Sunday, May 29, 2011

Sunday Morning Cartoon for You

Sad Reality

If results from national survey can be believed, more than 2 in 3 U.S. doctors witness other physicians disrupting patient care or collegial relationships at least once a month. More than 1 in 10 say they see it every day.

The survey involved 840 doctors, most of them leaders in their own physician communities.

"Disruptive physician behavior is the issue that just won't go away," says Dr. Barry Silbaugh of the American College of Physician Executives, which sponsored the project with the help of a Massachusetts-based group called QuantiaMD. "Our profession is still plagued by doctors acting in a way that is disrespectful, unprofessional and toxic to the workplace."

The college, he tells Shots, hopes the survey will shine a light on "the shadowy, dark corners of our profession" where doctors act in arrogant, demeaning and even physically violent ways. Silbaugh likened it to pilots "fighting in the cockpit."

Silbaugh says stress, long hours and red tape contribute to the bad behavior. "It's not getting any easier in this era of reform," he notes, "where the rules seem to shift from day to day and the financial rewards may be shrinking."

A 14-page white paper put out by the ACPE cited these examples:

A doctor who was being monitored because of a long history of rudeness again yelled at a nurse, resulting in "a significant medication error and harm to a child."

A prominent surgeon's habit of degrading comments aimed at nurses and support staff eventually resulted in "shoving and the OR."

A male doctor created "an intolerable work environment for a female physician" through "condescending, bullying" and refusing to acknowledge her supervisory role.

Three-quarters of survey respondents say they're concerned about disruptive behavior by fellow physicians. Virtually all say it affects patient care.

A little over a quarter of doctor-respondents admitted they had been guilty of disruptive behavior at one time or another. The most common reasons, respondents say, are workload and behaviors learned in medical school.

More than half the doctors surveyed say they've witnessed other physicians yelling, flinging insults, refusing to cooperate with other health care personnel and refusing to follow established rules.

Less frequent but not uncommon: Discriminating against colleagues or patients (24%), inappropriate jokes (40%), profanity (41%) and spreading malicious rumors (21%).
Least common, but disturbing, were cases of throwing things (14%), retaliating against perceived slights (13%), substance abuse (14%) and physical violence (3%).

The survey found mixed responses when it asked doctors how well they think their hospitals or practice organizations deal with bad behavior. Perhaps not surprisingly, female doctors were less comfortable reporting or confronting instances of disruptive behavior.

Respondents say health care organizations should develop clear policies and procedures for confronting bad behavior, disciplining it and preventing it by improving the culture of the medical workplace.

There's no way to know if the survey is representative. Nearly 10,000 doctors were invited to participate, but fewer than 10 percent did. "It is possible that the respondent group was either more interested in or more likely to have experienced or witnessed disruptive physician behavior," the white paper acknowledges.

Bad Bonus: For more detailed cases of doctors misbehaving, see this Google map of cases brought before medical boards across the country. Longtime investigative reporter William Heisel spent the better part of a year sifting through records for a series he called "Doctors Behaving Badly" on the Reporting on Health website.

Wednesday, May 25, 2011

Is There a Doctor Onboard?

Interesting article in Monday's NYTimes about doctors who treat emergencies on flights.  It was sort of funny for me to read because when my group was flying back from Haiti, this subject came up as we were in line to board.  The gyn-oncology fellow who was with us said that she usually tries to wait for someone else to answer the page because, "I'm a freaking OB/GYN!  If someone goes into labor on the plane, I got that.  But otherwise..."  And then the lady right in front of us turned around and said, "The older you get, the longer you wait for that other person."  Turns out she was an ER doc.  (Which, don't you think that's the kind of doc you want popping up for an emergency FIRST?  But anyway... )

When Doctors Are Called to the Rescue in Midflight
May 23, 2011

Dr. Matthew Rhoa is still haunted by one of his lowest moments as a physician. Several years ago, on the first leg of an international flight, he was just settling in for a nap when a flight attendant came on the public address system to ask, “Is there a doctor on the plane?”

Dr. Rhoa, who lives in San Francisco, didn’t push his call button. “As a gynecologist, I always waited for another doctor,” he said. “There’s never a need for a Pap smear at 30,000 feet.”

He fell asleep, only to be awakened an hour later by a second call for medical help. This time he answered, and at the back of the plane he found two anxious parents with their 18-month-old toddler, who had a cast on her broken leg and was crying inconsolably.

The girl’s toes were blue. Limbs can often swell in flight, and it was clear that the cast was much too tight. Dr. Rhoa slit the cast and pried it open. The girl stopped crying at once.

“I have been riddled by guilt to this day,” said Dr. Rhoa, who now promptly answers every call for medical help on a plane. “I never want that feeling again of a kid suffering like that when I could have done something sooner.”

Since the earliest days of commercial aviation, airlines have coped with medical emergencies in flight by calling on physicians who happen to be passengers. And as more people travel by air, the number of emergencies has risen accordingly.

“Passenger health is becoming more and more of an issue, because of increased life expectancy and more people flying with pre-existing conditions,” said Dr. Paulo Alves, a vice president at MedAire, a company that provides crew members with medical advice from physicians on the ground.

MedAire, which advises more than 60 airlines around the world, managed about 19,000 in-flight medical cases for commercial airlines in 2010. Although few were life-threatening, 442 were serious enough to require diverting the plane — and 94 people died onboard.

The numbers reflect a fraction of the actual number of in-flight emergencies. The Federal Aviation Administration does not track in-flight medical episodes, and airlines are not required to report them.

Airborne calls for medical assistance pose a singular challenge for physicians, who find themselves suddenly caring for a stranger whose history they don’t know, often with a problem well outside their specialty, in a setting with limited equipment but no shortage of onlookers scrutinizing their every move.

And they do this for no compensation. (The fact that Good Samaritan laws generally protect them from lawsuits is a small saving grace.)

So it is little wonder that many physicians hesitate before responding to an emergency call.

Three years ago, Dr. Peter Freed, a psychiatrist in Manhattan, answered a call for a physician during a cross-country flight. A passenger had just had a seizure. Dr. Freed told the flight attendant he had not practiced general medicine since his residency. Still, he was the only doctor to respond, and the flustered crew member told him she was grateful for any help at all.

The passenger, a woman in her 30s traveling from Europe, told Dr. Freed she had a longstanding seizure disorder. He had her take her medication and remained with her, hoping she would be fine for the rest of the flight. But after another 20 minutes, she developed the uncontrollable shaking of a grand mal seizure and fell unconscious.

He asked to speak to a neurologist on the ground, and within minutes the pilot was able to get one on the radio. But as Dr. Freed recalled, he was barred from the cockpit for security reasons and could not speak directly with the specialist.

“I talked to the flight attendant, who talked to the captain in the cockpit, who talked to the doctor,” he said.

Next came the question that many physicians who answer in-flight emergency calls face: Should the plane be diverted to a nearby airport? Ultimately, the decision rests with the pilot, but the pilot looks to the medical expert for guidance. And it is a decision that other passengers await most anxiously.
After calculating that it would take as long to divert the plane as to reach their destination, Dr. Freed decided against it.

Once the plane landed, an emergency medical team whisked the woman away. The pilot had Dr. Freed stand with him while passengers disembarked. As people filed past, they shook Dr. Freed’s hand and thanked him. But while that response was gratifying, the episode still felt unresolved.

“Doctors typically like to hear how cases end,” Dr. Freed said. “But I didn’t hear a thing. I never even knew her name. I still think about her.”

Physicians are not completely without backup in an airborne emergency. The F.A.A. requires that flight attendants undergo CPR training and that all United States airlines carry emergency medical kits and automated external defibrillators.

But physicians who get a firsthand look at the kits say the contents vary.

“With some planes, it’s a hospital in a box, and they have everything you could ever want,” said Dr. Paul Abramson, a primary care physician in San Francisco. “But often they look like they’ve been picked over.”

Dr. Abramson said one kit he was given had implements for ventilating a patient unable to breathe, but no bag to push air into the patient — a situation akin to having a gasoline nozzle and tank, but no fuel.

Another kit contained only enough intravenous saline solution to rehydrate a baby, not the 200-pound man he was tending.

Dr. Paul Sullam, a faculty member at the University of California, San Francisco, said he was on a plane several years ago when a passenger seemed to be having aheart attack.
The crew asked passengers if anyone had nitroglycerin tablets, small pills that are placed under the tongue to improve blood flow to the heart. No one responded. But when it asked for Valium, to calm the patient, “a forest of hands went up,” Dr. Sullam recalled.

The lack of standardization was criticized in a recent article in The Journal of the American Medical Association. The paper argued not only that the medical kits should be standardized, down to the number of latex gloves, but also that a method for reporting incidents should be consistent among all airlines.

“Aviation is held up as this paragon of safety, yet here’s this nasty thing that happens with no standard for reporting,” said one of the article’s authors, Dr. Melissa Mattison, associate director of hospital medicine at Beth Israel Deaconess Medical Center in Boston. “We know more about animals that die on airplanes than we do about people.”

Dr. Abramson, the San Francisco physician, has answered so many emergency calls on planes that he now carries some basic medications in his toiletries bag whenever he flies, including antihistamines, prednisone, sedatives and painkillers, all “just in case they don’t have it.”
He also books his flights with “Dr.” in front of his name. “That’s so that if I’m asleep, they might wake me,” he said. And he doesn’t take sleeping pills or drink alcohol in flight. “The last thing you want to do is be woken up and not be with it,” Dr. Abramson said.

“I kind of like doing it,” he continued. “Because it’s what I do, and it seems helpful, and it’s interesting to make do with whatever minimal resources you have.”

Dr. Abramson occasionally receives letters of thanks from the airline, and once received a free domestic ticket. “That was the best,” he said.

Dr. Sullam, of U.C.S.F., said United Airlines once showed its gratitude by sending him an Arnold Palmer putter. “They must have figured all doctors play golf,” he said. (He does not, but he still has the putter.)

Dr. Celine Gounder, an infectious disease specialist at Johns Hopkins who works in global public health, has answered numerous emergency calls on flights. After one such call, she was given a bottle of Champagne as she left the plane to rush for a connecting flight.

“I thought, ‘What am I supposed to do with this?’ ” she recalled. She returned it to a flight attendant.

Despite the pressures, the haphazard nature of the work, the lack of compensation and the risks, physicians continue to reach up and answer the call. In a world of insurance forms, rushed office visits and ubiquitous technology, many count such emergency calls among the purest expressions of their Hippocratic oath.

“You feel good about trying to help someone, and that’s the most important thing,” said Dr. Ingrid Katz, an infectious disease specialist at Brigham and Women’s Hospital in Boston. “But don’t expect anything. It’s solely for the benefit of the person in need.”

Saturday, May 21, 2011

Keep Austin Weird

A couple of weeks ago, I got to spend a reallylong, extended weekend in Austin with Jake. It was such a fun time- Austin is a great city, really quirky and unique and all totally right up my alley.  It was also great to get to see the place that's been home to him for the past two years, meet people that are important to him, get to know some of his favorite spots.  

Welcome to Austin!

Polvos- I <3 U 2!

self-portrait that's actually good of both of us! :)

best store name ever

study time by the water

flowers that met me at the airport upon arrival :)

love the spanglish everywhere

and all the tacos and burritos!!

mustache ride!

doing two things at once: walking and picture-taking

car2go!  best thing ever



their gals at annie's ice cream

good look, right?

lady parts! in an antique store

in the boot store!  smells so leathery and awesome in there

the green ones were some of my favorites

food stands everywhere = awesome

it tasted even better than it looks

Bill, the giant dog

In less than a week, I get to go back--but this time to help him move here, to Atlanta.  He has completed his MA, and is now saying goodbyes in Austin.  I think we are both really excited and really nervous about this transition, but mostly, I am just so, so happy that he will be close by.  We haven't lived in the same place since we were in college together, so it's been quite a few years, and although we have been really lucky in that our long-distance period has been relatively short... let's face it, long-distance sucks.  So we are thrilled that it's almost over.  (As long as we don't get raptured later today, that is.)

Thursday, May 19, 2011

Modern Medical Ethics

The issue of obesity is a really big one, no pun intended, and is only getting increasingly so, across all areas of medicine. Obese patients have a higher risk of complications in general, and the patient population in this country, as a whole, is becoming more obese. But it is particularly relevant, and of personal importance to me, regarding obstetrics. OB/GYN is a specialty I am very, very interested in... it's only my first year of school, and I'm trying to keep an open mind, here, but I really just think I would love to do OB. I get really excited thinking about it; I even think I might be kind of good at it. 
Anyway, there are serious downsides to this choice. The lifestyle of delivering babies aside, obstetricians face some of the highest rates of malpractice suits, and consequently, some of the highest malpractice insurance rates in medicine. Anything wrong with baby, and it is pretty tempting and pretty easy to turn around and blame the OB--and then pretty much impossible to prove that it wasn't her fault. For the most basic and natural of human processes that can and does go wrong in any countless number of ways and to any countless number of degrees, this strikes me as a tad unjust (can you tell that this is already a little bit of a personal sore spot for me?) All that to say, pregnancy for an obese patient can be a huge risk--in a medical specialty that already faces a lot of risk and high penalties for taking on that risk. 
On the other hand, it seems pretty clear that refusing a patient based on their weight is downright unethical, and most certainly not in the spirit of caring for those in need. And as the population continues to get bigger and bigger, this issue will only continue to grow as well.

What do you think about this?

Some ob-gyns in South Florida turn away overweight women

By Bob LaMendola, Sun Sentinel

In a nation with 93 million obese people, a few ob-gyn doctors in South Florida now refuse to see otherwise healthy women solely because they are overweight.

Fifteen obstetrics-gynecology practices out of 105 polled by the Sun Sentinel said they have set weight cut-offs for new patients starting at 200 pounds or based on measures of obesity — and turn down women who are heavier.

Some of the doctors said the main reason was their exam tables or other equipment can't handle people over a certain weight. But at least six said they were trying to avoid obese patients because they have a higher risk of complications.

"People don't realize the risk we're taking by taking care of these patients," said Dr. Albert Triana, whose two-physician practice in South Miami declines patients classified as obese. "There's more risk of something going wrong and more risk of getting sued. Everything is more complicated with an obese patient in GYN surgeries and in [pregnancies]."

Plantation ob-gyn partners Jeffrey Solomon and Isabel Otero-Echandi turn down any woman weighing more than 250 pounds.

Solomon and Otero don't want to begin seeing heavy women and then have to send them to specialists if they later develop problems, said their office manager, who asked not to be named. The two doctors, like several of the others with weight cutoffs, declined to comment.

"This is not a high-risk practice," the office manager said. "They are not experts in obesity."

Turning down overweight people is not illegal for doctors, but the policy worried leaders of physician groups, medical ethics experts and advocates for the obese, all of whom said it violates the spirit of the medical profession.

"If I had that policy, I wouldn't have a practice. I'd lose half my patients," said Dr. Maureen Whelihan, a West Palm Beach ob-gyn. "We never turn down anyone. We would see them, and if we had to, we would refer them to a specialist."

Leaders of eight local, state and national medical associations said they had never heard of doctors turning away patients solely because of weight. Several said obese people with no other health issues do not need special treatment.

"No doctor should be unable to treat patients just because they are heavy," said Dr. Bruce Zafran, a Coral Springs ob-gyn.

So far, the weight cutoffs have been enacted only by South Florida ob-gyns, who have long complained of high numbers of lawsuits after difficult births and high rates for medical-malpractice insurance. More than half go without coverage.

Ob-gyns for years have declined to see pregnant women who are overweight, typically sending them to specialists. It's new for them to turn down overweight women who are not pregnant, physician groups said.

Several ob-gyn offices said their ultrasound machines do not give good images of internal anatomy in obese women, making it harder to diagnose some medical problems.

The Plantation office manager said weight limits are not uncommon at offices owned, like hers, by the Coconut Grove medical services company VitalMD.

VitalMD treasurer Kerry Kuhn, an ob-gyn in Coral Springs, said he was unaware of his doctors setting weight limits, adding the company has nothing to do with doctor decisions.

"This is individual choice by a doctor," Kuhn said. "Doctors know who they want to treat."

Physicians, like any business, can decline service to whomever they choose for any reason — including personality conflicts — as long as it's not discriminatory. The American Medical Association advises doctors that they cannot reject patients because of race, gender, sexual orientation or infectious diseases.

Doctors also are allowed to drop patients, if they believe they lack the medical skills to properly treat them. They must send notices and refer them to other doctors.

But decisions about patients typically are made after assessing the individual's condition during an exam, not by ruling out an entire group, said Dr. Robert Yelverton, a board member of the Florida Obstetric and Gynecologic Society. He said he would discourage physicians from excluding the obese.

"Do I think it's a good policy? No," Yelverton said. "Overweight people need doctors. I don't know where a patient in that situation would go if every practice had that policy."

The AMA and the ob-gyn group declined to comment on doctors setting weight limits. A spokesman for the Obesity Action Coalition in Tampa said the restrictions sound like discrimination.

"This completely goes against the principles of being a doctor," James Zervios said. "Health care professionals are there to help individuals improve their quality of health, not stigmatize them according to their weight."

Tuesday, May 17, 2011


Yesterday was the GI exam and our FINAL anatomy exam.  

Which means that anatomy is over.  Which means that first year of medical school is just about over, and also that I survived it.  Leaving the test yesterday actually did feel like I had just passed a pretty big milestone- anatomy in med school is one of those things that I feel like I'd heard about forever, spoken of in hushed and awed tones, (or fearful or maybe resentful ones), sort of like organic chemistry was in my pre-med classes.  I guess it sort of makes sense, but I'm not entirely sure that its reputation is totally deserved.  Yes, at times, it was sort of gross, it took up inordinate numbers of hours, it could be incredibly tedious... but it was also just really cool.  

I mean, getting to dissect apart an entire, real human body... it was humbling and awe-inspiring.  Do you have any idea just how crazy-intricate and amazing your body is??  There is a LOT of shit in there, seriously.

won't be looking at this again (for a while, at least)

returned our skull and bone box, so studying no longer looks like this

too much?
For anyone curious about or considering donating your body to science, I highly recommend the book Stiff, by Mary Roach.  Totally fascinating.  Regardless of how you feel about donation, it might change your mind (in either direction.)  In any case, you will learn a ton of really interesting things about what happens to bodies once they are dead, if that's the sort of thing you enjoy.  (Which I obviously do, and I don't think that's weird, either.)

Now I have a day off, and the pressure of trying to ENJOY THE DAY OFF almost makes it impossible to actually do.  Do I take advantage of the extra time to do real-life stuff that I really should do, like starting to pack and clean and answer all the emails that I have been putting off?  Or do I use the day off to pretend it's like a weekend I don't have to study and just try to do something fun and relaxing?  And the tension between these two goals feels almost as stressful as just having a regular day of needing to study more than is actually possible.  (Almost... but not quite.  I'm actually treating myself to a massage this afternoon. :) )
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