Interesting public endorsements of marijuana research or legalization

I was actually pretty surprised that California voters voted down an initiative that would have legalized marijuana in the State of California (I mean, California!?)  Personally, I think it's medicinal use should be weighed against it's known side-effects just like any other medication.  I doubt many patients would want to take a prescription pill for pain that could cause drowsiness, multitasking problems, lowered sperm count or increased appetite.  However, research on marijuana as a medicine has been limited by its illegality.  It's pretty tough to do clinical trials in which the participants in the study have to admit to committing a crime.

Marijuana Majority (h/t Boing Boing) is a pretty interesting website on endorsements regarding the legalization or legitimization of marijuana research and/or use.

I'm not surprised to see endorsements from Willie Nelson or Kanye West, but I'm gratified to see endorsements from the California Medical Association and the American Medical Association.  On the other hand, I'm more surprised the see endorsements from The Economist and the Financial Times, not to mention from so many prosecutors and law enforcement officers.  And Glenn Beck?  Sarah Palin?  Wow.  Just wow.

I never thought Pat Robertson and I would agree on anything.  Who knew?  Mysterious ways, indeed...

Fatalities Linked to Monster Energy Drinks

Bloomberg News is reporting five recent deaths in young people who drank Monster shortly before their deaths.  The FDA notes that these are voluntary reports and allegations at this time.

The concern is that energy drinks can contain very large amounts of caffeine; far beyond standard cola beverages or coffee drinks. ER doctors treated over 13,000 patients in 2009 between 18 and 25 years old for symptoms involving energy drinks with or without other substances.

Currently, labeling the caffeine content is not required since the drinks are marketed as dietary supplements and not foods or drugs.

Should Lance Armstrong Still Be a Hero to Cancer Patients?

Armstrong has already been banned for life from cycling and lost his Tour de France titles due to overwhelming evidence that he cheated during those years by using performance enhancing drugs, including anabolic "body-building" steroids.

His comeback win in the Tour de France after diagnosis and treatment of metastatic testicular cancer was lionized, and he went on to found the Livestrong foundation for cancer survivors.

At 28 years old at the time of his diagnosis, he would not have been unusually young for it.  Testicular cancer is the most common malignancy in men of the 20-34 year age range.  On the other hand, using anabolic steroids with an undiagnosed testicular cancer would enhance its growth and spread in the same way that a woman on hormone replacement would fuel the growth of an undiagnosed ovarian or breast cancer.  Whether the steroid abuse could even outright cause a testicular cancer is not well known, but certainly it has been linked to pituitary gland, prostate gland and liver cancers.

As this article points out, using blood-doping agents and blood transfusion was not a common or particularly available practice early in Armstrong's career.  This leads to a real question of whether Armstrong's use of steroids caused or stimulated his testicular cancer.  I'd agree that anyone who can come out the other side of metastatic cancer has had to use some incredible internal resources.  On the other hand, I'm not so sure it's a good message to send cancer patients and young athletes to have Armstrong continuing to be so visibly involved in Livestrong at this  point.

Barry Ritholtz on George Carlin

Barry Ritholtz, one of my favorite economics daily reads comments on his use of George Carlin to proffer investment advice.  The advice itself is posted in the Wall Street Journal's Market Watch, and is a good read about investing and also about the human condition.

Barry goes on to cite and link to George Carlin's epic rant on The American Dream.  IMHO, truer words never spoken.  NSFW, and waaaaay before "the 1%" became a household word.

Technology in Medicine

This is a thoughtful piece in the New York Times discussing the evolution of technology in medicine.  It is less about breakthroughs in imaging or surgical techniques than it is about the role of technology at the bedside and the continued value of physical examination and of human rapport.

It is particularly evocative to me because of my somewhat unique place within the history of contemporary medicine.  As a doctor in practice now for twenty years, I trained at a time when many of my teachers were incredibly skilled in the physical examination.  Dr. Shaver, the cardiology professor, was famous for being as accurate as and echocardiogram.  For that matter, the echocardiogram was relatively new.  The safety of fetal ultrasound was still not known.  I assisted in as many open gall bladder removals as laparoscopic one because laparoscopy was cutting-edge at the time, no pun  intended.  At the same time, medical students were beta-testers of a program to help doctors make difficult diagnoses based on symptoms and findings such as physical exam abnormalities or blood test or X Ray results.  In other words, I entered medicine at a time of tremendous change in the development and use of technologies and also the very ways in which medicine is practiced.

Like the younger doctor in this article, my "ectopic brain" of pocket-sized books and cards has been happily replaced with an iPhone and dozens of incredibly useful medical applications. Like the older doctor, I have learned the real value of time spent with patients in gathering useful information, performing a skilled examination, establishing real and lasting trust, and coming to agree on plans and treatments.  Like both doctors, I have used electronic medical systems for years, but since I can't touch type and maintain eye contact with patients like the younger doctor (40-60 wpm, thank you very much), I rely on note taking and voice recognition transcription.

Something not really addressed in this article is the incredible opening of information available to everyone on the internet.  I think it's great that patients are now able to find useful information or share it without having to go to medical libraries to find it.  Internet information requires as much critical thought as any other kind, but an interested patient is an informed patient!

MediCare Open Enrollment is October 15 through December 7

Coming into the end of the year, this is your chance to change or enroll in a MediCare Part D plan.  Part D is optional, and adds coverage of prescription medicines through a number of commercial insurance companies in conjunction with MediCare.  MediCare Part A and B continue to cover hospital and outpatient medical needs such as hospitalizations, surgeries, doctor visits, lab tests or X-Rays.

The Part D Plan Finder is an easy way to identify plans you might like based on your zip code, the medicines you take, and what pharmacies you use.

These plans generally cover generic pills, so you mainly want to look at coverage of brand name pills you take, or ones that are shots or inhaled, since these tend to be the most expensive.  Also, please feel free to ask us if less expensive but equally good medicines are an option for you.

Please, please, please remember TANSTAAFL.  There Ain't No Such Thing As A Free Lunch.  If it looks to good to be true, it is.

 MediCare Health Plans With Drug Coverage that have zero dollar deductibles and zero copays on medications are worth every penny.

AARP MediCareCompete SecureHorizons (HMO) is an HMO.  That's why it says (HMO) right next to the name.

We have found that it is nearly impossible to get tests scheduled or referrals authorized with this plan.  If you don't like "Canadian Socialist health care", don't pick this plan.  If you want a zero deductible/zero copay plan and don't mind waiting over 3 months to get an MRI authorized for your knee pain, this is the plan for you.

However, this is not the plan for us.  We will not accept or keep patients who carry this plan.  It is simply too time-consuming and aggravating to get necessary care for our patients with it.

"Be so good they can't ignore you."

Steve Martin (the comedian, actor and art collector) passed on some advice for aspiring performers that really seems to resonate for anyone trying to turn a job into a career that they actually find challenging, stimulating and enjoyable.

I bring this up because I have a lot of patients who are young and trying to get a leg up in a famously down economy.

The idea here is that over a 10 year period of time, he simply focused on how to do what he did really, really well.  It may be that becoming happy, recognized and well-compensated for what you do may be less a matter of looking for "the perfect job" than putting your head down and doing what your job calls for really, really well. 

h/t Lifehacker

The Value of Annual Physicals

I am always surprised to read articles questioning the value of annual physicals. (Such as here or here.)

To be sure, no one is questioning the usefulness of appropriate screening tests for diabetes, high cholesterol, high blood pressure or for breast or colon cancer.  The debate usually is around whether a distinct and separate visit purely for such preventive concerns is absolutely necessary.

Theoretically, nothing specifically keeps doctors from ordering some of these preventive tests during a visit for some other specific reason such as a cold or other illness, or for a follow-up visit for ongoing chronic conditions such as diabetes.

However, in reality this is not so easily accomplished.  There may not be adequate time to discuss such tests in an already complex visit (nausea and weight loss in an elderly demented patient, or recent car accident with neck pain, shoulder pain and suture removal needed are mere examples).  Helpful parts of the screening physical examination may not be called for at that time either (for example, listening for cholesterol build-up in the carotid arteries of the neck in a person being seen for hip and knee pain).

Also, some tests require more time, information or examination.  A normal mammogram is not reassuring if there is actually a breast lump that would be noted on a physical examination.  An acceptable cholesterol result is different for someone with a strong family history of heart disease or stroke than for someone else.

I, and many other doctors, find that the only way to make sure that adequate time and care can be given to the entire range preventive care is to arrange a visit dedicated to this purpose- the annual physical.  I think the fact that people are living longer and having fewer heart attacks and strokes suggests we're on the right track in doing so.

Over the past few years, more and more of my professional time is being spent on issues, concerns or problems that seem to be related to or caused by patients' stress.  I guess I'm not exactly surprised since I see a lot of older patients on fixed incomes, military families with household members on deployments and I practice in an area with a 12% or greater unemployment rate.

Certainly, this can be frustrating as it makes it increasingly difficult to stay on time (never my strong point, I admit), but even more so because I real feel for folks who are just flat out telling me they are physically and emotionally overwhelmed by stress related to financial, employment, medical or family problems or all of the above.

Increasingly, I am coming to view this as part of a big picture with no obvious solution in sight.

Growing up in a strong union heavy manufacturing town (Pittsburgh, PA), I remember what "speed-ups" were about.  This was a short-term increase in work hours that was agreed to by the union in order to complete a big job order for the benefit of both the workers and the company.  Lately, with everyone scrambling like hell to get the same amount of work done by fewer people the whole economy feels like a giant, permanent speed-up.

Added to this is a sense that no matter how hard you work, it's impossible to excel in your work without sacrificing your family life.  Or, vice versa.

Time War is now being coined to describe the conditions over the past 20 or so years that are leaving us all in a sense of continual uncertainty, instability and anxiety for the future.  A bit like the Red Queen in Alice in Wonderland: running as fast as you can just to not fall behind, plus the potential to just sink without a ripple.

As a doctor, I'm also affected by the same forces at play, but a lot less so than many and grateful of it.  Also, I've never been so happy to be self-employed.  At the same time, I agree with the authors of this article that there is a tremendous rush for a quick fix just to cope, just to "take the edge off".  This ranges from antibiotics for viral infections to sleeping pills for what often amounts to overwork.  Agreed: why is everyone on Ambien?

Solution? Hope for the future?  IMHO, I'd be happy to see it agreed that the new "full-time" is 25-30 hours a week.  This seems like a reasonable way for people to have gainful employ and a family life. Companies may have to hire more people to get current workloads accomplished, but that seems reasonable and would certainly employ more people (many of them skilled).  A change in work and/or public school hours would be great, since it's tough to raise children if their pre-school or public school hours are vastly different than work hours.  I see nothing wrong or prohibitive about matching work and school schedules more closely.

In the mean time, healthy ways of reducing or coping with stress include realizing what really makes your life worthwhile, and not stressing over the rest.

Some New Developments in Weight Loss

As you might expect, there is a lot of ongoing study on what causes obesity and how people can successfully reduce total body weight.  Particularly, there is a lot of interest in the role of certain hormones (leptin, for example) in regulating appetite and fat metabolism.

Overall, humans are very well evolved and adapted to be able to withstand famine.  This is a good thing if you get lost in the woods, but in normal day to day life, it can make it challenging to maintain a healthy body  weight.

In the last month or two, several interesting things have come out.

First off, is the confirmation based on large studies that food journals work.  This is not surprising in many respects since keeping a daily record of what you eat and how many calories it amounts to would be very helpful in staying within a calorie budget and also seeing where the most effective improvements could be made.

The problem historically has been that keeping a food journal has been really tedious: booklets, paper records, calculators and so forth.  Admittedly this is also tough to even get started with if you are worried that you are going to see "too much information".

Happily, the Internet can help with this.  Free applications are now widely available which allow you to state your gender, height and current weight, and then develop a daily calorie budget based
on how much you would like to weigh and over what amount of time.

The concept of a calorie budget refers to a daily net calorie intake that should allow you to succeed, based on calories eaten minus calories burned off.

Lose It! and myfitnesspal are both web-based applications that allow you to select from a large variety of fresh and pre-prepared and restaurant foods, and an extensive variety of activities and exercises.  Both of these are free, and both are available as free iPhone and Android apps as well.  Personally, I like Lose It! because it has an exhaustive list of exercises and activities including household walking, vacuuming, housecleaning and about ten different levels of yardwork as well as athletic activities ranging from running to archery to skiing.  My wife prefers myfitnesspal because it has a better selection of fresh foods and scratch meals.

For those of you who find daily fixed work-outs a bit boring, Sworkit is a pretty cool circuit training application that allows you to set up and follow a series of exercises from 5 to 60 minutes  focused on specific body areas or whole body.  It allows you to vary your work-out day to day, and even includes yoga sequences and core strengthening!  This is also available as an iPhone app (I don't happen to know if it's also in the Android Market).

Another big study seems to link low-carb diets with being helpful and keeping weight you've lost from coming back.  (Atkins had a point after all?) Lots of people have had the frustrating experience of working hard to lose weight, and then have it come back over the next months even though they are continuing to diet and exercise regularly.  Apparently, decreasing calorie intake and increasing activity and exercise helps to reduce weight, but your body quickly responds by reducing metabolic rate.  This means your body burns off calories at a lower rate and stores more of it as fat even though you are not doing anything differently.  The study looked at diets where 60%, 40% or 20% of the dietary calories came from carbs and found that the 20% calories as carbs diet was the best at keeping the weight off.  This seems to work by countering the aforementioned down-regulation in metabolic rate. Interestingly, fat intake was not restricted in this study.  The  weight loss apps I described above could also allow you to regulate carb intake for both weight loss and weight maintenance purposes.

Last, but not least, one of three new drugs in the pipeline recently obtained final FDA approval.  Qnexa is actually a combination of low doses of two already existing generically available drugs, phentermine and topiramate.

Phentermine has been used as an appetite suppressant for decades.  Topiramate started as a drug to prevent seizures, has also been found to be highly effective at preventing migraines and its most common side effect has been weight loss.

Please do not hesitate to ask about healthy weight reduction: I am very happy to discuss it and am delighted to see patients succeed in their efforts and also reduce their need for medicines for high blood pressure, heartburn or joint pain!

Interesting Reads

• The Economix blog of the New York Times on the problems with both "trickle-down" and "trickle-up" economics. (Hint: in balance, the money stays where it's accrued.)
• Boing Boing with a story of cow-related fatalities and how it reflects on the way we assess risk. (Why are we afraid of sharks and air travel, when cows and driving your car are clearly so much more dangerous?)
• Xeni Jardin, a blogger under treatment for breast cancer on science-based cancer treatment versus quackery.

Lyme Disease

Hot weather is indeed upon us. It's the season for brush clearing, outdoor activities and also for potential exposure to Lyme Disease.

Fortunately, Lyme Disease is not nearly as common in California as it is in New England and the upper Midwest. Also, even within California it is not very common in El Dorado county. In fact, it only has occurred in 0.9 in 100,000 people in El Dorado county from 2002-2011.

While there are plenty of deer and plenty of deer ticks here, it seems that the Western Fence Lizard helps to keep Lyme Disease itself from being as common as it otherwise could be.  Ticks bite these lizards, but there seems to be something in the lizards' bloodstream that then goes on to kill of the Lyme Disease-causing bacteria in both the lizard and in the tick!

Within El Dorado County, the areas where it is most commonly seen is above Ice House and around Folsom Lake and El Dorado Hills.

It is worth bearing in mind that most Lyme Disease exposures occur in March and April, mainly because that is when the nymph or immature ticks are born. They are the main vector of Lyme Disease in humans.  The nymph is on the right in the photograph: note the significant size difference compared to the adult on the left!

 The best ways to avoid tick bites are:

• Wear shoes, socks, and long pants especially when you are hiking or brush-clearing.
• Wear light colored clothing: it makes ticks easier to see.
• Don't allow leaf litter to accumulate in "border zone" areas of trees near your home: ticks like to live and breed there.

Removing a tick is straightforward.  Use some tweezers to grab the tick as close to your skin as possible.  Pull the tick firmly and straight out.  (Jerking or twisting the tick can cause you to tear off its body, leaving its head still embedded in your skin.  Do not burn or apply noxious substances to the tick; you can injure yourself, and also cause the tick to regurgitate into your bloodstream which is not good.)

Once you have removed the tick, wash your hands and the bite site with soap and water and apply an antiseptic to the bite site.

Please see us if:

• You can't remove the tick, or its head is still embedded.
• You develop a flu-like illness or rash within a month or so of a bite.

Another word on "Obamacare"

I posted the other day on so-called "Obamacare" otherwise known as the Affordable Care Act.

By coincidence, Lifehacker posted on the subject in the form of a concise Q&A which is rather more approachable than my posting.  While I don't agree with all the replies, the comment thread is at least interesting and civilized.

On "ObamaCare"

With the Affordable Care Act ("ObamaCare", as it is also referred to in the news media) back in the news cycle, I have been asked several times a day what I think of it, or how it is affecting me.

So far, I have no sort of problem with it.

• It has improved "doughnut hole" coverage for MediCare patients with Part D plans (medication coverage).  This has been good because I have a lot of MediCare patients and accept new MediCare patients. They are all on fixed incomes, and this has helped to ease the burden of their medication costs.
• It has allowed 18 year olds to stay on their parents' insurance until 26 years old, whether they are in college or employed or not.  This has been very helpful, since the job market out there for people in this age range is very poor.  I can now see these patients in my office, as opposed to them hitting the ER in crisis mode, which is more dire and more expensive to everyone.
• The SCOTUS has ruled in favor of the requirement for all citizens to carry health insurance.  Whether you wish to regard this as a mandate or a tax is irrelevant.  Simple math demonstrates that insurance systems that allow people to opt out will fail.  This is apolitical and simply due to human behavior.  In a system where people can opt out of health insurance, the ones who will carry it are predominantly people with existing conditions (which are expensive).  People without health conditions often opt out.  When they become ill or need care, the cost of their care is then assumed by the taxpayers. In the mean time, the insurance companies have to levy higher premiums because of the disproportionately high percentage of people they cover who are expensive to cover.  This makes relatively healthy people disinclined to carry insurance because of its cost.  And so on, and so on...
• Yes, this assumes that uninsured people needing medical care will nevertheless receive medical care.  That is going to remain the case unless we all accept the idea that doctors and paramedics and nurses are not morally or ethically (let alone legally) required to render care.  Aside from the fact that this would be contrary to the Hippocratic Oath, we should not really want medical professionals to be able to refuse care on the basis of risk that it will not be profitable!
• I received $600 in reimbursement for this year as a small business owner who has provided medical insurance to my employees.  I imagine other small business owners who insure their employees are OK with this, too.  I'm comfortable with this.  Now, if I can also get reimbursement because I also offer dental coverage and retirement...
• I can't see that requiring states to create single websites that make it easy for consumers to comparison shop for health insurance is any problem.  Sounds like Google Shopper or Amazon to me, and insurance companies certainly aren't making it easy to compare coverages and prices on their own.  Hopefully, this will eventually work into a way for individuals and small businesses to combine into larger shared insurance pools, since the premium costs would be much lower.
• Requiring insurances to provide birth control?  Can't see why that's even controversial: undesired pregnancy is expensive to everyone, and there is no requirement of women to take any form of birth control here.
• Insurance companies can no longer refuse to insure you because of already existing medical conditions or pregnancy, and they can no longer look for ways to drop you if you develop a medical condition.  Can't say I see any problem here either, since these behaviors have been scandalous and, in the latter case, illegal and unethical.
• Insurance companies must spend a certain proportion of their expenses on actual medical care.  That would be nice; it's what they're supposed to be doing. Perhaps it will incentivize them to make administration more efficient.  Right now, over 30% of US medical costs are administration and paperwork.

As stated in earlier postings, I welcome any attempt to improve the delivery of medical care in our country which until now is the 47th best in the world, while outspending the top 10 by 300% per capita and committing the most medical errors of the top 19 world economies.  Frankly, I would have preferred an approach like Germany which has a cradle-to-grave basic entitlement insurance and a very active, competitive and strongly regulated commercial insurance industry where anyone can buy as much (or as little) additional health insurance as they wish.

The only things missing or under-utilized in the Affordable Care Act are critical elements that are present in objectively and measurably better healthcare systems; federal regulation of insurance companies, and government-sponsored medical treatment and device testing.  These were discussed, but went largely off the table due to cries of "big government" and "socialism".

I think Germany's approach is sound here: the German government does not permit insurance companies to raise annual premiums by more than 5-6%/year unless they can prove that the increase is warranted due to actuarial costs.  This keeps them from simply increasing premiums for pure profit motives. The lack of this regulatory oversight in the US could result in insurance companies increasing their premiums to defray the costs of changes required by the ACA.

Clearly, it is not good to have a medical research system as we do in the US in which the majority of medical research is funded by drug companies.  It is certainly known that drug companies only fund applied studies that might be to their benefit, and do not publish studies that result in unfavorable findings.  Nor would one expect a publicly traded for-profit corporation to do otherwise. I do not object to drug company sponsored research, but I think it is the role of federal government to fund or perform academic research, and also studies of head-to-head comparisons of different drugs or treatments and to make the findings widely known to doctors and patients.  It is telling that one of the largest US insurance companies (United) routinely sends its doctors such study findings based on UK research and not US research for exactly this reason.

At the individual level, the Obama administration's concerns for primary care doctors and especially rural ones has resulted in a satisfying increase in MediCare payments which I think is only right since rural primary care doctors have been historically the most lowly paid of all doctors in the US.

Have a great weekend!

On the Strength of Generalism

I was reading this article published in the Harvard Business Review over breakfast (yes, seriously) and found it to be a well written essay that reminds me of why I chose to be a family physician.

Admittedly, I have been a generalist by nature well before medical school. 

My high school required sciences and math through all four years, but I also took music and foreign language electives in all four years (and also typing for a semester, which turned out to be well worth it).

My college years focused on biochemistry, but came to be the broader study of ecological relationships between insects and plants.  However, I also took or sat in on a number of elective courses which have benefited me to this day.  Memorable favorites included calligraphy, music theory, welding, Western philosophy, Buddhism and an ROTC course in asymmetric warfare (I was not in ROTC, which made this pretty interesting).

I think all this simply confirmed an overall impression that everything really is connected to everything else.  Or, maybe everyone really is within seven social relationships of Kevin Bacon!

So, by the time I went to medical school I had no doubt that I wanted to be a family physician.  Why would you want to know 99% of one specific thing when you could know 85% about every thing?  To each their own, but I get variety in every day and always look forward to going to work.

(h/t The Browser)

Interesting Reading

• 

• Prejudice is a disadvantage. (Science Daily, h/t The Big Picture)
• Biomechanics are crucial to great running. (Wired)
• If you're going to use pass-phrases instead of passwords, use randomly selected ones. (Boing Boing)
• Requiring employees to work over 40 hours a week is bad for your business. (AlterNet)

Early Warning Signs of Cancer

News since last summer that raise real questions about the usefulness of screening for prostate cancer in men, and breast cancer screening in women under 50 years of age should not seem entirely negative.

It really helps to point out that in many cases it is more important for patients to be aware of some of the early warning signs of cancers. Do realize that in many cases, there may be perfectly benign causes for a particular symptom. However, consideration should be given to cancer as a possible explanation. Certainly, getting this checked out early is better than later.

Here are some common early warning signs of various cancers. Please note that most of the time, cancers do not cause pain early on. Also, enlarged lymph nodes from cancer spread are generally not tender or painful.

Brain Cancer:

• Unusual headaches, especially ones that cause vomiting or wake you up out of a sound sleep. (By unusual, I mean not a bad migraine in someone who has a long history of the same migraine headaches.)
• Personality or behavioral changes.

Throat Cancers:

• Pain, unexplained coughing or hoarseness. (Yes, GERD or "heartburn" is a common cause of cough, but so is cancer.)

Lung Cancer:

• Shortness of breath, coughing up blood.

Breast Cancer:

• Breast lump, blood or discharge from a nipple, reddened skin with the texture of orange peel, lymph node enlargement ("swollen glands") in the armpit.
• Blood from a nipple is never good.

Esophagus or Stomach Cancer:

• Loss of weight and/or appetite
• Things getting stuck during swallowing
• Feeling full easily
• dark black, tarry bowel movements
• throwing up blood

Liver Cancer:

• Nausea, bloating
• Loss of appetite, especially for cigarettes!

Colon Cancer:

• blood in your bowel movements
• sudden changes in your bowel movements
• loss of appetite and weight

Cervical, Uterine, Endometrial Cancers:

• unusually heavy bleeding
• bleeding after menopause

Ovarian Cancer:

• abnormal vaginal bleeding
• nausea, abdominal bloating (note how many benign things can also make you feel nauseous and bloated!)

Prostate Cancer:

• Noticeable development of difficulty getting a stream of urine started
  
• dribbling, interruption or hesitancy in stream
• Feeling like you can't completely empty your bladder
• blood in your urine

Skin Cancer:

• asymmetric border
• border that is wavy or notched
• color that is black, varied or pearly
• diameter larger than 6mm (end of pink pencil eraser)
• enlargement observed

Leukemia/Lymphoma (cancer of bone marrow or lymph nodes):

• easy bleeding or bruising
• weight or appetite loss
• lymph node enlargement
• night sweats

Please do not hesitate to see me about symptoms that may be a warning sign of cancer. You are not "taking up my time"!

What is normal sleep?

As posted on before, it is quite likely that the expectation of 8 hours of uninterrupted sleep was not biologically or historically normal until the industrial revolution imposed it artificially.

This discussion in the BBC's website (h/t Boing Boing) describes further how historical writings, diaries and anthropological study demonstrate that people normally slept in separate four hour blocks often with a few hours of activity in between alone or with others.

I must admit that it makes me wonder about the extent to which industrialization has been all progress!

Misdiagnosis

A contributor to Kevin, M.D. has an interesting post, which also comments on the writings of Dr. Jerome Groopman who has published on the patterns of physician errors in decision-making. I posted on Dr. Groopman's book before, and highly recommend it.

Overall, I agree that correct diagnosis or identification of medical problems is an art as well as a profession. Additionally, I do see that things that can make this more difficult than it already is include inadequate communication and over-reliance on technology.

On the other hand, most of this knowledge should be imparted in medical school and residency training. A great deal of medical education includes learning what lab and imaging studies can do, and what they also cannot do.

I am happy that my teachers imparted several valuable lessons for which I remain grateful and have helped me a great deal:

• "Let the patient talk for at least the first several minutes without interruption." (No one likes to be interrupted, and you'll learn more about what you want to know.)
• "90% of arriving at the correct diagnosis is based on adequate history-taking. Examination and tests rule-out or confirm your impressions." (This is the time-consuming asking of the right questions and paying attention to the answers. This is never wasted time.)
  
• "Ask whether the patient has any questions." (It's polite, and also helps to make sure everyone involved is "on the same page.")
• "Ask the patient what they think is going on: at least half the time they'll be right and save you a lot of trouble." (Yep, pretty much!)
  

For My Military Patients: On Imminent Danger Pay

As one of the very few local docs who sees active duty and military personnel and families, I have gotten some recent concerns or comments about changes in imminent danger pay.

This posting from Kit Up seems to address this nicely, and also provides a useful link and commentary.

(Credit: the graphic is the logo for Danger Close games.)

Interesting Reads

An interesting piece on the evolution of Japanese takes on Western cuisine and apparel. (Wall Street Journal)

The Surgeon General offers a way to create a family medical history; your taxpayer dollars at work! (Health and Human Services, h/t Kevin, M.D.)

Really cool interactive graphic comparing the size and scale of things from quantum foam to the observable universe! Who knew the Grand Canyon is bigger than Rhode Island? 4Chan, h/t Boing Boing. Requires Java)

Just for a hoot, calculate how long it would take for Mitt Romney to make your annual salary. (Slate, scripting required)

Treating Common Warts With Duct Tape

Common skin warts are actually caused by a virus. Your immune system will eventually get rid of the virus and allow your skin to return to normal. The catch is that this can take about a year!

If you don't want to wait that long, there are a number of ways to get rid of them. Freezing them with liquid nitrogen or surgically removing them can be done by me in my office. (Unfortunately, that freezing spray that you can buy over the counter is just not cold enough to get rid of warts, and the acid treatment often fails and is kind of painful.) Aldara (generically known as imiquod) is a prescription cream that can work, and does not sting or burn. However, it is very expensive and not covered by most health insurances.

As an intriguing alternative, duct tape may work (this link is for a technical audience and may require free registration) in getting rid of warts. Yes, duct tape: 101 uses, now 102!

There are only three clinical studies on this, though that's kind of interesting since you could imagine there would be none. The effectiveness is not 100%, but it also doesn't seem to be harmful either. The idea is that covering warts with duct tape causes localized inflammation and irritation, which in turn stimulates an immune system response that helps in getting rid of the warts. This is supposed to be how freezing warts works, too.

The treatment with duct tape in clinical studies is:

1. Cover the wart with a piece of duct tape for seven straight days.
2. Then, remove the tape for 12 hours overnight.
3. Repeat Steps 1 and 2 as needed for up to 6-8 weeks.

Again, there are no wart treatments that are 100% effective. However, this method can be helpful and seems otherwise to have no harmful side-effects unless you are simply allergic to duct tape.

Interesting Reads

Warren Buffet on the risks of bonds assets (ditto from Black Rock): (Bloomberg).

Interesting analysis of the Obama presidency to date,through the lens of the history of modern U.S. Presidents: (Atlantic).

Yves Smith on why the bank bailout sucks: (Naked Capitalism).

Matt Taibbi says "cry me a river" to Wall Street bankers: (Rolling Stone. profanity alert- it's Taibbi)

Could You Pass a U.S. Citizenship Test?

Just for hoots, try passing this 96 question citizenship exam found posted in that hotbed of communist sympathy the Christian Science Monitor.

All applicants for citizenship must pass a Naturalization Test, scoring at least 60% correct. 92% of applicants do so. Have a go at it!

Why Don't You Use a Computer?

I get asked every now and again by patients (usually while I'm writing in their chart) whether I plan to go to a computerized medical record.

I find that to be a really interesting question. Generally, I am a very enthusiastic computer user. I create web content, enjoy computer games, am versed in maintaining and securing wireless networks, and am proficient with several operating systems.

However, I have no plans to adopt "Electronic Medical Records" (EMR) unless they become far more useful than they are at present.

First of all, adopting EMR is shockingly expensive. Start up cost of adding new hardware, licensing software, training staff and doctors in their use and scanning existing paper records to EMR is about $50,000 in itself. This does not include future licensing or upgrades to equipment or software. It also does not include the 10-20% losses in income of the first 1-2 years of adoption due to a decrease in the number of patients that can be seen, as the implementation of EMR slows everything for 1-2 years.

Additionally, there is no widely accepted standard code set or open-source code for EMR. This means it is very easy to sink this kind of time and money into EMR for your office or group or hospital and be absolutely unable to use it to share crucial medical information with neighboring physicians simply because they using one of the other 10-20 most popular EMR platforms being marketed.

It should also be realized that EMR is not new, and has been around for a decade or two. It's intended primary use has never been to enhance the quality or consistency of medical care. Rather, it has been marketed as a way to fully document your visits in such a way as to justify your billing to insurance companies.

Unfortunately, EMR has not been fully re-vamped to optimize patient care and reduction of errors. Instead, features have simply been layered over and added on to the pre-existing systems. As a consequence, studies demonstrate that EMR does not result in improved care and actually results in increased error rates.

All of this may explain why the majority of doctors have not adopted EMR. A regular contributor to Kevin, M.D. nicely sums this up. You might not notice this here in Placerville, since Marshall has implemented an EMR system recently which can make it look like everyone now uses EMR.

I find it interesting that when I answer patient questions by saying that I don't plan to computerize my office the response is usually positive.

Most patients have commented that they find the use of a computer by doctors, nurses and physical therapists to be off-putting insofar as it limits conversation and eye-contact, and seems to take up time that would otherwise be spent examining or communicating with patients. I suspect they have a point here.

I'm sure it's possible to use EMR and not lose this human touch, but the current systems just aren't there yet and aren't likely to be there soon. I myself would rather not risk losing this element of human touch and communication with my patients.