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Category: Current Events

Rising Death Toll

My car ride home yesterday was quiet. Normally NPR is on, but the moment I heard the word “Gaza” I switched it off. I have heard too much about the rising death toll there—around 600 yesterday morning, if memory serves.

Rising death toll: I can’t count how many times I have heard iterations of that phrase since the current conflict in Gaza started. Or during others—Syria, Egypt, Iraq—the list goes on. It is a cold euphemism for loose limbs strewn about the street. A cold euphemism that protects us from other people’s reality: life among the grim reaper. A cold euphemism that allows us to hear the news, frown, throw up our hands, and move on with our day. I am as guilty of this as anyone.

How is this OK?

Yesterday morning, I heard that a hospital was hit. People died. There were supposedly military supplies nearby. And? This is justification? As a future physician, I am tasked with looking out for society’s most vulnerable—especially people who are sick or wounded, like those in that hospital, and those without physical protection or resources. The very people lumped into this rising death toll. This is unacceptable, in the worst possible way.

Don’t construe this as me siding with a political group. I don’t know who is right. No, I take that back—neither side is right; both are very wrong. Because their dual inability to keep even a temporary ceasefire is pushing that death toll ever higher. No, I’m not siding with politics. I’m siding with people. People who didn’t sign up for this. Who just want to eat and drink in peace. Say their prayers in peace. Work and play in peace. Live in peace. Instead, they are dead.

There seems no good way to conclude these thoughts except to say: I don’t know what to do about this. I don’t even know what to do with this information anymore.

And today, again, the death toll rises.

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More FIFA Soccer, Less of its Official Sponsor

Lionel Messi

Unlike an estimated 3 billion people worldwide, I’m a lukewarm soccer fan, at best. Nothing against the sport, I just never got into it. (Though I have to admit, watching Lionel Messi’s goal against Bosnia on Father’s Day – with my dad, of course – was pretty incredible. I could see soccer growing on me.)

But that’s besides the point. What interests me about the World Cup at this moment, and about other worldwide sporting events like the Olympics, is event sponsorship. Not as a marketer, mind you, but as a viewer, consumer, citizen, and future physician. I get that only heavy business hitters like McDonald’s can afford the $20 million it costs to be the World Cup’s sponsor and official restaurant. (The 2014 Sochi Olympics, by the way, marked the tenth consecutive games with the Golden Arches as official restaurant.) I also get that these sporting events cost money to run. I get that sponsorships help make them happen. What I simply cannot understand is why it’s acceptable to link fast food with fitness activities.

Take one look at any of these chiseled players (Ronaldo? Fabiano? Casillas?), and you and I both know that they don’t eat at Mickey D’s on a regular basis. But you and I are adults. I’m less concerned about adult viewers. They are adults, after all, and should be able to make their own decisions when it comes to food. As in, whether to eat quality or crap. To be completely honest, I don’t always make good food choices. I’ve even been known to eat at McDonald’s (please don’t tell my internist). But it’s always a conscious choice. My choice.

What bothers me is the insidious message that junk food sports sponsorship sends to children – children who are impressionable, both physically and psychologically. For kids around the world, soccer is religion, the players their idols. When kids start associating crispy chicken with corner kicks, or French Fries with their favorite midfielder, there’s a serious problem. It’s not just soccer, either. It’s football (American football), baseball, and hockey. The list goes on. I’m not saying this is the cause of our country’s childhood obesity epidemic – that would be dangerously simplistic. But it certainly doesn’t help the situation.

Obesity is no joke. And being healthy is not just about looking nice in a bikini. Both of these messages seem lost on a great many people, adults and children alike. I’m not suggesting anyone boycott McDonald’s (or the World Cup). What I am saying is let’s be real about this. Discuss it. Because none of it – not the obesity, and not the junk food sponsorship – is going away on its own.

 

The Centers for Disease Control and Prevention (CDC) on childhood obesity:

Statistics

  • Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years.
  • The percentage of children aged 6–11 years in the United States who were obese increased from 7% in 1980 to nearly 18% in 2012. Similarly, the percentage of adolescents aged 12–19 years who were obese increased from 5% to nearly 21% over the same period.

Health effects

  • Children who are obese are more likely to have problems with sleep apnea, bones, and joints, as well as self-image. They are also at higher risk for prediabetes.
  • Childhood obesity increases the risk for being obese as an adult.
  • Adult obesity is associated with higher risk of cardiovascular disease, diabetes, stroke, cancer, and arthritis.

For the Record …

Patient: What was my blood pressure at my last visit?

Doctor: That’s part of your medical record. I’d rather not say.

Sounds absurd, right? It is. And I’m guessing not many doctors have had that attitude. But prior to Congress passing the Health Insurance Portability and Accountability Act (HIPAA) in 1996, there was no federal law requiring health care practitioners to give you access to your own medical records or information. (Some states did have a law to that effect, though.) Now that access is guaranteed – even if you haven’t paid your bill – although practitioners are allowed to charge a “reasonable” amount for providing the information.

As more and more practitioners and facilities transition to electronic health records, some are piloting a new type of on-demand access: electronic patient portals. While they differ some in format or the extent of information available, the idea is that the portal is a secure, online repository of your medical information, from physician notes, to medication lists, to lab or test results, to upcoming visit schedules, and so on. These portals are often also interactive, allowing patients to schedule appointments, message their practitioners, and request medication refills.

Rush University Medical Center, which my internist is affiliated with, offers “MyChart,” its own patient portal system. There never seemed to be much reason to view it, though. After my recent run-in with the medical establishment, I decided to check it out, more for curiosity than anything.

Through the MyChart patient portal, I have access to a wealth of medical information, including these lab values.

It’s really pretty cool (at least for a curious pre-medical student such as myself; its efficacy for the general public is still a matter of debate; more on that later). For example, I was able to view all my labs from when I was in the ER, everything from my mono test (positive) to my strep culture (negative) to all of my CBC values. Upon opening up the CBC link, for example, two columns appear – both the standard ranges and my values.

OK, I’m no doctor (yet). So when I see values outside the normal range, or narrative values that make no sense to me, I have the tendency to become curious (at the least). For example, what the heck does “ATYP LYMPH / MODERATE” (at the very bottom of the screenshot) mean? Enter my good friend Google: this signifies that my immune system is actively fighting an infection. One Web site I found even specifically referenced infectious mononucleosis, explaining that mono produces a lymphocyte morphology with a dented cytoplasm, in addition to some other specific characteristics. So. I’ve got dented lymphocytes. Who knew?

So far, my use of MyChart has really been more for curiosity’s sake than anything, though. The true purpose of an electronic patient portal is to better patient outcomes, increase transparency in health care, improve coordination and continuity of care, enhance practitioner-patient communication, and foster a sense of ownership regarding one’s care (among other things). The question is: do patient portals live up to these goals?

To answer this particular query, I turned to another dear online friend, PubMed.* While my search on the subject is by no means exhaustive (or particularly scientific), here is a theme I found repeated:

We don’t know yet.

In fancier, more scientific language:

Evidence is mixed about the effect of portals on patient outcomes and satisfaction, although they may be more effective when used with case management. The effect of portals on utilization and efficiency is unclear, although patient race and ethcnicity, education level or literacy, and degree of comorbid conditions may influence use.

[Source: “Electronic Patient Portals: Evidence on Health Outcomes, Satisfaction, Efficiency, and Attitudes,” Annals of Internal Medicine, 2013]

Like I said.

The reason we don’t yet know how beneficial patient portals are is that they are relatively new, which means studies on them lack the longitudinality, detail, and context necessary to make convincing conclusions. The review article quoted above mentioned that in the studies they looked at, patient attitudes regarding the portals are “generally positive.” On the other hand, it seemed that not all patients had equal access to or understanding of the information available: “… more widespread use may require efforts to overcome racial, ethnic, and literacy barriers.” In other words, it becomes a health literacy issue, one complicated by the involvement of technology.

The review article’s bottom line:

Portals represent a new technology with benefits that are still unclear. Better understanding requires studies that include details about context, implementation factors, and cost.

That said, there is anecdotal evidence that patient portals are a positive development. Another article in the Annals of Internal Medicine, from 2012, looked at a group of 105 primary care doctors who provided electronic links of their visit notes to some 13,564 patients across three different practice sites. The self-identified goal of the study was to “evaluate the effect on doctors and patients of giving patient access to notes over secure Internet portals.”

The overarching result of the study:

At the end of the experimental period, 99% of patients wanted open notes to continue and no doctor elected to stop.

[Source: “Inviting Patients to Read Their Doctors’ Notes: A Quasi-Experimental Study and a Look Ahead,” Annals of Internal Medicine, 2012]

More detailed statistical findings, summarized below, were quite interesting as well (statistical ranges are given to represent the differences between practice sites).

Of the 5,391 patients who opened at least 1 note and completed a postintervention survey:

  • 77% to 87% across the three sites reported that the open notes helped them feel more in control of their care
  • 60% to 78% of those taking medications reported increased medication adherence
  • 26% to 36% had privacy concerns
  • 1% to 8% reported that the notes caused confusion, worry, or offense
  • 20% to 42% reported sharing the notes with others

After the intervention, the physicians were surveyed as well:

  • 0% to 5% reported longer visits
  • 0% to 8% reported more time addressing patients’ questions outside of visits
  • 3% to 36% of doctors reported changing documentation content
  • 0% to 21% reported taking more time writing notes

This anecdotal study has both strengths and weaknesses. A strength, and something I appreciate as a future physician, is that the authors did survey the doctors as well – important because anytime you introduce something new like this, you need the doctors on board to make it work. Making conclusions from this study, though, is dicey. The authors acknowledge this upfront with a “Limitations” section at the top of the paper: Only three geographic areas were studied. Most patients were already experienced in using such portals. Both doctors and patients choosing to participate and complete the final survey “may tend to offer favorable feedback.” The end survey response rate was low (41%).

Still, the results are something to think about. If, somehow, we could develop strategies for overcoming the racial, ethnic, and literacy barriers (as cited by the first review article), then maybe we could see more of these positive results across the general population.

Or … maybe not. But if it might help people take ownership of their health, I think it’s worth a try.

 

 

* In case you’re not familir with PubMed, it is basically a ginormous collection of scientific and medical journal articles online, curated by the US National Library of Medicine and the National Institues of Health. Some of them are free; others are available for purchase on the specific journal’s Web site. Being a Northwestern University employee, though, I have access to most of the articles at no charge. Gotta love connections.

Death In The Line of Duty: The Ultimate Sacrifice

The Friday, Dec. 14 shooting at Sandy Hook Elementary School has citizens across the United States, and the globe, mourning. And thinking. In part, about ways (such as more stringent gun control) to try and prevent such tragedies. It has the Newtown, Conn. town thinking about how to move forward amid the grief and shock. According to a Chicago Tribune article I read this morning, people across the town are taking down Christmas decorations, saying that celebrating a festive holiday during a time like this is unthinkable.

This tragedy, a massacre of 20 young students and 6 school staff members, got one of my friends, who is an education major, thinking about something else. Something more personal. I spoke with her yesterday on the phone, and the shooting came up (as I know it has among so many conversations in the last couple of days). She just finished a semester of class observation at a local middle school. Over the course of the past semester, she has told me multiple times how much the students meant to her, how much – even though they were not her own students – she cared for them and appreciated them. And yesterday, she told me all she wanted to do was go to the school and give each and every one of them a big hug, even though they would likely not understand why. She had thought long and hard about what it would mean to lose a student, and how that would affect her. And she could not even imagine what those community members, including those teachers, are going through right now.

But she also got to thinking about the school staff who literally gave their lives for their students. In that same Chicago Tribune article, I read about principal Dawn Hochsprung, in an attempt to overtake the gunman, paid with her life. And about 27-year-old teacher Victoria Soto, who tried to use her body as a human shield to protect her first-grade students, was also killed. One of Soto’s friends, Andrea Crowell, was quoted in that Chicago Tribune story as saying: “She put those children first. That’s all she ever talked about. She wanted to do her best for them, to teach them something new every day.” That day, Soto taught her students about the ultimate sacrifice: death in the line of duty.

Which got my friend thinking: Would she, as a teacher, be willing to die for her students in the same way Hochspring and Soto did? Would she feel OK about giving her life in exchange for her students’ lives? “And I decided that yes, I would,” she told me. I felt shivers go down my back, and tears well up in my eyes. I told her that this was a profound moment for her. Then she told me that she had begun thinking of herself more as a teacher than as a college student. This realization, I told her, was evidence of that newfound association.

And in the course of that conversation, my dear friend got me thinking (as good friends do). Would I, as a physician, be willing to give my life for my patients’ lives?

Granted, there are very few instances where teachers, or doctors, are called to do that. But I believe that  it is something that people who enter service professions such as medicine and education need to consider. As a teacher, you put your students first. As a physician, you put your patients first. Above yourself. Always.

People don’t normally think of medicine as a “risky” or “dangerous” profession. They often think of it as a posh one, at least financially. But there are risks involved. When a you makes a treatment decision, for example, you risk angering a patient (or a relative) and having them come after you. While I didn’t find a lot of examples of this on the Internet, I did find a few:
– 2007: a Chicago dermatologist was allegedly killed by a patient who (according the Daily Mail article I read) thought the acne medication he was given made him impotent
– 2009: a Las Vegas internal medicine physician was allegedly killed by a patient, possibly because he was in intense pain from prostate cancer and might have blamed the doctor (according to the Asian Journal article I read)
– 2009: a Kentucky physician was allegedly killed by a man whose motive may have been that the doctor denied him narcotics after the patient refused to give a urine sample (according to the Associated Press article I read)

Another risk to physicians is that of contracting a contagious disease during the course of treatment. In an American College of Physicians article posted on the AMA Web site, called “The Physician and the Patient,” there is a section on the “Medical risk to physician and patient.” The article clearly states that doctors must put their own health second to that of their patients’, and that refusing treatment to patients with potentially dangerous conditions is out of the question, ethically. Here is what the article had to say on the subject:

“Traditionally, the ethical imperative for physicians to provide care has overridden the risk to the treating physician, even during epidemics. In recent decades, with better control of such risks, physicians have practiced medicine in the absence of risk as a prominent concern. However, potential occupational exposures such as HIV, multidrug-resistant tuberculosis, and viral hepatitis necessitate reaffirmation of the ethical imperative … Because the diseases mentioned above may be transmitted from patient to physician and because they pose significant risks to physicians’ health and are difficult to treat or cure, some physicians may be tempted to avoid the care of infected patients. Physicians and health care organizations are obligated to provide competent and humane care to all patients, regardless of their disease state. Physicians can and should expect their workplace to provide appropriate means to limit occupational exposure through rigorous application of infection control methods. The denial of appropriate care to a class of patients for any reason is unethical.”

Whether a teacher, physician, police officer, firefighter, or other service professional will, indeed, give up their life in an emergency situation may be difficult to predict until the situation presents itself. But it is definitely something to consider.

For myself, and for those of my readers wanting to practice medicine someday, let us ask ourselves: What would we risk for our patients?