Dear TV Producers, You Forgot to Say “Don’t Try This at Home.”

Confession: I have been watching the reality show The Real Housewives of Beverly Hills. I don’t typically have time to watch television, but I end up attaching myself to one reality series for a season. Most often, it is a design competition or cooking show that I watch once a week, such as Project Runway or Top Chef.

Quite frankly, I don’t take shows like The Real Housewives seriously and often wonder if it is bordering on obscene to have such lavish lifestyles displayed on the televisions of homes across America (and around the world) during these hard economic times. But I was particularly disappointed in some of the footage that was shown on last night’s episode. On the show, one of the castmembers took an unknown amount of xanax (a prescription drug that can cause drowsiness and is used for particular types of anxiety) for a flight and was also filmed drinking alcohol (also an unknown amount, though it appeared to be more than 1 drink) while on it. She was clearly affected by the combination, exhibiting psychomotor slowing and slurred speech that was surprisingly more inappropriate than usual for this particular person. What’s worse is that her friends found her all the more entertaining while overly intoxicated and never once cautioned her (or the audience) against combining xanax and alcohol. As a matter of fact, I would argue, this combo seemed to be promoted by portraying this person as entertaining and funny and by devoting a fair amount of air time to her intoxicated state.

The risks of xanax-plus-alcohol were dangerously downplayed here. Both substances depress the central nervous system and can cause coma and death whe taken in excess quantities or used together. The combination of even small amounts can lead to dangerous levels of sedation, poor judgment, and unsafe situations.

I did a web search on the topic of xanax and alcohol and this particular episode to see if anyone else had commented on the high risk behavior depicted in the show. None of the search results explicitly pointed out the dangers of mixing the two drugs. In fact, most blogposts and articles painted it as “awesome entertainment.” The unfortunate fact is, though, that we now live in a time where more Americans die from prescription drugs than from car crashes.  So what makes for good television ratings makes a doctor like me cringe. Xanax is a high-risk medication. Irresponsible use of high-risk prescription drugs should not be glorified on television.

Dear producers, if you want to put that sort of behavior on TV – which I would rather you didn’t – then at least include a stern cautionary warning about it, even if it is only in writing at the end of the episode.

Hopefully, this particular castmember’s own doctor is watching the show and reminds her at her next appointment not to mix xanax and alcohol. Hopefully.

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A Message Worth Repeating

I thought to myself, “I am not going to post a link to this article. It has been circulated many times already on Twitter over the past week.”

But I read it. Not once. Not twice. THREE times. I shared it on Twitter twice.

And I changed my mind.

When doctors recirculate a blogpost over and over again, especially one about such a thing as death, they are sending us all an important message.

So, I share it here with you, as well:

How Doctors Die. 

After you read the article, if you do not know what a POLST form is, please see this link.

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For Safe Grilling, Use a Meat Thermometer

It’s the Fourth of July and you’re ready to have your friends and family over for a barbeque. You’re setting up your grill and going down your checklist. Meat? Check. Buns? Check. Beer? Check. Meat thermometer….?

What’s that? No thermometer?

Halt.

Go over to your kitchen right now and pull out that meat thermometer that’s been hiding in the junk drawer since two Thanksgivings ago. If you don’t have one, run to the grocery store and get one before you forget because you will be almost certainly be distracted when your guests arrive and and will end up relying on the false security of your vision.

According to the USDA’s Federal Safety and Inspection Service website, 1 out of every 4 hamburgers turns brown before it reaches a safe internal temperature. So, use that thermometer. Here is info from the website, followed by other important reminders:

USDA Recommended Safe Minimum Internal
Temperatures

Cook all raw beef, pork, lamb and veal steaks, chops, and roasts to a minimum internal temperature of 145 °F as measured with a food thermometer before removing meat from the heat source. For safety and quality, allow meat to rest for at least three minutes before carving or consuming. For reasons of personal preference, consumers may choose to cook meat to higher temperatures.

Cook all raw ground beef, pork, lamb, and veal to an internal temperature of 160 °F as measured with a food thermometer.

Cook all poultry to a safe minimum internal temperature of 165 °F as measured with a food thermometer.

Note that allowing meat to “rest” (which means waiting at least 3 minutes after pulling the meat off of the heat source, usually covered with foil) allows the temperature and “doneness” to even out.

Avoid using wooden cutting boards when handling meat, particularly if it is raw or potentially undercooked. Instead, use at least two dishwasher-safe, plastic cutting boards (one for meat and one for
vegetables).

DO NOT cross-contaminate. I repeat DO NOT cross-contaminate. That applies to working surfaces and marinades, too. Do not brush meat that is cooking on the grill with the same liquid your raw meat was sitting in. Instead, prior to mixing the marinade with the meat, save a portion of it for use on the grill.

So have fun and enjoy your time with friends/family, but protect them by following the guidelines above.

Have a Happy (and Safe) Fourth of July!

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What You Should “Pack” if You Are a Nomadic Healthcare User

 

Are you a nomadic healthcare user?

______________________________

no·mad noun \ˈnō-ˌmad, British also ˈnä-\
1
: a member of a people who have no fixed residence but move from place to place usually seasonally and within a well-defined territory
2
: an individual who roams about
— nomad adjective
— no·mad·ism noun

Origin of NOMAD

Latin nomad-, nomas member of a wandering pastoral people, from Greek, from nemein
First Known Use: 1579

Synonyms: drifter, gadabout, gypsy, knockabout,maunderer, rambler, roamer, rover, stroller, vagabond,wanderer, wayfarer, bird of passage

_______________________________________
*Modified from Merriam Webster online

 

A nomadic healthcare user – if there is such a term – is an individual who gets his healthcare from multiple places (different clinics/states/cities/etc). There are various reasons for this type of healthcare utilization that I have come across since I started practicing as a primary care internist.

Some reasons are obviously geographical:

• a move (to another city or state)
• travelling for long periods of time after retirement (ex: RV’ing )
• Wintering in other states

Other reasons are less obvious, but frequent, and still occur despite living in the same location:

• a job change (new insurance)
• doctors changing or closing practices
• an employer changing insurance, thus forcing a change in PCP due to cost (My pet peeve. This seems rarely cited as a contributing factor to fragmented healthcare/increased healthcare costs and can occur each year for some patients!)
• using the healthcare system “prn” (only as needed, calling up doctor’s offices as needed, going to the first local doc that has an appointment available)
• “doctor shopping” (going from doctor to doctor, searching for one that you agree with)
• second, third, and fourth opinions.

In the U.S., particularly in bigger cities, an individual’s healthcare can be quite fragmented due to all of these factors.

The result:

• Expensive care (primarily through repeated tests and scans that have already been done)
• Confusion among patients and their doctors
• Over- or under-immunizing

If you find yourself in any of the above “nomadic” situations, there are some things you can do to keep as much continuity as possible in your healthcare. If you need to switch primary care doctors, get records from the last one. It may cost you money, but it can be invaluable to the next doc and perhaps to the healthcare system as a whole by reducing redundancy of testing. They are your own records and you should have them. They may not be retrievable if the clinic went out of business.

Let’s say there was a fire in your doctor’s office and all the documents disappeared, the computer system was inaccessible, and you came to see me for the first time. These are the records that I would hope you have:

• Complete immunization record
• Labs from the last 2 years
• Medication list (exact dosages and frequency)
• Allergy list (reactions)
• Primary care notes from the last 2 years
• The last colonoscopy report + pathology report (if there was a polyp)
• MRI and CT reports within the past 5 years
• Specialist notes from the past 2 years (this one is more optional)

 As a side note, it would be curious to see how the “medical home” concept fits into some of this nomadic behavior. They seem antithetical by definition .

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There is a Plan B (and Sometimes a C,D,and E…)

Let’s say you are a patient and you see your doctor for a rash. He evaluates you and gives you a cream to try. The rash doesn’t go away. What is your next response?

1. Go to another doctor because that first one didn’t know what he was doing.
2. Go to another doctor because the first one did not recommend a follow-up appointment.
3. Use the cream for longer than the recommended period of time
4. See a naturopath because you would prefer to try natural therapies.
5. Call the initial doctor’s office for instructions.

 I hope your answer is #5.

 Unfortunately, I see choices #1 and #2 too frequently in real life. Why do I find this unfortunate? These options can lead to fragmented (expensive) healthcare.

Sometimes, a physician does not explicitly detail out all of the thoughts that go along with diagnosing and treating a patient, especially when rushed. They may come up with a diagnosis and treatment plan in minutes, but there is a lot of cerebral processing that occurs within a single patient visit. There are pros and cons to revealing all of this information. Pro: better understanding by a patient of the issue at hand and that there are other possible diagnoses for a single problem. Con: information overload and more confusion.

In the interest of time or of not overwhelming a patient, a physician may focus on the most likely diagnosis and not mention others or talk about them in detail. And, trust me, there are almost always other possibilities. It is rare to see a patient who has only one potential diagnosis when first evaluated. Even a simple cold can have what we call a list of “differential diagnoses” (a list of other causes for the same symptoms).

The inherent problem with only talking about the most likely diagnosis is that a patient walks away with an impression that there is only one potential diagnosis and one treatment plan. If physicians are not clear about follow-up and the treatment fails, patients may feel that perhaps they were “misdiagnosed” and they may look for another opinion.

Physicians should be better at informing patients at least about the next step by addressing what patients should do if their treatment does not work as planned. I try to do this consistently. A common parting statement I make is, “If this is not working as we discussed, [come back or call our office]. If I don’t hear from you I am going to think this issue has completely resolved.” Of course, for more serious issues that I want to monitor, like depression or uncontrolled hypertension, I plan a follow-up appointment. But for relatively minor issues, I don’t want to waste a patient’s time or block my schedule for other patients who need to be seen when an appointment is not necessary.

Doctors, try not to let the patient leave the exam room without a follow-up plan or at least letting her know she can contact your office if a treatment isn’t working.

Patients, keep in mind that – even if unspoken – your doctor has a plan B, and may even have plans C, D, and E in the back of her mind. If you’re tempted to get another opinion for an issue you just had evaluated once by another physician, consider not “giving up” too easily on that initial doctor. It would be wise to see if the doc has an alternative recommendation. I would be surprised if she didn’t.

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Healthier in 2011: There’s an App for That

Photographer: Nutdanai Apikhomboonwaroot, freedigitalphotos.net

This is it: the first workday after New Year’s. Do you have your plan in place for being healthier in 2011? Here are two important tips to stay accountable:

1. Make sure you commit to your workout days, by circling them on a calendar AND telling family and friends which days they are.
2. Keep a food diary.

Keeping a food diary can be done in one of two ways.  The old-fashioned way is when you write down everything you ingest in a day and the calories next to it. It very underrated. It works.  The newer way of keeping a food diary is, of course, with an app.

I just purchased MyNetDiary for the iPad because I read so many great reviews on it and wanted to test it out. In fact, it boasts a 4.5 out of 5 stars with 1110 ratings. The usability of this app surpasses the others I have tried. First, you enter your profile info (height, weight, age gender, and your goal weight) and your activity level. Then you can just start typing in foods. For example, I was able to enter a detail like a half tablespoon of catsup and a tablespoon of a certain brand of creamer. I didn’t think I would find a particular brand of apple chai oatmeal, but there it was. 170 calories.

As you enter the foods, it also tells you the fat/protein/cholesterol content as well as the calories. What is also nice is that you can modify to view sodium content, for example, if you have high blood pressure or heart failure. If you can’t find a food on the extensive list, you can create a custom food item.

If you have a goal for weight loss, it tabulates the current day’s totals and the remaining calories you can consume in order to stay on track.

There is a section for exercise, even mowing the lawn and playing with kids. The Progress section tracks your weight  in graphical form.

The app was certainly not free, but at $9.99, it may well be priceless if it gets you to your goal weight.

Healthier in 2011: Part 3 – Inspired by Recipes

This New Year, I will be cooking more. (Notice I did not say “I plan to” or “I would like to.” It’s best to be committed to making it happen). I used to cook so much more in the past, but my current commuting habits have made it difficult. Soon, I will be changing practice locations and saving a couple hours of driving time a day, and I have full intention on getting back to being in control of what is on my plate, at least most of the time. I found some inspiration in the January issue of Bon Appétit magazine.

In it, cookbook author Mark Bittman writes about changing his diet. http://www.bonappetit.com/recipes/slideshows/2011/01/mark_bittman_healthy_eating_plan#intro.

At a point in his life, Bittman was faced with the facts of his poor health and had to make a decision about how to turn it around – similar to many of the patients I see day after day. The best line in his article is “I didn’t want to eat like an Okinawan for the rest of my life.” [Okinawans are known for their longevity, which is attributed partly to their low-calorie, low-fat, mostly plant based diet].  I suspect that a lot of people cringe when a doctor recommends a healthier diet, envisioning rice cakes and salad after salad and other boring foods.  Bittman created a set of smart and simple rules for himself, with a specific motto: “Think plants first.” I alluded to this in my previous post (https://pulsus.wordpress.com/2010/12/27/healthier-in-2011-part-2-%e2%80%93-using-mind-games-to-eat-better/ ) .  He practices this by being  “vegan until six” or “less meatarian.”  While the mere idea of veganism is daunting to many, his 5 rules should not:

1. “Go (mostly) vegan.” I personally would modify this for myself by trying to eat mostly vegetarian. (I do like skim milk in my cereal).
2. “Minimize the meat.” Eat smaller portions of it than you typically do.
3. “Weigh it out.” When you see your weight creeping up, be a little more strict with the diet. That being said….
4. “Cut yourself some slack.” Do not berate yourself for slipping up in a day or a meal. Most importantly, don’t give up on your new pattern of eating. It is easy to give in to old habits when you are frustrated with yourself. Just try your best the next day.
5. “Make it your own.” Bittman’s rules can be used as a guideline for your own smart simple approach.

As far as Bittman’s recipes, I am looking forward to trying the Multi-Grain Pasta with Butternut Squash, Ground Lamb, and Kasseri (a type of cheese). It has 9.5 grams of fiber per serving! Also deliciously photographed is the Pear-Cranberry Turnover. It has 309 calories per serving, which is about 80 calories more than a particular ice cream in my freezer, but so much More nutritious.

Also in the magazine was a response by restaurant editor Andrew Knowlton to a question posed by a reader asking, basically, how he doesn’t get fat. (I am paraphrasing). Imagine having dish after dish of finest and richest foods served to you day and night. This is a recipe (ahem) for obesity. What was his secret? He says, “It took several years of dining out to realize that I did not have to clean my plate, no matter what my momma told me. I can still do my job without finishing the drumstick and breast in my fried chicken basket.”

Words to live by.

Healthier in 2011: Part 2 – Using Mind Games to Eat Better

Mindful eating is a great concept. There is even a center devoted to it. It involves thinking purposefully about what you ingest and why. However, when you are busy, it is easy to slip into old patterns.

Sometimes, having a few tricks under your sleeve can help. Some of these are like mind games. But the more often you do it, it will become habit.

• Eat on a smaller plate. I use my salad plate as a dinner plate.

 

• Make food very hard to get. For example, if you want a second serving, you should have to go back up to the kitchen to get it.

  

• Take a sip of water after every bite.

 

• Talk more if you are with a group. It will slow down the pace.

  

• When eating out, tell the waiter to box half of the dish prior to bringing out the meal.  Economical. It will be tomorrow’s lunch.

 

• Order a kids-sized meal whenever possible. (This is generally cheaper, too. If there is a toy involved, I hide it and save it to pacify a little one later).

  

• Redefine dessert (a little fruit will do just fine) and do not make it a necessary part of dinner. If we do this regularly in our families, our children will grow up to expect it.

 

• When presented with a meal, look at the vegetables as the main course, then the meat, then the carbohydrates. Note that this is the reverse of what we normally do.  

 

• At a buffet, do a variation of #5: serve yourself vegetables first and save the richer and carbohydrate-laden foods for last.

 

• Stash healthy snacks at work so that you are not tempted by the snack machine. Unsalted almonds, yogurt, peanut butter on a slice of bread, dried fruit with just a sprinkling of dark chocolate chips.

  

• Avoid saying “I can’t eat” this or that food unless you have an allergy to it or it interacts with a medication you are taking. Deprivation feeds longing and future binging.

 

• If you are inclined to have juice, water it down with 50% water.  (Saving money again)

  

•  When making a carb-laden dish (like pasta) load it with veggies and lean protein. You’ll eat less carbs per serving that way.

 

• Don’t tell yourself or anyone else that you are “on a diet,” which implies there is a beginning and an end. Remove the word from your brain.  

Healthier in 2011: Part 1 – my story

New Year’s Day is almost assuredly a time to start losing weight, evidenced by the yearly increase in gym memberships in January. But now, during this week after Christmas, is a great time to plan your strategy. Sometimes it takes inspiration and a few helpful hints to get going so I am devoting this week’s blog posts to both formulate my own plan – yes, I need to tune up my own diet/exercise routine – and to inspire you, the reader.

At the risk of TMI, here goes:

I have a love of food that started with plain gluttony and emotional over-eating but has evolved into the development of a more refined palate and balanced approach to eating. I think most people who see me think I have always been at my current weight or that I have a different genetic make-up that keeps me at my current weight. Or perhaps they think that I somehow have lots of time to fit in exercise. None of these is true.

I came from a household that frowned upon engaging in sports (avoid injury), did not allow me to play outside of our driveway (fear of abduction), and encouraged schoolwork and piano playing (all sedentary). In addition, in this dual-income household, I could eat what I wanted when I wanted. This meant four meals a day, with frequent snacking and soda drinking. Of course, I ate in front of the TV. You know those candy bars we had to sell as part of fundraising? I ate the majority of my box, grabbing change from my father’s coin jar to pay for it. Hey, I may have been a glutton, but I was not a thief. (The family coin jar was fair game to all, a lesson we didn’t learn in saving).

By the time I went away to college, I was at least 20 pounds heavier than I am now and had poor endurance, which was a little embarrassing.  What’s more, I had the premier meal plan, unlimited cafeteria access. What teenager wouldn’t have wanted waffles with all the works every morning and ice cream or cake every evening? So, I added even more pounds to my already overweight physique.

I found that I was getting shin splints every day and felt short of breath getting to my morning class and that became my wake-up call. I truly believed it was due to my weight. I have to admit, I was also surrounded by and envious of some beautiful, thin people. So I made radical changes in my diet and took up running. The changes were so radical, that I became underweight in the course of a few months. I was not intentionally trying to be thin, per se, but my strict diet and exercise routine would have made anyone underweight.

Well, that’s all fine and dandy, you might say.  You, Dr. Pourmassina, had the will to lose weight through a means that is impossible for me. Well, there is a twist to this story. I became so thin that I stopped having periods for some time. This is a common scenario when women are low in body fat or exercise too much. It is actually unhealthy because it increases the risk of stress fractures.

A doctor I saw told me that I needed to gain weight. Most women who have gotten to this point will refuse to gain weight because of all the effort put into losing it. But for me, it was an excuse to eat poorly again. I had a roommate who was as thin as a rail and always had chocolate and cookies in our dorm room. I never partook when she offered, because I was following my own rules so strictly. However, once I was given the OK to gain weight, I took it as a free pass to eat the way I used to. Well, it was actually worse. Why? After all that time restricting myself, I binged and binged and binged. I was never one for throwing up (like a bulimic), so back came my periods… and my weight.

OK, back to square one.

It took a few years – yes, years – but I finally found a balance. I started eating “good food.” I would go to fancier restaurants, order the cheapest dish (on a student’s budget), and found it much more interesting and complex than the junk I was eating. I was also exposed to better chocolate that was more satisfying. I looked at food as something to be enjoyed. I don’t mean the prior scarfing-down-and-stuffing-yourself kind of enjoyment, but one that leaves my mouth satisfied.

The basic inexpensive American diet is loaded with either sugar or sodium. I clearly remember eating tons of chips and then needing something sweet to balance it out. So I ate a bunch of cheap chocolate, which left me craving salt again. Does this sound familiar? And, to this day, I find drinking soda begets a craving for more soda, so I never purchase it.

Healthy eating takes vigilance, particularly if you have a sweet tooth and a penchant for carbohydrates. This is why I continually seek out food inspirations, whether it be discovering new vegetable recipes or reading magazines with tips on healthy eating. Because of my very conscious efforts, it is unlikely I will slip back into my prior bad habits. Not completely, anyway. I would be a fool to think I have conquered all my issues with food.

Questions to Ask to Make Difficult Treatment Decisions a Little Easier

We live in an era of medicine in America in which patients want to be involved in their healthcare. This is very satisfying to physicians like me, who prefer to educate and engage patients rather than just telling them what to do. Granted, there are some instances when a patient does need to be told what to do (ex: “You have appendicitis. You need surgery.”)

 However, when faced with a tough choice in treatment, it is often difficult to know what questions to ask your doctor. Sometimes, a diagnosis -cancer, in particular – can leave you dumbfounded and unable to absorb any further information.

I recently found out an elderly loved one was diagnosed with cancer. She comes from a generation that let the doctors run the show (paternalistic healthcare). Her son has been very involved and, faced with a decision to undergo chemo or not, they were both unsure of what the appropriate next step would be.

Because I am not a family member and I live far from her, I wanted to help her and her son with upcoming doctor appointments. I compiled a list of questions to ask the oncologist (cancer doctor). Really, though, this set of questions can apply to many situations where you have a difficult treatment decision to make.

1. What would happen if I did nothing?
2. What is/are the worst case scenario/side effects of the treatment you are recommending?
3. What is the likelihood the treatment will work?
4. If it doesn’t work, what next?
5. Is it possible to “watch and wait?” Perhaps re-evaluate the issue in a few months by re-imaging. (This may help avoid unnecessary treatments).
6. How soon do I have to make a decision?
7. What do you think about getting a second opinion? *

*(I personally do not take offense to this question, so don’t feel shy about it if you feel very unsure about what is being recommended. However, it is generally not a good idea to “doctor-shop” or try to find someone who will recommend what you specifically want. While there can be varying ways of treating the same thing, two opinions generally should suffice. There are always exceptions, but your healthcare can get more convoluted and expensive the more opinions you get. Often physicians will order redundant tests if they do not have easy access to the first set of data).

And, most importantly, try to convey to the doctor what your overall goals are. Is it independence? Is it living as long as possible? It might be staying healthy enough for a particular event (like a grandson’s wedding, or a child’s graduation).  I knew a patient who preferred to be in pain from poor circulation rather than undergo leg amputation. Perhaps in your own belief system, you want to do everything possible to stay alive, whether or not it means losing independence. There are myriads of views on personal healthcare and it is often difficult for doctors to know what your personal goals are.

One last tip, when you think you might be faced with a difficult diagnosis or discussion with your doctor, bring one friend or family member with you to be an extra pair of ears for you.