family practice issues and general life events

Archive for January, 2012

Obesity epidemic and school lunch standards

About 5 days ago, the USDA set guidelines for healthier school meals.  As a physician, I should get totally excited about that, but upon hearing the full story, I think my reaction is more of a what?  As the obesity epidemic reaches dramatic proportions, our children are not left out.  According to the American Academy of Children and Adolescent Psychiatry 16- 33% of children are obese.  This is a startling statistic but based on my patient population, I would estimate the number is closer to the 33% rather than the 16%.  But then again, I live in southeastern Oklahoma, and see a patient population of 45% Medicaid.  That is their primary insurance, it does not include those who qualify for Medicaid as a secondary insurance.  During medical school, I never imagined that I would be consulted by parents regarding their underweight child, only to determine he is the only one in the family that is on the growth chart and of a normal weight with respect to his height.  Or the number of children dragged in by their parents sure that their child has a thyroid problem, because it could not be that the only exercise the child gets is to get up off the couch to go to the bathroom between commercials, or that a large pizza is considered a serving size for them.  So I understand that obesity is a problem in our youth.  And I would applaud any efforts to help curb it, should those efforts actually make sense.

This is not an argument for whether I want to subsidize school lunches, food stamps or other government agencies.  These programs are in place, and for the moment, if we are to continue with them at least let their policies make sense.

Per the report found in Reuters  “The guidelines double the amounts of fruits and vegetables in school lunches and boost offerings of whole grain-rich foods. The new standards set maximums for calories and cut sodium and trans fat, a contributor to high cholesterol levels.”  And while I fully understand that, and the attempts to offer only fat-free or low-fat milk, and assure that proper portion sizes are given to children, I doubt that this is even possible to enforce much less implement.

My experience with cafeteria workers is that few if any realize what a proper serving size for an adult, much less a child.  I spend quite a bit counseling patients that serving sizes are roughly the size of their hand (since it is much easier to grasp and compare than carrying around a scale).  And currently, I have heard of schools allowing 2nd and 3rd servings to children.  With few exceptions there is not a child that ever needs a third tray of food.  (Those rare exceptions of underweight and active children this applies to the population that are not at that end of the spectrum)

Not to mention, the black market aspects that could foreseeable pop up.  Who is going to keep kids from bringing food from home?  I know it is being attempted in Chicago, but I remember sneaking brownies and gum into the classroom, where we weren’t allowed to eat as a child.  How are you going to determine if this is food from home, or from the cafeteria itself.

And the biggest reason that this will not work, the original proposal was blocked because potatoes were not initially allowed as a vegetable.  And pizza was also not allowed as a vegetable.  I like french fries and pizza as much as the next person, but let’s be real, health food they are not.  When the food manufacturers selling the food are allowed to dictate what constitutes health foods and what does not, there is a problem.  What child is going to pick an apple over french fries?  Will the school lunch still be able to meet the nutritional standards?  How precisely would those two be considered nutritional equivalents?

As a physician, I spend a lot of time talking to new diabetics and obese patients about their diets, and well pasta and potatoes appear to be the biggest contributors to the caloric intake.  It is what they learned from the USDA and their food pyramid.  The very same organization setting these standards.   The same organization which allowed the lobbyists to dictate the new standards.  And at what cost?

While I agree we have to start somewhere with educating the public and attempting to change the dietary habits of children before the suffer the health effects of obesity, including early onset Type 2 diabetes, hypertension, and high cholesterol, I don’t see this actually being effective.  Substituting whole wheat for white flour in pizza and spaghetti, while it looks like a wonderful idea on paper, may instead be thrown away in favor of other offering either by the school, or an entrepreneurial student.  And while I am in full support of the potential economic lesson this might lead to, it most likely will do little to help.  Nationwide standards have not helped to improve our education system, and without getting input from local officials and parents, I doubt that this will be much different.

Had change been truly desired in the school lunch program, input would have come from the parents, teachers, physicians, dietitians rather than the food industry who would have seen their potential profits cut.  The making of a pizza a vegetable merely because of its tomato paste (which is incorrect, since most use sauce which has a lesser concentration of tomatoes and tastes better) shows just what kind of answers we get from Washington.

Eczema and Atopic Skin Care

This is a matter that is very near to me.  I grew up with eczema, and at times it was bad enough that I would wear long sleeves in the summer to hide my arms covered in red bumps.  I didn’t like the looks, the questions, and the worst one being while in high school

“Are you shooting up, and just keep missing the vein?”

Not exactly comforting, especially at the age, when you are aware of every imperfection, and have buried yourselves in books and studying because you felt neither pretty, nor were you popular.  So if you weren’t those you had to be smart.  (Looking back, I am not sure what caused me to feel that way completely, since I had friends, and I did sports, but just never felt like I fit in)

And that was not the worse of the outbreaks.  That came during my second year of medical school, when after borrowing a shirt from my boyfriend (now my husband) that happened to be washed in a detergent, that I was allergic to, I broke out in hives.  Which would have been fine, had they just gone away with my normal routines, avoid too much wheat (especially pizza), moisturize with aveeno, oatmeal baths and steroid creme.  Except that it didn’t, and it took me on a year long quest to find a way to manage it better.  That was the year I discovered just how much stress can affect eczema as well.  And if you want to avoid stress, good luck with that in medical school.  After barely making it through the first year, I was set and convinced that I would have a better second year, and bring my grades up.  And even though it would not be numerically possible to make it to the top of the class, I could do it.

Anyway, it was through that journey that I discovered some basic things that could help keep it under control.  And that while flare ups happen, there are ways to minimize it.  And I learned that for an image obsessed culture, eczema can be horrible for one’s self worth and body image.  I wore a long sleeve wedding gown for instance because I did not want to chance a flare up that would show in my wedding pictures.

1.  Anyway, if possible avoid allergens.  Sometimes that is easier said than done.  If it is a food that is easily identified and removed, well great.  However, I had allergy testing done as a teenager, and my food allergies included wheat.  Good luck on diet that does not have wheat in it, in our culture.  I have done it for 18 months, and was fine, but not easy.  It might be easier now, with the gluten free fad (and I call it a fad, because it is not necessary for most on it, and the improvement in health probably results more from a removal of the preservatives from the diet, rather than the gluten itself)  But avoidance is the best step if possible.

2.  Take lukewarm showers and/or baths.  If you cannot tolerate that when you first jump in, well start warmer and then bring down the temperature as you continue to shower.  Though I don’t recommend it being too long of a shower, since water on the skin, can strangely enough dry it out.  Anyway the lower water temperature is due to the histamine that is released from higher temperatures on the surface of the skin.

3.  Do not use soap every day.  Soap is very drying and can lead to increase in irritation and itching on the skin.  Many people may find this to be gross, but unless you sweat heavily or have an intense body odor, daily soap usage is not necessary.

4.  Immediately after bathing rub yourself down with vasoline, and then pat dry.  The vasoline will help keep the moisture locked in, and doing it before you dry rather than after, will keep you from feeling terribly greasy.

5.  Use a good moisturizer, preferably without scent.  Cetaphil is my personal favorite, it is not as greasy and comes in a large container.  For those of you with babies, and are finding rashes, consider not using those that are “baby lotions.” While they are marketed for baby’s sensitive skin, that lovely smell associated with it often causes a baby to have a rash.  So either get unscented or use something else.

6.  Drink plenty of water, if you are dehydrated, you skin will be too

7.  Consider an over the counter antihistamine- If they do not make you too sedated, there is nothing wrong with using them.  Zyrtec, Allegra, and Claritin all went over the counter in their prescription form, and they range from non-sedating to less sedating.  Benedryl, itself is effective, though it causes many to sleep.  So some can only use it before going to bed.

8.  It is ok to try the over the counter hydrocortisone creme.  It is a good place to start.  Avoid you eye lids, and skin on the face is very thin, so consult your physician before use there.  Increased use of steroids, especially around the eyes could lead to cataracts later in life.

9.  I hesitate to write this, due to sun bathing leading to an increase risk of skin cancer.  But there are many that find UV light helpful for controlling their eczema.  Small doses with sunscreen on may help, but keep in mind that you do not want to burn and long term exposure or tanning will increase your risk for skin cancer, thereby trading one annoying skin condition for a potentially deadly one.

10. Talk to your doctor.  If the OTC medications are ineffective your doctor may be able to provide you with a stronger topical steroid, a different allergy medication, or the topical immunomodulators.  Occasionally steroids are needed either orally or through a needle if the outbreak is bad enough.  Or an antibiotic is needed if the rash has become infected.  Another medication that has had some success off-label is Singulair.  It is not approved for Atopic dermatitis, but it has been approved for both the treatment of asthma and allergic rhinitis.  But that is for your and your doctor to decide.  I have used it myself, on my son and with patients, and some really respond well to it.  However, since it is off-label, your insurance may not cover it for use.

11.  Another consideration for the most severe, is allergy testing followed by immunotherapy.  Sometimes it is not possible to remove all allergens from your life, and immunotherapy either via shots, and looking at some studies sub-lingual may be beneficial.  However, this is a two to four year commitment, so results will not be immediate.

There are no specific tests for eczema.  It is usually determined by both history and exam.  However, it is important to know that atopic individuals have an increased incidence of asthma and allergic rhinitis.  Your doctor might perform a spirometry if indicated.  And while eczema may be treated there is no cure for it.  It may flare up during times of stress or ingestion of new foods.  It is important to realize that this is a constant and often frustrating battle.  It is important that you keep a supply of your treatment available between flare ups, so that you don’t have to rush in for a steroid shot.  And in the case of children, remember it is possible for them to out grow it. 

When did my career become a secret?

A couple of days ago I noticed something. When people ask me where I work, I don’t usually introduce myself as a doctor.  It was one thing, when buying a car, that I would off-handedly say, “I work at the hospital.”  You are always told adding Dr to your name adds zeros to every purchase, buying a car, building a clinic, buying a house.  Anyway, in purchasing, you just don’t do it.

However, this time it was different.  I was eating dinner with my children at the Olive Garden, when the waiter asked what I did for a living.

I was wearing scrubs, so the question was initially, “So did you work all day.”

“Yes.”

“So what do you do?”

It was not the waiters fault, he was perfectly hospitable, taking care that our table had drinks and attention that anyone would appreciate.  We talked about the iPad 2, since I happened to have both children’s and mine with me.  And if I thought it would be a good deal to buy one, and if we liked ours.  All perfectly pleasant.  It was only when he came over during a discussion with my oldest, as to why I could not donate blood at his school’s blood drive the next day.  (Previous years, I have, but this year it was on a Wednesday, and most Wednesdays I barely have time for lunch much less time to drive 30 minutes to his school, donate blood, and return to work)  So I pulled up my schedule on the iPad, and showed him how full it was.  Still not overly impressed, he said, what about after work?  At that point, I promised him, if by some miracle of miracles, I were to finish by 4 pm, I would donate blood.  However, since I have yet to get out of the office by 530pm on a Wednesday in about 8 months, well it probably was not going to happen.  And this is when the above conversation happened.

I don’t know why I stuttered.  I am not really ashamed of what I do.  Obviously I would not be blogging about it online if I were.  But stutter I did, as I admitted that I was a physician.  Admitted, is this what the once noble profession I dreamed of being as a child came too?  Or maybe it was that I was caught off guard, since it was an early dinner due to having to leave work early in the afternoon to take my youngest to speech, and then kill time between therapy and a skate party.  And maybe that I was worried I would have to explain.

I spend a lot of my day explaining things.  Why I don’t take call, why I don’t go to the hospital regularly, why I have no desire to work in the ER, why I leave early on Tuesday and don’t see patients on Thursday.  And maybe that was the reason.  However, he did not ask for explanations, he actually was reassuring that my career was not equivalent to that of a drug dealer, even though some days, I think that is what I have become, at least in the eyes of some patients.

Maybe I spend too much time online, reading the terrible things people say about doctors, how they make too much money, they rush in and out of rooms too fast, they take too much time to get to their room, that they just don’t care.

I heard a joke once in training that the person who yells out first “Is there a doctor here?” is probably a physician themselves.  And sometimes, I wonder if that is true.  The days, weeks, months, years of fighting public perception as a money hungry individual willing to throw their patient under the bus for a dollar on one side, and the fighting for the dollars rightfully earned trying to provide the patient care that they deserve may have worn us down.  The time spent fighting against liability claims and fear of lawsuits despite no wrong doing, maybe those have worn us down as a profession.  The stories of physicians who have stopped to help someone on the side of the road and despite no wrong doing receiving a lawsuit for a bad outcome.  Maybe that is why we no longer stand up and say I am a doctor.  Or maybe, I just I don’t want to be chased through the grocery store to look at a mole.

And in my case, where my husband and I made the choice where he would take my call, so that one of us could be at home at night with our children, maybe I just didn’t want to explain one more time, why I don’t go to the hospital.  It is not that I can’t, it was that I put my kids before my career.  It is the years spent justifying why I don’t do shifts in the ER like my husband.  It is the time spent alone, at night, wondering if I made the right choice.  Did I do what was best for my patient?  Did I make a difference for the better?  Or what am I missing on that patient?

For the most part, I love my job.  I like that I am in most of my patients’ lives.  In many instances, after they get a recommendation from a specialist, they come back and ask me what I think they should do.  Or if they could have a second opinion, not necessarily that they disagree with the first, but that it is a major decision and they would like to have another perspective.  I don’t make as much in my clinic, as my husband makes doing his shifts in the ER.  I see the reports as to doctors not choosing primary care residencies, and I understand.  The money is not as good, and most of us graduate with a large amount of debt.  And you have to spend a large amount of time fighting, fighting insurance companies, fighting for payments, and watching the general population equate your training with that of a midlevel.  Even though you have twice as much training, 4 times as much debt, and way more liability.  And then at the end of the day, you notice the pile of paperwork- not visit notes, but other paperwork.  Prior authorizations, home health messages, home health certifications/re-certifications, various forms for patients regarding why they cannot work, disability questionnaires, and random notes that the patient wanted you to write for them yesterday.  Add to that orders that the specialist decides that they want done, but don’t want to obtain the prior authorization themselves, despite having the pertinent data needed to get the test approved, and yet they don’t send it to you.  So I understand why students are not choosing a career in primary care.

And maybe it is just a combination of all of those reasons that I don’t introduce myself as doctor out in public.  At maybe, just maybe that is why I stutter when asked what I do for a living.

Stop getting your medical advice from FaceBook

I have become over the last 18 months fairly familiar with social media.  I have a Facebook page, both personal and for my business, a twitter account, a google + (though they don’t think I know enough people), a business web page (though it needs help), am on Linked In and obviously have started blogging.  So I think i that I have a pretty good grasp on social media.  What I cannot understand is the number of people who seek medical advice off of Facebook.

I am not saying that they were asking if they thought something was worrisome, or if maybe they should seek help, but full out advice from a majority of people who are not physicians, and many who do not work in the medical field.  I don’t know how many people know the people they are seeking advice from, if you are like me, you have “friends” that you have never actually met, but maybe on a page or something struck up a conversation, or maybe in one of the countless games you friended, but know nothing else about them.

Anyway, my concerns are more from the medical prospective.  I will give an example of something that I am seeing even more frequently, a “friend” of mine (who I do in this case know in real life) said something about being tired and cold all the time, and she was going to see her doctor tomorrow.  One of her friends (who I don’t know, but assume that they are not a physician based on their comment) said “You need a thyroid test, but don’t let them get by with the screening test, it won’t be accurate because my uncle had thyroid and his first test was normal, but he made the doctor do more tests and his levels were actually low.  This type of thyroid does not show up.”

While it is probably legitimate to ask if it could be a thyroid, it probably should even be ruled out, there might be something else going on other than thyroid.  And if you were to tell your doctor, “my friend on Facebook thinks that my thyroid is not working, but don’t do the standard test.” they will probably ignore everything you said after “my friend on Facebook.”  And while I would hope they would work you up based on symptoms, your insistence on a particular test based on Facebook opinion may result in a large bill, that your insurance may not cover because it was not warranted.

The other concern about taking medical advice over the internet is the amount of herbal and vitamins people seem to advocate taking.  For most people a multivitamin is probably not a bad idea, especially if they are cutting calories or have some chronic condition.  However, not all vitamins are benign.  You take too much Vitamin C- well you are probably urinating expensive vitamins, but new studies are showing overdoses of Vitamin E may increase the risk of strokes, and I have seen cases where the overdosage of B12 causing symptoms that mimic a deficiency in B12.  Not to mention all the herbals that might interact with medication that they are on.

Rarely, due to liability concerns will you see a physician giving any advice on these sites.  I will to a few select people, and most of the time it is in personal messages, but occasionally on their page.  I gave my cousin advice one day on his page, only to see a while later, someone else say almost exactly the opposite.  And in this instance, while their advice wouldn’t have hurt the child, it would not help him either. 

I do however find it amazing the amount of bad advice out there.  People speak out against the evils of Big Pharma, and while I don’t believe that they are producing their products solely out of the good of their hearts, they would rather keep you alive for repeat business, and at least have to meet standards.  These same people love to speak about the greatness of the herbal industry and how they are good, ignoring that as an industry they received almost as much revenue as big Pharma last year.  And while there are good and ethical companies out there, their products are labeled as “food stuff” by the FDA and you cannot always be sure that you are getting what you are paying for.  And should a company not have what it claims, they are prosecuted under the deceit in advertising for all but the most malicious of offenders.

While I fully understand you can choose who you wish for you medical advice, but remember your physician went to 4 years of medical school, at least 3 years of residency, and spends countless hours a year reading journal and going to conferences in an attempt to be up to date in the latest medical knowledge and treatments.  Compare that education to your “friend” whom you may or may not know.  And remember in many cases free advice is worth what you paid for it.

Doctor heal thyself

Or why doctors should not treat themselves- or why doctors make horrible patients

 

I have not posted in a while, and well I blame being on vacation for that.  And it was a great vacation, even with me falling down and going boom.  I ended up missing two steps at the Annenberg Plantation on St. Johns in the USVI and falling and injuring my ankle.  I wanted it to get better immediately or come up with a better story, but I could not come up with anything good, and today being three days later, it is even more swollen, bruised, though pain has gone down considerably.

This is what I was trying to look at.

I don’t actually remember this view.  I was trying not to vomit from the pain in my foot.  I heard a loud pop, felt my ankle give way.  Apparently screamed, and my husband thought I hit my head.  Well, managed to limp around the ruins.  (they are not huge) And stumbled down the hill, didn’t want to mention that I wanted to vomit.  Glad it was the last stop, that I had to get out, not sure I could have walked much farther.  However, the Westin St. Johns is full of hills and stairs, which I hobbled up, and then sent the husband for a coke and Ibuprofen since I could not possibly get it myself, and short of phenergan or Zofran, it was my best chance to not vomit.  Anyway, that night prior to sending him out and ice here is what the ankle looked like

 

 

 

 

 

 

 

 

 

 

Not terrible, some bruising.  However terrible throbbing and pain.  And talk about impossible to get into a comfortable position.  Now the smart thing to do would be to spend the last day in the room resting it and icing it down.  And as a physician, I know that.  However, as a mother, I had promised to take my oldest out on a wave runner the next morning, and well let’s just say the mommy in my won that battle.  And it was great fun.  Though it had been 10 years since I had been on a jet ski, and it was in a lake not going over 10 mph.  Quick a bit of difference from the Caribbean Sea, 20 mph and having an 8 year old holding on.  Let’s just say, well we wiped out early.  But just once.  And we got back on and continued our island tour.  Wouldn’t have missed it for anything in the world

 

The next day, rest again, not an option.  We were flying home.  Another problem, I had brought two pairs of shoes- flip flops (which broke earlier in the week) and my Vibrams- neither of which provided good support for the ankle.  However, I did not need to try to work with a broken flip flop in addition to a sprained ankle.  So I chose the Vibrams. Now I don’t know how many of you have worn Vibrams.  World’s most comfortable shoes, except when your ankle is swollen.  In that case, not comfortable at all.  And not only did I have to clear customs in St Thomas, we had the pleasure of running across the terminal in Miami.  (We have never had luck with their trains there, so chose to walk from one end of the terminal to the other)  And did I mention we only had 45 minutes?

Already the bruising is there and it is swollen, and my shoe is tight.

 

Now that I am home, still not resting.  Needed to get back on the treadmill this AM, however, not able to go full speed and there was definite pain when I was at 4 mph.  But I did get 3 miles in.  And then we wrapped it, and headed to the boys’ belt testing.  And I was trying to work with my youngest and unfortunately, I jumped up and down on it.  Probably not the smartest thing in the world.  But it was good, the both achieved their new belts so it was worth it. Again mommy needs outranked knowledge as physician.  Anyway tonight, I am finally doing what I should.  I have it propped up in bed.  Bed I had to take off the Ace Wrap as it seems to have swollen more.  And this is what it looks like.

 

 

 

 

 

 

 

 

 

 

 

So where do I go from here.  Well I will rest it tomorrow.  Monday, I have a full schedule of patients, so will probably limp through the next few days.  Maybe if the swelling and the pain go away (like I hope) I will have nothing else to do.  If it continues I will have to seek a specialist’s opinion.  Not really what I want to do.  And fortunately my husband cannot argue with me on that.  He walked around for 6 months on a torn ACL, so I don’t have to worry about him forcing the issue.

However, it is probably a second degree sprain, and if I can work and do all that I want to on it, I will continue as normal.  Unfortunately, the first week back is always rough.  Though if I can get through that, I should be good.

 

Attitude makes all the difference

As I look all over social media today, I am noticing a pattern.  Well two patterns in one.  There are those that are hopeful and those that are not.  These are people I know from various times in my life, and ones that I know only online.  People I see everyday, some that I have never seen and others that I used to see.  Apparently 2011 really sucked and was the best year ever.  2012 is a time for change, for growth, and to stay the same.  Or maybe it is just a year that won’t “suck as bad as the one just finished.”  I am not trying to judge.  I don’t live their lives.  I don’t have their challenges,  but at the same time I wonder, wonder if maybe just attempting to be happier they would be.

This is not for everyone.  Some have lived tragedy that I don’t even want to imagine.  Yet, many of those attempt to be as positive as they can be.  Whether it is for their children, for their friends, or maybe it is the only way they can get through life.  

Others common everyday problems are a major catastrophe.  The dog vomited on the floor and they stepped in it in the middle of the dark is proof that the world is a terrible place.  (Stepped in dog vomit myself, not pleasant, but it is life.)  And maybe that is an unfair oversimplification, but most of you know the type of person I am talking about.  And all of us, are sometimes that way.  But really if everything is a super tragedy, what happens when a real tragedy struck.

Last night was New Year’s Eve, and I went to bed at 10 pm.  Real party animal, but my husband was working in the Emergency Room and I had two adorable boys to take care of and frankly watching the ball dropped lost its thrill a while ago.  So I stayed in.

I live a life of privilege.  It is hard to justify complaining some days, when I know others that have it much worse.  I work for what I have, and holidays are not a given.  Sometimes I have to miss out on school events for my kids, in order to take care of my patients in the office.  And while I don’t take call, my husband does as well as pulling shifts in the ER to help make up for the debt accumulated in medical school and starting a business.  And all of this allows us to take trips where we want.  And to enjoy things in life, that I never experienced before becoming a doctor 

New years tends to be a day for reflection and introspection.  A chance for a new start and a clean slate.  And maybe it should be, but maybe without the expectation that just because the ball dropped at midnight, everything is now shiny and new.  Wars, sickness, disease and your day to day problems do not go away just because the clock strikes midnight.  While it is a great thing to be hopeful for the new year, it should not be done with false expectations.  Life can be good if we let it, but often the best things in life take hard work and determination to achieve.  Being lucky usually requires hard work and determination to make it so you can be in the right place for that luck to happen.

And a lot does ride on your attitude.  People who are confident with their abilities tend to be more successful.  Those who look at setbacks not as failures, but at learning experiences see to be able to achieve more, to overcome more.  While there is nothing wrong with prayers and hopes and dreams, failure to act with those will not lead you to success.  Wishing without determination or drive will keep you where you are.  

So my hopes for all, is for a happy New Year.  I hope it is everything that you wish for it to be.  I hope it is a year that you achieve your goals or at least take the steps that you need to start achieving them.  Remember sometimes success is measured in single steps not miles.  As I write this I am watching my youngest go around the house in the new skates he got for Christmas, learning to balance and picking out what toy he wants to play with next.  For him anything in the world is possible, you only have to dream.  And then go after it on roller skates.  

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