What if I told you that there is a restaurant in New York City that serves only Macaroni and Cheese. That’s right – just Mac & Cheese. Made to order, in a dozen different variations, and served bubbling hot in individual cast iron skillets.
What one question could someone then ask you that would make you even happier than I just made you?
How about “Do you want that with or without breadcrumbs?”
Georgia Gongressman Phil Gingrey (R), who ran a “pro-life” Ob-Gyn practice in Marietta, Georgia before joining Congress, has tried to use the cloak of the medical profession to legitimize Rep Todd Akin’s remarks on pregnancy and rape, calling Akins “partially right” in claiming that “legitimate rape” rarely results in pregnancy.
“… ‘Look, in a legitimate rape situation’ — and what he meant by legitimate rape was just look, someone can say I was raped: a scared-to-death 15-year-old that becomes impregnated by her boyfriend and then has to tell her parents, that’s pretty tough and might on some occasion say, ‘Hey, I was raped.’ That’s what he meant when he said legitimate rape versus non-legitimate rape. I don’t find anything so horrible about that. But then he went on and said that in a situation of rape, of a legitimate rape, a woman’s body has a way of shutting down so the pregnancy would not occur. He’s partly right on that.”
And I’ve delivered lots of babies, and I know about these things. It is true. We tell infertile couples all the time that are having trouble conceiving because of the woman not ovulating, ‘Just relax. Drink a glass of wine. And don’t be so tense and uptight because all that adrenaline can cause you not to ovulate.’ So he was partially right wasn’t he? But the fact that a woman may have already ovulated 12 hours before she is raped, you’re not going to prevent a pregnancy there by a woman’s body shutting anything down because the horse has already left the barn, so to speak. And yet the media took that and tore it apart.”
Dr Gingrey, you should be ashamed of yourself.
As an Ob-Gyn, you must surely know that if anything, pregnancy rates after rape are higher than one would expect after a single act of unprotected intercourse, and there is absolutely no evidence to suggest that the stress of a rape prevents pregnancy. Even if you didn’t know it before Akin’s remarks, you should know it by now, since your own professional organization, ACOG, has called Akin’s remarks remarks “medically inaccurate, offensive and dangerous.”
This man may represent the state of Georgia, but he does not represent science or the medical profession on this issue.
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Update 1/15/13
Gingrey has since issued a statement on his remarks –
At a breakfast yesterday morning, I was asked why Democrats made abortion a central theme of the presidential campaign. I do not defend, nor do I stand by, the remarks made by Rep. Akin and Mr. Mourdock. In my attempt to provide context as to what I presumed they meant, my position was misconstrued.”
And I’ve softened my last statement on this post, having had 24 hours to cool down a bit.
They’ll be a lot of press this week over a study conducted in the UK reporting that the levonorgestrel IUD (Mirena) is superior to usual medical treatment for the treatment of heavy menstrual bleeding (menorrhagia).
“Usual” medical treatment for 75% of the women in the UK study was tranexamic or mefamanic acid – drugs that control bleeding through the coagulation pathway, and which are not widely used in the States.
Here in the US, we tend to use oral contraceptives and progestins to treat menorrhagia. Unfortunately, the UK investigators did not break out the comparison between these hormonal treatments and the IUD, so we really don’t know how well Mirena would perform compared to usual treatment here. However, given years of seeing how effective birth control pills are in decreasing menstrual flow, I’m going to assume that they still work as well as they always have, and not necessarily better or worse than the hormonal IUD. Each method has its pros and cons, and every woman is different.
The investigators also reported that the Mirena IUD was less effective than usual treatment in women whose BMI is under 25. This is not surprising, since heavier women could have an element of estrogen excess that would be better addressed by hormonal therapy such as Mirena or birth control pills rather than anti-fibrinolyics such as Tranexamic acid.
None of this, by the way, is meant to discourage women and their doctors from using Mirena to treat heavy periods – it is indeed a very effective treatment and one that I offer my own patients.
Just trying to give the anticipated hype some context and perspective.
May the New Year bring health and happiness to you and yours.
If posts are less frequent of late, know that I am healthy and busy and blessed with the most wonderful family and friends a person could have.
Sometimes real life just takes precedence over blogging. And that is as it should be.
See you soon.
This dish was inspired by some lovely fennel and crimini mushrooms I found at the West Side Market, where I had stopped for provisions on the way home from my voice lesson the other evening. A quick IPhone search in the store yielded an old recipe from Regina Schrambling for Hunter-Style Pasta, named for its use of ingredients that “evoke the forest in fall”. I also found this recipe from Epicurious. (Don’t you love what you can do with a phone these days?) Combining elements of both, I ended up with a hearty but not too heavy pasta that is a real keeper.
Serve with a large green salad and a crusty French bread. It also makes a fabulous lunch reheated the next day with a little Mozzarella cheese on top.
Farfalle with Fennel & Mushrooms
The key to this dish is to slice the fennel and the dried mushrooms really thin and the fresh mushrooms really thick. I also thought about trying it without the tomato paste – if you decide to make it that way let me know how it tastes.
Ingredients
Preparation
1. Soak the dried mushrooms in the hot water for about a half hour, till soft, then drain, reserving the liquid, and cut into very thin strips. Set aside. Strain the mushroom liquid if necessary and set aside.
2. While the mushrooms are soaking, start your water boiling for the pasta, adding a tbsp of salt to the water in a large pot. Toast the pine nuts on an un-greased baking sheet in a 300 degree oven for 5-7 minutes, stirring once, until golden brown. Remove from the pan and set aside in a bowl.
3. Heat the butter and olive oil in a large deep saute pan over medium high heat. Add the fennel, shallots and mushrooms, and saute until fennel is almost tender, about 12 -15 minutes. About halfway through the saute, start your pasta cooking. When the fennel is almost tender, add the garlic and fennel seeds and saute another minute. Add the white wine and cook off a bit, then stir in the tomato paste and mushroom liquid, cook a minute and then add the half and half. Season with salt, pepper and red pepper flakes. Cook over medium-high heat until the sauce is thickened, about 5 mins.
4. While the sauce is thickening, finish off and drain your pasta (leave a little pasta water on your pasta if the sauce is thick). Toss the pasta with the sauce and parsley right in the pan. Bring the pan to the table. Serve hot, sprinkled with pine nuts. Pass the Parmesan.
YIELD: 6 -8 servings
“There are no words.”
It’s what we all said on Friday, when we learned of the unspeakable horror visited upon the teachers and children at Sandy Hook Elementary School, and on their families, friends and neighbors.
On Saturday, we began to finally be able to talk about the horror, began to find the words to comfort those in pain, to remind us of what is real and important in our lives and to tell our children and family how much we love them.
And on Sunday, we listened as our President so eloquently spoke for all of us to the community of Sandy Hook, saying what we wished we could say to them. “You are not alone.”
Now it is time to find the words we need to say as a nation to make our country a safer place for our children and for us all.
Three simple words – Ban Assault Weapons.
You can say them here. Or here.
And demand that your representatives say them for you here. And here.
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More from Around the Web on This issue (Just a start – send me yours to add to this list)
The Komen Foundation set the bar low when it partnered with Kentucky Fried Chicken to fight breast cancer, urging women and their families to buy the fat-laden meals despite the fact that obesity increases the risks of breast cancer.
Now the Avon Foundation has slid right under that bar by teaming up with the makers of 5-Hour Energy Drinks to sell pink energy lemonade, with a portion of the proceeds going to fight breast cancer.
Really?….
This is, after all, the same Energy Drink that has been linked to 13 deaths over the past four years and is currently being investigated by the FDA. The drink that comes with a warning label stating “Do not take if you are pregnant or nursing, or under 12 years of age. If you are taking medication and/or have a medical condition, consult your doctor before use.” And despite claims that it only contains as much caffeine as a cup of coffee, the label also warns ” Do not exceed two bottles of 5-hour ENERGY® shots daily, consumed several hours apart”.
This is the drink we need to be buying to help fight breast cancer?
What’s next – Pink cigarettes?
When HPV occurs in the menopause, is it due to reactivation of a previous HPV infection or a newly acquired infection? That’s the question asked, but not properly answered in this doc’s opinion, by a new study published this week in the Journal of Infectious Diseases.
Researchers performed HPV testing in 843 women age 30-60, and found an increased prevalence of HPV infections among women in the peri-menopausal age group who also reported having had >5 lifetime partners, but not necessarily a new partner within the past 6 months. They concluded that this second lifetime peak of HPV infections (the first peak occurs in the second decade) was due, not to new HPV infections, but to infections acquired in the earlier years that were now re-emerging with older age and waning immunity.
The fact that we have not seen this peri-menopausal HPV peak in prior population-based studies, they say, is because most women in this age group until now have not had so many sexual partners.
The study’s findings contradicts what we are now telling women, which is that most HPV infections permanently clear within two years of an initial infection that occurs primarily during the second and third decades.
Erroneous conclusions based on a flawed study design
I take strong issue with the study’s conclusions, based on over two decades taking care of peri-menopausal women in a country where 50% of marriages end in divorce.
The flawed conclusions of this study stem from what I believe to be a flawed methodology – namely using 6 months as a cut off for defining women as having had a recent new partner, an artificial categorization that makes no sense socially or biologically. As a result, the researchers may have missed much of the important new sexual activity in their cohort that could explain an increase in HPV infection around the age of menopause.
Sex, HPV and the Middle-Aged Woman
Many women in their middle years have new relationships through divorce, dating and often, remarriage. HPV infection can occur at any time in a recent relationship, not just in the first 6 months (a part of which time many couples use condoms). These infections can persist up to 2-3 years before they clear and be diagnosed any point in that time frame.
In my own clinical practice, the overwhelming majority of HPV infections in this age group occur in women who have had a clear change in partnership within the past 1-5 years. Not surprisingly, theses HPV infections clear in the same 12-36 month time frame as the infections I’m diagnosing in the younger crowd.
Remember too, that it is at middle age that some of the husbands will start to wander – bringing home a new infection to a woman who has not had a new sexual partner in decades. The study does nothing to address this possibility. Not that any study can, of course, but you get my point.
A better study design would have been to ask how long the subject has been in her current relationship , and correlate that with HPV prevalence.
Bottom Line –
The study raises interesting questions, but unfortunately its design limits its conclusions, which to this clinician don’t make sense given what we know about HPV infection and the social lives of women.
While we cannot completely discount the possibility of reactivation of dormant HPV, this study, in my opinion, does little to answer the question it raises.
Unfortunately, the publicity around this study is sure to drive anxiety among every menopausal woman out there, especially as we are now telling them that they can back off on pap smears if theirs have been normal up till now. (I myself am not 100% comfortable with the new pap recommendations, by the way...)
What if you have a positive HPV and have not had a new partner?
I see two possible ways that a women can have HPV and not have a new HPV infection.
One is a longstanding persistent HPV infection that is only now causing precancerous changes, which as we know can take decades to appear. Is this reactivation of a dormant HPV infection or just delayed detection? After all, we only recently began testing for HPV, so unless we have a prior negative test, it’s hard to say, isn’t it?
The second is that menopause itself can lead to low grade pap abnormalities related to estrogen deficiency rather than true pre-neoplastic changes. In women without HPV, these are so called false positives. But in women who may have a persistent HPV infection, this estrogen-deficient pap may be the first time she has ever had an HPV test.
The important point with these two scenarios is that not every HPV infection necessarily comes from a new partner (or a wayward husband).
Which is good to know.
I admit it. I’m a house and home voyeur.
It was something I discovered while house hunting in Philadelphia over two decades ago – there is nothing more fun than going to an open house.
Not because I want to spy on others, though that’s part of the fun. But what I really want to do is get design ideas. See how real people in real spaces make it work. Look how they arranged their living room! What a clever closet! Is that really an IKEA kitchen? It looks gorgeous!
In the old days, my husband and I would sometimes spent entire Sundays at open houses, even after we were no longer in the market for a home. As our family grew, and time became more precious, I was forced to confine my house tour voyeurism to Halloween – ostensibly being a good parent accompanying my small daughters, what I was really doing was finding out what the folks on the 10th floor were doing with their place.
Unfortunately, that ruse lasted only so many years, at which point my kid and her friends refused to let me join them trick or treating, and the neighbors began to look at me funny when I showed up alone at their front door without a costume…
Fortunately, just around that time, I discovered Apartment Therapy, and I was off and running in the work of online home tours.
Now I can practice my addiction in the privacy of my own home, where I will sit up till all hours of the night checking out how the rest of the world lives. No one has to know. No one gets hurt.
And I get my fix.
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Home Tours Online
Here are just a few of the places I go for my fix of other people’s spaces –
This soup from David Tanis City Kitchen column in the NY Times is a revelation. The noodles, mussels and squid are perfectly cooked and tender, providing contrasting textures with the raw vegetable and herb garnishes. The broth will warm the cockles of your heart, and the flavors will lighten your soul.
Mr TBTAM made this soup for dinner last Thursday, despite my objections that it was too much work for a weeknight on which I had a lot of work to do. I was so glad he didn’t listen and went ahead and made it without me, even cleaning up the kitchen afterwards himself.
My friend Allen was glad too – he downed a bowl of the soup at 10 pm when he and Jane arrived from Minneapolis for a visit.
And I was even gladder two days later, when Mr TBTAM and I shared what was left of the soup for a quick lunch before heading to a Sunday matinee (The Anarchist – Patti Lupone was fabulous, unfortunately the script was not.).
So go ahead – Make this soup.
You’ll be glad you did.
(Recipe here. We used chicken rather than fish broth. I left the chiles out of my garnish – it was spicy enough without it.)
Open Culture points us to Koji Yamamura‘s powerful animation of Kafka’s nightmare short story “A Country Doctor”.
I was in great difficulty
So says the doctor as he tells us of how he was called in the middle of a nighttime blizzard to attend a dying boy, a house call that will ultimately force him to face his own shameful and tormented soul.
His own horse dead from overexertion in the severe winter, the doctor is forced against his will to leave his maid in the arms of a mysterious groomsman, the only person who will lend him a horse on this terrible night.
Arriving at the sick house, the doctor at first dismisses the boy’s illness as a short-term coffee overdose, ranting on about patients who torment his unnecessary emergency calls, his low pay from the district and the uselessness of his calling. Despite this, he gives the family a prescription for the boy because
it is easy to write prescriptions, but difficult to come to an understanding with people.
When it appears this is not enough to satisfy them, the doctor heads back to the sick bed only to discover that the boy is actually dying from a maggot infested wound that will become a flower, and for which there is no cure. At that point, he is surrounded by the villagers and his employers, exposed, literally, as the useless failure that he is, stripped of his clothes and laid in the bed with the dying boy.
Take off his clothes and he will heal.
And if he doesn’t cure, then kill him.
It’s only a doctor, only a doctor.
After convincing the boy that his wounds are actually not as bad as those of many others, which actually comforts him, the doctor escapes, naked on horseback through the storm, past the villagers and back into his home, accompanied by the chanting of children, who sing –
Enjoy yourselves, you patients. The doctor has lain in bed with you.
Wow.
In this short tale written almost a century ago in 1916, Kafka has embodied the inherent conflict between the humanly imperfect doctor and the society which both respects and ultimately despises him for his inability to save them all from death – for in modern society, the doctor has replaced the priest as the road to salvation.
Always demanding the impossible from the doctor. They have lost the old faith. The priest sits at home and tears his religious robes to pieces, one after the other. But the doctor is supposed to achieve everything with his delicate surgeon’s hand.
He also shows us the toll this conflict can take on the individual doctor, who has clearly become burnt out and as a result, useless to his patients.
I’ll never come home at this rate. My flourishing practice is lost. A successor is robbing me, but to no avail, for he cannot replace me. … Betrayed! Betrayed! Once one responds to a false alarm on the night bell, there’s no making it good again—not ever.
In some ways, the story portends the decline, not just of an individual doctor, but of the medical profession itself.
Called to society’s side, we fail to see the real problems in front of us, and even when we do, we are ill-equipped to cure them. But with the rise of the internet, we are being stripped bare of our robes of power, and sent on our way, while others who represent the gods of technology step into our place as the beacons of hope and immortality. If Kafka’s truths are indeed as timeless as they seem, these new gods will ultimately fail as well.
Then again, I may just be having a bad day.
It’s Hanukkah, and in our family that means latkes.
This year, our market seemed to be having a bit of a potato shortage, so I ended up using mostly Russets instead of my usual favorite Yukon Golds. What I did not realize was the the Russets have very little water in them, so when I did my usual potatoes-in-the-dish-towel-squeeze I ended up with a very dry potato mixture that required 4 eggs to stick together!
Lesson learned – If you use Russets, don’t drain the potatoes or onions after shredding them. Bittman says the Russets make better latkes than the more waxy varieties, but I still like the Yukon golds the best.
Despite my love of old traditions, I also think the food processor makes better shreds than the hand grater.
This years latkes were still delicious, despite (?because of) the extra eggs. Then again, there’s not much one can do to ruin a latke.
I take full credit for this dinner, because when my husband called me at work to ask “Shall I make that brussels sprouts pasta recipe from Melissa Clark’s column in the Times?”, I immediately said “Yes!”.
I thought it was delicious served with grated Parmesan, although, given the bite this dish packs, it was even better the next night with a dollop of sheep’s milk yogurt. (Yes, I am addicted to the stuff.)
Recipe here.
In a NYTimes Op-Ed piece entitled “A Shortcut to Wasted Time“, internist Leora Horowitz bemoans the erosion of the medical record, once a means to communicate about a patient’s health, now merely an electronic repository for the minutiae of a medical encounter required for docs to get paid for the work they do. Because, as she simply puts it –
Doctors are paid not by how much time they spend with patients, how well they listen or how hard they think about what could be wrong, but by how much they write down.
In her editorial Horowitz tells us that she spent 40 minutes counseling an anxious patient who was neither sleeping nor eating, and how she was unable in the current payment system to bill for that visit –
Last week, I spent 40 minutes with a patient who had just placed her mother into hospice care. My patient was distraught, not sleeping, not eating. I gave her some advice, but mostly I just listened. By the end of our visit, she was feeling much better. But I wouldn’t be able to bill much for that visit based on my documentation: I didn’t review her medical or family history, conduct a review of organ systems or perform a physical exam.
What the payment system tells me to do is to cut her off after 10 minutes, listen to her heart and lungs and give her a sleeping pill. Which doctor visit would you prefer?
There are many of us who agree with Dr Horowitz about the erosion of the medical record in the era of the EMR.
But I have to disagree with her when she says she would not be able to bill much for that patient’s visit.
Because there is a simple and ethical way within the current system to easily document and get paid for medically necessary encounters such as the one Dr Horowitz describes that does not involve check off boxes, cutting and pasting, or even a physical exam.
It’s called time-based billing.
When you spend >50% of the encounter in counseling and/or coordination of care, time is the key factor in deciding the level of service. Not history, exam or medical decision making. Just time.
How do I know this?
Because I’ve been the billing compliance leader in my department for almost a decade, reviewed hundreds of my colleagues’ charts for coding accuracy, and sat through more lectures on coding than anatomy classes. If there was a GME approved fellowship in medical coding, I’d be running the damned thing. That’s how I know.
Plus, I asked a certified medical coding expert.
Time based billing is like the WAYBAC Machine for the Medical Record
You simply document the chief complaint of the patient and the extent to which history and exam may have been done, what you talked about, including advice given and management plan, how much time you spent doing it, and indicate the diagnosis to support the medical necessity for your work.
Here’s when and how you do it, straight from the CMS Manual –
C – Selection Of Level Of Evaluation and Management Service Based On Duration Of Coordination Of Care and/or Counseling
Advise physicians that when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the type/level of service provided. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.
EXAMPLE
A cancer patient has had all preliminary studies completed and a medical decision to implement chemotherapy. At an office visit the physician discusses the treatment options and subsequent lifestyle effects of treatment the patient may encounter or is experiencing. The physician need not complete a history and physical examination in order to select the level of service. The time spent in counseling/coordination of care and medical decision-making will determine the level of service billed.The code selection is based on the total time of the face-to-face encounter or floor time, not just the counseling time. The medical record must be documented in sufficient detail to justify the selection of the specific code if time is the basis for selection of the code.
In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided.
In an inpatient setting, the counseling and/or coordination of care must be provided at the bedside or on the patient’s hospital floor or unit that is associated with an individual patient. Time spent counseling the patient or coordinating the patient’s care after the patient has left the office or the physician has left the patient’s floor or begun to care for another patient on the floor is not considered when selecting the level of service to be reported.
The duration of counseling or coordination of care that is provided face-to-face or on the floor may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling.
How Dr Horowitz could have billed that encounter
For Dr Horowitz’s patient, there were real complaints that the patient presented with and she probably did review (and update) family history. There were also some elements of exam – Constitutional (general appearance) and certainly Psychiatric (mood). She could document all of that, the total time she spent with the patient and the fact that more than 50% was spent (listening and) counseling, as well as a summary of the discussion points and plan.
Per CPT guidelines, the average time allotted to CPT 99215 is 40 minutes. So, I’d suggest she bill 99215 with a diagnosis of depression/anxiety, insomnia and weight loss.
Which brings up another problem
Of course, using a high level code like 99215, Dr Horowitz should be prepared for her chart to be audited, since insurers increasingly don’t want to pay for high level visits.
Which is whole ‘nuther post for whole ‘nuther day…
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WAYBAC machine image from Wikipedia