High Stakes Games

Oct 08 2014 Published by under Learning

Too many new faculty in academic medicine get lost.

They sign on with academic medical centers with the best intentions. They want to inspire the next generation of providers. They want to solve healthcare problems. They hope to make the world a better place.

Unfortunately, academic medicine provides many distractions.

Unlike our PhD colleagues*, we MDs often fail to teach our trainees anything about academic life. I came from an academic family. I knew about ranks and tenure and other issues, but I still didn't really know how to succeed in The Ivory Tower. Someone gave me the Faculty Handbook, including promotion and tenure (P&T) guidelines, when I showed up at my first job.

Yes, I wrote it all down!

Yes, I wrote it all down!

Have you ever read a faculty handbook? Have you ever tried to read a faculty handbook? These documents tend to be written with stilted dry language. The handbook for an entire campus also keeps things vague enough that it applies to all departments and sections; this provides little guidance for a new assistant professor. You have to find contacts who can give you the real dirt. How many papers are considered "a significant number?" What sort of funding counts toward the tally? Will case reports be held against you? How do you document your educational efforts?

Mentorship helps (those contacts described above). P&T workshops with department-specific information can help. Unfortunately, none of these can be used as a lasting reference. Clinician faculty, in particular, often lose sight of their goal. Patient care responsibilities and other tasks can distract them from achieving and documenting the things that matter for academia. They get a few years into their first appointment and discover that they are behind the eight ball. Many leave academic medicine at this point.

That's why I have written down wisdom collected from multiple institutions and many colleagues. I have tried to keep this brief guide chatty and useful, rather than an academic tome. Yes, it is vague in that it gives no specifics for any institution; however, it does help faculty members know what to ask their colleagues and mentors.

When you get down to it, P&T is really a game. You have rules, you reach milestones, you keep score, and eventually you can win.

Yes, this is my Big Surprise. The book is debuting soon, both in print and as an ebook. Learn more at the website, ThePromotionGame.com.


*Instead, our PhD colleagues prepare everyone for an academic career, even though we know there are not enough positions for every trainee and many will have to pursue careers outside of The Ivory Tower.

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Screening Urinalysis in Practice

Sep 18 2014 Published by under [Medicine&Pharma]

Guidelines based on evidence or expert opinion, even when available, seem to be followed only occasionally. What do pediatricians do in practice with screening UAs?

Pediatricians’ screening urinalysis practices. J Pediatr 147:362-5, 2005  doi:  10.1016/j.peds.2005.05.009

This survey study examined the self-reported practices of general pediatricians in the US at a time when UA was recommended at 2 ages: start of school, ~5 years old, and sexually active adolescents. They asked when all asymptomatic children seen in the practice were screened at least once with the following choices:

  • Infancy (<1 year of age)
  • Early childhood (1 to 5 years of age)
  • Late childhood (5 to 12 years of age)
  • Adolescence (12 to 20 years of age)

Yes, they included the only definitely recommended age in two choices in their survey (why didn’t someone see this ahead of time?). The majority of responders (78%) screened at least once, with 58% screening more than one age group, leading to the following results:

  • Infancy 9%
  • Early childhood 60%
  • Late childhood 55%
  • Adolescence 58%

Pediatricians reported that they felt this screening benefitted the children and their overall health. Beyond that, the survey did not attempt to elucidate the rationale for practices identified. Were physicians unaware of changes in guidelines?

What is the downside of screening so many, so often? Next up we will look at the costs of this practice.

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When to Pee in the Cup

Sep 11 2014 Published by under Kidney Function

Screening urinalysis (UA), usually performed by dipstick in a physician's office, ultimately results in a lot of referrals for nephrologists. I am reviewing this topic, and I will have a series of posts about UAs over the coming weeks. First, I want to start with a poll about what is really recommended for healthy, asymptomatic children:

What are the current recommendations for screening urinalysis by the American Academy of Pediatrics?Next week I will reveal the answers from the crowd, as well as what the real answer is.

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Forty-Six

Sep 06 2014 Published by under Kidney Function, Life of a Physician

It's been a dry week.

Zer0. Zip. Nada.

Today, the urine output box shows 46 mL overnight.

Less than an ounce, but an important sign of the return of kidney function.

Keep it up, kid.

Urine is golden.

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Mean Girls

May 16 2014 Published by under Feminist Musings

When LL was an actress, not a punchline...

 

The Queen Bee phenomenon can be quite distressing for women who aspire to leadership roles. This term describes a woman who achieves and then believes that having other women achieve will diminish her own achievements. Queen Bees tend to ascribe their own success to a lack of "girliness" and suggest that all women could achieve at the same level if they just followed her example. For a review of this behavior and some research on it, click here.

Mean Girls ostracize women who fail to fit in. In the 2004 movie, the top clique demeaned those who marched to a different drummer, failing to aspire to their standards. You simply can't have that; if anyone can set their own goals, how will those at the top of the pecking order continue to win?

In this month's issue of Journal of Women's Health (23 (5):365-7, 2014), Janet Bickel discusses some of the reasons women may hamper other women. Many factors enter into this behavior, including the lack of open competition in many girls' activities. Our female children have traditionally been funneled into activities without winners; instead of beating someone, they turn their aggression and ambition into gossip and other mental bullying.

It will be interesting to see if this behavior changes over time; more girls have been in competitive sports now, and even dance and cheer have become events with winners.

Another difficulty many women face is the overlap between their work relationships and friendships. Social relationships are often expected to trump "chain of command" relationships, even in work situations. This can be especially a problem between female physicians and nurses, as discussed in the article.

This piece gives us more to think about than immediate solutions, but studies on these phenomena are few and far between. Lucky for us, the article is open access, so you have no excuse not to click the link above (or here) and think. In the meantime, we should all keep these words from Madeleine Albright in mind:

“There is a special place in hell for women who don't help other women."

 

 

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My Arch Enemy

Apr 08 2014 Published by under [Medicine&Pharma]

Oklahoma is recovering from an outbreak of Escherichia coli which has kept me away from the blog recently.

E. coli, as we usually call it, lives all around and in us. A good chunk of that microbiome we keep hearing about includes this bacteria. Most strains happily thrive in our guts, living a perfectly benign coexistence with us. At times they may find their way into our urine or other problematic place, but they can usually be rapidly dispatched.

Some strains produce a toxin first noted in the bacteria Shigella, thus named Shiga Toxin. Autocorrect on my iPhone wants to change "shiga" to "shiva." This may not be an error. This toxin causes incredible inflammation within the bowel. When the gut gets inflamed, it lets water and other material flow on through, producing diarrhea. In this case, the inflammation is so intense that the gut bleeds. A bloody gut produces bloody diarrhea. Nausea, vomiting, and intense cramping complete the clinical picture. This is a case of the runs you will never forget.

Click to Enlarge

Click to Enlarge

In a small number of cases of hemorrhagic colitis, the toxin enters the blood stream and produces a systemic response called a thrombotic microangiopathy (TMA for short). In tiny blood vessels throughout the body (capillaries), the toxin damages the inside. Platelets (oblong lavender thingies in the diagram) activate on these areas of damage to begin repairs. These tiny clots get bigger over time and form a mesh or halt blood blow to an organ, impairing or shutting down its function.

Not all organs seem as prone to TMA damage. The kidneys seem to provide a playground for the toxin and platelets; kidney involvement ranges from the trivial to irreversible infarction or scarring of the kidneys. This is why we call this TMA hemolytic uremic syndrome (HUS), uremia being another term for kidney failure. Other organs can be involved, including the brain, pancreas, liver, and heart.

Obviously the kidney provides a major clotting magnet, or I would not be discussing this entity. We do not really know why one child gets colitis and develops HUS while another gets just a horrible case of diarrhea. Using antibiotics and anti-diarrheal drugs during the colitis can increase the risk of HUS, but they do not explain it all.

Since this syndrome was described in the 1950's mortality has fallen from ~50% to <5% just with supportive care. Mortality generally is confined to patients with significant central nervous system involvement. Apparent kidney recovery occurs in 95% of survivors, although most will develop other signs and symptoms of chronic kidney disease over the decades.

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Trying to Stop a Disruptive Train

Apr 04 2014 Published by under Life of a Physician

My week involved a lot of work with patients as some hemolytic-uremic syndrome came to town. While driving to and fro and using the restroom, I have read some tweets. At one point in a discourse, we talked about "antique" portions of the physical exam.

For example, in medical school they taught us to percuss heart borders. Percussion involves tapping on the chest and listening for the difference between the air-filled lungs and the relatively solid heart as shown in the video:

I cannot remember the last time I percussed a heart. Children do not hold still and quiet for such nonsense, and we get much more information from a chest xray. The latter also provides a lasting objective record of the findings that can be shared with subsequent physicians (or legal professionals). Most of the medical students I queried had no idea what I was talking about.

Many medical schools now incorporate inexpensive portable ultrasound machines into their curriculum. I envy these students who will be able to hear a murmur and figure out what it means on-the-spot. I know several pediatric nephrologists who have trained to perform their own ultrasound exams in the clinic. Unfortunately, its use is not spreading as fast or as far as it should.

Why? Hospital privileges.

When a doctor establishes a practice in a clinical facility, they usually have to be approved by a group at that place to make sure they are competent. I could apply for privileges for many procedures, but then I have to document my proficiency. Generally, they want to know what training you have and how many of the procedure you completed in the past 1-5 years. Imaging studies have fallen under the procedures heading. All those formal ultrasounds in the radiology suite generate lots of income for facilities.

They may not want us doing our own, even when we have the capability to record and store our images for the record.

The nice thing about disruptive technologies is that they are usually hard to stop. Eventually pocket ultrasound may replace even more of those "artisanal" physical exam skills. And that's OK if it makes for better care.

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Physician, Heal Thyself

Mar 31 2014 Published by under General Health

I had good intentions to blog last week. I had planned to fill out my #nephMadness bracket and blog about my choices. I had reviewed a topic, ready to discuss some medical science.

Then life interfered.

A bit over a week ago things were in their usual state of disarray for a Friday. I sat in my nurses' office, fiddling with the items on their table, including a wrist blood pressure cuff. I put it on and got a reading of 200/165. Yes, this is really high. After multiple readings with a variety of devices, including the gold standard (manual cuff and my nurse with a stethoscope), it became clear that I now have hypertension.

In retrospect, this should not have surprised me. After all, almost everyone in my family has developed high blood pressure at some point. I believe my mother's onset came during peri-menopause, a phase of life I now "enjoy."

I bought a cuff and picked up my first bottle of hydrochlorothiazide on my way home. The first few days got interesting since I had to fly to a meeting; gosh, diuretics do make you pee! By the end of the first week, my urine output was back to its usual amount. Today my blood pressure was 150/90. Not normal, but much improved and still decreasing daily, and all with a once-a-day drug that cost $3.51 for the first 30-day supply.

By the way, I felt completely fine. Even now that my pressure is down, I cannot point to a single symptom that would suggest my BP was high. Hypertension truly is a silent killer. Don't ignore it, and take your medication(s). It's important for your heart, your brain, your kidneys, and your life.

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Saturday Night #Thunder

Feb 24 2014 Published by under Uncategorized

Saturday evening I attended a very special event that I was banned from discussing until now.

In a children's hospital, you get used to celebrities doing things. Local personalities hand out goodies, making our patients and themselves a little happier in the process. Most of the time, they seem to target two patient groups. Premature babies get a lot of love, as do the kids with cancer. Other patients with chronic diseases receive less media attention. Kids with cancer might DIE! Children on dialysis will get transplants and be cured, right?

Not always. And a kidney transplant is hardly a cure, given life-long risks of immunosuppression.

I was delighted a few weeks back to hear that a local star wanted to do a party with our dialysis kids. Not only were they (finally) getting some special attention, but the celebrity would be my favorite OKC Thunder player, Serge Ibaka. My excitement was tempered by the fact that at first we nephrologists were not invited to the party.

Click to enlarge

Click to enlarge

I pouted a bit, but accepted my missed opportunity.

A few days later, I got the call that I could come. None of my family could come with me, but I was welcome to watch my patients interact and have some fun. I also was not to bring a phone or camera, although being on call meant I had to bring the phone. This loophole allowed me to take my completely unofficial illicit photo of the shot blocker at right. That's just the kind of rebel I am, folks.

The event took place in the hospital play zone. Each patient and their immediate family spent about 15 minutes alone with Serge (I shook his hand, I can call him that now, right?) and the kids got personalized Thunder jerseys, autographed in most cases. Then we all came together and he answered questions from the patients. After a group photo, he then shot baskets against the kids on an arcade basketball game (one girl even beat him; she is still glowing). Afterwards, he even posed for selfies with some of the teens. I have never seen such big smiles on the faces of these children; dialysis appointments rarely make you happy.

Things I learned or confirmed?

  1. Standing next to a 6'10" guy makes me feel even smaller than usual.
  2. During the games, Serge looks fierce, like he would not mind breaking your nose. In real life he is charming and quite attractive (and roughly the same age as my children; I have already heard all the Mrs. Robinson jokes this weekend, thanks).
  3. He speaks 5 languages, including his Congo tribal tongue, French, Spanish, Catalan, and English. Many of our patients and families have Spanish as their first language, so this was another delight.

Saturday's event left me with such a happy feeling. I am hoping others will take on the fight for kids with less publicly emphasized disorders, including the drive to raise money for research and treatment. All children deserve to have their health struggles acknowledged.

Thanks, Serge. Now go block some shots.

 

 

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Good Post, but Ad FAIL

Feb 19 2014 Published by under Alt Med

Today my Twitter feed (h/t @Scicurious) brought me a nice piece in Slate about Natural News, the source of about 100,000 "Shares" each day on Facebook. The site shares such scintillating stories as "eating whole lemons prevents cancer" and "Himalayan bath salts rid the body of toxins." The Slate piece by  does a nice job showing why some of these claims are complete bunk. Read the article; it is good.

However, I had to stifle a giggle and catch this screen shot:

Click to enlarge

Click to enlarge

Yes, right there beside this well-written, magic-medicine-debunking-post came an add for "the unique 'Body Acidity Test'" that will help you conquer your belly fat.

Perhaps this ad will provide fodder for another story in Slate.

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