As I was getting ready for bed last night a friend shared a tweet that immediately caught my attention.
The tweet was of a
paper that has just been published online, titled “Does physician gender
have a significant impact on first-pass success rate of emergency endotracheal
intubation?” and showed the abstract which began,
It is unknown whether female physicians can perform equivalently to male physicians with respect to emergency procedures.
Understandably, this got the backs up of a
lot of people, myself included. Who on earth thinks that’s a valid question to
be researching in this day and age? Are we really still having to battle
assumptions of female inferiority when it comes to things like this? Who on
earth gave this ethics approval, let alone got it though peer review?
I then took a deep breath and asked myself
why a respected journal, The American Journal of Emergency Medicine,
would publish such idiocy. Maybe there was something else going on. The best
way to find out is to read the paper so I got a copy and started reading. The
first thing that struck me was the author affiliations – both are associated
with hospitals in Seoul, South Korea. The second author had an online profile,
he is a Clinical Professor of Emergency Medicine. I couldn’t find the first
author anywhere which made me think they are probably quite early in their
career. The subject matter wasn’t something I could imagine a male early career
researcher being interested in so figured they are probably female (not knowing
Korean names I couldn’t work out if the name was feminine or masculine).
Every so often, my cynical self emerges from the dead. Maybe it’s a byproduct of social media, or from following Saurabh Jha, who pontificates about everything from Indian elections to the Brexit fiasco. Regardless, there are times when my attempts at refraining from being opinionated are successful, but there are rare occasions when they are not. Have I earned the right to opine freely about moving on from financial toxicity, anti-vaxers, who has ‘skin in the game’ when it comes to the health care system, the patient & their data, and if we should call patients “consumers”? You’ll have to decide.
I endorse academic publications; they can be stimulating and may delve into more research and are essential if you crave academic recognition. I also enjoy listening to live debates and podcasts, as well as reading, social media rants, but some of the debates and publications are annoying me. I have tried to address some of them in my own podcast series “Outspoken Oncology” as a remedy, but my remedy was no cure. Instead, I find myself typing away these words as a last therapeutic intervention.
Here are my random thoughts on the topics that have been rehashed & restated all over social media outlets (think: Twitter feeds, LinkedIn posts, Pubmed articles, the list goes on), that you will simply find no way out. Disclaimer, these are NOT organized by level of importance but simply based on what struck me over the past week as grossly overstated issues in health care. Forgive my blunt honesty.
Can we reduce over diagnosis by re-naming disease to less anxiety-provoking makes? For example, if we call a 4.1 cm ascending aorta “ecstasia” instead of “aneurysm” will there be less over-treatment? In this episode of Radiology Firing Line Podcast, Saurabh Jha (aka @RogueRad) discusses over diagnosis with Ian Amber, a musculoskeletal radiologist at Georgetown University, Washington.
My first job after residency was in a small mill town in central Maine. I joined two fifty something family doctors, one of whom was the son of the former town doctor. I felt like I was Dr. Kiley on “Marcus Welby, MD.” I didn’t have a motorcycle, but I did have a snazzy SAAB 900.
Will was a John Deere man, wore a flannel shirt and listened to A Prairie Home Companion. He was kind and methodical. Joe didn’t seem quite as rural, moved quicker and wore more formal clothes. I never could read his handwriting.
They each had their own patients, but covered seamlessly for each other. They were like a pair of spouses in the sense that they answered to each other as much as to their patients. They had to make everything work for the benefit of their shared practice, their shared livelihood. Their mutual loyalty was essential and obvious, although allowing for their differences in temperament and personalities.
Invited to stay on and enter into a partnership, I hesitated. How did I fit in? Could I follow in their footsteps and become an equal partner, covering for them and doing things similarly enough to fit in for the long haul?
You’re running late and many things didn’t go right today. You knock on the door and enter the exam room with an apology. If you’re like me, you have a few papers and an iPad or a laptop in your hand. You sit down and open the patient’s chart in your device or perhaps on the big desktop, eyes not exactly locked on the patient.
Only after getting to where you need to be in the computer do you really look the patient in the eyes. Your body language has been one of hurry and distraction. Now you try to repair the damage of that, so you try to show you’re settling down now, at least for a few moments. You might sigh, move your arms in a gesture of relaxation and say something to get the history taking underway.
So far, you’re failing. I do that often, too.
Here’s what we all know we need to do, but often don’t; we should follow these ABCs:
A – Attention:
Clear your mind. It doesn’t matter what happened in the other room with the other patient, or on the phone with the insurance company or the smug specialist or ER doc who pointed out the diagnosis you missed. Open the door (I always knock first) and immediately look at the patient. Make eye contact and observe them. Pay attention to how they look, what they are signaling. The computer can wait; a few moments of focused attention will usually save you time in the end. After all, red or teary eyes, a leg cast, a big bruise or change in grooming can make the visit go in a direction you wouldn’t have expected from he listed chief complaint. How many times have we heard a patient comment about another doctor: He didn’t pay attention to me. Do we always do that ourselves if we’re rushed or preoccupied?
What does it take to create a decision rule? In this episode of Radiology Firing Line podcast Saurabh Jha (@RogueRad) has a discussion with Robert W. Yeh MD MBA about the deep thought and complex statistics involved in creating a decision rule to guide therapy which have narrow risk-benefit calculus, specifically a rule for how long patients should continue dual anti-platelet therapy after percutaneous coronary intervention. They also discuss the motivation behind the legendary, and satirical, parachute RCT published in the recent Christmas edition of the BMJ, which delighted satirists all over the world.
Our Experience on Facebook Offers Important Insight Into Mark Zuckerberg’s Future Vision For Meaningful Groups
By ANDREA DOWNING
Seven years ago, I was utterly alone and seeking support as I navigated a scary health experience. I had a secret: I was struggling with the prospect of making life-changing decisions after testing positive for a BRCA mutation. I am a Previvor. This was an isolating and difficult experience, but it turned out that I wasn’t alone. I searched online for others like me, and was incredibly thankful that I found a caring community of women who could help me through the painful decisions that I faced.
As I found these women through a Closed Facebook Group, I began to understand that we had a shared identity. I began to find a voice, and understand how my own story fit into a bigger picture in health care and research. Over time, this incredible support group became an important part of my own healing process.
This group was founded by my friends Karen and Teri, and has a truly incredible story. With support from my friends in this group of other cancer previvors and survivors I have found ways to face the decisions and fear that I needed to work through.
How long does it take to diagnose guttate psoriasis versus pityriasis rosea? Swimmers ear versus a ruptured eardrum? A kidney stone? A urinary tract infection? An ankle sprain?
So why is the typical “cycle time”, the time it takes for a patient to get through a clinic such as mine for these kinds of problems, close to an hour?
Answer: Mandated screening activities that could actually be done in different ways and not even necessarily in person or in real time!
Guess how many emergency room or urgent care center visits could be avoided and handled in the primary care office if we were able to provide only the services patients thought they needed? Well over 50% and probably more like 75%.
Primary Care clinics like mine are penalized if a patient with an ankle sprain comes in late in the year and has a high blood pressure because they are in pain and that becomes the final blood pressure recording for the year. (One more uncontrolled hypertensive patient.)
Burnout is one of the biggest problems physicians face today. We believe that addressing it early — in medical school — through coaching gives physicians the tools they need to maintain balance and meaning in their personal and professional lives.
We say that after reading comments from participants in our coaching program, “A Whole New Doctor,” developed at Georgetown University School of Medicine. This program, born almost by chance, provides executive coaching and leadership training to medical students, who are exactly the right audience for it.
Medical students tend to begin their education as optimistic 20-somethings, eager to learn and eager to see patients. After spending one or two years on the academic study of medicine, they move to the wards where they observe the hidden curriculum — a set of norms, values, and behaviors conveyed in implicit and explicit ways in the clinical learning environment.
In the hospital, convenience and expediency, deference to specialists, and factual knowledge tend to replace the holistic and patient-centered care that is lauded during the preclinical years. This new culture nudges some students to the brink of burnout and depression. Some consider suicide.
A lot of Americans think they should be able to make an appointment with a specialist on their own, and view the referral from a primary care provider as an unnecessary roadblock.
This “system” often doesn’t work, because of the way medical specialties are divided up.
If belly pain is due to gallbladder problems you need a general surgeon. If it’s due to pancreas cancer, you need an oncologic surgeon. If the cause is Crohn’s disease, any gastroenterologist will do, but with Sphincter of Oddi problems, you’ll need a gastroenterologist who does ERCPs, and not all of them do. Now, of course, if you’re a woman, that abdominal pain may actually be referred pain from an ovarian cancer, best treated by a GYN-oncology surgeon, which anywhere in Maine means a drive down to Portland.
The other day I saw an older man for a second opinion. He had been through one hand surgery for a small tumor many years ago in Boston, and another unrelated operation for a fracture in Bangor a few years ago. Then, after a non surgical injury, he developed stabbing pains in the same hand. Someone referred him to a neurologist for EMG testing, which was normal, and the man told me that was all the neurologist did, not a full consultation.