NEJM: MGH doc and med student get real on clinical clerkships

From the New England Journal of Medicine:

 This Perspective article about the effect of the clinical clerkships on the professional development of medical students was written from the alternating perspectives of a teacher and long-time clinician, Katharine Treadway, and a third-year medical student, Neal Chatterjee, who is now an intern in internal medicine.

It ain’t pretty

Chatterjee: At the end of the year, we were asked to reflect, in writing, on our first year in the hospital. What eventually filled my computer screen had nothing to do with vital signs or chest pain.

I began to write, “I have seen a 24-hour-old child die. I saw that same child at 12 hours and had the audacity to tell her parents that she was beautiful and healthy. Apparently, at the sight of his child — blue, limp, quiet — her father vomited on the spot. I say `apparently’ because I was at home, sleeping under my own covers, when she coded.

“I have seen entirely too many people naked. I have seen 350 pounds of flesh, dead: dried red blood streaked across nude adipose, gauze, and useless EKG paper strips. I have met someone for the second time and seen them anesthetized, splayed, and filleted across an OR table within 10 minutes.

“I have seen, in the corner of my vision, an anesthesiologist present his middle finger to an anesthetized patient who was `taking too long to wake up.’ I have said nothing about that incident. I have delivered a baby. Alone. I have sawed off a man’s leg and dropped it into a metal bucket. I have seen three patients die from cancer in one night. I have seen and never want to see again a medical code in a CT scanner. He was 7 years old. It was elective surgery.”

 

Treadway on how powerful the clerkship experience is for med students: First, students are entering a foreign world where they face difficult, often overwhelming experiences. Second, the rules governing the responses to these experiences are unclear. It is not obvious to students that the beliefs and ideas with which they entered school still apply, so they take their cues from the behaviors they observe. Furthermore, since responses to these events are rarely discussed, students often erroneously ascribe a detachment and lack of caring to house staff and senior physicians. Third, these experiences have frequently gone unacknowledged and unexplored.

For the past few years, I have been a mentor to medical students during their clerkship year. As they have their first experiences with patients dying, they don’t know how they should respond, whether it’s OK to be upset. One student told me about his confusion when a patient he’d admitted to the hospital died and no one on his team even remarked on the death. It made him feel he wasn’t supposed to care. When, days later, his intern mentioned how bad she felt about losing the patient, he was relieved — it made him feel he was normal. His story revealed how vulnerable medical students are to the influence of behavior that contradicts their belief systems

 

MIT conference video: Conquering Cancer through Science and Engineering

Videos from the March 16 conference. Part one includes:

Opening and Welcome

David A. Mindell PhD ’96, Chair, MIT150 Steering Committee and Dibner Professor of the History of Engineering and Manufacturing and of Aeronautics and Astronautics, MIT
Susan Hockfield, President, MIT
Tyler Jacks, Director, David H. Koch Institute for Integrative Cancer Research and David H. Koch Professor, MIT

Session 1: Reflections on Major Milestones in Cancer Research and Technology Development

Session Chair: Nancy H. Hopkins, Amgen, Inc. Professor of Biology, MIT
Phillip A. Sharp, Institute Professor, MIT
Jacqueline A. Lees, Associate Director, David H. Koch Institute for Integrative Cancer Research and Professor of Biology, MIT
Robert S. Langer, Institute Professor and Professor of Chemical Engineering and Biological Engineering, MIT
Group discussion including Michael Goldberg

Click here for sessions 2-4.

Event this week: Social media and health

Don’t get enough of virtual Dr. Kevin — the NH doc billed as “social media’s leading physician voice”? See him in person in Boston this Friday. Sponsored by Racepoint, a  Boston PR company which is — take a deep breath –”… defining the new model of communications through an unrivalled understanding of the evolution of traditional and social media.”

Harnessing the Power of Social Media in Healthcare Communications — Interactive Panel Event in Boston

Date: Friday, April 1, 2011
Time: 7:30 – 9:30 am
Location: Joseph B. Martin Conference Center at Harvard Medical School – Room 217
77 Avenue Louis Pasteur, Boston, MA 02115

In today’s digital age, the health of a business can be measured by its ability to effectively connect with and engage its target audience online. Did you know:

  • 900+ hospitals are using social networking tools
  • 1 in 4 doctors plan to purchase a tablet for their practice in 2011 because of ease of use and mobility
  • 72% of physicians carry smartphones; 95% use the devices to download medical data
  • 72% of patients search for medical info online before or after doctor visits

Maine town fights for the right to raw milk, local poultry

It seems the raw milk debate has bubbled up with the local foods movement. Some people think unpasteurized milk is healthy. Most states ban it for fear of  dangerous bacteria. David Gumpert, who has chronicled the push for unpastuerized milk, reports on a Maine town that wants to be exempt from state and federal regarding food production.

Citing America’s Declaration of Independence and the Maine Constitution, the ordinance proposed that “Sedgwick citizens possess the right to produce, process, sell, purchase, and consume local foods of their choosing.” These would include raw milk and other dairy products, and locally slaughtered meats, among other items.

It wasn’t just a declaration of preference. The proposed warrant added, “It shall be unlawful for any law or regulation adopted by the state or federal government to interfere with the rights recognized by this Ordinance.” In other words, no state licensing requirements prohibiting certain farms from selling dairy products or producing their own chickens for sale to other citizens in the town.

What about potential legal liability and state or federal inspections? It’s all up to the seller and buyer to negotiate. “Patrons purchasing food for home consumption may enter into private agreements with those producers or processors of local foods to waive any liability for the consumption of that food. Producers or processors of local foods shall be exempt from licensure and inspection requirements for that food as long as those agreements are in effect.”

Gumpert talked about the issue on WBUR’s Here & Now this past summer.

More here from the Globe on the raw milk battle.

Quietly – since the accepted medical and public health wisdom is that raw milk is a dangerous source of bacteria, including listeria, salmonella, and E. coli – hundreds of consumers around Boston have made the same decision (to buy raw milk). A total of 24 Massachusetts dairies now have permits to sell raw milk, double the number two years ago.

Health writers honor reporting from the Globe and WGBH #boston #health

 Lots of organizations give out journalism awards, but these count. The Association of Health Care Journalists this year honors amazing reporting on organ trafficking, end-of-life care, dying hospitals and elder abuse. The list of winners is inspirational.  

The beat reporting prize goes the Boston Globe’s Kay Laser. Well-deserved. From the site.

 Kay Lazar’s 2010 Body of Work; The Boston GlobeLazar’s entry included stories about:

  •   Antipsychotic medications given to patients in nursing homes and the risks for patients that have dementia
  • The impact of earlier coverage of this issue: state regulators and industry leaders formed a task force and launched an educational campaign to reduce the inappropriate use of the medications.
  • An unintended consequence of Massachusetts’ pioneering health care reform law
  • The widespread practice of no-bid contracts in the Massachusetts Medicaid procurement system and the $400,000-plus salaries of officials involved in the contracting process.

 See the stories on the Web:

 Judges’ comments:

  Kay Lazar of the Boston Globe, for the range and depth of her health policy coverage, and its measurable impact. Her reporting on no-bid contracts for Medicaid and on “gamers” who exploited a loophole in Massachusetts’ universal health coverage law exposed costly problems and drew responses from state regulators and lawmakers. Her reporting on excessive use of antipsychotic drugs in state nursing homes prompted regulatory review and new training. Her news feature story about a storeowner with early-onset Alzheimer illustrated the impact of a devastating disease and the genetic testing quandary facing family members.

WGBH also brought home a first prize to radio reporting.

First Place: Rationing Health: Who Lives? Who Decides?; David Baron, Patrick Cox, Sheri Fink, WGBH-Boston

In 2010, PRI’s The World reported from South Africa, Great Britain, Zambia and India to examine how other governments manage the costs of delivering health services to the public. Each country, with its unique economic and cultural environment, provided an opportunity to spotlight different approaches to the challenge of rationing scarce health care resources: explicit rationing by committee, rationing by cost effectiveness, unintentional rationing, and innovation to avoid rationing altogether. The series, the result of a more than half-year reporting and editing effort, was presented along with a website and opportunities for interaction via Twitter and online discussions. See the story on the web.

 

Judges’ comments:

The terrific series addressed one of the hottest 2010 election topics in a different and fascinating way by looking at the realities faced in other parts of the world.

I was hooked by the first characters – doctors deciding who will get life-saving dialysis in South Africa.
It was clever to not start with the obvious – the much demonized British system – but smart not to wait beyond part 2 to address this country as well. Parts 3 & 4 were also very intriguing and the analysis in the final part was a nice way to button up the series without belaboring the points already made in the previous episodes. Great job. 

 

Harvard prof in New Yorker story on childhood trauma and health

Jack P. Shonkoff of Harvard’s  Center on the Developing Child at Harvard University gets a mention in this week’s New Yorker story “The Poverty Clinic.” The story profiles a San Franciso doctor who is trying to address the childhood  neglect, abuse and trauma that trigger health problems later in life.

Shonkoff is noted as a leader in this area, having edited the 2000 “From Neighborhoods to Neurons” study out of the National Academy of  Sciences, which “presents the evidence about “brain wiring” and how kids learn to speak, think, and regulate their behavior. It examines the effect of the climate-family, child care, community-within which the child grows.”

 Here’s a link to a panel held last year to follow up on the study. For more, the center is hosting an upcoming talk on the topic which is open to the public.

 Thomas Boyce, M.D. “A Biology of Misfortune: How Stratification, Sensitivity, and Stress Diminish Child Health and Development” April 12, 2011 4:00-6:00 p.m. , Kresge G2, Harvard School of Public Health,,677 Huntington Avenue
Boston, Mass.

This event free and open to all University students, faculty, and the general public.

ABSTRACT: Social class differences in early childhood adversity are among the most important and least understood determinants of human health and development. This lecture will propose the following three hypotheses: (1) maladaptive outcomes of social stratification in early childhood anticipate, parallel, and amplify the effects of inequality in adult societies; (2) these effects operate through central and peripheral neurobiologic and epigenomic circuits that are responsive to stress and adversity; and (3) extensive variation in stress responsivity reveals a subgroup of children with exaggerated sensitivity to both aversive and nurturing social conditions. The disproportionate prevalence of health and developmental problems among children with elevated sensitivity to context suggests a “biology of misfortune” that involves inter-related cycles of subordination, affliction, and adversity that have important implications for public health.

SPEAKER:

W. Thomas Boyce, M.D., is the Sunny Hill Health Centre/BC Leadership Chair in Child Development at the University of British Columbia, Vancouver, Canada, and a professor in the College for Interdisciplinary Studies and Faculty of Medicine. He is also co-director of the Experience-Based Brain and Biological Development Program of the Canadian Institute for Advanced Research and a member of the American Pediatric Society. A social epidemiologist and developmental-behavioral pediatrician, his research addresses the interplay among neurobiological, genetic, and psychosocial processes that leads to socioeconomically partitioned differences in childhood morbidities. He is also a member of the National Scientific Council on the Developing Child. His research has demonstrated how psychological stress and neurobiological reactivity to aversive social contexts operate conjointly to increase risks of physical and mental health disorders in childhood. His work seeks a new synthesis between biomedical and social epidemiologic understanding of human pathogenesis, with particular attention to its population health implications. Dr. Boyce earned his M.D. from the Baylor College of Medicine, completed his pediatrics residency at the University of California, San Francisco, and was a Robert Wood Johnson Foundation Clinical Scholar at the University of North Carolina, Chapel Hill

        Finally, I’m not one of those Red Sox fans who fumes at the thought of the Yankees.  I’m from Jersey, so I’m related to a few Yankee fans. Which is good, because this week’s Health Wonk Review is loaded with good links but studded with pictures of players from the evil ex-empire. All we have to say is: Go Sox!

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Harm reduction: Drinking tips to get you through St. Patty’s Day

Holyoke St. Patrick's Day Parade, sometime in the mid-1980s.

 

Enjoy St. Patricks Day but don’t be a fecking eedjet.  The Globe offer tips on how to drink without wrecking your health, ruining your diet or killing your friends.

Our favorite drinking delusion from the list: “Thinking you can’t get drunk at a sporting event.” Dedicated the people who usually sit behind me at Red Sox games. More here.

CBS News also has a story on how to take it easy and still celebrate. They also offer a list of the  “drunkest” states, based on a CDC study of binge drinking. We’re No. 11. Two other New England states make the list. Connecticut is No. 6 and Rhode Island is No. 8.

#Nurses, hospitals go to battle in Massachusetts

Nurses at Tufts Medical Center are protesting in the rain today. Expect to see  this battle played out elsewhere– Worcester, Quincy,  North Adams – as hospitals try to hold down costs. For more, check out.

Commonhealth: Mass. Hospital Association Steps Into Nurse Staffing Dispute

The Globe:  Nurses in contract disputes at several hospitals in Massachusetts, including Tufts Medical Center in Boston and Saint Vincent Hospital in Worcester, are increasing pressure with informational picketing and protests as hospital administrators warn of a possible strike. Update here.

Mass Nurses Association on TMC:

The nurses have serious concerns about recent cuts in RN staffing levels and other changes in how they deliver care that has resulted in nurses being forced to care for more patients at one time on nearly every unit. Those changes transformed this hospital from being one of the best staffed hospitals in Boston to the worst staffed hospital in the city. To compensate for chronic understaffing, TMC is using mandatory overtime and is forcing nurses to “float” from one area of the hospital to another where they might not be competent to provide appropriate care.

Tufts’ description of its nursing porgram:

Tufts Medical Center and Floating Hospital for Children have established a strong nursing culture based on the concept of primary nursing-a philosophy that gives nurses the authority and opportunity to assume care for their patients from admission to discharge. Primary nurses at Tufts Medical Center have the benefits of the resources and broad interdisciplinary expertise of a major academic medical center at their disposal, as well as a focus on patient centered care typically found in the community hospital setting.

Report:1/2 of all problem docs escape licensing board sanctions

A new report from Public Citizen finds that almost half of all hospital sanctions against problem docs do not result in action from state licensing boards.

According to Dr. Sidney Wolfe, head of Public Citizen’s Health Research Group “Either state medical boards are receiving this disturbing information from hospitals but not acting upon it, or much less likely, they are not receiving the information at all. Something is broken and needs to be fixed.”

The report found that about 300 Mass doctors were cited in the National Practitioner Data Bank (NPDB) for “clinical privileges revoked or restricted by hospitals”  Of those cases, 115 — or 38 percent, were not sanctioned by the state Board of Registration in Medicine.

According to the report, one Mass, one doc was cited by a hospital nine times, but never cited by the licensing board. The cases involved three medical malpractice cases resulting in $1.7 million in payments, two for failure to diagnose and one for delay in performance . One of the patients incurred” a major permanent injury.” Both were “obstetrics related.”

 More here:

Executive Summary

An analysis of the National Practitioner Data Bank Public Use File for 1990-2009 found that of a total of 10,672 physicians in the data bank with one or more clinical privilege actions — revocation or restriction of their clinical privileges — 45% also had one or more state licensing actions. However 5,887, or 55%, of these physicians — more than half — had no state licensing actions. This report is an analysis of violations by and the privileging actions taken against these physicians who, despite clinical privilege actions, escaped any state licensing action.

Types of violations causing Clinical Privileging Actions

The reason for the actions against these 5,887 physicians included:

  • 220 physicians disciplined because they were an “Immediate Threat to Health or Safety”
  • 1,119 physicians disciplined because of incompetence, negligence or malpractice
  • 605 physicians disciplined because of substandard care

Other categories of serious deviations of physician behavior/performance that resulted in clinical privilege revocation or restrictions included Sexual Misconduct, Unable to Practice Safely, fraud, including insurance fraud, fraud obtaining a license, and fraud against health care programs, and narcotics violations

Are we prepared for a Japanese-style nuclear disaster?

Two items on nuclear power today. Juliette Kayyem,  a former homeland security adviser for both Massachusetts and the US Department of Homeland Security, asks on today’s Globe Op/Ed page: Can the US handle a nuclear disaster?

The White House planning document for a nuclear event essentially admits that the public would be foolish to rely too heavily on the government. Sheltering in place (for any contingency) requires a few minutes to prepare your home with basic essentials, including water and food, and to ensure that your loved ones know where to go in the event that all communications are disrupted. It is that simple; no drama, no duct tape…

There is no doubt that nuclear safety will be the subject of a heated debate in the months to come. And that debate may serve as an important opportunity to challenge not only the nuclear industry’s assumptions about plant safety, but also our own assumptions about empowering ourselves to protect our well-being.”

Also, the investigative group ProPublica asks how well plant operators are prepared.As this story notes,  Mass Democratic Rep. Ed Markey has been pushing for safer rules and is not pushing harder.  

Can the US handle a nuclear disaster?

by John Sullivan, Special to ProPublica March 13, 2011

Published with permission.

As engineers in Japan struggle to bring quake-damaged reactors under control [1], attention is turning to U.S. nuclear plants and their ability to withstand natural disasters.

Rep. Ed Markey, a Massachusetts Democrat who has spent years pushing the Nuclear Regulatory Commission toward stricter enforcement of its safety rules, has called for a reassessment. Several U.S. reactors lie on or near fault lines, and Markey wants to beef up standards for new and existing plants.

“This disaster serves to highlight both the fragility of nuclear power plants and the potential consequences associated with a radiological release caused by earthquake related damage,” Markey wrote NRC Chairman Gregory Jaczko in a March 11 letter [2].

Specifically, Markey raised questions about a reactor design the NRC is reviewing for new plants that has been criticized for seismic vulnerability. The NRC has yet to make a call on the AP1000 reactor [3], which is manufactured by Westinghouse. But according to Markey, a senior NRC engineer has said the reactor’s concrete shield building could shatter “like a glass cup” under heavy stress.

The New York Times reported last week [4] that the NRC has reviewed the concerns raised by the engineer, John Ma, and concluded that the design is sufficient without the upgrades Ma recommended. Westinghouse maintains that the reactor is safe [5].

Boiling water reactors [6], like the ones hit by the Japanese earthquake, are built like nested matroyshka [7] dolls.

The inner doll, which looks like a gigantic cocktail shaker and holds the radioactive uranium, is the heavy steel reactor vessel. It sits inside a concrete and steel dome called the containment. The reactor vessel is the primary defense against disaster — as long as the radiation stays inside everything is fine.

The worry is that a disaster could either damage the vessel itself or, more likely, damage equipment that used to control the uranium. If operators cannot circulate water through the vessel to cool the uranium it could overheat and burn into radioactive slag — a meltdown.

Reports say a partial meltdown is suspected [1] in two of three reactors at the Fukushima Daiichi Nuclear Power Station in Japan, which was hit by the 8.9 magnitude quake and ensuing tsunami.

Reactors have multiple layers of equipment to make sure this never happens. But last year, Markey asked Congress’s investigative agency [8], the Government Accountability Office, to look into a long list of nuclear safety issues, including earthquake and flood protection.

Markey cited the 2007 Chuetsu earthquake [9] (6.6 magnitude) that hit the Kashiwazaki-Kariwa nuclear plant. The quake started a fire, spilled some low-level radioactive waste and damaged equipment that was not critical to the reactor. It led Japanese regulators to reassess earthquake danger near the plant, and Markey wanted GAO to see whether NRC had been on top of earthquake risk in the U.S.

As seen here, Hurricane Gustave damaged the River Bend Nuclear Generation Station in St. Francisville, La. (NRC photo provided by Union of Concerned Scientists)

He also listed a few cases in which other natural disasters had damaged nuclear plants, like a 1998 tornado that knocked out power to the Davis-Besse [10] plant outside Toledo, Ohio, or Hurricane Andrew, which knocked out power to the Turkey Point [11] plant south of Miami site for five days in 1992. In 2008, Hurricane Gustav damaged the River Bend Nuclear Generation Station in St. Francisville, La. [12]

At both Davis-Besse and Turkey Point, the plants’ emergency diesel generators kept the equipment running until crews fixed the power lines.

News reports have said the Fukushima Daiichi Nuclear Power Station went to backup diesel power after the quake but lost it, along with the ability to keep cooling water flowing.

Edwin Lyman, a senior scientist with the Union of Concerned Scientists, told Reuters [13] that U.S. reactors don’t have adequate backup power. “We do not believe the safety standards for U.S. nuclear reactors are enough to protect the public today,” he told the news agency.

NRC spokesman David McIntyre said the agency was not granting interviews about the Japan quake. He pointed to the agency’s website, which does have a lot of information on the seismic issues.

For instance, NRC regulations require that every plant is built to survive an earthquake larger than the strongest ever recorded in the area. The agency says it periodically updates earthquake estimations as more detailed information becomes available.

Most recently, the NRC spent five years reassessing earthquake risk for nuclear plants in the Midwest and eastern United States. The results of the study [14], which were released last September, confirmed that the plants were built to withstand the heaviest quake likely for their area.

However, the NRC found that the risk of earthquake was greater than expected in some areas, so the agency plans further research [15].

In an NRC meeting on earthquake safety last September, Torrey Yee, an engineer for the San Onofre nuclear plant near San Diego, said designers evaluate two levels of earthquakes: the maximum possible quake for a site; and an “operating basis” quake, usually about half of the maximum strength.

The critical structures and equipment at the plant are built to withstand the maximum quake, and the plant has to shut down for inspection if it sustains a quake higher than the operating basis.

The 104 commercial reactors [16] in the United States produce 20 percent of the nation’s power.

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