Every Blog Needs a Bouncer

Dr Wes has been dealing with some legal troubles related to comments on posts in his blog. While he declines to give details, we know that he was subpoenaed to appear in court regarding comments on a post in his blog. He fought the subpoena, and won. But the fight cost him financially, and it appears, emotionally. He’s now re-thinking his commitment to blogging.

But blogging, as I’ve found, also exposes one to malicious verbal attacks and subpoenas. As such, it is risky. There is no question that placing one’s online self in the world for all to see adds vulnerability and potential liability. When I told a colleague Friday about my recent predicament he responded, “Why the hell would anyone want to blog?”

I hear you, Dr Wes. I too have withstood malicious comments and personal attacks both in my comments section and on other blogs. It doesn’t feel good, and never fails to shock me to realize just how un-civilized other human beings can be.

But I say keep on blogging, Dr Wes. We need you voice. Your blog is one of the best medical blogs out there. Your clinical opinions, commentary and insight are unique and important, and no other blogger or mainstream media outlet can replace the contributions you’ve made to the conversation about cardiac electrophysiology.

I have to be honest, however, and say that I was surprised at some of the comments you’ve let stand on your blog. I would have hit the delete button almost while I was reading such comments, bounced them right the h_ off my blog, and never looked back. Heck, I’ve even closed comments on blog posts when the side conversations there got out of hand. After all, it’s my blog, my voice and my reputation. I’m going to control it as best as I can, and if that means some folks don’t get invited back, well, that’s my prerogative. They can always start their own blogs.

Because a medblog is not a chat room. I see it as more of a seminar that the med blogger hosts. The role of the commenter is to provide external context if the blogger fails to do this, to support and expand the argument or to provoke and to show opposing viewpoints if they exist. Not to trash, malign, libel, slander or defame.

That kind of behavior has no place on my blog.
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I got my bouncer from Wikipedia Commons, a free image source on the web

My EMR and I

It’s only taken Grunt Doc four days to fall in love with his new electronic medical record (EMR).

It took me a bit longer that that.

But then again, I was never the head over heels type of gal. My feelings for my EMR were more of a slow burn than a raging passion, and we’ve had out ups and downs. We’re more like Hepburn and Tracy than Romeo and Juliet, sparring and fussing with one another, but always ending with a grudging mutual respect and admiration.

And, like any good Tracy-Hepburn movie, our story has had a few scary moments. But each time, my EMR rescued me from the edge of the precipice.

Take, for example, the patient who forgot to tell me about the DVT she had since I had last seen her 6 months ago. I was about to prescribe birth control pills for her, and saw a few visits with a hematologist in her encounter list. A quick perusal of those visit notes tipped me, and I immediately changed the script to a progesterone-only pill. Of course, if the hematologist had updated the problem list and history portions of the chart, I would have caught it upon opening her record. Or better still, if my EMR had found that history itself and popped up a warning flag when I wrote the prescription. But there I go complaining…

There was the time I somehow missed that my patient’s pap was abnormal. But I get a monthly summary print out of abnormal paps from our lab, and caught it on that review. Of course, the EMR does not actually distinguish normal from abnormal paps – the results are still just a text field. It takes the path lab to do the compiling of the list for me. But I’m not complaining, am I?

How about the fact that I can check patient labs and do my charting work at our cottage, allowing me to get out of the office a bit earlier on weekends, or even work from home on the occasion? Now that’s a real benefit of my EMR! Of course, I can’t place radiology orders from home, though I still can’t understand why…

And speaking of radiology orders, why doesn’t my EMR remember the appointment date and not send me an overdue test notice until after that date? And why can’t it print out a med list for my patients when they arrive, since most of them forget to tell me about at least one med that they are taking? Or present me a better summary sheet upon opening a chart, or god forbid, let me design that first view myself?

There I go again, throwing plates at the EMR I love.

Because I really do love it, you know.

Most of the time.

Confessions of a Self-Help Junkie

It’s the self-help book to end all self-help books.

It’s called Confessions of a Self-Help Junkie and it’s written by my friend Linda Pruce, a self-described holistic speech therapist whose blog Enter the Circle is one of my favorite web destinations for biting wit, personal insight, feminist opinion and all around woo-woo.

Confessions chronicles Linda’s downward spiral into self-help hell and the resurrection that resulted from her realization that she was looking in all the wrong places for the truth she needed. Which, as Dorothy would say, was right in her own backside… I mean backyard…(Read on, you’ll get the reference…)

Readers of Linda’s blog willl recognize her unique writing style that blends self-deprecating wit with no-holes-barred frank personal insight –

I officially became a self-help junkie in September of 1998. I was sitting on my bed, minding my own business, breastfeeding my newborn and wondering whether it would be wrong to smoke a cigarette while nursing. As I was figuring out the logistics of this dilemma – Could I reach my cigarettes without breaking the baby’s seal on my breast? Could I blow the smoke towards the window instead of up the nostrils of my daughter? And, how do you explain a burn mark on the check of a 6-week-old?– I caught the start of Oprah’s fall season.

But don’t let Linda’s humor fool you – underneath that wit is a wise woman with lot of great advice. Take, for example, this passage on finding the seat of one’s self, or as Linda puts it, your “Authentic Soul Self” or A.S.S –

Finding your A.S.S. is just the first step and the easiest part of your journey. Once you find your A.S.S., you will need to pull your head out from inside it. This, otherwise known as enlightenment, is what most people are attempting to do – and is probably the hardest thing to achieve.

Confessions meanders through the world of enlightenment, taking choice bits from here and there, creating a salad of thoughts, advice and wisdom for the woman seeking peace and fulfillment. Along the way, it sometimes ventures dangerously close to the self-help world it derides, and I can’t say I completed any of the tasks or lists offered to me. But, after all, a Junkie loves nothing better that a fellow addict to shoot up with, and I know Linda couldn’t help herself but to lay out a few lines of self-help smack for her visitors. But hey, it’s her party…

The best parts of the book for me were when Linda tells us her story – how she learned, for example, to ask the universe for what she needed. (Once I figure out what I want, I’m definitely gonna’ try that for myself.) Or how she figured out why Sundays were always so stressful for her and her family, and then made it better. Or the simple rules for living she learned from her Grandma (who sounds suspiciously like mine).

Beautifully illustrated by Kristen Smedley with graphic design by Tomara Arrington, Confessions of a Self-Help Junkie is not only a great read, it’s a work of art. Too bad it’s not available in other than electronic form, or Oprah could put it on her coffee table. It’s that beautiful.

You can download the first chapter for free from Linda’s blog, or buy the e-book online. Then tell your friends, who’ll tell their friends, who’ll tell their friends, and if that whole Six Degrees of Separation thing really works, Oprah is sure to hear about it from Kevin Bacon.

Congrat’s Linda!

G-Spot Collagen Injections

Niko enjoys the bouncing cab ride a little more than she expected.

They call it the G-Shot. Collagen is injected on top of the G-spot (if it exists) to enhance its size. The G-Shot was invented by a Doc in LA (of course) who claims it enhances sexual arousal and gratification.

I hadn’t heard of the G-shot till yesterday, when OBS Housekeeper emailed me asking if it was for real. Apparently, Niko had her G-spot enhanced in the season opener of Lipstick Jungle. Talk about product placement – it was a silly plot angle that really made little sense in an episode that was about much more serious issues.

But what about it? Is the G-Shot legit?

Smells like a racket to me.

My definition of a racket? Any expensive medical procedure (in this case $1850) not covered by insurance, whose clinical outcomes have been reported on a website and in the media instead of a peer review journal. Not to mention those three little words that should set alarm bells ringing whenever you read them in conjunction with an invasive medical procedure -“Results may vary”.

Is the G-Shot safe?

The shot uses FDA-approved collagen, which, if administered correctly (into the vagina and not into the urethra), should be relatively safe. Urologists for years have been using collagen to “bulk up” the urethra as a treatment for urinary incontinence, although that treatment has yet to be proven to have more than limited efficacy.

But take a look at this partial list of possible complications from the G-Shot website –

Bleeding, Infections, Urinary retentions, Accelerated collagen re-absorption, No effect at all, Allergic reactions, Hematoma (collection of blood), Collagen site ulceration, Urethral injury, Hematuria (blood in urine), UTI (Urinary Tract Infection), Urinary Urgency, Urinary Frequency, Increased/worsening nocturia (waking up several times at night to urinate), Change in urinary stream, Urethral vaginal fistula (hole between urethra and vagina), Vesico-vaginal fistula (hole between bladder and vagina), Dyspareunia (Painful intersourse), Need for subsequent surgery, Alteration of vaginal sensations, Scar formation (vaginal), Urethral stricture (abnormal narrowing of the urethra), Local tissue infarction and necrosis, Yeast infections, Vaginal Discharges, Spotting between periods, Bladder Pains, Overactive Bladder (OAB), Bladder Fullness, Exposed Material, Pelvic Pains, Pelvic Heaviness, Collagen injected into the bladder or urethra, Erosion, Fatigue, Damage to nearby organs including bladder, urethra and ureters, Alteration of bladder dynamics, Post-operative pain, Prolonged pain, Intractable pain, Failed procedure, Varied results, Psychological alterations, Relationship problems, Decreased sexual function, Possible hospitalization for treatment of complications, Lidocaine toxicity, Anesthesia reaction, Embolism, Depression, Reactions to medications including anaphylaxis, Nerve damage, Permanent numbness, Slow healing, Swelling, Sexual dysfunction, Allergy to Collagen material, Collagen migration, Nodule formation

and you tell me – Are these risks you are willing to take for a procedure whose “results may vary”?

But what about the product testimonials?

Ah, the product testimonal. The hallmark of every new product marketing campaign. There is nothing that sells a product better than a woman with a story to tell who is being paid to tell it.

Product testimonials are not proof of efficacy. They are nothing more than a single person’s experience with a product or procedure. Even if it is a true experience, the circumstances are not controlled for other variables that might be effecting the outcome, including the placebo effect. And there has to be a significant placebo effect of G-spot enhancement.

Think about it. Suppose you are someone who actually believes the G-spot exists, making you a bit impressionable to start with. Now, I’m gonna’ put something into your vagina that you will be able to feel. It might be a bit uncomfortable, but not very much so. Or, as Niko says when Brooke Shields asks her if she is in pain – “I don’t know what I’m in, all I know is that I can’t sit through a 2 hour dinner.”

But what if I’ve told you that the uncomfortable sensation is really a sexual sensation? (Ah, the fine line between pain and pleasure..) Now, every time you notice the sensation, you’re going to naturally think about sex, aren’t you? And the longer the sensation lasts, the longer and more often you’re gonna’ be thinking about sex. In fact, you’re thinking about sex a lot more than you normally do. All the time, actually. And every time you have sex, that little bump I made is going to get knocked around, reminding you of what a sexy gal you’ve become, reinforcing those positive sexy feelings you are experiencing, and wait a minute – was that a multiple orgasm you just had?

Now, suppose instead that I injected a lump of collagen into your vagina and told you that it might make you feel uncomfortable. That sitting might be difficult for a few days. That there are potential side effects such as pain with intercourse or painful urination you’ll need to watch out for.

Now imagine how you would feel every time the cab you’re sitting in goes over a pothole. Scared? Annoyed? Angry?

See? The power of suggestion. In this case, not a placebo, but a nocebo effect.

Bottom Line

If the G-Shot proponents want to prove it really works, then they need to run a placebo-controlled clinical trial. It’s easy enough – one group gets the g-shot, another gets an injection of saline into the same spot, and the third group gets an injection of collagen into some other spot in the vagina.

I’m not holding my breath waiting for the trial. Nor should you.

Instead, I’d take that $1850 and spend it on something that will make you feel good about yourself. Maybe a food delivery diet. Maybe a dance class or a new bike. Or that trip to France or night course you’ve been thinking about taking for years.

Because if you’re feeling good about yourself, then feeling turned on isn’t that much of a stretch.

And that’s because your biggest erogenous zone is not the G-spot.

It’s your brain.

Diet Update – Week 9

I’ve lost 20 lbs since starting this little adventure on July 15.

Last week, I tried a different Zone diet food delivery service. (It was a bit cheaper) While I continued to lose weight, I did not like the food – it was fresh, but it was basically diet food. Every dinner was dry broiled fish or chicken and flavorless steamed veggies. Every lunch was a dry salad. The portions were huge, but there are only so many steamed vegetables and raw cabbage slaws a person can eat.

So I’m going back to my first Zone Diet food delivery plan, with it’s variety and flavor and smaller portions, (and incredible muffins) and sticking with it till I’m down to my wedding weight. If things go as planned, I’ll be there sometime in early spring.

It’s actually a good thing I have so much weight to lose, because it’s gonna’ take that long for me to relearn how to feel hunger, how to learn what to do instead of eat when I am stressed, and how to deal on my own with food cravings that seem to be either hormonally or carbohydrate mediated (or both).

This weekend, I went a bit out of control. I was between delivery plans, on my own and into the progesterone phase of my HRT cycle. It really scared me how quickly I went back to my old habits, and it was such a relief to have my food show up for me at the door on Monday morning.  I’m back in the saddle again, though 2 pounds heavier than I would have been if I hadn’t gone off program.  I think the hard part about what I am doing is going to be keeping the weight off once I am off this food delivery. 

I’m continuing to bike in Central Park (thanks, Linda for pushing me to do the second loop and Mr TBTAM for always being willing to come along…), walking (thanks Sarah for getting me going) and using my bike on errands rather than taking the car or bus. When I visited my friend Jane at the beach last weekend, I brought my bike with me and our visit became a nice long bike ride instead of a nice long eat and drink fest. (Thanks, Jane for going along with the plan!)

If When I get to goal, it will be as much due to my wonderfully supportive friends and family as it will be to my own efforts.

What’s Wrong with this Picture?

Hey guys, C’mon now! I thought we Medical Bloggers were a new voice, not just another vehicle for more of the same.

Letting Big Pharma sponsor your lunch organizing meeting at the Blogger Expo? You can’t afford a sandwich?

Congrats to the group on what sounds like a great meeting otherwise.

(Photo from Emergiblog)

Pubic Hair Dye

That’s right. It’s called Betty – Color for the Hair Down There”. Its the solution to that vexing problem faced by greying gals, redheads and bottle blondes who get outed when intimacy reveals their true colors.

I’m surprised someone didn’t come up with this idea sooner. Too bad they didn’t, because I suspect pubic hair dye is a product idea that’s come a bit late to the market. My own market research on the latest trends among women in styling of that area would suggest that there’s not much hair left down there to dye…

But let’s just say you’re a bit behind the times in that area, and feel the need to coordinate your colors. Should you consider Betty?

Is Betty Safe?

The manufacturer claims the product is “specially formulated to avoid irritation”, has natural ingredients with flowery herbal names, and “no ammonia or parabens”. But Betty does contain PPD – that’s paraphenylenediamine, the chemical found in almost all hair dyes. PPD is listed as high hazard on the Cosmetic Safety Database and is the ingredient responsible for most allergic skin reactions to hair color. PPD-enhanced henna tatoos can cause extremely severe skin reactions.

Pubic hair borders on some very sensitive areas of the body. The hair near the midline comes precariously close to the mucosal surfaces of the inner labia – skin that is almost like the inner surface of the lips on your mouth. This kind of skin would be much more permeable to the chemicals found in hair dye and certainly more likely to be irritated.

My advice would be to avoid this product.

Don’t Dye For Me

And please, please, don’t think about dying your pubic hair to impress your doctor, as Ralph seems to have done…

I love it! I have salt and pepper hair and a gray beard. Some grey down there and now it’s black. I can’t wait to shower at the health club or go to my doctor for a check up. I know he won’t say anything but he will think Wow hair so black down there. – Ralph (testimonial from Betty website)

We docs don’t care what color your pubic hair is.

Really.

In This Election, The Winners are the Children

International Medical Corps Program “Saving the Lives of Malnourished Children” has been chosen as one of 25 projects eligible for receiving up to 1.5 million dollars in funding from the American Express Members Projects.

Members and on-members alike can cast a vote on the American Express Site for their favorite project. The project with the most votes receives $1.5 million, 2nd receives $500,000, 3rd $300,000, and 4th and 5th $100,000.

So head on over before September 29th and cast your vote. Just one click could save hundreds of children’s lives.

It’s Not Insurance – It’s a Crap Shoot

My sister Ronnie is recovering from surgery that she underwent in the same week that her daughter had a concussion. While most of us in the same situation would be licking our wounds, Ronnie’s grateful. And thinking about those who aren’t as lucky as she is. Here’s what she wrote in her column in today’s Philly Daily News –

After years of excellent health, my family incurred, in one insane week, what must have been thousands of dollars in medical costs that would’ve thrown us into a financial tailspin if we’d not had the insurance to pay them.

Why, in the richest country in the world, should luck factor at all into something as basic as access to affordable medical care for America’s citizens?

…A 2005 Harvard study showed that about half of the 1.48 million Americans who filed for bankruptcy in 2001 did so for medical causes. Their out-of-pocket health-care expenses averaged $11,854 – and three-quarters of these people were actually insured when their illnesses began.

…every year more than half-a-million Americans who assumed that they were covered are forced into bankruptcy anyway just because they got sick.

Go read the rest of her excellent column then come back here.

Think she’s wrong? Think bankruptcy from health care costs is just a problem of the unprepared, financially dim-witted masses who don’t know how to work hard or manage their money?

Let’s ask my brother, the hard-saving financial conservative who believes we all sleep in the financial bed we have made with sheets woven from our choices about work, lifestyle and money.

Big Bro

My brother has a friend who is dipping deep into his retirement savings to pay for a catastrophic illness after passing well above his $1 million dollar lifetime cap. If things go on as they are, his friend is looking at potential bankruptcy.

When he saw what his friend was going through, Big Bro, ever the pragmatist, called his benefits officer and asked how much it would cost him to raise his lifetime health coverage cap to 2 million dollars.

The answer? It’s not possible.

That’s right. He cannot buy insurance through his employer, for any price, that will cover him above $1 million in health care payments.

He is currently exploring the possibility of buying some other sort of insurance, outside his employer-sponsored plan, to protect himself. We’ll let you know if he finds it.

Bottom Line

It’s not insurance. It’s a crap shoot.

See you in Vegas.

In Case You Were Wondering If Health Care is Broken…

I drained an abscess for a patient today. It was rather deep, and so I packed it, and ordered in visting nurse services over the weekend to change the dressing, irrigate and repack the wound, and was planning to see the patient again in a week to assess the healing process.

Well, turns out my patient’s insurance (a supposedly good PPO) declined to pay for visiting nurse services. When the patient asked the insurer “So what do I do to get the wound care I need?” their answer was “Go to the Emergency Room.”

Looking for a Stock Bump?

Release the results of your clinical trials to the media before the FDA and doctors get a chance to review them.

Allergan Inc. said that two large human tests of its Botox drug, best known for smoothing wrinkles, showed that periodic injections prevent headaches in adults who suffer from chronic migraines.

Even though details of the study weren’t released, the announcement, which surprised many physicians and investors, sent Allergan’s shares soaring 11%, or $5.95, to $60.53 at 4 p.m. in New York Stock Exchange composite trading. (WSJ Online)

The press release reports some impressive P values but no numbers, which makes me suspicious as to the real impact of the treatment on migraine. Statistical significance does not always translate to clinical significance. I recall clinical trials of vitamin E for hot flashes, in which the treatment showed a statically significant reduction in hot flashes – one less hot flash a day. For a woman suffering upwards of 10 flushing episodes a day, one less hot flash is a meaningless result.

This practice of announcing favorable results before the medical community has a chance to vet the news is becoming standard practice among Big Pharma. It’s showing total disregard for the peer review process. And the absence of a written and reviewed paper means that medical experts have no basis for comment on the story.

As a migraine sufferer, I tried Botox a few years ago. It did not work. I ended up with Mr Spock eyes for a few weeks and had no fewer headaches. I won’t be trying it again.

It’s only a study of one, and I haven’t published the data.

Just my little “press release”.

Female Urologists


Radio Freaks sings “Thank You Oh Lord for the Bladder”

The New York Times has an interesting article about the growing presence of females in the field of urology, historically a male-dominated surgical subspecialty. About 20% of urologists in training are female, many drawn to the field by their experiences working with female urologist mentors.

What the article fails to mention is that the rise in female urologists comes on the tail of an explosion of women into the field of Ob-Gyn. Many of these female gynecologists are also heading into urology fellowships, gaining the additional training and experience they need to become urogynecologists.

The female bladder, after all, is a close neighbor to the uterus, and the urinary and reproductive tract develop alongside one another embyologically. Bladder and urethral suspensions are longtime gynecology procedures, often combined with vaginal hysterectomy when there is concomitant uterine prolapse. In addition, the bladder often causes problems in pregnancy as well as in menopause, and is a target organ for the female hormones estrogen and progesterone. We gynecologists deal a lot with bladder issues in the course of our day.

As the population ages, we can only expect an increased need in doctors who are expert at dealing with the problems of the urinary tract, in women as well as in men. It’s great to see more and more women entering the field of urology.

BTW, kudos to our own Keagirl for her blog’s mention!

NYC West Side Greenway Bike Path

Here’s a great way to spend a beautiful September afternoon in NYC.

Get on your bike and head to the West Side. Head down to the Hudson River at around 68th street (the ramp down is just in front of Trump’s big apartment houses along the West side). When you get down to the river, head north.

Think about stopping for a free kayak ride. 

But the road and Mr TBTAM (Hmmm…he reminds me of someone…) beckon. So off you go.

As you head north, you’ll pass the 79th street Boat Basin (where Tom Hanks had his boat docked in “You’ve Got Mail”).

Remind yourself to come back for burgers and beer at the Boat Basin Cafe before it closes for the season.

Don’t stop to join all the folks hanging out on the grass, though that seems like a great plan for another day.

Around 86th street the path takes a little detour up into Riverside Park, giving you a chance to stop for a minute or two to admire the 91st Street Garden (site of the final scene from You’ve Got Mail…)

At 91st St, take the path back down to the river. Here, the crowds have thinned and you can do some more serious biking.

At St Clair St, near the Fairway Market, you must leave the path for a few blocks.

This gives you a chance to ride under the West Side Highway

and, if you are hungry, you can stop for Barbecue at Dinosaur Barbecue (nice review here).

But there’s no time to stop. Follow the signs back to the River Path – you’re heading for the George Washington Bridge!

Enjoy the culture shift north of 125th street. Boom boxes are playing salsa music, fishing poles and Spanish food carts line the riverside,


and there is some very serious volleyball going one.

Not far past the volleyball courts, the path along the river narrows abruptly. A sign will tell you that this is the path for walkers.

So you’ll head to the right and take the bike path (over on the far right in the photo).

This will take you through the woods and along the railroad bed.

You will emerge to gorgeous views!

Now it’s just a short ride to the George Washington Bridge.

If you have the energy, stop for a quick game of tennis at the free courts in the shadow of the Bridge. (Directions to the courts are here)

More likely, though, you’ll want to ride up and see the Little Red Lighthouse.

Now it’s time to take a break. Relax along the river, sit on the rocks, enjoy the boats and barges as they sail on the river. (We saw one barge loaded with antique railroad cars.) Marvel at the fact that you are in New York City on a beautiful day in September, feeling the breeze off the river.

When you’re rested, head on back. Don’t worry – other than the foray up to Riverside Park, the path has been completely flat, and you feel great.

And the ride back will be just as spectacular!