Photoshop Healthcare Reform

Congress clearly hasn’t gotten the picture on what America really needs for healthcare reform. Which means you’ll have to create it for them.

To that end, Dr Wes and his wife are holding the first and only US Healthcare Reform Photoshop Contest.

Bring us your snark, your wit, your creativity about the health care reform efforts encapsulated in a single photograph. Photographs in support or against the current efforts will be equally considered, and you, dear internet devotees, will be the final judge. The winner receives an iPod Touch.

See Dr Wes’ blog for rules, get out your cameras and your laptops and make it happen!

Dr Oz Gets it Right

As much as I rant against Dr Oz and as much as the Huffington Post is beginning to annoy me with it’s celebrity gossip and daily almost nude photos, they both just redeemed themselves this week with Oz’s wonderful column entitled. “Real Health Reform – What’s Next?”

We need to create a culture of health and wellness that fosters a nationwide understanding that personal behaviors are a major factor in health and well-being. And at the same time, we need to make the necessary societal changes so that all individuals are supported in making the correct choices. We need to make it easier to do the right thing.

Oz recommends changes as sweeping as reforming the food supply, changing how we feed our children in school, improving air and water quality and finding ways to reduce stress and incorporate physical activity into our daily lives. Its an agenda much larger than anything facing the Senate right now, but includes many things that most American people can start to do today that don’t require an act of Congress.

Ambitious, yes. Impossible, no.

Do the right thing.

I like it.

How to Delete a Calendar from Your iPhone

****Geek alert****
Ignore this post unless you came searching for this solution. 

After switching from Blackberry to Iphone, I forgot to remove Pocket Mac from my Macbook. As a result, when I synced my calendar to my iPhone using Mobile Me, a second calendar was created on my I Phone. Even when I removed Pocket Mac from my Macbook, he calendar remained. I searched everywhere for instructions on deleting it, without success. Then I figured it out. So simple.

Open up iCal on your macbook. You will see a list of your calendars on the top left. Cntrl click the one you want to delete, then scroll down to the “delete” option and Viola – Gone! Now re-sync your iPhone with iTunes. The offending calendar is gone.

This should work with any extraneous calender you’ve accidentally created on your I Phone. Mine just happened to be my Pocket Mac calendar.

Drugs for Cancer Prevention – NY Times Misses the Point

In yet another article addressing the war on cancer, The New York Times today tackles cancer prevention, focusing on alternative and mainstream Pharma products marketed to reduce the risk for cancer.

While author Gina Kolata seems to have done her homework when it comes to the failure of alternative medicine to prevent cancer, she has missed the story completely when it comes to telling why the medical profession and patients may have failed to embrace Big Pharma’s push to use their drugs to prevent breast and prostate cancer. Of course, that’s not surprising since almost exclusively, the experts she interviewed were those who conducted the clinical trials of these drugs.

Since I’m not a urologist, I’m not going to comment on the use of finasteride to prevent prostate cancer, except to point out that the one expert quoted in favor of its use has served as a consultant to Merck and AstraZeneca, both of whom make the drug, while the other works for Astra Zeneca.

So let’s talk about tamoxifen and raloxifene, two drugs that are approved for the prevention of breast cancer.

Tamoxifen and Raloxifene

The maker of Evista (raloxifene) is targeting both docs and women, urging them to calculate their lifetime risk for breast cancer and consider taking the drug if that risk for breast cancer is increased. Since raloxifene is also approved for treatment of osteoporosis, the drug makers are selling it as a two for one.

Both tamoxifen and raloxifene cut the risk for breast cancer in half among high risk women who use the drug for 5 years. Tamoxifen also prevents DCIS and LCIS in addition to invasive cancer, while raloxifene does not reduce these risks.

But, Tamoxifen can cause uterine cancers. The risk is low, about 1 in 500, but includes uterine sarcomas, a particularly aggressive tumor, and may persist even after the drug is discontinued. There is no screening for uterine cancer in tamoxifen users – ultrasound is useless, since the endometrium very frequently appears abnormal even if there is no cancer. We docs are left telling women just to tell us if they blee

Now, for women who are taking tamoxifen for treatment of breast cancer, the risk for uterine cancer is almost always outweighed by the benefits in terms of cancer treatment. But for woman who have never had (and may never get) a breast cancer, the uterine cancer risk is a deal breaker, especially when she asks what I can do to screen her and I tell her “nothing”. I can quantify it for her – look, your risk for breast cancer will be reduced from 20% to 10%, I might say – and your risk for uterine cancer increased by less than one percent.

Okay, I’m interested, she might say. So tell me – Are there any other risks?

Yes, I’ll say.

Both raloxifene and tamoxifen carry an increased risk of thromboembolism. According to the package insert for Evista (raloxifene), DVT occurred in 1 out of every 100 women using the drug for an average of 2.6 yrs, over twice the rate for placebo users. Fatal stroke risk was about 1.5 times higher in Evista compared to placebo users, though that risk was concentrated in postmenopausal women at increased risk. Unfortunately, nowhere in the marketing materials for Evista is there a risk calculator that helps me or my patients assess their personal risk for these complications from the drug.

So, I’ll fudge it. Now my risk calculation for this patient looks something like this – Breast cancer, lowered from 20% to 10%. Uterine cancer, increased by 0.2%, but no screening. Blood clot risk = 1%. Fatal stroke risk = 0.3% over 5 yrs if you have risk factors, miniscule if you don’t.

Okay, she’ll ask me. How is it going to make me feel?

Probably fine, I say, but there are some side effects that might bother you, the most common of which is hot flashes in about 10% of users. Some women experience joint pains and leg cramps as well. These symptoms can occasionally be severe, although only about 1% of users stopped the drug because of hot flashes in the clinical trials. And most women will notice an increase in vaginal mucus that, as a gynecologist, I don’t have concerns about. Not uncommonly, my patient will have had a friend who has experienced a bothersome side effects from taking Tamoxifen. That’s usually the kiss of death for any drug – a girlfriend with a side effect…

And oh yeah, there’s also the increased risk for cataracts with Tamoxifen, but not raloxifene.

Now, if a woman has osteoporosis, I can add that to the plus side of the balance scale for raloxifene use. Now I’ve got to do her risk for fracture based on her bone density and talk to her about the other options she may have to treat her osteoporosis as well.

Is anyone really wondering why we docs and our patients haven’t jumped onto Big Pharma’s cancer prevention bandwagon? We’re asking patients to balance competing statistical risks for conditions she may never get, in return for a benefit she may never need.

I do prescribe raloxifene it for treatment of osteoporosis, and if there is a strong family history of breast cancer, I may even try to steer my osteoporotic patients who are not at increased risk for clots towards using it. However, it is the rare patient who chooses this drug over a bisphosphonate such as Fosamax and Actonel when I inform her of the risks and benefits of both these classes of drugs. Even patients with strong family histories of breast cancer just don’t want the potential side effects of a drug in return for a reduced risks for a cancer they may never get.

Hello – Birth Control Pills?

Kolata completely misses out on the fact that millions of women are already taking a pill that reduces their risk for cancer – the birth control pill. It cuts ovarian cancer by up to 80% and endometrial cancer by almost half.

Like Tamoxifen and Raloxifene, the pill carries an increased risk of blood clots, a trade off many women are willing to make in return for prevention of pregnancy, which itself carries an even higher risk of clotting. Not to mention the benefits the pill can confer for women with menstrual disorders such as dysmenorrhea, menorrhagia, endometriosis and its efficacy in treating acne and even PMS. For most healthy young women, the balance of benefits and risks of pill use is favorable, even before considering the cancer prevention aspects of the p

For the record, I inform each and very patient who starts estrogen containing birth control that there is an increased risks of clots. I quantify it for them, tell them that it is a real risk and give them strategies they can use to minimize these risks. Surprisingly, that discussion has rarely deterred a patient from starting on hormonal birth control. It may be that pill patients are younger and feel more invincible than the older women being targeted by the makers of Evista. But I think most of them are actually weighing their risks of pregnancy against the risks of blood clots, comparing this to their perceived downsides of barrier methods and/or the IUD, and coming out on the side of using the pill.

Prevention is the holy grail for Big Pharma

Let’s face it – an indication for prevention of a disease grows the potential market of a drug by millions. But if you’re going to market a drug to healthy individuals, it better be free of risk or have some other benefit that patients can see right away.

Otherwise, it just ain’t gonna’ sell.

Which probably explains why Kolata tells the story of the cancer prevention challenge as though it were a failed pharmaceutical marketing campaign. Missing from her article, unfortunately, is the question that asks whether pharmaceuticals are really the right strategy to prevent cancer. Or that asks if we really mean to ask 100% of men over 50 to take a drug to prevent prostate cancer, when, in the same breath, we are telling them we should stop screening for it? Or whether 100% of women over 60 take a drug that increases their risk for thromboembolism and uterine cancer so that 20% of them won’t get breast cancers that some are suggesting may regress or be so indolent that they will die of something else before it kills them?

Of course, we could just sell them another drug to lower their clotting risks..

Macaroons for the Chemo Tummy

The good thing about being both a doctor and a cook is that when you don’t have any more medicine to offer, there’s always the food.

Case in point – my sister’s chemo-induced nausea. Despite maximum doses of Zofran, she still finds herself quite queasy, usually between meals. We decided to try some mint lemonade and bingo! – the stuff really works for her. She’ll nurse a tall glass all afternoon to help keep her tummy in control.

Then, her good friend Lorraine, an onco nurse, told us she heard anectodal reports from her colleagues that macaroons were also helpful for chemo and radiation induced GI distress, both upper and lower. Well, that was all I needed to head to the kitchen to whip up a batch of cousin Jessie’s macaroons. Indeed, Sis found them useful when she has that empty stomach queaziness. (They didn’t work if she had already eaten something that makes her nauseus.)

Unfortunately, Sis is now on a low residue diet and macaroons are off the list. Coconut is a nut, after all, so don’t overdo it, and avoid them completely if you are at risk for obstruction. And remember, both these foods are high in sugar, so take them in small doses. Fortunately, that’s the way they seem to work best – a sip here, a nibble there…

Minted Lemonade

Make lemonade either homemade or from canned concentrate. (I would not use powdered) in a 2 qt pitcher withy a lid. Tear up a whole lotta’ mint leaves (we use about a 1/4 cup torn leaves) and mix them in with the lemonade. Store in the fridge – it will keep for several days. Serve over lots of ice. Alternatively, freeze the mint with water in ice cube trays and use the mint ice cubes in your lemonade.

Jessie’s Macaroons

I’m sure any macaroon recipe would work, but these macaroons are the best I’ve ever had. Cousin Jessie makes for Passover every year, so of course, they are flourless. Be sure to use unsweetened coconut – the sweetened stuff has additives like propylene glycol and sulfites.

2/3 cup egg white
¾ cup sugar
1/8 tsp salts2 ½ cup natural coconut
1 tbsp cornstarch
1 tsp vanilla
½ tsp almond extract
1 tbsp white corn syrup
Almonds

Combine all ingredients, stirring well, in a moderate size saucepan. Heat over mod heat till warm. Off heat let stand 10 mins. Line baking sheet with parchment paper. Drop by tsp or small scoop onto baking sheet and place half an almond on top. Bake in 325 oven 18-20 mins till golden. Let cool on the paper. Store in a tightly covered container.
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Sorry for Poor Quality photo – it was taken with my old phone.

Impaired Physicians – in the Bathroom?

So I’m sitting here taking my required annual hospital online training, and I read that one of the signs of an impaired physician is “frequent bathroom use”.

Guess that puts all us perimenopausal and pregnant female docs who drink water and coffee and also happen to have bladders under suspicion.

Treating Vitamin D Deficiency

If, like me, you are doc who is increasingly screening for and finding vitamin D deficiency, you’re probably wondering the best way to replenish body stores of this essential vitamin.

I have found that simply telling my vitamin D deficient patients to increase their daily intake of Vitamin D3 to 800-1200 IU does not result in adequate levels. I have had success using 50,000 IU Ergocalciferol (Vit D2) weekly for 12 weeks, transitioning to 1000-1200 IU Vit D3 daily after that for long term replacement.

Now a study has been published showing that a regimen of 50,000 IU ergocalciferol weekly for 8 weeks, followed by 50,000 IU ergocalciferol every other week is effective for up to 6 yrs at restoring and maintaining adequate vitamin D levels in most vitamin D deficient patients. For those with normal levels to start, the every other week regimen alone is sufficient to maintain them. This regimen is fairly cheap, about $6 a month here in NYC.

This study reinforces the results of another recent study showing that, for most patients, Vitamin D2 is as effective as D3 in restroing and maintaining normal levels of vitamin D.

That’s good to know.

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11/30/10 UPDATE – New IOM guidelines tell us that levels of Vitamin D at or above 20ng/dL are normal, levels above 30 ng/dL have no proven benefit, and levels above 50ng/dL may be harmful. Most of my patients have levels in the mid 20’s, even with treatment, so I find this very reassuring.

My First I Phone Dinner

Driving home from Brooklyn Sunday afternoon, trying to figure out what to have for dinner, Mr TBTAM recalls a recipe for Butternut Squash Ginger Soup that he heard that morning on Weekend Edition. Using the google app on my new I Phone, I find the recipe and consult it at the supermarket, where I buy the ingredients we need. Then, still using my I Phone, I consult the same recipe in the kitchen and cook up the soup. Never once heading to the computer or printing anything out.

Now if someone could just write an app that does the dishes…

Butternut Squash Ginger Soup

Modified from the recipe on the NPR website. I made my own 5 spice, and found it quite strong, so I reduced the amount by half in this recipe. I also did not do the whole fried ginger and orange peel topping in the original, but it looks like a fun idea. I also decided to cube the squash before roasting it, both to speed up the process and to get additional carmelization. Finally, depending on the size of squash you use, you may find you need to add addtional broth to thin the soup a bit.

Soup

1 medium-size butternut squash
1 tbsp olive oil
salt and pepper
2 -3 cups of vegetable broth
2 tablespoons finely minced ginger
1/2 teaspoon Chinese 5 spice
1 cup white wine
Salt and pepper to taste

Topping

1 cup creme fraiche
1 tablespoon fresh squeezed orange juice

Preheat oven to 350 degrees. Peel and cut butternut squash in half lengthwise, remove seeds and then cut into 2 inch cubes. Toss with olive oil, salt and pepper and roast on baking sheet for about 30 minutes, tossing halfway through so it evenly browns. Put in food processor and process with ginger and spices till smooth. Add one cup of the broth into the feed tube, process a few seconds then transfer to a medium sized stock pot and whisk in remaining 1 cup broth and wine, adding more broth if soup seems to thick. Heat through until simmering. Salt to taste.

Mix creme fraiche and orange juice together.

Serve soup in bowl with creme fraiche swizzle on top.

Bye-Bye Consultation Codes

Consultation CPT codes are being eliminated by Medicare starting January 1. 2010. (The link is to the federal register – the relevent section starts p 162.)

In the CY 2010 PFS proposed rule (74 FR 33551), we proposed, beginning January 1, 2010, to budget neutrally eliminate the use of all consultation codes (inpatient and office/outpatient codes for various places of service except for telehealth consultation G-codes) by increasing the work RVUs for new and established office visits, increasing the work RVUs for initial hospital and initial nursing facility visits, and incorporating the increased use of these visits into our PE and malpractice RVU calculations.

Medicare claims the rulting will be budget neutral, and has balanced it with a 6% increase in RVU’s for office-based and 0.3% for in-hospital E&M services. There will be new modifiers used to identify the admitting physican and the consultants.

There’s still another 30 days to comment, though it appears pretty final to me. I’d expect managed care to follow suit.

I have mixed feelings on this one. It’s always nice to be consulted by a colleague on a challenging case, and to have this recognized by an increased reimbursement. But I know there are specialists out there who bill each and every new patient as a consult and require a referral physician name before even seeing any patient. I resent their consultant letters thanking me for referring my patient for a routine preventive service, when I never even made the referral.

One could argue that there needs to be compensation for the additional years of training and expense that specialists incur. At the same time, the imbalance in reimbursement between subspecialists and primary care has led to a shortage of primary care docs.

This ruling may be one small step towards a resolution of the primary care shortage.
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Addendum – According to this analysis, the elimination of consultation codes will save Medicare $534.5 million anually. The authors point out that the ruling “sends a signal that primary care cognitive services are not valued equally with such services provided by other specialties.”

On the Doctor Shortage

Well said.

To address the shortage of doctors and the incentives that compel young doctors to eschew primary care, Congress needs to think about how to increase doctor pay, institute malpractice reform, and provide subsidies to reduce the amount of debt doctors have to take on. Residency caps should also be raised so teaching hospitals can train more doctors. Without these actions new doctors would be foolish to enter primary care, and thankfully our medical schools do not recruit foolish people. (Herb Pardes, CEO New York Presbyterian Hospital)

The suggested interventions are not mutually exclusive, and movement on any of them will decrease the need for the others. If you reform malpractice and lower debt, doctor’s pay will increase as less income is funneled off to insurance premiums and interest payments.

(HT Howard Luks via Val Jones)

Mammogram Screening Comes under Question

Denise Grady frames the recent debate on mammogram screening in today’s New York Times. The article tag teams and improves upon Gina Kolata’s recent story on the topic.

These articles highlight what we health professionals have known for some time about mammograms – they are not perfect.

About 10% of cancers will be missed by mammography alone. About 65% of so-called “positive mammograms” end up being benign on biopsy. We really don’t know what we are supposed to be doing with DCIS – is it precancerous, and should we be treating it? And finally, some cancers are faster-growing and more likely to kill you than others, and mammography is not so good at figuring out which is which.

Countering this imperfection is the one very important little piece of information that barely gets mentioned in these articles about mammogram screening – the mortality rate from breast cancer is lowered by mammography, by about 20% or so, depending upon which study you quote.

If you’ve never really heard all this before, it’s not surprising. The debate now being played out on the pages of the Times has until now been held pretty exclusively among health care experts, with the results of that debate becoming the recommendations we all know and love – mammograms every 1 to 2 yrs from ages 40 to 50, then annually thereafter, till an as yet not defined upper age, when one weighs the need for mammograms against the overall health and projected longevity of the individual.

If it sounds complicated, well, that’s because it is. And until now, the approach doctors and patients took to complex issues like this was simply – we docs know more than you do. Allow us to weigh and measure the risks and benefits for you, consider costs while we’re are at it, and then we’ll tell you what we think is best and you’ll do it.

The price we are now paying for this simplistic approach to screening is a loss of faith on the part of the public, who have taken our endorsement of mammograms to be a guarantee of infallibility and a promise to lower breast cancer mortality across the board. We’ve struck out on both counts.

So now, like a parent whose child one day sees us as the imperfect humans we are, we docs are having a bit of a mid-life crisis. Do we stick to our guns and keep the same old recommendations, imperfect as they are? Or do we arm our patients with the facts and let them begin to make their own decisions about mammography?

One thing I think we do need to be careful about is allowing the pendulum to swing too far in the other direction – making the decision to advise women to forgo mammography due to a risk of over-diagnosis and over-treatment. This approach, framed in terms of prevention of anxiety and morbidity, but with an underpinning of financial cost savings, uses the same simplistic thinking we’ve used in the past to aim patients in the opposite direction, away from screening.

While there is much talk about how screening may not benefit more indolent cancers, the fact remains that we don’t have reliable non-invasive testing to identify which cancers are slower growing and which are not. Nor do we know how to stratify women into high and low risk groups for these cancers, other than genetic testing and imperfect modeling, which only identify a subset of at-risk women. To substitue another imperfect screening methodology for current guidelines just trades one set of problems for another.

I am more than happy to entertain the mammography debate with my patients, some of whom may want to forgo annual screening when they learn what I know. If I know my patients, I predict that most will continue to accept a chance of a false positives in return for a potentially reduced mortality from breast cancer.

But stay tuned – this discussion is likely to go one for some time.
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Orac takes on the topic. Nice discussion of the issues.

Phils vs Yanks

I’m from Philly, and I love New York. And now, both my teams are playing one another.

This must be how Mr Williams feels when Serena’s playing Venus in the finals. I wonder how he handles it?
Certainly not the way my father used to handle it when we kids set at one another fighting. He’d grab a shock of hair on each of our heads and bang our noggins together. (Not hard, just enough to get our attention…)
Go Phils! Go Yanks! Whoever wins, I’ll be proud. Now get out there and have fun!
Or I’ll knock your heads together.

Thank You, Mr Violinist, Whoever you are…

Mr New York Philharmonic Violinist in the third row stage left, whoever you are, thank you for making last night’s concert a truly joyous experience.

I mean, first there was the Egmont Overture (nice), then Emanual Axe playing Beethoven’s 3rd (such emotion), then the Symphonic Dances from West Side Story (I cried at the third movement), and I thought – why don’t they just stop the program there? What is this Three Cornered Hat business anyway? I was only here because it was Mr TBTAM’s birthday present, and while I like classical music and all, heading to the orchestra is generally not at the top of my Saturday night to-do list, forget it also being Halloween and the third night of the Yanks vs the Phils. Enough is enough.

Then I caught sight of you, barely able to contain yourself in your seat as you played the third part of the Three Cornered Hat, making music not just with your bow, but with your entire body. How much fun was it watching you? You played with pure, unadulterated joy, unembarrassed by the fact that you were the only member of your section moving anything other than the bow. You did not distract from the music, you channeled it, enhanced it. And I will never be able to listen to that piece again without thinking of you.
And smiling.
(Oh, and thanks to the rain delay, we got home by the bottom of the fourth inning, even though we had walked home instead of taking the bus.)