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Who is Caring for Fukushima’s Children?

October 19th, 2011

     While the world remembered the anniversary of the collapse of the World Trade Towers at the hands of terrorists on September 11th, I was also thinking of another anniversary. It has been six months since a 9.0 magnitude earthquake triggered a tsunami that crippled the Fukushima Daiichi nuclear power plant. Radiation fall-out from the disaster continues to be a significant health problem for the people of Fukushima and the dangers will in all likelihood continue for years to come.

     Children are at greater risk of the dangers of radiation for many reasons. Their minute volumes, or the amount of air they breathe in one minute, are greater than adults, causing them greater exposure to radioactive gases. They also live and breathe closer to the ground and therefore closer to nuclear fallout as it settles to earth. Radioactive Iodine is readily transmitted to human breast milk. (Cesium has been detected in the breast milk of seven women in the Fukushima area.) Cow’s milk also becomes quickly contaminated when radioactive materials settle onto grazing fields.

     The Japanese government has been slow to release information to its citizens. It was over a week after the accident before the Ministry of Agriculture and Forestry issued their first official notice to farmers to use only fodder stored indoors due to widespread contamination of rice hay.

     One month after the tsunami and nuclear disaster, the Fukushima prefecture was directed to adopt a much laxer standard for radiation exposure for children. The allowable dose of radiation for children was raised to 20 millisieverts (mSv) per year, the same dose allowable for adult nuclear plant workers. Physicians for Social Responsibility issued a statement calling the move unconscionable. (To their credit, many municipalities continued to enforce the previous stricter limits, adopting measures such as clearing contaminated topsoil from play areas.) Professor Toshisho Kosako, special advisor to the prime minister, resigned in protest. Faced with this significant backlash from parents and professionals, the Japanese government has since tightened its standards down to 1 mSv per year.

     Another professor, Tatsuhiko Kodama, head of the Radioisotope Center at the University of Tokyo, testified on July 27th before the Committee on Welfare and Labor in the Japanese Diet. He estimated that the uranium leak from the Fukushima Daiichi plant amounted to the equivalent of 20 Hiroshima atomic bombs. He describes being contacted by the mayor of Minami-Soma for help with decontamination efforts. When professionals from the Radioisotope Center arrived, they were presented with only one Geiger counter. When they dug a little further, they actually found 20 personal dosimeters, donated by the US Army. But the Board of Education at City Hall could not decipher the English manual.

     The American Academy of Pediatrics has also responded to the disaster with monetary aid from its Friends of Children disaster preparedness funds as well as support and advice. In a personal communication with me, Jonathan Klein, the academy’s associate executive director, said that the academy has sent their counterparts at the Japan Pediatric Society our guidelines for dealing with radiation disasters including the mental health effects in children.

     But decontamination efforts need to be ongoing. Radiation can accumulate in areas previously deemed decontaminated. For example, when it rains, contaminated water cascades down slides in playgrounds, pooling at the bottom: right where children land with hands out-stretched. Professor Kodama calls for improved food, soil and water inspection, using the newest technology available to Japan. He also calls for more accountability noting that “Tepco (Tokyo Electric Power Company) and the government have never clearly reported on the total amount of radiation doses resulting from the Fukushima nuclear accident.”

     The lessons from Fukushima need to be learned quickly and applied here at home. Seabrook nuclear power plant is trying to re-license its facility 20 years before the current license expires. Paul Gunter, a co-founder of the Clamshell Alliance, suspects this strategy is to avoid re-licensing hearings at a time when more problems could be expected at the aging plant.  In May 2011, the NRC’s on-site inspector at Seabrook reported that the concrete surrounding an electric tunnel at Seabrook Station nuclear power plant has lost almost 22 percent of its strength because it has been saturated with ground water for more than a decade. The concern is the possibility of electrical shortages in case of nuclear accident. It is just such shortages that crippled the Fukushima Daiichi plant and delayed clean-up efforts significantly.

     Mie Athearn, native of Fukushima and current resident of Rockland, Maine, recently led a march from Maine almost 200 miles to Japan’s General Consulate in Boston to draw attention to the ongoing health problems in her people in Fukushima. The devastation she witnessed when she returned to Japan after the disaster made her “want to appeal for stronger actions to protect children from radiation hazards.”

     Continued vigilance on all our parts is vital is lessons are to be learned and children protected.

I Worry, too

September 5th, 2011

     I was having lunch at The Purple Onion with my girlfriends on a recent summer afternoon. Seated outdoors on wrought iron furniture, we sipped iced teas, spooned spicy gazpacho into our mouths and watched toddlers go head to head on the monkey bars at the children’s park across the street. It was our Friday lunch ritual, the three of us taking advantage of the same day off to touch base and catch up in between our individual errands.

     Inside my purse, slung over the back of my seat, my cell phone began vibrating. I ignored it. This was our sacred hour, after all, me and my girlfriends. I heard the familiar bonk as the thing went to voice mail. We continued our meals— rosemary paninis and taco chips split three ways—as well as our conversations of husbands, work and life. My phone rang again. This time I rummaged through the junk pile that is my bag and checked the caller ID. My office. Strange. They never call me on my day off.

     I finished lunch with the girls, a bit distracted by the phone calls, an unease beginning to bubble up in my insides. We kissed cheeks and waved good-bye and each headed off to our cars and our respective days. I slid into the driver’s seat and dialed up the office. Jennifer answered, her voice cheerful and friendly as usual.

     “What’s up?” I interrupted her greeting.

     “Oh, Dr. B.,” she began, the cheeriness draining from her voice like water from a colander. “Ginger’s mom called, all upset.” We have a small office. There’s only one Ginger. No need to identify her further.

     “Yes?” I said, still not comprehending why she was reaching out on a Friday afternoon.

     “She was crying. It was hard to understand her. We offered to have her talk to Dr. Moran, but she really wanted to talk to you.”

     Scenarios ran through my mind: Ginger sick. Ginger hurt. Ginger dead.

     “I got her cell phone number, Dr. B. I didn’t know if maybe you wanted to give her a call.”

       I so appreciated my staff at that moment. In 3 ½ years they had never bothered me on my day off. But a crying mom had melted their hearts and broken protocol. I took down the number then sat in the Purple Onion’s parking lot and, with some trepidation, dialed up Ginger’s mom. It went to voice mail. I left a message saying that I understood she was trying to get a hold of me and to try again. I would try her back, too, which I did. Again. And again. An hour went by. I thought about Ginger, her developmental delays, her congenital abnormalities. Her worried mom. Had I missed something in Ginger’s work-up? Was someone else at this moment giving Ginger’s mom yet another diagnosis? Yet another reason to worry?

     I dialed the local hospital to see if she was in the ER. She was not. I called admitting. No Ginger there, either. I called the tertiary hospital where she sees her specialists. Nothing. I called her home again. No answer. I called the office. Ginger’s mom had not called back.

     I began interrogating Jennifer like I was Lieutenant Columbo. “Did she say anything? Anything at all? Anything that might hint at the problem?”

     “Well, she did say something about Early Intervention.” Aha! A clue! I called the local EI office, but Ginger’s case worker was gone for the day. They asked me if I wanted to leave a voice mail. I did. Then, I was done. What else could I do? For the rest of that afternoon, I fretted. The idea of carrying this angst, this not knowing, around with me all weekend was a distracting piece of lead in my stomach.

     Then my cell phone rang. It was Early Intervention. Apparently they had paged Ginger’s case worker. We had a long conversation. The team had had a meeting with Ginger’s mom and dad that morning explaining that she wasn’t really making progress the way they’d hoped.

     “Do you think she’s autistic?” I asked. The thought had crossed my mind.

     “We didn’t actually use the A word,” she replied.

     I was relieved. Not that Ginger wasn’t making developmental progress or that she needed further evaluation or might be autistic. But that this was something we could handle together. That she wasn’t dead. Because I was worried. Because I was beginning to think that maybe she was.

     This same thing happens in my practice, though on a smaller scale, on a daily basis. Over the weekend I might get calls from a teenager with abdominal pain or the mother of an infant with a fever. I ask my questions. I give my advice. But then, I worry. Not about everything or everyone. Some things are pretty straightforward. Strep throats and ear infections. Fifth disease and hand-foot-and-mouth.

     Some kids don’t have identifiable viral syndromes. I’ll see a slew of them in a row with high temperatures and the blahs. The little ones generally buy themselves at least a bladder catheterization. The older, verbal ones may complain of a headache. As long as they don’t have stiff necks or a petechial rash, I’m okay with sending them home with symptomatic care.

     But some just look sicker than the average bear. I will sometimes get a CBC on a small subset. I might even throw in a sed rate. It won’t zero in on the diagnosis, but it’s reassuring if it’s low. Those kids I might check on that night or the next day. I leave my message on the answering machine.

     “Hi. It’s me, Dr. Bornstein. Just calling to see how Jeremy’s doing. Call me when you get this, okay?”

     Then I wait. And wait. Often, the return call never comes. I guess no news is good news. But still, a phone call would be nice.

     Then there are the kids who don’t follow the usual course: the fever I thought would break and, even better, produce a roseola rash. It doesn’t. It stays up at 102. I’ve got the urine. I’ve got the blood. Now I’m thinking outside the box. Is there an abscess hiding somewhere? Is it not infectious at all? Maybe it’s Kawasaki Syndrome or something rheumatologic. Or worse, malignant. So I check on those kids, too.

     “Hi. It’s me, Dr. Bornstein. Just calling to make sure Haley’s fever finally went away. Call me when you get this, okay?”

     Nothing.

     I see the parents at the scheduled follow-up visit and comment on the unanswered call.

     “Oh, yeah. That was so sweet of you to call, Dr. Bornstein. But she was fine. We didn’t want to bother you.”

     But it’s no bother. It’s actually a relief to hear from a parent that the temperature is now just low grade or that the kid just ate a half a bowl of macaroni and cheese, or (best of all) “she’s back to her old self.” Now I can stop generating differentials in my head. Now I can sleep better.

     Ginger’s parents came in for follow-up the Monday after our frantic game of phone tag the previous Friday. They had had the weekend to digest the recommendations Early Intervention had made. They’d Googled and web-surfed and read up on the worst case scenarios and were feeling more prepared to take the next step in their daughter’s evaluation. We discussed various approaches and came up with a game plan. Everyone was happy. On the way out of the exam room, I broached the subject of my trying to return Mom’s frantic phone calls to the office. Ginger’s mom waved her hand dismissively.

     “Oh, we were freaked out for a while, but we finally decided to go to the beach and relax.”

     “Oh,” I answered, thinking of my own frantic hospital-calling.

     “But it was sweet of you to call us on your day off.”

     But my phone calls aren’t just public relations. We’ve got a web site for that. I suppose a call from one’s child’s pediatrician is good PR, but that’s not why I call. I do it for my own piece of mind. I do it because I worry, too.

Children and Miranda

June 23rd, 2011

     Last Thursday in a 5 to 4 decision the US Supreme Court ruled that age must be considered by law enforcement officers when deciding whether to inform a child in police custody of his Miranda rights. The decision reverses the North Carolina State Supreme Court. The case involved a 13-year-old seventh grader referred to in the proceedings only as JDB. JDB was suspected of being responsible for several local break-ins. He was taken from his social studies class by a uniformed police officer on detail at the school and for over thirty minutes, in a closed conference room was interrogated by the officer, a police investigator and two members of the school’s administration. He was not given Miranda warnings. He was not given the opportunity to call his grandmother who was his legal guardian. And he was not told he was free to leave.

     He eventually confessed to the break-ins. Only then was he told he was free to leave. His public defender argued to get the confession dismissed as the boy was not properly Mirandized. His motion to suppress was denied by the trial court. The court adjudicated JDB a delinquent. A North Carolina Appellate and State Supreme Court agreed.

     The issue was whether the youth understood that he was in police custody. The State Supreme Court found that his age is irrelevant.

     I find that astounding.

     The whole concept of “ignoring age” is foreign to me as a pediatrician. Our entire training is age-based. Listeria infections just don’t happen in five-year-olds. Multiple sclerosis may be in my differential diagnosis in a fifteen-year-old, but not in a one-year-old. Matching children’s ages with their expected developmental capabilities is what I do for a living. As we like to say in pediatrics, “children are not little adults.” In medicine, we are generally talking about their immature immune systems or under-developed neurons. But their judgment is under-developed, too. Children’s brains are still developing into their teens and early twenties. This seems to be a settled societal question, given the age requirements we put on certain rights and behaviors like driving a car, drinking alcohol, getting married or enlisting in the service.

     In writing for the majority, Justice Sotomayor noted the “commonsense reality…that children will often feel bound to submit to police questioning when an adult in the same circumstances would feel free to leave.” Indeed, when my kids were little, police were such trusted community figures that it was common to instruct children who were lost in a mall, say, to find someone in uniform that would help them.

     In writing for the opposing minority, Justice Alito laments that this decision turns Miranda’s custody determination into an “inquiry” that must account for age. He complains that police will now be required to make “on-the-spot judgments.” I would suggest that this is exactly what police are trained to do every day: make split second decisions. I also don’t think asking a child his age is exactly an “on-the-spot judgment.”

     Here in Massachusetts, children as young as 7 and as old as 13 can be charged with a crime. Here, we seem to understand the folly of treating children like adults. We understand that children’s potential for rehabilitation and redemption is significant. Our Juvenile Detention Alternative Initiative provides non-violent youth offenders with social services and keeps them out of jail where adults in for more serious crimes can have a negative influence on them. Massachusetts runs 57 facilities from group homes to locked units as well as community-based programs for youth offenders who live at home. The number of juveniles in custody in the justice system in the Commonwealth  decreased to 730 the entire year of 2010 from 1113 in 2006.

     Justice Alito contends that “safeguarding the constitutional rights of minors does not require the extreme makeover of Miranda that (this) decision may portend.” But I agree with the majority. Including age as part of custody analysis isn’t asking police to know something unknowable. It’s just common sense.

First Amendment Rights and Child Safety

May 12th, 2011

At each well child check-up, there are a plethora of questions to ask and topics to cover. Many of these questions and topics involve keeping children safe.
“Does your home have smoke alarms and carbon monoxide detectors?”
“Does your child wear a helmet when biking?”
“Is there a gun in your home and, if so, how is it stored?”
These questions are natural lead-ins to general discussions of child safety. But if proposed gun legislation pending in the Florida legislature is enacted, pediatricians in that state would be banned from asking that crucial third question under threat of sanction by the state’s board of medicine.
The National Rifle Association (NRA), which spent $10 million during the 2008 presidential campaign and is known to be one of the nation’s most powerful lobbying organizations, had pushed for an even stronger version of the bill: one that called for fining doctors $5 million if they asked about guns in the home.
The proposed law should be defeated for a number of reasons. Doctors need to be free to have private, trusted relationships and conversations with their patients and families, free from government involvement. Furthermore, gun safety is a real issue. The Center to Prevent Youth Violence (PAX) conducted an on-line survey last month among 817 13 to 18-year-old students across the country and found that 45% of them knew someone who had brought a weapon to school. Another 49% knew of another student who had made a threat to hurt themselves or others and 13% knew someone who’d been shot. Firearms are used in the majority of teen suicides.
“Whether I own a gun is none of their business,” said Florida republican senator Joe Negron. Well, with all due respect, Mr. Negron, if there’s a child in your home, it is my business. Because children are my business. Keeping them safe is my job. And I can’t do my job with a muzzle on my mouth.
We need to be able to counsel families about the safe storage of guns. But we can’t do that if we can’t ask the question: are they there? Over 40% of US homes have guns. More than 1.5 million American children live in a home with at least one loaded, unlocked firearm. Part of my job, if a family owns a gun, is to counsel them about its safe storage: locked in a gun safe with ammunition locked separately.
This isn’t a Second Amendment right. It’s a First Amendment right. It’s about my right as a doctor to ask the questions I need to ask to keep my young patients safe. I hope the Florida legislature agrees.

Becoming Our Own Parody

May 1st, 2011

I have a friend from college whose preferred method of communication is texting. I understand. She has a teenage daughter. She’s had to learn the language of OMGs and LOLs. But does that mean I have to?
My excuse for not blithely jumping onto the texting bandwagon used to be the technology. I had an old-fashioned cell phone. It had numbers, as in phone numbers. I could not punctuate my texts. I had no question marks or exclamation points. But now I own a Blackberry. I can no longer say I can’t text. I can just say the truth: I don’t want to.
I understand the efficiency of the text message. You can ask a question and get it answered without all the niceties. “Is Frank still looking for work? How does Amanda like community college?”
But isn’t that what we do as friends? As a society? Check in with each other? Ask how we’re doing? Share? To me, nothing says ‘I don’t want to talk to you’ like a text.
I’m not a technophobe. I’ve happily incorporated technology into my professional life, snapping pictures of rashes with my cell phone and emailing them to my dermatology colleagues for second opinions. I have an electronic medical record. I use technology socially, too. I have Facebook friends. I blog. I have a web site I update myself with links and scanned pdfs.
But in real life, with my real friends I want more. A real conversation. A cup of coffee. A dinner date. I want less Facebook and more face time.

The other day I had a mother in the office with her two teenage daughters. Only one of the girls was there for her physical; the other was just along for the ride. When I walked into the room and greeted the family, only the mother smiled and shook my hand. The girls were both busily texting.
“Put the phone away,” the mother told the one who was there for a check-up.
“Why doesn’t she have to?” the teen pouted testily, jabbing a finger in her sister’s direction.
“Because she’s not the one with the doctor’s appointment,” the mother pointed out.
“But she’s the one who’s texting me,” my patient wailed.
I was speechless. Here were two sisters sitting in the same room, communicating with their thumbs. I guess it has its advantages. The teen sisters were able to keep their conversation silent. They weren’t disturbing or interrupting anyone. But it is still a distraction to me, as their doctor. I would like to hear from teenagers directly, as well as from their parents. But I can’t engage them or hear about their concerns if they’re buried in a cell phone.
I’ve tried banning cell phones from the office altogether. But these requests are treated more like suggestions, suggestions that are routinely ignored. I’ve even had teenagers texting while I’m performing their annual Pap smear. I can appreciate wanting to distract yourself from an invasive gynecological procedure. But it’s still a barrier. I pride myself in making girls’ first Pap smears a comfortable, normal, even empowering experience and I can’t do that if I can’t see your face.
But I guess my problem with texting is even more basic; it’s just plain rude. When a friend of mine reaches for her cell phone and returns a text when we’re in the middle of a conversation, keeping up her end with ‘uh huh, yup, hmm..’ she’s just not there anymore. She’s having a conversation with someone else now, not me. Texting cuts us off from each other in real time. I worry that we will forget how to connect. By keeping our messages abbreviated (literally) will we forget how to respond emotionally?
As a parent and a pediatrician it breaks my heart when I see a mother texting with one hand while pushing her daughter on a swing with the other. She cannot be fully present or engaged in either activity. I sometimes see fathers in the bleachers at their sons’ basketball games, texting, not cheering.
In her new book Alone Together: Why We Expect More from Technology and Less from Each Other, MIT professor Sherry Turkle suggests that while constant texting may give the appearance of increased connectedness, these technologies may actually be keeping us isolated from each other. She argues that Facebooking is not the same as socializing. “Thumbs up or thumbs down on a web site is not a conversation.”
Amen to that. My in-box these days is often filled with emails of one word (if you can count LOL as a word.) How are we going to teach and learn the fine art of gentle discourse if we aren’t talking to each other?
The other night in my writing group, one member was describing being at a play recently and seeing a family of four all sitting side-by-side texting.
“We’ve become our own parody,” she observed. Touché.
Our challenge with all of this new technology is figuring out how to incorporate it into our lives in helpful and meaningful ways. No one is getting rid of their cell phones. Text messaging isn’t going away. It may someday be replaced with newer, faster, more immediate forms of communication, but for now, it’s what we’ve got. I hope we can figure out a way to use it to build connections, not barriers between us.

Word Fatigue

February 21st, 2011

     There was a story in the Boston Globe last week about “alarm fatigue.” In hospitals across the country, alarms designed to alert staff to critical changes in patients’ vital signs are often not heeded, lost among the many beeps and blares that have become background noise in emergency rooms and ICUs everywhere. In the hospital setting, warnings sound for all kinds of things from low batteries on infusion pumps to IV fluids running low. When my mother-in-law Sylvia was hospitalized last year, her bedside chair was equipped with an alarmed cushion. Whenever she stood up, an automated voice would warn, “Richard, sit down. Richard, sit down.” Apparently no one had bothered to re-program it to address Sylvia. Oh, and no one ever came to help Sylvia or Richard when the thing went off.

     I’ve discovered another kind of fatigue as I search a medical record for specific information. Call it “word fatigue.” While electronic medical records with their drop-down menus and point-and-click notations make charting legible and uniform, it is that very uniformity that makes these records difficult to digest. ER notes and nursery discharge summaries arrive on my desk daily looking frighteningly monotonous.

     I recently had a teenager make a trip to the emergency room for evaluation of a serious eating disorder. I scoured seven pages of notes looking for the one piece of information vital to his case: his weight. It was missing from the triage nurse’s vital signs, though there was a pain scale and a Glasgow Coma scale. It was also gone from the physician’s notes. Temperature was recorded, as well as his oxygen saturation, all well and good, but not a top priority for a boy with anorexia. On my third examination of the document, I finally found the weight. 56.6kg. It was in between “speaks English” and “safety screen: denied” (whatever that means.)

     A local newborn nursery has also recently switched over to an electronic medical record. Now instead of the familiar one page “yellow sheet” where I knew right where to look for birth weight, discharge weight and Apgar scores, I have to wade through 12 pages of “mother updated at bedside” and “reacts well to exam” (whatever that means) to find the one critical piece of information I need: “jaundiced in the first 24 hours of life.” (And those 12 pages are just for a two-day stay for a vaginal delivery. A baby born by Caesarian section can haul upwards of 25 pages into his first visit with me.)

     WBUR aired a very interesting story recently about a new technology that replaces the sounds of a patient’s heart beat, blood pressure and oxygen saturation with music. When the patient’s heart rate starts to rise dangerously or the O2 sat drops out of the normal range, the music becomes discordant, easily alerting attending medical staff to the trouble.

     Maybe I just need someone to sing me my patients’ ER notes.

Take Two of Anything and Call me in the Morning

February 1st, 2011

     We all know about the placebo effect. Patients often report improvement in their symptoms if they think they are taking an approved treatment for them, even if that treatment turns out be no more than a sugar pill. In typical studies comparing real drugs to placebo, patients are not told which kind of pill they are taking. By design, placebo studies involve a certain amount of deception. Indeed the terms “placebo” and “sham” are often used interchangeably.

     But two recent fascinating studies have challenged the notion that a patient needs to be tricked to benefit from the placebo effect. In a study performed at Beth Israel Deaconess Hospital and reported in the Boston Globe, nearly 60% of patients with Irritable Bowel Syndrome (IBS) reported improved abdominal pain and bowel symptoms even though they knew their pill contained no active ingredients.  In another study published in Developmental and Behavioral Pediatrics, children with Attention Deficit Hyperactivity Disorder (ADHD) on optimal doses of appropriate stimulant medication were able to have their doses cut in half by using placebo instead of half of their daily medication. Surprisingly, parents did not report any increase in the severity of their kids’ ADHD symptoms, even though they knew their children were taking the placebo, also referred to in this study as a “dose-extender.”

     What I find interesting about both of these studies is that placebo can work even when patients are fully aware that they are ingesting the “sham” product. Why might that be? Is the power of the pill that strong in our American culture that there doesn’t have to be anything in it for it to work?

     The authors in the Beth Israel study hypothesized that the taking of a pill “triggers a sort of unconscious conditioning in our body to begin the healing process.” Maybe folks feel empowered. Maybe they feel like they are doing something active to help themselves feel better when they take something for symptom relief. If that’s the case, maybe the “something” doesn’t have to be a pill. Maybe exercise, yoga or meditation would do the same thing.

     These authors also wondered if perhaps it was simply the visit with the doctor that made patients feel better. All patients in the study experienced “a warm, supportive patient-practitioner relationship.” This has real implications for us as healers. Years ago, in the days prior to immunizations and antibiotics, doctors could offer little more than care-taking in certain illnesses: A hand held. A whispered word. Maybe these placebo studies are confirming that role. Maybe everything old is new again.

Pass Protection for Patients

January 19th, 2011

     For anyone who has followed the New England Patriots and their beloved quarterback Tom Brady all these years, the disastrous 28-21 trouncing by the New York Jets in the recent play-off game was a real stab in the heart. The Jets managed to sack our QB five times last Sunday, despite the Patriots’ history of pitch-perfect pass protection.

     While drowning my sorrows in a bucket of Buffalo chicken wings and ruminating on this concept of “pass protection,” I started thinking about another kind of “pass-off.” That is: the “patient pass-off,” also called sign-out. Patient sign-out occurs in teaching hospitals when one resident’s shift ends and another begins. Interns try to convey crucial information about a patient’s care: what is happening with the patient, what needs to be followed up on. When I was a resident sign-out happened just once a day: when the end of one 24-hour-on resident’s shift collided with next’s. But with recent changes in residency duty hours, information sign-out between residents has become more frequent. In 2003, the Accreditation Council for Graduate Medical Education restricted residents’ working hours in response to concerns about resident sleep deprivation and its effect on patient safety. In 2008 the Institution of Medicine curtailed resident work hours even further.    With this restriction, the number of patient hand-offs increased. In fact, a 2006 survey published in the Archives of Internal Medicine   found that a member of a patient’s primary care team was present for less than half of that patient’s total hospital stay.

      Although sleep deprivation is very real among residents and potentially very dangerous for patients, poor transfer of critical information is also fraught with the possibility of error. One study published earlier this year in the journal Pediatrics looked at the process of patient sign-out. The study found that the single most critical piece of information about a patient was not successfully communicated 60% of the time, despite the post-call intern’s belief that it was. And for 69% of patients, the intern coming on duty failed to note at least one of the items the signing-out intern deemed most important to know. In fact, this most important piece of sign-out information was not mentioned by the in-coming intern for 40% of patients. These break-downs in communication occurred whether sign-out was verbal or written. What may be even more concerning is that, despite the documentation of this poor transfer of information, both the post-call and on-call interns gave themselves high marks (over 8 on a scale of ten for both groups) in the quality of their sign-out.  

     Clearly more studies are needed in this area critical to patient care and safety. The development of a web-based resident sign-out training program may improve the successful transfer of patient information. Theoretically, participation by the patients themselves could empower patients to act as their own safety advocates and improve outcomes. But the success of similar patient participation programs has been mixed at best. A “Partners in Your Care” program aimed to empower patients to ask their health care workers if they had washed their hands met with little success in a Cleveland VA Hospital. Although 60% of patients reported being willing to ask the doctor to wash his or her hands, none of the patients was observed during morning rounds to do so. And according to the 2001 book Making Health Care Safer there is insufficient evidence of the effectiveness of such patient participation programs to widely endorse them.   

     Maybe every sign-out team just needs a tight end to provide pass protection.

Grasping the Thorn

January 4th, 2011

Grasping the Thorn

     We tend to describe our feelings of social pain in very physical terms. We are crushed. We are heart-broken.  Our feelings are hurt. We naturally forge a mind-body connection with our language. Indeed, social pain, say from rejection or from the loss of a loved one, has been noted on neuro-imaging studies to activate the same part of the brain that lights up in the face of physical pain as well: namely the anterior cingulate cortex. Well, in a fascinating study published recently in Psychological Science, researchers at several large universities in the United States and Canada asked the question: if social and physical pain are mediated by the same neural mechanisms, might a simple pain-reliever such as acetaminophen (Tylenol) relieve the pain of social rejection? Their surprising conclusion?  Yes it can!

     They conducted two simple experiments. In the first, 62 healthy undergraduate students were randomized into two groups. One took 500 mg of Tylenol twice a day. The other took a placebo on the same schedule. Both groups recorded social pain as well as positive emotions they experienced each day. Reports of hurt feeling decreased significantly in the Tylenol group but changed not at all in the placebo group.

     In the second experiment, 25 healthy undergrads were randomized to take either 1000 mg of Tylenol a day or placebo. Then, they participated in a computer game while functional neuroimaging data was collected. In round one of the game, the study participant was included in the entire game. In round 2, participants were initially included, but then excluded by two other game-players. As the authors predicted, the folks who took Tylenol showed significantly less activity in the anterior cingulate cortex in response to social exclusion than those who took placebo.

    So what does this all mean? Surely we all shouldn’t start downing large quantities of acetaminophen. Just because we know how to blunt our feelings, that doesn’t mean we should, right? Isn’t learning to deal with hurt feelings and rejection a developmental milestone? A part of life?

     I started thinking about this study in terms of literary rejection. As a writer, I get rejected regularly: the New York Times. The Boston Globe. But if I start popping pills to mitigate the trauma of rejection, won’t I also diminish the highs of acceptance? Chicken Soup. JAMA. (JAMA!) Rejection is part of the writing life. It just comes with the territory. The best rejection comes with some helpful advice that may improve the piece or open up another venue for its placement.  Rejection keeps us striving. Without eight magazines rejecting the first iterations of an article, we might not learn what it needs to be accepted by the ninth. Or, as the French writer and physician Louis Ferdinand Celine noted, “I think all great innovations are built on rejections.”

     Writers are always told we have to develop some seriously thick skin to survive in this business. If we start dropping Tylenol with every rejection, perhaps we would fail to develop the appropriately bulky integument apparently essential to every successful author. Indeed, as Anne Bronte once observed, “…He that dare not grasp the thorn should never crave the rose.” But I do crave the rose. I love seeing my words in print. I’m thrilled whenever an article or essay is accepted for publication. I love keeping score.

     Now I have an agent. My book proposal for my memoir CRASH! will be sent out to all of the big houses starting in January. I am busy growing my thick skin in anticipation of each round of rejections.  On second thought, maybe I should buy stock in big pharma now.

Everything Matters

November 18th, 2010

Everything Matters
Five members of the Needham Massachusetts High School girls’ soccer team were recently suspended for allegedly participating in a hazing ritual. Local news outlets reported that, after the team secured a place in the Bay State Conference, several senior members of the team led more junior members around on dog leashes and hit them in the face with whipped cream pies. The suspensions may have been a routine response to an all-to-familiar offense, but in Needham’s case, the stakes were especially high. The girls’ suspension meant that they could not practice for or play in the next game, which just so happened to be the State Tournament.
This leads to the most disappointing, mystifying and just-plain-wrong aspect of this story. Instead of seizing this infinitely teachable moment to instill a sense of morality, of humanity into their children, the parents of the girls instead went to court, asking for an injunction against Needham High principal Jonathan Pizzi to allow the girls to play. But Judge Barbara A. Dortch-Okara ruled that since playing sports is a privilege, not a right, preventing their participation does not violate their right of due process. Actually, the word the judge used was entitled, which is exactly what these families seem to feel: entitled to participate in tournament play despite showing a distinct lack of leadership the night they qualified.
Some would argue that hazing is tradition and, as such, should be continued. With that logic, we’d still have segregation and women couldn’t vote. Others say the rituals are all in good fun. In Needham’s case, the hazing victims said they were fine with what happened to them, laughing even. But that’s a little like believing that a sex-worker or an exotic dancer is making her own choice, just because she says so. Sometimes the exploited don’t know they are being exploited until much distance and reflection make it clear.
But back to the parents. Caught up in the competitive chaos of the college admission process, these parents, no doubt, saw the suspensions not as lessons to be learned, but big black marks on their daughters’ applications. But I would urge those parents to take a step back and ask themselves: what’s more important here? Winning a soccer game or having a sense of right and wrong?
Definitions of hazing are outlined in the Massachusetts anti-hazing Statute, in place since the 1980’s. “Hazing…shall mean any conduct or method of initiation into any student organization…which willfully or recklessly endangers the physical or mental health of a student…” The words are open to interpretation, to be sure. But Needham High School staked out its territory high on the hill… with crampons strapped to their boots. Conversely, the girls’ parents have taken a position much farther down the slippery slope.
As a pediatrician, I often tell the parents of my patients: Remember. You’re teaching your children all the time, intentionally or not. Our children are watching us all the time, learning, taking cues. So what are the Needham girls learning from their parents’ behavior: seeking an injunction to allow their kids to play in the State Tournament. That soccer is more important than their teammates’ feelings or well-being?

I was in my pigeon pose today in yoga class. The instructor was trying to get us to pay attention to everything at once: our breathing, our spine, our hip flexors. “Everything matters,” she told us. Indeed. Maybe the Needham High School girls’ soccer team and their parents need to take a yoga class.