Converting to an Electronic Medical Record: Advice (and Cookies) From a Doc Who’s Been There

Over the past 12 years, I’ve gotten my office to run like a well-oiled machine, operated by a top notch office staff and fueled by the various office systems I developed myself. These included a tickler system for lab and radiology results, a patient chart organized so that I could retrieve whatever information I needed in an instant, patient information sheets I’d written myself, and, if you’ve been reading this blog for awhile, you already know about my little system for keeping track of return phone calls. It was mine, it worked for me, and gosh darn it, I liked it.

Going to an electronic medical record meant chucking all that away and starting from scratch using someone else’s system. It wasn’t easy.

It’s not as if I hadn’t known it was coming. I was on the implementation committee for 6 months prior to the go live date, and worked with the developers to customize and learn the system.

But that didn’t help as much as I had hoped when go-live finally came, the patients were streaming in, charts were backing up uncompleted and my computer inbox was crammed with lab results and patient calls and refills requests and staff messages.

To say I was stressed would be an understatement.

The hardest part was letting go of my old ways and trusting the new system to work for me. The good thing was that I did not entirely trust it, and so identified some bugs that needed fixing before they impacted the quality of care and the bottom line.

Things are getting better and better every day, and overall I would say the new system has more advantages than disadvantages. Results come back in real time, consult reports are available online, and I can retrieve a patient’s record from anywhere as long as I have my laptop and a good connection. The biggest plus is that I get to leave the office earlier, because I can do my chart work from home instead of staying at the office till 7 pm every day.

For those of you considering or about to undergo a similar conversion, I’ve compiled a list of tips for making the process go more smoothly. Some of these things we did right from the get-go, others we discovered during the implementation itself, and some are things no one told us that we wished we’d known beforehand. I hope it is helpful for those of you about to undergo a similar conversion.

TIPS FOR A SMOOTH EMR CONVERSION

  • Cut back your volume
    I recommend that you cut visit volume by 50% for the first month, then increase to 75% for the next month, then back to full volume by three months. Then be prepared to be swamped, because the first 3 months at full volume will be extremely difficult – count on working extra hours to keep caught up. It takes at least 6 months to a year to get up to speed with a new system. Which leads me to item 2…
  • Keep your Life Simple
    Don’t schedule any major changes or take on any major commitments for at least 6 months. That includes getting a grant or a chapter written, writing a new lecture with slides, planning a wedding, undergoing childbirth or taking that big trip to Africa. You are about to change your day-to-day life drastically. Do not underestimate how stressful this will be, both at work and at home.
  • Keep the paper reports for awhile
    Do not shut off the flow of paper laboratory and radiology reports until you are 100% sure that all test and radiology results are coming back to your online system, and that the system for tracking unresolved reports is working.We did this, and found that by 6 weeks we were able to turn off the paper laboratory systems, probably because they had been printing directly to our office printer for a few years, and we had already worked out the bugs.At 3 months we are still not 100% reliable with radiology report feeds, so we continue to receive paper reports for all radiology tests ordered. This is where a good part of the additional work hours predicted in item 2 arises. The dual system will drive you crazy reconciling what is back and what is not. But if you don’t do it, something will slip through the cracks, I promise.
  • Ask your patients to do some of the work
    Have all patients complete a new patient intake form that includes past medical, surgical and family history, meds, referring docs, etc. (Some systems are designed to let patient enter this information directly, ours is not.) Use this to complete the historical sections of the online chart, or scan it in somewhere easily retrieved at every visit. It is much faster that trying to review the old chart and catch all your patient’s history that way. You should still review that chart to be sure you got it all, but that part goes quickly.If you have a good nurse, PA or NP, this is a great role for them. But be sure they know what they are doing, since you will be the one liable for missed information.
  • Don’t forget allergies
    Make sure the allergies section of the EMR is completed at the first online visit.
  • Don’t give up your old chart too soon
    Keep your paper chart until you have seen the patient at least once electronically, and don’t give it up until you are comfortable that all the historical data you need to take care of the patient has been electronically entered. Not all conversions will have this option, and it is more budensome on your staff, but if you can, do it.The reason is simple – it just takes much longer to skim through a scanned chart than a live one. I learned this one the hard way, because I had my all my old charts scanned in at go live. I hate having to review my old charts as PDF files.
  • Take advantage of computer shortcuts
    Learn keyboard shortcuts early in the implementation. The keyboard is always faster than the mouse. And use macros, smart texts and smart phrases as much as possible.But be wary of any shortcut that auto-completes the online form. The last thing you want is data being entered for elements of the exam you did not actually perform.
  • Do a compliance audit early on in the implementation
    You don’t want to find out 6 months in that there are problems with documentation or coding resulting from the new system. By doing chart reviews early on, we discovered that certain CPT codes needed to be updated or added to the online system and that some very minor changes in the visit template led to better charge capture and less errors.
  • Work with your IT team
    – Give feedback early and often to the development and implementation team. They want and need it in order to customize the system properly to your practice. If you can, get on the initial development team, so that your input is heard from day 1.- Get to know the physician IT team leader and give your feedback directly to that individual on any issue that you feel impacts quality of care. The IT support team may not have the medical background to reliably distinguish simple technical issues from those that impact quality of care and need to be sent up the ladder. Such issues are probably affecting other practices as well, and the physician IT team leader needs to know about them.- Be patient with the IT team. They did not design the system, they are not perfect, and they are probably working their asses off to meet timelines and deadlines.- Keep a list of every issue you identify and refer to the IT team, then meet regularly with them and get follow up on every issue. Sure, it’s their job to do that, but they are probably working to implement more than one site at a time and things can get lost. Remember that ultimately it is your practice and your tail if things go wrong, so take responsibility from day 1 for getting it right.
  • Ergonomics, ergonomics, ergonomics.
    You will now be spending enormous amounts of time at the computer. (Unless you have a blog, in which case you already know this.) Sit up straight, get that screen at the right level, and that mouse where it won’t hurt your wrist. Hopefully you will have you exam rooms set up so you don’t have to turn your back to the patient to access their chart online.
  • Keep your options open
    Don’t tie you down to a single workstation before you really find out how your work flows during office hours. Make sure there are plenty of places where you can go to complete a chart or print out a prescription before a patient leaves the office.Right now, it is still faster for me to leave the room and complete the chart in my office, because the patients have to get dressed and the room turned over to another patient. Once I get faster at inputting data directly online in the exam room while I am talking to the patient, I expect this may change. But at least I have options, and that means I can keep patient flow moving.
  • Monitors: the bigger, the better
    Get a monitor screen big enough to easily read a full page pdf image. If you are viewing old charts and outside records as PDF files, it is much faster to page through a full screen view than to have to scroll down every page to get to the bottom because the full page view is too small to read.
  • Handling the residual paper
    You’ll still be moving a fair amount of paper through your office, such as old records, snail mail correspondence and outside radiology and lab reports. So get the fastest scanner your budget allows. Scanning is time consuming and staff intensive, so it will be money well spent up front.Don’t let the office-based scanning get behind. Fit scanning into the patient visit work flow as much as possible. If you batch it, it will pile up. Trust me on this. Farm out large amounts of scanning (like old charts) to a reliable vendor.Get a shredder for the paper you will need to discard after scanning. Better yet, subscribe to a shredding service.
  • Schedule a massage for week one
    No explanation necessary. This will help immensely with the next item, which is..
  • Be nice
    The conversion is just as hard for your staff as is it for you. Trust me. You are all on the same side. Getting angry, frustrated and annoyed helps no one, so get over yourself and just be nice.Which leads to my final, and most important piece of advice…
  • Bring cookies
    During our EMR implementation, Eric, our IT support guy, brought cookies every single day. We learned to love him for it. Whenever I stormed into his office, annoyed and frustrated, he’d offer me a cookie. I think it was those cookies which made our conversion a success. (Luckily I didn’t storm into his office more than once a day, usually around 4 pm…)

Here’s an easy cookie recipe that you can make and bring in to your office staff and the IT team when you decide to go electronic. It will make things go more smoothly, I promise.
—————————————————————————————————-

CHOCOLATE ORANGE TRIANGLES FOR AN EMR CONVERSION

2 oz.unsweetened chocolate, in pieces
2/3 cup all-purpose flour
1 stick unsalted butter, melted
2 large eggs
½ cup sugar
½ cup orange marmalade
1 tsp vanilla extract
¼ tsp salt
½ tsp baking powder
1 oz. Semisweet chocolate, in pieces

Grated orange zest for garnish
Chocolate glaze (recipe follows)

Preheat oven to 350 degrees. Pulse the unsweetened chocolate with the metal blade of a food processor 4 times, then process until finely chopped, about 1 minute. With the motor running pour the hot butter through the feed tube in a slow, steady stream and process until the chocolate is melted, about 30 seconds. Scrape down the work bowl.

Add the eggs, sugar, marmalade, and vanilla and process until combined, about 5 seconds. Add the flour, baking powder, salt and semisweet chocolate and pulse until combined, about 5 times.

Pour into a greased 8-inch square baking pan and bake in the preheated oven until a cake tester comes out clean, about 30 minutes. (watch carefully). Cool on rack.

Spread with the chocolate glaze and refrigerate until set, about 30 minutes. Sprinkle with the orange zest, cut into 2-inch squares, and halve the squares diagonally. Makes 32 cookies.

Chocolate Glaze
2 oz semisweet chocolate, in piece
2 tbsps. Unsalted butter
2 tbsps. Milk
1/4 cup confectioner’s sugar
1 tsp. Vanilla extract
Pulse the chocolate with the metal blade 4 times, then process until chopped finely, about 1 minute.

Combine the butter, milk, and sugar in a small saucepan and bring to a simmer, about 4 minutes. Stir in the vanilla. With the motor running pour through the feed tube in a slow, steady stream and process until the chocolate is melted, about 30 seconds.

(Recipe from Irene, who may have gotten it originally from Cook’s Illustrated, I’m not sure..)

Category: Second Opinions Food

Mushroom Barley Soup Memories

It’s unusually cold, even for December, that first winter in New York City. I’m living in the East Village and studying for grad school finals with my lab partner Robbie, who I think befriended me mostly so that I could tutor him in biochemistry, which he happens to be failing. In return, Robbie is getting me all tied up in knots by refusing to become involved with me because he is, as he puts it, no good for me.

Think Billy Crystal in the first part of Harry met Sally. Now make him cuter, even more cynical and a real sleep-around, then kick him out of his previous school for dealing pot and you’ve got Robbie, the not-so-nice Jewish boy from Brooklyn. An irresistible draw for a 21-year old Catholic girl still fresh from the Philadelphia suburbs.

It’s been dark for over 2 hours, and we’ve been sitting at the kitchen table in my 3rd Floor walk-up on St Mark’s Place since just past noon, reviewing the pathways for carbohydrate metabolism. “I’m starving”, says Robbie. “Let’s go for some Deli.”

“What’s that?” I ask.

He looks at me like I am the most pitiful bumpkin on the face of the earth. In fact, that is the word he actually uses. “Pitiful” he says, pulling me out of my seat. “C’mon. My treat.”

It was to be his only generous gesture in our entire relationship, aside from his initial refusal to get involved with me.

There is a line at the door of the 2nd Ave Deli, something I had never before seen at a restaurant. Especially on such a cold night. The maitre-d’ (could it have been Abe the owner himself?) takes pity on us, and passes out little plastic containers of warm applesauce and plastic spoons to the waiting diners huddled in the blustery entryway.

“We should have ordered in”, mutters Robbie, as he stomps his feet to keep warm. He is wearing only a hooded sweatshirt with a jean jacket on top.

I lick my spoon from the warmth of my big brown fur coat (10 bucks at Trash and Vaudeville). Robbie hated that coat. “That wouldn’t help,” I correct him, still in tutoring mode. “We’d still have to be out here. Plus, I don’t see a take-out window, do you?”

After staring at me for a full 30 seconds with a look of incredulity and mild disdain, Robbie explains the fine art of New York City Restaurant Delivery.

I give him a look of incredulity but not-so-mild distain. “I cannot believe that so many people have the nerve to call another human being and ask them to bring them their food in bad weather when they can go out and get it themselves!”

“Give yourself some time,”replies Robbie.

He was right, of course. But it would be almost a full year before I could gather the Chutzpah to order in for myself, one rainy night in the following November. The delivery boy turned out to be an old man. I felt so guilty I think I gave him the entire contents of my wallet as a tip, and then didn’t order in again for a year. Don’t worry – I’m over it now.

The line outside the Deli moves surprisingly quickly. Soon, they let us inside, past the long deli counter to a small table in the middle of the noisy, bustling room, where we struggle to fit our notebooks on a tabletop already crammed with water glasses and bowls of fresh pickles and cole slaw.

And it is there, while sitting at that table grilling Robbie over and over again on the biochemical reactions of the Kreb Cycle, that I have my first bowl of mushroom barley soup.

Eleusinian Initiation Rites

Now, you may not know this, but barley has religious significance dating back to ancient Greece. There, it was used to make kykeon, a nectar used in the Eleusinian Mysteries, which were the initiation ceremonies for the cult of Demeter and Persophone. It is said that the barley drink, now thought to have been contaminated with ergot, a neuroactive mold, led to psychedelic experiences that convinced the initiates that they had witnessed unspeakable, divine mysteries that satisfied the deepest longings of the human heart.

Is it so surprising, then, that I was to be initiated into the mysteries of the New York Delicatessen by ingesting that same magical grain? Believe me, that bowl of mushroom barley soup was the closest thing to a religious experience that I have ever had. I had drunk the holy water, been baptized in the broth and seen the light. And I would never be the same again.

I remember calling my father that night. “I’ve been raised in the wrong religion. Forget the church – I’m converting to Deli!” I hoped he understood. This was, after all, a man who ate Kielbasa like it was the holy host itself.

Soon thereafter, I would experience my first hot pastrami sandwich, my first cheese blintz and my first bowl of matzah ball soup. I would learn not to order my corned beef sandwich with cheese after a waiter gave me “the look”. I would know the difference between plain and marble rye and what a Dr Brown’s Cel-Ray was. I would, in short, became a New Yorker.

Epilogue

Dismantling the 2nd Ave Deli (more photos at Eater.com)

Not surprisingly, Robbie and I parted ways shortly after he passed biochemistry and, unable to find me to share the good news (I was home in Philly for Christmas), slept with my best friend Shari to celebrate. Shari was a fellow native New Yorker, and equally experienced, so I guess it was a good match, at least for one night.

Sadly, too, the story of the 2nd Avenue Deli was also to end, though not for some years (and for me, many meals) thereafter, when that fabled restaurant closed its doors forever in January, 2006.

So, I hear you asking, why tell this tale now?

Contrary to what you may think, it is not because I have found the recipe for mushroom barley soup in the 2nd Avenue Deli Cookbook (although it is, indeed, in that book, and on Epicurious).

No, it is because I want to tell you that last weekend I made a mushroom barley soup that is even better than the one I first tasted at the 2nd Avenue Deli once upon a time. You read me right. Even better. It is based almost entirely upon a recipe from, who else, my mother-in-law Irene.

As post-impressionism was both an extension of Impressionism and a rejection of that style’s inherent limitations, so this soup, made in the style I like to call post-Deli, both reflects and improves upon its predecessor, the great mushroom barley soup at the 2nd Avenue Deli.

And so I share it with you now, Dear Reader, in the hopes that when you make and enjoy it, you will think of that fabled dish once eaten in that now lost New York City landmark. As for me, my memories will be of a more personal nature, of a cold December night in the East Village when my New York gastronomical conversion began.

POST-SECOND AVE DELI MUSHROOM BARLEY SOUP

This is a very interesting recipe – you basically make soup twice – first a double broth, then removing these veggies, and making the soup itself with fresh veggies, cooking the meat even longer until it is succulent. It’s even better the second day.

1 tbsp olive oil
1-1/2 lbs. top rib, (flanken, with bone)
2-3 cans beef, veggie and/or mushroom broth (I used both beef and veggie)
Water to cover
1 onion, studded with two cloves
2 carrots, cut in thirds
1 large rib of celery, cut in thirds
2-3 sprigs fresh thyme
1 bay leaf

1 large onion, chopped
1 carrot, diced
1 rib celery, diced
½ cup barley, rinsed
1-1/2 lbs. fresh mushrooms, chopped coarsely. (I used a combination of white and baby belles)
A few dried porcini or shitake mushrooms soaked in hot water for 20 minutes
Salt and pepper

Heat olive oil in a large soup pot. Lightly salt and pepper the top rib and brown it in the oil. Add broth and enough water to cover meat. Add cut onion, carrots, celery, thyme and bay leaf. Bring to a gentle boil and simmer until meat is almost tender (about an hour).

Remove the cooked vegetables and discard or use separately. Add diced carrot, celery, onion, barley, and salt and pepper. Simmer ½ hour. Add all mushrooms and the liquid in which the dried mushrooms were soaking (strain it first). Continue cooking about another ½ hour or until the meat is tender. If you have time, refrigerate overnight and remove the fat. (I just skimmed it ater rmoving the veggies the first go round, and ate it that nght. It was not too fatty.) Reheat and enjoy!

If soup is too thick, add water to correct consistency. For an extra special flavor add two marrow bones when you add the chopped vegetables.

Category: Food

The Katrina Blog Project

One of my favorite medical bloggers, Dr Hébert, is posting a day-by-day diary of his life during Katrina on his blog Dr Hébert’s Medical Gumbo. He’s dubbed his account The Katrina Blog Project.

“This is the story of what a disaster looks like through ordinary eyes. It is like Exodus written not from Moses’ viewpoint but in the words of the last Israelite pushing his cart across the muddy bottom of the Sea of Reeds.”

Dr Hébert lived in St Bernard’s Parish, which was in the path of the eye of Katrina and was completely devastated by the hurricane and the massive storm surge that followed.

The blog starts Friday, August 26, and is currently on day 5. It’s a riveting, personal account that I encourage you all to read.

Me and Mr Bikram

This past Saturday, my friend L. talked me into signing up for a week of yoga classes at Bikram Yoga NYC. Of course, like any reasonable person who knows little to nothing about Yoga, I thought Bikram just happened to be the name of the yoga studio.

Boy, was I wever wrong.

MEET MR. BIKRAM

Bikram Yoga is not just the name of the yoga studio. It is the name for a school of Yoga developed by a guy named Bikram Choudhury. (That’s him up there, showing off. )

Mr. Bikram’s yoga is a copyrighted series of 26 standard asana Yoga poses performed over a 90 minute period, and”designed to scientifically warm and stretch muscles, ligaments and tendons in the order in which they should be stretched.”

Bikram claims to have cured his knee problems as a young man with this Yoga method. He then came to the US at the urging of the likes of Shirley MacLaine and Richard Nixon in the 1970’s, and opened franchises across America to spread his gospel. Truth be told, he is a bit of a controversial figure whose American business ways have led some to nickname him “McYoga“.

The Bikram Yoga Poses (from BikramYoga Madrid website)

THE CLASS

Looks like fun”, I said to L. as we stared at the poster of the 26 poses in the school lobby. “I’m pretty sure I can touch my toes if I bend my knees a little.”

Just before class, the nice guy standing next to the sign-up desk advised that I might want to purchase some vitamin C and minerals to take for my first class. I turned him down, figuring that I’d already sprung for the class, a rented mat and towels, and a big bottle of water.

“This place makes it’s money like the movie theater does on popcorn”, I muttered to L.

Wrong, again.

Because there was one little teensy-weensy detail about Bikram Yoga that I didn’t know at that time. It so happens that Mr. Bikrams’ classes are held in a room that is heated to (are you ready?) 104 degrees Fahrenheit. You read me right – 104 degrees. (For my readers outside of the US, that’s 40.5 degrees Celsius.) According to Bikram, the heat is necessary to keep the muscles warm and prevent injury.

Thanks, L.

As we entered the room, the heaters were blowing despite the 80 plus sunshine outside. Suffice it to say that we were sweating before we even laid our mats down. Good thing I rented those towels…

Our teacher (who, I should mention, was wonderful) took us through Mr. Bikram’s copyrighted series of 26 poses at a pace that I know was relatively easy, demonstrating for us while we rested between moves, urging us not to push ourselves, even giving me her towel to use to extend my stretch when it became evident that I could not reach my heels.

And in terms of the poses, I did much better than I would have expected. As I had discovered in other yoga classes, I found I have lots of flexibility in my lower spine, none in my upper, and that being overweight gets in the way of a good pose. But I held my own, I thought.

Till the class was over.

At that point, standing up after taking a little rest in “corpse pose”, I practically fell flat on my face from dizziness. And, as I went to put on my sandals, which had slipped off so easily when I began class, I found my feet were so swollen that I had to loosen the straps just to get them on.

L. wanted to walk all the way down to the river for a little al fresco lunch.

“Air conditioning”, I simply said, and that was that. We went for a nice healthy lunch, and I spent the rest of the day feeling like a damp dishrag.

THE AFTERMATH

The next day, Sunday, I felt even worse – nausea, headache, feverish and fatigued down to my bones. To compensate, I drank tons of water. Wrong move – my feet swelled even more, a situation aggrevated by sitting at the computer till all hours cleaning up the trojans that had crashed it via my husband’s email inbox. (E-email me if you want advice on this, I am now an expert…) At 1:30 am, I hit the sack feeling like I would never get out of bed again.

And then, the oddest thing happened.

I awoke at 6 am Monday feeling refreshed, alert, headache-free and more relaxed than I have felt in months, maybe years. We’re talking a sense of relaxation and calm that was peppered with energy. Still with swollen ankles, but happy as a clam. I literally floated through the day.

It lasted about 24 hours.

By Tuesday, I was back to my usual stressed-out, neck tightened, migraine-any-minute-now state. And my legs? +2 pitting edema up to mid-shin. I hadn’t seen ankles like those since my 39th week of pregnancy. They stayed that way till today (Thursday).

THE ANALYSIS

So, what happened to me?

According to the National Weather Service, Mr Bikram’s room had a heat index of 119 – in the “danger” range where “sunstroke, heat cramps or heat exhaustion are likely and heatstoke is possible with prolonged exposure and/or physical activity.” (Hmm…like 26 poses?)

So I’m sure that on Saturday and Sunday, my symptoms were the result of a mild case of heat exhaustion. Given that I tried to drink plenty of water during and after class, I expect that I inadvertently became both sodium depleted and over-hydrated (hypervolemic hyonatremia in med-speak). Which made me feel worse. And, in this particular situation, the osmotic forces generated by the imbalance between the hypo-osmolic serum and the relatively hyper-osmolic tissues leads to edema (swelling).

As this recent article in the NY times tells us, I did exactly what they are now advising marathon runners not to do. Because hyponatremia, at its extremes, can cause cerebral edema and even death. Experts now advise drinking limited amounts of electrolyte-laden fluids instead of tons of water.

THE UNEXPLAINED

Okay, so I’ve explained why I felt so bad Saturday and Sunday. What I cannot explain is why I felt so good on Monday. I’ve gone through everything I did, ate or drank for the prior 72 hours and the only thing different for me was that darned yoga class.

Now, the Bikram-Yoga folks believe that all that sweating releases toxins from the body. YEah, right. I never bought that sort of talk. Whenever anyone starts to talk about “toxic cleansing” I give them a lecture on the glories of the liver, colon and kidney, the mop-up crew of the human body.

But then again, I’ve lost track of the number of times my basketball and tennis-playing husband has commented on “how good it feels to sweat” whenever I complain about his damp gym shorts and sopping t shirts hanging on the shower rod. This guy lives on sweating, I swear.

Come to think of it, Mr TBTAM is probably the most relaxed, calm and happy person I know (except when he gets to thinking about the current state of American government…) It’s one of the reasons I married him.

Could it be that sweating really is the secret to happiness? Or was I just feeling so good in comparison to how bad I had felt in the acute throws of hyponatremic heat exhaustion?

I’ll never know. Because, although I have 2 more days left in my one week Bikram Yoga trial, I have too much to do in those 2 days to risk feeling that bad again.

But maybe some day soon, when I have the time to spare, I’ll try again. But next time, I’m bringing my own mat and towel, and drinking Gatorade instead of water. _______________________________________________________________

– See a 60 Minutes interview with Bikram Chadbury here.
– Read a New England Journal article about marathon-induced hyponatemia.
– For patients: Heat Exhaustion and Heatstroke: What You Should Know
– For Physicians: Heat Related Illnesses

Caegory: Second Opinions, Considerations.

My Faustian Dilemma

Faust in His Study: Rembrandt von Rijn (1606-1690)
A new birth control method is about to hit the US markets – It is a single-rod implant that contains progesterone, and it is called Implanon. Think of it as a new, improved and smaller version of Norplant. A single rod that releases low doses of a progesterone-type hormone called etonogestrel and is effective for 3 years. I promise I will do an informative post all about this new contraceptive sometime soon. But here’s why I’m writing about it today…

Implanon’s manufacturer has asked me to serve as a trainer, a doctor who teaches other doctors how to insert and remove the implant. They are offering to put me up at a hotel and pay me to attend a 1 1/2 day training session being held at a nearby city.

Why me? Well, I am a family planning advocate and sometime clinical researcher who writes chapters and review articles on contraception, sits on the medical advisory board of a local family planning organization and am the “go-to” person in my department for all things contraceptive. Plus I was an insertion and removal trainer for Norplant. So, I’m a natural for the job. (Not to mention the fact that I really do believe this method is a good thing.)

The fee being offered is certainly a reasonable one for my time as a physician – any less would be an insult, any more might look coercive, and the company is really handling this thing responsibly and reliably. The hotel is in a small northeast city that no one would ever visit unless their mother lived there. There is also a training in Orlando – a fact that I consider a disincentive if anything. (I listed it on the training registration form as my third and last choice of venue.)

And yet I am conflicted. Why? Well, the backlash against big pharma has gotten so huge, and I admit that I have gotten so caught up in the groundswell that any pretense of taking money from a pharmaceutical manufacturer feels a bit like selling my soul to the devil. Having recently said goodbye to drug samples, pharma reps and their lunches, the last thing I want to do now is to serve as a paid consultant to said Big Pharma.

Yet I really do want to learn about this method, and offer it to my patients, and I like the idea of training other physicians and residents about birth control. Also, the FDA requires that insertion training be done – the problems that ultimately led to Norlant’s downfall were the result of untrained clincians inserting the method improperly or botching the removals. Someday I will post about my and my patient’s experiences with Norplant –it is a tragedy and a travesty what the media and legal institution did to this method. Suffice it to say that, as a result of that experience, I believe I have an ethical obligation as an experienced Norplant provider to train my fellow physicians in this new method called Implanon. Because if we can keep the method safe, the docs informed and the lawyers away, we may just have a future with more contraceptive options for American women.

So here’s my dilemma – should I –

A. Go to the training and keep the money?
B. Stay home and learn it from someone else?
C. Turn down the money but still do the training?
D. Force myself to do the training in Orlando as penance for taking the money?
E. Do the training but ask the drug company to send the check to Planned Parenthood?

Any and all thoughts on this matter will be greatly appreciated. I need to make a decision by the end of next week, or I could end up in Orlando.

Ubi desinit Philosophus ibi incipit Medicus
(Where the phiosopher leaves off, there the physician begins)
Be a physician, Faustus, heap up gold,
And be eternis’d for some wondrous cure. (Christopher Marlowe. Dr Faustus)

Category: Second Opinions

Endless Mountain Life: A Trip to Berry Fields Farm

The trip to Berry Fields Farm from our cottage in the Endless Mountains of Pennsylvania took about 45 minutes – a lovely ride through the pine forests of World’s End State Park, past the covered bridge at Forksville and the rapids and swimming holes of the Loyalsock River, along a winding mountain road lined with cornfields, scattered trailers and wooden farmhouses, and finally, up a dirt lane marked with a sign that read “No Winter Maintenance”.

It is the Annual Blueberry Festival which has brought us to Berry Fields Farm on this day. Held in the first weekend of August each year, the festival is a chance for visitors to sample blueberry laden pies, cakes and ice cream, hear a little bluegrass and of course, pick some blueberries. But before I tell you about all that, let me tell you about the farm…

Berry Fields Farm is a tough little scrapper of a farm perched atop Cahill mountain just west of New Albany, Pa. The land, originally purchased by its owner Charles Gerlach as a hunting retreat, is not what anyone would call ideal farm land. It is remote, hilly, and rocky. Yet over the years, Charles and his wife Barbara have turned this isolated little patch of hilltop heaven into a small but vibrant piece of a dream called “sustainable agriculture”.

“What’s that?”, you ask? Well, according to the National Sustainable Agricultue Information Service:

Sustainable agriculture produces abundant food without depleting the earth’s resources or polluting its environment. It is agriculture that follows the principles of nature to develop systems for raising crops and livestock that are, like nature, self-sustaining. Sustainable agriculture is also the agriculture of social values, one whose success is indistinguishable from vibrant rural communities, rich lives for families on the farms, and wholesome food for everyone.

By nature, sustainable agriculture is a local phenomenon. But, like Johnny Appleseed’s trees, small organic farms like Berry Fields are cropping up all over America, the family farm re-invented for a new generation.

The idea of sustainable agriculture is not quite a pipe dream, but it’s close. According to Barbara, this kind of farming makes little to no profit. This fact, more often than not, forces the young couples who start such farms to abandon them when it becomes clear that they cannot generate the income needed to raise a family.

Because the Gerlachs are retired and their children grown, the financial challenges for them are a bit less onerous than for younger families. Still, they work the land alone, with no help save their guests at their B&B, visitors from as far away as Japan who pay for the privilege of working an organic farm. This, along with the income from their little farm store and restaurant, allows Berry Fields’ owners to sustain their dream. They are building additional housing for the student interns they hope will join them next year, bringing yet another “added value” to the farm.

“Added value” – that’s the sustainable agriculture movement’s buzz-word for human labor. Human labor that can ransform a $1 pint of blueberries into a $10 blueberry pie, $2 bars of soap or a $5 jar of jelly. The difference between a failing farm and a sustainable family business.

Barbara and Charles do more than grow berries. They raise goats, chickens, pigs and cows, and they do so naturally. The cows are raised on pasture only, making their meat leaner and healthier. The eggs laid by their chickens are rich in omega-3 fatty acids.

Raising organic animals is no easy undertaking, and the Gerlachs have had to make some tough choices in the process. When their goats acquired a parasitic infection, they removed them from food-producing because the treatment involved chemical antibiotic use. Did I say that Barbara and Charles are committed?

But back to the Festival, which is the real reason we came this day…

About 15 cars lined the road, and although there were never more than 30 or so folks at the festival at any given time, Barbara was worried that her guests would be put off by the crowds. “Crowds?” proclaimed my fellow-New Yorker friend L. “Why, more people than this live on your floor!” Of course, she was right. It was really more like a little gathering than a festival. Yet somehow, this tiny event kept us occupied for a whole afternoon on this beautiful summer day.

We picked blueberries, or were they really huckleberries? They were certainly smaller than the hybrids I am used to eating, but fresh and packed with flavor. While we picked, the musicians who call themselves Oak and Ivy wandered among the berry bushes serenading us with bluegrass and folk songs.

There were clothespins hidden in the berry bushes, and when my younger daughter found one, she was rewarded with a candy bar made with blueberries and chocolate. We ran into our neighbors there among the bushes, and even got a little lost at one point in the blueberry maze.

And of course, there was the food. There were pies and cakes baked by the members of the Sullivan County Art League.

My friend L had chili topped with blueberries, which she pronounced delicious.

I myself headed to the booth run by a local goat farmer, and it was there that I found my own personal Nirvana – what else do you call a place where one can combine the words “organic goat cheese” and perogie” in one delicious mouthful?

What I like best about Berry Fields is that it is so real. This is no Martha Stewart farmette, and while its owners may speak the langauge of the gentleman (and woman) farmer, they are anything but. No pretty clapboard county house, no picturesque red barn here. It’s about the food, the animals and the land, not visual appeal.

But I ask you – With views like this, who needs Martha Stewart?

Category: Considerations

What’s Wrong with These Trees?

While driving to our cottage in the Endless Mountains of Pennsylvania, I noted with some dismay many of these drooping young trees along Route 80 in the Poconos. We’re talking hundreds of trees, not just the few pictured here.

“What could be happening?” I wondered. Some disease? A new blight? Dehydration? Roadside fumes?

I decided they were birches, given the white trunks. So I went to the web, where I read about birch blight, and gypsy moths, and wood rot, but found no real answer to my question.

Then I found the website for the Pa Dept of Conservation and Natural Resouces, and emailed them my question. To my delight, I received the answer within 48 hours:

“I believe what you are seeing are gray birch trees. These are small, white barked birch trees that tend to grow in openings, like along highways. The ice storms of Jan. 2005 caused major damage to these trees. They are short-lived and tend to naturally suffer this type of damage. They reseed readily in openings and the storm damage has no effect on the overall birch population.”

Relieved that our forests were not on the verge of destruction, I went back to the web to read more about the drooping gray birch. There I found this wonderful essay written and read by Robert Finch as part of his NPR series Cape Cod Notebook. Although I encourage you to head on over and listen to this lovely essay in toto, here’s a bit of what Finch tells us:

If there’s a tree version of “white trash,” I suppose it would be the gray birch – tough, stunted, scraggly, generally disparaged, yet fertile and tenacious… After ice storms they’re often the most pitiful-looking trees in the neighborhood. Their thick heads of fine twigs and branchlets catch and hold the flying ice like nets, and bend the narrow trunks over into attitudes of despair.

Perfect description, Isn’t it? “Attitudes of despair.” Here’s more from Finch:

Robert Frost found a more hopeful and sensual image for this in his famous poem, “Birches,” where he describes their bent forms after an ice storm as being “Like girls on hands and knees that throw their hair/Before them over their heads to dry in the sun.”

You can read Frost’s entire poem here. Do read it. Like all of Frost’s poems about nature, it is also about life.

Don’t you just love the internet? You start out searching for tree disease information and end up learning the poetry of Robert Frost.

Category: Considerations

What’s Best? Blueberry Cake w/ Lemon Sauce

What could be better than fresh Vermont blueberries you stopped to pick along the way home from picking your daughter up at camp?

How about getting this wonderful little cookbook (© 1951) from said daughter, who bought it for you at a thrift shop in Brattleboro while on a camp field trip?

Or better yet, how about finding in that cookbook an amazing recipe for blueberry cake with lemon sauce?

But do you know what’s really best of all? I’ll tell you…

Blogging again, that’s what!

Blueberry Cake with Lemon Sauce
This was hands down the lightest, moistest cake I’ve ever made. It may have been the fact that today was incredibly hot yet not very humid. Or that I really did sift the dry ingredients three times. I’ll have to try the recipe again on a cooler day and see if I get the same results. And the lemon sauce – to die for. Let me know if you can think of other uses for this sauce. It is truly special – the combo of lemon and nutmeg really works.

1 1/2 cups fresh blueberries
2 cups flour
2 tsp baking powder
1/4 tsp salt (I used a scant 1/2 tsp kosher salt)
1/2 tsp cinammon (I accidentally left it out, and it was fine)
1/2 cup butter
1 cup sugar
2 eggs, separated
2/3 cup milk
Lemon Sauce (recipe follows)

  1. Wash and drain berries. Dust with 2 tbsp of the flour.
  2. Sift dry ingredients, including remaining flour, 3 times.
  3. Cream butter until light, add sugar gradually, and beat until thick and lemon-colored.
  4. Add well beaten egg yolks. (I didn’t beat first, just added them one at a time.)
  5. Alternately, add milk with dry ingredients, beating well. (I beat just enough to incorporate, being careful not to overbeat.)
  6. Fold in stiffly beaten egg whites.
  7. Fold in blueberries.
  8. Bake in a well-buttered and floured 8×8 inch cake pan about 35 mins in 350 degree oven. (I ended up with too much batter for this pan, that’s how light this cake ended up. I had to cook it a little longer to get the middle set. Next time I will use a slightly larger pan.)
  9. Remove and let stand 5 minutes before removing to wire rack.
  10. Serve hot with lemon sauce.

Lemon Sauce
Cook 1/2 cup sugar and 1 tbsp flour in1 cup boiling water over double boiler for 10 minutes (I ended up putting it directly over heat to thicken it up). Add 1/2 tsp nutmeg, 2 tbsp butter, and the juice and grated rind of 1/2 lemon.

Category: Food

Cell Phones in NYC Public Schools

Those of you not living in NYC may not know, but our mayor recently instituted mandatory random security scanning of middle school and high school students. In addition to confiscating weapons, they are also confiscating cell phones, because cell phones are banned in schools here.

I don’t have a problem at all with random security scanning to keep weapons out of the schools, or with banning the use of cell phones during school hours. But banning the carrying of cell phones is just ridiculous. Every kid in NYC, including mine, carries a cell, which my daughter uses almost exclusively to call me as she wanders the city throughout her day to and from school and to after school activities.

So unless they let her check the phone at the school door the way they do at the courthouse, she’s going to have her cell phone in her backpack or locker. Because there is no way that I am sending her out every day without some way of keeping touch with her. Call me crazy, neurotic or overbearing, but that’s just the way it is. I know kids survived without cell phones in the past, but the past became officially over on 9-11-02.

I wrote to the chancellor’s office opposing the cell phone ban, and here was the reply I received today via email:

Thank you for writing to Chancellor Klein regarding the Department of Education’s policy on cell phones. The Chancellor received your correspondence and he has asked me to follow up with you on this matter. I am responding on the Chancellor’s behalf.

While we sympathize with your concerns, it is the experience of many of our principals and teachers that if phones are allowed into school buildings, they will be used inappropriately….whether it takes the form of talking, e-mailing, messaging, taking photos or playing video games.. cell phones inevitably disrupt the school’s learning environment.

Students use cell phones during the school day in cafeterias, hallways, and even classrooms for reasons other than crucial communications with parents and guardians. Aside from simple disruption, students have used cell phones for far more serious offenses. In the past, for example, students have use cell phones to rally support during fights, to cheat on exams, and to take illicit photos of schoolwork or people.

In addition, students are not the only ones who are complicit: non-essential calls from parents regarding chores or reminders, for instance, are among the leading disruptions caused by cell phones in schools.

All of these situations negatively impact the learning environment and cannot be tolerated, which is why nearly all school leaders in our community agree with our policy banning cell phones from schools.

Parents should remember that they can reach their children when necessary at any time during the school day through the principal’s office or the school’s parent coordinator. We do not pretend this policy substitutes for the convenience offered by cell phones, but it does help ensure a far more stable, serious, and focused atmosphere for learning.

We are sorry for any inconvenience or hardship this policy causes you and your family. Please know that it exists solely for the purpose of maintaining safety and order in the school building. If there is a medical or other compelling reason that you feel requires you or your child to have a cell phone, please speak to the principal about it so that appropriate arrangements can be made.

Thank you again for writing the Chancellor.

When I was in high school. some kids used to pass notes to cheat and stir up trouble, but we didn’t ban the use of paper and pencil in response.

There is a rally at City Hall on May 11 at 4:30 pm for parents and students opposing the ban. Trust me, it will be well attended by parents and students. In the meantime, if my kid gets ger cell taken away during a random security screen, we’ll deal with it.

And I’m curious – for those of you with kids in schools outside of NYC, – what’s your district policy on cell phones?

Category: Considerations

AMA: That American Marketing Association?

I recently posted about a marketing scam called the National Honor Roll, and how my daughter was scammed into giving them her personal information through a school-based “college survey.” I was outraged, my daughter was outraged, and her school was outraged.

Turns out I’ve been scammed by the American Medical Association in pretty much the same way for over 20 years.

Last year, I became aware that Big Pharma tracks every prescription I write. Apparently, marketing companies obtain prescription data (absent patient identifiers) from large drug store chains and insurers. They then sell that information to pharmaceutical companies, who use it to target their marketing and sales force efforts.

What I did not understand until I read this article in the NY Times last week was that this information is fairly useless until it becomes merged with my corresponding personal information collected by the AMA. The AMA keeps something called the Physician Masterfile, a longitudinal tracking database on every doc in the US. You physicians know this – the AMA sends you the update forms and we all diligently fill them out, year after year, and send them in.

I never officially joined the AMA, having become a doc around the same time that it became known that the AMA got rid of the tobacco stocks in their portfolio only after their holdings were exposed by the press. But I have faithfully sent in my updated physician information to the AMA every year, thinking that somehow it was part of something bigger than myself.

And in many cases, it is. That database is used by academics, health departments and others for research, medical licensing and public health activities. And that’s just fine with me. What I object to is the fact that the Physician Masterfile is also licensed for marketing use.

I guess I should have realized it years ago. I must get 20 pieces of junk mail at my office a day, all of it selling me something. How else would all these companies know I existed? Truth be told, the AMA is quite open about the Physician Masterfile and it’s uses on their web site:

For more than half a century, the AMA has made the AMA Physician Masterfile available to the health care community to serve the public good and medical industry. Today, the AMA has contractual arrangements with Database Licensees who specialize in direct mail, marketing services, the management of complex pharmaceutical call reporting systems, data integration services, and other health-related and research activities. These sophisticated organizations offer high tech computer processing and file maintenance, as well as the development of new types of information products and state-of-the-art techniques for direct marketing. Users of the AMA Masterfile include: large pharmaceutical companies, hospitals, medical colleges and universities, medical equipment and supply companies, consultants, market research and investment firms, insurance companies, and commercial organizations.

The NY Times says that the Physician Masterfile nets 40 million dollars annually for the AMA. It is no surprise, then, that the AMA is doing their best to protect its licensing agreements from legislation aimed at restricting Big Phama’s access to presciption information. They’ve created something called the Prescription Data Restriction Program, with which they hope to appease legislators and doctors who are trying to control the flow of personal information. Again, from the AMA website:

The Prescribing Data Restriction Program (PDRP) will take data away from reps and their direct supervisors, but leave it available to the company for marketing, compensation, and research. The rules allow the industry to retain access to prescribing data for most purposes, but they require companies to police their own sales forces. If they succeed, legislators will turn their attention elsewhere, and the industry can hang onto one of its most valuable data sources.

I have my doubts about the PDRP. I don’t trust Big Pharma one bit to police itself or limit the use of the Masterfile information. And I really resent the sale of my personal information by the AMA. The AMA claims that physicians could always opt out of sharing information for marketing by phone, mail or fax. But not to sharing their Masterfile data with Big Pharma.

As of July 1, bowing to pressure from physicians and groups such as the American Academy of Physicians, the AMA will give also me the option to prevent my information from being shared with pharmaceutical reps. But that’s not enough. Because they will still be allowed to share my information with pharmaceutical companies for marketing research and other internal uses. I don’t have an opt out for that. And that’s just not right.

_________________________________________________________

Here’s how to do a limited opt-out of the the AMA Masterfile:

By E-mail
nocontact@ama-assn.org Do Not Release: norelease@ama-assn.org

By Phone
Call (800) 621-8335 Fax* (312) 464-4042

By Mail (requires signature and professional letterhead)
Department of Data Quality and Measurement
American Medical Association
515 N. State St.
Chicago, IL 60610

By Web
No Contact: www.ama-assn.org/go/nocontactform
Do Not Release: www.ama-assn.org/go/noreleaseform

Category: Second Opinions

Would You Give Me Samples?

(From the movie “Rent”. Click on link to view video in Real Player)

Note: This is an old post, lost in the site crash and re-posted today.

We have a new Drug Sample Policy here. It requires drug reps to make appointments rather than walk in unannounced. They must log in their samples. I must adhere to certain guidelines regarding storing, labeling and recording the samples I dispense. Also, we are officially no longer allowed to accept anything, not even pens. And no drug lunches, of course.

I believe this is a good thing.

These are a few things I have noticed since the new regulations (which I helped write) went into effect.

1. There are less samples in the closet. But I seem to have all I need.

2. I think twice. Because it is more work for me, I now think twice before handing medication to a patient who has a good drug plan and can get it at the pharmacy anyway. I still give out samples to those for whom it makes a difference financially.

3. More rep face time. This was unexpected, but really when you think about it, should be no surprise. Before, although reps may have shown up unannounced, I was also really good at avoiding them. Now, they get a fixed slot in my schedule to come to my office and pitch. And I’m not happy about this.

So last week, in a burst of righteousness, I turned down a whole bunch of Imitrex samples from the drug rep who visited. Because the truth is, the only person using the Imitrex samples in my office was me. The reps know I get migraines, and that I can’t accept gifts, so I decided that they must have been using the Imitrex to worm their little way into my heart (and my prescription pad). So I turned their dirty drug samples down.

But now I have a migraine, and no Imitrex, because I didn’t get my act together enough to get my own stash from the pharmacy. I think I’ll head down the hall to my friend the neurologist, who keeps a stash of Imitrex in her exam room closets. At least I won’t have to use the fire escape.

Category: Second Opinions
__________________________________________________________________
COMMENT-AUTHOR:medstudentgod, May 03, 2006
Well done!!! I’m glad to hear that there are offices out there that are taking the drug rep situation under control. Being a student I have seen them weasle their way around the office, act genuinely concerned about MY well being (despite having never met before) and dishing about all their samples to students. All of this is done, no doubt, to decrease student security safeguards when they become actual physicians. Therefore they are more apt to prescribe certain, expensive, new drugs without really knowing why. Thanks for your continuing discussion on this important topic.

COMMENT-AUTHOR:mchebert COMMENT-DATE:May 05, 2006
I am not as concerned about pens and lunches as you are, I guess. Drug reps are not the enemy. They just need to be counterbalanced.

But I have to ask the question, you use the passive voice here, as in “we are officially no longer allowed to accept . . .” Does this mean, TBTAM, that the decision was made by you, or do you work for someone who made the policy?

COMMENT-AUTHOR:TBTAM COMMENT-DATE:May 05, 2006
The new policy was handed down from the powers to be. I was asked to help write our department-specific guidleines following the new policy.

And you are right – they are not the enemy. I get a little carried away sometimes…

Grilled Fish w/ Mango Citrus Sauce

I know, I know. It’s been ages since I posted anything about food.

Finally, here’s a recipe for a delicious dish Mr TBTAM and I made together last night. It was nice to get some quality cooking time together…

Grilled Fish with Mango Citrus Salsa

We got the recipe from a great little site called Mango Recipe Guide. We used Mako Steaks and served it on a bed of rice with a side of brussel sprouts (blanched, cut and sauteed with a little onion, balsamic vinegar and mustard) and a nice Pinot. I don’t know if you can see the fish up there under all that salsa, but trust me it is there. You can use any fish, really. I think it would have been even better with Telapia, my latest favorite fish.

GRILLED FISH & MANGO CITRUS SALSA

For Fish
1 1/2 lbs. fresh fish (tuna, swordfish, mahi mahi)
3 tbsp.fresh squeezed red grapefruit juice
3 tbsp. white wine
2 garlic cloves, minced
1 tsp. cumin
1 tsp. chili powder
1/2 tsp. dried leaf oregano
1/2 tsp. sea salt
1/2 tsp. coarsely ground black pepper
1/3 cup olive oil
2 red grapefruit, sectioned for garnish
2 large mangos, peeled, pitted and sliced in 2 ” wedges

Mango Citrus Salsa
1 red grapefruit, peeled and sectioned
1 large mango, peeled, pitted and cubed
1 jalapeno pepper, seeded and minced
1 1/2 tsp. sugar
1/4 tsp. sea salt
1 cup diced green, red and yellow pepper
1 large orange, peeled and sectioned
1 medium tomato, diced
3 tbsp. chopped red onion
1 tbsp. chopped fresh cilantro

Place fish in large, shallow dish. Combine in small bowl, juice, wine, garlic, seasonings and olive oil. Blend well. Reserve 2 – 3 tbsp. for basting and pour remainder of marinade over fish. Chill for several hours, turning occasionally. Prepare salsa by combining all salsa ingredients in medium bowl. Grill fish about 6 inches from heat, basting with reserved marinade. Cook until fish flakes with a fork, allowing 10 minutes per inch of thickness, and turning once. Transfer to serving platter. Drain extra juice from salsa and spoon 1/2 cup salsa over each serving of fish. Garnish with grapefruit and mango slices.

Category: Food

Snaps to Brown University

I got a call from the on-campus Pharmacy at Brown University today, requesting refills on my patient’s birth control pills. Turns out Brown University is one of only 2 campuses in their state who have an on-campus pharmacy, which is affiliated with the campus Health Service. I’m sure that a lot of their business is antibiotics and other medications needed by the students there. But I’ll bet they fill a lot of birth control prescriptions. And I think that’s just great.

Anything we can do that removes a barrier between young people and contraception gets snaps from me. Most college health services require you to leave campus and go to a local pharmacy to fill your presriptions. Here in the big city, that’s not too much of a problem. But put a college in the middle of nowhere, and for students without a car, that’s a significant disadvantage. Some schools get around it by giving out pills for free through subsidy programs, which is even better. But if you can’t do that, an on-campus pharmacy is the next best thing, as far as I’m concerned.

And though I focus on the contraceptive issue (after all, it’s what I do), it’s even more impressive that kids with conditions like asthma and diabetes can get their meds right on campus.

What are snaps? Well, if Legally Blonde 2 was showing at your house two times this weekend (once with your younger daughter and her sleepover friend, and the next day when your older daughter insisted on seeing it before it went back to the video store), you would know…

Acupuncture and Infertility – The Jury is Still Out

Three separate studies on acupuncture in IVF patients were published this month in Fertility and Sterility, the premiere journal for reproductive endocrinologists. (You can’t link to full text without a logon, but abstracts are free.) One of the studies suggested that acupuncture improved IVF outcome, the other suggested that one, but not two, treatments was effective (that result made no sense to me), and the third study showed no difference. There were design flaws and issues with data interpretation that make all the results questionable.

Still, it’s good to see research on acupuncture. Hopefully, the design issues can be straightened out so that we get reliable data one way or the other.

Category: Second Opinions

Let’s End the Stigma of Herpes

“Jane, you have a herpes infection.” I say the words calmly, almost casually, but not lightly. Because I know what is coming next. The eyes that fill with tears. The sheer devastation as her world crashes down around her…

Why do we let this virus do this to us?

Herpes is a virus, just like influenza and chicken pox. It doesn’t discriminate. It looks for a mucus membrane to infect, and could care less whose mucus membrane it is.

Did you know that the genital herpes virus is the very same virus that causes fever blisters? (There are two tyes of Herpes, Type I and Type II. Type I has historicaly been associated with oral herpes, and Type II with genital infections, but they can each be found in one another’s territory.)

When I tell someone they have a fever blister, they barely flinch. So why is it when I tell them they have the very same infection in the genital area, they cry?

Maybe it all goes back to the shame we feel about our genitalia. Bardiac tells us that the origin of the word “Pudenda” (Old English for female genitalia, and the name of the nerve that supplies that area) is Latin for “Shame”.

Infection of the oral mucosa. Annoyance. Same lesion, same virus, on the genital mucosa. Shame.

And blame.

When you get a cold, do you pass judgement on the person who gave it to you? Wonder what kind of friends they have or what sort of other women they have dated? Even worse, break up with them?

And yet, I’ve seen it more than once or twice – I tell the woman she has herpes, and the guy, who probably was the one who gave it to her, breaks up with her. Well, good riddance, I say. He failed the herpes test, a true measure of a relationship.

It’s starting to be more and more ridiculous, this stigma around this virus. Do you know that most newly diagnosed cases of genital herpes these days come from transmission of Type I herpes to the genital area (because no one cares about fever blisters, remember)? So now, we are now feeling shame from getting a virus we got because we didn’t care about it in the first place…

If it’s the infection itself that upsets you, let me tell you that there are great drugs that can control the genital (and oral) outbreaks, so that the infection, frankly, is little more than an occasional minor nuisance to almost everyone of my patients who has it. And please be careful about letting Big Pharma tap into your shame to sell you daily medication. Use episodic treatment, along with a little sexual prudence, and you’ll do just fine.

Just in case you think I don’t know what you herpes sufferers go through, let me tell you that I’ve had fever blisters my whole life, along with most of my brothers and sisters. We probably all got it from my mom. I feel no more ashamed of myself for having fever blisters than you should for having genital herpes. Not to mention you have an advantage in that you don’t have to worry about herpes ruining your wedding photos.

Sure, I have to be careful not to kiss my kids or have sex with my husband when I think I am getting an outbreak. And I know that, despite all my care, they may get the virus from me anyway. But that’s life (and love).

Of course, take love out of the picture, and the whole thing changes. Which is why herpes is, as I said before, a good test of a relationship. And if it causes you to only have sex with someone you really care about, and who really cares about you, well, is that such a bad thing?

So stop feeling ashamed of yourself, and get out there and find someone to love. And remember, it’s just a fever blister in a different place. Nothing more, nothing less.

Category: Second Opinions