"Beauty" - at what price?

Wrinkles are bad.

So are small breasts.

Also crow's feet and age spots.

Jiggly arms and muffin tops.

Don't forget untrimmed pubic hair.

This tirade isn't limited to women.

Guys, are your muscles ripped?

Chest gleamingly hair-free?

Male member sufficiently enhanced?

On a regular basis, I see 9 to 11 year-old girls who tell me that they're cutting back on what they eat because they're "fat."  While I'm examining them, they will point to the normal pubertal fat deposit just below the belly button and bemoan this unwelcome detraction from a perfectly flat abdomen.  Although some of these girls are overweight, most are not.  What have we done, as a society, when preteen girls are this unhappy with their bodies?

Why are we allowing advertisers and mass media to define beauty? Since when did aging become a condition or disease to be treated?  How did 18-year-old Barbie doll figures become the standard of beauty?  Mass media and the beauty industry - admittedly only pandering to what consumers respond to - have picked up on our insecurities.  We are assaulted on a daily basis by advertisers' impossibly airbrushed and retouched models selling everything from stilettos to vitamins.*  These companies succeed at convincing us of our "flaws" that their products can "fix."

As physicians, we must beware of being caught up in this over-emphasis on appearance. We contribute Botox for wrinkles, silicone for sagging breasts, and the diet pills to lose 10 pounds.  In so doing, though, are we contributing to the problem?

Beauty treatments and the desire to look attractive are not, in and of themselves, fundamentally bad, and neither are the health care providers who assist with them.  The danger lies in allowing our focus on those treatments' goals to pervade our internal sense of self-worth.  As physicians, we have a sacred trust with our patients; we treat each person, regardless of appearance, with dignity and respect.  We must be cautious against contributing to the fallacy of perfect appearance with our skills and prescription pads.

Our intrinsic value as human beings has nothing to do with our skin and breasts and muscles.  Each of us can help to push back against these social pressures by teaching that the altered pictures of people in magazines make us long for what is unattainable.  We can compliment each other as often on our internal qualities as we do on new hairstyles or clothing.  My patients' resilience, patience, and thoughtfulness, often in the face of great struggles, are what is truly beautiful about them.

Let's shift the conversation toward that definition of beauty.

* A new movement is committed to exposing the excesses of retouching in the beauty industry: http://jezebel.com/5115667/2008-photoshop-hall-of-shame, http://www.sfgate.com/opinion/article/Jamie-Lee-Curtis-has-nothing-to-hide-2805025.php#photo-2210632, http://www.diet-blog.com/06/celebrity_retouching_10_reasons_to_revise_your_reality.php.

Perfume and office visits don't mix

That perfume that you heavily doused yourself in this morning may be your signature scent.  It may help you to feel more feminine.  It may be an important part of your overall persona.  When not in tight spaces with others, feel free to douse away.  As your doctor, though, I must ask that you refrain from wearing it (or at least as much of it) to office visits.

Along with about 8.4% of the US population (1), I have asthma. To promote good doctor-patient communication, I can't sit too far away from you.  To perform a high-quality physical examination, I must enter into your personal space.  Several minutes of inhaling that strong scent, however, can cause me to have trouble breathing.

I've never been brave enough to bring this up before, fearful of irrevocably harming our relationship.  You have the right to wear as much perfume as you like.  It's not your fault that I have asthma, and it's not your responsibility to help me deal with it. But the boundary between your rights and my responsibilities seems to be tilting more toward me.  I'm also compelled to speak up for the 1 in 12 people around you with asthma.  A quick Google search confirms that this is a common issue for us asthmatics. (2)

I despise these hypersensitivities that humiliate me with coughing fits after exposure to what should be innocuous stimuli; in a more perfect world, I could at least conceal my problem from those around me.  Maybe part of my reticence to broach this issue relates to an intense desire to present myself as "normal and healthy" to those around me, including my patients.

At the end of the day, too, I value the doctor-patient relationship too highly to jeopardize it for something as banal as perfume.  After all, docs sacrifice other elements of well-being to do their job.  Most of us buy into the premise that a career in medicine requires dedication and sacrifice.  So, for now, I will settle for this generic cyberspace plea:

On behalf of the 25.7 million Americans with asthma, please think twice about how much of that perfume you apply before heading out the door.

1 http://www.cdc.gov/nchs/data/databriefs/db94.htm
2 http://www.everydayhealth.com/specialists/allergies-asthma/feldwig/qa/painful-perfume/index.aspx, http://asthmamomlife.blogspot.com/2011/11/perfume-as-asthma-trigger.html, http://forums.webmd.com/3/asthma-exchange/forum/1875, http://whatallergy.com/2012-02/please-dont-wear-perfume

Recipe for a vital primary care workforce

Thanksgiving is just around the corner, and so it seems appropriate to share a recipe:

Recipe for a vital primary care workforce
1. Accept more students into medical schools who are likely to choose primary care.
2. Validate medical students' interest in primary care.
3. Provide adequate Family Medicine and General Internal Medicine training opportunities.
4. Enact meaningful payment reform.

Now, a sub-par cook such as myself needs a little more detail than just the basics to pull off such a complicated recipe...

1. Accept more students into medical schools who are likely to choose primary care.
Studies show that medical students who choose primary care are more likely to:
    Live in a rural area and/or plan to return to work in a rural area (1)
    Live in a disadvantaged area and/or plan to work in a disadvantaged area (2)
    Have grown up in a low or middle socioeconomic neighborhood (1,2)
    Not plan a research career* (1)
    Believe primary care is important and plan to practice primary care (1,4)
    Be indifferent about earning a high income after residency (1)
    Be female, older, and/or married (3)

2. Validate medical students' interest in primary care.
It's not enough to accept the right students into medical school; schools must also support interest in primary care.  Here's what's been proven to increase the number of grads choosing primary care careers:
    Increase mandatory rotation time in Family Medicine and General Internal Medicine. (2)
    Rotate at two or more Family Medicine sites. (4)
    Require a longitudinal primary care experience.  (3)
    Expose students regularly to academically credible FM/GIM faculty. (3)

3. Provide adequate FM and GIM training opportunities.
Medical school graduate numbers are increasing as new schools open and existing schools expand their class size, but there are not enough residency slots for all of them. Some estimate that we will need 52,000 new primary care doctors by 2025, largely thanks to the Affordable Care Act, (6) and our capacity to train them is lacking.  Additionally, few Internal Medicine residency graduates are practicing primary care these days, so the bulk of those 52,000 will likely need to be Family Medicine docs.  Unfortunately, Family Medicine residencies are not growing in numbers and capacity but are instead closing at an alarming rate. (5)

One of the local health systems here closed a Family Medicine residency program to "rebalance" their budget and workforce needs.  Those GME slots are going to a vascular surgery residency.  Local pressures are leading health systems to make short-sighted choices about what kind of medical specialities we are training our future physician workforce for.

4. Enact meaningful payment reform.
Payors devalue primary care by paying more for procedures and specialist care than for comprehensive, preventive primary care.  Case in point - our residency program practice earns about twice as much for doing a circumcision (a simple procedure that takes about 10 minutes) than for admitting a patient with complicated problems to the hospital.  We earn more for snipping off a skin tag than providing 45 minutes of direct patient counseling about chronic disease.  

The current "Medicare physician payment formula...rewards volume over quality and that discourages growth of primary care." (7)  Systems produce what they are designed to produce, and right now our payment system disincentivizes primary care by better rewarding procedures and specialists. Unnecessarily expensive care does not produce better patient outcomes, and it certainly won't help the US balance its bloated budget. (8)

Shifting our nation's health emphasis back to quality primary care will take deliberate effort by many parties.  I would argue, however, that the payoff will be more than worth it.  US counties with more primary care docs have lower health costs and longer life expectancies compared to counties with a heavier emphasis on specialists. (9) Yes, we need our specialist colleagues.  

But I'd argue, at this point in US history, that we need Family Medicine more.

1 http://www.ncbi.nlm.nih.gov/pubmed/1985676
2 http://www.ncbi.nlm.nih.gov/pubmed/14963077
*  Not to say that research in primary care isn't vitally important...just citing the studies.
3 http://www.ncbi.nlm.nih.gov/pubmed/7612128
4 http://www.ncbi.nlm.nih.gov/pubmed/15057616
5 http://www.ncbi.nlm.nih.gov/pubmed/14603401, http://www.ncbi.nlm.nih.gov/pubmed/1544533
6 http://www.thefiscaltimes.com/Articles/2012/11/19/Wanted-52000-More-Primary-Doctors-by-2025.aspx#page1
7 http://www.aafp.org/online/en/home/publications/news/news-now/government-medicine/20121107electionresults.html, http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/twentiethreport.pdf
8 http://www.jsonline.com/business/looming-primary-care-shortage-starts-with-med-school-to39lu9-134971463.html
9 http://bostonreview.net/BR30.6/starfield.php