Still better than an iPhone!!!

Posted on 2.5.13 at 10:00 am. No Comments.

Smartphones are now a part of most patient’s lives and there are a number of apps that can help with numerous aspects of health.  Some for instance can help with weight loss and diet. Other remind patient to take their medications.  But some apps take the next step and  claim to actually treat conditions or take the place of a physician by diagnosing a disease.  In 2011, several apps that claimed to use wavelengths of light from the phone to treat acne were taken off the market by the FDA.  Recently a study from the journal Dermatology JAMA, put several apps that claim to detect cancer  to the test.  The verdict?  Not so good.  The best app missed 30% of melanomas (a deadly form of skin cancer) and the worst was barely better than flipping a coin.  What would be a tragedy is for a patient to delay seeing a dermatologist after being falsley reassured by their iPhone.  A link to the article is below:

Monday, Feb  4, 2013 01:08 PM CST

iPhones make lousy dermatologists

New smartphone apps claim to provide medical help, offering false promises of correctly diagnosing skin cancer

By , Pacific Standard

iPhones make lousy dermatologistsEnlarge (Credit: calvindexter via Shutterstock)
This piece originally appeared on Pacific Standard.

Pacific Standard

Smartphones, like Swiss Army knives and SkyMall watches, have a few nifty features and plenty of useless ones. Who needs a checkbook when you’ve got Square, a toolkit when you’ve got iHandy Level, or a baby sitter when you’ve got Fruit Ninja? Encyclopedias, gazetteers, even boredom itself now seems obsolete.

Are dermatologists next? A slew of skin cancer-detection apps — with names like SkinVision, SpotCheck, and Mole Detective 2 — allow smartphone users to photograph and “analyze” their worrisome blemishes, offering diagnoses such as “problematic,” “high risk,” and “looks okay.” The free or low-cost apps base their findings on algorithms, rather than human expertise, and return results instantly. “Costs far less than an insurance copay, won’t leave a scar, and may save your life!” promises one advertisement. “The survival rate of melanoma is a dismal 15% at stage four,” warns another.

Anxious mole owners are sold. Breathes one reviewer, “Wow. Amazing. U can even save analysis and name mole to show dr or compare w next months photo.” (No app yet exists for turning text-speak into literate English.) “Have been worried about a spot on my dads face,” writes another. “Took a quick pic and got immediate feedback. Great idea, great results. Def recommended.”

Dermatologists are less than thrilled. In fact, they say, the apps are worthless. Writing in JAMA Dermatology, a team of physicians from the University of Pittsburgh put four melanoma apps to the test against 188 clinical images — pictures they’d taken of patients’ skin lesions and later determined, via biopsy, to be malignant or benign. How would a machine stack up against a board-certified dermatologist?

Not so well. Of the three auto-diagnosing apps, the best program missed malignant growths 30 percent of the time; a second performed only slightly better than flipping a coin.
One app, instead of using an algorithm, simply forwarded the photo to an accredited dermatologist, who responded with his considered opinion 24 hours later. At $5 per lesion, this was the most expensive program, though the e-doctor misdiagnosed just one in 53 melanomas.

Smartphones, the authors note, are becoming increasingly common in medicine; two-thirds of physicians use one in their practice. Health-conscious consumers, meanwhile, can choose among 13,000 wellness apps, from Alzheimer’s aids and blood sugar monitors to diet buddies and fertility calendars — a $718 billion market in 2011.

Cancer-spotting apps aren’t programmers’ first foray into dermatology. In 2011, the Federal Trade Commission sued into oblivion the makers of AcnePwner and AcneApp, both of which claimed to use blue and red light treatment to cure zits. (The latter went so far as to cite a study from the British Journal of Dermatology to support its claims.) Together, the apps were downloaded 15,000 times until the FTC forced their purveyors to cease and desist.

But then, teenagers will always be foolish and impulsive, quick to waste a buck on any passing fad. We adults should know better. A smartphone, it seems, does not a smart owner make.

What a shocker!!! Electronic Medical Records don’t save money or improve patient care!

Posted on 1.11.13 at 10:51 am. No Comments.

In previous blogs, I indicated the perspective shared by many physicians, that electronic medical records (EMR) won’t save money or improve patient care.  Despite the investment of billions in private and public money, data now confirms what we had thought.  The New York Times has an excellent article covering this:


In 2nd Look, Few Savings From Digital Health Records

By and
The conversion to electronic health records has failed so far to produce the hoped-for savings in health care costs and has had mixed results, at best, in improving efficiency and patient care, according to a new analysis by the influential RAND Corporation.
Jim Wilson/The New York Times

Dr. Alvin Rajkomar tracks patient data on a Samsung Galaxy Note. A new report questions whether electronic records reduce health care costs.

Optimistic predictions by RAND in 2005 helped drive explosive growth in the electronic records industry and encouraged the federal government to give billions of dollars in financial incentives to hospitals and doctors that put the systems in place.

“We’ve not achieved the productivity and quality benefits that are unquestionably there for the taking,” said Dr. Arthur L. Kellermann, one of the authors of a reassessment by RAND that was published in this month’s edition of Health Affairs, an academic journal.

RAND’s 2005 report was paid for by a group of companies, including General Electric and Cerner Corporation, that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005.

The report predicted that widespread use of electronic records could save the United States health care system at least $81 billion a year, a figure RAND now says was overstated. The study was widely praised within the technology industry and helped persuade Congress and the Obama administration to authorize billions of dollars in federal stimulus money in 2009 to help hospitals and doctors pay for the installation of electronic records systems.

“RAND got a lot of attention and a lot of buzz with the original analysis,” said Dr. Kellermann, who was not involved in the 2005 study. “The industry quickly embraced it.”

But evidence of significant savings is scant, and there is increasing concern that electronic records have actually added to costs by making it easier to bill more for some services.

Health care spending has risen $800 billion since the first report was issued, according to federal figures. The reasons are many, from the aging of the baby boomer population, to the cost of medical advances, to higher usage of medical services over all.

Officials at RAND said their new analysis did not try to put a dollar figure on how much electronic record-keeping had helped or hurt efforts to reduce costs. But the firm’s acknowledgment that its earlier analysis was overly optimistic adds to a chorus of concern about the cost of the new systems and the haste with which they have been adopted.

The recent analysis was sharply critical of the commercial systems now in place, many of which are hard to use and do not allow doctors and patients to share medical information across systems. “We could be getting much more if we could take the time to do a little more planning and to set more standards,” said Marc Probst, chief information officer for Intermountain Healthcare, a large health system in Salt Lake City that developed its own electronic records system and is cited by RAND as an example of how the technology can help improve care and reduce costs.

The RAND researchers pointed to a number of other reasons the expected savings had not materialized. The rate of adoption has been slow, they said, and electronic records do not address the fact that doctors and hospitals reap the benefits of high volumes of care.

Many experts say the available systems seem to be aimed more at increasing billing by providers than at improving care or saving money. Federal regulators are investigating whether electronic records make it easier for hospitals and doctors to bill for services they did not provide and whether Medicare and other federal agencies are adequately monitoring the use of electronic records.

Technology “is only a tool,” said Dr. David Blumenthal, who helped oversee the federal push for the adoption of electronic records under President Obama and is now president of the Commonwealth Fund, a nonprofit health group. “Like any tool, it can be used well or poorly.” While there is strong evidence that electronic records can contribute to better care and more efficiency, Dr. Blumenthal said, the systems in place do not always work in ways that help achieve those benefits.

Federal officials say they are drafting new rules to address many of the concerns about the current systems.

A handful of lawsuits have been filed over the systems. In the fall of 2010, for example, Girard Medical Center, a small hospital in Crawford County, Kan., hired Cerner Corporation to install an electronic records system. The hospital was hoping to obtain federal financing for it.But after receiving $1.3 million in payments, Cerner employees failed to get the system up and running in time for the hospital to qualify for federal incentive payments. The company then notified the hospital that it was abandoning the project, according to a lawsuit Girard filed against Cerner last year. The case is in arbitration. A lawyer for Girard and a spokeswoman for Cerner declined to comment.

Late last year, a physician practice in Panama City, Fla., filed a lawsuit against the health care technology firm Allscripts after the company stopped supporting an electronic records system called MyWay that it had sold to 5,000 small-group physicians at a cost of $40,000 per physician. The lawsuit said that the system had problems and that the physician group was unable to meet the criteria for federal incentive money. A spokeswoman for Allscripts said it would defend itself vigorously.

The 2005 RAND report helped Cerner executives and others sell the new systems, despite criticism at the time that the analysis was too rosy. RAND said that the report was not influenced by its financial backers and that, in fact, it disclosed the corporate sponsorship prominently in the report itself.

The study was harshly criticized by the Congressional Budget Office for overstating expected savings.

The new analysis was not sponsored by any corporations, said Dr. Kellermann, who added that some members of RAND’s health advisory board wanted to revisit the earlier analysis.

Dr. David J. Brailer, who was the nation’s first health information czar under President George W. Bush, said he still believed tens of billions of dollars could eventually be squeezed out of the health care system through the use of electronic records. In his view, the “colossal strategic error” that occurred was a result of the Obama administration’s incentive program.

“The vast sum of stimulus money flowing into health information technology created a ‘race to adopt’ mentality — buy the systems today to get government handouts, but figure out how to make them work tomorrow,” Dr. Brailer said.



Must see picture

Posted on 6.7.12 at 10:03 am. No Comments.

Dermatologists harp on their patient to avoid the sun to protect them from skin cancer.  But we should not forget that a great deal of wrinkling and aging of the skin is due to sun damage.  A perfect example of this is shown by a truck driver who received years of UV damage through the windshield of his car on the left side of his face.  Look at the results now:

Dermatologists cheating?!?!?!?!?!?!

Posted on 2.3.12 at 8:48 am. No Comments.

One bit of advise I give patients when seeking a new physician of any kind is to start by going to the specialty’s board website and looking at the list of board certified doctors in that specialty.  Board certified does not guarantee they will be a great doctor, but it is supposed to mean they at least have a minimum level of knowledge of the specialty as they have passed a rigorous certifying examination.  But what if the doctors did not pass the test honestly?

Recent headlines first in radiology and now in dermatology report residents sharing old exam questions and producing what they call “airplane notes.”  This name coming from the fact that this is what you should be studying on the airplane headed to take the test.  And now on the front page of CNN word that some dermatologists are cheating.  What an embarrassment for the specialty! I knew of this practice when I was a resident taking the test in 2003 and suspect it has spread since then.  Some residency programs at the time were notorious for this practice.  The University of Texas Southwestern Department of Dermatology, were I trained, was not one of them.  Instead during teaching sessions it was often mentioned that “this concept is important for board exams” or “this is board fodder.”  The word we were told was if we were ever caught with any “airplane notes” we would be kicked out of the program.   But it is human nature that some will seek short-cuts around any test and I am sure the practice goes on in every medical specialty.  It is up to American Board of Dermatology to come up with enough test questions so older items don’t have to be repeated year after year.  The article mentions that the dermatology board scrambles the approximately 300 questions from test to test to make it more difficult to memorize them????  300 questions?   For very bright dermatology residents that is not making anything difficult.

The board exam in dermatology I took in 2003 was filled with many antiquated questions covering concepts decades old.  I am sure that many of the same questions I took back in 2003, were repeated on this years examination.   While there have been many new areas of exciting research in dermatology in the last few years, few or none of these showed up on the dermatology board exam.  The test needs to be updated not to just reflect historical knowledge but to include the newer information more relevant to patient care.  This of course adds to the workload of the American Board of Dermatology, but is essential to preserve the integrity of the specialty.  Being board certified must mean that a physician has obtained a certain level of knowledge and mastery of the specialty, not that they were able to get the latest edition of the “airplane notes.”  It is up the American Board of Dermatology to end the lazy practice of using old test questions and instead produce unique tests  that better reflect the current practice of dermatology.  A copy of the CNN article is listed below.

Kent Aftergut, MD

(CNN) — Doctors studying to become dermatologists have, for years, shared exam questions by memorizing and writing them down after the test to become board certified, CNN has confirmed.

Reports of the use of what are known as “airplane notes” comes after revelations last month that radiology residents around the country for years also have used what are known as “recalls” to prepare for the written exam, which is one step in becoming certified by the American Board of Radiology.

In the wake of the CNN story, the group that oversees 24 medical specialties issued a statement condemning the use of the recalls.

The American Board of Medical Specialties said on its website that, “It should be made abundantly clear that recalling and sharing questions from exams violates exam security, professional ethics and patient trust in the medical profession. When it happens, the practice should be addressed swiftly and decisively. Whether someone is providing or using test questions, ABMS Member Boards enforce sanctions that may include permanent barring from certification, and/or prosecution for copyright violation.”

CNN has confirmed the practice also exists with dermatology, where the recalls are known as “airplane notes,” because residents write down as much as they can remember on the plane after taking the test.

In an anonymous e-mail to the American Board of Dermatology in 2008, a resident wrote: “The board needs to know that there is an organized effort year after year to, by verbatim, reproduce each and every question of the official ABD certifying examination minutes after its completion. So-called “airplane notes”…are well known to dermatology residents and are compiled, typed up and quietly distributed among residency programs across the country.”

The resident, now a practicing dermatologist, wrote, “Each year, minutes after the certifying exam is complete, there is an almost ceremonial meeting of examinees at a local hotel or restaurant there in Chicago. A feverish and collective effort is made by examinees from many programs to reproduce on paper as many questions as they can — verbatim — that they had just encountered. This is then integrated into an updated “airplane notes,” which then has questions from the year before, and the year before that, etc., in an organized fashion. These are even professionally bound at Kinko’s at times.”

In a response to the e-mail, the board’s executive director, Dr. Antoinette Hood, wrote: “The board takes every precaution to discourage this practice amongst graduating residents: maintaining strict security of items, minimizing the number of previously used questions, and requiring an honor code statement (signed two separate times) declaring that information will not be shared. Unfortunately we have no mechanism for enforcing the honor code or controlling interpersonal communications that occur after an examination. The real issue is how do we police professionalism and how do we identify the offenders?”

Hood said she has addressed this issue for several years during the board’s annual meeting by telling dermatology residents the practice is not allowed.

“I’ve never seen airplane notes, but I’ve heard about it,” Hood said.

“We really try to do something to prevent it from happening,” Hood said. “It’s a high stakes examination and people are naturally very anxious about it and that brings out the potential worst in people.”

Asked if she considered this cheating, Hood said, “Yes, but I can’t prove it – period.”

The board has warned residents that using airplane notes is illegal, because test questions are copyrighted.

“There are legal consequences to this practice, as the questions of the American Board of Dermatology are protected by copyright laws, and any reproduction, not approved by the board, illegal. But, of much greater importance, this practice is unethical and violates our professionalism and ethical standards, which are the basis for the trust given us by our patients,” one board newsletter obtained by CNN reads.

Dermatology residents confirm the practice has been widespread, but the value of the actual airplane notes varies depending on the accuracy of the memorization.

The dermatology board scrambles the approximately 300 questions from test to test to make it more difficult to memorize them. About 20% of the questions each year are recycled from old tests, compared with about 50% for the written exam in radiology.

“We scramble the questions so that discourages the rote memorization,” Hood said.

After a phone interview, Hood agreed to an an on-camera interview with CNN to discuss the recalls. But she abruptly canceled the interview two days beforehand, saying she had changed her mind.

While the use of airplane notes and recalls has been discussed for years in dermatology and radiology, they are not widely known outside those professions.

Dr. Gary Becker, executive director of the American Board of Radiology, said using recalls was cheating.

“I am saying it’s cheating. It’s a violation of our policy,” Becker said.

The allegation of cheating … smears the entire specialty with a broad and unjustified brush.
American College of Radiology

Dr. James Borgstede, the radiology board’s president-elect, said said the test-taking culture has changed since he took the exam in 1978.

“Right now, in radiology, jobs are hard to find. Board certification is very, very important. When I took the exam, you could still practice without being a board-certified radiologist. Now, that’s virtually impossible,” Borgstede said.

“So, a high-stakes examination, and the other thing is it’s a difference in culture. These individuals sort of view us as a system, and them as outside the system, and there’s this issue of sort of stick it to the man. You know, that we’re the system, and they can do this and it’s acceptable. We tell them it’s not acceptable.”

Becker said that despite the use of the recalls, the public is protected because of the overall training and an intensive oral exam that residents must undergo to become certified.

Next year, the board is rolling out a new exam for the first time in more than 10 years. Instead of two written tests and one oral exam, the first exam will be a “core exam” taken after three years of residency training, and the second certifying exam will be taken 15 months after graduation. The oral exam is being eliminated.

Meanwhile, The American College of Radiology, which does not certify radiologists, posted a statement on its website after the CNN story aired.

“The most troubling aspect of this report is the implication that all radiologists who pass these examinations are ‘cheaters.’ The allegation of cheating not only involves an unspecified and unidentified number of individuals, but smears the entire specialty with a broad and unjustified brush,” the statement said.

“Whether one considers the sharing of mentally recalled questions to be unethical, or simply a type of study aid, board certification represents significantly more than passing an exam, and should not be impugned simply on the basis of examination methodology,” it said.

Asked whether the group considered recalls cheating, a spokesman said it had no comment beyond the statement.

Other medical specialties contacted by CNN said they had not experienced that kind of systemic use of recalls.

The American Board of Family Medicine has sent investigators into test review company classes to ensure they aren’t teaching from old test questions.

“When we’ve investigated these groups and (gone) through these classes, we’ve never found old exams,” said board spokesman Robert Cattoi.

The board only re-uses “a very small number of questions” from old exams, he said. The American Board of Orthopedic Surgery re-uses about 20% of old questions each year.

“We know of no similar recall registry of questions such as was in your piece (about) the radiology residents,” said the board’s executive director, Dr. Shepard Hurwitz.

Morgellons Disease

Posted on 2.1.12 at 9:31 am. No Comments.

Morgellens disease is  a controversial condition where patients experience a persistent crawling sensation combined with a perception that fibers or organisms sprout from their skin.  This condition can be life altering and greatly affects patients’ quality of life. To date no infectious organisms have even been found to explain this condition and treating patients with a myriad of anti-parasitics and anti-biotics does not appear to result in any improvement.

Because of patient outcry, a few years ago the CDC started the largest study every performed of this condition and the results have been highly anticipated.  The study of over 100 patients suffering with this condition again showed no signs of infection.  Many patients with this condition are convinced they have an infection and become angry when told they do not.

Our first step when examining any patient is to first confirm whether or not they truly have an infection.  We see several common infections with parasites such as scabies as well as rare ones such as leishmaniasis.  Many patients with this condition will bring samples of their skin they have prepared.  One patient even sent us vials of her bath water.  We always look carefully at these specimens as well as the patients skin to rule out infection.

Once infection has been ruled out, we can often help patients with this condition if the patient is willing to work with us and accept the fact that they may not actually be infected.

This study greatly forwards our understanding of this condition and the patients that suffer from it.

A copy of an article covering this study is listed below.

Kent Aftergut, MD

Mystery skin disease Morgellons has no clear cause, CDC study says

By JoNel Aleccia

A strange disease in which sufferers say they find fibers, fuzz and other debris sprouting from sores on their skin is not contagious and has no clear cause, the largest-ever study of the condition called Morgellons has found.

Government health officials on Wednesday released the results of a four-year, nearly $600,000 review that found no infectious or environmental link to Morgellons, which reportedly plagues thousands of people in the United States and other countries.

“It’s a negative, but it really limits and narrows down the field of possibilities,” said Mark L. Eberhard, director of the division of parasitic diseases and malaria at the Centers for Disease Control and Infection. “By removing a couple of the big players — infections and the environment — that still leaves some wide-open territory about what could be the causes.”

The new study should reassure sufferers who worried about infecting family and friends, he added.

Researchers studied 115 people who reported Morgellons-like symptoms from the Kaiser Permanente health system in Northern California from July 2006 to June 2008, amounting to a rate of 3.6 cases of the disorder per 100,000 people. They conducted extensive interviews, tested patients’ blood and urine, and studied biopsies of skin samples. It’s considered the first detailed, population-based analysis of “unexplained dermopathy,” which is how researchers describe Morgellons.

The CDC and Kaiser Permanente initiated the study in January 2008, after CDC officials received hundreds of calls and e-mails about an odd, fiber-sprouting skin disease. By the time the study was launched, the agency had heard from some 1,200 people. The mysterious disorder was dubbed Morgellons in 2002 by a Pennsylvania mother of a toddler who reportedly suffered from the disorder first identified in 17th century France.

But scientists writing in the journal PLoS ONE also found nothing remarkable about the threads and fuzzballs patients reported emerging from lesions on their skin, which laboratory analysis showed were cotton or other fibers, possibly from clothing. They also couldn’t explain the creepy-crawling, tingling or pins-and-needles feeling that many sufferers said they experienced before rashes, sores and ulcers emerged. No parasites or mycobacteria were detected.

The scientists suggested that Morgellons victims may suffer from a condition similar to “delusional infestation,” in which people imagine bugs or other critters invading their bodies.

“No common underlying medical condition or infectious source was identified,” wrote Eberhard and his colleagues.

But people who believe they suffer from Morgellons said that was exactly the result they expected from a government agency trying to cover up a larger problem.

“I’m pretty sure they’ll say we’re all delusional,” said Jan Smith, 62, a Concord, N.H. woman who runs the website “Morgellons Exposed,”which details her 15-year battle with the perplexing disorder. Her theories include fears that Morgellons is caused by alien beings implanting nano-technology in humans.

“There’s so much more to this than a medical condition,” Smith said. “There’s something being hidden.”

Betsy Curry, 65, of Palm Bay, Fla., said she has endured sores and scabs all over her body for eight years, lesions that she said have extruded threads or fluff.  She didn’t expect the government report to offer any more help than the dermatologists and other doctors who dismissed her complaints.

“I’ve had years of doctors telling me something was wrong with me, I was crazy, I was too fat,” said Curry, whose condition was described on Inspire, an online support community.

“After eight years, it’s just something I accept.”

Morgellons sufferers were mostly white, middle-aged women, more than half of whom reported they were in poor health, the study showed. Like Curry, about 70 percent of the victims also suffered from chronic fatigue syndrome and more than 60 percent reported ongoing bodily aches and pains.

About 60 percent showed problems with cognitive functioning. About half had evidence of drugs in their system, including drugs to control pain, and nearly 80 percent reported exposure to solvents, the study showed. About 40 percent had skin lesions or abrasions that appeared to be caused by self-inflicted rubbing or scraping, researchers found.

But the study shouldn’t be interpreted to conclude that the problem is all in sufferers’ heads, Eberhard stressed. Instead, it should be a baseline for future research and encouragement for patients and their doctors to work together, harder, to find a cause.

“These people are definitely suffering from something,” Eberhard said. “It has impacted their lives greatly.”

Communication is a two-way street

Posted on 1.27.12 at 4:09 pm. No Comments.

Coming to a doctor’s visit is no different than any other consultative service you may receive; it is a give and take between patient and provider that requires involvement from all parties.  Here are some suggestions to make efficient use of your time with your doctor:

1) Make a To-Do List: identify your top 1-3 concerns that you would like to address during your visit.  Really take some time to narrow down what questions you have–many people make lists, but sometimes the questions are poorly organized and probably confuse more than clarify.  You will want to keep your lists as concise as possible so that you are not overwhelmed with the answers and that there is time to answer each one as completely as possible.  Your time spent preparing for your visit will be rewarded in knowledge and understanding.

2) Ask questions: This is the MOST IMPORTANT. Being in the medical field, it can sometimes be difficult to determine what level of understanding our patients may have.  We want to educate our patients without them feeling overwhelmed or belittled in the process.  Please know that we are doing our best, but if you don’t understand, speak up!  Don’t be shy, because this is your (or your child’s) health at stake.

3) Know your medications: At the dermatologist’s office, this includes all creams and lotions–prescribed and over-the-counter–that you may be using.  Don’t forget herbal supplements!  It is more difficult to know where we should go if we don’t know where we have been.  You may bring your medications with you, or, better yet, make a tiny list of them to keep in your wallet.  You never know when you may need them.  Also know your medical history, including allergies and whether you are or planning to become pregnant.

4) Be honest with yourself:  We really need to know more than “the medication didn’t work.”  Did it not work because it irritated your skin, or interfered with your makeup, or was too difficult to remember to use–or any other reason?  Help us to help you–we are invested in your success.  If there is a factor we can reduce or eliminate in order to see a treatment plan to completion, let us know.

5) Understand your limitations and exercise patience:  We will give you the best treatment plan out there with consideration for your budget; yet, even with the best of intentions, sometimes a particular treatment is denied or poorly covered.  We will do our best to help you understand costs ahead of time, but patients should do their homework too! Insurance and prescription plans, even from the same carrier, can vary widely, and patients often have more direct and immediate access to coverage information (usually via their website) than we have.  Again, do not be afraid to ask questions of your insurance carrier, your pharmacist, and your doctor to understand the treatment options out there.  We can explain why we chose a certain regimen, and we will make changes where we can.

At Dermatology Associates of Uptown, we take great pride in our service to patients, and we want your experience to be educational and therapeutic, and this is best achieved when both patients and physicians take an active, communicative role in health care. We look forward to the opportunity to be of exceptional service to you!

~Dr. Carter


“Nature vs nurture: How our hair care practices influence our hair growth”

Posted on 12.27.11 at 10:16 am. No Comments.

There are a number of causes for hair loss.  To name a few, these may include diseases, like a severe illness, a surgery, anemia, or lupus.  Hormonal imbalances, such as a poorly functioning thyroid, and must be ruled out. Psychological causes may be at fault, such as trichotillomania, where a patient may be–inadvertently or purposefully-pulling their hair out, or major emotional stressors such as loss of a loved one or depression may be at fault.  But sometimes, we are doing this to ourselves.

I’m speaking of traction alopecia, specifically.  It is very commonly said among the Black community that a woman’s hair is her crown; I believe this to be true amongst most races, but Blacks are especially prone.  Our hair care practices are amongst the most harsh–relaxers, body waves, color, sew-in and glue-in weaves, cornrows (or plaits), flat-irons and hot combs, are all culprits.  We pull on our hair, and then we wonder why it ceases to grow.  The stress to the edges of our scalp can often be too much to bear, and over time, can become permanent.  Models such as Tyra Banks and Naomi Campbell are gorgeous on camera, but to see them without their extensions is clear evidence of long-term damage that can be done. A similar fate can be seen in ballerinas of all backgrounds: they are known for their tightly apposed buns and smooth edges.

There is another form of alopecia that we see nearly exclusively, yet sadly, commonly, in Black patients called follicular degeneration syndrome, also known as central centrifugal cicatricial alopecia.  The names are a mouthful, but they speak to what is happening to hair follicles–they are forming cicatrices, or scars.  In this case, what is lost cannot be regained and the aim of treatment is to halt further loss.

In any case of alopecia, early recognition is key.  For traction, this is a process that often begins in childhood, even before a child learns how even to comb her hair.  For FDS, we can identify the inciting causes, eliminate symptoms, and try to minimize future hair loss with treatment.

An important addition to successful therapy is to shape a patient’s (and a culture’s) expectations and ideals of beauty.  We must embrace our hair rather than fight it, and there are definitely ways to mitigate the injury we do to this precious asset.  At Dermatology Associates of Uptown, we strive to educate patients on not only what NOT to do, but also what TO do with their hair.  In Dallas, we have so many stylists that are attuned to taking care of this type hair, and we have the knowledge and staff to aid you in this endeavor should you choose to walk that path. This is the story of both the personal, social, and psychological journey one woman took in her hair care journey; please enjoy:

~Dr. Carter

More bad news for tanners

Posted on 12.13.11 at 3:13 pm. No Comments.

Previous studies has shown that patients who use tanning beds are more prone to develop malignant melanoma, the most deadly form of skin cancer.   A recent article in the Journal of the  American Academy of Dermatology now shows that tanning also causes a nearly 70% increase in basal cell carcinomas (BCC) in young female patients.  While BCCs are not nearly as dangerous as melanomas as they do not spread through the blood or lymph nodes, they are often disfiguring and cause major morbidity. Will this new data change tanners habits?  Sadly probably not.  We have known the carcinogenic affects of smoking for years but many patients choose to continue to smoke.  Now we can finally tell patients with assurance that tanning will lead skin cancers in the skin.

An article from Reuters is listed below:

updated 12/13/2011 2:19:13 PM ET 2011-12-13T19:19:13

“All-Natural” Products for the Skin

Posted on 12.3.11 at 2:05 pm. No Comments.

One of the most common concerns we see in our practice is regarding proper skin care products, particularly for the face.  We are bombarded by promises of the superiority of natural and herbal therapies in the news, infomercials, and the internet.  Hardly a day passes when a patient asks for “all natural” treatment, or proudly states that they use shea/cocoa/insert-your-name-here butter or all-natural oil to moisturize their face.  This often precedes or follows a discussion regarding uncontrollable acne.

Of course, do what works best for your skin.  Some people swear by things like petroleum jelly, but we know now that the particle size of many of these jellies, butters, and oils is particularly large and may worsen acne.  Many commercial facial creams, however, will say  “non-comedogenic,” meaning, they will not clog pores nor promote comedone (read: acne) formation.  Plenty out there will contain other acne fighting ingredients, such as alpha and beta hydroxy acids (i.e. glycolic and salicylic acids) or retinol, also to help maintain clear pores.  I would encourage using products with the description as non-comedogenic on the label, and we can discuss which additives would be best for your regimen at your visit.

This discussion calls to mind one of my instructors from my dermatology training. To someone asking for all-natural remedies, he would say, “Well, poison ivy is all-natural, too.”  Sure, he was being facetious, but it does drive home the point that just because something is considered natural does not mean it is the best product to use.  On the other hand, many of our medications are derived from all natural sources or compounds: Aspirin & salicylic acid (willow bark), penicillin (penicillium mold), and tretinoin (Vitamin A derivative medication used for acne) are just a few examples. When used properly, these medications can be helpful; but these “all-natural” products can also be harmful in the wrong patient.  Don’t be afraid to ask–we, physicians and pharmacists, are more than willing to address your concerns regarding the medications and treatments we recommend.

We encourage you at Uptown Dermatology to bring your products at the time of your visit so that we can discuss your regimen.  We can recommend products to maintain healthy skin within your budget and prescribe treatments to help you look your very best.

~Dr. Carter


The sad future of health care.

Posted on 11.10.11 at 2:31 pm. No Comments.

If you want to get a good idea of the future of health care, look no further than this article.

Walmart wants to become the nation’s biggest health care provider and given their size and resourses, they probably will be.  There idea is that a Walmart will be a one stop shop.  Go and get diagnosed then buy your prescriptions on the way out.  Not necessarily a problem except their plan is not to have physicians treating patients but  unsupervised nurse practitioners or physican assistants with no doctor present.  Might be fine if you have a sore throat and just need a strep test, but any more than that and you are asking for disaster.  I don’t see this trend really affecting the field of dermatology but is more bad news for the long suffereing primary care doctors.  The rest of the article linked below:

Walmart — the nation’s largest retailer and biggest private employer – now wants to dominate a growing part of the health care market, offering a range of medical services from basic prevention to management of chronic conditions like diabetes and heart disease, according to a document obtained by NPR and Kaiser Health News.

(Illustration by KHN after photo by Walmart via Flickr)

In the same week in late October that Walmart announced it would stop offering health insurance benefits to new part-time employees, the retailer sent out a request for information seeking partners to help it “dramatically … lower the cost of healthcare … by becoming the largest provider of primary healthcare services in the nation.”

On Tuesday, Walmart spokeswoman Tara Raddohl confirmed the proposal but declined to elaborate on specifics, calling it simply an effort to determine “strategic next steps.”

But by midafternoon Wednesday, the retailer issued a statement saying its own request for information was “overwritten and incorrect.” The firm is “not building a national, integrated low-cost primary health care platform,” says the statement by Dr. John Agwunobi, a senior vice president.

The information request begins with the exact wording that Agwunobi says is incorrect, saying Walmart “intends to build a national, integrated, low-cost primary care healthcare platform.” The request goes on to ask firms to spell out their expertise in a wide variety of areas, including managing and monitoring patients with chronic, costly health conditions. The goal it says is for Walmart to become “the largest provider of primary healthcare services in the nation.”

The document spells out a tight timeline. It was issued to an unknown number of “strategic partners” on October 21 and final vendor selection is set to take place on January 13.

Analysts said Walmart is likely positioning itself to boost store traffic — possibly by expanding the number of, and services offered by, its in-store medical clinics. The move would also capitalize on growing demand for primary care in 2014, when the federal health law fully kicks in and millions more Americans are expected to have government or private health insurance.

“We have a massive primary care problem that will be made worse by health reform,” says Ian Morrison, a Menlo Park, Calif-based health-care consultant. “Anyone who has a plausible idea on how to solve this should be allowed to play.”

In-store medical clinics, such as those offered by Walmart and other retailers, could also be players in another effort in the health law: encouraging collaborations of doctors and hospitals who want to win financial rewards for streamlining care and lowering costs. Such collaborations, known as “accountable care organizations,” might contract with in-store medical clinics, says Paul Howard, a senior fellow with the Manhattan Institute for Policy Research. He has studied retail clinics, some of which have recently expanded to offer services beyond simple tests and vaccinations, such as helping monitor patients with diabetes or high blood pressure.

Walmart’s request goes even further, asking possible partners to provide information on how they would oversee patients with complicated chronic conditions, including asthma, HIV, arthritis, depression and sleep apnea.

While Walmart’s efforts to partner with others on health care could help lower costs for some patients and increase access to primary care services, health policy experts also say it raises questions.

Will expansion of in-store clinics, for example, further fragment care in the U.S. by drawing patients away from their established primary care doctors?  Would patients who need specialists fall through the cracks? Will patients seen by nurses or physician assistants at in-store clinics have just as good outcomes as those seen by doctors in more traditional practices?

“Maybe Walmart can deliver a lot of this stuff more cheaply because it is an expert at doing this with other types of widgets, but health care is not a widget and managing individual human beings is not nearly as simple as selling commercial products to consumers,” says Ann O’Malley, a physician and senior health researcher at the Center for Studying Health System Change, a nonpartisan Washington think tank.

And will it save money?  Because primary care services are not the main driver of health care costs in this country, “I would be surprised if this were a model that could truly attack cost problems,” says O’Malley.

Whatever it does to health costs, it may also be a way to boost foot traffic and sales in Walmart stores, says Colin McGranahan, a retail analyst for Sanford C. Bernstein & Co.

“Their traffic has been declining for over two years and they’ve been losing market share,” McGranahan says. “If you get someone in the door, you can also sell them milk and a shotgun.”

CVS/Caremark, Walgreen’s, Kroger, Target and others have recently reinvigorated efforts to open in-store medical clinics. The first such in-store clinics opened in 2000, but growth took off later in the decade.

Until recently, Walmart was the nation’s leader in opening such clinics, but has dropped to third place with about 140 such clinics, well behind industry leader CVS Caremark’s nearly 550 Minute Clinics and Walgreen’s 355 Take Care clinics, according to data tracked by Tom Charland, CEO of Merchant Medicine, a Minnesota-based research and consulting firm. About 1,300 store-based clinics are open nationwide, he says.

They have different business models. Walmart leases space to independent vendors, for example, while CVS owns and staffs its Minute Clinics.  While a few centers operated by retailers have doctors on site, most hire nurse practitioners or physician assistants to provide the care.  In 2007, Walmart CEO Lee Scott announced the firm would open 400 clinics by 2010.

But early efforts backed by venture capital money faltered and the firm failed to reach that number, says Charland. Walmart then switched strategies and began leasing to hospital systems primarily and it began to grow again. Still, last month, the firm appeared to be struggling: Walmart opened three in-store clinics, but closed 10, says Charland.

“This is an industry where people haven’t figured out how to make money,” he says.  Hiring nurses isn’t cheap – and business can be seasonal:  more people come in during the cold winter months and business can slow to a crawl in the summer.  “My guess is the whole purpose of [Walmart's] request for information is to find someone to help them because they’ve not been able to pull it off.”

CVS, which has run Minute Clinics since 2006, expects to break even for the first time this year, says Helena Foulkes, a CVS executive vice president in charge of strategy and marketing. It plans to keep opening clinics and is doing so at a clip of about 10 a month.

“We think the market will evolve so this will become a more important model,” says Foulkes.

Kristian Foden-Vencil of Oregon Public Broadcasting, and Chris Weaver, Sarah Barr, and Christian Torres of Kaiser Health News contributed to this story.