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."




One response so far

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.


One response so far

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.


Comments are off for this post

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.


3 responses so far

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.




Comments are off for this post

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.


Comments are off for this post

Nutcracker musings

Dec 03 2013 Published by under Kidney Function

December has arrived, bringing chilly weather and thoughts of nutcrackers...

Click for purchasing info

No, not this practical kind.

Click for purchasing info

Not even this decorative kind.

More like the dancing kind!

Click for purchasing info

Did you know that there is another kind of nutcracker?

A kidney kind of nutcracker?

Click here to read about this unusual condition, the nutcracker syndrome, at my other home online!


Comments are off for this post

Real Family Values

Aug 12 2013 Published by under Access

Stay of Hope Foundation

Imagine your happy life with a loving partner, some happy children, and perhaps a pet or two. You have comfortable careers with healthcare coverage. You are not rich - losing a paycheck would be a big problem - but you do not feel insecure.

Now one of your children gets sick. Their kidneys have failed! In addition to learning about new drugs and diets and dialysis, you find out that your insurance has restrictions on specialty care. If you want them to pay for the surgery, then your child has to move to a contracted center in another state. Sure, your state has a hospital that can do it just 2 hours from home, but this is not the "preferred provider" so only 80% of costs will be covered. That means more than $20,000 out-of-pocket.

So how bad would living at the out-of-state center be? Since we are talking about a child, there will have to be a guardian of some sort with them. You will need to relocate to a strange location for weeks to months, leaving behind your support system. Of course, you cannot continue to work during this time, nor can you contribute to the maintenance of your family in non-monetary ways. Who will feed the dog? To top it off, your insurer will reimburse you for living expenses while out-of-town, but you have to pay to move and start a second residence out of your own pocket. Where do you get that money?

Well, Medicare also covers patients with end-stage kidney failure. You have worked and paid into the system, so your child is eligible...if you start paying Medicare premiums. There goes $800 each month to make sure your kid gets covered some way.

It's enough to break a family apart. Or enough to inspire a mother start a charitable organization.

The Stay of Hope Foundation will provide a number of services for children and families facing these medical and financial pressures. Beginning in Oklahoma (charity starts at home, folks) the foundation will offer advocacy in dealing with insurers and financial support for living expenses, Medicare premiums, and other out-of-pocket expenses. The group just got its LLC papers; as soon as we raise the application fee ($850) we will start the long and winding road to 501(c)(3) status! Eventually, we hope to offer services throughout the USA.

This scenario has occurred on a few occasions during the decades I have practiced, so when I heard about Heather MacDonald's new work I volunteered for their board. Forcing families under the stress of chronic disease to split geographically or face financial disaster seems unkind at best (mean, wicked, and grinchy come to mind).

I am supporting this group with my time and treasure and pride. More information can be found on the website, as can a Paypal donation button and an address for old-fashioned checks. As I noted, we do not have that 501(c)(3) status yet, but we are working on it.

So spread the word. Give if you can. And help families deal with that spot between the rock and the hard place.


One response so far

"The primary is just for check-ups" - Socioeconomic Status and Care Choices

Jul 18 2013 Published by under Access, General Health

In the US, un- and under-insured patients use the emergency department (ED) and inpatient services disproportionately. In part, this occurs because these facilities provide care for all who seek it, regardless of ability to pay. However, even in countries with universal health coverage, low socioeconomic status patients seek care with the same patterns.

Reigning in health expenses in the US includes efforts to shift non-emergency care from the ED and the inpatient ward to the outpatient setting. In the 1990's, many states experimented with Medicaid HMO's, assigning the poor to primary care clinics as part of the effort. Success was limited at best, and we now find those least able to pay seeking care in the most expensive venues.

 A recent study from the University of Pennsylvania explores reasons that those with low socioeconomic status (SES) use more acute care and less primary care than patients with high SES. They invited 64 adult inpatients of low SES based on Zip Codes to participate in structured qualitative interviews; 40 agreed to the study. Of these patients, 12 (Profile A) had 5 or more acute care episodes in the prior 6 months. The remaining 28 individuals (Profile B) had 4 or fewer hospital encounters over the same period. Patients of the two profiles had similar income, sex distribution, and ethnicity. The major difference between the two groups seemed to be the presence of  a social support network for subjects in Profile B.

Click to Enlarge

Click to Enlarge

The figure shows themes that differed between the two profiles. All patients identified ease of access and quality of care as reasons for choosing hospital-based services. Profile A patients reported more chaotic lives than those with fewer encounters; they experienced more trauma, dysfunction, substance abuse, survival insecurity, and problems with activities of daily living. Profile B patients also experienced barriers, including the need to be caregivers; however, their social networks also provided support as well as this burden. Finally, Profile B patients saw their health issues as concrete problems to be solved, rather than an intangible challenge.

The study provides an important first step in improving care for low SES patients by identifying themes that influence their care choices. Like all qualitative studies, it gives no results with a p value but provides data to generate new hypotheses and policies. The study population was also limited to urban, primarily African American patients; the rural poor we see in Oklahoma may identify different barriers. Further study is clearly needed.

The study is available here; this is the citation:

Kangovi et al. Understanding Why Patients of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care. Health Affairs 32 (2013): 1196-1203     DOI:  10.1377/hlthaff.2012.0825

Comments are off for this post

What I Am Reading: MDs Online

Jun 06 2013 Published by under What I'm Reading

Click for Amazon

Right now, you are reading a blog. You obviously know something about the online world. You probably think of Web 2.0 as a generally friendly and useful place.

Your doctor probably thinks of it like those historic maps: "Here be monsters."

Enter this book by Kevin Pho, of KevinMD fame. His recent book provides a primer on the online landscape for medical practitioners. He outlines  the way patients use the internet and why it matters to healthcare providers. He reviews the usual social media platforms with their potential for good and evil. He also addresses reputation management for search engines; if you get your story out there it will rise to the top and trump what others may say.

For someone who is fluent in Web 2.0, the most interesting section dealt with various physician rating sites. He goes through a dozen of sites and outlines how you can monitor what your patients say. On most sites, physicians can see their information freely. I still haven't gone there; I mean, I have barely had time to write on this blog.

If you are reading this post, you probably do not need to read this book. You may know someone who could use this information, though.



Comments are off for this post

Older posts »