Saturday, March 26, 2011

Introducing Cancer Survivors New Normal with Dr. Linda

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Dr. Linda as we know her is introducing her new video blog series that focuses on cancer survivors and the "new normal" that occurs after a cancer diagnosis. No one, I repeat no one can know what it's like to have cancer more than Dr. Linda Timmerman. She is a two time cancer survivor and a life long educator. Plus, she understands the pain, terror, and crisis that people feel when cancer enters their lives. Please help me welcome Dr. Linda to

Wednesday, March 23, 2011

When health care research meets Trip Advisor

This is the time of year just after spring break when I enter the stress zone of planning the summer vacation.

I'm always on the quest of making everyone happy.

Finding some place that I can afford, where the kids will have fun and maybe get to experience something new, is always a challenge.

So, I search the internet far and wide for good deals and destinations.  One site that I always check out is Trip Advisor.

This travel website is populated with information on hotels, resorts, air fare, deals, and even food and restaurants.  But the heart of the site is the traveler reviews. These often number in the hundreds depending on the location and are many times candidly verbose.

Visitors can even give a score which is tallied at the top of the review to help you sort through the list.

So what does that have in common with health care research?

Well, frankly, if you relied completely on Trip Advisor you probably would never travel any where.

Let me show you what I mean.

Last year I thought I planned the perfect vacation (turned out, I did according to the family).  We used every (I mean, every) frequent flyer mile I had and the four of us traveled to Kona, Hawaii, one of the most beautiful and mysterious places on earth.

We stayed at the Fairmont Orchid in Kamuela which is on a  grand beach on the west side of the Big Island.  The grounds are impeccable, the staff is always at your beck and call, and virtually every room has a nice view.  I'm a member of the President's Club so the kids were able to get free internet as well as discounts on beach gear.

From the turtles that lounge on the beach to the prettiest sunset in the world, I could live there. 

Now to Trip Advisor:  here are the top reviews currently --

"I have to say that while we love the Fairmont, the level of service has become uneven, if not somewhat mundane."

"The service was average - long waits and average staff at breakfast. Room was nice, but dated. I saw three cockroaches in the hotel. The grounds were lovely but the overall experience was not worth the cost."

"For the price of this hotel, the room was a disappointment. First of all we were on the bottom floor, with people walking by constantly, so there was very little privacy. The bathroom had dust and dirt on the shelves, and the wall was filthy. There were 2 moldy pictures beside the bed..."

The take home message here is that each person has their own experience, and it is impossible to make everyone's stay perfect. 

We live in a society where expectations often exceed reality.  There is just no way to make everyone happy and provide perfection no matter how much you strive for this level. 

That brings me to health care. 

I recently had a lengthy discussion with someone regarding online treatments for a medical condition.  He had done considerable research, wanted to know the ins and outs of every perturbation of treatment, and why some people reported good results and some did not.

He finally wanted my opinion, and wanted me to weigh in on making a further review of these treatments and these patient experiences.

He just couldn't understand why some patients didn't report perfect results with at least one treatment.

I told him that unfortunately it doesn't work that way.  Every patient will have a different experience with virtually every treatment or procedure.

Sure, there is an "expected" outcome.  But we are dealing with a human body that is dissimilar from every other one on earth.  You just can't expect similarity.

But to even be more accurate, we are dealing with humans and their own expectations of what a successful outcome should be.  And that is even more challenging than the biophysics and physiology.  Humans rarely agree on anything.

So the take home message here is that research on medical procedures and treatments can be very valuable, but you should always take into context the individual nature of the reviews.

Otherwise, you would never travel anywhere, and you would never make a health care decision that could improve your life.

Sunday, March 20, 2011

The Blurry Line: When non-physicians practice medicine

It used to be that there were well defined roles.

Pharmacists dispensed medications on the order of a physician.

Nurses carried out care and healing as ordered by a physician.

Physical therapists helped patients heal their bodies on the order of a physician.

Physicians practiced medicine.

But that's all changing.  There is a hurrying pace to expand the scope of practice of non-physician providers to include elements of medical practice. The purported reason is the lack of availability of primary care physicians and access to care.

But, honestly, like almost all things in America, it's really not that altruistic.  It's about money of course.

And since it's about money, I've always been curious about the public's willingness to pay for information, time, or care from a non-physician provider at the same rate as if they were paying for a physician.

And when the stakes are high, like with your own health care, it looks like most people would only want the "best."

Now before I start getting hate mail or malicious tweets from the host of non-physician providers out there, I'm sure there are some in that group that practice good nursing, pharmacy, physical therapy, etc.  That's not what this is about.  I'm talking about medicine.

I'm sure if the airlines decide that airplanes have become sophisticated enough that flight attendants can be cross trained first as copilots and eventually as pilots, then the issue will become clear.

Someone once told me that to get hired by Southwest Airlines as a copilot in a 737 that it required 2000 hours in type and experience as pilot-in-command.  This is a hefty requirement but probably why the airline has one of the best records in the industry.

Now if you were to train a flight attendant with a fraction of that time, let's say 200 hours, would you feel as comfortable in seat 6B?  Even if your flight was on-time, everyone was friendly, and you had peanuts and a drink coupon?

But the analogy fits very well with medicine.

Let's take nursing:  its become somewhat politically incorrect to consider nursing any longer as a support role in health care.  There has been considerable growth in the industry in the role of becoming primary care givers.

Many states leave the determination of the scope of practice to the state nurse licensing boards which gives them broad latitude in defining what nurses can and can't do.

Much of this depends on the definition of the "practice of medicine" which has always been understood as the "diagnosis and treatment" of disease.

So nursing boards have morphed a term now to include the title: nurse practitioner, or NP.  These "advanced practice nurses" usually have expanded training, mostly from other advanced practice nurses  and some physicians, in the area of diagnosing and treating basic ailments.


I say supposedly because there are very few if any statutory limits on these advanced practice nurses.

Think for a minute that it might be one thing for a flight attendant to fire up the plane and taxi out to the runway, but it would be quite another to take off into the fog and rain of a messy evening.

So these APN's go into practice and begin to practice surrogate medicine.

The confusion abounds with patients who don't always know the difference from one provider to the next.  They just know their little girl has an ear infection and needs an antibiotic.

These lines even get blurrier when programs begin to offer "Ph. D." course work in nursing which then entitles the person to be referred to as "Dr. APN." Patients become confused:  just who is a "doctor" any more?

Now most of these non-physician providers are supposed to be either supervised by a physician or they are to practice under specific guidelines drafted and overseen by a physician.

But it is clearly not the same as having a physician see the patient or being immediately available for consultation.

(Think for a minute:  that flight attendant could always radio in for help....if they were to get into trouble...)

Many physicians like using non-physician providers of care because it increases through-put and therefore revenue for the practice.  These environments often deliver superb care in a team environment managing complicated patients.

Physician's assistants are one of the best examples of how the system can work well.  Usually these mid-level providers train directly with physicians, are regularly supervised, and have academic backgrounds that ground them in the basic science of medicine.

This type of preparation and apprenticeship is often lacking in other non-physician provider training programs.

But when advanced practice nurses want to open up a clinic and begin to practice primary care medicine, you really have to wonder if this is a good idea.

It's a slippery slope where most of the time no one gets hurt.

Pharmacists in many states can now give vaccinations and maybe even adjust the dose of someone's insulin to treat their diabetes.

Physical therapists may be able to diagnose a knee strain and begin corrective exercises and rehab.

Advanced practice nurses may be able to diagnose a sore throat in a 3 year old and start antibiotics.

So where does the slope end?  Despite the fact that medicine is becoming even more technical, the number of drugs is expanding at an unbelievable rate, and patients are generally sicker now than in the past (particularly with the economy challenging access to preventative health care services), there is a growing feeling that we need more non-physicians delivering health care.

And because of the purported need for access to primary care, legislatures are changing the statutes and regulations to expand the scope of practice of these non-physicians.

Physicians in the United States on average have completed a four year basic science undergraduate curriculum, four years of medical school, and typically 4 to 5 years of post graduate training in an internship and residency.

Most advanced nurse practitioners complete about 5 to 6 years of training total -- at least of three of which is spent solely in nursing.

So can a legislature obviate the need for medical school just by changing the law?  Of course not, but that is what is happening in many states around the country:  nurses, and other non-physician providers, are seeking independent practice.

This independent practice would remove even cursory physician supervision of their treatment of patients.

If lowering the standards was all that was necessary,  then one solution for the crisis in primary care access would be to shorten the requirements for physicians going to medical school.  I know, that's absurd.

With the technological advances in medicine and particularly surgical procedures and medication treatment -- the course of study cannot be condensed.

But to complete the tale of a story gone wrong, many advanced nurse practitioners never practice primary care. Instead they take up the practice of aesthetic medicine such as treating patients with cosmetic drugs like Botox or lip fillers.

To be fair, all of these non-physician providers in the proper setting offer advantages in our current health care crisis.  Working in a team under the supervision of a physician, health care delivery can be enhanced, access can be improved, and patients can get better service.

There is no better example than that of physician assistants.  This relatively new type of non-physician provider is probably the model that needs to be followed in expanding the scope of practice for medical providers.

Physician assistants usually complete a six year curriculum and even then there is typically a post graduate practicum or   on-the-job training program directly with a physician.  These professionals work hand in hand with physicians in caring for patients, have privileges to write prescriptions and perform some surgical procedures, and can help the physician in coordination of care for the patient.

In most states they are even supervised by the physician licensing board.

But as a rule, they don't have independent practice.  It is the perfect model to expand access of quality care.

Now, I'm usually a self-described progressive, and I'm always open to new ways to educate and treat patients.  But the last thing I want to do is to put patients in harm's way.

We shouldn't allow the access argument to blur the lines of right and wrong so much that we allow the training of our health care providers to be diminished.

If you want to practice in a support role working hand in hand with a physician to provide quality care, I'm all for it, and will work and lobby to make it happen.

If you want to practice medicine independently, then go to medical school.

Saturday, March 19, 2011

My skin cancer script: what I tell patients 40 times a day on how to recognize skin cancer

Moles are like stars.

And patients are like constellations.

And the number of these lesions is like the number of stars in the universe.

There is no way to see every mole, document every mole, or even have every mole examined by a dermatologist.

So patients play an important role in skin cancer diagnosis and recognition.  Teaching and educating patients on discovering these lesions is essential.

We have to make melanoma astronomers out of our patients.

So here's what I say:

1) "The most sensitive sign for a melanoma is a mole that is changing in size and color -- not specific, but sensitive.  So call me if you see a mole you are concerned about that is changing in size or color."

2) "Look for 'ugly ducklings.' That is, don't focus on your moles as individual lesions -- rather look at them as a group.  Look for moles that are ugly ducklings and don't look like their neighbors.  If you see one of these ugly ducklings, then bring it to my attention."

3) For non-melanoma skin cancer:  "You don't need to see me every time you get a pimple.  But if you get a non-healing wound or sore that lasts longer than six weeks, then we probably need to take a look."

The three steps are simple, but they represent good advice in finding skin cancer, particularly melanoma, early.

Friday, March 18, 2011

Your health records: more like a blog, or more like Twitter?

For over a decade I traveled 30 miles south to a rural clinic along I-45 in Fairfield, Texas. There I met one of those physicians that people always think of when they think the word "doctor."

Dr. John Keller is a community icon.

Born south of this small town, he practiced medicine there for over 50 years. Now he's retired, and the community is at a loss.

Though certainly not the cause, his retirement coincided with the roll out of a new electronic medical record, or EMR (sometimes AKA EHR).

This reminded me of a story from Dr. Keller that he related to me over a decade ago. He told me that when he first went into practice records were kept on 3"x 5" note cards.

As someone who has served in various administrative capacities over the years, I've always remembered Dr. Keller's initial non-electronic medical record. And I suspected that his care was super, despite the limitations of space on that card.

Today, EMRs are becoming more and more common. There is still significant resistance from some physicians because of the lack of a unified national standard of connectivity.

That is, one system still can't talk to another.

Plus there is the cost of implementation. Some estimates put this near $60,000 per physician in a practice.

In this day of declining reimbursement it's hard for many medical practices to take the plunge and invest in this new technology.

Plus there is the whole slew of resistance remarks that range from "it'll slow down my productivity," "I'm too old to learn," "there isn't one for my specialty," and on and on.

Personally (albeit I'm a self professed techno-nerd) I haven't seen any of these problems.

We use a nice cloud based system from AthenaHealth which allows us to limit our on site technical requirements and back up, is constantly up to date, and can be accessed anywhere. Patients can even log in to check their test results, pay their bill, or ask me a question.

The electronic prescribing is phenomenal. I haven't written more than a handful of paper prescriptions in a year or so.

But even with all this technology, I'm not sure that we practice medicine any better today than Dr. Keller did fifty years ago. We just document a whole lot more information.

But is it useful?

We're pretty good at not generating a ream of electronic information every time a patient comes in. Some EMR systems accomplish this task (conventional wisdom is that it might help with coding and therefore reimbursement).

But, we chart way more than Dr. Keller ever did. I hope it's still pertinent to our patients complaint.

What's amazing to me is that as we have advanced in our technology we have become more verbose in our ability to describe it.

You could say that we are "health care bloggers" in the patients' medical record.

Whereas Dr. Keller was more like Twitter. He kept his comments to probably less than 140 characters -- and he did just fine.

So Dr. Keller may have been ahead of his time. Maybe we should "follow" him.

Tuesday, March 15, 2011

How a dying child tells his parents he's ready to die

My good friend and Fort Worth pediatrician Gary Floyd relates this telling story about working with a family through the death of their child from cystic fibrosis.  Gary's story is compelling, really...downright tear jerking.  This video is part of a series from the Texas Medical Association that began as project from their creative social media guru Steve Levine.  Check out other videos from that series here.

Injections: Does hurting children now, hurt their health care decisions later

For a long time I ran a large multi-specialty group medical practice in a relatively small town. One of our most active divisions was pediatrics.

Ruby was a nurse in the department for almost 30 years and she had seen probably half the community's children grow into fine healthy adults.

But one day I ran into Ruby at the local Walmart about the time that a group of small children rounded the corner. I also stopped to visit with the nice lady.

The children, though, turned, ran, and cried to their mother.

Ruby commented to me that this was a common but unfortunate occurrence for her.

She was the "shot lady."

Hypodermic injections are one of the earliest memories that children have about health care. In fact, if you ask a young child about the necessity to go to the doctor, the child (and many adults as well) will respond, "I don't need a shot."

Physicians, nurses, and mothers over the years have devised a whole host of tricks to encourage children to get the needle.

Bribery is a favorite of mine: "we'll go get ice cream," "we'll stop on the way home and ...", or the most recent experience for an 18 year old in my office -- "we'll stop at Nordstrom's and get your makeup done."

Threats seem to work for some children. It usually is a threat about "worse pain" than the actual injection. If children are old enough to reason even a little, then the fear of being beat with a belt is usually enough to motivate one for the measles shot.

But it doesn't always work that way. A couple of years ago a father threatened to whip a 14 year old in my office if she didn't submit to an injection.

(Just for the record, I'm opposed to corporal punishment.)

Some nurses and parents are particularly good at trickery. Either there is a ruse on coming to the doctor in the first place ("mommy is here to see the doctor" only to find out that "little Johnny is getting a flu shot"), or my absolute favorite: "this won't hurt a bit."

Well, it never hurts me.

Sometimes health care workers can't bring themselves to completely lie about the pain, so they'll compare it to something more familiar and hopefully more palatable.

Like a bee sting.

That one always makes me calm down.

"Yes, it will feel like a small furry creature is inserting a stinger into your skin and blasting poison away."

You're calm now, aren't you?

Brute force is sometimes an option, particularly if it's a young child.

There is a device for young children called a "papoose board" which is a politically correct way of saying "straight jacket."

Children are strapped in the device which has various holes and openings that allow physician or nurse access to desirable locations -- like those for an injection.

This isn't effective when children get above three or four. They are just too strong and our staff and parents are too weak.

Attempts are sometimes made with this modality and usually everyone ends up in positions that would rival team wrestling at the Dallas Sportatorium.

Negotiation is sometimes employed, with very mixed results (usually followed by one of the items listed above.)

You see with injections there's really no "compromise." So negotiation is doomed from the beginning.

You can't end up only "injecting the needle a little bit" or using a "very small needle" or avoiding the injection altogether -- which is the only solution that most children will agree with.

But in the end, most children are traumatized in some way by the experience. I'm not saying that they shouldn't be receiving injections, rather I'm just saying most children leave with short-lived tears and long-term fear of physicians and going to the doctor.

So the question is does this affect their desire to go the physician later in life for regular, and possibly preventative health care?

Particularly if the primal image of your first health care experience is clouded with pain.

Do you put off the flu shot? The breast exam? The prostate exam? Just your annual physical because of some underlying deep seated sub-cortical negative early experience.

I think many patients do.

Going to the doctor is often a painful experience. Some things just hurt.

But I do believe that anything that physicians and nurses can do to mitigate the pain has a positive effect on that person's future health care decisions.

I like to compare it to swimming. As a scuba diver and water lover I think it's essential for children to learn to swim.

Aside from the obvious reason that it helps to avoid drowning, it also opens up a wonderful world of water sport experiences that otherwise might be avoided.

Children who are taught to not to fear the water, but learn how to interact with it in a positive manner -- playing, floating, blowing bubbles -- usually learn to swim quickly.

Their fear is gone and what comes with it is a learning that water can be safe.

Health care is no different for children.

If they are taught that physicians and nurses shouldn't be feared, then the overall calm atmosphere raises the pain threshold for the children.

Anxiety is the biggest cause for most pain. Children, and even adults, have "fear of pain."

Teaching patients and especially children that pain does occur with procedures but you are there to help them with it can go a long way to prevent an adverse outcome.

Of course, some children are just too small to be able to understand, or they carry with them feelings and fears from other providers into the office. In that case it's, of course, more difficult.

In our office it  is important to me that children have the least pain possible and the most positive experience. If we can find a less painful solution, we try to do that. If it's impossible, then we explain the procedure, and the pain, and we work with that patient to make it as comfortable as possible.

I would love to hear from parents and providers on their ideas and solutions to creating positive interactions with children and painful procedures. I'm sure I have a lot to learn.

And I don't want children to run away crying when they see me at Walmart!

- Posted using BlogPress from my iPad

Location:Dallas, Texas

Sunday, March 13, 2011

When Cancer is a Family Affair

By Linda Timmerman, Ed.D.

According to a report from the CDC, there are nearly 12 million cancer survivors in the U.S. today.

That's 12 million people seeking "new normal" in their lives. Twelve million journeys. Twelve million stories.

Every cancer survivor is an individual, and no two journeys are alike.

My family of cancer survivors is a microcosm of those 12 million courageous souls.

My 86-year-old Dad approached his diagnosis of bladder cancer some 20 years ago the way he has always approached life: philosophically and through scripture. Ask about his cancer and he'll respond: "It happens. My God is in control, and I don't worry about it."

He does, however, think deeply about his cancer.

Shortly after he had completed his three-year maintenance protocol of BCG (Bacillus Calmette-Guerin, an inactivated form of the bovine tuberculosis virus that is instilled into the bladder to elicit an immune response), he called me and asked, "now that my treatment is over -- do I tell people I HAD cancer, or do I say I HAVE cancer?"

He's deeply interested in knowing how he got bladder cancer in the first place: he was a smoker for a number of years, but hadn't smoked in over 25 years when diagnosed. He was a dairy farmer exposed to pesticides and chemicals virtually every day.

Truthfully, it was Dad who found an article about BCG in Reader's Digest in 1991, took it to his urologist, and said, "they say this is a fairly new and promising treatment for bladder cancer -- can we try it?" It worked for him -- he's been in remission almost 20 years.

Today, BCG is still the gold standard for immunotherapy for bladder cancer.

Dad spends hours pondering the fact that I, his only daughter (who is still 16 years old in his mind), has bladder cancer and that having a first degree relative with bladder cancer is a risk factor.

"How did I pass that on to you?" he'll ask. Is there some test your children can take to see if they carry the gene?

My Mom, on the other hand, approached her journey with fear and trepidation. Mom is the official family worrier. She called me one day to say that she was so worried, "things are going so well, I just know something bad's about to happen."

Mom thought her lung cancer diagnosis meant certain death.

She grew up in that era. She and I were both there when her mother, my grandmother, died -- drowning in her own fluids from breast cancer that had metastasized to the lungs.

Mom didn't know many survivors in her life.

Mom never came to see me when I was undergoing treatment for breast cancer. She just couldn't. And  I completely understood.

To this day, Mom can't believe that her cancer is gone. "All they did was remove the upper left lobe of my lung," she'll say. "The doctors say I didn't need chemo. It'll probably come back."

She has to worry. I completely understand.

My husband approaches his cancer stoically. He has had three melanomas, but rarely talks about it and doesn't want anyone to "make a big deal" of it. He has a skin condition that requires him to use ultra-violet light therapy weekly. It has to worry him that he exposes his skin to UVB light, but he does it without complaint.

He is vigilant. He visits his dermatologist regularly and uses sun screen religiously.

He and I faced our biggest fear two years ago when his daughter, my step-daughter, was diagnosed with a liposarcoma in her leg. This was different for our family: she was too young, and the mother of young children.

The biopsy was clear, but pathology on the very large tumor showed that approximately one-third of the mass was cancerous. They couldn't remove all of the tumor without removing her leg.

She is teaching us how to use humor to cope. She respects the disease, and she knows that she must be followed closely for the rest of her life. She will do what it takes to thrive and survive.

I cope by being involved.

I participate in cancer "causes," -- Relay for Life, the Koman Breast Cancer 3-Day walk, I attend a support group for bladder cancer survivors, I speak to groups, I counsel fellow survivors, I raise money for cancer research, and I blog.

I use this involvement to find my "new normal." I use it to challenge the disease that has invaded my life and the life of people I hold dear: my husband, child, mom, and dad. My prayer is that my children and grandchildren will never have to battle this disease in any form.

12 Million Survivors. 12 Million journeys. 12 Million ways to cope. It's a good thing. It gives me hope.

Linda Timmerman, Ed. D. is a two-time cancer survivor and life long educator. She blogs regularly about cancer survival and real information from real people with the disease.

- Posted using BlogPress from my iPad

Saturday, March 12, 2011

"docdano. com Live" Protesting in Wisconsin: Is Obamacare at the root of the debate?

I spoke last night to a group of young physicians at a venue across the street from the Wisconsin State Capitol at the height of the protest against the state government.

Amid the drum beats and screams of union organizers chanting how workers' rights would be eternally devastated because of the loss of collective bargaining, I lectured to a group of resident physicians on the benefits that await patients with the explosion in health care technology.

The root of the problem centers around a state, like almost all in the country, that is saddled with loss of tax revenues due to the downturn in the economy. This has resulted in massive budget deficits and hard choices.

Many states including Wisconsin have ushered in a flurry of Republicans who ran on campaigns of no new taxes, the need to cut waste and spending, and more state's rights.

So that's what the Republican Governor did from day one in office.

He first attempted to limit spending on education to trim the budget, but because of collective bargaining the negotiation of this type of decrease in the state spending was not palatable to the unions.

It didn't matter, really, because the Republicans had the votes to pass it anyway.

But instead of voting on this budgetary issue, the Democrats chose to flee to the land of Obama in Illinois to prevent the state legislature from reaching the critical number of votes to make a quorum.

For three weeks this stalled the debate and decision on the issue, until the Republicans decided to pull out the budget issues (which require the quorum) and vote instead on non-budgetary items - like collective bargaining.

So this lead to more protests.

I literally visited with hundreds of people in Wisconsin over the past week and different opinions abound from every direction.

Clearly if you are a member of the "haves" then you have no desire to give up a benefit.

That's normal.

One person told me that his daughter is a unionized teacher and she pays a whopping $23 a month for health care insurance with no deductible. Even if you factor in that there might be some requirements for her to see certain physicians in network or limitations on formulary and specialist access, this is still a bargain.

He went on tell me that the Governor's proposal would have raised this to $123 per month. I don't know if these numbers are accurate, but the change in benefit structure certainly spurred part of the protest that had national attention.

If you've read this blog before, you know that I'm not a fan of the Obamacare bill. And I think you are seeing in Wisconsin one end of the spectrum of the problems with the bill.

Let me show you why.

To pay for the extra benefits offered under the bill (like no pre-existing illness exclusion, limitations on the right of rescission of insurance if you're too sick to be in the plan, or extended coverage for children), then there will have to be either more money (read tax dollars or higher premiums) or a decline in benefits for those that are members of the "haves."

It's really that simple.

State governments who have been charged with implementing many of the provisions of the federal health care bill don't have the ability to print money or sell treasury bonds. Their only source of revenue is tax dollars.

A significant part of Obama's plan was to provide health insurance for "all Americans." And, unfortunately, a large number of the uninsured were to be covered with the under funded, limited access Medicaid system -- much of which is paid for by the states.

Finding revenue for Medicaid means that other state funded services - like education, or health benefits for teachers - have to be cut and shifted.

That is the only possible way to fund insurance for the "have nots."

I've been derided for one of my statements in the past, but I stand by it: the Obamacare health regulation was the largest transfer of wealth in American history.

So the union supported President now finds himself supporting the union backed protesters who are fighting against changes in state government that would be used to pay for the health care bill that he (and the unions) supported.

Wisconsin is only a microcosm of what is happening in every state that is now grappling with implementing the federal health legislation in a time of budget crisis.

It is an expensive bill, and now we are starting to pay the price.

I'm a big fan of expanding health care access and coverage for the "have nots." A country like the United States should be ashamed for having citizens that don't have access to quality health care. I'm just not a supporter of the big, expensive, inefficient and over-reaching federal health care bill that was passed last year.

Let's face it: the bill cost the taxpayers almost $1 trillion.

The payment for the bill is due now.

And lest you think that non-government workers will get a free ride and this is just an issue for state employees - it will filter down to every American.

As health plans shift to include the new benefits, pay the taxes and fees that are now required by the IRS, and see declining membership due to employees shifting to government subsidized insurance products there will no doubt either be an increase in your health care premiums or a reduction in your benefits.

The problem is that for many insured Americans there is no union to fight for your corporate benefits.

It will be left up to you.

One Wisconsin young man told me that maybe the Republicans should have left Congress when the health care bill was passed.

I reminded him that democracy doesn't work this way. We elect people to represent us and sometimes we win, and sometimes we lose.

I think the Obamacare bill is failure, but I believe strongly that we can keep what's good and fix what's broken. We just have to continue the debate, make compromises, and yes, probably make some sacrifices.

So it probably won't be the last protest I'll attend. Maybe next time I'll get to carry a sign...I'm not much of a drum beater.

- Posted using BlogPress from my iPad

Wednesday, March 9, 2011

Vaccinations: Is death the only motivator that works to promote immunization?

A recent conversation with my nurse and regular debating partner highlighted the passion that people have about vaccinations.

We were finishing up clinic and the topic of HPV came up.

(Now, don't be surprised. This issue is something that we deal with almost every hour of every day.)

There is a vaccination now for certain subtypes of HPV, which not only cause genital warts but also can lead to cancer in women and men.

Cervical cancer particularly is an epidemic disease among young women. And the "abnormal Pap smear" has become as frequent as many common diseases.

Women infected with the virus can develop dysplasia (atypical, precancerous cells) of the cervix which if not recognized and treated can lead to both a superficial and invasive malignancy.

The dysplasia needs to be treated with painful procedures like cryosurgery, or a cone biopsy where the affected tissue is surgically removed, to the possibility of a hysterectomy.

Aside from the fact that the vaccination is really directed to young women, it is clear that young men are also parties to the transmission of the virus. And, there is a cancer risk in men as HPV can lead to not just cometic genital warts, but also to penile cancer.

My nurse was adamant about her son not having the vaccination.

She is certainly entitled to her opinion and it's a common thought among many young parents these days.

Plus, lets face it, men serve as reservoirs of the disease for women.

So, why does she have such a strong opinion?

I mentioned this discussion to my father who in less than a month will be 91. He couldn't grasp why someone would ever turn down a vaccination.

His opinion is grounded in growing up where epidemic infections were a regular cause of death for young adults, including his family and friends.

"I can remember when my cousin died of polio. We burned all of her bed clothes and put phenol around the house," he told me.

"Then we buried her."

So what happened when the vaccine came about I asked?

"We lined up downtown at the community center. Everyone in town."

"No one felt like the government was forcing them to get vaccinated? Did anyone refuse?"

"I can't remember anyone who didn't want it. I mean, almost everyone had lost a member of their family, or a child. You didn't have to see many people in a wheel chair or an iron lung to put the fear of God in you about polio."

So that's the culture that I grew up in. My parents used every opportunity to have me punctured by a hypodermic to keep me from dying of polio, and lock jaw (tetanus), two kinds of measles, and whooping cough.

They must have also wanted to continue the blood line too because mumps was also put "at bay" and my testicles protected with a series of injections.

So maybe death is the big motivator for vaccination.

If you look at college campuses now almost all of them have been affected by meningitis. Students have died of the disease so frequently in the past few years and it is so contagious that most schools require vaccination before you can gain admittance.

I remember the first patient I ever admitted to the ICU as an intern almost 18 years ago now.

She was a 24-year old waitress at one of the Dallas cowboy bars. You know the drill: fever, chills, altered mental status, and finally collapse in the ER.

She got the finest treatment a major tertiary center could offer. But she still descended to the brink of death.

There was a ventilator, multiple consultants, loads of IV antibiotics, and plenty of hand holding from a pimple faced intern who saw someone younger than him dying.

There was no vaccination for meningitis in those days. We gowned and gloved when we took care of her. And we all took prophylactic antibiotics lest we succumb to the same fate.

And we waited, and yes, I prayed for her.

It's not that I just didn't want to strike out at my first bat with a patient in the ICU.

I met her family, her boyfriend, and friends. I got to know her.

And thankfully I witnessed her get better. It took the better part of a month, but we were able to give her the hospital equivalent of the perp-walk in a wheel chair to the front door with balloons, plants, and the to go bag containing the pink ice pitcher give-away from the hospital room.

But for the other diseases nobody dies.

Does this decrease motivation for vaccination?

It probably does. I can assure you my children will be vaccinated against meningitis.

Chicken pox maybe is an exception. Public health officials were successful in convincing parents in our state to require this for elementary school attendance.

I would like to think that it was because chicken pox can lead to devastating scars in children and to permanent pain in adults when it reappears as shingles.

More likely, the primary concern was the missed school days for the kids and missed work for the parents.

But today most parents line their kids up for chicken pox and also hepatitis B vaccinations without much consternation.

Oh, but not for the HPV vaccine.

It may be the social stigma of the disease, or the fact that their children either shouldn't be or won't be doing anything to put them at risk for the disease.

I even still the absurd argument I hear about the birth control pill: that it might promote promiscuity.

My opinion is no doubt clouded by practicing every day at a major urban metropolitan hospital. What I see is real world. But it may not be your world.

I guess I grew up with the values from my father. If modern medicine can protect children or adults from ailments or infirmities then I am easy to buy in.

Whether its small pox or HPV, I support vaccination and elimination of these diseases from the society I call home.

I no longer have to see someone die to become a cheerleader.

- Posted using BlogPress from my iPad

Location:Milwaukee, Wisconsin

Monday, March 7, 2011

Groupon: Are coupons really the right answer for health care?

I'm always fascinated by new technology and particularly ways social media works in our world.

So it was natural for me to sign up for, the internet based deal program that works with local vendors to offer special coupons and discounts for products or services.

Sometimes these deals are just incredible - from 50% off food products to half price golf to yoga for $19 per month rather than $140.

But what about using coupons for health care services?

Sounds odd, I know, but this has been a common practice for years with aesthetic services and cosmetic procedures or treatments.

It's not uncommon at all to see deals for "free Botox" or discounts on micro-dermabrasion or chemical peels.

But would you be influenced by a coupon for "free prostate exam" or "buy one get one free mammogram"?  Or would you just think that provider was weird?

It may sounds strange, but actually this happens every day.

It's hidden behind the cloak and dagger world of the pharmaceutical sample closet.

For years the drug sample has been the easiest tease to entice patients to try a different medication.  Sometimes they are very helpful -- a difficult medication to use (like an unusual dispenser for a spray on product), unusual side effects ("try it before you buy it"), or most commonly the patient has no money and they leave with a bag full of free drugs.

But these are certainly short term solutions and may or may not lead to a patient actually buying the product.

It's no surprise that most of the samples in the closet are for chronic medications -- not for something you have to take for a week or less.

But the interesting invasion into the sample closet has been the coupon.

Now not quite "groupon-like," coupons are now available for almost all name brand, non-generic medications -- particularly if they are early in their evolution of release.

This is how it usually works:  you decide you want to prescribe a new anti-hypertensive (an expensive way to say blood pressure medication).  Compared to a generic medicine which might fall under the $4 per month Walmart plan, this medication might be $300 per month.

But, there might be some advantages:  lower incidence of side effects, easier dosing regimen, or maybe its more effective.  There usually is a real medical reason despite what some Washington pundits might say.

Newer drugs usually work better.

But, nevertheless it costs $300. That's roughly half of some people's Social Security check.

Now with insurance this medication would be a lot cheaper (for the patient) but it is very likely that it would not fall under the "preferred plan" of their prescription drug coverage.

That means that it would likely cause a higher co-pay such as $50 as opposed to $5.

This is where the pharmaceutical coupons come into play.  Now, instead of advertisement laden boxes of pills, the sample closet is full of boxes full of coupons or discount cards.

Patients are asked to call a 1-800 number to activate the card, "register" (which means the company collects information on the patient, disease, and provider), and then the card can be used to off set part of the extra cost related to use of the expensive medication.

These cards usually function as "discount cards."  That is, they will provide either a certain reduction in your copay amount, or they will fix the total cost of medication at a certain point.

Most of the cards require you have insurance to use them.  There is no free lunch here, and the drug companies themselves don't want to be out the total cost of the drug, only part of their margin.

Sometimes there are limits on the amount of benefit you can receive.  The card may only be good for three refills, or it may be unlimited.  You want to make sure you check this carefully before you continue to refill your medication.

Pharmacies as rule don't like to deal with these cards.  Much like grocery stores don't like to deal with coupons.

There is an extra step for them, possibly some activation required on their part and certainly they have to carry additional float, in addition to your insurance, before they will get paid.

What's fascinating to me is that these provide a direct incentive to use a more expensive medication.

Now, as I've outlined here, there are some benefits of these cards.  But let's face it, these are expensive medications -- there is no free lunch.

It's the incentive that seems bizarre.  Physicians and hospitals are forbidden from discounting co-pays, not collecting deductibles, or for offering covered services for less than the contracted amount in most insurance contracts.

There have been several lawsuits already between rival health care systems in communities where one hospital might write off co-pays or deductibles to entice patients to choose their facility over the competitor.

This might be like a patient knowing that regardless if he has Blue Cross Blue Shield insurance, for example, they could choose either emergency room -- because the cost would be the same to them.

Patients with high deductible insurance plans are particularly susceptible to this type of gaming.  The catch is that the hospital is able to collect enough money on the subsequent procedure or test to offset the loss of the deductible.

The problem is for the insurance company and the other insured patients that are on the policy.

It removes the incentive to stay within network and comply with the contract that makes indemnity insurance work in the first place.

Everyone has to play by the same rules.

So why do pharmaceutical companies get to use these discount cards?

I'm not sure I can answer that question, but I hope I've been able to shed some light on these type of cards and discounts.

In some situations they may be very helpful.  If you require an expensive medication, particularly one that is new, be sure to ask your physician if the company offers any type of discount card.

If not, then asked them for a lower priced, generic alternative.

Otherwise, just be aware that these cards can get you established on an expensive medicine for you only to find out that the benefits were temporary.

Also be careful if the company is going to send you a rebate.  This puts the risk on you for collecting the money.

So although not quite type coupons, there are some discounts available for expensive medications.

You just may have to shop around and be an educated consumer-patient.

Study finds unnecessary breast biopsies: maybe needles should stick to being lost in haystacks

By Linda Timmerman, Ed.D.

So who do you listen to?

I get frustrated when I hear about research studies that say women don’t need mammograms every year or before a certain age, not all lymph node dissections are necessary, and now many breast biopsies are done just to line the pockets of physicians and hospitals.

A recent article in the American Journal of Surgery suggested that physicians are doing too many biopsies and should favor doing fine needle aspirations or biopsies (the "FNA").

The FNA is a procedure where a needle is inserted into the tumor either based on palpation of the lump or by the use of a sonogram to guide it to the proper location.

Then using suction, some of the cells are removed and examined under the microscope.

I thought about my friend, Robbie, when I read the findings of the research study.

Robbie found a lump under her arm. She was still young, so the doc thought it was probably just a cyst or infected lymph node. They did a fine needle aspiration (FNA). Results: all clear.

We celebrated with margaritas and Mexican food at Don Jose’s!

Three months later, the “lump” was growing – another FNA – good results – more margaritas!

Six months passed and Robbie went for her well woman checkup. Her OB/Gyn just didn’t like the feel of the lump – so a third FNA followed by the celebratory margaritas!

Fast forward a few weeks. Robbie dropped by to say she was going back to the surgeon. “I know it’s nothing, “ she said, “but it just bothers me knowing it’s there. I’m asking him to take it out.”

“Lump” removed – positive for cancer – invasive ductal carcinoma with lymph node involvement. A modified mastectomy, 8 rounds of chemo, and 35 radiation treatments followed – and Robbie’s been cancer free for 15 years.

Now to be fair, biopsies in general are samples.

Think of a loaf of bread.

You decide you want to serve it for Thanksgiving but you're not sure its fresh. So you pull out several slices and examine them. All ok. No green stuff here.

You put it on the table and then one guest pulls out a different piece, and guess what? A Pasteur prize addition to your holiday meal.

But FNA's are even more of a sample: small fragments of cells pulled through a hypodermic needle. Analysis requires special training and certainly has a margin of error that is bigger than examining a larger piece of tissue.

Robbie is alive today because she listened to her body and followed her “gut feeling” that the lump needed to come out.

So what’s the takeaway message?

If you find a lump, go to a center that specializes in breast cancer.

Find a surgeon and radiologist you can trust.

And most of all follow your gut feelings.

Listen to your body.

Maybe you’ll be one of the fortunate ones whose breast biopsy was unnecessary.

Linda Timmerman, Ed. D. is a two-time cancer survivor and life long educator. She blogs regularly about cancer survival and real information from real people with the disease.

Sunday, March 6, 2011

What Are the Odds? Why information discovery about cancer on the internet might be like online gambling

By Linda Timmerman, Ed.D.

You might think the first place you visit after being told you have cancer would be to a cancer doctor, or oncologist.

But you'd be wrong.

The first stop for most of us? The internet.

Google any form of cancer, and a plethora of websites are instantly available. Some are good, and some are downright dangerous (but that's for another blog).

We tell ourselves we're looking for information about the disease, where to seek treatment, what types of treatments are available.

But what we really want to know is "what's the prognosis?"

"Can I survive this cancer?"

"What are my chances?"

"How long do I have?"

I remember the evening a friend and colleague called and said, "Can you come over? The doctor says I have esophageal cancer, and my wife and I just need to talk."

Truthfully, I didn't even know there was such a thing as esophageal cancer -- so before grabbing my car keys and husband, I starting Googling.

Unfortunately, my friend and his wife were doing the same thing.

By the time we arrived at their home, they were completely focused on the statistics: the 5-year survival rate ranges from 70% to 5% depending on the stage of the cancer at diagnosis.

His first words were, "this thing is going to kill me."

I certainly advocate knowing everything you can about your disease. Some cancers have low survival rates primarily because by the time symptoms appear the cancer is too entrenched or has spread.

It's the nature of the beast.

But how one copes with and acts on this information is vital, I believe, for every survivor traveling the road to the new normal.

Greg Anderson, diagnosed with stage IV lung cancer and given 30 days to live in 1984, went on to found the Cancer Recovery Foundation. He interviewed over 16,000 cancer survivors who had been told they were "terminal" and shares their wisdom in his book, Cancer: 50 Essential Things To Do.

It's a "must read" for survivors. Cancer, say Anderson, must be dealt with on all levels: physical, psychological, and spiritual.

When I was diagnosed with breast cancer in 1997, my first act was to look to the sky and ask, "Oh God, what am I supposed to learn from this?"

On hearing the diagnosis of bladder cancer just last year, my first thoughts were, "Obviously, I'm a slow learner."

To live with cancer, we must know and believe that we can have a quality life and achieve wellness. If the five-year survival rate is 2%, then focus your energy on being in that 2% group.

Emile Coue, a nineteenth century pharmacist in France, encouraged his patients to practice positive affirmation rather than focusing on the fears associated with a serious illness.

His words still ring true: "Every day, in every way, I am getting better and better."

Linda Timmerman, Ed. D. is a two-time cancer survivor and life long educator.  She blogs regularly about cancer survival and real information from real people with the disease.

- Posted using BlogPress from my iPad

Saturday, March 5, 2011

Teen Wrinkles: Is Botox Appropriate for Teen Agers?

A recent article on concerning Botox use in teen age girls was somewhat alarming, but not surprising.

As with everything related to teenagers, there is continued pressure to do more, and to do it earlier.

You can fill in the blank here -- from drinking to drugs to sex to alcohol -- for eons teens have been creating a demand for those vices mostly left for adults.

But is Botox a vice?

Let's put aside medical necessity for a moment and focus on just the idea of catering to your teen's wants and desires.

If little Jane wanted something..."really really bad"...would she automatically get it?

Now before anyone here immediately jumps to the conclusion that "none of my girls are getting Botox" let me assure you that it's not that simple.

You only have to hang around my office for a day and see tattoos in 16 year olds, piercings in tongues, noses, and yes, labia's in 15 year olds, and very UVB florescent light bulb induced tanned 14 year olds.

Yes, just so you know, parents have a tendency to say yes.

My suspicion is young teen age girls can be a very convincing lot.  I have one, a young teen age girl that is, and she can create a very good argument on most issues.

Fortunately for now I'm good at holding strong to my opinions too.  The fruit doesn't fall far from the tree.

So you see it's not really a stretch to put Botox in the same category as these other body manipulations or treatments.

As for medical necessity, well that's another matter.

Botox, or botulinum toxin, for those that have missed the craze that has become the most popular cosmetic procedure in America, is a poison that is injected into facial muscles to induce temporary paralysis or weakening.

Sounds bizarre and dangerous, but it's really not.  It's so simple and relatively risk free that most people can have it done over the lunch hour and no one will ever know.

It's painless, most of the time "bruise less", and the results are gradual over a few days to a week.

You just start to get that "rested look" as the week goes on.

The primary use for Botox is for glabellar (between your eyes), forehead, and crow's feet wrinkles.  And it works exceptionally well here.

Cost is minimal compared to many other cosmetic procedures, but its effects are temporary in that you will require another treatment in 3 to 4 months.

How much?

It varies, but a good guess is about a $100 per month per area.  That is, for your forehead and crow's feet it might be about $400 every 3 or 4 months depending on how much medication is required to achieve the result you want.

The use of Botox though has expanded to other "off label" uses including softening of smoker's lines, correction of gummy smile, and treatment of bunny lines. 

So for teenagers you might wonder where is the clinical necessity?  I mean, as a group they don't suffer from glabellar rhytides or smoker's lines.  Right?

But there is another direction that Botox has taken over the last several years, and that is in the realm of "wrinkle prevention."

Now this may sound bizarre, but it actually makes some sense.

Here's how Botox used to work:  a woman would adamantly state that "I'm never having Botox."  At about age 35 there would be some accidental encounter with either an old high school boy friend or a 10x makeup mirror and a dermatology emergency would be created.

"I can't have this!"

"Why do I have this!"

A nice dermatologist in a black t-shirt would show compassion and understanding, "You're 35 dear.  It always happens at 35."

This would not be taken well by the patient.  Just for the record.

So Botox would now become a necessity and not a luxury or something that she "would never do."  It happens every day, read: every day, in our office.

But the story doesn't stop here.  I wish it could be so easy.

For most women, Botox is a miracle drug.  The wrinkles just fade away over a few days and now the old boy friends and makeup mirrors are much easier to face.

But for some, the results are not as dramatic.  As permanent vertical lines or wrinkles are imprinted on your skin, they may be softened but not erased by the cosmetic injection.

They just don't disappear.

This can be an alarming reality for many women who feel that modern medicine can fix anything.  And for many cosmetic problems, we can.  But it may be more complicated than a five minute Botox injection.

So this brings up the whole idea of "wrinkle prevention."

If you intervene early, weaken the muscles that are creating the permanent lines and wrinkles, can you obviate these cosmetic concerns as a person grows older?

This is the million dollar question -- and yes, it is a million dollar question because that is what is spent (hundreds of millions really) on this approach every day.

Women are coming in earlier and earlier even before wrinkles form to treat areas that are potential areas of cosmetic concern.

So this is the driving force for most teens.

It's just a natural course that these procedures have moved from those in their thirties, to the twenties, and now to the teens.

But is it appropriate?

Well for me, I don't think so.  Could you make some sort of credible medical argument?  Maybe.

Can you convince me?  Probably not.

My view of the world is that teenagers need to grow a few wrinkles.

Wrinkles show age and wisdom.  That might help you know you really shouldn't get your tongue pierced. 

Thursday, March 3, 2011

Gas Prices and Health Insurance

My good friend Tom Stewart posted the price he paid for gasoline this morning on FaceBook.

As a funny retort I mentioned he could use his savings on health insurance premiums to pay for the extra cost of gas.

He didn't think it was funny.

With the Obamacare bill that was passed last year and all the debate on health insurance for "all Americans," it will not come as a surprise for most that we will see little reduction in what we spend on health care.

First of all, the bill purportedly covers a host of new people (estimates are vague at best, but let's say 30 million) which aren't already covered.

There is a very real cost associated with these new participants in the health care scheme. No doubt they were accessing our health care system in some form or fashion prior to the new bill, but with the extra benefits afforded patients under the new plan, there will be additional costs.

States are now grappling with the fact that much of the cost of this health care bill is being passed on them, and of course on to the citizen tax payers.

We have seen the state response vary from attempting to obtain a waiver so they don't have to participate, to filing federal lawsuits (now on the way to the Supreme Court), to threatening Wisconsin-Democrat style political participation -- we'll just leave.

What's really interesting to me is the reason for the bill in the first place: "we can't afford these rising health care costs."

Mr. Obama used his town hall stump speech around American espousing how much health care costs add to the cost of a Chevrolet, how Medicare is going broke and won't be able to care for the baby boomers, and how cheap medications are if you buy them in Mexico or Canada.

So in the satirical wit that I'm known for, I thought I would try to draw some comparisons and contrast with the cost of Zocor and Shell Premium Gas:

1) Has anyone ever looked at the cost of energy used to produce a Chevrolet? From the coal used to make the energy to make the steel to the oil used to power the locomotives to carry the parts to a Detroit plant operated on electricity produced from natural gas and coal. Get the picture?

2) Theoretically Zocor will make you live longer and healthier. Has the rising cost of gas at the pump lead to being able to live longer and healthier with the energy we have?


Instead most energy companies use the added profits to search for more traditional energy sources rather than create ways to make do better with what we have.

You only have to drive through the northern part of central Texas and see the moon-scape remains of Chesapeake energy as they search for natural gas. With the advent of horizontal drilling technologies and "fracturing" they have created sources of "clean and affordable" natural gas.

3) The new health bill will limit the purchase of cheaper medications from foreign companies. Does any of our current energy policy limit the purchase of foreign oil?

4) We import most of our energy, and we export most of our drug technology to the rest of the world. If we limit the profits of pharmaceutical companies will we stifle drug innovation and new therapies or treatments? If we limit our reliance on foreign oil, will we then promote better reliance on living with what we have and promoting a more sustainable energy policy?

5) PHARMA is a new set of rules that prevent the pharmaceutical companies from entertaining physicians and consumers of health care services. Do we have similar rules relating to energy companies? I wonder if Halliburton has a Washington, DC office?

6) There might be a similarity in the two issues relating to radiation. The bill puts significant curbs on physician owned facilities -- mostly radiology services like MRI and CT machines. And despite the reliability and environmentally friendly nuclear power option -- we aren't building any significant plans anytime soon.

7) And do we provide energy for "all Americans?" I mean, we are talking about energy...isn't the availability of energy a basic right, like health care? You would be hard pressed to survive in today's world without using energy in some form or fashion. Are we providing a policy that helps my elderly parents with the cost of their electric or propane bill? What about young single moms who can't get to work because of the cost of gasoline? Are we providing energy vouchers to help them?

8) And what about the cost of health care and energy compared to GDP? This "gross domestic product" argument was one of the strong reasons that lead to passage of the greatest transfer of wealth in American history in the Obamacare bill.

The story was told that health care was making up "too much of GDP."

So, I ask, how much is too much? Have we applied the same argument to energy costs? Just saying.

Conclusion: the health care bill will add costs to most Americans in an economy that is increasingly dependent on foreign energy sources.

So every time you fill up that tank, don't think about how much you are saving on health insurance premiums.

Switch to mid-grade from premium.

That's what most patients will find their choice to be in their new health care insurance.

- Posted using BlogPress from my iPad

Location:Oil Country, West Texas

Wednesday, March 2, 2011

Does brown fat look better than white fat?

I learned early on in the practice of dermatology that patients like to look tan. It just seems to be a part of human DNA.

It just feels good for most people to be out in the Sun.

There is all the hubbub about melatonin, endorphins, and the like that are released when you spend the day sitting by the pool. But, personally, I think most folks simply think they look better tan.

I've spend the better part of my professional career with a sideline passion of stamping out the tanning bed industry.

They have been a likable lot to spar with: they're always tan, smile a lot (I think they also bleach their teeth -- I'll save that for another blog), and generally espouse junk science about the benefits of being naked inside of an adult sized EZ Bake oven.

And probably I would have had a hard time convincing the state legislature that they needed to be regulated if ten-year-olds hadn't been also subjected to tanning beds.

Yes, it's true. (I'll save parenting for another blog too.)

Tanning is addictive.

There are multiple studies about the addictive nature of recreational tanning. But do you really need a study to convince you that 20 minutes alone every day in a warm cocoon away from your phone (you can insert boss, teachers, children, whatever here) and listening to your iPod must feel good?

Men my age do the same thing with ESPN. It's called zoning out.

Now the difference is that men end up with love handles and an extra 20 pounds somewhere. Tanners end up looking cool.

And when you are fat and tan you look better than if you're fat and a stark white guy. At least that's what my patients tell me.

So is there a connection now with the epidemic we have of adult obesity and tanning? That's the question I pose.

Tanning certainly crosses cultural and BMI lines. There are thousands of self proclaimed health nuts who spend an hour at gym, cycle a hundred miles, or who run marathons and are as dark as a mahogany chest of drawers.

I've talked with these patients many times but I just can't break the nut of making them stop tanning. They just feel too good until they get a melanoma.

I had a patient recently ask me, "Just what am I supposed to do? I have to be outside."

The answer is you can be outside, but be smart about it.

Wear sunscreen of at least an SPF 30 (ignore those recommendations of SPF 15 or more; they were written by people near Canada), avoid mid-day sun and exercise or work outdoors in the morning or late afternoon, and wear a hat.

No one expects you to be a bat and live in a cave. You have to live your life and enjoy it.

But what about those people who don't exercise, eat a regular diet of McDonald's, and are well, not skinny?

Do they feel they look better if they are tan?

I think they do.

Of course the activities that get you tan are not bad: vacationing in Cancun, sitting by the pool, fishing with your buddies, or even recreational tanning.

But people look at their skin, fat or skinny, and perceive that it looks better if it's bronze. We have created a culture that tan equals health.

This of course is now regardless of body mass index.

But its not. That is, neither being fat or tan is healthy.

Both lead to their own independent set of problems.

So what can you do about it?

Well, for the fat part, we all know what to do (execution may be difficult): eat less and exercise more.

But for the tan part we have been stymied in the past because the only way to get tan was the primordial sitting on a beach towel in the sun, or paying $30 a month for a membership at Planet Tan.

There was always the "self tanner."

But for many of us this was the Vitalis-like concoction QT, a brown liquid that left your knees, hands, and elbows looking like a navel orange.

This scared a generation of Americans away from chemical, inorganic, and preservative containing self tanning products. And into the hands of a dermatologist treating skin cancer.

But that's not true anymore. Now there are a host of self tanners and spray on tanning devices that offer tans indistinguishable from those obtained the old fashioned way.

Neutrogena makes a very nice product that sprays a micro spray of self tanner that works very well. Its "no rub" nature makes it easy to apply in the morning before work and its slow onset of action just makes you start to look tan over a few days.

The machine of choice right now seems to be a device called Mystic Tan. Briefly, you stand upright, hold out your arms, listen to some Star War's type beeping, and it sprays you like a car wash. With a little rub down when your done and you have instant tan.

And finally there is the newest phenomenon: air brush tanning.

Long only available to either the rich and famous or those on Dancing with the Stars, airbrush tanning has now entered the mainstream marketplace.

Most places are charging between $25 to $35 and a technician sprays on the non-toxic, harmless tanning spray while you either wear paper undergarments or go commando.

It usually doesn't require any wiping down, dries instantly, and looks very natural.

Read: very natural. I'm the so called expert and I can't tell unless I look close.

And its a whole lot safer than baking in the sun or sitting in a tanning bed, regardless of your weight.

So, the best advice is to lose weight, eat a healthy diet, and stay out of the sun. But if you want to be tan, do self tanning.

Why? Because self-tanned fat looks better than tan real fat.

- Posted using BlogPress from my iPad

Location:San Angelo, Texas

Tuesday, March 1, 2011

Cancer Survivors New Normal: Dr. Linda Timmerman explores living through cancer -- twice!

 (Please join me in welcoming Dr. Linda Timmerman to  Linda is a two-time cancer survivor and patient champion with a long history in education and health care.  She will host a new video series blogging about cancer survival and the new normal that occurs after a cancer diagnosis. The focus will be on real stories from real people that survive, treat, or live with someone with cancer.)

By Linda Timmerman, Ed. D.

About a year ago, it became official:  I’m a “double D”! 

A Dual Diagnosis Cancer Survivor.

It was devastating in 1997 to hear the words from my breast surgeon, “what we have here is invasive ductal carcinoma.”   There are no words to describe how I felt thirteen years later when I heard my urologist say, “it’s a really large tumor and I’m 99% certain it’s malignant.”

During chemo and radiation for the breast cancer, all I wanted was a “normal” day.  I thought that would come at the end of treatment.

Silly me.

Cancer changes everything about life, physically and emotionally.  It took me several years to realize that “normal” simply didn’t exist.   So I started seeking my new normal – that place where I could feel comfortable, safe, and confident again. 

And I almost found it.

I no longer panicked when I made the annual appointment for my mammogram, chest x-rays, and blood tests.  I went days, weeks, and even a few months without thinking about cancer.  I changed careers, loved learning new things and meeting new people, my husband and I built a home on the lake and we bought a condo in the city.    

Our children got married and had children.  Life was good.

And then the day I’ve now named “Red Thursday” occurred.    Three surgeries, two rounds of chemo, and umpteen million tests later, I’m seeking that “new normal” again.  I still have two years of chemo treatments every six months and scopes of my bladder every three months, but I’m surviving.

During treatment, it’s physically difficult.  And there are days when I feel I’m hanging by a thread emotionally.  For right now, at least, that’s my “new normal.”    It’s very much like driving in the car with my GPS navigation system.  

Every now and then, I take a wrong turn – or I simply choose to go another way – and the voice sighs, “recalculating.”

That’s what happens in the new normal – we all recalculate and then press on.  Any like any journey where you’re not certain if you’re on the right path, there are both tears and joys in the unknown.

There are thousands on the road to new normal with me.  

My goal for this blog is to encourage cancer survivors to tell their stories, to become educated about their disease, and to draw strength and courage from each other.