Pont Neuf, Wrapped.Christo and Jeanne-Claude, 1985
Queensboro Bridge, Wrapped
NYC Department of Transportation, 2007
Ovarian Cancer Symptoms
Gilda Radner, who died of ovarian cancer at the age of 42, had symptoms for months before her cancer was finally diagnosed.
The American Cancer Society and the Society for Gynecologic Oncologists have issued a consensus opinion outlining the symptoms of ovarian cancer, and more importantly, urging women and their doctors to consider ovarian cancer in the differential diagnosis when these symptoms present.
What are the symptoms? They are vague and all too common – bloating, pelvic or abdominal pain, early satiety, and urinary sympotms such as urgency and frequency. But, when present and persistent for more than 2 weeks and less than 1 year (or in the case of urinary symptoms, persistent after treatment for a UTI), one must consider ovarian cancer in the differential. And consider it early, because this is one cancer that won’t wait around while you exclude everything else.
For almost 2 decades now, this is exactly how I have been practicing. As I’ve said before, I don’t hesistate a second before performing a pelvic ultrasound in women with any of the symptoms listed in the consensus statement. I happen to be pretty good with a vaginal ultrasound probe, and I have an amazing gynecologic radiologist to whom I can refer.
Despite this, in all these years, after performing or referring for thousands of sonograms (and not a few ca125 tests) in what I believe is an optimally aggressive screening approach for ovarian cancer in symptomatic women, I have yet to diagnose a single case of early ovarian cancer. Of the 5 or so cases (it is, after all, not a common cancer), all but one presented to me at stage 3 or more. That early tumor was a borderline cancer, and she would have done well no matter what I had done.
I wish I could say my aggressive management of symptoms has impacted ovarian cancer mortality. It’s certainly reassured a lot of frightened women and found quite a bit of benign disease. But ultimately, I just don’t think it has made a difference in terms of ovarian cancer outcomes.
Maybe it is because my patients with ovarian cancer ignored their symptoms for too long before coming in to see me. If so, then publicizing this consensus statement may make a difference. I certainly hope that it does. And despite my reservations about my practice’s efficacy, I’m not changing what I do, because at this point, there is nothing else I can do. It’s what I have to do, and what my patients deserve.
What we really need is a good early ovarian cancer screening test for asymptomatic women. (No, it’s not the Ca125 test.)
Or better yet, how about a pill to prevent ovarian cancer? Oh, wait a minute – we already have that. It’s called the Birth Control Pill.
_______________________________________________________________
Here’s the Consensus Statement:
Historically ovarian cancer was called the “silent killer” because symptoms were not thought to develop until the chance of cure was poor. However, recent studies have shown this term is untrue and that the following symptoms are much more likely to occur in women with ovarian cancer than women in the general population. These symptoms include:
- Bloating
- Pelvic or abdominal pain
- Difficulty eating or feeling full quickly
- Urinary symptoms (urgency or frequency)
Women with ovarian cancer report that symptoms are persistent and represent a change from normal for their bodies. The frequency and/or number of such symptoms are key factors in the diagnosis of ovarian cancer. Several studies show that even early stage ovarian cancer can produce these symptoms.
Women who have these symptoms almost daily for more than a few weeks should see their doctor, preferably a gynecologist. Prompt medical evaluation may lead to detection at the earliest possible stage of the disease. Early stage diagnosis is associated with an improved prognosis.
Several other symptoms have been commonly reported by women with ovarian cancer. These symptoms include fatigue, indigestion, back pain, pain with intercourse, constipation and menstrual irregularities. However, these other symptoms are not as useful in identifying ovarian cancer because they are also found in equal frequency in women in the general population who do not have ovarian cancer.
Thinking Blogger Award
Many, many thanks to fellow bloggers Dr Wes and KatieZ , who nominated me for a Thinking Blogger Award. It’s an honor to be a recipient of this award, and I am proud to display it on my sidebar over there.
But the best part is that I get to give the award out to 5 other blogs that make me think. And so, without further ado, I award this prestigious award to (drumroll, please…)
The Well-Timed Period. An incredibly interesting, opinionated and comprehensive blog about anything and everything contraceptive.
Enter the Circle: My friend Linda writes an insightful, brassy and funny blog. She’s also into the whole women’s empowerment thing and runs something called the Moon Lounge, yet remains completely normal.
Bardiac: Of course.
Celebrity Cosmetic Surgery: Just checking to see if you’re still reading. Well, it does make me think I’ll never get plastic surgery…
Aetiology: Everything a science blog should be.
If you’ve been tagged, here are the rules. And thanks to the awardees for your contribution to keeping my brain alive.
Grand Rounds 3:38
Jacob M Gershberg . Images from the NLM History of Medicine Webpage
Grand Rounds is up over at Dr Val’s Blog. It’s a nice edition – succinct and well-organized, with a short and long version. Plus, she included a post of mine that I hadn’t even submitted! Thanks , Dr Val! My favorites from the lot:
Kerri meets a sympathetic Barista:
Damn you, Starbucks. Just when I’ve thought I’m beyond your caffeinated claws, you reach back out and gently bring me back in.
Type-B Premed captures a slice of life in the ER that will tear your heart out.
“You’re sure?” Upon hearing the news, a perfectly manicured hand raised to her mouth to hide her trembling lip…
Dr Rob explains the genetic difference between men and women. Hilarious!
Many scientists believe that the feeling by many women that jeans make them look fat comes from the fact that there are more genes in a women’s body, and this is actually a cry for help from the chromosomal level.
Now head on over for the weekly best of the medical blogosphere!
Grand Rounds 3:38
Jacob M Gershberg . Images from the NLM History of Medicine Webpage
Grand Rounds is up over at Dr Val’s Blog. It’s a nice edition – succinct and well-organized, with a short and long version. Plus, she included a post of mine that I hadn’t even submitted! Thanks , Dr Val! My favorites from the lot:
Kerri meets a sympathetic Barista:
Damn you, Starbucks. Just when I’ve thought I’m beyond your caffeinated claws, you reach back out and gently bring me back in.
Type-B Premed captures a slice of life in the ER that will tear your heart out.
“You’re sure?” Upon hearing the news, a perfectly manicured hand raised to her mouth to hide her trembling lip…
Dr Rob explains the genetic difference between men and women. Hilarious!
Many scientists believe that the feeling by many women that jeans make them look fat comes from the fact that there are more genes in a women’s body, and this is actually a cry for help from the chromosomal level.
Now head on over for the weekly best of the medical blogosphere!
The Knife Sharpening Guy
This is fifth in a TBTAM special series called I Get it on the Streets. Links to the next post in the series are at the end of each post. Enjoy!
On any given Sunday, if you live in New York City and have your windows open, you may hear a clanging noise coming from the street below. If you do, drop whatever you are doing, run to your kitchen, grab your knives and head downstairs as fast as you can. Because Mike the knife sharpening guy will be there with his truck ready to give your steel a new edge.
That’s right – A mobile cutlery grinding service. A time-honored tradition that still exists in some US cities , unchanged from what I imagine it was years ago, when aproned housewives and the cooks of the rich listened for the clanging bell and headed downstairs, gathering around the truck to grab a few minute’s gossip with their neighbors as the cutlery man sharpened their knives.
Mike’s been sharpening New Yorker’s knives and scissors in this truck for years, having learned the trade from his father, who outfitted the truck before Mike was born. Mike remembers riding with Dad when he was as young as 5 years old. Now Dad is gone and Mike works fulltime in the DA’s office and has a grown son of his own. But he and his son still take the family truck out on weekends, driving from their home in Brooklyn over to Manhattan to sharpen knives, mostly on the Upper West Side. Word on the street is that they provide great service at a low price.
Today was the third time I’d seen Mike’s truck, but unfortunately I’ve never been able to get my knives to him. Once he was even in front of my building, but I was late for something or other and could not take the time to run upstairs for the knives.
I suggested that perhaps getting a web site and publishing a schedule would help folks like me to get him our business. But Mike didn’t seem interested in changing a thing. After all, he’s not in this business for the money. It’s really just an excuse for he and his son to spend some time together and keep the family tradition alive. But they did promise to head over to my neighborhood sometime soon.
I’ll put my doorman on the lookout for the truck, and ask him to buzz me next time Mike comes by. Hopefully, I’ll be home.
Or maybe I should just start carrying my knives around with me….
Hash Browns
Mr TBTAM makes a mean batch o’ hash browns. Some people call them home fries. I call them delicious. They’re great with fried eggs for breakfast, or cooked up with some roast beef for dinner (we call that hash). To make it healthier, use olive or canola oil.
The best way to be sure you have will be able to make home fries is to serve baked potatoes for dinner. Cook a few more than you’ll need, and you’ll have the makings of a great breakfast tomorrow.
Mr TBTAM’s Hash Browns
3 baked potatoes, skins on, diced
1/4 cup diced onions
1-2 tbsp vegetable oil
Salt and pepper
Ketchup and/or hot sauce
Heat a frying pan till nice and hot. Add enough vegetable oil to coat the bottom well and heat.
Add potatoes and lower heat to med high. Let sit about 3 minutes or so till bottoms of potatoes are browned. Add onion. Toss. Cook, watching carefully and turning only when the bottoms are browned, about every 3 minutes or so. After most of it is browned, you can toss a bit more frequently to prevent the onions from burning. The trick is not to turn too often and to let the potatoes brown before turning them, otherwise you end up with mashed potatoes.
Season with salt and pepper, remove from heat when perfect and serve immediately with ketchup and/or hot sauce.
Operation Garden Storm
The Aphids are back, and the annual struggle for control of my garden has begun.
I thought I’d gotten them all last year. But the evil-doers re-grouped and set up winter training camps in the soil of my containers, where they indoctrinated a whole new crop of young fighters. This spring they attacked with a vengeance, spreading their evil venom throughout my pristine garden, curling up my honeysuckle flowers and causing their leaves to drop, even threatening to swarm the day lilies before the first bud had even opened.
To make matters worse, the bastards have enrolled their allies in the axis of garden evil, the wooly adelgids, to infect my evergreens.
Wisconsin Department of Natural Resouces Website These insurgents hid in the old growth of my evergreens, beneath the bright green canopy of spring’s eruption. So that it was not until I trimmed the bushes back last week that I saw the tell-tale white cottony honeydew and dropping yellow leaves. It made me sick, I tell you. Sick.
But if these terrorists think that they can take control of my garden, they are wrong. Dead wrong. Because I’m taking them on with everything I’ve got. This, my friends, is war.
Phase 1 – Targeted Strikes
First, I bring out the garden hose. Nothing like a good strong spray to knock those buggers off the plant and onto the ground. Although this picture makes it look random, I actually use precision targeting, getting in close and hitting every infected flower or leaf I find. If there are too many aphids on a limb, I take the whole limb out. Sure, I’ll sustain some collateral damage, but it’s necessary for the survival of the entire plant. Then it’s on to…
Phase 2 – Organic Weapons of Mass Destruction
That’s right, I bring out the Neem Oil and insecticidal soap. These oils are safe to use yet highly effective, basically smothering the soft bodied aphids. The soap emulsifies the oils, making them more effective.
Of course, if I had gotten off my winter couch-potato ass in February, I could have sprayed a dormant oil then and I wouldn’t have this problem now. Sort of like if the FBI had gotten their act together a little earlier we wouldn’t be in this mess now…
Phase 3 – Take out the Collaborators
Then it’s time to get the ants. Ants, you see, farm the aphids for the honeydew and proteins that the aphids secrete. In return, the ants protect the aphids against other bug predators. (Sort of like the Taliban and Saadam…)
I take a mutipronged approach to the ants. First, I use landmines – Diotomaceous Earth (DE). DE is the fossilized remains of the shells of one-celled plants called diatoms that inhabited the earth’s oceans millions of years ago. Large deposits of DE can be found all around the world in areas where oceans once existed. DE looks like a fine white powder. But look more closely, and you’ll see that it’s like microscopic scrap metal, whose shards cut and break the ant’s limbs as they move past them.
Photo credit: Univ of California Dept of Paleontology Website
DE is safe to use, but I wear a mask that I fashioned out of paper towels as I spread DE around the base of my plants on a hot, windless afternoon. Die, you bastards, die!
Next, just in case the ants make it past the DE, I wrap my tree trunks with tanglefoot, a sticky substance that both repels and traps the ants and keeps them off the trees.
Finally, I plant deterrents at the base of the at-risk plants. From what I have read, ants hate spearmint.
Phase 4 – Special Ops
After I have done all I can do, after I have been covered in water from hosing and smell of neem oil, after I have scrubbed the tanglefoot off my hands, after the DE has had a few days to do it’s nasty work, and after enough time has passed to lull any remaining aphids into complacency, than, and only then, do I call in the Special Ops Unit.
(Double click on the arrow to view video)
That’s right, the labybugs. These babies have been training their entire life for this mission. One adult ladybug will devour up to 1000 aphids a day!
I purchase one bag of 500 ladybugs at my new favorite Garden Center, Hicks, out on Long Island. Then, under cover of night, I creep outside, and after hosing down the leaves of the plants, open the mesh bag of ladybugs and sprinkle the brave fighters over the honeysuckle bushes, the day lilies, the apple trees and the evevergreen boughs.
Of course, the biggest question is, will they stay? They did! Next day, they’re still there on my evergreens chomping away at the adelgids. I declare victory – for now.
Phase 5 – Post War Strategy
I may have won this battle, but this administration isn’t resting on its laurels. The insurgents are still out there, and I’m going to weed them out with weekly Neem spraying. And next February, come what may, I’m doing a dormant spraying.
This is one occupying force that’s not leaving.
Welcome to My Blogroll!
A much belated welcome to my blogroll to the following blogs that I have been reading for some time now.
Midwife with a Knife – A blog by an energetic fellow in Maternal Fetal Medicine. Brings back so many memories (good and bad) from my training days. And she’s a fellow foodie and chef! Commenter Hillary, an aspiring gynecologist and foodie, suggests that we all open a birthing center and B&B. Not a bad idea…..
Sugar and Ink – A pediatrician who, like me, started her blog as a food blog. She just recently began to reveal her medical self to the world.
Suddenly… Sudan: A riveting blog by a Canadian doc with medicins sans frontieres stationed in Sudan. Written in lower case, in a style that somehow reminds me of Camus.
today a boy came from “far away” to the hospital, accompanied by his father. his leg was full of holes from an infection that had festered for two weeks. he was thin from it, all angles. I lifted his leg off the bed to look at the other side, and it came apart at the knee.
last year, I went camping with my friend jehan. we paddled for hours to find our own lake. we set up camp, and the next day, in my hammock, after a cup of strong coffee, I ate a plum for half an hour.
Surgeon’s Blog: I re-discovered Dr Sid Schwab’s blog when I hosted Grand Rounds recently. He just finished publishing a nine-part series called “Operation: Deconstructed”, where he takes you through every step of a colectomy, from preop to dictation. If you’re a patient, you’ll come away with an understanding of How Doctors Think as good as any recently published book will give you, and we physician readers will learn something new in every post.
Dr Smak: Just discovered this rural family physician via a well-written comment to a recent post of mine. She’s a fellow gardener and has a nice bookshelf over there at her site. Stop on by….
Come See Me
My general feeling on phone medicine is this –
If it’s important enough to call me for treatment, then it’s usually important enough for you to take the time to come in so that I can diagnose you properly.
That goes whether it’s a vaginal infection, irregular menstrual bleeding or what you think is menopausal symptoms. I have found after years of experience that a phone call is a poor substitute for a good old fashioned in-person history and physical.
Although most patients are grateful to be offered an appointment, not every patient likes to hear this. These are generally those whose calls start out something like this – “I need you to call in….”. For such patients, any attempt from me to get even a little history is treated like an annoyance. This in turn really annoys me, and I have to count to 10 before explaining patiently that I need to hear a little bit about what is going on with them so that I can prescribe properly, and that in some cases it may be necessary for them to come in. Thankfully, all but a few patients understand this once I explain it to them.
The Exceptions
One notable exception to my rule is the patient calling with an uncomplicated UTI. Research has shown that phone diagnosis and treatment is both timely and effective, and most guidelines allow for phone treatment if the diagnosis is clear and there are no other complicating factors. Not to mention that the symptoms can worsen rapidly over several hours, so that timely treatment is important. But I always offer an immediate appointment, and find that many women are grateful for the chance to see me or my nurse personally for the problem.
Notable for not being an exception are calls for yeast infections. That’s because by the time they call me for this problem, most patients will have already tried an over the counter regimen themselves. And self-diagnosis of vaginal yeast infections is notoriously inaccurate.
What about contraceptive problems? Well, I’ll play around with your pills over the phone for problems like nausea or moodiness or acne, and am more than willing to call in whatever brand your new plan covers. Irregular bleeding can be a tougher problem – sometimes it’s from missed pills, or an expected side effect of the method a patient is on (such as Depo Provera or the IUD). That’s where a few more questions can be helpful. Hopefully you are in a place where you can talk about private matters – not the coffee shop or your cubicle at work. If not, then you’re better off calling me back later or coming in so we can talk personally.
Menstrual irregularities? Well, I generally let everyone have one off-cycle a year provided they have a negative pregnancy test and there are no red flags like very heavy flow or severe pain. But honestly, if your cycle was different enough for you to pick up the phone and call me, it’s probably worth coming in, don’t you think? Because I’d really prefer to see you in person. And if there is any chance that you are pregnant, there’s no way we’re handling anything over the phone. So come on in. Today.
What about Money?
I like to think my view on phone treatment is not affected by reimbursement. But I can’t honestly say that if I worked in a high-volume managed-care practice, I might not be more willing to treat more over the phone.
Not surprisingly, money often affects the patient’s decision to come in or not. It’s not unusual to get a call from a patient asking for phone treatment because I am not in her plan and she does not want to have to pay for a visit. In these cases, I will do what I can for her over the phone provided I can do so safely, but encourage her to change to an in-plan doc so that finances don’t affect her healthcare decisions.
The Future
It’s interesting to hypothesize how tele-medicine might change my practice someday. Or reimbursement for phone calls. But somehow I can’t quite imagine that I’ll ever be able to do a pelvic exam over the phone, so I wouldn’t predict my practice to change much…
Make a Date with a Date (& make some cous cous)
I’ve just discovered how much I love this marvelous fruit. It’s sweet, moist, and full of fiber. Although dried dates do contain sugars, they are very satisfying and one dried date contains about 24 calories – not bad if you’re using it as part of a larger recipe. Dates are a good source of vitamin A, B1 and B2, are high in potassium, calcium and iron and are also a decent source of magnesium.
What can you do with dates besides eat them whole? Well, I like to add a couple of cut up dates to my morning oatmeal. No need for brown sugar when you do that.
And here’s a great recipe for Sweet Moroccan Couscous that I served last week at my Choral Group’s Annual Party. Its not a genuine couscous in a couscouserie recipe, but everyone seemed to enjoy it, and I promised Sally I’d post it. Enjoy!
SweetCouscous
Recipe modified from the Lowfat Jewish Vegetarian Cookbook
1 1/2 cups liquid (I used 3/4 cup orange juice and 3/4 cup water.
1 cup couscous
1/4 cup pitted dates, finely chopped
1/4 cup raisins
1/4 cup dried apricots, chopped
1/4 cup slivered almonds
1 tsp cinammon
a few tbsp water
Toast almonds in small pan on stove over medium heat, stirring often until light brown. Let cool.
Bring liquid to boil in a medium size saucepan. Remove from heat, add couscous, cover and let sit for 15 minutes.
Meanwhile, in a separate pan, cook dates, raisins, almonds and cinnamon in as little water as necessary to heat and soften them a bit. Add to cooked couscous. Sprinkle almonds on top. Serve warm.
The Next Generation of Abortion Providers
An insighful article by Stephanie Simon in the LA times explores the reasons why some young doctors are gravitating to the field of family planning. It’s a career choice driven by passion, politics and a committment to choice.
I found that the sentiments of one young doctor interviewed in the article echo those that I felt years ago when I first decided to enter the field of Ob-Gyn….
…young doctors-in-training have found their own motivation to enter a field that they know will put them at risk of isolation, harassment and hatred. For them, doing abortions is an act of defiance — a way of pushing back against mounting restrictions on a right they’ve taken for granted all their lives.”It’s like when your big brother says you can’t do something,” Lederer said. “That just makes you want to do it even more.”
Most of these students are members of Medical Students For Choice, a group who’s motto is “Without providers, there is no choice”. How true.
Simon states in her article that there is no straight path to becoming an abortion provider. Actually, there is – a family planning fellowship. These comprehensive programs are at some of the best medical schools in the country, and combine family planning and abortion training with clinical and epidemiologic research and a master’s degree in public health. The fellowships are an important bridge between the provision of family planning services and the public health aspects of the field.
The intimidation of physicians being perpetrated by this government appears to be serving as a catalyst for some young men and women to enter a field that can only get tougher. They deserve our gratitude and support.
We got our green thumbs from Mom…
Manhattanhenge 2007
Manhattanhendge is that magical moment when the setting sun aligns perfectly with the east-west streets of New York City, shining gloriously through the canyons created by our stone monuments to the urban gods. It happens twice each year, in May and July.
The term Manhattanhenge was coined by astrophysicist and Hayden Planetarium director Neil Degrasse Tyson in 2002. Here’s Tyson explaining this unique New York moment –
One of these days I will plan and get a great photo from a prime spot, instead of my usual quick snapshot taken from wherever I happened to be at sunset. I get another shot this year on July 11th…
Addendum – Hmm…A bit of debate as to this year’s date for Manhattanhenge. I thought it was May 29th, AM NY says May 30, but apparently it’s May 31st this year! Dr Tyson – it’s time for an offical Manhattanhenge website to keep us all straight…
Addendum #2 – OKAY, Here’s the offical word from Dr Tyson (I emailed him and he replied!).
Manhattanhenge begins at 8:10 p.m. (May 30), and at 8:20 p.m. (July 13), at a cross-street near you.
Doctor’s Bad Handwriting
Learning the Palmer Method(From U of Buffalo Archives)
Dinosaur Doc is complaining that we docs are unfairly stereotyped as bad handwriters. Apparently #1 Dinosaur was once a calligrapher and has a gorgeous penmanship.
My handwriting is not just legible; it is lovely. Patients are often in awe of my prescriptions, instructions and Return to Work notes, usually accompanied by some crack about doctors and their handwriting…I know for a fact that I am not the only doctor with legible handwriting, and I am sick of listening to assumptions about my penmanship based on the letters MD after my name.
Well, #1, you may have been a calligrapher, but I was masterfully trained in the Palmer Method of handwriting by the nuns at my grade school. As testimony to the success of the Palmer method, my sisters, girlfriends and I all had beautiful Catholic girl handwriting, which usually looks something like this –
Interestingly, the boys did not seem to take as well to the Palmer method – I don’t recall my brothers’ handwriting ever being as “Palmerized”. It must be a girl thing.
My friend T. still has handwriting that would make the nuns proud. But, I am ashamed to say, my handwriting has completely deteriorated.
Was it medical school or leaving the church that caused the decline? I can’t say.
What I do know is that the situation is even worse when one considers my signature, which was so long in grade school that I had to hyphenate it across the page. That same signature has now shrunk to a mere squiggle which resembles the letter y in the word “try” up there.
So bad is my John Hancock that my daughter’s teacher did not believe it was real, and accused the poor kid of forging my signature on her report card. I had to send in a note to explain that I am a doctor who signs her name hundreds of times a day, and that indeed, this was what my signature had become. (Not to mention it was a great report card – what would my daughter’s incentive be to have hidden it from me and then forged my signature?)
All of which is a long way of saying that I beg to differ with you, #1 Dinosaur. I think most of us docs have pretty bad handwriting.
And you are clearly an exception to the rule.