In terms of actual New Year's Eves, this one's going to be kind of crappy. I woke up yesterday sick, and although I'm feeling better now, having slept for 16 hours, I'm still not back up to 100% yet. I have to go out and buy some champagne for our friend's party tonight, although I'm sure I won't be drinking any of it.
In other news, my hard drive died last week and I got it fixed by a random guy here in Absecon who fixed it quickly and for a very reasonable price. My data was saved, thank goodness, because it's been a while since I've backed up all my photos. The ironic part? I was going to do data backup next week at the first of the year. Oh well, all's well that ends well, right?
So 2008 was a pretty good year, I guess. No big complaints from me. In some ways, it was the last year that everything was as I've come to know it. Next year I'll be graduated, married, hopefully living on the east coast again and starting residency -- can you believe it?
Here's to hoping I can stay awake for another 12 hours to ring in the new year, that I feel better by Friday so I don't fail Step 2 CS, and that I survive two more interviews next week. Only two more -- the end is in sight! The only crappy thing that I'm aware of waiting for me in the new year is being on call my very first day back on Monday. One month of internal medicine -- my last chance to learn all the things I'm supposed to know before I become a doctor. My goal is to learn to listen to people's hearts once and for all. That's reassuring for a soon-to-be physician, isn't it?
Wednesday, December 31, 2008
Thursday, December 18, 2008
Provider "Conscience" Rule
This was announced today: Bush administration issues final provider conscience rule
I did my part and wrote to HHS to express my displeasure a couple months ago; did you?
What an obnoxious thing to do. It's a big F-you from the lame duck administration to start the new administration off with an annoying thing to try to overturn.
Oh, but Obama had better overturn this thing, or you'll hear a lot more for me.
Provider conscience, my ass. Whatever happened to the conscience of doing the right thing for your patients?!
I did my part and wrote to HHS to express my displeasure a couple months ago; did you?
What an obnoxious thing to do. It's a big F-you from the lame duck administration to start the new administration off with an annoying thing to try to overturn.
Oh, but Obama had better overturn this thing, or you'll hear a lot more for me.
Provider conscience, my ass. Whatever happened to the conscience of doing the right thing for your patients?!
Wednesday, December 10, 2008
Common sense is not so common: An illustration
We have a patient, a 40-something-year-old-guy who is kind of a drunk, kind of homeless, you get the picture. The story is, his family felt kind enough to make sure he was fed on Thanksgiving, and then his landlord (OK, I guess he's not actually homeless) felt sorry for him, gave him a $20, and dropped him off at the store.
He was found unconscious in a park over 24 hours later, surrounded by 24 beer cans, and hypothermic. Blah blah, etc, etc, now he's in the ICU. Spiking fevers every day and has altered mental status, which is why we (neurology) were consulted.
#1 on the differential is herpes encephalitis, and others include listeria, and lots of other fun stuff.
Infectious disease was also consulted for the fevers of unclear etiology and today we read their note, which included a nice tidbit about how the patient had a positive PPD test last week. And not just slightly positive, but 23 mm positive. The rest of the tuberculosis workup is now pending.
But today? The guy is still not in contact or respiratory isolation, his door is wide open to the rest of the ICU, and the respirators that prevent me from catching tuberculosis are nowhere to be found.
How likely is it that he has TB? Unclear, really, and probably low. But in a guy who can't give us his history, chronic alcoholic, found down in a park, and spiking fevers, I think his risk is a little higher than someone else's. But no isolation precautions in sight until a true cause is found.
Wonderful.
I go off service tomorrow and my next PPD isn't due until the spring. It had better be negative or we'll know why it isn't.
(This evening I've been doing a lot of coughing, just for the record.)
He was found unconscious in a park over 24 hours later, surrounded by 24 beer cans, and hypothermic. Blah blah, etc, etc, now he's in the ICU. Spiking fevers every day and has altered mental status, which is why we (neurology) were consulted.
#1 on the differential is herpes encephalitis, and others include listeria, and lots of other fun stuff.
Infectious disease was also consulted for the fevers of unclear etiology and today we read their note, which included a nice tidbit about how the patient had a positive PPD test last week. And not just slightly positive, but 23 mm positive. The rest of the tuberculosis workup is now pending.
But today? The guy is still not in contact or respiratory isolation, his door is wide open to the rest of the ICU, and the respirators that prevent me from catching tuberculosis are nowhere to be found.
How likely is it that he has TB? Unclear, really, and probably low. But in a guy who can't give us his history, chronic alcoholic, found down in a park, and spiking fevers, I think his risk is a little higher than someone else's. But no isolation precautions in sight until a true cause is found.
Wonderful.
I go off service tomorrow and my next PPD isn't due until the spring. It had better be negative or we'll know why it isn't.
(This evening I've been doing a lot of coughing, just for the record.)
Health News, Round 1: Reproductive Health
I subscribe to a bunch of RSS feeds for medical, health, and science news, so I thought I'd take this opportunity to share with you a batch of articles dealing with reproductive health.
Treatment: Flu vaccine for pregnant women is 2 for 1, Nicholas Bakalar, NY Times, Oct. 6
Flu season is here! Everyone should get their flu shot! (More will be discussed about this in a later post.)
Diabetes is a risk in pregnancy that carries risks beyond, Jane E. Brody, NY Times, Oct. 27
Can't stress this fact enough: glycemic control is very, very important, for everyone. I have a burning desire to get my own hemoglobin A1C checked, just for curiosity's sake, even though I know I have never had an abnormally high fasting blood glucose. I have a suspicion our thresholds for diabetes is going to be lowered for everyone -- pregnant or not -- in the coming years.
Pre-birth defects, William Saletan, Slate.com, Oct. 29
First-trimester screening is one thing, and we already have to counsel women who are unsure about whether to get it. We generally say, if you would continue with the pregnancy even if you had a positive (meaning bad) test result, and you're unsure whether to get the tests, then you don't need to. If the result of the test would influence your decision, then get the tests. Now, we are about to have all of this genetic data that we don't know what to do with. I'd rather get my own genomic analysis first before I get my fetus's done. I do love the irony of pro-life groups pushing for ultrasound laws on the one hand and railing against genetic testing on the other, though.
Our vote to end cervical cancer, by Lance Armstrong and John Seffrin, Washington Post, Oct. 30
The GAVI vote has been postponed until the spring, but still, I support all efforts to increase HPV vaccination both in the United States and around the world.
Risks: Extra pregnancy weight tied to big baby, Nicholas Bakalar, NY Times, Nov. 3
Gaining the right amount of weight during pregnancy is very important, but can be tricky. And if you think it's dangerous for a man to pause a second to long when asked, "Does this make me look fat?" just try telling a pregnant, super-hormonal woman that she's gained too much weight. Think talking about risks to the baby will help convince her? You haven't met all the women I have who smoke, drink, and use cocaine while they're pregnant. Of course, the cocaine users aren't generally gaining too much weight...
Having a baby: Depression linked to premature deliveries, Nicholas Bakalar, NY Times, Nov. 3
This is interesting. We know a lot about postpartum depression and its effects on maternal and infant health and maternal-infant bonding, but I haven't seen any prospective studies linking intrapartum depression to poor outcomes. I will say, though, that two of the three reported results in the study were not statistically significant, so I will remain skeptical of the study's outcomes (of course, there's no harm in screening for and treating intrapartum depression, so that's a moot point when it comes to individual physician practice).
Pregnancy..., Tamoeh Murakami Tse, Washington Post, Nov. 4
Ugh, vomiting. Even worse? Morning sickness. Even more worse? Hyperemesis gravidarum.
The Checkup, Washington Post, Nov. 11. This article has a few news briefs. Among them:
Caffeine, your baby, and you. In this brief, the results of a BMJ study are reviewed. The conclusion was that increased caffeine consumption during pregnancy was associated with higher rates of fetal growth restriction. I take issue with a couple of the statistical conclusions, but overall, this basically says that pregnant women should limit their caffeine intake to less than 100 mg/day, which is roughly one cup of coffee per day.
Improving a woman's love life. I think we knew this already, but another study has shown that a woman can experience an increased libido and sexual pleasure if she takes testosterone. Not too much, though, now!
HPV vaccine may prevent genital warts in males, AP, published in NY Times, Nov. 13
This isn't surprising news. This is why Merck included the warts strains in its vaccines, unlike GlaxoSmithKline. I had no doubts the studies would prove successful in men. By the way, the plural of "man" that should be used in this headline is "men," not "males." "Male" is an adjective, not a noun. The AP would be scolded by the UofL surgery department, which refers to its patients not just as "men" and "women," but as "gentlemen" and "ladies." Old-school style. Anyway, there's no reason not to vaccinate boys for HPV, too. Just like rubella -- boys can get rubella all they want with no problems, but we vaccinate them to protect the girls and their fetuses. With HPV, the boys actually get their own benefit -- preventing genital warts (which, yes, may be benign, but trust me, you still don't want them even if they aren't cancer) -- and the girls will get a double benefit -- preventing cervical cancer and genital warts.
Children of the clones, William Saletan, Slate.com, Nov. 20
This is just wacky. And cool. But still wacky. I'm definitely in that group of women who "want to get the degree, save a little money and buy the nice flat" before getting pregnant, plus I have that pesky medical residency to complete, so maybe I'll set my ovaries aside for a few years and get them reimplanted into me. By the way, the biggest irony of becoming an Ob/Gyn? It takes you so long to become one and it's so not ideal to have a baby during residency that you end up having to see one of your colleagues to get pregnant when it finally is time.
Foes of stem cell research now face tough battle, Kevin Frekking, Nov. 23, originally seen in Washington Post but now found via Google
I absolutely think stem cell research is important, and the current bans are ridiculous. One thing I found very interesting was that when I interviewd at UMDNJ-Robert Wood Johnson, they told us the Ob/Gyn department was in the process of starting up a stem cell research lab. I realized they're able to do that because New Jersey has approved funding of such research and is promoting it. (The department also had a division of epidemiology, which was pretty cool.) It's a good place to do research!
A hard choice, Patricia Meisol, Washington Post, Nov. 23
I linked to this article before, but it belongs here by subject matter, so here you go again. This was a really good article about the factors that go into deciding to be an abortion provider. To be honest, I think there are other points of view that are important too, like that of an Ob/Gyn resident. Do you opt out of termination training? Do you figure that out before you apply to residency, or do you just try to go to the best program and deal with it later? They're interesting questions.
Lose-lose on abortion: Obama's threat to Catholic hospitals and their very serious counterthreat, Melinda Henneberger, Slate.com, Nov. 24
This is interesting. My feelings on healthcare practitioners who have moral reasons for not participating in certain procedures or activities are as follows: That's fine, but you still have to take care of the patient. An ER physician I used to work with was Catholic and didn't believe in birth control. He sighed and moaned as he and his wife had son after son after son, and when a patient asked for birth control pills, he simply asked a colleague to write the prescription for him. No lectures, no outright refusals, just doing his job in a way that he could agree with and that didn't affect patient care. I worked with a nurse anesthetist in Whitesburg this spring who "didn't believe in tubal ligation," so he refused to anesthetize patients for them. The hospital was able to accommodate him and find another person to staff those cases. What would have happened if he were the only one and there was no one else? I'm not sure. Did he make his feelings known when he interviewed for the job? I'm not sure. It could definitely be a problem. Pharmacists refusing to fill Plan B prescriptions themselves? Sure. Refusing to then return the prescription to the patient and refusing to refer them to another pharmacy? Big problem. The guy in my class who fully intends to practice primary care medicine in the middle of the state AND who refuses to assist a woman in any way with finding an abortion practictioner? Big problem. Don't want to deal with reproductive health issues? Go into orthopedic surgery, not family medicine. As I'm interviewing for residencies, I and the other applicants question the Catholic hospitals a lot. I didn't even bother with Georgetown because of it, and I grilled University of Maryland (which has an affiliation with Mercy in Baltimore) about how my training and medical practice might be affected. I'm not even talking about going so far as pregnancy termination; I strongly believe that birth control pills, IUDs, and tubal ligation are perfectly normal and every patient should have a right to receive them if they want. Close the Catholic hospitals? Yes, it would make things easier for pregnancy prevention options. But they serve a lot of other patients, too, I can't deny that. I'm happy enough with the odd relationship that exists right now; just please don't screw it up in either way.
Couple's Wish: A better heart for baby, Part 1 and Part 2, John Kelly, Washington Post, Nov. 26 and Nov. 27
This is more about the baby, but even as a future Ob/Gyn, I think that's important. One of the things I like about obstetrics is the interface between prenatal and natal care, the chance to work with neonatologists, pediatricians, and pediatric surgeons. Everyone's working together to make sure the baby that is brought into the world is as healthy as possible. It's a nice feeling.
Having a baby: Exercise may reduce need for an epidural, Nicholas Bakalar, NY Times, Dec. 1
I have to start by emphasizing that there is absolutely nothing wrong with getting an epidural during labor. Epidurals come in very small doses and can be adjusted throughout labor. If you're otherwise healthy, you can walk with an epidural, and you can feel every one of your contractions and can definitely still push adequately. If you tear, then guess what -- you're already numb for the repair! Some of the worst tears I've seen are in women who choose natural childbirth and who simply aren't prepared for it, so they can't handle the pain and bust the baby out through their perineum, destroying everything in the way in the process. And then they jump through the roof when you have to numb them with local anesthesia to sew them up. Not pleasant. But if you're really motivated and mentally prepared, natural childbirth can be a great thing, too. I won't advocate either way. But this is pretty cool, if regular exercise can help a woman manage her labor better. Plus, it's good all around for her and the baby.
Parents torn over fate of frozen embryos, Denise Grady, NY Times, Dec. 4
This is another area of medicine I think could be improved upon. We create new technologies that are great, but don't put enough thought into the emotional implications ahead of time. I like the idea of giving embryos back to couples if they want them; I also don't care if a mother wants to keep her placenta if she wants to. I might think she doesn't know what she's asking for, but yeah, I'll give it to her, and help her fight the hospital if that's what it takes (there was a news story about that a while back). I'm pretty sure I know what I would do if I were in this situation, but I absolutely understand how tough a decision it must be.
Nursing grudges: Why do we protect the moral convictions of only some health care workers?, Dahlia Lithwick, Slate.com, Dec. 6
You already know how I feel about this. I refuse to give my patients false information, plain and simple, so the South Dakota law is absolutely ridiculous. And Bush/HHS's new proposed regulation? Completely and utterly ridiculous and aggravating. I can't think about it too much or I'll get really, really pissed off.
The Checkup, Washington Post, Dec. 9. Two news briefs this time.
Abortion's impact. It turns out that the best designed studies of abortion's emotional impact tend to find neutral results, while those with poor study design find abortion to have a negative emotional impact. Frankly, I'm not surprised. Study design is very, very important and can seriously affect study conclusions. (The second news brief is about physicians choosing not to stock or provide vaccines, and I'll touch on that in another post.)
Motherhood at 70: Meet the world's newest oldest mom, William Saletan, Slate.com, Dec. 9
Congratulations, technology, and I guess, to the new parents. You won't find me inseminating any 70-year-olds just because I can, though.
So there you go, an installment of health news. Hope you found it interesting; I definitely enjoyed sharing!
Treatment: Flu vaccine for pregnant women is 2 for 1, Nicholas Bakalar, NY Times, Oct. 6
Flu season is here! Everyone should get their flu shot! (More will be discussed about this in a later post.)
Diabetes is a risk in pregnancy that carries risks beyond, Jane E. Brody, NY Times, Oct. 27
Can't stress this fact enough: glycemic control is very, very important, for everyone. I have a burning desire to get my own hemoglobin A1C checked, just for curiosity's sake, even though I know I have never had an abnormally high fasting blood glucose. I have a suspicion our thresholds for diabetes is going to be lowered for everyone -- pregnant or not -- in the coming years.
Pre-birth defects, William Saletan, Slate.com, Oct. 29
First-trimester screening is one thing, and we already have to counsel women who are unsure about whether to get it. We generally say, if you would continue with the pregnancy even if you had a positive (meaning bad) test result, and you're unsure whether to get the tests, then you don't need to. If the result of the test would influence your decision, then get the tests. Now, we are about to have all of this genetic data that we don't know what to do with. I'd rather get my own genomic analysis first before I get my fetus's done. I do love the irony of pro-life groups pushing for ultrasound laws on the one hand and railing against genetic testing on the other, though.
Our vote to end cervical cancer, by Lance Armstrong and John Seffrin, Washington Post, Oct. 30
The GAVI vote has been postponed until the spring, but still, I support all efforts to increase HPV vaccination both in the United States and around the world.
Risks: Extra pregnancy weight tied to big baby, Nicholas Bakalar, NY Times, Nov. 3
Gaining the right amount of weight during pregnancy is very important, but can be tricky. And if you think it's dangerous for a man to pause a second to long when asked, "Does this make me look fat?" just try telling a pregnant, super-hormonal woman that she's gained too much weight. Think talking about risks to the baby will help convince her? You haven't met all the women I have who smoke, drink, and use cocaine while they're pregnant. Of course, the cocaine users aren't generally gaining too much weight...
Having a baby: Depression linked to premature deliveries, Nicholas Bakalar, NY Times, Nov. 3
This is interesting. We know a lot about postpartum depression and its effects on maternal and infant health and maternal-infant bonding, but I haven't seen any prospective studies linking intrapartum depression to poor outcomes. I will say, though, that two of the three reported results in the study were not statistically significant, so I will remain skeptical of the study's outcomes (of course, there's no harm in screening for and treating intrapartum depression, so that's a moot point when it comes to individual physician practice).
Pregnancy..., Tamoeh Murakami Tse, Washington Post, Nov. 4
Ugh, vomiting. Even worse? Morning sickness. Even more worse? Hyperemesis gravidarum.
The Checkup, Washington Post, Nov. 11. This article has a few news briefs. Among them:
Caffeine, your baby, and you. In this brief, the results of a BMJ study are reviewed. The conclusion was that increased caffeine consumption during pregnancy was associated with higher rates of fetal growth restriction. I take issue with a couple of the statistical conclusions, but overall, this basically says that pregnant women should limit their caffeine intake to less than 100 mg/day, which is roughly one cup of coffee per day.
Improving a woman's love life. I think we knew this already, but another study has shown that a woman can experience an increased libido and sexual pleasure if she takes testosterone. Not too much, though, now!
HPV vaccine may prevent genital warts in males, AP, published in NY Times, Nov. 13
This isn't surprising news. This is why Merck included the warts strains in its vaccines, unlike GlaxoSmithKline. I had no doubts the studies would prove successful in men. By the way, the plural of "man" that should be used in this headline is "men," not "males." "Male" is an adjective, not a noun. The AP would be scolded by the UofL surgery department, which refers to its patients not just as "men" and "women," but as "gentlemen" and "ladies." Old-school style. Anyway, there's no reason not to vaccinate boys for HPV, too. Just like rubella -- boys can get rubella all they want with no problems, but we vaccinate them to protect the girls and their fetuses. With HPV, the boys actually get their own benefit -- preventing genital warts (which, yes, may be benign, but trust me, you still don't want them even if they aren't cancer) -- and the girls will get a double benefit -- preventing cervical cancer and genital warts.
Children of the clones, William Saletan, Slate.com, Nov. 20
This is just wacky. And cool. But still wacky. I'm definitely in that group of women who "want to get the degree, save a little money and buy the nice flat" before getting pregnant, plus I have that pesky medical residency to complete, so maybe I'll set my ovaries aside for a few years and get them reimplanted into me. By the way, the biggest irony of becoming an Ob/Gyn? It takes you so long to become one and it's so not ideal to have a baby during residency that you end up having to see one of your colleagues to get pregnant when it finally is time.
Foes of stem cell research now face tough battle, Kevin Frekking, Nov. 23, originally seen in Washington Post but now found via Google
I absolutely think stem cell research is important, and the current bans are ridiculous. One thing I found very interesting was that when I interviewd at UMDNJ-Robert Wood Johnson, they told us the Ob/Gyn department was in the process of starting up a stem cell research lab. I realized they're able to do that because New Jersey has approved funding of such research and is promoting it. (The department also had a division of epidemiology, which was pretty cool.) It's a good place to do research!
A hard choice, Patricia Meisol, Washington Post, Nov. 23
I linked to this article before, but it belongs here by subject matter, so here you go again. This was a really good article about the factors that go into deciding to be an abortion provider. To be honest, I think there are other points of view that are important too, like that of an Ob/Gyn resident. Do you opt out of termination training? Do you figure that out before you apply to residency, or do you just try to go to the best program and deal with it later? They're interesting questions.
Lose-lose on abortion: Obama's threat to Catholic hospitals and their very serious counterthreat, Melinda Henneberger, Slate.com, Nov. 24
This is interesting. My feelings on healthcare practitioners who have moral reasons for not participating in certain procedures or activities are as follows: That's fine, but you still have to take care of the patient. An ER physician I used to work with was Catholic and didn't believe in birth control. He sighed and moaned as he and his wife had son after son after son, and when a patient asked for birth control pills, he simply asked a colleague to write the prescription for him. No lectures, no outright refusals, just doing his job in a way that he could agree with and that didn't affect patient care. I worked with a nurse anesthetist in Whitesburg this spring who "didn't believe in tubal ligation," so he refused to anesthetize patients for them. The hospital was able to accommodate him and find another person to staff those cases. What would have happened if he were the only one and there was no one else? I'm not sure. Did he make his feelings known when he interviewed for the job? I'm not sure. It could definitely be a problem. Pharmacists refusing to fill Plan B prescriptions themselves? Sure. Refusing to then return the prescription to the patient and refusing to refer them to another pharmacy? Big problem. The guy in my class who fully intends to practice primary care medicine in the middle of the state AND who refuses to assist a woman in any way with finding an abortion practictioner? Big problem. Don't want to deal with reproductive health issues? Go into orthopedic surgery, not family medicine. As I'm interviewing for residencies, I and the other applicants question the Catholic hospitals a lot. I didn't even bother with Georgetown because of it, and I grilled University of Maryland (which has an affiliation with Mercy in Baltimore) about how my training and medical practice might be affected. I'm not even talking about going so far as pregnancy termination; I strongly believe that birth control pills, IUDs, and tubal ligation are perfectly normal and every patient should have a right to receive them if they want. Close the Catholic hospitals? Yes, it would make things easier for pregnancy prevention options. But they serve a lot of other patients, too, I can't deny that. I'm happy enough with the odd relationship that exists right now; just please don't screw it up in either way.
Couple's Wish: A better heart for baby, Part 1 and Part 2, John Kelly, Washington Post, Nov. 26 and Nov. 27
This is more about the baby, but even as a future Ob/Gyn, I think that's important. One of the things I like about obstetrics is the interface between prenatal and natal care, the chance to work with neonatologists, pediatricians, and pediatric surgeons. Everyone's working together to make sure the baby that is brought into the world is as healthy as possible. It's a nice feeling.
Having a baby: Exercise may reduce need for an epidural, Nicholas Bakalar, NY Times, Dec. 1
I have to start by emphasizing that there is absolutely nothing wrong with getting an epidural during labor. Epidurals come in very small doses and can be adjusted throughout labor. If you're otherwise healthy, you can walk with an epidural, and you can feel every one of your contractions and can definitely still push adequately. If you tear, then guess what -- you're already numb for the repair! Some of the worst tears I've seen are in women who choose natural childbirth and who simply aren't prepared for it, so they can't handle the pain and bust the baby out through their perineum, destroying everything in the way in the process. And then they jump through the roof when you have to numb them with local anesthesia to sew them up. Not pleasant. But if you're really motivated and mentally prepared, natural childbirth can be a great thing, too. I won't advocate either way. But this is pretty cool, if regular exercise can help a woman manage her labor better. Plus, it's good all around for her and the baby.
Parents torn over fate of frozen embryos, Denise Grady, NY Times, Dec. 4
This is another area of medicine I think could be improved upon. We create new technologies that are great, but don't put enough thought into the emotional implications ahead of time. I like the idea of giving embryos back to couples if they want them; I also don't care if a mother wants to keep her placenta if she wants to. I might think she doesn't know what she's asking for, but yeah, I'll give it to her, and help her fight the hospital if that's what it takes (there was a news story about that a while back). I'm pretty sure I know what I would do if I were in this situation, but I absolutely understand how tough a decision it must be.
Nursing grudges: Why do we protect the moral convictions of only some health care workers?, Dahlia Lithwick, Slate.com, Dec. 6
You already know how I feel about this. I refuse to give my patients false information, plain and simple, so the South Dakota law is absolutely ridiculous. And Bush/HHS's new proposed regulation? Completely and utterly ridiculous and aggravating. I can't think about it too much or I'll get really, really pissed off.
The Checkup, Washington Post, Dec. 9. Two news briefs this time.
Abortion's impact. It turns out that the best designed studies of abortion's emotional impact tend to find neutral results, while those with poor study design find abortion to have a negative emotional impact. Frankly, I'm not surprised. Study design is very, very important and can seriously affect study conclusions. (The second news brief is about physicians choosing not to stock or provide vaccines, and I'll touch on that in another post.)
Motherhood at 70: Meet the world's newest oldest mom, William Saletan, Slate.com, Dec. 9
Congratulations, technology, and I guess, to the new parents. You won't find me inseminating any 70-year-olds just because I can, though.
So there you go, an installment of health news. Hope you found it interesting; I definitely enjoyed sharing!
Monday, December 08, 2008
Sleep -- a tricky subject
If you know anything about medical residencies, you probably know one thing: Residents work a lot. A LOT.
The current duty hour regulations, which went into effect in 2003, changed residency training from a cowboy operation of working as many hours as you could, and being proud of it, to a series of mandates regarding how long a resident could be at work. If programs are following the rules (and many, including surgery and Ob/Gyn programs, don't), here is what residents are doing:
Working no more than 80 hours per week, averaged over 4 weeks
Working no more than 30 hours in a row, plus an allowance of 6 additional hours for didactic/educational activities (like lectures)
Having 10 hours off between shifts
Getting one day (a 24-hour period) off per week, averaged over 4 weeks
Taking overnight call no more than every three days, on average
These regulations were created to address the issue of patient safety, which can be compromised when residents are fatigued, and at the critical time known as "handoffs," which is when one team hands over care to another care at the start of a new day or shift, according to studies. To accommodate these regulations, many residency programs adopted what is known as a "night float" system. It works a little differently in different specialties, but here is what the Ob/Gyn model I am most familiar with consists of:
As a resident, you are on one of a few services: labor and delivery, GYN oncology, benign GYN surgery, continuity clinic, or reproductive endocrinology/infertility. All except the first two are outpatient rotations, meaning they're mostly office-based or otherwise don't need coverage in the middle of the night by an in-hospital person. Labor and delivery, on the other hand, needs staffing 24/7. So one set of residents (generally one person from each training year) makes up the day team, working 7a-5p Monday-Friday, and another set of residents makes up the night team, working 5p-7a Sunday night through Thursday night. Then both of those sets of residents are off for the weekend and the residents on the other services take call for the weekend -- one team will finish their Friday work then stay Friday night until Saturday morning, have Saturday off, and work Sunday during the day again. Another set of residents will have Friday night off but take 24-hour call from Saturday morning to Sunday morning. Because of the number of residents in the program, you rotate through the call schedule and generally have 1 full weekend off per month. You switch services after a month, so you would do a whole month of night float (or day shift) at a time.
This past week, as many major newspapers reported, the Institute of Medicine published a report about resident duty hours and fatigue, and created a new set of suggested guidelines for duty hours.
Panel calls for changes in doctor training, NY Times, 12/2
Expert panel seeks changes in training of medical residents, NY Times, 12/2
Medical residents must sleep after 16 hours, experts urge, Washington Post, 12/3
Does more sleep make for better doctors?, NY Times, 12/4
The Catch-22 of catching z's, ACP Internist (the American College of internists) blog, 12/5
Here is the full IoM report, and here is a table summarizing the recommended changes. There will still be an 80-hour cap, but after working for 16 hours there will be a mandatory 5-hour nap period. The averaging rule will be removed for call frequency and time off frequency (call no more than every three nights, period, and a true one day off per week), and you will need 12 hours off after a night shift instead of 10. These recommendations were made based on more studies of fatigue and safety.
Initially, this sounds great. Less work, more sleep.
But there's another stipulation: Whereas before there were no rules about the number of nights you could work in a row, now there is. After working 4 nights in a row, you would now have to have 48 hours off. That sort of throws a wrench in the whole night float system.
Say you work night float Sunday night to Wednesday night, meaning you're done at, say, 7 am on Thursday morning. Now you have to take 48 hours off, which puts you at 7 am Saturday morning. I highly, highly doubt any program would have you take off an additional 10 hours until Saturday evening to do nights again (for a total of 58 hours off), which means when you get back to work Saturday morning, you're now on a daytime schedule. And in the meantime, there had to be another team to cover nights since Thursday night.
Asking around, it seems one of the only logical things to do is to have two night float teams, because that's the only way to cover 7 nights in a week. This will be a problem for many Ob/Gyn programs, because they don't take a ton of residents per year, so your available manpower is very tightly controlled. The bigger problem? That means I will go from doing 4 nights in a row to going back to a daytime schedule. The only thing that makes night float manageable is the fact that after a few days, your body gets completely used to being up at night and asleep during the day, and you do it for a month straight. Now, switching around every few days will screw your sleep cycle up tremendously. Plus, on a true call service, being required to stop working after 16 hours means you will have to have even more patient handoffs, which in itself is one of the risk factors for medical errors being made.
The AMA has already applauded the new recommendations, which means it is carrying a lot of weight and could realistically be put into effect in the near future. From a system standpoint, it definitely sounds great to let residents get more sleep. I did a month of night float this year, and with exactly 10 hours off after my shift, all I had time to do was go home, take a shower, and sleep. I didn't go grocery shopping or anything social for a month. But I was wide awake every night. During call services, it can definitely be hard to work for 30 hours straight, and I, as a student, usually get to get at least a few hours of sleep. There's no doubt sleep is good.
But if getting sleep means increasing the number of patient handoffs, I'm not sure the tradeoff is sound. If I'm tired, I still know, when asked by a nurse at 3 am, what that patient's story is and can address the nurse's concerns. If I hand off my patient to another resident, I do so with just a short written paragraph summary of the patient, his/her diagnosis, history, and issues, and maybe a 2-3 minute verbal summary of the same, and the covering resident almost invariably doesn't know as many details about my patient as I do, which means she might give the nurse the wrong order when she calls.
To have enough residents to fund two night float teams, plus cover everything else that needs to be covered, we're going to need more residents. I'm fine with that; there's already a predicted physician shortage, so medical schools are increasing their class size, and it only makes sense that residency spots should increase as well. But guess who pays for more residents: You. I'm going to be paid by the federal government, through the Medicaid system. So do you want to pay for more residents? When you can't even pay for your own medical care and might be on the brink of going on Medicaid yourself, given the economic situation we're in? Well, thank you if you do, but I can't imagine the government is going to be able to come up with the estimated $1.7 billion needed to make this happen any time soon, and I'm applying for residency NOW. With the current number of residents per year.
I worry about these regulations from a personal standpoint, too. Doing four nights in a row, then switching to a daytime schedule, would suck for my circadian rhythm and make working during the day all that much harder, I'm sure. Plus, there is a LOT I need to learn in my four years of residency, and even under the current duty hour regulations there are a lot of rumblings that residents can't learn all the Ob/Gyn they need to in four years. It takes time and a lot of practice to be a good surgeon, and being a good surgeon is a very important part of Ob/Gyn. Unfortunately (from a training standpoint), because we are doing fewer and fewer hysterectomies (because we can treat those problems medically first), there are already limited opportunities to practice before graduating, and if more of those opportunities are lost by being at home, well, that's going to be a problem. I'm not saying I want to be operating after being awake for 25 hours, but at some point, if duty hours on a weekly basis are limited, then the only logical thing will be to extend the number of years required in a training program. Working 80 hours a week and being fatigued for 4 years is going to suck; I really don't want someone to make me do five. Really.
The absolute most annoying part about all of this? It's happening now, while I'm applying to residency. That means that all the programs I've already interviewed at, they may have given me a schedule that's completely different than what they will have to effect on July 1. And I'm sure they can't give me any concrete answers about what they might or might not do. If I were already in residency, I would be able to give feedback to my program to help enact the new regulations in a way that made sense. If I were one year later in my training, I would apply next year when the programs had their new schedules in place and I could evaluate them objectively. Now, everything's a mess.
So I'm not sure if it's really that good a plan. A few more hours of sleep on a regular basis when there is a real risk it might still cause medical errors, at the risk of extending my training by another year? I'm really not trying to sound like one of those old, uphill-both-ways physicians, because I really hate when they bitch and moan about how poor my training is going to be now that I "work so little" compared to what they did. I'm pretty sure I'm being pretty damn selfish in not wanting a 5-year residency. What to do?
Me, I'm going to write a letter to my lawmakers after finals are over. You should, too.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
More posts to come soon. I still have stories from pediatric surgery to share, and plus I have fun ones from neurology now, too. I have a post percolating in my brain with my tips for airline travel with carry-on luggage. I have to tell you about how all of my residency interviews have been going, and I promise I will post my recommendations for treating common colds and bugs with over-the-counter medicines effectively (only 1 year late!). I of course also have plenty of other commentary on the medical news to share, also. In the meantime, I have to unpack from my most recent interview trip, repack for winter break, do a ton of laundry, clean up the apartment in preparation for being gone for three weeks (!), and, oh yeah, learn all of neurology. By Thursday.
One article I'll share with you now, though: A great piece from the Washington Post a couple weeks ago, a huge feature about what a medical student goes through to decide if she wants to become an abortion provider. They're many of the same issues I've dealt with, and it was interesting to have someone put my thoughts down on paper for me like that without even realizing it. A Hard Choice.
The current duty hour regulations, which went into effect in 2003, changed residency training from a cowboy operation of working as many hours as you could, and being proud of it, to a series of mandates regarding how long a resident could be at work. If programs are following the rules (and many, including surgery and Ob/Gyn programs, don't), here is what residents are doing:
Working no more than 80 hours per week, averaged over 4 weeks
Working no more than 30 hours in a row, plus an allowance of 6 additional hours for didactic/educational activities (like lectures)
Having 10 hours off between shifts
Getting one day (a 24-hour period) off per week, averaged over 4 weeks
Taking overnight call no more than every three days, on average
These regulations were created to address the issue of patient safety, which can be compromised when residents are fatigued, and at the critical time known as "handoffs," which is when one team hands over care to another care at the start of a new day or shift, according to studies. To accommodate these regulations, many residency programs adopted what is known as a "night float" system. It works a little differently in different specialties, but here is what the Ob/Gyn model I am most familiar with consists of:
As a resident, you are on one of a few services: labor and delivery, GYN oncology, benign GYN surgery, continuity clinic, or reproductive endocrinology/infertility. All except the first two are outpatient rotations, meaning they're mostly office-based or otherwise don't need coverage in the middle of the night by an in-hospital person. Labor and delivery, on the other hand, needs staffing 24/7. So one set of residents (generally one person from each training year) makes up the day team, working 7a-5p Monday-Friday, and another set of residents makes up the night team, working 5p-7a Sunday night through Thursday night. Then both of those sets of residents are off for the weekend and the residents on the other services take call for the weekend -- one team will finish their Friday work then stay Friday night until Saturday morning, have Saturday off, and work Sunday during the day again. Another set of residents will have Friday night off but take 24-hour call from Saturday morning to Sunday morning. Because of the number of residents in the program, you rotate through the call schedule and generally have 1 full weekend off per month. You switch services after a month, so you would do a whole month of night float (or day shift) at a time.
This past week, as many major newspapers reported, the Institute of Medicine published a report about resident duty hours and fatigue, and created a new set of suggested guidelines for duty hours.
Panel calls for changes in doctor training, NY Times, 12/2
Expert panel seeks changes in training of medical residents, NY Times, 12/2
Medical residents must sleep after 16 hours, experts urge, Washington Post, 12/3
Does more sleep make for better doctors?, NY Times, 12/4
The Catch-22 of catching z's, ACP Internist (the American College of internists) blog, 12/5
Here is the full IoM report, and here is a table summarizing the recommended changes. There will still be an 80-hour cap, but after working for 16 hours there will be a mandatory 5-hour nap period. The averaging rule will be removed for call frequency and time off frequency (call no more than every three nights, period, and a true one day off per week), and you will need 12 hours off after a night shift instead of 10. These recommendations were made based on more studies of fatigue and safety.
Initially, this sounds great. Less work, more sleep.
But there's another stipulation: Whereas before there were no rules about the number of nights you could work in a row, now there is. After working 4 nights in a row, you would now have to have 48 hours off. That sort of throws a wrench in the whole night float system.
Say you work night float Sunday night to Wednesday night, meaning you're done at, say, 7 am on Thursday morning. Now you have to take 48 hours off, which puts you at 7 am Saturday morning. I highly, highly doubt any program would have you take off an additional 10 hours until Saturday evening to do nights again (for a total of 58 hours off), which means when you get back to work Saturday morning, you're now on a daytime schedule. And in the meantime, there had to be another team to cover nights since Thursday night.
Asking around, it seems one of the only logical things to do is to have two night float teams, because that's the only way to cover 7 nights in a week. This will be a problem for many Ob/Gyn programs, because they don't take a ton of residents per year, so your available manpower is very tightly controlled. The bigger problem? That means I will go from doing 4 nights in a row to going back to a daytime schedule. The only thing that makes night float manageable is the fact that after a few days, your body gets completely used to being up at night and asleep during the day, and you do it for a month straight. Now, switching around every few days will screw your sleep cycle up tremendously. Plus, on a true call service, being required to stop working after 16 hours means you will have to have even more patient handoffs, which in itself is one of the risk factors for medical errors being made.
The AMA has already applauded the new recommendations, which means it is carrying a lot of weight and could realistically be put into effect in the near future. From a system standpoint, it definitely sounds great to let residents get more sleep. I did a month of night float this year, and with exactly 10 hours off after my shift, all I had time to do was go home, take a shower, and sleep. I didn't go grocery shopping or anything social for a month. But I was wide awake every night. During call services, it can definitely be hard to work for 30 hours straight, and I, as a student, usually get to get at least a few hours of sleep. There's no doubt sleep is good.
But if getting sleep means increasing the number of patient handoffs, I'm not sure the tradeoff is sound. If I'm tired, I still know, when asked by a nurse at 3 am, what that patient's story is and can address the nurse's concerns. If I hand off my patient to another resident, I do so with just a short written paragraph summary of the patient, his/her diagnosis, history, and issues, and maybe a 2-3 minute verbal summary of the same, and the covering resident almost invariably doesn't know as many details about my patient as I do, which means she might give the nurse the wrong order when she calls.
To have enough residents to fund two night float teams, plus cover everything else that needs to be covered, we're going to need more residents. I'm fine with that; there's already a predicted physician shortage, so medical schools are increasing their class size, and it only makes sense that residency spots should increase as well. But guess who pays for more residents: You. I'm going to be paid by the federal government, through the Medicaid system. So do you want to pay for more residents? When you can't even pay for your own medical care and might be on the brink of going on Medicaid yourself, given the economic situation we're in? Well, thank you if you do, but I can't imagine the government is going to be able to come up with the estimated $1.7 billion needed to make this happen any time soon, and I'm applying for residency NOW. With the current number of residents per year.
I worry about these regulations from a personal standpoint, too. Doing four nights in a row, then switching to a daytime schedule, would suck for my circadian rhythm and make working during the day all that much harder, I'm sure. Plus, there is a LOT I need to learn in my four years of residency, and even under the current duty hour regulations there are a lot of rumblings that residents can't learn all the Ob/Gyn they need to in four years. It takes time and a lot of practice to be a good surgeon, and being a good surgeon is a very important part of Ob/Gyn. Unfortunately (from a training standpoint), because we are doing fewer and fewer hysterectomies (because we can treat those problems medically first), there are already limited opportunities to practice before graduating, and if more of those opportunities are lost by being at home, well, that's going to be a problem. I'm not saying I want to be operating after being awake for 25 hours, but at some point, if duty hours on a weekly basis are limited, then the only logical thing will be to extend the number of years required in a training program. Working 80 hours a week and being fatigued for 4 years is going to suck; I really don't want someone to make me do five. Really.
The absolute most annoying part about all of this? It's happening now, while I'm applying to residency. That means that all the programs I've already interviewed at, they may have given me a schedule that's completely different than what they will have to effect on July 1. And I'm sure they can't give me any concrete answers about what they might or might not do. If I were already in residency, I would be able to give feedback to my program to help enact the new regulations in a way that made sense. If I were one year later in my training, I would apply next year when the programs had their new schedules in place and I could evaluate them objectively. Now, everything's a mess.
So I'm not sure if it's really that good a plan. A few more hours of sleep on a regular basis when there is a real risk it might still cause medical errors, at the risk of extending my training by another year? I'm really not trying to sound like one of those old, uphill-both-ways physicians, because I really hate when they bitch and moan about how poor my training is going to be now that I "work so little" compared to what they did. I'm pretty sure I'm being pretty damn selfish in not wanting a 5-year residency. What to do?
Me, I'm going to write a letter to my lawmakers after finals are over. You should, too.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
More posts to come soon. I still have stories from pediatric surgery to share, and plus I have fun ones from neurology now, too. I have a post percolating in my brain with my tips for airline travel with carry-on luggage. I have to tell you about how all of my residency interviews have been going, and I promise I will post my recommendations for treating common colds and bugs with over-the-counter medicines effectively (only 1 year late!). I of course also have plenty of other commentary on the medical news to share, also. In the meantime, I have to unpack from my most recent interview trip, repack for winter break, do a ton of laundry, clean up the apartment in preparation for being gone for three weeks (!), and, oh yeah, learn all of neurology. By Thursday.
One article I'll share with you now, though: A great piece from the Washington Post a couple weeks ago, a huge feature about what a medical student goes through to decide if she wants to become an abortion provider. They're many of the same issues I've dealt with, and it was interesting to have someone put my thoughts down on paper for me like that without even realizing it. A Hard Choice.
Wednesday, December 03, 2008
Lessons from "ER"
I watched an episode of ER the other day that featured a storyline in which a physician trying to take care of a child flashes back to the time when she misjudged her own son's medical status, declaring him less sick than he was, and he died.
It's not an uncommon lesson within the medical field; it's one of the reasons physicians are not supposed to treat their own family members. It's too easy to forget objectivity when it comes to the people you know so well, which means you could overlook something you shouldn't -- and wouldn't, if you were at work.
So when Moxie, started having really goopy discharge from her left eye a few days ago, then started keeping that eye half-shut a lot of the time, I was initially worried, then evaluated it a little closer and decided she probably just had conjunctivitis. No big deal, most likely a virus, and it should pass in a couple days.
At least, that's what it would be if she were a human.
She's a cat.
Maybe cats are different?
Since I'm going away for another round of interviews this weekend, I got a little more worried, and thought about that ER episode. Do I really know what she has? Is it really OK?
I guess, to be honest, I have a pretty good idea, but I'm not 100% sure.
And I would hate to come home Sunday night to find a dead cat. I mean, that's totally a worst-case scenario, but that's a scenario I don't want to face, so I guess I should take the cat to the vet.
She's overdue for her shots this year, which means the vet will probably give them to her.
And if she's going to get shots, then it would be the responsible thing to let her brother get his shots, too. After all, they're going east for the holidays and might hang out with some of their feline and canine cousins at various relatives' houses. Better safe than sorry.
The vet put fluorescein in her eyes and didn't see any corneal abrasions or ulcers. "Duh," I thought. She just has a viral conjunctivitis. Still, fluoroscein in a cat is kind of cool -- until she rubs up against you and get it all over your sleeve.
In the end, the vet diagnosed her with a viral conjunctivitis and gave me some neomycin/polymyxin drops to put in her eyes for the next 5 days. The thing is, I'm going to be gone for the next 4 days. And I know she doesn't truly need the drops -- just like in humans (but we commonly give them out in humans, too). But now I'm torn between being a cold-hearted clinician and a guilty pet parent. I was a little happier to learn the differential diagnosis included herpes, because I would definitely hate for her to have herpes conjunctivitis and not know it because she couldn't tell me she was in pain.
So $174 later, both cats have shots, Moxie is given the diagnosis I thought she would be given, has unnecessary eye drops that I still feel compelled to administer but can't because I'll be gone, and my fleece is stained fluorescent yellow.
Worth it, right? No dead cat when I come home Sunday, right?
This behavior of mine is going to stop before I become a mother, right?
Right? Because I don't want to be responsible for any ruptured appendices on my watch.
It's not an uncommon lesson within the medical field; it's one of the reasons physicians are not supposed to treat their own family members. It's too easy to forget objectivity when it comes to the people you know so well, which means you could overlook something you shouldn't -- and wouldn't, if you were at work.
So when Moxie, started having really goopy discharge from her left eye a few days ago, then started keeping that eye half-shut a lot of the time, I was initially worried, then evaluated it a little closer and decided she probably just had conjunctivitis. No big deal, most likely a virus, and it should pass in a couple days.
At least, that's what it would be if she were a human.
She's a cat.
Maybe cats are different?
Since I'm going away for another round of interviews this weekend, I got a little more worried, and thought about that ER episode. Do I really know what she has? Is it really OK?
I guess, to be honest, I have a pretty good idea, but I'm not 100% sure.
And I would hate to come home Sunday night to find a dead cat. I mean, that's totally a worst-case scenario, but that's a scenario I don't want to face, so I guess I should take the cat to the vet.
She's overdue for her shots this year, which means the vet will probably give them to her.
And if she's going to get shots, then it would be the responsible thing to let her brother get his shots, too. After all, they're going east for the holidays and might hang out with some of their feline and canine cousins at various relatives' houses. Better safe than sorry.
The vet put fluorescein in her eyes and didn't see any corneal abrasions or ulcers. "Duh," I thought. She just has a viral conjunctivitis. Still, fluoroscein in a cat is kind of cool -- until she rubs up against you and get it all over your sleeve.
In the end, the vet diagnosed her with a viral conjunctivitis and gave me some neomycin/polymyxin drops to put in her eyes for the next 5 days. The thing is, I'm going to be gone for the next 4 days. And I know she doesn't truly need the drops -- just like in humans (but we commonly give them out in humans, too). But now I'm torn between being a cold-hearted clinician and a guilty pet parent. I was a little happier to learn the differential diagnosis included herpes, because I would definitely hate for her to have herpes conjunctivitis and not know it because she couldn't tell me she was in pain.
So $174 later, both cats have shots, Moxie is given the diagnosis I thought she would be given, has unnecessary eye drops that I still feel compelled to administer but can't because I'll be gone, and my fleece is stained fluorescent yellow.
Worth it, right? No dead cat when I come home Sunday, right?
This behavior of mine is going to stop before I become a mother, right?
Right? Because I don't want to be responsible for any ruptured appendices on my watch.
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