Spaghetti and "Meatballs" from Forks Over Knives

Everyone loves pasta, so I wanted to share a recipe from the book Forks Over Knives.  A lot of you have probably seen the video, but if you haven't you can buy it on Amazon along with the companion cookbook. 

THE CLASSIC ITALIAN-AMERICAN dish gets a healthy makeover with millet standing in for the meat.  Loved this yummy and inexpensive dish.  You can simplify this recipe by adding your own favorite pasta sauce. I also used brown rice noodles in this recipe.

What I love about this book is that the recipes are very simple with ingredients you are use to seeing and using already.  You will find you have a lot of the ingredients in your home right now and can easily make a lot of the recipes by picking up just a few things from the store or getting them from your garden.  This is a great book for home food storage as well.  If you stock up on the cooking basics (page 12, 13, 14 & 15), and keep items on your shelves that you rotate, like vegetable stock, brown rice, quinoa, millet, whole grain pasta, various packaged & canned beans & lentils, various kinds of canned tomatoes, frozen berries & fruits, raisins, etc., you can create a 3 month or more supply of food that you rotate for your family.  You will also need to store some water. The recommendation is to have 1 gallon of water per person to last 2 weeks and 3 months of food.  I highly recommend this book to help you set up an excellent working kitchen and food storage plan. 

Some hints that have helped me with preparing my meals is to freeze a few items to make meal preparation easier.  I keep a bag of garlic in my freezer and pull them out as needed.  They work well frozen with my mincer.  I also freeze leftover parsley, cilantro, herbs and spinach. I can easily add these frozen veggies during my meal preparation.

Spaghetti and "Meatballs"
Printable Recipe
Serves 4

2 cups Vegetable Stock (page 23), or low-sodium vegetable broth
1 cup millet  (see below how to soak and prepare your millet before cooking)
1/2 teaspoon salt, or to taste
1 large yellow onion, peeled and diced small
6 cloves garlic, peeled and minced
1/2 cup minced basil
1/2 teaspoon freshly ground black pepper, or to taste
1/4 cup tomato puree
2 tablespoons arrowroot powder or cornstarch
1 pound whole-grain spaghetti, cooked according to package directions, drained, and kept warm
2 cups Tomato Sauce (page 25), heated  (I used my own favorite spaghetti sauce here)

1.) Preheat the oven to 350 degrees F.
2.) Bring the vegetable stock to a boil in a medium saucepan.  Add the millet and salt and bring the mixture back to a boil over high heat.  Reduce the heat to medium and cook, covered, for 20 minutes, or until the millet is tender.  Drain any excess water and keep warm.
3.)  Place the onion in a large saucepan and saute over medium heat for 7 to 8 minutes.  Add water 1 to 2 tablespoons at a time to keep the onion from sticking to the pan.  Add the garlic, basil, and pepper and cook for another minute.  Add the tomato puree and 1/4 cup of water and cook until the liquid is almost evaporated, about 3 minutes.
4.) Line a baking sheet with parchment paper.
5.) Add the cooked millet and the arrowroot powder to the onion mixture and mix well.
Using an ice-cream scoop, shape the millet mixture into 2-inch balls and place on the prepared baking sheet.  Bake for 10-12 minutes.
6.) To serve, divide the spaghetti among 4 individual plates.  Top with some of the "meatballs" and pour some of the tomato sauce over the prepared plates.

SOAKING MILLET
You must soak your millet the night before you plan on using it in your recipe. One cup of dried millet generally yields about 3 cups cooked. Measure out millet, place in a ceramic or glass bowl (never use plastic) and soak with purified water for 12-18 hours. For optimal soaking, add 1 tsp. apple cider vinegar.
Much like quinoa, millet is gluten-free and easy on the belly. It is also more alkalizing than other non-gluten grains. It is rich in B vitamins, iron, magnesium, phosphorous and potassium. Millet has an impressive amino acid profile, including the essential amino acid methionine, making it an excellent source of protein.  
Preparing Basic Millet 101 - Yogitrition

 

Women & Heart Disease: Know Your Risk, Protect Your Heart

Heart disease is often thought of as a health problem for men, but more women die of heart disease each year, killing approximately one woman every three minutes. An estimated 42 million American women live with heart disease, but many are unaware of the danger they face.

Heart or cardiovascular disease is any disorder that affects the heart's ability to function normally. Types of heart disease are coronary artery disease, congestive heart failure, cardiac arrhythmia, stroke, peripheral vascular disease and valvular disease.

It is important for women to know the warning signs of heart disease because these symptoms are likely to be different from those experienced by men. Women may experience common symptoms of chest pain and shortness of breath, but also have less obvious symptoms including:

• Discomfort in the back, shoulders, arms, stomach, jaw, neck or throat 
• Generalized pressure in the chest 
• Indigestion 
• Lightheaded
• Nausea and vomiting 
• Palpitations 
• Unexplained fatigue 

Once heart disease develops, it’s a lifelong condition that will gradually worsen unless lifestyle changes are made. Fortunately, women may be able to lower heart disease risk by more than 80 percent by making healthy lifestyle choices. These include:

• Exercising and maintaining a healthy weight.
• Following a healthy diet that is low in saturated fat and cholesterol, and includes a variety of fruits, vegetables and whole grains. 
• Finding ways to cope with stress.
• Managing high blood pressure.
• Knowing your family history and getting tested for diabetes.
• Lowering total cholesterol to less than 200 mg/dL.
• Not smoking and limiting alcohol.

Penn's Preventive Cardiovascular Program was designed specifically prevent the onset, recurrence and progression of heart and vascular disease. To learn more or schedule an appointment, please call 800.789.PENN (7366).

Health Care Organizational Ethics quoted in the New York Times

I'm a regular reader ot "The Ethicist" column in the Sunday New York Times. This morning's column started with a rather sordid situation:

My ex-wife is a physician. We divorced when I found out she was having an affair with one of her H.I.V.-positive patients. I feel compelled to tell the state medical licensing board and the professional societies to which she belongs about her affair. My reasons for doing so are that I feel an intense urge to retaliate her breach of trust and that she potentially exposed me to H.I.V. (fortunately, I tested negative). I also know that, as a physician myself, I should report her to protect other patients, so that she may get increased supervision at her workplace and treatment if needed. Should I report her even though my main motivation is revenge? NAME WITHHELD

After dispensing with revenge as a motive ("There’s no moral argument for ruining someone’s life just because she ruined yours"), Chuck Klosterman, the columnist, goes on to discuss doctor-patient sex. I was surprised to find a quote from "Doctor-Patient Sex: Why is it Unethical?", a 2009 post on this blog:

There is, however, a problem here. The fact that your ex-wife had an affair with someone who is H.I.V. positive is not a professional issue (and a physician would be well positioned to conduct such a relationship, as she would fully understand the risks). But the fact that the man was her patient is reason for concern. Personally, I can easily imagine situations in which a doctor could have romantic interactions with a patient and everything would be fine — but those hypothetical possibilities don’t make the practice acceptable. R.M. Cullen, a doctor in Auckland, New Zealand, has written at length about the import of a “zero-tolerance” policy when it comes to doctor-patient sexual relations. Here is the core argument, as interpreted by Jim Sabin, director of the Pilgrim Health Care Ethics Program at Harvard University: “Cullen argues — in my view correctly — that it is not necessary to prove that every instance of doctor-patient sex will be harmful . . . to establish that doctor-patient sexual relationships are unethical. The medical profession can, and should, adopt a zero-tolerance ethical stance based on a) the potential for harm to the patient with b) no offsetting potential benefits for the patient, combined with c) the inevitable harm to trust in the medical profession itself.” In other words, the potential downside is massive, the potential upside has nothing to do with medicine and the social take-away makes every other doctor look sketchy.


So does this mean you should report your ex-wife? If you agree with Cullen’s argument, you should. If you simply want to hurt her, your position is weak and immoral, but the action of reporting her itself remains defensible.

In the past five years I've written 20 posts on doctor-patient sex. These posts have had more than 25,000 page views - not much by internet standards but a lot for a blog with a wonky title and a somewhat esoteric focus. The 20 posts have received 128 comments. I have the impression that folks get to the posts via Google searches when they're concerned with the topic. I assume that was the case with Chuck Klosterman.

Public Learning about ACOs

"Culture beats strategy every time" is a truism in management consultation. The Accountable Care Organization concept is excellent strategy, but it won't get anywhere if our health system culture doesn't support it.

This morning I was happy to see a front page article in the New York Times about how Advocate Health Care is developing its ACO. The article is clear and informative. But the amateur medical anthropologist in me was struck by what the language reveals about the cultural context within which ACOs will thrive or crash and burn. In what follows, snippets from the article are in italics, followed by my editorial comments. I've highlighted key phrases - all of the emphases are mine:

On a stormy evening this spring, nurses at Dr. Gary Stuck’s family practice were on the phone with patients with heart ailments, asking them not to shovel snow. The idea was to keep them out of the hospital, and that effort — combined with dozens more like it — is starting to make a difference: across the city, doctors are providing less, but not worse, health care.

In recent years I've been careful to shovel snow slowly and not to overload the shovel. If I was one of Dr. Stuck's patients I would have appreciated a call from the nurse. But note the assumption that less care is likely to be worse. As a physician who practiced for 43 years my default view is that less is better/more is worse. Many of my colleagues think the same way. ACOs won't succeed unless we can nudge the wider public into understanding that "more" does not equal "better" and "less" is often an improvement!

For most health care providers, that would be cause for alarm. But not for Advocate Health Care, based in Oak Brook, Ill., a pioneer in an approach known as “accountable care” that offers financial incentives for doctors and hospitals to cut costs rather than funnel patients through an ever-greater volume of costly medical services. Under the agreement, hospital admissions are down 6 percent. Days spent in the hospital are down nearly 9 percent. The average length of a stay has declined, and many other measures show doctors providing less care, too.

Insofar as the kind of integrated care ACOs are designed to promote is the right way to deliver care, the changed payment structure is removing a barrier to doing the right thing, not "incentivizing" us like rats in a maze. I don't think I'm alone in finding all the talk about "incentivizing physicians" to collaborate with their patients and colleagues offputting. And if I were a naive patient I'd be suspicious of care that my doctor had to be "incentivized" to provide!

“It’s hard to imagine that you could start from scratch and do this and be successful in three years," said Dr. Lee Sacks, Advocate’s chief medical officer, noting that other systems may find it far harder to flip the traditional fee-for-services system on its head. “We had a running head-start going back to 1995.”

The organizations that joined in 1995 to create Advocate have a 100 year history of faith-based health care. As a non-Christian I found the Advocate mission inspiring. I would be proud to practice with colleagues who shared the values Advocate promulgates. I wish the article had taken the following great quote from Dr. Sacks that I found on the Advocate website:

"There is just a special feeling throughout Advocate Health Care. We regularly recognize those who exemplify our values of compassion, equality, excellence, partnership and stewardship, even though many of them would say that they were just doing their job.”

A piece of cheese at the end of a maze isn't what "incentivizes" health professionals - it's the privilege of being part of a caring profession whose values go back for millennia! The admirable clinicians Dr. Sacks is talking about would be stunned to be told that their comportment reflected economic incentives, not personal mission!

In some ways, accountable care resembles earlier efforts to control medical spending, including the health maintenance organizations that proliferated in the 1980s but fell out of favor, in part because they severely limited patients’ choices. But accountable care differs by giving doctors and hospitals a direct financial stake in saving money and a reason to invest in various programs of preventive care rather than relying exclusively on the fees they would normally earn from providing services.

This snippet tip toes towards getting the culture issue right, but it still misses the crucial point. Capitated payments facilitate investment in programs (and not just for prevention) that are not paid for in our cockeyed fee-for-service/widget-rewarding payment system. But that's not what gives doctors a "reason" to invest. The reason is that it's the right thing to do in light of a mission that even many athiest clinicians regard as "sacred."

So far, Advocate has achieved a small but significant savings of about 2 percent below projected costs, Blue Cross Blue Shield said, but it is not clear whether it can continue to make progress. Already, some Advocate hospital chiefs have expressed fears over losing revenue and warned about the threat to their financial performance. Doctors fret that their incomes may suffer. “We’re doing it because it’s the right thing to do for patients,” said Dr. Stuck, the Advocate family physician. “We’re not making more money.”

Dr. Stuck's point about doing the right thing speaks for itself!

“You’re trying to overlay a payment design onto a benefit model that allows a patient to go anywhere he wants,” said Steve Hamman of Blue Cross Blue Shield, noting that patients can undermine the advantages of the new approach if they ignore the advice or insist on unnecessary tests and procedures. “We can talk all we want about provider accountability and how important that is. But there is a measure of patient accountability that is critical as well.”

For readers who aren't familiar with the ins and outs of the ACO concept, this paragraph is referring to the fact that Medicare beneficiaries who are receiving their care from an ACO aren't "locked in" to the ACO network. If Dr. Stuck's patients want to go to the Mayo Clinic they can do so. This is likely to create clinical, economic and ethical challenges for ACOs. What if the Mayo Clinic does knee replacements better than the ACO? Do we have to refer patients "out"? What are the acceptable ways for ACOs to try to keep patients "in network"? And, most important, how do we engage patients and the public in seeing stewardship of shared resources as a societal imperative they share responsibility for?

We Yanks believe in magic bullets. That's why we have so many drugs in our medicine cabinets and drones in the sky. ACOs, alas, will not magically solve our health "system's" problems of quality and cost. The ACO is a good concept, but it won't thrive without a supportive culture. The otherwise excellent article in the New York Times shows how far we have to go to develop the culture we need!

(See here, here, and here for posts that discuss related aspects of the ACO concept.)

Should You Kill Your Disabled Child?

I've just read a remarkable book about this question: Rescuing Jeffrey, by his father, Richard Galli. I got to the book via "Calling It Quits: When Patients or Proxies Request to Withdraw or Withhold Life-Sustaining Treatment After Spinal Cord Injury," an article assigned to Harvard Medical School students for this week's class on end of life care in the required course on "Medical Ethics and Professionalism."

On July 4, 1998, Jeffrey Galli, 17 at the time, dove into the shallow end of a swimming pool and fractured his neck, injuring his spinal cord in a way that left him quadriplegic and unable to breathe without ventilator support. Richard saved his life by pulling him out of the pool and breathing through his nose. But when Jeffrey got to the Hasbro Children's Hospital in Providence, Rhode Island, and the extent of his injury became clear, Richard and his wife Toby considered whether the right thing to do would be to withdraw treatment and let Jeffrey die.

Galli renders the anguished flow of his thoughts and feelings in admirably spare prose. Not surprisingly for a 17 year old, Jeffrey had given no guidance about he would want to have done in a situation like the calamity he experienced. In his initial state of unconsciousness, and the next few days of impaired awareness, his parents had to make decisions for him. Galli initially felt that Jeffrey - a very physical boy who was not drawn to reading or other forms of "living in his mind" - would not be able to tolerate the helplessness and immobility of quadriplegia. But he recognized that he wasn't a reliable decision-maker. Perhaps he was the one who couldn't tolerate Jeffrey's condition. Galli conveys the way thinking about Jeffrey mixed with projection onto Jeffrey brilliantly. At one point he imagines pulling the plug on Jeffrey and then committing suicide himself!

When Jeffrey started to regain consciousness and began to fathom what had happened, his first reaction was "I want to die." But over the course of the ten days Galli's narrative describes Jeffrey first oscillates between wanting to die and wanting to live, gradually settling on the will to survive.

Galli provides a service to clear thinking by using harsh words to bring out harsh facts. For him the question isn't whether to "withdraw medical treatment from Jeffrey" but whether to "kill Jeffrey." In part, making that choice would have been an act of love - sparing his son from the suffering that he expected would be Jeffrey's fate. But in part the choice would have reflected his own suffering at the loss of a son with mobility. For that reason. "killing" wfelt to him like the right word.

The crucial help Galli received was from a physician whose name he does not give and who was not part of Jeffrey's ongoing treatment. The physician conveyed that the life vs. death decision didn't have to be made now. If Jeffrey decided in the future that life in a wheelchair with no use of arms or legs and no ability to breath on his own was not worth living, he could have the ventilator withdrawn. Galli concluded that letting the treatment proceed was not committing his son to a life of unwanted suffering.

The book is painful to read, but once I picked it up I couldn't put it down.

(Jeffrey completed high school and then college. For an article about him at the University of Rhode Island, see here. For a video of Jeffrey and his younger sister Sarah in 2012, 14 years after the accident, see here. And for a post I wrote about an adult patient with quadriplegia who elected to have his ventilator turned off, see here.)

Penn Fertility Care

The First Step in Getting Pregnant May Be Finding Out Why You Can't

When should you see a fertility specialist? If you've experienced the following events, it may be time for you to schedule an appointment with an infertility specialist:

• If you are under 35 and have been unable to conceive after a year of trying to get pregnant. 
• If you are over 35 and have been unable to conceive after 6 months of trying to get pregnant.
• When you've miscarried two or more times. 
• When other infertility treatments have not been successful. 

If you do not have regular menstrual cycles, or if you have had prior gynecological problems including endometriosis, pelvic surgery, tubal pregnancy or infections, you should seek assistance sooner.

Fertility evaluation diagnostic procedures at Penn Medicine can identify the causes of infertility. Sometimes, a diagnosis can be easy — just a matter of conducting a few simple tests. Other times, pinpointing the cause requires time and patience. In some cases, no cause of infertility can be found.

What to Expect at a Diagnostic Evaluation

A diagnostic evaluation often begins with a physical exam and a thorough health history. Afterward, your physician may further conduct additional testing using one or more of the following methods:

• Blood Test: A blood test will determine if there is normal ovulation physiology. Ovulation dysfunction can result from hormonal deficiencies, congenital defects, and age. 
• Assessing Ovarian Reserve: A physician evaluates the follicle stimulating hormone (FSH) level and antimullerian hormone (AMH). A blood test is performed that can determine the number/quality of eggs remaining in a woman's ovary. 
• Measuring Hormone Levels: A common cause of infertility is polycystic ovary syndrome (PCOS). This syndrome is genetically linked to hormonal imbalances thereby causing a condition that prevents ovulation.
• A hysterosalpingogram or sonohysterogram may be performed to evaluate the uterus and to determine if the fallopian tubes are open. 
• An ultrasound may be performed to evaluate the uterus and ovaries. 
• A semen analysis may be performed to evaluate the amount and quality of a man's semen and sperm. 

Penn Fertility Care works in conjunction with the Male Fertility Program and Microsurgery Section in the Division of Urology at the Hospital of the University of Pennsylvania. Penn's experts have extensive clinical experience in male infertility and have particular expertise in microsurgical reconstruction of the male reproductive tract.

Depending on the patient's condition, additional detailed tests may be performed to determine the cause of the infertility.

Learn more about infertility diagnosis and evaluation at Penn Medicine.

The 2 Cancer Screenings You Should Never Skip

The Mammogram
The mammogram remains the most important screening test in the detection of breast cancer and it likely saves thousands of lives every year.

Beginning at the age of 40, all women should have an annual mammogram to check for breast cancer. Depending on a woman’s personal risk, her physician may recommend she begin annual mammograms before the age of 40.

Schedule a Mammogram at Penn Medicine
Penn offers dedicated breast imagers with access to digital mammography, breast ultrasound and MRI. All mammograms performed at Penn are connected to a comprehensive breast cancer program at the Abramson Cancer Center, an NCI-designated comprehensive cancer center.

Also, most locations offer same-day, walk-in appointments.

Mammograms at Penn Medicine are offered at the following locations: 

• Penn Medicine Valley Forge
• Perelman Center for Advanced Medicine*
• Penn Presbyterian Medical Center
• Pennsylvania Hospital
• Penn Medicine Radnor

Schedule a mammogram at Penn Medicine
Call 1-800-789-PENN (7366) to schedule a mammogram at Penn.

The Colonoscopy
Colorectal cancer is one of the few cancers that can be prevented with screening. More than 90 percent of people diagnosed with colon cancer are age 50 or older.

Current screening recommendations in the United States include:

• Men and women over the age of 50 be screened for colorectal cancer
• Those with a personal or family history of colon polyps, cancer at an early age or certain chronic medical conditions be encouraged to be screened starting at an earlier age.

Although the incidence of colorectal cancer and cancer-related deaths is decreasing, colon cancer screening remains underutilized. Consequently, colorectal remains the third most common cancer worldwide and the second leading cause of cancer deaths.

One of the main barriers to colorectal screening is the lack of awareness of the disease. Colorectal cancer tends to not be discussed as openly as other conditions such as breast or lung cancer. Furthermore, the thought of undergoing a colonoscopy is not appealing.. This is compounded by the fact that there is a general misperception about the study.

Colonoscopy can detect early tumors, and more importantly pre-cancerous growths of tissue called polyps. Polyps can be removed at the time of the procedure, thereby preventing cancer from developing.

Colonoscopies at Penn Medicine are offered at the following locations: 

• Perelman Center for Advanced Medicine
• Penn Presbyterian Medical Center
• Pennsylvania Hospital
• Penn Medicine Radnor

Schedule a colonoscopy at Penn Medicine

Are you 50 years old or older? Make an appointment at Penn Medicine for your routine colonoscopy by calling 1-800-789-PENN (7366).

 *Digital breast tomosynthesis, a revolutionary way to perform mammograms combining traditional mammography with 3D technology, is offered at the Perelman Center for Advanced Medicien. DBT allows for more accurate pictures of breast health. Women who get their mammograms using the new DBT technology at Penn may find they are called less often for follow-up visits and more tests.Learn more about DBT at Penn, and how you can schedule your DBT mammogram at Penn.