So this is emergent care?

My teammate and I were sitting on the plethora of abandoned chairs in the emergency room. It was an odd time of the day for people to show up--right around lunch time--and it wasn't the right weather: too cold to be outside and accidentally or intentionally get hurt. Yet there were still patients in about half of the rooms, and because we were on call, all those patients who could be deemed fit for admission had to be processed by us. While we had been interviewing a man with suprapubic pain suspicious for bladder cancer, nearly continuous screams were emanating from a female patient nearby, drowning out the sounds of televisions, beeping monitors, and phone calls. I've been getting better and better at ignoring people screaming in hospitals. But this woman was loud and persistent and every once in a while I could hear the crashing of equipment or cheap furniture, and I'd wonder why a code hadn't been called yet or why nobody had tried to administer drugs.

I was incredibly saddened that the screaming had stopped--it is secretly my dream to rush in to help with a "Paging Dr. Strong" or "Code Grey" (combative patient/person). Alas, today was not going to be that day. Our intern had disappeared again so we had little to do except periodically check up on our patients through their electronic medical records. And then... an Emergency Medicine resident swept by and without hardly stopping asked: "You medical students?" "Yea," we both answered. "I need one of you to follow me." I started asking why as my friend was already standing up to follow him--she is way more instinctively helpful than I am. "To chaperone." Only as they were entering one of the private rooms did I kind of understand. Female patient. Delicate issues. Male doctors needed a female in the room. How obnoxious and unnecessary. So this is where politically correctness was taking us, that male doctors were no longer trusted enough to perform gyne check-ups without female supervision. 

Shortly thereafter, I was pulled away by one of the resident's on my internal medicine team to help out with ABG draws and paper work and phone calls. Eventually my teammate pages me.

"Hi Elora. It's Rebecca. Where are you?"

"The residence room. Why?"

"Okay. I need to tell you something. Will you be in the residence room for long?"

I looked at my computer screen, at the list of patients who were awaiting results of labs and imaging.

"Yea I'll be here."

to be continued. 

Gender Discrepancies (I/II)

Did you know women and men are actually quite similar? We really are. If we were all raised in a society that interacted with the two genders in the exact same way, we'd probably end up like some gender-neutralized weird race of alien a la Star Trek: The Next Generation. We'd still have the two separate sexes, but we probably wouldn't have this weird, polarized, gender dichotomy. The terms tomboys and janegirls, for example, would no longer make sense and be cast aside like the frivolous trash they are.

Yesterday, in our community groups (which is basically a quarter of our class plus one practicing physician from the surrounding area), we were asked to talk about American health care. We were asked vague questions by our community leader and what ensued was kind of hilarious and also pretty depressing.

On a side note: I talked entirely way too much, which is unfortunate because I hate people who act the way I acted yesterday in class. I will have to implement a more stringent foot-in-mouth policy for any future large discussion groups. I am also a crazy liberal. I need to stop telling people I'm a moderate since I clearly believe that taxes are necessary and the government should govern our personal liberties as little as possible (but I still think we should all have access to affordable health care because it should be a personal liberty).

There were a lot of nuances in our overall debate--this is to be expected since if we could formulate a clear solution to the health care problem in an hour and a half, than our government, as crappy as it is, would already be enacting such solutions as policies nationwide. But in the end, clumping all the nuances together and then defenestrating them because who actually gives a **** about nuances?--there were only two general positions a person could have: you believe Universal Health Care should be guaranteed for everyone or you believe that Health Care should be payed for by individuals in some way outside of paying taxes.

Good points can be made for either side, but as you recall, I threw all those nuances out the window, and it seemed for the most part that the most avid supporters of the opposing sides were also of opposing genders. Universal health care is somehow more appealing to more women than it is to men.

Although clarifying point: my sample size was quite small (n=48) and it wasn't as if no men liked the idea of universal health care. Some favored it. Also, not everyone talked so the real sample size is closer to around 20. So I might just be making up a ton of crap, in which case, I'm sorry if the following is just super offensive. 

I am trying to figure out why that is. Last year when I went to the American Medical Women's Association's National Conference in Miami, the keynote speaker kept commenting on how women are dearly needed in the medical field because women are natural healers and we just care more. It was pretty inspiring but it seemed kind of hurtful to the small amount of dudes I knew who are actually pretty loving people. But now that I think about it, do I actually know any guys who are selfless? Or are they just decent human beings who have yet to have their selflessness tested? How selfless are they, really? Because I don't think caring is quite enough. I care a lot about things but don't actually do anything about it because I am selfish. I really care about making sure people understand that America's  oppressed groups aren't all good to go now that we've slapped band-aids--Title IX and Affirmative Action--on the gaping wound that is injustice. But all I actually do is update my status on Facebook, maybe including a link to a blog article or a recent study.

But when I think about selflessness more, I realize a better question may be: do I know anyone who is selfless? 
Not many.
Well, that's depressing, seeing as I am in Medical School. But I guess everyone isn't being "selfish" per se, just too busy studying so that they can one day be selfless. <<>> This seems too nuanced. I will stop ruminating. 

If we just assume women care more, why is that so? Is it because we have the capacity to become mothers? Because men have the capacity to become fathers, which I have been assured can also be a full time job. Both of my parents were full time Surgeons, and I am sure they both cared about me equally, but I saw my mom much more than I saw my dad, so can we assume my mother was more selfless than my father? I think that is a far argument. Although we will never know for sure because my dad may have thought that by working longer hours, he would be able to give us more opportunities with the money he'd make, and to him, that would seem like a more valuable pursuit than teaching us how to tie our shoes. My dad may have been selfless. Conversely, my mother may have spent more time with us to show the world that she was not only capable of being a woman and a surgeon, but also a loving mother. My mom may have been selfish.

But either way, actions speak louder than words, and I saw my mom more than I saw my dad, even though they had similar jobs. I think this behavior must be socialized, because my mom didn't actually need to spend so much time with us. We could have just had babysitters who stayed at our house longer.

 Now that I've dragged you through my own internal thought process, let me actually tell you facts: female physicians make $17,000-a-year less than male physicians, on average, for doing the exact same amount of work. This number has been normalized, so any arguments that male physicians tend to work longer hours (as was the case for my parents) or that male and female physicians choose to enter different specialties or practice in different locations (as was not the case for my parents) does not at all affect the statistic that women make $17,000 a year less than men for doing the exact same work. Discrimination, of course, plays a role in this inequality, but another interesting point that the researchers brought up was that some of the blame actually falls on women: women will stop negotiating their wages with their employers at a lower rate than their male counterparts. You could see this as women having a lower innate self-worth (which is true in society overall but may not apply to physicians) or you could see this as women willing to do more "caring" for less economic compensation. That sounds a lot like selflessness to me.

What Constitutes a Mental Illness?

Exciting news everyone! My previous post concerning personal ambivalence towards diagnosing, labeling, and medicating mental disorders has gained some validation. Below is the reading--from an actual publication--describing the "confusion" in dictating what constitutes mental illness.

BRAIN AND BEHAVIOR

Descriptive Psychopathology: The Signs and Symptoms of Behavioral Disorders by Nutan Atre Vaidya and Michael Alan Taylor:

The DSM conceptualizes a “disorder” as a condition that is clinically significant and that causes distress or disability. This definition fails because it is overinclusive, incorporating as disorders non-illness such as demoralization, jealousy and revenge, and criminality. By the definition, normal pregnancy might be considered a disorder. Others have argued that a more precise definition of illness is: a condition that causes harm and that derives from dysfunction. Harmful dysfunction involves “something going wrong with the functioning of some internal mechanism, so that the mechanism is not performing one of the functions for which it was „designed‟ by natural selection.”

This conceptualization works for most presently recognized psychiatric disorders, but may fall short for some of the personality disorders.

Confusion also arises from the fact that persons who appropriately receive classification labels are by definition deviant, but deviance has several fathers. Brain structural and physiological lesions (genetic and acquired), maturational variation, and indoctrination at odds with the cultural context cause deviation. Further roiling the conceptual waters is the fact that some deviation is advantageous (e.g. high intelligence, talent).

vaccinations! get some

http://www.ct.gov/dph/lib/dph/VPD_US_statistics_2010.pdf
http://www.behance.net/leon_farrant/frame/2878481

We're learning about vaccines in microbiology. It really weirds me out that we have a chickenpox (varicella) vaccine now, because I didn't get one when I was a kid (it was created in 1995, by which time I had already had it). Also amusing: chickenpox affected over four million kids a year? That's crazy. 

Penultimate Bioethics Post

Haven't put anything up in a relatively long time, so here's something I just wrote for Bioethics. I do not know if it's very good (and in fact I am fairly sure my citations are incorrect), but it is incredibly interesting. We had to read an article and analyze it with bioethical principles. The article itself was amazing. I, too, hope to one day get my writing into NEJM or JAMA. 

In the New England Journal of Medicine's article, "Up in the Air -- Suspending Ethical Medical Practice", a physician recounts his experience on a plane in which a fellow, older passenger goes into cardiac arrest. There are a total of five physicians on the plane, and they all gather around the man to perform CPR. 

The problem arises when, after twenty-five minutes of basic life support (BLS) and attempted resuscitation, the man is still dead. As physicians, they decide to "declare the patient dead" (Shaner 2010); unfortunately, the airline they are flying on has a protocol that requires the flight attendants to continue resuscitation attempts until the plane lands if no one more qualified can do it. So the author and his wife (also a physician), continue to run BLS on a man who is clearly dead. 

The author goes into a beautiful explanation of why he was essentially forced to continue doing something that was futile in order to placate a company's protocol. I think that this situation brings up three good points that we've talked about in this course:

1) Kantianism

Here we must acknowledge that the actions the physician found himself having to go through had no real benefit to the "patient's" health and indeed were done not for a moralistic reason. "… to have moral worth, a person's motive for acting must come from a recognition that he or she intends that which is known to be morally required" (Beauchamp & Childress 344). But the physician, and indeed, all five of the physicians on the plane, did not recognize the continuation of BLS as being morally required. At one point, the author notes that a surgeon had left as soon as they had all been made aware of the company's protocol, saying "This is futile" (Shaner 2010). Thus an argument could be made that the remaining physicians continuing BLS were acting amorally (without morals). "If agents do what is morally right simply because they are scared, because they derive pleasure from doing that kind of thing, or simply because they seek recognition, they lack the requisite goodwill that derives from acting for the sake of obligation" (Beauchamp & Childress 344). The author acknowledges that it was not the best moral option to continue CPR, saying "to prolong [it] under the circumstances in which we found ourselves would be to subvert medicine's goal from the good of the patient to the benefit of the community" (2010). 

2) Contextual Features

What caused the author to continue BLS was not his own moral code (he was very much against it), but rather, the context in which the situation was occurring. Had the event taken place in public, rather than on private property, the physicians involved probably would have little trouble ceasing BLS when deemed inappropriate, or, as the author put it: "CPR should be deemed ineffective when it cannot be expected to meaningfully alter the natural course of the disease…" (2010). Unfortunately, "every medical case is embedded in a larger context of persons, institutions, financial and social arrangements. Patient care is influenced, positively and negatively, by the possibilities and the constraints of the context" (Jonsen, Siegler & Winslade 1998). The most affective context in this story is the institutional one. The author says, "We had knowingly delivered medically ineffective CPR. But we did so because of practical concerns arising from the demands of the airline's protocol" (2010).

3) Discernment

In the end, the author firmly believes that medicine and practitioners of medicine should have their own policies that supersede whatever social policies and protocols they may come up against. This is the thesis of the essay, and I believe this whole story is a very practical demonstration of the importance of discernment. In a way, discernment also echoes some of the features of Kantianism. Discernment requires physicians to "… make fitting judgements and reach decisions without being unduly influenced by extraneous considerations, fears, [etc]" (Beauchamp & Childress 40). The fear of litigation is what caused the airline company to create a protocol which in the end proved to be morally damning in this specific case. The airline may have lacked discernment for this and similar health issues, but physicians are more able to understand what is necessary in terms of health outcomes without worrying over "extraneous considerations." This is because all physicians should, over time, develop "practical wisdom," which is essentially a deep understanding of the situation from a purely health perspective. When we get bogged down by social concerns, we become more at risk for biasing our actions. In the end, the author concludes explicating a very thoughtful idea that I also hold quite fervently: "We should ensure that our medical policies and protocols exclude considerations such as mitigation of liability or the exclusive interests of third parties from playing a role in resuscitative decisions. Such policies will help support the efforts of physicians to act always for the good of the patient and within the bounds enunciated in the Hippocratic Corpus" (Shaner 2010). 

1. Beauchamp TL, Childress JF. Principle of Biomedical Ethics. 6th ed. New York, NY: Oxford University Press; 2009. 

2. Albert R. Jonsen, Mark Siegler, and William J. Winslade. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 4th edition. New York: McGraw-Hill, Inc., 1998. 

3. D. Malcolm Shander, M.D. "Up in the Air -- Suspending Ethical Medical Practice." New England Journal of Medicine vol 363; 2010.

Bioethics Self Challenge: How Ridiculous Can I Get?

Well, after challenging myself to write something more ridiculous than that one time when I wrote, "I think we can assume that this family is evil," I wrote something more ridiculous in the following hour. For context, I will say that we have to discuss health care issues using principles of biomedical ethics we have read about. I would elect to only read the bold, but sure, you can read everything else too.

Should it be legal for people to buy organs for transplant, if they would not be able to receive an organ by waiting their turn through the national database? 

This is an issue that involves Justice. Essentially, if we allowed people to buy organs instead of organizing everyone onto a wait-list, we would be defining wealth/capital as a relevant property. Relevant properties are defined as conditions/things "that persons must possess to qualify for a particular distribution" (243). In this case, "particular distribution" refers to organs for organ transplantation. As much as I would like to say I know what the relevant property for currently receiving health care in America is, I do not have a full enough understanding of health insurance to posit more than a few tentative ideas.  

Oh god, and then there's like three different main types of health care, so I should not begin to discuss this.  

Regardless, I think that changing the relevant property/requirement for receiving organ transplants is antithetical to the way medicine wishes to be practiced in this country. I think this is why less than 20% of the physicians surveyed thought it would be okay for people to buy organs that they may not otherwise receive. It is unfortunate that some people may not receive organs, but if it is something that is going to happen regardless, this grave misfortune should befall everyone equally. 

I also believe that changing the system into a monied one would simply make the process of organ transplantation much more complicated. 

More practically, it also feels wrong to treat transplantations in this fashion. I would argue that by failing to keep justice equally distributed among all persons, you are allowing maleficence to occur. Example! Let's say child Batman and child Spiderman both need liver transplants. Well, little Bruce Wayne (Batman) has really rich parents while orphaned Peter Parker (Spiderman) has only his lower middle class aunt and uncle to look after him. Many arguments have proven that both Batman and Spiderman are of around equal importance to society later on in life. Yet, had this hypothetical situation occurred, and if organs were doled out in accordance with payment and not according to wait lists, little Peter would not have made it. 

By changing the way the system works, and by allowing a subgroup of people to have more power in the system than others, you are creating a social inequality around something as serious as life and death. With great power comes great responsibility, and I do not think that anyone with an ethical mind could easily approve of this level of injustice.   

References:
Beauchamp TL, Childress JF. Principle of Biomedical Ethics. 6th ed. New York, NY: Oxford University Press; 2009.197-199