Laws Mandating Ultrasound Before Abortion Threaten Physician & Patient Rights

Part of me just shrugs my shoulders at the new laws being promulgated by state legislatures that require ultrasound prior to performing an abortion.

After all, in most practices, getting an ultrasound before doing an abortion is pretty much routine already. Doctors who do abortions don’t want to be surprised by an unexpectedly advanced gestational age, a uterine anomaly, an erroneous diagnosis or an ectopic pregnancy. Since most Ob-Gyns have an ultrasound machine in their office, the sono is fast and easy to do. Those docs who don’t have their own sono machines will refer out. And higher volume providers may employ a radiologist or sonographer to do the sonos in their practices.

So if we’re all doing ultrasounds anyway, what’s the big deal?

This is not about abortion – It’s about the practice of medicine and the rights of patients

The big deal is that patient and physician rights are being violated by legislators with an agenda that has nothing to do with the public health and everything to do with restricting access to a legal medical procedure.

We are not talking about a doctor ordering a radiologic test. We are talking about state legislators mandating that a patient undergo a medical procedure without her consent.

It’s not only invasion of privacy, and the physician-patient contract,  it’s assault on the patient. It’s mandating that “as a component of informed consent”, a woman undergo a procedure without her consent. (Amendments that require the woman to consent for the ultrasound were voted down.)

 

HC 462 – The Virginia Ultrasound Law

Abortion; informed consent.  Requires that, as a component of informed consent to an abortion, to determine gestation age, every pregnant female shall undergo ultrasound imaging and be given an opportunity to view the ultrasound image of her fetus prior to the abortion. The medical professional performing the ultrasound must obtain written certification from the woman that the opportunity was offered and whether the woman availed herself of the opportunity to see the ultrasound image or hear the fetal heartbeat. A copy of the ultrasound and the written certification shall be maintained in the woman’s medical records at the facility where the abortion is to be performed. This bill incorporates HB 261.

Do you see the legal precedent being made here?

Forget for a moment that this is about abortion.

Imagine instead that there is a law requiring you to get a chest x-ray before you can be treated for pneumonia. Or mandating that as a doctor, you order an MRI and show the patient the images before treating a headache. Or forcing a male patient to undergo a rectal exam before being treated for urethritis.

We’re not talking about whether or not these are things that are happening anyway as part of the current practice of medicine. We’re talking about a law requiring them to be done as a condition of treatment. The doctor must order the test and the patient must undergo the procedure. Or the doctor is breaking the law.

This is not just about abortion. Or women’s rights. Or Planned Parenthood.

It’s about the practice of medicine and the rights of our patients. It’s about physician-patient privacy and the authority of doctors to practice medicine without the fear of breaking the law.

All physicians and patients, whether they are male or female, pro-choice or pro-life, Republican or Democrat, should be outraged. Our medical societies and our patient advocacy groups  – every single one of them, whether related to reproductive care or not – should be fighting these laws, and engaging physicians and patients everywhere to fight back. Publicly and vocally.

With the passage of Virginia HB 462, eight states now have laws mandating that a woman have an ultrasound prior to an abortion.

How soon before it’s your state? Or your specialty? Or your practice? Or your body?

Writing that Works – Great Advice for Bloggers

Here are a few notes I took while reading Writing That Works, by Kenneth Roman and Joel Raphaelson. This book, written for business writers, and once recommended by famed ad exec David Ogeily to all his employees, also has some great advice for bloggers.

What to do before you start writing –  Put down first what you want the reader to do, next the three most important things the reader needs to understand to take that action, then start to write. When you’re done, ask yourself whether if you were the reader, would you take action on the basis of what is written.

A Paradox. Writing better does not mean writing more. It takes time to write well.

On length – Short sentences and short paragraphs are easier to read than long ones. And easier to understand.

Beginnings & Endings are important – Start with that single point you want your audience to take away. Conclude with a memorable way for them to do so.

Fact vs Opinion – Never leave your reader in doubt as to what is opinion and what is fact.

Finally –  The only way some people know you is through your writing. Your writing IS you.

The book has much, much more, including tips for writing and handling email, memos and letters. It’s very concise, a quick read, and would make a great graduation gift. A nice companion to my all time favorite writing book, On Writing Well by William Zinnser.
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More great advice on writing from David Ogilvy.

Turbo Scan – Amazing iPhone App

We’re on deadline for a grant application, and I needed to get my letter of commitment signed, scanned and emailed to the research office ASAP. The person in my office who has the scanner was at lunch.

TurboScan to the rescue! Print on letterhead, sign the letter, snap 3 quick pics of it with my iPhone4, let it process and then email the PDF to myself.  Less than 3 minutes.  Done.

TurboScan is not a free app, but as far as I’m concerned, it’s worth more than the $1.99 I paid for it.  (And no, I was not paid to write this post. I just love technology. And my iPhone, of course.)

Not Quite Rococo Torte – Another Gem From a Favorite Vintage Cookbook

Breadcrumbs in a cake? I’d never head of such a thing. But I had a few leftover baguette crusts in my freezer, and the memory of an amazing cake I’d made a few years back from this wonderful little vintage cookbook, Favorite Tortes and Cake Recipes by Rose Oller Harbaugh and Mary Adams.

If the authors were suggesting I use breadcrumbs in my torte, who was I to question? Besides, it was long past time to see what other gifts the book might have in store for me, other than the charming illustrations and typeface, which are a true delight.

I’m happy to report that Ms Harbaugh and Adams came through for me again, this time with a recipe for Rococo Torte with Mocha Frosting. A touch of cinnamon in the batter enhances the chocolate flavor of the not-too-sweet sponge-like cake that is filled and iced with just the right amount of mocha frosting.

What exactly is a Torte?

Ms Harbaugh and Adams tell us that tortes are “the cakes of European cooks”.  They are made light with eggs instead of leavening, with ground nuts, cracker or bread crumbs used in place of or in addition to a markedly small amount of flour. They can be filled with fruit pulp or whipped jellies, and extracts are used to flavor their whipped frostings.

Tortes are a favorite Passover dessert, since eggs rather than baking powder or soda create the leavening, and little to no flour is used. This rococo torte could be modified for Passover by substituting ground nuts for the flour and using ground matzo meal instead of breadcrumbs. (Alternatively, you can use ground nuts to substitute for both the flour and breadcrumbs.)

Why my torte is not quite Rococo

A bit of internet exploration yields evidence that the Rococo Torte recipe in my cookbook may hail from Hungary, where it is called  Rokokka Torta, and is made with a hazelnut filling and whipped mocha frosting. (Click the link to see a truly gorgeous torte!)

As I looked at the traditional Hungarian Rokokka Torta, I realized that I had used the wrong mocha frosting on my torte! The authors had actually suggested mocha whipped cream frosting, which is just what the Hungarian recipe uses. And indeed, there the right frosting was, on the same page of the cookbook as the frosting I had mistakenly made.

So it seems that my little torte is actually “not quite rococo”. But it’s simplicity makes it much less fancy than the traditional Hungarian torte, and it really is a delicious and lovely little cake.

NOT QUITE ROCOCO TORTE

  • 5 eggs, separated and allowed to come to room temp before using
  • 5 tbsp sugar
  • 2 tbsp homemade bread crumbs (recipe below)
  • 3 tbsp flour (cake flour if you have it)
  • 2 squares bittersweet chocolate, grated or processed fine in the food processor
  • 1/2 tsp cinnamon
  • shaved chocolate for topping

Preheat oven to 325 degrees fahrenheit. Butter and flour 2-8 inch cake pans. (I also lined the bottom with waxed paper.)

Beat egg whites till stiff. Set aside. Beat egg yolks till lemon-colored. Add sugar and beat well. Add bread crumbs and sifted flour and beat thoroughly. Beat in grated chocolate and cinammon. Fold in stiffly beaten egg whites. Divide between two 8-inch cake pans and bake for 25-30 mins till done. Fill and cover with Mocha Frosting or Mocha Whipped Frosting (recipes below) Shave some bittersweet chocolate on top.

The cakes did not immediately drop out of the pan for me, even after running a spatula around the sides, so I slipped the spatula an inch or so under one side and then used my hands to remove the cake, which was light and yet remarkably sturdy. (Alternatively, you could use two 8 inch spring form pans.) Here’s what the bottom looked like after I removed the waxed paper –

and what it looked like filled and frosted –

MOCHA FROSTING

Although at first it seemed like it was not enough, this recipe makes exactly the right amount of frosting for this cake. I substituted Kahlua for the mocha extract.

  • 1/3 cup sweet butter
  • 1 1/2 cups confectioners sugar
  • 1 tbsp cocoa
  • 1/2 tsp mocha extract (I used Kahlua)
  • 1 tbsp strong coffee (I dissolved a tsp of instant espresso into a tbsp of hot water)
  • Sift sugar and cocoa

Cream butter thoroughly in electric mixer. Add sifted sugar and cocoa. Add mocha extract. Add coffee a drop at a time until spreading consistency (I used the entire tbsp of coffee).

MOCHA WHIPPED CREAM FROSTING

  • 2 tbsp confectioner’s sugar
  • 2 tbsp cocoa
  • 2 tsp cinnamon
  • 1/2 pint whipping cream
  • 1 tsp mocha extract

Sift sugar, cocoa and cinnamon. Whip cream. Fold in sifter dry ingredients. Add mocha extract and whip till spreading consistency.

Homemade bread crumbs

Allow frozen bread to come to room temp. Slice into 1 inch slices and lay out on a baking sheet. Heat in a 250 degree oven till dry but not brown – about 15 minutes – turning halfway through so they dry evenly. Cool, then process in food processor till finely ground. Store in a tightly capped jar in the freezer till use.

Alternatives to Komen for Channeling You Dollars & Energy to Fight Breast Cancer

By now, you’ve heard that Susan G Komen For the Cure, which at first announced that it would withdraw its funding to Planned Parenthood for breast cancer screening programs, now appears to (but may not actually) have reversed that decision after an enormous public outcry.

Komen is not new to controversy.  Many have criticized their “pink-washing” campaign, which has promoted some very unhealthy products and brands in return for donations (Pink buckets of fried chicken? Really?…) But with this latest political move, they’ve gone too far for many of their supporters, some of whom say they will stop supporting Komen. Planned Parenthood, in the meantime, has raised record dollars since Komen’s initial announcement, topped off by a $250,000 matching grant from Michael Bloomberg.

I could go on and on about the controversy, but that’s not the point of this post, which is simply to answer the question I found myself asking – what should Komen’s former supporters do now? How can they channel their efforts to fight breast cancer if they are not going to give to Komen?

One option, of course, is to give to Planned Parenthood, The other option is to donate to one of the other charities on the front lines in the battle against breast cancer. Komen, after all, is not the only game in town.

Here are a few other places where your dollars will be put to good use fighting breast cancer. All of the following groups get high ratings from the American Institute of Philanthroy and/or Charity Navigator–

And if you’re not already donating to the fight against breast cancer? Well, maybe it’s time to start.

Dinner (Maze) & the Theater (Other Desert Cities). A Quintessential NYC Evening.

It’s one of my favorite things to do in New York. Dinner and a play.  It’s also among the most challenging combination of activities in the Big Apple to pull off well.

So much can go wrong – not having a reservation and spending a half hour wandering Restaurant Row with the tourists looking for a table (I’ve done that more times than I can count); finding out your dinner reservation has put you into a pre-theater mill where you’re herded like cattle at the slaughter (ditto); or rushing anxiously through an otherwise delicious dinner and then running like crazy to make curtain time (I call it doing the Times Square Bob and Weave).

Then there’s choosing a bad play (not often but it happens); choosing a great play that one of your company hates and everyone else loves (that play with the goat); finding out the lead is replaced by the understudy  (that Laura Linney play that wasn’t); and let’s not get into the lines at the ladies room, shall we?

Well, last night we pulled it off. Dinner at Maze and tix to Other Desert Cities. Perfect combo. (Not to mention great friends…)

MAZE

The only table available at Maze was at 5:30, and while I felt a bit like I was heading out for an early bird special, the timing was just right. So right that it’s going to be my new dinner start time for pre-theater. We had a wonderfully leisurely meal and great conversation unencumbered by worries about making curtain time. And had time for an absolutely perfect Margarita at the bar before sitting down to a fabulous meal.

The bread – best I’ve ever had at a restaurant, hands down. A lightly salted cross between a focaccia and a baguette is the best way to describe it. It felt very light on the tummy and we went through two little buckets – mostly because we needed it to sop up all the great sauces we had.

Two of us ordered the scallops appetizer – perfectly cooked with little bits of cauliflower and capers. (Sautéed sea scallops golden raisin purée, cauliflower beignets, crispy capers $18)

The single short rib ravioli appetizer had a surprisingly generous and delicious meat filling.

The sweetbreads appetizer was a bit of a disappointment. When I eat sweetbreads, I’m looking for that soft inner texture. These pieces were more like crackling sweetbreads. Delicious, just not what one would hope for.  A better description in the menu would have been helpful. (Oven baked beetroots caramelized sweet breads, celeriac mousseline, mache salad $18)

The Bronzino was truly amazing. Trust me, we sopped up every bit of that beurre rouge. (Filet of branzino spinach and artichoke fricassée, beurre rouge, crispy phyllo $26)

But the star of the evening? The little pot of fingerling potatoes in a shallot cream sauce that were served with the Trout Market special. (Whole roasted Idaho brook trout Sheldon Farm fingerling potatoes, orange and fennel salad $29) There were more than needed for one person, which meant we all got to share them. OMG. The potatoes were perfectly cooked and the sauce – well, we were all practically licking the pot to get every bit. I asked how they were made and got this much – shallots, garlic, chicken broth and I assume butter and cream and parsley. If anyone reading this has the Maze cookbook, let me know if the recipe is in there. (I tweeted Ramsay to see if he would share it – I’ll let you know if he responds.)

We all shared dessert – delicious. (Chocolate pudding stout ice cream, pretzel, peanut butter powder $9.00)

No one overate or over-drank, both of which can be disasterous before a play. Susan and I shared the Bronzino, MR TBTAM only had appetizers, Boyd shared his potatoes (OMG again…) and we all tasted one another’s dishes and shared the dessert.  It was a completely satisfying meal. The bill for 4 of us, including 2 beers and 1 glass of wine, but not the drinks at the bar, was $200.

Maze also has a pre-fixe theater menu during the week for $35. I consider that a real bargain.

Our early reservations meant we had time to enjoy a leisurely walk to the  Booth Theater on 45th St to see Other Desert Cities.

OTHER DESERT CITIES

What a cast.

I’ve loved Rachel Griffiths since Muriel’s Wedding, and she was fabulous as Brooke, a 30-something writer who arrives at her parent’s Palm Springs home to announce she’s publishing a memoir that revisits their shared tragedy and threatens to upend her parent’s carefully reconstructed life.  Stockard Channing it a tour de force as a Jewish-Texan Right-wing Mama Grizzly modeled on Nancy Reagan, and Stacy Keatch her completely sympathetic Papa bear counterpart. Judith Light is transformed as a recovering alcoholic aunt. (Why have I not seen her in a play before? I’ve been missing some amazing stage acting!) And I was thrilled to find Justin Kirk playing Brooke’s younger brother Trip – while there was much of Andy Botwin in Trip, it’s a character I happen to love, and Kirk plays the part beautifully. (His final outburst actually drew applause during the play.)

We found ourselves a bit confused as to the chronology of the play – which war were they talking about – Iraq or Vietnam? What year was it? How old is everyone supposed to be?  But that just gave us fodder for a spirited conversation at intermission, which was the first one in as long as I can remember that did not include a visit to the ladies room.

Hanging around talking afterwards, a nearby burst of applause made us realize we were near the stage door, from which the cast was emerging.

I got a few pics and had a brief conversation with Judith Light, who, after signing autographs and taking pics strolled off with her companion and merged into the crowd on 45th street.

It’s what I so love about New York. The Gods walk among us.

Pfizer Recalls Lo-Ovral & Its Generic Birth Control Pill. What Should You Do?

You’ve heard by now that Pfizer has recalled about a million birth control pills due to concerns the the hormone dosing and pill order in the packs could be wrong. This could affect the pills efficacy, exposing women to unplanned pregnancy.  There are no concerns beyond this about safety.

The pill they’ve recalled is called Lo-Ovral or its generic Norgestrel 0.3 mg/Ethinyl Estradiol 0.03mg. I’ve posted a list of the affected lots below. The first thing you need to do is check your pill pack against the list to see if you are taking a recalled pill.

If you’re not taking a recalled pack, take a deep breath and relax. Then share this post on Facebook or wherever you share, so that your friends who may be taking a recalled pill learn about it as soon as possible.

What should you do if you are taking a recalled pack?

Talk to your doctor about what you should do if you are taking a recalled pack. Here’s what I’ll be telling my affected patients.  (Disclaimer – What follows is advice I will be giving my patients.  What your doctor may want you to do could differ. )

  • First of all, don’t panic.  If you’re not spotting or bleeding out of schedule,  you’re probably still protected against pregnancy. But make no assumptions – Presume you are unprotected and follow the steps below.
  • Head immediately to the pharmacy for a new pack of pills.
  • If you’ve been sexually active since your last period, do a pregnancy test. If it’s negative (and it most likely will be negative), start your new pack immediately and use condoms for the next two weeks. Your next period should come at the end of your new pack of pills. If it does not, do another pregnancy test. If you don’t want to wait till then to be sure you’re not pregnant, you can do a second pregnancy test two to three weeks after the first.
  • If you’ve had sex in the past 5 days, discuss with your doc if you should consider taking emergency contraception.
  • If you haven’t been sexually active, no harm has been done. Get a new pack and start it right away. Use condoms if you have sex in the next two weeks.
  • If you’re pregnant, contact your doctor. What you decide is up to you, but know that accidental exposure to normal doses of birth control pills in early pregnancy should not impact the pregnancy outcome.

Greenwich Village Culinary Walking Tour

Sometimes it’s fun to act like a tourist and see your home through fresh eyes. That’s what we did yesterday, when we joined a Manhattan Walking Tour of the West Village that had tempted us with a great low-price offer on Gilt City.  Blessed with unseasonably warm weather, the company of good friends and a fabulous tour guide, we spent a leisurely 2 hours or so wandering through charming streets, learning a bit of history, architecture, fun facts and neighborhood gossip while sampling the unique culinary offerings of one of my favorite neighborhoods in New York.

Here’s a tiny bit of what we saw, learned and ate –

A Little History

Here are just two of the fun facts we learned-

Did you know that the reason the streets of the Village are so circuitous is because they followed the paths of stereams? And that those streams still can be heard running uner the streets? Minetta Lane is one such street.  (Here’s a fabulous blog post I found about a building with a tube that dips down into the Minetta stream and fills with water whenever the stream rises. Read the comments section of the post for more underground Manhattan steam stories).

Hudson Street is named appropriately, since it used to run alongside the river. After decades of landfill along the west and south sides of Manhattan, however, Hudson St now runs three blocks inland.

A little Architecture

We wandered off the main drag through winding streets past carriage houses and old horse throughs, saw the a teeny building covered in keys, the oldest house in NYC, the narrowest house in NYC, a former toy shop and the largest children’s play house ever built, and of course the building where Friends supposedly lived. And learned about landmark designation, and how some retailers are shamelessly getting around the rules. And what it means to be “86’ed”. (Hint – It has to do with an address we passed by…)

A lot of Gorgeous Blue Sky

You see more sky in the Village, where there are fewer tall buildings.

A Little Music

A Little Noshing

This was a culinary tour, after all, and in this regard, it did not disappoint. Here’s where we went and what we tasted –

The Chocolate Bar 

We skipped the exquisite chocolates and went straight for a classic NYC Egg Cream made with the requisite Fox’s U-Bet Chocolate Syrup, milk and soda water.  The Chocolate Bar has been credited with reinvigorating the egg cream after a long hiatus from the culinary repertoire of modern New York, though some would argue that the Egg Cream was doing just fine before they came along, thank you.  I’d ague that an egg cream is a lower fat alternative to a milk shake  and that it tastes, well… invigorating.

Il Cantuccio 

The Italian bakery has three branches – the other two are in Italy. The glass-windowed bakery is the heart of the store and was in action when we arrived.  The focaccio were deliciously fresh and reminded me of Rome.

Biscotti, made with prune or figs or chocolate, were practically right out of the oven. They cut them right in front of you. I bought a box home.

Fiaccio’s Pork Store

A NYC institution, with another store in Brooklyn. We bought sweet sausage with fennel to cook for dinner tomorrow night. Then we had rice balls – a first for me. Breaded, not fried and perfection!

The marinated artichoke hearts and mozarella were the best I’ve ever eaten (and I’ve eaten many before, trust me…)

We stopped briefly into Murray’s Cheese Shop, newly expanded and looking disturbingly neauveau (I liked the old place better…) and snuck into Amy’s Bread for a slice of chocolate cake for later.

Mamoun’s Falafel

Best baba ghanoush I’ve ever had. Eaten in Washington Square Park, just the way it should be.

A Little Off Tour Shopping

BookBook

You can’t walk by this wonderful independent book store without stopping in. So we did.

The Abingdon Square Green Market.

Understandably small in winter, but still wonderful.

The Meadow

Also not on the tour (maybe it should be?) . We stopped there on the way home, having heard so much about this store that sells – are you ready? – SALT. I picked up a tin sampler set of finishing salts – salt that’s put on food at the time you eat it, as opposed to salting your food while you cook it – and already have fallen in love with the black diamond salt.

But that’s another blog post for another day…

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Manhattan Walking Tours offers small group guided tours around Manhattan. Thanks to Alex for a fabulous tour. Look for us on the Wall Street history tour one of these days soon!

 

Sometimes My Patients Bring Me Food

Thanks DV for the wonderful Ardith Mae Goat Feta you brought me today at the Union Square Green Market after you found my blog and realized that I was a fellow foodie.  I had it for lunch and it was the best feta I’ve tasted to date. Not salty like so many I’ve eaten before. Just wonderfully fresh, rich and flavorful. I’ll be using the rest this weekend in a salad for sure. While I can’t get to Union Square on Fridays to get more, I discovered they also sell at the Columbus Ave Green Market on Sundays!

And the homemade Erba Toscana you learned to make in Italy?  The smell was driving me bonkers, so I actually sprinkled a little on the feta – OMG, delish. Can’t wait to use it on fish or chicken. Now I know what I should be doing with the herbs in my garden, instead of letting them die back over the winter.  (And what a great idea for holiday gift giving!) You are an inspiration.

Finding out your patients love food as much as you do. Just a little unexpected bonus of  the blog. (I do love it so.)

 

Are You Obligated to Tell Your Partner(s) that You Have HPV? This Doc Says No.

One of the most common questions I get from my patients who have had had an abnormal pap due to HPV infection is this –

Are they obligated to notify their past, current, future or potential sexual partners that they have or have had HPV?

I believe the answer is a qualified no. And here are the reasons why –

1. HPV is ubiquitous.

Close to three-quarters of adults have had HPV at some point in their lives. Ninety five percent of the time, that infection will clear within 1-2 years with no long-term consequences to themselves or their partners.

Although we can offer treatment or removal for genital warts and precancerous pap smears, there is no medical treatment to clear the HPV virus itself in an infected individual without these conditions. That’s the job of the immune system, which can be helped along in this regard by using condoms, avoiding tobacco and eating a diet rich in fruits and vegetables.

2. Unlike women, most men with HPV have no way of knowing they are infected.

Unless they have a visible genital wart, or a much, much rarer HPV-related cancer, most men who have HPV have no idea they are infected. That’s because there is no available HPV test for men. 

Women, on the other hand, if they happen to get an abnormal pap smear during the time they are infected, may very well find out that they have HPV. (I’m not going into the management of abnormal paps here, but suffice it to say that the overwhelming majority of abnormal paps due to HPV will resolve without treatment just as the virus itself resolves. Those that don’t, and which carry precancerous changes, can be effectively treated,)

3. Why then, should a woman be obligated to tell her partner that she has HPV? 

Given the ubiquitous nature of HPV infection, unless her partner is a virgin, the odds are pretty darned high that he already has had HPV. He may actually have the infection right now and be the one who gave it to her. On the other hand, he may have had it in the past and already be immune to the strain of HPV she has. Or be infected with another strain she does not have, so that she may actually be the one taking the risk by sleeping with him.

She’ll never know, and he’ll never know. Because he cannot be tested. Or treated.

4. HPV is not like chlamydia.

There is no role for partner notification and  treatment in preventing the spread of HPV. The only thing that partner notification accomplishes is to turn women with abnormal paps into pariahs, while the rest of the HPV infected men and women out there continue to copulate in blissful ignorance.

Which is why I don’t believe that every abnormal pap needs to turn into an STD confessional.

I do believe that all sexually active adults have an obligation to themselves and others to  prevent the spread of HPV and other STD’s by practicing responsible sexual activity.

That means being tested and treated for those STD’s whose spread we can stem through screening and partner notification, being vaccinated against those we can prevent, using condoms and limiting our numbers of sexual partners.

It’s not a moral message, unless morality means acting responsibly and maturely, and respecting one’s own health and that of others. By limiting one’s partners, I mean confining intimate physical relationships to those who we really care about. (Dare I use the word love?…)

In this context, some women may take HPV infection as a sign that it’s time to stem the one night stands.  A few may choose to hold off on relations altogether until their infection clears. The majority, who are already limiting their sexual activity to caring relationships, will make no changes in their behavior except perhaps to use condoms until the infection clears. And if they are already in a caring relationship, they usually end up discussing it with their partner. Because that’s what couples do – they talk about their lives, their health and their fears.

Which is very, very different from mandatory STD partner notification and treatment.

The Good News

The good news for HPV-infected women is that almost all HPV infections will clear. Once HPV is gone, your increased risk for cervical cancer goes with it. As does your risk for transmitting the virus to others. Which takes care of the issue of future partners.

The other good news is that getting regular pap smears will prevent the uncommon but important consequence of HPV infection – cervical cancer.

Genital warts are worth discussing with your partner.

I do think it’s worth discussing with your current partner if you discover that you have genital warts.More often that you’d think, the male partner may have  small, previously undetected genital warts that are amenable to treatment. He can visit his doc for a careful exam and get treated if warts are present. That in turn may help you clear the infection faster yourself, since your immune system won’t be under constant barrage with high viral loads from your partner.

Condoms are also worth discussing.

If you have an abnormal pap due to HPV, and you are not using condoms, it’s worth discussing the matter with your partner and asking him to use protection when you have sex. Women with HPV whose partners use condoms will clear the virus and return to normal paps faster than those who have unprotected sex.

There is a role for HPV vaccination.

I also support the use of HPV vaccination. Despite my objections to how it has been priced, marketed and legislated, the vaccine is safe and effective. Getting vaccinated after you’re infected won’t help you clear the infection faster, but can prevent new infections with the 4 strains that the vaccine targets.
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Sausage, Kale & Potato Soup with Fig Compote

If this is what you see out your bedroom window when you wake up –

This is what you have for lunch.


Sausage, Kale and Potato Soup with Fig Compote

I don’t know if I’m gilding the lily with the compote or not, but whenever I see sausages I think of figs, and I liked the richness a dollop of it added to the soup. Mr TBTAM thought the soup was perfect without it, but then he spread the compote on warm bread and ate it along with the soup. You can make and eat it either way. Or not at all. Because the soup really is delicious all on its own.

There are lots of recipes for this soup out there out there – this one is modified from Epicurious, found via Smitten Kitchen. We used Italian sausage, but I’d love to try it with Kielbasa or the more traditional Portuguese Linguica sausage. Smoked sausage will slice up easier than Italian, and would add a wonderful flavor. If you use linguica, you may not need the herbs since the sausage is spiced nicely. You can use white potatoes, sweet potatoes or both – I used what I happened to have around. Not sure why I added the carrot, it was probably not necessary.

2 tbsp olive oil
1 lb ( 2 medium) sweet potatoes, peeled, quartered lengthwise and cut into 1 inch slices
1 lb (2 medium) Yukon gold potatoes, peeled, quartered lengthwise and cut into 1 inch slices
1 large onion, peeled and chopped
2 large carrots – peeled and chopped
4 garlic cloves,  peeled and diced
1 coil sweet italian sausage, sliced 1/4 inch thick
1 tbsp fresh thyme leaves or 1/2 tsp dried
1 tbsp fresh oregano leaves, or 1/2 tsp dried
1 large bunch kale, washed, middle spine cut out and leaves torn or chopped into bite-sized pieces
6 cups chicken stock
Salt, pepper and a pinch of hot red pepper flakes for seasoning.

Heat olive oil in large pot over medium high heat. Add sausage and saute till browned on all sides.

Remove sausage and set aside. Try not to eat any. (You can drain them on paper towels and remove some of the fat from the pot if you want at this point.)

Add onions and carrots to the pot and saute till onions are transluscent, about 8 minutes.

Add potatoes and saute, stirring often, about 10 minutes or until they start to soften.

Add garlic and cook for one minute. Add broth, thyme, oregano and bring to a boil, deglazing pan as it heats. Turn down heat and simmer covered, till potatoes are soft, about 20 minutes.

Mash the potatoes in the pot with a potato masher, just enough to thicken the sauce a bit, but leaving plenty of potato chunks (this step is optional, and I may not do it in the future.)

Add the kale and the sausage

and heat till kale is wilted.

Season and serve hot, with fig compote on the side. You can stir a spoonful of the compote into your soup, or spread it on warm bread and eat alongside the soup. Or not.

Fig Compote

10 dried mission figs, stems removed and diced
1/2 cup white wine
1/2 cup chicken broth
¼ tsp salt
¼ tsp fresh ground pepper

Combine ingredients and simmer in a small pot over low heat, mashing the figs with a fork as they soften, until thick and rich. Serve either as a dollop in your soup or spead onto warm baguette slices.

Adapting Office Workflows to the EMR – or How I Restored Patient Face Time & Got Back the Joy in Medicine

The Problem : Lost Face Time = Lost Joy

One day, about 5 years into using the electronic medical record in my practice, I came to the realization that I wasn’t having fun anymore. I was sitting throughout most of every office encounter facing a computer screen, my back to the patient on the exam table across the room. The joy of face to face interaction with people, the real reason I went into medicine in the first place, had been replaced with the more pressing urgency of data entry.

My revisit routine went something like this – I’d enter the room, briefly greet the patient (undressed and sitting on the exam table) and then, apologetically saying “Let me just open your chart”, I’d log on and begin interacting with the more immediately demanding presence in the room – the EMR. I’d turn around as often as I could to look at my patient, but mostly I listened but kept my back to her and I typed. After which I’d rush over to her side, do the exam, then head back over to the computer to make sure I got all her orders, refills and charges in as required.  A brief goodbye, and I was on to my next patient.

As more and more mandatory clicks were demanded from the EMR to prove I was a good doctor – smoking history reviewed (click), medication reconciliation  (click, click, click,click), problem list review (erase duplicates from ENT , remove resolved problems, add today’s, then click that I had reviewed what I just did) – the actual moments of face time with my patients had become smaller and smaller, till they were almost an annoying distraction from the real task at hand – finishing my charts.

I found myself spending office hours longing for them to be over, and even more sadly, wondering just how many more years I needed to do this before I could retire.

Something had to change. Since the EMR wasn’t going anywhere, it was going to be up to me to make it work.

Renovating the Exam Room was not the anwser

My internist has a patient chair next to the desk in the exam room – I talk with her there, then she leaves the room while I change, then she comes back and does the exam, finally wrapping things up at the desk while I wait in my gown. Then I dress after she leaves.

I thought about pushing for our exams rooms to be renovated, but realized that I probably wouldn’t adopt my internist’s workflow. It just ties up an exam room for too long.

Advance chart prep was not the answer

I tried doing what some of my colleagues do – reviewing the charts of my patients the night before, creating a presumptive note based on her history and the scheduled reason for her visit (when I knew it) , even entering charges and orders for mammograms and birth control pill refills, all of which I could quickly edit and sign tomorrow when I saw the patient, freeing up the encounter itself for more personal interaction.

That idea lasted about a day. While it may work for surgical sub-specialists who hold office hours twice a week to prep charts the night before, it’s impossible for a doc like myself who sees between 15-24 patients a day, 4 days a week.  I had to find a way to get today’s work done today (and not at 4:30 am today, which is when another colleague does his chart prep).

Changing office workflow was the answer

I realized that my private office, which sits between my two exam rooms, is arranged so that I can type and look at my patient at the same time. So I decided to reserve all my electronic charting to my office, and leave the exam room to do what it does best – exams.

My patients now come to see me in my office before and sometimes after they’ve been examined – a workflow previously reserved for new patients. It’s a little more complicated for the office staff, but it’s working really well for me and for my patients. We’re both more relaxed and can both look one another in the eye while we talk and I type.

Its not just the office staff who’ve had to get used to the new workflow. Long-time patients can get thrown, despite my staff explaining that this is the new routine. One patient told me she felt like she was being called to the principal’s office. Another was convinced I had bad news for her. Once I explain my rationale, however, my patients are more than pleased with the new arrangement. Some have remarked on how much they like my office, and how its decor and wall art has allowed them to get a better sense of who I am.

Other pluses –  I’m no longer wasting precious time logging in and out of the EMR, since my office computer isn’t used by anyone but me. I’m physically more comfortable, and so is my patient. Our wrap up after the exam is that much more personal because I am able to enter her mammogram and refills and even her charges while she changes instead of in the exam room. I remember more of the visit later because I’m more fully present with the patient in the exam room. Finally, there’s less down time for me, since I’ve effectively added a third room to office hours and can see a patient in my office while the other two patients are either dressing or undressing in the exam rooms.

But the biggest upside to my new workflow? I’m having fun!  It’s like falling in love with medicine (and my wonderful patients) all over again.

The down side

The down side to my new workflow is that I’ve got to hold everything in memory between the time my patient leaves my office and when she is ready in the exam room, during which I may have seen another patient or two.  It can take me a second or two to ascertain who’s behind door number two, and sometimes I get it wrong. Which has led to an embarrassing moment or two when I opened the door with a comment related to a prior conversation in my office and realize the person behind it is not who I was expecting to see. I’ve since learned to keep my mouth shut until I’m entirely in the exam room.

The good old days 

In the good old days, I could pick up a chart from the rack outside the door, and in what seems life a few seconds, familiarize myself with my patient’s history (because I kept a great paper chart if I do say so myself…) before opening the door to greet her. During the visit, I could sit with the chart in my lap, jotting down notes as we spoke, my focus on my patient and my thoughts rather than a user interface. Once the visit was over, a few brief jotted notes and some well-placed check marks on the encounter form summarized the visit, a few scribbles on a prescription pad or radiology order form clipped to the chart finished the orders (the rest taken verbally by my tech), a check off or two on the superbill and I was done. The entire work of a patient’s encounter took place in one room (or just outside its door), and in one allotted space of time, during which I was hers and hers alone. My chart was there, sure, but it was not the dominant presence in the encounter the way the EMR is now.

Is the IPad the answer?

I find myself thinking a lot about the Ipad these days. While initially skeptical about its place in healthcare, I’m beginning to think that it may ultimately provide the best workflow solution for me. However, I’m worried about my ability to type into it – something that’s not easy to do standing up.  And its compelling interface could be even more of a distraction than the desktop. But its portability could allow me to review a patient’s chart outside the room just like the old days, and things like favorite lists and drop downs in the EMR could minimize typing.

Our EMR vendor at this point only offers a limited version for the Ipad, something that may be useful on call but not robust enough for office hours. So nothing new anytime soon.

That’s okay. I’m happy again. I can wait.
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Pauline Chen,MD wrote about this issue last year in the NY Times. She points out that some docs seem to handle the distraction of the EMR better than others, integrating it more seamlessly into their practice. If you use the EMR and have a workflow that works well for you, tell us about it in the comments. 

Annual Sonogram Screening Prolongs Ovarian Cancer Survival, but Does it Save Lives?

Results from the Kentucky Ovarian Cancer Screening Study at first glance look incredibly promising.  Among the over 37 thousand women who underwent annual pelvic sonograms, the 5-year survival rate for all women with ovarian cancer in the screened group was 75% compared with 54% for unscreened women with ovarian cancer from the same institution treated exactly the same otherwise. The investigators attribute this increased survival to earlier detection – 70% of the screened group were diagnosed at stage I or II, compared with only 27% in the un-screened group. Stage III cancers tended to be earlier (IIIa and IIIB instead of IIIC), and there were no stage IV cancers among women who were screened.

The investigators markedly improved on the positive predictive value of screening by boldly refusing to go where others have always gone before – to the operating room. They stood firm and watched cysts grow to as large as 10 cm before intervening, provided those cysts did not bear the defining characteristics of malignancy – namely solid areas and papillary internal growths. They also were not afraid to tweek their triage algorithm as experience with sonography improved. This is perhaps the biggest contribution from the study – permission to watch and wait.

Following a mean of 5.5 screens in 37,293 women, the authors achieved a specificity of 98.5% and a PPV of 8.9% with 11.1 operations per case of primary invasive epithelial ovarian cancer. This compares with a specificity of 98.4% and 19.5 operations per case of primary invasive epithelial ovarian cancer in the Prostate, Lung, Colorectal and Ovarian Cancer Screening trial, in which both ultrasonography and CA 125 were used as first-line tests.

But a closer look reveals important questions that must be answered before we can begin to recommend screening in the general population.

1. Could the results be explained by the healthy volunteer effect? This was not a randomized trial, just a comparison between women in the screening program and the rest of the population who got ovarian cancer in the same time frame outside the program.  We all know that folks who volunteer for studies such as this tend to be healthier in general than the overall population, thus skewing survival statistics in their favor. In this study, however, survival was equivalent between control and screened groups diagnosed in early stages, suggesting that it was indeed the stage shift that led to higher survival in screened groups and not just a healthy volunteer effect.

2.  How about lead time effect? This happens when cancer is identified a little earlier, giving the false impression that folks are living longer when it is really that they have just learned a little earlier about the diagnosis that ultimately will lead to their demise. All screening studies have this potential bias. This is why overall mortality and not just survival time must be the relevant statistic to compare between screened and unscreened groups.

3. Not all cancers were caught by sono. Twelve women developed cancer in the year after a normal screening test, with 7 deaths due to cancer in this group. Such aggressive tumors may never lend themselves to early detection, no matter what modality is used.

4. Major surgery remains the only way to ultimately diagnose ovarian cancer. In the Kentucky trial, 523 women, or about 1.4% of participants  screened ended up in the OR, and 86% of these women did not have cancer.  Until we have a less invasive was to get reliable pathology on ovarian cysts, we are going to be exposing healthy women to unnecessary surgery while chasing the elusive early diagnosis.  While this may be marginally acceptable in high risk women, expanding screening to the general population will lead to millions of avoidable operations, with their consequent risks, costs and mortality.

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Long-term survival of women with epithelial ovarian cancer detected by ultrasonographic screening. van Nagell JR, Miller RW, DeSimone CP, Ueland FR, Podzielinski I, Goodrich ST, Elder JW, Huang B, Kryscio RJ, Pavlik EJ Obstet Gynecol. 2011 Dec; 118(6):1212-21

Jacobs,I; Menon,U. Can Ovarian Cancer Screening Save Lives? The Question Remains Unanswered. Obstet & Gynecol. 118(6):1209-1211, December 2011.