The HPV Vaccine Controversy

Should HPV vaccination be mandatory for young girls? And, more pointedly, is it appropriate for the governor of Texas to bypass the legislature by using an executive order to mandate the vaccine in Texas?

Very interesting discussions on this issue over at DB’s Medical Rants. And in Dinosaur Musings. And on NPR. And in the letters section of the New York Times.

My thinking on this issue is colored by what I have come to know about Merck’s funding of the group called Women in Government (WIG), whose members have introduced most of the HPV legislation around the country. As you may recall, I wrote in December about the financial relationship between Digene, Merck and WIG. The Baltimore Sun broke the story in January, and then the AP picked it up, as did Fox News, Forbes and others.

In their reporting on the Texas mandate, the NY Times pretty much glossed over the flow of lobbying dollars from Merck into Texas. Merck declined to tell the Times how much they actually donated to Women in Government, which, by the way, carries a non-profit status.

Since then, Merck has been mysteriously removed from list of Business Council members at Women in Government. (Don’t worry – the old cached pages are still around).

“Members also play an integral role in planning for future growth, have the ability to attend our regional conferences, and support the financial stability of the organization.”

to this:

“Business Council members support the overall mission of Women In Government.

Fascinating.

Much of the opposition to mandatory HPV vaccination is coming from the usual anti-vaccine groups and the religious right. That’s unfortunate, because it is distracting the media from seeing the real story, which is the unprecendented influence of Big Pharma in legislating healthcare. And the use of Pharma-funded consumer “advocacy” groups to push Pharma’s agenda when the healthcare community does not respond fast enough for the shareholders. The push for mandatory HPV vaccination is not coming from any organized medical lobby that I have seen – it is coming from Merck.

Right now, because the HPV vaccine does more good than harm, the healthcare community and the media seem to be willing to let Merck slide on this one. But I believe it is a very slippery slope upon which we are allowing them to ride. They still need to get better at covering their tracks, but their recent absence from the WIG website proves they are fast learners in this regard. If they get any better, then a day will come when we will no longer know from where the influences are coming. And if the product being pushed is not the HPV vaccine but another Vioxx, I don’t want to imagine the outcome…

I will state again that I believe the HPV vaccine to be a good thing. And so far, I have trusted the CDC and the professional organizations who have recommended for use of this vaccine. I have even begun giving my patients the vaccine.

But in lobbying for making Gardasil mandatory less than one year since its FDA approval, I think Merck has gone too far in trying to assure the market for their vaccine. And when I see them covering up their relationship with the WIG and declining to say how much money they have given this group which is lobbying all over America for mandatory HPV vaccination, I find myself wondering what else they are hiding.

And that’s not a good way to feel about a company whose vaccine you are administering to your patients.
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Update: The American Academy of Family Physicians and the Texas Medical Association have both issued statments against mandatory HPV vaccination.

Nap…or Die

Midday napping is associated with lower cardiac mortality, according to this recent study in the Achives of Internal Medicine.

Among men and women, when controlling for potential confounders and using those not taking siesta as a referent category, those taking a siesta of any frequency or duration had a coronary mortality ratio (MR) of 0.66 (95% confidence interval [CI], 0.45-0.97). Specifically, those occasionally napping had a 12% lower coronary mortality (MR, 0.88; 95% CI, 0.48-1.60), whereas those systematically napping had a 37% lower coronary mortality (MR, 0.63; 95% CI, 0.42-0.93). Among men, the inverse association was stronger when the analysis was restricted to those who were currently working at enrollment, whereas among women, a similar analysis was not possible because of the small number of deaths.

Now if you’ll excuse me, I’m going to go lie down…
Van Gogh. Noon: Rest From Work (After Millet) 1889-90; Musée d’Orsay, Paris . From WebMuseum, Paris.

The One-Meal-at-a-Time, No-Diet Diet

In my determination to lose weight without dieting, I’ve decided to tackle my eating habits one meal at a time. Starting with breakfast.

I blow every diet with the first thing I put in my mouth – my coffee. I happen to like my coffee light with half and half and one sugar. And two cups of it, thank you very much. Without my coffee made that way, I feel deprived and miserable. So any diet I go on is destined to fail. Because if you start your day out feeling deprived, then it’s just a matter of time before you start to overeat.

The other problem with me and diet breakfasts is that they required a huge lifestyle change – getting up earlier to make breakfast and eat it at home. Oh, sure, I can get motivated, head to the store on Sunday night to stock in what I need for the week, set the alarm and do the right thing. I can even keep that up for a few days or a few weeks. But then throw in a 5 am migraine an early morning meeting, or a weekend too busy to shop for food and before you know it, I’m rushing to my friend Mark’s deli on the way to work, picking up my usual coffee and croissant or an egg and cheese on a roll and eating at my desk.

One of these days I hope to be one of those get up at 5 am, work out for an hour, eat a homemade smoothie and raw egg, pack a healthy lunch with 2 snacks and head off to work kinda’ gal. But I’ve finally come to terms with the fact that it’s just not gonna’ happen all at once.

After all, our eating habits are tied into our whole daily schedule. So going on a diet means changing everything. No wonder we fail. It’s just too much at once.

Now where was I? Oh, right – breakfast.

One day last month, my daughter was having what looked like a delicious breakfast – peanut butter with a tad of honey on bread. I tried it – delicious! Then I got bold and made myself a cup of coffee with a little low fat milk to go with it. And do you know what? Next to the peanut butter sandwich, that coffee was perfect! I didn’t miss my half and half and sugar at all! I think the peanut butter makes up for the cream and the teensy bit of honey for the sugar.

I’ve modified the sandwich a bit – I use 7 grain bread, less than a tbsp of peanut butter, just 2-3 teeny tiny drops of honey and skim milk in the coffee. Add a bit of fruit and bang – a great breakfast! Mark can make it for me at the deli (even deliver it to the office) if I don’t have time myself at home, so that part is solved too.

I’ve had this breakfast enough days now that it has the same homey, heart-warming feeling my old breakfasts had. I am convinced that for me, food has many psychological overtones. If it doesn’t have that warm cozy feeling, I don’t feel like I’ve eaten anything. So, instead of fighting those feelings, I think I need to find healthy foods that give them to me.

In the past two weeks, I’ve started working on lunch. Still haven’t found the sweet spot on that one yet, but I’m eating healthier in the searching process.

The result? I’m down 6 lbs. in less than a month.

I’m calling it the One-Meal-at-a-Time, No-Diet Diet. Think Oprah would go on it with me?

Week Night Warriors – Pasta w/ Shrimp & Artichokes

Last evening Mr TBTAM and I were debating whether to order in for the millionth time this month or try to put together a decent meal for ourselves and the kids on a busy week night when we were both dog-tired.

I am so proud of us that we didn’t give in to the stack of menus sitting in the drawer under the phone. Instead, armed with a glass of white wine each, we raided the larder to see what we could come up with that did not entail a trip to the store and could be on the table before 8 pm.

That’s it down there, and it was delicious. With a little side salad, it did the trick. Veni, Vedi, Comedi!

Pasta with Shrimp, Peas, Artichoke Hearts and Sun-dried Tomatoes

-1/2 bag frozen, uncooked shrimp from Fairway
-1/4 bag frozen artichoke hearts from Trader Joes (left by Irene on her last visit)
– A few sundried tomatoes that have been sitting in a little bag on the counter for the past three months, and that I was wondering if I would ever use.
-1/4 cup of frozen peas from an opened bag that’s been in the freezer forever (and that will remain there even longer because there is still 1/2 bag left)
-Half a lemon from the bottom of the drawer in the fridge that miraculously was still good
– 3-4 cloves garlic, sliced
-Olive oil
-Kosher Salt
-Fresh ground pepper
-1/4 cup white wine from my glass
-1 pound penne pasta

Put water on to boil for pasta, with a touch of salt. Put peas in a bowl with just enough water to cover; drain when thawed. Soften sun-dried tomatoes in some warm water for a few minutes. Drain and slice into slivers. Put artichoke hearts into a small saucepan, cover with water and a squeeze of lemon, and heat till boiling, then cook for 3-4 minutes till done. Drain and set aside. Thaw shrimp by running them under cold water, then peel, drain and pat dry. Season with salt and pepper.

Start pasta cooking.

Heat olive oil in saute pan will hot. Toss in shrimp and cook till pink. Remove shrimp to a bowl. Add a bit more oil to the pan, then saute garlic till aromatic (do not brown). Deglaze pan with a 1/4 cup white wine and remaining juice of the lemon. Add in the peas, artichoke hearts and sundried tomatoes and heat while wine cooks down a bit. Add shrimp back in, heat briefly

Drain pasta and put in bowl. Toss with shrimp mixture. Serve.

More on Merck and Women in Government

Apparently, I am not the only one to be a bit taken aback at the speed with which Merck’s HPV vaccine is being legislated into healthcare.

“A lot of us are worried it’s a little early to be pushing a mandated HPV vaccine,” said Dr. Martin Myers, director of the National Network for Immunization Information. “It’s not that I’m not wildly enthusiastic about this vaccine. I am. But many of us are concerned a mandate may be premature, and it’s important for people to realize that this isn’t as clear-cut as with some previous vaccines.”

He added, “It’s not the vaccine community pushing for this.”

Who is pushing it? Merck, of course. Via a group called Women in Government. More at the Baltimore Sun.

Update:
Mandatory HPV Vaccine legislation in Maryland has been pulled (Via Pharmalot) and The Associated Press has picked up on the connection between Merck and WIG.

Notes To Myself

What do you do with those little tidbits of information that you want to remember about a patient, but that you may not want to write in a chart for the whole world to see?

Case in point – A patient tells me her BRCA gene test results on the condition that I not put it in her chart. She paid for the test out of pocket, and is under no obligation to tell those results to anyone. I understand this, but if I don’t write it down somewhere, I won’t remember it the next time I see her.

In the past, this has not been a problem. I just put that information on a little stickie note in the chart. That way, it was right in front of my nose, but not shared if ever a copy of the record was requested.

The nature of my job means that I get told a lot of intimate stuff that relates to my patient’s gynecologic health. Perhaps there is a history of sexual abuse that impacts her ability to be examined. Or her husband is impotent, or has certain sexual needs that are affecting her. These details are important to our interaction both that day and on future occasions, but my patient’s insurer does not need to know then in such detail to confirm their medical necessity.

Simple. Just use a post-it! That way, if a colleague is seeing my patient for a related reason, I can pick up the phone and transmit the more sensitive information confidentially, sending over just the paperwork needed to care for the patient without blaring her personal life over the fax machine.

But now we have an electronic medical record, and my little post-it system is no more.

In the EMR, the only option I have is to make an entire encounter confidential, so that no other provider in our system can read it. I do use that option for the occasional celebrity patient or for the employees who wants their records uber-protected. But that does not work as well, in my opinion, for handling those little bits of personal information that count.

I wish so much that I were one of those doctors who remember every single detail about their patients, and rarely need to write anything down. Sadly, I am not. I can barely remember my wedding anniversary, let alone personal details about a patient I have not seen for months. I really do need these little notes to myself.

So, for now, it’s all going into the chart. (Or not, depending on just how sensitive the information is.) I’m trying to develop a little code system that will remind me, but that’s remains a work in progress.

If any of you out there using an EMR have tackled a similar problem, do tell me your solution.

Because if I don’t write it down, I will forget it. And that’s a promise.

Lunch from Russ and Daughter

Russ and Daughters is a New York institution – a smoked fish and gourmet specialty food shop on the Lower East Side. I’d say they have the best smoked fish in town. (Although Sables on the Upper East Side and Barney Greengrass on the Upper West are extremely close contenders, and I suspect if I were doing a post about either of them I would be calling them the best in town…)

There’s alway a line at Russ and Daughter, but it’s well worth the time spent in the queue. Or shop early, which is what we did, to avoid the crowds.

Plates of marinated artichoke hearts, smoked salmon tartare, sable, whitefish salad and herring in sour cream, served with warm bagel quarters and coffee made a delicious lunch on a recent Saturday. It’s salty fare, which made it the perfect prelude to a long afternoon spent wandering the stalls at the Union Square Green Market and St Mark’s Place in the East Village. There was no need for anyone to make a bathroom stop!

Grand Rounds Vol 3; No 18

Thanks to our favorite scut monkey, Signout, for hosting grand rounds this week. Signout is a first year medical resident with a wonderful blog.

For those of you not in medicine, the scut monkey is the lowest member of the team, and since it flows downhill, gets to do all the work. (Although medical students are technically lower, and can have tasks assigned to them by the scut monkey, it is ultimately the intern’s job to make sure the work gets done.)

Hopefully, she doesn’t think of grand rounds as scut work. Thanks, Signout.

Making Choices

I was in my third year of medical school working on the abortion service.

In those days, women were admitted to the hospital the night before their abortions in order for laminaria to be inserted. Overnight, these dried seaweed rods would moisten and swell, slowly stretching the cervical opening so that the procedure could be performed the next day without the need for dilating the cervix manually, thus decreasing the risks of tearing and bleeding.

It was a busy service, with upwards of twenty procedures a day, two days a week. We med students were assigned to do the admission histories.

I remember sitting with woman after woman while they told me their stories. A young teenager who had fallen for an older man, a man who had loved her, left her pregnant and was now nowhere to be found. Another, a haggard, tearful woman in her thirties, was adamant that her husband would never know that she had gotten pregnant the night that he came home drunk, beat and then raped her.

There was the newly recovered drug addict just getting her life together, still hoping to get her three children back from foster care. And the mother who had five children at home and was waiting to hear whether her sister would be able to stay with them tonight. Still another teenager, this one accompanied by her mother, who said nothing but never left her side.

Each decision to abort these pregnancies appeared to have been painfully made, and none was casual. Every one of these women had mixed emotions about what she was doing, and yet every one had a conviction that this was her only choice at this point in her life. The teenager seemed a bit less sure of herself, but she reiterated to me that this had been her own choice, and Mom was still hoping she would change her mind. It was her second abortion, and she would not tell me the circumstances of her becoming pregnant.

At one point, all the women were told to undress, put on their hospital gowns and meet in the patient lounge to hear about their procedure from the chief resident, who would then examine them one by one in the small exam room next door and insert their laminaria.

“Tell them to leave their underwear in their hospital rooms”, he told me.

“What?” I cried. “You mean they are all going to sit there completely naked under their gowns while you stand there in your white doctor’s coat and tell them as a group what to expect tomorrow? Can’t they at least wear their underwear?”

“I don’t have time to wait for them to take them off”, was his answer.

“But it demeans them…” I started.

In a tone of voice that told me I had already gone too far, he said simply “Just do it.”

So I did. I was, after all, just a medical student. And he was my chief.

But at that moment, I made my choice as to what I would do when I graduated. If this was how the men who worked in this field treated women, well, then we women needed to become gynecologists and start treating women as something other than cattle.

I also decided that day that I was pro choice. I wasn’t sure if I would do abortions, but I knew that if this was the world that women were living in, then this option had to be available to them until we had something better.

Later on, I would come to realize that the something better is safe and effective contraception, sex education, childcare, family-friendly work environments, healthy male-female relationships, child support and education. Of these, the one that I believe is most within our reach today is safe and effective contraception, and that is where I have concentrated my efforts. I subscribe to the belief that abortion should be safe and available, but rare. Unfortunately, those who most vehemently oppose abortion also oppose contraception, and seem to want to assure that abortion remains anything but rare.

In my career, as it turned out, I would butt heads more than once with the men who supervised me. But I would never again encounter such a blatant misogynistic attitude among any of the ob-gyn’s I was to meet. Sure, there were a few jerks, but also some not-so-nice women. And I will go on record as saying that many of the very best gynecologists I know are men, including those to whom I refer my friends and family.

I don’t know that we women gynecologists have changed this field as much as I thought we would. I think we are too busy just getting the work done. The field has changed most, I believe, in response to our patients and their advocates, who persistently raise the bar for all of us docs, men and women alike. And continue to demand reproductive choice.

So keep up the pressure, Ladies… We need your voice.

Got HPV? Have Some Carrots…

My patients who have HPV invariably ask “Is there anything I can do myself to help clear this infection?”

“Actually”, I tell them, “there is. Most importantly, don’t smoke. And eat your fruits and veggies.”

That’s right. Have a carrot. Or a tomato or some broccoli. Or better yet, a papaya. Because numerous studies suggest that women who eat more fruits and vegetables have lower rates of HPV infection, faster clearance of HPV once they get it, and lower rates of cervical cancer overall.

We don’t know which of the many vitamins and substances found in fruits and vegetables are responsible for this antiviral effect. It could be the combination of substances rather than separate vitamins themselves, since treatments using supplements rather than foods have not been effective. And it’s not at all clear if these foods are helpful once precancerous lesions are established. If veggies do work to prevent cervical cancer, it is most likely early in the natural course of HPV infection.

Large controlled trials are still needed, but, while we are waiting for that evidence, I see no down side to telling my patients with HPV to increase their dietary intake of fruits and vegetables if, like most Americas, they don’t get enough already.

How much fruit and vegetables? According to the American Cancer Society, everyone should have five or more servings of a variety of fruits and vegetables daily to help prevent cancer.

Here’s a great recipe for Carrots.

Glazed Carrots with Lemon (Adapted from the Silver Spoon Cookbook)
The original recipe used sesame seeds instead of pine nuts, and pearl onions instead of shallots. I’ve also made it substituting olive oil for the butter, and it tastes just a delicious.

1 ¾ lb carrots, fairly thickly sliced
3 tbsp butter
2 shallots, chopped
Strained juice and grated rind of ½ lemon
1 Tbsp pine nuts
1 tbsp chopped parsley
Olive oil for drizzling

Put carrots in a bowl. Add water to cover and a pinch of salt. Let soak for 15 minutes then drain. Melt butter in a pan and add shallots. Cook over low heat, stirring occasionally, for 5 minutes. Add lemon juice and rind and cook for a few minutes more. Add carrots, season with salt and pepper and cook for a further 10 minutes.

Meanwhile, lightly toast the pine nuts in a heavy skillet.

Transfer the carrots to a small serving dish, sprinkle with pine nuts and parsley. Drizzle with olive oil and serve.

Serves 4

———————————————————————————-
Here are a few references…

Int J Cancer 2005, 117 (4):629-637.

Cancer Epid Bio & Prev 2005. 14: 1149-1156.

JNCU Monograph. 2003;(31):29-34.

What’s Inside?

I, TBTAM the Marvelous, the disciple of the famed Carnac the Magnificent, can see into the future of American Healthcare. In this envelope I hold the answer to all questions. You need only ask and I will reveal…

Ah, Dr Wes, my cardiologist colleague – You say that Medtronics’ direct-to-consumer campaign for the Implantable Cardiac Defibrillator is giving you angst. You ask the Great One to predict whether this will change the way you practice medicine…

Well, take that stethoscope out of your ears and get that guidewire ready, my systolic-minded friend. Because from what I see, Medtronic has done all the right things to assure that your practice will never be the same again.

Medtronics’ Ad Campaign

That’s their Website ad up there. The campaign is called “What’s Inside?” It’s a catchy slogan, both a question and a play on words. What’s inside your body? What’s inside that device? It’s cute. I like it.

And speaking of cute, how about that ICD device itself? It’s sleek, small, and very high tech – I’ve never even had a heart attack, and I want one. In fact, it reminds me of an IPOD or a cell phone. (Do you think it comes in colors? Can I get skinz or ring tones for mine? )

How about the commercial? It’s brilliant, that’s all I have to say. (You can watch it on the web site, just click on the word commercial there). I get all warm and fuzzy when I watch it….

Inside this little device, you may just find…10,0000 more kisses. Snow. 200 more football wins. This is an implantable cardiac defibrillator, a device that’s always there with you, close to your heart, with the power to restart it in case of sudden cardiac arrest, one of the nation’s leading causes of death…

“Close to your heart”. Like your wife, and your grandkids, and your hometown football team. Inside. Close to your heart. It works for me. And for some reason, I’m getting thoughts of Winnie the Pooh. Don’t ask me what in that ad is doing it, but it’s undeniable. When I watch that commercial, I think of Winnie the Pooh.

But wait, I’ve left the best for last. Because at the end of the commercial, after the usual disclamiers and warnings, here’s what Medtronics promises…

An ICD could give you many more bedtime stories, tons of hugs and one more thing (Are you ready, Dr Wes?It’s three little words that will change the way you practice medicine forever..) …PEACE OF MIND.

That’s right. I almost didn’t believe it myself, but there it was at the end of the commercial, and on the banner at the Metronic website. In a marketing move swiped straight from the Digene’s HPV Playbook, Medtronic is selling peace of mind as an indication for their implantable defbrillator.

And so, Dr Wes, TBTAM the Magnificent now knows exactly what you are in for. (Plus, I have confirmed it on my Ouija Board. ) I would love it if I were wrong, and only time will tell, but here are my predictions…

Sometime in the Next Few Years…

1. Patients will start calling and coming in to their cardiologists asking if an ICD is right for them. Wives will come with their husbands because the men won’t really want to ask themselves. You will feel torn. You hate sudden cardiac death as much as your patients worry about it. You may even worry about it a bit for yourself. But you also know that ICD’s are not benign devices, and have risks. You do your best to help your patients weight those risks and benefits. This will not be easy, especially if Medtronics acts like Digene, and starts to coach patients on how to convince you they need that ICD for their Peace of Mind. You will stay strong and try to do the right thing.

2. Medtronic will partner with patient arrythmia advocacy groups (or create them if they don’t already exist). These groups will need a catchy name like “The Campaign the End SCA -Sudden Cardiac Arrest”, a celebrity or survivor spokesperson and a mission. Soon, everyone in America knows exactly what Sudden Cardiac Arrest is, and what an ICD can do for them. Some good will actually come of this, because ICD’s can be lifesaving, we all know that. But many patients will be confused by this information, and many many more will start to worry…

3. When cardiologists raise concerns about the potential for overuse of ICD’s, Medtronics will agree with them and promote the use of T-Wave alternans to better predict who needs the defibrillator. Fortunately, Medtronic either makes their own T-wave alternans or partners with a company who sells this device.

4. Legislation will need to be passed mandating coverage of ICD’s and T-wave Alternans on demand, regardless of indication. No problem. Medtronics will “partner” with some government lobbying group with a benign sounding name like “Women in Government” and get that legislation passed asap.

5. A few business-saavy cardiologists will make a fortune running a chain of drive-through ICD Centers implanting on demand. Most cardiologists, however, will continue practicing evidence-based cardiology, and will offer ICD’s to patients based on real indications, and not just peace of mind.

6. Tom Cruise will leave the Church of Scientology, get an ICD implanted for his Peace of Mind and become Medtronic’s spokesperson. Demand will soar.

7. The first doctor will get sued for declining to refer for an ICD. The story will run on 20/20, be picked up by Reuters and hit all the papers. The use of ICD will increase exponentially as cardiologists everywhere try to avoid a lawsuit. Medtronic stock will hit an all-time high.

8. Cardiologists everywhere will get sued for complications related to implanting the device or misfiring of the device. These stories will not get much newsplay. Malpractice rates for cardiologists will rise higher than those of obstetricians.

Welcome to my world, Dr Wes.

The Best of the Science Blogs

Thanks to the Herculean efforts of Bora Zivcovic, the very first anthology of science blogging has been published.

Bora asked for submissions just 3 short weeks ago, and along with a panel of judges waded through 218 blog posts (including one or two from yours truly) to cull out the 50 best blog posts of the year. My posts didn’t make the cut, but don’t let that stop you from reading this marvelous collection from writers who in their real life play physicists, doctors, astronomers, ecologists and more.

I’m just starting my reading, and already I’ve learned that the Big Bang is not really what I thought, that birds can fart, that you can’t divide by zero because it is meaningless (not because it is infinity) and that making love is really making music.

Click here to buy the book (also available as a pdf download) from Lulu publishers. (Great cover, huh?) Next year, they should publish it in time for the holiday shopping, it would make a great gift for the science lover you love…

Central Park Reservoir

The fog was so thick yesterday, it obscured the skyline and I forgot for a while that I was in the middle of the city. (Click here for more typical Reservoir views.)

Hands down, my favorite place to walk in Central Park. Especially when accompanied by good friends.

Fattening Up my Blogroll

Last week was annual De-Lurking Week. For those of you new to the blogosphere, lurking is when you continually visit someone’s blog without ever commenting. During De-lurking Week, lurkers are urged to come out from the shadows and join into the discussion.

In honor of delurking week, instead of commenting, I am going to put a link in my blogroll over there. Because a comment is a one time thing, but a link is forever… Here are just a few of the many wonderful blogs I’ve been lurking around for a long time, but never got around to linking to them until now:

  • Flea: One Pediatrician’s Persepective. Check out his great series on vaccinations.
  • Musings of a Distractable Mind. Great title, great images and one of the best Grand Rounds Ever.
  • Doctor Anonymous: The Unoffocial site of Blogaholics Anonymous. (Sign me up!)
  • DB’s Medical Rants: If you are a med student, check out his lecture on renal physiology.
  • Over My Med Body: The pictures alone are worth the visit, and not-too-shabby writing, either.

More to come…