Categories
Clinical Patient-Centered Care Psychiatry Public Health

If you don’t ask, you’ll never know

On the first day of my first rotation as a medical student, my preceptor shared this bit of wisdom: if you don’t ask, you’ll never know.  In the nearly 18 months that have followed, I think about those words on a daily basis. To my mind, asking questions does more than just help us gather data. Asking questions establishes the type of relationship we are going to have with our patients. There are so many questions I wish I would never have to ask, whose affirmative answers are often indicative of the cruelty of this world. But when I ask about things like whether a patient has been the victim of abuse, I hope it sends the message that the relationship we are about to embark upon is one that can withstand such unpleasantness.

Not only can it be excruciatingly frustrating when other practitioners don’t share this point of view, it potentially has grave consequences. Unfortunately, patients with mental illness often seem to be the victims of physician “brush-off.” As someone who plans to devote her life to working with the mentally ill, I can only hypothesize as to why the same patients I find so much joy in working with are often given sub-par medical care as compared to their non-mentally ill peers. Perhaps physicians feel uncomfortable providing care for patients who come across as different than the norm, or perhaps their medical problems are too frequently attributed to psychiatric causes.

I recently cared for a patient who was two weeks post-partum from the birth of her first child. Though she was being seen for psychiatric admission, multiple aspects of her health were addressed during our initial evaluation.  When asked about her post-partum health, she denied having been scheduled for a post-partum visit with her obstetrician. Casually, she mentioned that she was having some malodorous green discharge since giving birth. It doesn’t take a medical degree to know that green, foul-smelling discharge is not a good sign, let alone when it occurs in the immediate post-partum time period. We were able to secure a next-day appointment with our hospital’s obstetrical practice, and with the patient’s permission, called ahead to the clinic to alert them of her complaints.

The next day, the care team gathered around to read the note from the obstetrician who had seen our patient. The note comprised all of five lines.  There were no pending labs. There was no mention of a physical exam.

There was no mention of the discharge at all.

The American Congress of Obstetricians and Gynecologists (ACOG) states, “It is recommended that all women undergo a comprehensive postpartum visit within the first 6 weeks after birth. This visit should include a full assessment of physical, social, and psychological well-being.”[1] The issue here, though, isn’t really about post-partum care. The issue here is about how we as health care providers need to provide equal care for unequal bodies and minds, and how we need to protect and advocate for our patients.

Patients with mental illness undeniably have poorer overall health. The average lifespan for an American adult with mental illness is a striking 30% shorter than for a non-mentally ill individual.[2]  While it is known that mental illness itself creates difficulty in accessing the healthcare system, for mentally-ill patients who do access healthcare, their quality of care is demonstrably lower than it is for those without mental illness. Literature consistently demonstrates that patients with psychiatric diagnoses receive fewer preventative health measures and have overall poorer quality healthcare than patients without psychiatric diagnoses.[3],[4] No matter what field of medicine you are in, you will see patients with mental illness. For these patients who sometimes cannot speak for themselves, the role of the physician in patient advocacy becomes even more crucial.

I will never know exactly what transpired during that appointment between my patient and the obstetrician, but I do know that obstetrician did not ask the questions that needed to be asked, and therefore did not ascertain the information necessary to appropriately care for the patient. At our request, a different practitioner saw the patient again. This time, the appropriate questions were asked, the appropriate testing was completed, and ultimately the patient was diagnosed with a sexually transmitted infection. Left untreated by the first obstetrician, this infection could have caused my patient systemic symptoms and permanent infertility.

As future physicians, it’s important for us to keep asking questions. So often, I have been surprised by the information I find when I ask a question about which I almost kept silent. Equally as important as asking the questions, however, is doing something with the information that you receive. The good doctor isn’t necessarily the one that stops the green discharge; they’re the one the identifies the problem in the first place and advocates on behalf of the patient to get the best people for the job.

[1] https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Optimizing-Postpartum-Care

[2] http://europepmc.org/abstract/med/19570498

[3] http://journals.lww.com/lww-medicalcare/Abstract/2002/02000/Quality_of_Preventive_Medical_Care_for_Patients.7.aspx

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951586/

Photo credit: airpix

Categories
General Law Lifestyle Public Health

Keeping Abreast of Lactation Laws

Infant forced to go without milk, Mom says it’s not her fault.” This seems like the kind of terrifying headline that would be on the five O’clock news. Yet this is exactly what happens every day when the rights of women to breastfeed or express milk on the job go unprotected. One politician, Representative Carolyn Maloney (D-NY), has made it her mission to make sure that women can breastfeed without repercussions. I have to admit that when I first heard about Representative Maloney’s Supporting Working Moms Act, I was baffled to think that in the year 2017, breastfeeding in the workplace could cost a woman her livelihood. With a little research, I started to realize just how ill-informed I was on the legality of breastfeeding.

I was surprised to learn that currently, no federal legal protections exist to protect public breastfeeding. Furthermore, only 47 states have laws that legalize public breastfeeding.[1] Of those states, Michigan’s law is a mere three years young. Astonishingly, Iowa offers no legal protections for breastfeeding. Even though public breastfeeding might be legal in most states, it wasn’t until 2010 that breastfeeding in the workplace received its own set of protections. A federal breastfeeding provision called “Break Time for Nursing Mothers,” which was added as an amendment to the Affordable Care Act (ACA), makes it mandatory for companies with 50 employees or more to provide “reasonable” break time for women to express milk during the first year of their child’s life. This same provision also requires companies to provide a clean and dedicated space for breastfeeding in the workplace.[2] However, this provision only ensures the rights of “nonexempt” workers, meaning only those who earn hourly wages as opposed to salaries are protected. Even with the laws that protect the right to breastfeed in public, women can still face repercussions that range from fines to docked pay to even termination as a direct consequence of breastfeeding in the workplace . With the ACA in jeopardy of being repealed (possibly by the time this article is published), the future of breastfeeding is more vulnerable than ever. The Supporting Working Moms Act is meant to provide federal breastfeeding laws independent of the ACA, as well as expand protection to 12 million additional women, including public school teachers.[3]

The issue of breastfeeding is close to my heart, not only as someone who hopes to one day become a mother, but also as a future physician: I know the powerful impact that breastfeeding can have on a child’s health. In their policy statement on the use of human milk, the American Academy of Pediatrics affirmed their position that infants should be breastfed exclusively for the first six months of their lives whenever possible.[4] Breastfeeding can be challenging for a number of reasons, and it is important to respect the fact that not all mothers are able to breastfeed their children. However, for those who can and choose to do so, the benefits can be profound for both the mother and the child. According to the National Institutes of Health, breastfeeding helps infants fight infection, lower their risk of Sudden Infant Death Syndrome, and could possibly serve as a protective factor against developing asthma, allergies, and even diabetes.[5] Studies show that babies who are breastfed attain better educational achievement than their non-breastfed peers by the age of five.[6] From an economic perspective, breastfeeding has been shown to lower healthcare costs by reducing disease burden in the population.[7] Even though many of us will not be pursuing careers in obstetrics, at some point in our careers, we will all establish some connection to a new mother, whether she is your patient, your partner, or yourself. Being informed about the legality of breastfeeding can help us to provide these women with support and guidance and make sure that our littlest patients have the healthy start in life that they deserve.

References:

[1] http://www.ncsl.org/research/health/breastfeeding-state-laws.aspx

[2] https://www.dol.gov/whd/nursingmothers/Sec7rFLSA_btnm.htm

[3] https://maloney.house.gov/issues/womens-issues/breastfeeding-0

[4] http://pediatrics.aappublications.org/content/129/3/e827

[5]https://www.nichd.nih.gov/health/topics/breastfeeding/conditioninfo/Pages/benefits.aspx

[6] https://ora.ox.ac.uk/objects/uuid:13bde0c7-0070-43c6-9ae3-307478e8c42c

[7] http://www.reuters.com/article/us-breastfeeding-study-idUSTRE6342ZG20100405

Photo Credit: Roberto Saltori

Categories
Clinical Emotion Empathy General Patient-Centered Care

Opinions Aren’t Facts

I wanted to discuss an experience I had in the newborn nursery. I was assigned to Baby K—a small baby girl who was delivered by emergent cesarean section because her mother abused cocaine during her pregnancy. Looking through Baby K’s chart, an unsettling feeling came over me. This was one of the first times I directly saw how a mother’s behavior impacted her child. Before this, all my clerkships had dealt with adults who were responsible for their own health. Seeing an innocent newborn enter this world with a disadvantage because of her mother’s actions was disheartening.

With this in mind, I went to talk to Mother K the next morning. The chart stated Baby K was going to be given to her great-grandmother, and I needed to confirm this information. I could immediately tell that Mother K was upset when I asked her to confirm. She said, “Yes, she’s going to her great-grandma, but I’m still going be involved! I’m NOT giving up on her!” I realized that just asking the question caused her emotional pain. Especially since the social worker, the nurse, and probably several others, had also asked this question. She again assured me that she loved Baby K, but that she just needed to get her life together before she could care of her. After talking more to Mother K, I realized she was trying her best.

This experience opened my eyes to my perception of patients. After browsing Mother K’s chart and reading that she continued to abuse cocaine while pregnant and was planning on giving Baby K to another caretaker, I may have made the assumption that she didn’t want anything to do with Baby K at all. This assumption may have been reflected in the way I asked her questions, leading her to become distraught. Many patients, especially those who suffer from substance abuse, have lost complete control over their actions. Their mind is controlled by an addiction, and they need help before they can take care of others. After talking more with her, I learned that Mother K actually planned to enroll herself in a treatment center that has housing. After getting better, she yearned to resume care of Baby K. These are details that were never mentioned in any notes, but if they had been mentioned, may have altered my first impression of Mother K before I met her. I also learned that Mother K continued to use cocaine during her pregnancy because she didn’t realize its impact on Baby K. She used cocaine during her prior pregnancy with her older son, and he remained “normal and healthy.” Even though we, as medical professionals, can understand how abusing cocaine during pregnancy is directly detrimental to the fetus, many individuals may not understand this basic concept of maternal-fetal physiology. We thought Mother K’s use of cocaine was due to her lack of care for Baby K, when in reality it was fueled by her lack of knowledge.

The most important lesson I learned was not to judge patients based on chart review alone. I know this seems like “common sense,” but it can be easy to jump to certain perceptions after reading the tone of some of the notes in a patient’s chart. My goal in the future is to enter every patient’s room with a blank slate. Our duty has always been to provide the same quality of care for all patients, regardless of their actions or beliefs, but sometimes we let our feelings get in the way of this duty. I have struggled with this in pediatrics more than I have in any other specialty. When I talk to parents who are willing to move mountains for the health of their children, I feel endearment towards them. There is nothing stronger or more special than a parent’s love. In contrast, with parents like Mother K, it is easy to become frustrated. After examining Baby K, I kept thinking about her fragile little arms and small shrunken head. Baby K may grow up to have health consequences that could have easily been prevented. All I can do is allow this experience to shape future patient encounters. I’m going to try to place myself in each parent’s situation and ask myself: what information or advice would I find the most helpful right now? At the end of my time with Mother K, I gave her a tight hug—I’m rooting for her. I hope she is able to complete her treatment and be reunited with Baby K soon.

 

Photo credit: Weird Beard

Categories
Lifestyle

Blue bird day, fresh pow, and a baby on the way

Meet Laura Matsen Ko, orthopedic surgeon, avid runner/skier/hiker/cyclist, and new mother to a  beautiful baby boy, Logan.  Laura and her husband, both orthopedic surgeons at Orthopedic Physician Associates (opaortho.com), practice and adventure in the Pacific Northwest. Together, they developed the website, seattlejointsurgeons.com, which allows patients to access comprehensive and accurate information on orthopedic care.

I met Laura recently on Instagram via a post shared by Oiselle (oiselle.com), a Seattle-based women’s running apparel store named after the French word for bird. In the post, photographed by Kevin, Laura is captured as a pregnant backcountry skier posed on the summit of snowy Mt. Baker.  A flurry of follow requests, instant messages, and emails between us quickly snowballed into a cross-country friendship.  Our easy rapport is not unexpected considering our shared passions. We are both passionate about helping injured athletes (and specifically pregnant athletes) get back to their sports as soon as possible.  After learning of my research interests in antenatal exercise, Laura agreed to a semi-formal interview about her background and experiences related to exercise during pregnancy.

 

First, tell me a little about yourself. I did some Instagram sleuthing and noted scrubs, ortho, a lot of snow, and Thomas Jefferson.

I was born and raised in Seattle, Washington. I went to Whitman College in Walla Walla, WA where I enjoyed being an outdoor leader on backcountry ski trips and mountaineering trips. My senior year I decided to go out for Cross-Country, and surprised myself by placing 9th at Nationals (D3).  Then I bike raced that spring and got 2nd at Nationals (D2). That was a huge surprise and a thrill.

I went to medical school in Portland, Oregon at Oregon Health and Sciences University (OHSU) and continued on at OHSU in an Orthopedic Surgery residency. I did two Ironmans while I was there, including qualifying for, and finishing, the world championship in Kona, HI.

About that time I got to meet my husband who was a year behind me in the Orthopedic Residency, and I finally convinced him to go for a real date with me after one of our rainy runs together.  Throughout residency we trained for various marathons together and enjoyed active vacations; anything from cycling to backcountry skiing. 

After we finished residency, we headed to Philadelphia. I did a fellowship in Adult Reconstruction. I chose the field of hip and knee joint replacement surgery because it gives me the opportunity to help people return to the activities they enjoy using surgery and personalized rehabilitation.

 

How many years have you been a backcountry skier and mountaineer?

My father and older brother taught me in my teenage years.  We had been backpacking our whole lives, they had been climbing, and I always aspired to go out with them.  When I was 13 I took a year-long course with my Dad to learn how to safely rock climb, mountaineer, snow camp, and manage avalanche risk and rescue.  That winter my brother took me out in the backcountry and I got stronger and smarter. That summer we climbed five Washington volcanic peaks including Mt Rainier.

 

What kind of role does skiing have in your life?

Backcountry skiing is a wonderful treat—unlike running it does take a bit of equipment and a bit of driving but it’s totally worth it! I love getting out into the wilderness without anyone around. I equally love the hiking up (“skinning” up) the mountain as much as the fresh, sweet turns on the way down!

 

Tell me about your pregnancy.

Logan was my first pregnancy.  I have always been active, and continuing my activity seemed right to me.  I bike-commuted to my work at the hospital, rain or shine, which was about a 15-mile commute. I did this through my second trimester, and then we decided it was too high of a risk to continue cycling due to the short and often rainy dark days in Seattle.  My OB, husband, and father all pushed me to stop bike-commuting.  I ran up to two weeks prior to him being born.  I skied two days before he was born—in bounds alpine one day and three days of very rigorous backcountry skiing.  These were about 6 hour days of hiking hard uphill and then skiing down in fresh powder.  It was so fun to feel like I was sharing this experience with Logan.

Multi-night mountaineering trip in the Washington Cascades with husband Kevin at 18 weeks gestation.
Multi-night mountaineering trip in the Washington Cascades with husband Kevin at 18 weeks gestation.
Hike with my Dad at 19.5 weeks gestation.
Hike with my Dad at 19.5 weeks gestation.
Seattle Half Marathon at 32 weeks gestation.  Time: 2:00.
Seattle Half Marathon at 32 weeks gestation. Time: 2:00.

The day I went into labor I did elliptical and weights and performed a major total hip revision surgery.  Throughout the second half of my pregnancy I had some issues with SI joint and foot pain, but in general my body held up well.

I did a lot of research about heart rates, but the data seemed inconsistent. 

 

Laura’s difficulty navigating antenatal exercise guidelines is not surprising.  A study by Lieferman (2012) demonstrated that almost half of medical providers (48%, N=89) were unfamiliar with current national exercise guidelines for pregnant women and half of respondents advised a reduction in exercise in the third trimester, even for uncomplicated pregnancies.  Concurrently, a 2006 study demonstrated that about half of surveyed obstetricians recommended heart rate maximums and a reduction in exercise load during the third trimester—two policies not specified in current guidelines (Entin, 2006).

The American College of Obstetrics and Gynecology (ACOG) and the U.S. Department of Health and Human Services recommend that healthy pregnant and post-partum women engage in 30 minutes of moderate intensity exercise for most, if not all, days of the week (ACOG, 2015; DHHS, 2008).  Pregnant women who habitually perform vigorous-intensity aerobic activity may engage in higher intensities under the guidance of a medical provider.  Heart rate maximums are no longer indicated.  Instead, pregnant women use ratings of perceived exertion to monitor their exercise intensity.  For most women, moderate effort is comparable to a brisk walk, at an intensity one can maintain for hours. It should result in heavy breathing, but not so much that the exerciser is unable to hold a short conversation. Vigorous activity, on the other hand, should make the exerciser feel short of breath, but still able to speak a sentence.

Obstetrics (OB) providers are encouraged to educate women about the health benefits of exercise during pregnancy. These benefits include improved gestational diabetes control, lower rates of antenatal and post-partum depression, and relief for back pain.  There are several absolute contraindications to exercise during pregnancy, including incompetent cervix or cerclage, multiple gestation at risk of premature labor, persistent second- or third-trimester bleeding, and preeclampsia.  For a full list of absolute and relative contraindications, consult the ACOG Committee Opinion Number 650 (ACOG 2015).  Certain activities are also identified as safe or unsafe.  Unbeknownst by Laura, down-hill snow skiing is listed as an activity to avoid due to an inherently high risk of falling and subsequent abdominal trauma.

Laura continues:

I didn’t really follow [the guidelines] after talking with friends and reading.  I didn’t do sustained high intensity intervals, but if I was running stairs and my heart rate got up to 165-170 on the way up but dropped to 120 on the way down, I felt that my baby was getting sufficient perfusion.  Each mother has a different pregnancy experience and the biggest factor is to listen to your body.  Exercise made me feel happy and alive so I kept doing it.  Plus pregnancy can do such a warp on body image.  Exercise helped normalize my feelings about the changes in my body.

 

Why do you think it is most important to listen to your body?

We are all so different. As you’ve seen with your med student classmates, we need different amounts of sleep, caffeine, food, exercise, fresh air… so no single guideline will work.  We all must strive to learn our bodies. 

My physician friend had a 10-lb baby.  She was extremely active, and pre-pregnancy she ran and played soccer.  Obviously our pregnancy (and delivery and post-partum) experiences were totally different and not fair to compare.  She says she tried to play soccer 7 weeks post-partum and she “felt like her uterus was going to fall out.” Another physician friend had a 9 lb baby with a very large head.  She was walking over 5 miles a day until she delivered, but is challenged to get back to walking more than a couple blocks now (2 weeks post-partum) after her more traumatic vaginal delivery. A third physician friend who had always been extremely active in basketball and volleyball was placed on bed rest at 22 weeks for all three of her babies. 

I never want to be compared to other women or make other women feel that they just didn’t push hard enough because of my activity levels.  I’m one person and this was one pregnancy. The next pregnancy could be totally different!  These other women are a lot tougher than me—they had a more challenging pregnancy, delivery, and recovery.  And they had to be very patient with their bodies.

 

Did you have any conversations with your OB provider(s) about your exercise practices during the pregnancy?  

Yes… some. They thought I was a little nuts but were supportive.  Except for the skiing.  My OB was a little shocked to hear that I’d been skiing.

In the first couple weeks post-partum I mostly tried to work on some baseline fitness with walking and stairs.  I tried to wait until 6 weeks to really increase my activity but I wasn’t able to wait.

 

Explain the 6 week mark. 

Well I was told by my OB and the nurse practitioners to not exercise hard until 6 weeks.  BUT I started running at day 16 and as of 4 weeks was up to about 30-40 miles a week with one day of hill repeats and one day of fartleks. I made it to 8 miles in sub 8 pace with a couple 7:30 until around 4 weeks.  I think my first race will be a half marathon at 2.5 months postpartum.  I’m not going to be the fastest.  Partly because of recent pregnancy but also because of sleep deprivation, returning to work, and not having enough time in the day!

16 days post-partum. 7.2 mile run with baby Logan and husband Kevin at 8:37 minute pace.
16 days post-partum. 7.2 mile run with baby Logan and husband Kevin at 8:37 minute pace.

Do you have any friends who also skied during their pregnancy?  

 I knew people who were running and rock climbing in their pregnancy and a lot of friends who just stayed fit with walking.  I don’t know anyone else who skied during their pregnancy but I’m sure people out there do it!  I’d mainly suggest borrowing your father’s huge rain coat and possibly his ski pants because there is no way you’re fitting in your bibs from pre-pregnancy.  And don’t push the speed and steepness; mostly enjoy being out there!  You don’t want to fall.

There are definitely other pregnant skiers and a few inspired, future Mamas:

5

On the mountaineering trips, what, if any, issues did you have with harness fit?

Due to the season I didn’t mountaineer in the second half of pregnancy, so it wasn’t an issue.  One of my friends got a lower and upper body harness for her pregnant rock climbing trips.

 

What kinds of emotions did you encounter during your pregnancy when you were not able to do activities that you enjoy?

I found it super frustrating when others placed restrictions on me. My husband quickly found that he had to present my change in activities as a risk/ benefit. When he told me “no more cycling,” I just wanted to rebel. However he did recently have to fix a clavicle fracture on a woman who was 16 weeks pregnant. She got hit while bike commuting. Thankfully her fetus is okay.  That story will make me more conservative with my cycling in my next pregnancy.

At 4.5 weeks post-partum I restarted bike-commuting to work for some half days of clinic.  It felt amazing to be back out there and I was so much faster with less weight, higher lung capacity, and likely an increased hematocrit. 

 

Is there anything you want to tell future mothers? 

Listen to your body and don’t read too much.  Wear support stockings if you work on your feet.  Know that you will lose the weight.  Fast. 

 

Physicians?

Support your patients.

For future and current obstetrics providers, the Canadian Society for Exercise Physiology developed the PARmed-X for Pregnancy, a physical activity readiness medical questionnaire that guides discussions on exercise during pregnancy in an outpatient setting.  The form may be accessed online (http://www.csep.ca/cmfiles/publications/parq/parmed-xpreg.pdf) and is useful for most pregnant women.  Athletes, however, have sport-specific safety concerns, training goals, and requirements that may be unfamiliar to the average obstetrics provider.  These topics may be explored on an as-needed basis during prenatal visits.

A big thank you to Laura Matsen Ko for sharing your inspiring story!  Thank you also to my friend Hannah, who initially tagged me in the Oiselle Instagram post.

 

References

  1. Leiferman, J., Gutilla, M., Paulson, J., Pivarnik, J. (2012). Antenatal physical activity counseling among healthcare providers. Open Journal of Obstetrics and Gynecology, 2, 346-355
  2. Entin, P. L., Munhall, K. M. (2006). Recommendations regarding exercise during pregnancy made by private/small group practice obstetricians in the USA. J Sports Sci Med, 5, 449-458.
  3. American College of Obstetricians and Gynecologists. Physical activity and exercise during pregnancy and the postpartum period. Committee Opinion No. 650. Obstet Gynecol 2015;126:e135–42
  4. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans.  Department of Health and Human Services Washington, DC; 2008.

Featured image:
Laura Matsen Ko skiing. Photographed by Kevin Ko.