Specialties & Topics
- Arthritis/Rheumatic Disease
- Breast Cancer
- GERD/Peptic Ulcers
May 8th, 2013
After a false start, we’re back at it here on the Residency Training blog! From now on, I plan to post most Wednesdays, with some randomly dispersed surprise posts thrown in for good measure. As always, if there’s a specific topic you’d like to see addressed, feel free to make note of it below in the comments section.
That said, let’s get into this week’s topic. I do my best to stay on top of the current medical literature, which I often summarize and pass along to the housestaff and students during the preamble to my daily morning report sessions. While browsing recently, I noticed a theme that appeared in a number of publications: vaccinations.
Unfortunately, vaccinations have been a controversial topic, primarily driven (at least in my opinion) by the lay public and the media. The allopathic and osteopathic medical communities are slowly gaining some ammunition in the argument with the naysayers, and, fortunately, this has come in the form of high-quality data stemming from well-designed trials. I couldn’t be more delighted, as I truly believe vaccinations have been the single greatest medical intervention with the widest impact on humankind.
To touch on a just few of the recent papers centered on vaccinations that caught my eye recently:
- Genital warts in young Australians, 5 years into national human papillomavirus vaccination programme: National surveillance data – The HPV vaccine has caused somewhat of a controversy here in the U.S., as some parents have been reluctant to administer this vaccine to young children. However, this study provides some longitudinal data showing significant benefit just 5 years after a national vaccination program was enacted. It will be interesting to see just what impact the HPV vaccine has on malignancies with significantly longer follow-up. First Watch summarized the data and findings.
- Varicella Death of an Unvaccinated, Previously Healthy Adolescent – Ohio, 2009 – This article serves as an important reminder about “catch-up” vaccinations in our patients. This case was of particular interest to me, as we encounter many unvaccinated patients in our training hospitals. We can easily forget to address this topic in primary care, or simply relegate it to such low priority that we never discuss it — with so many other complaints to address during already-too-short office visits. First Watch also provided a nice summary of this article.
- Effect of an investigational vaccine for preventing Staphylococcus aureus infections after cardiothoracic surgery: A randomized trial – I found this interesting, because as it highlights the often-overlooked risks of vaccinations. This trial (somewhat surprisingly) showed excess postoperative multiorgan failure and death from staphylococcal infections after an investigational vaccine was administered prior to cardiothoracic surgical procedures. It does not establish a causal relation (and, it is interesting to ponder how this would occur, from a pathophysiologic perspective…). That said, in the past, other vaccines have been shown to cause more-severe disease. Journal Watch Infectious Diseases published a nice summary of this article
- Lack of association of Guillain-Barré Syndrome with Vaccinations – After reading the previous article, you may become more diligent about discussing potential side effects of vaccinations with your patients. In this study, researchers examined the longstanding link of Guillain-Barre Syndrome (GBS) with vaccinations (traditionally associated with the annual influenza vaccination). While this is a retrospective study (and hence the evidence is not quite as strong as a randomized, controlled trial), the sheer number of patients included is staggering. The investigators found no causal relation between GBS and any vaccines, and the benefits of vaccination far outweighed the risk of developing GBS.
- The success of the longstanding fight to eradicate polio is nothing short of incredible. Just 223 cases were reported in 2012, with a drastic and steady decline over the past few decades, largely due to an incredible effort to vaccinate at-risk populations in endemic areas. The Scientific Declaration on Polio Eradication outlines specific methods about how this will be achieved. It is a lofty goal, but one that I believe is definitely obtainable. First Watch discusses this statement.
What has been your experience with vaccinations and patients who resist getting them? How have you handled these patient interactions? After looking over these articles, let me know, and we can discuss it!
January 29th, 2013
Hello, Journal Watch enthusiasts! It’s a new year, and we are kick-starting the Chief Resident blog again. I am excited to share some of my ideas and thoughts with you this year. I’m currently serving as one of the chief medical residents at the University of Colorado Denver, with the first half of the year spent at Denver Health Medical Center, and the second half of the year at the Denver VA Medical Center.
I grew up in the medical-focused community of Rochester, MN, where the Mayo Clinic Health System dominates the skyline and conversation. I studied Biomedical Engineering as an undergraduate at Northwestern University, with a focus on biotechnology and biomaterials. I returned to the North Star state for medical school, at the University of Minnesota, and opted to venture west to Denver for my Internal Medicine training.
One of the major benefits of the UC Denver IM residency program is the diversity of hospitals and patients encountered on rotations; our core teaching sites include a VA medical center, a major academic institution, a public safety-net hospital, and a private facility. Each of these sites provided a unique view of medicine and a fantastic base upon which to build my interests in cardiovascular disease. I will begin fellowship this summer, and I am anxiously looking forward to it.
During my time as chief resident, I have been fortunate to play many roles: educator, attending physician, colleague, and conflict mediator, among many others. As a Journal Watch blogger, I look forward to sharing some of the things I have learned this year with regard to each of these roles. My particular interests are technology — both as it relates to medical education and to advancing medical care.
I may preferentially favor cardiovascular disease technologies; however, I hope to highlight some of the new and exciting technologies across all fields of internal medicine. I enjoy looking into the balance of introducing new technology with cost, particularly right now, given the Affordable Care Act and its associated mandates. Medical education is a large part of my position as chief resident, and learning about new teaching tools that incorporate novel technologies excites me.
I look forward to sharing my thoughts on current medical literature, and hearing your ideas and responses. Please post some of the topics you hope will be discussed this year, and I’ll look forward to reading your responses!
April 2nd, 2012
Gopi Astik, MD
While combing through my social media outlets recently, I came across an article that struck me. The article entitled “Why Doctors Die Differently” addresses a subject many professionals in the medical field know but don’t really talk about – that physicians die too.
The article explains how we, as physicians, understand the limits of medical therapy and procedures and often forego treatment when the end is near. It’s not that we are ready to die but that we understand the chances of surviving a cardiac arrest with complete neurologic function. We have seen the effects chemotherapy can have on patients and we sometimes think about quality more than quantity of life.
This article presented itself to me at the perfect time. I had a patient who was a 40-year-old female survivor of cervical cancer who was then diagnosed with aggressive cholangiocarcinoma. She was admitted to my service with symptoms of dyspnea and hypoxia caused by a pulmonary embolus that developed because she stopped taking her lovenox. On presentation, she was cachectic, weak, and in obvious respiratory distress. She had recently been told by her oncologist that there were no more treatment options because of the spread of the cancer. The patient never actually spoke during her hospitalization, partly due to her dyspnea and partly because her very supportive and vocal family would not accept that their loved one could not be treated and wanted to try every possible procedure, medication, and therapy.
I had multiple conversations with this patient’s family, but one conversation with her mother will stick with me for the rest of my life. I sat down with the patient and her mother alone after rounds (without residents and students) to provide details about the patients disease and prognosis. I explained that we had no more treatment options to offer and would like to make the transition towards palliative care. When I broached the topic of a DNR, the patient’s mother immediately refused. I tried to reiterate that we weren’t going to be able to treat her daughter and that the cancer would progress to the point where her daughter would not be able to sustain herself on her own. Her mother, who was obviously tired, frustrated, and sad looked me straight in the eye and said “What would you do if you were me?”
I couldn’t answer her question. I was taught never to make such decisions for patients and was told to keep my opinions to myself. I froze for a minute and politely said, “I can’t say what I would do as a family member but as a doctor, this is what I would do.” I know my response didn’t suffice and I felt I had let the patient and her mother down. I know that my perspective as a doctor is very different from that of a nonmedical family member. I also don’t have the life experience to literally put myself in the mother’s shoes.
I went home that night thinking about this conversation and tried putting myself in the patient’s shoes. If I had terminal cancer, I wouldn’t want my family members to have to make such decisions. If only there was a way for me to plan ahead in case something did happened …
“ding ding ding”
..the bells in my head went off, the light bulb turned on, and I decided that I had to fill out an advanced directive. I never thought I would fill one of these out at the age of 27, but I know now it’s the right decision. I also have asked my parents to fill out their advanced directives and assign a durable power of attorney for medical decisions.
I believe the reason so many more physicians than patients prepare these documents and have more perspective at the end of life is because we have seen what happens when people don’t prepare. This case and the article taught me much about my patients, my job as a physician, and mostly about myself. I’d love to hear about some of your thoughts about this topic.
March 2nd, 2012
Gopi Astik, MD
It seems that every time I am in clinic, patients bring in supplements they bought to prevent aging. I usually look at the product ingredients, which include vitamins and herbs, and ask myself three questions:
1. Why didn’t I market this? I could put vitamins and herbs together and sell it to the baby boomers saying it prevents wrinkles and Alzheimer’s and make myself a nice chunk of change.
2. Don’t they read the ingredients or ask somebody before spending this money?
3. See #1.
When this happens, I calmly look at the bottle and usually tell patients that the product doesn’t contain any harmful ingredients and advise them that it would be cheaper to take the multivitamin I had already prescribed than spend extra money for this concoction. Everyone is looking for the secret cure to aging that simply doesn’t exist…yet.
A recent summary in Journal Watch General Medicine describes a Mayo clinic study in which senescent cells were marked and destroyed with a compound. When transgenic mice carrying the marker were bred with mice that age prematurely, the animals did not develop age-related disorders and other diseases progressed slowly. Although this technique isn’t being studied in humans yet– and probably won’t help my 87-year-old patient do her “BINGO dance,” — the study paves the way for such research to begin and shows promise for younger folks like me.
On the flip side, another study summarized in Journal Watch alluded to overscreening for cancer in elderly patients. This issue actually came up for me and my medical students this morning. When we looked up guidelines about cancer screening, there were so many different guidelines, it was hard to know which ones to follow.
The patient was a 76-year-old man who had his last colonoscopy at age 65, and a recommendation for 10-year follow up was noted. When comparing guidelines, USPSTF recommends screening for adults aged 50-75, National Cancer Institute recommends screening for adults ages 50-80, and the American Cancer Society recommends screening beginning at age 50 with no upper age limit. With my limited experience and the fear that I could miss something, I erred on the side of caution and told the patient that I would like to screen him again, and he declined. I am probably one of the physicians contributing to overscreening of cancer in elderly patients, but guidelines would be a lot easier to follow if there weren’t so many conflicting ones in the first place.
I also find patients less and less apt to actually have tests done as they get older. A patient today excitedly told us she had earned the right to not have mammograms or pap smears by living to the age of 85. When I asked her about the downside of aging she said, “Honey, I’ll deal with my wrinkles just don’t ever ask me to put my legs in stirrups again.”
February 16th, 2012
Heidi Zook, MD
Staying up to date with the most recent advances in medicine is a challenge and a necessity if we want to offer patients the best care possible. That being said, being a physician is one of the busiest careers and finding free time to read journals is not exactly easy. That’s where Journal Watch comes into play — it makes this difficult task easier. Following in the footsteps of our predecessor, Dr. Greg Bratton, I’d like to share some recent Journal Watch content that has had an impact on me and potentially the way I practice medicine. Two of the articles are from the Journal Watch General Medicine Year in Review 2011 — a review of the year’s most important thematic areas in clinical research.
To Dr. Bratton — if you are reading, imitation is the sincerest form of flattery!
For Losing Weight, Commercial Programs Are Better and Cheaper Than Noncommercial Programs – Obesity is an epidemic in our country, and likely one of, if not the, largest consumer of healthcare dollars, yet we have so few tools to help prevent and control this disease. Many of the pharmacologic treatments that have existed in the past have been pulled off of the market. The idea that we could “prescribe” a commercial program might get more of a response than simply counseling on diet and exercise. Joining a commercial program could offer our patients the support, follow-up, and lifestyle coaching that a 20-minute office visit could never offer. That being said, this idea should not deter a physician from continuing to counsel their patients on how to maintain a healthy weight and stay healthy. This is a battle that we will all fight during our careers, just like heart disease and diabetes. The more tools we have, the better.
USPSTF Recommends Against Prostate Cancer Screening – Considering the controversy that developed in 2011 on the subject, I couldn’t resist discussing it as something that impacted my practice. During my interpretation of all of the recommendations that currently exist, I spoke with some of my mentors and more experienced colleagues on the subject. This is undoubtedly a controversial issue. On the one hand, many have experienced diagnosing prostate cancer in a younger man through screening, buying some lucky individuals a significant amount of quality life that they may not have otherwise had. On the other hand, many have seen individuals going through invasive diagnostic and therapeutic measures, with resulting morbidity from the procedures that may not have been necessary in the first place. Add in the potential cost of screening “…the cost to prevent one prostate cancer death through screening would be roughly US$5.2 million” and you end up with a difficult decision. At this point, I discuss the options, risk, and benefits with patients who would be appropriate for prostate screening. I believe that a strong family history as well as any symptoms that might suggest possible prostate cancer in a patient makes the argument on whether or not to screen quite a bit easier.
Atypical Femur Fractures with Bisphosphonates – This was another topic that led to difficult and, for the patient, confusing conversations. It is difficult to convince a patient to take a medication that may cause what it is, in theory, supposed to prevent. I have had discussions with all of my patients who have been on bisphosphonates longer than five years about these recent findings, but I think the following says it all: “Among women with FDA-approved, evidence-based indications for bisphosphonate therapy (i.e., documented osteoporosis or previous osteoporotic fracture), the number of typical hip fractures prevented by bisphosphonate therapy would outnumber the number of atypical femur fractures caused by treatment.” Well said, well said.
January 27th, 2012
Gopi Astik, MD
Nobody ever said that residency (or medicine in general) was easy. Still, I don’t think I expected so much of my time to be taken up by my job. Don’t get me wrong — I love what I do — but it’s not as easy as other occupations to “leave work at work.” As an intern, I was lost and confused many times about diagnosis and treatment plans for my patients. I’m not one to ask a lot of questions, so I took it upon myself to research these things after work. I usually made a to-do list of things that I did not know and had to look up and understand in the evening. I continued this habit throughout my residency. This was great for my learning but not so great for my personal life.
I was spending all day at work and then all evening thinking about (or preparing for) work. I didn’t have any time for me.
With the time commitment of the daily job for medical personnel, it is very important to find things to do outside of work to both relieve stress and give the mind some rest. I have been playing tennis as long as I can remember. I played competitively as a child and into high school and college. During medical school, I gave it up. I can’t say that it was only because I didn’t have time but also because I stopped enjoying it. I am a competitive person by nature and I think I was trying to challenge myself academically and put personal fitness on the back burner.
Near the end of my final year of residency, I started to notice the tennis courts at my apartment again. I started going out on the court by myself to practice my serves for 20 minutes here and there and I realized how much I missed playing. I found a group of residents who also play tennis and we started playing together as often as possible. We would meet at the park directly after work and play for 1-2 hours. Not only did this build camaraderie between coworkers but it was a great stress reliever and good exercise. I know not all people relieve stress with physical activity, but as recently reported in Journal Watch, even 15 minutes of low-volume activity can significantly lower mortality.
Playing tennis again was my way of “centering myself” and setting aside time for me again. I have seen positive improvements in both my attitude and productivity at work and at home. I’d love to hear what activities do the same for you.
December 16th, 2011
Gopi Astik, MD
Interview season is in full force at UMKC. I never realized before how much work goes on behind the scenes to prepare and conduct these interview days, but I sure do now! As a Chief Resident, I schedule residents to attend the applicant dinners, lunches, and tours, and to spend time with the applicants our lounge. This makes the actual interview days go by much smoother, because two of us are present at all times to speak to applicants and answer any questions.
I’m always fascinated by applicants who go through medical school later in life. Since I started at the UMKC 6-year BA/MD program, I really had no real-life experience when I went through this process. I’ve met many applicants who have had previous careers and decided, after years of being in the work force, that they wanted to pursue medicine. I really admire people who take the risk (and pay cut!) to go back to school to fulfill their goals. As someone who conducts interviews, I can attest that these applicants often are very prepared and are great to speak to. I look forward to talking to them about their previous endeavors and what exactly made them come back to medical school. I always ask if it was worth it, and everyone says yes … then again, I am interviewing them for a job, so who would say no?
I’m fairly new to “this side” of the interview process, but I wanted to share some tips that I’ve thought of so far for any current applicants. I’ve adapted some of these from the AMA website as well.
- Be on time – Whether you know it or not, the day has a schedule that many people rely on. If you are going to be late due for any reason, let somebody know. We have had applicants email a few days before their interviews to request a phone number for somebody in the program – just in case they get lost or have any issues. This shows us they are prepared and want to keep us informed if anything comes up.
- Research the program – It’s a given that somebody is going to ask you why you chose to interview with their program. If you have done your research, you will have an informed answer. Even if you are interviewing at your “home” program, know the details about what has changed or is changing to make sure your interviewers know you were paying attention.
- Look your interviewers in the eye and offer your hand – As a girl, I was never really taught handshake etiquette, and I don’t even know if I have that down now. Many people will ask for a firm handshake, but I won’t comment on that. Please look the interviewer in the eye even it its not in your nature to do so normally. When interviewees don’t look at me, it makes me feel awkward myself – I feel like they are being evasive for some reason.
- Prepare a few questions beforehand – We HATE asking you repeatedly if you have any questions, but we have to do this to fill the silences. We want to make sure you are informed before you leave. We are available all day to ensure that you can assess our program adequately. If you have a few generic questions prepared, you can ask them throughout the day whenever things get quiet — it makes you appear interested. It’s also nice to have questions ready, because each of your interviewers will likely ask you if you have any! Play this one by ear: If your interviewer appears rushed or mentions they have to be somewhere, he or she might not be the best person to ask that extra question, but most people would appreciate answering one question at the end of the interview.
- Interact with the other applicants who are interviewing with you – We don’t just want to hear what you have to say; we are also watching how you interact with your peers. In our program, being social is very important because we tend to spend a lot of time together outside of work. Being antisocial or extremely introverted is a negative in our eyes.
- DON’T use your phone or computer on your interview day!!!! – This boggles my mind. It is rude and unacceptable. I hate when people do this. Even if you think we won’t notice during the tour or during a quiet moment – we always see it. If you need to check in for your flight or make a quick call, ask the Chief Resident or coordinator who is with you if you can step away for a moment. Better that they think you are being formal in asking rather than the alternative – thinking you are rude and judging you for being on your phone or laptop.
- Don’t opt out of any of the interview day– Even if you are interviewing at your home program, go on the tour. Along with this, I would also say not to make travel arrangements that force you to leave early. Not being present for part of the day automatically makes me think that you aren’t interested. Even if you have walked those halls 1000 times, if you were truly interested in our program, you would take the tour and be excited about it. We understand sometimes you can’t schedule travel perfectly, so, if this happens, let the coordinators know as soon as you book your flight so they can plan your day in advance.
- Thank the program coordinators – As the Chief Resident, I get many thank you cards/notes from applicants, and I understand why, but the true credit for the interview day should go to the program coordinators. They work so hard behind the scenes to make sure everything goes smoothly for you and for everyone involved. They are the unsung heroes of this process and deserve a lot more credit.
I hope some of these tips help those of you going through this process. Any career decision is important but don’t stress yourself out. I suggest making a list of all of the things you would like your future program/workplace to have. At the end of every interview, write down what the program had and didn’t have on your list. This makes the decision easier at the end, and, who knows, you might end up choosing a program that it fits all of your needs/expectations but that wasn’t on your A list. I’d love to hear what other interviewers look for and recommend.
November 1st, 2011
Heidi Zook, MD
In an effort to get in shape, I decided to start working out with a personal trainer. Before the training sessions started, we met to talk about my general health. When it comes to health, I feel like I know what I’m doing — I’m a physician! Of course I know how to eat healthy and how to take care of myself (whether I choose to follow my own advice or not is another story). The discussion began with her asking whether I was taking any supplements. (A little background: I bought vitamin D supplements about a year ago, fully intending to take a daily dose. Unfortunately, the bottle is still nearly full.) The trainer advised me that vitamin D is beneficial in many ways and that I should be taking a daily vitamin D supplement. Did I already know that vitamin D offers multiple health benefits? Yes. Do I speak with patients routinely about their vitamin D intake? Yes. Do I strongly encourage my patients to take vitamin D? Yes. Did I start taking vitamin D daily only after my new trainer told me to do so? Yes. So, why did her telling me do to something I already know I should be doing get me to do it? That question doesn’t have such a straightforward answer. It seems ridiculous; I knew better than that! I guess the important thing is that she got me to do it, along with several other healthy behaviors that she reminded me about.
The idea of counseling in the clinical setting always seemed a bit redundant to me; I mean, who DOESN’T know that smoking leads to cancer, heart disease, and emphysema? Undergoing counseling myself with my trainer made me realize the power of instruction. When something is directed at you personally, and it’s coming from someone who is knowledgeable on the subject, it truly is powerful. This idea is reflected in a recent summary in Journal Watch General Medicine, “Counseling Can Encourage Intake of Cholesterol-Lowering Foods” (Oct 1, p. 153). Simple dietary counseling on two occasions led to a 13% reduction in mean LDL cholesterol levels compared with only a 3% reduction in the placebo group. Even better: the researchers found no significant difference in LDL reduction in the group who were counseled seven times versus the group who were counseled only twice. This article, along with my own experience, helped me reflect on what I can offer my patients: A little advice goes a long way.
October 20th, 2011
Gopi Astik, MD
Anyone involved in academic medicine probably is aware of the new ACGME duty-hour restrictions that went into effect on 7/1/2011. For those of you who aren’t, the new guidelines state that PGY1 residents cannot work for longer than 16 hours straight. If they do work longer, they require strategic uninterrupted naps. The restrictions on PGY2 and PGY3 residents are less stringent, but the total consecutive hours that a PGY2 (and beyond) can work was lowered from 30 to 28. One other change is that residents are mandated to have 8 hours off, and recommended to have 10 hours off, between shifts. As one of the chief residents when this change occurred, I really want to share my thoughts about it.
For our program, these new rules have meant a transition to shift work on all days of the week. We have had night float for the past 5 or 6 years, but we had overnight “long” calls during the weekends. I can see both good and bad things about this new call change. We avoid some resident fatigue, because interns work only 16 hours maximum. The problem is that, in order to accommodate for the shifts, giving interns an entire weekend off is very difficult. The Golden Weekend is becoming somewhat of a myth to our intern class. Transitioning to a shift-based call system also points out major flaws in our handoff process. We have noticed that our “checkouts”/handoffs were not relaying the needed information and, as a program, we’ve been trying various things to improve this process.
One thing I ask of every resident reading this page is — be nice to your chief resident! We didn’t make this rule, nor did we have any input into the decision, but we have to enforce it. The more restrictions that the ACGME puts on resident work hours, the more complaints I hear from attending physicians about having to pick up the slack. We often do not have the manpower to ensure that every service will have a “full team” of interns and residents to complete daily work, and we have to rely on staff physicians to fill the service gap.
Our job to ensure that residents do not work more hours than they are allowed and, thus, avoid citations against our program. Problems arise mostly when residents who are on weekday call (which ends at 7PM for us) delay leaving because of notes, orders, or patient care issues. If a resident does not leave until 9 or 10PM, they cannot come back into the hospital until 7 or 8AM. This means that those residents probably have not seen all of their patients before rounds begin, and the responsibility falls on other residents or the attending physician. I realize that this issue is a culture shock for some of the older physicians who “used to walk to work in a foot of snow uphill both ways,” but these are the rules, and we all have to live by them. So, please, cut your chief a break!
October 17th, 2011
Gopi Astik, MD
I always remember my mother trying to teach me things I didn’t agree with. Being the bigmouth that I was (am), I would voice my disagreement, and she would tell me that, one day, I would tell my kids the same thing. I, of course, did not agree. I felt the same way about some of the tedious things I learned to do in medical school. I didn’t understand why my attending always made me recheck blood pressures on patients when I saw them, after a nurse had already done that precise thing. I would recheck the blood pressure and mindlessly report the measurement back to my staff. I started noticing that the levels were usually lower when I checked them again in the room, and I thought this was because I was so good at checking them.
The study regarding clinic-based BP measurement discusses this issue in more detail. It states that many people who are diagnosed with hypertension by clinic-based measurements alone are not truly hypertensive. It proves the validity of “white coat hypertension” and the importance of serial blood pressure measurements prior to initiation of therapy. If patients are not truly hypertensive, we are putting them at risk for hypotension with BP-lowering medications and subjecting them to risk for adverse effects and the associated cost-burden.
I was recently in clinic and asked my student what a patient’s blood pressure was when she rechecked it in the room — to which my student rolled her eyes and went back to check. I had to laugh — I realize how things really do come full circle.