Saturday, March 7, 2009

Why doctors go to work sick?

In Marcus Welby, M.D., the early-'70s medical version of Leave It to Beaver, hospitals were depicted as sterile environments with shiny equipment and starched bed sheets. More recent medical dramas have gotten dirty: E.R., House, and Grey's Anatomy are a lot more likely to feature episodes in which a patient is admitted with a broken leg and later gets infected by flesh-eating bacteria. While not all TV medicine reflects real life (it's not that common to call a code black in order to extract a ticking time bomb from a patient's abdomen), new studies are published every month on hospital-acquired infections. Not even celebs are immune: According to reports, Michael Jackson suffered serious infection after his most recent nose job.

This raises an important question: Why do people get infected while in the hospital? The first and most obvious answer is that hospitalized patients are sick and vulnerable because their immunity is compromised. But hospitals are also dirty places that can (and do) serve you up a side of microbes along with that lukewarm bouillon. Hospitals house hordes of people with infections together in close quarters, and bugs are bound to spread. While some of this can be prevented through infection control, doctors frequently don't do a great job of washing their hands or their stethoscopes between patients. But there's another reason, which no one who works in a hospital likes to talk about: Doctors tend to show up to work sick.

Now, why would a doctor dare come to work with a contagious disease and examine my grandmother with germy hands?

More ...

Friday, March 6, 2009

Being and Mindfulness - Judith Warner Blog -

The other night at a dinner party, a friend described how she tried to practice mindfulness meditation to keep herself from losing it during an utterly wretched seven-hour layover in an airport while she was exhausted, ill and desperate to get home to her children.

"I kept trying to be all 'Be Here Now,'" she said, "but I just wanted to be anywhere but here."

We all laughed.

Then she described how, on another day, she'd managed not to bite off the head of a woman who'd been gratuitously mean to her 8-year-old daughter, but instead had stayed in the moment and had connected and been able to join with the woman in an experience of their common, sadly limited, humanity.

At which point, full of congratulations (and suppressing my own story of having lost my temper with a woman in an airport bathroom who, I felt, had addressed my daughter Julia with an unforgivable tone of officiousness and disdain), I was beginning to wonder what body snatcher had taken my cranky friend away and left this kindly, calm, pod person in her place.

Where was the woman I always seek out at school events to laugh with? Where was the black humor, the sense of absurdity?

I felt strangely abandoned.

It was, I realized, my first experience of being on the receiving end of someone sharing their journey on the road to mindfulness, the meditation and life practice that's all the rage now in psychotherapy, women's magazines, even business journals, as a way to stay calm, manage anger and live sanely. (David Foster Wallace, too, was writing a novel all about "being in the moment and paying attention to the things that matter," this week's New Yorker revealed.)

In the past, I'd been only on the other side of the divide. I had, it was true, sensed a certain sadness, even feelings of betrayal, in my husband Max's reaction to my proselytizing about my Pema Chödrön "Getting Unstuck" CD: "I never thought that you, of all people, would get into that New Age stuff," he'd said wistfully. But I hadn't realized that, when a person gets unstuck, the people around her can feel a bit left behind.

It has dawned on me lately, meditating on the Metro, thoughts silenced so completely that I can hear every page being turned by passengers up and down the car (I am above reading — I am present to myself) that being fully in the moment, all senses turned on, feeling your hands in your lap and the ground under your feet, is a very good way of not being there at all.

For me, this is a big part of the charm of the whole thing. I mean, it's a lot easier to feel a loving connection to others — to the madding crowd, that is — when you're entirely checked out. But it's not supposed to be that way.

More ...

Tuesday, March 3, 2009

Doctor and Patient - On Young Doctors and Long Workdays -

Two weeks ago, the Accreditation Council for Graduate Medical Education, the organization responsible for accrediting American medical residency programs, issued an open letter that outlined its plans to review, revise and enforce residency duty hours. The letter is part of continuing efforts to improve the way that medical residents, the recent medical graduates who care for patients, are trained in this country.

Five years ago, the organization established an 80-hour cap on resident workweeks, a move spurred in part by the 1984 death of Libby Zion, a young woman who was under the care of residents on call, and by years of legal wrangling. Despite the reforms, the organization came under criticism by a national panel of medical experts that said it had failed to address work hour violations that were "substantial and underreported."

I spoke with Dr. Thomas J. Nasca, the chief executive of the council, and asked him about resident duty hours, patient safety in teaching hospitals and the implications of further duty hour changes to the doctor-patient relationship.

More ...

Harvard Medical School in Ethics Quandary -

In a first-year pharmacology class at Harvard Medical School, Matt Zerden grew wary as the professor promoted the benefits of cholesterol drugs and seemed to belittle a student who asked about side effects.

Mr. Zerden later discovered something by searching online that he began sharing with his classmates. The professor was not only a full-time member of the Harvard Medical faculty, but a paid consultant to 10 drug companies, including five makers of cholesterol treatments.

"I felt really violated," Mr. Zerden, now a fourth-year student, recently recalled. "Here we have 160 open minds trying to learn the basics in a protected space, and the information he was giving wasn't as pure as I think it should be."

Mr. Zerden's minor stir four years ago has lately grown into a full-blown movement by more than 200 Harvard Medical School students and sympathetic faculty, intent on exposing and curtailing the industry influence in their classrooms and laboratories, as well as in Harvard's 17 affiliated teaching hospitals and institutes.

They say they are concerned that the same money that helped build the school's world-class status may in fact be hurting its reputation and affecting its teaching.

The students argue, for example, that Harvard should be embarrassed by the F grade it recently received from the American Medical Student Association, a national group that rates how well medical schools monitor and control drug industry money.

Harvard Medical School's peers received much higher grades, ranging from the A for the University of Pennsylvania, to B's received by Stanford, Columbia and New York University, to the C for Yale.

Harvard has fallen behind, some faculty and administrators say, because its teaching hospitals are not owned by the university, complicating reform; because the dean is fairly new and his predecessor was such an industry booster that he served on a pharmaceutical company board; and because a crackdown, simply put, could cost it money or faculty.

More ...

Short of Dentists, Maine Adds Teeth to Doctors’ Training -

Cindy Merrithew was nervous about having her teeth pulled, mainly because a doctor would be doing the work.

"I was skeptical," said Ms. Merrithew, 47, a nurse's assistant whose mouth is filled with damaged, brittle teeth. "I didn't know if they knew much about the dentistry field."

Dentists are in such short supply in Maine that primary care doctors who do their medical residency in the state are learning to lance abscesses, pull teeth and perform other basic dental skills through a program that began in 2005.

"Doctors typically approach the mouth from a distance," said Dr. William Alto, a physician at the Maine Dartmouth Family Practice Residency here in rural Fairfield, which conducts one of two dental clinics for medical residents (the other is at Maine General Hospital in Augusta).

"They say 'say aah,' take a look at the back of the throat and are done," Dr. Alto said. "Many physicians, even family physicians, have given up that part of the body because they don't have the skills."

Maine has one dentist for every 2,300 people, compared with one doctor for every 640, and the gap is expected to widen as both dentists and doctors retire over the next decade.

Nationally there is one dentist for every 1,600 people.

Maine has trouble recruiting dentists because many young graduates do not want to work in rural areas. The shortage is much less acute in Portland, the state's largest city. Maine also does not have a dental school — the closest are in Boston, about 50 miles from the state's southernmost town.

Last year the American Dental Association and the American Academy of Pediatrics announced a program to train pediatricians to apply fluoride and look for signs of tooth decay, a step already taken by some other states, including Illinois, Iowa, North Carolina and Washington.

In Maine, training physicians in dentistry provides a dental safety net for the rural poor who have never had one, doctors and dentists said. About two-thirds of the residents who have trained at the dental clinic now practice in the state, many in rural areas.

More ...

Monday, March 2, 2009

Good or Useless, Medical Scans Cost the Same -

When Gail Kislevitz had an M.R.I. scan of her knee, it came back blurry, "uninterpretable," her orthopedist told her.Enlarge This Image

Her insurer refused to pay for another scan, but the doctor said he was sure she had torn cartilage that stabilizes the knee and suggested an operation to fix it. After the surgery, Ms. Kislevitz, 57, of Ridgewood, N.J., received a surprise: the cartilage had not been torn after all.

She had a long rehabilitation. And her insurer paid for the operation. But her knee is no better.

More than 95 million high-tech scans are done each year, and medical imaging, including CT, M.R.I. and PET scans, has ballooned into a $100-billion-a-year industry in the United States, with Medicare paying for $14 billion of that. But recent studies show that as many as 20 percent to 50 percent of the procedures should never have been done because their results did not help diagnose ailments or treat patients.

"The system is just totally, totally broken," said Dr. Vijay Rao, the chairwoman of the radiology department at Thomas Jefferson University Hospital, in Philadelphia.

More ...

One Ride Forward, Two Steps Back -

Are forward-facing strollers having a negative effect on babies' language development? British teachers have for some time been observing a decline in the linguistic abilities of many children, and some have wondered whether this might be one contributing factor.

There may be something in this idea. Babies who face ahead cannot see their parents or caregivers and thus have difficulty interacting with them. On loud city streets, babies may have trouble even hearing parents talking to them.

Neuroscience has shown that brains develop faster between birth and age 3 than during any other period of life, and that social interaction fosters such neurological development. So, if babies spend a significant amount of time during their early years in forward-facing strollers, might it impede their language learning?

Britain's National Literacy Trust commissioned my research team to look into this question. No previous research had been carried out, and strollers, or "buggies" in British parlance, haven't always faced forward. In the 19th century, they were designed so that infants faced the person pushing them. It wasn't until the late 1960s that collapsible strollers emerged, with engineering constraints causing them to face forward.

We observed 2,700 families with young children walking along main streets in cities and villages throughout Britain. We found that forward-facing strollers were by far the most common, but that babies in them were the least likely to be interacting socially. When traveling with their babies in forward-facing strollers, caregivers were observed speaking to infants in only 11 percent of cases, while the figure was 25 percent for those using toward-facing strollers, and even higher for those carrying children or walking with them.

Could it be that parents who buy toward-facing strollers simply talk more? Probably not. In a follow-up exploratory study, we gave 20 mothers and infants aged 9 to 24 months a chance to try out both stroller types, and recorded their conversations. Mothers talked to their children twice as much during the 15-minute toward-facing journey, and they also laughed more. The babies laughed more, too.

Of course, infants do not spend all their time in strollers, but anecdotal evidence suggests that babies can easily spend a couple of hours a day in them. And research tells us that children's vocabulary development is governed almost entirely by the daily conversations parents have with them. When a stroller pusher can't easily see the things that attract a baby's attention, valuable opportunities for interaction can be missed.

Ours was a preliminary study, intended to raise questions rather than to provide answers. It is now clear that future research on the effects of stroller design would be worthwhile.

Meanwhile, the findings already encourage us to think again about how babies experience stroller rides — and other forms of transportation like car seats, shopping carts and slings. Parents needn't feel worried, but instead curious about the elements of the environment that attract their children's interest. The core message of our findings is simple: Talk to your baby whenever you get the chance — and whichever direction your stroller faces.

For their part, stroller manufacturers should keep in mind how much their products are likely to shape children's development. Let's give an award to the first one who can produce an easily collapsible stroller that faces both ways — and is affordable for all parents.