Marriage Equality Monday



Last week, the US Supreme Court announced its 2014-2015 case docket, and much to the dismay of LGBT advocates, the Court revealed they had yet to add a marriage equality case to their calender.  In a a supreme move (see what I did there), the Court announced that they would not hear an appeal from five states seeking to prohibit same-sex marriages, paving the way for an immediate expansion of marriage equality.

The justices on Monday did not comment in rejecting appeals from Indiana, Oklahoma, Utah, Virginia and Wisconsin, immediately ending delays on marriage in those states.  The decision also makes appeals court decisions in the 4th, 7th, and 10th circuit courts the law of the land, making marriage equality likely to come in 6 more states for a total of 30 states and the District of Columbia.

Huge.  Epic.  Monumental.

marriage equality

National Breast Cancer Awareness Month



I will undoubtedly get into trouble for this post.  So be it.

October 1st marks the beginning of National Breast Cancer Awareness month, an annual international health campaign organized by major breast cancer charities every October to increase awareness of the disease and to raise funds for research into its cause, prevention, diagnosis, treatment and cure.  Unless you’ve been living under a rock, you’ve undoubtedly seen pink colored products in mass quantities over the past few years.  It seems like everyone “goes pink” for October.

I don’t want to trivialize breast cancer with the remainder of the post.  As a physician and a surgeon, I recognize the critical importance of mammograms and the devastation that breast cancer causes to thousands of women each year.  I also do not want to downplay the important work that is done by some breast cancer charities to support research toward ending breast cancer as well as screening and treatment.  But  before you go buying pink products this October, I want to add a word of caution to everyone out there, particularly women.

First, despite all the charity events, the “awareness”, and the funding, breast cancer is NOT the leading cause of death among women.  As far as a woman’s individual health is concerned, a good diet, exercise, and avoiding smoking are far more important to prevent heart disease – which happens to be the overall leading cause of death for women.  Avoiding smoking is doubly important because it’s highly associated with lung cancer, which happens to be the overall leading cause of cancer deaths among women.

Second, people should be aware of the term “pinkwashing” – the outrageous corporate practice of selling products linked to an increased risk of breast cancer while claiming to care about (and profiting from) breast cancer.  I encourage everyone to visit the website for “Think Before You Pink“, because it highlights a lot of the hypocrisy in pink products.  One of the more striking examples may be the NFL, which started “going pink” in October 2009 to support women and breast cancer.  Given recent events surrounding the NFL and domestic violence, one might question how much the NFL really supports women.  Of note, domestic violence affects more women annually than does breast cancer, and October also happens to be National Domestic Violence Awareness Month.  Additionally, an analysis by Business Insider found that only 8% of the money spent on the plethora of pink gear sold by the NFL ended up going to research at the American Cancer Society, the supposed beneficiary of the league’s efforts. Since 2009, when pink first appeared on the field, the NFL has donated a grand total of $7 million towards the cause, while the league made $9 billion in revenue in 2012.

Third – be very critical of which charity you are supporting.  Susan G Komen Foundation is one of the most widely recognized breast cancer charity, yet only 15% of its donations in 2011 went toward breast cancer research, with less going toward screening and only 5% toward treatment.  For a charity that claims to be “for the cure”, spending nearly 43% of your donations on “public health awareness” seems a little suspect.  I’m not claiming that others are any better, but just be aware of where your money is going.  Donating directly to research institutions like Dana Farber or Memorial Sloan Kettering or to breast cancer survivor support groups might be more beneficial.

And finally, As the association Breast Cancer Awarness notes, pink ribbon products spread empty awareness – awareness that has failed to address and end the breast cancer epidemic. Pink ribbon trinkets on store shelves that promote “awareness” ultimately change nothing. We have more than enough awareness, but not nearly enough action that will make a significant difference to whether women get breast cancer or survive it. Awareness shouldn’t be the end goal; unfortunately, pink ribbon culture defuses anger about breast cancer and its devastating impact and distracts us from the meaningful actions that will achieve health justice.

Ultrasound – the new stethoscope?



If you walk around most hospitals, you’re likely to find a stethoscope hanging around the neck of a number of medical professionals.  It’s probably safe to say that no other instrument has had such a lasting impact on medicine as the stethoscope, and no other single piece of equipment has come to symbolize “physician” quite like it.

The stethoscope first debuted in 1816 in France, when physician Rene-Theophile-Hyacinthe-Laennec rolled a piece of paper into a cylinder and pressed it to the chest of a sick patient.  Almost 200 years later, the stethoscope is used by almost every medical provider and has changed minimally from its humble beginnings.  In addition to symbolizing the profession of medicine, it has come to represent an intimate part of the physical exam – when is the last time your primary care physician didn’t listen to your heart and lungs?

But as Drs  Soloman and Saldana point out in their article in the New England Journal of Medicine, ultrasound may prove to be the new stethoscope of health care.  Over the past 50 years, ultrasonography has increasingly worked its way into different parts of medicine.  Much like the stethoscope – the ultrasound is employed by a wide variety of physicians; long a standard tool in obstetrics and gynecology, ultrasound has become the most widely used and cost-effective imaging modality for cardiologist.  ED physicians use ultrasound to perform basic abdominal, cardiac, and obstetric evaluations, and even surgeons use ultrasound during trauma scenarios.  Ultrasound can be used to evaluate the heart, the blood supply, the uterus and ovaries, the liver and biliary systems, and the kidneys.  Ultrasound has become the preferred imaging method for investigating intraabdominal pathology in children (such as appendicities) and pregnant women given the lack of radiation, as opposed to xrays and CT scans.

And much like most emerging technology, ultrasound machines have become smaller, more portable, and cheaper over time.  I’ve even seen ultrasound apps for smartphones – perfect for use in the field or in developing countries with less medical infrastructure.  It’s not too hard to imagine a future where instead of listening to the heart and lungs with a stethoscope, primary care physicians examine the heart with a portable, hand-held ultrasound machine – thus providing a more accurate picture of the patient’s cardiac function as well as a potential billing opportunity and source of income for primary care physicians.

Ultrasound’s advantages – low cost, no radiation, portability – are precisely why the technology has expanded so rapidly in medicine.  Yet ultrasound has a few drawbacks to further implementation, the first of which is accurately interpreting the images (a drawback inherent in all imaging modalities).  Inherent in in the first drawback is the other drawbacks – ultrasound is a skill that needs to be learned.  Currently, ultrasound education occurs mostly during residency, where Emergency Medicine, OB/GYN, surgery and medicine residents learn to use ultrasound targeted toward their own specialties.  Surgical residents are taught how to perform ultrasound exams in trauma scenarios and for certain procedures, while OB/GYN residents focus specifically on gynecologic and obstetric procedures.  More detailed examination of the heart and vasculature often occurs during fellowship training in cardiology or vascular surgery.  And ultrasound technology is extensively taught during residency training in radiology.

In order for ultrasound to become the “new stethoscope” and gain wider implementation, education in the proper use of ultrasonography must begin at the same point where physicians learn how to use a stethoscope – in medical school.  Undergraduate medical education must routine incorporate training in ultrasound in order for the technology to become “point of care”.  We cannot expect all of our physicians to be facile in using ultrasound if we don’t teach all of our “physicians in training” how to properly use the technology.  As Soloman and Saldana point out, a generation of physicians will need to be trained to view ultrasound “technology as an extension of their senses, just as many generations have viewed the stethoscope.  That development will require the medical education community to embrace and incorporate the technology throughout the curriculum.”

the city you live in might determine your health insurance status



The US Census Bureau released figures this week of the uninsured rate in America’s major metropolitan areas.

Seven of the largest metro areas where the uninsured rate was higher than the 14.5% percent national average are located in states that refused to expand Medicaid – 2 in Florida, 3 in Texas, and 1 in Georgia and North Carolina each. The metro area with the highest uninsured rate was Miami, at a staggering 25%, compared to the national low of 4% in greater Boston.

cities people with health insurance

Preventing cancer


When we were growing up, our mothers often told us that we are what we eat.  Well, it turns out that some of us are apparently eating cancer.

The Atlantic made my job incredibly easy when they posted an article yesterday about America’s poor health habits and the association with cancer.  The article cites the American Association for Cancer Research’s new cancer progress report, which noted that roughly 50% of the 585,720 projected cancer deaths in the United States this year are related to preventable behaviors, with smoking being the biggest culprit.  But poor diet and sedentary lifestyles accounted for nearly one third of preventable cancer deaths.

The good news?  Smoking rates in the United States continue to decline, and smoking related cancers also seem to be on the decline.  Obesity rates, however, continue to climb in the US – and their associated cancers are also increasing.  Not to mention that smoking and obesity are synergistic – in combination, the two habits increase the risk for cancer.

cancer personal habits diet exercise smoking



According to domestic violence experts, more than three women a day lose their lives at the hands of their partners.  That means that since the night of February 15th in Atlantic City, more than 600 women have died.  So this is yet another call to men to stand up and take responsibility for their thoughts, their words, their deeds and to get help…. because our silence is deafening and deadly.

~James Brown




Tradition per se has no positive or negative significance.  There are good traditions, bad traditions pilloried in such famous literary stories as Franz Kafka’s In the Penal Colony and Shirley Jackson’s The Lottery, bad traditions that are historical realities such as cannibalism, foot-binding, and suttee, and traditions that from a public-policy standpoint are neither good nor bad (such as trick-or-treating on Halloween).  Tradition per se therefore cannot be a lawful ground for discrimination – regardless of the age of the tradition.

Wisconsin points out that many venerable customs appear to rest on nothing more than tradition – one might even say on mindless tradition.  Why do men wear ties?  Why do people shake hands (thus spreading germs) or give a peck on the cheek (ditto) when greeting a friend?  Why does the President at Thanksgiving spare a brace of turkeys (two out of the more than 40 million turkeys killed for Thanksgiving dinners) from the butcher’s knife?  But these traditions, while to the fastidious may seem silly, are at least harmless.  If no social benefit is conferred by a tradition and it is written into law and it discriminates against a number of people and does them harm beyond just offending them, it is not just a harmless anachronism; it is a violation of the equal protection clause…

- Judge Richard Posner, U.S. Seventh Circuit Court of Appeals in the panels unanimous decision striking down the appeal of Indiana and Wisconsin same-sex marriage bans

What killed Joan Rivers?


This morning, CNN published a story surrounding the death of the hilarious Joan Rivers, who died at New York’s Mount Sinai Hospital on Thursday after undergoing elective throat surgery at Yorkville Endoscopy.  Joan Rivers was laid to rest today with a star-studded funeral in New York City.

Though I have my own thoughts on the subject, we may never know what exactly led to Joan’s ultimate and unfortunate demise, as the medical examiner’s autopsy was “inconclusive”.  But beyond the loss of a powerful and history making female celebrity, Joan’s death brings up two incredibly important points to me as a health care provider.

The first is that we as physicians, particularly those of us who perform procedures, have become the victims of our own success to a certain extent.  We often remark that patients are undergoing a “routine” or “elective” procedure – I have often remarked that a patient is “just having a hernia repair”.  But as the CNN article points out, calling a surgery “routine” or “elective” doesn’t mean it is simple or risk-free.  Every procedure we do has risks, whether planned in advance (elective) or emergency surgery.  Even the most mundane procedures carry risks.

A good friend of mine who also happens to be a resident physician posted the following on Facebook, and I couldn’t agree more.  As a nation and as a medical profession, we’ve collectively done a terrible job at discussing end of life decisions and goals of care.  Melissa Rivers should be commended for following her mother’s wishes.

Since every recent national tragedy results in us needing to have a national conversation (on guns, mental health, race), can we please take Joan Rivers’ death and have a national conversation on goals of care?

Many of us residents have dealt with hundreds of situations like Joan, and from what the news says (I was not involved in any way in Joan’s care), Joan lost her pulse, and CPR/ACLS kept her alive, but she never regained her mental status. Her goals were pretty clear, as she said them on national TV: if she couldn’t be functional (doing stand-up comedy, using her brain), she didn’t want to be kept alive. And it seems her daughter Melissa respected what Joan wanted, didn’t fight to keep her alive – trach’d and peg’d and living in a nursing home for months or longer in a chronically critically ill state with decubitus ulcers and line infections just because she couldn’t let go. They decided to no longer keep Joan’s body alive with life support, as it’s what Joan had said she wanted.

So please, talk to your parents and grandparents about what they want in case of tragedy. Have clear goals. Respect what your family would have wanted. Make a reasonable decision. *gets off soapbox*