Zombies, Run!

Couch potatoes of the world, you have met your match.  What if your survival depended on your ability to outrun (or out-walk) a zombie horde?  What if exercise could be (gasp) not only fun but an entertaining adrenaline rush?

The "Zombies, Run" app* defies easy description - it tracks your pace and miles, it's an engrossing and well-acted story, and every now and then you'll have to run for your life to escape the zombies!  One of the residents mentioned it to me a few weeks ago, and I was hooked after the first time I tried it.  Three days a week, now, I put on my running shoes, put in my headphones, open the app, and tap on my next mission.  I set it to track my miles using GPS (outside) or accelerometer (treadmill), choose my playlist, and enable or disable zombie chases (more on that in a sec).  I then become "Runner 5," essential to the survival of the human race after a zombie apocalypse.  I run for medical supplies, ammunition, even rescue small children, all while the app's incredibly sophisticated story arc unfolds.  And, if I enabled those zombie chases, I will randomly hear "warning - zombies approaching" at times, after which I must either speed up by 20% for 60 seconds or drop my supplies to distract the zoms and get away.

This app is a blast.  I look forward to hearing what is going to happen next in the story as soon as I finish each mission.  The app design is very smart; you can't lose (if the zoms catch you, you just drop your stuff as above and the story continues), the characters frequently say encouraging things ("that's a great pace, Runner 5!"), the scenes mix with your own music**, and you can run or walk for whatever length of time you want (just stop the mission wherever you are and you can pick it up next time).  I am not a fan of horror or scary anything, and this story has just enough of an adrenaline rush for my taste without completely creeping me out (though I don't recommend running late at night with it...or maybe that's just me...).

As I was out saving the world this morning, I realized that I need to tell my patients about this app.  It's the perfect antidote to "boring" exercise, after all.  Prescribing apps is mainstream these days (check out Table 3 in the hyperlink), and apparently, patients want us to prescribe them more often .  So, I'm going to look for opportunities to discuss "Zombies, Run" with my patients this week, and I'll let you know how it goes.

After all, you never know when you might need to outrun a horde of zombies.

* Available for Apple and Android. The sequel, "Zombies, Run 2," is what I actually use (and is the hyperlink above) - all of the missions from the original "Zombies, Run" app but a 2nd season, tracks for races, and more.  And, at least as of this writing, it's 50% off right now...

** Jen's "Zombies, Run" playlist:
Muse's Absolution album
Survival (Muse)
Uprising (Muse)
Madness (Muse again - yes, Muse is the perfect zombie-running soundtrack!)
Help I'm Alive (Metric)
Another Way to Die (Jack White & Alicia Keys)
Awake and Alive (Skillet)
Never Surrender (Skillet)
The Great Escape (Boys Like Girls)
Save Our City (Ludo)
Battle Cry (Ludo)
New Way to Bleed (Evanescence)
Whisper (Evanescence)
Bring Me to Life (Evanescence)
Thank You for the Venom (My Chemical Romance)
Heaven Help Us (My Chemical Romance)
Breath (Breaking Benjamin)
Until the End (Breaking Benjamin)
Run (Addison Road)
I Just Wanna Run (The Downtown Fiction)

Punishing non-vaccinators isn't the answer

A resident sent me this article a few days ago and asked for my opinion:

http://www.medscape.com/viewarticle/812130

(apparently this is turning into a regular occurence!)

If you don't have Medscape access, it's basically calling for unvaccinators to be liable if they, or their unvaccinated child, makes someone ill.  While I am strongly in favor of vaccinations (and have written about my ire re: influenza myths before), I fear that this stance may be taking things too far.  Here's what I wrote back:

Vaccination is a victim of its own success; because we rarely see measles, or mumps, or polio in the US anymore, it doesn’t feel like a real risk to many people.  Compare that to the 1960s, when millions of children were in iron lungs fighting for their lives with polio – and people lined up with their children for hours for Dr. Salk’s then-experimental polio vaccine!  

I’m a little uncomfortable with the idea of punishing non-vaccinators.  Most of these non-vaccinators want to do what is right for themselves and their families, and they’re confused about the mixed messages that they're hearing about vaccine safety.  They've been put in a very difficult spot by Jenny McCarthy,  the now discredited Andrew Wakefield, and other villains of the anti-vaccine crusade.  Given that most of the diseases that we vaccinate against are rarely seen, I can see why someone would decide to “play it safe” by avoiding the risks that they have heard so much about when the risk of disease (“perceived susceptibility”according to the Health Belief Model) is very low. 

Remember, most people are rational actors – they make choices that make sense according to their knowledge, beliefs, and surrounding social norms.  Punishing people who don’t have medical degrees and have done their best to choose wisely for themselves and their families with these confusing, contradictory viewpoints will not help increase vaccination rates.
 

What would help, in my humble opinion, is1) publicizing outbreaks of these diseases in the world and in the US - when’s the last time that you heard about the pertussis outbreak in the US, for example, and how it’s killing infants?  why isn’t this front page news???  or the poliooutbreak in Syria?  some vivid pictures and stats would help put these diseases back into the public’s consciousness.
2) having a greater number of intelligent voices decrying Ms. McCarthy, Wakefield, etc.  they are using all of their energy to denounce vaccination, while docs have to divide their energy among countless issues in our office.  We need some public personas to publicly shift the debate.

 I'm not convinced that the blame game is going to solve undervaccination in the US.

EHRs are tools, not solutions

Yesterday, one of the residents in my program sent me an e-mail with this link:

Residents Skip Lectures to Catch up on Electronic Health Record (EHR) Charting
http://www.medscape.com/viewarticle/812566?nlid=36143_589&src=wnl_edit_medn_fmed&spon=34

Here is my response to her:

EHRs by themselves can’t make offices more efficient and often have the converse effect, like we are experiencing here.  As long as EHRs are used as data repositories and nothing more, they offer little advantage over dictating (though I, having mostly grown up with EHR, am far more efficient on EHR – even a bad one like ours – than dictating).

The only way EHRs make offices work better is when offices transform their practice around FULLY FUNCTIONAL systems.

What is a fully functional EHR?  One integrated with an automatic patient history program like Instant Medical History (http://www.medicalhistory.com/home/index.asp); a patient portal allowing e-visits and easy, asynchronous dr-pt communication; and the ability to easily create and maintain patient registries.  Along with a modern office workflow that emphasizes teamwork with a family doc leading nurses, MAs, pharmacists, and physician extenders, EHRs can then make doctor’s and patient’s lives better.  Under this model, docs only see patients for about 50% of the day, leaving the rest of the day to do e-visits, connect and coordinate care with patients using the patient portal, and take care of refills and other paperwork.

But a system without those essential components, plunked into an office still operating with mid-20^th century processes?  Disaster.  

EHRs are not a magic solution in and of themselves.  They are a tool to help us realize that better vision of 21^st century patient-centered care.

If you can find this book online or in the library, it is worth a read – even if you just read the speech about “Dr. Olderway” and “Dr. Youngerway”:

http://www.amazon.com/Escape-Fire-Designs-Future-ebook/dp/B008NBZ972/ref=sr_1_3?ie=UTF8&qid=1382468338&sr=8-3&keywords=escape+fire

I am excited to see your interest growing re: systems of care.  Our specialty needs people who are unafraid to challenge the status quo!

Jen

And that's all I have to say about that.

Juggling act

I'm feeling guilty about the Singing Pen right now.  Seems that this blog is getting the short end of the stick, lately, with my contributing to the AFP Community Blog, slogging through data entry on a research project, and trying to keep plugging away on my novel draft.

And yet, with all of that going on, this blog is still frequently on my mind. I still have ideas on a regular basis that could prompt a post, but I never get around to actually typing them out and getting it out there.

One of those ideas relates to the summer URI that I have recently recovered from. I have never called off work for a cold before, but this virus was a doozy.  I spent two days at home huddled on the couch with a box of tissues, watching a stream of stupid TV shows in a vain attempt to distract my psyche from my nose and sinuses.

That first day when I start to feel better is always a really good one, though.  I'm reminded to have gratitude for my overall good health and my ability to recover.  I always realize, looking back over the days of missed work (and not blogging or data-entry-ing or writing) that the world will still rotate just fine without those activities - and, that sacrificing exercise and good nutrition to get them all done will have consequences.  Those are the days that inspire me to restructure the juggling act.

I know it won't last; somehow, having a plate that is overflowing just a tad feels comfortable to me.  Or, rather, having empty space on my plate, even a sliver, makes me feel like a slacker.  So, I'm diving back in to all of the things I like to do, knowing full well that I probably should back off on something a bit.

But I'm confident that a virus will always be waiting to remind me that there's a better way.

Writing fiction

I've been writing for a long time.  I was an English major in college, and my current position requires a fair amount of writing.  I write and revise curricula.  I write resident and medical student evaluations.  I peer review for a couple of journals.  I've even published a few articles.

One of the things that I had always fantasized about writing, though, was fiction.  I am a decent medical writer, I think, and I figured that would translate to fiction writing at least a little bit.

Not so much, it turns out.  About a year ago I joined a local writers' group to try my hand at writing non-medical pieces.  And, even though I intellectually knew that I was in for quite a challenge, I had no idea just how much.  Writing fiction calls for a whole new skill set - developing believable characters, compelling plots, rich settings, and, strong dialogue.  I am having a lot of fun learning, though, and the other writers have been patient, honest teachers.

I learned to play the piano before I learned how to sing.  When I first started learning how to sing, I knew how to read music from playing the piano, but that didn't help me learn how to hit pitches and use vibrato.  Similarly, being a competent medical writer helps me construct sentences, but that hasn't made learning how to write fiction much easier.

For the first time in a while, I am new at something, and that newness is accompanied by nerves and humility. It is, perhaps, not a bad reminder about how all of those new interns feel this month. And though part of me wishes that I could fast-forward through the struggle of learning to write fiction, part of me is also enjoying the process of discovering technique and my own writer's voice.  

I hope that I can always find something to be "new" at.

I love July 1!

I admit it: I love July 1.  There's so much energy in the air.  True, some of that energy is nervous energy - newly minted PGY1s trying to fit into the "doctor" role, PGY2s and PGY3s adapting to new responsibilities, new attendings working independently for the first time.

I can still remember July 1 of my intern year, now ten years ago.  I remember how I was both excited and nervous as I drove to the hospital that morning.  I was simultaneously thrilled to finally be a doctor and terrified that I would hurt a patient with a thoughtless mistake.  I paid careful attention to everything my attendings and seniors did, anxious to show them that I deserved the M.D. after my name.

Some people refer to July 1 as "National Don't Go to the Hospital Day."  But I think that, on July 1, residents are more closely supervised than any other day of the year.  This morning on inpatient rounds, I double-checked patient history details, drug dosages, and orders for tests.  Just yesterday that kind of micromanaging would have stifled the residents' confidence and independence - but the difference between today and yesterday is as big as it gets during the academic year.  I will enjoy watching how quickly those out-loud double checks (I still do it quietly behind the scenes all year, of course) become unnecessary this week.

So, to everyone who is experiencing a role change today, I say congratulations.  Put all of that nervous energy and enthusiasm to work benefiting patients and your colleagues.  Ask for help when you need it - this doesn't go away when you're an attending, by the way, and it shouldn't.  One of medicine's greatest joys for me is the infinite, ever-changing amount of knowledge to absorb.  It's impossible to be bored as a family doctor.  And, every day, remain thankful for the privilege of doing what you are doing to help others.

Happy New Academic Year, everyone!

Habits

Well, I've managed to fall out of the habit of blogging again for a while.  It's easy to do, especially this time of year.  We're busy at the residency program saying good-byes toour graduates, and we're busy orienting the new interns who will start next week.  We're reassessing curricula, tallying patient numbers, and trying to prepare for what the Accreditation Council of Graduate Medical Education will throw at us next.

Getting and staying in the habit of blogging on a regular basis has been tough for me.  I don't think I've ever had more than a 3-4 month stretch of regular blogging since I first started doing this 2 and 1/2 years ago.  And, yes, academic medicine is not for the faint of heart, but why can't I stay in the habit of blogging consistently?

The noun "habit" has several definitions, but here are the ones of interest to me lately:

* a settled tendency or usual manner of behavior <her habit of taking a morning walk>
* a behavior pattern acquired by frequent repetition or physiologic exposure that shows itself in regularity or increased facility of performance
*an acquired mode of behavior that has become nearly or completely involuntary <got up early from force of habit>

(Thanks, Merriam-Webster!)

For me, at least, I think my failure to maintain a regular blogging habit all comes down to how I use the hours of each day.  So, I've been seeking out advice about how to better manage my time.  I recently read a book called Early to Rise, and the author challenges readers to consider how waking up an hour or two earlier every day (and then going to bed earlier, too) enables better use of the 16 or so hours we're awake each day.

After reading it, I had to admit that, despite my best intentions, I often lack motivation to do the things I promise to myself to do in the evenings - exercise, writing, connecting with family and friends.  I also have been consistently sleeping in until the last possible minute before rushing through my morning to get to work on time.

So, I figured I'd give it a try for 30 days.  I'm currently on day 8 of waking at 5:30 am to allow time for prayer, writing, and exercise most mornings before work.  Ungh.  (My bedtime has shifted back to 9:30 pm.  Double ungh.)  It is not fun, but I have to admit that I am getting a very satisfying start to my day by accomplishing so much even before I leave the house - not to mention that my evenings are more relaxing instead of a guilt-fest regarding what I "should" be doing.

Do I miss sleeping until 6:30-7 every morning?  You betcha.  Will this 5:30 thing become a habit?  I'm not sure yet.

But here's a new post, at least, that suggests it's might be doing me some good.

Shared decision making

(The following was originally posted on the The AFP Community Blog on 4-22-13.)

Let’s say you’re seeing a healthy 21-year-old woman in your office for contraception management.  She takes no other medicines, has no personal or family history of blood clots, and has no contraindications to estrogen.  She is interested in a long-acting contraceptive that she won’t have to worry about remembering every day.  IUD, subdermal progesterone implant, q 3 months injectable progesterone – how do you choose?

Or, how about this: a 45-year-old man presents with frequent migraine headaches.  You review the best evidence for migraine prophylaxis in adults and are stuck deciding between propranolol and amitriptyline.   Which do you use?

Gray areas like these abound in Family Medicine, even with the ever-growing primary care evidence base.  In both of these scenarios, no one option is clearly superior to the other.  All of those contraceptive options would be efficacious for the 21-year-old woman, and, likewise, the efficacy of propranolol versus amitriptyline for the migraineur is probably a toss-up.

These types of situations, where multiple reasonable treatment options exist, provide an opportunity to involve the patient in the decision.  Shared decision making (SDM) brings the patient’s preferences into the conversation and gives them some ownership over the final choice. 

I wish that I could tell you that SDM has a rigorous evidence base behind it, but like many behavioral interventions, few quality studies exist to suggest patient benefit.  A study last week in the Annals of Internal Medicine, however, may help to reinforce SDM’s value.  Weiner et al engaged patients who surreptitiously recorded their office visits with Internal Medicine residents.  The residents who adapted their care plan to meet their specific patient’s preferences had, in return, improved compliance from their patients. 

This study was small and needs to be replicated in bigger settings, but its finding makes intuitive sense: patients invited to be involved in treatment decisions tend to have better adherence with those treatments.  

You can ease the loss of the extra time it takes to do SDM by billing for the time spent in counseling (10 min = 99212, 15 min = 99213, and 25 min = 99214).  Just be sure to document as such in your encounter note.

In 2010, AFP also published a nice SDM review, along with a helpful framework for the office.  You can find that Curbside Consultation here: http://www.aafp.org/afp/2010/0301/p645.html.

I welcome your thoughts on the practical use of SDM in the busy family doc’s practice.  

Overuse injury

After a three month running hiatus due to the indomitable combination of bad weather (I hate treadmills) and work busy-ness this past winter, I decided last month to pick up my running routine right where I had left off in December.  Two weeks later, with aching ilio-tibial bands and tarsal tunnel syndrome in my left foot, I was forced to stop to allow these overuse injuries to heal.

I knew that I should have started gradually.  Just walked for a week or two, or alternated walking and jogging the first few times out.  But I didn't want to have to wait for my body to re-acclimate to the demands of running.  I just wanted to go.  I readily admit to pushing myself harder than I should sometimes.  Even when I know better, I always want to believe that I am physically capable of more than I am.

Unfortunately, this same tendency creeps up in my work life.  I tend to dive head first into projects without taking the time to think, first, about how big the project might truly be.  I set task deadlines that my brain thinks are reasonable but that I soon discover are impossible.  Despite having lived through these scenarios multiple times, I still keep creating unrealistic "to do" task lists.

List fatigue is the overuse injury of my work life.  And, every time I pile too much on, I am forced to stop, reassess everything, and plug it back into a more realistic schedule.  I hate having to stop working just to figure these things out, just as I hate having to stop running to let IT bands or shin splints or tight hamstrings recover.

I think that ambition and perseverance have many positives about them, but they can be a double-edged sword.  I'm now using a "couch to 10K" app to force me to increase my running time gradually.  I have used this method before with success, and maybe, some day, I'll use it at the get-go next time I have a running hiatus.  I have to admit that my feet and legs are much happier for it.

If only I could find a "couch to work" app, I'd be all set.

Supporting a couple with infertility #NIAW

Before my husband and I joined the 1 in 8 couples in the US with infertility, I don't think that I would have thought much about how to support a friend or family member with infertility.  Not to mention that society's infertility taboo can make these conversations difficult for everyone involved.

Hopefully these resources will make them easier:

I'll start off with RESOLVE.org's great advice: http://www.resolve.org/support-and-services/for-family--friends/infertility-etiquette.html

RESOLVE New England expands on a few of those ideas: http://www.resolvenewengland.org/2013/04/how-to-support-a-friend-or-family-member-with-infertility/

The "I'm Not a Fertile Myrtle" blog gives a more personal spin: http://imnotafertilemyrtle.wordpress.com/2009/04/03/the-dos-and-donts-of-supporting-someone-going-through-infertility-treatment/

This about.com page provides excellent perspective about how to talk about your pregnancy/baby with an infertile friend: http://infertility.about.com/od/familyandfriends/a/10-Things-To-Stop-Doing-If-You-Want-To-Support-Someone-With-Infertility.htm

Scroll halfway down this page from Band Back Together to read "How to Help a Friend with Infertility:" http://bandbacktogether.com/how-to-help-a-friend-with-infertility/.  I really like how this section emphasizes listening to and validating the infertile friend's story.

It is my sincere hope that these "infertility etiquette" resources will help break down the barriers among friends and family that often accompany an infertility diagnosis.

What does infertility feel like? #NIAW

Before having to deal with infertility myself, I had never even thought of pondering this question.  I knew that there were some people in the world who had trouble getting pregnant, that some of them needed medication or procedures to get there, and that some ended up childless or adopting.

Before having to deal with infertility myself, those facts were impersonal and emotionless. Honestly, I probably would have struggled to understand "what's the big deal?" if someone told me they were devastated by infertility.

I know better, now.  I know, for me at least, what infertility feels like.  

It's like being half a person.  My body may never swell with new life.  Even though all of our testing has been "normal," I still feel that something is wrong with me, that I am somehow broken or defective.  Am I still a woman, if I can't do what women are biologically created to do? 

It's like a constant shadow, slippery and elusive.  Multiple versions of my future continually morph and change before me.  I hesitate to make plans for 6, 9, 12 months from now. What if we actually do get pregnant?  What if we don't?  Will we need to plan around a cycle of IVF, or will we have given up?  Cruel hope persists, though despair returns with every unsuccessful cycle.

It's like the death of a dream.  I fight to avoid grieving for the child we may never have. Would that child have had my husband's hazel eyes?  My stubborn chin?  Played a musical instrument?  A sport?  Been a doctor, like us?  Or might that child have had some talent neither of us could have imagined, making it all the more miraculous?

A few weeks ago, as my husband and I struggled to deal with the end of another unsuccessful cycle, some part of me began to rebel against these thoughts.  As spring began to make itself known here, I realized that I was making the stakes too high with each cycle.  Failure was becoming too devastating.  I had to accept, truly and deeply accept, the possibility that we will be unsuccessful - that we will not have a biological child.  The battle between hope and despair was sapping my soul, and I was tired of feeling so paralyzed about the future.  And, somehow, by the grace of God, I decided to stop fighting the grief and embrace it.  

I still want a child, and my husband and I are not ready yet to stop trying.  Accepting that it may not come to be, though, has greatly reduced my emotional exhaustion. Don't get me wrong - it's still a challenge.

But it's time to widen my focus back out to the innumerable blessings in my life.

Join the movement: Bring infertility out of the shadows #NIAW

First comes love
Then comes marriage
Then comes baby in the baby carriage....

But what if that carriage is empty?

For 1 in 8 couples in the US, an empty baby carriage is a painful reality.  My husband and I are part of that "1."  We watched our friends build families while we faced disappointment, month after month.  After a year, we began to seek help as to why our dream wasn't coming true.  Like 20% of couples with infertility, though, comprehensive medical testing did not reveal an answer.

We decided that we weren't going to share our struggle with friends and family.  It was just too personal, too intimate.  We feared becoming objects of pity and, instead, kept our fear in the shadows.  We reserved our tears for the darkness after we turned out the lights at night.  We forced away the ugly jealousy that engulfed us when a friend or family member announced a pregnancy.

Slowly, though, a few of our friends sensed the masked despair behind our childlessness. They shared their infertility stories with us, stories we had not known much about (as they all, happily, had children by this time). The sense of relief that rushed in when they welcomed hearing our story was profound.

I started searching for others.  I found blogs like Life Without Baby, Infertile Myrtle, and The Infertility Voice.  I read Silent Sorority.  I scoured The National Infertility Association's website, RESOLVE.org.

These narratives showed me that, somewhere along the way, our silence had morphed from privacy-protection to shame-avoidance.  Keeping our story untold meant that we had bought into society's unspoken infertility taboo.  The shadows were becoming intolerable.

April 21-27 is National Infertility Awareness Week (#niaw).  I'll be sharing resources and information on The Singing Pen this week in support of #niaw and the millions of other couples with an empty baby carriage. With my husband's full consent, I am adding our story to countless others in hopes that we will all step out of those shadows together.

Infertility is not a curse, a judgment, or a penance for some prior sin.  We did nothing to deserve it.  It is a medical condition that, like many others, medical science still doesn't fully understand.  It cannot diminish our accomplishments or lessen our worth.

And we must refuse to allow it to define us.

Resident work hours

When I was a fourth-year medical student in 2002, I signed up for an intense "sub-internship" rotation in Family Medicine.  My goals for this rotation were two-fold: first, I wanted to make sure that I was ready for intern year and, second, I needed a good letter of recommendation to match into a good Family Medicine residency program.

On this rotation, I was essentially treated like the other interns.  I had patients assigned to me and was supervised by the senior resident on the team.  I took ownership of my patients, made treatment decisions, and even wrote orders (all approved and co-signed by the senior resident, of course).  I took night call (along with the same senior resident).  In short, I lived the same life that the interns did, just with more supervision and guidance.

The interns on the service took q5 night call, meaning that every fifth night they each stayed in the hospital admitting patients and responding to emergencies.  So, like the other interns, every fifth night, after working the full day (since 7 am), I stayed in the hospital overnight.  The next day, I worked my regular day, typically leaving around 6 pm.

As you can imagine, these 35 hour shifts were not a whole lot of fun.  Some nights I only got a couple of hours of sleep.  But I slogged though, I learned what I needed to learn, and I got that letter.

When I started residency in 2003, the ACGME began to limit resident work hours. Studies had shown that brains that had been awake for 24 hours functioned like brains exposed to a blood alcohol level of 0.10 (legally intoxicated in most states).  Anecdotes abounded of mistakes made by tired residents.  So, during my residency, I was only permitted to work 80 hours a week, no more than 24 hours at a time, and I had to have 10 hours off between shifts.

Mind you, 80 hours a week is still tiring.  But I felt that these limits were reasonable.  I had accepted, long ago, that the goal of residency was to become a competent family doctor.  I knew that residency was my one opportunity to establish a foundation of skills for my whole career, and I was willing to put in the work to get there.

A few years ago, though, the ACGME decided that further limits were needed on resident work hours.  Fueled by a report from the IOM, the ACGME decreed that residents needed to gradually adapt to working long hours during residency.  So, now first year residents may only work 16 hours without a break.  Senior residents, by contrast, have far fewer restrictions.

I was skeptical of this change, but figured I'd wait to see what would happen.  Interns would now have additional time to sleep, study, and recreate.  With this additional rest and study, surely they'd provide better care.  And, surely they'd be happier, right?

Well, Dr. Pauline Chen in the NY Times this week challenges this notion:

Now, two years after the 16-hour mandate was established, studies on the outcomes are being published, and the results reveal one thing....
Contrary to expectations, these studies have shown that interns have not been getting significantly more sleep. Moreover, they are not happier, nor are they studying more. In one national survey, nearly half of all doctors in training disapproved of the regulations altogether. Another study revealed that interns were spending less time in educational activities because the additional time required for such conferences and lectures would push them over the 16-hour limit.  In addition, there has been no significant improvement in the quality of care since the work limits took effect. 

These findings ring true for me.  Limiting shifts to 16 hours means that everybody has to work more shifts to cover the work.  A full 24 hours off is far more restful than just 12 or 18 hours, but with more shifts that happens less often.  Additionally, with these more frequent shift changes, handoff errors may be happening more often.

It's my fervent hope that the ACGME reverses the decision on 16 hour shifts for interns, but in the meantime, I'm trying to help my residency program respond by authoring a new, longitudinal patient safety curriculum.  I'm currently wading knee deep in best practice articles about handoffs, quality improvement, and other tenets of patient safety.  If you have any useful patient safety resources, I'd sure appreciate hearing about them as I put this together.

Because, at the end of the day, the discussion shouldn't be just about the residents - our patients must be our utmost priority.

ACGME = American Council on Graduate Education
IOM = Institute of Medicine

The Seasons of Residency

I've been a Family Medicine residency faculty member for nearly 5 years, and I've come to observe the yearly cycle of a residency over that time.  Reminding myself of that cycle helps me weather and celebrate the peculiarities of each time of year...

July-September: Adjustment
Every resident's role changes on July 1.  For the first-years, it's their first day of being called "Doctor."  Second- and third-year residents have increasing responsibility for supervision, and their outpatient responsibilities grow.  Even though many in the lay public will joke that July is "National Don't Go to the Hospital Month," the fact is that residents are never more tightly scrutinized than these early months.  We faculty watch everything, every decision, every order, that the residents are doing.  These are the days of intern presentations that take twenty minutes and nervous second-year seniors who page for confirmation that their plan is on the right track.

We welcome these calls and the long presentations, though, because this is the time of year when residents welcome our teaching the most.  Our pearls and presentations keep residents in awe, and they can't get enough feedback, both encouraging and corrective.

October-December: Recruitment
Fourth-year medical students start interviewing at residency programs, but in Family Medicine, sometimes it feels like we're the ones being interviewed.  Although interest in Family Medicine has been rising, we often still approach recruitment with nervousness. Not filling in the National Residency Match Program will wreak three years of havoc; a common saying goes that "two bad matches in a row kill a program."  The nation's Family Medicine residencies are all vying for those best and brightest, and they all roll out the snazziest red carpet they can afford to attract them.  Good residents = good future family doctors in the region, since most family docs stay within an hour or two of their program after graduation.

So, for three months, every day will bring another applicant to our program.  We take them out to breakfast and lunch.  We rearrange our schedules to meet them during the day.  The residents take them out to dinner and e-mail them afterwards.  Everybody, faculty and resident alike, is in best behavior "company" mode.  Meeting a great applicant and hearing that there might be mutual interest allows for imaginations of the happiest kind about the future, and that's what sustains you during the times when all the wining and dining gets a bit tiring.  One thing became crystal clear to me during this past interviewing season, though: Family Medicine's future is looking bright.

January-March: Dysthmia
True, most programs will still have a trickle of applicants into January, but most will be wrapping up.  It's dark when you drive to work and dark when you drive home.  It's impossible, especially, for the interns to believe that they still have just as much of their intern year left as they have finished.  The light in the proverbial tunnel is too dim too see. Everyone is tired, sad, and dysthymic.  Some resident in your program will invariably threaten to quit medicine and go work in a coffee shop/department store/ice cream parlor (most of the time, they won't, even if they really did mean it when they said it).

Teaching during this time is often a struggle.  The residents just want to slog through their work and get a break.  Our emphasis often morphs into support and validation mode, reminding our learners just how far they've come in the last six months - even if they don't see it yet.

April-June: Cruise Control
The match list is out!  The interns are cheered by the rows of faces on posterboard in your office, the faces of the applicants who will be replacing them in three months as they move up the ladder to become second-years.  The days are longer, the sun is back, and the residents' confidence starts to catch up with their skills.  The third years have signed contracts (or matched into fellowships) and are pleased with their secured futures.

None of the residents are calling you as much anymore; though you miss getting to help them, you're also proud of their growing independence.  They ask harder questions now when they do ask, not just "what" and "how" questions but the "why" questions that will make them such great docs.  Graduation for the outgoing third-years and orientation for the incoming first-years are planned simultaneously.

And, just like that, July 1, "New Year's Day" for residencies, dawns again.

Why your patient might not be following your advice: The Health Belief Model

In my last two posts, I've been sharing some introductory ideas about Health Behavior Theory (HBT).  I'd like to take things a step further today and delve a little more deeply into some specific concepts.

Let's explore one of the most well-studied health behavior theories - the Health Belief Model (HBM).

The HBM states that our health choices are a direct consequence of our perceived susceptibility to a disease, our perceived severity of a disease, and the perceived barriers that keep us from adopting better habits.

Perceived susceptibility, perceived severity, and perceived barriers are three of the main constructs from the HBM.  The word "perceived" is very important; these assumptions are based on individual perceptions and deductions based on a combination of environment, experiences, and personality.

"Perceived susceptibility" refers to how at risk we think we are to a particular disease.  In my master's thesis,* I studied the literature on adherence to high blood pressure medications.  Turns out that people who think they're not at risk to have high blood pressure (even if they really do have it) don't take their meds.

"Perceived severity" refers to how bad we think having a particular disease is.  Turns out that people who know they have high blood pressure but don't think it's a particularly dangerous condition (they don't know, for example, that high blood pressure can lead to heart attacks, strokes, or kidney failure) don't take their meds.

"Perceived barriers" almost always boils down to one of three obstacles: not having enough money, not having enough time, or not having enough social support.  If people can't afford their high blood pressure medication, they're not going to take it.  If they don't think they have the time to exercise, they won't.  If the foods we tell them to eat are different from the food their friends and family eat, they probably won't eat them.

Identifying which of these constructs is at play when a patient isn't following our advice is key to improving adherence with our recommendations. Doctors and health professionals can help patients change their perceptions, and thereby change their attitudes about treatment - but only if we've taken the time to identify what is making it hard for our patients to follow our advice.

We can do this by being careful listeners and asking thoughtful questions.
   "What kind of person do you think gets high blood pressure?" (perceived susceptibility)
   "What kinds of problems can result from high blood pressure?" (perceived severity)
   "What has made it hard for you to take your medicine?" (perceived barriers)
These  questions can uncover if an HBM construct is at play. Only after identifying and validating** our patients' beliefs and attitudes can we gently correct incorrect assumptions, supply additional knowledge, and/or problem-solve with our patients.

"Because I said so" doesn't work with patients, but exploring their beliefs and attitudes about disease and treatment can go a long way toward helping them to improve their health.

* Here's a summary of my master's thesis that was published in 2009 if you're interested: http://www.ncbi.nlm.nih.gov/pubmed?term=2009%5Bpdat%5D+AND+A+proposed+new+model+of+hypertensive+treatment+behavior+in+African+Americans.&TransSchema=title&cmd=detailssearch. 
(I focused on African Americans since I was primarily serving an African-American neighborhood  in my prior job.  I did a subsequent unpublished literature review that showed the same concepts basically hold for most white patients.)

** As the residents I teach are probably tired of hearing me say, "validating" does not equal "agreeing."  We can acknowledge to our patients that we can see how their belief makes sense to them without necessarily agreeing with the accuracy of that belief.  Patients who feel that their beliefs are unvalidated are unlikely to accept our alternative belief.

Why don't our patients do what we tell them?

This question was what drove me to graduate school for a Master's in Public Health a few years ago.  I was finishing up my Family Medicine residency at, arguably, one of the top residency programs in the nation.  I had been well trained in both medical science and doctor-patient relationship skills.  Yet my patients still consistently did not adhere to my advice.

I was not disappointed in my MPH studies.  It turns out that most people (with the exception of the cognitively challenged) are rational actors.  They make decisions that seem rational to them, based on their personalities, environments, and social pressures.  One person may not agree with another's decision, and yet both will arrive at his/her own decision based on some rational process.  This tenet is the basis of Health Behavior Theory (HBT).

Here's one scenario:

3 year child sees her parents drinking soda pop at dinner every night.  She gets juice to drink several times a day.  When her parents give her a taste of their soda pop, she immediately realizes that this stuff is much tastier than water or milk.  This same child has a TV set in her bedroom, so she sees advertisements for juice and soda pop frequently.  She lives in a disadvantaged neighborhood where there are no grocery stores, just corner markets.  Soda pop is cheap, and WIC covers juice, so there's always some of both at home.  Her parents, who like drinking soda pop and have no reason to believe it could hurt their health, begin acquiescing to the child's frequent requests for soda pop.

Before long, this 3 year old is now 14.  Her high school cafeteria stocks Starbucks Frappucino, which makes her feel very grown-up when she drinks it.  The school vending machines can't sell soda anymore, but there's lots of juice and flavored waters still to choose from - not to mention that she usually picks up a 20 oz bottle of Mountain Dew or Pepsi on the way to school to help her wake up, since school starts much earlier than her teenage circadian rhythm prefers.  Milk and plain water are anathema to her.

She grows into a young adult, who presents to your family practice office.  She tells you that her dad was just diagnosed with diabetes, so you screen her and find that she has pre-diabetes.  When you talk to her about switching her beverages to water or zero-calorie sodas, she looks at you like you're from outer space.

This hypothetical patient learned, from a very young age, that sugared beverages taste good.*  Her experiences provided her with the perceived norm that everyone drinks soda pop and juice multiple times a day.  I now have fifteen minutes during this appointment with her to overcome twenty years of belief and experience that have led to her sugared beverage consumption behavior.

Sounds difficult, right?

Just telling her that sugared beverages are bad for her, and if she doesn't do anything she'll end up with diabetes, won't work most of the time.  What can work, interestingly enough, is asking her (non-judgmentally) about her specific beliefs about soda pop.  What has she seen, what has she heard, why does she like them, etc.  Then, it's possible to gently explore these beliefs together. I've found that patients are usually much more interested in hearing doctors' advice if they feel they've been heard and respected first.

In my next post, I'll talk a little about some of the more specific constructs, or ways of thinking about health attitudes and beliefs, in HBT.  Identifying which one is at play with your patient may just help you both achieve a better outcome.

* And they do taste good.  The manufacturers of these beverages know exactly what they're doing.  Soda pop is very inexpensive to produce, so it can be sold for a huge profit margin while still keeping prices affordable.  High profit margin, tasty product = big bucks for these companies.  Sugared beverages are so ubiquitous and socially acceptable that it's hard for me to imagine how anyone is able to resist them.

Our health isn't all up to us

I inherited motion sickness from my father's side of the family.  I can't sit in the back seat of a car for more than 10 minutes without becoming sick.  I take meclizine before every plane flight.

I inherited asthma from my mother's side of the family.  Exposure to perfume, 90+ degree temps with 90+% humidity, or even a good laugh will all prompt me to cough.

These two maladies of mine have one thing in common - multiple people over the years have informed me that they're "all in my head."  Among the advice I've received:  

       "You just need to distract yourself."

       "It's all stress.  You need to relax."

       "Yoga. Yoga will realign your energies."

       "You're taking too much medication.  Your body is reliant on it."

Upon hearing these statements, I rapidly cycle through the following emotions: Hurt. Indignation.  Disappointment.  Anger.  None of those emotions provide a good starting point for hearing this advice, which I have to admit is probably well-intended.

But, if I am honest with myself, I can't pretend that I am not guilty of thinking some of the same things about my patients.  I get frustrated that my overweight patients continue to choose unhealthy foods and avoid exercise.  I bite my tongue when my patient with liver damage continues to drink alcohol.  Maybe blaming others makes us feel better about ourselves, and it might even make us feel that we're invulnerable to the disease under discussion; we're making the "right" choices, after all, and that somehow makes us superior to the afflicted person.*  I am certainly guilty of those same thought processes.

When I catch myself thinking this way, I try to override these thoughts with the knowledge I gained through my studies in Health Behavior Theory (HBT).  The basic tenet of HBT is that each individual believes that the health choices he/she makes are rational and reasonable.  These choices are usually based on 1) the priorities their environment imposes on them and 2) their beliefs about health.  For example, if a person grows up in a poor neighborhood where most people are overweight and with limited access to healthy food, this person will likely deduce that being overweight and eating fast food everyday are normative conditions.**

HBT teaches that blaming others for their health problems helps no one.  Whether it's motion sickness, asthma, mental illness, fibromyalgia, obesity, diabetes...most 21st century health conditions are due to some combination of genetics, environment, and personal choice.  Health is a combination of personal responsibility along with the luck of the genetics and environment we're born into.

Maybe if we could spend less time on blame and more time on supporting each other - and creating healthier environments - our good intentions might result in more than just hurt feelings.

* I can't take credit for these ideas - that belongs to Susan Sontag and her ground-breaking book Illness as Metaphor. If you are interested in learning how and why humans assign emotional value to various diseases, this short book is a worthy read.

** This is a terribly oversimplified description of HBT.  I'll discuss this topic further in a future post, but if you'd like to read more in the meantime, check out: http://www.gchd.us/ReportsAndData/ClioModelPlanningProcess/PDF/HealthBehaviorTheoryfromGenCoHlthDpt%20ClioBook.pdf and  http://www.unc.edu/~ntbrewer/pubs/2008,%20brewer%20&%20rimer.pdf.

Hitting the "reset" button

When I asked a colleague to cover my patient in-box for my vacation last week, she said, "Of course.  Hitting the reset button is very beneficial."

I've never thought of vacation in those terms.  According to researchers, the blissful effects of a vacation wear off within days to weeks. (1)  I've always considered vacation as little more than a brief blip of respite among a mostly hectic, busy life.

I've been thinking about her comment a lot during this past week off, though.  Perhaps I've been thinking about vacation incorrectly.  What if vacation could be more than just a time to escape?

What if vacation could help to reset us back to that best, brightest version of ourselves?

Like most others in medicine, I don't mind working hard.  It's the price I pay to have the incredible privilege of caring for other human beings.  Most days, I truly enjoy what I do.

But the constant stream of responsibility and worry and stress adds up.  By the time my husband and I left last week, I was struggling to find the energy to truly give it my all at work.  The enthusiastic, committed teacher and doctor in me was worn out.

So, last week, I made a conscious effort to reset.  I lived in the moment and let all of those pressures go.  I ate and slept and toured.  I basked in the temporary release.

And, unlike prior last-Sunday-nights-of-the-vacation, I am ready to return.  Oh, I know, there'll be a big pile of mail and journals and patient issues to sort through waiting on my desk.  The usual busy-ness of the day will be compounded by catching up on e-mail and office events.

But, this time, I'm ready.  I have the mental and physical energy to put the best version of myself out there.  Vacation doesn't have to be just a break; it can be a chance for a fresh, new start.

I hit the reset button, and it feels good.

(1) http://www.dailymail.co.uk/travel/article-2021473/The-health-effects-holidays-wear-just-weeks--breaks-say-experts.html, http://www.npr.org/templates/story/story.php?storyId=111887591

Saying "yes"

One evening a few weeks ago, I attended the local Academy of Medicine meeting.  I was just inside the door taking my coat off when our executive director approached me.

"There's a news team here looking for someone to interview about the flu outbreak.  Could you help them?"

He went on to say that the news crew had been waiting for an Infectious Disease doc to walk through the door, but they were getting impatient.  Feeling my Family Medicine pride swell within me (along with the stage "ham" who can't resist a chance to perform), I said, "yes."

I have some definite workaholic tendencies, so I try to think about most requests for 24 hours before responding.  I've gotten better at saying "no" over the last few years, especially to projects that don't meet my own professional goals.

But the spontaneous "yes" moments in my life - those moments where my limbic system leapt ahead of the rest of my brain and I said "yes" with magnificent joy -  have all led to good things (my husband, my fellowship, my stage experiences).  In those moments, the "yes" erupted from a place so deep inside of me that I may never access it consciously.

Last night's "yes" definitely came from that same inaccessible place. As a family doc, I often feel like I am fighting a war against all of the mis-information that my patients come across.  They didn't go to medical school, and I know it's unfair to expect them to recognize Dr. Oz's propensity to recommend non-evidence based treatments or Jenny McCarthy's insane reasoning regarding vaccines.

Each of us in medicine can be part of the solution.  In my prior city, I contributed a short patient education column about every other month to a neighborhood paper.  I like to write, I like to stand up in front of people, and, most importantly, I like to promote Family Medicine and honest health information every chance I get.

And, if I convinced just one person watching the evening news last night to get a flu shot, it'll have been worth it.

The "annual pap exam" should be a relic

Early in 2012, I took myself to get my pap smear for the first time since moving here.  It was normal.  Yesterday, in the mail, I got a postcard reminding me that I was due for my "annual exam."  This postcard made me most unhappy.

In 2009, the American College of Obstetrics and Gynecology (ACOG) and The United States Preventive Service Task Force (USPSTF) advised docs that yearly screening for pap smears is unnecessary. (1) These recommendations were updated in 2012 to advise that pap smears every 3 years are sufficient to screen for cervical cancer. (2)

These changes are based on sound science.  The overwhelming majority of cervical cancer is caused by the Human Papilloma Virus (HPV).  Pretty much everyone who has sex will, at some point, be infected by this virus.(3) Most people's immune systems clear out the virus before it can damage any cells, though, which is one reason cervical cancer is rare despite HPV's ubiquity.  

Cervical cancer is an extremely slow-growing cancer, which is why the experts now recommend screening just every 3 years. (2)  Heck, if you're over thirty and the doc checks for HPV along with your pap and both are negative - voila! - you get a 5 year pass.

So, what do I do about this postcard?  I don't need another pap smear until 2015.*  There is no evidence-based reason to have a pelvic exam in the interim.  I am not overdue for any other health care needs.

My options at this point seem to be:

1. Ignore the card.  

2. Call the office and say, politely, that I actually don't need another pap smear until 2015.

3. Mail the postcard back along with a copy of the current ACOG and USPSTF guidelines.

In general, I prefer the direct approach, which makes option 1 (passive) and option 3 (passive-aggressive) distasteful.  On the other hand, I'm still pretty new in town, and it's not that big of a town, so I am fearful of igniting trouble with option 2.

I liked this office and doc when I went there, and I don't want to appear impertinent.  I should be willing to hear their side of things.  But science is science, and I want to share my side, too.  Which is that I will not, under any circumstances, submit to another pap smear before 2015.

Hand me the phone.

(1) http://bit.ly/TQApmE

(2) http://bit.ly/cyDcWj

(3) http://www.ashastd.org/std-sti/hpv/what-women-should-know.html

* I should have insisted on getting the HPV testing, too, and then it'd be 2017, but I was trying not to be a typical doctor-patient...

Funeral Homes

I'm always a little anxious during the drive to a funeral home to pay my final respects to a patient.

Last week, I took my first such trip since moving here, and the nerves returned. A paranoid voice inside me wondered, again, if someone at the viewing would blame me for their loved one's death.

Admittedly, this has never happened.  Family members are invariably appreciative of these visits, and I am often introduced proudly to multiple family members as "So-and-so's doctor." These new acquaintances then usually shake my hand or even hug me.  They sometimes express surprise that I am there (which makes me a little sad, since I was taught that attending patient viewings and/or funerals is a natural duty of the family physician and an important opportunity to say goodbye).

When a patient of mine dies unexpectedly, I usually comb through the chart, looking for any mistake I might have made.  It's a ridiculous compulsion based on the impossible idea that I am omnipotent enough to foresee every possible problem that might happen to my patients.  I'm not omnipotent, of course.  And, no matter how good of a doctor I am, all of my patients will eventually die of something.

But I always wonder - did I miss something?  And, I figure, if I'm wondering that, maybe my colleagues are. Or my patient's surviving family.

Overall, I consider myself reasonably comfortable with the end of life as a family doc.  I am disheartened when patients and/or families insist upon invasive, aggressive care that I know to be futile.  I've talked about hospice and end of life wishes with patients and families numerous times.  But, maybe, obsessively sifting through charts and worrying over what others think of me reveals that I'm not really that comfortable with death.  I am, frankly, ashamed of the hubris I must possess to assume that the end of a patient's life has much of anything to do with me at all.

Maybe that discomfort's not so bad, then; it certainly reminds me that I am only human myself.