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Obsessive Compulsive Disorder Can Be Devastating, But Highly Treatable

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“It’s my OCD.” I hear that on and off from friends and patients who half-jokingly use the term to describe overly careful behavior (such as double-checking to make sure the stove is off) but don’t actually have obsessive-compulsive disorder. True OCD can be a devastating disease. Patients have intrusive, uncontrollable thoughts and severe anxiety centered around the need to perform repetitive rituals. They can be physical such as hand washing or mental such as counting. The behavior significantly interferes with normal daily activities and persists despite most patients being painfully aware that the obsessions or compulsions are not reasonable.

OCD affects 2-3 percent of the world’s population. We’ve seen characters with the disorder portrayed in television (e.g., Tony Shalhoub’s Adrian Monk) and in film (e.g., Jack Nicholson’s Melvin Udall in “As Good As It Gets.”) Yet it’s still associated with stigma, shame, and an alarming level of ignorance by many health professionals. On average, people look for help for more than nine years and visit three to four doctors before receiving the proper diagnosis. In an excellent review article on the subject, Dr. Michael A. Jenike, offers three helpful screening questions: “Do you have repetitive thoughts that make you anxious and that you cannot get rid of regardless of how hard you try?” “Do you keep things extremely clean or wash your hands frequently?” And “Do you check things to excess?” He suggests that answering “yes” to any of these questions should prompt an evaluation for possible OCD. Of course, these are just screening questions and keeping a spotless kitchen doesn’t mean you have a disorder.

For this week’s CBS Doc Dot Com, I interviewed Jeff Bell, KCBS radio broadcaster and author of Rewind, Replay, Repeat: A Memoir of Obsessive Compulsive Disorder and When In Doubt, Make Belief: Life Lessons from OCD. He poignantly told me about the mental anguish associated with his illness, how it threatened to sabotage his career and personal life. His OCD focused on a fear of unintentionally harming others. He found himself unable to drive a car because every time he hit a bump he was afraid he had run somebody over; each time, he needed to get out and check. Even walking to work presented a challenge. He explained that a twig on the sidewalk could stop him in his tracks and fill him with what he knew were irrational thoughts but was powerless to control. Maybe somebody would be harmed by the twig if he didn’t move it. But if he did move it then maybe somebody would be harmed who wouldn’t have if he had just left it alone.

Jeff Bell sought treatment and turned his life around. His message is that others can do the same. Highly successful approaches including cognitive-behavioral therapies and medication can help the majority of patients. But only those who ask for help.

Resources for OCD include: The Obsessive Compulsive Foundation, The Association for Behavioral and Cognitive Therapies, and The New England Journal of Medicine.


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Urinary Incontinence: A Taboo Subject?

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Urinary incontinence affects millions of women – 38% of women over the age of 60 – yet only 45% ever seek help for it. Men suffer from the problem too but at about half the rate. Only 22% of men seek help.

Why is this a taboo subject? One reason is that it’s an embarrassing – even infantilizing – problem. But patients’ shame is, well, a shame. Because urinary incontinence – the involuntary leakage of urine – can often be treated quite successfully. The first step is to make a proper diagnosis. One common type is “urge incontinence” – the bladder contracting when a person isn’t ready to urinate and can’t get to the toilet fast enough. Another common type, especially after childbirth or in athletes, is “stress incontinence.” It happens when there is a weakness in the pelvic muscles supporting the bladder and urethra (the structure through which urine exits the bladder), causing the urethra to lose its seal and allowing urine to escape when there is increased pressure on the bladder (e.g. coughing, sneezing, laughing, lifting, or exercise). As women get older, it’s more likely they will develop urge rather than stress incontinence. A very simple three question test has been created to help with the diagnosis.

It’s important to get a complete, head to toe medical evaluation because urinary incontinence may be a symptom of an underlying condition (e.g., neurological problem, diabetes, urinary tract infection, chronic bladder inflammation, or even a tumor) or may be a result of medication. Talk to your primary health provider and/or gynecologist. If needed, a specialist (e.g., urologist or urogynecologist) can be consulted.

Treatments for urge incontinence include bladder retraining and pelvic muscle exercises, medications to relax the bladder, and decreasing fluid intake. Approaches to stress incontinence include weight loss if obesity is present, a vaginal pessary, and surgery.

In today’s segment of CBS Doc Dot Com, Dr. Lori Warren and Dr. Jody Blanco, gynecologists with expertise in urinary incontinence, discuss the problem. You’ll meet a woman who overcame her embarrassment, sought help from Dr. Blanco, and is now symptom free after surgery.

There are several online resources on the subject, listed at the end of an excellent discussion in the online medical database, UpToDate.com.

Are You Afraid Of Alzheimer’s?

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There are few conditions more frightening to my patients – and to me – than dementia. It’s easily the most common fear voiced in my office. One woman recently said, “I couldn’t think of her name and I’ve known her for years; I think I may have Alzheimer’s.” Another patient, a physician, half-jokingly asked, “How do I know if I’m losing it or have just misplaced it?” Behind his nervous attempt at humor was a deadly serious concern.

The most common form of dementia in the elderly is Alzheimer’s disease. According to the Alzheimer’s Association, it affects as many as 5.3 million Americans. Especially cruel is the twilight phase when patients can still understand what they are losing, when they can see the receding silhouette of their memories but cannot reclaim what they’ve lost. This was brought home to me very poignantly last year when I interviewed 65 year old Carol and her husband Mike about Carol’s Alzheimer’s. At one point, Carol could not remember how long she’d been married even though I had just reminded her two minutes earlier. At another point, Mike – a retired cop – broke down talking about his wife’s illness. All the words in the world cannot adequately describe the anguish conveyed by the looks on their faces, the tone of their voices.

Often forgotten in the tragedy of dementia are the caretakers, frequently family members whose lives are torpedoed by the devastating illness. In this week’s CBS Doc Dot Com, I speak with Gloria Signorini, an 80 year old woman with dementia and with her daughter, Joanne, who has put her life on hold to take care of her mother. Mrs. Signorini’s physician, Dr. Gayatri Devi, an expert in dementia at NYU Langone Medical Center, provides perspective about Alzheimer’s and other forms of dementia.

** Editor’s Note: Please click on this link to watch the video (I’m having technical difficulties embedding it here)**

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ADHD Drugs Abused By College Students

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This week’s episode of CBS DOC DOT COM took me to a college campus where I got schooled by two students about the widespread use of ADHD (Attention Deficit Hyperactivity Disorder) meds – by kids without a diagnosis of the condition – to study, stay attentive, and sometimes just to feel good.  A 2005 Web survey found that 5% of US undergraduates reported having used stimulants over the previous year for non-medical reasons.  But the real number may be much higher, especially if you listen to the students I interviewed with Dr. William Fisher, a psychiatrist at Columbia University Medical Center.

Features of ADHD include inattention, hyperactivity, and impulsiveness.  A national survey in 2003 reported that about 4.4 million children in the US have been diagnosed with ADHD and 56 percent take medication to treat it. It’s estimated that about one to two thirds of the children with ADHD continue to have symptoms in adult life.

ADHD medication was in the news last week with a report that medication use in elementary school children improved math and reading scores.  The gains – equal to about a fifth of a school year in math and a third of a school year in reading – still left the treated children lagging behind kids without the disorder. The study fans an ongoing debate on who should receive medications such as Adderall and Ritalin.  These medications – along with behavioral/psychological therapy and educational interventions – help patients with ADHD; but they’re also being used by students and adults who have not been diagnosed with the disorder.

These drugs have potentially serious side-effects such as high blood pressure, irregular heart beat, and dependency.  Doctors prescribing them for patients with ADHD should be carefully weighing the risks and benefits.  People taking them on their own are rolling the dice with their health.  No matter what you may feel philosophically about using these stimulants, the risk-benefit of their use in patients without ADHD has simply not been established.

I feel strongly that ADHD medications should only be used under the guidance of a physician. But that’s apparently often not the case.  In today’s segment, we explore this issue further. Why do people without ADHD take stimulants? How do they start? How does it make them feel? Is society’s metronome pulsing so much faster today that people feel pressured to take drugs just to keep up?  Click here for a fascinating related article which appeared recently in The New Yorker.

Click here to see a video on this topic.

Physicians And The H1N1 Flu

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Yesterday I visited the Centers for Disease Control in Atlanta and was taken inside the command center, where almost 100 staffers have been working around the clock to monitor and stem the current outbreak of flu.

I first spoke to Toby Crafton, the manager of the command center, who oversees the day-to-day operations. He and his team have been preparing for a possible pandemic of flu or another infectious illness for years. I also spoke to Michael Shaw, PhD, who heads up the virology labs that are studying the H1N1 virus causing the current outbreak. He’s spent a career learning the laboratory techniques that are so urgently needed right now. The third person I spoke to was Dr. Richard Besser, Acting Director of the CDC, who has been working at the agency for 13 years and is an extensively published expert in infectious diseases.

I mentioned that last week I had received an email notification from the New York City Department of Health (NYCDOH) about how I should be managing my patients with flu-like symptoms. The advice was actually not intuitively obvious to me. For example, the Department of Health said that for patients with mild illness, treatment with anti-viral meds like Tamiflu and Relenza was only recommended for patients who also had underlying conditions that increased their risk for complications due to influenza. Dr. Besser pointed out that it was especially important right now for physicians to stay up to date with the recommendations being made by public health officials. Doctors can contact their local department of health and sign up for the same type of email notification that I received.

This brings us to the main point of today’s blog post. Many of us – patients and physicians alike – have been thinking about the influenza virus for about a week. Public health officials like the teams at the CDC and the NYCDOH have been thinking about it for years. Physicians, me included, are used to practicing medicine based on “clinical judgment.” We understand that medicine is an art and not a science, that there are many different ways to approach a problem, that there’s often no clear “right” or “wrong.” We are also used to doing things “our way”, whatever that way is. But this is not a time for doing things “our way” if it’s at significant odds with strong recommendations being made by public health officials. There are recommendations that may seem logical – like prescribing medication for somebody with mild flu symptoms “just in case” that nevertheless go against the judgment of people who have trained for years to think about how to deal with an epidemic.

What if you’re a physician who strongly disagrees with a suggestion of public officials? Then challenge that recommendation publicly. Bring the discussion to light; maybe you’re right. While this is no time to go rogue, doctors have an obligation to think carefully and independently and to challenge recommendations that seem illogical. But don’t silently do things your own way.


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