patient population

Top 5 reasons I loved oncology...

1. Research. Given my research-heavy background, I knew coming into residency that I wanted a specialty or subspecialty that meshed well with research. Now internal medicine is a pretty research-focused specialty, but Hem/Onc is probably the most research intensive subspecialty branch of internal medicine. It’s not that I’ve figured out exactly how I want to balance my MD/PhD, but I at least want the possibility for it to be there. 

2. Patient compliance. One of the biggest frustrations in medicine is medical non-compliance. It’s rampant, and it’s almost unavoidable. In general the Hem/Onc population is an exception to that rule. These are some of the most compliant patients you’ll ever encounter… sometimes to a fault. But it’s refreshing. They just want to live. 

3. Patient population. I’ll be honest, working with oncology patients just makes me happy. It’s not just the compliance issue. It’s everything about them. I can relate to them in ways that I can’t with any other patient population. I get where they’re coming from. I understand their fears. Most of them are really nice people dealing with a really crappy situation. I feel like a have way better good person-to-asshole ratio in Hem/Onc.

4. Sick, sick, sick patients. A good proportion of onc patients are pretty dang sick at baseline. The ones we see on the wards are dealing with an acute problem on top of that baseline sick. Lots of multisystem problems with competing comorbidities. It’s great for people who like complex problem solving.

5. Infectious disease, my second love. I won’t lie. While oncology is my first love, I really enjoy infectious disease. The good part about oncology is that infectious disease is a big problem. Neutropenic fevers. Crazy abscesses. Lot of pneumonias. Lots of room for antibiotic stewardship. I dig it.

Overall, I’m pretty sure this is my jam. At this point the only possible specialty to uproot Hem/Onc is a combined Hem/Onc + Palliative fellowship.

anonymous asked:

As a student nurse it feels like a lot of the RNs forget that patients are people and have needs and emotions. I was assigned to an elderly female patient with dementia who was agitated and afraid and everyone was quick to pin her as the worst patient on the unit but no one would take the time to try to connect with her. It took me all of five minutes to take her by the hand, calm her down, tell her where she was, why she was there. Do you find this happens often in the hospital setting?

Hi- I think that it takes a special type of person to be a nurse. And I think it takes an even more special type of person to be a geriatric nurse! I would agree with you that at times nurses may be more focused on tasks that need to be completed, clinical concerns, and documentation and this causes them to overlook a patient’s emotional needs. I also think that with certain patient populations (psych patients and geriatrics for example) it takes extra training or more experience to be able to manage the patient and their behaviors. And…not all nurses are good at this! Kudos to you for recognizing this and being able to do this and I hope it’s something you continue to do and role model and teach other nurses!

At my hospital there are actually classes that are taught to try to improve in this area (not only for geriatric patients but also psych patients and even just for the general patient population that is more challenging). We have also implemented a team that helps to support nurses when there are behavioral concerns that come up with patients that a nurse can call that will come to the bedside to help to work with the patient. This is beneficial not only for the patient but also they provide education to nurses to teach them how to work with certain patients. For example, we had a slightly confused elderly patient recently who was demanding to return to his assisted living facility before the transfer had been set up and he was trying to leave AMA and it wasn’t safe for him to go on his own (I honestly started thinking I was going to have to follow him back to his facility)! The more we tried to talk to him to explain we wanted him to be able to go back too but we were working to get this set up, the more agitated he was becoming. We called the behavioral team to come help and they were able to help us get him calmed down and also did some education on the spot for how we should work with the patient and communicate with him in the future. It was so helpful.

I know this is a long response to your question, in short I’ll say, yes- I think what your describing happens in the hospital setting. But I also think it is something that has been recognized as an area that needs to be improved. I don’t know if you’ve heard of NICHE care modules? This is education that is focused on the geriatric patient population as well and what nurses can do when taking care of patients to improve outcomes. Here’s a link:

Hope this helps!

How to Pick an ICU Area ...

Cardiovascular ICU (CVICU)- Superiority complex of nurses.

Coronary Critical Care (CCU)- Where CVICU nurses go to retire. The oldies, but goodies.

Surgical ICU- The catch all for patients that fit in all or none of the other ICU’s patient population.  Can do everything, but also won’t be a dick about it.

Trauma ICU- I can literally see this patients guts, hobbies include transfusing blood through a pressure bag all day e'ry day.

Medical ICU- You get a GI bleed! You get a GI bleed! You get a GI bleed! Everybody gets a GI bleed!!!

Neuro ICU- The head bone’s connected to the neck bone, the neck bone’s connected to the…help us out here???

Music has also been shown as an effective, drug-free way to relieve pain, which is crucial in special patient populations like children who don’t have the benefit of prescription strength pain killers especially designed and tested for them. A randomized, controlled trial conducted among post-operative pediatric patients showed that listening to their favorite music had significant reduction in pain as compared to the control group: those who simply put on noise-cancelling headphones. A group of scientists in Germany also found that listening to live harp music lowered stress hormones in premature infants living in a neonatal intensive-care unit.

anonymous asked:

What was it like to work in the ER?

The ER is a very interesting, dynamic, and sometimes a very hectic place.

Every day is different.

  •       Somedays, it’s considerably slow. Less than half of the rooms are filled up and everyone gets discharged and there are no critical cases.
  •      Other days, you’re drowning. There are more patients than beds and your doctors are juggling multiple critical patients at once and everyone feels like they’re in a never ending clusterfuck and everything is on fire.

Originally posted by battlestargalacticat

You never know what you’re going to see

  • Each patient has a new and unique medical complaint (usually). In one bed you’ll have a patient with a simple URI, while somewhere else in the ER you’re trying to manage a patient with flash pulmonary edema who is very close to needing an advanced airway.
  • Patients can deteriorate and become very ill, very quickly and sometimes without warning. It doesn’t happen often, but sometimes even the most simple seeming medical problems can turn into catastrophes. 
  • Even though it’s your job as a physician, nurse, medical student, etc to be able to recognize within moments of interacting how acutely ill a patient is, our patients can sometimes surprise us.
  • The variety of medical problems you see is fascinating. Depending on your patient population, you’ll see a variety of medical issues, and it’ll constantly keep you thinking. You might even run into a patient with Lupus.
  • Just kidding.


  • Care of the traumatic patient is one of the defining differences between those who work in the ER, and those who work in other areas of the hospital. The ER staff is highly trained and always prepared to treat trauma patients, and we work tirelessly to help stabilize and do what we can to treat them. 
  • Trauma can get messy, it can get stressful, and it is never easy.
  • That being said, it can be an adrenaline rush.

Originally posted by stochasticmind

The ER is tiring…

  • Both emotionally and physically
  • On a busy day you might not stop moving for your entire shift (especially the nurses). You might forget to eat, and there have been times when you don’t even feel like you have time to use the bathroom. No matter how sore you are, how hungry you are, or how much your feet hurt, the ER does not slow down for you. 
  • Emotionally….emergency medicine is probably one of the most draining professions out there. You see people at their worst. Your patients aren’t always nice to you, and I can’t even think about how many times I’ve been yelled at or seen someone get yelled at by an angry patient.
  • Loss is can be really hard. When you take care of so many critical patients, death and bad outcomes become a regular part of your job. Nothing is harder than seeing the passing of a pediatric patient, or having to diagnose someone with terminal cancer.

Regardless, it is extremely rewarding

  • You have the privilege to help thousands of patients every year, many of whom have no where else to go but your ER.
  • You learn to celebrate the wins. The patient who you coded for over an hour who somehow managed to walk out of the hospital a week later? You’re going to remember that case for the rest of your career. You hold onto those wins, and it reminds you of why you show up every day.
  • Your coworkers at the ER become your family. You guys go through tough times together, and everyone becomes closer because of it. Even though I don’t work regularly at the ER anymore, some of my closest and most trusted friendships have been born from there. 

In the end, the ER is an interesting place. It’s extremely challenging and a tough specialty, but there is no where else I would rather work.

anonymous asked:

Why did you decide to take this job? I know you didn't want to originally...

Here’s the story of how I came to take this job. It’s long, but relevant to understanding where I am now. 

For those of you who went back and read that post or who remember it, you’ll remember that I was super excited about this job. I had been promised that it could be adapted into exactly the type of practice I wanted and that there was tons of opportunity for growth. In reality, I have found that nothing in the practice is changing. I thought I loved working in rural areas, and maybe I would if I had some support and a patient population I enjoyed, but I’m not loving it now. I don’t love geriatrics or nursing home care, and that’s the majority of my practice. 

But even though I’m stressed, depressed, and burned out and I don’t love the place I’m in, I still believe it’s where God wants me for now. Some of y’all may read that and think I’m totally insane. Let me explain.

A month ago I really doubted whether I had misread God and wondered if I had made a huge mistake by taking this job. I have felt since my senior year of high school, and continue to feel, that my ultimate calling is foreign medical mission work. A month ago I felt like taking this job was forsaking that calling, but now I see it as a small part of a bigger plan. 

A friend of mine from residency recommended I read the book The Dream Giver by Bruce Wilkinson. I was skeptical, as I am when anyone tells me a book changed their life. The first part of the book is a parable about a guy who leaves his ordinary comfortable job and home to pursue his Big Dream. Along the way he encounters family and friends who bully him and try to persuade him to turn back before he even leaves the city limits. He is able to resist them and keeps going, only to run into a river that he can’t cross. Someone comes along and offers him a boat to get across. Then he keeps walking, feeling that surely he was getting close to the city where his dream was. Then the land turns to desert. He wanders there for the longest time. He prays and can’t feel God answer him. But all along the way his basic needs–water, food, direction–are provided for him. At the end of the desert he sees the city where his dream is in the distance. But in between him and the city are giants that he must conquer. Once he battles the giants, he reaches his dream. 

I feel like this place is my desert. When I left Residency Town I left my comfort zone socially, geographically, and medically. My best friends and a counselor friend all pushed me to stay and told me I was crazy to leave and go to this other place. My family even wanted me to stay in ResidencyTown, even though my new town is closer to them. I was able to break a contract that I didn’t think was going to be breakable and I came here to TinyTown. 

It didn’t take me long to see that TinyTown wasn’t my BigDream destination, but rather a wasteland I had to get through on the way. I am certainly learning things here. I am essentially on my own, which is how I would likely be in a foreign missions situation. I’m learning to handle things myself that previously I would have ordered consults for. I’m learning to value my free time more and to take better care of myself (albeit grudgingly) both mentally and physically. Though this place is tiresome, I feel that it must be preparing me for something better in the future. Here I have to depend on God for companionship when I’m lonely, uplifting when I’m depressed, rest when I’m exhausted, and knowledge when I don’t have a clue, not to mention trusting him to provide for my physical and fiscal needs. 

I’m trying to change my perspective on this place. My patients are not easy for me to love or even relate to on a basic level many times, but I’m using those times as opportunities to build my own character and become more deeply rooted in God’s love, so that it can then overflow from me to my patients and coworkers. My prayer this past week has been for God to teach me how to see people the way he sees them and to begin to love them the way he loves them. 

So even though this place feels barren and overwhelming and I complain about being exhausted all the time, I’m choosing to trust that something better is going to come from my time in this place. 

If you’ve read this far and are so inclined, please pray for me to remain faithful even when I’m not hearing from God. Pray that this place will build the skills and character I need to thrive in my next place. And pray that I will have patience and trust God’s timeline. 

How I came to find this book….
I was working one day and I popped into one of my six patient’s room as I do every morning for 7 o'clock vitals. I was suprised to see how young this patient was as the majority of my patient population is much older. This kid was my age (22). He seemed quiet and reserved. Out of the corner of my eye on his bedside table I saw this book and I ofcourse asked him about it. He told me it was about a doctors stories and I asked him if it was any good. He told me it was and that it resonated greatly with what he was going through and went on to say that before all “this” happened he was planning on going to medical school and that hopefully after this blows by he can continue pursuing that dream.

That really affected me in the sense that - here I am with this opportunity to pursue the same exact dream while he has this horrible illness that might never go away consequently never pursuing the dream. Sometimes I feel like I’m throwing it away because I get really stressed and anxious about the process and the grades and then my vision gets cloudy and I forget why Im doing this. So a lot of the time I just take a step back to take the time to remember.

I highly highly highly suggest you read this book. Its contents and the way the author conveys these stories, is in my opinion, excellent.


I saw a patient in clinic a few weeks ago. She was in her 30s, a new patient, and in with some minor complaint. A “I just noticed this and wanted to make sure it wasn’t anything serious” visit. And it wasn’t. So then I moved on to my healthcare maintenance questions. Flu shot? She’d get one today. Pap? Up to date. Birth control? None. 

Turns out she already had several kids, really didn’t want any more, and knew she should be on something but just hadn’t gotten around to it. So we talked about various options, I gave her some information, and she left. I told her when she decided, then come back and we’d get her squared away.. A few weeks later she came back and got an IUD. That day, ironically, was November 7th. 

I, like many residents, work with a patient population who generally has the deck stacked against them. These are people who benefit greatly from expanded government support of healthcare. Our clinic is federally funded and so we see those benefits every day. For example the cost of a mirena out of pocket is about $850. This patient qualified for the maximum financial assistance that we have and got her mirena for $10. 

Just think about that for a minute. That’s perhaps the most life changing ten bucks she’s ever spent. Certainly much more beneficial than the reassurance I gave her about the problem that brought her in. She has a basic level job and is getting by; but how would unintended pregnancy change that? 

The importance of the social determinants of health cannot be understated. If you are reading this right now and think otherwise, then please take some time to reflect on your privileged place in society. There are many days both in clinic and in the hospital where I feel that health is NOTHING BUT social determinants. I think many of my colleagues would agree. 

The worry that I have now is that our new president elect cannot comprehend this concept. And based on everything we know about him as a person, trying to explain it to him would be akin to lecturing a dog on nuclear physics. 

And so I worry that people will suffer because a narcissistic sociopath will never act to address the social determinants of health. 

I worry that good people who are working hard and getting by will be pushed into the margins. 

It seems impossible to escape worry at this time. Both on an individual and national level. But I take some solace in the fact that our healthcare system is bigger than any one man, even the president. I believe that our individual actions of kindness and decency every day matter.  And for now, that is what I choose to hold on to. 

“Caring is the essence of nursing” - Jean Watson

Life Lesson #25 – It saddens me every time I see a nurse who has become hardened by time and exhaustion. Remember that your patient is vulnerable and illness, stress, pain - almost every deviance from normal and comfort can manifest as sadness, irritation, anger and, yes, ungratefulness. Remember that if you can no longer be understanding to every patient that comes onto the unit, then, perhaps it is time for a change, for self-reflection. A nurse without compassion is like the sun without its light.

I know some will disagree and will scramble to give examples of how wrong or narrow-minded or ignorant I may seem from the above paragraph. Before you judge, know that I don’t judge others. It frustrates me, angers me, saddens me, but I don’t judge them because I am in no way perfect. Before you judge, know that the above is just as much a reminder to myself as to everyone out there. Before you judge, know that I work with a patient population that many have turned their backs on, given up on, a population that many think don’t deserve to have a nurse.

I work in mental health. I am a nurse, police officer, a parole officer, a maid, a laundress, a guidance counsellor, a social worker – all in one. I have been shoved, pinched, spat at, slapped, punched, kicked in an assortment of locations on my body, sometimes all in one day. I have worn bruises like badges, gotten blood work when my skin is broken and the occupational health department knows my face to my name. Just last summer I was on modified duties for an extender period of time, a majority of the time I was pulled from the unit for safety’s sake. 

But, still, compassion is the backbone of my practice.



The Daraprim pill costs less than $1 to produce, but CEO Martin Shkreli, a former hedge fund manager, defended the 5,000% price increase saying, “We needed to turn a profit on this drug.”

The Infectious Diseases Society of America, the HIV Medicine Association and other health care providers wrote an open letter to Turning Pharmaceuticals, urging the company to reconsider.

“This cost is unjustifiable for the medically vulnerable patient population in need of this medication and unsustainable for the health care system,” the groups wrote.

(full post »here)


Overbrook Asylum

(1 of 3)

Construction of northern New Jersey’s Essex County Hospital for the Insane, known locally as Overbrook Asylum, began in 1896 and continued through the early 1900s. It was built to ease overcrowding at Newark Hospital, but it wasn’t long before it started experiencing some trouble of its own.

Thousands of mentally ill patients who required daily care were sent to Overbrook, and it was soon operating at full capacity. To handle this enormous patient influx - as well as provide for the needs of the workers - Overbrook grew into a small town complete with farms, a power plant, firehouse, theater, school, bakery, and much more. It even had a semi-professional baseball team. The facility required so much fuel and other resources that a railroad stop was constructed to service it.

There are a lot of stories of tragedy at Overbrook, and given the time period and the nature of the institution, many of them are surely true. But one stands out. As reported by the New York Times, Overbrook’s boilers failed for 20 days during the frigid winter of 1917. Twenty-four patients froze to death in their beds, and many more suffered frostbite. 

Along with other asylums, Overbrook began to decline in the 1960s with the advent of new psychiatric medications and other treatments for mental illness. By 1975, it was maintaining only a very small patient population and most of the buildings were abandoned. By the mid 1990s, no more patients remained. The buildings and their contents - including patients’ records dating back to the late 1800s, were left to rot.

During the latter half of the 20th century, Overbrook became a New Jersey legend. Ghost stories proliferated, and venturing onto its decaying grounds became a rite of passage for many youths in the region.

In the 2000s, a lot of the buildings were torn down. Yet, a massive complex of structures remains - a testament to Overbrook’s former dominance of the surrounding area.

I visited in April 2014.

(For more photos of this site, see sets two and three.)

The Gender Pay Gap in Medicine is Serious

Today, I waited for seminar to start and watched as the ortho residents excitedly signed their contracts for next year. To my surprise, I found out that no two residents make the exact same amount. For example, some residents are on a “research track” and make about $3K more than non-research track residents. The only female resident, moving on to PGY5, makes about the same amount as a male resident moving on to PGY3. Wtf?! Am I missing something here?

Unfortunately, I didn’t ask her why. At least not in front of everyone. But I could tell her mood was in a sour place and she was NOT happy. Maybe it was something else? Because it seemed like none of the residents knew how much other residents were earning. But, I thought this pay gap was being resolved?

I have a strong, strong feeling that the gender gap in pay isn’t changing at all. And it won’t. By the time I am in residency, I’m certain I’ll make less than a male resident in the same year. Even though I would probably have more degrees, training, and possibly more experience. Maybe it’s just this program?

Why does it feel like medicine is stuck in 1950? We have different technology, some different faces and backgrounds, but the “old ways” are static. When will medicine reflect the changes in the patient population?

Wayfaring Thumps Bibles, Respects Patient Autonomy

theintelligentarefullofdoubt replied to your post: zandraau replied to your post: theirm…

Don’t you think it’s unethical to use the patient-doctor relationship for bible-thumping? There’s a reason they make you sign this.

beakempire (Guest):

Why would you try to push your faith on vulnerable patient populations? Isn’t it kind of taking advantage of people, especially those in dire situations, who feel they would receive better care if they subscribe to their care provider’s religious beliefs? Seems self-serving

do think it is unethical for a doctor (or anyone) to force their beliefs on a patient or on any person. I also would agree that it is unethical for a doctor to only see patients of their same faith or to require their patients to listen to an evangelistic spiel when they come for medical attention. 

However, I do think it is fair, ethical, and, yes, evidence based, to offer spiritual care to all patients and then let them decide as they would with any other treatment or therapy whether they will accept it. 

It is not the healthy who need a doctor, but the sick (Luke 5:31). People go to doctors seeking many types of healing: physical mostly, but commonly emotional and yes, spiritual as well. My job as a doctor is to be an intermediary between the patient and their treatments. I don’t push Jesus on people any more than I’d push a potentially dangerous elective surgery on them. But I do offer spiritual care when I think it may be warranted. 

When I talk about evangelizing to patients, I don’t mean corralling them into a tent and preaching at them all night before they can get their Rx for their blood pressure meds. I don’t believe in forcing people into faith. We attend to people’s medical needs first and give them our full attention (James 2:15-16, Matthew 25:31-46), and afterwards invite patients to come to a second, later event that is faith based (Romans 10:14). Patients are free to come or not come, and their treatments have already been given to them before they are even aware of a religious aspect. 

I don’t think it’s my job to save people. That’s up to Jesus. I do believe it is my job to offer my patients (and others) some hope and comfort, whether it’s physical or spiritual. I offer up what I know, and if they do not agree, that’s fine. I’m glad to point them in another direction if that’s their choosing.  I believe we call that the ethical principle of autonomy.

Here’s where I take this one step further. This post may get uncomfortable for some of you. Feel free to jump to the tl;dr. 

I believe the Bible wholeheartedly and believe that it is my duty and my privilege as a Christian to tell others about Jesus. I believe the narratives about Jesus are actual historical events. I believe there is definitely something to be learned from the fact that when Jesus went town to town to preach and teach, he first healed the sick (Matthew 10:7-8; Matthew 9:35; Mark 6:7, 12-13; Luke 9:2; Luke 10:1,9). I think that when we care for people’s most basic physical and emotional needs, we can form a relationship with them that paves the way to dealing with spiritual matters (Acts 3:6-8, 12-13, 19-20). Often physical healing precipitates spiritual healing. And lastly, I think it’s important to my own personal faith and relationship with Christ that everything I do, in my job or my leisure, I do for Jesus (Colossians 3:17).

I am fully aware that these “no proselytizing” contracts exist to keep people from abusing patients and to prevent the organizations from the appearance of sending mixed-messages. Also, Christian evangelism is illegal in many countries, so these contracts can help keep employees and volunteers safe and out of jail cells. But regardless of legal consequences, requiring me to sign a paper saying that I would not tell others about Jesus would be equivalent in my mind to telling me I wasn’t allowed to go to church. Both are acts of worship in my mind, and to willingly sign away my freedom to worship would not be ok with me.

If I believe in the ethical principle of beneficence and in the Christian principle of being “unashamed of the Gospel” (Romans 1:16), what kind of doctor am I if I knowingly withhold something that I believe may be helpful for my patients? I don’t force or require my depressed patients to go to counseling or to take SSRIs, but I do explain how these things may be helpful for them. Similarly, I feel that I should offer a spiritual solution that may help my patient or my fellow man. 

Finally, to those who say that I should not broach the subject of faith or spirituality unless a patient specifically brings it up, I ask: should I wait for my female patients to ask for pap smears and GC/Chlamydia screening before I offer screening to them? Should I wait for a patient to present with HIV before I ask them about IV drug use or high risk sexual behavior?  Should a patient have to come to me with rectal bleeding from colon cancer before I ask them about their bowel habits? Should my alcoholic patients have to ask me where the nearest AA meeting is before I intervene? I know that faith is a sticky subject for many. But so are vaginal discharge and poop habits and addiction and sexual habits. It is not the healthy who need a doctor, but the sick (Luke 5:31)

And finally, I think it warrants saying that in my 14 years of being a Christian, I have never once thumped a Bible.

Tl;dr: I don’t push my faith on anyone, but if I am a real believer, how could I not at least offer the hope I have to others?

heartinsalah  asked:

I'm interested in surgery but I wear a head scarf/long sleeves for religious reasons, and I have heard that in the OR they are not allowed. Is this true?

it’s true that in order to scrub, your arms and hands must be exposed from the elbows down. this is in order to preserve sterility and reduce the risk of infection to the patient, since we will be making incisions. the head scarf would not be a problem, since we wear caps and masks (for the same reason of sterility). 

this brings up an interesting ethical dilemma that i’ve discussed at length with some of my colleagues who happen to be devoutly religious. one of my junior residents observes the jewish sabbath and as such is “forbidden” to do any sort of work during the period of sundown friday until sundown saturday. however, he says that he rationalizes this (working during the sabbath) because providing patient care is a matter of life and death, and his religion allows for breaking or bending the rules in such cases. he still won’t take the elevator or push the automatic buttons on the doors because that’s considered work, but he’ll come in and take care of patients and put in orders and whatnot, which he is technically not “supposed” to do according to his religious beliefs. another of my junior residents, who is a practicing muslim, takes time each day for his prayers, but if there is some kind of emergency happening, he will defer it to another time.

i happen to be an atheist, but i respect that religion is a cornerstone for many people and i think that there is absolutely a place in surgery for you. i don’t think that you should be discouraged from this career because of your religious beliefs. i think it is vitally important to have more diversity in surgery, because our patient population is incredibly diverse and it would be weirdly paternalistic and detrimental to our patients if all surgeons were still old white straight republican dudes like back in the day. 

however, i would counsel you that because what we do is a privilege and in many ways the ultimate responsibility (taking care of human life), you are going to have to make sacrifices in order to do this job, sacrifices that aren’t specific to religious beliefs. it is up to you to decide if those sacrifices are worth it, and you will have to reconcile that personally with yourself. my coworkers who i mentioned above have expressed to me that they don’t see it as opposing their religion because they are deferring some of the “rules” for the greater good, which is to be able to take care of sick people. i don’t believe in a higher power, but if i did, i can’t imagine that they would punish you for not wearing your scarf or exposing your arms if you did those things in order to save lives every day in their name.

Alcohol, tobacco, drug use far higher in severely mentally ill

In the largest ever assessment of substance use among people with severe psychiatric illness, researchers at Washington University School of Medicine in St. Louis and the University of Southern California have found that rates of smoking, drinking and drug use are significantly higher among those who have psychotic disorders than among those in the general population.

The study is published online in the journal JAMA Psychiatry.

The finding is of particular concern because individuals with severe mental illness are more likely to die younger than people without severe psychiatric disorders.

“These patients tend to pass away much younger, with estimates ranging from 12 to 25 years earlier than individuals in the general population,” said first author Sarah M. Hartz, MD, PhD, assistant professor of psychiatry at Washington University. “They don’t die from drug overdoses or commit suicide — the kinds of things you might suspect in severe psychiatric illness. They die from heart disease and cancer, problems caused by chronic alcohol and tobacco use.”

The study analyzed smoking, drinking and drug use in nearly 20,000 people. That included 9,142 psychiatric patients diagnosed with schizophrenia, bipolar disorder or schizoaffective disorder — an illness characterized by psychotic symptoms such as hallucinations and delusions, and mood disorders such as depression.

The investigators also assessed nicotine use, heavy drinking, heavy marijuana use and recreational drug use in more than 10,000 healthy people without mental illness.

The researchers found that 30 percent of those with severe psychiatric illness engaged in binge drinking, defined as drinking four servings of alcohol at one time. In comparison, the rate of binge drinking in the general population is 8 percent.

Among those with mental illness, more than 75 percent were regular smokers. This compares with 33 percent of those in the control group who smoked regularly. There were similar findings with heavy marijuana use: 50 percent of people with psychotic disorders used marijuana regularly, versus 18 percent in the general population. Half of those with mental illness also used other illicit drugs, while the rate of recreational drug use in the general population is 12 percent.

“I take care of a lot of patients with severe mental illness, many of whom are sick enough that they are on disability,” said Hartz. “And it’s always surprising when I encounter a patient who doesn’t smoke or hasn’t used drugs or had alcohol problems.”

Hartz said another striking finding from the study is that once a person develops a psychotic illness, protective factors such as race and gender don’t have their typical influence.

Previous research indicates that Hispanics and Asians tend to have lower rates of substance abuse than European Americans. The same is true for women, who tend to smoke, drink and use illicit drugs less often than men.

“We see protective effects in these subpopulations,” Hartz explained. “But once a person has a severe mental illness, that seems to trump everything.”

That’s particularly true, she said, with smoking. During the last few decades, smoking rates have declined in the general population. People over age 50 are much more likely than younger people to have been regular smokers at some point in their lives. For example, about 40 percent of those over 50 used to smoke regularly. Among those under 30, fewer than 20 percent have been regular smokers. But among the mentally ill, the smoking rate is more than 75 percent, regardless of the patient’s age.

“With public health efforts, we’ve effectively cut smoking rates in half in healthy people, but in the severely mentally ill, we haven’t made a dent at all,” she said.

Until recently, smoking was permitted in most psychiatric hospitals and mental wards. Hartz believes that many psychiatrists decided that their sickest patients had enough problems without having to worry about quitting smoking, too. There also were concerns about potential dangers from using nicotine-replacement therapy, while continuing to smoke since smoking is so prevalent among the mentally ill. Recent studies, however, have found those concerns were overblown.

The question, she said, is whether being more aggressive in trying to curb nicotine, alcohol and substance use in patients with severe psychiatric illness can lengthen their lives. Hartz believes health professionals who treat the mentally ill need to do a better job of trying to get them to stop smoking, drinking and using drugs.

“Some studies have shown that although we psychiatrists know that smoking, drinking and substance use are major problems among the mentally ill, we often don’t ask our patients about those things,” she said. “We can do better, but we also need to develop new strategies because many interventions to reduce smoking, drinking and drug use that have worked in other patient populations don’t seem to be very effective in these psychiatric patients.”

I started my new job!

It’s at Clinic, doing Specialty.  Specialty is much more technical than Old Specialty and serves a more diverse patient population, and I think I’m going to like it.  (Specialty also has a lot fewer uncomfortable ethical issues than Old Specialty.  Not zero, but fewer.)

Seems to be going okay so far.  It’s hard to tell during orientation–sitting in a conference room reciting mission statements and reading policy manuals doesn’t give you much idea what the real work will be like.  So I don’t really know.

I’ve got a good feeling about this one, though.  They seem very organized and professional at Clinic, and god that’s a breath of fresh air.

Peds Preceptorship Week 1

Here are my reflections on my peds preceptorship week 1

Disclaimer: This reflection ended up ridiculously long (oops) also remember I am not a fully formed med student much less a fully formed human and these are not my fully formed opinions (these aren’t even my fully formed thoughts) 

-Newborns are literally the cutest things I’ve ever seen omg so new to the world just wide eyed looking around 

-Less kids cry with the pediatrician than they do with the person who comes to give the vaccines (whether it be an MA or nurse or whoever), at least in my one week’s experience. But apparently some kids cry at everyone no matter what. 

-There is still plenty of wailing coming from the rooms though. Kids cry very loudly. They have many things to say without words. 

-I really need to learn Spanish (and not just the “I understand what someone is saying” kind of learning, I mean like actually being able to communicate with another person by SPEAKING) 

-Working at a community health clinic (vs. being in private practice) allows you to spend more time with your patients, apparently, at least in this circumstance (~20ish patients per day vs. ~40ish in private practice)

-The patient population at this clinic is ~70% Medicaid, which is awesome because many places aren’t able to see that large of a percentage (due to lower reimbursement rates than Medicare, private insurance). This is accomplished partially by grants and also Medicaid requires more documentation than other insurances? at least in this instance. 

-It’s going to be really hard to fix the obesity problem in this country if school lunches do not get healthier. Lower income families get free/reduced cost breakfast and lunch for their children.  How are the kids supposed to eat healthy if they don’t have tasty healthy choices??? What kid isn’t going to pick pizza?? 

-I feel like there should be a way to talk about someone’s health without zeroing in on their weight. Yes, children who are overweight/obese are more likely to be that way as adults. Yes, it is important to get them to start eating healthy and exercising. But the way my doc brings it up it sometimes feels like the weight part is the only part that matters and not about just generally being healthier. I mean, I get not wanting to beat around the bush about it but at the same time it’s important to not mess a kid up. I don’t understand how there is enough time to have that conversation in 15 minutes. He does do a good job of giving suggestions (like making junk food a once a week thing, not once a meal thing and finding a physical activity you like to do, cutting down on soda, eating fruits and veggies with a lean protein, etc.). And he does a good job of making sure the parents are paying attention and are really listening. I think some of the parents might be in denial about it as well, so I can see how the direct approach works with that. Some of the parents say things like “well he’s just tall for his age” and like “oh he’s hungry all the time, he’s growing”. Which is well meaning but reversing the kid’s course while young would be a great thing for their health later on by starting these healthy habits. I think overall it is a good approach but I just wish there was a better way to say it so that a child’s face doesn’t fall when it is brought up (but like there probably isn’t or he would be doing it already). 15 minutes is definitely not long enough to address the systemic factors promoting this epidemic either. 

-ADHD is definitely an important issue. We had an interesting discussion about the prevalence of it. 

-Children have to come to the clinic a lot for well visits. I guess I had forgotten that growing up. It makes sense, to make sure everything is a-okay but I didn’t realize it was so often. 

-I thought it would be a more even split breastfeeding vs. formula but at this clinic pretty much everybody does formula

-Seeing more than one kid in a family for a clinic visit is totally a thing, especially if multiple are sick. They still all need separate notes though (knew this one from scribing, actually!) 

-Joking about little boys having girlfriends seems a little strange. Like the children laugh and it makes them more at ease but like, what if they wanted a boyfriend? Or neither? Why should they even be thinking about that stuff right now? It seems like it would make more sense to use something else absurdist to make them laugh not related to that. 

-I asked a lot of questions about various zebra diagnoses (for instance, things that come up from the newborn screen where they screen for all kinds of things, like enzyme deficiencies etc). There aren’t that many day to day (because surprise, they are zebras!). I really am interested in zebra things but I’m not sure I would enjoy working with patients who have them (because I’ve only ever seen them in books and it’s still very abstract, i don’t want to wish those on patients).

-The morning flies by and this is literally the most chill summer I’ve had in many years. 

-No surprise, I look too young to be in a white coat. I probably could alleviate that some by wearing makeup. But nah. I mean probably 3rd year I will but at this point I have no interest in having to do that every day. 

-I’ve gotten to go in and see patients by myself and do their history and physical. It’s interesting to see the dynamic in the families as they take turns sharing the history (or stay silent, as many kids do around a new person). I might actually be decent at this for normal pediatrician visits by the end of the summer. 

-This is going to sound judge-y and I mean this in a concern for a systematic whole rather than individual parents: A decent number of young ones (2 or under) came in with a phone or an iPad in their hands. I totally get why a parent might want to do that (I mean, especially if they are worried about the kid acting up/being distracting while another kid is having their check up). The recommendation currently is that children under 2 do not even watch television. I am imagining the same goes for a small electronic screen right next up to their faces. I just worry about what is going to happen to their brain. I know that when I was growing up the internet/computer games were starting to be a bigger thing and i’ve felt my attention span start to lapse over the years the more time I spend with electronics (that might not be true for everybody who uses electronics but it is for me). What happens if you do that with kids who are even younger? I also just don’t understand why elementary school children have cell phones (I saw so many while I subbed). Honestly I sound like a Luddite right now but I also think technology has plenty of good to offer (like in the elementary school classrooms some teachers have an iPad during their rotations that kids use to learn how to read/spell/do math/etc. and it makes it more engaging for them). It’s one of those everything in moderation things. Technology isn’t going away. 

-I’ve been able to ask a decent number of questions but feel like I am running out of small talk. 

-Trying not to fuss too much at myself about deciding if i would enjoy being a general pediatrician and instead I am just soaking it all in.