Wellness Wednesday: Quantify Yourself

I have always said that knowledge is power. This is especially true in this digital age since we have access to so much searchable knowledge. I have also always said that one of our primary goals in our medical practice is to empower women to take charge of their own health.  It is therefore natural that I am very interested in helping women to empower themselves through the use of technology.

It turns out that one of the most powerful things we can do to take control of and change our own behaviors is to observe, record and track them. This habit is called quantification. People who do this regularly as a part of their self improvement are participating in the "quantified self’ movement. Livescience.com defines the quantified self movement as a “movement which aims to measure all aspects of our daily lives with the help with technology.” 

Quantifying ones habits such as hours of sleep, minutes of exercise, or calories eaten, does not necessarily need to be done with a high tech device. It can be done with paper and pencil. However, since smart phones are nearly ubiquitous, these records are most often kept on these small powerful personal devices.  Of course there is a proliferation of different apps for this, one for every topic and several for many parameters. Not only is there a proliferation of different software apps to help with quantification, there is a proliferation of different hardware such the Apple watch and the FitBit. 

If the patient and I decide to follow some detail of her health such as her blood sugar, we begin some sort of record keeping. The patient makes the measurements, records them and naturally evaluates them herself as she goes through the week. This alone often results in substantial improvement in her numbers, since she can begin to discern patterns and the reasons behind them. Taking measures to push the data toward better performance is gratifying day by day. It becomes like a game that the patient is determined to win. This is called ”gamification" and it too, it is powerful in behavior change.

When the patient comes in to review her data, she can get even more benefit when we analyze her data together. If we add another layer such as her diet, and superimpose it graphically on the blood sugars in her records, we can see a cause and effect relationship between what she eats and her blood sugars over time. Sometimes a third layer of data such as activity can be added into her records and we can use this variable to improve her blood sugar control even more. 

This kind of record keeping puts the facts and the control in the hands of the patient. It is much more effective than a doctor simply telling her to eat better and exercise more. It has been my consistent observation that all sorts of patients have success with this type of approach. Moreover, in reading about this "quantified self movement" it seems apparent that this technique can be used for many types of conditions, like weight, exercise, autoimmune activity, sleep problems and even mood disorders. It can also be used for broader issues of life performance, in relationships and on the job. 

I hope this introduction into the quantified self movement has inspired you to learn more. Here are some fun references which makes for very interesting reading.

The Quantified Self, a TED talk by Gary Wolf

The Quantified Self at Livescience.com

The Beginners Guide to Quantified Self, at Technori

Why You Should be tracking Your Habits ( and how to do it well) at Lifehacker.com

The Quantified Self: How Cold Hard Data Improves Lives, at Bloomberg.com

The Data Driven Life, at the New York Times 

How Self-Tracking Apps Exclude Women, at The Atlantic

Medical Monday: Skin Deep

What does it take to be beautiful ? I mean physical beauty. It it feels so awkward to even ask this since, in general, beauty is mostly a matter of the heart.

 You might be surprised to hear about my idea of physical beauty. Basically, to me, physical beauty equates with health. Every face, every age, every body type, hair type or skin color is beautiful when it is healthy. 

Skin is especially telling. It is the first thing we see. The skin of the face is vulnerable and worthy of our protection. It is sun season again, and I would love to see everyone take pride in and care of their skin. 

What are the main steps to beautiful skin ? 

• Optimize your fitness, nutrition and hydration. 
• Cleanse and moisturize twice per day. 
• Exfoliate once per week.
• Sun (UV) protect ardently. 
• Never tan. Never. 
• Be assured sunscreen is safe.
• Chose a broad spectrum sunscreen with SPF 30 or greater. 
• Chose a water resistant brand. 
• Apply 15 minutes before going out so it will soak in. 
• Reapply every 2 hours. 
• Consider a hat or SPF clothing. 
• Get a partner to "watch your back" for any suspicious moles. 
• See your dermalogist for any concerns. 
• Enjoy summer. 
• Be beautiful. 

Wellness Wednesday: How to have a Healthy Argument

I would like to say that couples and families can get to a point where they do not have arguments. However I believe that is unrealistic. Instead, I would present to you a list of rules which will help the arguments that do occur be fair, responsible and healthy. 

Click HERE to learn more.

Medical Monday: Gardasil Gets an Upgrade

Most of you are familiar with Human Papilloma Virus, aka HPV. This is the very prevalent virus which causes precancer and cancer of the human anogenital area. When I first started training in gynecology, fighting HPV seems like such an uphill battle, since it spreads so easily and is so prevalent. And then came the idea of a vaccine. It seemed too good to be true. 

Gardasil was developed and released. I am proud to say one of my friends was involved. It protects against two strains of HPV known to cause cancer, and two which cause condyloma or warts. Physicians all over the world rejoiced, but adoption rates weren't what we had hoped. 

Gardasil was initially studied in girls and women since the disease caused in women is more common and more severe. And so it was initially approved only for women. I got all my children vaccinated, and even the boys before it was approved for boys. One of my sons did some research after he got his shot, and approached me later, asking, " Mom isn't this just for girls ? " I reassured him that nothing bad would happen. It works just as well in boys and men, who distribute the virus, usually without having any disease themselves.  It eventually was approved for boys. 

Now Gardasil has been expanded to cover NINE viruses ! It is worth noting who is eligible to receive it: 

Boys ages 9-15.

Girls and women ages 9-26. 

 I expect that the age differential in eligibility between boys and girls is simple a case of what groups have had validating studies done, and I anticipate that the boys group will be expanded to the same age group as girls eventually. 

Chilling statistics anyone? 

" In 2013, coverage of at least one dose of HPV vaccine was 57.3% among adolescent girls and 34.6% among adolescent boys2. According to the CDC, for every year that coverage does not increase, an additional 4,400 women will develop cervical cancer3. Furthermore, if health care providers increase HPV vaccination coverage to 80%, it is estimated that an additional 53,000 cases of cervical cancer could be prevented during the lifetime of those younger than 12 years." 

reference: ACOG Clinical Practice: The 9-Valent HPV Vaccine 

Gardasil has had a very good side effect profile, with just some arm soreness at the site. We believe its benefits far outweigh the risks. 

To learn more about HPV, please see Pap Smears, HPV and Cervical Health. 

Medical Monday: C Section Delivery

Do you know about VBAC, TOLAC and RCS? Obstetricians love acronyms. The website section about C sections has been updated and expanded to include a comprehensive section on VBAC (vaginal birth after C section), TOLAC (trial of labor after C section) and RCS (repeat C section). Go to the general C section page, then scroll down to the part on Repeat C sections and VBAC.  

Click HERE to learn more about this hot alphabet soup. 

Structure Sunday: Labor and Vaginal Delivery

Two thirds of American women will delivery vaginally. It varies, state by state from a high of about 40% to a low of about 23%. What accounts for this? Although the matter is complex, suffice it to say it is all about the labor. When we follow the course of a labor, we are following many things: cervical dilation in cm, effacement, and the descent of the baby into the pelvis. We are also tracking the contraction pattern as well as the fetal heart tracing and maternal vital signs. 

To learn more about Labor and delivery, Click HERE. 

Wellness Wednesday: Induction of Labor

Induction of labor is a hot topic. Some patients are dead set on avoiding it and some are begging for it. Induction of labor simply means using medicinal or mechanical means to start labor before it has on its own.

Inductions may be elective (by choice) or medically indicated. They may be accomplished by a variety of medicines and techniques. Induction of labor is an important tool in the Obstetric tool box.

Get a balanced perspective on induction of labor HERE. 

Wellness Wednesday: Knowledge is Power. Get some.

I recently finished and published the website's pages on Infections in Pregnancy. At the bottom of those pages, I have added that much again in a new section called "Other infections of Perinatal Significance". Now this may sound way too scientific and unrelated to daily life, but nothing could be further from the truth. These are the big time everyday infections we hear of each week: Pertussis (whooping cough), Bacterial Vaginosis, Toxoplasmosis, Influenza, Herpes, Chicken Pox, and more. Learn more about these common infections and how they pose special risks to pregnant women. Learn what you can do to protect yourself and those around you. 

And, also coming tomorrow, will be a special section on Preterm Labor. Learn the facts and figures as we know them, and how we handle Preterm Labor today. Hint: It is not how we handled it even 5 years ago. 

Medical Monday: Another Obstacle to Health Care: Anti-science

What does vagina steaming and the recent measles outbreak having common ? Need a hint ? OK. What can make people on both sides of the political spectrum mad ? You guessed it ! The anti - science movement. 

According to that venerable site rationalwiki.org, anti science 

" refers to persons or organizations that promote their ideology over scientifically-verified evidence,[3] usually either by denying said evidence and/or creating their own." 

Recall that science is advanced through the scientific method, which involves testing hypotheses with experiments, then revising said hypotheses. Experiments should be on done on that which is measurable, done blinded, controlled, and should be reproducible and peer reviewed by the appropriate scientific institution. Science is always undergoing a process of refinement based on observable facts. 

This should be clear. Yet the media and advertising to which we are daily exposed has become a brew of fake science and real science. How is a person to know the difference ? Well you can use your gut feeling of course. ( And I have a bad feeling about vagina steaming.)  Or, you can have a look at my section of this site where I try to give some help on this issue. It is called Information and Learning. I try to give you some tools with which to navigate the information stream coming at you every day. 

Let's look at some hot news topics where anti-science is in play: climate change, genetic engineering, vaccines, juice cleanses, GMO food, stem cell research, and yes vagina steaming. These topics are especially hot in election years, and when money is involved. 

Here is a great article in Scientific American about a science quiz given to presidential candidates 2012. 

Click here to either laugh or cry. 

Here too, is a fair handed look at anti-vaccine sentiment on both sides of the aisle from Slate. 

Here is fantastic compendium of articles from various writers on the anti-science movement from Huffington Post. 

I would like everyone to take a charitable look at the nature of our national dialog. Feelings are running high, especially in the wake of the recent measles outbreak. In this climate, where there are many voices clamoring to be heard, let us keep the dialog civil and ahem, scientific, whenever possible. 

In that spirit, I will share with you an article about one of my favorite most well intentioned celebrity health gurus, Gwyneth Paltrow. Don't get me wrong, I love Gwyneth. Her site, Goop.com is full of lovely recipes and pretty unaffordable clothes. She has a holistic approach and a lovely positive attitude which really does count for a lot. HOWEVER, I cite this article below to show that sweet well intentioned people can get it wrong. Enjoy, and remember that laughter and affection are the best medicines. 

Three Reasons You Definitely Shouldn't Get Your Vagina Steamed , from Women's Health 

Medical Monday: Evaluating Medical Reports in the Media

Everyone is interested in medical news. It is inherently sensational. But, it is challenging to report, and even journalists with the best of intentions have a hard time getting it right. 

When an intelligent patient comes to the office and spends 15 minutes with her doctor, and the doctor goes through a detailed explanation, under the best of circumstances, only part of that will be correctly remembered. Here are some links if you are interested in reading more about that : 

How Much Can Patients Learn in a 15-Minute Doctor Visit?

New Prescriptions: How Well Do Patients Remember Important Information?

Long term clinical trials: how much information do participants retain from the informed consent process?

The difficulties are on both sides. Doctors have crammed schedules. They aren't always the best of communicators. Sometimes the doctor and the patient have differing agendas for the visit. And the patients are often distressed about what they hear, which impairs understanding and memory. 

Consider classroom learning. I need to hear things and be thinking about them, take notes, see diagrams about the topic, get handouts, look it over,  and repeat it all before it is really ingrained. This type of thing is also what patients need to understand a topic. They know this and so they head for the internet. That's where it gets exciting. 

Since I am in the process of building a website for patients, I have been researching other doctors' websites. They range from the sublime to the ridiculous. Most of the sites have some useful information. However too many of them contain unfounded claims and conflicts of interest by way of selling unproven remedies. In many cases the remedies involve foods or supplements which in limited lower quality studies, showed promise, but were never followed up or proven. 

I will highlight perhaps the most prominent of these internet doctors, Dr. Mehmet Oz. With the most impeccable of academic credentials, and a media empire to boot, he is under serious fire for making unsubstantiated claims and hawking unproven products. The best documentation of this to date is through Vox Media, what I would call the thinking person's news network. Until I read the series of articles at Vox, I had no idea, since I do not have a TV. Check out this entertaining and informative debate here. 

Meanwhile, if you would like to read more about how to safely navigate the internet, check a  series of pages on my site, starting HERE.  There are lots of internal links so be prepared to click. I really put my heart into these pages since I believe strongly in freedom of information and the patient empowerment movement. I hope they are beneficial for you. 

Medical Monday: Increasing concern over narcotic pain medications

The Flathead Valley has a problem with narcotics. I am told this is not unique to our Valley. I never thought I would have this much first hand experience with narcotics, even heroin. 

Problems with narcotics affect our women of childbearing age. Narcotic use in pregnancy is associated with low birth weight, preterm labor, SIDS and several major birth defects, as well as a lengthy neonatal withdrawal. 

Narcotics are a class of drug which acts in our body though our body's own neurotransmitter and receptor system. We have many neurotransmitters, tiny molecular messengers that allow us to feel sensations and even emotions. Neurotransmitters like dopamine bind, lock and key style, to specific receptors in nerve cells and set off a reaction which make perception possible. 

Narcotics also fit these nerve cell receptors. While bound at the receptor, narcotics can block pain and simulate pleasure. That is why they work, and that is why they are abused. 

If only that were the whole story. You see, when a narcotic binds at the receptor, it stimulates an electrical potential, or pulse, down to the end of the nerve cell, and there another neurotransmitter is secreted, further conveying the signal. If there is constantly narcotic at the receptor, the molecules at the other end get depleted and the system no longer works. 

The patient initially experiences relief with use of the narcotic. If too much is used for too long, it begins to no longer work. Worse still, more drug barely produces the feeling of being at baseline. No drug comes to feel worse than bad; hideous, in fact.  More and more needs to be used to even feel baseline. This is the basis of addiction. 

Patients, caregivers, and bad luck are responsible when things get out of hand. It is always easier to give or take a pill than to treat, cure, or work on things. Physical methods like exercises and therapy take time and are not always perfect. Surgery is expensive, and not always the answer to pain. Other nonnarcotic medications may be partial solutions. 

Life can be hard and confusing. Well meaning people can slip unknowingly from using pain meds to treat real pain, to using them to treat other things like withdrawal, anxiety, or their ability to deal with life. Those of us who care about these people need to start from a place of knowledge and compassion. No one really signs up to be miserable. 

MEDICAL MONDAY: The medical facts behind helmets and skiing.

This article is written in honor of my brave niece who is recovering from a ski accident. 

She is very athletic and very experienced. She is not reckless, and was wearing a helmet. Nonetheless, she caught an edge, lost a ski,  flew out of bounds, hit a tree, lost consciousness and went down a tree well. Luckily, a patrol just happened to be skiing right behind her and dashed down after her. She and my sister in law, who nearly passed by the single ski on the trail, hauled her out, and our awesome Alert Helicopter evacuated her. Her helmet suffered a big gash. She got a concussion and some hairline spine fractures. People keep saying she is so lucky that that she was wearing a helmet. 

It wasn't luck. The data and recommendations are crystal clear and their family follows them. I have summarized them here for you. They come from a review article which was published in the Journal of Trauma and Acute Care Surgery in April of 2014. This review combined the findings of 16 prior well designed studies which examined the effects of helmet wearing on both skiers and boarders. Here are some of their key findings: 

• Injuries in boarders are more numerous and more serious.
• Incidence of injuries are higher in males, and those under 17 years of age. 
• A 1996 study showed the average inpatient cost of a skiing or boarding injury to be $22,000.
• There are 600,000 ski and snow boarding related injuries per year in North America.
• About a fifth of these are head injuries.
• About a fifth of these head injuries are severe enough to cause loss of consciousness of concussion.
• That's about 24,000 people per year losing consciousness or having a concussion with their head injury.
• The 16 studies collectively showed anywhere between a 30%-60 % reduced incidence of head injury while wearing a helmet. 
• They also showed decreased incidence of loss of consciousness upon striking a fixed object while wearing a helmet. 
• Wearing a helmet is not associated with increased rates of other injuries, poorer responses to stimuli, or riskier behaviors. 

The authors concluded that helmets should be strongly recommended and that policies should be put into place to promote their usage. 

My niece is going to be fine. But she has a few challenging weeks ahead of her. She will miss her finals, miss her sports, and end up with lots of physical therapy and doctor visits instead. We are just grateful she is with us and, and still moving and smiling. 

Medical Monday: A plague of pyelonephritis !

I don't know about other professions, but in medicine there is an old intern's tale that things come in threes. It can be ectopics, miscarriages, twins, or this last week : pyelonephritis. Pyelonephritis is infection in the kidneys. It's awful. But good news: it's easy to diagnose and treat. I might add, it's easy to prevent. 

What is it and how can it be prevented ? To start thinking about kidney infections, think first about bladder infections. They are very common. Women get them because their urethra is all of about 3 cm long and the bacteria in the area can ascend quite easily. Whenever there is irritation or dehydration, infection has a chance to set up.

An undiagnosed or neglected bladder infection simply ascends up the urethra to the kidney, and if the patient is dehydrated, run down, or otherwise compromised in some other way, she can develop a kidney infection. Forms of " other compromise"  include, but are not limited to, kidney stones, other illnesses or pregnancy. 

Bladder infections have the symptoms of burning, urgency, or difficulty voiding. They are diagnosed by symptoms and a dip test. They are easy to treat with tablets taken by mouth and generous hydration with water. 

Kidney infection symptoms are more systemic, including fever aches, nausea, and backache. These infections are deep within the body and have gotten through several defenses. They require IV antibiotics or shots, and good hydration. If a pregnant woman gets a kidney infection, she must be admitted to the hospital, usually for a few days. Pyelonephritis is linked with preterm labor. 

How can we prevent kidney and bladder infections ? First and foremost, hydrate well. Women need 2 liters of water a day, and pregnant women need 3 liters per day. A good rule of thumb is to keep your urine looking nearly clear. Urinate after sex. Keep yourself well rested and in a good general state of health. Finally, don't wait to call in if you think you might have a bladder infection. If you wait too long, you could get pyelonephritis. 

Wellness wednesday: Sleep and how I am not doing a good job of it.

I try to model the health behaviors that I teach. But this is one area where I am falling short of my goals. I simply do not engineer enough sleep into my schedule. I am writing about this now to put this whole sleep situation under a microscope and see what I can learn. 

Here are some important and interesting facts about sleep:  

Sleep affects mood, memory, performance and metabolism. 

Lack of adequate sleep contributes to obesity. 

Most people need between 7.5 and 8.5 hours per night though the range is 5-10. 

There are distinct sleep types called owls and larks who keep late and early hours, respectively.

Serious sleeps problems can lead to mental health problems. 

Drunk and drowsy driving are equally dangerous. 

Wow ! It seems we need to take sleep more seriously. Now more that ever sleep science is a well developed field and is often practiced within the department of Neurology. Furthermore, Sleep Medicine is a well defined field  providing diagnosis and help for those in need.

There is a great deal that we ourselves can do to improve our own sleep: 

According to the National Sleep Foundation at sleepfoundation.org, the following are a few  " Healthy Sleep Tips " :

1. Have consistent wake times and betimes, 7 days per week. 

2. Have a consistent and relaxing bedtime routine, just like for a child !

3. Avoid all but short naps in the day. 

4. Exercise to cardio levels every day. 

5. Make your bedroom cool, quiet and  dark. 

Patients often tell me they cannot sleep because their mind is busy with all their stresses, challenges or projects. I think it is helpful to address these briefly as a written list before the bedtime ritual begins. Then they are dealt with in a constructive way, and thinking about or dealing with the items can be "rescheduled " for the next day. 

I realize that I have been thinking about sleep as almost a dispensable luxury. However it is actually a health requirement. Newer research indicates sleep drives the metabolic clearance of the brain. In other words, waste products are cleared from the brain during sleep. 

My education, training and profession have trained me to disregard this need, and I realize a little perspective is in order. I am very enthusiastic about other health habits like exercise and nutrition. Thus, I have decided to reclassify sleep from " waste of time " to health habit. I have also played with tracking my hour of sleep. In this way it becomes a goal to shoot for, and I become more determined to meet the goal once I have set it,  a strategy like this makes it like a game. This is called " Gamification". This gamification will become easier with new devices and apps coming on the market. But all you really need to make your sleep better is some information and a decision to take action. 

Medical Monday: Infections by the numbers

Ebola is on everyone's mind. Worldwide the death toll is approximately 2000 people most of whom were in West Africa. People are not aware that it is not easily spread. The odds of getting it in United States are vanishingly small. Sadly there is not yet any vaccine for Ebola. 

To put the death toll from Ebola into perspective consider these numbers: 

9,700,000 children under five per year die from  preventable disease.

250,000 per year,  probably more from flu or flu related complications. 

100,000 per year die of measles of cholera 

1,500,000 per year die of diarrheal disease

Now let's consider our little corner of the world, Montana. Flu season officially started at the end of September. This year Montana has had 5 confirmed cases so far. However, in the previous reporting year we had a total of 3192 cases, 313 hospitalizations and eight deaths that attributed to influenza, with the bulk of cases being in December and January. 

What about Montana's other common preventable infectious disease ? It's Pertussis of course. It is also known as whooping cough. However in the previous reporting year we had a total of 661 conference cases. There were 361 hospitalizations and 15 deaths, mostly of people over 65.

Our scourges, flu and pertussis,  are vaccine preventable diseases. What about theGuillain-Barr syndrome (GBS) , or temporary paralysis ? It too has been studied and it's incidence in the US is around 3000-6000 cases per year whether or not a vaccine was or was not received. It has been determined that one is much more likely to get GBS after flu than after a flu vaccine.

 As I look at the disease rate time charts for prior seasons of each of these vaccine- preventable diseases, I see that we are right ahead of the big bumps in numbers of cases. I hope we get ahead of the curves this year. Pertussis and flu vaccines are available everywhere now. 

A letter to my California friends about Montana, guns and culture

Last night we attended a lovely reception for my aging in-laws in honor of their long patronage of Western art. We viewed everything from Charlie Russell paintings to traditional doeskin dresses. How fitting then was it that the reception was held at a shooting club. Entertainment included the shooting of trap. I was captured in photo while shooting, and Echo my daughter declared the image Facebook worthy. But a concern rose in my mind, so I wrote this letter. 

Dear California friends,

We Montanans stand with you in your grief and outrage at the recent violence in Santa Barbara. We share your concerns about gun safety. As my daughter posts these photos of me shooting. I am concerned you will consider it insensitive in light of the recent tragedy. So I offer the following thoughts.

I think these type of photos are apt to translate very poorly on the current national stage.   It is not difficult to confuse issues of guns in California, guns in the tragedy versus guns in Montana at a shooting club. I want you to know I have given it some thought, on whether I should, out of sensitivity, ask Echo not to post pictures from the party. I decided rather that I would let happen what would naturally happen, especially since her posting is out of a sense of pride and celebration. 

Something up here in Montana feels naturally resistant to violence of that particular nature. Sure we have our rare crazies like anywhere else. Up here though they more often than not leave society and hole up in the mountains. Observing more generally, one finds there is a modicum of knowledge and more importantly a code of honor associated with firearms that has not exported to more urban places with weapons. Perhaps this is related to how we educate our kids. Hunter's Safety is taken here by the majority of kids when they turn eleven. It is several nights a week for several weeks, conducted by Fish Wildlife and Parks together with the schools. It is a really big time investment for the parents and kids and a colorful community rite of passage. There is a small but important book given to every person during the program. It is called " Beyond Fair Chase" and it is about the ethics and traditions of hunting.  Consider having a look. 

Beyond Fair Chase: The Ethic and Tradition of Hunting

$5.36

By Jim Posewitz

Buy on Amazon

Maybe the secret sauce is the social cohesion all this engenders. Here, guns signify responsibility and together with hunting, and a bit of independence. At the same time, hunting means family time, gatherings of friends and magnificent meals. 

Hunting culture teaches several other things worth mentioning. It puts one deep into nature, illuminating both its grandeur and intimacy. It requires teamwork, planning, patience and perseverance. It makes graphic the power and potential violence of weapons and hints at the horror of war and crime. Lastly, It brings ordinary people close to loss of life. I have heard more than one cold wet, weapon burdened hunter come in and wonder how war or massacres could have ever taken place. In this setting, hunting seems to sensitize us to these realities, rather than desensitize. People, nature, life and death are brought into close juxtaposition and we come to understand them better. 

I feel Montana voices are especially important in the discussion on weapons related violence. It is my hope that lessons from hunting culture can contribute something toward making cities safer.

Sincerely, 

Gina 

California girl transplanted to Montana