Thursday, December 30, 2010
Monday, December 27, 2010
On the other hand, the testing is several days long, requires flight and accommodations (you pay) at a specific center, is extremely costly (~$3500), and requires lots of tedious preparation. Much of the tedium is related to small details that are quickly forgotten and have very little relevance to day-to-day practice.
I do, of course, see the need for some sort of self-governance for professions like medicine which helps protect the public from quacks and weirdos. However, the very complexity and cost of the whole examination process suggests that perhaps the "board" has become a too big and powerful bureaucratic machine...
At any rate, I am reaching out for support. I have over a thousand pages of reading and thousands of practice examination questions to go over in the next 99 days. On top of working two jobs, caring for children and remodeling the house. It feels pretty daunting. It's hard to even open the review textbook (I'm on page 284 of 1391!!!!). That's probably why I'm writing now... avoidance.
On that note, time to get back to work. One of my resolutions is to post something interesting daily that I come across in my studying for the next... 99 days.
Monday, June 11, 2007
My 4-year old son has been wondering this for the last couple months, since he found out that God is everywhere... He asks if God is bigger than a giant, if he is big enough to lift mountains, if he is bigger than sky, etc. I have assured him over and over again that NOTHING is bigger than God.
Today he was looking at his long shadow in the late afternoon sun on the deck, and he looked up at me and said, "Is God bigger than his shadow?"
Wednesday, April 18, 2007
Saturday, April 14, 2007
Here is the text of President Bush's response to the Senate's passage of S.5 - recommending federally funded embryo creation:
Scientists believe that stem cells have the potential for medical breakthroughs in treating debilitating medical diseases and disorders. However, the advancement of science and medicine need not conflict with the ethical imperative to protect every human life. I am a strong supporter of scientific research -- which is why I authorized the first federal funding for research on embryonic stem cells, under careful safeguards, starting in 2001.
My policy unleashed an unprecedented scientific effort using the stem cell lines my policy approved for funding. While encouraging -- not banning -- research, my policy also ensures that federal funds are not used to create incentives to destroy, or harm, or create living human embryos for purposes of research.
The Senate today voted in support of legislation to overturn these safeguards. I believe this will encourage taxpayer money to be spent on the destruction or endangerment of living human embryos -- raising serious moral concerns for millions of Americans.
Research using human embryonic stem cells is still at an early stage, and it will be years before researchers know how much promise lies in therapeutic applications. I believe this early stage is precisely when it is most important to develop ethically responsible techniques, so the potential of stem cells can be explored without violating human dignity and life.
S.5 is very similar to legislation I vetoed last year. This bill crosses a moral line that I and many others find troubling. If it advances all the way through Congress to my desk, I will veto it.
Meanwhile, exciting and significant scientific advances have been reported over the past few years on uses of stem cells that do not involve the destruction of embryos. These advances using adult and other forms of stem cells are exciting. Some have even produced effective therapies and treatments for disease -- all without the destruction of human life.
The second bill that passed the Senate today, the Hope Act, builds on this ethically appropriate research by encouraging further development of these alternative techniques for producing stem cells without embryo creation or destruction. I strongly support this bill, and I encourage the Congress to pass it and send it to me for my signature, so stem cell science can progress, without ethical and cultural conflict.
Again, the logic is simple. If these embryos are human beings, we cannot create them to destroy them. The underlying principle, of course, is that embryos are human beings, therefore cannot be killed for any reason, because every human being has the right to life. If the embryo is not a human being, I'm fine with IVF, with all its extra frozen embryos; I'm fine with abortion, with stem cell research and discarding of lab-manufactured embryos, etc. But prove to me, and to yourself, that this unique, self-growing organism that in a few short weeks (see picture) looks distinctly human, already having a complete set of human DNA... you must prove to me against all the evidence, that it is not human.
Monday, December 25, 2006
Flynn makes the point that our sympathy is usually focused on the parent struggling with infertility rather than with the child conceived in the sterile petri dish with donor sperm. Careful consideration of both helps to understand why those who condemn IVF and sperm banks are not unsympathetic to infertile persons, but are prioritizing the wellbeing of the human beings who in the end will be called the "products" of a patented process.
Tuesday, September 26, 2006
And that's how the days go, saving lives, one paper at a time.
Patient charts grow fast than bacterial colonies in hospital. In a matter of days, a half-inch folder can grow several inches, all to say "Mrs.-M-had-pneumonia-and-it-got-better-and-we-sent-her-home." But think of all the people employed in making those notes and filling those forms. Doctors, nurses, physiotherapists, occupational therapist, social workers, case managers, unit clerks, personal care assistants, etc. They have good job security, they feed their families, all by writing notes.
And patients seem to get better if you just let them be. So I'll just stick to writing notes.
Wednesday, July 26, 2006
The DNR order (also called DNAR in some hospitals for "Do Not Attempt Resuscitation") is a medical directive for a patient in a hospital or chronic care facility which instructs the care providers NOT to attempt to resuscitate a patient in the event that the patient's heart stops beating or the patient stops breathing.
A resuscitation commonly involves the following:
-CPR (chest compressions and mouth-to-mouth),
-Defibrillation or Pacing (electric shocks to try to get the heart going again), and
-Intubation (putting a tube down the throat and hooking it up to a ventilator to breathe for the patient).
The majority of patients in a hospital do not have a DNR order on their charts, which means that if they "code" (cardiac or respiratory arrest) the doctors and nurses will use the resuscitation protocol to try to "bring them back." Naturally, this is the default for anyone coming into a hospital, at least in North America today, as far as I know. No one is a default DNR because of age or medical condition, as far as I know. That being said, there are certainly some medical conditions in which resuscitation attempts will be futile, and we should consider them at some point. But first,
How does someone get a DNR order?
1. First thing to remember is that the vast majority of patients in normal hospitals (excepting children's hospitals) are elderly people. Most of them are sick with more than one, often four or five, illnesses and on multiple medications. Many of them are "frequent flyers" who come into hospital anytime their heart failure gets out of control or they get a pneumonia. For these patients you can bet they have at best one or two years left to live, but no one can predict that they this admission will be their last. (On that note, studies show quite conclusively that doctors are notoriously bad at judging prognosis for heart disease and the like -cancer is easier. Judgement gets worse the better a doctor knows the patient. And errors are made equally on both sides - patients die a lot faster when we expect them to pull through just fine, and they pull through when we were sure they were breathing their last breaths.)
2. There are some people who openly say - I don't want anything done: if I die, let me die in peace. Few and far between.
3. For most patients, it is the responsibility of the admitting doctor to ascertain with the patient what direction will be taken in the event, even if highly unlikely, that a patient will code. It is the nature of this discussion which determines what "order" the doctor will write on the chart.
Friday, July 07, 2006
Thursday, February 02, 2006
Thinking doctors aren't technicians. They try to see the big picture. They know that, as doctors, they are no more qualified to make ethical conclusions than a software programmer or a fine-dining waiter.
Non-thinking doctors think (?) they are experts in almost any area, especially the ethics of their own profession (end-of-life issues, beginning-of-life issues). In one of my classes in first year medical school, the question was put out there, "should doctors be able to make their own ethical codes?"
Obviously government legislative bodies make laws on the basics dos and don'ts. But physicians are left to establish their own "standard of care" that often goes beyond the law. A case in point is protection of conscience laws and the "duty to refer" for abortion that has become the standard of care in many places.
Read any medical association's Code of Ethics and see what you find - should we be letting doctors, as doctors, impose their majority opinions on the members of their professions?
Many people look at internship as a kind of slavery - long hours, long nights, almost continually paged for little things by patients, nurses, staff doctors - the one who does all the grunt work, all the miles of paperwork (in my hospital we say, "saving lives, one paper at a time.") Like most things in this "career" of medical education, it shouldn't be as bad as they make it out to be.
In fact, medical education must be a cake walk compared to what it used to be. I am eternally grateful to activist feminists who have made medical school and residency a humane occupation. I won't go into details - it would be too embarassing to recount how many hours medical students used to be instructed in anatomy, for instance, and how many hours were spent in the labs, etc. compared to how much is required now... But I certainly have no complaints.
Sunday, November 13, 2005
John was a cute little boy with bright brown eyes which smiled by themselves. His arms and legs wouldn't quite do what he wanted them to, always overshooting his carefully calculated attempts to grasp things, but they were his own. His perfect little ears fit nicely on each side of his head, nicely suited to frame his small face, even though he is deaf.
He was born at 25 weeks gestation, 15 weeks (almost 4 months) premature. His neonatal pediatricians had predicted he would never make it home alive. His developmental pediatrician, when he did go home, had said he would never walk, talk, think or laugh. His mother, 19 years old, had never laid eyes on him since her C-section. For months he languished, all alone, in a hospital crib in a standard North American tertiary care center. Such things were only supposed to happen in Russia or Romania... When the Children's Services finally took notice, he had been neglected for seven months. Sure, John got his feeds, he had good nursing care from both good nurses and bad, and he was resucitated when he stopped breathing, so he couldn't complain... except he was a little infant, growing up all alone in a hospital bed, in a body that couldn't do what he told it to.
This retrospective scenario becomes more striking when you find out that, at three years of age, little John knows over 200 signs. His new parents, who've had him for more than two years, are delighted to tell everyone about his subtle mood changes, his love for iceskating and how he pulled down the Christmas tree last year. It's quite a sight to see him snuggle close to his mom and eat his pureed diet, and how carefully he tries to touch his little light-up toys.
His adoptive mother's only regret is that she missed being with him for the first seven months of his life. "There's so much time that we can never get back," she says. "He could have had so much more..."
She wouldn't give him up "for all the tea in China."
I guess the moral of little John's story is that every outcome prediction isn't right, that we have every right to hope, and that every drop of love counts.
Tuesday, November 08, 2005
Maternal Serum Screen
Also known as the Triple Screen, this 2nd Trimester maternal blood test looks at levels of alpha-fetoprotein (AFP), betaHCG, and unconjugated estriol (uE3) in maternal serum. Some centers also look at inhibin level and pregnancy associated plasma protein A (PAPP-A). (They can also check some of these levels in the first trimester, and integrate the results with the Triple Screen.) The first important point is that these tests are not diagnostic tests. They simply try to quantify the statistical likelihood or risk that the baby has one of three disorders: Down Syndrome (Trisomy 21), Edward's Syndrome (Trisomy 18) and open neural tube defects like spina bifida.
It is important to realize that this test, while posing no physical risk to the mother, does not get her any closer to knowing whether or not her baby has one of those three disorders. In fact, using the 2nd Trimester maternal serum screen by itself for Down Syndrome, the false positive rate is about 7%. If you screened 1000 women, 70 will have a "positive test" and only one baby will have Down Syndrome. (There are also, of course, false negatives.) The very real risk, here, is that 69 women will have tremendous psychological stress and worry for no reason. Many of them will move on to have amniocentesis for no reason. Amniocentesis carries a 1 in 200 risk of miscarriage, among other less common risks.
Other tests in what's called the IPS of integrated prenatal screen include 1st trimester serum levels (mentioned above) and a Nuchal Translucency (NT) ultrasound. The NT is done in week 11, 12 or 13, and measures the thickness of the fold at the back of the developing baby's neck, which is correlated with an increased risk of Down Syndrome. This is not a diagnostic test either. In combination with the serum tests it can help lower the overall false positive rate.
Amniocentesis and chorionic villus sampling (CVS) are actual diagnostic tests. A long needle is placed through the abdomen to sample the amniotic fluid or the chorion. Cells from the fluid can be analyzed to determine the baby's sex and presence of all sorts of genetic abnormalities. (The price goes up for each abnormality tested for). After one of these tests one can have a fair degree of certainty as to the presence or absence of a genetic or chromosomal disorder. Amnio has a 1/200, and CVS a 1/100 risk of miscarraige.
On the other hand, a routine ultrasound to check baby's anatomy at around 18 weeks can pick up an open neural tube defect in most cases.
Can you do anything about these disorders? Certainly not Down's or Edward's - no cure for these. For isolated menigomyelocele, a type of open NTD, there is promising research underway showing that intrauterine surgery, between weeks 24 and 30, can be of some benefit when compared to postnatal surgery. However, there are a lot of risks attached to surgery in utero (death being one of them), so that this surgery is not offered routinely.
The conclusion is that a routine 18 week ultrasound for anatomy will pick up many abnormalities in a baby (open NTDs, polycystic kidney disease, gastroscicis, etc.). Surgery, in the future, may be a routine option for some of these, but not really at the moment. As far as I can see, there is no reason to increase stress and worry with a Maternal Serum Screen if you are not going to abort the baby or risk miscarraige from amniocentesis or CVS.
As far as the safety of ultrasound goes, I know of two large, randomized controlled trials, that demonstrate the safety of ultrasound in pregnancy. Keiler et al, in BJOG, 1997, looked at 4637 randomized pregnancies and found no reduced hearing, no reduced vision, and no difference in height/weight at ages 1, 4 and 7. Ultrasounds have been around for almost two generations, and there has yet to be a study showing detrimental effect. On the other hand, as Leivo et al. showed in a study of 9310 women, perinatal deaths were reduced in the ultrasound group (deaths around the time of delivery). It is a safe and cost-effective means to be reassured about the health of the baby instead of rushing of to a C-Section. It's also been shown to significantly increase parental bonding, as well as objectively reducing pregnancy-related anxiety levels.
Monday, October 10, 2005
The rest of the world is quite divided on the issue of screening pregnant women for "defective" babies. Polls show roughly fifty-fifty, I'm told. But routinely, and in Canada, by law, women must be offered access to state-of-the-art tools that will detect the presence of "defects" such as Down Syndrome in the preborn baby. While there is some rhetoric about simply "presenting women with information and leaving them with the choice" the reality in 80% of the cases is that the babies who are discovered to have defects are "terminated".
It is interesting to hear the experts themselves in this area. Their surveys find that 80% of physicians also say that they would terminate if faced with the same defects in their own pregnancy. Yet they do not connect this with why 80% of patients do the same. They only comment that "the issue makes for a good coffee table discussion" but when it becomes a personal reality, we are all under the same pressures to make the choice to abort.
It's quite a perplexing situation, but still quite a black and white issue: the majority of physicians recommend prenatal screening as a tool to eliminate disease and cut health care costs, etc. The rest of us are quite uncomfortable with (at least strongly divided on) the idea of prenatal screening as a society. Women are benignly being offered "information" that pressures them into aborting because, among many reasons, there is little in the way of support for parents of disabled children. Abortion seems a quick and painless fix. After all, you can just try again...
Thursday, September 29, 2005
In a medical ethics class on assisted suicide and euthanasia, I kept pushing our professor to acknowledge the dysfunctional logic in assuming that a person in a coma or vegetative state was a non-person. She continued to maintain that they weren’t thinking, and therefore weren’t persons. But we think we are persons not because we think, but because we are the kind of thing that can think. That’s why uncle John in a coma is still a person, and when he wakes up, he’s the same person. That’s why aunt Mary is a person even though she’s asleep on the couch in front of the TV. That’s why my two-year-old is a person even though he can’t yet count, read or reason… Not only does this kind of faulty reasoning justify infanticide and other unthinkable atrocities, it also leads to many contradictions of common sense.
As the discussion progressed, we came to the issue of the physician’s responsibility, especially in regard to referring. I was very surprised to hear even some of the more respectable students arguing that by becoming physicians we “abdicate our role as moral agents.” It just seems so silly, that in order to further a patient's right to do whatever they want, I have to be willing to break with any value, tradition, culture, etc. that I have ever held dear. And that’s one of the most tragic realities: that even good people are so confused about life, the truth, and who we are.
Tuesday, August 16, 2005
Here I was, holding a retractor, peering into a deep whole in a man's side, looking at his kidney which the surgeon was (rather vigorously) trying to free from the surrounding fatty tissue. The patient was a 50-something year old gentlemen who recently found out that he had disseminated renal cell carcinoma. His prognosis was poor. All this had come upon him rather suddenly. And now he was asleep on the operating room table.
It was a pretty quiet operation, as things go. The surgeon grunted and puffed away, muttering obscenities under his breath. The kidney, apparently, was being stubborn. The tumor was bigger than originally thought. My mind wandered, which happens often to whomever is holding the retractor. Then the incessant buzz of the background music stopped and over the radio waves, clear as could be, I heard:
It's hard to describe how fitting that song was, in that moment, amid the sterile steel and bright lights. One of those ironies of life, I guess.
Wednesday, July 13, 2005
1. "Reproductive rights" means to not reproduce.
2. Conferences on "population growth" really mean "demographic control."
3. Feminist policy implementation means savage violence to women's bodies.
4. Equality for women in the workplace means "men need not apply."
It begins: "Apparently heeding George Washington's call to 'labor to keep alive in your breast that little spark of celestial fire called conscience,' physicians, nurses, and pharmacists are increasingly claiming a right to the autonomy not only to refuse to provide services they find objectionable, but even to refuse to refer patients to another provider and, more recently, to inform them of the existence of legal options for care."
Here is the rest of this bioethical song and dance in the New England Journal of Medicine, perhaps the most prestigious of medical journals, on the subject of conscience and professionalism. What is nice about this article is that it sums the debate up rather nicely, and reveals the disdain of the bioethics movement for all things moral.
A congenial old man, on the rotund side, was in for a "triple bypass." Well aquainted with the medical system, he appeared quite relaxed. We talked about the usual pre-operative subjects. I listened carefully to his heart, and as usual, heard only the soothing "lub-dub, lub-dub."
Minutes later, I put him to asleep. Then there was some cutting, and then a quick zip with a modified jigsaw. Et viola! The surgeon was holding this man's beating heart in his hands.
I don't know which was more mind-blowing: that a live man's beating heart was in the surgeon's hands, or that, at that moment, the surgeon was conversing with the nurse about sushi...
Thursday, July 07, 2005
As part of my anesthesia rotation I have been learning to do epidural and spinal blocks for women in labor. My first case yesterday morning was a C-section for a woman in her early forties, only 19 weeks pregnant.
The average Joe knows that 19-week-old babies can't survive outside of mom. Nonetheless, I was informed that this baby had a "lethal fetal anomoly." So the baby would likely die before delivery, during, or soon after. The reasoning behind "delivering early," as far as I can guess, is to relieve the mother of the last few harder months of pregnancy - because the baby will die anyway.
Now what is the point of continuing a pregnancy once you know your baby cannot live outside the womb? If baby will die on the day of delivery, why not deliver sooner and get the whole tragic ordeal overwith and get on with life? Is there really a difference between letting the pregnancy go to term, and inducing early, when the end result is the same?
There's a big difference - morally, psychologically, emotionally and even physically. The moral issue is huge: when the direct effect and intent of inducing labor early is to bring about the death of the infant, the act is immoral (it is murder, abortion, etc.). However, the intent and direct effect of delivering the baby at the end of pregnancy -induced or not- is that the baby moves from the now inappropriate location of the womb to the appropriate location outside. (After nine months, a baby's appropriate environment is outside the womb. Those that don't get out, don't make it.) So when a mother delivers her terminally ill baby at term, and it dies in her arms, this death is unintended and only an indirect effect of the delivery.
Psychologically, when an anomalous baby is "terminated" early, the parents remain very fragile and forever scarred. There is enormous guilt because there was immoral intent. The parents did not want their baby to die, of course, but what they did caused its death. If they wait till the baby comes by itself, they suffer to watch their baby die, but they had no hand in its death. On the contrary, they were able to participate fully in its short but beautiful little life.
Emotionally there is a lot of stress - not to mention bitterness and resentment. This one is hard on marriages, especially if one spouse pushed for it (often the father) and one would rather have waited. I think the majority of pressure for early delivery is from the doctors - they don't offer much support if you want to keep your baby to the end of pregnancy.
Physically, there is a lot of benefit to continuing a pregnancy. When a pregnancy is artificially interrupted, there are many hormonal effects - most of which we don't understand well at all. Post-abortion research is beginning to bear this out (e.g. breast cancer, fertility, etc.). Even so, the whole argument is that a woman will be much better of physically if she avoids the last few months of pregnancy. That may be true.
The Rest of the Story...
So I showed up a little late to the operating room, and didn't have to participate. I just observed from the head of the bed where Dad was sitting next to Mom's head. Before I knew it there was this tiny little bluish squirmy thing on the warming table. She had cute little fingers and toes. She even had her fingers in her mouth. Everything about her was right, just small. She would have fit perfectly in my hand. She was soft and warm to touch and I could feel her little heart beating fast. She was perfect.
They wrapped her in a little knitted blanket and gave her to her Dad to hold. He broke down sobbing. Mom couldn't really move on the OR table, but just stared kind of glassy-eyed at this little creature. I put my arms around Dad's shaking shoulders, and did my best to console them. And then the pager went off and I went off to another job. Another encounter with medicine. It's hard to see the positive side to this one. But out of all this evil good will come.