Mr. B, the patient who first stirred my interest in family medicine, was a spry former World War Two fighter pilot who came to the ER complaining of an irregular heart beat. I remember him regaling me with stories about the Battle of Britain while his wife dutifully stood by his side in the chaos of the crowded emergency room at a private hospital affiliated with my medical school. It was just my third clinical rotation.
Early the next morning, Mr. B suffered a stroke, a common complication of atrial fibrillation. As a result, he lost the use of most of the left side of his body and sank into a deep depression. Later, after there was nothing more to do in the way of acute care, my medical team transferred Mr. B to a rehabilitation facility down the street. There, I continued to monitor and encourage his slow and painful progress for several more weeks. Later that year, when I applied to family medicine residency programs, my care for Mr. B became the core story of my application essay. I had decided to join a medical specialty that cared for the "whole person," rather than a single body part or organ system, and in my mind, helping Mr. B recover from his complex illness was the perfect example of what family doctors do best.
The essay worked - I was accepted to my first choice residency program. But looking back on that episode now, more than a decade later, I realize that I missed a crucial piece of the story. I never thought to ask Mr. B's wife, his primary caregiver, how she was faring. What personal trials must she have gone through in caring for her formerly independent husband and coming to terms with this permanent change in his health and its effect on their daily lives? I can only guess, but I'll never know.
Two recent magazine pieces written by caregivers describe how hard it is to support a loved one suffering from chronic illness. In "Letting Go of My Father," reporter Jonathan Rauch tells the story of struggling to care for a father with a rapidly progressive neurological condition, and his belated discovery that many friends and colleagues were encountering the same challenges with an elderly parent. In "On Caregiving," psychiatrist and medical anthropologist Arthur Kleinman relates how caring for a spouse with Alzheimer's disease taught him more about "the moral core of caregiving" than a lifetime of patient care and academic research. Kleinman observes:
Caregivers protect the vulnerable and dependent. To use the experience-distorting technical language: they offer cognitive, behavioral, and emotional support. And because caregiving is so tiring, and emotionally draining, effective caregiving requires that caregivers themselves receive practical and emotional support.
Such support can be offered by family physicians and a variety of other professionals. It would have helped a great deal if as a medical student I'd known that there were established office tools for assessing "caregiver burden," including emotional and physical health. An article in this week's Los Angeles Times provides useful advice and resources for caregivers, including practical tips on confirming the diagnosis, financial and legal planning, and elder care support services. The author's most important tip: "don't go it alone." To that, I'd add that primary care clinicians should do everything we can to recognize and address the needs of caregivers, not only for the well-being of patients like Mr. B, but to sustain the health of their families and communities.
Thursday, July 29, 2010
Tuesday, July 27, 2010
VBAC and home birth: evaluating the evidence
Thanks to a recent pronouncement from the American College of Obstetricians and Gynecologists, my two-year old daughter, who arrived via a vaginal birth after Cesarean section (VBAC), may not be a medical rarity for much longer. In a previous post, I discussed possible causes for the steep 15-year decline in the percentage of U.S. women who have delivered a child vaginally after a previous Cesarean birth (currently fewer than 1 in 10). In March, at a conference held at the National Institues of Health in Bethesda, Maryland, an expert panel concluded that the scientific evidence did not support ACOG's existing recommendation that surgical and anesthesia personnel be "immediately available" during a trial of labor. However, they found evidence that this restrictive requirement had caused many hospitals without 24-hour availability of these services to discontinue VBAC entirely.
To its credit, last week ACOG released an updated version of the guideline that states that a trial of labor is a reasonable option for the vast majority of women who desire a vaginal delivery after a previous Cesarean, including those who have had more than one prior Cesarean and those carrying twins. While continuing to assert that mothers and babies are best served by access to emergency resources, they add: "Respect for patient autonomy also argues that ... [an institutional no-VBAC policy] cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery." Amen.
Now I'll to turn to another controversial maternity care topic: home birth. The subject of a widely viewed 2008 documentary and Time Magazine story, out-of-hospital births represented less than 1 percent of all births in the U.S. in 2005, according to government researchers. A recent meta-analysis of previous studies comparing planned home and planned hospital births that concluded that the former was "associated with a tripling of the neonatal mortality rate" elicited a variety of reactions from health professionals in the U.S. and abroad, ranging from ACOG's reiterating its opposition to home births to calls for more research by the American College of Nurse Midwives and the UK's Royal College of Obstetricians and Gynecologists.
I agree that more research is needed. But as for the analysis itself, there are at least two reasons to question whether it should cause many (or any) women to reconsider their home birth plans. First, while "tripling" in neonatal deaths sounds scary, this is a relative rather than an absolute difference in risk. Reading the fine print, neonatal death occurred in 0.15 percent for planned home and 0.04 percent for planned hospital births. That's an absolute risk difference of just 0.11 percent, or about 1 extra death for every 1000 births. This difference is very close to the small increased risk of neonatal death during attempted VBAC versus repeat Cesarean section (0.8 extra deaths for every 1000 births), which ACOG has acknowledged should be a mother's choice.
Second, all but 3 of the 12 studies included in the meta-analysis were conducted prior to the year 2000, in populations with much lower Cesarean rates than in the U.S. Overall, only 9.3% of women in the planned hospital birth groups had Cesarean deliveries - a far cry from the 32% that currently occur in the U.S. So while this study's results are most applicable to countries in other parts of the world that have Cesarean rates of 10% or less, it's not clear if it captured the maternal complications that invariably result from doing 3 times as many surgeries.
The bottom line? The available evidence indicates that planned home birth is no riskier for babies, compared to planned hospital birth, than is attempting VBAC compared to choosing a repeat Cesarean delivery.
To its credit, last week ACOG released an updated version of the guideline that states that a trial of labor is a reasonable option for the vast majority of women who desire a vaginal delivery after a previous Cesarean, including those who have had more than one prior Cesarean and those carrying twins. While continuing to assert that mothers and babies are best served by access to emergency resources, they add: "Respect for patient autonomy also argues that ... [an institutional no-VBAC policy] cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery." Amen.
Now I'll to turn to another controversial maternity care topic: home birth. The subject of a widely viewed 2008 documentary and Time Magazine story, out-of-hospital births represented less than 1 percent of all births in the U.S. in 2005, according to government researchers. A recent meta-analysis of previous studies comparing planned home and planned hospital births that concluded that the former was "associated with a tripling of the neonatal mortality rate" elicited a variety of reactions from health professionals in the U.S. and abroad, ranging from ACOG's reiterating its opposition to home births to calls for more research by the American College of Nurse Midwives and the UK's Royal College of Obstetricians and Gynecologists.
I agree that more research is needed. But as for the analysis itself, there are at least two reasons to question whether it should cause many (or any) women to reconsider their home birth plans. First, while "tripling" in neonatal deaths sounds scary, this is a relative rather than an absolute difference in risk. Reading the fine print, neonatal death occurred in 0.15 percent for planned home and 0.04 percent for planned hospital births. That's an absolute risk difference of just 0.11 percent, or about 1 extra death for every 1000 births. This difference is very close to the small increased risk of neonatal death during attempted VBAC versus repeat Cesarean section (0.8 extra deaths for every 1000 births), which ACOG has acknowledged should be a mother's choice.
Second, all but 3 of the 12 studies included in the meta-analysis were conducted prior to the year 2000, in populations with much lower Cesarean rates than in the U.S. Overall, only 9.3% of women in the planned hospital birth groups had Cesarean deliveries - a far cry from the 32% that currently occur in the U.S. So while this study's results are most applicable to countries in other parts of the world that have Cesarean rates of 10% or less, it's not clear if it captured the maternal complications that invariably result from doing 3 times as many surgeries.
The bottom line? The available evidence indicates that planned home birth is no riskier for babies, compared to planned hospital birth, than is attempting VBAC compared to choosing a repeat Cesarean delivery.
Saturday, July 24, 2010
Common Sense Family Doctor celebrates its first birthday
Exactly one year ago, on July 24, 2009, I posted the first entry in this blog. I'd like to thank instructor David A. Taylor and my science writing classmates at The Writer's Center in Bethesda, Maryland, for encouraging me to channel my creative energies in this way. 124 entries later, Common Sense Family Doctor is still going strong! In case you've missed any, below are links to a compilation of my favorite pieces.
July and August 2009
September and October 2009
November and December 2009
January and February 2010
March through May 2010
Adverse Effects in Pulse Magazine, May 2010
Family Health Guide, May through July 2010
As always, thank you all for reading, commenting, and otherwise expressing your support.
- Kenny Lin
July and August 2009
September and October 2009
November and December 2009
January and February 2010
March through May 2010
Adverse Effects in Pulse Magazine, May 2010
Family Health Guide, May through July 2010
As always, thank you all for reading, commenting, and otherwise expressing your support.
- Kenny Lin
Wednesday, July 21, 2010
What soft drinks and cigarettes have in common
Judging by the outrage sparked by the American Academy of Family Physicians' agreement with Coca-Cola to produce patient education materials about obesity, and the respected ScienceBlogs website's brief flirtation with a nutrition blog sponsored by PepsiCo, many health professionals consider soda to be nothing less than the "new tobacco." There are many good reasons to think so. The average American consumes approximately 50 gallons of soda each year, which is thought to be a major contributor to our current epidemic of obesity, the details of which I discussed in a previous post. In 2004, the Centers for Disease Control estimated that obesity killed almost as many people in the U.S. per year (about 400,000) as tobacco did, and predicted that it would soon surpass it as the number one cause of death.
Taxes on cigarettes have proven to be very effective at discouraging their use, and early versions of the U.S. health reform bill sought to do the same by taxing sugar-sweetened beverages. In addition to reducing soda consumption, the penny-per-ounce tax would have raised billions of dollars to expand coverage for the uninsured and fund public health campaigns targeting other lifestyle behaviors that lead to obesity, such as physical inactivity.
Using time-tested tactics borrowed from Big Tobacco a generation ago (when Phillip Morris and other tobacco companies openly attacked and distorted the science linking smoking to lung cancer, heart disease, and other causes of death), the beverage industry quickly flooded Washington, DC with lobbyists and challenged research linking soda consumption to obesity. As reported in the Los Angeles Times, an industry-funded coalition calling itself "Americans Against Food Taxes" spent millions of dollars in key states to discourage Congress from including the tax in the bill - and won. State governments lost, too. Earlier this year in New York State and in Washington, DC, websites and airwaves were blanketed with "anti-tax" messages that were so effective at generating political opposition that neither of these proposals even came to a vote.
I admit that connecting soft drinks with obesity and premature death isn't quite as instinctive as knowing that inhaling a burning carcinogen-delivery system is bad for you. After all, the beverage industry argues, extra calories can come from many sources other than what people drink. But sugar-sweetened beverages are unique among junk foods in that their calories don't make us feel "full." We just keep on drinking, adding empty calories in 40-ounce Big Gulp containers or going back to the dispenser for free refills.
The president of the American Academy of Family Physicians recently wrote in the Annals of Family Medicine that there was nothing unethical about the organization taking hundreds of thousands of dollars from Coca-Cola in order to produce apparently unbiased educational content. She is wrong, and I would say this if a candy or fast-food company stepped forward with a fistful (okay, a briefcase-full) of cash next year. No one expects an organization of family doctors to say that soft drinks are good for you, but in taking Coca-Cola's money, what the AAFP is effectively telling patients (few of whom will ever visit the FamilyDoctor.org website) that soft drinks aren't really bad for you. That's the message that smokers were hearing a few decades ago, and most of them aren't alive today to wish that they had been told otherwise.
Taxes on cigarettes have proven to be very effective at discouraging their use, and early versions of the U.S. health reform bill sought to do the same by taxing sugar-sweetened beverages. In addition to reducing soda consumption, the penny-per-ounce tax would have raised billions of dollars to expand coverage for the uninsured and fund public health campaigns targeting other lifestyle behaviors that lead to obesity, such as physical inactivity.
Using time-tested tactics borrowed from Big Tobacco a generation ago (when Phillip Morris and other tobacco companies openly attacked and distorted the science linking smoking to lung cancer, heart disease, and other causes of death), the beverage industry quickly flooded Washington, DC with lobbyists and challenged research linking soda consumption to obesity. As reported in the Los Angeles Times, an industry-funded coalition calling itself "Americans Against Food Taxes" spent millions of dollars in key states to discourage Congress from including the tax in the bill - and won. State governments lost, too. Earlier this year in New York State and in Washington, DC, websites and airwaves were blanketed with "anti-tax" messages that were so effective at generating political opposition that neither of these proposals even came to a vote.
I admit that connecting soft drinks with obesity and premature death isn't quite as instinctive as knowing that inhaling a burning carcinogen-delivery system is bad for you. After all, the beverage industry argues, extra calories can come from many sources other than what people drink. But sugar-sweetened beverages are unique among junk foods in that their calories don't make us feel "full." We just keep on drinking, adding empty calories in 40-ounce Big Gulp containers or going back to the dispenser for free refills.
The president of the American Academy of Family Physicians recently wrote in the Annals of Family Medicine that there was nothing unethical about the organization taking hundreds of thousands of dollars from Coca-Cola in order to produce apparently unbiased educational content. She is wrong, and I would say this if a candy or fast-food company stepped forward with a fistful (okay, a briefcase-full) of cash next year. No one expects an organization of family doctors to say that soft drinks are good for you, but in taking Coca-Cola's money, what the AAFP is effectively telling patients (few of whom will ever visit the FamilyDoctor.org website) that soft drinks aren't really bad for you. That's the message that smokers were hearing a few decades ago, and most of them aren't alive today to wish that they had been told otherwise.
Sunday, July 18, 2010
Guest Blog: Residency regulators are back
Danielle Ofri, MD, PhD is the author of three books about her experiences as a general internist at NYU School of Medicine and serves as editor-in-chief of the Bellevue Literary Review. The following post originally appeared on her blog on June 25, 2010.
**
How many hours can a doctor work?
The residency regulators are back. About ten years ago, the national organization that accredits residency programs (ACGME) set out its first guidelines about how many hours a doctor-in-training can work. Interns and residents finally achieved the vaunted 80-hour workweek. (New York State was 15 years ahead on this, having mandated an 80-hour work week in 1989, stemming from the Libby Zion case.)
Every patient wants a doctor who is well rested and alert, but limiting residents to 80 hours per week wasn’t as simple a panacea as it seemed, as I wrote in an editorial in the Resident Hours Perspective NEJM shortly after the ACGME regulations were issued.
Practical issues abounded, mainly concerning the increased number of hand-offs required, as patients had to be cycled between teams of doctors. Less quantifiable, though no less concerning, was the inevitable progression toward “shift-mentality” and a decrease in professionalism.
In fact, the 80-hour workweek did not decrease errors and did not increase sleep time for the doctors. The ACGME has recognized this and has now issued a new report. In essence, they have admitted what all of us who teach new doctors already know, that medicine is far too complex to apply simple formulas. What really helps doctors-in-training practice good medicine, decrease errors, and maintain a high standard of professionalism is good supervision.
It might seem like stating the obvious, but fresh-off-the-boat interns need near-total supervision. These eager new doctors were medical students just an eye-blink ago, and a parchment diploma did not ratchet up their clinical skills overnight. A good supervisor needs to watch closely and teach intensively during this early period.
Over the next several years, as the residents gain skill and confidence, supervisors can ease back, offering more opportunities for independent decision-making. The overall thrust is that the quality of medicine delivered by residency training programs depends heavily on the quality and quantity of supervision provided.
The changes in this area are palpable. When I did my medical residency training almost twenty years ago, senior physicians (attendings) were barely present. The attending showed up once a day to see all the newly admitted patients during an “attending rounds” session, and then returned to his or her private practice. We were on our own for the rest of the patients’ care, even if it lasted weeks.
Now, I am an attending at the very same hospital, but the model is entirely different. When I spend a month supervising a team on the medical wards, I am there full-time. We still have that attending rounds session to talk about new admissions, but we also have the rest of the day. I don’t follow two steps behind my residents and interns every waking moment, but we talk constantly during the day. I also examine the patients independently to make my own clinical assessment. We work as a team six days per week and I can be reasonably sure that we are all on the same page with the patients’ care.
Do errors still happen? Are residents still exhausted? Yes, and yes. But I do think patient care is better for it.
The trick now is to teach them independence and to foster the do-whatever-it-takes-for-your-patients credo that suffused my training years. Not to mention the joys and rewards of medicine.
But that can be done in 80 hours, or at least I am hoping so.
- Danielle Ofri
**
How many hours can a doctor work?
The residency regulators are back. About ten years ago, the national organization that accredits residency programs (ACGME) set out its first guidelines about how many hours a doctor-in-training can work. Interns and residents finally achieved the vaunted 80-hour workweek. (New York State was 15 years ahead on this, having mandated an 80-hour work week in 1989, stemming from the Libby Zion case.)
Every patient wants a doctor who is well rested and alert, but limiting residents to 80 hours per week wasn’t as simple a panacea as it seemed, as I wrote in an editorial in the Resident Hours Perspective NEJM shortly after the ACGME regulations were issued.
Practical issues abounded, mainly concerning the increased number of hand-offs required, as patients had to be cycled between teams of doctors. Less quantifiable, though no less concerning, was the inevitable progression toward “shift-mentality” and a decrease in professionalism.
In fact, the 80-hour workweek did not decrease errors and did not increase sleep time for the doctors. The ACGME has recognized this and has now issued a new report. In essence, they have admitted what all of us who teach new doctors already know, that medicine is far too complex to apply simple formulas. What really helps doctors-in-training practice good medicine, decrease errors, and maintain a high standard of professionalism is good supervision.
It might seem like stating the obvious, but fresh-off-the-boat interns need near-total supervision. These eager new doctors were medical students just an eye-blink ago, and a parchment diploma did not ratchet up their clinical skills overnight. A good supervisor needs to watch closely and teach intensively during this early period.
Over the next several years, as the residents gain skill and confidence, supervisors can ease back, offering more opportunities for independent decision-making. The overall thrust is that the quality of medicine delivered by residency training programs depends heavily on the quality and quantity of supervision provided.
The changes in this area are palpable. When I did my medical residency training almost twenty years ago, senior physicians (attendings) were barely present. The attending showed up once a day to see all the newly admitted patients during an “attending rounds” session, and then returned to his or her private practice. We were on our own for the rest of the patients’ care, even if it lasted weeks.
Now, I am an attending at the very same hospital, but the model is entirely different. When I spend a month supervising a team on the medical wards, I am there full-time. We still have that attending rounds session to talk about new admissions, but we also have the rest of the day. I don’t follow two steps behind my residents and interns every waking moment, but we talk constantly during the day. I also examine the patients independently to make my own clinical assessment. We work as a team six days per week and I can be reasonably sure that we are all on the same page with the patients’ care.
Do errors still happen? Are residents still exhausted? Yes, and yes. But I do think patient care is better for it.
The trick now is to teach them independence and to foster the do-whatever-it-takes-for-your-patients credo that suffused my training years. Not to mention the joys and rewards of medicine.
But that can be done in 80 hours, or at least I am hoping so.
- Danielle Ofri
Thursday, July 15, 2010
The doctor will "tweet" you now
There’s a lot of evidence that to prevent many serious health conditions, including diabetes, obesity, heart disease, and stroke, making healthy lifestyle changes are just as good, if not better than, taking medications. Lifestyle changes may consist of stopping unhealthy behaviors such as tobacco and excessive alcohol use, or starting healthy behaviors such as moderate daily exercise and eating adequate amounts of fresh fruits and vegetables.
As anyone who has ever tried to quit smoking or make radical changes to their physical activity or dietary routines will be quick to tell you, though, making healthy lifestyle changes is hard! Family physicians do our best to support patients trying to make these changes. Unfortunately, with the exception of smoking cessation (where a few minutes of advice from your doctor can make a difference), doctors can’t provide nearly enough counseling in the limited time available at a typical visit. Patients trying to change their lifestyles for the better are most likely to succeed when they receive supportive messages again and again and feel that they aren’t alone in their efforts.
Social media tools such as blogs and Twitter offer a new venue to promote healthy and discourage unhealthy lifestyle behaviors. In addition to receiving regular supportive and educational messages, patients can share their own stories with a community of people undergoing the same types of struggles. Smokers who are seeking support to quit the habit can exchange tips with thousands of fellow nicotine addicts at http://www.twitter.com/quitsmoking123; patients with alcohol problems can join a “virtual AA group” at http://www.twitter.com/alcoholicsanony; and anyone interested in improving their physical fitness can find virtual lifestyle coaches and trainers at http://wefollow.com/twitter/exercise.
In addition, as recently reported in the Los Angeles Times, there has been a recent explosion in the number of consumer healthcare applications for smart phones. Many of these free or low-cost apps are designed to help improve physical fitness or encourage weight loss. Although their track records are slim, and none have yet been proven to be effective in changing behaviors, it’s probably worth giving them a try. I would recommend checking with your family doctor first to make sure that an app that you are considering provides reliable information.
**
This post was first published on my CommonSense MD blog at Family Health Guide.
As anyone who has ever tried to quit smoking or make radical changes to their physical activity or dietary routines will be quick to tell you, though, making healthy lifestyle changes is hard! Family physicians do our best to support patients trying to make these changes. Unfortunately, with the exception of smoking cessation (where a few minutes of advice from your doctor can make a difference), doctors can’t provide nearly enough counseling in the limited time available at a typical visit. Patients trying to change their lifestyles for the better are most likely to succeed when they receive supportive messages again and again and feel that they aren’t alone in their efforts.
Social media tools such as blogs and Twitter offer a new venue to promote healthy and discourage unhealthy lifestyle behaviors. In addition to receiving regular supportive and educational messages, patients can share their own stories with a community of people undergoing the same types of struggles. Smokers who are seeking support to quit the habit can exchange tips with thousands of fellow nicotine addicts at http://www.twitter.com/quitsmoking123; patients with alcohol problems can join a “virtual AA group” at http://www.twitter.com/alcoholicsanony; and anyone interested in improving their physical fitness can find virtual lifestyle coaches and trainers at http://wefollow.com/twitter/exercise.
In addition, as recently reported in the Los Angeles Times, there has been a recent explosion in the number of consumer healthcare applications for smart phones. Many of these free or low-cost apps are designed to help improve physical fitness or encourage weight loss. Although their track records are slim, and none have yet been proven to be effective in changing behaviors, it’s probably worth giving them a try. I would recommend checking with your family doctor first to make sure that an app that you are considering provides reliable information.
**
This post was first published on my CommonSense MD blog at Family Health Guide.
Subscribe to:
Posts (Atom)
