Category: Lifestyle

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
General Lifestyle

Goals between 1st and 2nd Year

When we were young, summer days were our most free. Our neighborhoods suddenly became hives of activity; kids playing baseball in the streets, video game sessions lasting all day, trips to the pool, family vacations, and most importantly, no school. Those days of summer seemed too short, and during the long winter months when school seemed to stretch on forever, I often sat and daydreamed of the days when I could wear shorts and a t-shirt. For many, summer vacations can last through college, with time spent abroad or back home enjoying the comforts of their childhood. Medical school, however, changes the game.

For those who come straight to medical school from their undergraduate institutions, the last true summer might be the one between the first and second year of medical school. In fact, most schools give students several weeks off to decompress after the long struggle of first year. Therefore, it’s worth asking: what do we do with this time? With that question in mind, I went out and queried fellow students from all years, as well as several physicians in practice and in academia, in order to collect ideas. Not surprisingly, there were a huge variety of answers, but they divided into two basic camps. About half said to do something, anything, to prepare ourselves for our future careers, and the other half said to enjoy the last vestiges of our youth.

The arguments are valid on both sides of this debate. Amongst those who said to do something “productive,” about 75% said to, more specifically, gather experience in an area of interest. Whether through shadowing or more formal experiences such as research opportunities, the idea is to gain whatever knowledge and experience you can to make choosing a specialty easier. Additionally, these measured voices said, you will gain a little extra something on your CV that might impress residency programs. For instance, a friend who had an interest in mental health and addiction medicine spent the summer doing research in a major university setting. He applied months in advance and said the experience changed his life. On the other hand, the remaining 25% said to spend time studying for the Boards. “They’ll creep up on you quickly, so best to start early,” one professor told me. He suggested creating a plan of action for the summer, including high yield topics to review each week.

The “do nothing” crowd, or those on the other side of the argument, also had their say. Many advocated that this last summer is the perfect chance to do a few things that simply won’t be possible in the years ahead. “For those who enjoy traveling, take the chance to get away,” they repeated again and again.  A student who recently matched into PM&R told me that he went to Europe for 4 weeks, rode the train, met lots of great people, and “stayed as far away from studying as [he] could.” He added that this gave him the chance to recharge his batteries before tackling the challenges of second year and beyond. While traveling Europe might not be possible for all of us, finding ways to decompress should be. A family medicine physician who has spent 20 years in practice told me that he went home, saw family, and spent lots of time fishing.

In the end, there is no clear path. Just like with everything else, how to spend that last summer is a very individual choice. My own experience involved taking time off to rest and reflect, and also spending a month locked in a room with some fellow students crafting a business plan for a student-run free clinic, which, after a lot of work and fundraising, opened the next year. I also completed a 2 week internship in rural medicine. I wouldn’t change anything about the summer; both of those work experiences motivated me in different ways regarding the type of physician I want to become, while taking time to rest rejuvenated me for the trials ahead. No matter what you choose, remember to do what makes the most sense for you. If you need the rest, take the chance to get it. If you want to work on something you feel passionate about, do that. While it may seem like another multiple-choice question, in the end, there is no wrong answer.

Featured image:
travelling by Elvira S. Uzábal – elbeewa

Categories
General Lifestyle

Goals for the Summer

The beginning of December is when it begins. Around winter finals, people already start to ask – What will you do over the summer?

“Should I apply to a summer fellowship?”

It’s reasonable that we want to make the most of the summer. Considering the prevalence of ordered, dutiful personalities in medical school[1], it’s no surprise that this precious time – the last summer vacation of our lives (at least, in the US school system) – is wrought with indecision.

“Are you doing research over the summer?”

We go to second-years and faculty to ask for advice. We post on Facebook or other social media outlets. We ask career counselors. They all say to take things easy. Second year is hard, so do something that is important to you. Go travel. Spend time with family. They say things like, you only have to do research if you want to go into a competitive specialty. We search Google and find resources about summer fellowships and research opportunities.[1]

“What should I do over the summer?”

I am reminded of the memoir When Breath Becomes Air, written by the neurosurgeon-in-training Paul Kalanithi. In the book, Kalanithi writes about a similar situation during his undergraduate sophomore summer. He had to choose what to do with his summer, because he had been accepted both “as an intern at the highly scientific Yerkes Primate Research Center, in Atlanta, and as a prep chef at Sierra Camp, a family vacation spot for Stanford alumni on the pristine shores of Fallen Leaf Lake [… which] promised, simply, the best summer of your life. […] In other words, I could either study meaning or I could experience it.”[1] Ultimately, he chose the job as the prep chef. And despite the outrage of his biology mentor over the lost research opportunity, Kalanithi still became a neurosurgeon.  He said his experience at the camp was meaningful, invigorating, and had lasting effects on his perspective when he returned to school. It’s a little different in medical school, but the principle is the same.

“When you look back on the summer, how will you feel?”

I struggled to decide what to do with my summer. I felt like there were a lot of options, but was unsure of what to pursue – I could conduct research on campus, be a medical volunteer at free clinics, work at a global health mission, spend time with family, travel with friends … there were too many options. I felt like all of the options were possible as long as I submitted an application on time. The most difficult part was that at my school, summer lasts only one and a half months.  Ultimately, the time constraints limited me to only one or two activities, and I wanted to choose an activity that would be “the best summer of my life.”

I had started the application for a summer research fellowship, submitted it, and was waiting to hear back. Meanwhile, I heard friends talking about how they were planning to go on trips in-state and

abroad, get married, or just spend time at home. Other friends were awarded fellowships at other academic institutions. I wondered how valuable it would be for me to spend another summer putting in forty or more hours of research a week when I had spent a number of undergraduate summers doing that before. In fact, I realized, my last real break was the summer between high school and undergrad.

In my final year of undergraduate studies, a retiring professor told the class that he was most excited about the opportunity for extended break from academia. He expressed regret that he had not taken more breaks throughout his career. My friend and I had discussed this together; we wondered whether a break from school or work could really be as meaningful as he said. I’m beginning to realize what he meant now, as my classmates and I fight through burnout during our first year in medical school. The importance of self-care cannot be overlooked.

I weighed the pros and cons of each option. When it came down to it, my ideal break consisted of: (1) reconnecting with family and friends, (2) spending time with literature – both reading and writing, and (3) exploring future career options. While important, career-building was not the most important summer activity because I still have the rest of my training and the rest of my life to work on it. For me, time with familiar people and literature are sources of enduring happiness. At the end of the day, I take comfort in cultivating these life experiences. I worked hard to create an opportunity that would incorporate all three of these items. I’m planning to spend the summer at home, relaxing and working on a small project I managed to set up with a mentor nearby.

For those coming up with their own summer goals, I suggest considering the following points:

  1. What are the pros and cons of the options you have considered so far?
  2. How much time can you allot to each of your options?
  3. Is there something you would regret missing out on?
  4. What will rejuvenate you for the upcoming year?
  5. If you could do anything, how would you spend an ideal summer?

References:

  1. There was an actual study published on this. Lievens, et. al. (2002). Medical Education, 36, 1050–1056.
  2. Interested readers may want to peruse the following pages:  “Summer Opportunities for 1st-Year Students” from Indiana University and “Summer Opportunities for Medical Students” from the Medical University of South Carolina.
  3. Kalanithi, Paul. (2016). When Breath Becomes Air. Random House, New York, NY. 31-32.

Featured image:
San Francisco Peaks from Kendrick Mountain Fire Lookout Tower by Al_HikesAZ

Categories
Emotion Lifestyle

Could mindfulness meditation help us to care for patients?

“We can only give away to others what we have inside ourselves”-Wayne Dyer

Empathy is the ability to understand and experience life from another person’s perspective, which allows an individual to care for others in a genuine way. In medicine, it is arguably one of the most crucial qualities required to be a good doctor. Research shows that empathetic doctors are perceived as better caregivers, and are less likely to face malpractice suits. (1-4) In another study, which looked at how physicians’ empathy affected clinical outcomes for diabetic patients, it was found that the physicians perceived as more empathetic were more likely to have patients with blood sugars and cholesterol levels under control. (5)

Demonstration of caring and altruism during the medical school application process is almost essential for entry. However, several studies have shown that student empathy is negatively affected by medical education, particularly on entering the clinical years of training. (4, 6, 7) Various factors have been explored to explain this. The higher workload of the clinical years, exam pressures, as well as facing the realities of medicine on the wards (as opposed to previously idealised media images), could all be contributing to the phenomenon.

Moreover, medical students come from a background of overachievement, and stress and anxiety can result from not performing to the standards they expect of themselves. (4) Perhaps as medical students we have also learnt to put on a mask of compassion, kindness and emotional distance to protect ourselves from the realities of life; or maybe it is emotional blunting from just meeting too many ‘people with problems’. (7) Whether the reason for our rise in cynicism is attributed to one or all of these explanations, it seems apparent that the care and compassion we are able to show to patients is primarily associated with our own mental state. With a continuous backdrop of studying and time pressures, the stresses of all life events are heightened.

There has been a large amount of research into the stress, burnout rates and psychological consequences of medical school training. In one multicentre study at American medical schools, burnout was found to be common amongst medical students, and it increased by year of study. (8) The general consensus is that the medical school experience is challenging and demanding, requiring resilience and a balanced lifestyle.

Could medical schools provide more support to ensure students are well equipped to face a career filled with emotionally demanding situations, whilst maintaining the levels of empathy and emotional understanding crucial for strong doctor-patient relationships? All schools offer some level of student support, such as counselling sessions for those students that are experiencing mental difficulties or life challenges. Unfortunately, it has been shown that a clear stigma continues to exist against mental health and guidance in simple life matters. This has been described as “the hidden curriculum”, a culture that exists where doctors and students are led to believe that we are invincible and cannot become ill, either mentally or physically. (9) Often the first signs of vulnerability to mental health issues manifest at medical school, which actually leads to breakdown much later on. (10) Rather than allowing our future doctors to reach their breaking point before seeking help, we could build strong foundations and encourage introspection alongside academic learning. This would help our medical students and doctors truly reach their potential.

One avenue that has been explored to prevent ‘compassion fatigue’ and burnout is through the practice of mindfulness meditation. One study found that post-intervention levels of anxiety and depression were significantly reduced. (11) Mindfulness is currently taught at 14 medical schools and is continually gaining popularity. The University of Rochester School of Medicine and Dentistry (USA) and Monash Medical School (Australia) are unique in that they have fully integrated mindfulness into their core curricula. (12) One study found statistically significant reductions in tension-anxiety in students on a mediation-based stress reduction (MBSR) program (from 14.5+/-7.2 pre-intervention to 12.4+/-7.0 post-intervention) in comparison to controls (11.3+/-6.3 pre-intervention to 13.4+/-6.9 post-intervention). (13)

What is Mindfulness?

Meditate by Caleb Roenigk
Meditate by Caleb Roenigk

Mindfulness is a process to become more conscious of the present moment in order to manage thoughts, feelings and strong emotions. (14) Although it was historically known as a Buddhist practice, with the aim to alleviate suffering and cultivate compassion, it can be practised without spiritual or religious affiliation. In the late 1970s, Jon Kabat-Zinn, a physician at the University of Massachusetts Medical Centre, developed Mindfulness-Based Stress Reduction (MBSR), which takes away the esoteric aspects of the practice while retaining the core elements.  This has gained considerable popularity, particularly in the field of pain relief. (15)

 

A study into the effects of meditation practice on the brain, conducted at Harvard School of Medicine, found that with meditation there was increased gray matter in the frontal cortex, an area associated with working memory and executive decision-making. There was also thickening of three key regions displayed in the table below. (16)

Untitled

 

 

 

Furthermore, the amygdala, the area of the brain associated with the fight-or-flight response, and thus a key contributor to feelings of anxiety or stress, became smaller. (16) A second study by the same group found that practice for only 8 weeks appears to enhance regions of the brain associated with memory, sense of self, empathy and stress. (17)

Medical school and life as a doctor is a demanding career path. Thus, it can be argued that it is the responsibility of medical educators to both equip students with the academic knowledge required and the emotional intelligence to handle the day-to-day challenges. Mindfulness offers a method to teach medical students how to practically handle stressful emotions and situations, which helps them to become more centred, caring and empathetic. We can only give as much as we have, so it seems intuitive that students who are happier and mentally strong will provide better patient care. The evidence for mindfulness practice is very encouraging and it is interesting to see that two medical schools have already incorporated these practices into their curriculum.

Will mindfulness become as core to the medical school curriculum as the study of anatomy? If we value the mind as much as we do our bodies, then maybe it should.

Meditate and Prosper by Juhan Sonin
Meditate and Prosper by Juhan Sonin
  1. 1. Halpern J. What is clinical empathy? Journal of general internal medicine. 2003;18(8):670-4.
  2. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. Jama. 1997;277(7):553-9.
  3. Brownell AKW, Côté L. Senior residents’ views on the meaning of professionalism and how they learn about it. Academic Medicine. 2001;76(7):734-7.
  4. Newton BW, Barber L, Clardy J, Cleveland E, O’Sullivan P. Is there hardening of the heart during medical school? Academic Medicine. 2008;83(3):244-9.
  5. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians’ empathy and clinical outcomes for diabetic patients. Academic Medicine. 2011;86(3):359-64.
  6. Ren GSG, Min JTY, Ping YS, Shing LS, Win MTM, Chuan HS, et al. Complex and novel determinants of empathy change in medical students. Korean journal of medical education. 2016;28(1):67-78.
  7. Hojat M, Vergare MJ, Maxwell K, Brainard G, Herrine SK, Isenberg GA, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Academic Medicine. 2009;84(9):1182-91.
  8. Dyrbye LN, Thomas MR, Huntington JL, Lawson KL, Novotny PJ, Sloan JA, et al. Personal life events and medical student burnout: a multicenter study. Academic Medicine. 2006;81(4):374-84.
  9. Sayburn A. Student BMJ: Why medical students’ mental health is a taboo subject. London: Student BMJ; 2016 [accessed 4 Apr]. Available from: http://student.bmj.com/student/view-article.html?id=sbmj.h722.
  10. Marshall EJ. Doctors’ health and fitness to practise: treating addicted doctors. Occupational medicine. 2008;58(5):334-40.
  11. Shapiro SL, Schwartz GE, Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. Journal of behavioral medicine. 1998;21(6):581-99.
  12. Dobkin PL, Hutchinson TA. Teaching mindfulness in medical school: where are we now and where are we going? Medical education. 2013;47(8):768-79.
  13. Rosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med. 2003 15(2): 88-92.
  14. Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. Jama. 2008;300(11):1350-2.
  15. Kabat‐Zinn J. Mindfulness‐based interventions in context: past, present, and future. Clinical psychology: Science and practice. 2003;10(2):144-56.
  16. Lazar SW, Kerr CE, Wasserman RH, Gray JR, Greve DN, Treadway MT, et al. Meditation experience is associated with increased cortical thickness. Neuroreport. 2005;16(17):1893.
  17. Hölzel BK, Carmody J, Vangel M, Congleton C, Yerramsetti SM, Gard T, et al. Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Research: Neuroimaging. 2011;191(1):36-43.

Featured image:
Meditation by Sebastien Wiertz

Categories
General Innovation Lifestyle Public Health

A New Type of Pharmacy – On Food Pharmacies and Their Importance for Type II Diabetics

In a world where drug companies and pharmacies remain pervasive, an innovative take on the word “pharmacy” is being developed in Redwood City, CA. A new food pharmacy has just opened up, stocked with fresh fruits and vegetables. Just what the doctor ordered – literally! Instead of paying supermarket prices for these foods, all you need is a prescription from the doctor.

The first of its kind, this food pharmacy is an annex to the existing Redwood City free clinic known as Samaritan House. Patients with type II diabetes can get a prescription for fruits, vegetables, and even fish from a physician, and then pick up the free food at the pantry to help better manage their diabetes. The food is procured and delivered by the Second Harvest Food Bank, which is one of the largest food banks in the nation, feeding almost a quarter of a million people each month. Second Harvest also provides nutritious cooking demos given by local nutritionists1.

This one-year pilot program serves as a reminder that food is often overlooked as a primary method of treatment and prevention; a reminder we might need during our incessant drive to memorize pharmaceuticals and their mechanisms of action. Even when it is known that a patient’s congestive heart failure and diabetes may not be adequately controlled long term by medication alone, oftentimes physicians are strapped when it comes to options. Providing education on proper nutrition to a patient who simply cannot afford fruits and vegetables remains the passive and limited option, whereas food pharmacies such as Samaritan House are active steps in the right direction.

 

Source(s):

1http://www.sfexaminer.com/food-pharmacy-for-diabetics-launched-in-redwood-city/

Featured image credited to the US Department of Agriculture

Categories
Lifestyle

Blue bird day, fresh pow, and a baby on the way

Meet Laura Matsen Ko, orthopedic surgeon, avid runner/skier/hiker/cyclist, and new mother to a  beautiful baby boy, Logan.  Laura and her husband, both orthopedic surgeons at Orthopedic Physician Associates (opaortho.com), practice and adventure in the Pacific Northwest. Together, they developed the website, seattlejointsurgeons.com, which allows patients to access comprehensive and accurate information on orthopedic care.

I met Laura recently on Instagram via a post shared by Oiselle (oiselle.com), a Seattle-based women’s running apparel store named after the French word for bird. In the post, photographed by Kevin, Laura is captured as a pregnant backcountry skier posed on the summit of snowy Mt. Baker.  A flurry of follow requests, instant messages, and emails between us quickly snowballed into a cross-country friendship.  Our easy rapport is not unexpected considering our shared passions. We are both passionate about helping injured athletes (and specifically pregnant athletes) get back to their sports as soon as possible.  After learning of my research interests in antenatal exercise, Laura agreed to a semi-formal interview about her background and experiences related to exercise during pregnancy.

 

First, tell me a little about yourself. I did some Instagram sleuthing and noted scrubs, ortho, a lot of snow, and Thomas Jefferson.

I was born and raised in Seattle, Washington. I went to Whitman College in Walla Walla, WA where I enjoyed being an outdoor leader on backcountry ski trips and mountaineering trips. My senior year I decided to go out for Cross-Country, and surprised myself by placing 9th at Nationals (D3).  Then I bike raced that spring and got 2nd at Nationals (D2). That was a huge surprise and a thrill.

I went to medical school in Portland, Oregon at Oregon Health and Sciences University (OHSU) and continued on at OHSU in an Orthopedic Surgery residency. I did two Ironmans while I was there, including qualifying for, and finishing, the world championship in Kona, HI.

About that time I got to meet my husband who was a year behind me in the Orthopedic Residency, and I finally convinced him to go for a real date with me after one of our rainy runs together.  Throughout residency we trained for various marathons together and enjoyed active vacations; anything from cycling to backcountry skiing. 

After we finished residency, we headed to Philadelphia. I did a fellowship in Adult Reconstruction. I chose the field of hip and knee joint replacement surgery because it gives me the opportunity to help people return to the activities they enjoy using surgery and personalized rehabilitation.

 

How many years have you been a backcountry skier and mountaineer?

My father and older brother taught me in my teenage years.  We had been backpacking our whole lives, they had been climbing, and I always aspired to go out with them.  When I was 13 I took a year-long course with my Dad to learn how to safely rock climb, mountaineer, snow camp, and manage avalanche risk and rescue.  That winter my brother took me out in the backcountry and I got stronger and smarter. That summer we climbed five Washington volcanic peaks including Mt Rainier.

 

What kind of role does skiing have in your life?

Backcountry skiing is a wonderful treat—unlike running it does take a bit of equipment and a bit of driving but it’s totally worth it! I love getting out into the wilderness without anyone around. I equally love the hiking up (“skinning” up) the mountain as much as the fresh, sweet turns on the way down!

 

Tell me about your pregnancy.

Logan was my first pregnancy.  I have always been active, and continuing my activity seemed right to me.  I bike-commuted to my work at the hospital, rain or shine, which was about a 15-mile commute. I did this through my second trimester, and then we decided it was too high of a risk to continue cycling due to the short and often rainy dark days in Seattle.  My OB, husband, and father all pushed me to stop bike-commuting.  I ran up to two weeks prior to him being born.  I skied two days before he was born—in bounds alpine one day and three days of very rigorous backcountry skiing.  These were about 6 hour days of hiking hard uphill and then skiing down in fresh powder.  It was so fun to feel like I was sharing this experience with Logan.

Multi-night mountaineering trip in the Washington Cascades with husband Kevin at 18 weeks gestation.
Multi-night mountaineering trip in the Washington Cascades with husband Kevin at 18 weeks gestation.
Hike with my Dad at 19.5 weeks gestation.
Hike with my Dad at 19.5 weeks gestation.
Seattle Half Marathon at 32 weeks gestation. Time: 2:00.
Seattle Half Marathon at 32 weeks gestation. Time: 2:00.

The day I went into labor I did elliptical and weights and performed a major total hip revision surgery.  Throughout the second half of my pregnancy I had some issues with SI joint and foot pain, but in general my body held up well.

I did a lot of research about heart rates, but the data seemed inconsistent. 

 

Laura’s difficulty navigating antenatal exercise guidelines is not surprising.  A study by Lieferman (2012) demonstrated that almost half of medical providers (48%, N=89) were unfamiliar with current national exercise guidelines for pregnant women and half of respondents advised a reduction in exercise in the third trimester, even for uncomplicated pregnancies.  Concurrently, a 2006 study demonstrated that about half of surveyed obstetricians recommended heart rate maximums and a reduction in exercise load during the third trimester—two policies not specified in current guidelines (Entin, 2006).

The American College of Obstetrics and Gynecology (ACOG) and the U.S. Department of Health and Human Services recommend that healthy pregnant and post-partum women engage in 30 minutes of moderate intensity exercise for most, if not all, days of the week (ACOG, 2015; DHHS, 2008).  Pregnant women who habitually perform vigorous-intensity aerobic activity may engage in higher intensities under the guidance of a medical provider.  Heart rate maximums are no longer indicated.  Instead, pregnant women use ratings of perceived exertion to monitor their exercise intensity.  For most women, moderate effort is comparable to a brisk walk, at an intensity one can maintain for hours. It should result in heavy breathing, but not so much that the exerciser is unable to hold a short conversation. Vigorous activity, on the other hand, should make the exerciser feel short of breath, but still able to speak a sentence.

Obstetrics (OB) providers are encouraged to educate women about the health benefits of exercise during pregnancy. These benefits include improved gestational diabetes control, lower rates of antenatal and post-partum depression, and relief for back pain.  There are several absolute contraindications to exercise during pregnancy, including incompetent cervix or cerclage, multiple gestation at risk of premature labor, persistent second- or third-trimester bleeding, and preeclampsia.  For a full list of absolute and relative contraindications, consult the ACOG Committee Opinion Number 650 (ACOG 2015).  Certain activities are also identified as safe or unsafe.  Unbeknownst by Laura, down-hill snow skiing is listed as an activity to avoid due to an inherently high risk of falling and subsequent abdominal trauma.

Laura continues:

I didn’t really follow [the guidelines] after talking with friends and reading.  I didn’t do sustained high intensity intervals, but if I was running stairs and my heart rate got up to 165-170 on the way up but dropped to 120 on the way down, I felt that my baby was getting sufficient perfusion.  Each mother has a different pregnancy experience and the biggest factor is to listen to your body.  Exercise made me feel happy and alive so I kept doing it.  Plus pregnancy can do such a warp on body image.  Exercise helped normalize my feelings about the changes in my body.

 

Why do you think it is most important to listen to your body?

We are all so different. As you’ve seen with your med student classmates, we need different amounts of sleep, caffeine, food, exercise, fresh air… so no single guideline will work.  We all must strive to learn our bodies. 

My physician friend had a 10-lb baby.  She was extremely active, and pre-pregnancy she ran and played soccer.  Obviously our pregnancy (and delivery and post-partum) experiences were totally different and not fair to compare.  She says she tried to play soccer 7 weeks post-partum and she “felt like her uterus was going to fall out.” Another physician friend had a 9 lb baby with a very large head.  She was walking over 5 miles a day until she delivered, but is challenged to get back to walking more than a couple blocks now (2 weeks post-partum) after her more traumatic vaginal delivery. A third physician friend who had always been extremely active in basketball and volleyball was placed on bed rest at 22 weeks for all three of her babies. 

I never want to be compared to other women or make other women feel that they just didn’t push hard enough because of my activity levels.  I’m one person and this was one pregnancy. The next pregnancy could be totally different!  These other women are a lot tougher than me—they had a more challenging pregnancy, delivery, and recovery.  And they had to be very patient with their bodies.

 

Did you have any conversations with your OB provider(s) about your exercise practices during the pregnancy?  

Yes… some. They thought I was a little nuts but were supportive.  Except for the skiing.  My OB was a little shocked to hear that I’d been skiing.

In the first couple weeks post-partum I mostly tried to work on some baseline fitness with walking and stairs.  I tried to wait until 6 weeks to really increase my activity but I wasn’t able to wait.

 

Explain the 6 week mark. 

Well I was told by my OB and the nurse practitioners to not exercise hard until 6 weeks.  BUT I started running at day 16 and as of 4 weeks was up to about 30-40 miles a week with one day of hill repeats and one day of fartleks. I made it to 8 miles in sub 8 pace with a couple 7:30 until around 4 weeks.  I think my first race will be a half marathon at 2.5 months postpartum.  I’m not going to be the fastest.  Partly because of recent pregnancy but also because of sleep deprivation, returning to work, and not having enough time in the day!

16 days post-partum. 7.2 mile run with baby Logan and husband Kevin at 8:37 minute pace.
16 days post-partum. 7.2 mile run with baby Logan and husband Kevin at 8:37 minute pace.

Do you have any friends who also skied during their pregnancy?  

 I knew people who were running and rock climbing in their pregnancy and a lot of friends who just stayed fit with walking.  I don’t know anyone else who skied during their pregnancy but I’m sure people out there do it!  I’d mainly suggest borrowing your father’s huge rain coat and possibly his ski pants because there is no way you’re fitting in your bibs from pre-pregnancy.  And don’t push the speed and steepness; mostly enjoy being out there!  You don’t want to fall.

There are definitely other pregnant skiers and a few inspired, future Mamas:

5

On the mountaineering trips, what, if any, issues did you have with harness fit?

Due to the season I didn’t mountaineer in the second half of pregnancy, so it wasn’t an issue.  One of my friends got a lower and upper body harness for her pregnant rock climbing trips.

 

What kinds of emotions did you encounter during your pregnancy when you were not able to do activities that you enjoy?

I found it super frustrating when others placed restrictions on me. My husband quickly found that he had to present my change in activities as a risk/ benefit. When he told me “no more cycling,” I just wanted to rebel. However he did recently have to fix a clavicle fracture on a woman who was 16 weeks pregnant. She got hit while bike commuting. Thankfully her fetus is okay.  That story will make me more conservative with my cycling in my next pregnancy.

At 4.5 weeks post-partum I restarted bike-commuting to work for some half days of clinic.  It felt amazing to be back out there and I was so much faster with less weight, higher lung capacity, and likely an increased hematocrit. 

 

Is there anything you want to tell future mothers? 

Listen to your body and don’t read too much.  Wear support stockings if you work on your feet.  Know that you will lose the weight.  Fast. 

 

Physicians?

Support your patients.

For future and current obstetrics providers, the Canadian Society for Exercise Physiology developed the PARmed-X for Pregnancy, a physical activity readiness medical questionnaire that guides discussions on exercise during pregnancy in an outpatient setting.  The form may be accessed online (http://www.csep.ca/cmfiles/publications/parq/parmed-xpreg.pdf) and is useful for most pregnant women.  Athletes, however, have sport-specific safety concerns, training goals, and requirements that may be unfamiliar to the average obstetrics provider.  These topics may be explored on an as-needed basis during prenatal visits.

A big thank you to Laura Matsen Ko for sharing your inspiring story!  Thank you also to my friend Hannah, who initially tagged me in the Oiselle Instagram post.

 

References

  1. Leiferman, J., Gutilla, M., Paulson, J., Pivarnik, J. (2012). Antenatal physical activity counseling among healthcare providers. Open Journal of Obstetrics and Gynecology, 2, 346-355
  2. Entin, P. L., Munhall, K. M. (2006). Recommendations regarding exercise during pregnancy made by private/small group practice obstetricians in the USA. J Sports Sci Med, 5, 449-458.
  3. American College of Obstetricians and Gynecologists. Physical activity and exercise during pregnancy and the postpartum period. Committee Opinion No. 650. Obstet Gynecol 2015;126:e135–42
  4. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans.  Department of Health and Human Services Washington, DC; 2008.

Featured image:
Laura Matsen Ko skiing. Photographed by Kevin Ko.

Categories
Emotion General Lifestyle Reflection

Loneliness: The Epidemic of the Modern Age

“God, but life is loneliness, despite all the opiates, despite the shrill tinsel gaiety of “parties” with no purpose, despite the false grinning faces we all wear .. Yes, there is joy, fulfillment and companionship – but the loneliness of the soul in its appalling self-consciousness is horrible and overpowering.”
– Sylvia Plath (1)

Who amongst us has not felt the hand of loneliness? The first breakup as a teen, the rejection letter lying on the kitchen table, children moving away for the first time, the little cracks in a marriage beginning to show. If loneliness is so widespread, so ‘normal,’ why do we need to talk about it? Aren’t we generally attracted to the more rare and wonderful aspects of life? Aspects like the documentation of  odd and wonderful medical conditions, the extremes of human behaviour that we can analyse with such voyeuristic enthusiasm. The topic of loneliness has instead been taken over by the arts; a subject for novelists and philosophers to dissect rather than scientists and clinicians.

Loneliness can be defined in a couple of different ways: emotional and social loneliness. Emotional loneliness occurs in the absence of an attachment figure, while social loneliness occurs in the absence of a social network. Emotional loneliness has been compared to a child’s feeling of distress when they feel abandoned by their parent, while social loneliness is the feeling of exclusion by a child whose friends have left. Thus, loneliness can be described either as a devoid outer world, or an empty inner world.

On the other hand, the cognitive approach suggests that loneliness stems from one’s social expectations not being met. Could it be that through our reliance on social media, our expectations for relationships have become exaggerated? As we scroll through our Facebook feeds, we become an outside observer to the fruitful lives around us; to parties we have missed, weddings we have declined. And so we draw a comparison to our own lives, thinking of ourselves as hollow shells in comparison to these roaring waves we see around us.

But what is the opposite of loneliness? Is it social connection? Is it the number of contacts we display on our phones? The number of parties we are invited to every month? Or the feeling we have of being valued? Is it being able to share a chuckle while watching a movie, reading a novel with a soft hand by your side, or simply being present in another’s life and being acknowledged?

Loneliness is different from solitude. Solitude can be an enlightening experience, leading to increased creativity and growth. Some of the best ideas have come through hours of sitting at an office desk, staring at a piece of paper. Just because more people in today’s society are living alone, does not mean that loneliness is on the rise. We must be careful not to mix these terms together. Loneliness is very different from solitude. Loneliness is the feeling of despair and alienation. It develops from the need for intimacy, and from the feeling of rejection when one fails to find it. It is described as a social pain; what is the equivalent of morphine for the pain of loneliness?

The power of loneliness can be illustrated through the effects of solitary confinement. It has been suggested that prisoners who have been through solitary confinement develop psychiatric disorders such as depression and anxiety, often turning to self-harm as a means of escape. Solitary confinement is described as a form of psychological torture, with one Florida teenager describing his experience as “the only thing left to do is go crazy.” Humans are social creatures. Without stimuli and control, is it any wonder that depression, hypersensitivity, and psychosis develop? This isn’t just an abstract concept that we are talking about, something for the philosophers to discuss at their round tables. It has implications with regards to disease, happiness, and relationships. It can be found in every aspect of our lives, in every infant and every adult – it is something that needs to be examined more closely through our microscopes.

“The most terrible poverty is loneliness, and the feeling of being unloved.” 
― Mother Teresa (2)

The topic of loneliness has fascinated novelists, poets, theologians, and philosophers, all attempting to give meaning to this beast. Yet psychoanalyst Shmuel Erlich suggested that the meaning of loneliness remains “an enigma” (3).

The concept of loneliness looks deep at the need for human connection. Through the rise of science and technology, a result on our emphasis on empirical modes of thought, we have gained considerable scientific knowledge and a whirlwind of medical technology. Yet what has happened to the conversation involving spirituality, social customs, and personal relationships? What has happened to the human perspective? Dig as deep as you like into the functions of the human body, the junctions between the cells and the DNA mutations – just remember that the knowledge that is discovered needs to be applied to a living, breathing human being. Can we quantify the despair of loneliness, the cracks of a thirty-year marriage, the grief of a mother who has lost her child? We may spend our lives pursuing wealth and status, but ultimately it is meaning that we all search for in the end.

“Existential aloneness is necessarily a part of serious illness.”
– S. Kay Toombs (4)

How does it affect us as doctors?

As healthcare professionals, we are trained to be objective, to look at the statistics, and arm ourselves with the jargon of relative-risk and correlations. But walk into any hospital, and you will not see wards filled with numbers and graphs. You will see vulnerability, the eyes of loss, of angst and fear. You will see people tested to their limits, people whose lives are cracked and crumbling – people who have entered the threshold of loneliness.

Is loneliness a pathological condition? Intolerance for being alone was once a criterion for the diagnosis of Borderline Personality Disorder in DSM-III, while more recently, loneliness was found to increase risk of mortality by up to 26% (5). It can be argued that loneliness can have a purpose in our lives; it can form the path towards self-acceptance, growth and spiritual transcendence. The existential perspective goes so far as to say that loneliness is what it means to be human. It argues that through loneliness, one can begin to question one’s own existence, and thereby create meaning for oneself in a world that has lost all meaning. Western literature paints loneliness as a vital part of being human. It is seen as an obstacle one must climb through during the various experiences of life – through change, bereavement, love and loss. It has been argued that just as joy is made brighter through the experiences of sorrow, loneliness shines a light on the meaning of our life. Yet loneliness has also been linked to alcoholism, depression and suicidal ideation. At what point do we as healthcare professionals need to step in and help someone climb out from this abyss? Where do we draw the line between self-discovery and pathology?

Loneliness can also manifest itself through illness, both physical and mental. The feeling of a broken body, of being a burden on one’s family, can lead to helplessness. Roles that were once worn with pride are now cast aside: the mother, the carer, the provider. These can lead to a loss of self-identity and raise questions about how one can contribute to society. Ultimately, being ill can be an isolating experience, raising questions about one’s reasons for existence and the value of one’s life. As healthcare professionals, it is our duty to guide our patients through this journey. It is our responsibility to help them discover their own meaning for this loneliness, to help them affirm their identity. It is not always distraction or drugs that a patient needs, but an open conversation, which can help patients to gain new perceptions on what it means to be human. The role of the professional is not to provide answers or interpretations, but to listen, to share and to understand. It is a difficult task, filled with uncertainty and anxiety for both practitioner and patient, but it is also human.

We often cast aside people who are deemed lonely; they are the shy recluses, the self-pitying. We suggest that the cure for loneliness is simple: join clubs, create hobbies, meet new people.

By following such advice, we forget something vital: you do not have to be alone to be lonely. It is more than just being independent or respectful of others’ privacy; it is a feeling of distress. Loneliness illustrates our need for human intimacy. So where can we find this painkiller to drug us against such distress? Which specialist will take away our aches and pains? You do not need to be a trained medical professional to combat loneliness. Just remember, Hello is the most powerful word against loneliness.

As a final thought I want to leave you with this person’s experience of loneliness: https://www.youtube.com/watch?v=6-usOHfSQuA#t=23

To the one who set a second place at the table anyway.
To the one at the back of the empty bus.
To the ones who name each piece of stained glass projected on a white wall.
To anyone convinced that a monologue is a conversation with the past.
To the one who loses with the deck he marked.
To those who are destined to inherit the meek.
To us.

– Flood: Years of Solitude by Dionisio D. Martinez (6)

References

  1. Plath, S. 2002. The Unabridged Journals of Sylvia Plath. Anchor Books.
  2. Silouan, M. 2011. The Poverty of Loneliness [Online]. Available at: http://wonder.oca.org/2011/11/16/the-poverty-of-loneliness/ [Accessed: 8th January 2016]
  3. Erlich H. Shmuel, “On Loneliness, Narcissism, and Intimacy,” American Journal of Psychoanalysis58, no.2 (1998): 135-162.
  4. Toombs, S.K. 2008. The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patient. Springer.
  5. NHS Choices. 2015. Loneliness ‘increases risk of premature death’ [Online]. Available at: http://www.nhs.uk/news/2015/03March/Pages/Loneliness-increases-risk-of-premature-death.aspx [Accessed: 8th January 2016]
  6. Dionisio, D., Martinez. 1992. Flood: Years of Hope; Years of Solitude; Years of Reconciliation; Years of Fortune; Years of Judgment; Years of Vision; Years of Discourse. 22: 159-162

Featured image:
Maré vazia no mar de Wadden by Luis Estrela

Categories
Lifestyle Narrative Reflection

Latest Entry

The in-class assignment was simple: write a short paragraph of your thoughts about narrative medicine. But after ten minutes, my paper was a mess; pen lines angrily crossed out sentences that had been started but not finished, my usually neat penmanship was messy, my vocab unsure. My writing screamed hesitation. After begrudgingly turning in my assignment, I realized just how long it had been since I had written in my journal, which I had left tucked away in a nightstand in my childhood bedroom. I thought it was an appropriate place to leave the book—covered in cheesy flowers with a creased binding—that had chronicled my high school and college years. As I was packing for medical school, it seemed almost off-putting at the time to continue to chronicle the next chapter of my life—what I naively perceived to be the real challenges of medical school—on the same page as my previous entry, in which I complained about the trials and tribulations of learning how to drive stick shift and tackling organic chemistry. Instead, tucked away in my new bedroom, is a leather-bound journal, a gift I received for medical school, emblazoned with the words “FOLLOW YOUR DREAMS.” Every inch of it is covered in cartoon birds. It has been sitting in a drawer since I moved in, untouched.

As I juggle this new chapter as a busy first year med student, that seemingly simple assignment reminds me how much I miss, and clearly need, a nightly journaling routine as my outlet to find peace with my hurried thoughts at the end of a hectic day. It is all too easy to fall into the daily hustle and bustle of med school life such that every day seems almost like the one before. Study, extracurriculars, preceptorship, sleep. Lather, rinse, repeat. All too often, before I fall asleep, I find myself falling into the trap of using my phone to mindlessly relax; catching up on my Facebook newsfeed, scrolling through photos on Instagram—or, if we’re being totally honest here—catching up on celebrity gossip (let’s just say, I’ve definitely been keeping up with the Kardashians). But by the time I “unplug,” my brain is often wired. So much for unwinding.

Yet, even as I write this entry (yes, write, not type!), I understand how relaxing it is to unwind and take the time to process the day’s events with the written word. To really chronicle how every day is not like the one before, but how each day actually brings a new perspective as a result of what I had done that day: conversing with a new classmate, grasping the latest material in class, practicing the hands-on skills I’ve obtained in my preceptorship, etc. I see how important writing about these experiences is for me; to have something tangible to look back upon, years after medical school. To read through each chapter—to remember how I had stumbled when learning to measure blood pressure and take a patient history—just as I reflect now when I read back on my teenage struggles.

It’s important that we, as future physicians, find whatever it is that provides us with this sense of mindfulness, whether it be exercise, meditation, spirituality, etc., and hold on to it. It is through this self-awareness that we can see not only how we have changed, but even more importantly, to find a moment’s peace in the midst of the commotion that each day brings as we pursue careers in medicine.

So, when I go back to my childhood home to visit my family, I’ll be sure to pack up my journal.

Featured image:
12.2.2010 <homework> 321/365 by Phil Roeder

Categories
General Lifestyle Reflection

New Job

Every 4 weeks I start a new job. New boss, new co-workers, new hours. This is both the curse and blessing of a medical student in the clinical years. There are some rotations I just can’t wait to end, while others I wish could go on all year. (If there are any of my preceptors reading this blog wondering which category they fit into, don’t worry, yours was definitely the one I wanted to continue forever!) Since I’m a non-traditional student, I had a few jobs over the years. For instance, I worked for a couple years as a civilian contractor for the military. I was doing stuff that sounded really important on paper but was perhaps a bit more mundane in real life. In those days, I knew career civil servants who had been doing the same thing for 30 years or more, sometimes scarcely moving from their desk. I cringed at the thought, but for them, 4 weeks was like a day, and even my entire 4 years of medical school would be seen as no time at all. In fact, one old curmudgeonly co-worker once consoled me after my project was shot down by a Colonel who was also our boss: “Don’t worry, we can get that done when the next guy comes along. These military guys move on after 3 years anyway.” I remember thinking, “In 3 years?! I’m not waiting that long!” It’s no wonder I don’t do that job anymore.

There have been other jobs along the way that have been equally confounding. My first job after grad school was at a non-profit science and tech operation. I was so excited about what I was doing; I thought I really was playing a big part in the volumes of analysis that they put out. Then, a couple months after I started, my boss took me out to lunch for Secretary’s Day, which I promise is a real thing. I sat there eating my meal in utter confusion. I was apparently an assistant, and I always thought I was an analyst.

I recently started a new rotation, my ninth “new job” since beginning my third year. Nowadays it takes me just a couple hours to figure out if it’s going in the good or not-so-good category. Luckily, this one seems to fit squarely in the former. It’s a clinic position, so I have to learn where everything is, and of course most importantly, who to talk to about lunch, as in if there will be any free meals and on which days. This office is used to medical students. I can tell because they made very little initial effort to welcome me. That’s not to say they weren’t nice, indeed they very much were. But there is a different mentality for those who see faces like mine come and go every month. They already know me to a degree, since I’m just the interchangeable body inside the same white coat, with the same 3 or 4 books stuffed into my pockets, and the same questions. They won’t waste their time unless I turn out to be “one of the good ones,” whatever that means.

Sometimes as I wander through all these positions as such a neophyte, I think, does a med student even matter? Are we contributing? The short answer is probably no, until you get that one patient who starts talking maybe just a bit more because the med student seems to have a little more time. Or that patient who feels better just from having been heard, or perhaps reveals some small detail that they didn’t tell anyone else.  Then, in those few moments, I don’t mind being new on the job. I remember that being new is not always a bad thing. In fact, occasionally it can come in handy.

Featured Image:
Lost? by Susanne Nilsson

Categories
General Lifestyle Technology

Keyboards and Stethoscopes: A reflection on digital etiquette in medical school

February 26th marks the 47th anniversary of the landmark freedom of speech case, Tinker v. Des Moines. This case concerned a group of students who wished to wear black armbands to protest the Vietnam War. When their school banned the armbands to quash the protest, the students decided to sue, and the case made it to the United States Supreme Court. In the final ruling, Justice Abe Fortas wrote, “It can hardly be argued that either students or teachers shed their constitutional rights to freedom of speech or expression at the schoolhouse gate.” When writing his response, Justice Fortas probably didn’t imagine the digital age that we would be living in just half a century later.

Thanks to the power of the Internet, people can connect from thousands of miles away and ideas can go viral in mere seconds. The freedom of expression that the Internet affords us is practically limitless. The Internet can bring greater awareness to important humanitarian issues like ALS through the Ice Bucket Challenge, but its power as a terrorist recruitment tool can also be harnessed to spread chaos and destruction.

I wonder, as medical students, what our responsibilities are towards using social media responsibly, and how we balance these responsibilities without sacrificing our freedom of speech. In observing our class Facebook page and reflecting on my own bevy of social media faux pas, I have come up with the following five suggestions that I believe strike a balance between our professional responsibilities as medical students and our First Amendment rights.

  1. If something on Facebook offends you, have a face-to-face conversation with the person who posted the content. Avoid writing an angry response or a long rant, which can perpetuate further miscommunication. If a face-to-face conversation is not possible, give yourself a cooling off period before you respond.
  2. Never take down someone’s post without first talking to him or her about it. In our class, we’ve had a few situations where administrators of our group pages have taken down posts that they deem to be offensive or inappropriate. Conceivably, this was done to protect the integrity of the group and keep our Facebook page a “safe space”, but in reality, taking down someone’s post violates their freedom of speech and can make them feel unsafe. Before choosing the safety of the many over the safety of the few, talk to the person who posted questionable content and see if they will alter or possibly remove their post on their own.
  3. No babysitters! School administrators and faculty should not “babysit” class Facebook groups. A class Facebook page should be about fostering a sense of camaraderie amongst students, not about representing a school’s public identity. Therefore, the page should be private, and it should be the collective property of the students who chose to use it. Should disputes arise, they should be settled amongst students. Administrators should avoid getting involved in social media disputes unless they are directly asked to step in. Handling miscommunications and managing uncomfortable situations with our colleagues is important training for our professional careers.
  4. It’s okay to be a backstage comedian. Though this is likely my most controversial suggestion, I strongly believe that in our high-stress lives as students, and later as physicians, we benefit from being able to let off steam in a protected environment. A few months ago, we received a rather outrageous and somewhat distasteful lecture from some guest speakers. Not surprisingly, certain members of our class took to Facebook to share their “fond memories” of this unforgettable class. Somehow, the school administration was alerted to this content, and the students were asked to remove their posts. It’s only natural that from time to time, we’re going to find humor in something that happens in school or in the workplace. I think that it’s healthy to derive enjoyment and levity from these occurrences. In his writing, Immanuel Kant argues that laughter at an event is not a show of superiority, but rather an acknowledgement that the event differed from any reasonable expectations. Acknowledging the comedy of a situation is not at odds with our professional identities when it helps us to process and move on with overwhelming or uncomfortable events.
  5. Express yourself! I love when my classmates post articles that they find that I would have never otherwise discovered, or when a discussion from class spills over onto Facebook page. It makes me feel like I’m part of a community of people who value learning and exploration, and I have learned a lot from these posts.

Reach out to me on the MSPress Facebook page! I would love to hear your thoughts on Facebook and social media etiquette in medical school.

Featured image:
Der Blogger… by Dennis Skley