cshapiro

I'm having some trouble getting my sympathy going this morning.  I drove to work in -15 weather at 6am.  I have meetings at 7 and begin rounds by 8am.  All this to be at my office by 9 for my first patient(who is running late so I have a few minutes to catch my breath.)  Life is tough, up at noon to wake to the endless sunshine of Florida.  Enjoy it while you can but don't get to used to it.  I know you want to go to med school and all med schools start at 7:30 or 8am latest.  It gets worse as an intern but even in fourth year you can have seminars at 5:30 or 6:00am.  Have a good term.

cshapiro

I'm sorry you got the impression that the whole rant was at you.  I certainly didn't want to imply you didn't have manners.  I was just making the point that just because helping people sometimes creates expectations of you, I don't think it should discourage you.  I think in a civilized society it should be expected to be helpful and we should try to meet these expectations.  I personally believe kindness is a state of mind and I teach my children to make it their habit.  I hold the door for anybody, I don't try to figure out if this person deserves it or not.  I know some people do try to take advantage but most people don't like to ask for help and if they are asking it's because they really need it.  I find it's best to just grin and bear it even when someone is being inconsiderate.  An example of this happened last Sunday night.  Everyone on my street knows I'm a doctor and I try to help out in an emergency or if someone is trying to decide whether or not to go to the ER.  In a pinch, after hours, I am happy to look in a few ears or write a prescription.  Last Sunday, I was just sitting down to dinner with my family when the doorbell rings.  It's a neighbor asking if I can see her for something.  I invited her in, she told me her problem and then I asked her how long it has been bothering her and she answers "three weeks".  For 3 weeks she couldn't be bothered to see a doctor and now during my dinner time with my family on a Sunday evening she decided "it's time".  While I think she was taking advantage of me a bit, she still was suffering and I felt it was best to help than to refuse.  I preferred to err on the side of kindness.  If she was ringing my bell, something must have been bothering her to motivate her to do it.  In the end I think it's a better example for my children and it takes a lot to counter the message of selfishness that is all around us.

cshapiro

I haven't replied in a while here so congratulations on your little girl on the way.  My first 3 were girls and they are the best.  Girls when they are little are so amazing and fun.  My oldest is a teenager going to university next year and she is still amazing and fun but now I do get a bit more gray every day.  She wants to go to med school and live in Boston just like her old dad so I really haven't got much to complain about.  As far as giving up caffeine, I know some people do but thees days there are lots of pregnant doctors and residents in the hospitals and none of them give up caffeine and they threaten to rip the head off anyone who suggests it.  I don't have an opinion, I hate coffee and tea and never touch the stuff.  I'm about the only med student that never drank coffee.

cshapiro

It is amazing that you are getting to go back to Israel and it's great how you are publicizing and helping such an important cause.  I envy you.  I have not been back in ages.  It's so hard to get away and when traveling as a family it gets very expensive just for the airfare.  Enjoy!

cshapiro

It's only around -20 here but it's cold enough.  In general I always liked winter but about now I have had enough.  Since Friday it hasn't been above -10 once.  I guess it's the price of being Canadian.  I don't think you are complaining.  It's been a long hard winter this year and it has been tough on a lot of people.  Luckily I am able to park underground at work and walk right into the hospital without going outside.  My hospital is the only one that has parking that you don't need to go outside.

cshapiro

I'm glad it went well for you.  Nothing can take it out of you like a move but once you get back to civilization it will all be worth it.  I just spent a week up in northern Ontario.  I had to do a surgery in Bracebridge.  I was never so glad to come home in my life.  Everything was just so...... backwards.  The simplest things were so complicated.  I had been in the area before for a vacation and never noticed it but when you are living there and working there you notice things you don't on a vacation.  There were a couple of times I just wanted to shout "is everyone here brain dead"!!  It's scary to think that for so many people this is the hospital that they rely on when they are really sick.

cshapiro

Old school friends are the worst!  You end up doing stuff that you used to do all the time when you were in school.  It's easy to think that we can still behave like we are 20 but the next day we remember just how long ago school really was

cshapiro

I see quite a few of you are sick and I'm really sorry to hear it.  I have one piece of advice as a patient not a doctor.  Be very careful not to get dehydrated.  It happened to me a few weeks ago and I ended up spending a week in ICU.  I was stubborn about it and my wife tried to convince me to go to the hospital but I refused.  I went to bed one night after arguing about it and woke up 3 days later in the ICU unable to remember how I got there.  Doctors really are the worst patients.  I turned a simple illness into a life threatening one and should know better.  I hope you all get well soon.

cshapiro

Forget about listening to my own advice.  I should have listened to my wife's advice.  She told me I was an idiot and wondered what I did for almost twenty years of medical training. She's not wrong.  I hope you finally get to feel better.

cshapiro

I have had the shot and I am planning to give it to my kids.  As far as the risk of the vaccine goes, it's not really a new vaccine, it is essentially the same as the seasonal flu vaccine and carries the same risks.  I hope you find the following article helpful.  Generally older people have at least partial immunity to H1N1 because of an outbreak in the late 40s early 50s and are not a priority for vaccination.  In Canada most of the serious cases of the virus have been in people in the prime of life with no underlying medical issues and in Toronto a 12 year old, otherwise healthy boy died of H1N1 just a couple of weeks ago.  He died within 24 hours of showing symptoms.

From Medscape Medical News
Hospitalization, Death From H1N1 Influenza Can Occur at Any Age
— H1N1 influenza is emerging as an equal-opportunity threat, seriously affecting people of all ages — not just younger people, as had been thought — according to the results of a surveillance study from California published in the November 4 issue of the Journal of the American Medical Association.

"Pandemic influenza A(H1N1) emerged rapidly in California in April 2009," write Janice K. Louie, MD, MPH, from the California Department of Public Health, Richmond, and colleagues. "Preliminary comparisons with seasonal influenza suggest that pandemic 2009 influenza A(H1N1) disproportionately affects younger ages and causes generally mild disease."

However, data on the clinical features and populations at risk for complications from H1N1 influenza infection are still emerging, the authors add.

The aim of the study was to describe the clinical and epidemiologic features of H1N1 influenza cases that led to hospitalization or death.

The investigators studied all cases of California residents who were hospitalized or died with laboratory evidence of H1N1 infection that were reported to the California Department of Public Health between April 23 and August 11, 2009.

During that time, 1088 cases that led to hospitalization or death were reported in 41 of 61 local health departments, with most occurring in June and July. Of these, 344 (32%) were children younger than 18 years.

The median age of all cases was 27 years (range, <1 – 92 years). The overall rate of hospitalization or fatality per 100,000 for all age groups was 2.8 and ranged from 11.9 in infants younger than 1 year to 1.5 in those aged 70 years or older.

The highest hospitalization rates per 100,000 were in infants 1 month old (35.8) and 2 months old (21.1). These rates were lower in infants aged between 3 and 12 months, ranging from 4.2 to 12.6 per 100,000.

The median length of stay in hospital was 4 days.

Although infants were hospitalized at greater rates than adults, individuals aged 50 years or older had the highest rate of death once hospitalized, the authors report.

The overall fatality rate was 11%. In children younger than 18 years, the death rate was 7%, and in persons older than 50 years, it was 18% to 20%. The median time from onset of symptoms to death was 12 days, and the most common causes of death were viral pneumonia and acute respiratory distress syndrome.

Sixty-eight percent (741/1088) of patients had risk factors for seasonal influenza complications.

Obesity a Risk Factor for Hospitalization

The study also found that a high number of hospitalized adult patients were obese. Of the 268 adults aged 20 years or older with a known body mass index (BMI), 156 (58%) were obese, as defined by a BMI 30 kg/m2 or higher. Of these, 67 patients (43%) were morbidly obese (BMI ? 40 kg/m2).

Sixty-three percent of obese patients had comorbidities associated with influenza complications such as diabetes, asthma, and renal disease.

"We found a surprising number of obese persons in this study," Dr. Louie commented to Medscape Infectious Diseases. "Our proportion of morbidly obese persons was much higher than in the general population. Others are reporting similar findings. We need to study further to find out if obese persons were also more likely to have other risk factors not yet diagnosed, like asthma or diabetes."

The study findings emphasize the importance of vaccinating children, as well as caregivers of infants younger than 6 months of age and pregnant women, she added.

"H1N1 has a reputation as a mild illness, but we found that almost one third of our hospitalized cases became severely ill and required mechanical ventilation. Over 10% died," she said. "Also, there is a perception that the elderly have some immunity. However, we found that if elderly persons were admitted to a hospital, they tended to be more likely to die from their H1N1 infection."

She emphasized that clinicians should be thinking about H1N1 infection, as well as seasonal influenza, when a person presents with fever and respiratory symptoms.

Rapid Influenza Tests Not Reliable

She added, "Clinicians should not rely on the rapid tests for influenza done in the clinic, because these can be unreliable, especially in adults. If a patient is not looking well or has risk factors like pregnancy, antiviral treatment should be started right away while awaiting test results with [polymerase chain reaction]. Many studies have shown that early treatment can make a big difference as far as hospitalization and death for influenza."

Commenting on the study for Medscape Infectious Diseases, John Bartlett, MD, professor of medicine at Johns Hopkins University School of Medicine in Baltimore, Maryland, said the authors did everybody a big favor by doing the study.

The big surprise here, he said, was the severity of H1N1 infection in older individuals.

"We've all emphasized the fact that this is a disease of young people and elderly people are relatively spared. A lot of people, including myself, have told older people not to worry about H1N1, that it's not their problem. I think we have to think twice about that now," he said.

This does not mean that all older people need to be vaccinated, he added. Rather, it means that clinicians need to be more cautious in advising them of their risk.

Dr. Bartlett also noted the finding that obesity appears to be a risk factor for hospitalization. "Everybody has been talking about this, but the CDC has never really recognized that as a risk per se. But it just keeps coming up. It came up in Canada, it came up in Mexico, and it came up in California. I think we are going to have to try to figure out why people who are morbidly obese tend to handle this flu less well. A lot of them in this series had comorbidities, but a lot of them did not."

Dr. Louie and Dr. Bartlett have disclosed no relevant financial relationships.

JAMA. 2009;302:1896–1902.

cshapiro

I'm sorry, but there are a couple of misconceptions in your posting.  Firstly 5 months is definitely too young to have the vaccine so it isn't relevant to you specifically.  Just to clarify, babies get their mother's antibodies from the mother's blood in the womb not from breast milk and you can only provide antibodies for your child that you yourself have.  Since you never had H1N1 then you don't have antibodies to protect your baby.  Also contrary to popular belief, getting a flu shot (H1N1 or otherwise) cannot give you the flu or make you a carrier.  There is no live virus or even dead virus in the shot.  There are just fragments of the virus' DNA that produce an immune response that will cause your body to produce the right antibodies.

cshapiro

Over perscribing of antibiotics is a huge problem everywhere.  Usually the problem is patients insisting on them.  It still is the Dr's fault since it is our job to educate our patients not just give them what they want to get them off our back.  Most resperatory infections are viral but almost every Dr prescribes antibiotics for them.  As a surgeon I don't eally have the issue but I see how kids are handled by their family docs and they almost always come to me with various issues from over use of antibiotics.

It's frustrating being sick and not being able to do anything about it but sometimes we just have to plod through a bit of a cold for a few days and take it easy.  Don't give up hope, there still is chicken soup!  Feel better everyone!

cshapiro

Hi Penny.  I hope you are doing well.  It's always nice to hear from you.

There are two thing that were in the post that I would like to respond to: "A lot of doctors don't believe in herbal remedies but I figured what harm would it do to try it."

Firstly, all doctors believe in herbal remedies.  Many of the drugs we prescribe are derived from herbs and certanly there are many herbs which have been proven to provide theraputic value.  What many physicians object to is, the touting of untested herbal remedies as cures.  The vast majority of herbs have no scientific evidence behind them and in fact some have ben tested extensively and been found to have no value medicinally whatsoever and they are still advertised and sold as miracle cures.  I just think that herbal products should be tested and regulated for safety and efficacy.  I have never heard of chasteberry so, I have no opinion on it whatsoever.  There are some proven herbs that help with women's hormonal issues such as shepherds purse that I know have been studied and found to be safe and effective.

Secondly, the commonly stated "what harm can it be" is something that is based on falsehood.  People think that if something is natural it is therefore harmless and this is a lie.  Any herb, vitamin or supplement of any kind can potentially be harmful.  If an herb affects the body then it can have side effects and dangers the same as any drug.  Without proper study there is no way to know the potential for harmful interactions, overdose or toxicity.  There are many toxic plants and herbs in the world and just because something is natural does not mean it is safe.

cshapiro

I think this article says all that needs saying.

Evidence-based medicine is the rallying cry of a generation of physicians. So why do so many physicians ignore the evidence when it comes to dietary supplements?

Today, 73% of US adults use some kind of supplement at least once a year, according to a recent FDA-sponsored survey.[1]

Much of that use can be traced to physicians' practices. Many children -- my own daughter included -- are prescribed a chewable multivitamin by their pediatrician. Yet no major medical group or government agency recommends them for otherwise healthy children or adults, because evidence-based reviews have found no benefit. Indeed, a review in the Journal of the American Medical Association concluded that antioxidant vitamins slightly raise the risk of premature death.[2] Another study, just published on May 15, found that heavy multivitamin use in men increases the risk of advanced or fatal prostate cancer.[3]

Beyond vitamins, some physicians even recommend herbal remedies and specialty supplements.[4] Yet randomized trials supported by the National Center for Complementary and Alternative Medicine have concluded that glucosamine-chondroitin does not relieve arthritic pain,[5] that echinacea does not prevent colds,[6] that black cohosh and other herbs do not relieve the symptoms of menopause,[7] and that saw palmetto does not relieve benign prostate hyperplasia.[8]

The evidence for potential harmfulness, meanwhile, grows ever stronger. Since 1983, the American Association of Poison Control Centers has tallied more than 1.6 million reports related to the use of supplements, including 251,799 serious enough to require hospitalization.[9]

While only a minority of physicians recommend herbs, surveys show that most fail to even raise the subject when taking a history.[10] As a result, case reports of interactions with prescription medications have become commonplace in the medical literature.[11]

It's time for physicians to face [the fact] that the majority of their patients use supplements. They need to ask all their patients about them -- Do you take vitamins? Do you take any herbs or other supplements? -- and apply evidence-based standards in discussing their merits.

That's my opinion. I'm Dan Hurley, medical journalist and author of Natural Causes: Death, Lies and Politics in America's Vitamin and Herbal Supplement Industry.

cshapiro

Please read this before doing anything drastic.  So called "bio identical" hormones can be very harmful and are something to be avoided.

Bioidentical Hormones
Estrogen is Good. No, It’s Bad. No, It’s Good

by Harriet Hall, M.D.

Menopausal women used to have no escape from the sufferings of the dreaded “Change.” In the mid-20th century, they were offered a reprieve. They could take a pill to replace their missing hormones, and feel back to normal. That was good in itself, but then they found that replacing estrogens could prevent osteoporosis and hip fractures. We knew there were some risks, but we thought the benefits outweighed the risks. Some doctors recommended all menopausal women take estrogens to “stay young.” Then there was more good news: evidence seemed to show that hormone replacement therapy (HRT) could reduce the risk of heart attack, stroke, and cancer in postmenopausal women.

The optimism came to a screeching halt in 2002, when the Women’s Health Initiative (WHI) study said, “OOPS! It looks like hormones do more harm than good.” Thousands of women were scared into going off their hormones. Sales of Premarin dropped from $2 billion to $880 million. Some of these women tried other remedies and then went back to Premarin because it was the only thing that worked for them. Doctors learned to prescribe more selectively, and sales are rising again.

Now all of a sudden hormones are being touted as a miracle cure for whatever ails you. Suzanne Somers has a new book, Ageless: The Naked Truth about Bioidentical Hormones, recommending everyone take supplemental hormones, even men. My local newspaper has been advertising seminars by an MD on hormones for menopause, weight control, and romance: “Skinny Hormones, Happy Hormones, Youthful Hormones and Sexy Hormones.” Anti-aging clinics and longevity doctors are promoting bioidentical estrogen and progesterone along with testosterone, thyroid, and human growth hormone to prevent aging. What’s going on?
book cover

The claim is that Premarin and Provera, the drugs studied in the WHI study, are artificial and harmful, while bioidentical hormones are natural and harmless. Some also claim that bioidenticals prevent aging and the diseases associated with aging and make people feel better than they ever did before. What is the evidence behind these claims?

First we need to understand what the WHI study really said. It has been misrepresented and misinterpreted. Media reports gave the impression that HRT was killing women. Not so. Over 10,000 person-years, women on estrogen plus progestin had 7 more coronary events, 8 more strokes, 8 more pulmonary emboli, and 8 more invasive breast cancers than women who didn’t take hormones; but they also had 6 fewer colorectal cancers and 5 fewer hip fractures, and the same number of deaths overall.

So women weren’t dying because of HRT, but they were increasing their risk of some diseases while reducing their risk of others. Overall the risks exceeded the benefits. Current recommendations are to use HRT for a limited time only to control menopausal symptoms, and not to use it for disease prevention. Most of us think these recommendations will be altered in the future as we learn more about risk factors and genetic susceptibility. Meanwhile, we try to individualize advice: your doctor is more likely to recommend HRT if you are at very low risk of cardiovascular disease and at high risk of osteoporosis or colorectal cancer.
Evil Big Pharma Plot?

The bioidentical folks tell us that Premarin and Provera are unnatural and harmful substances cynically foisted on us by Big Pharma to make profits. They don’t seem to realize that all doctors are either women, married to women, or sons of women, who presumably are more concerned about women’s health than about Big Pharma profits, and that doctors have read all the same information they have. They recommend estrogens and progesterone from natural plant sources. Premarin comes from pregnant mare’s urine: that seems more natural to me, since we’re much more closely related to a horse, another mammal, than we are to a plant. And the plant isn’t used in a natural form; it’s used as the basis of laboratory synthesis. And there is a reason that we started giving women progestins like Provera instead of natural progesterone: natural progesterone is not absorbed well. Progestins were reliably absorbed and dosage easily controlled.

“Bioidentical” is not standard medical terminology. It’s their way of saying it is the same exact chemical compound found in the human body. But there are lots of different estrogenic compounds found in the body, including estriol, estradiol and estrone. Nothing we do is likely to replace all the estrogenic compounds in exactly the way they occur in the body. There are around 30 different estrogens in Premarin. One, equilin, is present in horses but not in women. Curiously, that “unnatural” element appears to be neuroprotective and is being studied as a possible treatment for Alzheimer’s disease. There’s no solid evidence that any supplemental mixture of hormones is ideal. Anything that has hormonal effects may have hormonal side effects, and for all we know good old Premarin and Provera may be less harmful than some other mixtures.

Compounding pharmacists make up the bioidentical remedies, often in the form of a cream. Advocates themselves recognize that there is inconsistency between pharmacies, and they may have tried two or three different compounders before they hit on one that seems to work consistently for them. In one survey, about a third of the compounded samples tested had substandard amounts of drugs. The FDA is concerned about the growing popularity of compounding and the need for better regulation.

There are hypothetical reasons to think “bioidentical” hormones should be superior to Premarin and Provera. But there are also hypothetical reasons to think that they may be no more effective and no safer. The only way to know for sure is to test them in a properly designed placebo-controlled trial. Until this is done, most of us feel more comfortable with the devil we know than the devil we don’t know.

What other options are there for hot flashes? Several other prescription drugs have been tried, including antidepressants, but they don’t work as well as estrogen and they all have side effects. A number of alternative natural remedies have been tried, from chasteberry to wild yam. According to The Natural Medicines Database there is insufficient evidence to support any of these but black cohosh, soy, and flaxseed; and these are only rated “possibly effective” and “possibly safe.” Black cohosh was the most promising — until a recent well-designed study found black cohosh no better than placebo.
Bioidentical Insanity

Suzanne Somers and others keep harping about “balancing” your hormones. I have difficulty understanding this concept. Hormones are complicated. There are lots of different estrogens; estrogen levels are higher early in the monthly cycle and progesterone peaks later in the cycle: if you graph them, you see that each follows a curve, and the ratio between estrogens and progesterone is constantly changing from day to day and hour to hour. So what can the bioidentical advocates mean when they say they are “balancing” your hormones?

I finally realized that they don’t have any idea what they’re “balancing.” When they do lab tests, they use salivary levels, which they think are more reliable (most endocrinologists disagree). Since they know the test only reflects one instant in time, they feel free to disregard it except as a rough starting point. Instead, they have the patient report any symptoms such as insomnia, dry skin, or lack of energy, interpret those symptoms as signs of unbalanced hormones, and adjust the dosage.

It would be bad enough if they stuck to menopause, but Somers recommends hormone regimens for every age group, including adolescents, and for both men and women.

This creates a scenario where wishful thinking and testimonials take precedence over science, where quackery can go hog wild. Patients get to obsess about every little ache and sniffle, doctors get to tweak their prescriptions, and if patients don’t improve, they just say the balance isn’t quite right yet and they try again. Lots of personal attention and caring. Certainty that they have the answer to all their problems. Enthusiasm over a new method. Oh, and they combine the hormone therapy with all sorts of diet and exercise advice, and with handfuls of supplement pills, detoxifications, homeopathic remedies, and of course the FaceMaster machine that Suzanne sells and uses regularly for electrical facelifts. If you’re still not feeling perfect, you can try going to sleep at 9 PM. And sleeping in total darkness. Or add some testosterone just for the heck of it. There’s always something more to try; there’s always a satisfying explanation for everything.

The doctors who support these true believers are creating an elite following of self-absorbed, self-deluded, obsessive-compulsive health nuts. I suppose it’s nice for these people to have a hobby.


Barb,
I hope you feel better and only wish for the best of health for you but this isn't the way.  This stuff can be quite dangerous and is very expensive to boot.