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Phantom Pain And A Plastic Brain

Gruesome costumes abound at Revolution Health today. Characters from popular horror movies seem to be a favorite, some employees even toted plastic chainsaws and spouted red ink/blood. As I was chased down a hallway by a ghoulish colleague who pretended to amputate one of my arms, I began to think – maybe this could be the subject of an interesting blog post? [Enter awkward segue here.]

Did you know that one in every 200 people in the United States has had a limb amputation of some kind? While the majority of amputations occur due to poor circulation (usually related to diabetes), some are caused by trauma, cancer, or birth defects. Limb loss is not a fictional issue, but a real concern for more people than you think. The good news is that most folks do very well with prostheses and rehabilitation programs. But since this is Halloween, I couldn’t resist discussing a potential complication of limb loss: phantom pain.

Phantom pain” is the term used to describe pain sensations in a missing limb. Although this may sound impossible at first (how can a person feel pain in his foot when that same leg was amputated already?) the reality is that the brain takes some time to adjust to limb loss. The human brain has entire sections devoted to sensing input from and delivering movement messages to our arms and legs. When an arm or leg is lost, that part of the brain continues to function for several months or more. And so as the local brain cells lack the usual input from the nerves in the absent limb, they fire in a spontaneous manner that is perceived as cramping, aching, or burning.

How on earth can you treat this kind of pain? As you can imagine, it’s quite tricky. Some of the more successful approaches involve helping the brain to adjust to the loss of sensory input by touching or massaging the stump and walking on a limb prosthesis. These new sensations help the brain to adjust to the body’s changes. In fact, imagining moving the lost arm or leg can result in some relief of the perceived pain. This is the one case I can think of where imaginary exercise can be of real benefit to your body!Some folks do require special pain medicines (tricyclic antidepressants, seizure meds, and beta blockers can help modestly) to cope while their brain adjusts to the new input. However, most amputees experience the sensation that their limb is still there, but without any pain or unpleasantness. Phantom sensations and phantom pain almost always resolve with time – which is a testament to the amazing flexibility (or “plasticity“) of the human brain.

That being said, I hope you each have a safe Halloween – and that your only potential injury comes from a ghoul with a plastic chain saw.This post originally appeared on Dr. Val’s blog at

Are Cash-Only Medical Practices The Wave Of The Future?

MedPage Today issued a special report on a rising trend: cash-only medical practices. I guess I’m ahead of the curve, since I’ve been seeing a cash-only primary care physician for 2 years now – and I love it.

Dr. Alan Dappen is available to his patients 24 hours a day, 7 days a week, by phone, email and in person. Visits may be scheduled on the same day if needed, prescriptions may be refilled any time without an office visit, he makes house calls, and all records are kept private and digital on a hard drive in his office.

How much would it cost to have the luxury of a personal physician on-call for your every whim?

Would you believe only about $300/year?

What’s Dr. Dappen’s secret to success? He accepts no insurance, keeps his overhead low, offers full price transparency, has physician extenders who work with him, and charges people for his time, not for a complex menu of tests and procedures.

“I believe in doing what is necessary and not doing what is not necessary. The healthcare system is broken because it has perverse incentives, complicated reimbursement strategies, and cuts the patient out of the billing process. When patients don’t care what something costs, and believe that everything should be free, doctors will charge as much as they can. Third party payers use medical records to deny coverage to patients, collectively bargain for lower reimbursement, and set arbitrary fees that reward tests and procedures. This creates a bizarre positive feedback loop that results in a feeding frenzy of billing and unnecessary charges, tests, and procedures. Unlike any other sector, more competition actually drives up costs.”

After building a successful traditional family medicine practice in Fairfax Virginia, Dr. Dappen felt morally compelled to cease accepting insurance so that he could be free to practice good medicine without having to figure out how to get paid for it. He noticed that at least 50% of office visits were not necessary – and issues could be handled by phone in those cases. Phone interviews, of course, were not reimbursable by insurance.

“The physical exam is a straw man for reimbursement. Doctors require people to appear in person at their offices so that they can bill for the time spent caring for them. But for longstanding adult patients, the physical exam rarely changes medical management of their condition. It simply allows physicians to be reimbursed for their time. Cutting the middle man (health insurance) out of the equation allows me to give patients what they need without wasting their time in unnecessary in-person visits. This also frees up my schedule so that I can spend more time with those who really do need an in-person visit.”

Health insurance is certainly necessary to guard against financially catastrophic illness. And the poor need a safety net beyond what Dr. Dappen can provide. But for routine care, “concierge medicine” can make healthcare affordable to the middle class, and reduces costs by at least 50% while dramatically increasing convenience. For the right patient, this is a welcome relief from having to wait to be seen by in-network providers or from being billed non-preferred rates as an uninsured individual. I applaud Dr. Dappen for his efforts in healthcare reform, and look forward to a movement where costs are driven down by putting patients back in the payer seat.

Why Do People Enjoy Being Frightened?

As Halloween approaches, I was asked a really interesting psychological question from Lauren (of Love, Lauren fame) at Revolution Health. She asked, “Why do people like to be frightened? I don’t like horror movies or haunted houses, but some people love that stuff. Why, Dr. Val?”

I scratched my head and looked at her for a moment as images of Saw, Freddie Kruger, and Jason Voorhees (the only Dutch Halloween “slasher” protagonist I know) went through my mind. I offered an unsatisfactory reply, and promised to take this up with someone more learned in the ways of fear. Luckily for me, Dr. Andrew Gerber- a thoughtful psychiatrist whose research focuses on brain response to emotion (how perfect) was up to the task. Here’s what he had to say:

Our enjoyment of being afraid is a wonderful example of how the human mind works in mysterious ways that are often not immediately transparent to our own introspection. Psychiatrists, psychologists, and cognitive scientists are coming up with new ways to study exactly these sorts of things (located in a psychological structure called the “dynamic,” “adaptive,” or “cognitive” unconscious) and have a variety of possible explanations.

1. We like to feel things strongly.

Even if something has a negative part to it, it can be overridden by our preference to feel something as opposed to nothing. This may be the same phenomenon that drives our curiosity (even when it gets us into trouble, like a cat), our restlessness, or the discomfort of boredom. Increasing evidence from brain imaging studies tells us that a large part of our brain is devoted to processing intense emotion. It’s pretty likely that these regions were very important in our evolution and survival as a species.

2. We love the experience of a building up of tension and relief.

The best part of all about being scared on Halloween or in a scary movie is the huge relief at the end when we or our hero emerges safe and sound. A part of us remembers the whole time that relief is coming, so the tension part is worthwhile. There are lots of experience in our life that have the same kind of tension and relief pleasure to them – for example, missing a loved one and then seeing them, being hungry and eating a delicious meal, or being really tired and then getting to relax. You might say that the more the tension builds, the more the relief feels good. Brain imaging studies show that motivational systems located in the deep and archaic part of the brain operate on a tension and relief principle. When this works well, we feel motivated to go about the business of our lives. This very system can go awry in disorders such as depression and drug addiction.

3. We like to work through old situations and make them come out better.

For better or for worse, humans are consummate problem solvers and when things didn’t go well in the past, we like to replay the situation and have it come out differently. We all recall the experience of being scared as a child when it didn’t feel so good. This makes it all the more fun as older children or adults to replay that experience but this time to have the experience come out in a more positive way.

And there you have it – our brains crave “tension and release” to feed parts of our large emotion-processing centers, we like to problem solve in controlled environments where the outcomes are not truly dangerous, and we derive pleasure from strong emotions. That being said, I prefer action flicks to the horror movies myself. Though I’m a sucker for a good Sci-Fi thriller. What about you? What’s your favorite “tension release” movie?This post originally appeared on Dr. Val’s blog at

School Gives Birth Control Pills To 11 Year Old Girls

You might have seen the recent news about the middle school in Maine – King Middle School, in the Portland school district – that is planning to provide birth control to pre-teens, without requiring explicit parental consent. School officials argue that this will help to prevent pre-teen pregnancies, and estimate that at least 5 out of 135 of their 11- to 13-year-old female students are sexually active already.

While I absolutely sympathize with the desire to avoid pre-teen pregnancies, and I do understand that there is a reality here that some very young children will become sexually active at the tender age of 11, I personally do not support giving pre-pubescent girls hormone-altering tablets. We do not have good studies demonstrating the safety of such therapies in children, and until we do it’s just not medically sound to be offering this treatment. (For example, we don’t know what extra estrogen does to early breast buds, or whether there’s an increased risk for developing breast cancer later on.)

I also think that 11 year olds are not physically and emotionally prepared for sexual intimacy – and the prematurity of this event could be quite harmful for their psyche. We know that 11- and 12-year-old brains are not fully developed to think the way adults do, so there’s really no telling what impact it could have or what long term psychological effects might result.

Apparently sex before the age of 14 is illegal in Maine, so (although there’s no doubt that it may happen prior to that age) it seems that the state’s legal system is not in step with their school system, and that needs to be looked at. It is inconsistent to claim that an activity is illegal for children and then enable it with tax dollars.

I suppose that education about the use of condoms and access to them (without aggressive promotion of them) may be acceptable at this age. After all, condoms can prevent STDs and don’t have medical effects on the body as a whole. But my plea is that parents take the lead here – and educate your children about the risks of STDs, pregnancy, and the emotional damage that premature sex can have on a young person. Advocate for abstinence as a first choice, explain that condoms are non-negotiable, and try to help them turn their focus away from sex and towards more age-appropriate endeavors.

A new Dove advertising campaign asks parents to talk to their kids before the beauty industry does, and I think the same goes for sex and the media. Today’s parent must launch a preemptive strike against the over-sexualization of children, or risk having their 11 year olds taking estrogen patches from a school nurse without their consent.This post originally appeared on Dr. Val’s blog at

E. Coli: Beef Recalls and Hamburger Safety

Several frozen hamburger meat recalls have been issued in the past month.  First it was the Cargill. Inc. plant in Butler, Wisconsin (supplying Sam’s Club) recall and now it’s the J&B Meats, Coal Valley, Illinois (supplying Tops and Sam’s Choice Brands).

So how does this meat get contaminated?  As I mentioned in an earlier blog post about cows, they are kind of dirty creatures.  They tend to stand around in manure and flick it all over themselves.  In addition, there are certain intestinal bacteria that colonize them (including a certain type of E. coli, called 0157:H7) that are harmless to them, but are very harmful to humans.  If their manure is used to fertilize veggies (or gets into the veggie’s water irrigation supply) - spinach poisoning can result. If the bacteria get into hamburger meat (as can happen during the butchering process and meat grinding) beef recalls may be in order.

E. coli 0157:H7 poisoning is scary because it can cause life-threatening illness (bloody diarrhea and kidney damage), especially in the young and immunocompromised. There are no antibiotics to treat it, and so the best “treatment” is prevention.

Keep in mind that the vast majority of meat is not contaminated with this bacteria, and that the small risk is usually associated with hamburger meat in particular. Ground beef (as you can imagine, though it’s a little disgusting to think about it) is more likely to have been in contact with the bacteria-laden intestines of the cow, since many different parts of the animal are used and ground into hamburger. It is much less likely for a whole steak, for example, to be contaminated with E. coli.

According to the USDA, one cannot rely on meat color to be sure that a sufficiently high temperature has been achieved in the cooking process. The best way to be sure that your hamburgers have been hot enough to kill any potential bacteria lurking therein is to use a thermometer and to make sure that the center of the meat reaches 160 degrees Fahrenheit.

So the take home message is this:

  • Ground beef may be contaminated with E. coli bacteria, especially if it’s purchased at Sam’s Club or Tops.
  • Regular beef is less likely to be contaminated.
  • Don’t rely on meat color to ensure that it’s safe to eat.
  • Cook all red meat to 160 degrees Fahrenheit to be sure that any bacterial contaminants are killed.
  • See your doctor immediately if you have bloody diarrhea, fever, or other symptoms of E. coli poisoning.

This post originally appeared on Dr. Val’s blog at

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