Categories
Clinical Emotion General Humour Lifestyle Literature Medical Humanities Narrative Reflection

On Playing Doctor

An excerpt from “Playing Doctor: Part Two: Residency”

By: John Lawrence, MD

As was her habit, she [the surgical chief resident] had called to check in with a surgical nurse to see how each of her patients was doing. They were discussing each patient when the nurse stopped to mention that there was a code team outside a room on the sixth floor with a collapsed patient.

My girlfriend quickly realized that it was one of her patient’s rooms, then raced back to the hospital, sprinted up six flights of stairs, and dashed onto the sixth floor, where she encountered a chaotic group of people surrounding one of her patients lying unconscious in the hallway.

The internal medicine residents and attending physician running the code were about to shock the unconscious patient because he had no pulse. As we’ve discussed previously, no pulse is bad.

Suddenly, in the middle of their efforts, and much to everybody’s surprise, the 5’1” surgery chief ran up, injected herself into their midst, ordered them to stop, and demanded a pair of scissors.

Nobody moved. The internal medicine attending exploded, wondering who the hell she was and what she was doing. It was his medicine team in charge of the code, and this patient had no pulse. Protocol was shouting for an immediate electric shock to the stalled heart.

Paying little or no attention to his barrage of questions, she grabbed a pair of scissors and now, to everyone’s complete and utter shock, cut open the patient right through the surgery wound on his abdomen.

Let me recap in case you don’t quite appreciate what’s going on: she cut open a person’s abdomen in the middle of the hospital hallway—and then stuck her hand inside the patient!

When the chairman of surgery came racing down the hall, he found his chief resident on the floor wearing a full-length skirt, with her arm deep inside an unconscious patient, asking, “Is there a pulse yet?”

The furious medical attending was shouting, “What are you doing? Are you crazy? What are you doing?”

And she kept calmly asking the nurse, over the barrage of shouts and chaos, “Do you have a pulse yet?”

Suddenly the nurse announced, “We’re getting a pulse!”

Which immediately quieted everyone.

Being an astute surgeon, she remembered thinking that the patient’s splenic artery had appeared weak when they operated on him. She correctly guessed that the weakened artery had started bleeding, and that his collapsing in the hallway was due to his rapidly losing blood internally. She had clamped the patient’s aorta against his spine with her hand to stop any further blood loss.

From the sixth-floor hallway the patient was rushed to the O.R. with my girlfriend riding on top of the gurney, pressing her hand against his aorta, keeping the guy from bleeding to death.

She then performed the surgery to complete saving his life.

The guy took a while to recover. Being deprived of blood to the brain had its detriments; when he awoke, he was convinced the 5’1” blond surgeon in the room was his daughter. When he was informed that no, she wasn’t his daughter, he apologized, “Sorry, you must be my nurse.” That comment, one she heard all too frequently, did not go over well.

To put this somewhat crazy event into perspective, within a day or two, the story became the stuff of legends told throughout surgical residencies across the country—and this was before social media sites existed to virally immortalize kitten videos.

Opening a patient in the hallway and using her hands inside the guy to save his life? This feat, treated by her as nothing more than a routine surgical moment, was akin to knocking a grand slam homerun in the ninth inning of the World Series in game seven to win the game—well, something like that. It’s what little kid wannabe surgeons would dream of if they cultivated a sense of creativity.

And to be fair, I thought it was an exciting episode, but she was always running off to save lives as a surgeon. The moment however, that finally put this accomplishment into perspective for me occurred when I was having dinner with her brother, the ace of aces surgeon, along with several other all-star surgical resident friends. This was a few weeks later, and without her present.

Eventually their surgery discussions (because that is pretty much all that this group of surgeons discuss when stuck together: surgery, ultra-marathon running, and more surgery) turned to loudly bantering back and forth about the whole event.

They boisterously argued about how much better they would have handled the whole situation, and wished they had been there to save the day instead of her:

“You dream of something like that going down.”

“Can you imagine being that lucky?”

“Should have been me.”

“Oh man, I would pay to have something like that happen.”

All the young surgeons agreed that this was their medical wet dream, being the rebellious action hero, on center stage, in such a grand case, in the middle of the hospital, no less, calmly saving a life in front of everyone with attending physicians yelling at you.

Then there was a moment of silence, total quiet as everyone reflected on the event…

“But you know what?” her brother finally said, looking around at everyone, then shaking his head and chuckling, “I never would have had the balls to do it.”

And every single surgeon around the table slowly nodded their head in agreement—they wouldn’t have either.

True hero.


Playing Doctor: Part Two: Residency is a medical memoir full of laugh-out-loud tales, born from chaotic, disjointed, and frightening nights on hospital wards during John Lawrence’s medical training and time as a junior doctor. Equal parts heartfelt, self-deprecating humor, and irreverent storytelling, John takes us along for the ride as he tracks his transformation from uncertain, head injured, liberal-arts student to intern, resident and then medical doctor.

Categories
Interview Lifestyle

Residency Interview Tips for a Virtual Cycle!

Virtual interviews are in full swing for medical school, residency, and fellowship applicants. Here are some tips to make the most of your interviews. Wishing you all the best!

Making a good virtual impression:

In the virtual format, your first impression is not your firm handshake or tailored suit. It will be the quality of your internet, audio, and video! Make sure you are well prepared to stand out. Here are some supplies you may consider for Zoom interviews. Although these are just suggestions, we recognize that many individuals face financial barriers that may limit access to technology:

  1. Audio: Headphones with a microphone (prevents reverb from your computer audio), consider noise reducing microphones to block out any background noise.
  2. Lighting: A bright lamp or ring light placed in front of you so your face is well lit. May consider having it higher than eye level so you are not squinting and looking directly into the bright light.
  3. Video: Webcam with 1080p quality (can consider buying an external webcam which will have much better quality than a laptop webcam).
  4. Reliable internet 
    1. You may check your internet speed by typing “internet speed test” into Google. 
    2. Consider a wifi extender if you must be far away from your main router. It will expand the reach of your internet to parts of the building that may not get good service, and prevents lag for a seamless interview.
    3. Have a backup internet and computer option if things go wrong– can use your phone’s mobile hotspot in case you lose your main wifi connection. Borrowing or using a backup ipad, laptop, or desktop computer can also be helpful if your computer breaks down suddenly.
  5. Background: 
    1. A chair that does NOT swivel (so it’s not distracting).
    2. Put your setup against a white or neutral background (can use removable wallpaper or a blanket if you don’t have this available). 
    3. May also consider an interesting and professional background item like a bookshelf, fun painting, plants, or your favorite photos can make for a great conversation starter and highlight your hobbies! 
    4. If you have your bedroom as a background, make sure it is clean and spotless.
      1. Tape something by your camera to remind you to make eye contact with the camera while speaking.
      2. Download and test the interview platform beforehand (Zoom, WebEx, etc).

Answering Questions: 

Prepare a GREAT answer to each of the following questions:

  1. Tell me about yourself
  2. Why this specialty
  3. Why this school
  4. Strengths and weaknesses
  5. Interesting/challenging patient case
  6. Behavioral: 
    1. Time you failed
    2. a mistake you made
    3. working on teams, being a leader
    4. dealing with a conflict
  7. What do you do for fun?
  8. A short spiel about EVERY activity on your application, what you did, and what you learned from it. 
  9. Be able to talk intelligently about any research including your role, the hypothesis, analyses, results, and conclusion.
  10. Any questions for me?

Staying organized for interview invites!

You will be getting a LOT of emails. 

  1. Make a calendar where you are writing down dates of all interview invites as you schedule them so you can quickly glance if you get a new invitation and so you don’t double book yourself. Can sync your calendars across different platforms (ie Outlook to Gmail/google to iOS).
  2. Have a separate email account just for your interviews that will spam you with notifications so you are very unlikely to miss anything.
  3. Be professional and cordial in all emails that you send to the program coordinator, residents, etc.
  4. Here are all the ways you can get a notification about an interview invite:
    1. Text messages (set up forwarding in gmail to your phone number)
    2. Email notifications (enable notifications on your phone)
    3. Email forwarding to your main/school account
    4. Desktop notifications
  5. Here are the major platforms for scheduling interview invites
    1. Thalamus
    2. ERAS (noreply@aamc.org)
    3. Interview Broker
    4. Direct emails from the program coordinator

Best of luck!

Categories
General Healthcare Cost Humour Lifestyle Opinion Pharmacology Psychiatry Psychology Public Health Reflection

Well, Well, Well: Products and services compete for shelf space in trendy wellness market, but are they worth your money?

When a friend recently asked me to join them for a class at Inscape, a New York-based meditation studio that New York Magazine described as the “SoulCycle of meditation”, I was skeptical. On the one hand, I usually meditate at home for free, so paying almost $30 for a meditation class seemed a bit silly. On the other hand, my meditation practice had dropped off considerably since the beginning of the year. Maybe an expensive luxury meditation class was just what I needed to get me back into my regular practice. Stepping off bustling 21st Street into the clean modern space, I heard the sounds of, well…nothing. It was incredibly quiet. Before getting to the actual meditation studios, I had to pass through Inscape’s retail space. The minimalistic shelves hold a variety of supplements, tinctures, and powders that include unique ingredients like Reishi medicinal mushrooms and cannabidiol extract. Many contain adaptogens, herbal compounds that purport to increase one’s resistance to stress, though their efficacy has never been quantitatively proven.[1] These products’ promises run the gamut from shiny hair and stress relief to aura cleansing. I may be a super-skeptic, but even I am not immune to the lures of top-notch marketing. With great consideration, I purchased one of the many magical powders for sale labeled as ‘edible intelligence.’

Since wellness has become trendy, a considerable space in the retail market has opened for associated products dedicated to helping people live their best lives. As Amy Larocca pointed out in her June 2017 article The Wellness Epidemic, “[In the wellness world] a loaf of bread may be considered toxic, but a willingness to plunge into the largely unregulated world of vitamins and supplements is a given.” Even a recent episode of Modern Family poked fun at the wellness trend when Haley Dunphy applied for an ultra-competitive job with fictional wellness guru Nicole Rosemary Page. During her interview at Page’s Nerp company headquarters, Page laments, “People say that Nerp is nothing more than a con-job, a cash grab vanity project from a kooky actress. I want to turn Nerp into the next Disney-Facebook-Tesla-Botox. It’s a world changer.” Though Page is a fictional character, I can’t help but wonder whether the character was inspired by the very real Amanda Chantal Bacon, the founder of Moon Juice, which bills itself as an adaptogenic beauty and wellness brand. Bacon’s Moon Dusts retail for $38 a jar and come in varieties such as Spirit, Beauty, and Dream.

The bottom line is that a sense of well-being needn’t come at the price of thirty-plus dollars an ounce. In fairness to those who choose to spend lavishly, I believe that plunking down a chunk of cash might create an intention to use and derive value from a product, thus positively influencing one’s perception of how well the product works. Rest assured, however, that living with intention and gratitude can be just as easily accomplished without spending any money at all. Carving out time in the day to create a small ritual for yourself can be as simple as spending a few minutes in the morning listening to jazz as you drink your first cup of coffee or allowing yourself to become immersed in a good book before drifting off to sleep. These simple acts allow us to bestow kindness upon ourselves that is especially important in our stressful and busy lives as medical students. My suspicion is that by performing such rituals with intention, we derive much of the same benefit whether our mug is filled with the trendy mushroom coffee or just plain old Folgers.

I’m always thinking about ways I can improve my own well-being, but as graduation approaches I also find myself thinking about how these practices might help my patients as well. One of my fundamental goals as a future psychiatrist will be to help my patients see the value in themselves and in their own lives. I predict that for many of my patients, achieving this goal will depend perhaps on medications but also on the deployment of simple wellness tactics such as I described. I’m not going to lie…I’m still intrigued by many of the wellness products that can be found in places like Inscape, Whole Foods, and the Vitamin Shoppe, especially when I think about the potential benefits they might have for my future patients. I figure that if these products do even half of what they promise to, some of them might even be worth the money. So what happened when I added a sachet of intelligence powder to my usual morning smoothies? Pretty much nothing. At one point, I got excited when I began to feel my fingers getting tingly. Then I realized I had been leaning on my ulnar nerve. Not so brainy after all.

[1] Reflection Paper on the Adaptogenic Concept, Committee on Herbal Medicine Products of the European Medicines Agency, May 2008.

 

Photo credit: Open Grid Scheduler / Grid Engine

Categories
General Lifestyle Reflection

Running

For just split seconds, I am floating, flying, feeling the space pass by. Then the flying ends, subtalar joint and plantar fascia absorbing the first impact of my landing. Gastrocnemius, soleus, and Achilles tendon maintain my stance, and along with my hamstring orchestrate takeoff. Then I am flying again, rectus femoris and iliopsoas swinging my leg forward.

My feet beat the drum of the earth, sarcomeres lengthening and then shortening, orchestrating flight and breath and blood flow. They lengthen and shorten, again and again. Intercostals and diaphragm labor rhythmically, cycling through hunger for air and fleeting relief.

As re-oxygenated blood returns to my left atrium, my attention returns to my thoughts. At first they fought for an audience, demanding my attention as I focus instead on the world around me, but soon it’s just me and my thoughts, as the air streams across my face. My legs stay strong, but beg me to stop. As I finish my run, my thoughts are with me, but whispering politely instead of shouting for attention, willing to leave as quietly as they came.

It isn’t the running, it’s the calm, the quiet, the peace in the cacophony. It isn’t the running, it’s the brisk morning breeze, the bronze fall leaves, the stars between the stars in the night sky. It isn’t the running, it’s me passing through space – a shooting star in the night sky trying to shine bright in the milliseconds I have to add a little light to the world. It isn’t the running, it’s the feeling of perfect harmony as the rhythm of my legs and arms and breath seems to match the rhythm of the world. It isn’t the running, so it is the running.

In the singularly focused chaos of medical school, running was just what I needed to reconnect with nature and the city around me. Earlier in medical school, a friend had asked me if I ran, and I answered, “Nope! Why would I run? I only chase soccer balls and cookies”. I am grateful that we are able to change, and I am now able to see beauty where I could see none before.

Photo Credit: Mark Hesseltine

Categories
disability Emotion Lifestyle Patient-Centered Care Psychology

Nodding Along

My grandmother was a strong and compassionate Egyptian woman, a mother of three, and a pathologist. On a glass slide, exactly like the ones she used daily, cells from her colon biopsy were identified as undifferentiated, and within days she was diagnosed with Stage IV Colon Cancer.

Although I am learning how to care for people in sickness and health, someday, the chest compressions will be applied to my chest. Disease knows no discrimination, and death unites us all. Thousands of cancer diagnoses and precise and growing knowledge of cancer cell types did nothing to protect my grandmother from that which she knew so much about.

In Egypt, cancer is called ’the bad disease’, and bad it is. Over the next couple months, we watched as the bad disease took our beloved grandmother away from us. During that time, my family members, and my grandmother, had to make a series of challenging decisions that they were very obviously not prepared to make.

Medical advancements, although the main reason we are living longer lives, have caused the complexity and variety of end-of-life decisions to be ever increasing. Uneasy about the series of decisions that my family had to make and handicapped by my ignorance, I found myself reading Being Mortal by Atul Gawande. Atul Gawande led me through a vulnerable and imperfect but inspiring conversation about death and dying, exposing our medical system’s inability to understand health beyond the one-dimensional, and presumptuously noble, endeavor to prolong life at any cost.

While reading Being Mortal, I found myself enthusiastically nodding along, agreeing with the theme of the book: we need to change everything about our simple but destructive approach to aging and our increasing elderly population. Our singular approach to prolonging life simplifies complex social and medical decisions. It seems the attitude now is that longer life is all that matters. Ensuring nutrition and shelter is our only standard for a viable living environment for the elderly. We are failing our parents and grandparents.

Atul Gawande’s presentation of ideas changed how I perceive aging and our healthcare decisions at the end of life. I became a strong advocate of having conversations about the inevitability of our death and the choices we want to be made during our end-of-life care. I was convinced that society and healthcare should ensure that the elderly remain the authors of their own stories for as long as they are willing, and actively empower them to do so. Nutrition, shelter, and minimizing fall risk are minimums of care, not acceptable standards.

The Literature in Medicine Student Interest Group at my school decided to read Atul Gawande’s Being Mortal, and I could not be more excited. In the middle of our meeting discussing the book, as I was passionately sharing my ideas, it occurred to me that although I was full of strong opinions, I had done absolutely nothing to be a part of the solution. My grandfather had come to live with us after his wife of 55 years, my grandmother, passed away from colon cancer, and my only roles/concerns in his care have been to ensure food, sleep, and meds. My strong opinions had not inspired my actions.

Nodding along to Atul Gawande’s criticisms of our medical system is easy, but having an honest conversation with my grandfather about his priorities and end-of-life care preferences as he reaches 90 years of age is not so easy. How might I empower my grandfather to continue to be the author of his story? Believing that healthcare is a right and not a privilege is easy, but carrying out the responsibility that this belief invokes is not so easy. How might I work to help provide all my neighbors with equal access to high-quality care? Practicing the invaluable intervention of presence is not easy, and working day after day to hone my abilities at the art of empathy is not easy. How might I overcome my doubts, fears, and insecurities, and avoid being frozen into lack of compassion?

Too often my strong opinions do not inform my actions. Too often my hate for dysfunctional and unjust systems overshadows my love for the people in the systems. I call myself to love my neighbors more than hate the systems, for love is actionable and hate is stifling and tiresome. Let love fuel the tank, for compassion-based activism is the only kind that goes the distance.

Photo Credit: Dan Strange

Categories
General Lifestyle Opinion

Too Many Eyes Between the Thighs: Sex and Surveillance

There’s a special bond between students and their teachers. As someone who used to teach young children, I know firsthand how students can trust teachers with certain aspects of their lives that they don’t feel comfortable disclosing to other adults. But, students in the Salem-Kaiser school district in Oregon may want to think twice about what they tell their teachers. That’s because district policy stipulates that teachers are mandatory reporters of all student sexual activity. This policy means that teachers who have knowledge or suspicion of students’ sexual activities must file a formal report with the Department of Human Services, local law enforcement, or a school resource officer. What’s more, because they are mandatory reporters, a teacher could actually face disciplinary action and fines if they fail to report known student sexual activity. This law even applies to faculty members making reports on their own children if they are students in the district. The year is 2017, but this puritanical policy is straight out of the 17th century.

As a former high school student, I’m appalled by this policy. As a future doctor, I’m deeply troubled. When culture permits our libidinous drive to become an object of surveillance, sex becomes a deviant activity. In criminalizing the natural and healthy exploration of sexuality, we imbue sex with shame.

I could not help but see a link between this policy and the reports of sexual violence that have been dominating the media over the past month. My immediate reaction was that this attitude of surveillance around sex is the fertile soil from which the Harvey Weinsteins of the earth spring forth. In an article about the Harvey Weinstein scandal published in New York magazine, Rebecca Traister writes “What we keep missing, as we talk and reveal and expose, is that this conversation cannot be just about personal revelation or speaking up or being heard or even just about the banal ubiquity of abuse; it must also address the reasons why we replay this scene, over and over again.” Traister sees the perpetuation of crimes of sexual abuse as indicative of a foundational gender injustice; I see them as the result of a culture that was built upon austerity.

America is littered with vestiges of our Puritanical culture. The very fact that we can’t show the bare breast on Instagram, or that we’re still trotting out the story of Janet Jackson’s costume malfunction from Super Bowl 2004 is, to me, an indication that the body is subjected to surveillance when it’s recognized as a vessel of sexuality. Sarah Silverman’s June 2017 appearance on Jimmy Kimmel Live! illustrates this. She holds up a picture of a penis that she drew while hospitalized and correctly assumes that the picture is intentionally blurred to viewers at home, per FCC regulations. She then facetiously tells producers that what she actually drew was a stalk of asparagus, and the picture instantly becomes clear. The image is, in a way, treated as criminal, and is subject to surveillance via pixelation, and yet that surveillance is instantly removed when the association with sexuality is removed.

In a way, we’re all responsible for allowing crimes of sexual violence to occur. My intention here is not to negate the free will of an individual who chooses irresponsible, repugnant behaviors, but to suggest that we have fostered a culture which, in a way, suggests that abhorrent sexual behaviors may be the basest way to get one’s needs met. When two 16-year-olds are in a healthy, consensual sexual relationship, and this relationship gets reported to the authorities, we are sending the message that even an appropriate sexual encounter is considered an act of deviance. And it starts even at a more localized level than the school. If kids are not hearing about sex in their households and are not raised with the understanding that sexual appetite is as normal a bodily function as urination or defecation, the overwhelming message is, at the very least, that sex is something that needs to be hidden away, or more damaging still, that sex is shameful.

Sexual violence is borne from the “sex = shame” mentality. When we classify the perpetrators of these crimes as being “sex addicts,” it excuses these damaging and vile behaviors as an unfortunate error of biology rather than viewing them as a product of learned behavior. This is not to say that sex addiction isn’t a real pathology, but rather to point out that we may be confounding biology with behavior. Though sex addiction has never been classified as a diagnosis in the Diagnostic and Statistics Manual (DSM), most experts agree that the diagnosis of a sex addiction would require a higher-than-average sex drive coupled with compulsive sexual behaviors even in the face of negative consequences. Sexual drive is a difficult feature to quantitatively measure, but I suspect that a high sex drive is not the cause for most crimes of sexual violence. I strongly believe that by committing acts of sexual violence, perpetrators are primitively attempting to meet their needs. In other words, while the sexual appetite is normal, the internalization of the “sex = shame” mentality is so embedded in the psyche that the sexual act becomes a part of this narrative. When one believes that one’s sexual drive is shameful, libidinous urges cannot be openly discussed, and instead may be dealt with in a way that is clandestine and non-consensual. Larger issues of power and privilege, though out of the scope of this writing, come into play when individuals are enabled to act out these violent behaviors.

Sexual violence is systemic. If we don’t change our cultural attitudes toward sex, we will continue to foster an environment which is likely to create sexual criminals. Young people who are just beginning to explore their identities as sexual beings through relationships with others are most susceptible to the internalization of the “sex = shame” narrative. If we don’t learn to shed our Puritanical vestiges and celebrate the healthy, safe, and consensual sexual exploration of these young people, we will continue to support a society of people who are reduced to committing crimes of sexual violence.

References:

YThe Conversation We Should Be Having: https://www.thecut.com/2017/10/harvey-weinstein-donald-trump-sexual-assault-stories.html

Internet sex addiction: A review of empirical research: http://www.tandfonline.com/doi/abs/10.3109/16066359.2011.588351

Is Sex Addiction Curable? http://www.newsweek.com/sex-addiction-curable-kevin-spacey-seeks-rehab-condition-does-not-exist-703541

Salem-Keizer staff told to report student sexual activity, including own kids: http://www.statesmanjournal.com/story/news/education/2017/10/31/oregon-mandated-reporter-salem-keizer-staff-told-report-student-sexual-activity-including-own-kids/798865001/

Sarah Silverman on Near Death Experience: http://abc.go.com/shows/jimmy-kimmel-live/video/featured/VDKA3871414

Photo Credit: Wyatt Fisher

Categories
Lifestyle Public Health Reflection

#BoPo: Body positivity in the age of obesity

When I was younger, I loved watching the televised broadcasts of New York Fashion Week. I grew up in the heyday of heroin chic, which meant that the runway was a seemingly endless parade of vampire-pale, stick-thin waifs. I knew I would never grow up to look like these women, no matter how hard I tried. Even though I was perfectly happy to develop my own unique sense of style, I had an awareness that no one on television looked like me.

Fast forward two decades. The landscape of beauty has changed dramatically. I can’t yet say we’re living in a whole new world, but as a society, we’re making steady progress toward diversifying our expectations of beauty. More colors, shapes, sizes, and sexual identities are being beamed over the airwaves and into our living rooms.

The strides we’ve made toward diversifying our media did not just happen overnight. They occur as part of a larger historical context that has rebelled against normative standards of beauty for decades. The Fat Acceptance Movement, started in the mid 1960’s, is considered to be an offshoot of Second Wave Feminism. In 1967, the group held a 500 person “fat-in” in Central Park, NY wherein people carried signs of pro-fat messages and burned diet books. This was followed in 1969 by the creation of the National Association to Aid Fat Americans (NAAFA) which held a yearly summer convention until 2015. More recently, in 1996, the Body Positivity Movement was started by friends Connie Sobczak and Elizabeth Scott. Their goal was to help girls and women foster positive self-images so they could lead more fulfilling lives. Today it exists as an organization known as the Body Positive. Just a few weeks ago, this organization hosted the third annual CurvyCon. This convention was organized by two self-described plus size fashion bloggers to help women “chat curvy, shop curvy and embrace curvy.” All of these organizations and movements undoubtedly have their own platforms, but what they all share is a desire for bodies of all appearances to be accepted into society.

I firmly believe that every body is worth loving, but moreover, that every body is a body worth caring for. I see care as being a balance between the emotional and physical aspects of well-being. While I am hopeful that the shifting tide of acceptance in media translates more broadly to mean that us non-Hollywood folk also find value in ourselves and others no matter our physical appearance, as a health care provider, I am concerned that the Body Positivity Movement may be construed as an acceptance of obesity. If we accept ourselves for who we are, and who we are is unhealthy, then I question whether we are really showing ourselves the love that we claim.

I think what the Body Positivity Movement does well is emphasize self-value on the emotional spectrum of care. Where body positivity endeavors seem to lag, however, is in the promotion of physical health. Physical health can be just as challenging to realize as emotional health, yet it is just as important. Diabetes, hypertension, and hyperlipidemia are real diseases whose prevalence strongly correlates with obesity. They do not discriminate between people who love their bodies and those who don’t. They can affect and ultimately kill anyone whose body mass index falls into an unhealthy range. Our government makes the realization of physical health all the more difficult by setting up barriers for people to receive quality health insurance. Financial barriers are only one aspect of this problem. Any policy that allows for the proviso of health barriers, in the form of exclusions, special criteria, and added financial burden for people with pre-existing conditions, is a policy that does not believe all people to be equally worthy of care and is therefore an injustice.

Even though a key focus of the Body Positivity Movement is self-love, this does not mean people have to go it alone. As future physicians, we can partner with our patients and aim to help them strike a balance between their emotional and physical care. To me, this means helping our patients foster emotional self-love while also being conscious of physical health. While monitoring sensitive aspects of our patient’s physical health such as weight, infectious disease, and heritable conditions may be challenging, perhaps in part because they may draw on our own personal insecurities, we can discuss these topics using sensitive, collaborative approaches that are respectful of the patient’s emotional well-being. Ultimately, our goal should be to meet our patients where they’re at in terms of care and be a supportive force to propel them forward.

References:

The Body Positive: http://www.thebodypositive.org/about

Brief History: The Fat-Acceptance Movement: http://content.time.com/time/nation/article/0,8599,1913858,00.html

The Curvy Con: http://www.thecurvycon.com/about

Overweight and Obesity: Signs, Symptoms, and Complications: https://www.nhlbi.nih.gov/health/health-topics/topics/obe/signs

Photo Credit: Crystal Coleman

Categories
Clinical Lifestyle Patient-Centered Care

Running Low and No Longer Running

I recently completed a rotation in endocrinology, and I learned valuable lessons about diabetes management in both the inpatient and outpatient setting. Today, I wanted to share a clinical pearl generally not discussed in lectures: Diabetic patients often gain weight because of the fear of hypoglycemia.

That’s right. The fear of hypoglycemia drives patients to eat a little more at meals. Let’s backtrack. Patients who have persistently elevated sugars are often started on insulin in addition to oral agents. Depending on their insulin regimen, patients may not eat enough after an insulin dose to prevent a drop in blood sugar. Patients who experience a hypoglycemic event try their best to prevent it from occurring again. This is understandable—fainting is scary and should not be taken lightly (pun intended).

The problem is that patients counteract this fear of hypoglycemia by either eating more after an insulin injection, or by exercising less. This impedes diabetes management. In addition to advising our diabetic patients to monitor their carbohydrate intake, we urge them to start some form of physical activity. Physical activity enhances the body’s insulin sensitivity—it gets to the core of the problem (insulin resistance) and improves overall cardiovascular health as well. But how can we encourage these lifestyle modifications if our patients are getting lightheaded after injections?

The answer: carbohydrate counting and education.

Not the answer: increasing insulin.

My attending explained that “increasing insulin” is actually what happens in some cases. For example, let’s say a patient named Sara comes in for her follow-up appointment and unknown to us, has “fear of hypoglycemia.” Sara brings her glucose meter, and the sugars are poorly controlled. Part of the reason for this poor control is secondary to a) eating more after an injection to prevent fainting and b) decreased physical activity to prevent fainting. Now, if we just treat her numbers, we would increase her insulin.

The lesson here is that one can’t just treat the number in medicine. Talking to the patient, even for a few minutes, will provide the story. Increasing the insulin perpetuates a viscous cycle, and breaking the cycle comes from better regimen management. Validating patient concerns about hypoglycemia and educating them on injecting based on carbohydrate intake is invaluable.

Photo Credit: Melissa Johnson

Categories
General Law Lifestyle Public Health

Keeping Abreast of Lactation Laws

Infant forced to go without milk, Mom says it’s not her fault.” This seems like the kind of terrifying headline that would be on the five O’clock news. Yet this is exactly what happens every day when the rights of women to breastfeed or express milk on the job go unprotected. One politician, Representative Carolyn Maloney (D-NY), has made it her mission to make sure that women can breastfeed without repercussions. I have to admit that when I first heard about Representative Maloney’s Supporting Working Moms Act, I was baffled to think that in the year 2017, breastfeeding in the workplace could cost a woman her livelihood. With a little research, I started to realize just how ill-informed I was on the legality of breastfeeding.

I was surprised to learn that currently, no federal legal protections exist to protect public breastfeeding. Furthermore, only 47 states have laws that legalize public breastfeeding.[1] Of those states, Michigan’s law is a mere three years young. Astonishingly, Iowa offers no legal protections for breastfeeding. Even though public breastfeeding might be legal in most states, it wasn’t until 2010 that breastfeeding in the workplace received its own set of protections. A federal breastfeeding provision called “Break Time for Nursing Mothers,” which was added as an amendment to the Affordable Care Act (ACA), makes it mandatory for companies with 50 employees or more to provide “reasonable” break time for women to express milk during the first year of their child’s life. This same provision also requires companies to provide a clean and dedicated space for breastfeeding in the workplace.[2] However, this provision only ensures the rights of “nonexempt” workers, meaning only those who earn hourly wages as opposed to salaries are protected. Even with the laws that protect the right to breastfeed in public, women can still face repercussions that range from fines to docked pay to even termination as a direct consequence of breastfeeding in the workplace . With the ACA in jeopardy of being repealed (possibly by the time this article is published), the future of breastfeeding is more vulnerable than ever. The Supporting Working Moms Act is meant to provide federal breastfeeding laws independent of the ACA, as well as expand protection to 12 million additional women, including public school teachers.[3]

The issue of breastfeeding is close to my heart, not only as someone who hopes to one day become a mother, but also as a future physician: I know the powerful impact that breastfeeding can have on a child’s health. In their policy statement on the use of human milk, the American Academy of Pediatrics affirmed their position that infants should be breastfed exclusively for the first six months of their lives whenever possible.[4] Breastfeeding can be challenging for a number of reasons, and it is important to respect the fact that not all mothers are able to breastfeed their children. However, for those who can and choose to do so, the benefits can be profound for both the mother and the child. According to the National Institutes of Health, breastfeeding helps infants fight infection, lower their risk of Sudden Infant Death Syndrome, and could possibly serve as a protective factor against developing asthma, allergies, and even diabetes.[5] Studies show that babies who are breastfed attain better educational achievement than their non-breastfed peers by the age of five.[6] From an economic perspective, breastfeeding has been shown to lower healthcare costs by reducing disease burden in the population.[7] Even though many of us will not be pursuing careers in obstetrics, at some point in our careers, we will all establish some connection to a new mother, whether she is your patient, your partner, or yourself. Being informed about the legality of breastfeeding can help us to provide these women with support and guidance and make sure that our littlest patients have the healthy start in life that they deserve.

References:

[1] http://www.ncsl.org/research/health/breastfeeding-state-laws.aspx

[2] https://www.dol.gov/whd/nursingmothers/Sec7rFLSA_btnm.htm

[3] https://maloney.house.gov/issues/womens-issues/breastfeeding-0

[4] http://pediatrics.aappublications.org/content/129/3/e827

[5]https://www.nichd.nih.gov/health/topics/breastfeeding/conditioninfo/Pages/benefits.aspx

[6] https://ora.ox.ac.uk/objects/uuid:13bde0c7-0070-43c6-9ae3-307478e8c42c

[7] http://www.reuters.com/article/us-breastfeeding-study-idUSTRE6342ZG20100405

Photo Credit: Roberto Saltori

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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