Thursday, June 30, 2011

Prescribing exercise


from the American Trails Organization
 As most patients know, doctors are slowly (and often reluctantly) moving over to the mandated electronic medical record systems.   Being one of the reluctant ones, I must confess that the great advantage of the EMR is the ability to call in and track prescriptions for patients.  I know for instance if a patient is filling a prescription and I can be sure that the prescription is legible and actually received by the correct pharmacy.

So what to do with all those pre-printed prescription pads?

I recently discovered that I can write prescriptions for exercise and patients take the recommendation more seriously.  After all, I explain, exercise will often get you healthy as much as an antibiotic or a diet.  And we know that it prevents all kinds of diseases and ailments including heart disease, diabetes, cancer and arthritis.

For an overweight person who is not exercising I now recommend my own version of "interval training" which according to the Mayo Clinic simply means this:

It's not as complicated as you might think. Interval training is simply alternating bursts of intense activity with intervals of lighter activity.

Take walking. If you're in good shape, you might incorporate short bursts of jogging into your regular brisk walks. If you're less fit, you might alternate leisurely walking with periods of faster walking. For example, if you're walking outdoors, you could walk faster between certain mailboxes, trees or other landmarks.

I will start with a simple prescription for twenty minutes of walking three times a week.  I suggest making the 10-15 minute period in the workout very fast paced or up a hill or set of stairs.  How do you know if you are working intensely enough? Simple.  Push yourself for those five minutes until you are out of breath and cannot carry on a conversation with an exercise partner.  Then spend the last five minutes cooling down.

Benefits:
  • increased aerobic capacity
  • mental health benefits
  • increased ability to keep up
  • urge to exercise sets in (after 2-3 weeks)
  • possible weight loss
  • improved tone
One exercise I love to recommend is that folks take their bikes on the Rails to Trails paths.   These are restored railbeds all over the country, including several miles of them in Westchester County where the grade is rarely over 5 degrees and there are seldom cross streets.  It is possible to do interval training at a rapid pace just by going faster without the fear of traffic.   One of my favorite trails crosses the Croton Reservoir.   Out West, the American Parks association is promoting Park Prescriptions, the same idea of exercising but they are marrying this salutary habit to national parks where the trails can be fantastic and fun.
Happy Fourth of July and Happy Trails!

Thursday, June 23, 2011

What Would Help You Quit Smoking?

This week the FDA announced that it would require cigarette manufacturers to display graphic photos of the dark side of smoking tobacco on the top half of all packages. 

Now if this:

and this:




aren't grotesque enough, could this possibly have more impact?:

“These labels are frank, honest and powerful depictions of the health risks of smoking, and they will help encourage smokers to quit, and prevent children from smoking,” said Kathleen Sebelius, the secretary of health and human service in a statement at the time of the release of the new policy. Really?


The FDA claims to have done its research and come up with these "scientifically" proven methods of discouraging use.  But the problem I see with kids and teens smoking is that many of them never see the pack.   According to Marketplace, a public radio sponsored website, a pack of cigarettes in New York now costs over $10.   That's around the hourly rate for suburban teenage babysitters.  So you can imagine that it is unlikely that most smoking kids actually buy a pack.  What they do is share and sometimes buy one cigarette at a time from a friend or supplier. 

So what could the FDA have imagined as a more likely way to reach smoking youth?  They could require manufacturers to actually write on each cigarette paper itself.  "Do you really need this cigarette?"  "Could you think of another way to spend a dollar?"  Or how about a sort of measuring tape printed (in organic harmless ink, of course) that might say: "Stop now and kill this butt."

I'm open to suggestions but the point is that each and every stick needs to be a warning or reminder or encouragement to stop.   Data shows that over 85% of teens who smoke wish they could quit.  With all of the research, I wonder how many FDA scientists were hanging around the designated spot at the local high school where kids smoke with impunity and adults seem to turn a blind eye.

Maybe we should ask the kids how to help them quit.     If you know a smoker, try asking him or her.  I am not sure the FDA did that.

Monday, June 20, 2011

Graduate, But You Don't Need to Leave!

Not a day goes by without a blog, email, listserve post, journal article or query in my office about how best to transition older teens and young adults to "adult" medical care. This is especially of concern for patients with special health care needs, or SHCN, the acronym that is currently in vogue. SHCN include medical diagnoses such as diabetes, cystic fibrosis, and congenital heart disease; emotional illnesses such as depression, eating disorders, and anxiety; and developmental disabilities such as autism spectrum disorders, mental retardation and learning differences.

Last week the New York Times published an article   by Perri Klass, a Boston pediatrician who frequently writes about current medical topics, called "The Graduation that May  Carry Unnecessary Risk" referring to graduation from the pediatrician with nowhere to go and no help in transitioning. 

This article is woefully lacking in understanding of what Adolescent Medicine physicians do.  As a board certified specialty, adolescent medicine physicians fill exactly the role that Dr Klass is calling for.  In her article she gives parenthetical mention to adolescent medicine physicians as managing reproductive concerns but fails to mention that most adolescent medicine physicians are trained to and capable of --and actually enjoy--caring for the special needs of all patients as they age up. This includes primary care, psychological counseling for the patient and the family and communication with the myriad of specialists involved in complex care.

In my practice in White Plains, not only are we committed to this transition (up to age 26) but we are organized physically (with a separate space for teens and young adults) and medically (with board certified care available for all older patients) to respond to this growing need.  As the waiting rooms of internists fill with the aging population, young adults--especially those with SHCN,  require a comprehensive program that can address all their concerns. We have that, right here.

Sunday, June 12, 2011

The most unwanted souvenir from travel abroad


As a frequent international traveller, I have been giving guidance, advice, immunizations and  prescriptions to  my patients and families for some time.  Because I am a licensed yellow fever vaccine provider I often hear from patients planning trips beyond western Europe.

Now, however, we hear of outbreaks of measles in France and other European countries.  This year alone, there have been over 5000 cases of measles in France.   Most of these occurred in children who were not vaccinated at all or were inadequately vaccinated against measles.  Measles is not a mere nuisance of childhood.  It often involves significant illness (that would definitely ruin a vacation), potential for hospitalization and a non-negligeable mortality. Pediatric News (available here with free signup) reports that in January and February of this year there were 28 cases of "import-associated" measles in the US.  Patients had either traveled abroad or were exposed to someone who had.

Generally speaking the target group here is infants less than a year of age who have not yet had the recommended vaccine, typically given right after the first birthday.    It is now suggested that these infants be vaccinated before a trip abroad (except to Canada and Australia) and then again once they are over 12 months of age. If you have friends or family traveling with young children be sure to remind them to look up the current recommendations and take them to their pediatricians who may not be aware of the current practices given the recent outbreaks overseas.

Most teenagers and young adults have been fully vaccinated against measles.  However, a surprising number of patients have not been fully vaccinated against measles often by parental choice.  Sometimes this involves a religious exemption to required vaccines.  Sometimes there have been concerns about safety of the vaccine (Did it cause autism?) and these concerns have never been addressed and updated since new research has overturned this theory. If I see patients like these who are now over 18 and responsible for their own health I will have a conversation about risk and benefit, especially if they are going abroad.  After all, the risk with measles (and other illnesses like pertussis-whooping cough) is not just to the patient herself but to vulnerable people in her midst.

image from bluedeerhealing.com

Thursday, June 9, 2011

"Stepping Away"

Suffering from a broken heart?  Missing your classmates already?  Worrying about college? a job?  Life in general?  Feeling in love?  Sensing the urge to write poetry? Keeping  a journal?


This week's New Yorker magazine treats us to a feature called  "Starting Out" that showcases five wonderful short autobiographical pieces by authors who recount or recollect what it's like to be an adolescent or a young adult.  When they are supposed to be on the brink of bigger things and moving on or out or up, they are sometimes confused, dejected, rejected and bewildered.

Jennifer Egan in "Archeology" writes about spending a gap year and working as an archeologist for a while to satisfy and dismiss a passion. In less than a page, Junot Diaz writes in "The Money" about understanding his neighborhood and the moral revelation afforded him by a theft.  Tea Obreht tells us in "High School Confidential" about the ignominy (and the lessons) in having her written word mocked and disrespected. 

"Where I Learned to Read" by Salvatore Scibona is a funny one-pager about a near high school dropout who is turned on to the esoteric and exceptional Great Books program at St John's College, always an intriguing school on the early lists of a few of my children. 

Finally, in "Shacks," and in very few choice words, Edward P. Jones conveys the pain of having his letters ignored by his love interest, Sandra.   But he also conveys the strong allure of writing when he says: "I don't know what I would have done if I hadn't had it in me to write those letters, those stories, to Sandra."  Writing is a tool, he says, that helps to create a little shelter, or shack, that we can inhabit, however briefly. 

One of my favorite writers, Jhumpa Lahiri, tells us in "Trading Stories" ( in another section of the magazine) about her own development as a young writer and what the craft did for her:

"...writing is one of the most assertive things a person can do.  Fiction is an act of willfulness, a deliberate effort to reconceive, to rearrange, to reconstitute nothing short of reality itself."

There are many situations and emotions that draw us to the keyboard or paper.  For teens and young adults, often awash in emotions, life changes, uncertainty and possibility,  writing is a way for them to center themselves and to try on or explore intense feelings. In these uncertain economic times, writing can be a life saver and serve a therapeutic purpose.  But it might also just be the start of a career.

image from Googleimages. com

Friday, June 3, 2011

A Piece of the Pie


Don't miss that phrase:
"We Specialize in Pharmaceutical Catering."
More about that in a bit.

My office building is a four story modern one that is essentially all medical offices.  A real goldmine for pharmaceutical drug reps.  They can park once and do what they do best--peddle their pharmaceuticals to busy doctors and their staff.  One might ask how, in these times of shortened and harried office visits does a rep expect to get the attention of the ultimate prescriber.

  This was made slightly more difficult by a two year old movement spearheaded by PhRMA, a drug company trade group with an eye to cleaning up their act and not appearing to be bribing doctors.  According to a 12/30/2008 article in the New York Times,  the pharmaceutical industry "agreed to a voluntary moratorium on the kind of branded goodies --Viagra pens, Zoloft soap dispensers, Lipitor mugs — that were meant to foster good will and, some would say, encourage doctors to prescribe more of the drugs." So the pens are gone. In fact there are doctors who proudly display their pen collections as historic mementos of a time gone by.   But there are still plenty of opportunities to influence and cater to doctors.

DR Caren and his Pharmaceutical Pen Collection
And that's where the pizza comes in.  Staff lunches for several hundred dollars, including many different types of pizza, salads and drinks are commonplace in offices, unless they are actively forbidden and stopped.   There are frequent invitations to free dinners at nice local restaurants with compelling speakers on topics that are not even necessarily related to the drugs the company sells.  Some companies make it more subtle than they used to.  After all, it defies one's commitment to science and purity to admit that one might be swayed by a fabulous prix fixe menu (of $0) where the fine print at the bottom says "Merck." 

Fortunately there is another voice out there.  The website NoFreeLunch is dedicated to the principles that I was raised on as a resident at Babies Hospital (part of Columbia Presbyterian) under the often austere chairmanship of Michael Katz, MD who did not allow drug reps in the building.  If we heard "GI Rounds" on the overhead PA, it was not so that we could be regaled with "pharmaceutical catering" but to be invited to bring our own lunch and discuss a case of gastrointestinal disease. (I know, I know, doctors can do really gross things while they eat.)

There is ample evidence to suggest that doctors are indeed influenced by these friendly, apparently collegial overtures.   But doctors can and do make the pledge not to participate in this insidious enterprise.  From No Free Lunch comes this pledge:

"I, __________________, am committed to practicing medicine in the best interest of my patients and on the basis of the best available evidence, rather than on the basis of advertising or promotion.   
I therefore pledge to accept no money, gifts, or hospitality from the pharmaceutical industry; to seek unbiased sources of information and not rely on information disseminated by drug companies; and to avoid conflicts of interest in my practice, teaching, and/or research."

No Free Lunch invites doctors to participate by emailing the pledge to Pledges@nofreelunch.org.  Encourage your doctors to do so.  I did.