Tuesday, December 22, 2009

Patients Come Bearing Fruit

In yesterday's inbox was a packet from a former patient who sent her twenty page college essay entitled "Taming Mental Chaos:an integrated approach to treating anxiety disorders." Because we had spent years together managing her anxiety in all of its manifestations and trying a variety of approaches ---I write this blog with her permission, without mentioning names--, she thought I would be interested in how far she has continued the exploration. Not only has she incorporated relaxation and cognitive behavioral therapy techniques into her life, but she has gone on to become a certified yoga instructor and to teach others! This paper is her expression of gratitude toward and recognition of all that yoga can do to promote a more mentally, and physically, healthy life.

As a parent, a physician, and a teacher, there is hardly a more gratifying moment than the realization that one has passed on something important to a child, colleague or student. At the top of her paper was a quote from Plato who said back in the day: "The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated." Since what adolescent medicine physicians are fortunate enough to do best is to integrate body, soul and mind in their practice, I felt moved by what my patient sent, knowing that some of the seeds of her discovery were planted at my desk.

Monday, December 14, 2009

Seven Ways for Grandparents to Reach Teens

As promised, I culled some wonderful ideas from the eighty or so retirees I spoke to in Green Valley, Arizona last week. Fortunately my talks ended in lively give and takes and I think I took away as much as I offered them.
The overwhelming impression I was left with was how isolated and out of touch grandparents often feel with respect to teenagers. Here are some ideas for staying in tune with this generation on the go.
ONE: Pick at least one electronic mode of communication. Email, Facebook, cellphone, text messaging, or Skyping are some of the most accessible ones. Use a library or take a course in order to learn these "languages." Without them there is not likely to be much sharing.

TWO: When you see your grandchildren, ask them to show you their Facebook page. Like a scrapbook or a photo album it's a window into their world, their friends and their thoughts.

THREE: Tell them stories. Search for ways that your life relates to theirs: war stories with mesmerizing detail; graphic tales of depression hardship (without too much self-congratulation); how you met your spouse; your best friend growing up; when you were bullied;the dirt on their parents.

FOUR: Share a hobby with them: a card game, a round of golf (with them driving the cart), ping pong, fishing (and learning to clean the catch), chess, or your valuable stamp collection.

FIVE: Rent or see a movie together (You buy the popcorn!) Engage in conversation by asking them what they thought first.

SIX: Expect that interactions may happen in sound "bytes", not lengthy satisfying chapters. Try not to be judgmental about the rapid pace of their lives. Catch them when you can!

SEVEN: After all, tell them you love them.

Tuesday, December 8, 2009

Off to Arizona to Talk Teens to Grandparents

With only minutes to spare before I leave for the airport for two speaking engagements in Green Valley, Arizona, I will share with readers what I hope to accomplish. I am going to speak to two different groups of retirees in their beautiful southern Arizona desert community.

I hope this will be a two-way street. I have something to say about teens and young adults (ala David Brooks in my last post) and I am eager to hear what the senior generation has to say about teens. I am motivated by what I see as a need for grandparents who live at a distance from their families to stay in touch rather than to retreat into old age and give up on trying to understand the marvelous youth in their midst. And I hope to use this experience as a starting point for writing that will reach them on an ongoing basis.

My main points for discussion are:
Communication: it is possible to stay in touch with kids, now more easily than ever but it might require getting educated
Young adults: they are fabulously involved in making the world a better place
Sexuality: yes, it's there. What do you really want to know?
Immunizations: look how far we have come!
Education: what is autism? what is ADD? What's up with this generation?
Alcohol: How can grandparents help the bingeing generation?

I will be sure to let you know what I find out!

Saturday, November 28, 2009

Thank you Bob Herbert and David Brooks

As I begin to see light in my refrigerator again and continue to clean and put away dishes, I am thankful for the chaos and mess that my children have wrought. And for my dishwasher that keeps on purring.

I am also grateful for articulate people in positions of power who speak out for our children. In today's New York Times, Bob Herbert waxes poetic about the innocent joys of children watching Macy's Thanksgiving Day parade. And he admonishes the adult world for continuing to tolerate a society that is unfair to the disadvantaged, that engages in "stupid" wars, and that perpetuates a "hideously dysfunctional" education system.

On the PBS Newshour on Wednesday night, David Brooks struck a more hopeful but less specific note when he closed the hour by mentioning how grateful we can be for young people under thirty in our country. He noted how many wonderful, creative and laudable activities they are all engaged in. And he reminded us that in these times of reflection about where our country is going and what our values ought to be that these kids are out in front.

In my family and professional circle, I know of countless young people who are looking to the Peace Corps, Teach for America and the military;engaging in internships in all manner of health care and education institutions; providing low or no cost legal and medical services to the poor; and seeking work across the globe. A few years ago Brooks coined the term "the odyssey generation" for these college grads who may wander, switch, experiment, question, turn around, and seek their paths. They are surfing the globe in search of the best mix of work, play, contribution and meaning.

I feel blessed by their optimism, agility, and ability to look at this complex world in a relatively directed way and work to see their way through.

Tuesday, November 24, 2009

Orchid or Dandelion?

As you look around the Thanksgiving table on Thursday and size up friends and family, try this new framework for thinking about loved ones. Would Uncle Larry be best described as a dandelion--a hardy, rugged, weed-like character who can push up through the asphalt and survive with little attention? Or would he best be described as an orchid, an unusual and finicky guy who has required hot-house conditions but has made good--and then some--in his circuitous life?

In an article in December's The Atlantic entitled The Science of Success, David Dobbs elaborates on this metaphor in a thought-provoking way that might have bearing on how we view and raise our children. He cites a number of research studies that show what might seem intuitively obvious--that environment and parenting (read nurture)impact personalities and have huge effect on the expression of certain emotional/psychological genetic tendencies (read nature). We know that if a person has an inherited tendency to depression, an unfortunate confluence of life events (divorce, death, debt or disease to name the big D's of life) or any one of them alone can be enough to trigger severe psychological disorder.

What Dobbs says we have not taken into account is the idea that these genetic tendencies must have survived in the gene pool for some "reason." In fact, he says, a genetic predisposition for some emotional "disorders"--and he especially looks at ADD (attention deficit disorder)--may actually impart a selective genetic advantage under the right (hot house?) conditions. The energy, ability to multi-task, and the creativity and flexibility inherent in some of these folks will make them productive contributors to society at levels beyond those of the dandelions in our midst. But only if their disorganization, inattention, proclivity to accidents and poor judgment doesn't get the better of them first.

So what is a parent to do? My answer would be that we need to be realistic about our genetic tendencies (look at Uncle Larry with an objective eye), recognize potential emotional and psychological problems early in our children, and learn to be "professional parents" to the more complicated plants under our care. And now, in addition, we can be thankful for their presence in our midst and optimistic that with careful nurturing they will bloom and flourish alongside the hardy dandelions.


Wednesday, November 18, 2009

Unfriending Hits Home

Many of us have heard by now that yesterday the Oxford English Dictionary (OED) announced its word of the year-- “unfriend.” At first I thought “how modern!” of the OED to choose a word associated with social networking.

Then I heard on NPR that “unfriend” actually dates back to the 17th century and meant about the same thing it does now, although it is currently exercised in previously unthinkable and creative ways on Facebook and elsewhere. No longer is an actual gauntlet or epee required to “unfriend.”

So hearing this, it could not have been more timely to see a patient in my office yesterday afternoon who was describing the drama of her last year and a half as she emerged from a painful middle school experience and has begun to settle nicely into high school. In the process, however, she has had to “unfriend” a MeanGirlWannabee or two. Liberating herself from the toxic influences of these personalities was not a negative move at all. Instead, I supported her decision to be herself and to accept that not everyone is “friend” material. The dewy eyes that I saw as we talked were a clear indicator of the intensity and anguish involved in the decision and process of extricating herself from an old group. Not to mention the scary steps of judging, navigating and cultivating a new set of companions moving forward.

There may be pain in severing relationships whether that happens electronically or through face to face negotiation. Having language to describe what happens in the new world of e-communication—apparently “sexting” was a runner-up for Word of the Year—will go a long way to encouraging dialogue as we all grow and evolve with the many new inventions quite literally at our fingertips.

Sunday, November 15, 2009

Health Care Reform and Restoring Dignity to Medicine

With so much talk about health care reform it's easy to lose track of the individual stories of people across the country who live, get sick, need care and "consume" health care. There is probably no better way to appreciate these stories than to hear Anna Deveare Smith tell them. The actress, interviewer and playwright is currently in performance in New York with her "Let Me Down Easy" show which is a distillation of interviews conducted with over 300 patients and people across the country over the past eight years. From this vast trove, Smith has developed 20 roles that she plays on stage in her one woman show.

Her project started as an assignment from a Yale medical school professor who asked Smith to show doctors how to gain understanding and insight from really listening to patients' stories. But she goes way beyond her original assignment to show us how the likes of Lance Armstrong, Ann Richardson, a rodeo rider and a New Orleans Charity Hospital physician look at illness and suffering in the broadest sense. We learn from Smith about our health care system, about the ways folks struggle with life and death and the life cycle, and about how to rescue "grace and kindness" in a world of suffering, disappointment, and broken hearts.

One of the best segments is about the notion of charging one price for whatever ails you. It makes complete moral sense that the cost of whatever problem a patient has should not be based on its threat to his or her life. In an interview on public television with Bill Moyers
Smith says that when people are charged a "flat rate" for care, "that's when you'll get your good doctors," when money doesn't matter any more.

Now that Wall Street can no longer necessarily pull the best and the brightest, we can hope that the helping professions will attract some of those best and brightest for the right reasons--namely to engage with people. Prospective doctors will see that they can treat themselves to the joy of medicine through patients' marvelous stories, not merely because of a dearth of money-making jobs elsewhere.

Friday, November 6, 2009

Hands Free Parenting

In its online article, "Nagging Goes High Tech", ABC news reported that 63% of parents say that texting has improved communication with their kids. On the other hand, it can easily be seen by teens as a new way for parents to breathe down their necks. "One time my mom got my report card and texted me, telling me I was grounded for two weeks," recalled Jessica Purcell in the ABC report.

During a recent parents' meeting at my childrens' high school, the principal implored parents not to text kids during the day as it is not only disruptive, but bad parenting. For instance, he said, it is not a good idea to text right after the math test. Let your child process his thoughts, feelings, anxieties and concerns or even his elation over the test before you try to edit those sentiments by intruding with :"How did it go?" The principal went on to describe a parent who phoned the math teacher after such a test/text situation before the school day was even over! How will we teach our kids resilience and self-reliance if we don't allow them to tussle with and deal with emotion-laden moments on their own?

It is useful to remind ourselves that teens change their feelings and viewpoints very quickly and it is often healthier (and brings less drama) to wait a few hours and see how they have sorted things out for themselves without parental input.

Monday, November 2, 2009

Play the Pneumonia Game with your kids and students

Today is World Pneumonia Day. I had no idea until I received a clever email from Save the Children entreating me to play "Mission Pneumonia". Never one to turn down a challenge (I love the SAT question of the day, for instance), I clicked into the game. It is an apparently simple strategy to get you to donate money (of course) but just as important it teaches us about pneumonia:

  • pneumonia is preventable and treatable;
  • a child dies from pneumonia every 15 seconds somewhere in the world
  • community health workers are a powerful force against the #1 killer of children under 5

What are the most critical actions you can take? Log on and play the game at Mission Pneumonia.



Monday, October 26, 2009

Mouth to Mouth CPR give you the willies?

No More!

In 2005 the American Heart Association changed its recommendations about CPR. In the case of a witnessed cardiac arrest, they no longer suggested using mouth to mouth resuscitation. Now in a study reported in the Journal Watch Emergency Medicine, it appears that a victim is almost twice as likely to survive an out-of-hospital cardiac arrest with effective chest compressions alone compared to the older routine of mouth to mouth plus chest compressions.

Part of the original rationale for changing the recommendations was that not only is it more effective (which this study supports) but it will make it more likely that people will actually step up to the plate and start basic CPR while waiting for expert help to arrive. Tell your kids about this and watch this two minute YouTube clip about how to do chest compressions. It could save a life, maybe even your own!

Monday, October 19, 2009

Parenting Style affects Driving Record

As if we needed any more evidence that the way we raise our kids affects the way they walk (or drive) in the world, the official journal of the American Academy of Pediatrics, Pediatrics, just published a well done study to show it. The authors reviewed almost 5700 responses by 9-11th graders to the 2006 National Young Driver Survey. Parents are divided into four parenting styles based on the kids' assessment:

1) authoritative(lots of support and lots of rules/monitoring)
2) authoritarian (lots of rules without the support)
3) permissive (lots of support but no monitoring)
4) uninvolved (none of any of it)

Of some concern is the fact that 19% of kids described their parents as "uninvolved." Compared with these kids, the children of authoritative parents had half the crash risk in the past year, were less likely to drive when intoxicated and were less likely to use a cell phone while driving. Interestingly, there was no significant difference between permissive and uninvolved parents.

So once more, we learn that parenting matters, and parenting style matters even more. Now if only we can figure out how to be authoritative without being a "helicopter parent."

Thursday, September 24, 2009

Shame on Who?

Caster Semenya, an 18 year old track star from South Africa who won the 800 meter race in Berlin in August has been the object of intense media scrutiny ever since she ran. Not because she outran her competitors by a few seconds, but because the sports world has been weighing in on whether it is fair for her to run as a woman.

Caster is intersex. Some 0.5 to 1% of the general population is thought to have characteristics that are intersex. In Caster's case she has typical-appearing external genitalia of a woman but the internal gonads (sex organs) of a male and therefore produces testosterone and not estrogen. This explains her flat chest, her deeper voice, her facial hair, and maybe her muscular build (she also works out and trains a LOT to get that body). As hard as it is to make the mental leap to understanding that sex is not necessarily a binary, either-or phenomenon, we must stretch our minds and get educated. It is not ok to sit back and pass judgment or gawk at a variation of nature. Semenya is different but she is not a freak and she is not alone. As Lisa Belkin blogged in the New York Times, we need to tell our children about this; it's a matter of tolerance.

I believe Caster when she says that she just learned about this from the media and the recent tests that the International Athletics Associations Federation have put her through. I believe her father that he thinks of her as a girl. I believe the reports that she has withdrawn and is depressed over having her life and gender identity exposed publicly. For gender identity is something we each decide for ourselves;no test can make that choice;it is a psychological phenomenon. Usually gender identity is in harmony with one's body as it most likely was for Caster until she entered puberty and developed external male characteristics.

What I have trouble believing is that no one in a professional capacity--counselor, coach, physician, nurse--ever questioned the pubertal development of Caster. By most standards a young woman without a period by age 16, who was developing hirsutism and had no breast development deserved an evaluation. If that evaluation was done and not shared with Caster in the most competent, delicate, compassionate and informed sort of way, well shame on them!

Because someone did not do his or her job with complete competence, this young woman is having her body dissected on the world stage and in the blogosphere and her achievements diminished by sceptics who do not understand the science behind it all. Let's keep the legitimate debate about athletic competition separate from the discourse about Semenya's sex.

********

If this piques your interest and you want to read a moving novel, extremely well researched and written of the life of an intersex adolescent, try Middlesex by Jeffrey Eugenides.

Thursday, September 17, 2009

Don't pass down your depression

It looks like it might actually be possible to "immunize" our children against one of the afflictions most feared by all parents--mental illness. A recent study by Judy Garber, PhD of Vanderbilt University that was published in the reputable journal JAMA(Journal of the American Medical Association) provides some hope.

It is known that adolescents with depressed parents are more likely to develop major depression themselves. Whether there is a genetic component to this or can be attributed to environmental factors is not what matters here. What matters is that Dr Garber's work shows that a group of adolescents who have been depressed in the past and were considered at risk for serious depression could be taught techniques that helped to significantly lower their symptoms when studied nine months later.

The techniqes are called cognitive behavioral therapy and can be as simple as teaching a patient to "think positively." They are also taught problem solving skills, and ways to recognize and "re-frame" negative or potentially self-destructive thoughts. Cognitive behavioral techniques are often just a translation of age-old ways of looking at the world and helping people manage daily stresses.

The Vanderbilt treatment program included eight weeks of 90 minute group sessions and then monthly "booster" sessions for small groups of students. Parents were also involved in two informational meetings.

What Garber's work suggests to me is that we should probably start thinking of mental health prevention as part of our plan for our children in the same way that vaccinations and "physicals" are. Kids deserve a "mental" at every visit to their health care provider. I might even go so far as to say that our schools should begin to consider "emotional education"(Emo-Ed, can't you see it now?) as well as physical education in our curricula. Good mental health is not a given, but it can be taught.

Tuesday, September 8, 2009

Insurance morass

Back from vacation! Springing into Fall!

Although it was never my intention to use my blog as a way to complain, I saw Julie and Julia last night and Amy Adams' blogging inspired me to share a story that is only a thinly veiled gripe.

In these times of debate about health care, I have been struggling with the idea of joining insurance plans to make myself more accessible to a wider range of patients than I can see otherwise. In addition to the New York State plan for low income families and children (Child Health Plus), I have been on the Aetna panel for over a year. About nine months ago I decided to apply for four other plans in the hopes that their reimbursements would be reasonable enough to sustain my practice.

The way the application process works is the doctor applies (many documents, reams of paper, phone calls) and time goes by. We did that in January. Eight months later (this July) Blue Cross sent a letter announcing my acceptance. At this stage (and not until then)an applicant is able to know what the reimbursement schedule will be. So, once I saw the numbers ($52.16 for a thirty minute visit; $63.84 for forty-five minutes) and did the math, I decided not to join. HOWEVER, Blue Cross put me on their roster without my approval and listed me on their website in August.

So what difference does it make? The problem is that patients who may be on Blue Cross now submit their superbills from my office to Blue Cross and are told that they only owe me the co-pay because from the company's point of view I am a BC provider. So now, I am struggling to try to get someone to answer the phone at Blue Cross and cancel my listing which I never authorized in the first place.

This one tiny example serves to demonstrate the monolithic, bureaucratic, and confusing nature of the insurance system we work under.

I honestly wish for Blue Cross employees that they find meaningful work one day. Work that does not involve arguing with doctors' offices; refusing care to patients; nitpicking over whether a doctor asked ten questions or twelve; denying claims for routine procedures (eg urine tests); wasting paper, ink and postage; and breaking patient confidentiality by looking over the shoulders of doctors and pharmacists.

And now I am off to look up the recipe for boeuf bourguigon.

Thursday, August 20, 2009

HPV/Gardisil vaccine clears major safety hurdle

In the August 19, 2009 issue of the Journal of the American Medical Association, a major review of the safety of Gardisil (the vaccine against human papilloma virus first licensed in 2006)was published. This is the first publication of a comprehensive analysis of all the data by the Centers for Disease Control and the FDA. It is based on the data collected by the VAERS (Vaccine Adverse Events Reporting System). This means that this is a safety report based on the track record of this vaccine AFTER it was approved and has been administered over 23 million times.

VAERS is a national, government-sponsored reporting system. All reports (12, 121 for Gardisil) are screened and any serious problems are thoroughly investigated. Most reports were minor (fainting--at the same rate as tetanus shots; dizziness;nausea;headache;and local reactions)

Thirty two reports of deaths were made of which only two are still being investigated as possibly caused by the vaccine. All others were serendipitous (caused by diabetes, illicit drug use, viral illness, or heart failure none of which were linked to the vaccine).

All in all the safety record appears very similar to the data that was presented from pre-licensing trials. The only major change I have implemented in my office has been to watch girls for an extra ten minutes after their shot to guard against a dangerous fall from a fainting spell.

It is good to remember that about 11,000 women are diagnosed with cervical cancer each year in the US alone. About 4000 die from the disease each year. The HPV vaccine effectively protects against the main types of virus that cause 70% of these cancers.

In the global picture where folks across the world are dying at alarming rates of the common illnesses of diarrhea, malaria, influenza and pneumonia it may seem a luxury to vaccinate against a relatively rare disease with a relatively expensive vaccine. I remind patients that we ARE lucky to have this vaccine. Just as we are lucky to have good education, roads, and other amenities of a "developed" country. But let us also remember that American minority women still contract and die from cervical cancer at much higher rates than Caucasian women. Research shows that this discrepancy is due to a problem of access to medical care-- as we know a thorny problem that our country has yet to solve.

Tuesday, August 11, 2009

Dietary Supplements for Weight Gain in Teens

I am starting a "guest blogger" opportunity for any professional who does not have a personal blog but has something smart, useful, funny, new, or otherwise entertaining to say about issues related to health for adolescents and young adults.

This post is by Dr Karen Reznik-Dolins who is a registered dietician
and licensed sports nutrition expert. Her practice is in Mamaroneck
and she can be reached at karen.dolins@gmail.com

If you are interested in writing as a guest blogger,
please contact Dr Engelland at engelland@aol.com

Not a day goes by that I don't speak to a teen who has at least
considered taking supplements in order to enhance performance
or looks. This brief blog entry offers some simple, wise advice:

In my practice in Mamaroneck and with Columbia University athletes, I see plenty of kids and teens reaching for protein powders, experimenting with creatine, and other supplements in their attempts to gain weight and lean body mass. It scares me. It scares me because these types of dietary supplements are generally not studied in kids under 18. That means that your kids are experimenting on themselves.

There’s been tons of research on the purported benefits of protein powders. The consensus among scientists is clear: protein powders are no more effective than any other source of calories. What’s disturbing is that the dietary supplement industry is largely unregulated as a result of the 1994 Dietary Supplement Health and Education Act (DSHEA). Quality control varies, and laboratory analyses find varying levels of active ingredients along with other, potentially dangerous, ingredients that aren’t listed on the label.

What I tell kids trying to bulk up is simple: eat 6 times a day, don’t skip meals, be sure to fuel your workout with a pre-exercise snack, and follow your workout with recovery foods. It can be as simple as having a bowl of cereal with milk, and it works every time.

Thursday, August 6, 2009

Big Kids Come Home

I loved the New York Times piece today entitiled "Our Children, the Rude Houseguests" by Michelle Slatalla in which the author humorously tells about her (almost) grown children, ages 18 and 20, sharing the house with mom and dad during this Summer Recession of 2009.

The expectations for young adults have changed in many families, especially those who can afford the luxury of contemplation. Is it because they have been coddled and supported in ways we boomers could never have expected as kids (and if you think we had it harder, go ask a child of the Great Depression about how tough it can be)? Many of us have grown up alongside our own children to such an extent that we actually enjoy the company, companionship, conversation and creativity of our grown kids almost as much as we enjoy the company of our contemporaries.

My kids make me feel youthful and they challenge me constantly whether it's on my parenting skills viz-a-viz the youngest siblings in the family or on my perennial memory loss with respect to technology ("I showed you that last week, Mom"). I don't actually mind helping them (helping is the operative word) do their laundry. And the rewards of cooking the old standards and the favorites are still powerful and meaningful.

Nonetheless, I have said for a long time that I expect my children to move out, on and up from the family homes because I believe that is really what they are supposed to do. To a certain extent it is selfish on my part-I am ready for space and time, privacy and freedom. And I think there is great value in sharing a New York apartment with four or five others for a few years while everyone gets his or her bearings, relationships and salary established.

On the other hand, I hope they won't choose to live too far away for too long. As I contemplate leaving a big house, getting an apartment with a kind and competent super and simplifying my life, I am mindful of the need to keep a semblance of a nest for them to return to, even if it means blowing it up before they lie down in it.

Tuesday, August 4, 2009

LIsten Responsibly

The Hearing Alliance of America reported in 2005 that 15% of college graduates have a level of hearing loss equal to or greater than their parents. This is thought to be caused by listening to high volume music. Other audiological symptoms include distortion, tinnitus (ringing) and hyperacusis(loudness). What to do about this silent epidemic?

A recent article in Pediatrics, THE journal of the American Academy of Pediatrics, reports the results of a panel of experts discussing the problem of MP3-induced hearing loss among teens. Experts included scientific researchers, medical doctors, community health professionals, educators, youth workers, music entertainment experts and enforcement authorities.

The general consensus was that teens, manufacturers and parents are the most relevant parties to be involved in prevention of hearing loss. To their credit, I think, the experts agreed that it is unlikely that teens and young adults are likely to police themselves in this regard. The general recommendation is that the industry will need to regulate itself in order to protect the hearing of the nation's youth. Volume-level regulation for MP3 players may be necessary through use of a noise limiter. . It was also recommended that authorities should initiate a public health campaign to raise awareness of the problem.

As a practicing pediatrician and a school district physician, I am surprised that a standard hearing test was not recommended at the middle and high school ages. Many pediatric offices and clinics are equipped with reliable equipment for testing hearing as are many school nurses' offices. A mandate to test and counsel on this important issue would go a long ways toward raising awareness.

Taking a cue from the beverage industry, we can imagine the slogan: "Don't Text and Drive" along with "Please Listen Responsibly."

Thursday, July 23, 2009

Heads Up: You CAN"T walk and text at the same time!

This week the media have focussed on the dangers of multi-tasking while driving. A resurgence of some old data shows that the risk of an accident while talking on a cell phone is far greater even if one is using a "hands-free" system. In my experience, hands free is rarely so--either because the earpiece needs adjusting or because hands are required for dialing. Recent work has shown that using a cell phone increases the poor coordination and concentration necessary for driving to the equivalent of a blood alcohol level of 0.08, the legal limit!

A 2009 study in the professional journal Pediatrics highlights another danger of cell phone use among young people worth considering. It really is no surprise that crossing the street while talking or texting has its own risks. While the study was done in kids, I think the lessons apply to all of us who have a hard time clamping off the technological umbilical cord.

In this study middle schoolers were tested in an ingenious interactive virtual environment. The kids who were on the phone were less likely to look both ways before crossing the street. They were more likely to be hit by a car or have a close call when crossing.

Since phone use has become second nature for so many of us, we need reminders that we should adjust our bad habits. Here are a few suggestions:

  • Crossing guards in our communities should warn kids about crossing and cell phone use.
  • Tell your kids to remind you while in the car together that you should get off the phone or let them take the calls!(Kids love to reprimand their parents)
  • Put a sticky reminder on your child's dashboard.
  • Remind your spouse to set a good example.
  • Ask your taxi driver to hang up if he is driving you.

Monday, July 13, 2009

Yuck! Doctors' Cell Phones Are Gross!

I was recently at Montefiore Hospital with a patient and noticed a sign on the spotless waiting room wall: "Have we washed our hands? It's ok to remind us!" I though how mortified I would feel if a patient had to remind me to wash my hands before doing a physical exam. And now there is something new to remind your physician about in order to keep you healthy.

A recent study published in the Annals of Clinical Microbiology and Antimicrobials was conducted in Turkey. Two hundred health care workers had their hands and their mobile phones swabbed and cultured. Fully 95% of the phones were contaminated with bacteria. We would not expect them to be sterile. However, over half of the phones were contaminated with Staphylococcus aureus, of the variety called MRSA that has acheived notoriety recently because of its resistance to more common antibiotics.

So imagine if your doctor has greeted you, washed her hands, begun to chat with you then interrupts to answer her cell phone. What usually happens is that she would then snap the phone shut, apologize (you hope) and resume her conversation or exam with you. OOPS, bacteria have now been transferred to you from the phone. Can you be courageous enough to remind her to wash again? Can she be gracious enough to accept your observation, new-found knowledge and chutzpah?

I suggest you try if the situation ever arises. It would be a true litmus test of a doctor's compassion, conscientiousness, and ability to learn. And maybe this message should go VIRAL!

Thursday, July 2, 2009

Do campers need Tamiflu for "Swine Flu"?

Several calls have come in this week from parents who are inquiring about swine flu (novel H1N1) virus. The story is usually something like this: a few kids have been "definitively diagnosed" with Swine Flu and the camp has sent home an email letting parents know their children, in spite of their best efforts, have been exposed. They are being asked to call their pediatricians and ask if they would like the exposed (but not yet ill in any way) children to have prophylactic Tamiflu, the most commonly precribed anti-viral drug for prevention and treatment of novel H1N1 influenza.

My philosophy and that of numerous other experts(American Academy of Pediatrics, Centers for Disease Control, and New York State Health Department) is that prophylactic medication is not indicated for the vast majority of patients. If a child has labile asthma, or heart disease or is on chemotherapy or is otherwise in a weakened immunologic state and particularly at risk for complications of the flu, prophylactic medication may be indicated.

If a child comes down with typical symptoms of the flu (fever, headache, body aches, cough, and cold symptoms) Tamiflu can be given within 48 hours of the onset of symptoms. Even then, it only mitigates the illness by about 24 hours. And although this is anecdotal, this year's H1N1 flu seems to be fairly mild, causing illness for only a few days.

My personal feeling is that for the majority of people this flu is a fairly mild illness and I would just as soon we allow our children to develop some natural immunity. Natural immunity is the reason that most people born before 1957 have not had this flu. The flu virus from those years had some genetic resemblance to this current H1N1 and most adults over age 52 are actually partially immune due to exposure in childhood.

Another reason that prophylactic medication (usually given for 10 days) does not make sense is that exposure will not cease after ten days. Are we to give Tamiflu all summer long to campers as more and more kids turn up with the illness?

Fortunately this "Pandemic Flu" has not had the scarey consequences that were originally feared. It is unfortunate that the concern and planning that so many school districts went through this Spring is now transferred to camps. And of course the extraordinarily rainy weather has not helped any of us. Campers are huddled together indoors in relatively unsanitary environments because lightning could strike at any moment outside! If only it meant we saw more of the "Dear Mom, Dear Dad".....as a result.

Tuesday, June 30, 2009

I'm not fat! Are so, fatso!

A study from 2005 in the Journal of Adolescent Health reported about appearance-related teasing among middle school age girls. The study was conducted among 372 girls in one school in Tampa Bay, Florida.

First, what did the girls say about how often they are teased? Twenty-three percent of participants in the study reported appearance-related teasing by a parent. 13% were teased by mothers and 29% by siblings, according to the survey.

This teasing was a significant predictor of body dissatisfaction, depression, lowered self-esteem, bulimic behavior, and restricted eating.

Middle school is a time when the average male body is becoming longer and lanky (if it is changing yet at all) and the average girl's body is becoming thickened around the middle. It is this midriff thickening that many girls complain of. And it is just at this time that an insensitively placed comment can ignite an eating disorder. One of my patients once told me she started her diet that became full-fledged anorexia nervosa the day the boy at the locker next to hers called her "Sara Lee."

Doctors, nurses, teachers, coaches, parents, and brothers and sisters need to know that words CAN hurt. Each patient should have the opportunity to discuss any bullying, teasing, harassment or worse that she is experiencing in her environment before a self-destructive response has a chance to flare up.

Thursday, June 25, 2009

Plan B Goes Generic

The Food and Drug Administration announced today that Plan B, the revolutionary morning after pill will be sold as a generic drug after August 24, 2009.

What is Plan B again? Plan B is the most commonly prescribed emergency contraceptive on the market. It was designed and marketed by Barr Laboratories to meet a demand for a simple, effective, safe, and relatively side-effect-free alternative to previous versions of the morning after pill. Only recently the FDA approved its sale over the counter to people under 17.

This new announcement is a good thing if it results in less expensive alternatives to the brand name. In my experience the $35 cost of Plan B can be a stumbling block for teens who need to pay out of pocket in order to protect their privacy( I always warn my patients that insurance companies do not seem to follow the same ethics about confidentiality that the medical profession does and if their privacy is paramount, they need to fork over the cash for their Plan B).

We owe a debt of gratitude to Women's Capital Corporation and Barr Laboratories for the enormous effort and investment they put into developing this product and working to acheive its FDA approval for over the counter use for teens. Hooray!

Friday, June 19, 2009

ADHD and Medication: cause for alarm?

Just when the calls about Swine (H1N1)Flu started to abate, the phone and email box filled up this week with concerns about children taking medication for Atttention Deficit Hyperactivity Disorder.

That’s because it was big news across all media this week. A study, "Sudden Death and Use of Stimulation Medications in Youths"* has parents and providers everywhere scrutinizing the results. It is generally agreed that somewhere near 5% of the general pediatric population has a diagnosis of ADHD, so that means this information has the potential to affect at least one kid in every classroom. In addition to legitimate use of medication one needs to consider the current fad of students buying or borrowing the prescribed medications of their friends to use as study aids. The results of this current research ask us to sit up and pay attention.

What is the brouhaha about? This epidemiological study from Columbia University and the New York State Psychiatric Institute published in the June issue of the American Journal of Psychiatry examined the risk of sudden unexplained death(SUD) in young people taking stimulant medication (eg Methylphenidate (Ritalin).

The study used official vital statistics from across the US and identified 564 cases of SUD in children ages 7 through 19. They were compared with 564 youth who died as passengers in motor vehicle accidents. Data was collected and studied for the years 1985 to 1996. Without going into exhaustive detail, suffice it to say that there is very little criticism about the methodology in this ambitious work. The control group was well matched, the methods of inquiry and verification were excellent, several confounding factors (like underlying diseases in victims) were accounted for, and the results appear to be reliable and statistically significant.
Results showed that ten children (1.8%) of the SUD group showed evidence of stimulant use (almost all methylphenidate, the generic name for Ritalin) as opposed to only two (0.4%) of the motor vehicle fatality group.

Here are some of the most fundamental concerns and questions raised by this new information:

  • The data in this study was collected from records more than twenty years ago and the newer formulations of longer acting medications (eg Adderal XR, Concerta) were not prescribed yet.
  • A statistical association does not prove causality. For instance, it is possible that the genes that code for ADHD in an individual also put that person at a slightly higher risk of a sudden cardiac event.
  • The numbers of exposed children was extremely small. Although the data showed a statistically significant difference, we need to remember that the percentages still remain extremely low.
  • In a misguided haste to dismiss medications for ADHD as unsafe, we must not forget the very high likelihood of harmful and unhealthy behaviors associated with untreated ADHD. Alcoholism, motor vehicle accidents, school failure, antisocial activity and other accidents are many times higher in adolescents who are not on medication when it is indicated.
  • This study makes people want to do something (like an EKG) before prescribing medication even though the study does not at all address whether there is any way to predict who might be at risk from the medications.
  • A statistical nugget to underscore the rarity of the problem was pointed out by Dr Laurence Greenhill, a child psychiatrist in practice in Mamaroneck, one of the lead authors in the study, and the President-elect of the American Academy of Child and Adolescent Psychiatry. It would be necessary to treat 250,000 children before one might expect to encounter SUD associated with stimulant treatment. On the other hand, it would only take treating two children with medication for their ADHD to see beneficial effects on the symptoms.


What is the current advice for kids already on medication?
Most clinicians have been alerted to the statistical increase in SUD over the past few years. The current recommendation by the FDA, the American Academy of Pediatrics, and the American Heart Association is to have a careful assessment of family cardiac history done before prescribing medication. Only when such a positive history exists is an electrocardiogram or other test recommended. For others, no screening cardiac tests are necessary. If there is any question of a family history, it should be discussed with the prescribing doctor.

Although it is fair to downplay the risks in diagnosed patients who need the medications in order to function well, it is also fair to point out to those who might abuse stimulants that every medication has risks, known and unknown. When an otherwise healthy college sophomore combines Adderal with Red Bull, coffee, alcohol, insufficient sleep and stress, any number of side effects are possible, including cardiac ones.

Monday, June 15, 2009

Two Birds with One Stone: Pregnancy and HIV?

How cool is this?

Imagine how the world could be a better place if a simple, non-invasive device could prevent pregnancy and HIV at the same time. Researchers at Weill Cornell Medical College (my alma mater!) have come up with such a thing. It is a small vaginal ring (I am not sure how similar to the popular hormonal Nuvaring it is) that is impregnated (funny word choice in this context) with non-hormonal chemicals that not only prevent pregnancy but also prevent HIV and possibly other sexually transmitted diseases. The study was published in the journal AIDS in May of this year.

Researchers note that in addition to this Two-for-One, such a method leaves the power in the hands of women who are the ones most likely to be affected by pregnancy and HIV through vaginal intercourse. If the new device is similar in size and shape to Nuvaring, the vast majority of men are not aware that a woman is wearing one in her vagina. One can only imagine the number of situations around the world where such a device could be life-saving and life-enhancing for all involved.

Thursday, June 11, 2009

Just Say NO is not enough

Today Mamaroneck High School held a day of speakers, workshops, and fun for graduating seniors. I was there because I led two workshops on "Avoiding the Freshman Fifteen". Attendance seemed good, in no small part because of the dreary weather, I am sure. But those of us who went, were lucky enough to hear Bernie McGrenahan give his rolicking routine on the perils of college partying.

Standing on the auditorium stage with only a water bottle and a mike for props, Bernie took us on a roller coaster ride through his blurry, high, highschool years and then on to college where he partied and drank excessively, and was arrested for DWI twice. His storytelling is brilliant, and people laugh, sometimes embarassed at laughing at such a terrible tale.

Bernie painfully tells about his younger brother's struggle with alcohol and depression and ultimate suicide. And about his other brother, Sean, who is mentally retarded and completely lovable. After a six month jail term for a third DWI, Bernie gave up drinking and drugs and has been clean for 21 years.

The power in Bernie's story is in its humor but also in his keen awareness of what adolescent drinking is really like. He sends caveats to kids about drinking and driving (Don't even think of it!), how to plan ahead on how much drinking to do, how to get home and with whom("No means No when it comes to the ladies") and about warning signs that they might be troubled drinkers (you cannot stick to your plan for the evening, you are skipping class, you are losing friends, you cannot stop drinking once you start, you get angry at the suggestion that you should cut down, and you lose track of what is "normal" drinking).

Bernie is spending the summer talking to the military overseas about decision making and I am sure just making them laugh and feel appreciated. In the Fall he will resume his gig at colleges and high schools around the country. His website is HappyHourComedy. I highly recommend him to any school or college administrator or counsellor trying to reach adolescents and young adults.

Tuesday, June 9, 2009

Twitter: Guiding parents and others of us in the dark

The enormous advantage to having signed up for Google alerts about all things "Teen" is that everyday a new blog or website pops up with fun, useful, new, or even ridiculous information. Today I want to share with you a site that explains Twitter and its impact on teens in the simplest of terms. Click here to access this concise article by Sarah Newton who writes the blog, Teen Coach/GenY Guide.

As with all new steps in technology evolution, there are sure to be aspects of Twitter no one has thought of that will emerge with time. If you have experience with your teens or young adults and want to share a Twitter story, please comment at the end of this post. And please don't feel hemmed in by 140 characters!

One thing I have already heard from parents in my community is how quickly a house party can go "viral" because of Twitter. Something new to be aware of!

Tuesday, June 2, 2009

Why Blog?

Thanks for clicking through to my blog. I am new at this and hope to make a small contribution to the daily discussions on line. As many of you know I have been writing in the Larchmont Gazette for many years, trying to make adolescent news relevant to a local audience. In addition I send a newsletter from my office quarterly. These endeavors will continue.

However, with more and more social networking, our world necessarily and impatiently expands into the world beyond our small communities. There are many people to hear from and there are even more listening out there.

So, why would I decide to do this? Blogging satisfies my need to teach satisfies my wish to filter the news bombarding all of us helps me focus on medical news that can help parents and professionals do a better job will contribute to my platform as I work on a book on parenting teens will hopefully add a voice of experience and reason to the blogosphere!

I hope you will join this adventure with me. Become a follower; make my blog an RSS (what is that anyway?) feed; or make it a favorite. But above all, please send it along to friends and family and COMMENT! Comment by clicking on "comment" at the end of each blog entry.

If all else fails, ask one of your children to show you what to do!

Thanks for coming along!

Monday, June 1, 2009

Parenting Teens-adjective or verb?

About a month ago I signed up for any new books or blogs on "parenting teens." My email inbox is crowded now with these Google Alerts. What has come in is most interesting and unexpected. What I was hoping to find was all news related to books on parenting of adolescents. I am getting plenty of that, including Beth Harpaz' funny book 13 is the New 18 and other things my children taught me while I was having a nervous breakdown being their mother. Check it out for a light, fun read.

But I am also getting a look at a number of publications, blogs and books that address "parenting teens"--meaning "teens who parent"! Bristol Palin's publicity for her new baby and her ironic trumpeting of "do as I say not as I do" is only the most public example of teenagers who are parenting. As of 2006, the birth rate for 15-19 year olds started to rise whereas it had fallen steadily by over 30% over the previous 14 years.

The easily accessible internet can be a tremendous resource for teens most in need of information. I will be following with interest to see where advice is coming from and how supportive bloggers actually are of these young, vulnerable parents.

Wednesday, May 27, 2009

Over the past few weeks . . .

Over the past few weeks I have been crawling and climbing up the learning curve on blogging. I have been exploring a multitude of websites and news publications on parenting teens. There are some wonderful whacky things out there. Everything from moms sharing news on diapers to true confessions about terrible parenting errors people have committed. I have discovered a sorority of bloggers at blogher.com.

In addition I am discovering how to get my self into the blogoshpere by "introducing myself" online to other bloggers. I was able to connect with a reporter who is interested in how doctors are beginning to use social media as a part of their practice,either as promotion or as a way to communicate with patients. Since I do both, I was written up in their blog.

I love that line about "limitless knowledge and a connection on a whole new level is the true power of the healthcare/social medical relationship." I have no illusions: I will never catch up to my kids or my patients when it comes to this stuff, but I feel a whole lot more savvy and linked in than a month ago!

Sunday, May 24, 2009

So we know they're drinking. Now what?

This week I hosted a group of nine local moms in my office to chat about the realities of alcohol and our kids. We talked about how the "just say no" campaign does not really appear to have worked so well. The numbers of kids drinking and the frequency and amounts consumed are remarkable, as recent surveys and my office contact with kids show.

A few random but important points emerged from our conversation:
  • The debate about lowering the drinking age back to 18 is a real one, especially on college campuses (and initiated by college administrators)
  • The culture among teens has become one of binge drinking, often with the goal being drunkenness, just shy (hopefully) of illness.
  • We need to consider carefully the value of "teaching our kids how to consume alcohol" even if that takes place in our own homes and with us before they go off to college.
  • We need to look at how we adults consume alcohol. Recent US government-sponsored programs are helping folks Rethink drinking
  • Data shows that binge drinking before age 16 increases the risk of alcoholism in a vulnerable child by eight fold.
  • It is possible to enforce certain absolutes: curfew time, checking in upon returning home; never, ever, driving after drinking; protecting friends from dangerous alcohol poisoning or vulnerable social situations;holding off on drinking altogether until at least age 16 (or more).
  • It is possible to teach some safe drinking rules without endorsing illegal imbibing. Kids should be taught to avoid alcohol when tired, depressed, hungry, angry, thirsty, sad, or alone.
There are no easy answers to this problem. But it is worth considering the merits of a "risk reduction" approach to alcohol and teens rather than avoidance of the issue or punishments that do not teach or lead to underground, even more worrisome activities. Cheers!

Monday, May 18, 2009

Dads' and daughters' discoveries

A recent study of teen sex has shown that in two-parent households, when Dads get wind of their daughters’ sex lives—especially when the girls’ self-described behavior is “risky” (“premature”, multiple recurrent partners, or poor use of birth control)--fathers ratchet up their attention.

This increased attention from Pop apparently has a measurable effect on girls’ subsequent sexual behavior. This effect is small (7% change—whatever that means in real life) but apparently deviates from previously held notions that parents look the other way or become less involved when risky teen sex is involved. The study (published in the journal Child Development, May/June 2009*) whose lead author is Rebekah Levine Coley, did not discuss how exactly Dads showed their increased interest or involvement in daughters’ lives.

Did they ground them?
Did they punish them?
Were they just "disappointed"?
Did they play more Scrabble with them?
Did they take them to a doctor and get them birth control pills?
Did they just talk to them? What did they say?

How many ways can we imagine that a Dad might react to his daughter’s “risky sex” in ways that would lead her to curtail her activity? Send your ideas to me, please!

*This article in its entirety is not available free online so I have pasted together bits and pieces from multiple on-line reviews.

Saturday, May 9, 2009

Pedal Power

How many bikes do you and your friends have rusting and gathering dust in your basement or garage? With my large family that rides, we have collected more than a few over the years. Today, at last I was able to recycle them to a cause I want to share with you. Pedals for Progress organized a collection station in the driveway of a local church. Within minutes of my arrival volunteers had de-pedaled and rotated the handlebars on my two old Treks and were ready to stack them in a UHaul to ship off to one of many countries they supply. Nicaragua, one of the nations highest on my radar screen since I worked there last year building houses with Bridges to Community, has received over 30,000 bikes through P4P.

Pedals for Progress points out that they ship more than mere bikes. A bike can provide access to a livelihood or an education for the poor of the world. And what does this have to do with adolescents? As our world shrinks to a more global neighborhood, our responsibility toward our brothers and sisters abroad is as great as toward those at home. I remember meeting teens in Nicaragua who could not get to junior high or high school because they had no transportation (or means to pay for public access to) public schools that were several kilometers away.

I urge you to check out Pedals for Progress and put your used bikes to work for others! It feels great. And saves our landfills too.

Thursday, May 7, 2009

OOPS! It's the Morning After!

Just kidding.

But actually, yesterday, May 6, was the National Day to Prevent Teen Pregnancy! The most recent US data (2007) shows that the teen (15-19 year olds) birth rate has crept upward to 42.5 births per 1000 population. Read that another way: 4.25% of teens ages 15-19 had a live birth in 2007. Not pregnancies, not sex, not abortions, not the morning after pills. Live Babies! The data does not tell us how many of these were planned pregnancies, but most child and adolescent experts would agree that the risk to the health and long term well-being to the mother(education, earning potential, physical and mental health) and to the child (risk of prematurity, abuse, learning disabilities, school problems and more) is significant in teen mothers

If you know a teen or are one, first bookmark my blog, and then check out this website:

www.stayteen.org

and take the scenario-based quiz that will test your savvy on issues of sex and contraception. If you are a teen, ask your parents to take it too! Then go back to my earlier post on sex education by cell phone and the Morning After Pill.

And I promise the next post will not be about sex!

Wednesday, May 6, 2009

National School Nurse's Day

As a school district physician as well as a practicing doctor for teens, this has been some crazy week. On some of the first days of the Novel H1N1 (alias Swine Flu) news there were nearly hourly updates in my email from the CDC, the New York State health department, the school nurses with whom I work and the superintendent and other important administrators who were working in good faith to stay abreast of the latest news. School nurses' offices bore the brunt of the onslaught as jittery parents arrived wearing masks and hundreds of anxious calls were fielded so no major individual or public health mistakes were made.

All this took place while the daily work of the school nurses continued apace: checking for head lice, listening to an allergic child wheeze, putting band-aids on minor booboos, helping a diabetic child with her insulin, referring an injury to the emergency room, and many more.

So it is fitting that this day is designated an official day to recognize the work of the school nurse. Even in my relatively well-to-do community there are hundreds of children without an accessible or available doctor who takes their insurance plan and many more who have no insurance at all. For these children (and often for their parents as well) the school nurse is the first line of information, comfort, and help.

It is my honor to work with these soldiers of public health. It is my hope that as we move into a new era of health and insurance coverage, the school will continue to be a center of community well-being and will be allowed to extend its reach and even be reimbursed adequately for its work.

Tuesday, May 5, 2009

Cinco de Mayo

Dinner time is always a time for me to challenge assumptions. So last night after watching President Obama flub the Cinco de Mayo greeting (because it was Quatro de Mayo), we began discussing what it really is. There was one vote for Mexican independence, another for the Day of the Dead and one "not sure/undecided.

Well turns out to be "none of the above. Cinco de Mayo is a regional holiday, according to Wikipedia, that celebrates the 1862 victory of a poorly armed, small Mexican army from the state of Puebla against the French military who were widely expected to win. Sounds like Hannukah and the Macabees to me!

Although it is widely celebrated in the Mexican diaspora in the US, "Cinco de Mayo is not "an obligatory federal holiday" in Mexico, but rather a holiday that can be observed voluntarily," according to Wikipedia sources. Wouldn't it be nice, since so many in Mexico are still quarantined from public places and staying home to prevent the spread of H1N1 influenza, if the government would just declare it a big day of fiesta and allow el pueblo to let its hair down. A sort of Passover, come to think of it, for those who have come through this plague that, so far anyway, isn't one. Masks or no masks, Feliz Cinco de Mayo!

Sunday, May 3, 2009

Sex Ed by Text

Today's New York Times Style Section (why does most news related to teens seem to appear in this section?) has a lead story about a pregnancy prevention program in North Carolina. What makes this program different is that teens can anonymously text a query to a Text Line and within 24 hours, often faster, they will get a reply from a trained, live counselor.

Brilliant. Kids don't get complete sex ed in high school (in North Carolina schools are mandated to teach an abstinence-only curriculum);they forget what they are told in class; they make dumb mistakes; they have a hard time talking with parents; and devour any opportunity to talk privately and confidentially to an adult (no question is off limits in my office and I am amazed at what kids need to know).

Not without controversy. Those who would rely on abstinence only education prefer to do their teaching at home and not lose control to a cellphone! Data unfortunately shows that this tack has not been working too well, both in terms of the knowledge imparted (values and plumbing both get short shrift) and in terms of prevention of unwanted pregnancy.

From my opportunities to chat with parents about teen sexuality and sexuality in general, I would say someone should start a hotline like this for ADULTS!

Friday, May 1, 2009

FDA Approval of Plan B for 17 year olds

For the past two years, Plan B or the Morning After Pill, has been approved as an over the counter medication for use by women and can be purchased over the counter by men or women over age 18 with ID. For young women under 18, a prescription is necessary in addition. There has never been any scientific doubt as to the safety and efficacy of the medication for women under age 18. The current policy was agreed upon by the Bush administration as a sort of compromise between the medical and the conservative communities.

However, now it appears the FDA is set to extend approval of its sale over the counter to women (and men) 17 and over. What difference does a year make? Let’s look at the CDC data from the 2003 National Youth Risk Behavior Survey (an enormous study that polled almost 200 high schools across the country. According to my back-of-the-envelope calculations, there are approximately 12 million teens who are sexually active between the ages of 17 and 18. If we consider that only about half of all episodes of intercourse in this age group are protected by a condom we can see that there are literally millions of moments when a morning after pill could be a wise choice.

Of course, better to use a condom each and every time since nothing protects better against STDs.

Thursday, April 30, 2009

Swine Flu and You

What kind of doctor would I be if I didn't blog about Swine Flu today? There is so much information out there, streaming in from the radio in my car, the television on the kitchen counter and from multiple sources in my email. In the interest of keeping this simple, here are ten basic facts worth understanding:

1.There are two important issues: contagion and virulence.

2.Contagion (how readily the virus can spread) is clearly in play here. We know that this new Swine Flu virus has emerged in dozens of countries. It most likely will emerge wherever there are humans. The rapid emergence of the virus in many different places in the world accounts for the WHO's increasing the alert to a Level Five yesterday.

3.Virulence(or the severity of disease) of this microbe is still unclear. Although the mortality rate for Swine Flu in Mexico is over 10%, the data so far in the US and elsewhere do not bear this out. Perhaps there have been many more undiagnosed cases than were tested. Obviously this would increase the denominator and lower the mortality rate.

4. It is quite possible-but not known for sure yet- that for most people this Flu will not be more severe than the regular seasonal flu.

5.The seasonal flu vaccine is not effective against the Swine flu as far as we know.

6.The drugs that can be used to treat swine flu should not be used preventatively unless a clear diagnosis of the new virus has been made or there is a high likelihood that it will be. Health departments have clear guidelines about this. Although some pharmacies seem to be out of the drugs, there is a huge amount in the US government's stockpile.

8. Preventative treatment --say after exposure to a person with fever, but not diagnosed with Swine Flu or merely to "prevent" contracting the Swine Flu is not effective, advisable or even ethical. We all bear some responsibility for the judicious treatment of these cases and preserving the drugs for those who really need them.

9.Inappropriate use of the anti-viral drugs will only increase the likelihood of this Flu Virus becoming resistant to the medications we have.

10. What can we do to prevent the Flu? Wash hands frequently and well. And sneeze or cough in a conscientious manner: into the bent elbow without "aerosolizing" the spray.