Healthy Policy

Conquering the crutches

I'm ready to author a mini round up. I'm not finished yet -- the doctor says it will still be two or three months until I'm completely back to normal.  From here I get tortured by physical therapy and try to erase my limp, but it's all uphill as far as I'm concerned.

It started with this procedure. (look here to see my post-surgery x-ray)  The total cost of my surgery was $21,113, and that doesn't include any of the follow up appointments. 

I stayed in the hospital for two nights, an experience I had managed to avoid since the age of thirteen, but quite valuable as I've continued my foray into health policy.  I wrote a lengthy post describing my experiences, but I'd make these main points: you will see dozens of people, most of whom you don't know, and they will poke and prod you and bug you regardless of whether you're sleeping, going to the bathroom, or bright eyed and bushy tailed.  Also, don't expect to get any rest.  Or have anyone know anything about you besides your procedure.

Once I was released from the hospital, I had a leg brace comprised of straps and hinges at the knee.  It wasn't bad really, and made me feel more like a basketball star or skier who tore a number of ligaments than a girl whose childhood bone disease left her leg requiring some tweaking. 

And then there were the crutches.  Three months of hopping around on two, unable to carry anything for myself (although I did devise some creative hopping patterns to carry small things a few feet).  Three months of fearing steps, refusing escalators, and avoiding wet pavement.  Three months of sore armpits, rambo-esque biceps, and dwindling leg muscles.

Following my foray into two crutchdom, I was introduced to the single crutch.  For the first time in three months I fetched my own coffee.  My single crutch became more of an appendage, or a presentation I took with me everywhere.  Whenever I sat down, I searched out a place to lean it where it wouldn't tumble over.  It fell repeatedly; I learned the only way a crutch doesn't fall over is if you lean it against a brick wall or similarly rough surface, or lay it on the ground.  I flung it into my passenger seat when driving, it fell over with a clang constantly when shopping, and sat as a constant reminder of an annoying friend to be carried everywhere.  But I don't want to complain too much-- it also afforded me the ability to walk semi-normal, my armpit mostly calmed, and it represented progress.

The next step after the single crutch is either more of the same or total freedom.  My appointment, scheduled for six weeks after the move to one crutch, was a source of stress and anxiety -- will I be making enough progress to move on?  Or will I have to endure this awkward way of moving for any number of additional weeks? 

And after 18 weeks, I've finally done it.  My x-ray showed enough improvement to let me walk without assistance.  There was concern early on that my bone wasn't healing and additional efforts might be needed to make it do so (i.e. a bone graft).  So after four and a half months of slow progress, my doctor was as happy to let me go as I was to leave.  I felt like Steve Martin pretending to walk in Dirty Rotten Scoundrels -- ridiculous grin on my face and all. 

I know it's all uphill from here, and that I don't have to fear going back to the doctor and taking a bad x-ray.  My leg feels heavy and unwieldy; I have a small limp and it takes a lot of concentration to try to move as normal as possible. 

But as summer rapidly approaches, I know I'm lucky enough to be released from my body's shortcomings, and I will be able to do whatever I want, barring training for a marathon. 

Now that's progress.

Mumps and the Midwest

My initial reaction to the Midwest Mumps outbreak story was "Hooray for being vaccinated!"  Then I read this:

Mumps, a viral infection, is usually not serious, and there have been no reports of deaths. The most troubling aspect of the epidemic is that many of the patients had been vaccinated. Does this mean that millions of people who thought they were safe actually are not?

So, uh, considering I live in Kansas, I'm feeling a bit worried...

And then the article goes on to suggest that there might be significance that many of the afflicted are young adults (read: college age), rather than children.  Crap.

Trust, doctors, and race

A new study unearthed evidence that blacks trust physicians less than whites.  The study, from the University of Pennsylvania, found nearly 45% of blacks have low trust levels, compared with 33.5% of whites.

The finding that there is a racial disparity in terms of practitioner trust doesn't surprise me at all.  That's due, in part, to a recent discussion with my long-term pediatrician (who works at an acute care children's hospital) about treatment issues he sees.  We talked about defensive medicine and lawsuits, but the part I found most intriguing was our discussion of racial disparities at the hospital.  He told me that low-income black patients in the metro area just don't trust the doctors, particularly at the ER, and often give false phone numbers and addresses, which makes follow up impossible.

The UPenn study attributed much of the lack of trust to the fact that many blacks are uninsured and seek care in the ER, where the staff changes often.  This makes perfect sense to me -- the experience of medical treatment chiefly through an ER setting, where you wait hours to see anyone, see a different doctor every time, and have an invasive, thorough medical history taken each visit, is quite different than visiting a consistent primary care doc.

What's interesting about the study as well is that the race of the physician didn't impact trust level, as one might expect it would.  And that speaks to grave, structural trust problems between the African American population and medical practitioners.

Latino trust levels were not examined in this study.  My pediatrician didn't believe that Latinos had as many issues with trust, but I wouldn't just take his word for it.  Language barriers and fears of deportation create further hurdles for these families. 

Many low-income patients continue to use the ER for care even when they have insurance (whether it's Medicaid or otherwise).  The question for public health experts and medical practitioners, then, is to figure out how to decrease this utilization, which will lower health costs while building trust and more consistent care. 

The various intracacies of medical devices

This post by Chronic Babe is a great round of up trying to engage in sexual activity while being affixed to medical devices.  Well written, straight forward, and non-apologetic (as it should be)!  Well done, babe.

Calling Bill and Melinda Gates!

Please donate some money to this:

Researchers are closing in on a breakthrough microbicide gel to help prevent HIV infection in women, scientists said on Monday, but a lack of funding by major pharmaceutical companies is hampering research.

For those of you who won't know, microbicides are gels or creams, usually inserted vaginally, that help prevent sexually transmitted infections.  The chief target of current microbicide research is to prevent HIV infections. 

Microbicides are the ugly stepchild of already poor funding for HIV medications.  That's because the people they'll help the most are women in third world countries who have extremely patriarchal marriage arrangements (read: most of Africa and India).  Many men in these cultures make regular visits to the local prostitute, where they contract HIV and bring it home to their wives, who pass it on to their children.  Because condom use is taboo (especially women requesting that condom use), women have little ability to protect themselves from infection.

The development of a microbicide for HIV would give these women power to protect themselves and their children.  But a successful anti-microbial agent hasn't been developed yet, although a few are in the final stages of clinical trials.

Microbicides would also be significantly cheaper than treatment with HIV medications, which people in third world countries have essentially zero access to. 

Good Read

This WSJ article on how doctors are seeking to improve their primary care practices is an interesting read. 

Get your tests people

From WaPo:

Despite strong evidence that tests like a blood pressure check every two years are worthwhile, barely 50 percent of U.S. adults receive the diagnostic and preventive screenings that many medical experts recommend. Several factors explain why many Americans remain unaware that they have hypertension, colorectal cancer, high cholesterol and other lethal conditions: the proliferation of recommended tests, doubts about the value of some once-standard exams and time demands that keep many doctors from performing systematic screening.

Explain to me how the value of blood pressure cuffs has been questioned? (those drug store things don't count)  If people aren't getting their blood pressure checked every two years, it's because they're not getting/going to check-ups. 

In a study published last year, Duke University physicians suggested why compliance with screening standards is so spotty: "Taken together, the time needed to meet preventive, chronic and acute care requirements vastly exceeds the total time physicians have available for patient care," they said

If the patients don't show up for their physicals, that's one thing, but is it really that tough to screen for the basics -- blood pressure, high cholesterol, and diabetes?  Colorectal cancer is a different story, you have to get an oh-so-pleasant colonoscopy, but surely the others aren't such a problem that primary care docs aren't doing their purported aim -- verifying the general health of their patients. 

Physical therapy and me

So I've been doing physical therapy the last few weeks.  There's lots of different types of PT offices.  There's the ones that serve mostly athletes or people injured in sports, and the therapists tend to be very fit, A-type personalities, who wear tight shirts (that goes for the men and women) and it's all a glorified in-shape machine.

Then there's my PT office, which is in a medical plaza building that, as far as I can tell, serves mostly old people.  It's probably the smallest PT office I've ever seen; the staff consists of a calm, harmless middle aged man and an intensely religious assistant in her mid twenties.  The other patients are all over fifty, with the exception of one high school age girl who tore her ACL.  The other patients seem to have shoulder/neck injuries, so they spend their appointments stretching their arms or getting massages or anti-inflammation massages with some little microphone thing. 

And what are my exercises?  The newest additions consist of walking around the room sideways and backwards.

But they fooled me at my small old people physical therapy office!  The first day I went they gave me 8 exercises -- mostly 80's exercise video-style leg lifts and a theraband.  But every time I go I get more and more and more.  Now I have like 25 exercises, including the silly walking sideways and backwards, and a variety of other weird things.

The real kicker is I'm not even bearing full weight on my leg yet -- what will they come up with when that happens???

Hospital Story Time!

It's Friday, and that means fun story time.

Today's story is not about yours truly, who has managed to stay out of the hospital since surgery, thankyouverymuch.  It's about my mom, who went under for surgery yesterday.

And may I just take a second to remark that it's so much more fun to collect hospital stories as a visitor/friend/advocate than as a patient.  (Here's my impression of my hospital stay back in December)

-----------------------------------------------------------------------------

They wheeled my mom into her spacious private hospital room.  She was fairly woozy, but happy to be out of the recovery room, where she told me the other patient had been moaning (a low, growling moan) f0r about an hour.   Within a minute an attractive nurse in bright pink scrubs enters.  She surveys the room, my mom, me and my dad, and picks up the chart. 

She begins to ask my mom the usual "Welcome to the hospital, are you in pain/are you nauseous/do you want ice chips" questions.  Her speech is fairly clear, except for the harder consonants, which are muddled, and I immediately realize: she's deaf.

In my non-patient humble opinion, I think it's fantastic that a deaf person is a nurse.  She reads lips incredibly well.  But for my mom, this isn't the best situation.

Because my mom is also deaf, and she left her hearing aids at home.

My mom has a degenerative disease that affects her hearing.  Because she's been losing it slowly over the last thirty years, she hasn't learned sign language.  She can understand people for the most part, when she has her hearing aids on, but the nurse's muddled consonants confuse her. 

At one point a woman comes in with cleaning supplies and starts disinfecting all the counter tops in the room.  Immediately my mom freaks out and asks for a cloth to put over her nose and mouth (apparently cleaning solvents are very bothersome when you've just left surgery) (Also, I'm quite sure the room should have been cleaned before my mom was actually in it, but I digress).

So my mom is laying there holding the blanket over her mouth, trying to talk to the nurse, who now can't read her lips, and they're both looking at me to interpret.  It's the deaf leading the deaf, except they can't communicate.  This strikes me as a pretty amusing irony.

Aside from the deaf nurse, they had a nifty e-prescribing system, where the tech scans both the patient's hospital bracelet and the medication before administering.  The tech wheels around a little cart with a laptop attached.  It's quite mobile, and I was very impressed. 

And can I just say that ever since I got in to health policy, I'm a total nerd at doctors/hospitals.  I'm like a detective taking note of everything I see, and I get excited by e-prescribing systems.  My family must think I'm crazy...

Are you obese?

A new study from UNC-Chapel Hills found that only 15% of obese people correctly identified their weight class:

About 90 percent of normal weight adults and 85 percent of overweight and obese adults accurately self-reported their weight and height such that the BMI calculated using those self reports fell in the same category as actual BMI.

That accuracy changed, however, when researchers asked participants about their perceived weight status, that is, if they would consider themselves NOW to be underweight, normal weight, overweight, or obese. Seventy-one percent of normal weight and seventy-three percent of overweight adults classified themselves correctly, compared to only 15 percent of obese adults who correctly considered themselves to be obese.

If you read this Washington Post article, however, it's perfectly understandable where the confusion comes from:

A 5-foot-10-inch adult _ both male and female _ is overweight at 174 pounds and obese at 209, according to the U.S. Centers for Disease Control and Prevention.

Did you know that? (Doctors, you're not allowed to answer).  I definitely didn't, and this is where the disconnect is coming from: messages have been unclear about the point at which we are considered obese.  Sure, there's the BMI calculator, but how many of us actually use it?  Or trust the result?

The sample size of this study was very small (~100), so more research is certainly called for.  But better education efforts need to get going, ASAP.

Also, do most PCP's take your BMI at annual physicals?  If doctors aren't telling their patients that they're obese when they are, that will certainly impact patients' self-image.  It would be an uncomfortable conversation, but if your doctor won't tell you you've reached that dangerous weight point, who will?

Aetna is going to kick some diseased butt

Good news for public health advocates:

Aetna officials on Wednesday announced plans to expand the number of disease management programs offered by the company from six to 30, the Hartford Courant reports. Aetna currently offers disease management programs for asthma, chronic heart failure, coronary artery disease, diabetes, end-stage renal disease and lower back pain. Under the expansion, Aetna will begin to offer disease management programs for conditions such as cancer, HIV, hypertension, migraines, peptic ulcers, rheumatoid arthritis, sickle cell disease and stroke. Aetna will group the disease management programs into categories such as pulmonary, orthopedic, oncology, "neuro" and gastrointestinal under the name Aetna Health Connections.

This makes me very happy.

Patient safety research

Health Grades released the results of their annual patient safety survey today.  The results are unfortunate; medical error is still persistent and there's a sizeable gap between the top and low performing hospitals.  Among the findings:

• Medicare patients going to hospitals ranked among the top 15 percent in terms of patient safety incidents had, on average, 43 percent lower incidence of patient safety incidents compared bottom-ranked hospitals

• If all hospitals performed at the level of the top 15 percent, 280,134 fewer patient safety incidents and 44,153 fewer deaths among Medicare patients would have occurred, saving $2.45 billion during the years 2002 through 2004

• Approximately 82% of the 304,000 deaths were "potentially preventable"*

• Approximately 1.24 million total patient safety incidents occurred among the nearly 40 million hospitalizations under the Medicare program over the years 2002, 2003 and 2004. That compares with 1.18 million over the previous three-year period, and 1.14 million over the years 2000, 2001 and 2002

Pretty dismal stats.

The good news is that high performing institutions who made concerted efforts to reduce error saw results, and have an average of 43% less errors. 

Bottom line: we've got a long way to go on patient safety, but when efforts are made, they work.  Our challenge will be how to get enough money for the bottom performing hospitals to make better safety efforts.  Unfortunately, when your ER is constantly on the verge of closing, it's hard to scrape up extra funds to reduce error.

*this sample is Medicare patients.  These patients are probably more likely to die from error than a general population sample.  But the number of errors should be generalizable.

Sick? Should you ask the internets?

I can relate to this.   I got a cold/bronchial thing recently and went in search of what over the counter meds are the most effective.

That task is easier said than done, partly because the data surrounding Sudafed versus Mucinex versus nothing is just not all that accessible online.  And for someone fairly familiar with medical terminology, making sense of papers is remarkably difficult, in part because without good access to the journals online (i.e. NEJM, JAMA, etc), you can't even get to that step.

And then you have the absolute dogmatic followers of certain remedies versus others.  My mom, for instance, is a True Believer in the power of Mucinex, whereas I never feel much relief from any given OTC med, unless it's Benadryl (for a bad allergy attack) or ibuprofen.

But even though we'd prefer to use these websites as diagnostic tools, we still have in the flesh doctors for a reason -- they're the ones with the multi-year trainings to most reliably figure out what's wrong with us!  What these sites are the best for is getting more information on an actual diagnosis, followed by a range of treatment options to help you decide what's best for you. 

But I think they can be quite lacking in realistic portrayals of exactly what various procedures entail.  Much of this is on the part of the medical establishment -- doctors are trained to be positive with patients and not to speak frankly about the amount of pain/suffering involved.  But it's my personal belief that it's essential for patients to have realistic expectations -- otherwise they can fall prey to self-doubt and frustration because their treatment schedule is behind or worse than they thought it should be.  That can create enormous frustration and pessimism, which we all know is bad for recovery. 

The WebMD information often seems overly cheery and rose-colored, like not enough of it is edited by patients who've actually had the procedures and can compare their experience to the official description.  Perhaps a new, helpful feature could be discussion boards/blogs attached to descriptions of various diseases, where patients can express their experiences and give potential patients a more realistic view of their recovery. 

ED's and the uninsured

The percentage of uninsured patients visiting emergency departments is apparently in sync with the general population:

Most emergency department patients have health insurance and regular primary care physicians, according to a study published on Wednesday by the American College of Emergency Physicians, the Los Angeles Times reports.  For the study, researchers from the Robert Wood Johnson Foundation and the University of California-San Francisco surveyed 32,669 households in the U.S. in 2001. According to the study, respondents without health insurance accounted for about 15% of ED visits. In addition, the study finds that about 84% of respondents who visited EDs four or more times annually had health insurance and that 81% had access to primary care through a physician or a clinic. About half of respondents who visited EDs four or more times annually were enrolled in public health insurance programs such as Medicaid or Medicare, and one-third had private coverage, the study finds. The study estimates that about 45 million U.S. adults made a total of 80 million visits to EDs between July 2000 and June 2001. Some experts said that the study indicates an expansion of health insurance alone would not significantly help EDs address problems with overcrowding, which they said results in large part because patients cannot obtain appointments with their physicians or must wait for hospital beds (Yi, Los Angeles Times, 3/29).

As 15% of the population is uninsured, this makes sense.  What's more interesting here is the realization that 45 million adults made 80 million visits -- which means that several patients (the majority being insured) are visiting the ED too often.  I've been a patient in the ER maybe twice in my life; several of these patients are going almost twice a year (and others certainly more). 

But I think most ED docs could tell you that an expansion of insurance alone would be insufficient to fix our emergency problems.

Teddy bears cause autism

This is a great graphic from Grand Rounds:

Health disparities, revisted

Matthew Holt has an interesting editorial from Brian Smedley on the recent health disparities study:

This view, however, squarely contradicts what the vast majority of research studies have found for decades – that some patients, most notably African Americans, Latinos, those who don't speak English well, and in some cases, women – receive a lower quality of health care than their counterparts, even when they have similar health insurance and are treated for the same health conditions in the same hospitals. This applies across the gamut of health care, ranging from basic services such as screening and immunization, to primary care, to more expensive, high-tech, specialty procedures.

 

These are the conclusions of literally hundreds of studies published in peer-reviewed journals over the last two decades.  And while a few studies, such as the Asch study, find that disparities are diminishing or that all groups receive equal (albeit poor) treatment, their findings must be considered relative to the massive volume of evidence to the contrary. Even the U.S. Department of Health and Human Services' National Healthcare Disparities Report, released in January and which represents the most comprehensive survey of its kind, finds that, despite some areas of improvement, racial and ethnic healthcare disparities persist, and are worsening in some areas.   For example, the NHDR found that Latino patients with diabetes are receiving poorer quality care today than they were even a few years ago. 

Smedely doesn't discuss where the research disparity comes from, but clearly there's something to think about here.  Asch's study may very well be abberration, but the bottom line is that quality of care is poor, and everything else tells us it's even worse for the actual poor.   Also, remember again that Asch's study only looked at what happens after patients get to the hopsital -- it says nothing about those who can't afford care. 

When care harms

This post about two cancer patients' last months of life, one through the medical system, one with no medical care, is worth a read.

Depression and pharmaceutical effectiveness

Sad news from the largest ever study on depression:

Antidepressants fail to cure the symptoms of major depression in half of all patients with the disease even if they receive the best possible care, according to a definitive government study released yesterday.

Significant numbers of patients continue to experience symptoms such as sadness, low energy and hopelessness after intensive treatment, even as about an equal number report an end to such problems -- a result that quickly lent itself to interpretations that the glass was either half empty or half full.

The $35 million taxpayer-funded study was the largest trial of its kind ever conducted. It provided what industry-sponsored trials have rarely captured: Rather than merely ask whether patients are getting better, the study asked what patients most care about -- whether depression can be made to disappear altogether.

The study only examined the effectiveness of drugs, not therapy, so it's unclear how many people continue to suffer.  But it's still disheartening.  I can picture those "Depression Hurts" commercials -- and it hurts more than we know when you can't fully recover. 

Docs and Charity

This Kaiser Daily  report on docs and the amount of charity care they provide is pretty interesting.

Equally Terrible

I've been meaning to post on this for awhile, but hadn't really figured out the direction to take.  A new research project by RAND found that regardless of race, age, or income, patients in the U.S. receive equal care once they get to the doctors office.

But, about that care.  It's pretty bad.  In fact, according to the study, patients receive the correct care about 55% of the time.  The glaring comparison that enters my brain is school (a year ago at this time I was in college, taking exams and such).  If I'd done 55% of my work on average, I never would have made out with my degree. 

But there are some major limitations to this study.   It doesn't investigate the effect of a 55% appropriate care level on patient outcomes.  So we don't know if the care grade should be an F or an automatic expulsion. 

Further, and this is key, the study only examined what happens once patients make it to the doctor:

Certainly some people have better access to healthcare than others, and previous studies have shown that people without health insurance get sicker and die younger than those with insurance. But this study wasn't about access to care. It was about what happens after people reach a hospital or doctor's office.

Once they're in the door, regardless of how long it took to get there, they get what they need about half the time, regardless of who they are or even whether or how they're insured, the study found. Recommended care included things that have been scientifically shown to be medically effective and are accepted as the best standard for various conditions. The researchers looked at 439 such measures of quality for 30 common medical conditions and preventive care.

That throws a wrench in things, and explains the multitude of studies showing racial and income health disparities.  Patients need to get into treatment on a regular basis, and use those incomes, to have a true comparison. 

The good?  Patients are given equal treatment and this study found no evidence of bias based on population characteristics.  Considering things like residual (and actual) racism, xenophobia, etc, it's quite impressive that our medical system treats everyone the same.  That's truly something to be proud of.

Now if we could just get them to treat everyone the same, but more accurately, we'd be golden. 

Docs and Religion

From Forbes:

When the man arrived at the emergency room, it was clear to Dr. Dana King that he was having a heart attack -- and that he was terrified.

"I could see the look on his face," said King, a family physician and a professor of family medicine at the Medical University of South Carolina in Charleston.

King took immediate medical steps to help the man. But he also did something a bit unexpected. "I took his hand and attempted to comfort him. I asked him, 'Are you a religious person?'" King said.

"He looked at me like he was looking at me for the first time," King recalled. "A wave of relief came over him. He could see that I was making a connection on a different level. We prayed together, right in the middle of the emergency room. It was a short prayer, but it was just a way to touch someone intimately."

The patient, in his late 40s, survived. King doesn't think it was just the prayer that saved the man's life. Without the life-saving medical treatment, he wouldn't have lived.

I'm not a particularly religious person, but I see nothing wrong with doctors asking patients if they're religious, and then offering to pray with them.  Because while the effect of prayer on health status is unclear, one thing isn't: optimistic people live longer, and if you're feeling confident and connected with your doctor, you're probably feeling a little optimistic.  Stress and fear harm the body, surely it's better to avoid these feelings and give patients a deeper sense of safety and security.

Further, I'm not sure why this is surprising or newsworthy:

Curlin and his fellow researchers surveyed 1,260 practicing physicians in the United States. They found that 76 percent of the doctors believe in God, and 59 percent believe in some sort of afterlife. The researchers also found that 90 percent of the doctors attend religious services at least occasionally, compared to 81 percent of adults in the general population. And 55 percent said their religious beliefs influence how they practice medicine.

If you take Americans as a whole, 81% identify themselves with a specific religion, and 76% identify themselves as Christian.  So doctors are like the rest of the nation. 

Bird Flu: Oh no

Via Medpundit, there's some Very Bad News on the bird flu front:

The H5N1 virus responsible for the current virulent strain of bird flu has evolved into two genetically distinct strains, US scientists have confirmed.

...Back in 2003 we only had one genetically distinct population of H5N1 with the potential to cause a human pandemic. Now we have two

Prior to 2005 every known human case of bird flu had been caused by a particular subtype of the H5N1 virus, which infected people in Vietnam, Cambodia and Thailand.

But the latest analysis by the US Centers for Disease Control and Prevention identified a genetically distinct variant which appears to have emerged last year, infecting people in Indonesia.

So now there's two possibilities of virus strain mutations into human flu pandemics.  Not be alarmist about this, but doesn't that mean that it's now twice as likely that the bird flu could become a human pandemic?

Kate Update

I had my fourth post-op appointment yesterday, and progress is finally being made (if you're new to the site and haven't been keeping up with my surgery, my original post on it is here.)  My bone is showing some healing, so my doctor graduated me to one crutch.  This was the first morning in 13 weeks I got my own coffee and carried it to my desk.  I have one free hand and use the crutch essentially as a cane.  I also don't have to wear my basketball star brace anymore.

A few notes this far out: do not believe the amount of time WebMD says it will take to heal.  If it took me, a healthy 22 year old, 13 weeks to move to one crutch, it is taking your average person with this procedure (usually individuals in their sixties) as long, if not longer.  WebMD says 10-12 weeks for full weight (i.e. no walking assistance).  Interrogate your doctor more -- I thought at 12 weeks I'd be high-tailin' it out of Kansas City and on to Washington, D.C.  I have another six weeks before I'm well enough to move to a whole new place. 

Don't get me wrong -- progress is progress.  My leg will get strong quickly now that I'm walking on it; I can carry things, and it's a marketed improvement from before I went into the doctor.  Every time I see my doctor he schedules my next appointment for six weeks -- this was (and continues to be) unexpected.  Ask how far apart your appointments will be; that will give you an idea of what your progress will be like.  Sorry I don't have my current x-ray to post, but rest assured it's still looking fairly similar to this.

Concientious Objectors?

Shadowfax has a great post examining the ethics of refusing care:

I do not see how pharmacists, who I generally respect as health care professionals, get off carving out a 'conscientous objector' exemption to providing care to certain persons of whom they disapprove.

Perhaps it is my own background that makes me so sensitive to this issue. I am compelled, both ethically and legally, to provide care to a great many persons whom I dislike or disapprove of. I have cared for Neo-nazis, drug users, spousal abusers, child abusers, felons great and petty; I have cared for individuals who have insulted me and assaulted and injured my staff; I have cared for individuals whose behavior I found deeply immoral and objectionable. I have no legal exemption to refuse to provide them with health care, nor would I claim such a right were it a legal option for me. Because it would be wrong.

Pharmacists have been refusing to dispense a medication that is only birth control pills, that IS NOT an abortion, vs. being required to care for child abusers?  Really, where do they get off?

There are plenty of people that all of us have deal with/help in our everyday life that we'd rather not.  But that's life!  There are plenty of things people do I believe are morally reprehensible, but when your professional calling is to give people medical care, you do it. 

We all know what happens to children that aren't wanted -- they grow up to become the individuals Shadowfax describes in his post. 

Hungry?

So that sleeping medicine Ambien?  Apparently it does funny things to you:

The sleeping pill Ambien seems to unlock a primitive desire to eat in some patients, according to emerging medical case studies that describe how the drug's users sometimes sleepwalk into their kitchens, claw through their refrigerators like animals and consume calories ranging into the thousands.

The next morning, the night eaters remember nothing about their foraging. But they wake up to find telltale clues: mouthfuls of peanut butter, Tostitos in their beds, kitchen counters overflowing with flour, missing food, and even lighted ovens and stoves. Some are so embarrassed, they delay telling anyone, even as they gain weight.

The reactions range from fairly benign sleepwalking episodes to hallucinations, violent outbursts and, most troubling of all, driving while asleep

Personal Anecdote Time

Re: Dr. Andy's post about compulsory vaccination, I have a couple anecdotes.

When I spent a summer in DC I had the opportunity to attend a congressional hearing on Hormone Replacement Therapy.  At one point the committee chairman went on a diatribe about vaccines and autism, and how his grandson is autistic and clearly it's the vaccine's fault.  Then he said asked the chairwoman of the heart, lung, and blood institute why the NIH wasn't doing anything about this (gee -- I don't know, because it's the FDA's jurisdiction??).  Keep in mind this has nothing to do with Hormone Replacement Therapy, which is for menopausal women.

Next in Kate's special anecdote file is the girl who got measles in one of my classes at Santa Cruz.  Now, being Santa Cruz and all, this wasn't too terribly surprising (not because there's lots of measles going around, but because there's a lot of ultra-natural people).  But a 20 year-old got measles!  It's ridiculous.

The main issue I have with "conscientious objections" to immunization is the person who it really affects isn't choosing at all.  They could get something terrible like, say, measles (or heaven forbid, Hepatitis B), down the road because of their parent's scientifically unfounded beliefs. 

Fortunately we're fine as long as the vast majority are vaccinated.  Who knows where my classmate got measles from, but she didn't spread it to anyone else. 

How to entertain yourself while being an invalid

This is a little out of the blue, and I'm not quite done with my convalesence yet, but you might be just starting your surgery/etc, so here goes:

How to entertain yourself when it's difficult to leave your house:

1. Start a blog.  Convince yourself that people are reading it, so you must write something in it everyday.  By a certain time (like 10 am).  That will give you a sense of accomplishment and reason to get up before one in the afternoon.  Otherwise the days become long and aimless (surprisingly so since you're sleeping in the afternoon).

2.  Find some favorite shows.  I've been watching Project Runway -- there's a new episode every week and I honestly look forward to it.

3.  Avoid message boards unless you have a major dilemma.  A lot of the people on message boards have serious complications and they will inevitably scare you to death.  You don't need to be scared like that (bad for the heart) -- continue on in ignorant bliss.

4.  Fiction, fiction, fiction.  Non-fiction is great and all, but if you only to make out to read non-fiction, you won't finish anything.  So far I've read: Jonathan Strange and Mr Norrell (Susanna Clarke), White Teeth (Zadie Smith), A Heart Breaking Work of Staggering Genuis (David Eggers), The History of Love (Nicole Krauss), and I just started The Red Tent.  All fabulous books.

5.  Don't watch too many sports with super muscled people running around.   The Olympics almost made me throw off my crutches watching all those ridiculously active atheletes.  Remind yourself that the Olympic mogul skier will probably be in your position down the road anyways.  And who really wants their thighs to be as big as Apollo Ono?

6.  Try and make little traditions or appointments.  Again, this helps pass the time and keeps you from feeling like you're stuck in purgatory.  Make a coffee appointment with a friend every Thursday, or go see a movie every Tuesday.

7.  Always be thankful, but don't feel bad about needing/asking for help.  Don't be stubborn.  Don't wear yourself out doing things by yourself that others can help you with.*

Hope that helps someone.

*my bad

Frustrations

I think the thing that frustrates me the most, after 10 and half weeks on crutches, is that I can't make peace with the fact that it takes me a lot longer to do things. 

Today I'm going to attempt cleaning my room.  Instead of being leisurely, taking my time to slowly crutch around while trying to balance things in one of my hands, I will hop like a madwoman all over my room.  When you hop on one leg, you get a fair amount of momentum going, so I'm sure these hops will be tempered by running into/collapsing onto my bed.  I will lay there staring at the ceiling for a minute, cursing my bum leg, then recommence the hopping.

It's quite a spectacle really.

Dr. Walker

Graham is a med student in California.  He's from my hometown and  I got to meet him last December.  He was a warm, intelligent, great guy, and I know he's going to be an incredible doctor. 

That's why you have to read this absolutely beautiful post about his patient.

Friday Fun Resources

Via Matt Holt, a Chicago couple has started a non-profit tee-shirt biz for patients with serious or chronic illness to help them feel the lighter side.  They feature shirts like: "Death: Been there, done that", "Chicks dig scars," and "Warning: High Voltage (defibrillator)".

My personal favorite is, "Think I look bad? You should have seen the other guy," because I like to mess with people when I go out on my crutches and tell them I was in a knife fight (punchline: I might have a brace, but the other guy has no leg).

It's a great project, so pass it on to friends/family who would enjoy.

Medicare leads the way for weight-loss surgery

Via Kaiser, Medicare has agreed to pay for three types of weight loss surgeries:

Three of the most commonly performed bariatric procedures -- Roux-en-Y gastric bypass, gastric banding and biliopancreatic diversion with a duodenal switch -- will be covered as long as beneficiaries obtain the services at centers that have been certified as well qualified by the American College of Surgeons or the American Society for Bariatric Surgery, the Post reports (Stein, Washington Post, 2/22). To qualify for the surgeries, beneficiaries must have a body mass index of more than 35 and one or more weight-related health problems, including diabetes, heart disease or sleep apnea, according to CMS. In addition, beneficiaries must have tried other treatments unsuccessfully, USA Today reports. CMS officials said they do not know how the new coverage will affect costs, though they believe the costs will be significantly less than what Medicare spends on coronary bypass or heart defibrillators.

Far from the UK's recent bias towards those with obesity, Medicare is going where many private insurers refuse to.  It's good to see they've added some qualifiers like trying other treatments and suffering at least one obesity-related disease, although I wonder how strictly those guidelines will be adhered to.  Unfortunately, when you get over 65, it's fairly difficult to lose weight through exercise and diet has to pick up much of the slack, so surgical options might be more appropriate for this age group.

I'm quite surprised that weight loss surgeries are only  $20,000 -40,000, as my own minor leg surgery was $23,000.  One frustrating insurance practice is their inability to recognize that denying treatment for current illness will end up costing them a lot more down the road.  Maybe they think they can get away with it in our shifting employment market because there's a fairly good chance that a claimant will be on another plan down the road when they incur these costs.  But with Medicare, you can be fairly sure an enrollee will stay a Medicare enrollee, so the trade-off of paying for surgery versus not paying and later being responsible for cardiac care is easier to predict. 

I'm also curious to know how many people over 65 would qualify for this.  It seems most people needing this kind of surgery are between 20 -- 40, and can recognize the long-term impact of such a drastic procedure.

One more thing -- how much higher is the death rate over age 65 for these procedures?  That's worth looking into, because it's major surgery with a fairly high risk of death, and being over 65 surely increases that risk.  It probably depends on the patient's BMI.

Ladies and Gentlemen

Always pay your prostitutes.

Regulating herbal therapies

I'm going to expose my lack of medical training here, but re: this new study:

A large, seven-year study of healthy women over 50 found no broad benefit from calcium and vitamin D supplements in preventing broken bones, despite widespread endorsement by doctors for the supplements.

The study, whose results are being reported today, also found no evidence that the supplements prevented colorectal cancer, and it found an increased risk of kidney stones.

Isn't there evidence that women can only increase their calcium levels before 40?  And after that calcium levels fall drastically, and taking supplements can't do anything for it?

I'm strongly in favor of regulating supplements and herbal products.  Consumers spend billions of dollars a year on products whose therapeutic evidence is usually weak at best.  It's great that NCCAM was created, but  its research has proven less than encouraging so far: St. Johns Wort has no value in moderate or major depression, Echinacea doesn't do anything for colds, and vitamin E does nothing for joints.

I went to college in Santa Cruz, CA (home of the "natural lifestyle") and natural pharmacies were everywhere.  It's not wrong that people want to do things naturally, but they deserve to know that the treatments they're paying for (many cost upwards of $100/month) have no evidence to back them up. 

Difficult trade-offs

I just want to link to this post of Joe Paduda's in light of my recent post on bone stimulators.  My situation is only putting off treatment that makes patients heal faster.  Cancer drugs put off death.

I'm going to go out on a limb here and say, despite the enormous cost, if anyone in your family has ever died of cancer (as in mine) or a family friend (or even friend), which again, has happened to one of our family friends, you know months count.  They really do, especially at advanced stages of illness.  I believe that especially when you're paying for health care as a nation, these kinds of costs that can preserve some semblance of the person for a few more months are worth it, if the patient and family want it.

The bottom line isn't, and should never be, cost.  It's care.  It's mercy.  There's a big difference between unnecessary MRI's and putting off a terrible death so someone has a few more months with their loved ones.  Sure it's an enormous cost, but I believe it's worth it.

What do you think?

Conflict of interest

Roy Poses of Health Care Renewal has a great post about enacting ethics reforms between physicians and device makers:

USA Today has weighed in about stricter standards for physicians' relationships with pharmaceutical and device companies, leaning heavily (as did the New York Times previously) on the recent article in JAMA by Brennan et al.  Unlike the Times, USA Today ladeled blame about evenly on physicians and industry. And the editorial's position on which of the specific rules advocated in the JAMA article should be adopted, I must say, mirrors mine.  But, in my humble opinion, USA Today stumbled badly on the issue of enforcement. The editorial endorsed enforcement by academic medical centers, without raising any questions about whether their leadership is more ethical, or less conflicted than physicians. Furthermore, it also suggested that "managed-care groups can help enforce rules for their participating doctors."

I'm often astounded at reporters' ignorance when it comes to health policy.  I understand that it's complicated, but thinking that managed care is a panacea for ethics problems is one of the worst ideas I've heard in awhile.

In any case, readers of Health Care Renewal know that academic institutions are having plenty of their own ethics problems as well.  Take the University Medicine and Dentistry of New Jersey, which has a federal investigator, UC-Irvine which is apparently incapable of running organ/bone marrow donation programs, and Sheffield University which fired a professor for questioning methods in a pharmaceutical research study. 

What Managed Care can do, however, is refuse to cover drugs that have been clinically shown to be either less effective than older medications or no more effective.  At the National Health Policy Conference, one speaker showed a power point detailing the efficacy of various blood pressure medications and their prescription rates.  Calcium Channel Blockers, the newest group of drugs, are actually much less effective than dirt-cheap diuretics, yet still enjoy popular prescription rates.  Using this information, insurers should refuse to cover calcium channel blockers unless the physician submits an additional request for use if the patient has bad reactions.  It's really that simple. 

What makes a great doctor?

This is a great post by the Cheerful Oncologist on what it takes to be a great doctor.  CO says:

1. A great doctor loves the written word.

2.  A great doctor is curious.

3.  A great doctor is observant.

4.  A great doctor is a problem-solver, not an excuse-maker. 

5.  A great doctor enjoys the company of other people.

6.  A great doctor has no hidden agenda.

And finally, a great doctor possesses fortitude

As a life-long (and intensively treated) patient, I'd add two more to this list.  8. A great doctor is a great communicator and 9. A great doctor chooses a great nurse

In my mind, you can be as incurious as you like, but you have to be able to talk with your patient and their family frankly and in layman's terms.  Don't use anatomical language without explaining what it is (for example: instead of saying "there might be a tear in your meniscus" say, "there might be a tear in the cartilage in your knee, which is called the meniscus"). 

A great nurse makes all the difference in the world.  Not just for the doctor's work load, but for the patient's impression of the doctor.  I can pretty much guarantee I wouldn't have nearly as positive of an opinion of my surgeon if his nurse wasn't the best nurse I've ever met.  She makes our next appointment while we talk to the doctor.  She comes in before and after him to brief us/see if we have any questions.  She called me yesterday morning to check in and see how I was doing (I'm nine weeks out of surgery, mind you, not one).  She makes a strong impression that I'm receiving top-quality care. 

So there you go.  Don't forget to speak down on earth with the rest of us and appoint a great representative. 

Not so small

Medicare is going to start covering some ultrasounds:

Medicare beginning next year for the first time will cover ultrasound screening for abdominal aortic aneurysms for high-risk groups of beneficiaries, the Wall Street Journal reports. Categories include those who have a history of aneurysms in their family or males who have smoked more than 100 cigarettes in their lifetimes, according to the Journal.

Considering how high smoking rates used to be, I would imagine a large percentage of male seniors have probably smoked more than 100 cigarettes in their lifetime.  They should be tested, but with that criteria, it's not exactly going to be a tiny group. 

Fixing primary care

The American College of Physicians released a stark warning this week:

Primary care is on the verge of collapse," said the organization, a professional group which certifies internists, in a statement. "Very few young physicians are going into primary care and those already in practice are under such stress that they are looking for an exit strategy... The group has proposed a solution -- calling on federal policymakers to approve new ways of paying doctors that would put primary care doctors in charge of organizing a patient's care and giving patients more responsibility for monitoring their own health and scheduling regular visits.

On top of the inefficient way the U.S. health system provides insurance, our care delivery structure is quite perverted.  We have many many more specialists than other nations, many of whom have a "gate-keeper" system to centralize care. 

The U.S. doesn't need (or want, for that matter) a gate-keeper system as they exist in other countries. But we could do a much better job of streamlining care, and as ACP suggested, give primary care doctors' more responsibility for organizing a patient's care (as long as that greater responsibility results in a decreased patient load).   Americans loathed having needed a referral from their PCP everytime they set up an appointment with a specialist, so trying to implement that nation-wide won't work.  Instead, if we can put more focus on preventative care, and adopt a system where a PCP taking excellent care of their patient (pay for performance, anyone?) does result in a significant payment. 

Another benefit of more streamlined care is a reduction of errors.  If a PCP has all the information on medications and treatment for their patient, they can better evaluate if they're receiving unnecessary care (or not receiving necessary care).  But again, for this kind of system to function properly, PCPs must decrease their patient load.  That means insurance needs to start valuing care differently. 

There's also something to be said for utilizing more nurse practitioners and physician's assistants, who can provide the same, "My nose is running and I've got this awful cough" care at a much lower cost than M.D.'s.  If these practitioners become more in charge of urgent care it frees up PCPs to take on the role of health manager. 

HRT back again

A new study in the Journal of Women's Health reported that hormone replacement therapy may not have the horrible effects we think: 

Some researchers are testing a new theory, that hormone therapy is beneficial for the heart when it is initiated early, during a narrow "window of opportunity" around the time of menopause and before women develop an excessive buildup of atherosclerotic plaque.

A chief criticism of the hormone study, part of the national Women's Health Initiative, was that it included women much older than the average hormone user, who typically initiates therapy around the time of menopause. The average age of the participants in the study was 64. The average age of menopause is 51.4, and some studies suggest that women who initiate hormone therapy later may miss the chance to benefit from the treatment.

This month, a paper in The Journal of Women's Health added credence to that idea. It reported that women who started therapy soon after menopause reduced the risk of coronary heart disease 30 percent, but that the benefit appeared to diminish the longer women waited to initiate treatment.

I understand the criticism that the women in the study were older on average and that could have affected the results.  But there's two different things happening here.  One is that menopause is uncomfortable and frustrating.  The other is that medicine looks at menopause as a disease to "fix". 

Now that women are living longer there's good reason to try and relieve discomfort associated with menopause.  But we should be wary of the pharmaceutical industry's push for HRT.   They have a lot riding on widespread hormone use -- for years it was touted as a product that makes you "look younger". 

Talk about this "window of opportunity" is unsettling too, mostly because it's almost impossible to find out when that is.  For some women it might be 48, others 52.  And if you miss the window, you're taking a substantial risk. 

Hormones are still on the market, and you can believe doctors who say things like this are prescribing it for people who aren't  suffering from severe menopause symptoms:

"Personally, in my heart of hearts, I think there is a benefit," said Dr. Mary Jane Minkin, a clinical professor of obstetrics and gynecology at Yale. "However," Dr. Minkin said, "I'm politically incorrect if I say that." ... "Three years ago, the message was, 'You're going to die if you don't stop taking this,' " said Dr. Minkin, who takes estrogen and is a paid speaker for drug companies that make the estrogen products she prescribes.

Sorry doctor, but "heart of hearts" isn't a good enough reason to prescribe a product that has been proven to increase the risk of heart disease, breast cancer, and stroke.  The fact that she's a paid speaker for drug companies isn't easing my mind either.

For some people, the risks associated with hormones are a reasonable trade-off.  But when doctors are whispering in patient's ears "don't worry, hormones are perfectly safe", that trade-off isn't made clear. 

Med school teachings

Graham has an excellent post on changes to be made in medical school curricula:

But one area where I think we’re lacking—because medicine has changed so much—is the treatment of the chronic disease. We focus so much on the acute still in medicine, when our patients have primarily shifted to the chronic. Sure, as residents we have clinic time where we see patients as outpatients in a chronic disease setting—but most of our residency (and much of our medical school) training is still focused on the acutely ill patient. While this definitely hammers home important concepts in many diseases, which can then be translated to the outpatient basis, I wonder if there’s more we should be learning. If you look at physicians as a whole, they’re not working in hospitals, taking care of acute patients. They’re working in private practices, seeing outpatients.

In terms of care, the U.S. is great at acute treatment and really lousy at preventative care.  Perhaps the focus of medical school is reinforcing this problem? 

I have to think, however, that this is a difficult balance to strike, there only being so many years we can keep people in medical school.  But our system produces much less general practitioners and primary care physicians than other nations, another  undesirable result of the medical school curriculum (and also of market distribution, of course -- specialists get paid a lot more).  Both of these facts are costly in our health system -- specialists are more expensive than generalists,  and poor management of chronic illness can result in hefty costs over time. 

I think Graham's onto something...

Surgery Blogging

It's Friday, so I figure it's time for something light, you know, like talking about my surgery. 

I had my second follow up appointment yesterday (I'm now four weeks out) and my first x-ray post surgery.  If you don't remember what they did to me, or were too lazy to follow the link, or new to the site, refresh your memory here.

I want to start off by saying that my doctor/nurse team is incredible.  My surgeon never makes me feel stupid, or like he's in a hurry, or like I'm just a bone detached from a body, he's not awkward, he makes jokes with me -- he's not the typical orthopedic surgeon.  The nurse is eminently capable, actually books my next appointment <i>for</i> me while I talk to the doctor, she's so bright and organized.  My mom and I always thank her profusely after appointments and she sticks by her refrain: "It's all because I've got a great doctor.  He treats me like an equal and we're a team."  It's heartening to know such great people are in charge of your care.

But enough gushing, it's time for the goods:

This is my super awesome badass new bionic femur.  As of yesterday. 

Now, if you take a close look at this x-ray (you can also click on it and open it in a pop-up window) you'll notice that where they did the actual osteotomy my bone is offset.  My doctor brought in my x-ray and I kinda cocked my head to the side, giving my most puzzled but trying not to freak 0ut that my bone is totally off look.   

Let's just give this some context now.  Don't forget that I'm the person who's been a little malpractice obsessed lately with Baker's book.  And here comes my doctor with an x-ray that looks like my bone wasn't put back together right.  I'm feeling a little sick.

The doctor looked from me to my mom (who is much better at just appearing concerned) and said, "Oh! Before I say anything else, the bone is supposed to look like that.  See, when I did the osteotomy, I shifted the bone over -- the plate will hold it in place as the bone grows in at the sides.  It won't look like that forever!"

Deep breath.  It's okay -- it's supposed to look like that.  I'm good. 

Then the usual appointmenty stuff -- I can now bend my knee 30 degrees, put approximately 25 pounds of  weight on that leg, and another 6-8 weeks on the crutches.  But everything's healing as it's supposed to, particularly my bone which is supposed to look that way.  I think.

What to expect when you're expecting to be hospitalized

When I left the hospital a few weeks ago, I penned this post about all the annoying things hospital people will do to you during your stay. And here comes future M.D. Graham substantiating every part:

Kate says: Do not expect to rest in the hospital, especially post-surgery. Invariably someone will declare their presence five minutes after you nod off. This includes the physical therapy person who gleefully announces, the day after they cut open your leg and put a huge plate in, that it’s time to learn crutches and practice stairs!

Graham says: You will not get any sleep; people will constantly be bothering you with questions, physical exams, or lab draws.

Kate says: Do not expect to get any real information out of your doctor, as you will only see him/her for three minutes at 6:30 a.m. By the time they’re done, you will still be rubbing your eyes trying to figure out which health practitioner is bugging you this time.

Graham says: You will be told lots of things, by lots of people, often things that use medical mumbo-jumbo. It will be confusing, probably–which test you’re getting, or what medicine you’re on. Many times people suck at explaining this stuff in normal terms, so please, please ask.

Kate says: Plan ahead! The second you need to use the bathroom, do it! Invariably someone will come to take you to some test if you wait, and you will get stuck on the x-ray table for 45 minutes while they find someone to transport you back to your room. That also goes for your pain meds – order your next one an hour early. It will take an hour to get it, and it will feel like the longest hour ever.

Graham says: You will be poked and prodded, have your blood drawn–multiple times per day, from multiple arms and wrists.

Between the two of us, you'll know everything to expect before you go into the hospital. Think of our posts as primers of sorts.

Ah, medicine.

I am very expensive

So I just received gold for a health policy wonk. It's a nifty piece of paper illustrating, ever so vaguely, the cost of various medical procedures and gadgets. That's right -- it's the bill from my surgery and hospital stay. The total cost: a whopping $21,113.44 -- hoo!

How did this little body get enough work done to equal the cost of a brand new car? Let's see:

It's kinda fun to guess what these generic items are referring to. "Other implants"? I believe that's the metal plate and screws now inserted in my femur -- a cool $2,624.

But that's not the expensive column. Oh no no no no.

"Operating Room Services"? That'd be the surgery itself -- $12,672. "Pulmonary function" -- my breathing tube -- $360.00 "Pharmacy" -- I'm guessing that's the anesthesia -- $1,204.44

There you go, folks. I am the sole reason health care is so expensive in this country. My surgery was only one hour and 45 minutes. And it cost over $20,000. Without it, I would have worn out my knee in a decade, been in terrible pain, and needed a knee replacement at the age of 32. If putting a plate in my leg is $20 Gs, I can't imagine how much a knee replacement costs.

But while I'm very expensive, I'm also very lucky. I have insurance which will pay for the vast, vast majority of that cost. The copay I owe hasn't come in yet, but I'll be sure to let you know when it does. Probably won't be nearly as exciting as my itemized bill, though.

She's not cancer!

Patti has a beautifully put post on what it's like to have chronic illness:

It's hard to believe it's been four months since I was diagnosed with stage III colon cancer. During that time I've had a colon resection and four chemo treatments AND played lots of bridge, some golf, taken trips to New York, Atlanta, and Orlando, gone out for lunch with friends dozens of times, continued my Monday morning with Meals on Wheels, and -- well you get the idea.

Some days, even some weeks, I have so many medical appointments, see so many doctors and nurses, and have so many tests, that I start to feel like my whole life is about cancer. I just want to shout, "I'm not cancer!"

I am Patti. A Christian woman, wife, mother, grandmother, friend, bike rider, golfer, volunteer, card player, lover of books and music, traveler, and animal lover, and I have cancer.

But make no mistake, I AM NOT CANCER!

Her framing of "being cancer" rings so true for those of us with chronic illness (I have nothing approaching the seriousness of cancer, thank God) -- our illness often supercedes our identity. In some ways this is only natural; life must be planned around your situation, your appointments, etc. But can be damaging coming from friends and family who only inquire about the illness, and particularly doctors who have difficulty separating the person from the disease. It's so essential to preserve the other parts of your life -- and much too easy to get swept up in the gravity of disease.

New Advance for Ovarian Cancer

My grandmother died of ovarian cancer and there's some evidence of genetic susceptibility, so this is good news (although still totally short of a cure and I wonder if there's a decrease in mortality rate):

A rarely used treatment that pumps cancer drugs directly into the abdominal cavity can add 16 months or more to the lives of many women with advanced cases of ovarian cancer, doctors are reporting.

Medical practice should change immediately to reflect the findings from the study, being published today, as well as those from several earlier studies, cancer experts say.

In the United States there are more than 22,000 new cases each year, and 16,000 deaths. Currently, most women receive chemotherapy intravenously. They should still do so, but many should get the drugs abdominally as well.

To Push or Not to Push

From MedSleuth:

The January issue of the American Journal of Obstetrics and Gynecology reports that for women giving birth, having a "coach" tell her to push during contractions makes almost no difference in shortening labor, and may actually increase her risk of subsequent problems with her bladder, researchers at UT Southwestern Medical Center have found.

Dr. Steven Bloom and his colleagues found that "coaching" a mother to push during labor makes little difference in the birth. A previous study has shown that coaching may actually cause damage to the bladder and pelvic floor.

"Oftentimes, it's best for the patient to do what's more comfortable for her," said Dr. Steven Bloom, lead author of the paper and interim chair of obstetrics and gynecology at UT Southwestern.

In the study, UT Southwestern researchers focused on second-stage labor - the time in which the cervix is fully dilated and the baby begins to descend. This report follows an earlier one that found a rise in pelvic-floor problems among coached women.

The new study involved 320 women at Parkland Memorial Hospital who were giving birth for the first time, had uncomplicated pregnancies and did not receive epidural anesthesia. They were randomly assigned, with both groups tended by nurse-midwives. Of the two groups, 163 were coached to push for 10 seconds during a contraction, and 157 told to "do what comes naturally."

For women who were randomly assigned to the coaching group, the second