Monday, March 16, 2015

Naturopathic Doctors vs. MDs

When I moved to New Hampshire 11 years ago, I was in for a bit of a medical culture shock. One of the biggest surprises was my first realization that there are "Doctors of Naturopathy," or "NDs" in New Hampshire who are licensed to practice medicine.  In New York, I had had no experience with this.  This is not to say that people there didn't see people who practiced "alternative medicine."  What I'm talking about are practitioners who had attended a school of naturopathy and held themselves out to be primary care physicians with equivalent education and training to mine.


My first encounter with this was a patient who came to me because she had been diagnosed by her ND with "heavy metal poisoning."  She actually was my partner's patient, but had been squeezed onto my schedule as an emergency appointment because she wanted to be admitted to the hospital immediately to begin treatment.  My curiosity was piqued when I saw the chief complaint on my schedule.  How does an adult in Portsmouth, NH end up with heavy metal poisoning?  Had she had some kind of toxic exposure at work?  What kind of neurological problems was she manifesting?  Imagine my surprise when I walked into the room and saw a well-dressed, healthy looking woman in her late 40s.  She told me that she had seen a local ND for fatigue and difficulty losing weight (her weight was perfectly normal, by the way).  The ND had tested her for heavy metal poisoning.  She told me she was given some sort of pill, and then had her urine tested for heavy metals.  She handed me a lab report that looked something like this:


I'd never seen anything like this.  I asked her about her history and possible exposures...there was nothing significant.  I asked her very specific questions about neurological symptoms- there were none.  I performed a neurological exam, and it was normal.  I did a quick test of cognitive status, and it was normal.  I then excused myself from the room and went to my office to make a quick call to a doctor I knew who specialized in occupational medicine and toxic exposures.  He gave a sigh after I outlined the case, saying "I'm seeing more and more of this crap.  The test is worthless.  The pill was a chelating agent (a medication that binds to metals in the body).  This makes them pee out metals, but the reference ranges for the results are based on what you should pee out when not given a chelator.  It's a way to make patients think there's a problem and then they can be convinced to do all sorts of useless, expensive therapies to cure their 'toxicity.'"  I thanked him and hung up.  I went back to the patient and explained, trying to be diplomatic, what I had found out.  She didn't exactly believe me.  I offered to repeat the testing, by checking both her blood and urine for any heavy metal issues.  She accepted.  The tests were normal.  I called her and gave her the results.

I never heard from her again.  She transferred out of the practice.

That was my first experience.  I've had many others through the years...and most of them have been similar. In my experience, most patients that see NDs around here end up being diagnosed with one of several diagnoses- heavy metal toxicity, chronic Lyme disease, adrenal fatigue, or systemic candidiasis.  I'm not going to go into each of these issues, save to say that all of those diagnoses are controversial, so say the least.  Perhaps in another post.

I was also quite surprised that in addition to NDs being licensed to practice medicine in the state of New Hampshire, they are able to prescribe pretty much anything I can.  Here's a link to their formulary.  Then, I found out that licensed naturopaths are considered primary care doctors here.  Just like me.  So, silly me, I figured that their education and licensing process must be just like mine, right?  Well, here's a link to the requirements to get a naturopathic license in NH.  Here's a link to what's required to get a license to practice medicine in NH.  Keep in mind, in order to get a medical license in NH, you also have to submit an application to the Federal Credentialing Verification Service (FCVS).  Here's a link to the FCVS requirements.

Equivalent?  You be the judge.

Clearly the licensing requirements for MDs are much more stringent than for NDs.  But what about the education?  NDs claim that their education is actually more complete than traditional medical school, with more classroom hours.  Since I've only gone to medical school and not naturopathic school, I've had to take their word for it.

Until now.

There's a new blogger in town, and her name is Britt Hermes.  She attended Bastyr University, which is really the premier naturopathic school in the US.  She then practiced as a naturopath, and gradually became disillusioned with naturopathy and the practice thereof.  She's blogging about her experiences  and her move away from naturopathy, and in doing so has truly exposed the deficiencies in the education given at Bastyr.

Head on over to ScienceBasedMedicine for the full post.  It's long, but definitely worth your time to read.  Some highlights:
I recently scrutinized my transcript, course syllabi, and student clinician handbook. (Here is a table detailing my coursework into more readable categories based on my transcript; credits were translated to hours based on all of my courses syllabi.) I graduated with 1,224.5 hours of clinical training, of which 1,100 hours were in what Bastyr considers “direct patient contact.”.....
More on what Bastyr considers "direct patient contact"...
On a clinic shift, one faculty member (a licensed naturopath) supervised several naturopathic students. ...Each clinic shift had a specific structure that included three elements: shift preview, patient appointments, and shift review.
Shift preview and review took place in the first 30 minutes and final 30 minutes of shift. During these periods, primary students roundtabled their patients. The patient’s medical history, previous visits to the clinic, and previous naturopathic assessments were discussed. Patient cases were presented in a standardized S.O.A.P. (subjective, objective, assessment, and plan) format. The supervisor usually asked students about differential diagnoses and treatment protocols. Medical standards of care were almost never discussed on my clinic shifts, with notable exceptions for one or two of my supervisors who insisted on it, to the dismay of many students. I often heard statements such as, “the patient has a strong vital force and it is expected that the patient will heal in 3 to 4 weeks’ time with proper self-care and home hydrotherapy treatments.” Sometimes, the preview and review was attended by first-year students completing their Clinic Entry 1 requirements. These students generally did not contribute to the discussions but their time was considered “direct patient contact.”
Actual patient care accounted for three hours of a clinic shift.
Patient care visits were typically attended by two students, a secondary and a primary. Appointments lasted anywhere from one to two hours. During an appointment, the primary student charted the patient’s current medical complaint and relevant history. This charting included a typical medical intake, such as the seven attributes of the medical complaint, a review of systems, past medical history, medications and supplements taken, family history, social history, dietary patterns, and so on. Vital signs, like blood pressure and temperature, were usually taken by a student. The patient intake also included information thought relevant to naturopathic diagnoses, like toxin and heavy metal exposure, use of plasticware in cooking and eating, birth history, pesticide exposure through eating non-organic foods, food intolerances, religious affiliations, and a host of subjective assessments relevant for energy therapies (homeopathy, flower essences, UNDA numbers, etc.).
Let me tell you about direct patient care in medical school.  Let's take my internal medicine third-year clerkship.  It was 12 weeks long.  The first 6 weeks were all on the inpatient side.  We were part of a medical team on the wards, consisting of an attending physician, a resident, an intern (first-year resident) and the medical student.  We would typically arrive around 5 AM to start pre-rounds on our patients, and there were usually between 15 and 20 patients to a team.  Pre-rounding is where you check up on how your patient did overnight, examine them, check labs, etc.  After pre-rounding is morning report, which would be a didactic presentation of an interesting case.  Then comes formal ward rounds.  This is where the team rounds with the attending.  Presentations of the patient are made at the bedside.  A care plan is made for the day.  Interesting physical exam findings are shared among the team.  This usually takes at least 2 or 3 hours.  Then it's time for "lunch."  Lunch is always eaten in the lecture hall, because there's a didactic lecture during lunch.  After lunch, it's time to start doing any new admissions that have come in during the day so far. If you're the lucky team on call, this will last until 11 PM.  If it's just a normal day, it'll last until about 6PM.  At 6 PM, you do a final quick round on your patients, make sure they're figuratively tucked in for the evening, and then sign out their care to the night float team who will cover them until you come in at 5AM the next morning.

And you do this six days a week.  One day off for good behavior.

The next six weeks are luxurious in comparison, because they're outpatient.  You work alongside a primary care physician in his or her office.  So, it's much better hours.  We'd start around 7AM with hospital rounds on their patients, then see patients in the office until 5 PM, and then go back to the hospital to check on any inpatients or do any admissions.  But we got both Saturday and Sunday off!

By the way...the internal medicine rotation is considered to be one of the "easy" rotations, schedule-wise.  During my surgery and OB/GYN rotations, for example, there were days where I didn't even bother going home for 2 or 3 days at a time, because it just wasn't worth it.

And check this out:
Our student clinician handbook contained a list of broad medical categories such as cardiovascular disease, hepatobiliary disease, and female gynecological disorders, for which students were required to demonstrate medical competency. Medical competency in these areas was based on the number of appointments a student clinician had with a patient with that category of disease. The number of appointments varied. For example, competency for cardiovascular disease required treating two patients with any type of heart/circulatory disease. Competency for hepatobiliary disease required treating just one patient with any liver or gallbladder disease. Any patient needed to be seen twice to achieve competency.
While students were required to see a variety of primary care conditions in order to graduate, the majority of students never had the opportunity to see an actual patient suffering from such conditions.
Some diseases were very common in the teaching clinic. To the best of my memory, these included irritable bowel syndrome, anxiety, food allergies, fibromyalgiachronic fatigue, adrenal fatigue, chronic Lyme disease, chronic mononucleosis, chronic back pain, and esophageal reflux.
Less common diseases included hypertension, asthma, hypercholesterolemia, anovulation and menstrual problems, and acute illnesses such as the flu, pneumonia, bronchitis, gastroenteritis, and conjunctivitis. Students used to fight over seeing acutely ill patients as these patients were so rare!
Patients suffering from serious diseases, such as diabetes, cancer, and HIV/AIDS, could only be seen on specific clinic rotations. If students were unable to have direct contact with a mandatory health condition required for competency (due to a lack of patients and a lack of variety of disease in the clinic overall), students could present to fellow students on their clinic shift on the disease/condition to earn competency. A presentation usually lasted about 10 minutes and would cover the basic etiology, differential diagnosis, and naturopathic and/or medical treatments of a condition.

They were considered to be competent in treating all cardiovascular diseases by seeing two patients with any type of cardiovascular disease?  This is incredible.  Also, please take note of what Britt says about the dearth of patients with serious disease.  This is incredibly important to note.  You can't be a good primary care doctor unless you've seen a lot of serious disease.  Here's the thing.  Any idiot can diagnose and treat 90% of what we see on a daily basis in a primary care office.  The problem is with the other 10%.  Those are the patients with strange presentations of either common or rare illnesses.  You need to have seen a ton of stuff to be able to accurately diagnose a patient who is presenting in this way.

Now, I posted above about patient contact during my third year medicine rotation.  In the fourth year, I did a medicine sub-internship.  This is basically where as a fourth-year student, you pretty much function as an intern.  So it was more of the crazy rounding schedule above, plus some.

Once I graduated, the training wasn't finished.  Internal medicine is a 3 year residency.  You're not supposed to work more than 80 hours a week (what a luxury!) but in truth, we often did.  By my calculations, going off of 80 hour weeks, I had more than 11,000 hours of patient care in my 3 years of residency.

Naturopaths don't do a residency.

Tell me again how they're qualified to call themselves primary care physicians?

Do you want to see the doctor who is considered competent to treat all cardiovascular disease after seeing two patients with hypertension?  Or do you want the doctor who has completed over 12,000 hours of training in internal medicine alone, not to mention several thousand hours of surgery, OB/GYN, psychiatry, pediatrics, family medicine, and neurology?

Your choice.  Your decision.  After all, it's your life.  Literally.



Monday, February 23, 2015

A Lesson in Female Anatomy

Yet another reason why lawmakers need to keep their politics out of the exam room.

Some lawmakers in Idaho are trying to pass a bill to prevent doctors from prescribing medical abortions (the abortion pill) via telemedicine.  Medically speaking, a medical abortion, if done early, is safe and effective.  This is also an important option, as there are only four abortion providers in the whole state of Idaho.  95% of the counties in Idaho have no abortion provider.  Of course, certain lawmakers can't but help to stick their nose into women's reproductive rights.

Well, get this:

An Idaho lawmaker received a brief lesson on female anatomy after asking if a woman can swallow a small camera for doctors to conduct a remote gynecological exam. The question Monday from Republican state Rep. Vito Barbieri came as the House State Affairs Committee heard nearly three hours of testimony on a bill that would ban doctors from prescribing abortion-inducing medication through telemedicine. Dr. Julie Madsen was testifying in opposition to the bill when Barbieri asked the question. Madsen replied that would be impossible because swallowed pills do not end up in the vagina.

Yes.  you read that right.  This male lawmaker actually thought that if a woman swallowed a "small camera" a doctor could conduct a remote gynecologic exam.  Look, I understand that not everyone is a doctor.  I understand that not everyone is going to have knowledge of anatomy, although, really, this is pretty basic stuff we're talking about here.  But is it too much to ask that people who are stupid enough to think that the vagina is connected somehow to the GI tract try to refrain from passing laws affecting said vaginas?

I've got news for you, Rep. Barbieri.  You also can't get pregnant from oral sex.  Surprise!

Anyway, I'm just appalled by this and really have nothing else to say.  So, Captain Picard and Commander Riker, you have the bridge.


Sunday, January 18, 2015

We Went to Disneyland and All We Got Were These Stupid Measles.

No, not my family.  Unfortunately, that's what several families have to say now about their recent trip to the Happiest Place on Earth.

I've watched the emergence of anti-vaccination sentiment over the past few years with a mixture of fascination and horror.  While in med school and residency, the idea of people willingly turning their nose up at vaccination never crossed my mind.  I mean, vaccines!  No brainer!  The biggest success story of modern medicine!  Eradication of smallpox!  Polio eliminated from the developed nations of the world!  How in the world could anyone be opposed to such a thing?

Then, in 1998, Andrew Wakefield published a small case study in the Lancet that hypothesized a link between the MMR vaccine (the combination vaccine for measles, mumps and rubella) and autism.  At first, this didn't get too much press in the US.  However, in England it became a Big Deal.  Even though his paper did not explicitly state that the MMR caused autism, Wakefield held a press conference before the article was even published calling for suspension of the use of the MMR vaccine.  This led to a rather spectacular fall in MMR vaccination rates in the UK over the next decade.

Then, in 2005, the proverbial you-know-what hit the fan in the US.  Robert F. Kennedy Jr. wrote an article called "Deadly Immunity" which was published in Rolling Stone Magazine.  This article claimed that there were excessive amounts of thimerosal, a mercury-based preservative, in childhood vaccinations, basically leading to mercury poisoning and causing autism.  You can still read the full article on RFK Jr's site.  You're not going to find it anymore on Rolling Stone or Salon.com. Both magazines retracted the article and wiped it from their sites after it was shown to be riddled with inaccuracies and downright falsehoods.

Now, interestingly, the MMR vaccine has never contained thimerosal.  In addition to this, out of an abundance of caution, thimerosal was removed from US childhood vaccines in 1999.  Today, in 2014, autism rates continue to rise.  It's not thimerosal causing it.

It's also not the MMR.  The studies have been done, and the science is in.  As if that wasn't enough, The Lancet retracted Wakefield's paper after overwhelming evidence showed that he was paid by plaintiff's lawyers to find a link between the MMR and autism.  In addition to this, Wakefield himself was trying to develop a alternative vaccine that would be "safer."  He performed unethical, invasive tests on children, leading to potentially deadly complications in one of them.  Other scientists were unable to replicate his original findings.  In 2010, the British General Medical Council pulled his license to practice medicine.

You'd think this would be enough to put the fears about the MMR to rest.

It's not.  Not even close.

I followed these issues only very peripherally until 2007, when I gave birth to my first child.  That's when I fell down the true rabbit hole.  Like any new parent, I wanted to do my best for my little one.  And, like any new parent, I turned to the internet to lead me to what, exactly, "the best" was.  That's when my eyes were opened to a whole world of woo.  I was stunned to find that there were entire forums dedicated to not vaccinating, among other things.  Forums where if you dared to correct someone or even share a dissenting opinion, you were shouted down, accused of being paid by Big Pharma, or just flat-out banned.  And it wasn't just autism that vaccines were supposed to cause.  They also caused SIDS, autoimmune disease, encephalopathy, allergies...the list goes on and on.  How were they causing all of this?  Well, sometime it was the thimerosal.  Sometimes it was the MMR.  Sometimes it was "too many too soon."  Sometimes it was aluminum.  The goalposts were constantly moving.

These issues are complex and I could probably write forever on it.  However, other bloggers have been at this for much longer than me.  I suggest starting with Respectful Insolence, which is written by a cancer surgeon who has been at this for more than a decade.  Science-Based Medicine is also an excellent site.  The Panic Virus, by Seth Mnookian is an excellent book and a quick, fascinating read.

The upshot of the entire vaccination controversy is that rates of vaccination are falling.  They are the lowest in areas where parents are the wealthiest and best educated.  This may seem counter-intuitive at first, but it really makes perfect sense.  It's the Dunning-Kruger effect in action.  A minimal amount of knowledge leads to an immense overestimation of expertise.  Therefore, educated people truly believe that they can research some things on Google and gain the same level of expertise as scientists who have been studying this stuff for years.  These are also a group of people who are used to nothing but success in life.  They labor under the assertion that being able to afford the best in organic food, healthy lifestyle and alternative medicine will protect them from infectious disease.

Anyway, refusing vaccines is leading to the inevitable outcome- we are starting to see the resurgence of once-eliminated diseases.  During Christmas week, someone visited Disneyland in California who was becoming ill with the measles.  Measles is one of the most communicable viruses known- up to 90% of people exposed will become infected if they are not already immune.  The vaccine is highly effective- between 95-98% effective.  Just check out this graph.




But it only works when you use it.  And when immunization drops below a certain threshold, outbreaks will occur, which is exactly what happened at Disney.  The outbreak seems to have been traced to an unvaccinated woman in her 20's.  From this one index case, there are now 51 active cases in four states.  The exposures continue- a clinic in San Diego had to be shut down after six siblings visited with measles.  Since the measles virus is airborne, the virus can linger in the air for hours after an infected person had been in the vicinity.

As quickly as things seem to be spreading, this story is also a testament to the effectiveness of the measles vaccine.  During Christmas week at Disneyland, there are an estimated 80,000 visitors a day. Even estimating that only 80% of those visitors were vaccinated, that is 64,000 potential exposures. It's hard to find out exact numbers of how many of the 31 directly infected at Disney were vaccinated, although reports state that "most" were unvaccinated.  However, let's say, for argument's sake, that they were all vaccinated.  That still represents  an incredible effectiveness rate of greater than 99%.

Despite what many anti-vaccine websites will have you believe, measles is not benign. In developed countries, the mortality rate is 3/1000.  Other complications include pneumonia, ear infections, deafness, and SSPE, which is fatal. I have no doubt that if vaccination rates continue to drop, we will start to see some of these complications occurring.  Just look at what happened in France:
Although few measles cases were reported in France during 2006 and 2007, suggesting the country might have been close to eliminating the disease, a dramatic outbreak of >20,000 cases occurred during 2008–2011. Adolescents and young adults accounted for more than half of cases; median patient age increased from 12 to 16 years during the outbreak. The highest incidence rate was observed in children <1 year of age, reaching 135 cases/100,000 infants during the last epidemic wave. Almost 5,000 patients were hospitalized, including 1,023 for severe pneumonia and 27 for encephalitis/myelitis; 10 patients died. More than 80% of the cases during this period occurred in unvaccinated persons, reflecting heterogeneous vaccination coverage, where pockets of susceptible persons still remain. Although vaccine coverage among children improved, convincing susceptible young adults to get vaccinated remains a critical issue if the target to eliminate the disease by 2015 is to be met.
Scary.  Not the future I want to envision here.

One more issue.  Another story made the news- a young woman, unvaccinated by choice, was refusing to be quarantined after being exposed to her sister while she was infectious with measles contracted at Disneyland. The selfishness exhibited by her is breathtaking.  She doesn't think it's fair that she should be quarantined when she's not even sick.  Her mom think's it's "not nice" that her daughter is being "threatened."  Well, I think it's "not nice" that someone who is potentially infectious sees nothing wrong with wandering about the community, infecting those too young to get vaccinated or who are immunocompromised by illness or chemotherapy.

Here's my take: if you want to practice 19th century medicine and turn your nose up at vaccination, be prepared to suffer the 19th century consequence- quarantine.



Get your vaccines, people.  Make sure your boosters are up to date.  Vaccinate your children.  Remember, the good old days often weren't that good.  Let's move forward, not backwards.



Thursday, October 16, 2014

Dragon-isms 2

More incredibly accurate office notes via my voice recognition software!


1.  I've instructed her that she needs a new parous uterus as the one that she has is quite worn out.

I assure you, I've never told anyone that she needs a new uterus because her old one is worn out, just because it's been used a couple of times.  (What I actually said was that she needs a new pair of shoes.)


2. His visiting nurse called on Friday with concerns that he was gaining weight and that he had two falls, one backwards into a set of orders for amiodarone down the stairs.

Sets of orders might be overly verbose and complicated, but rarely knock people down the stairs.

3. hismood.Hestakingbetweenoneand3pillsaday

This was just really weird, and I don't know if it was a Dragon thing or a Microsoft thing.  At any rate, there were just no spaces between any words.

4.  Also Pebble Beach Ranexa 150 p.o. q.d. to help with the side effects.

Even Dragon knows that doctors are always thinking about playing golf!

5.  Continue current medications.  Follow up in 6 lungs.

Months!  Not lungs!

6.  She is a professor of urination.

Urination, UNH...po-tay-to, po-tah-toe.

7. Her previous doctor is retiring.  She is sexually abusing a couple of different doctors to decide which one she ultimately wants to see.

That's...an interesting way to choose a new doctor.

8.  Mother died of a heart attack.  Father is out of cabbage.

Coronary Artery Bypass Grafting (CABG)...not the vegetable.

9.  He tells me that this year he really changed his diet and is now eating a pale yellow diet.

I guess that Dragon is not up on the latest paleo diet craze.  

10. He is taking several supplements to improve his memory and joint pain. He got scabies at a health food store.

I believe he got his supply at the health food store, not scabies.  If it was scabies, he really ought to re-think his shopping choices.

Tuesday, October 14, 2014

Free To Be You and Me?




Every boy in this land grows to be his own man
In this land, every girl grows to be her own woman
Take my hand, come with me where the children are free
Come with me, take my hand, and we'll run...
Marlo Thomas, "Free To Be You and Me" 1972


This post has nothing to do with medicine, running, or motherhood.  However, it's my blog and my bully pulpit, and I'll use it as I see fit.

This post is about sexism, misogyny, and assholes.  Three things that, to my dismay, are apparently alive and well here in New Hampshire.  I was lucky enough to grow up with two parents who always taught me to value myself.  I was never, ever told that there was something I couldn't do because of my gender.  I have fond memories of the family singing along with Marlo Thomas on the 8-track while we barreled down the highway.  That's why it always feels a bit like cold water being thrown on me when I come across a blatant example of sexism.

Now, I don't have my head in the sand.  I experience a small degrees of sexism on pretty much a daily basis.  But it's comparatively subtle stuff...things like patients asking me, "Who takes care of your kids while you're working all the time?  Don't you miss them?" (For the record, their Dad takes care of them, and no, I don't miss them while I'm at work and they're at school.  Jeez. Our bond isn't that fragile).  Sometimes it's even more insidious.  A recent example is the day camp calling me instead of my husband about an issue at camp, even though he is listed as the primary contact.  Apparently only the mother is qualified to do anything that involves childcare?  That's insulting to both me and my husband, who rocks the fatherhood gig.

However, I've never experienced anything like the nastiness that is going on in the 2nd District US Congressional race.  Incumbent Ann Kuster (D) is being challenged by Marilinda Garcia (R).  I'm not going to get into their politics- this is not my district, and I haven't been following this particular race.  That's not what is post is about, anyway.

I want to talk about Steve Vaillancourt's opinion on the race.  Mr. Vaillancourt is a member of the NH House of Representatives.  Now, before you get too impressed, keep in mind that the NH House is the fourth largest democratic governmental body in the world, only behind the UK Parliament, the Indian Parliament, and the US Congress.  For a tiny state, it's ridiculously large. There is one legislator to about every 3,000 residents of NH.  Perhaps that's why we all feel free to run our mouths off around here.

Mr. Vaillancourt doesn't seem to care too much about the issues affecting the 2nd District.  It appears that, first and foremost, what is most important is the looks of the two candidates.  Yes, you read that right. Here is what he says...

It was late the other night when I saw some polling data which went by too fast for me to write down, and I've been unable to find it on Google. It might have been from Fox's Red Eye show (3-4 a.m.--I told you it was late)...or maybe I'd fallen asleep and was dreaming.

I seem to recall hearing that a new survey is out revealing that, with two caveats, an attractive candidate can have as much as a seven to ten point advantage over a less attractive (or even an unattractive) candidate....

In New Hampshire's second congressional district, if I may be so bold as to speak the truth, Republican Marilinda Garcia is one of the mot attractive women on the political scene anywhere, not so attractive as to be intimindating (sic), but truly attractive.

How attractive is Marilinda Garcia? You know how opposition ad makers usually go out of their way to find a photo of the opponent not looking his or her best. Well...Democrats and Annie Kuster supporters can't seem to find a photo of Marilinda Garcia looking bad at all.

As for Annie....oh as for Annie...and before I continue, I offer that caution, caution, caution, gain.

Let's be honest. Does anyone not believe that Congressman Annie Kuster is as ugly as sin? And I hope I haven't offended sin.

If looks really matter and if this race is at all close, give a decided edge to Marilinda Garcia.

How ugly is Annie Kuster? .....

By now you probably know why I think of Annie Kuster whenever I walk by Mados; sad to say, but the drag queens are more atrractive (sic) than Annie Kuster....not that there's anything wrong with that.

I've promised myself for years not to use this anecdote, but after seeing the story about the seven to ten point boost for the attractive, the story has political relevance.

Annie Kuster looks more like a drag queen than most men in drag.

Lest you think I've taken the quotes out of context, please check out the link for yourself.  It's worse, because it's festooned with pictures of drag queens just to make his point.

He's been called out by numerous news outlets, but feels justified in his views, given that he gave us a "warning" before writing the piece that it might be offensive to the "PC police."

I also want to call the Democratic side to task.  Peter Sullivan (D), yet another state rep from Manchester, has compared Marilinda Garcia to Kim Kardashian.

Sullivan's tweets included saying Garcia was "Al Baldassaro (state Rep. Al Baldasaro, R-Londonderry) in stiletto heels, a lightweight and (former House Speaker Bill) O'Brien clone." He also called her a "right-wing, homophobic, anti-worker shill for the Koch Brothers," and said when you combine O'Brien and Kim Kardashian you get Marilinda Garcia.

In this case, he's devaluing someone based on her good looks, which is just as bad.

How is it that more than 40 years after Marlo sang to us about being "free to be you and me," people still act like this?  I have two sons.  I hope that every day I present them with an example of a strong woman whose worth is based on her deeds and actions, not on her looks.  I don't know if Mr. Vaillancourt has children.  If he does, I hope to God that he did not raise sons with his attitude or daughters who were disparaged.

Mr. Vaillancourt seems to feel that he does not owe Ms. Kuster an apology.  You know what?  I agree.  Actions speak louder than words, and an apology would be nothing but hot air.  And since actions speak louder than words, I hope that the voters of NH in his district take the opportunity to vote this sexist jerk out of office this November.

Tuesday, September 23, 2014

Never a shortage of bad ideas....

Everyone seems to know that there is a shortage of primary care physicians.  In the next 6 years, there is a predicted shortage of over 20,000 primary care docs.  There are lots of reasons for this- primary care doctors make less money, have more paperwork, have to see more patients...I could go on and on.  Of course, in the United States the prestige of a job is directly proportional to the paycheck received, so...you do the math.  The fact remains that only about 30% of medical school graduates go on to a primary care residency, and even fewer than that actually end up doing primary care, as many people who do an internal medicine residency eventually specialize.

Now, I obviously love doing primary care. I love seeing patients for years and having an ongoing relationship.  But I will admit that I seem to be part of a dying breed, and I would love to see that change.  However, true change will take a whole lot of adjustment in the US medical system.  Since that's hard to do, Missouri has decided to take another tack.

Missouri has passed a law that creates a new entity- an "assistant physician."  No, not a "physician assistant"- PA's have been around for decades.  A PA is a health care provider who has completed a masters degree and is certified by the Board of Medicine.  They work under the direct supervision of a physician.  An "assistant physician" is something else entirely.

First, a quick review of the US medical education system:
1. high school
2. 4 years of college
3. 4 years of medical school
4.  1 year of internship
5. 2-4 years of residency
6. 1-? years of fellowship

Primary care doctors stop after step 5.  For example, after high school I did 4 years of college at the University of Rochester, 4 years of med school at the University of Rochester,  1 year of internship at St. Vincent's, 2 years of residency at St. Vincent's, and then I stayed on for an extra year as the Chief Resident.  Specialists go on to step 6.  A cardiologist has a 3 year fellowship.  An endocrinologist has a 2 year fellowship.

Medical students apply to residency during their fourth year of med school.  It's a very competitive process, because there are only about 29,000 first-year residency spots available for about 40,000 applicants. Now, there are only about 16,000 graduates from US med schools a year, but there are also graduates of international medical school competing for spots, along with those who did not match in a previous year and are trying again.  In 2014, internal medicine filled 99.1% of its spots through the match, and family medicine filled 95%.  The most competitive spots, in specialties like orthopedics, radiation oncology, plastic surgery, etc pretty much fill completely.  The remaining spots go quickly in a process called SOAP.  1,075 positions were filled during SOAP, which leaves about 10,000 medical school graduates without a residency spot.  The vast majority of these are graduates of international schools, but about 500 US students were left without a residency.

Missouri has decided that these unmatched medical school graduates are perfect to fill the primary care void in rural areas.  They've decided that if a graduate passes Step 1 and Step 2 of the USMLE, they can work with an established doctor for 30 days and then basically go out on their own.  Forget about the fact that they don't have to pass Step 3 of the USMLE and obtain an actual license.  They have to be within 50 miles of a designated preceptor and have 10% of their charts reviewed by said preceptor.

This idea is so bad that it really, really blows my mind.  First off, these new graduates are one of two groups: either they are a bottom-of-the-barrel student who truly could not get into any program or they really wanted a competitive specialty and couldn't get it.  Both are poor candidates for primary care.  One group probably can't hack the difficulty of it, and the other has no interest in primary care at all.  Add to this the fact that US medical schools are not set up to graduate doctors who are ready for practice. That's what residency is for.  Med school teaches you the science and the basics.  The true training comes from residency.

Primary care is difficult.  I'm biased, of course, but I think it is one of the hardest specialties.  For many sub-specialists and surgical specialties, the diagnosis is already made by the time the patient reaches the door.  Look at the most competitive specialties that I listed above.  Not as much in the way of cognitive work in those specialties.  Of course, they have amazing other skills, but historically, cognitive work in medicine is incredibly undervalued.  After all, how do you put a price tag on a physician's thought process and diagnostic acumen?  It's difficult.  Anyway, what I'm saying is that in primary care a patient doesn't walk up to you and announce, "Hey, I'm experiencing an occipital lobe infarct!"  They come in and say, "I'm kind of dizzy and not myself."  And you are left to figure it out.

The last place in the world that a new grad with no residency training should be is in a rural area taking care of patients who have not had adequate primary care in ages.  Those patients are likely to be sick, sick, sick.  They need and deserve real health care, not some new grad who has no training and doesn't really want to be there in the first place.  Missouri seems to be operating under the delusion that some care is better than no care at all.  They forget that poor care can do actual harm to a patient, and someone who doesn't know what he's doing can be a true danger to others with a prescription pad in his hand.

I also want to know what sucker physicians are going to agree to be preceptors for these assistant physicians.  The liability implications of this make my head spin.  No way would I agree to be responsible for the actions of some wet-behind-the-ears new grad who is 50 miles away from me.  No way.

Look, there are always going to be difficulties in getting physicians to practice in rural, remote areas.  That's why the areas are rural and remote.  No one else wants to live there, either.  But this is the wrong way to go about solving this problem.


Sunday, September 21, 2014

Race Report- Wallis Sands Triathlon

Well, I lived to tell the tale.  No shark encounters.

The day started off with the alarm going off at the ungodly Sunday hour of 5:40.  The next thing I noticed was the sound of rain.  Pouring rain.  A look out of the window confirmed it- there was a downpour.  A quick check of the weather forecast was useless- according to Accuweather and Weather.com, it was just cloudy with a chance of a shower.  Ha.

I spent the next half hour drinking my coffee and playing a mental game of "Will I or Won't I?".  In the "Won't I" column was the fact that I'd be standing around in the rain for at least an hour or more before the race, all my stuff would get wet, including my socks (I HATE running in wet socks), the ocean was probably going to be rough, road bikes tend to skid a lot on wet roads, and my bed was looking really, really cozy.

In the "Will I" column was the fact that I had trained for this damn thing.  And spent the money on the damn wetsuit.

So I went.

It was still pouring when I got to the race site.  It finally let up enough for me to get out and pick up my race packet.  I brought my bike and stuff over to the transition area, at which time it started pouring again.  Luckily I had put everything in a big garbage bag.  I left it there and went and hid in my car, hoping that no one would think my stuff was actual garbage and throw it away.

About a half hour before race time, the rain finally let up.  I finally went and got my stuff all set up.  Right about this time, my friend Sarah showed up to cheer me on.  And good thing she did, because it was time to get on the wetsuit.

So, it was hard to do this while sitting on a bench with nice, dry skin and feet.  Doing this while standing in a puddle with very damp skin and soaking wet feet really made for a great time.  If Sarah hadn't been there for me to hang on to, there's a good chance my race would have been over before it started, the damn wetsuit abandoned.


Then it was down to the beach for the start.  I was in the third wave to start, otherwise known as over-40-old-fogeys.  I was getting nervous...the water was nowhere as rough as my disastrous swim last Saturday, but it certainly wasn't calm, either.


Man, I'm short.


That first buoy was looking really far away.  No time for further panic, we were off.  I ran in and started dolphin diving, and then started swimming.  And started panicking.  There were big waves.  And choppiness.  And water was going up my nose.  And...I seemed to literally forget how to swim for a second.  Like, I bobbed there in the water and started doggy-paddling.  Then I mentally screamed to myself, "WHAT ARE YOU DOING???"  So I started swimming again.  No good.  I was really freaked out.  So, I flipped onto my back and started doing the backstroke.  And at one point laughed out loud, because I was actually passing other swimmers while doing the backstroke.  It was so ridiculous.  Here I was, doing the backstroke because I was too freaked out to put my face in the water, and I was doing it fast!  Finally, I touched bottom and ran out.  My swim time was a minute faster than my swim last year, for a swim that was farther.  



The transition was a lot slower.  In addition to getting out of the damn wetsuit, I was trying to get most of the sand off of my feet.



The bike ride was great.  I had practiced the route several times, since the race was in my town.  No wind, very flat course, and a nice surprise- many freshly paved roads!  My ride time was 5 minutes faster than last year's same length ride.


Then onto the run.  I was actually a bit nervous for the run, because running seems to make my back flare up more than any other activity.  I haven't really done much running lately, but luckily my back held out.  Just a bit of cramping in the last mile, but nothing I couldn't run through.  My time was 5 minutes fast than last year's.  It helped that there were no trees or boulders to scramble over.



So there you have it!  It was a really well-organized race and the scenery of Rye can't be beat.  I was glad to have improved my time.  Next year- more practice swims in open water!