Obamacare: Health Care Exchanges Launch

The Countdown is on. . .

Starting October 1st (that's two days from now), the next big component of The Affordable Care Act (aka the ACA aka Obamacare) is being rolled out: enrollment in State-Based Health Insurance Marketplaces or Health Exchanges.

While bizarre commercials bounce around the Internet with creepy Uncle Sam appearing during a woman's speculum exam and Congress bickers its way toward a federal government shutdown, I maintain some optimism that these exchanges-- though imperfect-- are going to increase certain people's access to health insurance and, in turn, health care.

For those of us who have health insurance through large employers, and for those with Medicaid or Medicare, it's likely not much will change. But for individuals, families, and small businesses who buy health insurance on the open market (and particularly for those who haven't been able to afford to do so because it is so freaking expensive), things are about to change. Hopefully for the better.


I think of the exchanges as "Kayak.com for Health Insurance".

If you are not familiar with Kayak, you should be. It has nothing to do with health care. Or health insurance. Or the government. It's a handy, user-friendly website where one can book travel, including flights, hotels, rental cars, and vacation packages. (Disclaimer: I do not work for Kayak, own any stock in Kayak, have any relatives who work for Kayak, or make any money from Kayak. . . I'm just sayin' I like Kayak).

If, for example, you want to fly to Boston to visit your aunt, you input your home city, the city you want to visit, your travel dates, and other parameters, and Kayak searches around the web for the best available flight, ranking the results in order of price. Kayak is quite intuitive, simple to navigate, anticipates some basic twists, allows you to tailor your search  (e.g. would you be willing to leave from a nearby airport? how long of a layover will you tolerate? do you have a preferred carrier?), and makes booking a flight much simpler than booking in the past. I remember, as a child, calling individual airlines one-by-one, keeping detailed notes in the corners of phone books about who flew, when, how much, how long the stopover was, etc. And then calling back again, only to be told the prices were different. Kayak streamlines the process.

To be clear, I'd much rather that Obamacare was rolling out "Kayak for Healthcare" rather than "Kayak for Health Insurance". Or even better, "Kayak for Primary Care". Wouldn't it be super awesome to be able to go online, pick your parameters for a primary care physician and get clear options?

What would your input options be? Gender?  School where he/she studied?
Years since training? Special skills?  Interest in children or obesity or drug addiction or women's health? Funny or serious? Office within 20 miles of your home? Uses integrative medicine? Communicates via email? Office efficiency? Has weekend/evening hours? Delivers babies? Speaks Spanish? Makes good eye contact? Listens?

I would LOVE that. Wouldn't you?

Rather than the mercy of a Google search or a review or two on Yelp or Angie's list, you could have some idea of what you might be getting when you choose a physician. Ah, choice, imagine that?! You may even actually have some idea of what to expect before waiting six weeks to get in to see someone then realizing you cannot stand her bedside manner or her office and having to wait another six weeks to get in with someone else.

Maybe next century.

In the meantime, we are stuck with its predecessor: Kayak for Health Insurance, the Marketplace.

This new Marketplace business means that-- if you are on the search for health insurance-- there is literally a website for you to go to, enter a bit of your family's information (family size, annual income, and zip code) and find out what kind of health insurance plans are available to you.

And the information the exchange spits back at you, like Kayak,  is actually helpful. It includes:

1. Whether or not, rather than buying on the exchange, you might be eligible for a state-based program like Medicaid, which is expanding under the ACA from minimum 100% of federal poverty level to 133% federal poverty level ($31,321 for a family of four in 2013)
2. What health plans are actually available in your geographic area
3. How much the monthly premium will be
4. What you get for paying that premium, including: your annual deductible, maximum annual out of pocket expenses, co-pays, medication costs, cost for ER visits
5. AND how much the government will subsidize your payments. Here's the deal: if you make between 138-400% of federal poverty level, you are eligible for a federal subsidy to help you pay your monthly premium (Families who make under 138% of the federal poverty level will now be eligible for Medicaid). 
6. That means you might actually be able to afford real live health insurance. And you even get to choose if you want that subsidy up front, monthly to help with those payments, or at the end of the year rolled into your tax refund.

http://www.concept-w.com/works/2012/04/gold-egg-silver-egg-and-bronze-egg/

You can scroll around through "the cheap-o plan" (aka The Bronze) up though the Silver, Gold and as high as the "Cadillac plan" (aka The Platinum) and see what money up front gets you versus money at the time of service.

Let's be honest, the Silver plan won't get you tea and massage in the waiting room, but you will get reasonably priced medication co-pays and decent out of pocket expense for things like x-rays (which can get costly quickly). And, probably the most amazing novelty is that at least you actually know what you are getting. Transparency.

The other good news is that all the exchange plans have to have certain (and thankfully decent) minimum requirements, promising evidence-based preventive health care like standard prenatal care, screening mammograms, pap smears, birth control, breastfeeding support, recommended vaccines, colon cancer screening, and more. See here for more details.



Every state is rolling out Marketplaces in slightly different manners. Here in California our exchange is called Covered California. You can find the website at www.coveredca.com. California is one of sixteen states rolling out its own exchange; many other states are working in a state-federal partnership, and nineteen states are using the federally run marketplace, rather than create one for themselves.

Check out this website for detailed state-based info on which states are doing what. If you live in Texas or Arizona or Pennsylvania, or one of the other 19 states that are not creating a state-based system, the federal exchange is available at www.healthcare.gov. It's a good start but lacking in specifics so far. More details, per them, will be available on October 1.


In my practice, I take care of plenty of families who are kind of 'in the middle' of the road for a lack of a better label. Some might call them working poor, others live just a bit off the grid. They are literally not poor enough to qualify for MediCal (California's version of Medicaid) and not rich enough to pay out of pocket for health insurance. I think the Exchange is going to be BEST for them.

Here's an example. I just experimented myself with Covered CA:

• I entered a family size (e.g. 2 adults, 2 children), ages of adults (36 and 37), a mock annual salary ($60,000), and our zip code here in Sonoma County.
• Covered CA spits out four different plan options for me and my imaginary family, including an explanation of how much I would pay monthly. We would have the choice between: Anthem Blue Shield, Blue Cross, Western Advantage, and Kaiser. 
• In each of those plans, we can choose between Platinum, Gold, Silver and Bronze plans
• Cost ranges from $750 (Bronze) to $1408 (Platinum) per month.
• Platinum obviously costs the most up front per month with less cost when I utilize the service
• Bronze costs the least but has the highest deductible and highest co-pays
• For my imaginary family, my monthly premium for the Silver plan would be about $1000 per month. That's a lot! However, based on my imaginary income of $60,000/year,  we would also be eligible to get a monthly tax credit of $601 from the federal government, which brings my monthly premium down to $400/month.
• I know, I know, still seems like a lot, BUT it's better than anything currently available for a family of four AND comes with guaranteed services and a clear explanation of how much an primary care visit will be ($45 in my example) and an x-ray ($45). 
• And as far as I know, right now, no family of 4 would be able to find health insurance with guaranteed coverage for this price.

So there you have it. I encourage you to hop on and play with their calculator. You can find it here. If nothing else, it's a great place to toodle around and waste valuable time.

The Marketplace, in my opinion, is not the shining star of Obamacare. Exchanges still leave much to be desired. Namely, we are still at the will of the insurance companies and costs are still spiraling out of control. The true shining stars are the parts of legislation that guarantee people won't be denied care because of pre-existing conditions, the parts allowing children to stay on parents' insurance until age 26, parts of the Medicaid expansion, the inclusion of free preventive health services, and the closing of Medicare's donut hole for senior prescription costs.

Imperfect? Yes.

Health care for all? Definitely not.

But it's an improvement: transparency is always a good thing. And options are nice.

Enrollment in the Exchanges starts 10/1/2013 and coverage starts 1/1/2014. Hop on, check it out, and let me know what happens.

If I could ask my doctor for a few things. . .

Unfortunately, on occasion, doctors get to be patients.

Over the last several months, I have had the irritating experience of being a patient more than I ever have been in my life. Though my job as a family doctor is high-stress and often exhausting, I must say that I definitely prefer being a doctor to being a patient.

"Being a patient" means spending inordinate amounts of time rearranging my life to get to appointments, camping out in sterile waiting rooms reading stupid magazines, sitting half-naked in chilly uncomfortable exam rooms (still reading the same stupid magazines), standing in tortuous pharmacy lines late at night because that's when I find them most bearable, trying to remember to take my annoying  medication as prescribed, impatiently holding on the phone line waiting to speak to a real live person (who may or may not talk to me like I am a real live person), refreshing my email neurotically to see if the doctor wrote back yet, and-- perhaps most frustrating of all--just wondering and worrying is everything going to be okay?

During many of these special hours driving back and forth between being a doctor and being a patient, I have compiled a list of things I wish my doctor would do when I come to see her.

Here's my analogy: birth plans. My pregnant patients regularly come in during the last weeks of their pregnancies with a written document called their "Birth Plan".  A birth plan is an outline of what a woman (or a couple) want for their birth-- essentially a list of requests about what happens before the baby comes (e.g. music, lighting, opportunities for movement), when the baby is born (e.g. who cuts the cord, who identifies the gender), who the family wants in the room (mother-in-law, yes or no), who bathes the baby, whether they want the baby to get eye ointment, and any other range of requests that seem right to them.

Some providers roll their eyes at birth plans; some consider them offensive and silly. But I love to see what my patients write down-- because it gives me good insight as to what they actually value and what they fear. I also want to know what they want from me, so that I can do the best to give them the experience that they want to have.

I'll stop here and remind you that I am imperfectly human (my patients are already well aware of this fact). I run late. I don't always listen. I rush people more than I'd like. I don't always model the kind of care I would hope to have.  And, therefore, it's probably a really good thing to regularly be reminded about what it feels like to be a patient. After all, then I can be a better doctor. (In a similar vein , my medical assistant recently had a gynecological exam in which her provider warmed the speculum; it was such a positive experience that she is now a consistent speculum-warmer for our patients. Thanks for that!)

What follows, below, is my personal version of "A Birth Plan for A Routine Patient Encounter". I'm sure your version would be different. I'd be curious to hear, in fact, how it would differ.

For clarity, the first bullets are so critical, I think, if my provider couldn't manage them, I might just get up and leave (naked  butt, ugly gown and all). The second part is my dream state, my fantasy, my paradise, my utopia of relationship-based health care.
_________________________________________________________________________
Doesn't matter if I come to see you because it hurts to pee or because I broke my wrist or because I am feeling down. At bare bones minimum, please, provider, when I come to see you about whatever medical issue I deem important enough to be here:

• Be kind
• Take a good history
• Think logically
• Speak in language I understand
• Explain clearly what you are thinking and why
• Order the appropriate lab tests and imaging studies to evaluate my diagnosis
• Interpret results of those tests and studies correctly and in a timely matter
• Help me understand the results and how they influence your initial diagnosis
• Develop an appropriate treatment plan
• Evaluate how that treatment is working (or not working)
• Re-evaluate and start again.

And because you already do of all the above, dear provider, and because you are not the random urgent care person that I am only going to see once and never again, provider, now, can you try being even better than a good clinician? Can you try to treat me like you want to be treated? Or even better, like you want your child to be treated?

Please,


1-Sit down. Yes, sit down. Take your hand off the door knob, grab a seat and sit with me. When you stand over there by the sink with your arms crossed across your body, you make me feel like I am contagious or dirty or risky. When you hover over me while I lay vulnerable on the table, you make me feel small and powerless. I know you're busy--your staff already made that clear-- so am I. Sit down, please, and take a moment to talk to me, eye-to-eye. Person to person.

2-Listen to me, particularly the subtleties of me, the parts of me that are not the same as the last patient you saw. I am unique and special. No one knows my subtleties better than me, so if you don't stop and listen, you are missing out on a serious opportunity. This is not just about not interrupting me (we doctors have all been quoted the studies that, on average doctors wait 23 seconds before they interrupt their patients). This is about not talking and actually listening.

3-Remember my name. And if you don't remember my name, act like you do. When you remember my name, I feel immediately like a person. And feeling like a person makes our interaction so much better than me feeling like a number and you feeling like  a computer.

4-Call me by name. See #3. I am Veronica, after all, that's what you should call me.

5-Apologize for leaving me half-naked in a room for thirty minutes (or 3 minutes that felt like 30 minutes) because it's the nice thing to do. If you were sitting like me instead of standing there like you, you'd be uncomfortable too. The rooms are breezy, the paper gowns are humiliating, and everyone knows I've been waiting longer than planned. I do know you're busy, and I had a lousy magazine to read, but an apology from you means the world. It makes me feel respected.

6-Ask about my 3-year-old.  He's the most important thing on my planet. My entire world revolves around him. I spend every possible moment with him, and this visit replaces that time. Plus, when you ask me about my son, it shows you actually care who I am when you ask. You don't have to remember all the nitty-gritty details of my life. But remember this one, it's the most important to me.

7-Acknowledge that I drove 2 hours for this 15 minute appointment. This ties back into #3. If you remember my name, you may also remember that I live sixty miles from this clinic. And not only was the traffic on the bridge horrible but it took me 20 stressful minutes to find a parking space that wouldn't cost me an arm and a leg. So ask me about the traffic or parking or the seventeen other things I had to juggle to make this happen.

8-Touch me. I don't care if it's a quick hug, a shake of my hand, or a pat of my shoulder. But please do something more than put that cold metal thing in my vagina. Touch is healing.

9-Ask me if I have any questions and act like you actually want to answer them. If I don't have one right on the tip of my tongue, don't dash out the door in relief; stand there for ten whole seconds to see if I can come up with one. Because once you disappear, you are virtually impossible to get a hold of. You have a battalion of folks standing guard in your honor.

10-Finish the visit with a healing sentiment, or at least something encouraging. Let me give you some examples. I am not asking for poetry: "I am sure this is going to work out okay" or "I really feel you are going to get better" or "I will be thinking about you this week". You don't have to lie to me or give me false hope. But you can encourage me. And the sentiment you leave me with, sets my tone for my two hour trip home. And for the next two weeks. And until I see you again.

What is up with mammogram recommendations?

If you are a woman between the ages of 40 and 50, and you have breasts, you just might find yourself wondering the following: What is up with mammograms? Do I need one or not? Why can I not get a straight answer from anyone? 

And if you are over 50, it's similarly confusing, the question is just slightly different. You know you definitely need a mammogram and you were well-indoctrinated by the medical system and media that you should get one every year, but now you're hearing something different: So, do I need a mammogram every year or every other year?

http://www.idealpharmacyla.com/index.php?id=24

Everyone you know and trust and want to believe is all over the map:

• Your mom (who you definitely love but who drives you a little crazy) calls on your 40th birthday to remind you to get a mammogram ASAP. "It's time, honey, she says, you're 40. Oh, and happy birthday."
• When you finally make an appointment to see your primary care physician for an annual exam, not only does she tell you that you don't need a pap this year (more on this in a different post), she also reassures you, "Things have changed, dear, and you don't actually need a mammogram until you turn 50." Sweet, you think. No cold duck bill in the yoni. And no mammo. Saved.
• Then, while sitting in the waiting room at your kid's dentist appointment, you read a really good article in a trusted magazine proclaiming that Obamacare requires that your health insurance pay for mammograms starting at age 40, every year. Huh, now you're really confused.
• A few days later, your best friend from forever ago calls to tell you she saw a great news special and she has firmly decided she will wait for the boob-squeezing to start at fifty and not a minute earlier. She's going to email you the link. She's sure you'll agree.
• And voila, the next day you get a letter in the mail from the local women's health center saying you are overdue for your annual mammogram.

What the heck?!

When to start mammograms and how often to get them is a super duper confusing, controversial, emotion-packed, historical-political-economical-statistical nightmare. And I will warn you from the start that I am not going to give you a simple answer. There is none. But I do want to walk with you through parts of the story, talk about the recommendations, review the numbers, generate a little discussion, and let you consider what's best for you.

(And stay out of your neighbor's business, she can decide what's best for her).

Let's start with my favorite advisory group, the United States Preventive Services Task Force (USPSTF). They are the ones that have generated a whole bunch of hoopla since their updated breast cancer screening recommendations were released in 2009. As I have explained previously, the USPSTF is a non-industry sponsored group of experts that looks at the best evidence we have for and against certain preventive services (e.g. mammograms) and makes recommendations to the best of their ability.  They make recommendations about HIV screening, colon cancer screening, blood pressure screening, the new lung cancer recommendations (see older post), baby aspirin, and more.

We hope they do all of this grounded in the best available science and as free from bias as possible.

In 2002, the USPSTF was in line with everyone else; they recommended that breast cancer screening (i.e. mammograms) start at age 40 and be done every one to two years.  However, in 2009, after reviewing some newer studies, the USPSTF updated their recommendations, now calling for biennial (that's every 2 years) mammograms starting ag age 50, ending at age 74. For younger women (those ages 40-49), they recommended informed decision making between patients and providers. In other words, according to the USPSTF, while women age 50-74 should get a mammogram every other year, women ages 40-49 should weigh the risks and benefits of screening mammogram and make a decision that feels in line with their personal priorities. Maybe you should, maybe you shouldn't.

Hmmm. . .and so begins the controversy. Or shall I say controversies, because there are two main issues that really set the country off:

1) Mammograms every other year: Before 2009, mammograms were recommended every one to two years, but, on the recommendations of their primary care providers, most women still did them annually. What does it mean to space mammograms out? Does that mean my health insurance won't cover an annual mammogram? What if something is missed? Why have I been told for years that women need a yearly mammogram? Are you denying me the right to know and delaying possible life-saving treatment?

2) Mammograms not automatically recommended from ages 40-49 raised even more concerns: I have friends who were diagnosed with breast cancer in their 40s. What if I am one of those women who is unlucky enough to have breast cancer in my 40s and it's missed? What if I want one at age 40? Why would I NOT want to know? What is my risk?

The updated USPSTF recommendations angered a whole lot of women, the politicians who represent those women, the powerful breast cancer lobby, and several professional medical groups as well. There was a literal revolt. Op-Eds were published in papers all over the country, local politicians held special meetings, breast cancer survivors and their supporters were up in arms.

The new recommendations were especially poorly timed because they were released right smack dab in the middle of health care reform, and many people took this as evidence that the US government was on their way to "rationing" care by limiting women's access to screening. People were worried that by endorsing delayed and less frequent screening, they were being offered second-rate health care.

Notably,  additional powerful groups that make breast cancer screening recommendations include The American Cancer Society, The American College of Gynecologists and Obstetricians, The American College of Radiology, The National Cancer Institute, The American Medical Association, and The American Academy of Family Physicians (AAFP). When the USPSTF took this leap in 2009, all of the other groups stuck to their guns (aka the older recommendations) that breast cancer screening should begin at forty; most advocate that they should still happen annually.

Four years later, the only group that has sided with the USPSTF is the AAFP. The issue is so touchy, in fact, that it is being treaty uniquely during implementation of The Affordable Care Act (aka Obamacare). A  section of the new law requires that all health insurers provider specific preventive health services to all people; those requirements are based entirely on current USPSTF recommendations, with one exception: breast cancer.

Rather than fund screening services based on the updated 2009 recommendation, the only non-current recommendation that will be implemented in the ACA is the 2002 recommendation. Huh. There is even a special asterisk on the list of preventive services saying just this. ("The Department of Health and Human Services, in implementing the Affordable Care Act under the standard it sets out in revised Section 2713(a)(5) of the Public Health Service Act, utilizes the 2002 recommendation on breast cancer screening of the U.S. Preventive Services Task Force").

Now that is power. Some people call this a victory. I call this terribly confusing. After all, if I should trust the USPSTF, the ACA should as well.  If the USPSTF is using good science, and good science has revised the recommendation, shouldn't we be using the revised recommendation?  Or, to the contrary, if the USPSTF is using bad science and the recommendation is bunk, shouldn't it be thrown out?

Certainly makes me wonder  (particularly late at night when I should be sleeping) what is behind all this? It is science? Is it emotion? Is it fear? Is it something else?

So what is up with the USPSTF recommendation? Are they rationing my care? Who should I believe?
In my mind, the USPSTF stands apart from other groups as the least biased advisers we have on many health care issues. Though not perfect, they are probably the best we have. 

Our other options, like those mentioned above, include groups that often stand to benefit, either financially or emotionally from the financial side of that service. For example, we have:

• The Radiologists, who stand to make more money the more mammograms women get AND, to their credit, probably truly believe the more imaging the better (that's their specialty, after all)
• The Gynecologists, who are worried if women don't get an annual gyn exam (including pelvic, pap and mammo), they might run out of things to do and business to keep themselves afloat (they are also believers in what they do)
• The Various Cancer Societies, who rely on the emotional impact of the personal struggles of people with cancer to raise funds for basic science research and services (both good things) but, in so doing, may occasionally forget that there are lots of people who don't have cancer

In an ideal world, all these groups would have your best interests in mind, but in the real world, you have to be a little skeptical. Or at least thoughtful.

Here are 4 questions I would love for you to consider when making your decision about when to start and how often to do a mammograms: 1) Do screening mammograms save women from dying from breast cancer? 2) Is a screening mammogram going to prevent ME from dying from cancer? 3) What's the harm of doing a mammogram earlier (i.e. before 50)? 4) What's the deal between every 1 year to 2 years?


1) Do screening mammograms save women from dying from breast cancer?
 The answer is yes, probably.

If you are a woman between the ages of 40 and 74, screening mammograms have been shown to reduce breast cancer specific mortality. (Remember: Screening means you 1-Don't have additional risk factors (like a personal or family history) and 2- Are having it done when all is well and fine, not when you notice a lump. If you meet either of these criteria, screening goes out the window). It's actually pretty tricky to figure out how much mammograms reduce this risk, but for women ages 39-49, getting a mammogram probably results in 15% reduction in mortality. For women 50-69, getting a mammogram results in about 22% reduction in mortality.

That being agreed upon, one of the most sensitive areas of discussion right now is how to determine whether or not mammograms actually over-diagnose (they probably do) and lead to unnecessary over-treatment. In other words, how do we know whether a mammogram that detects a cancer  is actually detecting a stable cancer that would have stayed static (i.e done nothing) for years?

As physicians, we see a problem-- especially cancer-- and we feel compelled to treat it. This is what most patients want, right? So, what if we never knew that cancer was there (i.e. no mammogram)?  Or what if we diagnosed the cancer and did nothing but watched it?  Without question, nowadays, as soon as a cancer is detected, a woman is immediately immersed in the craziness of cancer treatment. The question that remains is, does she need it?

Remember, breast cancer isolated to the breast doesn't actually kill people; breast cancer that spreads outside of the breast does. We know beyond a doubt that breast cancer kills (in 2009, over 40,000 women died of breast cancer in the US alone). But is all breast cancer the same? Doctors and patients like to assume that by finding cancer in the breast and eradicating it, we are doing a good thing, but some researchers are wondering how true and universal this might be. 

2) Is a screening mammogram going to prevent ME from dying from cancer?
Great question, impossible to know. This question actually begs two further questions: First, am I going to have breast cancer? And will that breast cancer kill me? Remember, there are lots of other ways to die. If you are over 50, odds are you will die of a heart attack. If you are under 30, odds are it will be a car accident.

The older we get, the more likely we are to get breast cancer (see data table). In the US, in total about 130 per 100,000 women will get breast cancer. About 25 per 100,000 will die from breast cancer. Unless you are black. Then  the number is higher: 35 per 100,000. (see graphs). If you live in California, your risk is different of getting and dying from breast cancer than if you live in Texas (see maps).

In medicine, we often talk about how many people we need to test or treat, to get a certain outcome. The is called the Number Needed to Treat (NNT).  The USPSTF uses these statistics in their formal recommendations,  and I think it's helpful to consider them because I am not sure I am in agreement.  From the available studies we have, the number we need to invite to screen (NNI)  to prevent one breast cancer death depends on how old you are:

if you are           this many women your age need to be screened to prevent one death
ages 40-49         1904 women
ages 50-59         1339 women
ages 60-69         377 women

In plain English, 1904 women ages 40-49 need to have a mammogram to prevent one woman from dying of breast cancer. 1339 women ages 50-59 need to be screened to prevent one woman from dying of breast cancer. And in the 60-69 group, 377 women need to have screening  mammograms to prevent one woman from dying of breast cancer.

If you are that one lady that lives, then gosh darn it, you are lucky and you are so happy you were screened. But, remember, overwhelming odds are that you are one of the 1903 others. Or the 1338. Or the 376. But the question I struggle with is whether or not there is really a difference between the 40-49 group and the 50-59 group? After all, there are definitely and without a doubt some women in the younger group who will get breast cancer.

Am I willing to subject 1904 of my patients to mammograms to prevent one woman from dying? I don't know the answer, but it doesn't sound unreasonable. After all, I don't want any of my patients dying from preventable causes. I certainly feel like I should at least offer them the educated choice.

3) What's the harm?
A false positive is a test result that is wrong. The test says you have the disease but you actually do not have it. False positives in breast cancer screening are higher the younger you are.  This is partially because breast tissue is denser in younger women. Also cancer rates are lower. But it's mostly because the more mammograms you have, the more likely someone (i.e. the radiologist)  is going to see something that looks abnormal, call it positive, and recommend follow up.

When screening begins at age 40, the cumulative probability of a woman receiving at least one false-positive recall after ten years is 61% with annual and 42% with biennial screening.  The cumulative probability of false-positive biopsy recommendation is 7% with annual and almost 5% with biennial screening (see this citation for more specifics, you nerds).

So, if you get your annual mammogram, there is a 60% chance in the next ten years that you will have an abnormal result that will turn out NOT to be cancer but will likely stress you out, require follow-up appointments and decrease your quality of life temporarily. There is a 7% chance you will wind up with an unnecessary biopsy.

There is a lot of debate about how disruptive these false positives are and whether or not they actually matter to women. In fact, more than once, I have had patients follow up after a false positive result proclaim something like, "I am so glad I had this done!" That woman feels relieved and happy to have been told something was wrong and then, upon further consideration, to be reassured. This is odd. The end result would have been the same with or without the mammogram (she doesn't have breast cancer) but somehow going through the test, getting a positive result, having follow-up testing, and then getting good news, has some people coming out the other side feeling well-taken care of. 

Is this our goal? Should it be? 

Is more better?

http://www.cfhi-fcass.ca/publicationsandresources/Mythbusters/ArticleView/08-07-01/f701d4d0-53b8-4bad-bbca-a370194455ec.aspx

Don't forget, the other harms of mammography include radiation (the equivalent of 15 chest xrays, that's WAY less than a CT scan) and pain (many patients really hate the boob squeezing component of mammograms), copays (though those should be disappearing with the ACA implementation), cost to the health care system (billions of dollars) time away from work for appointments, stress about the test itself, and more. 

Nothing comes without a cost.

4) What's the deal between every 1 year to 2 years?
If you are between the ages of 50-69, the evidence shows fairly convincingly that there is no increased risk of missing something by spreading out your mammograms to every two years. This applies even if you are on hormone replacement therapy or have dense breasts. You may still be getting a letter from your local radiologist that you are due for your yearly mammogram, but take a moment to reconsider before you pick up the phone and schedule your appointment. You are probably doing yourself a greater favor waiting for another year to pass by.

The story is only slightly different for younger women. If you choose to start earlier screening between ages 40-49 and have extremely dense breasts (about 12-15% of women in this age group meet this criteria), then biennial screening probably does have an increased risk of missing something. Ask you radiologist where your breast density falls. Then decide if you should be having annual versus biennial screening. Remember, 85% of women in this category should be able to comfortably do mammograms every two years and feel confident that are fulfilling their preventive health goals. (You may reference this article for more details). Also please remember, the more often you have mammograms, the higher your risk of your false positives. This may be a risk you are more than willing to accept.

This is a really really good time to talk to your primary care provider. Weigh the potential risks with the benefits and make a decision that feels right for you. Sorry for the complexities. Thanks for sticking in to the end. Ultimately the decision is yours.

_________________________________________________________-

Additional references:
http://www.nytimes.com/2013/04/28/magazine/our-feel-good-war-on-breast-cancer.html?pagewanted=all&_r=0
http://www.aafp.org/afp/2012/0115/p176.html
http://jama.jamanetwork.com/article.aspx?articleid=1722196
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3699693/#!po=52.5000
http://online.wsj.com/article/SB10001424127887323539804578260241902140764.html
http://annals.org/article.aspx?articleid=474984
http://www.ncbi.nlm.nih.gov/pubmed/17404352
http://www.ncbi.nlm.nih.gov/pubmed/22037165

Turn the Seat Around

First, I must confess. I fear that what I am about to write might appear hypocritical, or at minimum incongruent.

I did it. I was the one who turned my son's car seat around. Against my husband's wishes. After months of trying to persuade him, I just did it-- without shared decision-making, without permission, without blessing. I was in the parking area outside of my mother's house, and I simply unclipped the seat, flipped it around, and clipped it back in. It took my husband a week to notice.

My son was two-and-a-half at the time, and my arguments were definitely not evidence-based. My primary motivations were convenience and annoyance: I was frustrated by not being able to hear what he had to say when I was driving; I was forever trying to reach my right arm back in impossible positions to wipe his runny nose; I was traumatized by the one time he threw up and I had no idea until I got out of the car; I wanted to see his eyes in the rear view mirror.

My husband and I bickered about this transition for months. Each time we traversed the topic, he threw my own words at me, the very evidence-based information I had shared with him after a lecture I had attended on motor vehicle safety years before: "He is safer facing backwards. The longer the better". Gosh, why doesn't he remember so clearly all the other things I want him to remember? My husband still gets emotional when the topic of the car seat comes up-- he even threatened, as I was writing this entry, to turn him back around.

And he is right. No doubt about it.

Children are safer facing backwards. Adults are safer facing backwards. Shoot, if the driver could be facing backwards and still drive, the driver would be safer too. Here's why.

We have made great strides in motor vehicle safety since my family drove across country in 1982. I was five at the time; the dog and I were carefree and entirely seat belt-free in the backseat area of our VW Rabbit. The seat was even removed for our comfort! It was a play land of books-on-tape, baby dolls and art projects, and it turned out to be both a fun and uneventful trip. Nowadays, our children are strapped in five-point harnesses just to run to the grocery store. And, though annoying and restrictive, this is a good thing. Car safety has been a great public health success story.

I don't think you'll be terribly surprised to learn that pediatric motor vehicle accident deaths have been cut in half in the last thirty years. Yes, in half. Car seats work. (Can I hear "Woot woot" for car seats!?) And while we should definitely celebrate this amazing improvement, motor vehicle crashes are still the leading cause of death in children in the US (see here for the data).  In 2009, 1314 children ages 1-14 were killed in car crashes, and an estimated 179,000 were injured. I think you would agree that one child dying in a car crash is too many.

Until recently, it was recommended (in the US) that infants and toddlers be kept in rear facing car seats (RFCS) until at least age one year and a minimum weight of twenty pounds. Once children reached those milestones, parents were told (often by their doctors) that they could keep their children rear-facing but only if the car seat could accommodate them, based on height and weight. If not, they were advised to use a front facing car seat (FFCS). As most RFCS had weight-limits around 22 pounds, many  parents interpreted this counsel to mean not only that they could turn their child around, but in fact they should. And they did.

Even with the old recommendations, it was reported at the time that 30% of children were turned around before the age of one.

In March 2011, the American Academy of Pediatrics (AAP) together with the National Highway and Traffic and Safety Administration (NHTSA) updated their recommendations. They did so based on several US and European studies showing that children facing backwards (in RFCS) are simply safer than children in any other type of seat in any type of crash.

Much of the data already existed for decades--extracted from Volvo test data done in Sweden-- showing that RFCS are safer. In a Swedish study, looking at accidents involving 3670 children from 1987-2004, ages 0-15 years, testers found the most protection for RFCS (90%, compared to unrestrained child). Boosters for children ages 4-10 were found to be 77% effective (compared to unrestrained). Please do note that they are not comparing RFCS to FFCS. (Here are links to the studies, if you are interested: Jacobsson et al. 2007, Isaksson-Hellman et al. 1997).  As a result, in Sweden, it is standard practice for all children to be facing backward until age four and then transitioned immediately to a booster seat. It's tough to even find a FFCS!

The big US study that turned the tables was published in the Journal of Injury Prevention in 2007 (Henary et al. 2007) and found the following key findings:

• Children in FFCS  were more likely to be injured than children in RFCS in all crash types (rear, frontal, and side)
• In side-crashes, children in FFCS were  5.5 times more likely to be injured than children in RFCS
• In frontal-crashes, RFCS were marginally safer, 1.2 times safer than FFCS (but, interestingly, this was not noted to be statistically significant).
• Looking specifically at children between the ages of one and two (previously many were turned around), this age set was also 5.5 more likely to be injured in FFCS compared to RFCS
• The overall effectiveness of RFCS was 93%, compared to FFCS, which was 78%

A 2009 paper published in the British Medical Journal (BMJ) was titled "Advise use of rear facing child car seats for children under 4 years old". Similar to the US, standard in Great Britain has been to turn children around at 9 kilograms (19.8 lbs, which is 8 months of age for an average boy).

Why are RFCS better?
 Babies are shaped differently than adults. They are more head and less body (see image below). They also have weaker necks than we do and are not designed to withstand high impact crashes even at relatively slow speeds. RFCS have been shown to better support torso, neck, head, pelvis, and to distribute the  impact of a crash throughout the entire body rather than just at sites of belt contact. Because of their disproportionate head and weaker necks, providing targeted support changes outcomes. It keeps children safer.
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Add caption

Thankfully, these days, most of the newer infant car seats actually have new weight limits (up to 40 pounds), making it more convenient to keep children rear-facing. However, I cannot even tell you how often parents look at me sheepishly, tell me they've already turned their child, and basically state they have no intention of turning them back around.

Personally, I start counseling my parents about the updated recommendation to keep their children facing backward at the 6-month well-child visit. I remind them that driving our kids around town is literally the riskiest thing we do to them. This is no joke.  I repeat the message at the 9-month and 1-year visits. Why be so redundant? Sometimes I feel like a nag, but I am trying to catch families before they make the switch-a-roo. Because it's virtually impossible to go back. And because, for reasons that are kind of unclear, people have a hard time with this issue.

When I counsel people to reconsider, parents often give me similar reasons to the ones I gave my husband. They want to see, hear, and physically access their child while driving. The child seems happier; they don't cry so much. They also more often than not shrug and say, "Well, he is just too big to have his feet crammed up there against the seat like that." My response? Does your child ever complain of achy knees or a stiff back? Doubt it. Most little ones have no idea that they are supposed to "feel uncomfortable" with their legs up against the seat. They are comfortable in almost any crazy, bizarre, and twisted position. I mean, do you ever watch them sleep? I am sorry, but this is a projection problem-- in other words, my adult self definitely would feel uncomfortable in that position for any length of car ride; therefore, my child must feel terribly cramped too.

http://babyology.com.au/wp-content/uploads/2011/04/Child-seats.jpg

In fact, my son (it's been not quite six months since he was turned around), still positions his two feet up on the front seats with his legs extended in exactly the same way he was positioned when he was facing backwards. With rare exceptions, as exemplified in Sweden, where it is standard practice to keep ALL children facing backwards until age 4, children  of all sizes do just fine crammed into that rear facing seat.

Please make an informed decision and at least consider the implications of turning your child around before the age of two. Remember, as my husband correctly says, "He is safer facing backwards. The longer, the better."

And for more information on which car seats to how to install them, check out this site.

http://farm2.static.flickr.com/1204/1024886238_c9321f8bf6.jpg

Additional References
http://injuryprevention.bmj.com/content/13/6/398.full (injury prevention)
http://www-nrd.nhtsa.dot.gov/pdf/esv/esv19/05-0330-O.pdf (swedish study)
http://www.cdc.gov/features/passengersafety/


https://sites.google.com/a/umich.edu/cpsbestpraci/resources/rear-facing-child-restraints
http://community.nytimes.com/comments/www.nytimes.com/2011/03/22/health/policy/22carseat.html
http://www.carsafetyrules.com/swedes-save-more-lives-with-policy-of-keeping-one-year-olds-with-rear-facing-car-seats/0403/

The Newborn Hearing Screen

Friends of mine from college have two beautiful daughters, ages four and six. We spent the weekend with them recently, and my husband and I took great pleasure covertly listening to the six-year-old reading to our preschooler. She is a bright and eloquent first-grader, and one would never guess in a thousand years that she has mild-to-moderate hearing loss. This is why: her hearing loss was detected on routine screening when she was just one day old. It was picked up so early that she was given speech, language, and audiological support (including weekly home visits, baby groups, and even  hearing aides) by the age of six months. I distinctly remember sitting at our dinner table almost five years ago watching her father sign the letters of words so she could "spell". She recognized the entire alphabet in sign, and it was a great party trick to have a one-year-old verbally spelling D-O-G-G-Y and T-A-B-L-E.

To her parent's surprise, her little sister was diagnosed with almost the exact same hearing loss two years later, also after being screened at the hospital where she was born. Both girls have been getting amazing support from the county Early Start Program since before they could sit up. And thanks, in large part, to early diagnosis and intensive interventions, they are both wonderful communicators!

http://blogs.rch.org.au/ccch/files/2011/08/BDP_2660.jpg

These little girls are the inspiration for this post about Early Identification of Hearing Loss and the Newborn Hearing Screen.

National attention for newborn hearing evaluation peaked after the 1993 National Institutes of Health (NIH) Consensus Development Conference on Early Identification of Hearing Loss. This was a group of experts including otolaryngologists (aka Ears, Nose, & Throat doctors/ENT), speech and language therapists, audiologists, neurologists, speech pathologists, nurses, pediatricians, and more who came together to digest the science and make formal recommendations about why, when, how, and who to screen for childhood hearing loss.

What came of the Consensus conference were formal recommendations to implement 1) universal newborn hearing screening for all babies born in the U.S. 2) early intervention programs for those children identified as hard of hearing.

Hearing loss is actually one of the most common congenital birth defects, affecting 2 to 3 out of every 1,000 children. More than 50% of hearing loss is thought to be genetic.

At the time of the conference in 1993, the average age of diagnosis of hearing loss in children was three years of age. We know that language development literally starts as soon as a baby lands on this planet, and the most critical period of language and speech development is actually the first three years of life. Animal studies have shown that auditory deprivation during this time (i.e. not allowing animals to hear during the first years) actually interferes with the neuronal infrastructure, literally messing up the development of speech and language brain cells.

In other words, "You have to use it [your ears] or lose it [your hearing, speech and language]."

So, if congenital hearing loss wasn't being picked up until, on average age three years, and age zero-to-three is the most important period for speech and language brain development, we were missing a very serious window of opportunity to maximize a child's auditory potential. Especially because there are good studies that show that addressing hearing loss early does improve communication for the rest of that child's life.

Thank goodness, there has been remarkable progress.

Since 1993, all 50 states and the District of Colombia have established early hearing detection and intervention (EHDI) laws or voluntary compliance programs. Thirty-six states (including California) have legislated that hearing screens be performed at the time of birth in hospitals and birthing centers.

California's newborn hearing screen program started in 1998. Previously in California (and many other states) only "high risk" infants were being screened ("high risk" meaning babies who spent at least two days in the neonatal ICU-- these little guys actually have a 10-fold increased risk of being hard of hearing, those with structural skull or facial abnormalities, or those that had a family history of hearing loss). By screening only "high risk" babies, almost 50% of hearing loss was being missed at birth. 

The National Center for Hearing Assessment and Management reports that detecting and treating hearing loss at birth for one child saves $400,000 in special education costs by the time that child graduates from high school.

http://www.speechbuddy.com/blog/wp-content/uploads/2012/07/Baby-with-Hearing-Aid.jpg

Okay, let's do some math: with 550,000 babies born in California each year, it is estimated that annually 1,100 children will be identified as hard of hearing by the CA newborn screen. Screening in California currently costs $30 per child. That means the system spends $15,000 per year per child diagnosed with hearing loss (550,000 x 30/1100); yet early screening has been shown to save $30,000 per year per child (400,000/13 (K-12= 13 years of public education spending)). Final calculation: $30,000-15,000=$15,000. By paying up front and screening babies early, we are saving the system $15,000 per year for each child with hearing loss.

Isn't that cool?! Not only does screening improve a child's quality of life, it actually saves the system money! 
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How is the newborn hearing screen done?

There are actually two different ways to do a hearing screen:
1) Automated auditory brain stem response (ABR): the newborn's ears are covered with big headphones that emit a series of clicks. Electrodes placed on the baby's neck and forehead, measure brainwave responses to the clicks in the baby's brainstem. The computer compares those responses to "normal" responses and spits out a "pass" or "fail" report. See the video here.
2) Evoked otoacoustic emissions testing (EOAE) tests the cochlea, the part of the ear most involved in what is called peripheral auditory system. A small microphone is placed in the baby's ear canal and tests the cochlear ear cells echo response, also to clicks. Just like ABR, the computer generates a "pass" vs. "fail" report.

Both tests are relatively quick and easy and can be done within minutes on an alert but quiet newborn baby.

As I have mentioned in previous posts, there is almost always a downside to screening tests.The downside in the case of the newborn hearing screen is the potential for a large number of false positives. This means that many children who initially "fail" the screening test will actually wind up having normal hearing. Super stressful if you're a parent worried that your child might be hard of hearing. In fact, the rate of false positives is as high as 30% (i.e. 3 out of 10 "fails" will actually turn out to pass) if the test is done only one time; the number comes down to about 1%  (1 in 10) if a "failed" test is repeated. So any time a baby doesn't pass initially, it's standard to repeat the screen as a double check. False positives can cause stress and anxiety for families during what is often already a stressful time; however, the risk associated with further evaluation is minimal (no invasive testing, no radiation), so I think it's probably worth it.

For those families who choose to have a birth center or home birth, the newborn hearing screen is still available to you through what are called "outpatient testing centers". Here is the link for all the California outpatient testing centers; those of you who live in other states should be able to ask your local hospital where the testing is available. It is covered by most insurances and Medicaid. 

What happens if a baby does have hearing loss? 

If a baby "fails" one of the screening tests, then  the test is repeated. If the baby "fails" a second time, he/she is referred on for diagnostic testing and genetic evaluation. This has been shown to get the age of initiation of hearing aides down to about six months (Just as happened in the case of my friends' girls).

The goal of programs for early detection of hearing loss is to have a diagnosis in infants (before three months) and initiate services by six months of age. As happened for my friends, babies who don't pass the initial screen are referred onto diagnostic testing (Remember the difference between "screening" and "diagnosing": screening is meant to pick up anyone who MIGHT have the condition; diagnosis is meant to confirm of those picked up who ACTUALLY has it).

Babies who receive a diagnosis of hearing loss are referred to what in California is called the Early Start Program. But, don't fret, every state has a program for children ages 0-36 months who have a developmental delay and meet specific requirements. Check this site out for more information on the programs in your state.

Here is the important message: ANYONE can make a referral to Early Start, including parents, medical care providers, neighbors, family members, foster parents, and day care providers.

I was at the park just this week talking to a mother who was frustrated because she had broached the topic of her child's speech delay to her pediatrician, who then reassured her rather than referring her son for an evaluation. She continued to be convinced that her son needed some extra help and ultimately did the mama-bear thing and called herself. Please ask your primary care provider for guidance, but, seriously, if you don't feel like you are getting the help you need, trust your intuition. You can call yourself. The number for Early Start Services in California is (800)515-BABY.

What happened to my friends' little girls after they turned 3?
After our protagonists graduated from the Early Start Program at age three, these little ladies found themselves at the Jean Weingarten Peninsula Oral School for the Deaf (JWPOSD), a nurturing and rigorous environment that expanded on their early intervention and really got them ready to attend their local public school. Their mom told me, "JWPOSD not only taught the kids to listen and talk, but also to think."  When the now-six-year-old's kindergarten teacher sent her mother a video of her sharing an "All about me" poster in front of 20 non-hearing-impaired classmates, her mom sent the video on to some of her former teachers and therapists. They were absolutely thrilled that the shy child they had taught was so expressive and confident. Success!


 (On a random note, 70% of acquired hearing loss (i.e. hearing loss that wasn't present at birth but developed over time) is picked up by PARENTS. Please take note, providers, parental concern should be enough to merit evaluation. And parents, don't be afraid to speak up to your primary care provider!)


Additional references:
http://www.ncsl.org/issues-research/health/newborn-hearing-screening-state-laws.aspx
http://www.infanthearing.org/screening/index.html
http://www.aafp.org/afp/2007/0501/p1349.html
http://consensus.nih.gov/1993/1993HearingInfantsChildren092html.htm
http://www.asha.org/Advocacy/Issue-Briefs/

Maggie will not die without her Xanax

I am often a little behind on television. This is due, in large part, to the fact that we don't actually own a television. I share this to clarify why my husband and I are currently watching the very beginning of Season 1 of HBO's acclaimed drama The Newsroom, while the rest of you are watching the end of Season 2.

Back here in Season 1, during a very sweet scene, my attention was drawn to an awkward piece of dialogue--it first caught my ear because the writing was oddly stilted and then held me because the content was downright infuriating.

http://buzzhub.files.wordpress.com/2012/08/newsroom-hbo.jpg

It went something like this:
The smart young protagonist runs outside to the back patio in the midst of a full-blown panic attack. Her unrequited love bends down to comfort her. In between a series of witty and tender words in which he skillfully calms her anxiety, he manages to say, "Maggie, where's your Xanax?" She tells him she forgot it at home, and he responds with a furrowed brow, "You must always have your Xanax with you for moments like this. You need it. Don't ever leave home without your Xanax."

Uh oh. Red flag. Big red flag. GIANT red flag.

First, Xanax (and its generic equal alprazolam) is one of the most addictive and, frankly, troublesome medicines I prescribe. Sure it has its place, but it is not the equivalent-- as implied in this scene--to an epinephrine pen, which would be essential in the case of an allergic reaction. Maggie might very well feel like she may die, she might even call 9-1-1, but a panic attack, though frightening, is not actually life-threatening. I assure you, Maggie will not die without her Xanax.

Second, Xanax is a brand name drug that is actually now available in generic form. There is no reason for the screenwriters to use the brand name unless they are advertising the brand.  Hmmm. . .is drug-brand name-dropping on TV legal? Should it be? Is it ethical?

Third, are you agitated? Because I am. I think I need a Xanax.

Xanax for president?
Xanax (pronounced ZAN-ax) is the number one prescribed psychiatric medication in our country and has been in the number one position since 1988. In 2012, there were more than 47 million Xanax prescriptions written in the US. Forty-seven million! Most experts believe it to be the most successful anti-anxiety medicine on the market because of aggressive marketing by its maker, Upjohn. Upjohn has convinced patients and physicians alike that Xanax is the most effective treatment for panic attacks and panic disorder. That's why Maggie is taking it.

Xanax is a member of the benzodiazepine family (affectionately called "benzos" in the medical world). The benzos are a class of medicines used to treat anxiety that also includes lorazepam (aka Ativan, ranked #4 on the list of top psychiatric medications), diazepam (aka Valium, #9 on the list) and clonazepam (aka Klonipin). All of the benzos work on the brain's GABA receptors, which essentially are our "downer" or "quieting" neurons. Xanax activates our "downer" neurons, thereby turning down and quieting our anxious selves. Got that?

Even though you and I are supposed to believe Xanax is better than the other benzos for panic, a 2011 review of studies comparing Xanax to the other benzodiazepines found that Xanax was not, in fact, superior to any of the other benzos for panic disorder (see this link, if you are interested in the actual analysis). Xanax has also been shown to be notably inferior to two better treatment choices for panic: Cognitive Behavioral Therapy (CBT) and antidepressants (specifically, selective serotonin reuptake inhibitors, like Prozac and Zoloft, as well as tricyclic antidepressants, like Elavil).

CBT is a specific type of therapy that has been shown to be particularly effective in panic disorder--73% of patients are panic free after three to four months of CBT (I'll write about CBT in a future post). Studies of anti-depressants also show them to be effective (61% of patients are panic-attack free after 12 weeks of one of these medications). Okay, so admittedly neither of these treatment choices are foolproof (I, too, would like to see the results closer to 100%), but they do help a lot of people.

http://cdn1.tauntr.com/sites/default/files/BOSH-Xanax.jpg

The reason people like Xanax for panic is similar to the reason my husband likes his albuterol inhaler for his asthma: it works fast. Unfortunately, however, both Xanax and albuterol do little, if anything to prevent the next attacks. And Xanax does worse than doing nothing; in fact, Xanax leads to a triple whammy of benzo-badness: 1) It is addictive, 2) It causes rebound anxiety, and 3) It turns your brain into mush.
Sound enticing?

Just to be clear, my issue with Xanax is not specific to Xanax, it's just that Xanax is the incumbent benzodiazepine and has held that office for much longer than two presidential terms-- Xanax has been top dog since George Bush Senior was elected President.

Addiction
Okay, so there is a lot of tiptoeing around in the world of addiction medicine around semantics. Care is often taken to distinguish "dependence" from "addiction". "Dependence" is a term used to describe "physical dependence"-- that is, bodily adaptations that result in withdrawal when drugs are discontinued (e.g. If you stop drinking your two cups of coffee cold turkey, you'll probably get a really bad headache). "Addiction" is a term used to refer to "the loss of control over the intense urges to take the drug even at the expense of adverse consequences" (e.g. You lost your home and got divorced as a direct consequence of your gambling addiction).

Scientists all agree that Xanax leads to physical dependence. It changes the brain, at least during the time you take it, and perhaps forever. In fact, withdrawal  from any benzodiazepine can kill (unlike withdrawing from Prozac or morphine, both of which can make people miserable but won't actually kill them). Almost everyone who takes a daily or twice daily dose of Xanax develops dependence; not everyone gets addicted. There is a certain subset of people who can take Xanax on a regular basis without it having adverse consequences on their lives, but the risk of physical dependence leading to addiction is high.

Xanax is also a known drug of abuse. National rates of hospitalizations due to all benzodiazepines actually tripled between 1998 and 2008 (see national data). Benzodiazepines are often abused in combination with alcohol or other drugs (like opiates). In fact, benzos were recorded as contributing causes in 30% of prescription painkiller overdose deaths in 2011. Large numbers of high school students admit to having tried a benzodiazepine, most commonly Xanax. Some clinic systems have even stopped prescribing Xanax altogether because of drug-seeking behaviors (see story in NY Times from 2011).

Please remember that benzodiazepine withdrawal can be deadly. If you have been taking regular benzos for any length of time and you decide you want to stop taking them, you should work closely with your physician to do so. Don't stop them on a whim.

Rebound Anxiety and Rebound Insomnia
We have known since the benzodiazepines came on the market that they cause what we call "rebound anxiety" and "rebound insomnia". This basically means the more benzos you take, the more anxiety you have. Bummer. And not exactly what you were hoping for.

Brain Mush
Known effects of the benzodiazepines include sedation, decreased attention, and anterograde amnesia. In simpler terms, benzos make you sleepy (which is why they are used by anesthesiologists to put you  to sleep for surgery); they make you a little less "tuned in" (which is excellent for panic, not so excellent for driving your kiddos to school); and they make you lose your ability to create new memories during the time the medication is working (looking to forget what is just about to happen to you?).  Another bummer.

It's also pretty clear that some combination of those effects lead you to be a little less cognitively sharp. Brain mush is a very technical term for the dulling effects of benzodiazepine use; there is convincing evidence that long-term use of benzodiazepines causes people to score lower on neuropsychological tests. The longer you are on them, the worse you score (see here for study). Same is true in elderly people (here is that study).

Is there an appropriate time for benzos?

Yes, I think there is a time and a place for benzos, but they must be both prescribed and taken with care. You should work closely with your provider to discuss the risks and benefits and really take benzos only when absolutely needed. And, please, don't share them with your neighbors-- this is not a neighborly good deed.

Examples, in my opinion, of appropriate uses of benzos:

• I had a patient recently flying back East to her 50th high school reunion. She is terrified of flying and even more terrified of seeing her former classmates. I gave her a few tablets for the flight, both ways. I'm stingy, I think I gave her 6 pills.
• I have a patient with advanced dementia who gets super anxious before coming to any dentist or doctor's appointments. Her son gives her a baby dose of lorazepam before the visits, and we avert hours of drama for her and him.
• I had a patient recently assaulted at the transit center. He is having some flashbacks and panic when getting on the bus in the evening to go home. He is working closely with a therapist and considering starting an antidepressant, but he really needs to keep riding the bus to work in spite of his current symptoms. This is a temporary and urgent fix.

What about Maggie?
Well, let's be clear here. I am not Maggie's doctor. I don't have a relationship with her, nor do I know her well enough to know why she is taking Xanax and whether or not it is an appropriate choice. I have not probed her psychiatric history, I don't know her substance abuse history, and I don't know what other prescription or recreational drugs she uses. I can make an educated guess, from this scene, that she experiences panic attacks. In this context, it's hard for me to make a therapeutic decision for her.

I would say, if she has simple panic attacks that are random and infrequent, then yes, Xanax (or any of its equivalents) is probably an okay medicine for her. For very occasional use and only in combination with an adequate trial of cognitive behavioral therapy. I would also like to know what she is doing for her own self care (she has a super stressful job) and how she intends to manage stress going forward. I'd be worried she may have some underlying anxiety disorder that isn't be addressed. If she gets panic attacks any more often than infrequently, she should probably consider a trial of an anti-depressant.

I'd also say that Maggie shouldn't be advertising her Xanax to you. Decisions about your diagnosis and which medications are appropriate for you should be a matter of discussion with your primary care provider, not some pharmaceutical advertisement. Or some cute smart girl you see on TV.

Now let's talk about product placement (aka 'name dropping') of pharmaceuticals
I am not that media savvy. I'm forever missing references to pop culture, and I can never confirm or deny a particular star's presence in a film. So maybe it is not shocking that I had no idea that pharmaceutical product placement was "a thing" until I watched the Xanax scene. When I started researching material for this post, I found that others have been talking about the topic for years; the earliest policy research dates back to 2005. Have you ever noticed a drug-name being dropped on your favorite show?

I could take this opportunity to launch into a diatribe about direct-to-consumer advertising to patients (Cut to commercial: music plays, previously incontinent grandma cured by the magic medicine runs through an open field and hoists her grandchild above her head, huge smile on both faces, music fades.). But direct-to-consumer advertising is a big topic for another day. For today, I want to consider specifically the issue of pharmaceutical product placement in TV and movies. Should it be allowed?

According to Nielson Media, product placement is defined as "any verbal or visual integration of a brand into a plot line". Examples of common products intentionally placed in the way of TV and movie cameras include Mercedes-Benz vehicles (the 2012 winner for making the most big screen appearances), Apple computers (a close #2), Budweiser beer, and the classic example of E.T.'s Reeses Pieces.

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Turns out one of the first pharmaceutical product placements was in 2005 by the pharmaceutical company, Organon, which placed posters for Nuvaring, a birth control method, in the background of episodes of Scrubs and King of Queens. Soon after, analysts started noting Zoloft (an antidepressant) and Lap-Band (a patented procedure for gastric bypass surgery) being dropped into certain daytime soap operas. Even though I love birth control, I want people to know about anti-depressants and gastric bypass surgery, this still seems wrong.

Marketers are banking on our emotional relationships to some fictional character in some fantasy world to subtly persuade us that the medication our favorite character is taking is what we need too. This doesn't seem like a good way to get educated. 

In contrast to the examples mentioned above, some viewers might assume that the inclusion of medication brand-names in screenwriting is unavoidable. Some might argue that using brand names captures "how doctor's speak" or literally "how patients talk about their medications." What do you think?  If a scene is going to realistically cover a health issue, must the writer specifically mention a medication by name? Does it make the dialogue more real? Does it lend credibility? Or is it merely advertising?

I can share with you that, as a physician who cares about the undo influence of pharmaceutical companies on my practice, I very consciously try not to use brand names when speaking with patients or other providers about medications. In fact, writing "Xanax" over and over for this story is killing me. I do firmly believe that the more I see, write, read, and say a name, the more likely I am to prescribe and use that drug (rather than generic or equivalents that may be less expensive and just as good). I also know that I am human, my patients are human, and marketing works on humans.

There is no way to confirm that the name dropping is actually funded by the pharmaceutical companies because transactions between private companies and the media outlets are not privy to public information. So we won't really know. But we can guess. And my guess is that the makers of Xanax paid for Maggie's scene.


The practice of pharmaceutical product placement is also questionable from a legal perspective. The FDA has strict guidelines about what information needs to be included in pharmaceutical advertising (that's why we always hear that raspy voice at the end of the TV commercial reminding us that, "in rare circumstances we could die or lose our fourth digit on our left foot by taking such-and-such medication"). But, does the FDA consider this advertising? As far as I can uncover, the FDA, FCC and FTC currently do not have specific guidelines to address the use of prescription drug references in fictional entertainment. This gap clearly leaves some space for abuse-- and puts us at risk for some serious manipulation.

After all, if the cute smart girl is taking Xanax, why wouldn't I want it too?
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Additional  references on benzodiazepines:
http://www.psychologytoday.com/blog/how-everyone-became-depressed/201306/benzo-hysteria
http://psychcentral.com/lib/top-25-psychiatric-medication-prescriptions-for-2011/00012586

Additional references on product placement
http://www.pharmalive.com/sites/default/files/blogs/attachments/product-placement.pdf
http://www.marketingpower.com/AboutAMA/Pages/AMA%20Publications/AMA%20Journals/Journal%20of%20Public%20Policy%20Marketing/TOCS/summary%20spring%2008/Pharmaceuticaljppmmay08.aspx
http://www.rxentertainmentinc.com/what-we-do/product-placement/