NIH’s Medicine in the Media Course – Time to Go Big

The NIH is doing it’s best to get science writers on the right track when it comes to responsible health reporting by holding an annual course on Medicine in the Media.

The National Institutes of Health’s Office of Medical Applications of Research (OMAR) presents a free annual training opportunity to help develop journalists’ and editors’ ability to evaluate and report on medical research. The course curriculum builds on the best of prior years’ offerings to create an intensive learning experience with hands-on application.

When I read about the course on Gary Schwitzer’s tweet stream, I got really excited and started scouring the NIH course site to listen to some of the fabulous speakers in the 2011 course, which just finished in July. I was disappointed to discover that that the course, while free, is by application only, limited to 50 participants and not broadcast or archived on the web.

While limiting the course this way will certainly serve to create an elite group of science reporters, it won’t help the thousands of local news outlets playing “pass on the press release” health reporting that continues to be the main feeding source for health information for so many Americans.

Here’s a call to the NIH to open up its course content to the public and the media at large, in the same way that so many of its events are broadcast and archived. Imagine if every health editor and reporter were to take the course online. And while we’re at it, how about every medical center and university employee responsible for writing press releases? In a very short time we could have major impact on the quality of health reporting in this country. Which would translate into a better informed public.

Now that’s my tax dollars at work.

Blog Break

Heading off to the Pacific Northwest and California for a two week vacation.  I’m going to see how long I can survive off the grid.

See you when I return!

CNN Does a Nice Job Covering the Aftermath of the Mammogram Controversy

Kudos to CNN’s Lisa O’Neil Hill for a well-balanced and thoughtful article on the mammogram controversy. Absent from the article is hyperbole and stridency that make the medical community sound like a bunch of cats and dogs. Instead of “Them’s fightin’ words” soundbites, O’Neil Hill gives a well-written summary of all the major viewpoints on the issue.  She took the time to understand everyone’s point of view, and chose quotes that illustrate the fact that this is not a fight, but an intelligent discussion about how to maximize the benefits and diminish the harms of a less than perfect screening test for breast cancer.

“The initial recommendation from the task force caused a great deal of confusion, which was unfortunate because what I think they were trying to say is, I think, something very reasonable. The way they said it and the way it came out was very unreasonable,” said Dr. Otis W. Brawley, chief medical officer of the American Cancer Society.

“What the task force was trying to say is mammography is an imperfect screening tool and there are some harms associated with it, but there are also some benefits associated with it,” he said. “They were trying to say the benefits are not nearly as good as we would all like.”

Moyer said Brawley is on target.

“In many, many instances, our recommendation has been interpreted as a ‘don’t do it.’ That is incorrect,” she said. “It’s something that needs to be discussed on an individual basis. For some women, it will be consistent with their values to choose to have a mammogram between 40 and 50. For other women, they will choose not to, and those are both reasonable decisions.”

I strongly encourage you to read and share the article.

Helix – Playing the Hand You’re Dealt

If your DNA determines who you are, and defines both your strengths and limitations, then you could say we all live our lives with a pre-dealt deck of cards.

That’s the premise of a new card game on display as part of the Talk to Me exhibit which opened at MOMA this week.

Players send in swabs of saliva; the designers send it out to be analyzed and then generate a customized 50-card deck from each player’s specific DNA…The deck allows players to become shadow versions of themselves, with all their genetic cards on the table, and in the game, as in reality, life depends on how the cards are played, not on which cards are dealt. The effects of any trait depend on the player; the challenge of the game is how to contend with or take advantage of it. A player with a great deck can still lose if the game is played without strategy, and a skilled player with a weaker deck can win.

Fascinating idea. A life lesson in a card game.

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We visited the Talk to Me exhibit Saturday with friends, including Helix’s graphic designer Mike Essl. Congrats Mike on being included in this amazing exhibition!

If you haven’t yet been to Talk to Me, You MUST go.

An Astoria Garden

Mrs P and her husband own a laundromat in Astoria, a business that leaves her little time for her garden, and so she apologizes for the disarray on the rooftop outside her kitchen door. I have come for the gardenia plant whose pot has broken, a gift she had offered a few weeks ago, when she came to her annual visit bearing their fragrant blossoms as a summer offering. (When I had called her today, her first sentence to me, before I even had time to give her her sonogram results, had been “When are you coming for the gardenia plant?”…)

But I hardly notice the pots and dirt piled around the table, because I am too busy imaging I am on an island in Greece, which is where most of the enormous and beautiful plants in her garden are from. How she got them here is a miracle, as is the fact that her gardenias, which cover an entire wall, have made it through every winter since she started the garden, sheltered in the large rooftop shed.

Everything and anything is used here as a container, from kitty litter boxes to paint buckets to blue steel drums.  Mrs P waters the garden herself using the hose in the corner, feeding the plants with Miracle Gro and using sulfer powder occasionally to battle fungal spots on the leaves. And despite what Mrs P calls neglect, her garden, while not exactly groomed, is healthy and thriving. So much so that an intertwining of three separate vines threatens to overwhelm the satellite dish hanging from the brick wall.

She gives me large cuttings from the enormous and sturdy basil plant that she tells me is from Israel, a basil whose leaves are tougher, shinier and smaller than those of the sweet basil I have known. The smell is like no basil I have ever smelt – pungent, yet almost flower-like, but she promises me that I can use it in cooking, along with the leaves of the small Greek globe basil plant that she gives me because she has not found the time to pot it herself.

We lament that her duties downstairs prohibit us sharing a coffee, and yet she keeps lengthening our visit as she heads to make me yet another cutting to take home, going from pot to pot to be sure I have a sampling of every color of the low succulent that grows anywhere she has a bare spot in the garden. (What name is it again? And that yellow one? Why did I not write them down?…)

Finally I have to make her stop. I am so worried that I will not be able to nurture all these children she has given me, afraid that her gift to me will be wasted. After all, it is I who have not fed my apple trees once this summer, who have let the rhodedendrun overgrow into the azalea and negelected to trim the dead limbs from the dogwood. But her faith in me renews my faith in myself, and my promise to her to take care of these cuttings is also a promise to my own neglected garden.

We walk downstairs and spend a few minutes with her husband in the laundromat, lamenting the state of the economy, and comparing their fast-paced, no rest for the weary life here in America to the life in Greece, where instead of mopping the floors at 8 pm, Mr P might instead be shutting up shop to head to a Taverna, and where Mrs P would have time to take care of her garden the way she would like. But there is the mortgage on their building to pay, and the business to run, and a grandchild on the way, and they cannot understand how their fellow countrymen find time to eat out in the evenings when there is so much work to be done.

We promise to meet again, next time for a coffee, and I tell her that I will bring a pie. As we stand outside saying goodbye, a neighbor walks up to ask if Mrs P can spot clean an evening dress, a job she gladly agrees to, telling the young woman bring it by first thing in the morning. “We open at 7:30 am” she says.

Later that evening, as I place my cuttings into water and put them on the kitchen windowsill,  I find myself wishing that the American Dream had just a little more time set aside for gardening.

The Annual Mammogram – It’s What Women Want, But Is it For the Right Reasons?

Most women in their 40’s believe they should have annual mammograms, regardless of what screening regimen their doctor might recommend.

So say researchers in Massachusetts who surveyed women (primarily white, highly educated) ages 39-49 presenting for annual checkups. They gave the women a fact sheet about the new USPSTF guidelines on mammogram screening in their age group, and asked them to read one of two articles either supporting or opposing the guidelines. The researchers then asked women about their beliefs, concerns and attitudes about breast cancer and mammogram screening. Here’s what they found –

  • Women overwhelmingly want annual mammograms – Close to 90% of women surveyed felt they should have annual mammograms, regardless of what their doctor might recommend.
  • Women overestimate breast cancer risks – Eighty eight percent overestimated their lifetime risk for the disease, with the average estimate being 37%. (The correct lifetime risk for breast cancer is 12%). This is consistent with previous research on breast cancer beliefs.
  • The media may not influence women’s opinions about screening guidelines – No matter which article they read, close to 90% felt that that the (USPSTF) guideline changes were unsafe and 84% would not be comfortable delaying screening mammograms even if their doctor recommended it.
  • Friends and Family are a strong influence. Seventy six percent of women reported having a close friend or family member who had been diagnosed with breast cancer. Secondary analysis showed that 92% of those with a close friend or family member with breast cancer vs 77% of those without a close friend or family member with breast cancer felt women should continue to undergo routine mammography in their 40’s despite the new USPSTF guidelines.
  • The experience of false positive mammograms only reinforces women’s faith in mammogram screening. Ninety two percent of those with a prior false positive mammogram expressed discomfort with the USPSTF guidelines vs 79% of those who had not had a false positive mammogram.

This finding suggests that these patients were more likely to view the additional imaging and biopsies as a near miss rather than a false alarm. This is an important finding because it is in direct contrast to the conclusions drawn by the USPSTF, which cited psychological harm from false-positive results as one of the major risks of screening mammography in the fifth decade. Our findings are consistent with other research showing that women are very tolerant of false alarms if they perceive the issue being addressed as significant.

Breast cancer awareness or breast cancer misinformation?

Previous studies have shown that women not only over-estimate their personal risk for getting breast cancer, but also inflate their 10-year chances of dying from breast cancer by over 20-fold. They also wildly overestimate the efficacy of mammograms in lowering breast cancer mortality, believing it to be almost 100 times as effective as it actually is in reducing breast cancer deaths.

Who can blame women for believing they are at higher risks for breast cancer than they actually are? After all, breast cancer awareness campaigns have been among the most successful outreach programs ever created, with the pink ribbon being used at this point to market everything from jewelry to Kitchen Aid mixers. Whether these campaigns have actually had any impact in reducing deaths due to breast cancer remains a point of some debate, and there are those who credit the declines in breast cancer mortality more to new treatments than to increased uptake of mammography screening.

Have we lost women’s trust? 

With the disagreement among doctors about guidelines, the miscommunication of recommendations by the very folks writing the guidelines and the resulting confusion in the media attempting to report these guidelines, it’s no wonder women don’t trust their doctor’s recommendations and have made their own decisions about screening.

At this point, it’s probably easier to just write the mammo referrals once a year and move on. After all, the American College of Obs-Gyn agrees that women should be offered annual screening. And my medical-legal risks align nicely as well, since failure to diagnose breast cancer is one of the biggest reasons gynecologists get sued.

But it that the right thing to do?

Call me crazy, but I happen to think that an informed screening choice is still the best one.

I’m not giving up yet. My patients want to make their own decisions about mammograms, and that’s just fine with me. But I’m going to do my best to be sure that decision is not just a gut response to an inflated sense of risks, but a careful decision informed by risks as well as benefits of screening and realistic expectations about what mammograms can and can’t do to lower breast cancer mortality.

To that end, here are some great resources for getting better informed about breast cancer screening –

  • National Cancer Institute  mammogram information. NCI recommends having mammograms every 1-2 years starting at age 40
  • ACOG pamphlet on mammography – ACOG recommends that women be offered annual mammograms starting at age 40.
  • American Cancer Society information on breast cancer screening – ACS recommends having annual mammograms starting at age 40.
  • USPSTF guidelines on mammogram screening – USPSTF recommends having mammograms every 2 years from ages 50-74. The decision to start biennial screening in women under age 50 should be individualized.
  • Breast Cancer Coalition -31 myths and truths about breast cancer

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Davidson AS, Liao X, Magee BD. Attitudes of women in their forties toward the 2009 USPSTF mammogram guidelines: a randomized trial on the effects of media exposure. Am J Obstet Gynecol 2011;205:30.e1-7.

ACOG’s New Mammogram Recommendations – Not What You Think

The American College of Obstetrics and Gynecology has issued new breast cancer screening guidelines recommending that mammography be offered annually to women beginning at age 40. This is a change from their prior recommendations for mammogram screening every 1-2 years in women ages 40-49, and annually thereafter.

The media is playing the announcement as a face off between ACOG and the United States Preventive Services Task Force (USPSTF), which initially recommended against routine annual mammograms in women in their 40’s, but later softened that statement by saying that the decision to start mammograms in the 40’s should be an individualized one.

But is it really ACOG vs USPSTF? 

Here’s the statement from ACOG’s press release–

Based on the incidence of breast cancer, the sojourn time for breast cancer growth, and the potential for reduction in breast cancer mortality, the College recommends that women aged 40 years and older be offered screening mammography annually.

Here’s that statement in context in from the ACOG practice bulletin (requires paid subscription)-

Based on the incidence of breast cancer, the sojourn time for breast cancer growth, and the potential for reduction in breast cancer mortality, the College recommends that women aged 40 years and older be offered screening mammography annually.

However, as with any screening test, women should be educated on the predictive value of the test and the potential for false-positive results and false-negative results. Women should be informed of the potential for additional imaging or biopsies that may be recommended based on screening results. The physician should work with the patient to determine the best screening strategy based on individual risk and values. In some women, biennial screening may be a more appropriate or acceptable strategy. Some average-risk women may prefer biennial screening, which maintains most of the benefits of screening while minimizing both the frequency of screening and the potential for additional testing, whereas other women prefer annual screening because it maximizes cancer detection.

Hmm…..That’s not really so different from the USPSTF guidelines, which state –

The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.

There is a difference, however. By starting with a statement to offer mammography annually, ACOG seems to be trying take the USPSTF recommendations for individualized screening and put some teeth into them. They are also, I think, aligning themselves with the majority of women, who favor annual screening, regardless of its potential harms. (More on this tomorrow…)

As a clinician, what I think ACOG is saying is that I should be sure I offer an annual mammogram, even if the patient and I end up making an individual decision about having screening that goes another way. It’s a strategy that assures that every woman has the opportunity to have an annual mammogram if that is what she wants, ideally after she has engaged in a discussion that takes into accounts the benefits as well as harms of screening in the context of her own risks, beliefs and concerns.

I think that’s right.

Unfortunately, ACOG’s press release says nothing about individualizing screening decisions

It’s incredible, really.

Just like the USPSTF, ACOG has written a press release and summary statement that does not exactly match it’s recommendations or place them in context. Worse still, they have placed their full recommendations behind a paid subscription firewall, assuring that few folks other than gynecologists will have access to them. This deprives the public (and many reporters and bloggers) of the opportunity to read what is an extremely well-written summary of the current state of knowledge about breast cancer screening.

ACOG has also missed a real opportunity to better inform women about the magnitude of breast cancer risk (much lower than most women think), and the limitations of mammography (much greater than most women think).

Finally, and most importantly, by leaving out any context of individualized risk assessment, benefits and harms of screening, and shared decision making, ACOG has left the simplistic misperception that anything other than an annual mammogram is bad medicine.

And that’s just not fair.

To me, or to my patients.

And, as any women who has tried to fit into a one-size fits all pair of pantyhose will tell you, it’s a set up for failed expectations and anger on all sides.

Not to mention a really bad run.

Contraceptive Coverage – Solved.

There are those who argue that mandating that insurers cover contraception is violating their conscience rights by forcing them to pay for others to use immoral methods of birth control.

That’s okay. I get it.

So here’s what I propose.  

Each insurer will have two pools of insureds – those who are willing to have their premiums pay for birth control and those who are not.  Each pool would also be responsible for covering the costs of pregnancies, abortions and children born into the pool, and the premiums paid by the pool members would reflect these costs.

One guess as to which pool will have the higher premiums.

Okay, that’s solved. Next?…

Summer Sunday Pesto made with Mint, Basil & Parsley

Summer weekends at the cottage, the need to get back to the city leaves no time for a proper supper on Sunday, so I try to make a nice mid-afternoon lunch. Warm weather demands that the meal feel light, but it must be substantial enough to hold us through the long ride home (allowing, of course, for a stop for ice cream along the way). Leftovers from Saturday night’s dinner help round out the meal and keep the trunk empty going home.

I love setting the table for lunch at the cottage – something we rarely, if ever, do at home for lunch. Gathering around the table gives us a chance to sit with friends to talk or play one last game of scrabble. Sometimes, we’ll take a picnic to the lake instead if that’s where we decide to spend those last precious hours.

This past weekend, I wanted to use the basil and parsley growing in the herb garden, but traditional pesto seemed too heavy tasting for a hot summer afternoon. Lemon and mint came to mind, and luckily, I had both leftover from dinner the night before. The combo got rave reviews, and made for a great flavor for serving room temperature pasta at a lakeside picnic.

I’m looking for ways to use the remaining two cups of this minty pesto that I’ve stored in the freezer. Any ideas?

Summer Sunday Pesto made with Mint, Basil & Parsley

I decided to toast the pine nuts and garlic slightly for a more mellow flavor, although I think this pesto would have just tasted just fine if both were used raw. This recipe makes about 3 cups pesto – use one cup for the penne and freeze the rest.  Serve the pasta with sliced tomato and mozarella on the side, and tall glasses of iced seltzer with a splash of lemonade and a sprig of mint.  

  • 1- 1 lb box penne pasta
  • 2 cups lightly packed basil leaves
  • 2 cups lightly packed flat leaf Italian parsley
  • 2 cups lightly packed mint leaves
  • 3 cloves garlic, peeled and smashed whole
  • 1/2 cup pine nuts
  • 1 cup olive oil
  • Juice of 1 lemon
  • 1 cup grated parmesan cheese
  • Kosher salt to taste

Put a large pot of lightly salted water to boil.

Toast the pine nuts and garlic over medium-low heat in a large skillet, shaking frequently to toast lightly and evenly.  Cool. Put basil, parsley and mint leaves into bowl of food processor, along with garlic and pine nuts, and pulse till combined. (You may have to stop and scrape down the sides a few times.) Continue processing till fine, adding oil and then lemon juice through feeding tube. Using a rubber spatula, scrape the pesto into a large bowl. Fold in the cheeses. Salt to taste. Remove two cups of pesto for freezing, leaving about a cup of pesto in the bowl.

Cook the penne till al dente. Drain and add to the remaining one cup of pesto in the bowl. Toss to coat. Let cool and serving a bit later at room temp.

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I’m submitting this post to Weekend Herb Blogging, a long running weekly carnival of recipes using fresh herbs and plants, hosted this week at  Almond Corner.

Managing my EMR Results InBox

My practice has been using the EPIC electronic medical record for 5 years now, and it’s taken about that long for me to figure out how to tweak the system to make myself more efficient, and for the system to evolve to a place where I could tweak it myself.

Case in point – Quick Actions.

EPIC’s most recent upgrade includes little self-made macros called “quick actions” that turn repetitive tasks into a mouse click. I’m using quick actions to manage my results in basket in much the same way you may be using Rules in Outlook to manage your email.

Some of my macros are actually little work-arounds for a system that is not yet entirely integrated and a patient population that has not yet embraced online results communication. About half of my patients sign up for online results – I’m working hard on the rest…

Like many of you, I like a clean inbox, but need a place to park messages that are awaiting some future task for completion. I’ve decided to use the “results notes” inbasket for this purpose, so you’ll see some of my macros moving messages there.

I now have the following Quick Action options whenever I view a lab report –

  • Normal Pap – creates a standardized normal pap letter, sends it to my secretary to print out and mail and inserts a little addendum note to the encounter that results were sent.
  • Left message – After I’ve called and failed to reach a patient about a lab result, adds “left message ”  addendum to the patient’s visit note and moves lab result to my results note in-basket, where it will sit till she calls me back (or I call her again, don’t get me started on the phone tag game…).
  • My Chart – Inserts a little note into the patients EMR that her results were released to her via My Chart – an online patient communication system that sort of lives outside my EMR with incomplete integration, so I put that little note in so I know I communicated results to her. It’s faster than searching through the My Chart inbasket later.
  • Hold for HPV – Moves mildly abnormal pap results into my results notes inbox where it will wait for the HPV result, which comes a few days later.
  • Failed mammo – creates a reminder letter to patients who have failed to get their mammogram, the order for which is sitting in my “overdue results” basket, and sends the letter to my secretary to mail it. I then delete the overdue message from my inbasket.

Any other EPIC users out there have Quick Action macros that are working well for them? If so, feel free share them with us in the comments section .

Flatbread with Eggplant, Peppers & Olives (Coca de Recapte)

This traditional Catalan flatbread is based on yet another recipe from Williams Sonoma Barcelona cookbook. Coca recapte are savory pastries made with meat or fish and vegetables, the combination of which depends, apparently, on what is in the larder. Or, as Catalan food blogger Anna at the Good Food Room describes it :

Recapte” is Catalan for “Alright, after a hard work’s day, let’s see what we have left and how we can turn it into a meal”…

Well, this coca recapte was made after a hard day’s play following an early evening swim and a day spent antiquing, playing scrabble, biking and hanging on the front porch. In true Barcelonan style, we did not eat till well after 9 pm. Not quite the same as a visit to Spain, but just as nice.

Flatbread with Eggplant, Peppers & olives (Coca de Recapte)

I love the technique for cooking eggplant in this recipe – roasted the same way you roast peppers. This coca recipe uses baking powder, but other coca recipes I’ve seen used yeast. In the future, I think I’ll make this using Mark Bittman’s pizza dough recipe.

For the dough

  • 1 2/3 cups all purpose flour
  • 1/2 tsp salt
  • 2 tsp baking powder
  • 1/2 tbsp olive oil
  • 1 egg yolk
  • 3/4 cup water

Topping

  • 1 red pepper
  • 1 green pepper
  • 1 medium eggplant
  • 1 large sweet onion, very thinly sliced
  • 1 clove garlic, minced fine
  • 12 black olives, pitted and coarsely chopped
  • salt and pepper to taste
  • 2 large ripe tomatoes, thinly sliced
  • 1 tbsp butter
  • 5 tbsp olive oil, plus a tad more to grease the pan

Preheat oven to 450 degrees fahrenheit. Place peppers and eggplant on baking sheet and roast, turning them so they char evenly on all 4 sides, about 45 minutes.

While veggies are roasting, slice and caramelize the onions. In a cast iron skillet, melt 1 tbsp butter in 1 tbsp olive oil over moderately high heat. Add sliced onions, turn down the heat to medium and saute, stirring frequently, until onions are caramelized, about 10-15 minutes. Cool.

Remove roasted vegetables to a brown paper bag to cool about 15 minutes.

While the roasted veggies are cooling in the bag, make the flatbread dough. Sift flour, baking powder and salt into a bowl. Make a well in the center, and add olive oil and egg yolk. Gradually add water, mixing into the flour with a wooden spoon. Turn dough out onto a lightly floured surface and knead for about a minute until soft, smooth and elastic. Form into a ball and place into a large lightly oiled bowl. Cover with a kitchen towel and leave in a warm place for 30 minutes until dough puffs slightly.

Peel cooled roasted veggies, discarding the stems, seeds and skins. Slice into thin strips, then toss gently with onions, garlic and olives. Season generously with salt and pepper. Set aside.

On a lightly floured surface, roll out dough to fit a lightly oiled 12 by 9 inch baking pan.  Press dough into pan and trim edges if need be.

Cover the base of the dough with the tomato slices. Brush with 2 tbsp olive oil. Arrange the veggies evenly over the tomato slices and drizzle with remaining oil. Bake until edges are starting to brown, about 25 minutes. Remove from oven, let cool slightly, slice into squares and serve warm.

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Coca Recapte around the web

Manhattanhenge 2011

So incredible, to see the orb of the setting sun, heralded by its own reflection on the skyscrapers on the far West Side, slide into the air between the canyon walls of 42nd St, where it hovered for a few precious moments, aligned perfectly with the east-west grid of Manhattan, before sinking into the horizon over New Jersey.

Even more incredible, that the sunset was visible at all, given the thunderstorm that swept across the island less than an hour before. We almost didn’t go.

So glad we did.

Manhattanhenge occurs twice a year. Try and see it at least once in your lifetime.