Tag Archives: Medicine

Posts that relate to medicine in some way.

Rio Political Declaration on Social Determinants of Health

“Invited by the World Health Organization, we, Heads of Government, Ministers and government representatives came together on the 21st day of October 2011 in Rio de Janeiro to express our determination to achieve social and health equity through action on social determinants of health and well-being by a comprehensive intersectoral approach.”

The Rio Political Declaration on Social Determinants of Health was subsequently adopted with “five key action areas critical to addressing health inequities:

  1. To adopt better governance for health and development
  2. To promote participation in policy-making and implementation
  3. To further reorient the health sector towards reducing health inequities
  4. To strengthen global governance and collaboration
  5. To monitor progress and increase accountability

“We, Heads of Government, Ministers and government representatives, solemnly reaffirm our resolve to take action on social determinants of health to create vibrant, inclusive, equitable, economically productive and healthy societies, and to overcome national, regional and global challenges to sustainable development. We offer our solid support for these common objectives and our determination to achieve them.”

CIRCUMCISION: Another Baby Dies

Joseph for Genital Integrity reports in his blog entry, CIRCUMCISION: Another Baby Dies, that “Connor James was born on Thanksgiving Weekend, Friday, November 25th in Pittsburg, PA. On Saturday, November 26th, Baby Connor bled to death following his circumcision. Circumcision claims yet another life.” He goes on to discuss other baby boys that have died in the US as a result of this barbaric practice and mourns their loss. Peace to the boys and their families. Shame on the medical community!

[NOTE: A reader notified me on 2/15/12 that she lives in Pittsburg and has been unable to substantiate this claim. It is possible that Connor James is urban legend however there  many other cases that have been verified and published by reputable sources; A Young Life Passes, and a Ritual of Birth Begins published by the New York Times is one example of many. The International Coalition for Genital Integrity estimates that around 100 male infants die in the US each year due to circumcision complications. Infant male circumcision is an awful procedure and an unacceptable contributor to infant mortality.]

 

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.

More evidence against DEX for prenatal treatment of CAH

Related post – Prenatal steroids to prevent boyish baby girls (5/19/11)

On 10/19/11 Science Translational Medicine published the research of Dr Emily Tam, MD, assistant clinical professor of child neurology at UCSF, et al demonstrating Preterm Cerebellar Growth Impairment After Postnatal Exposure to Glucocorticoids. Per study abstract:

“As survival rates of preterm newborns improve as a result of better medical management, these children increasingly show impaired cognition. These adverse cognitive outcomes are associated with decreases in the volume of the cerebellum. Because animals exhibit reduced preterm cerebellar growth after perinatal exposure to glucocorticoids, we sought to determine whether glucocorticoid exposure and other modifiable factors increased the risk for these adverse outcomes in human neonates.”

MRI studies were performed on 172 premature infants exposed to steroids before birth in order to evaluate resultant structural abnormalities of the brain. Betamethasone (the drug of choice to minimize the risk of neonatal respiratory distress syndrome in premature infants) was not associated with measurable differences from controls. However, both dexamethasone (DEX) and hydrocortisone were associated with an 8-10% decrease in the size of the cerebellum, the part of the brain responsible for motor control, balance and cognitive function. The association between cerebellar hypoplasia and impaired motor and cognitive function is well established.

So what does this have to do with congenital adrenal hyperplasia (CAH)? As discussed in my earlier post, Prenatal steroids to prevent boyish baby girls, DEX is a controversial treatment offered to women at risk of having a female fetus with CAH with the only aim being to avert masculinization of her genitalia (enlargement of the clitoris, fusion of the labia and elongation of the urethra). This treatment unnecessarily exposes 7 out of 8 fetuses to high levels of DEX (60 times higher than a normal physiologic level) and many of those female fetuses with CAH aren’t even at risk.

This article provides further evidence that DEX is dangerous, shrinks brains in addition to clitorises and may result in lifelong deficits in motor and cognitive capabilities. Other known risks for babies are:

  • Decreased birth weight
  • More shyness, social anxiety and emotionality
  • Less sociability
  • Poorer working memory (ie reading comprehension) and self-perceived scholastic competence
  • Less masculine males with more neutral gendered behaviors

DEX treatment is NOT the standard of care, it is experimental and controversial and mounting evidence continues to demonstrate that its risks outweigh its benefits.

“Physicians should not sell themselves short in imagining that they cannot — with their words as much as with their knives and drugs — influence parents to accept their children’s bodies and the possibility that their children could lead rewarding lives with those bodies.”
Dr Elizabeth Reis, PhD

Adults bully 10-year-old UK trans girl

James Connell, Worcester News, reports that adults — not children — are the biggest tormentors of a 10-year-old MTF child in the UK. According to her mother:

“She is within her mind a girl but she has a boy’s body. She is the same as everybody else apart from the fact she doesn’t feel right in her own body. It’s not a phase. It’s not a choice. What child would choose to be completely miserable? I don’t expect people to understand. I just don’t want people abusing my child. I don’t want her to be called a freak. I want her to be left alone.”

Sounds like a reasonable request to me. As is common for other trans kids with supportive parents, she will most likely be protected from puberty and the undesired physical changes that accompany it with the use of hormone blockers. Only after she is old enough to understand the implications of gender reassignment will she be permitted to consent to cross hormone therapy.

Israel’s 1st publicized pregnant man

Sarit Rosenblum, y net news, reports that doctors were “shocked” when Yedioth Ahronoth, a 24 year-old man, presented to a central Israel emergency department and was found to be 7 months pregnant. Could this be the same “Y” mentioned in my only published “Dear Dr Pate”? If so, congratulations and good luck to you guys! Thanks for coming forward with your delightful news.

Medical myths

Sometimes even doctors are duped, say Rachel Vreeman and Aaron Carroll. Seven myths were selected for critical review. Despite their popularity, all of these medical beliefs range from unproved to untrue.

  1. People should drink at least eight glasses of water a day
  2. We use only 10% of our brains
  3. Hair and fingernails continue to grow after death
  4. Shaving hair causes it to grow back faster, darker, or coarser
  5. Reading in dim light ruins your eyesight
  6. Eating turkey makes people especially drowsy
  7. Mobile phones create considerable electromagnetic interference in hospitals

Newborn male infant circumcision declining in U.S. says CDC

Centers for Disease Control and Prevention reports that newborn male circumcision (NMC) is on the decline in the U.S. as evidenced by 3 separate studies: the National Hospital Discharge Survey (NHDS), the Nationwide Inpatient Sample (NIS) and the Charge Data Master (CDM). Incidence of NMC decreased from 62.5% in 1999 to 56.9% in 2008 in NHDS (AAPC = -1.4%; p<0.001), from 63.5% in 1999 to 56.3% in 2008 in NIS (AAPC = -1.2%; p<0.001), and from 58.4% in 2001 to 54.7% in 2010 in CDM (AAPC = -0.75%; p<0.001).

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Medical misogyny

Girls can wear jeans
And cut their hair short
Wear shirts and boots
‘Cause it’s OK to be a boy
But for a boy to look like a girl is degrading
‘Cause you think that being a girl is degrading
          – Madonna, “What It feels Like For A Girl”

I am a bit of a news junkie and because of my habit I am repeatedly angered by the ongoing abuse of women around the world: rape for “correction” or as a “weapon of war”, mutilation and honor killings are but a few examples. However a couple of topics in recent weeks have actually made my jaw drop, not because the harm sustained by the affected women was any greater but because of the misuse of medicine and surgical skill to further misogynistic schemes. In India, the selective abortion of female fetuses is nothing new but in select locations and for the right price parents can find physicians who will surgically change their little girls into boys. In the US, the rights of the fetus seem to be surpassing women’s rights given that women have become prisoners within hospitals, undergone surgery without their consent and have even been charged with murder over fetal well-being. These cases demonstrate the pervasiveness of misogyny and the degradation of medicine by its collaborators.

Girls to men

Baby boys naturally outnumber baby girls by around 6%; in other words, for every 100 girls born there are 106 boys that accompany them. Perhaps this is a good thing given that nearly everywhere people seem to prefer boys over girls. Clara Kim, Time NewsFeed, reports “Contrary to the stereotypical notion, girl bias or boy obsession isn’t limited just to Asia. A Gallup poll shows that such a mindset is prevalent in the U.S., too and has been for at least 70 years. The poll asked 1,020 American adults, if they could have only one child, which gender they would prefer. Forty percent of the participants said a boy, while 28% answered a girl. This is not much different from the first poll results in 1941, which were 38% and 24%.” But while Americans are for the most part content to raise whichever gender comes their way, other cultures take a more active role in increasing the rate of male births.

S V Subramanian, a Professor at Harvard School of Public Heath, published in 2009 that “according to the most recent census, for every 1000 males, there were only 933 females, and the corresponding ratio for ages 0–6 years was 927 girls for every 1000 boys. The disproportionate distribution of sexes, at least in more recent years, has been surmised to be driven largely through the use of medical technologies by physicians and prospective parents to determine the sex of fetuses followed by selective abortion of female fetuses. This explanation was initially suggested in the 1980s, and has gained considerable acceptance since then. Some 10 million female fetuses are estimated to have been aborted over the last two decades in India.” By these numbers it appears that there are around 8% more boys than girls among the youngest generation of India and that 2 of every 100 pregnant women with female fetuses choose to abort based on fetal sex alone.

And now there is another way to ensure male offspring. Amrita Kadam of Hindustan Times, India reports that “Girls are being ‘converted’ into boys in Indore – by the hundreds every year – at ages where they cannot give their consent for this life-changing operation. This shocking, unprecedented trend, catering to the fetish for a son, is unfolding at conservative Indore’s well-known clinics and hospitals on children who are 1-5 years old. The process being used to ‘produce’ a male child from a female is known as genitoplasty. Each surgery costs Rs 1.5 lakh [~$3400 US dollars]. Moreover, these children are pumped with hormonal treatment as part of the sex change procedure that may be irreversible. The low cost of surgery and the relatively easy and unobtrusive way of getting it done in this city attracts parents from Delhi and Mumbai to get their child surgically ‘corrected’.”

Dean Nelson of The Telegraph, UK reports that “Indian doctors have been accused of conducting sex change operations on young girls whose parents want sons to improve the family’s income prospects.” It’s not just a preference for boys that is driving the femicide, it is also money. “People don’t want to share their property or invest in girls’ education or pay dowries.” Regardless of parental motivation there remains the doctors’ compliance and lives destroyed by it.

Contrary to Dr John Money’s debunked theory that gender identity is flexible to the whims of social upbringing, medical observation as well as experimentation have proven that gender identity is not malleable. David Reimer was one of Dr Money’s greatest success stories until the truth about his life became known. David’s story began with a botched circumcision that destroyed his infant penis followed by his parents decision to follow Dr Money’s advice to surgically reassign his sex and to raise him as a girl. Unfortunately, David never accepted his forced female gender role and began living as a male at the age of 15. He continued to suffer years of severe depression, financial instability, a dissolving marriage and eventually committed suicide in 2005. His tragic story is catalogued in the bestseller biography: “As Nature Made Him: The Boy Who Was Raised as a Girl” by John Colapinto.

Similarly in Palestine, teenage girls with an intersex/DSD condition that masculinizes them at puberty may be forced to change their clothes and present themselves as boys but their core identities do not change. “‘Only my appearance, my haircut and clothing, makes me look like a boy,’ Ahmed says, gesturing with his hands across his face. ‘Inside, I am like a female. I am a girl.'”

Modification of body parts by physicians without medical indication and without the consent of the person receiving it is tragic and should be criminalized. This is especially true of the sex organs given that at best, surgery permanently alters cosmetic appearance, sensitivity and sexual function. At worst, surgery can result in horrific disfiguration and/or death. Given these risks I strongly believe that non-medically indicated genital surgeries, including circumcision, should be banned for all minors.

Fetal incubator

As if unemployment, home foreclosures and ongoing wars in Iraq and Afghanistan weren’t enough to keep our legislators occupied, the Republican War on Women continues to escalate. According to the Associated Press as reported by MSNBC:

  • “In 1987, a Washington, D.C., judge ordered a woman who was dying of cancer to have a C-section, which she had refused, to save her fetus. The baby died within two hours of delivery and the mother died two days later. An appeals court later ruled the judge should not have ordered the C-section.
  • “In 2003, prosecutors in Salt Lake City charged an acknowledged cocaine addict who had a history of mental health problems with murder when she refused to have a C-section for two weeks before finally agreeing to the procedure. One of her twins died in the womb during the delay. Through a plea deal, the charge was later reduced to child endangerment.
  • “In 2004, a hospital in Wilkes-Barre, Pennsylvania, obtained a court order to force a woman to have a C-section because her seventh baby was oversized, but the order was too late. The mother, whose first six children each weighed nearly 12 pounds (5 1/2 kilograms) at birth, went to another hospital and delivered a nearly 12-pound girl naturally.
  • “Also in 2004, a judge in Rochester, New York, ordered a homeless woman not to get pregnant again without court approval after she lost custody of several neglected children.”

In 2009, Wikipedia records that “Samantha Burton, a mother of two, was twenty-five weeks pregnant in March of 2009 when she experienced a premature rupture of membranes and displayed signs of premature labor. At the urging of her obstetrician, she sought care at Tallahassee Memorial Hospital. She found not to be in labor, but ordered to remain on bed rest. Her obstetrician, Dr. Jana Bures-Forsthoefel, refused to allow her to leave the hospital to garner a second opinion and then obtained a court order from the Circuit Court of Leon County which required Burton to undergo “any and all medical treatments” that her physician, acting in the interests of the fetus, deemed necessary. The Court held the hearing by telephone with Burton being required to argue her case from her hospital bed without the assistance of an attorney or independent medical opinion. Three days into her court-ordered confinement, Burton underwent an emergency C-section, at which time the fetus was found to be dead.”

In 2010, a law was enacted in Utah that criminalizes unacceptable forms of miscarriage. According to David Usborne of The Independent, UK, “While the main thrust of the law is to enable prosecutors in the majority-Mormon state to pursue women who seek illegal, unsupervised forms of abortion, it includes a provision that could trigger murder charges against women found guilty of an “intentional, knowing or reckless act” that leads to a miscarriage. Some say this could include drinking one glass of wine too many, walking on an icy pavement or skiing.” The 17-year-old whose case ignited the discussion that led to the law is currently defending herself before the Utah Supreme Court.

In 2011, NARAL Pro-Choice America reports that “We are tracking 470 anti-choice bills in 2011 — nearly three times as many as last year.”

And finally, according to MoveOn’s Top 10 Shocking Attacks from the GOP’s War on Women:

  1. Republicans not only want to reduce women’s access to abortion care, they’re actually trying to redefine rape. After a major backlash, they promised to stop. But they haven’t yet. Shocker.
  2. A state legislator in Georgia wants to change the legal term for victims of rape, stalking, and domestic violence to “accuser.” But victims of other less gendered crimes, like burglary, would remain “victims.”
  3. In South Dakota, Republicans proposed a bill that could make it legal to murder a doctor who provides abortion care. (Yep, for real.)
  4. Republicans want to cut nearly a billion dollars of food and other aid to low-income pregnant women, mothers, babies, and kids.
  5. In Congress, Republicans have a bill that would let hospitals allow a woman to die rather than perform an abortion necessary to save her life.
  6. Maryland Republicans ended all county money for a low-income kids’ preschool program. Why? No need, they said. Women should really be home with the kids, not out working.
  7. And at the federal level, Republicans want to cut that same program, Head Start, by $1 billion. That means over 200,000 kids could lose their spots in preschool.
  8. Two-thirds of the elderly poor are women, and Republicans are taking aim at them too. A spending bill would cut funding for employment services, meals, and housing for senior citizens.
  9. Congress just voted for a Republican amendment to cut all federal funding from Planned Parenthood health centers, one of the most trusted providers of basic health care and family planning in our country.
  10. And if that wasn’t enough, Republicans are pushing to eliminate all funds for the only federal family planning program. (For humans. But Republican Dan Burton has a bill to provide contraception for wild horses. You can’t make this stuff up).

Summary

The abuse of women is atrocious in any form but utterly unacceptable within the medical community. It is incomprehensible that physicians would tinker with the genitalia and sex of rearing of innocent little girls given the scientific evidence we already have regarding gender identity formation and durability. It is also unacceptable for physicians to debase women to the level of fetal incubators. End genital mutilation and no wire hangers, ever!

The professional imperative for obstetrician-gynecologists to discontinue newborn male circumcision.

The professional imperative for obstetrician-gynecologists to discontinue newborn male circumcision.

Smith JF, Department of Obstetrics and Gynecology, New York Medical College, Westchester Medical Center, Valhalla, USA
Am J Perinatol. 2011 Feb;28(2):125-8. Epub 2010 Aug 10.

Abstract

Newborn male circumcision has been practiced for millennia for a variety of medical, social, religious, and cultural reasons. Indications for routine circumcision remain controversial, with proponents and dissidents arguing their sides vigorously. Popular in the United States, it has persisted in the scope of practice of obstetrics and gynecology, a field specializing in the opposite gender. To excel in women’s reproductive health, we should no longer passively accept or actively maintain this procedure in our specialty. Steps are suggested to remove the residual and improper inclusion of circumcision from the scope of practice of obstetrics and gynecology.

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