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Category: Medical Practice

2020: Entering the Year of the Midwife

By MICHELLE COLLINS, PhD, CNM, FACNM, FAAN

The World Health Organization has named 2020 the Year of the Nurse and Midwife. However, most Americans have never experienced a midwife’s care. In my over 30 years working in maternal-child health, I’ve heard plenty of reasons why. Families are understandably nervous about that with which they are unfamiliar, and nervous about pregnancy and birth in general, with good reason. The cesarean birth rate in the US has more than quadrupled since the early 1970’s, yet we aren’t seeing healthier mothers and babies as a result. In fact, compared to the prior generation, women in this country are 50% more likely to die in childbirth, and for women of color (particularly black women) that risk is three to four times higher than white women, regardless of the woman’s education level or socioeconomic status. For those expecting a baby in the new year, let me set the record straight about midwifery care.

Today’s certified nurse-midwives (CNM) and certified midwives (CM) have earned a minimum of a Master’s degree, as well as have passed a rigorous certification exam. A third category, certified professional midwives, are not required to have an academic degree, but they must also must pass a certification exam “based on demonstrated competency in specified areas of knowledge and skills.” Midwives are intensely educated both in normal, as well as in complications of, pregnancy and childbirth, and are well-prepared to address emergencies as they arise.

Midwives generally care for women with low-risk pregnancies; however, most pregnancies are low-risk. And in those instances when a patient’s pregnancy or birth becomes high-risk, the midwife collaborates with physician colleagues to provide comprehensive team care to result in the best outcome for mother and baby.

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Revisiting the Concept of Burnout Skills

By HANS DUVEFELT, MD

I looked at a free book chapter from Harvard Businesses Review today and saw a striking graph illustrating what we’re up against in primary care today and I remembered a post I wrote eight years ago about burnout skills.

Some things we do, some challenges we overcome, energize us or even feed our souls because of how they resonate with our true selves. Think of mastering something like a challenging hobby. We feel how each success or step forward gives us more energy.

Other things we do are more like rescuing a situation that was starting to fall apart and making a heroic effort to set things right. That might feed our ego, but not really our soul, and it can exhaust us if we do this more than once in a very great while.

In medicine these days, we seem to do more rescuing difficult situations than mastering an art that inspires and rewards us: The very skills that make us good at our jobs can be the ones that make us burn out.

Doctors are so good at solving problems and handling emergencies that we often fall into a trap of doing more and more of that just because we are able to, even though it’s not always the right thing to do – even though it costs us energy and consumes a little bit of life force every time we do it. And it’s not always the case that we are asked to do this. We are pretty good at putting ourselves in such situations because of what we call our work ethic.

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Reference Manuals May Be Facing Obsolescence

We must ensure their relevance to contemporary patient care

By LONNY REISMAN, MD

It’s 1992 and disruptive technologies of the day are making headlines: AT&T releases the first color videophone; scientists start accessing the World Wide Web; Apple launches the PowerBook Duo.

In healthcare, with less fanfare, a Harvard physician named Dr. Burton “Bud” Rose converts his entire nephrology textbook onto a floppy disk, launching the clinical tool that would ultimately become UpToDate. Instead of flipping through voluminous medical reference texts, such as the Washington Manual, doctors could for the first time input keywords to find the clinical guidance they needed to make better treatment decisions.

The medical community embraced UpToDate’s unique ability to put knowledge at their fingertips. Today more than 1.7 million clinicians around the world use UpToDate to provide evidence-based patient care with confidence. For many, it along with other reference sources has become foundational to providing high quality medical care.

More than just an easy-to-use reference, UpToDate has gone on to improve patient outcomes, according to the Journal of Hospital Medicine.

In the new era of 21st century digital medicine, however, there are opportunities to go further in support of clinicians and patients. Reference tools must be powered by predictive and prescriptive analytics, be personalized to individual patient circumstances, and be integrated into clinician workflow. In some cases, clinicians may be unaware of which questions to ask of a computerized reference manual, or how to incorporate the nuances of an individual patient’s case into the general insights of a reference. Searching for heart failure treatment, for example, may be too broad a query and the resulting recommendations therefore may not provide optimal care for a specific patient’s unique medical circumstances. New digital health solutions that consider patients’ co-illnesses, contraindications, symptomatology, current treatment regimens, and hereditary risks are essential.

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Doctoring at Christmas

By HANS DUVEFELT, MD

I find myself thinking about how being a doctor has come to impact the Christmas Holiday for me over the years. I have written about working late and driving home in the snow and dark of Christmas Eve in northern Maine; I have shuffled Osler’s written words into something that speaks to physicians of our times; I have written about the angst around the Holidays I see in my addiction recovery patients.

This year, my thoughts go to the way Christmas is a time of reconnection for many people. We reconnect with family and friends we may not see as often as we would like, and many of us reconnect with secular traditions dating back to our childhood. Many people also reconnect more deeply with their Christian traditions, the ancient celebration of Hanukkah or the newer one of Kwanzaa.

As a doctor, I think Christmas is a time when individuals are more open toward others, more willing to extend “good will toward men” (Luke 2:14). It can be an opener for future relationships to form or grow, a time to share our humanity in the context of experiencing something larger than ourselves and our everyday existence. It allows us to get a little more personal by sharing something of what we all have in common – the need for togetherness with those we love.

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Thou Shalt Not Try to Outsmart Me

By HANS DUVEFELT, MD

Medical researchers and their groupies – early adopters, thoughtleaders, those easily influenced or whatever you want to call them – never seem to learn that when you try to outsmart Mother Nature or Our Heavenly Father, whichever appeals more to your world view, you usually get your hand slapped.

When I was a resident (1981-1984), I got penalized if I didn’t offer postmenopausal women estrogen-progesterone replacement therapy because it seemed obvious that if women with endogenous estrogen didn’t get many strokes or heart attacks and women without estrogen did, all we needed to do was make up for God’s or Mother Nature’s oversight in not keeping the estrogen coming after age 50.

Then the Women’s Health Study in 2000, almost 20 years later, showed that women on Prempro had more strokes, blood clots and heart attacks, and more breast cancer on top of that, than women who accepted the natural order of things – menopause with all its symptoms and inconveniences.

The same things has happened with osteoporosis – more subtrochanteric femur fractures after five years of Fosamax than in untreated women.

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Switching to Outpatient Surgery for Everyone’s Benefit

By AMY KRAMBECK, MD

The trend toward less invasive procedures, shifting from inpatient to outpatient, has changed the face of surgery. Industry-changing leaps in technology and surgical techniques have allowed us to achieve our treatment goals with smaller incisions, laparoscopy and other “closed” procedures, less bleeding, less pain, and lower complication rates. As a result, patients who used to require days of recovery in the hospital for many common surgeries can now recuperate in their own homes.

Outpatient procedures grew from about 50% to 67% of hospitals’ total surgeries between 1994 and 2016,1,2 and outpatient volume is expected to grow another 15% by 2028,3 with advantages for patients, surgeons, insurers, and hospitals. In my hospital, where bed space is at a premium, my colleagues and I were able to make a significant impact by switching minimally invasive surgery for enlarged prostate, also called benign prostatic hyperplasia (BPH), from inpatient to outpatient.

New Opportunity with an Advanced Technology

BPH affects about half of men in their 50s, with the prevalence increasing with age to include about 90% of men 80 and older.4 As a result, BPH surgery makes up a significant portion of urological procedures in any hospital.

I have been performing BPH surgery for 11 years. There are several options, including transurethral resection of the prostate (TURP) and suprapubic prostatectomy, both of which require hospital stays and bladder irrigation with a catheter due to bleeding. Another less frequently utilized surgical option for BPH is holmium laser enucleation of the prostate (HoLEP). HoLEP causes fewer complications and requires shorter hospitalization.5 Specifically, its postoperative morbidity is the lowest among BPH surgeries.5,6,7  HoLEP has the least bleeding, shortest catheter time, and low rates of urinary tract infection, plus patients are less likely to require additional treatment for BPH as they age compared to other available therapies.5,6,7  

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The Public Health To-Do List is Choking Doctors and Jeopardizing Patients’ Lives

By HANS DUVEFELT, MD

“By the way, Doc, why am I tired, what’s this lump and how do I get rid of my headaches?”

Every patient encounter is a potential deadly disease, disastrous outcome, or even a malpractice suit. As clinicians, we need to have our wits about us as we continually are asked to sort the wheat from the chaff when patients unload their concerns, big and small, on us during our fifteen minute visits.

But something is keeping us from listening to our patients with our full attention, and that something, in my opinion, is not doctor work but nurse work or even tasks for unlicensed staff: Our Public Health to-do list is choking us.

You don’t need a medical degree to encourage people to get flu and tetanus shots, Pap smears, breast, colon and lung cancer screening, to quit smoking, see their eye doctor or get some more blood pressure readings before your next appointment. But those are the pillars of individual medical providers’ performance ratings these days. We must admit that the only way you can get all that health maintenance done is through a team effort. Medical providers neither hire nor supervise their support staff, so where did the idea ever come from that this was an appropriate individual clinician performance measure?

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“Chasing My Cure”: A Book Review

By CHADI NABHAN, MD, MBA, FACP

Have you thought about your own mortality?

Who hasn’t, given the frequency of seeing death and grief depicted in the media or through real life encounters with friends, relatives, neighbors, or patients? These incidents trigger uncomfortable and sometimes uneasy thoughts of how we might personally deal with potential illness and disease. The same thoughts are soon displaced by the busyness of living. 

Despite dealing with the death of his mother from a brain tumor, we learn David Fajgenbaum was healthy, living life to its fullest, and a future doctor in the making. He may have thought about his own mortality as he grieved the death of his mother, but likely never imagined anything dire would happen to him. Fajgenbaum was pushing forward on several fronts, including leading a non-for-profit organization for grieving college students, symbolically named “Actively Moving Forward” or “AMF” after his mother’s initials, all while first playing college football and then attending medical school. By all accounts, this was a vigorous young man, meticulous about his diet and physicality.  When he became ill, it was a blunt reminder that life is unpredictable.

In his book “Chasing my Cure”, Dr. Fajgenbaum takes us back to the time when he first got ill.  He vividly describes his physical symptoms and various scans which detected his enlarged nodes. Interestingly, we learn how long he was in denial of these symptoms, thereby delaying medical attention in favor of studying. This neglect of self-care highlights part of his personality, but also represents the pressure and expectations placed upon a majority of medical students. 

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Presenting Complaint: Social Injustice

By ANISH KOKA, MD

Bobby

It took some doing, but I had finally made it to Bobby’s home.

It was a rowhome tucked into one of those little side streets in the city that non-city folks wouldn’t dream of driving down. As I step in, I’m met by the usual set up – wooden steps that hug the right side of the wall leading up to the second floor.  Bobby certainly hasn’t made it up to the second floor in some time. At the moment she is sitting in her hospital bed in the living room. The bed is the focal point to a room stuffed to the gills with all manners of stuff. At least three quarters of the stuff seems to be food. Cinnamon buns, Doritos, donut holes, chocolate frosted Donuts, crackers, Twinkies. The junk food aisle at Wawa would be embarrassed by the riches on display here.

Bobby weighs in at four hundred pounds, 5 foot 5 inches. She has a tracheostomy from multiple prior episodes of respiratory failure that have required ventilatory support. I’m here at the request of a devoted primary care physician that still makes home calls. I’ve looked through the last number of hospital stays. The last few discharge summaries are carbon copies of each other. Hypoxemic respiratory failure related to pulmonary edema complicated further by morbid obesity. Time on the vent. Antibiotics. Diuretics. Home. Return to the hospital 2 weeks later. The last echocardiogram done was 3 admissions ago. A poor study. Not much could be seen due to ‘body habitus’.

I sit on the side of the bed trying to acquire my own images of her heart. I talk to her as I struggle. Bobby is 58, the youngest of three sisters, and the only surviving member of the family. Her elder sisters died of respiratory complications as well. They both died with tracheostomies. The conversation is circular. The problem according to Bobby is the tracheostomy. Everything was fine before that. I explain that a prolonged period of time on the ventilator on a prior admission prompted the tracheostomy, and that the multiple recent admissions to the hospital that required a ventilator seemed to validate that decision. She doesn’t waver. Both her sisters died shortly after they got tracheostomies. Bobby thinks the physicians taking care of her sisters had a hand in their demise. “They didn’t care.” “We told them they were sick.”

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The Liability of Outside Provider Orders and What Could be Done About It

By HANS DUVEFELT, MD

As a family doctor I receive a lot of reports from emergency room visits, consultations and hospitalizations. Many such reports include a dozen or more blood tests, several x-rays and several prescriptions.

Ideally I would read all these reports in some detail and be more than casually familiar with what happens to my patients.

But how possible is it really to do a good job with that task?

How much time would I need to spend on this to do it well?

Is there any time at all set aside in the typical primary care provider’s schedule for this task?

I think the answers to these questions are obvious and discouraging, if not at least a little bit frightening.

10 years ago I wrote a post titled “If You Find It, You Own It” and that phrase constantly echoes in my mind. You would hope that an emergency room doctor who sees an incidental abnormal finding during a physical exam or in a lab or imaging report would either deal with it or reach out to someone else, like the primary care provider, to pass the baton – making sure the patient doesn’t get lost to followup.

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