Breast Screening Decisions – A Mammogram Decision Aid

bsdsite2

I’m proud and excited to introduce you to Breast Screening Decisions, an online Mammogram Decision Aid designed to provide individualized, unbiased information that can help women ages 40-49 decide when to start and how often to have screening mammograms.

Breast Screening Decisions (BSD) was created in the wake of the 2009 US Preventive Services Task Force recommendations that every woman in her 40’s make an individual decision about when to start and how often to have mammograms. Not all medical groups agreed with the USPSTF recommendation, adding to the confusion many women feel about the mammogram decision and putting providers in the difficult position of having to steer each patient through the controversy to a decision that feels right for her.

Breast Screening Decisions is a support tool for shared mammogram decision making between women and their health care providers. Women ages 40-49 can access BSD online at their own convenience, then bring in the BSD summary to a preventive care visit, where an informed discussion can occur, leading to a decision about screening mammograms that both patient and her provider can feel good about.

Breast Screening Decision is not designed to influence mammogram decisions, but to inform and reduce anxiety around the decision-making process for both women and their providers. We want to help women make the decision that is right for them, whatever that decision may be.

Who Should Use Breast Screening Decisions?  

  • Breast Screening Decisions is for women ages 40-49. Women outside this age group should not use the site, as the data presented will not apply to them
  • Breast screening Decisions is for women at low to average risk of breast cancer. BSD starts with a breast cancer risk assessment – a series of questions to help women find out their own breast cancer risk. Women at higher than average breast cancer risk based on personal or family history are then advised NOT to use BSD, but instead to speak to their doctor about which breast cancer screening modalities are best for them – usually annual mammogram, but sometimes with the addition of sonogram or breast MRI.

A Tour of Breast Screening Decisions

Breast Screening Decision starts with a breast cancer risk assessment – a series of questions to help women find out their own breast cancer risk, which is then shown to her visually –

BSD YOUR RISK

The user then sees possible mammogram screening outcomes for women such as herself –

mammo bsd

including information about both the benefits as well as possible harms of screening mammogram. BSD also includes lots more info on breast cancer and mammograms that women can access through pop ups and link outs.

The heart of BSD is the option array – where BSD users can scroll through the various screening options available to them, using a a grid which displays the breast cancer mortality outcomes for each possible mammogram screening schedule – every year vs every other year or starting at age 40 vs  starting at age 50. (I love this page of the website…)

bsd mortality

The user then is shown a summary page of their breast cancer risk and possible outcomes –

bsd summaryBSD concludes with a series of questions to help women clarify their concerns and personal values around breast cancer screening.

bsd values

And finally, BSD users are given a summary to save or print out, and bring to their appointment with their health care provider.

bsd summary

An Invitation

If you are a woman ages 40-49 or her provider, we invite you to use Breast Screening Decisions, and hope it will prove to be a valuable resource in making individualized decisions about mammograms.

We welcome collaborators interested in studying the effectiveness and impact of BSD in clinical practice. If you’re interested in collaborating with us, please contact us – Margaret Polaneczky, MD (mpolanec@med.cornell.edu) or Elena Elkin, PhD (elkine@mskcc.org).

The BSD Back Story

It all started in December 2009 with a blog post I wrote explaining the United States Preventive Services Task Force Recommendations on Screening Mammograms. I was as confused as my patients were about the recommendation that the decision as to when to start and how often to have screening mammograms be an individualized one that takes into account a woman’s risk for breast cancer, as well as her personal values and concerns about breast cancer and mammography.

How the heck was I going to accomplish that in a 15 minute office visit, let alone be confident that the choice my patients made was indeed an informed one? My knee jerk response was just to ignore the recommendations and tell everyone to get an annual mammogram, regardless of who they were or what they may have wanted to do. I would certainly be supported in that tactic by my own ACOG, as well as the National Cancer Institute and of course the American College of Radiology.  Not to mention, it’s the fastest way to get off a controversial topic in the midst of busy office hours and the safest choice medio-legally.

But as I wrote that blog post and started to wrap my head around the facts about mammography as we know them today, I began to understand why some women might make a choice different that I would be recommending. In fact, I already had more than a few women in their 40’s ask me if they could skip their annual mammograms – healthy, low risk women, with no family history of breast or breast-linked cancers, some of whom had already had one or more false positive mammograms.  They wanted to back off the annual screening, and they wanted my support.  I stumbled through an office counseling session, doing what I could to confirm their low risk status, and we usually ended up compromising on an every other year schedule, while I remained worried that I was setting myself up for a lawsuit.

This was not going to work long term – not for me or for my patients. They deserved my support in making this choice, and I deserved some support in making sure their choice was an informed one, and in supporting them when they chose an option other than annual screening.

The blog post I wrote on the topic had received so much positive press (The Washington Post called it the “clearest assessment of the controversy you’re likely to find”) that I knew I was onto something. So I approached Al Mushlin, Chair of Public Health at Weill Medical College where I work, and told him I wanted to build a web-based mammogram decision aid. He hooked me up with Elena Elkin, brilliant outcomes researcher at Memorial Sloan Kettering and grant writer extraordinaire. We (well mostly Elena) wrote a grant and got funding from the Cornell CTSC. And together with our amazing research coordinators Paige Nobles and Val Pocus (both of whom unexpectedly turned out to also be web-savvy, graphically-minded visual artists), with input from Al and from experts in mammography and breast cancer, along with feedback from beta users in our target population, we build the first version of BSD (Thank you, Marwan Shouery) and piloted it with over 150 women and their providers at the primary care and Ob-Gyn practices at Weill Cornell Medical Center. We hope to publish the results of our pilot study soon, but suffice it to say that BSD was well received by women and providers alike.

For reasons related to firewalls and such (lessons learned), we had to rebuild BSD from scratch for public access (Thank you, Mohammad Mansour and colleagues), and that is the site we are releasing today.  Other than some new colors, prettier formatting and a new font or two, BSD is the same site as the one we researched. The research site will remain behind a very tight firewall for use in future research.

So now..

Almost four years, many many hours of collaborative work and thousands of dollars later, Breast Screening Decisions is finally live to the public.  

Just in time for the next USPSTF update on mammogram screening …

 

Calcium – Forget the Supplements. Get it in Your Diet.

MILK“How much calcium should I be taking?”

It’s a question I get several times a day from women of all ages, but mostly from those in the menopausal and peri-menopausal age group.

The answer I almost always give is – less than you think.

And for most women, probably none.

It’s not that I don’t think calcium is important

It is. Adequate calcium and vitamin D are critically important in building and maintaining a healthy bone mass.

But most women, with the exception of those who can’t tolerate dairy, are already getting a significant amount of calcium intake in their diet.  So much so that taking calcium supplements adds little to their overall health.

In fact, the US Preventive Services Task Force recently recommended against routine calcium and vitamin D supplementation in healthy post menopausal women.

What harm can a little extra calcium do me? 

More than you might think. Calcium supplementation can lead to –

  • Kidney stones Too much calcium can lead to kidney stones, a risk confirmed by the Women’s Health Initiative Calcium Study. In this study, women were given 1000mg a day of calcium plus 400 IU of vitamin D (regardless of vitamin or dietary intake) or a placebo.  Not surprisingly, there was a significant reduction in fractures in women over 70 who took their calcium as prescribed, but at the price of a 17% increase in kidney stones. For every 10,000 women taking calcium, there were two less hip fractures but 5 extra cases of kidney stones.
  • Constipation. Calcium can also cause constipation, so why take more than you need? (If constipation is a problem for you, try taking calcium with magnesium).
  • Interference with absorption of both iron and zinc.

You may also have heard that calcium supplementation can lead to heart disease.  It’s still an open question.  Some studies suggest up to a 20% increase in heart disease in men and women who take calcium supplementation. Other studies do not find this risk, or find it only in men and not women. In the Women’s Health Initiative study cited above, no increase in coronary calcium scores were seen in women who took 1000 mg of calcium daily, which is a reassuring result.

Calcium and other vitamins and mineral pills are called “Supplements” for a reason

They are meant to supplement, not replace, the primary source of calcium intake, which is food.  

So instead of taking supplements, get your calcium in your diet.

What About Vitamin D? 

Its a question without a good answer. The USPSTF recommendations only applies to Vitamin D doses under 400 IU.  We don’t know if higher doses of D are worthwhile or not, although the WHI study suggested they are beneficial when taken with calcium in preventing fractures in post menopausal women.

My Recommendation

Unless you’re at increased risk for fracture (You can calculate your fracture risk here), forgo the supplements and get your calcium from dietary sources.

If you don’t eat dairy, look to non-dairy calcium sources, and only take as much calcium supplementation as you need to make up the difference between dietary sources and the RDA for your age group.

I’m not adverse to vitamin D supplementation, but I recommend doses of 800IU daily.Dietary Sources Calcium

Chart from NIH Dietary Fact Sheet on Calcium

Additional Reading

A slightly different version of this post originally appeared on Web MD.

On Abortion, Jail, Parental Responsibility & Bad Judgement

scales abortion vs safetyJennifer Whalen, a 39 year old mother of three from rural Pennsylvania, is serving a 9-18 month jail sentence for purchasing and dispensing abortion-causing medications to help her teenage daughter abort an unplanned pregnancy.

The case is being used as an example of the lengths that women will go to to end a pregnancy when abortion is not immediately and freely available.

And perhaps it is.

But it’s also an example of just how easy we expect everything to be, and how those expectations are leading us to do things that are really, really stupid.

Because make no mistake. What Whalen did was stupid, irresponsible and dangerous.

Abortion is legal in Pennsylvania.

It was available to Whalen’s daughter with parental consent (which she clearly had) at a safe facility 75 miles away. That’s about an hour and 15 minute ride. Not the end of the world.

Yes, Pennsylvania has an absolutely ridiculous law requiring a 24 hour waiting period, meaning Whalen might have had to take time off from work to get her daughter an abortion. Or not – because the abortion facility nearest them has Saturday hours.

And yes, Whalen and her husband had just one car. And no health insurance for the $400 procedure.

I get it.

I really do. This was not going to be something easy.

But this is an abortion. A medical procedure that, while exceedingly safe, needs to be done by someone who knows what they are doing. Whalen, while not a licensed RN as previously reported, works in a healthcare facility as a nurses aide. So I’m sorry, but she should have known better. And I don’t quite buy it that she did not know that buying abortion pills online without a prescription was illegal.

And I won’t get into the ethical issues of aborting your daughter’s pregnancy, but it raises so many concerns about coersion that I know the docs at Geisinger Medical Center were right to report the case to the authorities after Whalen took her daughter to their ER during her induced miscarriage.

So, in case it’s not obvious by now…  

I’m not jumping on the “Poor Jennifer Whalen, she had no choice, she was ignorant, she was scammed by online sellers of abortion pills and sent up the river by those mean doctors in the ER” bandwagon.

Yes, I’m pro choice. Yes, I abhor the rash of abortion restrictions being passed by state legislatures across this country. And yes, I truly wish that abortion were freely available at every doctor’s office in every small community everywhere.

But it’s not.

And in this reality we have, parents like Jennifer Whalen have to make choices – to do the right thing, even when it’s the harder thing, or to do what’s easy.

She chose the easy route, and I think by now she knows that she made a bad judgement.

Now, do I think Whalen deserves a 6 month prison sentence? 

Of course not.

Whalen was not setting herself up as an abortion provider. She was not selling her services or posing as a health professional.

One time, she purchased medication over the internet for her daughter, who by all accounts took the medication freely and of her own accord. The medication, thankfully, worked as advertised.

But rather than come up with a way to turn this case into something positive for Whalen, her family and the community of women at large, Montour County DA Rebecca Warren and Judge Gary Norton chose instead to criminalize a mother for making the wrong choice in a very tough situation.

Warren says this case is not about Abortion Rights , but about “endangering the welfare of a child“.

Because sending a mother to prison is really good for her children, right?

Talk about bad judgement.

Putting Up Irene & Rita’s Fresh Summer Tomato Sauce

Ever since I first saw Mrs Frake putting up pickles and mincemeat in the movie State Fair, I’ve wanted to put up something.

As opposed to putting up with something, which basically describes my life.

I did once put up a few small jars of blackberry jam with the kids while vacationing on Block Island. We tried to sell the jam at the playground – I think someone bought one jar – then used the rest of the jars pretty much immediately. And that was the end of my putting up.

Until this week, when I was faced with forty pounds of South Jersey Roma tomatoes (Thanks Patty!) a few days after meeting blogger Marissa McClellan, who was selling her book Food in Jars at the Union Square Greenmarket and two days after my mother-in-law Irene sent me a recipe for what she is calling the best tomato sauce she’s ever made.

The stars had aligned. It was time for a real put up.

A Warning

First of all, I must warn you. This tomato sauce recipe has not been formally “tested” as safe for canning.  However, it is not dissimilar in amounts of olive oil, garlic and peppers to other recipes I found on the web that are tested for canning. Just to be safe, I’m freezing all but one jar of my canned sauce, and will update this post in 6 months or so when I open up the one unfrozen jar to see how it fared.

Of course, you don’t need to put up this sauce. You can just make it, use it and eat it right away.

A Second Warning

Forty pounds of tomatoes is a lot of tomatoes.  Unless you have a 3 day empty weekend, or are willing to give up three to four straight week nights (for me happily coinciding with Ken Burns’ The Roosevelts on PBS) and a bit of sleep, I do not recommend starting with such a large amount of tomatoes.  I spent an entire evening making 5 quarts of sauce, not to mention the clean up time, which left me getting to bed well after midnight and still with 20 pounds of tomatoes.

The next night I got smarter, I thought, and made oven dried tomatoes. (That post is coming up) The first batch was a disaster, and while the second batch turned out okay, I had to set the alarm to check the tomatoes every few hours overnight.  That left me with about 10 pounds of tomatoes. Those I will blanch, skin and can tonight.  Hopefully, it will go quickly.

How I canned this sauce

I canned my sauce using a water processing method. (This is as opposed to using a pressure canner.)

  • Make the sauce as directed, multiplying by 6 and using about 18 pounds of tomatoes.
  • Towards the end of the vegetable roast, fill a large stockpot with water, place a 12 inch metal cake cooling rack on the bottom, then fill and submerge 5 one quart mason jars in the water. (Your jars should not sit directly on the bottom of the pot – you can put a dish towel there if you don’t have a rack or a trivet to use).
  • Boil with the lid on for 10 minutes (My stock pot lid has a steam scape valve – very handy), then turn it down on a very low heat to keep the jars warm so that they will not break when I you add the hot sauce.
  • Boil the lids in small saucepan and turn them down to keep as well.
  • After the sauce is made, and has simmered for 10 mins or so as directed, remove the mason jars from the water bath with a pair of tongs (I need to get a jar lifter for future efforts, this was a bit precarious). Fill the jar, wiping away any excess sauce near the top and leaving 1/2 -1 inch airspace, then put on the lids and finger-tighten them.
  • Return the now-filled jars to the stock pot, sitting them neatly on the submerged cake racker and removing the excess water from the pot with a small sauce pan, so that the final water level is 1-2 inches above the top of the jars. (Since the jars are now filled, you don’t need as much water in the pot.) I was able to fit 5 quart jars in my large stock pot.
  • Bring the water to a rolling boil, cover the pot and let it boil for 45 minutes. (This is an extra ten minutes over the recommended processing time for quart jars at sea level, but I wanted to be  safe. Processing times do vary by elevation – you can check here for the right time for your location).
  • After processing, I remove the jars to a towel-covered counter top and let them sit and cool overnight. As mine cooled, I could hear the lids popping (a good sign that the vacuum seal has worked).  Although some folks say to remove the outer rings and just let the cans sit with the vacuumed lids atop, I’m leaving the rings on.

Bottom Line

Putting up is fun, but laborious. It’s not an undertaking to be taken lightly, and you must be sure to do it safely. I learned a lot this first go round.  Stay tuned for more next season.

RITA & IRENE’S FRESH SUMMER TOMATO SAUCE

Irene&Rita's Tomato Sauce

This recipe comes from my mother-in-law Irene, the world’s greatest home cook, via this delightful email she sent to me a few weeks ago-

Hi Peggy,  Here it is 10am Sunday morning and I just finished making the best tomato sauce I ever made.  I was sitting in the dentist’s chair on Thursday going through 2-1/2 hours of dental fun.  The dental assistant, Rita and I were having some delightful conversations about food.  She’s a vegetarian and we had a lot to talk about when I didn’t have a lot of stuff going on in my mouth.  At one point she told me of a fresh tomato sauce she makes that’s very good.  All she gave me were the basic ingredients, without amounts,  the oven temperature and the time —tomatoes, red pepper, garlic, olive oil, 350 oven for an hour and a half.  I had to figure out how to do it and season it.  Here’s what I came up with.

This recipe is for one batch of sauce. I multiplied the recipe by 6, using about 20 pounds of tomatoes, and got 5 quarts of sauce.

  • 5 large summer tomatoes, quartered (or 3-4 pounds roma tomatoes, halved)
  • 1 large red pepper, seeded and cut in 1/6ths
  • 1 bulb of garlic, unpeeled (that’s a bulb, not a clove)
  • 2 tsps. sea salt
  • lots of freshly ground black pepper
  • 1 tsp. sugar
  • 1/4 cup olive oil

Do not peel the tomatoes, the pepper or the garlic, the skins come off easily when they’re finished roasting.  Place all ingredients in a large roasting pan. Place in 350 oven for 1-1/2 hours.

Remove from oven and let cool for about a half hour until the tomatoes and pepper and garlic are cool enough to handle and peel. Peel the tomatoes and peppers into a large sauce pot, discarding the skins. Squeeze the roast garlic into the pot and discard the skins. Using an immersion blender, blend tomatoes, peppers and garlic to a smooth sauce. Add back the oil and juices from the pan as needed to thin the sauce to the right consistency (I used about 3/4 of it). Heat to boiling and then simmer 10 mins.  Season as necessary.

Use immediately, or pour into prepared canning jars and process.

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Some great links on canning

The Music of The Children Act

Music features prominently in Ian McEwan’s new book The Children Act. The book’s protagonist Fiona Mayes, a family court judge, is also an accomplished pianist, and both she and her husband Jack are lovers of jazz.  Almost every important moment in the book, aside from the first scene and Fiona’s time in the courtroom, occurs while music is being played or listened to.

I love how McEwan weaves the musical themes seamlessly throughout the story, informing character, time and place. I listened to the Audible book (a fabulous performance by Linsday Duncan), and found myself wishing that someone had thought to add a score to the recording.

For those of you reading the Children Act and also wondering what it might sound like, here are some recordings and a little context from the novel.

Bach’s Second Partita in C Minor for Keyboard

I loved this passage, as Fiona walks to work, trying to distract her thoughts from her failing marriage by recalling the Bach Partita, a distraction that of course, fails.

Children.

The inevitable thought recurred as she moved on to the demanding fugue she had mastered, for love of her husband, and played at full tilt, without fumbling, without failing to separate the voices. Yes, her childlessness was a fugue it itself. A flight. This was the habitual theme she was trying now to resist. A flight from her proper destiny. A failure to become a woman, as her mother understood the term.

How she arrived at her state was a slow patterned counterpoint, played out with Jack over two decades, dissonances appearing then retreating, always reintroduced by her in moments of alarm, even horror, as the fertile years slipped by, until they were gone, and she was almost too busy to notice.

Down by the Sally Gardens

Fiona visits a young man with leukemia in the hospital as she tries to decide if the court will force him, a Jehovah Witness, to take blood products that will save his life.  In a very non-judicial moment, as he plays Down by the Sully Gardens on his violin, she sings along. That moment and that song decide the case for her, sealing his fate and binding them together in a way she had never anticipated.

Keith Jarret – Facing You – (First track) In Front

Jarrett ‘s Facing You was “one of three or four albums that formed the soundtrack” of Fiona and Jack’s early relationship. Jack now uses the album to begin to bring them back together.

..the technical facility, the effortless outpouring of lyrical invention as copious as Mozart’s, and here it was again after so many years, still holding her to the spot, reminding her of who she and Jack once playfully were.

Hector Berlioz: Les Nuitsd’ete – Villanelle  / Gustav Mahler Ich bin der Welt abhanden gekommen (I Am Lost to the World)

The book culminates in a live performance by Fiona and a tenor colleague, a performance that coincides with her learning of the fate of the young boy. The combination of such beauty and such sadness in the two pieces they perform mirror the young man perfectly.

I have become lost to the world, where I used to waste so much time;
It has been so long since it heard from me, that it may well think that I have died!
I don’t care if it thinks me dead, for I really have died to the world.
I have died to all the world’s turmoil, and I rest in a silent realm.
I live in solitude in my heaven, In my love, in my song.

Patient Identifiers, Hospitals & the EHR

FIngerprintCurrent Joint Commission standards call for the use of two patient identifiers to avoid mixing up patients with the same or similar names. For inpatients, these identifiers are usually the name and the medical record number (MRN).

Which is fine if the only place you need to identify the patient is your own hospital.

But your hospital’s MRN is meaningless to me and my EHR.

So if you send me a copy of my patient’s chart (or her lab result or mammogram report) and all that’s listed on the top of the page is her very common name and your MRN, I have no clue who this patient is.

(My EHR gives me a box to check to confine the search to my own patients, but that button only works about 10% of the time.)

So please, hospitals, start adding the patient’s date of birth to your printed reports and records.  And EHR vendors, you could make it easier for all of us by defaulting to a header that includes the date of birth as an identifier.

Thank you.

 

The Not So Scary Truth About HPV

http://www.dreamstime.com/stock-images-emotion-2-image597604There’s a downside, I think, to educating the public about the link between HPV infection and cervical cancer.  And that’s scaring the bejesus out of every woman who happens to find out she has HPV.

It’s not surprising that you’re scared.

You see, we want you to know that HPV infection is linked to cervical cancer, and that we have a vaccine against HPV that can prevent cervical cancer. So we’ve been doing our best to get the word out. (With no small bit of help from the HPV test and vaccine manufacturers.)

But in our zeal to get you screened and vaccinated, we sort of forgot to tell you something equally important. And that something is this –

Pretty much everyone – 80% of US adults- will get HPV at least once, if not more than once, in their lifetime. At any given time, 20-30% of US women ages 14-59 have HPV. That’s right – a third of the female population. If you include men, there are about 20 million persons at any given time in the US who have HPV.

The overwhelming majority of HPV infections do NOT lead to cervical cancer. Around 95% of the time, the infection clears, usually within 1-2 years, without you, or anyone, doing anything

Yes, the problem with HPV disease awareness is that it ultimately makes every woman feel like she have a bull’s eye on her cervix. Which may a good way to get her in for HPV testing and vaccination, but is actually misleading women about an infection that basically everyone gets at some point in their lives.

The Not So Scary Truth About HPV

The truth is that while having HPV is a necessary precondition for getting cervical cancer, it’s also true that almost all HPV infections DO NOT lead to cancer

Think of it this way. Getting in a car is a necessary condition for having an automobile accident, but in fact, most of us will make it to our destination alive. Same thing with HPV. The chain of events that ultimately leads to cervical cancer starts with HPV infection, but almost all the time something intervenes to prevent cancer. That something is called your immune system.

If for some reason, your immune systems doesn’t do the job, and you’re in the 5% of women with HPV who don’t clear the infection, we have ways to monitor you closely so that if a precancerous lesion arises, we can treat it. Years before it becomes cancer.

But I have “High Risk” HPV 

So does everyone else with a positive HPV test.

“High risk” HPV subtypes are called that simply to distinguish them from the “low risk” types that cause genital warts.  Current HPV tests only screen for the “high-risk” types. So by definition, if you’re HPV positive, you have a “high risk” strain. (Someone really needs to change the name of that test…)

But if everyone has HPV, and most infections clear without treatment, then why do we test for it? 

HPV testing is better at finding precancerous lesions that Pap smear alone, so what the Pap misses, the HPV test will find. It’s so good that it’s being considered as a replacement for the pap smear as the first line test for cervical cancer screening.

The HPV test is also good for weeding out the false positive Pap smears. A mildly abnormal pap (ASCUS) can be safely ignored and repeated in a year if the HPV test is negative. This saves a lot of women unnecessary testing.

The other good thing about HPV testing is that if it’s negative, you’re really in the clear. So much so that if both the Pap and HPV test are normal, the risk for cervical cancer plummets, and you can safely wait up to 5 years between pap smears.

The problem with HPV Testing

The problem with HPV testing is that it has a very high false positive rate. Most of the women with HPV  actually do not have precancerous lesions. They just have HPV.

That’s what happened to NYC Councilwoman Melissa Mark-Viverito, who then went public with her HPV diagnosis on Twitter. Ultimately, when she had additional testing after her HPV diagnosis, she found out that she was fine.

Of course, you don’t want to ignore the fact that you have HPV.

You should take it as a sign that you, of all people, need to get your pap smears regularly. Or , if your doctor recommends it, have a simple office procedure called a colposcopy – a magnifying lens that looks for tiny abnormalities on the cervix that are too small to be seen by the naked eye, but if found, can be treated so that you never get cervical cancer.

But know that it would be exceedingly unusual for you to actually have cervical cancer just because your HPV test is positive. This is about finding precancerous lesions, and ultimately, preventing cancer.

So if you have HPV, don’t be scared. But be smart.

If you have HPV, odds are overwhelming that you’re going to be fine.  Between the HPV test and the pap smear, if you have anything precancerous, we’ll find it and we’ll treat it. Years before it becomes cervical cancer.

In the meantime, there are things you can do to help your immune system along. Things like not smoking, using condoms, getting enough sleep and getting 4-6 servings of fruits and veggies each day. Women who do these things clear the virus faster, although ultimately most will clear it anyway.

So do be smart and get screened. And follow through on whatever testing is recommended based on that result.

But please. Don’t be scared.

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More good info on HPV and cervical cancer.

A slightly modified version of this post first appeared on WebMD.

Corn, Zucchini and Chickpea Fritters

Fritters corn zucchini chickpea
Our first dinner in the empty nest.

We dropped our youngest off at college, which to our delight is a mere two hours drive north along the lovely Taconic Parkway. To say the campus is bucolic is an understatement, with the Catskill mountains on the horizon, and a lovely little town just a short ride away.  This was a happy day for us all, the culmination of an amazing summer for the entire family. She’s launched and we’re so happy for her. (And can’t wait to come back up to visit on parent’s weekend…)

After settling her in, we explore the area, following dead end roads like fingers that end at the Hudson River. We stop at an amazing little farm stand, where we find fresh corn and heirloom tomatoes.

Heirloom tomatoes

A little further down the road, the guy who owns the pastry store is selling huge zucchini from his garden at a little table out front of his shop. Of course we have to buy one.

At home later that evening, we find a recipe to combine our farm finds, and eat delicious vegetable fritters al fresco on one of the warmer days of this unseasonably cool summer, sitting on the terrace at the table which until now was too small for a family dinner. Now with just the two of us, it’s just the right size.

We share a beer and talk about the future.  Yes we miss the kids, but then we think of each of them – one settling in at her new college, the other launching a theater career (and a play opening!) in our hometown -and we are just so happy for them that we would not have it any other way.

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CORN, CHICKPEA AND ZUCCHINI FRITTERSfritters cooking

This is my own modification of a recipe from The Wednesday Chef, who herself modified a recipe from Taste.com/Au. Feel free to change up the herbs you use. Makes 12 fritters. If that’s too many fritters for one meal, the leftovers heat up nicely for lunch the following day. My mother in law Irene, who made these a few days after we did, instead froze the extra batter to make another day.

  • 1 15-oz can of chickpeas, drained & rinsed
  • 1/2 cup milk
  • 2 eggs
  • 3/4 cup flour
  • 1/2 tsp baking powder
  • 1 tsp salt
  • 1 large zucchini, grate
  • 2 large ears of corn kernels (about 2 cups)
  • 2 tablespoons chopped fresh mint leaves
  • 3 scallions, thinly sliced
  • Zest of one lemon
  • Canola Oil
  • Plain sheep’s yogurt and hot sauce for serving

Process chickpeas until roughly chopped.

Whisk milk and eggs in a measuring cup. Mix flour, baking powder and salt in a bowl. Gradually add milk mixture to flour, whisking until smooth. Stir in chickpeas, zucchini, corn, mint, scallions and lemon zest.

Heat a shallow layer of canola oil in a large skillet over moderately high heat. Add 1/4 cup mixture to pan. Spread slightly with a spatula. Repeat to make 3 more fritters. Cook for 2 to 3 minutes each side or until golden and cooked through. Transfer to a plate and cover or keep warm in a 200 degree oven. Repeat with remaining mixture to make 12 fritters. Serve with freshly sliced heirloom tomatoes, a dollop of sheep’s milk yogurt and a splash of hot sauce.

I’m Writing for WebMD

http://www.dreamstime.com/stock-photography-typewriter-keys-image14524512

I’m now writing for WebMD. Just one to two blog posts a month.

Here’s my first post.

It’s kind of exciting to actually be paid to write, although I don’t think I’ll be quitting my day job anytime soon.

I’ll be cross posting the Web MD posts here a week later, so you can read me here or there, and nothing will be lost from this blog.  (It is, after all, my baby.)

Let’s see where this thing goes…

Appetizers for Summer Book Club

Book Club appetizers

As much as I love book club, I love hosting it even more. Because hosting means I get to leave work early and do my favorite thing in the whole world – spend the late afternoon in my kitchen. I’m rarely at home at that time of day, when something wonderful happens to the light in our apartment as the sun begins to peek out from behind the tall apartment towers just south of us, and pours into my kitchen.  Add in NPR or a good book on tape and I’m in heaven.

The evening promised good weather, so we planned to meet on the roof.  I took my cue for the menu from the book we were discussing – “My Brilliant Friend”, set in Naples – and went for a Mediterranean theme. (Plus I had a whole mess of amazing, pitted Castelvetanos olives and a jar of fig preserves.)

In an amazing feat of pre-planning, something highly unusual for me, I actually decided on the menu and bought all my ingredients the day before, so I was able to head straight home and got to work around 4 pm. Luckily, Mr TBTAM was home early as well, and I put him to work weeding the rooftop garden, which we had ignored for most of the summer.  Somehow I managed to pull it all together by the time the group arrived at 6:30, with a little help from my friends who arrived first.

The discussion was as always, interesting and spirited, and we went till dark. This is one great bunch of women, and I’m thrilled to be a part of the group.

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Book Club Appetizer Menu

  • Fig & Blue Cheese Savories
  • Olive all’Ascolana
  • Manchego cheese with Firehook Za’Atar flatbreads
  • Nectarine segments and dried apricots
  • Wine; Mint lemonade
  • Cappucino almonds (Thanks, Amy!)
  • Sunflowers for the table (Thanks Stacy!)

Fig and Blue Cheese Savories

FIG AND BLUE CHEESE SAVORIES

These delicious babies come from The Runaway Spoon, found via Food 52.  I used a wonderfully pungent Roquefort style sheep cheese (Ewe’s Blue) from Nancy & Tom Clark’s Old Chatham Sheepherding Company.  I did not have a one inch round cookie cutter, so I used a floured 1 inch soda bottle cap. You may be tempted to make these bigger, but do not. The small size is perfect. They can be made ahead and kept in layers separated by waxed paper. They freeze beautifully.

  • 1 cup flour
  • 1/2 cup butter, room temperature, cut into four pieces
  • 4 ounces blue cheese, cut into several chunks
  • Ground black pepper
  • Fig preserves (about 1/4 cup total)

Preheat the oven to 350 degrees. Line a baking sheet with parchment paper. Process the butter, blue cheese, flour and a few grinds of black pepper in the food processor until the dough starts to form a ball. Dump onto a lightly floured surface, knead a few times to pull the dough together and roll out to 1/8 inch thick with a floured rolling pin. Cut rounds out of the dough with a floured 1-inch cutter and transfer to the parchment-lined baking sheet. Using the back of a round half-teaspoon measure or your knuckle, make an indentation in the top of each dough round. Spoon about ¼ teaspoon of fig preserves into each indentation. Bake the savories for 10 – 14 minutes, until the preserves are bubbling and the pastry is light golden on the bottom. Let cool on the baking sheet for at least 10 minutes, the remove to a wire rack to cool.

Can be made ahead or frozen in an airtight container in layers separated by waxed paper.

Olive all'Ascolana

OLIVE ALL’ASCOLANA  – Vegetarian Version

This recipe comes from Arielle Clementine via Food 52. It’s inspired by the classic Italian stuffed olives, which have a spicy meat stuffing and use olives from the Ascoli region of Italy. (Here’s a wonderful video on how to make the real thing, which I must try one of these days.)  I made some fresh breadcrumbs for this recipe, but did not toast the crumbs as I usually do, since they would get crisped as they fried. I had no mustard seeds, so used a pinch of dried mustard instead.  I fried them in my electric fryer, a kitchen appliance I only use otherwise for latkes, and it worked beautifully.

  • 24 large green olives, pitted
  • 1/2 cup goat cheese
  • 1 teaspoon whole mustard seeds
  • 1 teaspoon fresh rosemary, chopped fine
  • 1/4 teaspoon crushed red pepper flakes
  • 1 garlic clove, minced
  • 1 cup all purpose flour
  • 1 egg, beaten
  • 1 cup breadcrumbs (fresh or panko)
  • 1/3 cup freshly grated Parmesan cheese
  • 1 cup vegetable oil (I used canola oil)
  • parmigiano reggiano, for sprinkling
  • zest and juice from one lemon, for sprinkling

Mix the goat cheese, mustard seed, rosemary, chile flakes, and garlic in a small bowl. Stuff the olives with the cheese mixture (I used my fingers, rolling the filling like a small cigar and sliding it into the pitted olive.) Put the stuffed olives on a plate and refrigerate for 20 minutes. While the olives are chilling, heat the oil in a heavy-bottomed frying pan to 375 degrees. Set up three plates for your breading station (Flour, beaten egg, breadcrumbs+grated Parmesan) When the olives have chilled, roll half of them in the flour, then in the egg, then in the bread crumb/Parmesan and carefully drop them into the heated oil. Fry until golden brown, about one minute per side. Transfer to a plate lined with paper towels to drain, and repeat with the remaining olives. Pile on a plate and finish with a shower of freshly grated cheese and lemon zest and a spritz of lemon.

The Berlin Wall in New York City

Berlin Wall in NYC
Meeting friends for dinner last evening at Valbella, I was surprised to discover that the strikingly painted concrete slab on display in the tiny plaza outside the restaurant is actually a section of the Berlin Wall.

That’s right. The Berlin Wall. Tucked away in a lovely little plaza on the north side of E 53rd between 5th and Madison. How could I have lived in NYC for over 20 years and not known it was there?

Berlin Wall in NYC
This section of the wall was illegally painted in the 1980’s by Berlin street artists Therry Noire and Kiddy Citny. Noire, who lived a mere 5 meters from the west side of the Wall, was the first street artist to paint on the wall, a risky act of political rebellion that he and the other street artists he inspired continued until the Wall came down in 1989.

To paint the Berlin wall, to transform it, to make it ridiculous, to help to destroy it.

– Therry Noire

Amazingly, the sections of wall on display at 520 Madison are the very ones Noire is painting in the  1987 Wem Wenders Film “Wings of Desire”.


After the wall came down in 1989, the East German Government, seeing the value in the art Noire and his fellow artists had created, ultimately auctioned off huge sections of the wall in Monaco, which is probably where Jerry Speyer of Tishman and Speyer, the owners of the plaza at 520 Madison, purchased this piece of history in 1990.

The artists who painted the Wall have seen very little of the income from the sale of the sections that bear their paintings, and it is not known where the profits from their sale, supposedly slated for humanitarian causes by the East German government, ultimatley ended up.

Kudos to Speyer for sharing his piece of the Wall with the public in this lovely little respite in midtown.

I encourage you to visit the Wall. If you choose to eat al fresco at Valbella, as we did on this warm summer evening, you’ll have plenty of time to  consider this infamous piece of history and the spirit of courage and freedom that both its demolition and the remarkable artwork painted on it represent.

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MORE READING

Berlinermauer The Berlin Wall (from Wikipedia)

Dense Breasts on Mammogram – No Need to Be Afraid

Mammogram Fatty and Dense

Only in America can we find a way to scare the bejesus out of a woman with normal breasts and a normal mammogram. But that’s exactly what happened when NY Times reporter Roni Caryn Rabin read her normal mammogram results letter –

A sentence in the fourth paragraph grabbed me by the throat. “Your breast tissue is dense.”

I can’t really blame Rabin for being afraid. The information about breast density in her mammo letter was mandatory verbiage crafted by legislators as part of a law that all women be told if they have dense breasts on mammogram.

“Your mammogram shows that your breast tissue is dense. Dense breast tissue is very common and is not abnormal. However, dense breast tissue can make it harder to find cancer on a mammogram and may also be associated with an increased risk of breast cancer. This information about the result of your mammogram is given to you to raise your awareness. Use this information to talk to your doctor about your own risks for breast cancer. At that time, ask your doctor if more screening tests might be useful, based on your risk. A report of your results was sent to your physician.”

Raise awareness? More like raise the alarm. The information mandated by the law is just enough to scare any women who happens to have dense breasts, but not enough to help her understand what this really means.

If you’ve gotten a letter telling you your breasts are dense, don’t be afraid. Having dense breasts is entirely normal, especially if you are under age 60.  Here’s what you need to know –

What is Breast Density? 

Breast density is a radiologic assessment of how well x-rays pass through the breast tissue. It is a surrogate for how much of the breast is composed of glandular tissue and how much is fat. The radiologist reading the mammogram classifies the breast composition as one of the following –

  • Almost entirely fat (<25% glandular)
  • Scattered fibroglandular densities (25-50%)
  • Heterogeneously dense breast tissue (51-75% glandular)
  • Extremely dense (> 75% glandular)

Breast density is subjective.

Different radiologists may give the same mammogram different ratings. Use of computerized density measurement could alleviate inter-observer variability, but there is not yet a standardized computer rating system. For the purposes of the law, dense breasts are defined as those that are heterogeneously dense or extremely dense.

Breast density can vary across a woman’s menstrual cycle and over her lifetime.  

The same women being scanned at a different time of month or at a later year can land into a higher or lower breast density category, and may or may not get that extra statement in her mammogram letter. Recent research suggests that a single breast density reading may not be the best way to predict breast cancer risk, and that the risk may be confined to those women whose breast density does not decrease with age.

Dense breasts are extremely common, especially in younger women. 

According to a recent report of mammograms here in New York City, 74% of women in their 40s, 57% of women in their 50′s, 44% of women in their 60′s and 36% of women in their 70′s have dense breasts.

Increased breast density may be a risk factor for getting breast cancer. 

The mechanism is unknown, but it may be that breast density is just the end result of other factors that increase breast cell proliferation and activity – factors like genetics and postmenopausal hormone use.

How much of a risk? Well, it depends on what study you read and who you compare to whom. If you compare the two extremes of breast density in older women, those with extremely dense breasts have a three to five-fold higher cancer risk than those with mostly fatty breast. The risk is lower than that in those in the middle category of breast density and in younger women, though not well-defined.

The truth is, we really have no way to translate individual breast density into individual risk. Researchers are trying to see if breast density can be incorporated into current risks assessments such as the Gail Model, but at this point, breast density has not been shown to add much more than we already know about a woman’s risk from using these models.

The problem with breast density as a risk factor is that most women at some point in their lives have dense breasts. Should we really consider 75% of women in their 40’s to be at increased risk for breast cancer?

I don’t think so.

Dense breasts can obscure a cancer on mammogram.

This makes mammogram less reliable in women with dense breasts. Digital mammograms may be better at finding breast cancers in women with dense breasts who are also perimenopausal or < age 50, but it is not known if this translates into better outcomes. Additional testing with ultrasound and MRI can find cancers that mammograms miss in women with dense breasts. Unfortunately, breast ultrasound and MRI screening tests are less specific than mammograms – three times as many biopsies will be done, most of which will not be cancer.

Breast cancer patients with dense breasts are not at increased risk of death.

In a study of over 9,000 women with breast cancer, no association between increased density and death from cancer was found. In fact, it was obese women with lower breast density who had the higher risk of death, possibly because their fatty breasts may be a more favorable environment for tumor growth.

We do not know if additional breast cancer screening beyond mammograms saves lives.

Sonogram and/or MRI for breast cancer screening is currently not recommended based on breast density alone. Additional screening beyond mammography is only used in women at highest risk for breast cancer – those with cancer in a first degree relative with a high risk gene mutation, a family history suggesting one of these mutations, a Gail model or other combined lifetime breast cancer risk assessment >25% or a history of chest irradiation. Even in this group, declines in morality with the additional screening have not yet been shown, and the false positive rate of this additional testing is extremely high – only 20% of abnormals are cancer when biopsied.

There are no recommendations to use sonogram and MRI in otherwise low risk women, and none that have shown that using it based on breast density alone saves lives.

Additional screening beyond mammograms adds significant costs to breast cancer screening.

For some women, this additional cost may not be covered by insurance. While Connecticut has passed a law mandating that insurers cover additional sonograms, New York State has not.

What should you do if you’ve been told your breasts are dense on mammography? 

If you are at increased risk for breast cancer due to personal or family history, you may want to consider adding ultrasound or MRI screening.

Otherwise, at the point there is no recommendation that you do anything other than continue screening at whatever interval you and your doctor have decided is right for you. If you decide you want a sonogram, understand that you will need to accept the additional false positives and biopsies that may result and that the additional screening has not been shown to decrease deaths from breast cancer in women at average risk.

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More info on mammograms and breast density

Lemon-Fennel Chicken with Mushrooms & Scallions

Fennel lemon chicken and spinach

For years, my friend Susan (of the famed Chicken Salad Susan) has been making her Italian grandmother’s sautéed chicken breasts with breadcrumbs, parmesan and fennel.  Not too long ago, she was also on a diet program that included an amazing recipe for pan fried lemon chicken. I decided to combine both her recipes, and now have a killer entree that I’ve made almost weekly since she first shared it with me.

LEMON FENNEL CHICKEN WITH MUSHROOMS & SCALLIONS

You can just make the chicken breasts, and you’ll have an amazing entree. Or just cut up the chicken breasts, skipping the breading, and have another amazing entree. But together? OMG.

Ingredients

  • 1 pound boneless, skinless chicken breasts,  pounded thin
  • 1 egg, lightly beaten
  • 1/4 cup flour
  • 1/4 cup homemade breadcrumbs
  • 1/4 cup Parmesan cheese
  • 3  tbsp fennel seeds
  • 1 tsp lemon zest
  • Juice of 1 lemon
  • 1/2 cup reduced-sodium chicken broth
  • 3 tablespoons reduced-sodium soy sauce
  • 2 tablespoon canola oil
  • 10 ounces mushrooms, quartered
  • 1 bunch scallions, cut into 1-inch pieces, white and green parts divided
  • 1 tablespoon chopped garlic

Preparation

Whisk 3 tablespoons lemon juice with chicken broth and soy sauce in a small bowl and set aside.

Rinse chicken breasts and pat dry. Place flour on a dinner plate. Lay a 12 inch long piece of wax paper down on the counter. Mix the bread crumbs and Parmesan and spread out onto the wax paper. Sprinkle some fennel seeds atop the crumb/cheese mixture in such a density that every bite of the breast you are about to coat will have a fennel seed on it. Lightly coat a breast by dipping in the flour and shaking off, then dip into the egg, then into with the breadcrumb, cheese and fennel mixture, coating the second side in a different spot on the wax paper so that it too gets the fennels seeds on it in the right distribution. Set aside on a plate. Scatter some more fennel seeds if you need to and continue dipping and coating and scattering more fennel seeds as needed to be sure that each breast has enough fennel seeds on each side. Toss any unused breadcrumbs and flour. (Of course, you could just mix the fennel seeds in with the breadcrumbs, but this is how Susan does it, and I assume how her grandmother did it, so that’s how I do it.  There is power in tradition, and I respect it when I can.)

Heat oil in a large skillet over medium-high heat. Add chicken and sauté 2-3 minutes each side, until just cooked through. Transfer to a plate with tongs and cover with tented foil.

Add mushrooms to the pan and cook for about 5 minutes – enough to cook but not to dry them out. You want them plump and juicy.  Add scallion whites, garlic and lemon zest. Cook, stirring, until fragrant, about 30 seconds. Add the broth mixture to the pan; cook, stirring, until thickened, 2 to 3 minutes. Add scallion greens and the chicken and any accumulated juices; cook, stirring, until heated through, 1 to 2 minutes. Serve.

Baba Ganoush, Lebanese Style

Babaganoush, Lebanese Style

My friend Paula and I threw a Middle Eastern dinner party on my rooftop last Saturday evening.

It was really all Paula’s idea. You see,  her dad once ran a Lebanese market in Worcester, Mass. Paula inherited not only her father’s butcher block kitchen table and meat grinder, but a real love for the foods of her ancestors. I can tell you that enthusiasm is highly infectious, having caught it from her last year while sitting at the table at our cottage rolling grape leaves under her tutelage. So when Paula proposed a joint party – she’d provide the food and I, the venue and sous chef duty – I jumped at the idea.

The menu was perfect for the warm summer evening – Appetizers of fresh feta, olives, baba ganoush and pita served with red Lebanese wine, followed by a dinner of grilled lamb kabobs, rice pilaf, stuffed grapes leaves and green salad.

The lamb for the grape leaves? Paula ground it herself that morning.The mint? Dried on her dining room table just a few weeks ago.  And the recipes? Handed down from her father’s generation to her – via the parish cookbook of the St George’s in Worcester. With a few gems culled from May Bsisu’s wonderful cookbook The Arab Table.

We culled the guest list from the ranks of our friends we knew would appreciate the lemony pepper bite of the baba, the saltiness of the feta and the earthy flavors of the lamb, but would also be open to sampling my first attempt at homemade pita bread (a valiant but mistimed effort), and most importantly, open to getting to know one another. We also asked the guests to bring a reading to share that would be appropriate for the gathering.

And so it was that we dozen found ourselves at a picnic table drinking wine under the waxing moon and twinkling lights on one of the most beautiful nights of the year, eating a most delicious meal and afterwards, listening to the words of Kahil Gebran, EB White and Maya Angelou, along with readings about Lebanese and Irish immigrants to America,  capped off with the words of a modern young Jew and the intimate details of the days before the music died.

Our only regret was that the late hour at that point limited our chance to discuss the readings we had shared – a  lesson we will keep in mind as we plan our next Mediterranean salon.

Oh yes, there will be another. Because we’ve barely sampled the mezze or ventured into the kibbe.

And I’ve got pita to perfect.

BABAGANOUSH

Baba Ganoush (Eggplant bi Tahini), Lebanese Style

This recipe is originally from the famed El Morocco Restaurant in Worcester, where Paula’s aunt once worked in the kitchen.  This is a much more lemony baba ganoush than you may have tasted before, and is the first baba I’ve ever really loved. The trick is getting the texture just right – too much smoothness and its just a other puree. Not enough and the odd texture of the eggplant dominates the flavors. When Paula told me she makes hers by cutting it over and over again between two knives, I took that as my cue to bring out the wooden bowl and chopper, and the result was a perfectly textured baba.  You can use less lemon if you like – start with one and only add more if you think you’d like it that lemony. (I have a feeling lemons may have been smaller when this recipe was first written.)  Don’t skimp on the pepper and use a coarsely ground sea salt or large grind kosher salt for flavor. Serve with homemade pita chips.

Ingredients

  • 1 large eggplant, skin on, cut in half lengthwise
  • 3 tbsp sesame tahini
  • Juice of 2 lemons
  • 2 cloves garlic, finely minced
  • 2 tbsp water
  • Salt and pepper to taste

Instructions

Brush the eggplant with a little olive oil and broil, turning it frequently, until the meat softens, about 15 minutes total.  (f you want to grill it, that would be even better…)

Scoop out the softened eggplant meat into a large wooden bowl, discarding the skins. Add the tahini, lemon, garlic and chop until the eggplant is blended, but still recognizable as eggplant. (Alternatively you can use a pastry blender or two knives. If you must use a blender or food processor, be very careful not to pulverize it into an unrecognizable puree.) Avoid long stringy pieces – its a relatively fine chop.  Add water and salt and pepper to taste. Garnish with parsley, lemon or a scallion.  If you want to drizzle a bit of extra virgin olive oil on top, go ahead. No one will complain.

My Wooden bowl and chopper

 

Seven Things You Can Do to Help Reduce Prescription Errors

Pill BottleI just got off the phone with a very upset patient who discovered that her pharmacy has been giving her the wrong medication for the past 5 months, substituting a similarly spelled antibiotic for her rheumatoid arthritis med. She was tipped off when she realized how bad she had been feeling of late and decided to check the expiration date of her med, only to find it was the wrong drug. I won’t get into the unethical behavior of the pharmacist when she pointed out the error, something I’ll be reporting on her behalf to both the head of the pharmacy chain and the state Pharmacy board.

But that’s not the point of this post. The point is that, despite all our fancy technology and advances in healthcare, medication errors can and will occur.

So what can you do, as a patient, to be sure that your prescriptions are correct?

1. Keep a list of your current meds with you at all times. Include brand or generic name, dose and frequency. Paper, online, or on your phone – wherever its easiest and most accessible. But a paper list in your wallet will cover you in emergencies, so consider that even if you use your phone routinely.

2. Cross check and update your med list with your provider at every visit. In quality parlance we call it medication reconciliation, and it’s one of the most important things we docs do at a patient visit.  You’d be shocked how many patient come to a visit without knowing the names of the drugs they are taking. Now, if I go to prescribe a new medication, how can I be sure it doesn’t interact badly with something you are already taking? Or even if you may already be taking the very med I am prescribing? If I’m lucky, your pharmacist will pick it up, but only if you’ve filled a prescription in his system before. Don’t leave it to chance. Take charge.

3. Ask for an updated list of your medications and prescriptions before leaving your doctor’s office. Most EMR’s can create a current med list, so ask your doc or his/her staff for a copy. If you use it as your med list to carry with you, we’ll all be on the same page.  Alternatively, if your practice gives out an AVS (after visit summary) at check out, that usually will have your med list on it.

4. If you’re tech savvy, use the practice portal. Your providers practice portal has a med list. Take it upon yourself to check the portal between visits to be sure your med list is up to date and correct. You can usually print your med list yourself from the patient portal.

5. Cross check every med after you pick it up against the prescription your provider wrote. This includes refills. Use your printed med list, the portal or your AVS to check what your provider wants you to be taking. If you don’t have that, you can ask the pharmacist for a copy of your prescription. Don’t wait till side effects occur, as my patient did, to double check. Your health is too important for that.

6. Don’t hesitate to speak up if you think a prescription is wrong. You take it once a week, and now it says twice a week? Say something. And it’s not just the pharmacist who can make a mistake. Your doc isn’t perfect either. In fact, we’re less perfect in some ways since we started using the EMR to write prescriptions. More than once, I’ve caught myself typing in a prescription in the wrong patient’s chart – with up to 4 charts open on the computer screen at a time, it happens, trust me. Recently, my EMR made every part of a prescription a discrete field or check off box from a drop down, so that writing a single prescription is more like completing an online tax return than ordering a med. I hate it. It used to be so much faster (and safer) for me to just write or type out the frequency and dose. So please, stop me if you think I got it wrong. 

7. Finally, don’t forget that so called “natural” supplements are meds too. Don’t  get me started on the over use of these unregulated products. (And yes, overuse of prescription drugs as well, but at least we know whose making them and what’s in them.) But do know that many, many interactions can occur between so called “natural” products and prescription meds. So if you’re taking any kind of supplement, vitamin, herb or natural product, be sure to add it to your med list.

Any more suggestions or ideas? Tell us in the comments section.