Balancing family life and medicine

The impact of medicine on a doctor's family was briefly touched on during today's behavioral science lecture. The lecturer shared this old cartoon and I thought it was pretty funny. There seems to be a trend in medicine that is moving away from the all-consumed physician who is defined by medicine. While this can obviously be detrimental for the doctor's personal life, it has also been shown to be detrimental for that doctor's professional life as well. Feeling burnt out and depressed are serious risks for doctors, and the compulsiveness that is a defining characteristic of most doctors is a trait that can lead to these negative consequences.

While it is recognized now that it's important for doctors to maintain somewhat of a balance in their lives, this wasn't always the case. Our lecturer today recalled a secondhand (which is now thirdhand as I tell it...) story of Dr. DeBakey's address to first year BCM students. Dr. DeBakey is legend around BCM and even in other parts of the country for being one of the best surgeons of the modern era. Reportedly, he was pretty obsessed with his work. In the story that I heard today, he supposedly told first year students that they had to give up all outside interests and devote themselves entirely to medicine. Nobody has ever said anything close to that while I have been here, and I think it reflects a change in focus in medical education. Reducing residents' maximum work week to 80 hours is another piece of evidence in that trend.

Even though people generally agree now that it's important to balance medicine and your personal life, I don't think that necessarily makes it any easier to do. I attended an event on Sunday evening where different medical residents from my church described the difficulty in attaining this balance. One of their spouses commented that they, in all reality, basically functioned as a single parent for a large part of the time. It sounds a bit intimidating. Without strong support from friends, church, and extended family, I imagine it would be extremely difficult to hold a family together during residency. And that's not to say it wouldn't be difficult with that support.

But I've seen people balance medicine and family quite well, not least the example of my parents. It's a topic that is on my mind quite frequently, even though I'm only a first year medical student. This Memorial Day weekend was the 4th in a row that I haven't studied, and I feel very fortunate that I've been able to do that. I'm sure I would benefit from putting in more study time, but I'm also sure that taking that time off to spend with my family and to spend on a bit of personal leisure is good, too. Probably even better.

I think part of me realizes that life is only going to get more busy, and that if I can't take time off now then I will probably never feel like I'll be able to.

The parasites on your money

You've probably always heard about how dirty money is. And truly, it's filthy. You never know where that $1 dollar bill in your wallet has been. How often do you hold something that has circulated through the hands of hundreds of other people throughout the past 10 years? Aside from holding money, probably not very often. If you're a little infectious disease trying to infect somebody, landing a gig on a piece of currency like a dollar bill would be the chance of a lifetime.

So yes, we know money is dirty, but just how dirty is it?

Today, I found out a partial answer to that question. We just started the fun, or maybe I should say disgusting, part of infectious disease. Parasites. Who doesn't love seeing a bucket of worms that used to be inside someone's intestine? Just do a google image search and you'll see what I mean. I'm traditionally not very squeamish (otherwise I probably wouldn't be in medical school), but some of the pictures of parasite infections really make me squirm.

And, one of the factoids I heard today made me squirm.

Scientists did a study in Nigeria to see how dirty the money was. They took bills of small and large denominations and studied to see how many pathogens they could recover. Hookworm was on 8.5% of the bills, and Ascaris, another type of worm, was on 4.5%. Staphylococcus bacteria was on about 30%.

Eww! Luckily, hookworm and ascaris aren't nearly as prevalent in the US, although they still infect people in the southern states. That doesn't mean our money isn't gross. And that doesn't mean there still isn't a chance your local $1 bill has a worm parasite on it.

Yum! Lick that dollar bill!

Where's the normal visual field blocked?

I'm studying right now for my PPS test today. PPS stands for patient, physician, and society, and it's where we learn all of our doctor skills. We have a written test today and my OSCE is in 2 weeks. I was reading in Bates' Guide to Physical Examination and read something I hadn't noticed before.

If you had to guess, which quadrant of your vision would be the best?

In other words, think about your left eye. With your left eye looking forward, there are four different quadrants that you can see: upper left, upper right, lower left, and lower right. Which one of those quadrants has the largest field of vision?

If you think about it, you'll probably get the answer: lower left. The lower right is blocked by your nose, and the upper quadrants are blocked by your brow. Your lower left does not have obstacles to block your field of vision, so you can see significantly further out peripherally than the other quadrants. This means that as a whole, with both eyes, our peripheral vision is by far the best in the lower areas.

If you want to think about it from an evolutionary point of view, this also makes sense. Most of the big bad predators out there are ground animals, and so are the beasts of prey that we hunt. Having a large field of vision in the lower peripheral area would thus be pretty important for survival. 

In case you didn't cheat and look at the picture, here's an outline of the normal visual field.

Dr Clumsy Fool

Physical exam skills are something I lack. Or maybe the better way to say it is confidence in my physical exam skills is something I lack. In 2 weeks we have a test called the OSCE, which stands for objective structured clinical examination. I'm not really that nervous for it, although if I don't pass I'll have to remediate during our 1 month summer break and that would be the biggest bummer ever. So, today I was eager to take the chance to practice my skills on a standardized patient. In addition to interviewing and reporting on a patient, the OSCE will also test our physical exam skills. These include vital signs, cardiovascular, lung, abdominal, cranial nerve, eye, ear nose and throat, and a screening neuro exam.

These exams are pretty much the bread and the butter exams of primary care physicians. And so far I hate them. I tend to dislike things I'm not instantly good at, and I'm not good at examining patients. I'm a great thinker, but add in a physical dimension and I feel clumsy. The thing is, I've been thinking my whole life, and I've only just started examining patients. I've gone to clinic 10 times this year and seen about 3-4 patients each time. Of those patients, I've only gotten to examine 1 or 2 of them. So I guess it's understandable that I still haven't developed my skills.

But it means I've felt clumsy for a long time. Some medical schools don't start having you see patients until the very end of your second year, right before your rotations. This way, your rotations might be more of a shock since you haven't had as much practice with your doctor skills. However, I'm not sure which way is better. With our way, you don't see enough patients frequently enough to really ever progress in your skills, and you grow at a snails pace and thus feel like a clumsy fool all year. When you get thrown into the water you learn how to swim, and I'm sure once rotations start I'll get enough practice where things really start coming together better.

So I know I should be patient with myself, but it sure is frustrating when you practice on a standardized patient and have the hardest time even finding his pulse. Sure, he was pretty overweight and probably didn't have the best circulation, but come on! I can't even find someone's radial pulse?! When taking his blood pressure I do it twice and still can't hear it very well? I listen to his heart and can barely hear anything? He literally has no reflexes?? It turns out he really doesn't have reflexes and I'm not a total moron. At least not completely.

I guess the session with the SP was good practice. And at least I know I still need to practice. But it's hard to get used to feeling like Dr. Clumsy Fool. Hopefully I'll improve so I won't have to!

Diseases that affect Hispanics

As a learning issue for my IPS session today, I was supposed to come prepared to share Hispanic disease prevalence and disease risk factors. It was actually difficult to find an organized list of what diseases Hispanics are likely to get. Here is my synopsis of what I found and links for further follow up. I hope it’s a decent resource.

First, though, I would be amiss if I didn’t mention that it is difficult to define what the term Hispanic actually entails. As a fairly culturally-ignorant non-Hispanic white person, I tend to think of anyone from Mexico or South America as Hispanic. I actually have no idea what the official definition is. I do know, however, that the term Hispanic as most people see it covers an extremely diverse group, with lineages that mix European Caucasians and indigenous Americans and Africans. It’s a pretty big melting pot. For this reason, there aren’t a lot of genetic diseases that Hispanics are unusually susceptible to.

With that disclaimer, here are some of the more important diseases that affect Hispanic Americans, with comparisons to non-Hispanic whites.

Diabetes

·         Hispanics are twice as likely non-Hispanic whites to develop diabetes

·         Percentage of people diagnosed with diabetes over the age of 20

Mexican American	Non-Hispanic White
12.4%	6.4%

·         See http://minorityhealth.hhs.gov/templates/content.aspx?lvl=2&lvlID=54&ID=3324

HIV/AIDS

·         Hispanic males are 3 times as likely to contract HIV than non-Hispanic males.

·         Hispanic females are 5 times as likely to contract HIV than non-Hispanic females.

·         http://minorityhealth.hhs.gov/templates/content.aspx?lvl=2&lvlID=54&ID=3327

Alcohol-related problems

·         Less likely to drink alcohol then non-Hispanic whites, but those that do drink are more likely to binge drink and become alcohol dependent

·         White Hispanic men have the highest rate of alcohol related cirrhosis

·         See http://pubs.niaaa.nih.gov/publications/HispanicFact/hispanicFact.pdf

Mental Health

·         Immigration poses serious emotional challenges, which include marginalization and discrimination

·         Hispanics generally rely on family and church as coping strategies for mental health problems and are thus less likely to seek professional care for this illness

·         See http://www.healthyminds.org/More-Info-For/HispanicsLatinos.aspx

Cancer

·         Since many Hispanics in America are immigrants from developing countries, they are much more likely to experience cancers of the stomach, liver, and cervix. These are all related to infectious diseases that are not seen or are better controlled in the US.

·         Of all cancers that Hispanic females get, they are most likely to contract breast cancer. But they are actually 27% less likely than non-Hispanic whites to do so.

·         Hispanic males are most likely to get prostate cancer, but they are 12% less likely than non-Hispanic white males to get it.

·         See http://www.cancer.org/acs/groups/content/@nho/documents/document/ffhispanicslatinos20092011.pdf

·         See http://minorityhealth.hhs.gov/templates/content.aspx?lvl=2&lvlID=54&ID=3323

Osteoporosis

·         Hispanic women are just as likely to develop osteoporosis as non-Hispanic whites.

·         See http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Background/hispanic_women.asp

Protective factors about being Hispanic

·         Smoking

o    Hispanics are less likely to smoke than any other group except for Asian Americans. 15.8% of Hispanics smoke compared to 22% of non-Hispanic whites.

o    See http://www.lung.org/stop-smoking/about-smoking/facts-figures/hispanics-and-tobacco-use.html

·         Heart Disease

o    Hispanics are 20% less likely to have heart disease than non-Hispanic whites.

o    See http://minorityhealth.hhs.gov/templates/content.aspx?lvl=2&lvlID=54&ID=3325

·         Stroke

o    Women are 20% more likely to have a stroke than other groups, but men are less likely

o    http://minorityhealth.hhs.gov/templates/content.aspx?lvl=2&lvlID=54&ID=3330

Healthcare disparities

·         Although Hispanics may or may not be more likely to develop certain diseases, they are less likely to get treatment for them

·         Examples:

o    HIV -- Hispanics are six times above the national average in terms of HIV-related deaths, although they are only about 3 times as likely to contract HIV.

o    Asthma -- Hispanics are twice as likely to die from asthma than non-Hispanic whites

o    Immunizations -- Hispanics are less likely to receive immunizations than non-Hispanic whites

·         See http://www.cdc.gov/minorityhealth/brochures/HL.pdf