tag:blogger.com,1999:blog-64547825349561845572024-02-08T09:47:08.279-08:00Larval Doctor: Some Day, I'll Be a PupaLarval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.comBlogger18125tag:blogger.com,1999:blog-6454782534956184557.post-68719678340370888222014-03-02T13:26:00.002-08:002014-03-02T13:26:22.166-08:00Breastfeeding: the Sibling (study)<div dir="ltr" style="text-align: left;" trbidi="on">
The study is here: <a href="http://www.sciencedirect.com/science/article/pii/S0277953614000549">http://www.sciencedirect.com/science/article/pii/S0277953614000549 </a><div>
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<b>Background</b>: I'm a Bayesian -- I feel strongly that an analysis of the foundation of evidence on which a study rests and what the prior probability of a claim is fundamental to evaluating the claim.</div>
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Therefore, here's a brief analysis of the prior studies:</div>
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It is well accepted that breastfeeding is important in developing countries and premature infants because of the decreased risk of necrotizing enterocolitis and diarrheal illnesses [citation left as an exercise to the reader.] </div>
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However, although breastfeeding is extremely culturally emphasized with the "breast is best" mantra and the "babyfriendly" hospital initiative restricting access to formula, the prior literature showed little support for a <b>clinically significant</b> impact of breastfeeding on <b>term infants in the developed world</b>. In addition, it was strongly suspected that the majority of effect in published studies was related to the <b>association bias</b>. These facts are absolutely necessary to know in determining how likely you are to find the Colen, et al. study to be valid. Therefore, I include here a limited literature review to emphasize the point. (It is also important to note that benefits of breastfeeding have also been exaggerated by the <b>publication bias</b>: i.e. negative studies are unlikely to be published, especially given the current breastfeeding politics.)</div>
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<li><i>Intelligence: </i>Studies consistently support an effect of breastfeeding on intelligence. This effect is consistently so small as to be likely considered trivial to the average person. For instance, Erikson, et al. found that breastfeeding has the same effect on intelligence as the sex difference, less effect than irregular breakfast and would not have had a significant p-value had the authors used a Bonferroni correction. (<a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3827334/#!po=46.4286">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3827334/#!po=46.4286</a>) The extremely hyped study last summer in JAMA pediatrics (http://proxy.library.upenn.edu:9291/article.aspx?articleid=1720224) found the effect size to be <b>0.35 verbal IQ and 0.29 nonverbal IQ points per month breastfed.</b> This is considered to be the premiere study on intelligence and breastfeeding.</li>
<li><i>Asthma</i>: The evidence is very limited. The currently most cited study is <a href="http://proxy.library.upenn.edu:2082/pubmed/24298900">http://proxy.library.upenn.edu:2082/pubmed/24298900</a>, which finds that infants who are exclusively breastfed for 2 months or more are less likely to wheeze by preschool age, but equally likely to go on to develop asthma <b>and</b> infants who are exclusively breastfed and then supplemented are <b>more</b> likely to wheeze than those who transition to formula and the effect size and the p-values both are not very significant. Nonetheless, there are several, similar quality studies making the same claim. Plausible to have a very small effect.</li>
<li><i>Obesity</i>: The "it study" is <a href="http://proxy.library.upenn.edu:9291/article.aspx?articleid=1725448">http://proxy.library.upenn.edu:9291/article.aspx?articleid=1725448</a> this Japanese study, which showed that among 7-8 year olds,<b> only 7-8% of those exclusively breastfed</b> for up to 6 months were overweight (with 7% at 6-7 months, and 8% for 2 months), <b>compared to 9% of formula fed children</b> and <b>1.5-2.9% obese vs. 3.5-3.9% obese.</b> However, a randomized control trial of pro-breastfeeding interventions that succeeded in substantially increasing breastfeeding in the intervention group did not find any difference in weight <a href="http://www.ncbi.nlm.nih.gov/pubmed/19106322">http://www.ncbi.nlm.nih.gov/pubmed/19106322</a></li>
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<b>So, in summary, in starting the study there is some evidence of a very small positive effect of breastfeeding in reducing asthma and obesity and increasing intelligence. This effect is statistically small and clinically small and may be completely accounted for by sociodemographic differences.</b></div>
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<b>Introduction:</b> What does this study add? The goal of this study is to use paired sibling controls to eliminate sociodemographic differences from consideration as a potential confounding factor. </div>
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<b>Methods:</b> </div>
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<li>The study chose to look at 11 outcomes: BMI, obesity, asthma, hyperactivity, attachment, compliance, math ability, memory ability, vocab, reading comprehension and "scholastic competence"</li>
<li>Subjects were recruited between ages 4-14 in 13 waves over a 24-year period </li>
<li>Results such as obesity and asthma were coded at the age that they developed </li>
<li>Information was gathered through maternal and child interviews</li>
<li>There were 4,071 families (8,237 children) recruited</li>
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<li>3,153 families in the sibling cohort (7,319 children)</li>
<li>665 families in the discordant sibling cohort (1773 children)</li>
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<li>sibling was defined as sharing the same mother</li>
<li>Breastfeeding was binary: any breastfeeding v. no breastfeeding</li>
<li>The following confounding variables were measured: survey year, maternal age at time of birth, patient age, ethnicity, marital status, region of the country, maternal education at time of interview and birth, income at time of birth and interview, maternal employment at time of birth and interview and insurance (private, public v. none), birth order, preterm status, smoking during pregnancy, alcohol during pregnancy, and prenatal care in the first trimester</li>
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<b>Results:</b></div>
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It's worth noting in their demographic data that this is <b>old</b> and therefore, only 10-11% of women worked full time in the year after their child was born and a whopping <b>30-31%</b> smoked during pregnancy -- so probably demographically very different than the modern woman.</div>
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Beyond that side note, it is notable that in the discordant sibling sample, there is slightly higher percentage of <b>woman of color</b>, slightly lower educational attainment (<b>12.5 mo v. 13</b>) and slightly lower income (<b>62k v. 68k at time of birth)</b></div>
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<b> </b>When they compare outcomes between breast and bottlefed infants, they find large benefits in breastfeeding in their intelligence, behavior and obesity measures, <b>which is almost completely nullified, and in some cases even reversed by evaluating paired siblings. After this step, no statistically significant differences are seen</b></div>
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<b>Discussion:</b></div>
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What this study adds most importantly is it validates the strongly suspected hypothesis that differences between breast and bottlefed infants were largely accounted for by confounding variables. </div>
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The major limitations are worth noting; however,</div>
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<b>Exclusivity</b>: The very loose criteria for being "breastfed" was simply having received any breastmilk. It could be argued that there is a subpopulation of breastfed children who breastfed for longer/higher percentage of nutrition who performed better and are buried in the sample.</div>
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<b>Rarity of discordance:</b> I would argue that discordant breastfeeding among siblings is rare and a woman who formula feeds one or more of her children is likely not representative of the average breastfeeding mother. We can speculate that they are more likely to supplement, and the formula fed child is more likely to be higher in the birth order, which gives them an intelligence and behavior advantage, thus confounding the results. <b>This can also be seen in that the discordant group was relatively disadvantaged to begin with, </b>so even less likely to have been exclusively formula fed and possibly subject to more effect from other environmental factors. </div>
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Larval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.com0tag:blogger.com,1999:blog-6454782534956184557.post-16744731193303805422011-08-12T11:01:00.000-07:002011-08-12T11:01:59.651-07:00How to TeachIn our orientation to becoming senior residents, we were talking about how to teach. It's common for a lot of residents to feel like teaching is a burden -- teaching less experienced residents and medical students is essentially an additional job and our primary job is pretty much all-consuming. Therefore, I wanted to share a couple of tricks, especially for new interns, about what I've learned about teaching in the last year (especially teaching medical students)<br />
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1. Probably the biggest point about teaching is that you DON'T need to be an expert to teach. Lots of interns still feel very inexperienced and diffident. It's normal to feel threatened by teaching. It's normal to feel scared about what will happen if a medical student asks you a question and you don't know how to answer. There's two prongs to addressing these fears:<br />
A) As an intern, you have really learned a lot in the last year/year and a half of training that you have compared to a medical student. Think back to when you were a third year, just starting rotations. Everything was new. Even if you don't know a lot about a topic, what you have to say is valuable to a medical student<br />
B) It's totally okay to be honest about your limitations. If a medical student asks me a question I don't know the answer to, I usually encourage them to look it up and let me know. Everyone learns by looking things up and that's a really healthy habit to get into. I don't think of it as me being an inferior teacher by resorting to having the med student look it up (or looking it up with them), I think of it as me teaching them how to learn. <br />
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2. Time. Time is the perennial enemy of the resident. The secret is that teaching doesn't need to take a lot of time -- if you're clever about it, you can even net time from teaching.<br />
A) Make your limitations clear. If I don't have a lot of time to teach, I make it really clear how much time I do have by saying things like: "let's talk about asthma for five minutes" or "here's the five things that are really important to know about Kawasaki disease." This makes the discussion feel complete, rather than rushed. If there are questions I can't answer due to time, I treat that limitation the same way I treat my knowledge limitations -- encouraging the student to seek some answers on their own and regroup with me later.<br />
B) Remember how much you learn by doing. People feel guilty making medical students do work. That's a really, really silly attitude. Most medical students realize that the currency in which they get paid is teaching and the currency with which they pay is by doing work. Even with that transaction aside, medical students are not just there to learn the academic side of medicine; they are there to learn the practical side of medicine. Have a ton of orders to write that's keeping you from teaching? Awesome! Medical students need to learn how to write orders. They also need to learn how to examine patients, talk to nurses, write prescriptions, call outside labs to check on results, call consults and the million other day to day things that make intern's lives hectic. I'll be honest -- it usually does take me more time to teach the medical student how to do these things than to do everything myself, but it doesn't take THAT much more time and I don't feel guilty for ignoring my student. <br />
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3. "But I don't know WHAT to teach!" or "I don't know HOW to teach!" It's unfortunate, but we're never really taught how to teach well. Not as medical students and not as residents. But it's not that different from anything else you teach yourself how to do: you learn it by doing it over and over, watching what mistakes you make and trying new things until you get it right. For me, a lot of how I learned to ad lib teach was by creating a couple short teaching talks that I could give and giving those over and over until I felt confident. I learned how the would go, solicited feedback on them from the med students and perfected them. If I'm stressed out or intimidated, I still go back to them. It works best if they're things that are common, so that they're likely to be relevant to one of your patients, likely to be something you know well and likely to be something the student will use again. <br />
For peds, I think the newborn exam is perfect. It's fast, easy to teach, easy to teach while you're getting work done (like admitting a newborn), something all pediatric residents know well and something that's usually totally new to students. <br />
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4. Teaching repays you. Besides being fun, making you feel like you've contributed to the next generation of doctors and helping you recruit med student minions to help get your work done, I think the biggest benefit of teaching is how much you learn by doing it. Medical students ask questions I never would have thought of and by having them look it up for me (or looking it up with them), I've learned things I never would have on my own. But even more importantly, by spending my time thinking about how to boil down topics to a few essential points to make them quick and easy to teach, it really helps me remember things.Larval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.com1tag:blogger.com,1999:blog-6454782534956184557.post-75734839991874800222011-08-10T18:58:00.000-07:002011-08-10T18:58:41.462-07:00More Stuff I LearnedThe emergency department (and life in general) has kept me really busy lately, but here's some stuff I learned recently:<br />
1. Syphilis can be painful, despite medical school teaching that it isn't (luckily, I didn't learn this from personal experience!) Chancroid and lymphogranuloma venerum are the two leading differentials for painful genital ulcers, but both are unusual in the United States.<br />
2. Appendicitis has a largely heritable component. Courtney asked me in conversation why some people get appendicitis and others don't. Lit review shows that about 50% of the variability is explained by genetic factors. Who knew?<br />
3. Although MRSA is not a major player in causing otitis, it should be covered when treating mastoiditis<br />
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In other news, I found out that I'd been knitting in the round WRONG for the last 10 years. Apparently, you hold the needles close to you and the cables away from you!Larval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.com0tag:blogger.com,1999:blog-6454782534956184557.post-78564155415481998832011-08-08T15:15:00.000-07:002011-08-08T15:15:03.601-07:00How to talk to teensI had a really frustrating experience in the ED the other day.<br />
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I needed a urine specimen from a teenager. Everything had been ordered and I was busy dealing with an actual emergency (it does happen sometimes!) when the nurse came up to me and told me that the patient was refusing to provide a urine specimen and she needed me to talk to the patient.<br />
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So I went in to the room and said "I heard you had some questions about the urine specimen. What questions can I answer for you?" The teenager refused to even make eye contact with me. The mother said "She doesn't want to pee in a cup." <br />
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"Okay..." I responded, a little confused for how the mom became the spokesperson for this decision. I addressed the teenager again "can you tell me why not?" <br />
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She shrugged, but neither her nor her mother proffered an answer. I was a little frustrated, but it also seemed like no one had tried the common sense response so far, so I decided to go for it. "I think that you probably think that it's gross to pee in a cup. To be honest, I know it's weird and it feels strange. Unfortunately, I need for you to do it so that I can make sure you're healthy, so not providing a urine specimen isn't a choice right now. The choices are that you can pee in a bed pan, you can pee directly into a cup or you can pee in a hat (a thing you place on the toilet to catch urine.) If you don't like any of those options, we can use a bladder catheter, which is a tube that we put into your bladder through your urethra. Those are the only choices I can offer you right now. Do you have any questions?"<br />
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She now made eye contact. I held my gaze steady. I was pretty willing to be the adult in this circumstance. She shook her head. "OK. Do you have a preference?" She shook her head again. "OK, I'll have the nurse come in and show you the hat and the bed pan and you can choose." <br />
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She peed in a bed pan.<br />
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The demographic in the emergency department is always a little different. A lot of times we have parents who just don't know how to tell kids that certain things aren't options. Certainly, not all parents are this way (and in the particular case that this is based on the parent was a great parent, who was just at the end of her rope for reasons that weren't relevant to the story.) I was pretty impressed by how easily I reached consensus on what was going to happen. Sometimes, it just takes firmness and explaining what is and is not up for discussion. Larval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.com0tag:blogger.com,1999:blog-6454782534956184557.post-39965358123322536112011-07-23T17:05:00.000-07:002011-07-23T17:05:07.150-07:00Quiet Call DayToday's been really a quiet day. One of the things that I love about being on call in the NICU (OK, I just generically love the NICU) is that there's bedside nurses for all of the patients. If I want the nurse, I can just walk to the bedside and talk to her (there's about four male nurses in a cohort of several hundred NICU nurses and none of them are working today.) This is great for collaborating with the nurses on the plans, and also just creates a really nice work environment. I know most of their names (on my side of the NICU there's two residents, about 5 NPs and probably 75 plus nurses; I try to know all of their names, but it's hard.) They all know me. If I want something, I can go and talk to them face to face, without needing to call or page to find them. I walk around every 4 hours, or so, to check in and it goes quickly and I feel involved and in the loop and like a good doctor. <br />
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Most floors aren't like this -- most floors some nurses change at 7am and some at 11am and some at 3pm and some at 7pm and some at midnight and it's hard to know which nurse has whom and if you can't find the nurse, there's a million places where s/he might be. It's harder to be a team. <br />
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Since it was so quiet, I was chatting a lot with the nurses, mostly about them and their lives, but also about being on call and what it's like. The fact of the matter is that I like my life with call a lot more than any of the alternatives. I like that for a total of 28 hours, I'm really the doctor for these babies (I have a fellow and an attending, but they're mostly only involved when I call them.) <br />
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And there's an asceticism to taking call that can be very rewarding in an odd way. Expelled through the hospital doors in the morning, sleep-deprived, blinking in the bright sunlight, having been in artificial lighting for the last 28 hours, shockingly warm after 28 hours of frigid air-conditioning, you feel reborn into the world. Little pleasures like breezes and being able to eat whenever you feel like it feel poignant. <br />
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It's my last call for a month, before I go to the emergency department. I'm a quarter done with calls for the entire year (an advantage of being in genetics) and at the end of the year have nearly five months with no call...I think I might miss it a little.<br />
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Three things I've learned <strike>today</strike> this week<br />
1. Congenital diaphragmatic hernias - are associated with pulmonary hypertension<br />
2. The differential for congenital diaphragmatic hernia is eventration, where the diaphragm is weak, but not truly herniated<br />
3. Hypokalemia can, in and of itself, cause an electrolyte-wasting tubulopathyLarval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.com0tag:blogger.com,1999:blog-6454782534956184557.post-5181300998799106842011-07-12T16:37:00.000-07:002011-08-10T19:08:36.631-07:00So one of my patients was just* diagnosed with cancer. The psychiatrist e-mailed me. The psychiatrist, because we'd thought that all of her symptoms were related to her (overwhelming) anxiety and rushed her out of the hospital.<br />
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(*N.B. this post was quarantined for several months, in addition to changing of several possible demographic features to ensure that there is no clear connection to any specific patient)<br />
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I had inherited the patient from the previous intern when I came on, which is always hard, because you don't really get your own first impression. My attending had felt really strongly about the psychiatric nature of her symptoms and about rushing her out of the hospital. I wasn't sure I agreed, but I didn't have a strong sense of the patient and my attending was very strong willed. On the second to last day of her admission, I talked on the phone with the psychiatrist and she had said to me: "you know, I'm still not convinced that all of her symptoms are psychiatric" and I'd replied "off the record, I'm not sure either."<br />
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But to be fair, the next words I'd said were: "but I am convinced that she has nothing physiologic that is rapidly progressive or threatening her well-being or will benefit from an inpatient admission." And that, even with the retrospectoscope, I completely stand behind. I'm not even convinced, even now, knowing that we're discussing a patient with a metastatic malignancy diagnosed one week later, that any of the symptoms for which she was admitted have anything to do with her cancer. (She got diagnosed after presenting with a totally new symptom a week after discharge)<br />
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You hear these horror stories of missed cancer diagnoses, by Horrible-Bad-Doctors and think "how could they not have known." And the answer, at least in this case is two-fold<br />
1. Patients with high levels of anxiety and high levels of somatization bombard you with every complaint that they can think of and every possible diagnosis that they read in the internet and it's hard to see the forest for the trees. You think "well, I can't think of a diagnosis that contains all of those symptoms" and "all of the diagnoses that this patient has suggested don't fit" so you dismiss the entire package. And 99% of the time, that's the right response. But even hypochondriacs and patients who somaticize develop true organic illness, buried among the somatic complaints. <br />
2. The goals of a hospital admission from the point of view of being a doctor are different than the goals of a hospital admission from the point of view of being a patient. As a doctor, a patient should be in the hospital only so long as necessary to establish a safe discharge (in which airway, breathing, circulation and hydration/nutrition can be accomplished.) It's my job in the hospital to make sure that the patient doesn't have anything rapidly progressing that would make them unsafe, but not my job to diagnose every symptom. Diagnosis is largely left to the outpatient realm. <br />
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It's still scary. I'm glad someone diagnosed it.Larval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.com0tag:blogger.com,1999:blog-6454782534956184557.post-17179780328762866212011-07-12T15:59:00.000-07:002011-07-12T15:59:44.237-07:00Three more thingsThis afternoon, after call, I went to a lecture by my department chair on the history of inborn errors of metabolism. He focused on how the discoveries leading up to the modern understanding of inherited genetic diseases revolutionized how humanity thinks of itself. Namely, the idea that inherited characteristics and even more specifically, the mind is governed by biochemical principles. It was a really inspirational, fascinating talk. Anyway, posting post-call, so without further ago: here's what I learned today<br />
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1. Neonates generally don't benefit from ventilator rates less than 10 (this only kind of counts -- I totally knew this, but didn't make use of my knowledge at 5:30 AM.)<br />
2. People with PKU who are treated early average a normal IQ but often have subtle cognitive differences, especially decreased executive functioning.<br />
3. Glycogen storage disease type I patients cannot ever mobilize glucose in response to glucagon, but type III patients can if they have been fasting for less than 2 hours.<br />
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Bonus: Apparently the phrase "Selling coals to Newcastle" is similar to "Preaching to the choir," because Newcastle exports a lot of coal. However, it's historically inaccurate because lots of people have profited by selling coal to Newcastle. Honestly, to me, it sounds like an Iron Dragon reference. (Selling dragons to Nordkassel?)Larval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.com0tag:blogger.com,1999:blog-6454782534956184557.post-39279513339967378972011-07-11T18:24:00.000-07:002011-07-12T16:00:11.098-07:00Three things I learned todaySo I've been doing something new. Actually, it's not quite new - I did it at the very beginning of last year, too. But I've been trying to formally think about three things that I learned in any given day. Often, they're about medicine. Not just because the vast majority of my waking hours are spent physically in the hospital, but also because one of the huge advantages of where I live and where I work is that I have a half-hour walk each way, which is a fantastic time to reflect (and also where I get most of my reading done.)<br />
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However, I consolidate new information well by writing. I often write in my Little Black Notebook and over the years have amassed huge amounts of information in my Little Notebooks; however, my handwriting is little even proportional to the Little Notebooks and there's no search function on the Little notebooks, so I thought I would start trying to blog. It has the added bonus of being a form of microblogging that's based on something I already do, which tends to help me overcome my barrier to writing. <br />
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For those of you readers not interested in medical science, I'm going to tag these posts 3til to make avoidance easy (no promises that there won't be non-science contained in future posts.)<br />
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So without further ado, here are three things that I learned today:<br />
1. Jaundice in newborns can be caused by UTIs. This is especially true of conjugated hyperbilirubinemia and jaundice that starts after 8 days of age.<br />
2. Cori's disease (Type IIIa glycogen storage disease) can cause hypertrophic cardiomyopathy. In retrospect, I could have derived that information from what I already knew about glycogen storage diseases and cardiomyopathy, but I didn't, so there.<br />
3. Many little known things about NEC: <br />
a. usually in the TI or colon<br />
b. not associated with the rate of feed advance OR with the timing of starting feeds<br />
c. not associated with trophics (this is cheating as I totally knew this already and tried to show off on rounds by saying so, but I was "corrected," so I'm including the recorrection.)<br />
d. IS associated with acid blockadeLarval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.com0tag:blogger.com,1999:blog-6454782534956184557.post-9774640712501689922011-03-02T16:14:00.000-08:002011-03-02T16:14:09.563-08:00HopeWe went to talk to women who are living in the homeless shelter or transitional housing today. It was pretty interesting -- a lot of really articulate, dignified women. I had a lot of respect for some of them, especially two of the older women, one of whom had double digits of sobriety under her belt. I've learned from taking care of grandparents who have drug addictions just how hard getting sober and staying that way for so long can be.<br />
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One of the things that came up at the very end is the distrust that people develop in doctors because they're told that a loved one will die or has a very grim prognosis and then does well instead. I kind of automatically stepped into my script for patients with terminal prognoses. It's a script I built under the tutelage of an excellent palliative care doctor (seriously, the institution that housed my medical school is famous for many things, but it is not as famous as it deserves to be for the quality of its medical ethics and palliative medicine departments, both of which I was fortunate to spend some time with as a medical student.) <br />
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The script, supported by recent evidence in the pall med literature starts by emphasizing that it's important to have many different types of hope. I explain that based on the evidence in front of us, we think that (specific outcome) is the most likely and it's important to know that so that we can make plans based on the possibility of that outcome. It then acknowledges that parents hope that I'm making an error or hope for a miracle and that those hopes are reasonable and that I want parents to have those hopes. In a slightly antagonistic environment, like the one that developed today, I try to diffuse the tension by saying "my hope for your child is that 10 years from now you'll be telling everyone what a stupid doctor I was and how your child (survived, had a good cognitive outcome, etc.) despite what I said. I sincerely want nothing more for you."<br />
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And then I try to transition to saying "but, if (negative outcome) happens, I want you to have hopes for that, too, so that's why it's important to focus on (negative outcome) for a while." This conversation takes different turns depending on the negative outcome, but I try to guide people to realizing that they can both hope for a miracle AND hope that if their child passes away that they have a pain-free death or that if their child has cerebral palsy that they will continue to be able to care for the child at home. <br />
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It's counter-intuitive to give people permission to hope for miracles. It was initially really uncomfortable, because often my medical knowledge tells me that a miracle won't happen. I've learned to make my peace with that cognitive dissonance. I feel like parents feel like I'm on their team when I let them want a miracle.Larval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.com0tag:blogger.com,1999:blog-6454782534956184557.post-74357408774059867322010-10-14T15:44:00.000-07:002010-10-14T15:44:14.783-07:00The Medical CodeI spend a lot of my life thinking about language and the way that we use it. In my personal life, I'm a stickler for the precision of language; within my social group I have participated in originating several turns of phrase that cover concepts that are otherwise difficult to describe (in my social group the phrase for these phrases is "consensual language" -- i.e. language that means what it does merely because everyone in the social group consents to the definition.) On my walk to work on Saturday, I was thinking about how groups larger than my social group similarly, but less explicitly, co-opt certain words or phrases to inevitably express a specific idea.<br />
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This is particularly true in medicine -- both among doctors and between doctors and patients. Junior doctors present patients to an attending and are expected to use these phrases to paint their conclusions before stating what their opinion is. Similarly, despite the fact that taking a good history is a dying art, specific words that the patient uses can point to a differential. Perhaps the most famous example in all of medicine is the "Levine Sign" -- when a patient, while describing their chest pain, clenches their right fist closed over their mid to left heart (it is considered near-pathognomonic of angina.) In the past week, there were a couple of examples in my life that got me started thinking.<br />
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The first was also my very first role-reversal in the (misnamed) Attending Effect -- where a junior doctor, despite taking a good history, fails to be told a key piece by the family, which is then elicited by a more senior doctor (but not necessarily the Attending.) I'd sent my junior medical student to get a history from the family, while I took care of another patient. By the time I'd arrived, my medical student had spent at least 30 minutes very extensively getting the history and had done a very thorough job. Within 5 minutes of my arrival, I asked my first question: "When did your son get his Nissen fundoplication?" The father answered that it had occurred one month prior.<br />
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Afterwards, my medical student said to me, clearly frustrated: "I had just asked a past surgical history. The father swore his son had never had surgery. How did you know he had a Nissen?" And the answer was a single word: I'd walked in while the father was describing his cognitively normal 7 year old son "retching." There are only two things that I can think of that cause cognitively normal kids to retch without ever vomiting. The first is having a Nissen. The second is having a non-organic program (such as food aversion, attention seeking for some reason.) Given the rest of the history I'd heard in two minutes, the word "retch" was code for "Nissen" -- the father had essentially told me unasked that a Nissen had been placed, because I knew what to listen for.<br />
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The second story that led me to think about this was an event with an attending. I had admitted a little girl whom we suspected had epilepsy, who had been started on an anti-seizure medication, but was having adverse side effects from the med. In the course of picking a new medication, my attending became unconvinced that she even had epilepsy in the first place. Her EEG was negative. He asked me to repeat her semiology (clinical characteristics of a seizure). I started with "she has many types of events..." And he appropriately interrupted me, saying "so, she doesn't have epilepsy." I had used the code incorrectly (the code for seizures involves stereotyped movements, which should fall into one of few similar categories every time.) This time, rather than repeating word-for-word what I had been told, I instead made my case, using selective information: "yes, but one of the types involves being nonresponsive, with her eyes open, followed by rhythmic jerking, during which time she has bowel and bladder incontinence, and then is sleepy for half an hour afterwards." We started her on a new anti-seizure drug. <br />
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But perhaps the best story that I have on the code of medicine happened Saturday morning, when I arrived at work. We had admitted a new patient with "seizures" to the service. Having heard the story (by report, she was a teenager who had a history of having "jerks," which lasted seconds for years, but on the day prior to admission had had a "cluster" of "jerks," lasting minutes, which suggests a diagnosis of juvenile myoclonic epilepsy), I put in orders for an EEG and seizure precautions, and went to go see her. <br />
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The main differential diagnosis in a teenager who is having seizure-like activity is a new epilepsy disorder (and then there's a diagnostic dilemma within epilepsy, which is beyong the scope of this discussion) and pseudoseizures (also called non-epileptagenic epileptaform events, non-epileptic seizures, psychogenic-seizures and a host of other, confusing, names.) The way you tell the difference is usually with a good history and an EEG. An EEG is tough, because often, events don't get captured on EEG and then if the baseline of the EEG is abnormal, it's easy to call it epilepsy, but if the baseline is normal it's impossible to rule out epilepsy on interictal (between seizures)EEG. Therefore, a good history is the go-to tool in diagnosis. <br />
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Therefore, I started with a very careful history of what happened when she gets the jerks. She told me the jerks usually started in her head/neck, but sometimes spread down to her body. She described them as lasting seconds, but often occurring in clusters. All of that is a beautiful history for juvenile myoclonic epilepsy, and the beautiful thing about juvenile myoclonic epilepsy is that it's a type of epilepsy that will show up on EEG, even without a seizure, so I was getting pretty ready to call it a day for history taking. But then, as I was wrapping up the case in my head, she said "the movements begin with this compulsion to move." Carefully, I responded "'Compulsion' means something very specific to me, and I want to hear exactly what it means to you." She defined it: "I get this urge to move and it gets worse and worse and I can put it off, but then it overwhelms me and I have to move." And I realized that I'd also missed a huge piece of the history: she'd told me that right before her clusters started, she'd been playing in the band. Now, with a new diagnosis in hand, I asked "have you ever gotten a jerk while playing your musical instrument?" She hadn't. The diagnosis was clear. She had tics, not seizures. Tics are a different movement disorder, one which rarely gets confused with epilepsy, because the movements are typically not stereotyped and are always voluntary (not voluntary in the sense that the patient wants to do them, but voluntary in the medical code, meaning that the patient can delay doing them, and is giving in to an urge to move by choosing to move in the way that they feel the urge to do so.) The keyword in the whole case had been the "compulsion." I canceled the EEG and her seizure precautions. <br />
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We sent her home 90 minutes after admission (a new personal record), having done no diagnostic testing except a thorough history, which is why being fluent in the code is so important.Larval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.com0tag:blogger.com,1999:blog-6454782534956184557.post-56172392648444020932010-08-07T13:26:00.000-07:002010-08-07T13:26:34.091-07:00When (and what) to discloseIt's always hard to be part of a genetics consult. It seems more encompassing than infectious disease or cards or the other organ specialties. It's a lot easier to say to a parent: "Mrs. Smith, I think that there's something wrong with the baby's liver (or even brain)" than just "I think that there's something wrong with the baby."<br />
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I wasn't thrilled to tell the mother at all that we were getting genetics to look at her new baby, which had been perfectly healthy as far as anyone knew up until 10 hours before (also known as the time of birth.) But at the same time, it's not the sort of thing you can completely withhold, either. Luckily, there was more to this particular patient than just having unusual facial features, so at least I could give the parents a reason I was calling the geneticist, instead of "your baby looks funny" (N.B. I would never actually say that, but it is hard to explain to a parent that their baby is dysmorphic in lay language. We usually use the word "differences," but I was having a particularly hard time in this case. We'd gone through me telling the family that the baby had some facial differences and the family insisting that the baby looked like their other kids. Which, fine, but when I see a picture of your other kids, I know that's not true and I don't want to disagree about it.)<br />
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Complicating the whole situation was the fact that the overnight team thought that the baby had Down Syndrome. I still am not exactly sure what the team said to the family, but when I came on it was immediately clear that the baby did not have Down syndrome. So I also wanted to let the family know that if they'd heard the words "Down Syndrome" to take those words out of their head. Unfortunately, to me and to the genetics team that came to officially consult, it was clear that the patient looked syndromic; however, there was no particular syndrome that sprang to mind. <br />
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I would say about 50% of genetics consults (fewer for experts, more for novices) fall into this category. Something is wrong and that something is...?? That's a really hard conversation to have with any family. Often, if the patient is on the floor or in the unit and going to stay for a while, we won't mention that genetics is coming until the testing is done and we have an answer (I usually will mention something vague like "we're doing some testing to see if we can come up with one answer that ties together everything that is going on with your child.") However, when the child is a well baby, they go home after 2-3 days, so we have to discuss it before results are back. It's a terribly hard conversation: "we've sent genetic testing; there may be a genetic disease that your child has, but I won't be able to give you any more information for at least 2-3 weeks. What questions do you have?" And then, of course, in this situation "well, I disagree with the overnight team; it's not Down Syndrome, but I don't know whether it's better or worse." (I didn't say that, either.)<br />
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I did my best. I told the family that until we know more, there's no point in starting to worry. I told them to enjoy the child, learn more about them as an individual and love the child for the next couple of weeks. I told them until we have answers, we'll deal with each problem as it comes up and troubleshoot each one. But it's hard. Genetics is a field people go into because they want to be able to give families answers. We hate vagaries and unconnected symptoms. I wish that there were a way to both be honest and open, but not throw parents into this diagnostic grey zone for weeks.Larval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.com0tag:blogger.com,1999:blog-6454782534956184557.post-86127996991900353232010-07-22T18:12:00.000-07:002010-07-22T18:12:02.888-07:00The Sad Part of PediatricsI'm never sure where the line in the sand is between appropriate blogging and toeing HIPAA, but what I was taught in med school was follow the letter of HIPAA and this situation has been eating at me and needs to get blogged. <br />
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One of the things that I love about being a pediatrician and having my own clinic is the continuity of care. I am these people's pediatricians. I had my fourth visit with a four-week old today and it was the most awesome thing ever. Next week, I have a visit with one of my babies from the nursery, the younger brother of one of my patients and a well visit with one of my personal patients. That's also totally awesome. (The best thing about the newborn nursery is when I ask patients who they want their pediatrician to be and they say "can I come see you?")<br />
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Things that are less totally awesome: having continuity of care means I'm the one who knows when the ball gets dropped. So one of my babies is still in the "neonatal" period (first month of life) and has missed twice as many visits than it is weeks old. They've come to a whopping one visit. While at that one visit, I felt like the parent was really disengaged and they even left the room while I was examining the baby. They didn't schedule another visit, so I called the family and reminded them how important it was to be seen. They agreed, I gave them the benefit of the doubt and overbooked my schedule in order to see them at a convenient time for the family. <br />
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I think this story is going somewhere obvious, but I was still really sad when they didn't show up. So, luckily, I have good social work resources. So we did some exploring. And there are...other issues (the kid isn't really getting fed) and we've warned the family that this is likely going to become a DHS case (our version of CPS). But it makes me really sad. I feel guilty for my role in getting authorities involved, even though I know that it is absolutely the best for this kid. I want to believe that every parent is trying to make things work and is doing their best for their kid. But in a lot of ways, that's a naivete born out of primarily doing inpatient peds, where parents cared enough to at least bring their kid to medical attention when things were bad. I really hope things turn out OK for this kid, but also for this family and that having authorities involved will be a needed wake up call.Larval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.com0tag:blogger.com,1999:blog-6454782534956184557.post-40037407528726813242010-07-18T07:02:00.000-07:002010-07-18T07:02:17.435-07:00Prenatal/Neonatal VisitsOne of the problems that I think faces all doctors is that we lose perspective on the gap between what we know and what most people know. This is particularly obvious in my newborn visits. Like most doctors when doing newborn teaching for a family my goals are<br />
1. Making sure that the family is feeding the kid correctly<br />
2. Making sure that the kiddo is being put to sleep in a safe environment<br />
3. Making sure that they're using a carseat and doing so correctly<br />
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Many doctors also use this time to talk about smoke detectors and smoking and carbon monoxide detectors, but I'm a rebel. I will see my newborns again in one week, and it's pretty unlikely anything will change on that front, so I can talk about those things at the two week visit. Why do I care? Because there is only so much information that parents can handle. And instead of talking about smoke detectors, etc. I try to answer the most common parents concerns (both that they have at the newborn visit and that will cause them to come back unnecessarily between the newborn and the two week visit)<br />
1. The equivalence of the hospital brand of formula and the formula that WIC gives out (This is the number one question I get asked)<br />
2. Things normal newborns do -- sleep a lot, get blue hands and feet, breathe funny and strain when they poop (I also try to talk about the line between the normal form of each of these and their pathologic equivalent and when it's worth bringing the kid in for a sick visit.) In infants with dark skinned parents, I like to let them know the skin will get darker (in my patient population fathers worry about mistaken paternity because the newborn is light).<br />
3. Things many normal newborns have -- I let parents know if their kid has a murmur or an umbilical hernia or a hemangioma and that it's normal and how I expect it to change over time.<br />
4. Things that I expect to change before they see me again -- kiddo should start eating more, jaundice should fade, if stools haven't changed from meconium they will, formula kids may get constipated (and that's OK)<br />
5. Things that have already happened and what they meant -- most parents do not understand why their kid got a hepatitis B vaccine in the nursery, what the newborn screen was for, what "that test that they took the baby away to do" was (hearing), or why the baby had black stools at birth and I usually go over some of that. <br />
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So by the time we're done going over all of that it's a HUGE amount of information. And that's before I have the nurse come in and give them teaching on how to use a rectal thermometer and how to mix formula. It's a ton of information.<br />
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In Ohio, we had new parents come in for prenatal visits. I could talk to them about everything except the particular normal variants that their kid had. Then we would review at the newborn visit, and I would have the time to talk about smoking and home safety and all that jazz and they would have room in their brain to listen. For some unknown reason we don't offer prenatal visits here and I feel like everyone loses out from that. <br />
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The time to tell parents how to properly feed a newborn is not when the newborn has already been at home for five days. I'd love to reinforce the need for a jaundice check at day of life three or four, but when parents don't come in to see me until the kid's a week old, at that point there's nothing I can do. <br />
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I also think that there's some (a minority) of pediatricians who make up for the lack of prenatal visit and still manage to cram in home safety by sacrificing discussing parental concerns. And I think the reason that happens is that pediatricians lose sight of the knowledge gap. The result is that I've had kids come into the emergency room for glabellar hemangiomas (a normal birthmark. Also called an "angel kiss.") When this happened I asked the parents "Hasn't the kid had that since birth" and they said "well, yes, but it kept getting darker and darker and now he's crying and it's even darker." So I asked, "what did your pediatrician tell you about it?" And they said "oh, our pediatrician never mentioned it." <br />
So it's possible that the pediatrician did give them a great talk on what the hemangioma was and what to expect and the parents didn't remember (because they were on information overload!)<br />
But there are also pediatricians for whom hemangiomas are so routine (about 25-50% of babies have one) that they forget to teach about them. And then, as hemangiomas do, they get darker with time and darker when the kids cry and the parents panic.Larval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.com0tag:blogger.com,1999:blog-6454782534956184557.post-36383244375139374952010-06-13T16:37:00.000-07:002010-06-13T16:37:01.111-07:00<div style="background-color: white; color: black; counter-reset: __goog_page__ 0; font-family: Verdana; font-size: 10pt; line-height: normal; margin-bottom: 6px; margin-left: 6px; margin-right: 6px; margin-top: 6px; min-height: 1100px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Tomorrow, I am going to walk into the largest and best children's hospital in America and pretend to be a doctor who works there. Or at least, that's what it feels like. It feels unreal. In some ways, the last five years of my life have been a lot of learning how to play "the game" -- learning to put the best foot forward, make a good impression, meet the right people, get the good test scores & accumulate the symbols of ones status and knowledge. Completing med school feels almost like a purely symbolic task, performed to sate my determination and showcase my ambition and intellect, but having nothing to do with actually becoming a doctor.<div style="margin-bottom: 0px; margin-top: 0px;"> By and large, I know that the ways in which the above are actually true are minimal compared to the other ways in which med school was important in my life -- what I've learned about really caring for other people (not just as a turn of phrase), how to perform myriad clinical tasks from procedures to telling someone that their loved one has died and learning massive amounts of biomedical science. I know that I am the best I have ever been -- the smartest, most educated, most knowledgeable, but also the most compassionate, most understanding of ethics and least cynical I have ever been. I know that I can be a resident and that I will be a good doctor. I know, intellectually, at least, that I deserve to be a doctor at America's best children's hospital. That doesn't stop me from feeling like an impostor, though.</div><br />
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<div style="margin-bottom: 0px; margin-top: 0px;"> I think that part of the feeling of unreality is that the dream of being a resident at this particular hospital, or even a hospital like it, is less than a year old. Just over one year ago, I decided that if I was serious about making a career of clinical genetics, I needed more training in it than what I had gained from my home hospital. My home institution had a genetics department that I love and that treated me extremely well, but, by their own admission, was small and not equipped to prepare me to deal with a large, academic genetics department. In search of the best place to have a genetics experience, I landed on the hospital that had trained my favorite teacher and mentor. I never once considered that I would try training there for longer than one month -- the hospital was large, with a reputation for being snooty and, I felt, too prestigious to take me. </div><div style="margin-bottom: 0px; margin-top: 0px;"> I changed my mind last August, after stepping foot in what will be my work home for the next five years. There was something in that atmosphere -- it buzzed with scientific curiosity; little things, like the protocols for hand-washing, were clearly laid out and it was clear that from every level, there was an investment in improving the hospital even more. But moreover, it was a giant place for kids and every single person I met from MAs to world-famous MD/PhDs cared about providing the best care for children anywhere. I wanted to be a part of that. I had never been exposed to such a large-scale, free-standing children's hospital before. I had no idea that they even existed. My home hospitals, largely out of necessity, shared the most specialized of sub-subspecialists between adult and pediatrics. This hospital had the most arcane specialities just for kids. Every day I came home even more impressed with the hospital. I knew I wanted in.</div><br />
<div style="margin-bottom: 0px; margin-top: 0px;"> However, even for pediatricians, getting a residency spot is competitive. I walked out my last day trying to commit details to memory, just in case it was the last time I ever set foot in the hospital. And my application process was rocky: I was denied an interview. It was overturned, but I knew that my dream was over. I focused on the less "reach" programs. When I came for my interview I repeated the ritual of committing the hospital to memory on my way out. I knew it was goodbye. </div><br />
<div style="margin-bottom: 0px; margin-top: 0px;"> For all of that, I wasn't shocked when I matched at The Hospital -- correspondence between interview day and Match Day was very encouraging -- but by that point, the journey had been so hard fought that it felt symbolic, rather than real. Last week, when I entered The Hospital for only the second time since interviews was the first time it hit me: this <i>is</i> my home hospital know. I work here. I'm part of this. Weird, right?</div><div style="margin-bottom: 0px; margin-top: 0px;"> </div><div><br />
</div></div>Larval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.com0tag:blogger.com,1999:blog-6454782534956184557.post-64771621984553466922010-02-13T17:25:00.001-08:002010-02-13T17:49:30.875-08:00Larval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.com0tag:blogger.com,1999:blog-6454782534956184557.post-12038915008914154662010-02-13T16:16:00.000-08:002010-02-13T17:27:26.851-08:00Reflections on palliative medicine<span style="font-family: arial; font-size: 85%;"> I spend a lot of my time thinking about dying. Not in a morbid way, but in the way in which death is an inevitable portion of my job. One of the things that I had never really given any consideration to is how rare of a characteristic this is in a pediatrician . I mentioned my interest in palliative medicine to one of the younger students and he replied with "but I thought you wanted to go into pediatrics?"<br />
It's true that kids die very rarely. However, it is also true that the sorts of conversations that happen at the end of life have a lot in common with the sorts of conversations that happen in pediatrics. In both there is a time at which we no longer make decisions as directed by the patient personally, but as directed by someone who (hopefully) loves the patient and makes decisions in the way in which they think that the patient would. Many geriatricians and palliative medicine doctors would argue that the difference is that in the care of the adult who is no longer able to make decisions for himself or herself, we have a history of decisions that he or she has made and (in the rare, but ideal case) a set of directives that has been left. However, there is a multitude of evidence now that the decisions that we say we would make in given circumstances are not the decisions we do make when we are in the circumstance. The inherent problem in the concept of "substituted judgment" (i.e. making a decision on someone else's behalf in the way in which we think that they would have made the decision were they able to themselves) is that it requires the idea of a static identity. Do you make decisions on the basis of what the person would have wanted a year ago, even if they may have had some dementia at that point or as they would have ten years ago before they had any dementia or as you predict that they would be now if the person who they were ten years ago never developed dementia? <br />
This is in fact more complicated with kids, although I would argue it is more difficult the older the child is. With a baby one can make certain generalizations -- no one will fault a physician for assuming that an infant will value life, wellness and cognitive function. The other major wrench that makes this easier is that the younger the patient, the more likely that if you can get them to survive you can get them to good long term prognosis -- children are extremely hardy. On the other hand, teenagers have their own independent thoughts and values and those should be taken into account; however, if a teen is catastrophizing, for instance, how much of that is a normal developmental position and how much is the teen's personality. <br />
I had a case of a teenager who was near, but not at, the age of majority. This teen had a diagnosis that was inevitably terminal, likely within the next few years at the outside. The teen wanted to transition to focusing completely on palliation, rather than curative therapy. The parents wanted to continue to try more curative therapy, reasoning that the field could change sufficiently within a couple of years that new treatment may be available. In this particular case, the prognosis was really quite grim, and ultimately, after many meetings with the family, the decision was made to transition to palliation and the patient passed away. However, what if the prognosis were not grim? Treating cancer typically requires several months of treatment, during which the patient may lose their hair, will experience extreme fatigue and be nauseated. If the prognosis is terrific, it is easy to suggest that the parents should require their minor child to undergo it. If the prognosis is truly terrible, it is viewed as cruel to force a child to undergo it. But what should be done in the intermediate cases? Patient-centered medicine dictates that we allow the patient to weigh the costs and benefits in their own value system. But for children, several months is a very long time and the future gain seems very theoretical; therefore, the gain assigned by most children will be less than most likely would be assigned by the same individual were they an adult. On the other hand, bodily autonomy is an important developmental milestone throughout childhood, and it feels uncomfortable to force a child to undergo such physical discomfort. <br />
On the other hand, I've spent five weeks on services focused on end-of-life discussions, and at least in my experience, most of the media attention on end-of-life issues is really overblown. The vast majority of the time, the patient and the treatment team agree in their view of where the patient is at in the life course; what reasonable goals are for care and when to transition to palliation as a primary goal. When there's disagreement it seems to be roughly evenly split between the patient ready to be done with curative therapy before the treatment team and the treatment team before the patient. Both ways, the conflict is typically resolved usually by a discussion of what the patient's goals are.<br />
My current attending likes to focus on the "levels of hope" -- that it's typical and normal even for patients who are terminal and know that they are terminal to still hope for cure. That this is not unrealistic or denial, but rather analogous to the person who buys a lottery ticket or gets average grades but applies to Harvard medical school. He asserts that this is not at all unhealthy, as long as it is not the exclusive focal point. The patient should also have hopes that are not dependent on a cure, such as resolution, relationships, spiritual closure or whatever is important to that particular patient. Patients who don't want available curative therapy usually don't have anything against curative therapy, but are hoping not to have more pain, for example and patients who do want curative therapy, when it's not really realistic, often want it for the sake of something else. By focusing on these primary goals, rather than what needs to be done to get there, it's easier to get the physician and patient on the same page. It's a good technique. I'm not sure whether it will be helpful in a pediatric setting, but it's another tool in the toolbox, which I'm sure I'll use some day.<br />
In the last six months, especially, the majority of tools I've been gaining have been communication and philosophical skills and efficiency; not that I've stopped learning physical exam techniques or medical science, but the ratio is changing. When I interviewed, I referred to these as "ancillary skills" -- that most medical schools focus on scientific knowledge, but that to be a good doctor, it's important to know how to be a professional, to know how to have hard conversations, to know when a conversation is necessary and when to let the decision a patient or family makes stand unchallenged, etc. It's February; in five months, there will be patients for whom I am their primary care doctor. There will be babies for whom I will have been the only pediatrician that they've ever had. That, more than the idea of being the intern on-call for the NICU, more than the idea of being the first doctor in the room for a code, more than the idea of having to do lumbar punctures and arterial lines, scares me. That is what motivates me to learn as much as I possibly can (even though senioritis is kind of creeping up on me.) I want to be the sort of pediatrician that my teenage patients can come to about sex and drugs; I want to be the sort of pediatrician who can counsel worried parents about vaccines; I want to be a trusted advisor. I've learned a shockingly large amount in the last four and a half years; I think I'm going to be OK. <br />
</span>Larval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.com0tag:blogger.com,1999:blog-6454782534956184557.post-90931637875721894082009-03-19T10:39:00.001-07:002009-03-19T10:39:47.506-07:00Patients telling me I'm "the best doctor [they]'ve ever hard" makes me very uncomfortable. For awhile, I joked, privately, that statement on its own was diagnostic of a personality disorder. (There's some validity there; patients with personality disorders, especially borderline, have a tendency to pick out "best" and "worst" doctors, and especially will pick trainees to be the "best" because we're easy to manipulate.) However, last week, one of the most psychologically stable patients I ever had expressed how grateful he was to have me on his team and praised my knowledge and compassion. <br /> On the one hand, I know I'm skilled clinically. On the other, medical school is nothing if not liminal. I can be a great medical student, but that means nothing. A medical student, by itself is not a state of being. Who's ever heard of telling a caterpillar that it's beautiful -- or worse: that it's good at being a caterpillar? Of course, I strive to be a good doctor, but that doesn't parallel with being a good doctor, or at least not completely. When patients tell me I'm the "best," it's scary; I want to respond with all of the things that I don't know, all of the mistakes that I make every day. Most of the time, though, the urge is overwhelming to hide things I don't know, to avoid admitting my weaknesses and above all, not to let anyone see my mistakes. Being a good medical student involves admitting these things; using them as stepping stones, growing through self-examination. I know, but at the same time, I want to be a good DOCTOR, and I worry that my weaknesses aren't acceptable. <br /> I was stressed in the lab -- I'm having trouble writing my first first-author papers; I'm behind, because stress makes me procrastinate, and I'm getting overwhelmed. The more time that passes, the less I want to talk to my PI, because the more I feel that I haven't done enough. One of my coworkers said "well, what did you think? You would cure cancer all by yourself as a med student?" It's true -- I'm a student. I'm supposed to make mistakes and lean on others, but it's hard to remember. I tell myself "perfect is the enemy of good" nearly every day, but we're encouraged so strongly for so long to look good on paper so that we can get into a good college, good med school, good residency, good job. Liminal -- trying to be something else, never settling. I worry that I'll spend the rest of my life constantly focused on the future, rather than trying to optimize the present. I don't have an answer for that.<br /> My mentor told me a story about when he was in training, he received a call about a patient with an eminent medical emergency. His attending was detached and discouraged questions and had left for the night. My mentor was new, and he knew that he couldn't manage the case on his own and he knew that mismanaging the case would result in permanent disability to the patient. He called another attending, who was not on service, in the middle of the night to discuss the case and the patient did well. It takes a lot of courage to do that. It takes being able to admit that you have a lapse of knowledge to a boss. It's clearly the right thing to do -- being a doctor isn't about the doctor; it's about the patient. I adore and respect my mentor...but I'm scared that I don't have the courage; that I'm too concerned about my own self-image that I would be too diffident about getting yelled at for asking a "stupid" question that I'd try to manage it on my own, and I'd never forgive myself if something bad happened. To be totally honest, I'm scared of even writing that in a public forum -- scared that you're all going to judge me for being too self-absorbed for doing the right thing. The only defense I have is that I hope that by knowing this, by thinking about it and by being honest about my barriers, I will prevent myself from actually making the mistake when it's not just a thought experiment.Larval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.com0tag:blogger.com,1999:blog-6454782534956184557.post-39949650958390777402008-10-30T20:35:00.001-07:002008-10-30T20:35:19.475-07:00<span> </span>Writing has never come easily for me. My parents had to be called in to my third grade classroom, because I refused to put words to paper. There are reasons -- as most people who know me can imagine, I need structure, and my hippy school didn't really teach grammar. Even more difficult to me was semantics -- having ideas that were of supreme importance but being unable to grasp how to convey these ideas in words. It's still very much a struggle for me. <br /><span> </span>I knew, about one year ago, that I needed to go back to blogging. There's good evidence that medical professionals who write in at least a semi-structured manner have a higher level of empathy, decreased depression, and in general, are better at self-criticism and self-improvement. It makes sense -- medicine has the illusion of a solitary pursuit. One of my favorite medical concepts is "causitry" -- using a case to determine principles, especially in ethics. The connotation is that the case is used instead of a rational derivation of principles. The parallel, I think, is key to how physicians view themselves. We think of ourselves as cases, without connection to others moving around us. Some of this is the structure of medical training, which is systematically designed to innure the medical student to illness, suffering of physical and emotional varieties and, ultimately, death. On the one hand, training as part of a team is emphasized more in medicine than anywhere else I have been exposed to; on the other, close friendships among coworkers are rare and self-exclusion from the patients and global culture is an unspoken expectation. Discussing ones own emotions is a social taboo -- although technically encouraged, the "unwritten curriculum" mandates disparaging all such conversations. One's difficulties and mistakes are an even more unforgiveable conversation -- allowed among other healthcare professionals; but there is a stigma to sharing the lack of perfection in medicine as a whole with the lay personnel. I remember the conversation that made me leave Oberlin Hillel -- "you can discuss problems with Israel, but only with Jews." So, there's one excuse not to write. But, in the end, it requires buying in to all of the problems that I see in medicine -- that is the sort of physician that it is easy to be, but not the sort of physician that it is good to be. I struggle every day to be the sort of doctor to share decision making with my patients, to avoid paternalism, not to glorify medicine or exaggerate the science behind my decisions. Being open is a requirement for trust, and ultimately, being open with myself is an obligation that I have both to my self and to my patients.<br /><span> </span>I still hate writing. I'm a very verbal thinker -- if I can't think of the word for something, or I can't phrase it correctly, I very literally can't think it. At the same time, I'm not a linear thinker -- I will frequently formulate thoughts from the same starting point and go different directions and then return to the starting point and go somewhere else -- trying to mold these thoughts into words that must go marching on in the same direction, leaving the other vetors of thought to the wayside frustrates me. It makes me feel flattened. I feel shallow -- the thoughts that mean so much in my head mean so very little on paper. I write this in a google doc page, reassuring myself that if I hate these words, I need never publish them. (I will because I will force myself -- I know that if I don't, I will only be making it harder for myself to blog next time and I have committed myself to writing.)<br /><span> </span>I can't remember where I was going with this, other than to commit myself to writing and to explain why it is so damn difficult for me and to commit myself to write on a regular basis.Larval Doctorhttp://www.blogger.com/profile/04007950140885612489noreply@blogger.com0