Category: Clinical

Categories
Clinical General Lifestyle Narrative Opinion

In the Business of Medicine, Be Your Own Boss

As medical students, we exist between two worlds. On the one hand, we’re tasked with learning as much as we can about the practice of medicine from our preceptors, many of whom have decades of experience. On the other hand, we’re always thinking about our place in the future of medicine and fantasizing about what our unique style of practice will look like. While I feel indebted to the seasoned physicians who graciously give of their time to teach us, a recent interaction reminded me that I am the boss of my own practice of medicine.

It started out as a morning just like any other. I needed to finish rounding on my patients before a noontime meeting where I was slated to give a small presentation. The last patient on my roster had been particularly troublesome for our service. She had been admitted for worsening congestive heart failure and although she was relatively young, and had a very supportive family, she did not seem willing to make any of the lifestyle changes that would improve and possibly prolong her quality of life. Nurses, doctors, and respiratory therapists had been trying to get her to wear her CPAP mask during this hospitalization, but for reasons that we didn’t completely understand, she had been refusing to wear it for the past two months.

After a quick exam and what seemed like a futile imploration to try her CPAP again that night, she started telling me a bit about her life prior to becoming ill. I knew the time was coming closer and closer to my meeting, but I couldn’t leave while she in the middle of divulging such personal information. Our conversation dwindled, and I stepped toward the door, when she tearfully mentioned that her dog had recently died. Again, my thoughts drifted toward the upcoming meeting, but I also wanted to be sensitive to this very meaningful event in my patient’s life. Trying to be polite, I asked when her dog had died.

“Oh, about two months ago,” she replied.

I paused. “Is that about the time when you stopped wearing your CPAP mask at home,” I asked.

She stopped to think. “Yes, I think it was exactly around that time.”

Thinking that the timing of her dog’s death coinciding with when she stopped using CPAP might be more than coincidental, I offered my condolences for her loss, and assured her that I wanted to come back later in the day to talk more about her dearly departed pet. I felt relieved to see that I had only run a minute late, so I hightailed it to the meeting. As I stopped to pick up the materials for my presentation, I heard my attending calling my name from the hallway. I couldn’t wait to tell him that I had stumbled upon a very useful piece of information to help us understand why she stopped using her CPAP machine.

“I know I’m a minute late-I got stuck with our patient,” I explained. “I couldn’t just couldn’t leave when she started talking about her dog who recently died, but I may have a clue as to why she won’t wear her sleep mask.”

He looked dismayed. “You have to figure out how to get out of those conversations,” he told me curtly. “That’s just the business that we’re in.”

His last words “the business that we’re in” struck me so profoundly that I can still replay them in my head as clearly as if he was standing right across from me. I have not had a temper tantrum since childhood, and yet, in that moment, everything inside me wanted to shake my head and bang my fists in passionate disagreement. I understood immediately that whatever business this physician is in is not the same business I’m planning to go into. As a student, I still have a lot to learn, but one thing I know for certain is that patients should always take precedence over meetings. After all, without fostering the relationships we have with our patients, medicine would be a business in bankruptcy.

Medicine has a rich history of being passed down from generation to generation, but like anything else, aspects of medical practice may become antiquated. As the next generation of physicians, it’s up to us to hone our judgment and decide whether we will accept the status quo or make a new path forward. We get to decide what the business of medicine means to us. Whether we work for a large corporation or go into private practice, each one of us is a boss-in-training of our own future practice. It took some not so sage advice from a preceptor to remind me that meaningful and collaborative relationships with my patients are the cornerstones of my business of medicine.

 

Photo credit: Christophe BENOIT

Categories
Clinical Lifestyle Public Health

What’s the Deal with Vaginal Breech Delivery?

Back in May, I attended the 2016 American College of Obstetrics and Gynecology (ACOG) Annual Scientific and Clinical Meeting in Washington, D.C. On my first day, I watched Dr. Annette E. Fineberg, a board certified obstetrician and gynecologist from Sutter Davis Hospital in California, present a short film on upright vaginal breech delivery. The movie featured a woman at term deliver in the operating room by resting on all fours on her hands and knees. She swayed her bottom from side to side in order to promote fetal descent and as a way to cope with pain, as she did not receive an epidural. The baby crowned, bottom first, and then slowly spontaneously delivered its legs, trunk, arms, and finally, head. A successful vaginal breech delivery (VBD)!

Ever since watching that amazing film, I have been interested in reading and talking about VBDs. But on the residency program interview trail, I have begun to notice a trend that some providers seem to have strong, negative attitudes regarding VBDs of singletons. One person even glared and incredulously responded, “No one in the country does those.” I think Dr. Fineberg and the other clinicians I have met that do would disagree.

But I do wonder why providers feel so strongly about a particular position regarding more controversial topics in reproductive health. In regards to vaginal breech delivery, I think that a big prejudice is the absolute horror stories every seasoned OB/GYN has to tell about the time they saw a baby’s head get stuck. These accounts are upsetting, sad, and help explain why someone might think me ridiculous for even asking about training in vaginal breech delivery.

The most common response, though, that I receive is something like, “We don’t do those. But you will probably not find many programs that do since ACOG does not recommend vaginal breech deliveries.” This reply is less emphatic and more accurate if following the 2001 ACOG committee opinion, which states, “planned vaginal delivery of a term singleton breech [is] no longer appropriate.”1 The reasoning in 2001 was largely based on results from the Term Breech Trial, a large, multi-institution, randomized control trial comparing planned vaginal birth with cesarean deliveries for term singletons with breech presentation. This study indicated that neonatal morbidity and mortality significantly increased with vaginal breech versus cesarean section delivery.2

Since the 2000 Term Breech Trial, clinicians have begun to question if vaginal breech deliveries should have a strict ban. Instead, there is evidence suggesting that vaginal delivery is a safe option in select women with breech presentation. The authors of the Term Breech Trial performed two prospective studies in which they examined maternal and child outcomes at both 3 months and 2 years post-partum. At two years post-partum, there was no longer a difference in mortality nor neurodevelopmental delay in the children born by vaginal breech delivery versus cesarean section.3 Retrospective studies with specific protocols similar to those described in the Term Breech Trial have shown excellent neonatal outcomes for vaginal breech delivery of term singletons.4-6 In 2015, Berhan and Haileamlak published a meta-analysis of 27 articles with a total population of 258,953 women comparing the morbidity and mortality of term singleton breech mode of delivery between 1993 and 2014. While the relative risk of perinatal mortality and morbidity was 2-5 times higher in planned vaginal delivery versus cesarean, the absolute risks of several variables, including perinatal mortality (0.3%) and fetal neurologic morbidity (0.7%), were low.7

In the updated committee opinion on vaginal breech delivery published in 2006 and reaffirmed in 2016, ACOG states that “planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management.”8 The Royal College of Obstetricians, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and the Society of Obstetricians and Gynaecologists of Canada report similar recommendations.9-11 According to the ideal candidate for a term, singleton vaginal breech delivery is the following:12-14

  • Frank or complete breech presentation with flexed or neutral head attitude;
  • Estimated fetal weight between 2500 and 4000 grams;
  • A patient willing and comfortable with a trial of labor;
  • Clinically adequate maternal pelvis.

Contraindications to vaginal breech delivery are categorized as a fetal, maternal, or provider factor:12-14

Fetal Factors

  • Incomplete breech;
  • Hyperextended neck;
  • Cord presentation;
  • Fetal growth restriction or macrosomia;
  • Congenital anomaly incompatible with vaginal delivery (e.g. thyroid mass).

Maternal Factors

  • Patient unwilling to attempt/uncomfortable with a trial of labor;
  • Clinically inadequate maternal pelvis;

Provider Factors

  • Lack of operator experience.

Obstetrics governing bodies agree that external cephalic version—whereby a provider uses their hands on the abdomen to rotate the fetus in utero from breech to vertex presentation—should be recommended and attempted first before considering vaginal breech delivery. And all leading sources recommend that an experienced provider needs to be leading the delivery.

But if there are few opportunities in residency to practice vaginal breech delivery, how will there BE any future providers who qualify as experienced?

First and foremost, I hope to enter a residency program that provides me with the training I need to be a competent women’s health provider. But I also intend to seek training in vaginal breech deliveries, whether it is via simulations—which RCOG notes is an appropriate way to build experience 9—or via an elective at another institution where there may be further opportunities. My goal is twofold: (1) offer the best individual options for mode of delivery to my future patients; and (2) help lower cesarean section rates in the United States. Hopefully, I will get the right match!

References

  1. American College of Obstetrics and Gynecology. ACOG Committee Opinion No.340: Mode of Term Singleton Breech Delivery. Obstet Gynecol. 2006 Jul;108(1):235-7.
  2. Hannah ME, Hannah WJ, Hodnett ED, Saigal S, and Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet. 2000;356(9239):1375-1383.
  3. Whyte H, Hanna ME, Saigal S, et al Term Breech Trial Collaborative Group, Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol. 2004;191:864-871.
  4. Guiliani A, Scholl WM, Basver A, Tamussino KF. Mode of delivery and outcome of 699 term singleton breech deliveries at a single center. Am J Obstet Gynecol. 2002;187:1694-8.
  5. Alarab M, Regan C, O’Connel MP, Keane DP, O’Herlihy C, Foley ME. Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol 2004;103:407-12.
  6. Borbolla Foster A, Bagust A, Bisits A, Holland M, Welse A. Lessons to be learnt in managing the breech presentation at term: An 11-year single-centre retrospective study. Autralian and New Zeland Journal of Obstetrics and Gynaecology. 2014;54:333-339
  7. Berhan Y, Haileamlak A. The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: A meta-analysis including observational studies. BJOG 2015: DOI; 10.1111/1471-0528.13524
  8. American College of Obstetrics and Gynecology. ACOG Committee Opinion No.265: Mode of Term Singleton Breech Delivery. Obstet Gynecol. 2001 Dec;98(6):1189-90.
  9. Guideline No 20b: The Management of Breech Presentation. Oxford: RCOG, 2006.
  10. Kotaska AK, Menticoglou S, Gagnon R. SOGC Clinical Practice Guideline No. 226: Vaginal Delivery of Breech Presentation. JOGC. June 2009.
  11. RANZCOG, Cobs-11: Management of the Term Breech Presentation. Melbourne: RANZCOG, 2009.
  12. Hofmeyr JG, Lockwood CJ, Barss VA. Overview of issues related to breech presentation. UpToDate: Accessed 10/11/2016
  13. Hofmeyr JG, Lockwood CJ, Barss VA. Delivery of the fetus in breech presentation. UpToDate: Accessed 10/11/2016
  14. Secter MB, Simpson AN, Gurau D, et al. Learning from Experience: Qualitative Analysis to Develop a Cognitive Task List for Vaginal Breach Deliveries. JOGC 2015

Photo credit: MIKI Yoshihito

 

 

Categories
Clinical Narrative Reflection

Red Rash

As I sat in the audience, I stared up at the image being presented on the screen. It was what looked to be another red rash. The content for the Dermatology grand rounds was admittedly beyond my clinical training. Nevertheless, I found it fascinating to slowly discover the complexities of the skin as each case was presented. As I thought about each slide I began to ponder Dermatology as a specialty. I wondered what it meant to be a dermatologist. I briefly reflected on the stereotypes associated with the profession and then realized that every specialty had stereotypes. My brief daydream was interrupted as the next image on the screen appeared. I was anxious to see what it was in hopes that I could identify it, but to my dismay it looked like just another red rash.

Later, as I scurried behind the attending in my official looking, yet noticeably shorter white coat, I wondered what type of red rash I would be observing next. As I entered the exam room the woman sitting there immediately shocked me. Her face read of complete sorrow and hopelessness. However, it was not her face that struck me, it was her skin. It was red, dry, and seemed to be peeling off of her as if she was shedding her skin. It looked terrible and seemed to feel even worse. It was then that I saw the attending spring to life. He began discussing her symptoms with her. When he had gathered the information he needed she began to tell him how the illness has been affecting her life. Skin diseases or issues with the skin can sometimes be viewed or reduced to something inconsequential or unimportant compared to other serious diseases such as diabetes, heart disease, or cancer. However, as I looked at this woman, I imagined her waking up in the morning and standing in front of the mirror and being unable to focus on anything other then this rash covering her entire body. It was then that she described the shame, embarrassment, and humiliation she experienced when others would stare at her, whisper about her, or when she would occasionally catch a glimpse of herself in a store window. The thought of her disease staring at her in the face when she brushed her teeth each morning made other serious illnesses that hide under the skin seem preferable.

After listening to her describe her quality of life it made complete sense as to why she felt so hopeless. It was in the moment that I had a strong desire to help this woman. I wanted to relieve her of this suffering. Fortunately, the attending was already in action. He began to describe his treatment plan while validating every one of her feelings and concerns. It was as if he knew what it was like for her to lose sight of herself and only see her skin. As the sorrow slowly drained from her face, I saw something incredible, hope.

It was then I realized that every slide I causally coined as a “red rash” belonged to actual people who have lives, families, and most importantly feelings. I assigned them a label that they never asked for and most likely hide from everyone they encounter. Assessing and treating the human body is an immense responsibility, but so is connecting with people. Now when I see the images at grand rounds I no longer see a red rash. I see a person who with the proper treatment and compassion can become whole again.

 

Photo credits:

Featured– Jean-Pierre Dalbéra

In-text- Taylor Thomas

Categories
Clinical Emotion Empathy Narrative Reflection

Takotsubo

Valentine’s Day is not typically kind to medical students. While many couples share flowers and romantic dinners, my fiancé and I looked forward to escaping the hospital just long enough to exchange sweet-nothings over take-out sandwiches. Though lacking in outward displays of affection, this Valentine’s Day was imbued with something different. A few weeks ago, a patient taught me that love, it turns out, can exalt us and confound us, but it can also, literally, break our hearts.

He was a thin man in his late seventies, a mop of unruly gray hair on his head. He came into the emergency room one evening, unable to catch his breath and complaining of severe chest pain. An EKG was rapidly obtained and showed concerning peaks and valleys of electrical activity. Troponin levels were rapidly increasing in his blood. TC, it appeared, was having a heart attack.

Image courtesy of Med Chaos

Though still in the early stages of my medical training, I knew what would come next. In rapid succession, TC would be rushed to the cardiac catheterization lab, and a stent would be placed in his coronary arteries, restoring desperately needed blood flow to his heart. He would recover. His loving wife and adult children would visit him in the hospital. In a few days he would return home.

I was wrong. Try as they might, TC’s doctors were unable to find any blocked arteries in his heart. With nothing to stent open, TC was admitted to the medicine ward for careful observation. Miraculously, his condition stabilized.

The next morning he was feeling better. Not wanting to forego his calisthenics, I found him walking along the bustling hospital corridor, pausing briefly outside each room to greet his fellow patients. As I corralled him back to his room for morning rounds, I couldn’t help but notice the gold wedding ring hanging from a length of frayed twine around his neck. He caught my gaze and smiled, “pretty, isn’t it?”

Lowering himself carefully to his bed, he explained why he no longer wore the ring on his finger. His wife, he lingered on the word, had died almost three months ago. His children, long since grown, had come home for a while, but were now back to their own lives. He’d considered moving into a smaller place—less lonely he figured—but he couldn’t bear the thought of discarding any of her things.

Later that day, TC went for an echocardiogram which immediately revealed his diagnosis.

He had Takotsubo cardiomyopathy, also known as “broken heart syndrome.” It is a rare condition, but strikes most commonly after a period of great emotional turmoil. Marked by chest pain and shortness of breath, the initial presentation is not at all dissimilar to a heart attack, so committed in its mimicry that the EKG and blood findings are often identical.

Although the pathogenesis of Takotsubo cardiomyopathy is not completely understood, it is postulated that adrenaline, released in times of great emotional distress, may overwhelm and eventually damage the heart. With enough damage, the heart breaks, contorting itself into a characteristic shape—wide at the bottom with a distinctively narrow neck. The shape resembles a Japanese takotsubo pot, a vessel historically used to trap octopus.

As a trainee in the field of medicine, my classroom preparation taught me to be objective—to plumb the pertinent facts of a patient’s history and physical exam in order to provide effective treatment. But it is patients like TC who teach me that good doctoring requires something more. Though less tangible, it is clear that one’s physical and emotional well-being are inextricably linked.

Several days later, heart ostensibly healed, TC was ready to return home. He stepped into the elevator, turned, and waved goodbye. A gold ring shone brightly on his finger.

Photo credit: Chandrahadi Junarto

 

Categories
Clinical Emotion Empathy General Patient-Centered Care

Opinions Aren’t Facts

I wanted to discuss an experience I had in the newborn nursery. I was assigned to Baby K—a small baby girl who was delivered by emergent cesarean section because her mother abused cocaine during her pregnancy. Looking through Baby K’s chart, an unsettling feeling came over me. This was one of the first times I directly saw how a mother’s behavior impacted her child. Before this, all my clerkships had dealt with adults who were responsible for their own health. Seeing an innocent newborn enter this world with a disadvantage because of her mother’s actions was disheartening.

With this in mind, I went to talk to Mother K the next morning. The chart stated Baby K was going to be given to her great-grandmother, and I needed to confirm this information. I could immediately tell that Mother K was upset when I asked her to confirm. She said, “Yes, she’s going to her great-grandma, but I’m still going be involved! I’m NOT giving up on her!” I realized that just asking the question caused her emotional pain. Especially since the social worker, the nurse, and probably several others, had also asked this question. She again assured me that she loved Baby K, but that she just needed to get her life together before she could care of her. After talking more to Mother K, I realized she was trying her best.

This experience opened my eyes to my perception of patients. After browsing Mother K’s chart and reading that she continued to abuse cocaine while pregnant and was planning on giving Baby K to another caretaker, I may have made the assumption that she didn’t want anything to do with Baby K at all. This assumption may have been reflected in the way I asked her questions, leading her to become distraught. Many patients, especially those who suffer from substance abuse, have lost complete control over their actions. Their mind is controlled by an addiction, and they need help before they can take care of others. After talking more with her, I learned that Mother K actually planned to enroll herself in a treatment center that has housing. After getting better, she yearned to resume care of Baby K. These are details that were never mentioned in any notes, but if they had been mentioned, may have altered my first impression of Mother K before I met her. I also learned that Mother K continued to use cocaine during her pregnancy because she didn’t realize its impact on Baby K. She used cocaine during her prior pregnancy with her older son, and he remained “normal and healthy.” Even though we, as medical professionals, can understand how abusing cocaine during pregnancy is directly detrimental to the fetus, many individuals may not understand this basic concept of maternal-fetal physiology. We thought Mother K’s use of cocaine was due to her lack of care for Baby K, when in reality it was fueled by her lack of knowledge.

The most important lesson I learned was not to judge patients based on chart review alone. I know this seems like “common sense,” but it can be easy to jump to certain perceptions after reading the tone of some of the notes in a patient’s chart. My goal in the future is to enter every patient’s room with a blank slate. Our duty has always been to provide the same quality of care for all patients, regardless of their actions or beliefs, but sometimes we let our feelings get in the way of this duty. I have struggled with this in pediatrics more than I have in any other specialty. When I talk to parents who are willing to move mountains for the health of their children, I feel endearment towards them. There is nothing stronger or more special than a parent’s love. In contrast, with parents like Mother K, it is easy to become frustrated. After examining Baby K, I kept thinking about her fragile little arms and small shrunken head. Baby K may grow up to have health consequences that could have easily been prevented. All I can do is allow this experience to shape future patient encounters. I’m going to try to place myself in each parent’s situation and ask myself: what information or advice would I find the most helpful right now? At the end of my time with Mother K, I gave her a tight hug—I’m rooting for her. I hope she is able to complete her treatment and be reunited with Baby K soon.

 

Photo credit: Weird Beard

Categories
Clinical Emotion Empathy General Patient-Centered Care

Are you a cheerleader or a fan? Examining motivation in medicine

One of my favorite aspects of medicine is the relationship between health and lifestyle. I think of lifestyle as all of the “stuff” that affects patients outside of the exam room, including diet, exercise, family relationships, and living accommodations. All of these things affect the physical body in ways that are not always immediately apparent. In my most recent rotation, my preceptor and I treated several obese women complaining of low back and hip pain.  Thinking about the relationship about weight and musculoskeletal pain, I was surprised that my preceptor never made suggestions to patients about increasing their activity level or improving their diets. “I’ve realized that I’m not a cheerleader,” he told me, when I questioned him. “Trying to make people change only ends in heartache for me.”

It’s difficult to think about how patients can change their lifestyles without first thinking about their motivation for change. January happens to be the perfect time talk about motivation since this is the time of the year when people are making those pesky New Year’s resolutions.  W.D. Falk, a philosopher, writes about motivation as a direct product of one’s morals, and divides motivation into two subtypes: motivational internalism and motivational externalism. Motivational internalists believe that one’s motivation for doing something is directly linked to how the activity in question relates to one’s morals. In other words, if a patient is convinced that exercise is a good, morally correct thing to do, that moral conviction will be enough to motivate them to exercise. On the contrary, motivational externalists see no link between one’s moral convictions and their motivation. No matter how important or morally correct our patients think something is, their motivation for changing their lives has to come from some external source. A patient may believe that exercise is a morally good activity, but this belief alone is not enough to actually motivate them to exercise.

Acknowledging the existence of these two groups (and of course, many shades of grey in between!) will allow us to understand how we may best help our patients without using a “one size fits all” methodology. Some patients may able to find the impetus for change within themselves. These patients may articulate specific plans to achieve a goal or they may have independently improved their own wellbeing in the past. Other patients may need external motivating factors to make changes necessary to improve their health, most often in the form of a trusted confidant. We need to use our best clinical judgment to decide which approach would work better for each patient.

My preceptor’s comments also helped me recognize that in addition to understanding our patients’ capacities for change, we also need to think of our own capacities for motivating our patients. Some physicians are cheerleaders willing to stand on the front lines with their patients. These practitioners feel energized by helping people make positive changes and are willing to make an emotional investment in their patients’ lives. They help their patients set goals, consistently communicate with patients about their progress, and are willing to act as an emotional support whether or not the goals get met. Other physicians may not see themselves as cheerleaders for change. These physicians still have a responsibility to discuss aspects of their patients’ lifestyles that need improvement; however, their role might take form as a “fan” in the stands, rather than a cheerleader on the sidelines. They can still cheer on their patients and check in with them about their lifestyle changes, but may need to help patients find someone else in their healthcare team who is willing to do the ground work that it takes to help patients set and reach goals. In fact, I believe that it is far better to honestly acknowledge that you are a lousy cheerleader than to try to help your patient, only to become disheartened by their lack of progress and abandon them out of sheer frustration before their goal is met. It’s only through an honest acknowledgement of our own abilities and limitations that we can help our patients change their lifestyles for the better.

 

Photo credit: Jeff Turner

Categories
Clinical General Law Opinion Patient-Centered Care Pharmacology Public Health

Access to Contraception

Contraception is essential to a woman’s health, empowerment, equality, and independence. This belief is championed by the Center for Reproductive Rights, Guttmacher Institute, Planned Parenthood, and others. More importantly, governing bodies of health care overwhelmingly defend access to contraception:

 “Contraception is a pillar in reducing adolescent pregnancy rates.”

  • The American Academy of Pediatrics [1]

 “Clinicians should discuss all contraceptive methods that can be used safely by the patient, regardless of whether a method is available on site and even if the patient is an adolescent or a nulliparous woman.”

  • American Academy of Family Physicians [2]

“The American College of Obstetricians and Gynecologists [ACOG] supports access to comprehensive contraceptive care and contraceptive methods as an integral component of women’s health care and is committed to encouraging and upholding policies and actions that ensure the availability of affordable and accessible contraceptive care and contraceptive methods.”

  • American College of Obstetrics and Gynecology [3]

“Access to safe, voluntary family planning is a human right. Family Planning is central to gender equality and women’s empowerment, and it is a key factor in reducing poverty.”

  • United Nations Population Fund [4]

“This policy supports the universal right to contraception access in the United States and internationally.”

  • American Public Health Association [5]

“Family Planning, an integral component of sexual and reproductive health, is a critical pillar for health and development; it is also a human rights issue…When women are denied their right to and choice of family planning methods, they become trapped in a vicious cycle of poverty, poor health outcomes from ill-timed pregnancies and limited capacity to fully realize their potential.”

  • World Health Organization [6]

 

Contraception is regarded by the CDC as one of the 10 greatest public health achievements of the 20th century.[7] Of the many reversible contraceptive options available, implant and intrauterine device are most effect, with less than 1% risk of failure for both perfect and typical use compared to an 18% failure rate for typical male condom use.[8] Of course, condoms are the only available contraceptive method that also protects against transmission of infections, including the human immunodeficiency virus (HIV) and human papilloma virus transmission through certain makes of condoms.

Benefits of contraception include: improved health and well-being, reduced global maternal mortality, pregnancy spacing and subsequent health benefits, increased participation of females in the workforce, and economic independence for women.[9]

In the United States, 70% of women ages 15 to 44 years old are sexually active and do not want to become pregnant. Thus, 70% of reproductive aged women are at risk of unintended pregnancy. The Guttmacher Institute, a leading researcher of reproductive health, reported that consistent and correct use of modern contraception (i.e. condom, hormonal contraception, long-acting method, or permanent method) without any gaps in use during all months a woman is sexually active resulted in 68% of sexually active reproductive age women avoiding an unintended pregnancy.[10] These women accounted for only 5% of unintended pregnancies that occurred in 2008. In comparison, 41% of the 3 million unintended pregnancies were a result of inconsistent modern contraceptive use and 54% resulted from nonuse.[10]

Sadly, in addition to other Catholic-based religious organizations, the United States Conference of Catholic Bishops argues that contraception does not prevent unintended pregnancy nor reduce abortion rates.[11] The USCCB also does not believe that contraception is basic health care.[12] Instead, the USCCB states,

 “Contraception is an elective intervention that stops the healthy functioning of healthy women’s reproductive systems. Medically it is infertility, not fertility, that is generally considered a disorder to be treated.”

Let me be clear. Access to contraception is basic health care. 222 million women globally have an unmet need for modern contraception.[4] This burden is highest in vulnerable populations such as adolescents, those from low socioeconomic households, those with HIV, and internally displaced persons.[4]

The WHO issued guidance and recommendations on “Ensuring human rights in the provision of contraceptive information and services,” in which officials outline nine priority actions policy makers and providers need to take to ensure that human rights are protected in the provision of contraceptive information and services.[13] These steps include:

  1. Non-discrimination in provision of contraceptive information and services
  2. Availability of contraceptive information and services
  3. Accessibility of contraceptive information and services
  4. Acceptability of contraceptive information and services
  5. Quality of contraceptive information and services
  6. Informed decision-making
  7. Privacy and confidentiality
  8. Participation
  9. Accountability [of programs that deliver contraceptive information and services]

In regards to current politics and policy proposals, accessibility of contraceptive options includes affordability.

Under the Affordable Care Act (ACA) healthcare law, preventative women’s health services—including well-woman visits; screening for gestational diabetes; human papilloma virus testing; counseling for sexually transmitted diseases; counseling and screening for HIV; contraceptive methods and counseling; breastfeeding support, supplies, and counseling; and screening and counseling for interpersonal and domestic violence—are covered without any co-payment, co-insurance, or deductible.[14] For reference, if the ACA healthcare law were not in place, the average out-of-pocket cost for birth control would be $78-$185 per year.[14] For myself, my oral contraceptive pills cost $30 per month, totaling $360 per year! This was a financial burden as a student—but essential for my overall health—and so, I budgeted. But not everyone has that capability.

The ACA’s expansion of health care coverage and improved access to care also resulted in reductions in delayed care, as well as improved maternal and newborn outcomes. From 2010 to 2014, the proportion of women who reported delaying or forgoing care due to cost concerns dropped by 3.4%.[15] The health care law also funded the Strong Start for Mothers and Newborns Initiative, a collaboration between the Centers for Medicare & Medicaid Services, the Health Resources and Services Administration, and the Administration on Children and Families. The initiative aims to reduce preterm birth rates and improve maternal and newborn health outcomes. This is key because full-term babies have improved outcomes compared to those born in an early, term elective delivery.

The United States Human Health and Services notes that actuaries, insurers, and economists generally estimate that contraception provisions are at least cost-neutral and may, in some cases, result in cost-savings when taking into account the costs and benefits of unplanned pregnancies.[14] In 2009, the UNPF and Guttmacher Institute published a detailed report explaining how family planning and maternal and newborn health services saves lives and money. Preventing and/or postponing unintended pregnancies results in fewer expenses due to the decreased need for maternal and newborn health care and the management of unsafe abortions.[16] In addition, ensuring standards of maternal and newborn health care reduces the rates of complications and subequently incurred high costs.

Keeping these considerations in mind, our current political climate is of great concern because on January 20, 2017, President Donald Trump issued an executive order to repeal the ACA.[17]

I received an email update this week from ACOG reporting that the AAFP, American College of Physicians, AAP, ACOG, and American Osteopathic Association mailed a joint letter representing over 500,000 physicians asking the White House and Congressional leaders to “stand with us and for America’s women” because “healthy women can better participate in our economy and our workforce, and can reach higher levels of educational attainment.” The letter also identifies four priorities moving forward, one of which is to ensure that women have affordable access to evidence-based care.[18]

ACOG’s committee opinion on access to contraception emphasizes full implementation of the ACA requirement that,

“…new and revised private health insurance plans cover all U.S. Food and Drug administration-approved contraceptives without cost-sharing, including non-equivalent options from within one method category (eg. levonorgestrel as well as copper intrauterine devices).” [3]

Throughout the next few months and years when you are voting or exercising your right to debate the very real challenge we face to reduce health care costs, please remember that investing in family planning and maternal and newborn health care services saves money. And remember that leading healthcare organizations—the very governing bodies who set the standards for evidence-based care—strongly advise that the White House and Congress to write healthcare laws that ensure affordable women’s health care and access to contraception. I urge readers to fight for access to contraception, a necessary and significant human right.

For more information about available contraceptive options, please see the “Birth Control (Contraception): Resource  Overview” published by ACOG, available at http://www.acog.org/Womens-Health/Birth-Control-Contraception#Patient.

References

  1. Committee on Adolescence. Policy Statement: Contraception for Adolescents. Pediatrics. 2014
  2. Klein DA, Arnold JJ, and Reese ES. Provision of Contraception: Key Recommendations from the CDC. Am Fam Physician. 2015;91(9): 625-633.
  3. American College of Obstetricians and Gynecologists. Access to contraception. Committee Opinion No. 615. Obstet Gyneco.l 2015;125:250-5.
  4. United Nations Population Fund and Center for Reproductive Rights. Family Planning. Available at: http://www.unfpa.org/family-planning. Accessed November 29, 2015.
  5. American Public Health Association. Universal Access to Contraception; Policy 20153. November 2015. http://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2015/12/17/09/14/universal-access-to-contraception. Accessed: November 28, 2016.
  6. World Health Organization. Family Planning Summit, 11 July 2012: WHO’s Commitment. Available at: http://www.who.int/reproductivehealth/topics/family_planning/WHO_commitment_fp.pdf?ua=1. Accessed: November 30, 2016.
  7. Sonfield A, Hasstedt K, Kayanaugh MI, Anderson R. The social and economic benefits of women’s ability to determine whether and when to have children. New York (NY) Guttmacher Institute; 2013. Available at: http://www.guttmacher.org/pubs/social-economic-benefits.pdf. Accessed: November 29, 2016.
  8. Guttmacher Institute. Contraceptive Use in the United States. September 2016. Available at: https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states. Accessed: November 29, 2015.
  9. Starbird E, Norton M, and Marcus R. Investing in Family Planning: Key to Achieving the Sustainable Development Goals. Glob Health Sci Pract. 2016;4(2):191-210.
  10. Guttmacher Institute. Infographic: Contraception is highly effective. July 2013. Available at: https://www.guttmacher.org/article/2013/06/infographic-contraception-highly-effective. Accessed: November 28, 2016.
  11. Emergency Contraception Fails to Reduce Unintended Pregnancy and Abortion. Available at: http://www.usccb.org/issues-and-action/human-life-and-dignity/contraception/fact-sheets/emergency-contraception-fails-to-reduce-unintended-pregnancy-abortion.cfm Accessed: February 2, 2017.
  12. Fact Sheet: Contraceptive Mandates. Available at: http://www.usccb.org/issues-and-action/human-life-and-dignity/contraception/fact-sheets/contraceptive-mandates.cfm Accessed: February 2, 2017.
  13. Ensuring human rights in the provision of contraceptive information and services: Guidance and recommendations; 2016. Available at: http://apps.who.int/iris/bitstream/10665/102539/1/9789241506748_eng.pdf?ua=1. Accessed: November 28,2016.
  14. S. Department of Health & Human Services. Fact Sheets: Women and the Affordable Care Act. Available at: https://www.hhs.gov/healthcare/facts-and-features/fact-sheets/women-and-aca/index.html. Accessed: November 28, 2016.
  15. Simmons A, Taylor J, Finegold K, Yabroff R, Gee E, and Chappel A. The Affordable Care Act: Promoting Better Health for Women. ASPE Issue Brief;2016:1-10.
  16. UNFPA and Guttmacher Institute. Adding it Up 2014: The Costs and Benefits of Investing in Sexual and Reproductive Health. UNFPA, Guttmacher Institute. 2016;1-56.
  17. The White House Office of Press Secretary. Executive order minimizing the economic burden of the patient protection and affordable care act pending repeal. Available at: https://www.whitehouse.gov/the-press-office/2017/01/2/executive-order-minimizing-economic-burden-patient-protection-and. Accessed: January 2, 2017.
  18. Healio Family Medicine. AAFP, ACP, others join forces in new effort to protect women’s health. Available at: http://www.healio.com/family-medicine/womens-health/news/online/%7B1b88e282-cd33-402c-a97a-bea5ef45238f%7D/aafp-acp-others-join-forces-in-new-effort-to-protect-womens-health . Accessed: January 2, 2017.

Photo credit:

Blue coat photos

Categories
Clinical Narrative

Why I Stand with Planned Parenthood

After writing “ Storytelling and Patient Advocacy,” I cuddled up to a cup of warm coffee and reflected on the various moments in my life that inspired me or motivated me to take action. I thought about my story; why I applied to medical school and why I have certain research interests. Then I asked why I want to improve access to and the quality of reproductive health care. Immediately I thought about the question friends and family frequently ask me: “Why would you support Planned Parenthood if you want to help women?” My answer is this story:

As a third year medical student who will soon be applying to an obstetrics and gynecology residency, I am afraid.  The recent violence in my community and continued aggression against Planned Parenthood suggests that aligning oneself with the organization is risky.  Becoming an obstetrician gynecologist (OB/GYN) has been my dream since elementary school, so I feel anxious when family members share concerns that publicly supporting Planned Parenthood ensures I will not match to an OB/GYN program.  Will standing with Planned Parenthood keep me out of a program?  Is it OK to discuss abortion training on a residency interview?  Or do I need to use code like, “What family planning training opportunities are available?”  And in light of the attack on the clinic in Colorado, is my life in danger?  A pro-reproductive rights provider and avid supporter of Planned Parenthood wrote to me, stating that she is afraid to rotate at their clinics for fear of an attack.  She hauntingly added, “The terrorism is working.”  I almost never employ self-censorship, yet I too hesitated to continue to develop a professional relationship with Planned Parenthood.  Even scarier is to discuss that affiliation publicly.  A friend reminded me that in times of confusion or fear, it is best to have a mantra that can elicit courage.  My inner voice reminds me, “Be a rock star woman.”

A couple years ago, after my reproductive and endocrinology module, and after being influenced by readings about sexually transmitted disease (STD) pathology, I requested a full STD screen during my annual well-woman exam. The nurse told me, “We don’t do that here. You’ll have to go somewhere like Planned Parenthood.”  I left embarrassed and did not follow-up with another clinic.  Enter my third year clerkships when, on a pediatric service, my team treated a 15 year old female who was 21 weeks pregnant presenting with “vaginal pain and fainting during sex.”  I was ecstatic to finally manage an obstetrics (OB) case, and I excitedly took a medical history.  While writing my notes, I overheard a group of nurses say that this girl would not have “gotten herself pregnant” if she knew how to use a condom.  I interjected that the American College of Obstetrics and Gynecology now recommends long-acting intrauterine devices (IUDs) as the leading contraceptive option for adolescents because it is the most effective, safe, private, and does not rely on user consistency (ACOG, 2012).  Three nurses and a resident mistakenly retorted that IUDs cannot be given to adolescents or females who have not been pregnant due to increased risks to the uterus.  Because an intrauterine device is placed inside of the uterus during an office pelvic exam and contains a small string that trails into the vagina, old theories warned about uterine perforation, pelvic inflammatory disease (PID), and subsequent infertility.  They are wrong.  There are no cases of infertility following IUD use, no increased absolute risks for PID, and minimal incidence of uterine perforation (ACOG, 2012; ARHP, 2015).  Shockingly, this has been known in the medical community for more than a decade, yet there continues to be widespread ignorance about it among healthcare professionals.

I observed a similar case during a later clinical experience.  I listened to the physician refuse an IUD to a young woman with a history of unintended pregnancies based on his belief that adolescents are promiscuous and will develop pelvic infections.  His words, “We don’t offer those here.  You’ll have to go somewhere else like Planned Parenthood.”  Do you see the pattern?  It is no secret that judgement, ignorance, and prejudice exist in healthcare.   What is a medical student to do when faced with blatant disregard for clinical guidelines and scientific evidence that has been undisputed by science for over a decade?  I decided to contribute to the advancement of research and education by volunteering with Planned Parenthood, an organization that provides safe, up-to-date, and judgement-free care.

I regularly volunteer at Planned Parenthood as a patient escort, walking patients from their vehicles to the clinic doors.  Let me set the scene.  My local office is visited by anywhere from three to more than twenty protestors daily.  They stand on the sidewalk mostly shouting and waving signs at passing cars.  A few people silently pray with a rosary.  The first time I arrived, I had to excuse myself to the restroom because the hateful screams of “Baby killer with blood all over your hands!” were too shocking for me to bear.  Eventually I became better equipped to disregard protestors. However, that took time, and if I, a student medical provider, was mortified when my gynecologist’s office told me to go to Planned Parenthood for a standard STD screen, can you imagine the emotions a young patient experiences when walking from their car at a Planned Parenthood clinic, listening to protestors scream?  So I stand for hours in front of a Planned Parenthood clinic, deflecting the endless onslaught of insulting remarks, in the hopes that people can feel a little more secure receiving an STD screen, a pap smear, an IUD placement, or yes, an abortion.

The fact remains that Planned Parenthood is a leading provider of reproductive health care services.  A central focus is prevention, encompassing STD and cancer screening as well as contraception.  They provide prenatal services and references for those choosing to pursue adoption, in addition to abortion services and other reproductive health care.  The Guttmacher Institute, another source of global sexual and reproductive health, reported in July 2015 that half of all pregnancies each year (greater than 3 million) are unintended; the same statistic that has existed for two decades (Guttmacher, 2015).  More than half of women of reproductive age (13-44 years old; 38 million) need contraceptive services, and 20 million of those women require publicly funded services and supplies.  In addition, the average Planned Parenthood health center serves significantly more women seeking contraceptive services than all other publicly-funded safety-net clinics.

An interview on Fresh Air with Jonathan Eig, author of The Birth of the Pill: How Four Crusaders Reinvented Sex and Launched a Revolution, made me think more about Planned Parenthood’s role in women’s health care.  In the book he describes the challenges scientists and Margaret Sanger faced when trying to develop a “magic pill that would allow women to control when and if they got pregnant”—Wouldn’t that be great?  Oh wait, we thankfully have that now in pill, patch, injection, implant, and intrauterine device forms.  The developers of the pill studied progesterone’s effect on inhibiting ovulation under the guise that they were studying infertility treatment.  I wonder if the current, hostile climate surrounding Planned Parenthood will later be compared to the ludicrousness of 1950s-era United States, when our country outlawed female contraception, while allowing men to easily purchase condoms.  When I learn about the backlash surrounding the development of birth control, arguably the most important invention of the 20th century, how could I let threats prevent me from supporting an organization that is one of the few to consistently provide safe and evidence-based services without judgement?  The answer is, I cannot.  My career goal is to help women access and achieve the best reproductive care.  That is why I stand with Planned Parenthood.

References:

American College of Obstetrics & Gynecology. (2012). ACOG committee opinion no. 539: Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices. Obstet Gynecol. 117(6):1472-83.

Association of Reproductive Health Professionals (2015). The Facts About Intrauterine Contraception [Fact Sheet]. Retrieved from http://www.arhp.org/Publications-and-Resources/Clinical-Fact-Sheets/The-Facts-About-Intrauterine-Contraception-

Guttmacher Institute. (2015). Publicly Funded Family Planning Services in the United States [Fact Sheet]. Retrieved from http://www.guttmacher.org/pubs/fb_contraceptive_serv.html

Featured image:
Me (far left) escorting guests to the annual Planned Parenthood of Southwest and Central Florida Fundraising Gala.

Categories
Clinical Opinion

Mental Disorders: Are We Over Medicating?

In 1948, the World Health Organization (WHO) defined health as “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.” However, mental illnesses are not seen in the same light as physical illnesses. People who get labeled with psychiatric diagnoses often carry a heavy burden of social stigma regarding those diagnoses, and are generally uncomfortable disclosing and/or discussing them openly.

In ordinary conversation, it is not considered strange to mention that you had an appendectomy or discuss how you’ve been dealing with your diabetes for years. However, saying that you’ve been manic-depressive for years or that you’ve been desperately trying to overcome panic attacks is something that typically generates a negative response, and raises red flags for some people.

Why is mental health perceived so differently than somatic and physical health?

My inspiration for writing this piece was a debate about mental disorders held at the Emmanuel Centre in London, entitled: We’ve Overdosed. Psychiatrists and the Pharmaceutical Industry are to Blame for the Current Epidemic of Mental Disorders. Psychoanalyst Darian Leader, and accomplished author on the issue Will Self, argued for the “overdosed” side, while Dr. Declan Doogan and Professor Sir Simon Wessely, president of the Royal College of Psychiatrists, argued against it.

Is it true that mental disorders are made up by big pharma? Or is it just that we have a difficult time accepting that our psyche can, indeed, be a subject (or object, depending how you see it) of pathologic deviance and aberration? And that such aberration could and should be subjected to medical treatment?

Some critics view mental disorders as illnesses that have no definitive pathomorphological substrates. Are physicians overprescribing these agents to satisfy big pharma interests? Do they purposefully try to make the psychiatric bible (a.k.a. Diagnostic and Statistical Manual of Mental Disorders – DSM) thicker and thicker in each subsequent edition by bloating it with irrelevant and artificially fabricated diagnoses?

No one is claiming that every form of deviation from the “gold standard” of behavior (if such thing exists at all) is and should be proclaimed as a psychiatric disorder. No one is saying that every psychiatric disorder needs to be treated pharmacologically. No one is denying that many psychotropic drug treatments, unfortunately, fail among some patients. No one is saying that some classes of psychotropic drugs don’t induce debilitating side effects.

However, as future physicians we always have to remember that we will have a person with a problem sitting in front of us. This person will be seeking our help. We only have what is available to help them. We can only fight with the weapons that we have. Yes, sometimes treatment in psychiatry feels like we are trying to kill a mosquito with a rocket launcher. But it is the only thing we have got and for some it can be a salvation, regardless of the collateral damage.

My psychiatry professor once said, “if there is an equivalent of hell on Earth, it would be in a soul of a depressed person.”  I could not agree more.

Severe mental disease is not a joke. It is not something that can be solved with a thoughtful late afternoon conversation, by reading a line or two from Coehlo, or by reciting a poem by Neruda. Sure, activities like those are great adjuncts and can help ameliorate the situation to a degree, but people who are in trouble often need and demand much more from us.

Let’s not forget that when we’re talking about mental disease we are talking about the state of a diseased brain (physical) and mind (cognitive/psychiatric), which is most likely due to a neurochemical imbalance within the central nervous system circuits. This imbalance needs to be medically treated, especially in cases where it severely interferes with daily living. For some people, psychotropic medication is their only hope and the only chance they are going to get. For some people these medications perform miracles. We do not have a right to deny them such a possibility.

References

  1. Angermeyer MC, Matschinger H. The stigma of mental illness: effects of labelling on public attitudes towards people with mental disorder. Acta Psychiatrica Scandinavica. 2003;108(4):304-9. doi: 10.1034/j.1600-0447.2003.00150.x.
  2. Schomerus G, Schwahn C, Holzinger A, Corrigan PW, Grabe HJ, Carta MG, et al. Evolution of public attitudes about mental illness: a systematic review and meta-analysis. Acta Psychiatrica Scandinavica. 2012;125(6):440-52. doi: 10.1111/j.1600-0447.2012.01826.x.
  3. Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. Jama. 2010;303(1):47-53. Epub 2010/01/07. doi: 10.1001/jama.2009.1943.
  4. Arroll B, Elley CR, Fishman T, Goodyear-Smith FA, Kenealy T, Blashki G, et al. Antidepressants versus placebo for depression in primary care. Cochrane Database of Systematic Reviews. 2009(3). doi: 10.1002/14651858.CD007954.
  5. Leucht C, Huhn M, Leucht S. Amitriptyline versus placebo for major depressive disorder. The Cochrane database of systematic reviews. 2012;12:Cd009138. Epub 2012/12/14. doi: 10.1002/14651858.CD009138.pub2.

Featured image:
Reeve041788 by Otis Historical Archives National Museum of Health and Medicine

Categories
Clinical Opinion Public Health

The Opiate Epidemic: A tragedy for patients is a warning to physicians

As student doctors, we are entering the medical field in the middle of a raging wildfire: an “opiate abuse epidemic.”[1] The media would have us believe that addicted patients are perpetuating the problem of opiate misuse and overuse, but opiate misuse and overuse might only be a symptom of a larger problem: a medical culture in which physicians fail to practice good prescribing habits.

Overprescription and subsequent overuse of opiates is undoubtedly further complicated by the ambiguous disease process of chronic pain, a topic which deserves its own time and attention. Questioning provider prescribing practices, however, may be the only path forward in making sure that the tragedy of this crisis does not escalate further. In my mind, there are several features that characterize ideal, quality prescribing habits. First, quality prescribing should place an emphasis on patient education about the drug being proposed. A patient should also be screened for the risk of developing any side effects. Included in this should be a review of any other medication that the patient is currently taking, and potential drug-drug interactions. If necessary, a pharmacist should be involved in this evaluation. Finally, a plan between the physician and the patient to manage care should be established. For medications known to be highly addictive, this might involve a phone call a week later, and a follow up in-office appointment to see how the patient is reacting to the prescribed drug. If at any point these benchmarks for safely prescribing a medication cannot be met, then the treatment choice should be reevaluated.

It was curious timing that in the middle of this epidemic, on May 5, Hawaii House Bill 1072 quietly died in the Hawaii state senate.[2] Bill 1072 “Relating to Prescriptive Authority for Certain Psychologists,” was meant to allow psychologists to have medication prescribing privileges in order to compensate for the Hawaiian physician shortage.[3] At first, I was relieved to read that the bill had not passed the Senate. As a future physician, it’s unsettling to imagine another profession encroaching on the special modalities that we have at our disposal to treat patients, such as our prescribing privileges. But then I had a second thought. If the average physician fails to exercise high-quality prescribing practices, then perhaps clinical psychologists, who by definition study human behavior, might actually make better opiate prescribers than the average physician. In general, psychologists spend time listening and learning about their patients’ history and behavior patterns, offer counseling education, and meet with their patients on a regular basis. This model of health care encompasses many of the aspects needed for ideal prescribing habits, as previously described.

You don’t need a medical degree to understand that opiates are powerful drugs that have many side effects and can lead to addiction.  What we don’t yet seem to understand, as a profession, is how to effectively communicate these risks, or evaluate the best patient candidates for the use of opiates. A 1992 study by Wilson et al. found that when physicians increased the time of their patient interactions by just 1.1 minutes, there was a statistically significant increase in the amount of health education that a doctor could incorporate into a standard visit.[4] While it’s difficult to get specific data about the average length of a typical doctor’s visit[5], a 2013 article from the New York Times suggests that the average new physician spends only eight minutes with each patient.[6] If you have ever participated in a standardized patient encounter as part of your medical school curriculum, you have undoubtedly experienced the struggle to perform a history, physical exam, and basic patient counseling in 14 minutes. When you take into account the level of patient screening and education that the prescription of opiates, or any narcotic, demands, it seems implausible that a doctor can satisfy the requirements necessary to safely discharge a patient with an opiate prescription in such a short span of time.

In response to the opiate crisis, the ultimate long-term goal for the medical community should be to better understand chronic pain, and devise alternative treatment modalities for this diagnosis. In the meantime, however, the medical community should view this unfortunate situation as a call to reevaluate the quality of our prescribing practices. Current and future doctors need to commit ourselves to being worthy of the privilege of the prescription pad, so that it remains a treatment tool and not a source of patient harm.

References:

  1. http://www.cnn.com/2016/05/11/health/sanjay-gupta-prescription-addiction-doctors-must-lead/index.html
  2. www.civilbeat.com/2016/05/2016-session-ac-for-schools-help-for-housing-and-homeless/#.VyzIubQqa3o.mailto
  3. http://capitol.hawaii.gov/measure_indiv.aspx?billtype=HB&billnumber=1072&year=2016
  4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1881485/
  5. http://www.ajmc.com/journals/issue/2014/2014-vol20-n10/the-duration-of-office-visits-in-the-united-states-1993-to-2010
  6. http://well.blogs.nytimes.com/2013/05/30/for-new-doctors-8-minutes-per-patient/

Featured image:
Medication by Gatis Gribusts