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Video: Grassroots Healthcare Reform Driven By Doctors

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Dr. Alan Dappen, Dr. Steve Simmons, and nurse practitioner Valerie Tinley are regular contributors to the Better Health blog. I’m a big fan of their innovative medical practice, and decided to follow them during one of their work days as they deliver affordable, quality healthcare to patients in Virginia.

This is how primary care used to be… and a model that deserves more attention.

The Friday Funny: The Homeopath’s ER

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Top 10 Reasons To Break Up With Your Doctor

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Being with the wrong doctor can have grave consequences – literally. As a practicing physician, I’m the first to admit that no doctor is perfect, especially me. I’m in a field that is eternally humbling, with my next mistake potentially hiding just around the corner. The stakes are enormous and the number of tasks I must juggle often daunting. From my point of view, I’m trying my best. But from the patient’s point of view, that may not be enough. So how do you know when it’s time to call it quits with your doctor? Here are ten reasons to make you think twice about continuing with the status quo:

1) You feel your doctor isn’t listening to you.
Listening isn’t waiting to speak. One of my favorite and most beloved teachers, Dr. Alfred Markowitz, once told me, “If you let patients talk long enough, they’ll actually tell you what’s the matter.” Studies show that, on average, doctors let patients talk for 18-23 seconds before interrupting. Patients are allowed to finish their opening statement of concerns about 25 percent of the time.

You want a physician who not only is willing to hear what you’re saying but who’s intrigued by interpreting nuances of words and body language, who notices when you hesitate a millisecond before answering a question that’s hit a hidden sore spot. Don’t be shy about confronting a doctor who isn’t listening. And leave if your concerns aren’t addressed.

2) Your doctor can’t communicate effectively with you.
Your doctor not only needs to be a great listener but has to be able to explain things to you in a way that you can understand. You’ll know it when you don’t hear it.

3) The doctor isn’t taking you seriously.
This is a deal breaker. It may happen if your doctor jumps to a conclusion about the cause of your symptoms before considering other possibilities. Even if you’re a hypochondriac, your hypochondria needs to be seriously addressed. And even hypochondriacs get real illnesses.

4) You have a problem with the office staff.
Office personnel represent the doctor. If they’re unfriendly or unkind then you’re starting off on the wrong foot. And it gets worse if they’re inefficient. Messages must be given to the doctor, insurance forms filed, tests properly scheduled and results reported. Last week, a survey of primary care practices found that patients were not told of abnormal results an average of 7 percent of the time.

5) You’re kept waiting too long.
Doctors can be delayed by unpredictable medical emergencies. But if it happens consistently then the doctor is probably scheduling inefficiently. A clue you’ve been in the waiting room too long: if you pass completely through menopause while waiting to discuss your hot flashes.

6) It takes too long to get an appointment.
Routine annual visits can be scheduled months in advance but new problems and ongoing medical complaints need to be addressed in a timely fashion.

7) The doctor’s too busy.
This may develop over time, as the practice grows. If messages are going unreturned, insist on talking to the doctor. If the problem continues or the doctor always seems to be in a hurry then you may need to find somebody else.

8) Your doctor gets annoyed by questions.
This may be a reflection of other problems listed above such as the doctor being too busy or not taking you seriously. Whatever the cause, it’s unacceptable. Not only are patients entitled to careful consideration of questions, those questions may provide doctors with important clues. “Why do I get a stomach ache every time I eat a slice of toast?” may lead to the diagnosis of celiac disease, a condition in which gluten – a component of wheat, rye, and barley – is toxic to the body. If a doctor doesn’t immediately know the answer, a perfectly good response is, “I don’t know but I’ll research it and get back to you.”

9) Your doctor is too arrogant.
God save us from the brilliant doctors. You probably need to be a B+ student to be smart enough to learn everything you need to be a great doctor. But you also need to be A+ in empathy, listening, carefulness, keeping an open mind, logic, and common sense. Doctors who think they are brilliant scare the heck out of me. I’ve seen them make huge mistakes as they take short cuts or rely on their instincts without seeking help from others or adequately listening to their patients.

10) It just doesn’t feel right.
As with any relationship, sometimes you can’t put it into words but you just know it’s wrong. Don’t fight your instincts.

For this week’s episode of CBS Doc Dot Com, I visit the Mount Sinai School of Medicine in New York City and speak to Erica Friedman, the director of the Morchand Center, where budding doctors are schooled on bedside manner by treating actors pretending to be patients.

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What Can Weekend Warriors Learn From Elite Athletes?

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For this week’s CBS Doc Dot Com segment, I thought I’d cover something completely non-controversial: what can weekend warriors learn from elite athletes? But I’m starting to believe that in this era of evidence-based medicine, nothing may be truly knowable. I went to the studios of the world famous Ballet Hispanico in New York City and spoke to athletic trainer Megan Richardson. She took me through the motions, emphasizing the importance of warming up and stretching in preventing injury. It sounded good and it felt good. But proving in the medical literature that it’s effective is another thing. An online search quickly produced multiple conflicting reports and advice: stretching definitely works, stretching definitely doesn’t work; stretching only works if you do it my way. Click here for a sampling:

PubMed:Warm-up And Stretching PubMed: Stretching Perspectives BioMed Central: The Effects Of Stretching

My friend and CBS colleague, Richard Schlesinger, offered his solution. ”I get around it by neither stretching nor exercising.” Had I listened to Richard, my blog post would have ended right here. But I figured I needed at least one more paragraph so I contacted a true expert on the subject, Ian Shrier MD, PhD, a specialist in sports medicine and Associate Professor at McGill University. He has a PhD in physiology and is Past-President, Canadian Academy of Sport Medicine. He’s not a huge fan of stretching right before exercise.

“First, the stretching, whether with or without warmup, does not improve performance. It makes you run slower, jump not as high, and makes you weaker.” And “stretching definitely can hurt people if you overstretch; people do it all the time if they force the stretch.”

He added, “I don’t think it hurts you in general if you do it properly but it doesn’t prevent injury.” He’s more supportive of stretching at other times, including after exercise, saying, “Regular stretching at other times is beneficial. It makes you stronger, jump higher, etc, and there are three studies suggesting it reduces injuries as well, although the results were only significant in one.” He adds that “stretching is analgesic; it allows you to put your muscle through a wider range of motion without feeling tension. And that may be why ballerinas say that stretching helps them.” Dr. Shrier spells out his take on the subject in detail in a chapter called
Does stretching help prevent injuries?

For me, Dr. Shrier’s most interesting advice, especially for weekend warriors, was about the importance of warming up. He explained that muscles need energy to function properly. Energy is mainly produced inside of cells in structures called mitochondria. When you are resting, your mitochondria power down. During exercise, it takes awhile for the cell to rev up the enzymes needed for breaking down fat and carbohydrates for fuel and for using oxygen to make energy from that fuel. If you start running at full speed without warming up, your body will produce lactic acid. Lactic acid can impair muscle function for awhile, preventing you from sprinting efficiently at the end of the race.

So Dr. Shrier suggests gradually warming up. He estimated it takes about 3 to 5 minutes to efficiently go from one level of exercise to the next – for example, going from rest to a ten minute mile or going from a ten minute mile to a seven minute mile. If you go for a jog, “you walk, then jog slowly, and then pick it up. Elite marathoners might go for a fifteen to twenty minute jog before they run a marathon. That allows them to run faster at the beginning of the race. They run the second half of the marathon faster than the first.”

In summary – and I suspect that I am the first person today to tell you this – don’t outpace your mitochondria.

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A Medical Transgender Primer

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Transgender issues have been in the news with the recent announcement that Cher’s daughter, Chaz Bono, is transitioning from female to male. This subject has been plagued by misunderstanding and fear of the unknown. Transgender children are often shamed, bullied, and made to feel totally alone. As adolescents and adults, they face denial of adequate medical coverage and other forms of discrimination – and worse. Just two months ago, a Colorado man was found guilty of murdering an 18 year old transgender woman in what was judged to be a hate crime.

Chaz’s decision to go public with his private struggle is extremely brave. His publicist said,

“It is Chaz’s hope that his choice to transition will open the hearts and minds of the public regarding this issue …”

Step one in reaching the public is defining terms. The terminology surrounding gender issues can be confusing. “Transgender man,”, “transmale,” and “affirmed male” have all been used to refer to a biological female who transitions to a male. I found a glossary of transgender terminology offered by the NCTE to be extremely helpful.

What exactly does transitioning mean? It’s the period during which somebody starts to live as his/her new gender. It can include changing a name or legal documents, taking hormones, and getting surgery. One misconception is that transitioning requires surgery. It doesn’t. As Mara Keisling, the Executive Director for the National Center for Transgender Equality (NCTE) told me, “Most transsexuals don’t get surgery. This is about gender identity, not about genitals.”

There’s a lot of controversy and confusion but experts agree on two crucial concepts:

1) Being transgender is not a choice.
2) Biological sex and gender identity are two different things.

There are people whose external appearance is female but who have felt they were male since they were toddlers – and vice-versa. Norman P. Spack, M.D., an endocrinologist at Children’s Hospital in Boston, Dept. of Pediatrics, Harvard Medical School, has been treating transgender patients since 1985 and significant numbers of teenagers since 1998. Most of his patients have told him “as far back as they can really remember that they were in the wrong body.” Dr. Spack said, “there’s a heavy skew to under 6 years.”

Dr. Spack points out that because transgender has been labeled as a psychiatric illness (“Gender Identity Disorder”) by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), patients are not adequately covered by health insurance. He says that the insurance industry will cover psychiatric costs but denies hormonal and surgical therapy, claiming they are non-covered cosmetic treatments. A step forward came in 2008 when the American Medical Association House of Delegates passed a resolution supporting “public and private health insurance coverage for treatment of gender identity disorder in adolescents and adults” and opposing “categorical exclusions of coverage for treatment of gender identity disorder in adolescents and adults when prescribed by a physician.” But for now, many transgender patients continue to receive inadequate medical coverage and therefore inadequate medical care.

Nobody knows how many transgender people exist. The very definition of transgender can differ from study to study. Some only count people undergoing hormonal/surgical treatment; others rely on self-identification. In the Netherlands and Belgium, estimates based on patients receiving surgery and/or hormones were about 1 in 12-13,000 for transfemales and 1 in 30-34,000 for transmales.

But Mara Keisling told me those estimates are way too low. “Our best estimate is that one quarter to three quarters of one percent of Americans are transsexuals.” That’s 2.5 to 7.5 in a thousand. Dr. Spack’s estimate is about one in a thousand.

We are not close to understanding all the variables that go into determining why someone feels trapped in the body of the wrong sex. Parents often feel guilty but the wide consensus is that parenting does not cause a child to be become transgender. Research in animals suggests that there are critical periods of development during fetal or neonatal life during which exposure to testosterone influences the sexual differentiation of the brain But we’re far from putting together any sort of unified theory of gender identity that weaves together genes, cell biology, hormones, brain wiring, and nurturing.

Experts stress that transgender is part of a wide continuum of gender identity. As Stephanie Brill and Rachel Pepper say in The Transgender Child: A Handbook for Families and Professionals, “Today, gender can no longer really be considered a two-option category.” They emphasize the importance of patients and families understanding that they are not alone and that there are competent professionals who can help. They say they wrote the book, which I found to be very helpful, to “provide caring families with helpful tools they can use to raise their gender-nonconforming children so they may feel more comfortable both in their bodies and in the world.” The authors quote Dr. Spack who, referring approvingly to the Dutch treatment of adolescents by delaying puberty and giving them hormones, said: “Suicide attempts, so frequent elsewhere, are almost unknown because parents and children know that they will be taken care of and will ultimately join a society known for its tolerance.” Referring to his own patients, Dr. Spack told me “They may be anxious, they may be depressed, but many, many no longer have psychiatric diagnoses after they are treated properly.”

In today’s video segment of CBS Doc Dot Com, I speak to Dr. Ward Carpenter of the Callen-Lorde Community Health Center in NYC, a facility that provides care to patients across the spectrum of gender identity and sexuality. In the segment that follows, Dr. Carpenter explains what surgery and hormones can entail. A warning: it’s a graphic description. Its purpose is not to shock but to educate. Hopefully, better education will lead to less misunderstanding, less fear, and wider acceptance for people like Chaz Bono.

Other Resources:

NCTE: Understanding Transgender Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline

True Selves: Understanding Transsexualism by Mildred L. Brown and Chloe Ann Rounsley

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