Anesthesiology News - A Farewell Letter to Residents

It is that time of year again. Just when we have all the confidence in the world that you know enough to do no harm, it is time for you to graduate and start your careers!

These are a few things I know for sure about your career in anesthesia:

1. You are going to make mistakes. In the beginning, there will be more than you expected; and as the years move forward, there will be less. My advice is pay attention to your mistakes. The growth potential from our failures is exponentially higher than from our successes. Own your mistakes; people tend to have more respect for those who are honest than those who point fingers. If nothing else, you will be able to sleep better at night.
2. Someone will die on your table. This is anesthesia. You are aware of the life-and-death stakes. I hope you will be able to learn something from the case. Becoming a better anesthesiologist from these cases is one way we can honor our patients. And most importantly, pay attention to your own well-being. These events have the potential to be very traumatic. Please talk to someone whom you can trust about your experience and feelings. Just because you are a doctor does not mean that you are immune to the human response to death.
3. You will save a life, likely many times in the course of your career. It is quite possible that you will not receive the recognition you deserve for your efforts on behalf of your patients. Realize that without you, those patients most likely would not have made it off the operating room table. Pay attention to your successes so that you can build on them—and repeat them.
4. You never are really finished. After what feels like 24/7 in the operating room for three years, you are thinking that nothing will come through those doors that you can't handle. Wrong. Residency is just a foundation. You have much left to learn about your craft. My hope for you is that you continue to learn every day for the rest of your career. If you are paying attention,the learning will happen naturally with little effort.
5. Duty hour regulations, two breaks and a lunch are over. Nobody cares anymore if you are up for 24 hours straight. If you are going home exhausted, you are probably doing a great job.Pay attention to your life beyond medicine. It is so easy in our profession to burn out, or worse, turn to drugs or alcohol to cope with the daily stresses of our jobs. If you have friends, parents, a spouse or children, pay attention to them when you are not at work. One day, you are going to retire. The time you invest in these relationships is far more important than what kind of doctor you were. Anesthesia is a fantastic career, but you must have a life outside the operating room—it will keep you sane.

Most of all, I wish you a life filled with all that you deserve. Medicine is a noble profession, and you have chosen a field that takes patients through a vulnerable, stressful event in their lives. Be aware of your contributions, and take pride in your work. I take pride in my work, and you are certainly a huge part of my job. It matters to me that you are paying attention, and that you give a damn. While I am sad to see you go, it is part of our cycle of life in medicine. Be good, and know that I am proud of you, and thank you for all that you will do for our field and for our patients.

As always,

Ellen

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Ellen R. Basile, DO, is assistant professor in the Department of Anesthesiology at the University of Oklahoma and the Children's Hospital at OU Medical Center, in Oklahoma City.

http://www.anesthesiologynews.com//ViewArticle.aspx?ses=ogst&d=Correspondence&d_id=46&i=ISSUE%3a+June+2014&i_id=1068&

Mental-Health Debate - Princeton Alumni Weekly

A recent lawsuit and coverage in The Daily Princetonian have prompted a campus debate about how the University treats students dealing with depression and other mental illnesses. Some students and mental-health advocates argue that these policies threaten to undermine student confidence in the University's counseling offerings, discouraging students from seeking help.

In March, a student sued the University, seven administrators, and the Board of Trustees in federal court. The student, who attempted to commit suicide, withdrew for a year and has since returned to campus. The lawsuit alleged that University officials disclosed confidential counseling records to campus administrators, who he said left him no choice but to withdraw. He also alleged that the officials discriminated against him because of his mental illness.

The student's lawsuit follows a similar complaint he made to the U.S. Department of Education's Office of Civil Rights. The office dismissed all of the student's claims and closed the case in April, University spokesman Martin Mbugua said.

In an anonymous op-ed in the Prince, another student recounted the decision to voluntarily take a year off without telling the University it was for mental-health treatment. The student wrote that when the University found out, it required the medical records from treatment as a condition for the student to return to campus.

Zhan Okuda-Lim '15, chair of the Princeton Mental Health Initiative Board, said the controversy could affect the willingness of students to seek help from Counseling and Psychological Services. The University reported that 17 percent of undergraduates and 21 percent of graduate students use CPS offerings each year.

"Students that I have spoken to ... have said that 'I'm worried if I went to CPS and were really open and honest, the next thing is I get an email'" about having to leave campus, Okuda-Lim said.

Representatives of the University's health and campus-life offices vigorously defended their approach to mental health. Without exception, they argued, the University acts in the best interests of the student and the campus, regardless of liability or public-relations considerations.

Administrators met with students, wrote letters to the Prince, and released an FAQ last month to clarify their policies.

About 35 students withdrew or took a leave of absence last year due to a "self-described mental-health issue," Mbugua said in a statement. In only three to five cases, he said, the student did not initiate the withdrawal conversation.

The University contested the assertion that it automatically forces students who have attempted or considered suicide to withdraw. "Most students who have been hospitalized because of an acute suicidal crisis can return to campus and resume their studies in the same semester, and many do," Mbugua said.

In the lawsuit, the student alleged that officials acted rigidly, without a "meaningful interactive process" between the student and administrators. Mbugua said that the University's general practice is for college deans to work closely with a student to develop an individualized plan for academic accommodations.

But, he said, "if the student continues to be at extremely high risk (perhaps because of a refusal to engage in appropriate treatment) for a longer period, then it becomes less likely that the student would be able to manage his or her academic obligations" and therefore should leave campus. Requiring a withdrawal has occurred fewer than five times in the past decade, according to the University's FAQ, but a student "may not unilaterally decide to remain enrolled when the evaluation indicates that his or her life may be at stake."

As part of the consultation process, the University requests medical information to determine whether the student can safely stay on — or return to — campus, said Calvin Chin, the CPS director.

As for routine visits to CPS, all information is kept confidential unless there is "imminent danger to self or others" or if the student chooses to authorize the release, John Kolligian, executive director of University Health Services, wrote in a statement.

Mental health has become a controversial issue at other colleges. Two students at both the University of Pennsylvania and George Washington University (GWU) committed suicide in 2014. At Harvard University, a student and a recent graduate committed suicide on campus this year. A dental student at Columbia University was found dead in the Hudson River last month from suicide.

Against this background, the rights of students facing mental illness, and the responsibilities of universities, have gained national attention. GWU and the City University of New York both settled lawsuits brought by students who had been removed from campus.

An underlying question in those cases and others is whether a school should force or encourage suicidal or depressed students to leave campus. At Princeton, if students fall too far behind on their coursework, "the student, in consultation with the dean, may conclude that it makes better sense to withdraw," Mbugua said, until "the student is able to focus on academics with less impact from a health condition."

Requiring students to leave can be counterproductive, said Darcy Gruttadaro, director of the Child and Adolescent Action Center at the National Alliance on Mental Illness. "Forcing them off campus is punitive and is not fair to the student, because you're making a fundamental change to their life circumstances," she said, which can hurt their recovery.

University officials pointed out that they must also act in the best interest of the campus, not only of individual students. Cynthia Cherrey, vice president for campus life, addressed this issue in a letter to the Prince, saying the University must "protect as fully as possible the health and well-being of all members of the campus community."

In recent years, Mbugua said, the University has boosted counseling resources, reduced wait times for non-urgent care, and expanded group therapy and workshops.

Okuda-Lim said he appreciates the administration's willingness to engage with students, and he said he hopes the University will take feedback seriously. "Moving forward, actions are going to speak bounds and bounds more than words," he said.

http://paw.princeton.edu/issues/2014/06/04/pages/8826/index.xml

Apple's on-stage HealthKit goof proves it still has to earn the trust of the health community | VentureBeat | Health | by Mark Sullivan

Monday at Apple's Worldwide Developer Conference, an image flashed up on the screen behind VP of Software Engineering Craig Federighi. It was a screen shot from Apple's new Health app (or a mockup thereof), showing a user's blood glucose level.

But Apple biffed the measurement for blood glucose level, as Aaron Rowe of biochemical testing device maker Integrated Plasmonics pointed out. It's measured in mg/dL. Apple's slide said "mL/dL."

Of course, this probably says nothing about the finished version of the Apple Health app we'll see released with iOS 8 next fall. But it does raise an important issue for any company embarking on the new frontier of healthcare biosensing and informatics, no matter what form: To achieve the vision of a unified, consumer-driven health platform, they're going to have to get the real, clinical healthcare stuff right.

It's no secret that many in the healthcare community have serious doubts about the accuracy of the consumer health apps and gadgets available today. And a number of studies have reinforced those doubts. Consumer apps and devices are often inconsistent in their findings, reporting very different results in two tests of the exact same conditions. Clinicians are especially suspicious of apps that rely on the user to self-report key body metrics.

And that's just the data collection part. The hard part is processing the data and taking meaning from it in a way that improves care. If developers don't get this right, caregivers won't use the consumer health data collected in their apps, devices, and platforms.

"It will be really important for companies to justify their interpretations of the information they provide to achieve physician buy in," said Dr. Molly Maloof, a San Francisco Bay Area clinical physician focused on health optimization. "Otherwise, these consumer-focused devices will be written off as health toys rather than health tools."

More ...

http://venturebeat.com/2014/06/04/apples-on-stage-healthkit-goof-proves-it-still-has-to-earn-the-trust-of-the-health-community/

When Doctors Ignore ‘Do Not Resuscitate’ Orders - The Daily Beast

When it's my time to go, I hope it happens without a fuss.

In the event that I suffer from a terminal illness, once the point has been passed where a return to health or meaningful quality of life is no longer a realistic possibility, when further treatment will do nothing but fill my days with more of itself, then I want that treatment to end. Though I hope such plans are a long, long way from ever being enacted, my husband and other loved ones know that I would not want "heroic" measures to prolong my life, and would choose a peaceful rather than a protracted death.

I am not alone in this. A new study in the online journal PLOS One reports that most of my fellow physicians feel the same way. The authors of the study surveyed over a thousand doctors, and just over 88 percent of them reported wanting an advance directive that would stipulate "do not resuscitate" (or DNR) status at the ends of their lives. I would have answered precisely the same way.

Those results do not surprise me in the least.

I cannot imagine going all the way through medical school, to say nothing of residency, without witnessing cases where patients received medical care that prolonged their existences but not their lives. It is a common enough occurrence that I would generalize it to essentially every graduate of medical school. We've all seen patients given interventions that preserved the functioning of their organs without any hope that the people themselves would have anything but misery to number out their days.

Why is this so? Why does the same study report that doctors will often override an advance directive if it conflicts with their clinical decisions that further treatment is warranted? Why would we order medical care that we do not want for ourselves?

At io9, George Dvorsky mentions the cynical possibility that physicians might do this for the sake of charging for lucrative end-of-life treatments. In the Pulitzer Prize-winning play Wit the central character is subjected to prolonged end-of-life interventions because her doctors care more about their medical studies than about her. I would love to believe that this never really happens, that members of my profession put the wishes and well being of their patients before any other considerations, but I would be a fool to be so naive. Sadly, even the mother of a close friend of mine was treated in this manner. I am sure that this happens, as loathsome as I know it to be.

However, I do not believe that most physicians opt for extensive treatments for their dying patients for this kind of reason. I suspect that for most of us, it's due to a more complicated and less appalling set of considerations.

First of all, prolonging and supporting patients' health and life is the entire reason for taking care of them in the first place. With the limited exception of medical providers who specialize in palliative care, we strive for our patients to recover, to leave our practices and clinics cured, or (failing that) well enough to have a baseline quality of life that justifies our being involved in their care in the first place. Letting go of this cardinal goal can be immensely difficult. If we can't make people better, then what exactly is it that we're accomplishing?

Further, there is always the fear of being accused of not doing all we could. The more we treat a patient, the less ambiguous our attempts to give them the best care possible. What better defense can there be against the threat of legal action than a full-court press at the very end? Though it's a difficult factor to quantify, I suspect this kind of rationale undergirds a lot more of the aggressive end-of-life care that patients receive than many medical providers would care to acknowledge.

There seems to be little space for any kind of nuanced or challenging conversation along these lines in our society at this time. One need look back no further than 2009 and the blight on our political discourse that comprised the "death panels" discussion, in which quondam vice-presidential aspirant Sarah Palin proclaimed that the Affordable Care Act would empower faceless bureaucrats with the authority to pull the plug on grandma.

Deemed the "Lie of the Year" by PolitiFact, what the law would have done (before the specific provision was stripped) was compensate doctors for appointments where they actually talked with patients about their wishes for end-of-life care. Thanks to the former governor of Alaska, physicians who choose to sit down with people and hear what they would want if they were dying cannot get paid for doing so.

But really, this kind of conversation is hard for doctors in general. We are not nearly as good as we ought to be at talking about the reality that even the best we can offer won't fix everything, and that everyone eventually dies of something. In modern medicine, every death is a defeat, and every illness is merely a chance to prove our worth as diagnosticians and healers.

As a pediatrician, I am generally spared this kind of conversation. Almost all of my patients are basically healthy. But even when I had a chronically ill patient who had a DNR order and was showing signs that he might be dying, I made sure to mention that more aggressive treatment was available should the mother opt to choose it, though I certainly did not push for it.

Watching a patient die without trying to stop it is not only contrary to our impulse to fix things, but it is obviously an irrevocable clinical decision. I can understand all too well how members of my profession would be terrible at making it.

And yet we must do better. We cannot routinely deliver medical treatments that we would not want for ourselves if patients have made the same decisions we would. I would want my loved ones to advocate fiercely on my behalf to have my end-of-life wishes honored, and we must improve our ability to honor similar wishes when they come from people who have entrusted their care to us. Dying patients are among the most vulnerable that we will encounter in our careers, and our duty to minimize suffering we would spare ourselves is a sacred one. 

http://www.thedailybeast.com/articles/2014/06/03/when-doctors-ignore-do-not-resuscitate-orders.html?

Faces of Breast Cancer - Well - NYTimes.com

If you live with breast cancer, love someone with breast cancer or worry about your risk for breast cancer, you are part of a global community of women and men whose lives have been touched by the disease. We asked our readers to share insights from their experiences with breast cancer.
Here are some of their stories. More will be added over the coming weeks.

http://www.nytimes.com/projects/your-breast-cancer-stories/