Tag Archives: Life

Bits and pieces of my personal life.

Couch to 5K anyone?

Last year I blogged about barefoot running and had high hopes to start running again. I did run for a while but perhaps I tried biting off more than I could chew and tired quickly. Summer faded into Autumn which blew away with the frosty winds of Winter. Now the days are stretching longer and longer and Spring is literally right around the corner. Time to get off the couch again!

One of my coworkers just told me about a cool little workout guide for those of us who’d like to start running but are not quite sure where to begin. Couch-to-5K is a running plan from Cool Running for the out-of-shape beginner (like me) to gradually improve running distances and in the end to run a 5K race (approximately 3.1 miles). You can get the gist of the workout for free at the link above or you can pay $20 for all the bells and whistles. OR, for a limited time only, you can get the iphone app for $0.99.

So I bought the app. I have a choice of 3 coaches:

  • Constance: “She got off the couch and finished a 5K, so this Couch-to-5K alumna can help you do it too.”
  • Billie: “She’s no-nonsense: she won’t be your cheerleader, be she’ll get you off the couch and across the finish line.”
  • Sergeant Block: “He’s as ‘hard Corps’ as they come. Follow the training plan, or he’ll make you drop and give him 50.”

I’m going with Billie and I’m going “barefoot” with my Vibrams. The app also helps me locate and register for local 5K races. I’m going to aim to run sometime in April or May. Wish me luck! Better yet, join me!

10 seconds of fame

On 2/7/12 I was interviewed by CBS Minnesota news reporter, Esme Murphy, for her story, Mannequins Become Test Patients For Regions Doctors. The linked interview and video shows me discussing the benefits of simulation for improving patient care. I include this post in my blog not because I’m trying to toot my own horn — 10 seconds on a local channel is so groundbreaking! — but because I have been asked by several readers to consider video blogging and I figured that this was a quick way for those interested to see a more life-like representation of myself.

The whole experience was both somewhat unnerving and hilarious because my team and I were not forewarned until minutes beforehand. We had just found a lull in the day to grab some lunch from the cafeteria and headed back to our workroom when my attending stated that our presence was requested in the simulation lab for a news report. We were to simulate an uncomplicated delivery using NOELLE™, one of the pricey mannequins mentioned in the interview. However, when we arrived it became apparent that they also wanted to interview us and I, being the chief resident, got chosen to shoot from the hip. No preparation, just 1, 2, 3, action!

After my little blurb we moved over to NOELLE™ for the simulated birthing experience. While we had experience with various other components of the simulation center, none of us had ever worked with NOELLE™ before, a head shaking, blinking blonde who intermittently talked, asked questions and screamed through contractions. We did not have gloves, other safety precautions or any of our other tools needed for routine vaginal delivery. Thank god they refrained from simulating the gushes of amniotic fluid and maternal blood and excrement. Eventually NOELLE™’s baby was delivered via the conveyor belt through her pelvis by our bare-handed emergency department resident as she squatted on the floor. Fun times were had by all. 🙂

Who’s your “doctor”?

“When I see a bird that walks like a duck and swims like a duck and quacks like a duck, I call that bird a duck.”
James Whitcomb Riley (1849–1916)

As healthcare continues to evolve in the U.S., more and more “midlevel practitioners” are taking on roles formerly provided by physicians. Examples of midlevel practitioners include the physician assistant (PA), doctor of pharmacy (PharmD) and advanced practice registered nurses (APRN) such as the certified nurse midwife (CNM), nurse practitioner (NP), certified nurse anesthetist (CNRA) and doctor of nursing (RN, PhD). Some of these providers may be unintentionally called “doctor” or request that their patients refer to them as such, however it is very important to recognize that they are NOT equivalent to — or substitutes for — the traditional physicians of Western medicine.

What is a doctor?

According to Merriam-Webster, the word “doctor” literally means “teacher”. Given that around 700 years have past since its first use in the 14th century, its modern meaning includes both the academic doctor of philosophy (PhD) as well as the healing art doctors of medicine (MD), osteopathy (DO), podiatric medicine (DPM), dental surgery (DDS), chiropractic medicine (DC), naturopathic medicine (ND) and veterinary medicine (DVM).

What does it take to be a physician?

As delineated above, there are many paths to gaining the title but the training involved and the credentials earned are not equivalent. In Western Medicine there are only 2 types of physicians: the MD and the DO. While they arise from independent roots (allopathy vs osteopathy respectively), the training involved is essentially the same except for minor details that occur during medical school. To become a physician we all must take the same arduous path.

  • Pre-medical school
    • Completion of a Bachelor’s Degree – A 4+ year process in any field of study including the sciences (BS) as well as the arts (BA or BFA). A competitive GPA is generally felt to be 3.6 or higher.
    • Prerequisite course work – Must be completed in biology, chemistry, physics and math in addition to regular course work.
    • The Medical College Admission Test (MCAT)Administered by the Association of American Medical Colleges (AAMC), the MCAT “is a standardized, multiple-choice examination designed to assess the examinee’s problem solving, critical thinking, writing skills, and knowledge of science concepts and principles prerequisite to the study of medicine. Per the Princeton Review, it is a “5-1/2 hour, computer–based test that has the reputation of being one of the most challenging standardized tests.” Over the past 2 years (2010-2011) the average score has been 25 out of 48 possible points. A competitive score is generally felt to be 30 or higher and only around 1/3 of test-takers will achieve this score.
    • Other considerations – Competitive GPA and MCAT scores alone are not enough to ensure admittance to medical school. Other considerations include experiences in leadership, community service, medicine and research as well as letters of recommendation, your personal statement and of course how well you interview.
    • Chances – According to the American Medical Association, “For the 2010-2011 entering class, U.S. medical schools received 580,304 applications from 42,742 applicants, an average of 14 per applicant. There were also 31,834 first-time applicants—up 2.5 percent from 31,063 in 2009-2010.” The AMA also noted that, “American allopathic medical schools enrolled 18,390 first-year students for 2009” and “nearly 13,000 applicants competed for 5,100 available slots” in osteopathic medical schools. So given 23,490 total positions and 55,742 applicants, the chance of acceptance based on these numbers alone is 42%.
  • Medical school – Another 4+ year process for those fortunate enough to gain admittance. Medical school serves to form the foundation of medical knowledge that we build upon in residency. It costs an average of $30,000 per year for tuition alone; it does not include books, supplies and living expenses. Can you drink water from a fire-hose? That’s what it feels like being deluged with information, struggling to retain it and continuing to compete against peers. How well we do has a direct effect on our ability to obtain a residency position not only in a location of our choosing but also in the field of our choosing – surgical residencies (general surgery, OB/GYN, urology, etc) are more competitive than medical residencies (family medicine, internal medicine, pediatrics, etc). In addition there are 2 more standardized tests we must complete — the United States Medical Licensing Examination (USMLE) steps 1 and 2 — that along with yet another personal statement, more letters of recommendation and interviews are evaluated for residency positions. We obtain either the MD or DO degree when we graduate from medical school depending on the program.
  • Residency – All residents are doctors given that we have completed 8+ years of higher education and have graduated with the degree from medical school. First year residents are commonly referred to as “interns”. Residency serves as a kind of apprenticeship or on-the-job-training and thus, in spite of our extensive education, we actually make less money than the nurses with whom we work. Residency can be as short as 3 years or greater than 5 years depending on the chosen specialty.
  • Fellowship – For those of us who want to sub-specialize, yet another level of training awaits (the fellowship) with its own process of evaluation and competition. Those of us who do not complete a fellowship are loosely referred to as “generalists” and those who do so are called “specialists”.

All in all to become a physician you are looking at a minimum of 11 years of rigorous higher education: a bachelor’s degree (4+ years), medical school (4+ years), residency (3+ years) and possible fellowship (1+ years). Now that we have explored what it means to be a physician of Western medicine, let’s discuss the process of becoming a midlevel practitioner.

Types of degrees

  • BA/BFA/BS – Bachelor of arts/fine arts/science (4+ years)
  • MA/MS – Master of arts/science (2+ years following a BA/BFA/BS)
  • PhD – Doctor of philosophy (4+ years following a BA/BFA/BS)

Physician extenders

  • Physician assistant (PA) – 6+ years (BA/BFA/BS plus MS in physician assistance).
  • Nurse practitioner (NP) – 6+ years (BS in nursing plus MS in nursing).
  • Certified nurse midwife (CNM) – 6+ years (BS in nursing plus MS in midwifery).
  • Certified nurse anesthetist (CNRA) – 6+ years (BS in nursing plus MS in nurse-anesthesia).
  • Doctor of nursing (RN, PhD) – 8+ years (BS in nursing plus PhD in nursing).
  • Doctor of pharmacy (PharmD) – 8+ years (BA/BFA/BS plus PhD in pharmacology).

Now I’m really not trying to dis on my fellow healthcare providers. In truth PAs, APRNs and PharmDs are needed to improve the accessibility of healthcare to citizens around the country. I am merely trying to point out that large differences remain between midlevel providers and physicians: their training is less comprehensive, less rigorous and certainly less competitive. To compare the two is to compare a Lexus with a Kia: both are cars but their builds are very different.

Why does this matter?

A recent data brief from the National Center for Health Statistics (NCHS) arm of the Centers for Disease Control and Prevention (CDC) noted that over the past 8 years (periods 2000-2001 to 2008-2009):

  • Outpatient visits attended only by APRNs have increased by 50%
  • People that live outside of major cities are 6 times more likely to be seen by a midlevel practitioner
  • Midlevel practitioners are utilized heavily by general medicine (21%) and OB/GYN (19%) compared to pediatrics (8%) and general surgery (6%)

Summary

As we move forward in the improvement of healthcare delivery in the U.S., it is important that we don’t lose sight of quality as we push for quantity. Most aches and pains and even chronic conditions can be (and probably should be) managed by physician extenders, however under the supervision and guidance of the physicians from whom they extend. To permit the practice of medicine without the physician is egregious and frankly dangerous. The next time you see your “doctor”, make sure you understand what kind of “doctor” s/he is. If you are seeing a midlevel provider, inquire about the supervising physician and how s/he is involved in your care. If there is no physician involved I highly suggest that you find yourself a real “doctor” or be prepared for the increase in medical error that will inevitably come. And in response to Mr Riley, quoted above, I would caution: Beware the decoys! They have become quite sophisticated.

Are you REALLY SURE you want your OB/GYN to cut your little boy?

Circumcision remains highly marketed at the hospital I mentioned in an earlier post. Although there were at least 3 of us who did not want to perform circumcisions at the beginning of my residency, I remain the only one who has stood my ground. Many residents do not want to do them but do not have a “moral objection” and thus feel they must so as to not shift their work onto other residents. New medical students rotating through labor and delivery are expected to ask new mom’s if they want their sons to be circumcised and to chart it in their notes. There is no discussion about the controversial nature of this procedure nor the option stated that they have the right to opt out. Medical students in particular are less likely to rock the boat because they know that their grade depends on it. It is quite frustrating to me to see how resistant people are to change and how easily people cave-in to peer pressure.

I am especially frustrated that OB/GYN residents and providers continue to feel that they are competent to perform the procedure.The tradition of OB/GYN physicians performing male infant circumcisions began many years ago when they used to deliver babies in the homes of their patients and was born out of convenience; after delivering the baby it seemed appropriate to go ahead and perform the desired circumcision as well. Nowadays the vast majority of deliveries by OB/GYN physicians occur in the hospital with pediatricians and other specialists readily available so convenience is no longer an valid argument. Moreover, OB/GYN residents in general receive scant education in the anatomy and pathophysiology of the penis. Those that choose to perform circumcisions are essentially performing the “simple” procedure without the associated medical knowledge required of all other surgical procedures. And unlike other surgical procedures, the postoperative follow-up and management of complications are performed by pediatricians and other specialists instead of the OB/GYNs who performed them.

A recent article by Dr Brian Le, MD found that while the majority of 27 respondent obstetric-gynecology residents “planned to perform neonatal circumcision when in practice, 44% had no formal training in circumcision and most were comfortable performing routine neonatal circumcision. Overall respondents were less comfortable evaluating whether the a newborn penis could undergo circumcision safely. When presented with 10 pictures of penises and asked to determine whether the neonate should undergo circumcision, 0% of respondents correctly identified all contraindications to neonatal circumcision with an average of 42% of contraindications identified correctly.” (Le B. Mickelson J. Gossett D. Kim D. Stoltz RS. York S. Sharma V. Maizels M. Residency training in neonatal circumcision: a pilot study and needs assessment. Journal of Urology. 184(4 Suppl):1754-7, 2010 Oct.)

I recently performed a Medline Ovid search (looking for primary literature) and found that while there are over 50,000 articles in OB/GYN’s two most respected journals — Obstetrics & Gynecology (aka the Green Journal) and the American Journal of Obstetrics & Gynecology (aka the Gray Journal) — only 43 of these articles address male circumcision. Thus OB/GYN physicians write only 1.1% of the articles relating to male circumcision and represent only 0.076% of the articles they produce. Finally, the American Congress of Obstetricians & Gynecologists (ACOG) continues to reject exhibition of circumcision dissident materials by Intact America at their national conferences because ethical consequences of this procedure are apparently “beyond the scope of the practice of obstetrics and gynecology.”

In summary, while  OB/GYN physicians have a long tradition of performing male infant circumcision and many continue to be more than happy to take a whack at infant penises, there is mounting evidence that they are deficient in the medical knowledge required to do so safely, they are uninterested in learning how to improve their skills and they do not contribute to respected literature to perfect techniques. Are you REALLY SURE you want your OB/GYN to cut your little boy?

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Throwing wrenches at the gears

I just finished my first week back on the labor and delivery service and happened to be on call on Saturday. As we were discussing patients in the workroom my senior resident inquired if I had asked a patient whether or not she wanted her son circumcised. I replied that I had not asked and that I would not be asking that question of anyone in the future.  Well sparks flew!

At this particular hospital infant male circumcision has become so institutionalized that it is treated almost as casually as a fast food worker asking, “Do you want fries with that?” “So you had a boy, huh? You want a circ with that?” On one hand we are appalled at the female circumcision that so many of our Somali patients have undergone yet we barely bat an eye at the other. Why are we so horrified by the surgical modification of female genitalia by another culture when we are so flippant about surgically modifying the genitals of our own infant boys?

So what is female circumcision anyway? It is a procedure done in parts of Africa, Asia and the Middle East where as little as the clitoral hood to as much as the entire clitoris and labia are excised. What little tissue remains after this procedure grows together (often aided by leg binding) sometimes leaving  a hole so small that sexual intercourse is physically impossible. In the U.S. we code it as “female genital mutilation” but of course no such verbiage is used with infant male circumcision. Now granted, I completely understand that cutting off some penis skin is not nearly as morbid as cutting off a clitoris. But less bad is still bad! Both procedures are forcefully performed without the consent of the individual receiving it and both have permanent consequences.

Many physicians and new parents justify their decision to participate in infant male circumcision for social or religious reasons. Others speak to its public health merit in reducing the transmission of HPV (the virus that causes cervical cancer in women) and HIV (the virus that causes AIDS). Yet all of these excuses (and yes, they are excuses) fail to consider the rights of the people involved. Infant boys are clearly unable to provide informed consent. Period.

One of the four ethical principles to which we prescribe as physicians is “Autonomy” – the right of each patient to make informed medical decisions regarding his/her own care. Also within the Hippocratic oath we take is the principle “First, do no harm.” It is impossible to honor these guiding ideals while performing circumcision or any other elective cosmetic genital surgery on infants and children.

And why are OB/GYN providers doing circumcisions anyway? For a specialty that prides itself on treating women only it is quite surprising how many providers perform this little side gig on infant boys. What infant penises have to do with women’s health I’ll never understand.

So what happened with my refusal to participate? Well I met with the residency program director today who affirmed my right to refrain from participating in procedures I am morally opposed to. I will not be forced to ask patients if they want us to maim their sons. I will continue to wear my Genital Autonomy badge with honor and I will continue to throw wrenches at the gears of status quo.

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Chronologic acceleration

I have now completed 4 rotations of my intern year which means that 24 weeks have gone by since the last time I wrote in my blog. So much has happened over that span of time but I have frankly been either too busy or too tired to write about it. Residency is not nearly as difficult as I was expecting – perhaps because I love what I am doing! – but it certainly eats up a lot of time. The march of time seems to be accelerating as my world spins faster and faster.

Since residency started in June I have now caught 38 babies (vaginal deliveries) and cut out 23 more (Cesarean sections). That’s 61 kiddos I’ve assisted bringing into this world! I have also either performed or assisted in many other procedures. Each experience is so much fun and my knowledge and skills continue to grow exponentially. The night before last I received my first obstetric baptism; just as the infant’s head was starting to crown (visible without the need to manually separate the labia) with me poised to catch, it’s bag of water (amniotic sac) burst and showered me. Fortunately there was no baby poo in the fluid (meconium) and I was wearing protective gear but it still managed to wet my hair. The first of many I’m sure.

During my first rotation I managed to take a tumble off my bike and break my left pinky just past my knuckle (5th proximal phalynx). I bike commuted all summer and early fall and on this particular day it was raining. As I attempted to veer across some railroad tracks along the parallel S-curving bike path my bike completely slipped out from underneath me and I dived face first toward the pavement. After skidding to a stop using my elbows and chest as breaks I noticed that in addition to the minor scrapes I had sustained my pinky was deviated away from my other fingers at an abnormal angle. Long story short, the orthopedic surgeon offered me two options: either wear a cast to my elbow for 6 weeks or have a plate and screws surgically placed (open reduction internal fixation). Given that I need my hands to do my job, I underwent surgery and was able to perform surgery on others the next day. It’s still not completely back to normal but the pain is gone and it is completely functional. Morals to the story are: 1, Don’t try to bike across wet train tracks at an oblique angle. 2, I am breakable after all! And 3, these hands are priceless and I have to be more careful in the future.

Patrick and the dogs finally moved our stuff up from Utah in August, 2 months after I had started residency. I had missed them so much! We are currently living in the Powderhorn Park neighborhood in a large 3 bedroom duplex that we love. We occupy the top floor of an early twentieth Century home with 12 foot ceilings, wonderful architectural details, lots of light and a large screened in balcony overlooking our front lawn. The house sits in the middle of an entirely fenced in yard that the dogs enjoy. We have lots of rabbits and squirrels which the dogs love tracking and gobbling up their turds before we can stop them. Yuk! Copper actually caught a rabbit in our yard one morning and almost wouldn’t let it go when Patrick protested. Fortunately the rabbit was not injured and bounded away when Copper finally opened his jaws. Just the other night Patrick was telling me that both dogs were asleep on the couch and whimpering in their sleep. They must have been picking up on each other because apparently they started whimpering at each other louder and louder. Patrick tried to videotape it but unfortunately failed. That surely would have been a contender for $10,000 in America’s Funniest Home Videos.

Patrick continues to look for work and takes of the house, dogs and me in the meantime. His big news is that he will be getting a cochlear implant in the next few weeks. His hearing has digressed to the point where he can no longer hear on the phone even with state-of-the-art hearing aids and he is now legally deaf, no longer just hard-of-hearing. Technology is now available however to insert sound-sensing electrodes deep within his inner ear to stimulate his auditory nerve replacing the function of inner ear hair cells. Patrick is a bit nervous about the procedure because the insertion of the electrodes into his cochlea will effectively destroy what little natural hearing ability he still has and he states that he is grieving this loss. On the other hand he is excited to go bionic (or Borg if you’re a Trekkie) and to hear probably better than he has ever heard in his life.

JD and Kayla have yet to visit but will be here for 2 weeks during the winter break. And they are growing like weeds! JD is enjoying junior high – I can’t believe I’m old enough to have a kid in junior high! – except all the homework. Kayla seems less interested in school though she is just as bright; she’d just rather play or read on her own.

Fall is now gone with all the vibrant colors that go with it. In its place are the monochromatic tones of winter with blinding sunlight, lengthening shadows and sleepy landscapes. The temperature is still bearable usually in the 30s to 40s and I continue to mentally brace myself for the arctic blast that I’m told is right around the corner. I am however looking forward to ice skating outside on one of the many lakes like so many faded holiday images of a not so distant past.

Although I am much less communicative than I have been in the past I hope you all know that you are often in my thoughts and I wish you happiness, peace and light.

Land of 10,000 Lakes

Actually there are 11,842 lakes in Minnesota and let me tell ya, it is one beautiful state! I have now been living in Minneapolis for one week. I flew in with only four bags and am currently subletting a room within walking distance of the U of MN. Today really was my first day to do some exploring though as I was in orientation all week long. One of my classmates was kind enough to lend me a bike to get around so that I can take my time to consider my options before purchasing my own. I rode out to the hospital where I will have my first rotation as a brand new doctor (I graduated 6/4/09) and enjoyed the Greenway (a paved biking/running trail) and the beautiful scenery as I passed the northern rim of Lake Calhoun. I had to stop at the Freewheel Bike shop on the way however to buy some padded bike shorts and a new squishy bike seat — I have not cycled for many years and while my legs are definitely burning I must say that it is my tush that is hurting the most. Yikes! As my commute is 7 miles (14 round trip), I should definitely get some great exercise and start burning off all the extra poundage I added during medical school.

On Monday I begin my first rotation — obstetrics at a hospital that has over 4000 deliveries each year. During my five weeks there I should deliver 50-80 myself. Given that I only had the opportunity to deliver a few placentas during medical school, I am very excited. My other 8 classmates are all starting on different rotations at the four hospitals we will work at this year. I am sure that I will have much to write about as I move forward in my career. I just hope that residency does not age me as much as medical school!

People of the Mountains

I finished my last rotation of medical school on 4/24 and will receive my diploma on 6/4. Rather than staying put in Portland for the interim, Patrick and I decided to move to Utah for the month of May and are staying with his mother in her beautiful historic home. It is so nice to be in a totally different environment and let myself recharge my battery for residency, which I will begin 6/8 at the U of M in Minneapolis.

The move, while physically exhausting as Patrick and I did it all by ourselves, was also an enlightening experience. We decided to try to get rid of as much of our stuff as possible before the move and advertised our moving sale on Craig’s List and at OHSU. Only a few people responded and we sold a couple of items at greatly reduced prices. I was glad that the items were no longer in our possession nor our responsibility but I also felt rather empty from the transactions; the few dollars we earned from the sale did not make up for the psychological drain of trading personal items for money. We were still determined to downsize our possessions however and decided to donate them instead of selling them. We loaded up our rental truck with almost all of our possessions and took them over to a Portland charity for people with AIDS. We even donated our only vehicle to another charity that serves the homeless. The difference of experience between selling and donating was night and day. Feelings of emptiness and exhaustion were replaced with joy and contentment. I also was able to feel the freedom of letting go that I had been longing for. Giving is so much more satisfying than selling.

Today I helped Patrick in the garden and mowed a GIANT yard until I had blisters on my palms and my muscles quivered. We ate fish and chips and drank fresh lime soda from the local Daley Freez and enjoyed soaking up the sun and watching our dogs bound about the yard. While doing chores in a small town may not seem like much of a vacation to some, for me it is exactly what the doctor ordered. I feel tired but stress-free and happy. I’m also very glad to have this opportunity to get to know my mother-in-law better as we’ve spent little time together over the past 7 years Patrick and I have been together. Our kids will also be visiting us here and they will get a chance to spend time with their grandma for the first extended time period. Family time in the top of the mountains.

O-BAM-A! O-BAM-A! O-BAM-A!

What an amazing day. Barack Obama is president of the USA! He has united a deeply divided country and filled our hearts with hope when before there was only despair. He is the leader that our country has been waiting for so many years. While I was not alive during the presidency of John F Kennedy, I imagine that Obama will be remembered in much the same light. For the first time in almost a decade I feel proud to be an American once again. And Obama is not a man of empty promises, like so many other politicians. Already the White House website has changed to reveal the transparency of his agenda and the reflection of his vision. He recognizes that equal rights for LGBT persons are not special rights, as so many religious naysayers have claimed. They are civil rights and he will fight for them as president of the USA. You should really check out http://www.whitehouse.gov/agenda/civil_rights/ to see for yourself!