What a Dog

Have I mentioned that I like to sing in the shower? Perhaps not. It’s not something I tell everyone. It used to embarrass my kids. They’d insist that there be at least 3 closed doors between my shower and their ears. A lot of good that did—they both know my whole repertoire, down to the third verses. Shower acoustics make all of our voices echo with a resonance that most of us can’t create with our limited breath support and vocal skills. The humidity helps too, along with the hot water that relaxes tense muscles, and the privacy and nudity that disinhibit and free us to experiment and let loose. So what, you say. We all sing in the shower. Granted, but you don’t sing what I sing, and I’d like to share some of that music with you. Relax; I am not extending 6:30 AM invites to anyone. You don’t have to listen to me either. Just take some time to check out the real singers on YouTube using the links below. Smiles and surprises, I promise.

Miss Peggy Lee was born in 1920 in North Dakota. From small town radio to Hollywood clubs, she made it to Benny Goodman’s big band as his featured vocalist. She acted, wrote music and lyrics and continued to perform into her 70s. She has been compared to The Great Gatsby’s Daily Buchanan; “she brings others close to her with the softness of her voice. There’s a creamy warmth to the tone of her voice that gives it a sensually conspiratorial quality”. (Discovering Great Singers of Classic Pop By Roy Hemming and David Hajdu; Newmarket Press, 1991). For me, her voice is cream, honey and sex. Everyone has covered her seminal Fever, including me in the shower. I like to deliver the line, “Julie, baby, you’re my flame”, in a voice that’s a mix of Charlie the Tuna and Andrew Dyce Clay. He’s a Tramp from Disney’s Lady and the Tramp is another of my Peggy Lee songs. She wrote the lyrics and was the voice of that bushy tailed junkyard vixen who made all the male dogs howl (don’t miss the link below). I change “He’s” to She’s and “rover” to big tease. It works for me. She also wrote the Siamese Cat song and was the voice of both cats. I don’t do that one. I’m more of a dog guy.

Another Peggy Lee classic that I don’t do is Why Don't You Do Right (see link). As a guy, there are some songs that just don’t cross over, unless you’re willing to go Outrageous! (classic flick) and do the drag thing. I admit, I do sing Johnny Mathis’ When Sunny Gets Blue and Misty, but I still prefer Jessica Rabbit’s shape to Roger’s. Jessica, by the way, covered Why Don’t You Do Right (see link) vamping to a gape-jawed Bob Hoskins. My jaw dropped too when I discovered who gave Jessica her voice. Believe it or not, it was Amy Irving. She was, you may remember, the girl in Carrie, Yentyl, and Crossing Delancy. She also happened to be married to Steven Spielberg in 1988 when Who Framed Roger Rabbit was released. Spielberg founded Amblin Entertainment. Amblin made Roger Rabbit. I don’t think it was a coincidence that she got the job. And I am absolutely sure that Amy Irving sang in the shower. Not good enough, though. They divorced in 1989.

The last link is for those of you who prefer the real thing to cartoon characters. Cameron Diaz knocked everyone’s socks off in her film debut, The Mask. The body and moves are hers, but the voice belongs to Susan Boyd, a journeywoman singer and actor who you can see in reruns of Happy Days. The wolf in the audience is Jim Carrey who is a cartoon character with or without the celluloid.

Enough words. It’s time for you to get a taste of the Indomitable Miss Peggy Lee and Jessica/Amy/Cameron/Susan doing their thing. Then, if you really want to laugh, picture yours truly singing Miss Lee in the shower. “Fever ‘till you sizzle. What a lovely way to burn”.

http://www.youtube.com/watch?v=cO3hrVaVzP0&feature=related

http://www.youtube.com/watch?v=jdqvX-n25gs

http://www.youtube.com/watch?v=yy5THitqPBw&feature=related

http://www.youtube.com/watch?v=WfjuZVG4wGM&feature=related

With A Capital T

I volunteered to give a Grand Rounds talk to the Stamford Hospital Medical Staff on a topic that is hot in Gastroenterology and has been bugging every GI doc in the US for the past year. The topic is the use of anti-acid Proton Pump Inhibitor medications (Prilosec, Nexium, Protonix, etc.) along with Plavix, a blood thinner that is used, among other things, to prevent clotting of coronary artery stents. Last year a French study said that PPIs could interfere with the anti-platelet effect of Plavix and possibly cause coronary stents to clot off leading to heart attacks and death. That single study, which was done in test tubes, not lab animals or people, was publicized by the news media, embraced by cardiologists and pharmacists, and has caused many doctors to have their patients stop taking PPIs. It has also caused many patients to stop taking PPIs on their own or at least question their Internist, Cardiologist and/or Gastroenterologist. Last November the FDA got into the act and now recommends against the use of both Prilosec and Nexium with Plavix.

I am in the process of deciding how to approach my talk and hope to use you, my readers and friends, as a sounding board to help me focus and organize my thoughts. Let me jump to the bottom line first. Although some PPIs do interfere with the activation of Plavix in the test tube, in real life prospective studies published in the past year, done on people, there has been no increase in heart attacks or death in those co-treated with PPIs and Plavix. The only increase in morbidity (bad stuff happening short of death) or mortality has been secondary to GI bleeding from stopping the PPI. PPIs have been proven to heal ulcers and protect against GI bleeding. If someone has an ulcer or some other GI lesion that could bleed, drugs like Plavix make the bleeding much more severe and difficult to stop. America’s foremost Cardiologist, Eugene Braunwald, the Harvard guy who writes the foremost Cardiology textbook, wrote a paper saying that we should not stop PPIs in our patients who are taking Plavix but rather get back to thinking about preventing GI bleeding. Still, I get calls daily about my patients being taken off PPIs because they have been told the whole class of drugs will cause them to have a stroke, heart attack or die.

Am I the only doctor reading the literature? No, I’m not. I’m going to try not to let my anger or frustration get in the way during my talk. The studies are out there and I’ll present them. That, however, is not enough for me. I’d like to open a discussion on how we doctors do or should respond to new medical studies, all of which these days appear in newspapers, TV news, talk shows and the like. Do we give in to mass hysteria? Do we wait for corroboration or expert opinion? Do we act based on how it affects our income?

Last spring I gave another Grand Rounds, along with a panel that included a cardiologist and hematologist, on the use of blood thinners in patients having GI endoscopic procedures. The PPI/Plavix issue had just started and I was asked for my opinion. What I said was that more study of the topic was needed, as in fact was recommended by the original study’s authors. In the interim, because of the serious question of stents clotting off, heart attacks and death, I said that it would be prudent to use another anti-acid medication if possible and to make sure if a PPI was to be used along with Plavix, that it was being used for a strong indication. Now, a year later I’d like to practice evidence based medicine and tell my patients not to stop their PPI even if they get a new stent and are put on Plavix. Unfortunately, with Cardiologists and Pharmacists, not to mention the FDA, still saying to stop the PPI, I can’t, without creating discord and setting myself up for potential litigation if a bad outcome would occur. I’m facing a tail wags the dog situation where the established untruth trumps evidence and expert opinion. That’s what I’d really like to talk about.

There are billions of healthcare dollars being spent on unproven procedures and treatments. Even when expert guidelines and recommendations exist (remember my mammography blog?), public opinion and inertia and fear and greed rule. I wonder how popular a theme that would be for grand rounds? Better, I guess, to be a team player, give the public what they want and let me and my colleagues keep selling you stuff you don’t understand and can't use—to use a Music Man analogy, expensive musical instruments that you teach yourselves to play by concentrating, Professor Harold Hill’s think system. Friends, we got trouble right here in River City. That’s Trouble with a capital T that rhymes with P and that stands for PPIs and Plavix.

Harold Hill: A man can't turn tail and run just because a little personal risk is involved. What did Shakespeare say? "Cowards die a thousand deaths, the brave man... only 500"?

http://www.youtube.com/watch?v=s60hOgqLFGg

2010, Looking Up

“The best way to have a good idea is to have a lot of ideas.” This Linus Pauling quote was the solution to a recent New York Times Sunday crossword puzzle. I knew when I read it that it would be the inspiration for a blog, I just didn’t know what the blog would be about. As I set out now to write, I still am not entirely sure. You see, I am no genius. For whatever reason, I just don’t have as many ideas as Pauling, a Nobel Prize winner for Chemistry and Peace. Albert Einstein agreed with Pauling. He was passionate about imagination and said it was more important than knowledge. It was his ability to be persistent, and be willing to imagine and fail 99 times that allowed him to be recognized as a genius when, on his hundredth attempt, he succeeded. The more you read about Einstein, the more you’ve got to like him. My joke about sex at 60 is that I’m for it, but you should at least pull over to the side of the road first. Einstein said the same thing in a different way: “Any man who can drive safely while kissing a pretty girl is simply not giving the kiss the attention it deserves”. I wonder what the first 99 girls were thinking.

I do have some ideas. Usually, they come to me at 4 AM. To those of you who have been faithful to PinpointAnalysis, you may remember my Naybob Bobblehead doll. Now that was a great idea. Can’t you imagine how many parents would buy one with their face on it for their kids in college. I’m sure it would be a big seller, especially if it contained an audio chip with a recording of the parent’s voice, “No, no, no!” I’d follow it up with one for the college freshman to balance out the parental advice with some that spoke more to the id. For the guys, there’d be the YeaMeg doll. It’s head would bob in the yes direction only and the recorded voice would be Meg Ryan’s from the Deli scene in “When Harry Met Sally” (see link below).   An orgasmic yes, yes, yes, yes would do it for me. For the ladies I’m still not sure. It would have to be a multidirectional bobblehead, one that could be pushed in any direction. I think I’d leave the audio chip out, you know, keep him strong and silent, or just plain dumb. There would have to be a changeable face option, Antonio Banderas one day, Brad Pitt the next. The problem is that it might be nice to leave out the face altogether, a la Xaviera Hollander’s zipless sexual encounter. I haven’t yet figured out how to make a bobblehead with no face and a tight ass.

Another idea of mine is the Backapplicator. This invention is a long rectangular shammy towel designed to allow sunbathers to apply suntan lotion to their own backs. Utilitarian and feels good too! Imagine kiosks at the beach where you could either buy a Backapplicator or lie down on a massage table and be lathered up like a shoe getting buffed. I’d start this one out in California.

With the New Year approaching some of us reflect on the year, or decade, that is ending. Others look forward to the year to come and make resolutions of all sorts. Einstein said that our main problem is that we have perfected our means to get things done but are confused in our aims. For those of you who are reflectors, I think you’d have to agree. I’m more of a look forwarder. This coming year I’m going to follow the advice of two great Americans, Satchel Paige and Pat Paulsen. Baseball legend Paige said, “Work like you don't need the money. Love like you've never been hurt. Dance like nobody's watching”. Paulsen never won a US presidential election despite trying six times. Still, I’ll aspire to follow his campaign slogan, “I've upped my standards. Now, up yours”.  A very happy and healthy New Year to you all.

http://www.youtube.com/watch?v=F-bsf2x-aeE&feature=PlayList&p=0C96102F6BAD11D0&index=0&playnext=1

Falling Out Of Bed

This blogging gets tougher as the days get shorter. The news media do not have the luxury of a warm den, a leather chair and a hi-def TV with cable and DVR to wallow in (like I do) as the season takes its toll on their affects. They must produce copy to meet their deadlines, deadlines that in the age beyond CNN no longer wait until five PM, but rather exist in real time, ever ready to shake, jolt and revolt us. I have no such constraints and I readily admit, my readers, that it has been two weeks since my last blog-fession.

We are in the midst of Tiger frenzy. A friend asked me to comment in my blog. Pinpoint Analysis is what he may have hoped for, but I’m thinking, these days that, like my brother Bill joked, my postings tends to be not at all analytic, a bit obtuse and written (who said it?) by a pinhead. What, me worry? Heck no. Here goes…

Hiding Tiger, Revealed Transgressions is nothing more than an ancient Greek tragedy. How the mighty have fallen and all of that. It’s Oedipus with his eyes out or the Emperor with no clothes. We elevate our modern heroes up on 90 million per year endorsement pedestals and delight in their falls. For some of America Tiger was more than a king or hero, he was a god. There was a website tigerisgod.com. Forgive me, but I can’t go on without playing the race card. Tiger was revenge. He beat the white guys at their game. He proved yet again, the physical superiority of blacks. He took the white guys' trophies, prize money, endorsement contracts and even their blond Viking goddess. For white America, he made us feel less racist. Corporate America showed us how colorblind they could be… when there’s profit to be made. They turned him into a billion dollar brand. No matter what bad consequences may come as a result of Tiger’s infidelity, if rich blacks, Asians, Jews and women can now be members in formerly white only clubs, I’d say Tiger did good. Without Tiger (and Oprah) there’s no way Obama would be President. They showed America’s power brokers that a black product could be packaged, sold, return a profit and inspire along the way. A shake up like this forces us to face the wide racial divide that still exists in America, and that is good too. Amid comparisons between Tiger and OJ, SNL skits and all of ESPN’s self-righteous pundits telling Tiger how to live his life, my favorite quote was from a black 20 something, who when interviewed on the street, said that he would never have voted for Obama if Obama had not been married to a black woman. That thought had never occurred to me. Of course not, I’m white.

For Tiger and his family, I wish them the best. No one really wants to be, or live with a god. For the rest of us, there’s still a lot of work to be done as a country, and as we all must admit, behind our own closed doors too; as husbands, wives, children, parents and friends. Before the year is over please, someone, get me up out of this leather chair. There’s some holidays and a new year coming. If there’s work to be done , let’s do it together.

Tigger: There's no difference between plunging 10,000 feet to the jagged rocks below and falling out of bed.

Piglet: Oh, really?

Tigger: Sure, haha! Except for the splat at the end they're practically similar.

NEJM -- On Mammography -- More Agreement Than Disagreement

NEJM -- On Mammography -- More Agreement Than Disagreement   


This week’s blog is serious. Please take a few minutes and click on the link above to read the New England Journal article on mammography in women between 40 and 50. Before you start reading, take a moment to recognize and acknowledge your biases. After you have read the article I’d like to discuss some of these issues with you. The issues that come to mind for me are breast cancer, cancer screening, women’s health, health care rationing, the health care crisis, the government’s role in health care decision making, technology and its limitations….there’s a lot to talk about.

In order for an online discussion to take place, you have to use the comments area at the bottom of the blog. You can use your name or be anonymous. If this format works, we can use it to discuss other issues in upcoming weeks. If not, it was worth a try.

Some food for thought:

• In 2009, some 192,370 American women will be diagnosed with breast cancer, accounting for more than one in four cancers diagnosed.

• In 2009, an estimated 40,170 women will die from breast cancer; only lung cancer kills more women. This corresponds to 25 deaths per 100,000 women, down from 35 in 1989.

• Data from 2006 -- the most recent statistics available -- showed that about 2.5 million American women have a history of breast cancer. Most of these women were cancer-free. Others were still undergoing treatment.

• From 2002 to 2003, there was sharp decline in breast cancer rates, particularly for women aged 50 to 69. This reflects the drop in hormone replacement therapy by menopausal and postmenopausal women that began in 2002. Breast cancer rates have remained about the same since 2003.

• Since 1990, breast cancer death rates have dropped steadily. The decline has been greater among women under 50 (3.2 percent per year) than among women over 50 (2 percent per year).

• From 1997 to 2006, breast cancer deaths dropped by 1.9 percent a year among white and Hispanic women, 1.6 percent a year among black women, and 0.6 percent annually among Asian-American and Pacific Islander women. Death rates have stayed the same for American Indians and Alaska Natives.

“The choice is not between health care rationing and some undefined alternative, since there is no alternative. Rather, the choice concerns what principles we will use to ration health care. In the United States, we have traditionally rationed health care in the same way we ration expensive cars: those who can afford to pay for them are those who can have them. The alternative currently being considered in health care reform would involve a shift to other principles, such as those rooted in considerations of fairness, efficiency, and efficacy.” Robert D. Truog, M.D. From the same NEJM issue as the article above.

17% of Congress are women.

The Republican National Committee’s health plan covered abortion for its employees beginning in 1991. When feminists pointed this out this year, the Committee Chairman withdrew the coverage.

Among uninsured women, only 30 percent had a mammogram during the past two years, compared with about 70 percent of insured women.



I am interested in what you have to say!

Cay-ent Get They-uh From He-uh

Dr. PETER AMES GOODHUE, M.D.

Announces His Retirement from

THE PRACTICE OF GYNECOLOGY

Effective January 1, 2010

So reads an announcement on page 7 in Sunday’s Stamford Advocate. An announcement, paid for by the doctor himself. It seems sad, and wrong. In another era this would be front page news with a two inch banner headline. There would be a feature story and additional commentary with testimonials from his thousands of patients, not to mention from the thousands of children he delivered over the past 50 years. But Stamford is no longer a small town and the Advocate is no longer locally owned or beholden to the community. Stamford is a far cry from the back country Maine that Peter loved and brought to the rest of us with his storytelling.

When I began my medical practice in 1987, Peter Goodhue was the President of the Stamford Medical Society. The Society was an organization that met four times a year in local restaurants. There was a brief business meeting, an occasional outside speaker and then a dinner. If there was a speaker, the presentation was always short, sometimes educational, sometimes political but never so intrusive as to distract from the primary purpose of the Society, doctor sociability. Before Christmas there would be a silly card game where winners got free turkeys. Once a year there would be a dinner dance with spouses invited. That era, along with the Society, has passed. Doctors are too busy or ill-tempered to want to socialize with each other. The rubber chicken dinners can’t compete with ritzy drug company seductions at the best restaurants. We have too many other responsibilities and too large a community to relax or be collegial. Peter, however, remains to this day the epitome of collegiality.

He is handsome with a full head of silver hair, a ruddy complexion and an easy smile that brings a sparkle to his Paul Newman blue eyes. He is always well dressed with a trademark bowtie, usually bright colored and flowered. And he speaks slowly in that Maine sort of way. As President of the Medical Society, he would begin his meetings with a story. If you have never heard a Mainer story I encourage you to do so. They are unique regional Americana at its best. They are told slowly with the distinctive “they-uh, he-uh” Maine accent and a Bob Newhart deadpan. Think the opposite of Henny Youngman with his one liners and you have Bert and I—the comedy team that brought Maine humor to the mainstream.

Amazingly, neither Bert nor I, Marshall Dodge and Bob Bryan, were from Maine. They were Yale undergrads with connections to Maine from summer vacations, great ears for dialect and a talent for low rent sound effects. Their original album, recorded for family and friends, went on to sell more than a million copies. They inspired the storytelling of Garrison Keillor (Lake Wobegon Days) and were forerunners to other styles of regional American humor such as southern redneck, as perfected by Jeff Foxworthy.

Excuse the digression, but what native New England story would be complete without one. Peter’s stories went on and on and, if there was a punch line, he never got to it in the first fifteen minutes. The audience of doctors would groan, and then try to hurry him up, and finally shout and heckle to get him to stop so we could eat our dinner. It was of no use. Peter would finish when he was good and ready. Now, after 50+ years of practicing Obstetrics and Gynecology I guess he is good and ready. He is retiring. One story ends and the next one, hopefully just as long and rich with that same Mainer spirit, begins. Q: Have you lived in Maine all your life? A: Not yet.

Sample Maine storytelling at:

http://www.islandportpress.com/BIwhichway.html

A Thing and Two

The sun sure did shine, and I wanted to play,
Still we sat and we sat on that beautiful day.

I sat there with Barbara, we sat there we two

We were waiting for Himes, our new congressman who

Was to talk to us doctors about a new bill

Being bandied about up on Capitol Hill.

We doctors grew restless, we bided our times,

Just who does he think that he is this Jim Himes!

We heard he’d been talking to town halls of late

He was dealing with folks spewing venom and hate.

Though he was a freshman, of little import

Fear mongers set out free discourse to abort.

I cut him a break as I sat and I waited

He just tried to listen and ended up hated.

A bit late and flustered he entered the hall

He looked like an intern who’d just come off call.

He said he was sorry, yes friends, fancy that

A humble young man, not no Cat in the Hat.

He was a bit slim with an oversized collar

He was poised, I believe he had been a Rhodes Scholar.

Retired real young, he said those were the facts.

He made all his millions at Goldman and Sachs.

Now some would not trust one so young and so wealthy

To keep us in health and to make health care healthy.

But me, I believe that a man who’s patrician

Is less apt to be a corrupt politician.

Our own Constitution was drafted you’ll note:

A Pres’dent gets in by Electoral vote.

So back to Jim Himes, what did he then do?

He pulled out of his tall hat Thing One and Thing Two.

No kidding, he said it. He said that Thing One

Was though smoking and drinking and eating were fun

They were bad for us one and thus bad for us all.

And in order to get healthcare spending to fall

It was up to us doctors to somehow arrange

To institute effective life style change.

Thing Two then chimed in with a screech and a shout

Saying docs, pretty soon all our money runs out.

If we don’t all spend less getting sick people cured
We’ll be unemployed and we’ll be uninsured.
Great Britain’s care’s cheaper, Canucks they pay less
It’s spending and costs got us into this mess.

I listened to Himes going on with offenses
And sat on the fence not yet come to my senses.
Did he think that changes in base human nature
Could come from a bill he and his legislature
Would magically cook up and somehow then pass?
Was he bold and enlightened or foolish and crass?

My friends, I’ve no knowledge of mirrors and smoke.
I’m a doctor and sometimes I tell a good joke.
But big steps, they scare me. Small steps they seem wiser
And if to Obama I was an advisor
I’d say be more cautious. Don’t go risking it all.
Take it small step by small step or you and we fall.