Abortion on the Web

In countries where abortion is illegal, a group called Women on Web is offering medical abortion over the Internet. (via National Women’s Health Report)

Clients complete an online questionnaire and are then contacted by a doctor who prescribes the medications that are then taken at home to induce abortion. The medications are mifepristone (RU-486) and buccal Misoprostol. (Buccal is holding the medication in your cheek till it dissolves.) The vaginal route for misoprostol is avoided so that no evidence of pills is left to implicate a user.

The group has published outcomes on 484 women from 33 different countries who received their services in 2006-7. Follow up was obtained via e-mail or phone for 367 women.

About 8% of the women never took the medication. For those who did, outcomes were reasonable for the method used – Between 6 and 12% reported having to have a D&C for bleeding or incomplete abortion, which presents as an early miscarriage and can be treated safely in a medical setting. Continuing pregnancy rates were less than 2%.

These results are similar to those reported in the initial clinical trials of mifepristone here in the US.

The Royal College of Obstetricians & Gynecologists has released a statement saying that it “neither approves or disapproves” of the work provided by Women on the Web. More from that statement –

The results from the study demonstrate that Early Medical Abortion is safe and acceptable to women, confirming other studies including the recent pilot study conducted by the Department of Health in May. The study also shows that women are capable of safe self-administration of drugs provided they receive good and clear instructions, are aware of the possible side-effects and the nature of complications which indicate that further medical attention is required.

And more from the BBC on the UK reaction.

What are the legal issues?

Women on the Web claims its services are legal, even in those countries where abortion is not, since the receipt of medications for home use does not violate customs laws. They do not offer the service in countries where abortion is legal.

The Women on the Web Site

I went to the site, and have to say that I am quite impressed with the quality of the service.

Women are told to go have an ultrasound if it is available to confirm their gestational age before using the service. (Ultimately 80% do so, an impressive percentage) For women where ultrasound is not available, instructions are given to determine gestational age, which prior research has shown to be accurate in most cases.

All cases are reviewed by a doctor for contraindications before medication is released. (I wish they had reported how many women were refused medication for medical reasons or referred elsewhere so I could get a handle on this aspect of the care.) Women are told to seek care for complications in a medical setting. Warnings about undiagnosed ectopic pregnancy, probably the most serious risk of this procedure, are clear and frequent.

The site uses idealized data from other clinical trials in their information about complications. (Now that they have their own data on outcomes, I would urge the group to use that info to guide women in their decision as to whether or not they wish to use this service.)

The site also asks women to post a photo and /or their experience on the site, in an attempt to remove the shame surrounding the procedure. For women who don’t want to use their own photo, the generic photo up there is used. The photo is a sexy, braless blonde in a mini dress. …what’s that about?

How do I feel about this?

Uncomfortable is probably the operative word. I like to see medicine practiced face to face whenever possible. Plus, I’m a law abiding citizen, whether I like the law or not.

But I know that I feel this way because I practice medicine in a country where abortion is safe and legal (for now, at least). If I were practicing in one of the countries where abortion is illegal, and seeing the consequences of those laws in the lives and health of my patients, I might feel very differently. As a physician, I’d probably prefer to handle the miscarriages that result from an early Internet-based medical abortion over the complications from a botched curettage.

Mostly what I hope is that someday, contraception will be free and available to all women so that few women have to seek abortion, legal or illegal.

Doctors Dropping Medicare – The Domino Effect

When the docs in my area began dropping Medicare, their patients had no where to go but to the docs like me who still participate in the plan.

And so, over the past year or so, I began seeing more and more new older patients in my practice. The shift in my practice demographic was almost palpable as these new Medicare patients began filling my appointment book months in advance for routine annual visits. Add in a few retiring docs, and the influx of older women became too much to ignore.

On the day I saw seven new Medicare patients, all coming from the practices that had stopped taking Medicare, I knew that I had to do something.

The Practice Impact

Now I already see more Medicare than most of my colleagues in 0b-gyn. I’m known for managing menopause, and that tends to draw an older crowd to start with, who move into Medicare as they age. Plus, I like the older patients, and almost went into geriatrics at one point.

But this was getting to be too much. The Medicare patients were taking all my new patient appointments.

You see, unlike younger patients, Medicare patients usually call far in advance for their appointments, and fill up my new patient slots for weeks to months at a time. That leaves no room for the 25 year old who just moved to Manhattan and needs her pills refilled within the month, the 35 year old who thinks she is pregnant, the 45 year old with hot flashes who can’t wait till March, the Italian tourist with the UTI or the 16 year old whose mom just found out she was having sex. If I don’t have the slots to see these patients soon, they’ll find someone else who does.

These younger patients provide the variety that drew me to this field in the first place – the opportunity to care for women at all stages in their reproductive lives, with medical problems that change with each decade. My research arena is contraception and std’s, and that means younger patients. I especially love the teens, and ran the adolescent gyn and teen pregnancy clinics at my former jobs. I really missed seeing these patients in my practice as the older patients began taking all the new patient appointments.

What are the financial impacts? Well, if the visit is medically complicated, Medicare pays reasonably well for my time, although it’s still less than half of what I get from managed care for the same services. At current volume levels, it’s not that much of a problem. But if Medicare were to increase much beyond that, it could impact the bottom line significantly.

And finally, I have to be honest and admit that my temperament is not suited to seeing a large volume of elderly patients in one day. I can’t stand having patients waiting in my waiting room because I am behind. Older patients just take more time per visit, no matter what the reason. I can handle a few Medicare patients a day, no problem. But more than, and I am guaranteed to get behind on schedule. And that stresses me to no end.

My Response

In response to this rapid change in my practice demographic I advised my staff that if a non-Medicare patient called, for whatever reason, she got offered an appointment immediately, even if it meant adding her onto the beginning or end of an already full day.

I thought that would solve the problem.

But after a few months, it became clear that this was not working. New patient slots continued to be filled months in advance by the Medicare patients.

So I put a moratorium on new Medicare patients except those referred by colleagues for a problem. I am continuing to see my current Medicare patients, as well as my own patients who transition into Medicare.

I feel terribly guilty about all this, but it’s working. I’m seeing more and more new younger patients. The Medicare new visits are still coming, but on a more limited basis, and overall Medicare now comprises about 20% of my visits. Which is fine for now. This solution is working for me and for my current patients, as well as for my referring docs.

Of course, it’s not working for those women out there still looking for a new gynecologist.

Sorry, Doc

No more pens and mugs.

WASHINGTON — The pens, pads, mugs and other gifts that drug makers have long showered on doctors will be banned from pharmaceutical marketing campaigns under a voluntary guideline that the industry is expected to announce Thursday. (Via NYTimes)

Would cold, hard cash do instead?

I’m from Philly

So says the Accent Quiz. Amazingly correct. Try it yourself.

What American accent do you have?

Your Result: Philadelphia

Your accent is as Philadelphian as a cheesesteak! If you’re not from Philadelphia, then you’re from someplace near there like south Jersey, Baltimore, or Wilmington. if you’ve ever journeyed to some far off place where people don’t know that Philly has an accent, someone may have thought you talked a little weird even though they didn’t have a clue what accent it was they heard.
The Northeast
The Midland
The Inland North
The South
Boston
The West
North Central
What American accent do you have?
Quiz Created on GoToQuiz

Uh Corse, if yuz wanna’ rilly tawk ike a Fluffian, en yuz godda moove ‘ere, dgrive over the Wall Women Bridge to Sener Siddy or Sow Shreet and rute for dem Iggles. ‘En yuz are rilly tawkin ‘ike a Fluffian.
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(Hat tip to Addicted to Medblogs, who also appears to be addicted to waste-of-time web things like this quiz, and feels it is her duty to get the rest of us addicted as well. Head on over for more Time Killers)

Summer Squash, Pea and Red Onion Salad with Feta

Mr TBTAM made this wonderful salad from Melissa Clark’s Recipe in today’s new York Times. In addition to getting the recipe, I encourage you to read the article on how she created the recipe – it’s a lovely story about how buying and eating locally can lead to a wonderful new dish.

The salad is delicious, and calls for blanched peas, and raw zucchini. I liked it, but could also see this salad with the zucchini blanched as well. We liked the zucchini slices halved as you see them in my photo up there, rather than whole as Melissa did them.

For the salad, Mr TBTAM used fresh sweet sugar snap peas, which normally we would eat whole, pod and all, raw and by hand – summer’s candy as far as we’re concerned. Now we are left with all the empty pea pods. Any ideas on what to do with them?

Grand Rounds, Vol 4, No 42 – The Seinfeld Edition

Most things in life can be related, one way or another, to an episode of Seinfeld.

It’s true. That TV show which claimed to be “about nothing” pretty much said everything that needed to be said about, well, everything.

Take this week’s Grand Rounds, the best of the Medical Blogosphere. It’s totally Seinfeld. Every post. Why I can hear Jerry, even now…

Grand Rounds? Can someone please explain what that’s about? I mean, is it Grand as in “large”? Or Grand is in “Isn’t that grand?”

No one says “Isn’t that grand?” anymore unless they’re 95 and in a nursing home for retired stage actors. In which case they should definitely not be practicing medicine.

And why do they call it “Rounds”? Is everyone standing in a circle singing Row, Row, Row Your Boat? What’s that got to do with medicine?

Or is it Rounds like a round of golf? D0 you guys keep score? “I shot a bogey on that appendectomy today. Lost a Titelist sponge somewhere behind the cecum.”

Doesn’t that make your nurse sort of like a caddy? “Nurse, hand me my 9 scalpel. Or do you think I should wedge it out?”

Grand Rounds. Now that I think if it, it sounds like some sort of Melba cracker you serve with cheese. “Would you like some Gruyere on a Grand Round? Oh do try it – It’s Grand!”

Cut to Jerry’s apartment, where his friend Dr Crippin, visiting from the UK, is ranting about how he is tired of the livers of his fellow citizens being given out to foreigners. Not an English citizen? NO LIVER FOR YOU!

Kramer tells the group he wants to listen in on doctor’s conversations, and wonders if Jerry’s deaf girlfriend, who reads lips, can hang out out in the OR and find out what they are saying. Joshua Schwimmer reminds Kramer about the fiasco when he tried that last time, and suggests that instead, Kramer hang out online in the Doctor’s Room at Friend Feed.

RL Bates has a great post on the retracted nipple – when it’s normal, when it’s not, and how to manage both. Elaine appears not to have that problem, as everyone who got her Christmas card can see.

Jerry may have gotten in trouble for using the F- Word in a Yogurt Shop, but Rural Doc finds out it can be pretty f*$#ing helpful in the Labor and Delivery Room. Great post!

When Kramer drops a Junior Mint into an open abdomen during surgery, the patient is miraculously cured. But Doc Gurly reminds us that lack of proper sterile technique can have disastrous consequences.

Dr Shock tells us that drug use does not appear to be related to drug policy, as countries with more stringent policies (e.g., the US) did not have lower levels of illegal drug use than countries with more liberal policies (e.g.,The Netherlands). Meanwhile Jerry and George wonder where Holland is.

Jerry, Elaine, George and Kramer are waiting at the Chinese Restaurant for a table. “You ever notice how happy people are when they finally get a table?” says Elaine. “They feel so special because they’ve been chosen. It’s enough to make you sick.” Dr Jokes overhears Elaine. “Hmm.. I wonder what would happen if the restaurant treated her as if she were sick, and used the medical office model?” Unfortunately, Elaine never finds out, because they never get a table.

The wait for the restaurant on the show occurs in real time – 23 minutes. During which time, basically nothing happens. Well, nothing other than the earth moving. And The Samurai Radiologist can tell you exactly how far it moved during that wait in the restaurant. Or during the time you had sex. Or any thing you happen to be doing. Pretty cool.

Dr Toni Brayer shows us just how impossible it can be to figure out what the costs are for a hospital procedure. Reminds me of the episode where George finds out be needs his tonsils removed.

GEORGE: (To Jerry) Let me ask you something.. How much do you think it would cost to have tonsils and adenoids removed in the hospital?

JERRY: Well, an overnight stay in a hospital? Minor surgery? I dunno, four grand.

GEORGE: Uh-huh. And how much does the healer charge?

KRAMER: First visit? Thirty-eight bucks.

GEORGE: Oh, yeah? Holistic.. that’s what I need. That’s the answer.

Elaine’s boss, J Peterman, is off again on a world jaunt, this time to visit his friend the traveling Doc Kate. She’s in Pakistan, training the locals on how to diagnose and treat Sexually Transmitted Infections. Stay safe, Dr Kate.

George has a massage that stimulates him in a way he’s a bit uncomfortable with. Next time he should just read Fixing Posture and learn to take care of his back himself. And if he decides on aquatic therapy, Dean Moyer at the Back Pain Blog has everything he needs to know.

Elaine can’t sleep because a dog is barking outside her window. Or, wonders Dr Nancy Brown, is it just her hormones?

Kramer loves his hot tub. It relaxes him. And it’s not just in his head. Relaxation techniques can favorably affect the expression of stress related genes, according to new research discussed at Neuroanthropology.

Elaine has a rash that needs diagnosis, but no doctor will look at her rash because she has been labeled as a difficult patient. Too bad she didn’t see House. He’d have figured it out, knows Monash Medical Student, just as he diagnosed this week’s case of subacute sclerosing pan-encephalitis.

When the conversation gets rough, try to find the humor, says Barbara Kivowitz at In Sickness and in Health. Maybe that’s why Julia Dreyfuss can’t stop laughing every time Mr Costanza tries to get off that famous line “You wanna’ piece of me?“

Kramer hires an intern to get all his stuff done. Too bad he didn’t read Apple Quack’s two part post on project management.

The group has a contest to see who can remain “Master of their Domain” the longest. Kramer is the first to go. Maybe it because he eats watermelon, which JC Jones tells us increases blood flow to the genitals and may increase libido.

Anesthesiaoboist has compiled a very nice gallery of Medicine in Art, including my favorites, the ancient Persian drawings. I think she might also have included this painting of the famous Dr Van Nostrand…

Did you know that it was Rodney Dangerfield who gave Jerry Seinfeld his biggest break, by featuring him on his HBO special? Maybe Diabetes needs a break too, says Amy at Diabetes Mine. It’s the Rodney Dangerfield of diseases, ranked by the public lower than other less serious diseases as a cause of mortality.

The Cockroach Catcher has a fascinating post this week about how dried Chinese plums can be used as natural oral rehydration therapy. Hmm..maybe Kramer should try some. Those pretzels are making him thirsty.

Kramer and Jerry’s landlord has replaced their shower heads with low flow models to save money on water, and no one feels like themselves without a good shower. That’s pretty much what the government has been trying to do with health care costs since Medicare was started. At least I think I got that right. It’s very complicated, and Covert Rationing does a great job of trying to explain it.

George’s girlfriend can’t have sex with him for 6 weeks, and he discovers that without sex, he gets smarter. Maybe he should have read Dr Alvarez’s post on brain health and found some other way.

David E Williams has written a fascinating post about how a man’s Google search led to his conviction for murdering his wife using ethylene glycol. Hmm.. Do you think George might have googled “wedding envelope glue death“?

Vitum Medicus compares the med school class of 1960 to that of 2010, in his post Are Today’s Medical Students Wusses?. Hopefully, they are nicer than Elaine’s boyfriend who breaks up with her after he becomes a doctor. Or, as he puts it “I’m sorry, Elaine. I always knew that after I became a doctor, I would dump whoever I was with and find someone better. That’s the dream of becoming a doctor.”

Elaine loves her Big Salad. But she’d better be careful- those tomatoes may have salmonella, says Paul Auerbach. Read his post for a great summary of the problem, plus some great advice on food handling.

R Murse summarizes California’s new regulations to help fight prescription drug abuse, but it’s too late to catch Jerry’s drug-using accountant, who’s already left the country.

For Chronic Babe, mixing it up occasionally is important in keeping healthy habits, whether it’s a change in routine or a new recipe. I’d say that’s something to dance about, wouldn’t you?

Kramer, as always, is the only member of the group with a heart (most of the time, anyway)… He’d have liked these following posts –
  • Little Hailey has an incurable and fatal disease, and her only hope may lie in an experimental treatment being done in China. InsureBlog’s Henry Stern asks whether the airline that was supposed to fly her there did the right thing by refusing to.
  • Dr Val tells the story of a young teenage mother who beats the odds in her review of the book Glori, a Different Story.
  • PalMD uses a special pen when he writes notes to the relatives of recently departed patients. It’s too important a task to relegate to anything else. What a nice post.
  • Susan Palwick of Rickety Contrivances has a wonderful post telling of a moving encounter she had with a pscyh patient.
  • One of Dr Rob’s favorite patients is dying. His post reminds me of all the wonderful patients I have, and how they enhance my life. Thanks, Dr Rob for a wonderful post.
  • Sudeep Bonsai wonders just how aggressive to be in treating an elderly depressed and very ill patient with congestive heart failure. Sounds to me like he did the right thing. See what you think.
  • How to Cope with Pain has some suggestions to awaken Joy. She’s clearly a glass half full person.
  • My heart goes out to Lisa, who has Cushing’s Disease. Stop on by and give her an encouraging word.
And that’s it, folks. Proof that everything in life, or at least in the medical blogosphere, can be related to Seinfeld.
Thanks to all who submitted posts. I tried to include everyone, although a few duplicate posts on the same topic came in, and so I took the one that arrived first. A few posts arrived late on Monday, and I’m sorry I just could not include them. If that was your first time submitting, and I didn’t include you, please don’t be discouraged – after all, there’s always next week!

Thanks as always to Nick Genes of Blogborygmi, who makes it all happen. Next week’s Grand Rounds will be held at Unprotected Text.

Just Another Nuisance Malpractice Case

I just heard from the lawyer defending a med mal case on which I gave expert opinion. The case was filed by a woman who claimed her miscarriage was caused by a hormonal birth control method that her doc initiated during an early pregnancy that she charges he should have diagnosed.

I can’t give further details, but suffice it to say that medically, this plaintiff had no case. The birth control in question does not cause miscarriages and there was no reason the doctor would have suspected that she was pregnant at the time the method was initiated. Although the doc did not do a pregnancy test, it would have been negative since the patient was only 1-2 days post conception at the time.

The case settled for $7,500 before any depositions were even taken.

The Defense Lawyer was thrilled. As far as she was concerned, $7,500 is “essentially nuisance”. With just a few hours work on my part, I had saved her thousands of dollars and countless man hours trying this case. Since the doc involved was a hospital employee, he was not named, so no harm was done. She wants to use me again as an expert.

The Plaintiff’s Lawyer made a few thousand bucks – not bad for a couple of hours work. He’s learned that these nuisance cases may not be windfalls, but if you file enough of them, they pay off. In fact, they’re the bread and butter of his practice, and are probably putting his kids through college.

The Plaintiff may not have gotten rich but this nuisance case has given her enough cash to pay off some credit card debt or take the kids to Disney World. Plus, she has a story to tell everyone she knows. Those doctors caused her miscarriage, and they had to pay. Not as much as she would have wanted, but they paid nonetheless. Her lawyer said something about “no admission of guilt”, but she doesn’t believe that – her lawyer just wasn’t as good as he could have been. Certainly not as good as her cousin’s lawyer, who’s promised her a hundred thousand dollars for her premature baby.

Friends, acquaintances and friends of friends of the plaintiff will hear the story. They will tell their friends, who will tell their friends. The story may even make it into an Internet chat room.

Some women using the same contraceptive method will hear the story and become worried. If it causes miscarriage, what will it do to their future fertility? More than a few will be frightened enough to stop their birth control, and will have an unplanned pregnancy. Perhaps an abortion. Perhaps another child they cannot afford to raise, either financially or emotionally.

I wouldn’t call this case a nuisance. I’d call it a tragedy.

Biking the Pine Creek Trail

These days spent in the Endless Mountains of Pennsylvania are like stepping back in time. The lack of development in the area has kept it preserved in so many ways.

But one nice development has been the completion of the Pine Creek Rail Trail – 62 miles of flat gravel that runs from just north of Williamsport through Pine Valley into the Pine Creek Gorge, known as the Grand Canyon of Pennsylvania, to the town of Wellsboro, Pennsylvania. There’s lots to do along Pine Creek, including hiking, fishing, swimming and birding. But it was the biking that attracted us.

We did a 22 mile ride in the mid-section of the trail yesterday, biking from Blackwell to Slate Run and back. Although this ride did not take us through the Grand Canyon, it’s a lovely ride through the Valley, perfect for those who might not want to pack food and picnic, because there are several places to stop and eat.

Blackwell to Cedar Run

Blackwell is a tiny town with a nice hotel/restaurant and that’s about it. There was plenty of parking available at the trail lot, so we parked there, despite the fact that the trail guide suggested that bikers use the Rattlesnake Rock access and leave Blackwell to the boaters. There are bathroom facilities and a pump for water.

As we took the bikes off the roof, we discovered that the nut holding my front wheel on had somehow come off. Luckily, we found a place that rented bikes.

No one was there, just the honor system, take a bike, leave the money in the locked box.

The bike could have used a bit of oil, but was good enough, and I had not trouble keeping up with Mr TBTAM and the girls.

The path is a 2% grade going N-S, so it’s easy biking either way. The gravel surface is well maintained, but its width is deceptive – it can drop off fairly steeply in places, so I wouldn’t ride more than 2 abreast.

There are a fair number of bridges to cross – old RR trestles and small foot bridges across tiny feeder streams.


Cedar Run is an adorable little town with nothing more than a general store and an Inn.

We arrived after 2 pm, and though lunch is served only from 11-2, they felt sorry for us and made us panini sandwiches, which we ate us on the shaded side patio.

Meanwhile, the front porch was a continuous stream of bikers and locals coming for their renowned homemade ice cream.

The Cedar Hill Inn is across the street. I’m told the restaurant is very good, and the rooms lovely (though no air conditioning, I assume from the fans in the windows).

Cedar Run to Slate Run

From Cedar Hill to Slate Run the trail winds through a wide valley. On this stretch, we saw a rattlesnake.

and hundreds of tiny, perfect little frogs hopping across the trail.

Mr TBTAM saw some great birds – one with a bright orange vest, and several hummingbirds.

There are camping grounds and primitive cabins along the creek as you approach Slate Run, where there is a large General Store with pretty much anything a person might need, including sandwiches, food, sundries, a huge bait and tackle shop and lucky for us, air for our tires.

I am told the nearby Manor Inn has a good restaurant for lunch, but we did not stop there.

The Ride Back

We put on speed on the return trip, with nothing more than a stop for water at Cedar Run. That’s the downside to doing a trail and not a loop – riding back over previously ridden ground. But it was a great work-out and a lot of fun, so we’re not complaining.

We plan to return again in early Fall to do the upper part of the Trail from Wellsboro to Blackwell, arranging with Pine Creek Outfitters to meet us at ride’s end and shuttle us back to your starting point, so that we can cover more ground in a one day trip.

Bottom Line

If you’re looking for a great place to bike for riders of all ages, the Pine Creek Trail is it. Make it a weekend, and stay in Wellsboro or one of the towns along the trail. Fall is probably best for the gorge, but summer is pretty darned beautiful as well.


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I used the antique settings on I Photo to make the photos look old. I’m having fun playing with my new MacBook…

Grand Rounds in Manhattan Next Week!

Central Park, NYC (Photo courtesy of Wiki Commons)

As you’re heading out for vacation this weekend, don’t forget that Grand Rounds will be held here next Tuesday 7/8/08.

Send your submissions to tbtam(at)rcn(dot)com by 8 pm Sunday, July 6.

The Marcellus Shale – Your Shi Poo Pi!

Turns out that our summer house in the Endless Mountains of Pennsylvania is sitting on top of a large vein of Marcellus Shale, which in turn is housing one of the largest natural gas fields in the United States. No one cared about the Marcellus Formation until recently, when new drilling techniques first used in Texas were applied to the Marcellus and lo and behold, there was gas in them thar hills!

Most of the drilling in the Marcellus Formation will be horizontal and underground, with large quantities of water used to create fractures in the rock to release the gas. It’s a process that allows a single visible well to extract gas from a very large underground acreage, making the entire process financially feasible and quite profitable. The Marcellus could potentially yield enough natural gas to supply the entire country for 2 years, with an estimated market value of trillions of dollars.

The Gas Rush is On

Land lease negotiations with the locals in our area are in full swing as gas companies compete for rights to drill wells on their land. The first to sign contracts got fairly low rates, but land owners have since learned to negotiate in groups, and the lease price has gone up considerably in the past year. Land leases in our county are currently going for $2000 an acre, with 15% royalties.

Part of me is really happy for the locals living in the sparsely populated rural areas being targeted for drilling. These folks deserve a break. And, if they play their cards right, they will surely get one. Why, farmers formerly earning a sustenance living could become millionaires if their wells produce as expected!

The Environmental Questions

Of course, there are many concerns about the environmental impact of the drilling. Although the underground nature of the process means a relatively small visible footprint, the huge quantities of water that must be used could threaten local water supplies. The trucks needed to carry that water from areas outside the drill zone can create noise and pollution and damage roads. There are also concerns about quality of the water in the area, since most of us get out water from wells. The Gas Companies tell us that the wells are drilled well below the water supply and with casings to protect the aquifers. But who ever trusted an energy company with the environment?

Last night was one of the first meetings on the environmental impact of what will likely be decades of natural gas development in the area. Some good advice came from the meeting, the most important of which was to test your water both before and after drilling starts and not to allow drilling within 200 yards of the water source. Given that most of the drilling is underground, I don’t see how the latter can be reliably enforced.

The DEP is getting involved, and advises landowners to be proactive in monitoring drilling going on on or near their properties, and to report any potential violations to the DEP.

I wonder if any of the folks over at The Pump Handle can comment on the potential health impact of natural gas drilling…

More Information

  • Penn State Extension is doing a marvelous job of educating the public about the issues. Their Natural Gas Wiki has everything you need to know, from how the gas is mined to how to negotiate a land lease contract.
  • Geology.com is another great source of information on the Marcellus Formation mining.
  • Catskill Mountainkeeper does a nice job of summarizing the environmental issues.
  • OGAP, the Oil and Gas Accountability Project, has a free downloadable 220 page booklet called Oil and Gas at Your Door, written specifically for landowners and others affected by oil and gas development.

Shi Poo Pi?

Of course, whenever I hear the name Marcellus, all I can think of is Marcellus Washburn, the Music Man’s lovable sidekick, played by the late Buddy Hackett. Hackett started his show biz career in the Catskills, another area on the Marcellus Slate Belt that is being targeted for natural gas mining. So I know that, were Hackett alive today, he’d be singing this song…

Shi-Poo-Pi!

Well, the well you dig on the very first try
Is usually a shy one
And the well you dig on the second time out
Is sure to be a dry one
But the well you drill on the third time around,
Slate on the top, gas in the ground!
That’s the well you’re glad you’ve found–that’s your
Shi-Poo-Pi!

Shi-Poo-Pi! Shi-Poo-Pi! Shi-Poo-Pi!
The gas that’s hard to get!

Shi-Poo-Pi!Shi-Poo-Pi!Shi-Poo-Pi
But you can mine her yet!

Summer’s First Corn

On the way home yesterday from dropping our younger daughter off at camp in the Pine Barrens of New Jersey, we stopped at a farm stand for our first corn of the summer. Sweet white Jersey corn, fresh from the fields.

Paired with fresh Jersey tomatoes, it’s one of our favorite meals on a hot summer night. That’s the whole meal. Just tomatoes and corn. Washed down with a cold beer, of course.

Where do you get your favorite summer corn?

What is the Role for Breast Sonogram?

The WSJ has an article this week discussing MRI and breast sonogram as adjuncts to mammogram, and the debate going on in the medical community as to how these modalities should be used. The article does a nice job framing the debate that is occurring among physicians regarding when to use these modalities.

Medical practitioners are divided about the proper role of ultrasound in breast-cancer screening. Wendie Berg, a radiologist at a clinic in Lutherville, Md., who was the lead author of the study published in JAMA, says she recommends ultrasound screening to some women who don’t have evidence of very high risk that would justify an MRI. “It is a judgment call. The denser the breast, the more difficult the mammogram is to read, the more likely I am to recommend an ultrasound,” she says.

But Constance Lehman, a University of Washington professor of radiology who led a study published last year in the New England Journal on MRI screening, says she never advises ultrasound for patients. “We find it ineffective as a screening tool,” she says. “It’s not even in the same ballpark” as an MRI.

I’ve been actively debating the songram issue with an internal medicine colleague. She’s anti-sono, I tend to favor the screening method, but with caveats. She and I decided the issue is pervasive enough to discuss publicly, and are setting up a debate forum this fall with a panel of respected breast specialists and radiologists to see if we can come to some resolution on the matter.

Will let y’all know how that turns out.

Does a Brief Cessation of Hormone Therapy Lead to a Better Mammogram?

Since we know hormone replacement therapy (HRT) increases breast density, it seems logical that a short break from hormones prior to a mammogram might improve mammographic sensitivity. In fact, some doctors would recommend that women on HRT stop their hormones for as long as several weeks prior to a scheduled routine mammogram.

However, a recent study in Maturitas suggests that stopping HRT for as long as a month before having a mammogram makes no difference in mammographic breast density.

Researchers in the UK enrolled HRT users who were willing to have a mammogram, then stop their hormones for 4 weeks and repeat the mammogram. The mammograms were read by two experienced radiologists and scored for breast density using two different visual methods and two different computer methods.

All told, 44 women completed the study. The researchers found that stopping HRT for 4 weeks made no difference in mammographic density measured either visually or by the computer. In addition, there was no significant effect on breast tenderness during mammography.

The study’s findings stand in contrast to other studies that suggested stopping hormones might be helpful prior to mammography. But these studies were either confined to women with abnormal mammograms or compared groups of women to each other (case controls).

What makes this study especially compelling was that it used women as their own controls, included women who had used HRT for longer than one year, and was in the setting of routine mammograms. In addition, the researchers used several different techniques for measuring breast density, and found agreement among them in their results.

Weaknesses of the study are that it was relatively small, and that duration of HRT use varied within the population studied.

If supported by other studies, these findings are not so good news for women on hormone replacement hoping to mitigate some of the adverse breast effects of their hormones, at least as it relates to mammographic sensitivity and specificity. However, it is good news in that women should not be asked to suffer without their hormones without a proven benefit.

What is Mammographic Breast Density?

Mammographic density is a measure of permeability of x-ray, and an indirect measure of the density of breast tissue. Increased breast density is an independent risk factor for breast cancer, but is more likely a marker for underlying biologic differences in breast composition rather than a pathologic process in itself.

HRT can increase breast density, though not in all users. Intermittent progestin HRT regimens cause less of an increase in breast density than continuous regimens, and new low dose regimens may not increase breast density at all.

I tell my patients that reading a mammogram of a dense breast can be like looking through fog. If there’s an abnormality there, it may be harder to see. By contrast, a mammogram of a fatty breast is like a clear blue sky. Dense breasts are also harder to examine, and I am less confident in my ability to detect small masses in a woman with dense breast tissue on exam.

There’s a lot of active discussion these days as to how to improve breast cancer screening in women with dense breasts. Use of digital mammography, sonogram and MRI may improve detection of breast cancer in women with dense breasts, but the latter two come at a price of increase in false positives and biopsies.

What Should You Do?

Here comes the usual answer – Talk to your doctor. When data in the literature conflict, and there is not a clear recommendation as to which is the best way to go, then it’s really up to you to bat it around with your doctor before making any change in your hormone regimen before a routine mammogram. There is certainly no serious downside to stopping HRT for a short time, and if you’re willing to do so in order to have a better mammogram, then I say go for it.

To be honest, though, I do not routinely advise my patients to stop their hormones before having a routine mammogram. Stopping HRT for as little as a few days for some women can mean re-emergence of bothersome symptoms, including vaginal bleeding.

My experience is that a woman willing to stop her hormones for 4 weeks because she was worried about mammographic density would be a woman who would probably not ever take HRT in the first place. Most of my patients these days who choose to use HRT are truly miserable without it, and living the kind of high functioning lives that would be adversely impacted by a month off HRT. Without proven benefit, I see no reason to ask these women to stop hormones before a routine mammogram.

However, this reasoning on my part is very likely influenced by the fact that I don’t hesitate to order breast sonogram for women with dense breasts on mammography, especially if the radiologist hedges their reading by stating that the breast density “may lower the sensitivity of mammography in this patient.”

But that’s another controversial topic for another day, so stay tuned.
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– Weaver K et al. Does a short cessation of HRT decrease mammographic density? Maturitas. 2008 Apr 20;59(4):315-22.
–Mammogram information from the NCI.
–Improving Breast Cancer Screening– Info from the NCI

Grand Rounds at Shrink Rap

This week’s grand rounds can be accessed from two slick I Phones over at Shrink Rap – Click the buttons to read the posts! An amazing little piece of geekwork. I’m totally impressed.

Just disappointed my post didn’t make it. (I guess that’ll teach me to submit it on time next time…)

Head on over for the best of this week’s medical blogosphere.

Healthcare 3G

Twice as fast. Half the price.

Sounds good, right? It should – it’s the slogan for the new Iphone 3G. Everyone wants one, including me.

Ironically, this is also the slogan for modern medical care.

Because as the reimbursement goes down, docs are seeing more and more patients. Half the price, twice as fast.

You get 15 minutes, tops, talking to a back of a person typing madly away at a computer while you talk. We can take some additional history while we examine you. Write that script even as we’re telling you what we’ve found. Print out that script or referral faster than you can get dressed, and have it all ready for you by the time your check out. No need to ask questions – here’s a print out with the answers to ones you didn’t even think of. Now on to the next room!

Want it even cheaper and faster? Head over to your nearest in-store clinic and see a nurse practitioner instead of a doc. Heck, we’ll even start making nurses doctors – that’ll really lower the price.

Now, we all know that as electronics get cheaper, the quality starts to suffer a bit. Laptops konk out after 3 years. DVD players last just long enough for us to catch the last season of the Sopranos. That new fancy cell phone’s battery won’t hold a charge longer than an hour.

Same thing in health care.

Because fast works for things like sore throats, vaginal infections and vaccinations. But better not have a complicated problem, or need coordination of care between specialists, or god forbid, need to talk to someone because you’re anxious or depressed. We can’t handle that. Not at these prices. Sorry.

Of course, when that cheap DVD player breaks, you can just head out to Best Buy and get another.

Unfortunately, that option won’t work in health care.

Not to worry. That’s why we have lawyers.
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This post was written in response to a call for submissions to Grand Rounds at Shrinkrap 6/24/08.