted a few hours past the deadline, didn’t make the finals.

That’s okay. We still think it’s great – if not off pitch in a few spots. (There was no time for perfection.)

We also discovered that if you play it say, 20 times in a row, especially when your companions are sick and tired of hearing it, or when they are trying to fall asleep, or when there’s a pleasant lull in the conversation – it’s even better!
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Music by Irving Berlin. Lyrics by Pat Federoic, Mary Lou Rittenhouse, Rosemary Jenkins, Ronnie Polaneczky & Peggy Polaneczky. Karoake Soundtrack from Pocket Songs Karaoke “Sisters in the Style of Better Midler & Linda Rondstadt.” Performed by Ronnie, Ro and Peg.

Why and When Women Have Abortions

A well written editorial by Wendy Savage in the Guardian should be required reading across the globe for anyone who needs or wishes to understand the reality in which women make reproductive choices.

Savage wrote the piece in response to comments by Jeremy Hunt, Britian’s newly appointed secretary of health, who wants to lower the abortion limit in that country from 24 to 12 weeks.

Jeremy Hunt, the newly appointed secretary of state for health, has unwisely shown his bias against the legal abortion limit laid down by the1967 Abortion Act and amended by the 1990 Human Fertilisation and Embryology Act. He told the Times in response to a question about when life begins: “Everyone looks at the evidence and comes to a view about when they think that moment is and my view is that 12 weeks is the right point for it.” It is hard to understand what evidence he has read that leads him to the bizarre conclusion that the limit should be reduced to 12 weeks.

Savage challenges Hunt’s assertion that the evidence supports his views by first showing us how the current limit of 24 weeks in the UK was decided –  based on medical science,  not personal opinion.

In 2007 the House of Commons science and technology committee published its 12th report on Scientific Developments Relating to the Abortion Act 1967. It concluded that although improvements in survival of babies born over 24 weeks had occurred since the upper limit was reduced in 1990, that was not the case for those under 24 weeks. This was based on the first Epicure study, a study of 4,000 premature babies (born from 22 to 26 weeks) treated in all the neonatal intensive care units in the UK and Eire, in 1995.

Since then the second national study of babies born in 2006 has been published and there is no significant change in the number of extremely premature babies surviving.

She explains how an arbitrary limit of 12 weeks makes no sense in the real world, where free access is not universal and where obstacles to abortion abound  – some of those obstacles within the very health system that Hunt now leads.

Some 91% of abortions now take place below 13 weeks and delays in the system have been reduced considerably, but some women still face difficulties from GPs who make them wait for unnecessary pregnancy tests or refer to a hospital consultant whom they know does not perform abortions. About a third of GPs are not prochoice and they should tell women this and refer to another partner who does not share their views but this does not always happen despite the GMCC guidance. Sometimes women are erroneously told that they are too far advanced in the pregnancy to qualify for an abortion, and younger women are more likely to accept the doctor’s view. These problems are less common today than 10 years ago.

She explains how it is that some women don’t come to their decision to have an abortion until the second trimester.

Research by Ellie Lee and colleagues published in 2007 into why women present late found that irregular periods was cited by a third, and a fifth continued having periods. A third were using contraception. In a quarter their relationship had broken down and a quarter were frightened of telling their parents. Women could give more than one reason and 41% were unsure about having an abortion and a third suspected they were pregnant but did nothing about it-possibly using denial as a defence mechanism. This shows that however good the service, there will always be women who present in the second trimester.

Finally, she tells us why the 1% of abortions that occur in later gestation will always be necessary – because some fetal anomalies, many incompatible with life, are not diagnosed until later in gestation.

Although the nuchal screening test for Down’s syndrome is available in most areas now, and allows a termination soon after 13 weeks compared with after 20 weeks when an amniocentesis was needed, other abnormalities are not picked up until the anomaly scan which is done at 18-20 weeks. Women are often devastated to learn that their planned and wanted pregnancy has not developed normally. They need time to come to terms with this and decide whether to continue with the pregnancy or have an abortion. Sometimes more sophisticated ultrasound to look at structural defects in the heart or genetic studies to see if there is a chromosomal abnormality are needed to make a diagnosis so the woman and her partner can make a fully informed decision. This all takes time and reducing the limit, as David Cameron would like, to 20 or 22 weeks would put more pressure on women and might even increase the rate of abortion at this later stage.

The one piece of evidence Savage leaves out is that limiting access will not prevent abortion, but will only serve to move it into settings where the procedure will be unsafe. The decline in maternal mortality that occurs when abortion becomes legal is undeniable. We cannot go back.

This is the real world that women and their families inhabit. 

It’s a world where not every pregnancy is planned, where not all women are in the position to determine when and how they become pregnant and where  not every pregnancy is diagnosed in time to allow for abortion before an arbitrary 12 week time limit. A world where the healthcare system actually works against early abortion, and where devastating fetal anomalies still occur and are not always diagnosable early in pregnancy.

The evidence shows that the best way to limit abortion is to increase access to contraception

And the best way to limit the gestational age at which abortion occurs is to stop trying to limit abortion in the first place.

Buying a Hybrid

Our new Ford C-Max SEL

It was time to buy a new car. Our wonderful 2003 Ford Taurus had 130,000 miles, and we’d put in quite a bit of money  in upkeep and repairs in the past year. Nothing unusual, just the things that start to go after that many years and miles. TIme to move on.

With all the ranting we do against fracking (our cottage is on the Marcellus Shale), the decision to go hybrid was an easy one. But could we get the mileage we wanted in the car we needed at a price we could afford?

Our priorities were –

  • Price – We knew hybrid meant more money than we’d ever spent on a car before. (Our Taurus was an end of season used dealer  model for just 14K – did I mention we are cheapskates when it comes to cars? ) But there is a break even point on hybrids, and we knew we had to just do it.
  • Mileage – We were looking for something comfortably above 35 MPG city and highway. The higher the better.
  • Cargo room  – Our Taurus has a generous 16 foot trunk, and that’s barely enough for us on trips to the cottage, where the lack of local supermarket means schlepping groceries as well as luggage  for 4.
  • Comfort – Our Taurus is really, really comfy, especially in the back seat. But our kids said they’d rather have to use a pillow in the back seat on a long ride than sit with suitcases, so cargo room was more important.
  • Power Drivers Seat option  – I’m not tall. I need to pull the seat way up to drive and then back again to get out of the car comfortably  And I often adjust during the ride. I thought this would not be an issue with any model car. But I was wrong.
  • Solid feel – Mr TBTAM has an issue with lighter cars for both safety and drive feel. Not a deal breaker.
  • Leather interior – our Taurus leather interior still looks like new after 9 years.  No compromises on this.

We’re not yet empty nesters, so the tiny hybrids were out (great mileage, no cargo room). So were the hybrid minivans (great cargo room, not great mileage).

I’d been waiting for the C-max for two years, convinced that it would offer me what the Prius would not in terms of comfort and space. Then Toyota came out with the Prius V, and I knew we had to consider it.

Other Things We Considered

  • Going electric. Unfortunately, electric batteries eat into trunk space. Also, our garage is not yet equipped to charge us. (And where they are, it’s not cheap  – $98 a month or $3 an hour for charging.) Finally, most of our driving is distance – electric shines best for commuting. We could not see an advantage to electric at this point for us in NYC.
  • Giving up the car altogether. We were car-less our first 10 years in NYC, and had survived. But the price (and often limited availability) of car rentals in NYC , our addiction to Costco, and the ability to pop down to Philly and family on a moment’s notice kept us car owners.
  • Diesel – we didn’t see a big advantage over hybrid, and the diesel high mileage cars were too expensive anyway.
  • Non hybrid cars with good gas mileage – None came close to the hybrids we were considering in terms of fuel savings. Plus, it felt like taking baby steps –  our environmental stance demanded a leap.

Why we did not buy a Prius

We thought the Prius V had everything we needed. But not quite. Here’s why –

  • The driver’s seat in the V is not power adjustable, even on the highest end model! (What’s that about, Toyota?) You need to pump a lever to raise and lower it and reach below to move it back and forth.
  • The comfort factor – the Prius V had more cargo room, but less head and leg room than the C-max. We weren’t sure the added cargo space was worth it.
  • The weight of the car. Mr TBTAM likes a more substantial feel to a car, and the Prius feels a lot lighter than the C-max. (Others might see this the other way around, and call the C-Max too heavy  – it’s all in the buyer’s eye…)

The 3rd generation Prius came very close to being what we wanted. It has a power drivers seat in the higher end models and beats the Cmax in mileage and price (though not by much in either). The cargo room was acceptable, and it looked great. But it is smaller, lighter and noisier than the Cmax. Most importantly to me, visibility seemed compromised – there is a blind spot on the front window if you pull up the seat as I do to drive, and the back window is split and seems small. Although they say you get used to the small rear window, I couldn’t see past the salesman in the back seat on my test drive.  (Hint to Totyota dealers – don’t sit in the middle next time you take a customer out for a test drive…)

In the end, the benefits in terms of price and mileage on the 3rd generation Prius were not enough to beat the C-Max for us.

Why we got the CMax-SEL

Mostly because I am totally in love with this car!  It has everything I want – 47 mpg city & hwy, power driver seat, decent cargo space (24.5 cu feet behind the second row), leather interior,  plus a few things I didn’t know I wanted  – back up camera, automatic foot operated hatch and sun roof.  And I could have given up the sun roof, but it really brightened the interior in a way I did not expect. (Another hint to dealers – if you want folks to buy sun roofs, take them out in a model that has one on a sunny October day…)

It seems as if I am not the only one who loves the C-max. While we were waiting for the salesman, another couple test drove the car we were looking at and by the time we came back from our test drive, they had already put an offer down on it. But that’s okay -it had options we did not need (like park assist – we know how to park, thank you). The one we’ve ordered will come in at our price limit – even with the sun roof – thanks to a dealer rebate.

I’ll post again after we’ve gotten our new car and driven it awhile

I am no stranger, after all, to post purchase regret. And real world mileage  can differ from posted MPG’s – though knowing my husband, he’ll be one of those hybrid drivers who tweak their driving style to get the best milage they can.

So stay tuned…

Now for the real question –

Does anyone want to buy a well-maintained used 2003 Taurus?

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Here’s a comparison on the three vehicles we looked at on Cars.com. And for the record, no one paid me to write this post. I just wanted to share our process thinking it may interest others making a similar purchase decision.

Vinod Khosla Thinks I’m Narrow-Minded

There’s a (tiny) bit of a discussion going on in Twitter about a post I wrote responding to Vinod Khosla’s statement that 80% of the work that doctors do will one day be replaced by computer algorithms.

(BTW, the title as cross-posted on the Health Care Blog -“The Day the Electronic Medical Record Tried to Kill Me“-  was not mine. My original post, if anyone is interested, was entitled “Will Doctors be Needed in the Future?” THCB’s new title made it look like my post was just another rant against the EMR. It was so much more than that.)

What I said

In my post, I talked a bit about the marketplace-driven IT innovations in healthcare, and medicine as seen through the eyes of the IT entrepeneurs. I questioned just how much of what doctors do today can really be replaced by algorithms, particularly the doctor-patient relationship.

I then asked if Khosla was right and answered myself – Maybe. I stated that we were in the midst of a huge disruption in healthcare, and reflected on how I was already seeing signs of that disruption in my current practice.  And while I still did not see anything changing too much just yet, as far as the future Khosla predicted? I wasn’t so sure.

I then stated that if there is a revolution in healthcare, we docs needed to make ourselves a part of it now. I urged my fellow physicians to become involved, in order to be sure that what happens in the IT-driven healthcare future actually improves our patients’ health beyond what we are doing today. 

It’s a completely legitimate concern, and, I believe, an extremely important one.  As an example, I cited the evolution of the EMR – a system that has created high hopes and caused huge disruption at enormous cost, even as we continue to struggle to find conclusive evidence that EMR use actually improves patient outcomes.

I then began to wonder what the future would look like if replacing 80% of doctor’s work with technology actually freed us up to do the real work of medicine. I imagined us then redistributing ourselves around the globe, virtually and actually, to take care of the entire planet. And called that the ultimate disruption in healthcare.

A pretty optimistic vision of the technological future if you ask me.

I thought my post was a thoughtful take on Khosla’s vision, not a takedown of it.

And yet, on Twitter, Khosla has called my post a “Usual muddy interpretation and narrow mindedness of what I said.”

How is my interpretation muddy or my take “narrow-minded”? As the end user whose work life has been radically impacted by technology, and a doctor who bears significant responsibility for the health outcomes of my patients, I think I have a right to discuss my thoughts about the healthcare technological revolution without being called “narrow-minded”.

What may be narrow-minded is Khosla’s representation of doctors as part of the problem and not the solution. I won’t get into his calling us “lazy”, or his implications that it is only the top 20% of docs – whoever they are – who are worth having around.

Maybe it’s simply that Khosla has decided that Steve Jobs was right when he said that  –  “A lot of times, people don’t know what they want until you show it to them.”

In which case, I guess we docs (and by extension, our patients) are just supposed to shut up and wait until Khosla and the rest of the IT gurus show us what we want.

Or risk being called “narrow-minded”.