Wednesday, May 28, 2008

$75 for three prescriptions? Are you freaking serious?

Of course, that's not what I said at the pharmacy counter--hey, it's not Ahmed's fault that my copay for trade-name drugs is $25 (yes, the pharmacy tech's name is Ahmed; I'm not being a dick. At least not about that). But, having long read Drugmonkey and The Angry Pharmacist's blogs, and being more than vaguely aware of the shenanigans that drug companies get up to, I knew chances were good I wasn't really over a barrel. In fact, I consoled myself, I'm probably getting a really good deal considering what the prices would be WITHOUT insurance (now can you see why I was so freaked out when I thought I'd be off my parents' insurance when I turned 23? Thank G-d the city extended the age to 25. Woot!). And lo, I went to drugstore.com to check the prices; and lo, it turns out that with insurance I pay about 12% of the Average Retail Price of the prescriptions I get. Did you hear that? My insurance is like a 90% off coupon. Which means 1. People without insurance are even more thoroughly screwed than I originally thought and 2. Holy crap, drugs are expensive.
Here's the breakdown (I included some of the other meds I take, even though I didn't have to get them filled the other day and thus they weren't included in the $75):
Depakote ER, 500 mg: 240 for 90 pills
Effexor XR, 150 mg: 250 for 60 pills
Singulair 10 mg: 112 for 30 pills
Lorazepam 1 mg: 15 for 30 pills
Levothyroxine, 150 mcg: 20 for 30 pills
Cytomel, 25 mcg: 50 for 30 pills

Notice how the generics are way less expensive? Seriously, I can't tell you how thrilled my parents were when my Zoloft went generic a few years back. Granted, for us it just meant the copay went from $50 to $10 (though saving $40 a month is hardly chump change). Based on these numbers, I'm sure the people without insurance were even more thrilled. Then again, the people without insurance probably weren't taking Zoloft--they were probably on either TCAs (tricyclic antidepressants), MAOIs (monoamine oxidase inhibitors--nasty things, when you really stop to think about it; granted, they can help with depression, but they also interact with EVERYTHING on God's green earth, including foods. And these aren't "Oh, you'll feel a little weird" interactions. These are "Your blood pressure will go through the roof and you'll stroke out and die" interactions) or the SSRIs that had already gone generic, like fluoxetine.

Interesting side note: Fluoxetine has since been repackaged as Sarafem, as a treatment for "PMDD," or Premenstrual Dysphoric Disorder (known once upon a time as PMS). Don't get me started, but I'll just say that it's more than a little suspect when there's a mental disorder that's predicated solely on what I would consider a NORMAL female state. Yeah, it sometimes sucks to have your period. Trust me, I know. Used to get horrible, I-want-to-kill-myself PMS. And yes, there are certain interventions that help with mood, bloating, etc. But does that mean it's a disorder? American life has become so medicalized...what were once just, meh, parts of living have become illnesses or syndromes (Am I going to get into trouble going into med school with this sort of attitude?). Granted, there are times when intervention is warranted--I'm just saying that pathologizing every deviation from the norm might not be the way to go. 55 and can't perform like you used to? Have some Levitra. Going through menopause and don't have quite the same vim you did when you were 30? Premarin for you. Women who get bitchy before their periods can have some Sarafem, little kids who can't pay attention get Adderall, and people who are made twitchy and nervous by life in general get a script for some benzos.

Also interesting: every time Big Pharma comes out with a new drug for a particular "disorder" it seems like there's a media blitz--not just advertising, but news puff pieces, articles in magazines, earnest editorials in professional journals. Take bipolar disorder in children: drug companies recently came out with approval for use of an existing drug in kids (I think maybe it was Depakote, but I'm not certain) and suddenly there's an explosion of 'experts' telling doctors and parents, "Your kid might be bipolar. It's wildly underdiagnosed!" Pardon me if I'm a leeeetle skeptical. This said as someone who's been on various drugs for severe depression/bipolar disorder since I was 11. I'm not saying it doesn't happen; I'm saying it pays to look at who's giving you your information.

Tuesday, May 27, 2008

So somehow, a while back, I got into the template and was fiddling with things. Of course I managed to set the sidebar at the bottom of the page somehow (meaning it's no longer a sidebar per se, but more of a footer, or bottom bar, or something like that). Does anyone with Blogger familiarity know how the hell I can fix it? I just wanted to add some new links, I swear...
I beat the clock this year--before Memorial Day even arrived, I already managed to have poison ivy. This is the price we pay for being simultaneously outdoorsy and sensitive, like that camp counselor with the scruffy beard that first summer you were a counselor, too--remember how he could rappel and rock climb all day and then play you a song he wrote on his guitar by the campfire in the evening? Sigh...
Damn you, urushiol (that's the name of the oil that produces the rash--did you know it can stay 'active' for up to 5 years? Even on hard surfaces or dead plants? Yes, Toxicodendron--that means you, poison oak, ivy and sumac--I understand you need to protect yourselves from being munched and/or molested. But isn't five years of lurking about a little much? Using something like that to protect yourselves is like finding out you have aphids in your garden and then going after everything in your entire backyard with a blowtorch). I haven't been wallowing in any vegetation lately--especially not up to my neck, which is where the rash showed up. Thus, I am currently blaming the dog for bringing in the oil on her fur.

Monday, May 26, 2008

Indiana Jones and the Willing Suspension of Disbelief to account for an even more Dubious Hypothesis

Yeah, ok, whatever, the movie wasn't supposed to be an accurate portrayal of pre-Columbian history, or physics, or Russians, or what happens when an atomic bomb goes off...but damn did Cate Blanchett look good in that Russian worksuit, with her high black boots and--for the love of all that is good and holy--a rapier. As in a sword. She had pistols and a Kalashnikov at various points in the movie too, and all I can say is that if her character wanted to work me over, I'd go red in a second and never look back. Ahem. It was a pretty good film all the same; an early summer movie to go see when your brain is on overdrive from all the sudden stimulation of the scenery outside (warmth! sun! flowers, leaves, shorts! hormones!) or as a Memorial Day escape from the drudgery of your 9-to-5 job, when you realize that your kids are going to get 3 months off "work," while you're going to toil away like a drone year round until you retire or die. Wow, I'm just a little ray of sunshine today. Anyway, to recap--Movie: good. Overall believability: bad. Cate Blanchett: arousing. There you go.

Thursday, May 22, 2008

Klinefelter's, Turner's, and Pregnant Men

Are you a girl or a boy? Are you a boy or a girl? --Le Tigre, "On Guard"
OK, let's say from the beginning that I'm going to be as careful and sensitive as I can be, and that I'm still probably going to misstep and say something wrong. But, in light of the recent spate of publicity for the pregnant man who appeared on Oprah, I thought it might be a good idea to talk about sex/gender from both a medical and a feminist studies perspective--because I really wish those two perspectives were cozier, anyway. Yes, I'm talking to you, male pediatrician who told me when I was 11 that my debilitating made-me-vomit cramps were 'in my head' and that PMS has been collectively imagined by whiny women since the dawn of time. So I'm going to try to be careful with the pronouns and definitions, and if I say something totally out of line feel free to take me to school in the comments, but give me a little slack.

OK. Gender and sex, as anyone who's taken a women's studies class can tell you, aren't the same. Gender is largely socially constructed--how men and women are supposed to act, dress, talk, and so on. Sex is thought of as biological--male or female rather than man or woman--but of course since biology is a 'constructed' discipline, you can't really get to PURE biology, as evidenced by the intransigent (nice word, huh?) difficulty in answering what "should" be a very simple question: How do we define sex, biologically? Well, here are some of the answers--and some of the problems with those answers:
1. According to chromosomes--two Xs make a female, and XY means you're a guy. OK, I guess, but what about people with Turner's syndrome? They have only one X chromosome, no other X or Y. Their genitals are externally "female," and most have uteruses, but ovaries are underdeveloped and since estrogen isn't produced in quantity, secondary sexual characteristics (breasts, menstruation, etc) don't happen. A person with an XXY karyotype (a 50 dollar word for what chromosomes someone has), or Klinefelter's syndrome, should be female too then, right? No, that person 'looks' male--the only tip-offs to the chromosomal hanky-panky are "michroorchidism," ie small testicles, low testosterone, and sterility. Crap. And then there's androgen insensitivity syndrome, where someone has XY chromosomes but, because their cells aren't sensitive to male hormones, they develop into what we'd call "females" at birth. Nothing much happens at puberty--in part because they have testes rather than ovaries or a uterus in the pelvic cavity (the testes should usually be removed, because hanging out inside the body increases the risk of testicular cancer), and in part because the cells aren't sensitive to androgens, and those are the hormones that get the party started (with body hair especially) at puberty. Hmmm.
2. Ok, not chromosomes--what about just using the body? The whole "girls have vaginas..." thing we learned in kindergarten? Yeah, about that. Aside from the exceptions listed above, there's such a thing as being "intersexed," or born with "ambiguous genitalia"--not clearly fish or fowl, you might say. According to the Intersex Society of North America, about 1% of people are intersexed to some degree. A lot of times these people are 'sexually assigned' shortly after birth--a baby with an 'enlarged' clitoris has it cut to 'normal size' (which of course does away with the ability to orgasm a lot of times--gee, thanks, Doc), or a small penis is refashioned into a clitoris. Needless to say, the sex these people are assigned, since they're not doing the assigning, doesn't always line up with what they feel later in life. There's a lot a mental anguish associated with this, not to mention dealing with the fact that your genitals were carved up when you were a kid. Seriously, go to ISNA's website and find out more about it; it's a silent outrage that surgeons are wielding their knives this way. Even though the rationale is often to save the patient "the pain of being different," it's misplaced and often harmful treatment.
3. OK, fine--chromosomes don't always do it and neither do bodies/genitals...what about hormone levels? Well, Klinefelter's and Turner's patients have levels of hormones that often don't fall clearly into male or female territory...not to mention the fact that postmenopausal females and preadolescents have very different hormone levels from reproductive aged men and women. So is a postmenopausal female not female because she doesn't make as much estrogen as she used to? Does picking up a Premarin prescription suddenly make her a chick again? If my friend Steve starts popping estrogen like Mentos, does that make him female?

Clearly this is a complicated question, one that no single factor accounts for and that no one person can answer definitively. Sex, perhaps just as much as gender, depends on a lot of factors--not least the way the person identifies him or herself. Which is why, if that guy in Cali says he's a pregnant man, I believe him. Biology may have a lot of say, but biology is still not destiny.

Tuesday, May 20, 2008

Where's the 'first do no harm' line again?

Scalpel wrote a post earlier this month about a cutters' (ie, self-injury) forum, and in the course of the commenting someone mentioned a young man who cut himself so severely and so often that his hemoglobin was chronically in the toilet--like in the low single digits (normal is around 13). Eventually the doctors who had been giving him blood transfusions cut him off--no pun intended, because man, joking about this would really mean I'm going to hell, like today, instead of at some vague and ill-defined point in the future--and lo, he 'rationed' his cutting so that he wasn't sucking down packed cells like Vlad the Impaler at happy hour. In all, I think this could be called a positive outcome for all concerned, assuming the guy learned to 'make do' with less cutting and maybe--just maybe--picked up some alternative coping skills.
But here's my question: I could just as easily see this going another way...what happens to the treatment plan when Joe Kidd shows up in the ER with a hemoglobin of 5? Is it justifiable to withhold treatment? Do you catch and release, bumping him up into the double digits and waiting for him to come back (a less extreme example might be someone whose wounds routinely need sutures)? Should he be given another transfusion, but this time also be forced to enjoy a 72 hour vacay on a mental health unit? To those who balk at involuntary commitments, what about making receipt of the blood contingent on his signing into the psych ward? Does dressing it up in different clothes change the ethical implications?
What about providing potassium for a purging anorexic or bulimic who presents with a 2.9? Of course you do it the first time, and the second, and the third. But what about the fifteenth? Does the answer change if she's actively engaged in outpatient therapy, or if she's been in and out of treatment centers? What's the point at which you say (and ostensibly this would be a primary care physician, not someone down at the ER), "Hey, why don't you take these 40 mEq of potassium every day until I say stop?" Or is that, as some physicians argue (boneheadedly, in my opinion, and as though attempting to prove to all and sundry just how little they understand about eating disorders) merely giving patients "permission" to purge?
In short, when does "This is what you SHOULD be doing, dammit!" turn into "OK, if you're going to do that anyway, here are ways to reduce the risk and here's a safety net"?
And just a little devil's advocacy here (I swear I've never been able to look at Al Pacino the same way since I saw that movie--hands up everyone who got the reference), it is beyond standard practice for patients to come in, say "I kind of tried to walk more and watch what I ate, but not really" and have the doc shrug and write out scripts for Zocor, Glucophage and Benicar. So who gets enabled when, and what makes the difference? Is it simply that some behaviors (cutting, eating disorders, chronic suicidality) are so dramatic and hold such stigma that extreme measures 'become' justified, even at the expense of respecting the person's autonomy? Or is that precisely a caregiver's role at times: to make treatment decisions a patient isn't able or qualified to make, and to act in her best interest (even if it means denying her wishes) when she can't?

Monday, May 19, 2008

I've read that one 'therapy' for chronic worriers--people with generalized anxiety disorder, OCD, and folks who are just nervous Nellies by nature--is to set aside time specifically to worry. Worry like hell for ten minutes, or twenty, schedule 10:30 to 10:40 as "worry time" in your DayTimer, and for the rest of your day forget about it. In that spirit, here are some of the things I'm worrying about right now--and once I've typed them out, I am resolutely going to ignore them for the rest of the day.

1. Finding an apartment/therapist/psychiatrist/group of friends/place of worship/girlfriend/good pizza place in St. Louis (If you have all those things, I find there's very little else to want)
2. Global warming and climate change
3. The impending gas crunch, and whether I'll be able to get around StL without a car
4. How I'm going to juggle two appointments on Thursday when it's my first week back at work after vacation and I can't exactly ask for the day off
5. How much I'm going to miss one of my housemates, who's moving back to California on Tuesday
6. The caloric content of that cinnamon roll I ate for "breakfast" (breakfast in quotes because meals imply some sort of redeeming nutritional value, of which a cinnamon roll--especially from the hospital cafeteria--has absolutely none. Why, by the way, do hospitals always have such incredibly unhealthy food in their cafes? Is it just a job security thing?)
7. When I want to have my last day at work--the middle of June? The end? I was planning to go all the way to the end of July, but screw it...this could very well be the last summer off I ever ever have, and I'll be damned if I'm going to spend it abstracting data and cold-calling people for clinical studies.
8. The extent to which I've accrued overdue fines on library books, and wondering at what point librarians in black leather thigh-high boots are going to show up at my door with riding crops (actually, I think I've seen a web site or two devoted to just such a scenario--mrowr!)
9. The fact that I promised myself I'd quit smoking before I started medical school (it was a lot wittier to say when I was a sophomore in college)
10. Whether or not I'm going to put in the window AC unit that is currently sitting in my closet, seeing as it's going to get almost to 90 F today
11.Whether a year off school has made my mind flabby and inert, like Renee Zellweger in the Bridget Jones movies, and whether I'll be able to whip it back into uber-toned, quasi-anorexic Renee-Zellweger-in-Chicago shape
12. Whether I should run the Hospital Hill 10 K, like I planned to, or bow out (it's nationally known as a very difficult, very hilly run--but I feel like doing the 10K instead of the half-marathon is already a compromise...hmmm...)
13. Filling out all the financial aid paperwork I need to do, because I'm not made of money and my parents have made it very clear that they're done providing finiancial assistance for my education
14. The disappearing honeybees--mentioned in a waaay previous post--who are soon going to affect US agriculture in a big way
15. The fact that my uterus, ovaries, pituitary and hypothalamus appear to be getting their signals crossed, resulting in my having--while not yet 'real' periods--irregular, annoying, unpredictable spotting a few times a month. I don't have much money in the 'new underwear' budget, yo? And I wouldn't have worn my date skivvies if I'd known this was going to happen.

Self-indulgent navel-gazing over, for the time being. My apologies, and thanks for your patience.
Affirmation of the day, just dorky enough for me to laugh when I say it: "Jesus thinks I'm awesome." And he does.

Thursday, May 15, 2008

I GOT ACCEPTED TO WASH-U MEDICAL SCHOOL IN ST. LOUIS!!!

Wednesday, May 14, 2008

I went to the doctor today, to get the whole "whoo-hoo, non-exertional tachycardia and syncope" thing re-checked, and I have to say: the walls in that office are thin. Like, "this must be a HIPAA violation somehow" thin. (See how this stuff has gotten to me? I think about HIPAA even when I'm not at work! They're inside my head, I tell you!)

Woman In The Next Room was describing what I'm assuming was a skin infection to the poor medical student in there with her (I go to a teaching clinic--not an 'I don't have insurance so put me on a sliding scale and let the interns poke me with sticks' teaching clinic; it's a classy joint. Think of it as a 'teaching clinic' the way you'd think of Mayo in Rochester as a 'teaching hospital.' Only not THAT good):
"Four centimeters by four centimeters. It hurt like there was a boil comin' in, you know? Only it never come to a head, so I tries to ignore it." Oh my. This is the very, very thin, rather unkept woman I saw in the waiting room. No judgements, despite the fact that she looked a lot like the people living near my grandma's rural Missouri estate, and who turned out to be manufacturing (and consuming, 'cause you always have to taste a little of what you bake) large quantities of crystal meth. Just sayin', I wouldn't be surprised to find out that this was MRSA. I tried really, really hard not to listen, but there weren't any magazines in the patient rooms, or even any pictures on the walls to distract me. Also I'm inherently nosy.
"Then my boyfriend, he says, 'The skin's turnin' black, it's dead, go to an emergency room,' and I go, and it was dead..." Oh sweet suffering Jesus.
Nurse: "I see they gave you a prescription for antibiotics in the ER...have you finished those yet?"
"No, I never filled 'em. I figured they gave me a shot in the emergency room, so I didn't need to take no more pills."
At which point I wanted to take off my shoe, bang it on the wall, and yell, "YOU are the cause of antibiotic resistance in this country! YOU are why I had to take three courses of antibiotics to treat one case of pneumonia last year! YOUR new name is Typhoid I-can't-fill-a-four-dollar-Keflex-prescription Freaking Mary!"
It also came out, in the course of the conversation, that the ER doc noted on her chart that she was 'not to receive further narcotics from the facility.'
"I don't know why he would say that." That particular, slightly softened, just-a-little-bit-higher voice of a person who is lying like a rug.
"It says here you're on *mumble mumble* and Flexeril...it says in the ER notes you take 10 mg of Flexeril a day, but our records say 30. Someone must have made a mistake...could you tell me which it is?" Oy veh.
Anatomical navel-gazing: The Eyes Have it (ha ha ha...no, seriously, I'm sorry, that's a tagline more appropriate for a dorko space-filling paragraph 'item' in Discover magazine, not a fine publication such as this. I apologize).

Today's lesson? "Central Heterochromia Iridis" (pull that one out at cocktail parties!)

When people ask me what color my eyes are, I've always said "blue," but the truth is it's a little more complicated. While most of my irises are blue, I have a central ring of hazel-brown around the pupil. I always assumed that everyone's eyes were that way, and didn't ask anyone about it (sort of like I once thought I was a genetic freak because my eyes appear to be different colors based on what I'm wearing...then half my friends said the same thing, and I felt like a spaz for thinking it was something bizarre and special). Turns out it's not very common...it's a form of "heterochromia iridis," which just means--break it down now--different...colored...irises. Seriously, label something in Latin or Greek and you can sell twice as much of it for three times the price. If 7-11 renamed the Big Gulp the "Macro Dipsia" and had people in white coats sell 'em they could charge five bucks. It's the mystique of the thing, and people act as though 'big words' are some kind of magical incantation...just like when philosophers or lawyers start talking about "post hoc ergo propter hoc" fallacies everyone goes quiet. Except other philosophers and lawyers, who are just pissed someone else busted out the Latin first.

So anyway, this is caused by differential deposition of melanin (the pigment that gives color to hair, skin and eyes...the more of it you have, the darker you are; albinos don't have any, which is why they're so pale) in the iris. Lighter colored areas, obviously, have less melanin than darker areas. In the case of central heterochromia, the rarest kind (yee haw, I am special) this can also be caused by the buildup of toxic substances (eek!). People with the central form are sometimes referred to as having "cat eyes." Thanks, Wikipedia! Oh, side note--people with Wilson's disease, a genetic inability to process extra copper in their bodies--can develop rings around their irises over time, too. These are called Kayser-Fleischer rings and can look like heterochromia except that, y'know, they develop over time, and if you have Wilson's disease you'll probably be having some issues with your liver (and other assorted organs...pretty much all of them, eventually) that will let you know there's a problem. So freak not.

I learned all this because I was plucking my eyebrows this morning and thought, y'know, in all this time I've never looked to see if this two-toned eye business is anything unusual. Googled "eyes two colors" and bam--Wiki be praised!

Thursday, May 08, 2008

So I missed the boat on Sexual Assault and Rape Awareness Month (say that five times fast). It was April. My bad. I think it's great that there's a month and all, I just feel a little...put out that we NEED to have a month devoted to saying, "Oh, yeah, rape is a bad thing. Um, you shouldn't make people have sex with you if they don't want to. And if someone forces you to have sex, you should report them, 'cause that's *kind of* a felony." We don't have a "Don't Kill People" month (I nominate January, when everyone's kind of depressed after the holidays and has just spent a week solid at the in-laws' place). We don't have a "Don't steal things" month. Admittedly, the circumstances around "acquaintance rape" are a little harder to negotiate sometimes, but that just means you need to stop for a minute and think--ladies AND gentlemen *cue the song by Saliva.*
Just because I let you in my apartment doesn't mean I'm letting you in my pants.
Just because you paid for my drink doesn't mean you paid for a happy ending.
If you think I'm a bitch for saying no, keep pushing and see what a bitch I'll be at your trial.
ON THE OTHER HAND--
If we both say yes, there's a lot of fun stuff we can do.
Sex is a lot better when it's, you know, a two-person thing.
An enthusiastic, willing partner is a lot sexier than the other kind.
I'm trying to make little teal ribbons to send out to friends etc. (Teal being, apparently, the universally accepted 'rape survivor' color) but I went into my box o' sewing notions and realized: damned if I could tell you periwinkle from teal from robins-egg blue. Periwinkle is apparently the eating disorders awareness color, so that might also be apropos (although ED awareness week is in March--interesting how that only gets a week, eh? I suppose it's better than just getting one day, like Micturation Syncope Day or something--and would mean I'm even further behind the times). Blargh.
Happy May! and for those of you who were wondering: Micturation syncope is when peeing makes you pass out. It's a real thing; google it. Fun, eh?