Training rural family doctors

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In a recent report from the University of Washington’s WWAMI Rural Research Center, “Family Medicine Residency Training in Rural Locations”,[1] Chen et. al. repeat their 2000 study of rural training in the US. They note that this is very important given the health needs of the American people, 20% of whom live in rural areas, most of which are underserved given the less than 9% of doctors who practice there (Primary Care and Rural Areas, April 28, 2010; Medicare Costs in Rural America: A case of reaping what we haven't sown?, March 26, 2009). Most rural training is of family doctors, but a majority of it comes from urban programs.

How is this so? This is because over 90% of the family medicine residency programs in the nation are located in urban areas, and only 7% in “large rural areas”; it is very hard to have a program entirely in a “small rural area” as the requirements for family medicine training include a great deal of time spent in the hospital and working with other specialists. Nonetheless, the authors surveys discovered that nearly half of the family medicine programs felt that training rural doctors was an important part of their mission.

From the Executive Summary: “Rural residency programs provided a higher proportion of rural training than urban programs, but because more programs were in urban settings, there was more rural training in urban than rural programs. Overall, 15% of respondents had a formal RTT [rural training track]; of these, 61% were in rural and 10% in urban programs. Rural residency programs conducted 83% of all rural residency training in RUCA[2]-defined rural areas. Comparing the 2000 and 2007 surveys, rural training increased from 372 to 408 FTEs, but rural training in urban programs declined from 186 to 79 FTEs, resulting in an overall decrease in the amount of rural-focused family medicine training.” See figure for example of a “RUCA map” in a state (Kansas) with a high percentage of “isolated rural” areas; Other states (say, New Jersey) look different!

The authors found that while virtually all (99.9%) of the training FTEs reported as rural in rural programs in fact occurred in rural (RUCA-defined) areas, only 21.7% of those reported by urban programs were in such areas. The net result was that only 7.3% of family medicine residency training FTEs are in rural areas, with 83% of these conducted by rural programs. Interestingly, to me, a higher percentage of urban programs listed rural training as “very important” (45.3%) than listed urban (underserved) training (40.4%).

The authors discuss the policy implications of this situation, including the possible impact of several components of the ACA health reform law that encourage training in rural areas. An important one has to do with Medicare funding of GME (residency) positions, the arcane but major source of funding for such training (Funding Graduate Medical Education, May 25, 2009; Public Law 111-148, Sect 5506, p 661). The change would make it easier for non-hospital sponsors of training (such as community health centers, an area the authors have also written about[3]) to receive this funding (Public Law 111-148, Sect 5508, p.668). The law – and policy – also favors redistribution of unfilled GME spots to rural hospitals. However, there are counterpressures: many big urban hospital training sites are “over their cap”, meaning they have more residency positions than are funded by Medicare. In these cases, the hospital, or another entity, funds the positions; these are virtually always in those specialties that make more money for the hospital, not in primary care, and certainly not in rural tracks (Primary Care and Residency Expansion, January 7, 2010 ). As they expand, in response to the demand for more physicians and medical school class increases, they will exert great political pressure to have new GME slots assigned to them to help cover their costs.

So here is the situation:
· There is a tremendous shortage of doctors in rural areas.

· Rural family medicine training programs, particularly those located in rural areas, are very effective in producing physicians who will practice in those rural underserved areas.

· Only 7.3% of family medicine (FM) residency positions are in such rural programs. This is way better than any other specialty, and may in fact be higher because while the authors did not count many of the trainees claimed as rural by urban FM residencies because they are not actually occurring in RUCA-defined rural areas, “Training locations may be defined as 'urban' using RUCA definitions but may still be sparsely populated and serve a predominantly rural patient populations.”

· Even if all FM positions claimed by their sponors as rural are in fact so, FM residents are only about 10% of all residency positions (2,630 of 25,500 in 2010), and virtually no other residents are trained for, not to mention likely to enter, rural practice…despite the need for other specialists, especially general surgeons, in these communities.

· ACA has a number of components that target an increase in the production of rural physicians (particularly family doctors and general surgeons, Public Law 111-148, Sect 5501, p. 534), but even if these are fully implemented, and taken advantage of by students, it will be many years before they have a significant impact.

· Despite these ACA changes, there will be counterpressures to use many of the new training slots for training non-primary care residents in urban sites, and particularly in academic health centers; these will come from both the academic health centers and their teaching hospitals themselves, the subspecialty physician medical societies, and the medical students themselves who overwhelmingly prefer to live in urban areas, as well as to earn the much higher incomes of subspecialists.

How might this be changed or modified? The provisions in the ACA law funding of GME slots to non-hospital settings such as community health centers, preferentially training primary care doctors (and general surgeons), and supporting the growth of community health centers and health extension services are a start, but they are not sufficient. The key is going to be greater incomes for doctors practicing primary care and general surgery in rural areas compared to those practicing subspecialties in urban areas. Supply and demand is insufficient; while there is demand for such doctors in rural areas, there is demand for more subspecialists by urban hospitals that see them as cash cows. Medicare sets reimbursement rates, as almost all payers model their rates as percents (usually higher) of Medicare’s. The reimbursement has to change so dramatically as to make primary care doctors in rural areas make, if not more, at least not nearly so much less as subspecialists in cities.

This financial change will begin to level the playing field. Medical students who have no interest in rural practice can still stay in urban areas, and even in subspecialties, but they should have to pay a financial price, making less than they would if they were to practice in what (to them) might be considered a less desirable area. As long as we make some careers pay a lot more, often for no more or even less work, as well as be located more popular (urban metropolitan) areas, we cannot expect any different outcome from the one we currently have.



[1] Chen FM, Andrilla CHA, Doescher MP, Morris C, “Family Medicine Residency Training in Rural Locations”, Final Report #126, WWWAMI Rural Health Research Center, University of Washington School of Medicine Department of Family Medicine, July 2010.
[2] RUCA = Rural-Urban Commuting Areas; a measure of population density that accounts for nearness to an urban area; obviously two counties may have similarly low population densities, but if one is surrounded by similar counties while the other is adjacent to a county with a large – or moderate – urban area, the first is “more” rural.
[3] Morris CG, Chen FM, Training Residents in Community Health Centers: Facilitators and Barriers, Annals of Family Medicine, Nov2009;7(6):488-94

Breast cancer screening: conflicting evidence? what are the important questions for health?

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Several new, and sometimes contradictory, studies about breast cancer and screening mammography have recently appeared in the medical literature. In a recent study from Norway, published in the New England Journal of Medicine, Kalager et. al[1] looked at the impact of mammography screening of women 50-69 years old in that country by comparing groups of women who were screened and those who were not screened between 1996 and 2005 and comparing them both with comparable groups for the 1986-1995 period. They discovered a significant decrease in the rate of breast cancer detected in women who were screened – but also in women who were not screened. The decrease was greater in the women who were screened, but this only accounted for 1/3 of the reduction in breast cancer mortality in that group; while the reductions in each group were statistically significant, the difference between them was not (quite). Overall the reduction in the death rate in screened women was 7.2 per 100,000 woman-years, and in the non-screened group 4.8 per 100,000 woman-years.

Meanwhile, Cancer published an article from Sweden looking at mammography screening for women who were 40-49 years of age. Because not all Swedish counties screened women that age, they were able to do a retrospective comparison between those counties who began screening at 40 compared to those counties who began at 50. Hellquist, et. al.,[2] found a significant risk reduction (a relative risk of 0.74 for women invited to screening and of 0.71 for those actually screened). Over 16 years of the study “…there were 803 breast cancer deaths in the study group (7.3 million person-years) and 1238 breast cancer deaths in the control group (8.8 million person-years)”, or converting to the same units as the other study, a reduction of 3 deaths per 100,000 woman years, from 14 to 11. The authors note that 1252 women this age would need to be screened to prevent one death.

The Swedish study provides data to support screening women at 40 (although the reduction was greatest in the 45-49 group, which is not surprising as the incidence of breast cancer increases with age). The Norwegian study shows that the rate of breast cancer has decreased anyway. The Swedish study is not a randomized controlled trial, but rather solely a historical comparison, and thus did not control for differences between the women who got screening and those who did not that might have affected breast cancer risk.

So which are we to believe? Both, to the extent that we can understand the methods used. The question is what are we to do? “We”, here, being both women who might choose to undergo mammography screening, and doctors who have to decide whether to recommend it, especially to those under the age of 50. For me, it will involve discussions with each woman, dependent on her individual risks and preferences. The population health benefit is small but significant; while for any woman the risk reduction might be of value regardless of the cost, that woman (and everyone else) has to also bear the cost of screening all those women – 1252 to save the life of one woman 40-49 in the Swedish study. Clearly, women who have a higher risk (family history) will benefit more, since they are more likely to have breast cancer than those without such a family history.

The cost is not only all those mammograms, but the cost of further tests (additional views or ultrasound) in women with questionable results (more common in younger women who on average have denser breasts), in biopsies – not without risk, though low – and pathology reports, discomfort etc. Not to mention what that money might otherwise be spent on. Feeding the homeless? Providing prenatal care? Fighting HIV/AIDS? Building more bombs? Bailing out big financiers? I would certainly agree that there are social programs that could more effectively use the money currently being spent to screen low-risk younger women for breast cancer with far more social benefit; I would also acknowledge the very low likelihood of any saving in mammography screening being used for such purposes rather than other high-tech medical care or further health system profit.

A more important question, perhaps, is why, at any age level, are certain parts of the population – poorer and minority women – less likely to be screened? To the extent that screening does detect cancer in earlier stages, when intervention can be done, and thus make a difference in mortality, why is it not being done as effectively with minority women? For example, African American women are less likely to get breast cancer, but more likely to die from it.

But people do want “answers”, definitives. Newspapers like to publish “breakthrough” research that seems to provide them. When the “answers” seem contradictory, it leads to frustration for many, and a decision to do what they had planned to do anyway, to do what seems to make “sense” (and what they can afford). After all, if sometimes we hear that Vitamin C or E or beta-carotene is a wonder drug to prevent cancer, or Alzheimer’s, and later studies show that it isn’t, and sometimes may even create greater risk, what are we to do?

One thing we could choose to do is to listen to those who are sure that they have the answers, even when these are based upon no data or carefully-selected data. If someone advises people based upon a single study, regardless of the scientific quality of that study and how often its results might have been refuted by later studies, they can be more confident and sure of themselves. This can inspire confidence on those they advise. (I am reminded of the story told by a colleague, fresh out of residency, who was practicing with farmworkers in the Imperial Valley of California. These folks, he said, are used to going to a doctor who listens to their problem, nods, tells them what they have, and gives them a shot to fix it. “I,” he noted, “listen, then tell them to take off all their clothes, examine them for a long time, and then finally tell them I’m not sure what it is, but it probably doesn’t need a shot – and that the shot might even be bad for them – and likely it will go away with time. Who are they going to trust?”). Showing confidence in your opinion is very persuasive. Thus the term “confidence men” (now shorted to “con”).

By the way, I don’t think this is such a good choice. That studies may seem contradictory is part of the nature of science, of how the studies were conducted, on whom, with what controls, using what methods. A future blog will discuss the work of Dr. John Ioannidis, whose work has raised questions about how much of the work published as research is true, made recently au courant by David H. Freedman’s article in the November Atlantic “Lies, damned lies, and medical science,” and some of the important lessons to be learned – and not learned – from his work. Nonetheless, this confusion does not justify complete nihilism – do whatever you want and it’s all the same – or much less undertaking treatments that have never really been studied. (See Drugs, Tobacco, Doctors and the Health of the Public, September 10, 2010.)

In the meantime, remember that there are probably not too many magic shortcuts to better health. A healthful diet and more exercise will make you fitter and stronger and able to do more things; reading and thinking and doing puzzles are interesting, stimulating and fun, whether they prevent Alzheimer’s disease or not.

[1] Mette Kalager, M.D., Marvin Zelen, Ph.D., Frøydis Langmark, M.D., and Hans-Olov Adami, M.D., Ph.D, Effect of Screening Mammography on Breast-Cancer Mortality in Norway, N Engl J Med 2010; 363:1203-1210.

[2] Hellquist BN, et. al., Effectiveness of population-based service screening with mammography for women ages 40 to 49 years, Cancer published online Sept 29 ,2010
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Health and income: "what's new?" or a good resource

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This is a guest post by Kim Kimminau, PhD, Associate Professor of Family Medicine at the University of Kansas School of Medicine and Director of the Center for Community Health Research.

I come from a family where my parents, one a first generation American and the other a child immigrant, and the first in their families to complete high school, would say to me “so, somebody actually pays you to do that?”, and the “that” was my life’s work – the study of human health through time and space (aka, biological anthropology) and to conduct research. For them and so many others, reading the titles of research grants or peer reviewed articles was an exercise in a delightfully sardonic mix of tongue-twisted, mispronounced terms, outright mockery and guessing what and why anyone would want to spend “good money” (as my father would say) to study such things.

Apparently, the time has come. I have become my parents.

In the online Robert Wood Johnson Foundation’s News Digest on public health I learned from a UPI story that a Gallup poll was recently conducted among 200,000 U.S. adults over the span of nine months (http://www.upi.com/Health_News/2010/10/18/US-health-well-being-tied-to-income/UPI-74081287460458/ ). This alone is pretty mind-boggling – a huge poll by almost any standard. I read on. What was learned from the survey was that “the more money Americans make, the better physical emotional and fiscal well being they report.” Really? Who could possibly be surprised at this finding? Using my parent’s lexicon, more importantly, who would waste good money on measuring this?

The article went on to say that poor adults are three times more likely to smoke, eat less healthy options and exercise infrequently. Those with lower incomes are more likely to report having been told they have a chronic disease and, more than their more affluent counterparts, poor Americans report being obese and having twice as many colds and flu. So I braced myself, waiting some intrinsic “blame the victim message” – if only “those people” (and yes, I detest such speech) would stop eating fast food, get a job, stop wasting their money on cigarettes and cell phones, and take care of themselves, these statistics would be very different. But wait, this information was put out by the Robert Wood Johnson Foundation….surely a more valuable lesson about determinants of health was imbedded in the UPI report? But no, the article ended.

So I did some digging. I took some time to learn that Gallup entered a 25-year partnership in 2008 with Healthways (a publicly traded NASDAQ company, headquartered in Tennessee and led by CEO Ben Leedle (who, interestingly, has ties to Wichita, KS)). They conduct a daily nationwide survey that produces the Gallup-Healthways Well-Being Index. Not only is this the largest “behavioral economic database ever created” the Well-Being Index can be used to drill down to associated state, congressional district and city level reports. Eureka! While I was busy dissing the effort, I actually uncovered a fascinating resource that monitors the pulse of the nation on a variety of indicators that I should have been paying attention to over the past two years.

The methodology being used is commendable. Each daily sample includes a minimum quota of 150 cell phone respondents and 850 landline respondents, with additional minimums to ensure representative gender within each region. Using Current Population Survey figures for the 18 year old and older non-institutionalized adult population and including Spanish language interviews, they have a 98% representative adult sample. They measure 6 domains of well-being: emotional health, physical health, healthy behavior, work environment, basic access, and a sixth called “life evaluation” (it includes 2 questions that use the Cantril Ladder scale (Cantril, 1965)). As with any rating system, our first inclination is to look at where we fall on the scale, so in this case, I clicked on “Kansas” to review the most recent summary report (the report includes data collected during 2009. You can also click on “snapshot findings” to see data collected during the most recent 6 months. What that profile tells you is that you should be happy if you don’t live in West Virginia.)

The Kansas report can be found at: http://www.well-beingindex.com/files/2010WBIrankings/KS_StateReport.pdf . (And Nebraska at http://www.well-beingindex.com/files/2010WBIrankings/NE_StateReport.pdf, and you get the drill!) You may be surprised that our state is the last state in the top quintile for overall well-being (up from 22nd in 2008). What’s more, among our three largest cities, Topeka (not Wichita or Kansas City) ranks worst on overall rank. Finally, if I were running for political office in the 1st Congressional District, I’d be worried about the fact that constituents report the worst life evaluation scores compared to the other three districts by a long shot.

But back to the bigger picture. I’d urge you to go to the well-being index home page http://well-beingindex.com/monthlyWBIreport.asp and click on the “daily pulse” tab of the dashboard. I’m a numbers person, but just looking at the daily distance between the orange line of those “thriving” and the green line of those “suffering” should give us all a reason to reflect on why poor people smoke, eat empty calories and at times feel hopeless and helpless. The distance between those doing well and not well is enormous, and the need to close the disparities gap couldn’t be clearer. I plan to return regularly to this page to review how health reform implementation begins to bend these curves, especially on the “basic access” and the “physical health” tabs for the index.

While I’m happy that I inherited the genetic predisposition of skepticism from my parents, I’m equally happy that my training has made me a data dumpster diver and that this superficial article yielded a great return of a new resource for me.

Live and learn. That was another of my parent’s favorite sayings.
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Lower Costs in Grand Junction: More Primary Care, Less High Tech

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Grand Junction, Colorado, and particularly the medical care system in Grand Junction, Colorado, has been getting a great deal of publicity since the health care debate began, because it is a community with lower health-care costs, combined with high health status, compared to much of the country. While well-known to health policy analysts for many years, and particularly featured in the analyses of the Dartmouth Atlas of Health Care, it gained greatest fame when Dr. Atul Gawande published “The Cost Conundrum” in the New Yorker in June, 2009. While the focus of the article was the exceedingly high per capita cost for Medicare in the border town of McAllen, Texas, including how unfavorably those costs compared to the other border town of El Paso, Grand Junction was prominently cited as a community in which Medicare costs, and all health care costs, were exceptionally low. This little town on the western slopes of the Rocky Mountains has become a potential model for those who believe health care costs can be controlled while maintaining or increasing quality, and a bugbear for those (mostly those profiting from medical care, or funded by corporations that so profit) who fear limits on medical costs.

The most recent, and brief and pithy, article, “Low-cost lessons from Grand Junction, Colorado”[1] comes from Thomas Bodenheimer and David West in the October 7, 2010 issue of the New England Journal of Medicine. They cite the statistics on health care and costs in Grand Junction and Mesa County from the Dartmouth Atlas: “…average per capita Medicare spending in Grand Junction was $6,599 in 2007 — 24% lower than the national average and 60% below high-cost Miami”, while maintaining high quality, including high performance on preventive metrics. They note that “…data on mortality and morbidity from the Robert Wood Johnson Foundation and the University of Wisconsin's County Health Rankings database show that the population of Grand Junction's Mesa County is far less healthy than those of some U.S. counties with high Medicare costs (www.countyhealthrankings.org), although it is number one in Colorado in the quality of clinical care provided. One would expect less-healthy communities to have higher costs.”

Bodenheimer and West cite 7 characteristics of the Grand Junction medical system that they believe are responsible for this situation and might be replicable (if “generally not without political battles”):

“These are leadership by the primary care community; a payment system involving risk sharing by physicians; equalization of physician payment for the care of Medicare, Medicaid, and privately insured patients; regionalization of services into an orderly system of primary, secondary, and tertiary care; limits on the supply of expensive resources, including specialists, beds, and equipment; payment of primary care physicians for hospital visits; and robust end-of-life care.”

The payment system is based upon the Rocky Mountain HMO, begun in the 1970s and involving most of the providers in the western slope. This HMO gained the attention of scholars years ago, and was described in a case study by Wellever and Moscovice in the Journal of Rural Health in 1998.[2] One of the key parts of the “Rocky” is that it contracts with both Medicare (via a Medicare Advantage program) and Colorado Medicaid, so that providers, who are largely independent in solo or small groups, are paid more or less a single rate, regardless of the insurance (Medicaid, Medicare, or contracted with Rocky via an employer). This makes costs and reimbursement much more predictable and allows physicians to provide the appropriate care for patients, without trying to figure out what their insurance will pay for. It provides the physicians with the security that would, in fact, characterize a single-payer system.

The other critical component is not only leadership by primary care (and predominantly family) physicians, but an appropriate balance between primary care doctors and specialists, and a limitation on the expansion of procedural services that may not be necessary. The key quotation from Bodenheimer and West here is “Because only one hospital can offer interventional cardiac procedures, there isn't room for many cardiologists in Grand Junction; with such limits on facilities and workforce, the rates of such procedures remain low. The same applies to other types of expensive procedures.”

This is entirely the opposite of what happens in most communities, in which competing hospitals seek to add more facilities and hire or contract with more subspecialist physicians in order to increase the income of both physicians and the hospital. As I have discussed in the past (e.g., Cancer Care and Hospital Advertising, January 16, 2010; Doctors, their Patients, and Health Reform, August 6, 2009) and as the Dartmouth Atlas makes clear, the number of expensive services provided to patients is very different in different parts of the country, and demand is very “elastic”; that is, it is often determined not by need but by the availability of physicians and facilities. That is, supply drives demand, rather than vice versa. Hospitals in other communities compete for doctors and patients (insured patients, let us be clear!) so that they can have a bigger “market share”. This “business” rather than health, approach, can be insidious, destructive, and expensive enough, with overbuilding resulting in overcapacity. More serious, however, as Kelly reminds us,[3] than seeking a bigger market share is the complementary business practice of expanding the market – finding new “customers” for your product – in this case, high cost procedures.

Do I know if the number of interventional cardiac procedures (or any other procedures) done in Grand Junction is the “right number”, or if the system that exists there and limits them means that too few are done? No, of course not. We can look at data cited by Bodenheimer and West that suggest that it is not far off, that health status is not decreasing, and that preventive services on discharge are higher than average. But I do know that there is a “right number” and that it is determined by the health status of the patient population and the risk/benefit ratio from doing procedures, not by the driver of “more is better”. Arguable for other consumer goods (e.g., cars, music, toothpaste), the idea of “expanding the market” for expensive medical procedures – widening the field of those who are “eligible” so that we can have “more business” and make more money, is outrageous and immoral, as well as ridiculously expensive. This is true for procedures which are highly advertised and of little or no medical value as well as for procedures that can be important and lifesaving when utilized appropriately in the right patients. The money not spent on unnecessary high-tech procedures can provide more primary care to more people, and improve health outcomes.

Grand Junction, Colorado may not have all the answers to our health care system, any more than Canada or Britain or Switzerland do. But it is doing a lot of things right, it is saving money, and it is improving the health of the community, and that’s a lot more than most areas in the US are doing.


[1]Bodenheimer T, West D, “Low-cost lessons from Grand Junction, Colorado”, NEJM 7Oct2010;363(15):1391-3
[2] Wellever A, Moscovice I, “Rocky Mountain HMO”, J Rural Health. 1998 Summer;14(3):211-23
[3] Kelly PJ, Personal communication.

Obat herbal untuk sakit kepala kita

Bila Anda merasa bahwa mengonsumsi aspirin adalah satu-satunya cara mengusir sakit kepala atau pusing yang mengganggu, sebaiknya anda berhentilah. berikut ada obat herbal untuk sakit kepala:
Feverfew. Tanaman yang mempunyai bau mirip jeruk nipis ini merupakan antiperadangan dan bekerja seperti ibuprofen. Tumbuhan semak dari keluarga asteraceae ini sangat populer sebagai herbal untuk mengatasi migrain. Selain itu, herbal ini juga diyakini bisa menghambat zat-zat kimia penyebab ketegangan pembuluh darah di kepala. Sebuah studi menemukan, 2/3 dari pasien migrain sembuh setelah menggunakan feverfew secara teratur. Untuk menjamin tingkat keamanan dan menentukan dosis yang tepat, ada baiknya berkonsultasi dulu dengan dokter.

1. Peppermint. Herbal satu ini telah digunakan selama ratusan tahun untuk mengatasi sakit kepala. Semua bagian tanaman ini, mulai dari kandungan minyak, flavonoid, phenolic acids, dan triterpenes bisa digunakan sebagai obat. Studi pertama mengenai manfaat peppermint dipublikasikan pada 1879. Publikasi ini didukung oleh penemuan berikutnya di Jerman pada 1996. Studi ini menemukan, cairan ethanol yang mengandung 10% minyak peppermint sama efektifnya dengan 1.000 miligram acetaminophen dalam meredakan sakit kepala. Studi lain menemukan, 32 partisipan yang menggosokkan minyak peppermint di ubun-ubun mengalami pengurangan rasa sakit yang signifikan.
2. Cobalah menggosokkan atau memijatkan minyak peppermint ke ubun-ubun, turun ke kening, dan ke belakang leher. Cara ini dinyatakan efektif meredakan sakit kepala akibat gangguan pencernaan dan migrain dengan cara menimbulkan efek dingin pada kulit dan merilekskan otot-otot cranial. Selain itu, Anda juga bisa menggunakan teh peppermint untuk meredakan migrain. Caranya, tuangkan satu cangkir air mendidih ke dalam wadah yang berisi 1-2 sendok teh daun peppermint kering, kemudian tutup dan biarkan selama 10 menit. Saringlah campuran sebelum diminum. Untuk meredakan migrain, minumlah 1-2 cangkir teh peppermint dingin setiap hari.
3. Passionflower. Herbal satu ini bersifat menenangkan. Mengonsumsi teh passionflower sebelum waktu tidur bisa membantu Anda mendapatkan tidur yang lebih nyenyak. Satu percobaan klinis menemukan kalau herbal ini bisa menurunkan tingkat kecemasan. Selain itu, passionflower juga diyakini mengandung antiperadangan dan penghilang rasa sakit, sehingga sangat bagus untuk migrain. Dosis yang dianjurkan sebanyak 4-8 gram herbal kering 3 kali sehari. Untuk membuat teh, Anda bisa menyeduh 0.5-2.5 gram passionflower ke dalam air mendidih selama 15 menit dan diminum 2-3 kali sehari.
4. Ginko biloba. Daun ginko biloba merupakan herbal yang populer untuk meredakan sakit kepala. Herbal ini bisa memperlancar aliran darah, sehingga cocok digunakan untuk sakit kepala yang dipicu oleh gangguan sirkulasi. Beberapa studi yang dilakukan para peneliti dari Perancis menemukan, herbal in efektif meredakan sakit kepala vaskular (migrain, sakit kepala berantai, dan sakit kepala akibat mabuk). Salah stau studi bahkan menyebutkan kalau ginko bisa mengurangi migrain hingga 80%. Tapi, herbal ini bisa menimbulkan efek samping jika digunakan dengan obat sakit kepala seperti aspirin dan lithium. Karena itu, ada baiknya berkonsultasi dulu dengan dokter.
5. Cabe merah. Cabe merah mengandung komponen capsaicin, yang diyakini meningkatkan daya tahan terhadap rasa sakit. Cabe merah dinyatakan efektif meredakan sakit kepala berantai (cluster headaches), dan umum digunakan dalam bentuk semprot hidung (nasal spray). Sebuah studi yang meminta partisipan menggosokkan obat yang mengandung capsaicin di bagian dalam dan luar hidung menemukan kalau pasien mengalami pengurangan 75% rasa sakit dan frekuensi sakit kepala, dalam waktu 5 hari.
6. Chamomile. Herbal ini mengandung antiperadangan dan komponen penghilang rasa sakit yang bisa membantu meredakan ketegangan emosional. Karena itu, herbal ini cocok untuk membantu sakit kepala akibat ketegangan. Chamomile bisa ditemukan dalam bentuk teh siap seduh.

Selamat mencoba!

"Top Doctors": Who are they -- and who are they not necessarily?

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I have written about the US News and World Report ratings of “Best Medical Schools” (Rankings of Medical Schools: Do they tell us anything?, Sept 25, 2009; A New Way of Ranking Medical Schools: Social Mission, June 20, 2010). Another popular concept is identifying “Best Doctors”. Seems like every local magazine (“Your City’s Name Here!”) has a list of Top Doctors in various specialties. At another level, the airline magazines have full page ads (www.topdoctors.com) where they list 6 or 7 “top doctors” in a given specialty (orthopedics, plastic surgery, cardiology…never primary care!), usually one in each of several major metropolitan areas. The idea here seems to be to attract the business of well-to-do people who are flying, and may need, say, a rotator cuff repair or a breast augmentation. In addition, if you put a doctor’s name into an internet search engine, most of the “hits” will not be links to her/his office, but rather listings – sometimes accompanied by ratings – on a variety of sites. So what does this mean? Are these listings reliable? Should you go to a “top doctor”?

Why not? We all want to go to a good doctor. And isn’t a “top doctor” even better? Of course, if we think about it, we might want to know the basis on which these top doctors are selected; that makes sense. After all, if a site lists the “best cars” and we discover the criteria is which ones are capable of the highest speeds, or hold the largest number of people or cargo, that’s great if what you are looking for is a fast or big car. But if you want, say, a high-mileage car, probably these cars are not the “best”.

Unfortunately, it is very difficult to find out what the criteria are. Even more difficult than finding out how US News ranks medical schools. Some of them are from patient surveys – you are randomly called, or more likely solicited to fill out a survey on what you thought of your doctor. There are problems with this method, although it is nice to know people like their doctors. First, it is not a scientific sample. Maybe people who are happy with their doctors are more likely to fill out such a form. Or (more likely) maybe those who are unhappy with her/him are. Second, people can only evaluate what they can evaluate, and that may or may not be what is important to you. If a doctor listens, shows caring, responds in a collaborative manner – a person can rate that, and maybe that is important to you too (it should be). But maybe you are not interested in collaboration; maybe you just want a doctor who will tell you what to do (probably not if you are reading this site, or reading “top doctor” surveys, but many people are).

Most determinants of physician quality, other than interpersonal skills (and these are very important!) are beyond the ability of patients to assess. Because people really have no way of knowing about many components of the quality of care that they get, much of what they evaluate hospitals (and to a lesser extent, physicians) on is their “hotel services” – are the rooms big? Clean? Well-furnished? Is the food good? More relevant to quality among things people can evaluate are “how are you treated”? Are people attentive? Do they explain things to you? Are your questions answered? (This is, of course, not the same thing as getting whatever you want; receiving medical care is not shopping in a convenience store!) Finally, while a patient can know if they had a good outcome or not, they have no way of knowing if it might have been better – or worse – with a different doctor, or hospital.

If you are, say, having surgery, it might be nice to know how satisfied people are with the surgical results. Or how often people die. It is very hard to get this data, and harder still to control for important causes of variation (we call them “confounders” in research; things that might be associated with both the condition and the outcome). For example, one surgeon might have a very much higher mortality rate than another – until you find out that s/he is operating on the sickest people, the ones who were at highest risk for death, the ones the other surgeons wouldn’t dare to operate on – and that is why a higher percent of his/her patients die; if someone else were operating on the same population, their mortality rates would in all likelihood be much higher.

So what do these ratings mean? Usually not much. One thing that most of the “top doctors”, especially the ones in the airplane magazines, seem to have in common is fancy addresses: Rodeo Drive, Fifth Avenue, North Michigan Avenue. They have their practices in rich neighborhoods and take care of rich people. This may make them the most famous, especially among the folks who the people who write these articles talk to. And, likely, they are among the most financially successful, and thus able to pay to get their names on some of these lists. What it most certainly does not mean is that they are the best doctors, in any of the ways that you might mean it (nicest, best surgical outcomes, best listener, wisest, most highly respected by his/her colleagues, you pick it!). It also doesn’t mean they are not good – or maybe even among the best doctors -- but it is scarcely a guarantee. What they are is doctors who have, for a variety of reasons, chosen to take care of rich people in fancy neighborhoods. The reasons may be ego, a desire for status, a desire for bigger incomes (really a common one) or even a prejudice against or revulsion for poor people.

They are presumed to be the best because they are the ones who take care of rich people, and rich people get the best, right? They have the best cars, and houses, and jewelry, and yachts, and everything else, so they must have the best doctors, right? Wrong. What they have is the doctors who want to take care of rich people. Any medical school has some students who are looking toward such a career, as a prominent rich-people’s doctor, just as others are planning to work in middle class, working class, or poor communities. Or in rural areas. Or in third-world countries. I’ve got news for you – the students in the latter groups are not less smart or less skilled than those in the former group. They probably are more committed and have more developed social values. The densest kid in the class could be on Park Avenue and the smartest practicing in the ghetto, the country, or in Africa.

I don’t know the association of skill as a physician or surgeon and the socioeconomic groups that they care for. I know of both good and not-so-good doctors in all groups. Certainly, every time a celebrity dies of an overdose, we hear of some “Dr. Feelgood” who supplied them with dope, a doctor who was – at least before this adverse publicity – a “top doctor”, a “doctor to the stars” – but not my any measure a good, not to mention “best”, doctor. While elite offices can offer you nicer furniture, less crowded conditions, and more people who look like you (if you are rich), if you are really looking for the “best doctor”, it’s a crapshoot. S/he may be working in the free clinic across town.

So what do you do? Pretty much what you do now. Take recommendations from friends – provided that you think that the friend values the same things as you do in a physician. One who listens. One who is old. One who is young. One who has a nice office or office staff. Maybe one who has – if your friend can tell – helped them to improve their health. Now that would be a good one!
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Tip-tip sehat bagi kita

Bagi kita yang mengerti tentang kesehatan maka kesehatan atau kebugaran bukan hanya sebatas fisik, tetapi juga mental Anda harus tetap sehat agar tetap semangat beraktivitas. Karena itu perhatikan diri luar dan dalam. Caranya, simak tips berikut.

1. Makan teratur dan jaga kebugaran Anda
Secara rutin, makanan sehat dan olahraga ringan dapat menyebabkan perubahan yang cukup banyak pada mood Anda. Anda akan merasa lebih berenergi dan bisa menjaga diri sendiri. Ada keuntungan tambahan dari terlihat bugar dan bahagia yaitu meningkatnya rasa percaya diri.

2. Lakukan sesuatu yang Anda sukai
Buatlah daftar hal-hal yang Anda nikmati dalam hidup. Tidak masalah bila itu tampak tidak beraturan pada awalnya. Mulailah untuk melakukannya satu persatu dari hal terkecil setiap hari. Dan raihlah hal-hal besar nantinya. Hobi atau ketertarikan yang bisa menyerap seluruh minat itu bagus, walaupun mungkin saja hanya dilakukan satu jam seminggu. Tapi jangan terlalu berlebihan sampai-sampai Anda tak punya waktu untuk hal yang lain.

3. Cari teman yang banyak
Seseorang yang pemalu juga bisa memiliki kehidupan sosial yang aktif, cobalah bergaul. Temui orang baru dan ingat, teman yang baik belum tentu harus satu pikiran dengan Anda. Hindari orang yang merugikan Anda setiap waktu dan tidak pernah berterima kasih atas support yang sudah Anda berikan. Cari komunitas baru yang bisa membuat Anda tertawa dan terinspirasi.
4. Pelajari bagaimana mengendalikan stress
Jangan takut akan tantangan. Tantangan itulah yang akan membantu Anda mengembangkan kepercayaan diri. Mengatasi stress bukan berarti harus pasif dan terus berdiam diri. Untuk membantu, baca buku-buku self-help atau browsing ke internet tentang cara-cara menyenangkan untuk mengatasi stress.

5. Jadikan diri Anda berarti
Semua orang pasti punya nilai lebih. Tak ada yang bisa membuat diri Anda merasa tidak berharga kecuali Anda sendiri. Anda pasti punya kelebihan yang Anda tidak sadari. Coba pikirkan apa kelebihan Anda dan buat daftar tertulisnya. Tanpa disadari daftar Anda pasti cukup panjang. Ingat terus isi daftar tersebut.

6. Hindari lingkaran kesedihan
Jujurlah akan perasaan Anda. Tapi jangan sampai terjebak dalam kesedihan dan menceritakannya pada orang lain secara berlebihan. Hal itu akan membuat Anda terlihat menyedihkan. Hindari terduduk diam tanpa melakukan apapun seharian, apalagi bila Anda sedang merasa tidak bergairah. Coba untuk tetap sibuk atau lakukan sesuatu yang membuat Anda rileks.

Dan bagi anda yang sehari-hari di depan komputer sebaiknya membaca tip-tip berikut:
Berikut adalah dua belas tips sehat berkomputer yang saya dapat dari ebook internet sehat 2010. Selengkapnya anda bisa download di sini.

1. Gunakan kursi yang secara dinamis dapat diatur tinggi-rendah dan senderan punggungnya.
2. Posisi monitor bagian paling atas setidaknya setinggi 5-8 cm di atas arah pandang mata.
3. Untuk menghindari efek silau dari layar monitor, bisa gunakan filter atau pelindung anti-silau.
4. Duduklah dengan jarak sekitar satu rentangan tangan dari monitor.
5. Kaki harus dapat menjejak pada lantai atau pada pijakan kaki yang stabil.
6. Jika menggunakanalat pemegang/penjepit dokumen, tingginya samakan dengan layar monitor
7. Antara siku dan pergelangan tangan sejajar dan lurus saat menggunakan keyboard / mouse.
8. Lengan dan siku berada dalam posisi santai dekat dengan tubuh Anda.
9. Monitor dan keyboard posisikan di tengah hadapan Anda.
10. Gunakan keyboard yang memiliki bagian pengungkit di bawahnya untuk mengatur posisi.
11. Gunakan alas kerja atau meja yang stabil dan tidak goyah.
12. Sesekali lakukan istirahat pendek dengan berdiri, perenggangan dan melihat arah lain. Atau lakukan senam ringan sekali-kali.