E Cigarettes

Harm reduction is a term we use often in both medicine and public health. The idea is a simple one: rather than offer one smack-down solution to a risky behavior (i.e. "Stop that"), we offer modifications to that behavior that are aimed at reducing bad outcomes (i.e. "If you are going to do that, let's help you do that more safely"). Those of us who are parents use a hybrid of the smack down and harm reduction on a rotating basis.  For example, in certain circumstances, we might find ourselves saying, "I am sorry, little dude, you are never ever allowed to jump off that curb on your skateboard into the street again."  But in a slightly different version of events, we may also find ourselves saying,"Okay, if you are going to keep jumping off the curb, let's at least get you a helmet and wrist guards, and please pick a curb that isn't a death trap."

http://constructbirmingham.files.wordpress.com/2010/03/kid-skateboarding3.jpg

Examples of harm reduction supported by current public policy include exchanging needles for people using injection drugs (to prevent the spread of HIV and Hepatitis C), supplying sex-workers with condoms (to prevent the transmission of sexually transmitted diseases), and teaching adolescents to use designated drivers when out drinking (to prevent accidents). These approaches are very different from the 'just say no' smack-down approach, and for some people, the idea of doing anything that supports peoples' bad behaviors rubs them really wrong. Crazy wrong.

Opponents to harm reduction argue that in tolerating risky behaviors (e.g. injection drug use, underage drinking), we send people the message that these are acceptable behaviors, and in framing the behavior as acceptable,  more vulnerable populations (e.g. children) will be initiated into those behaviors. Supporters of harm reduction argue that we must diversify our methodologies: avoidance of risky behaviors would be ideal, but it is essential to have options that can improve safety even if those options do nothing to extinguish the actual behaviors.

In my role as a family doctor, I have learned that if I don't consider the possibility of middle ground, I often find myself stuck in the same place (and all alone)-- this is particularly true with patients who aren't able or ready to make the changes that I am asking them to make. Then I fail. And so do my patients. So, right here, right now, I will confess that it's not entirely outside of my clinical repertoire to condone one of my alcoholic patient drinking a single beer every other day or my diabetic patient eating an occasional bowl of ice cream. Yes, you heard me right, harm reduction is in my bag of 'doctor tricks'.

This brings us to the latest harm reduction debate: E-Cigarettes.

http://www.ecigaretteuser.com/wp-content/uploads/2012/12/what-is-an-electronic-cigarette.jpeg

E-Cigarettes (short for "electronic cigarettes") are battery-powered devices that deliver nicotine not through combustion or smoke, but rather through vaporizing or "vaping". Basically, a battery powers a heating element, which vaporizes a liquid solution (aka E-juice). E-juice usually contains a combination of  propylene glycol and/or vegetable glycerin, and/or polyethelyne glycol 400, some flavors and some varied concentration of nicotine (see box below for more specifics on these ingredients).

Most E-cigarettes are designed to look and feel like a 'real cigarettes', including the experience; the user actually gets a hot puff of gas when he/she inhales and sees a puff of vapor (not smoke) when he/she exhales. Some taste like a favorite brand.

There is no nasty smoke for a neighbor to inhale, no stink on your smoking jacket, and few official regulations. In fact, currently there is no federal or California law that restricts where people can use e-cigarettes (see this link for more details). In stark contrast to cigarette smoking, which is highly regulated, you can actually use e-cigarettes in most public places, like the airport, a restaurant, or even your doctor's office. Local jurisdictions can impose restrictions by adding e-cigarettes to their local definitions of "cigarette smoking", but many have not yet done so. 

"Starter kits" cost between $50-70 online, e-liquid refills cost around $2.50 for a 30mL bottle. Informal research shows individuals on average "vape" between 2-5ml/day, making e-cigarettes significantly cheaper than a pack per day habit of cigarettes (under $1/day for E-juice versus $6.45 for a pack of cigarettes in California).

I have several patients-- all long-time cigarette smokers-- who LOVE the e-cigarette alternative: many have never successfully quit tobacco, and they feel strongly that vaping is a healthier alternative to smoking. They spend less money on e-cigs than 'real cigarettes', they cough less, they stink less, and the world isn't nearly as annoyed with them and their vaping as they are with their cigarette smoking.

In fact, just this week, one of my e-cigarette smoking patients (with a history of smoking 2 packs per day for the last 40 years, now switched entirely to e-cigarettes) pulled one out and puffed right in front of me. I would have had no idea that anything happened if I hadn't been sitting there watching him do it.

Contents of E Cigarettes
Propylene glycol	A man-made liquid substance that absorbs water. Officially per the FDA, "generally recognized as safe" rating in food (GRAS), used as preservative in food, tobacco products, a solvent in drugs. But also found in antifreeze and solvents. More info here.
Vegetable glycerin	Made directly from vegetable oil (usually coconut, palm), used in manufactured food for sweetness, to keep things moist, also moisturizers (cosmetics), herbal essences, and common in cough medicines
Polyethylene glycol 400	Low molecular weight version of polyethylene glycol, often used industrial compound found in many consumer products, including automotive antifreeze, hydraulic brake fluids, some stamp pad inks, ballpoint pens, solvents, paints, plastics, films, and cosmetics.
Nicotine	A toxic colorless or yellowish oily liquid that is the chief active constituent of tobacco. Acts as a stimulant in small doses, but in larger amounts blocks the action of autonomic nerve and skeletal muscle cells. Nicotine is also used in insecticides
Water	You know what this is!

Is this all creepy or awesome?

Depends on who you ask.

The Federal Drug Administration (FDA) and other public health agencies want e-cigarettes regulated. Initially, the FDA tried to block the sale of e-cigarettes entirely in the US, claiming that they were unapproved "drug and drug delivery combinations". E-cigarette manufacturers successfully challenged the FDA's position in court, and e-cigarettes were allowed into the US market in 2007.

Interestingly, e-cigarettes were not originally manufactured or distributed by the tobacco industry; in fact, they were invented in China in 2000 (legend says the pharmacist inventor's father actually died of lung cancer, and he was looking for an alternative to tobacco) and were direct competition with big tobacco when they arrived on the US market.  However, this year, three big tobacco companies have joined the mix and are now marketing their own e-cigarettes (see this story). 

Phew, thank goodness! I was starting to convince you (and myself) to actually like e-cigarettes. Now that we have big tobacco involved, things are automatically creepier. No doubt about it.

In 2010, a federal appeals court held that e-cigarettes could be regulated by the agency as tobacco products rather than as drugs or drug delivery combinations. Because e-cigarettes are now labelled as tobacco products, state and local governments officially have the authority to regulate the them under the Family Smoking Prevention and Tobacco Control Act. This means, for example, that it is prohibited to sell e-cigarettes to minors. Most recently the FDA is also threatening a ban on selling e-cigarettes on line.

The FDA would prefer that e-cigarettes be officially considered a "tool for smoking cessation" and/or nicotine replacement (i.e. things people use quit or cut back on smoking, like nicotine patches or nicotine gum) because this labeling would make the companies liable to FDA oversight. But e-cigarette companies are super duper smart--and a little slippery. They make no claim anywhere that e-cigarettes are designed to help people stop smoking. Instead, they offer e-cigarettes as a "recreational alternative" and  "safer alternative to smoking cigarettes" and/or "designed to be specifically used in places where people are not allowed to smoke" (increasingly in public places, airports, etc). This way, they skirt the FDA's oversight power. Hmmm. . .

States and local jurisdictions are definitely getting hip to the situation and are passing their own regulations. For example, in 2013 New Jersey enacted a law becoming the first state to prohibit the use of e-cigarettes in indoor public places and workplaces. King County, WA passed a similar local law. In 2012, the state of Oregon passed a law prohibiting the use of tobacco products (including e-cigarettes) in state agency buildings and on state agency grounds. The US Department of transportation banned the use of e-cigarettes in airplanes. Thanks!

What are people worried about?
As far as I see it, people against e-cigarettes have three basic objections:
1) E-cigarettes are inherently bad
2) E-cigarettes are an open doorway to 'real cigarettes' and other tobacco products (which are inherently bad)
3) There is so much money involved, the e-cigarette industry is booming (over $1billion last year, expected to triple this year to over $3 billion), and if there is that much money involved, something bad must be happening.

Well, are they that bad? I already told you what was in them (see box above), and they definitely seem less bad than cigarettes. But do we really know how bad they are? Many anti-smoking groups argue that just because there is not data showing e-cigarettes are safe doesn't mean they are actually safe. Possibly true. Everywhere you look, the powers that be say "this has not been studied". Well, true and not true.

A paper published in 2011 by the Journal of Public Health Policy set out to review the current information on e-cigarettes at the time. Much to the dismay of many health agencies in town, they concluded the following fairly convincing arguments that e-cigarettes may not be so bad after all:

1-There isn't much dangerous in e-cigarettes. As of 2011, more was known about the contents of electronic cigarettes than we know about the chemicals in tobacco cigarettes. As of 2011, sixteen studies had been done characterizing the contents: propylene glycol, glycerin and nicotine. The two agents the FDA has expressed most concern about tobacco-specific nitrosamines (TSNAs)  and diethyelene glycol  (DEG, a toxic agent found in antifreeze and breaks down to toxic agents). TSNAs, one of the main classes of cancer-causing agents known to be in tobacco, were found trace amounts, equivalent to that found in the nicotine patch and orders of magnitude lower than the TSNA levels found in cigarettes (500-1400 fold reduction). In addition, DEG was found in only 1 of 16 studies. Definitely concerning to find DEG at all in the e-cigarettes but hardly an overwhelming problem. Perhaps the presence of these chemicals has been exaggerated?
2-E-cigarettes may actually decrease tobacco craving. There is a small study showing that e-cigarettes may decrease the quantity of cigarettes and aid current smokers in smoking cessation (shhh, manufacturers don't want this word out). Another small study showed evidence that e-cigarettes reduce tobacco cravings.
3-Carcinogens are present in only trace amounts. A direct quote: "Thus far, none of the more than 10,000 chemicals present in tobacco smoke, including over 40 known carcinogens, has been shown to be present in the cartridges or vapor of electronic cigarettes in anything greater than trace quantities."

In addition, most anti-tobacco groups argue that smoking e-cigarettes is a gateway to smoking other cigarettes and tobacco products. This correlation has not been studied (yet), but it's probably a reasonable concern. The e-cigarette industry has come under fire for marketing techniques around e-cigarette flavoring (chocolate and strawberry, seem quite enticing to young people). Additionally, opponents also worry that the mere action of vaping an e-cigarette simulates the habit of smoking (in contrast to nicotine replacement like gum or patch, which is entirely different).

http://www.e-cigarettepedia.com/wp-content/uploads/2009/03/ecigpedia-illustration-2-1006x1024.jpg

What do I think?
I will take a tripolar stance on this one. All are equally valid:

Opinion #1, My smack down: People should not ever ever ever start smoking or vaping cigarettes of any type. Smoking is gross and addictive and dangerous and does nothing to make humans healthier or happier. 

Opinion #2, The mom in me: I would not want my son to smoke either 'real' or electronic cigarettes. The e-cigarette industry is clearly booming, and I worry that young people are the most vulnerable to be advertised to, enticed to, and sold on their ability to make the world a better place. I think we should all be acutely aware of the power of marketing, and we should stand firm in our message to young people that even e-cigarettes are not sexy.

Opinion #3, The harm reducer: For current smokers, quitting smoking altogether is hands-down the best possible action they can take for their health. However, sometimes it is just not going to happen. Let's be honest. For those long-time smokers who are doing their best to fit into this smokeless world and just cannot seem to find a way to kick the habit, I say, e-cigarettes seem like a pretty reasonable alternative. They are probably safer, definitely cheaper, and for sure better for their lung disease (and their friends and neighbors).


Additional References:

https://www.health.harvard.edu/blog/electronic-cigarettes-help-or-hazard-201109223395
http://www.palgrave-journals.com/jphp/journal/v32/n1/full/jphp201041a.html
http://www.webmd.com/smoking-cessation/features/ecigarettes-under-fire
http://www.wisegeek.com/what-is-vegetable-glycerin.htm
http://changelabsolutions.org/sites/default/files
http://changelabsolutions.org/sites/default/files
http://changelabsolutions.org/sites/default/files/E-cigarette_FactSht_FINAL_%28CLS_20120530%29_October21_2011_0.pdf
http://publichealthlawcenter.org/sites/default/files/pdf/tclc-fs-regulatory-options-e-cigarettes-2013.pdf

Every person on the planet came out of his/her mother

Driving home bleary-eyed from a birth last week, I noticed three different homeless people wandering down Mendocino Avenue. Funny how even in sleepless stupor, one can pick out a homeless person from several blocks away: an odd shuffled step, an overladen backpack, a bizarre motion of an arm, some difference between them and everyone else walking down a busy street at 10am. Considering I had been up all night, it's funny that I cared to notice-- but I bring attention to this specifically because it isn't the first time I've noticed.

Photo from http://onesassydoctor.blogspot.com

I see people differently after I have witnessed birth. 

It's almost as though someone hits reset. As though the world is raw material. And every person I encounter is a newborn baby.

No, it is not that I picture them drooling and wailing in a onesie;  it's that I am invited to remember-- for a few hours at least-- how every single person on the planet came out of his/her mother. Every single person was born. No joke. The clerk at the grocery store, the woman speeding around my corner, the cruel dictator, the young soldier convicted of treason, the elderly man sharing a lane with me at the YMCA, the President, the scary looking guy I just passed on the trail, my own mother, and even those three homeless people stumbling down Mendocino Avenue. They were all born.


And in these post-birth hours, wearing what I secretly call my 'birth glasses' (others might simply chalk it up to adrenaline or perhaps fatigue), I often wonder what life was like for those particular babies (now-turned-suffering-adults) when each one came into the world.

Was she wanted? 
Did his mother hold him tightly to her chest and tell him she loved him? 
Was his father there? 
Did someone in the room cry in joy? Or in sadness? 
Did someone sing her happy birthday and nuzzle her tiny button nose? 
Did someone knit him a hat? 
Was her mother high? 
Was he wrapped in a special blanket, bought just for the occasion? 
Was there laughter? 
Were his ten tiny toes admired by all who entered the room? 
Did she take her first breath already knowing she was loved?

I sure do love my 'birth glasses'.  I find that they grant me more love, patience, and sympathy for each of my patients. And for everyone else I encounter in the hectic dance of life.

Do I really want to know? How will knowing be helpful?

This is my question to you:  Do you want to know?

You say you do. You may think you do. But, do you really?  Do you really really want to know?

This may seem like a trick question, but I am not being sly. I promise. Let's be clear here. This is your body, your health, your life, not mine.

And before we proceed, one word of warning: once you know, you cannot un-know. 

If after pausing a moment to ponder the question, you are now leaning in the direction of answering something to the tune of, "Yes, insanely weird doctor, I definitely always want to know. Please order the test."-- then please now ask yourself a few follow-up questions.  Will knowing be helpful? What if it comes up positive? Or negative?  Can I do anything with the information? (Other than stay up at night worrying and/or searching the Internet for an answer). Will it change the outcome? Does the information give me options? And perhaps most importantly: Will it make my life longer and better and richer and fuller?

Patients often look at me like I am totally insane when I ask them the 'do you want to know' question-- as though knowing is always better than not knowing. Just today, my patient looked stunned when I questioned her request for an imaging study of her brain. She looked at me suspiciously (as though I was suggesting we maybe sacrifice her dog) and asked, "What do you mean there could be something inside of me that I don't want to know about? How in the world could knowing make things worse?"

Many of us assume that all medical information equates to useful information. And perhaps, even more tightly embraced is the notion that the more medical information we have, the better off we are. This is deeply embedded in our American ethos and exemplified by our outrage that there is actually a waiting period in Canada to get an MRI.  As your clinician, I want to challenge this notion.

Yes, medical information can be amazingly powerful (e.g. Congrats, you're pregnant! No, you don't have HIV. You are cancer free. Your heart is working just fine). However, medical information is not always useful--and, I would argue, it can even be remarkably unhelpful.

There are two reasons I encourage you to be careful about what you ask for: First, you might find out something you don't actually want to know and second, what you find out may not matter at all.

Hear me out:
1) Incidentalomas: Yes, definitely looks (and sounds) like a fake word, but believe it or not, this is actually a term we use with some frequency in medicine. Incidentalomas are things "incidentally found" when we are looking for something else-- often the result of an imaging study like a CT scan or an MRI scan. In other words, we found something we weren't looking for.

Consider this example:  Dr.Careful wants to be sure his patient, Lina, doesn't have appendicitis, so he orders a CT scan of her abdomen. Thankfully, the CT scan confirms that Lina's appendix is totally normal, and she is able to avoid surgery. However, in the scan report, Dr. Careful discovers that Lina has some funky little blip on her kidney. Now what? Is the blip causing her pain? Is it cancer? Is it important? Who the heck knows?!?

Occasionally incidentalomas are blessings-- because we find a tumor that would have taken a long time to appear and is still in its early stages, so treatable or curable. However, more often, incidentalomas are just pains in the rears. We (clinicians and patients)  feel compelled to investigate further that silly little incidentaloma, which often means more tests, more imaging (i.e. more radiation exposure), and even unnecessary surgery. And often, the incidentaloma would have just lived happily ever after tucked away in our belly never causing problems. Here is a great case in point written in the NY Times awhile back. Interestingly, in the end, the columnist doesn't complain about how he had unnecessary surgery. Instead he marvels about a greater "appreciation for the glory of life". I don't know about you, but I'd hope to be able appreciate the glory of my life life sans unnecessary scans and definitely without unnecessary surgery!

2) True positives that we don't actually care about. The example that always comes to my mind for this phenomenon is that of prostate cancer (more on PSA in another post). But for now, you should know that somewhere in the ballpark of 60% of men after age 60, 70% of men after 70, 80% of men after 80, and 90% of men after 90 will have prostate cancer. Did you catch that? That is, if you open up a 90-year-old man's body after he dies from whatever cause, you will find that he has actual real live cancer in his prostate. The numbers are impressive! 

However, the numbers of men for whom prostate cancer causes death or even illness is much much lower. Though 1 in 6 men will be diagnosed with prostate cancer in their lifetime, only 1 in 36 will die from prostate cancer. A recent 2012 study  randomized 731 men with localized prostate cancer to radical prostatectomy (i.e. really big surgery with lots of side effects) versus observation (i.e. just watch and wait, no surgery). They found NO difference in the numbers of men who died. None. In this study, in fact, only 7% of men with known prostate cancer (in both groups) actually died as a result of prostate cancer, and it didn't matter if they were treated or not. This begs the question, did knowing and treating prostate cancer improve these men's lives? Did it make them healthier and happier? Was knowing better?

_________________________________________________________________________________

Okay, enough blathering for now. You get my point, I hope. What I want you take home is that the decision to take a test or have a scan is not a black or white one, but rather one that requires communication with your provider and the ability and space to ask some serious questions. I am not saying don't get the test, I am only asking you to be an empowered patient and ask yourself and your clinician two questions, "Do I really want to know? How will knowing be helpful?"


In case you are interested, here is a quick list of tests that I would want to talk about with my patients before ever ordering or even considering. Certainly doesn't mean I would NEVER order them as a physician (there are clear times and places when these tests are super important) or never get them as a patient, but I would just be mindful before taking the leap:

1) MRI of the back for low back pain (Unless you have clear neurological symptoms, routine MRI has not been shown to improve patients' health) more info
2) CT scan of the belly (especially for vague reasons, You should know that a single CT scan of the belly = 769 chest x-rays of radiation exposure!) more info
3)  PSA (prostate specific antigen, controversial screening test for prostate cancer for men, touched on above) more info

4) Prenatal genetic screening (tests women get in first and second trimester of pregnancy, offered to all pregnant women) more info
5) HPV testing (in the presence of a normal pap smears--26% of us will test positive. That's a lot of partner disclosing!) more info
6) Genital herpes blood test (1/6 of us will test positive!) more info

Each of these examples could be a post in and of themselves. And time, allowing, I promise to write on each of these. For now, I welcome your thoughts and your questions.

Prescription painkillers (I)

Gina was one of my most challenging patients. She had overwhelming anxiety, and with just a phone call, she could make our clinic spin like a top. I knew pretty early on that she had a tendency to overtake medicines-- and not just the addictive ones. She even overtook non-prescription medicines like acetaminophen (aka Tylenol), diphenhydramine (generic for Benadryl, an anti-itch and allergy medication) and omeprazole (generic for Prilosec, an acid reflux medication).

She was a beautiful woman, and though her mental health issues were intense, she was really quite endearing. Each time I saw her, she gave me a big hug; she also often brought me thoughtful little gifts. At one visit, she brought a beautiful silk flower clip for my hair. (I sometimes wear it on tough days in clinic). A few months later, she gifted me a picture of her swimming with the dolphins in Hawaii. That picture hangs above my desk; she is smiling broadly in it, and I love to think of her without pain and without anxiety.

I last saw Gina one Wednesday morning more than a year ago. She had just had a successful hysterectomy and was particularly anxious. She had a history of chronic back and hip pain and was on small doses of methadone for this pain. Two days later she was found dead in her own bed.

I was not surprised to learn that, on autopsy, unsafe levels of methadone were found in her blood. She clearly overdosed on her prescription painkillers and never woke up. I will never know the whole story, but I doubt she did so intentionally.

Prescription pain medication overdoses are on the rise-- over 14,800 deaths in the US in 2008 (that's more than cocaine and heroin combined, and more than motor vehicle accidents too). When you see the term "prescription painkillers",  this usually refers to the opiate or narcotic pain medicines: vicodin, (hydrocodone), oxycontin (oxycodone), morphine, and methadone. Unfortunately, these are medications often prescribed for surgical procedures like wisdom teeth extractions or appendectomy, or even during simple ER visits for minor trauma. These drugs aren't inherently evil-- they work quite nicely for people with acute pain that is self-limited. I personally prescribe them for every one of my post-cesarean section patients and often for patients with fractures (e.g. broken legs).

Check out this image from the Center for Disease Control (CDC):





According to the CDC, most prescription pain medications are prescribed by primary care doctors (yup, that's me). And, perhaps even more alarming as someone who prides herself on her care of women, recent data released shows that prescription painkiller overdoses in women have increased 400% since 1999 (they have also increased dramatically in men by 265%). More than 5 times as many women died as a result of pain medication overdose in 2010 than in 1999. And opiates are involved in 1 out of 10 suicides. Ay!

We need to do better.

Clinicians (ahem. . .myself included) need to be more careful about how we approach pain, what medications we offer our patients, what are our expectations. We need to use the statewide databases and really encourage our patients to get rid of leftover medications (rather than share them with family members). We also need to screen women (and men) for risk of abuse/misuse and be clear about our plan from the get-go with ourselves and our patients.

Patients (that's all of us) need to be aware that these painkillers are a group of potentially addictive medications. There is an appropriate time and place for their use, but pain meds should be used wisely for limited periods of time. They may or may not actually help people feel better but definitely can kill (or make you impotent, depressed, constipated, and dysfunctional).

Do me a favor, go to your medicine cabinet right now and throw out that leftover Vicodin you have sitting there from your last encounter with the healthcare system. I know you've been keeping it around 'just in case', but it just ain't worth it. Don't share it with your neighbor or your partner or your kid. Pitch it. Or, even better, throw it down your toilet (though please don't do that with the rest of your prescription meds- click here for more info,).

Other things to read:
1) http://www.drugabuse.gov/publications/research-reports/prescription-drugs/trends-in-prescription-drug-abuse/how-many-people-abuse-prescription-drugs
2) http://www.cdc.gov/vitalsigns/PrescriptionPainkillerOverdoses/index.html

To circumcise or not to circumcise. . .

I know, I know, you already have an opinion. Acknowledge it.

You're circumcised, and it's the only way to be.
You think circumcision is torture, and you would never do it to your sweet baby boy.
You're Jewish, and Jews don't think about it, they just do it.
You've been with an uncircumcised man, and immediately after you suffered a terrible yeast infection (which you are certain was directly related to his intact foreskin).
You think it's dirty to have a foreskin.
You think it's sexy to have a foreskin.
You think it's dangerous to have a foreskin.
You think an uncircumcised penis is really weird looking.
You think a circumcised penis looks too manicured and--dare I say it--naked.

So, imagine this: You are eight months pregnant. You are pretty certain you are having a boy, and you and your partner just cannot come to a shared decision about this. Should you circumcise him or not?

After turning to your mom and dad (and his mom and dad), your great uncle, the great world wide web (please do be careful), your brother, your pastor, and a psychic (or two), you decide to come to me-- your trusted family doctor-- to ask for my opinion. This is what I would say:

1) Circumcision is a sociocultural phenomenon. Your kid may or may not look like his buddy in the locker room. It depends on so many factors: where you live, what education level you have, what ethnic background you are, what sociocultural background his friends are, and a smattering of other random influences. You may be interested to know that in 2009, 54.5% of newborn boys in the US were circumcised. (Whenever numbers runs around 50%, I almost always feel like one cannot go wrong). Interestingly, rates of circumcision vary markedly based on US regions: highest in the Midwest at 75.2% and lowest in the West at 24.6%. For more details see this AHRQ report on circumcision.

2) There is good data that circumcision will protect your child from some medical conditions. Two main ones, to be precise: urinary tract infections (UTI) and sexually transmitted diseases (STD). Circumcision decreases a baby boy's risk of UTI in his first year of life (the risk of a UTI in an uncircumcised male infant is pretty freaking low, usually quoted at about 0.07 (or 7 cases per 1000 babies) and the risk reduction brings it down to .018 or 1.8 per 1000 babies. Darn rare. Circumcision has no effect on UTI after your baby boy turns one). Circumcision has also been shown to reduce heterosexual transmission of HIV by 60% (pretty impressive!)-- these are all really interesting studies coming out of sub-Saharan Africa and probably cannot be translated to mainstream US, but that's still a moving target (maybe another post, but here is a link, if you are interested).

3) The American Academy of Pediatrics (AAP) changed their official stance on circumcision pretty recently in 2012 (here's their statement). In 1999, they concluded the medical benefits were not proven to outweight the risks. In 2012, they decided that the preventive health benefits of circumcision outweigh the risks of the procedure. Much of their decision was based on these new studies coming out of Africa around HIV transmission. After AAP's official statement in 1999, rates of circumcision went down about 12%. Now that they changed their mind again, will rates go up? Time will tell, but probably yes (especially because insurers will likely start paying for circumcisions again).

4) I have NO idea whether or not removing your child's foreskin will affect his sexual life (or the sexual life of his partners). I have no idea how to help you determine the validity of this claim. You're on your own.

5) The procedural part of me (that part that loves taking off your moles and putting in your IUD) really loves doing circumcisions-- I promise I will do a good job and make him look handsome. I will be careful. I will perform the procedure with love and finesse and get him back in your arms asap. You can even watch me do it, if you wish.

6) But you should know that the scientist and evidence-based gal in me, the one that swore to do you know harm and minimize risks vs. maximize benefits really questions the benefit of circumcision for your little guy. His risk of having a UTI in the next year is so low, and his risk of STDs can be mitigated in so many other, less permanent ways. I am not sure I buy the AAP's new stance. Though the risks of circumcision are small, I will be tying down your newborn, injecting him with anesthesia, causing him to bleed (just a bit) and using a razor blade to remove a bit of extra skin on his penis.

In the end, the obvious reality is that YOU are the parent(s). You get to decide this in the first few hours or days of your sweet boy's life, but please do realize this is only the FIRST of countless important and unimportant decisions you will be making for and about your little boy:

Will he use a binky?
Does he have to wear shoes when he is running around outside?
Will you give him cow's milk?
Will you make him eat all his peas?
Does he sleep in his own bed or yours?
Can he have a toy gun?
What about peeing on the tree in front of your house?
Will he go to public kindergarten?
What is your policy on video games?
Can he watch a PG movie at age 8?

The list is endless.
Good luck.
(And it's not fair to ask me what I decided to do with my little one. It shouldn't matter. The decision is yours to make).

How much is that birth in the window?

At the end of my morning today, I met a lovely couple pregnant with their first baby. They had been trying to grow their family for quite some time and were deliciously excited to be sixteen weeks pregnant. They also happen to be American citizens living and working in Bangladesh. A few hours later, I had another nice visit with a sweet couple I know well and their beautiful two-month-old  baby girl, born at a local hospital after an attempted home birth.

The odd link between the two couples and my topic for the day is the cost of birth.

Couple #1 has a European health insurance plan (their insurer in Bangladesh is European) that puts a cap on reimbursement for the cost of birth. That cap is somewhere around $8,000 for a vaginal birth and $25,000 for a cesarean section. They are trying to decided if it's worth it (financially, emotionally, and more) to fly back to the US (or to fly instead to Bangkok) for the birth of their child.

Couple #2 planned and paid privately for a home birth, which didn't happen as they had hoped (Home birth rates in Sonoma County run about $5000 including all prenatal care, the actual birth, and home visits postnatally as well). After a long labor at home, Couple #2 ultimately transferred to the local hospital, where they had a vacuum-assisted delivery of their healthy baby girl. They do have good health insurance, which covers their birth (you might want to sit down for this one: their bill was over $40,000, despite the fact they were at the hospital less than 2 hours before their baby was born). Over the last few weeks, amidst their postpartum stupor, they have been carefully reviewing the bills from the hospital and have noted several incorrect billings, including a bill for epidural anesthesia and anesthesiologist services (The mom did not have an epidural and never met an anesthesiologist in the hospital). They won't actually be paying this crazy bill (presumably their insurance companies will negotiate some middle ground), but as responsible consumer-patients, they are at least paying attention.

According to The Agency for Healthcare Research and Quality (AHRQ), the US national average charge for a delivery continues to rise:
$10,657 charge for NSVD, no complications
$13,749 for NSVD with complications
$17,859 cesarean, no complications
$23,923 cesarean with complications

As one might imagine, the charges are even higher here in California (because everything from a gallon of milk to a single-family home is)-- over $15,000 for a vaginal delivery and over $38,000 for a cesearan with complications. 

But please be aware that "charge" does not equal the same as "payment" and that just because a hospital charges a certain amount to an insurance company does NOT mean the company will pay them that amount. In fact, the current Medicaid reimbursement for a vaginal delivery is $2,972.89; cesarean is $3,373.59 (data as of 2007, you can see the report here).

I did spend my lunch hour trying to find out for dear couple #1 what their true cost would be to deliver in the hospital here in Sonoma County. First, I called United Healthcare (their insurance servicer). I spent over an hour on hold and finally got a manager to give me a quote, which was clearly under what it would actually cost them: He quoted me $2500 for a vaginal delivery, $3600 for c-section, but those quotes were only what the physician costs would be (doesn't count the night in the hospital, the IV, the nursing services, the medications, etc.

I also called the hospital I work at to request a quote on their behalf. To my surprise on the billing department's phonetree, there was actually a real choice: push 1 if you are looking for the quote of a cost of an upcoming procedure. "Progress!"  I exclaimed as I pushed #1. I left my cell phone and my name (remember, I am a doctor with privileges at this hospital, meaning I actually delivery babies there. (Update, it's been 2 weeks, still waiting for a callback. Will let y'all know if it every comes. Don't hold your breath. This stuff is bizarre-o).


If this stuff gets under your skin, and you haven't been reading the NY Times series on healthcare cost craziness, you really should. Check it out here.

And, for more information on the costs of other things, you can go here, but make sure you have a big bowl of ice cream, use the restroom, and call your mother before you sit down to sort it all out-- you might be stuck awhile.