Physician, heal thyself

weight

It’s been quite a while since I posted last, but today it feels like the right thing to do. I’m supposed to be working on a presentation I’m giving on the 11th , but I’m going to take a little break.

So one of my ongoing personal struggles has been my weight. I have struggled with it my entire life and total understand why losing weight is not as easy as skinny people make it sound.

The best shape I was ever in was during my years as a competitive gymnast in junior and senior high school. Though I was quite fit by general standards I was always embarrassed about the stubborn layer of belly fat that I could never lose to show off my ripped abs. After that I went to college and my physique went downhill.

When I finally got fed up with the extra weight I started working out again and trying to eat right. Yet after 2 years of trying I was still above my goal weight. So I joined LA Weight Loss and the weight melted off. Check out how skinny I got in the photo from 2005! After enough people pestered me that I was getting too skinny I stopped the diet and within 6-12 months was heavier than I had been before. I have contemplated doing the LA diet again numerous times but I honestly hated it — I like REAL food, sorry! — so I stayed heavy.

Well, my weight continued to creep up until I was barely able to fit into my 36 inch pants and I could not wait to take them off when I got home from work because they were so uncomfortable. I was too proud to go up another pant size. Check out the muffin top hanging over my pants just a couple months ago. Vanity aside, I am soon to have my 40th birthday and with my family history of diabetes I knew that I needed to make some major changes.

Where to begin?

Obesity in adults is defined as a having a Body Mass Index (BMI) greater than 30. The BMI is a number calculated from your height and weight alone; it does not take into consideration gender, ethnicity, bone density or lean muscle mass. In spite of these limitations the BMI remains the most utilized marker of overall body composition and a good tool to see where you are. You can find out your own BMI using the calculator from the CDC (Centers for Disease Control and Prevention).

BMI between
18.5-25 is normal weight
25-30 is overweight
30-40 is obesity
30-35 is class 1 obesity
35-40 is class 2 obesity
40 or more is class 3 obesity
40-50 is morbid obesity
50 or more is super morbid obesity

As I alluded to above, obesity is not just about looks. Rarely a day goes by in clinic that I’m not counseling at least one patient to lose some weight. Studies have shown that the majority of overweight women with irregular menstrual cycles only have to lose 5% of their current body weight to get regular periods again. And that’s a big deal for women who want to become pregnant. Infertility aside, obesity is associated with many medical conditions including heart disease, stroke, type 2 diabetes and certain types of cancer, some of the leading causes of preventable death.

Though diet books and spokespeople abound and the diet industry rakes in approximately $35 billion a year from U.S. citizens, Americans are on average getting fatter and fatter. According to the CDC over 1/3 of us are obese — not just overweight. My current BMI is 31.7 and places me in this category; thus I also have a higher risk for all of the conditions mentioned above.

So why don’t all us fat people just lose weight? It is certainly not for a lack of trying. You can ask any person with extra pounds and the vast majority of us will tell you that we have tried numerous times to lose weight. In fact, while some of us are successful at losing some weight for a period of time (note my 2005 pic above) 80-90% of dieters fail in our attempts to keep the weight off permanently (my 2012 pic). It is very hard to stick to a special/fad diet to lose weight to begin with and damn near impossible to stay on that diet indefinitely to keep it off.

The easiest way to lose weight and to keep it off for good is to make healthy eating choices and to watch how much you are eating. Several free eating guides are available from the USDA , the CDC and the FDA. But what it all boils down to is Calories and that input equals output.

What is a Calorie?

It is a measure of the heat produced by the combustion of food products. In general, 1 gram of protein or 1 gram of carbohydrate has 4 Calories of energy and 1 gram of fat has 9 Calories. The U.S. Recommended Daily Allowance (RDA) is 2000 Calories. Some of us need less, others more. Though we may not think of them as such, people with a low metabolism are like cars with high fuel efficiency. A little fuel goes a long way. People with high metabolism are like gas guzzling trucks; they need lots and lots of fuel throughout the day.

This analogy breaks down when we talk about overeating. If you try to put too much gas into a car the tank will simply overflow. The body of a person who eats too much will convert all those extra Calories into fat. Our bodies make fat to have reserve for when food is not available.

In modern society, low quality foods with high Calories have become remarkably less expensive than their high quality low Calorie counterparts. For example, ramen noodles cost less than $1 per package but have 400 Calories each. On the other hand apples cost $1 to $3 per pound but generally have less than 100 Calories each. So, if you are financially challenged then you are more likely to be fat.

We can try to increase our Caloric needs (decrease our fuel efficiency) through exercise, but exercise can be difficult if you are working long hours and cannot afford a gym membership — running down the road is generally an option only for people who are already in shape and accustomed to inclement weather. Again the cards are stacked against those with less means or with physical limitations.

I mention socioeconomics and other limitations because it is important for people to consider them. Just like the old saying, “Walk a mile in my shoes”.

Now before I continue rambling on, please know that I am speaking for myself and have not been paid nor asked to endorse the product I am about to discuss.

So, knowing that I am “blessed” with remarkable “fuel efficiency” and have difficultly finding time to exercise I knew that I needed to reduce my Calories. And if I was going to make a permanent lifestyle change that I would have to do it with the foods I am already eating, not start another fad diet.

For anyone who has tried it, keeping a food diary and counting Calories is a pain in the ass. It is tedious, time consuming and requires a decent amount of math skills. I had previously bought a Calorie counter pocket book but even that was painful for me — what do I do when I can’t find the food that I’m eating? There had to be another way.

MyFitnessPal

I was looking for a free Calorie counter app on my iphone when I discovered “MyFitnessPal”. If you don’t have a iphone they also have a website. What I love about this app is that it is so easy to use. I don’t have to eat special food and I can almost always find the food I’m eating in its database. I recently ate a Wendy’s Asiago Grilled Chicken Club Sandwich WITH the dressing (570 Calories) and am still losing weight.

Given my gender and activity level, the app tells me that I am supposed to eat 1610 Calories daily if I want to loose 2 pounds per week. If I increase my activity or want to eat more, I simply change the settings and the app recalculates how many Calories I should eat.

Too lazy to look things up? The barcode reader makes it super easy to simply scan the packaging of whatever I’m eating and presto, all the nutrient info is at my fingertips.

What if I eat more or less than the serving size suggestion, like when I eat 3 servings or only 2/3 of a serving? No biggy, the app allows me to make this adjustment and does the math for me.

I must confess that I am still not working out as much as I’d like to be… Working 14-30 hour days in residency just about kills me and I don’t have it in me to do much more than eat, and sit on the couch with my husband for an hour or 2 before going to bed. But if I were, the app has the ability to not only record exercise activities but also to on the spot increase my Calorie budget for the day with the Calories I burn.

I started dieting after Thanksgiving because I seriously ate like a pig and felt like a beached whale for 2 days afterward. I was not going to wait until New Years Eve this year to make my annual resolution. Since then, I have been losing weight on a weekly basis eating exactly what I want, just less than I would have eaten before. I occasionally do feel a little more hungry than I like but often a small healthy snack will tide me over until my next meal. And now that I’m in the groove it is getting easier and easier to stick to the plan. I’ve already lost over 10 pounds! Not that I can see it yet — I still have that annoying muffin top — but my pants are starting to feel looser and that makes me happy.

I was going to do this diet thing all by myself but after thinking more about it I decided that I should share my journey with you. Maybe if you see this physician heal himself, it will inspire you on your own journey. Best wishes to all of you and happy holidays. I’m going to go make myself something to eat!

Related posts

LGBT Travel Destinations Uncovered

For LGBT (lesbian, gay, bisexual and transsexual) tourists, destinations which are rife with like-minded, tolerant and fun people like themselves are highly desirable. There is an ever-increasing amount of destinations that specifically cater for the LGBT component of the tourist demographic, and this article aims to uncover and describe some of the best locations around for those looking for a thriving LGBT community to engage with on holiday.

Buenos Aires

Buenos Aires has become one of the most exhilarating and renowned gay destinations in South America. Its rapid rise as a prominent gay-friendly city was consolidated in 2004 when the windy city became the first city in Latin America to legalize civil unions. In 2010, the city’s progressive values extended to granting gay couples full rights regarding gay marriage and adoption. This makes it perfect for gay couples looking to enjoy a honeymoon or even get hitched abroad. The cosmopolitan city also boasts a wide range of attractions and amenities that specifically cater to and aim at a heavily commercialised and celebrated LGBT community. With a host of gay bars and clubs to choose from, nightlife for the LGBT constituent of the tourist cohort is electrifying and vibrant.

Gran Canaria

Situated amongst the sun-kissed cluster of Spanish Canary Islands located on the west coast of Africa, Gran Canaria is another utopian haven for LGBT tourists. With a plethora of gay beaches, Gran Canaria’s golden coastline openly welcomes all to its crystal clear, water-lapped shores. When the glorious Gran Canaria sun sets on the beaches, the fun continues long into the night, as there is a vast array of gay and lesbian bars and clubs to visit, as well as a range of decadent restaurants offering fine Spanish cuisine. The popular Yumbo Centre is an exhilarating, atmospheric complex rife with numerous gay bars, clubs and restaurants. Meanwhile, for those seeking a calmer, more culturally enriching holiday experience, Gran Canaria is home to a range of picturesque pine forests and quaint villages to visit. The island’s awe-inspiring landscape also boasts jaw-dropping mountains to admire and hike, and stunning lakes to visit.

The astounding landscape of Gran Canaria is a sight to behold.

Sitges

Located just south of the majestic Barcelona, Sitges is a more serene and relaxed option for LGBT tourists looking for a laidback, calm holidaying experience. With a pedestrian town centre, visitors can escape the noisy hustle bustle of traffic they may suffer to endure at home, and saunter around the town at leisure. It also hosts an annual ‘Gay Pride Sitges’, which promises plenty of entertainment, live acts, pool parties and the renowned ‘pride parade’, which attracts thousands of visitors-last year over 60 thousand revellers were in attendance.

Sitges boasts a serene and lavish atmosphere amid a stunning natural landscape.

Choose a cruise

For the more intrepid tourist, cruises offer an unparalleled opportunity to experience a broad array of cultures and countries in one expansive trip. Consult online cruise reviews for those seeking reliable advice on which cruises offer the most exhilarating experiences. RSVP offers a rare all-gay Mediterranean cruise on which 2100 LGBT guests enjoy exotic excursions across Mediterranean countries, including the aforementioned Sitges, the renowned Casablanca, Ibiza and Valencia, with indulgent and luxurious voyages at sea forming welcome breaks between each new venture. Indeed, there are enough entertainment amenities, poolside activities and events taking place onboard to make visitors feel reluctant to ever want to leave the ship!

Ship-dwellers will marvel at the luxury to be enjoyed onboard a quality cruise.

The Big Apple

New York is another city universally renowned for its thriving LGBT community. Recently becoming the 6th US state to legalize gay marriage, it is ideal for couples seeking to get married in a vibrant and exciting foreign location. With such a vast array of fascinating attractions and lively entertainment venues to visit, the city famous for being one that never sleeps will leave visitors up all night trying to enjoy every experience the city has to offer. Home to the gargantuan Empire State Building, visitors can scale the tower’s heady heights to gain a glorious view of one of the most awe-inspiringly vast metropolises in the world. Also boasting the iconic Statue of Liberty, New York offers a culturally enriching and humbling experience for its visitors, who for the duration of their holiday will appreciate the unmatched joys of the American Dream.

Visitors of New York will wonder at the rich history of the renowned city.

Lisa Williams is a freelance travel writer from England who specialises in international travel, cruises and mostly writes with a younger audience in mind. Most of her travel experience came in her twenties when she spent several years in Asia.

Young women are in danger

I have begun the first rotation of my last year of residency: Pediatric and adolescent gynecology with reproductive endocrinology and infertility. Today when I was reading I came across some sobering statistics regarding young women (see below). As it is Father’s Day, I would like to encourage all parents to take the time to talk with your children as they honor you. Talk to your kids about dangerous activities their peers are definitely participating in. Give them encouragement to swim against the powerful current of peer pressure. Educate them on what to do when various situations arise. Give them information that they can use personally as well as to share with their peers who choose to engage in risky behaviors. Though both of my kids are steadfast in their personal decisions to “wait till marriage” before having sex, they have both been educated all about condoms and birth control and know where to go for more information should they or their peers require it. There are a lot of excellent resources online, links to several of them follow below. Don’t ignore the elephant in the room! Be the “Best Dad in the World” and protect your daughters (and sons) by arming them with education!


Young women, grades 9-12 (2009 CDC data)

Physical danger
–  83% rarely wear bicycle helmets
–  23% have been in a physical fight in the past year
–  8% attempted suicide in the past year
–  8% rarely wear seat-belts

Substance use
–  43% drank alcohol in the post 30 days
–  34% have used marijuana
–  19% currently smoke cigarettes

Weight
–  59% are actively trying to lose weight
–  33% think they are overweight
–  24% are actually overweight
–  15% have gone 24+ hours without eating to try to lose weight
–  6% have taken diet substances without doctor supervision
–  5% have intentionally vomited or taken laxatives to lose weight

Activity
–  32% watch at least 3 hours of TV every school day
–  30% do not ever participate in physical activity lasting longer than an hour

Sexual activity among young women aged 15-17 years (2006-2008 CDC data)

–  27% have had vaginal intercourse with a male partner
–  21.5% did not use contraception the first time they had intercourse
–  13.1% still do not use contraception though they continue to be sexually active

–  In 2006 there were

–  349,145 new infections with chlamydia
–  246,250 reported pregnancies
–  59,648 new infections with gonorrhea
–  28,388 emergency room visits for sexual assault
–  344 new infections with syphilis
–  185 new infections with HIV/AIDS

Death per 100,000 women aged 15-19 years (2006 CDC data)

–  36.8 all causes
–  18.9 accidents
–  2.9 murder
–  2.8 suicide
–  2.5 cancer


Youth resources

The Birds & Bees Project provides comprehensive reproductive health information to youth and adults. The message in all materials is positive, respectful, developmentally appropriate, and aims to compliment the education and values that people receive from their families and communities.

Born This Way Foundation is building a braver, kinder world that celebrates individuality and empowers young people.

Center for Young Women’s Health provides education, clinical care, research, and health care advocacy for teen girls and young women.

girlshealth.gov was created by the U.S. Department of Health and Human Services’ (DHHS) Office on Women’s Health (OWH) to help girls (ages 10 to 16) learn about health, growing up, and issues they may face.

Girls Incorporated inspires all girls to be strong, smart and bold through a network of local organizations in the United States and Canada.

Gay, Lesbian and Straight Education Network (GLSEN) is the leading national education organization focused on ensuring safe schools for all students.

I wanna know! offers information on sexual health for for teens and young adults. This is where you will find the facts, the support, and the resources to answer your questions, find referrals, and get access to in-depth information about sexual health, sexually transmitted infections (STIs), healthy relationships, and more.

It Gets Better Project is an inspiring collection of over 10,000 user-created videos from around the world that was created to show young LGBT people the levels of happiness, potential, and positivity their lives will reach – if they can just get through their teen years. The It Gets Better Project wants to remind teenagers in the LGBT community that they are not alone — and it WILL get better.

National Suicide Prevention Lifeline at 800-273-TALK (8255) is a 24-hour, toll-free, confidential suicide prevention hotline available to anyone in suicidal crisis or emotional distress.

Planned Parenthood: Info for teens provides information about STD testing, pregnancy tests, sexual orientation and more. You can even chat live with a trained counselor.

The Trevor Project at 866-4-U-TREVOR (866-488-7386) is a 24 hour help line that is available to anyone who needs a listening ear.

What do you know about colon cancer screening?

  • Colon cancer is the 3rd most common cancer diagnosed in women.
  • It is also the 3rd leading cause of cancer death.
  • The American Congress of Obstetricians and Gynecologists (ACOG) recommends that women without known risk factors begin screening at age 50.
  • The screening method with the best detection rate is colonoscopy every 10 years.
  • Women with African ancestry should begin screening at age 45.
  • Screening should begin:
    • At age 40 if:
      • A biological parent had either a colon polyp or colon cancer before age 60.
      • 2 or more biological parents or children had polyps or cancer at any age.
    • 10 years earlier than the age a biological parent was diagnosed with colon cancer. (If a parent was diagnosed with colon cancer at age 40, screening should begin at age 30).
    • Within 8 years following diagnosis of inflammatory bowel disease (ie ulcerative colitis or Crohn disease).
    • At age 21 in individuals with a family history of hereditary nonpolyposis colon cancer (HNPCC). They should also consider genetic counseling and testing.
    • At puberty in individuals with a family history of familial ademomatous polyposis (FAP). They should also consider genetic counseling and testing.

Care of the prematurely retracted foreskin

Dear Dr Pate,

I’ve read some of your (awesome) posts and have a random question I’m hoping you can answer! :) I know of a mom whose son was forcibly retracted when he was 7 months old. Unfortunately, she was told that after that point, she needed to continue doing it, which she did for another year following that incident. Now she knows that was wrong. The problem is that he’s fully retractible now (even though not “naturally” so), and she doesn’t know if she should continue asking him to retract himself to clean it (as she would a naturally retractible child), or not. He’s only 2 years old, and resistant to doing so. I’m inclined to say leave it alone and that just soaking in the bath will be good enough, but wanted to double-check. If he doesn’t retract to clean, would it encourage adhesions or infection?


Dear KD,

Thank you for your kind comments and your excellent question! I am inclined to tell her to leave it alone as well given that kiddos do not have the same amount of body secretions as teens and adults. Likewise, I can’t image that other cultures around the world pay even a 10th of the interest in either the excision or maintenance of the foreskin as we do in the U.S. Do little girls really need to be taught anything more to wash briefly in the tub? The same should apply to little boys. However, I am not a pediatrician so I asked my colleagues for their opinions which follow below. Best of luck to the little tyke and thanks again for writing.

Sincerely,

James Pate, MD
http://jamespatemd.com


I agree with you and would have advised the same. If he is resistant to retraction, I would leave it alone. It may re-adhere, but I would imagine that it will detach over time without undue intervention despite the earlier forcible retraction. If not, he can use steroid cream if indicated. I don’t see it becoming infected.

On the other hand he may become more amenable to retraction and cleaning in the coming months which would make it a non-issue. He may be objecting because he’s two years old. But I see no reason to compel him to do something he doesn’t want to do at this time.
―Dr Paula Brinkley, pediatrician


I just wanted to assure you that your advice was just right! We need not retract the eyelid to wash under it, and mucous membrane will keep adjacent tissues from adhering one to the other. In most non-circumcising countries, from what men have told me, they often are taught little and generally figure out hygiene on their own. If they are told something, it’s usually around puberty, probably when secondary sex hormones are produced.

We don’t teach girls to pull their prepuce back to wash under it and we don’t put Q-tips or anything else into their vaginas to wash them. The body is self-cleaning. And, little boys need a normal sense of unconcerned boyhood. The baby’s objections to having his foreskin messed with is the message to which everyone should listen.

There are three great articles that you might find helpful at http://www.nocirc.org/articles. They are:

―Marilyn Milos, RN, Executive Director, National Organization of Circumcision Information Resource Centers (NOCIRC)


In my opinion, you don’t have to be a pediatrician to answer this question – most pediatricians don’t know anything about taking care of the foreskin anyway! – so I’m going to offer my own take on this.

There are no controlled studies on correct care of the intact penis, so the best we have to go on is a good understanding of the structure and development of the foreskin, plus common sense.

The few studies that I know of that looked at retractability, foreskin hygiene, and outcomes are so methodologically problematic and ignorant of the natural development of the foreskin as to be completely worthless guides (Kalcev 1964, Krueger and Osborn, 1986).

Most of the “literature” on care of the intact penis are merely opinion pieces. One would hope that this “opinion” would be based on a solid knowledge of the development of the intact penis, and/or extensive experience in conservative care of the intact penis, but unfortunately this is not the case, as we all know, and there is a lot of mistaken and potentially harmful advice given.

“I did an inservice on care of the intact penis 6+ years ago where I dug up as much literature on it as I could (17 articles, 2 of which were from CIRP and NOCIRC). I am attaching a summary of some of the advice from these handouts that I posted at Mothering.com some years back, plus some additional quotes that support the idea of “leave it alone”.

Here’s the general consensus from these handouts:

  • If the FS is non-retractable, no matter how old the boy is, all that need be done is to wash off the outside. PERIOD.
  • Once the FS is retractable AND the boy is developmentally able (generally have the motor dexterity and ability to follow instructions by about age 4-5), he can be taught to retract, rinse, replace. [Note, this makes the idea of requesting a 2 year old to retract and clean himself seem pretty pointless.]

Sources that specifically mention frequency suggest:

  • In childhood: this rinsing might be done say only “occasionally”
  • By puberty: more “regular”, or “daily” rinsing is suggested

Although some older articles will recommend that parents retract the child (based, I believe on a preconception of the foreskin as problematic, and ignorance of the natural development of the intact penis), most do NOT say this, and a number do support the idea of leaving it alone (see my Mothering post attachment). In fact there is one great quote from Canadian pediatric urologist Peter Anderson stating that “there’s no evidence there’s any need to clean under the foreskin before puberty.”

Remember that the foreskin is designed to keep the ooky stuff out (tight outlet in childhood, sphincter-like action of the peripenic muscle), and that it is flushed outward multiple times a day with sterile urine, thus keeping itself clean.

As a John Geisheker likes to point out, “Our primate predecessors were unlikely to head down to a nearby river every day to scrub their children’s genitals. Nature would quickly eliminate those who needed such care. Only those tough enough to not require genital cleansing would have survived. We are those survivors. … Mid-19th century English-speaking boys and girls did not suddenly require aggressive genital hygiene when their ancestors, for hundreds of generations, survived nicely on benign neglect.”

If this 2-year-old is resistant to having his foreskin retracted, by all means, leave it alone! It is unnecessary from a hygiene point of view, and could be more psychologically distressing than its worth. He will discover the joys of retracting himself when he’s ready and interested himself. In the meantime, it is quite possible that just playing with his penis in clean tub water might be all the cleaning needed. Since the average age to full retractability is somewhere are age 10, I would encourage this young mom to sit back, respect her son’s own time table and emotional boundaries, and just let nature take its course.

―Gillian Longley RN, BSN, MSS, Colorado NOCIRC


Rather than re-invent the wheel and write a longish, potentially unwelcome, or over-obvious email, I am attaching several articles we at DOC wrote for Psychology Today magazine on this very issue.

The short answer, (which I suspect you know instinctively), is that urine is sterile and the boy-child is ‘washed’ at each urination. The notion that intact (not C’d) boys need special hygiene is an invented one of Anglophone origin, its sources easily traced to the mid 19th century, a time of great anxiety about masturbation (even among toddlers) as a source of disease. This was before Koch (1879) and others identified pathogens.

In evolutionary terms, the notion that boys need special genital hygiene makes no sense. Our primate ancestors were likely far more concerned with foraging for food and finding a safe place to sleep each night. There was no time or motive to scrub the genitalia of their offspring (and my primatologist neighbor tells me no such behavior has ever been seen in the wild).

We are their descendants who never needed any such care. The infant vulva and infant penis, like the infant eyes and mouth, are self-defending and self-cleaning. It could hardly be otherwise.

―John V. Geisheker, J.D., LL.M. Executive Director, General Counsel, Doctors Opposing Circumcision (D.O.C.)

I’m on the hunt

On 6/11/12 I officially enter my LAST year of residency and am finally starting to see the light of a very long and arduous tunnel. My senior resident colleagues and I are just now starting to be inundated with emails and phone calls from recruiters and practice representatives from across the nation. As the Baby Boomers move into retirement, and along with them the physicians of the same generation, the demand for new recruits continues to grow. As is true of real estate, for many of us it’s all about location, location, location! Positions in coveted downtown city locations are never short of applicants but beyond the cityscape and adjacent suburbia lies an ever expanding need for medical professionals.

The Washington Post recently posted the above image generated with esri software that geographically identifies areas of increasing medical need. Areas that are dark orange are already in great need of medical providers and they are likely to continue to grow in dimension.

Having grown up in a suburb of Seattle (Kent, WA), I don’t think I would have given rural medicine any consideration prior to medical school which I completed at Oregon Health & Science University in Portland, OR. OHSU prides itself in fostering a love of primary care among its students as well as an appreciation for rural medicine. During my time there I completed 4 rural rotations in primary care, family medicine, neurology and surgery lasting approximately 8 weeks each.

I was required to complete a community project in my primary care rotation in Coos Bay, OR. I elected to research the issue of rural physician shortage in terms of physician recruitment and retention. I had the opportunity to interview local recruiters as well as rural physicians of multiple specialties. I also conducted a survey of the 3rd and 4th year medical students regarding their experiences with and interest in rural medicine. I then compiled this data into a written manuscript: Recruiting and Retaining Physicians in Coos Bay: Assessment of Medical Student Interest in Rural Medicine and Rural Physician Perspectives on Their Practice. I later presented this data at the 25th Annual Oregon Rural Health Conference. My presentation can be found here.

I discovered that there are a lot of benefits to working rural areas including making a difference for an underserved population, becoming part of a “close-knit” community and having a larger scope of practice. Fringe benefits include outdoor activities, simpler lifestyle, lower cost of living and potential student loan repayment.

Some of the more challenging aspects of working in a rural area are cultural and political differences. It seems that the more diverse and populated communities are, the more liberal and tolerant they are as well. Rural America is more homogenous in character and conservative in opinion. White Anglo-Saxon Protestant (WASP) physicians tend to find a home away from home more easily, especially when they share the same values as the communities they enter. Those of us who are different often feel like outsiders who are simply extended cordial hospitality with an arms-length handshake. The vast difference between city and rural amenities can also contribute to culture shock, homesickness and isolation.

My partner and I are willing to consider rural locations among our opportunities. Both of us have moved extensively, Patrick more than I, and we enjoy the adventure of new experiences and making new friends. The issues I foresee being problematic pertain to the differences I alluded to: I am a partnered gay father in addition to being an OB/GYN resident physician; my personal life cannot be separated from my professional life. Patrick and I have been committed to each other for the past 10 years. I have been a father even longer. I feel that it is a travesty that we live in the 21st century yet continue to be treated as a second class citizens. Because our relationship is not recognized in the majority of States we suffer mentally and financially. Although more and more insurance companies are choosing to include same-sex partners, many do not. I have worked too long and too hard to accept employment with a group that will not allow me to insure my family.

Another issue is abortion. The Republican-lead War on Women is in full force and a record number of anti-choice ballots continue to make their way through state and federal legislatures. We are rapidly returning to the pre-Roe Vs. Wade era. Some sobering statistics are the following:

  • Approximately 1/3 of women require an abortion procedure over their lifetime.
  • Over 90% of OB/GYNs have had patients request abortion services.
  • ONLY 14% of OB/GYN providers provide them.

While this may be great news for the anti-choice audience, women AND children are already suffering much and may be soon forced to suffer more. The U.S. foster care system is overflowing with abused, neglected and unwanted children. Shall we increase their numbers? Women have many deeply personal reasons for seeking abortion. Sometimes they are truly in danger of dying because the pregnancy is too great a strain on their pre-existing medical conditions. Other times they simply cannot afford yet another mouth to feed. Although abortion access isn’t really one of my soap boxes, I cannot consider myself a defender of social justice and turn a blind eye to this dilemma. Abortion is legal in this country and is a part of comprehensive OB/GYN practice. I cannot ethically permit my scope of practice to be limited by religiously or politically motivated restrictive work covenants.

And then there are my professional interests which include issues pertaining to the LGBTQI (lesbian, gay, bisexual, transgender / transsexual, queer / questioning, intersex) communities, Mayer-Rokitansky-Kuster-Hauser syndrome (Mullerian anomalies) and polycystic ovarian syndrome (PCOS). The majority of gender and sexual minority patients receive sub-optimal and inadequate care. And although PCOS affects around 7-8% of women it is often the elephant in the exam room that is repetitively ignored. I must also make myself available to these underserved populations.

One recruiter wrote to tell me that “the 232 clients my colleagues and I are working with nationwide will not be able to provide you with all of those items. If they are really non-negotiable factors, I will not be able to assist you with your search.” Fortunately there are many other recruiters that do not share his lack of vision.

Although my personal life and professional ambition may “offend” some I am confident that I will find the right place for me. The map is wide open and opportunity calls.

Bankrollers of hatred

“Therefore whatsoever ye have spoken in darkness shall be heard in the light; and that which ye have spoken in the ear in closets shall be proclaimed upon the housetops.” — Luke 12:3

It’s been quite some time since I’ve chosen to quote the bible however I just couldn’t resist the irony. In 2008 the Mormon church (Mitt Romney’s church) bankrolled / steamrolled the California Proposition 8 election in order to eliminate the rights of same-sex couples to marry. This blatant act of discrimination by a politically-motivated religious entity is without precedent in modern history. Mormon temples across the nation were picketed and even a documentary, 8 : The Mormon Proposition, was released in 2010.

Though the Mormon church continues to try to clean up its post-8 image, the church continues to be associated with anti-gay extremism in addition to its history of polygamy. For more information about Prop 8, check out the Human Rights Campaign (HRC) Prop 8 decision analysis or Wikipedia.

Though I cannot remember the source, I recently downloaded a pdf of the 2008 IRS schedule B of the National Organization for Marriage, Inc (NOM), another anti-gay group. Here is some interesting data from that form:

  • $2 million was collected from a list of 50 contributors.
  • 41 individuals with 29 unique last names contributed $1.5M (74% of the pot).
    • 36 individuals (88%) were from CA and contributed $806,000 (54% of individuals’ contribution and 40% of the total pot).
    • 4 others were from AZ, 3 from PA, 2 from CT, 2 from NY and 1 each from MA, RI and VA.
    • One extended family of 9 gave $265,000.
    • A man in his 70s living in PA gave a whopping $450,000, the largest individual donation. His wife contributed another $100,000 making their combined contribution 37% of the individuals’ contribution and 27% of the total pot.
    • Only 10 women contributed, and of these only 2 were living independently and not obviously related to other male contributors. This pair of women had an average age in their 70s and their contribution was $14,500 (less than 1% of the pot).
    • The average age of contributors was early 50s and no one under age 50 lived independently of an older contributor.
    • The most expensive home owned by a contributor appraises at $3.8 million. The average appraisal of contributor homes is $1.2 million.
  • 9 companies donated $525,000 (26% of the pot), 5 of which are based in CA.

Enough data crunching. Clearly the bulk of anti-gay legislation funding provided to NOM is from so-called “christian” organizations and their largely older, male, affluent members in CA. Oh, and one elderly, very affluent couple in PA.

Contrary to marketing in Africa, circumcision does NOT prevent HIV transmission and may increase it

Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: methodological, ethical and legal concerns. Journal of Law & Medicine. 19(2):316-34, 2011 Dec.
Abstract
“In 2007, WHO/UNAIDS recommended male circumcision as an HIV-preventive measure based on three sub-Saharan African randomised clinical trials (RCTs) into female-to-male sexual transmission. A related RCT investigated male-to-female transmission. However, the trials were compromised by inadequate equipoise; selection bias; inadequate blinding; problematic randomisation; trials stopped early with exaggerated treatment effects; and not investigating non-sexual transmission. Several questions remain unanswered. Why were the trials carried out in countries where more intact men were HIV-positive than in those where more circumcised men were HIV-positive? Why were men sampled from specific ethnic subgroups? Why were so many participants lost to follow-up? Why did men in the male circumcision groups receive additional counselling on safe sex practices? While the absolute reduction in HIV transmission associated with male circumcision across the three female-to-male trials was only about 1.3%, relative reduction was reported as 60%, but, after correction for lead-time bias, averaged 49%. In the Kenyan trial, male circumcision appears to have been associated with four new incident infections. In the Ugandan male-to-female trial, there appears to have been a 61% relative increase in HIV infection among female partners of HIV-positive circumcised men. Since male circumcision diverts resources from known preventive measures and increases risk-taking behaviours, any long-term benefit in reducing HIV transmission remains uncertain.”

If the WHO/UNAIDS really wants to turn the epidemic tide, distribute free condoms!

Is it lawful to use Medicaid to pay for circumcision? NO!

Is it lawful to use Medicaid to pay for circumcision?.
Journal of Law & Medicine. 19(2):335-53, 2011 Dec.

Abstract
“Since 1965, tens of millions of boys have been circumcised under the Medicaid program, most at birth, at a cost to the United States Federal Government, the States and taxpayers of billions of dollars. Although 18 States have ended coverage since 1982, the United States Government and 32 States continue to pay for non-therapeutic circumcision, even though no medical association in the world recommends it. Many cite American medical association policy that the procedure has potential medical benefits as well as disadvantages, and that the circumcision decision should be left to parents. This article shows that Medicaid coverage of circumcision is not a policy issue because it is prohibited by federal and State law. As American medical associations concede, non-therapeutic circumcision is unnecessary, elective, cosmetic surgery on healthy boys, usually performed for cultural, personal or religious reasons. The fundamental principle of Medicaid law is that Medicaid only covers necessary medical treatments after the diagnosis of a current medical condition. Physicians and hospitals face severe penalties for charging Medicaid for circumcisions. Medicaid officials and the Federal and State Governments are also required to end coverage. It is unlawful to circumcise and to allow the circumcision of healthy boys at the expense of the government and taxpayers.”

Don’t waste taxpayer dollars on destructive “cosmetic” procedures on un-consented infant boys!

Do medical students have to assist circumcisions?

Dear Dr Pate,

I am a 2nd year medical student that will be starting rotations soon. Coming across your website, I noticed you were an intactivist OB/Gyn. I am also an intactivist and realize there will be many procirc doctors with crazy mindsets. It is expected that there will be issues with doctors when I refuse to help with this operation.

Do you have any advice for me at this point?
Do you get a lot of resistance to your views and how do you deal with it?

I read through your blog briefly, there are some interesting things contained there. Thank You!


Dear P,

Thanks for writing! You absolutely have the right to refuse to participate in any way of the circumcision process including offering the procedure to new parents when you round on patients, discussing it with interested parents who bring up the topic, consenting parents for the procedure, observing and performing circumcisions. Check out the pamphlet Conscientious Objection to the Performance of Non-therapeutic Circumcision of Children: A guidance for healthcare providers from Doctors Opposing Circumcision. You will likely get some flack, but it is absolutely worth it. I have blogged quite a bit about experiences with my residency program regarding the subject. Senior residents in particular were not happy with my stance given that they then “had to do my work”. Whatever. No one can make you do anything you are morally opposed to. Check out the links on my website for information about intactivist organizations. There are a LOT of resources for you and for the parents you will come in contact with. Thanks for your willingness to stand up for personal autonomy and “do no harm.” Feel free to write again at anytime. Good luck!

Sincerely,

James Pate, MD
http://jamespatemd.com

This blog is a mix of life experience, medicine, science, social issues and politics.

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