Friday, June 14, 2019

Please, be kind to your doctor. We need it.


By Sara R. Ahronheim, MD
Montreal Physician, Emergency Medicine

This article originally appeared on KevinMD.com.

There’s always so much to write about, and there’s never any time.  I work too much; it’s become evident recently that I need to cut down.  I have started noticing that things affect me much more than they ever did; there are days I hide my tears, and days I show my tears, when before the tears would have waited for the occasional (yes, occasional) shower.  This is a function of my level of exhaustion; if I were to plot it out on a bar graph like the kind my daughter is learning to understand in third grade, the intersection between the extremes of “time at work” on the x-axis and “lack of me time” on the y-axis would be the way I feel right now.  Burned out.

Burnout: a small word we use a lot recently, to describe a very complex situation.  Physicians (and I can only speak for this category of person as I am one) are suffering.  Many of us won’t mention it, won’t give it breath to solidify itself in our lives.  If we say it, we make it real, when it’s often easier to just push it away and deny it’s existence.  Burnout.  There, I said it again.  To be honest, I’m not always sure this is where I am; but I’d like to learn how to prevent getting there.

Physician wellbeing is another catchphrase, like “wellness”, that is getting a lot of air time these days in conversation and at conferences.  This is something I can hang my hat on, that I want to be a part of.  In my little corner of existence, I am going to step up and start working on improving my, and my colleagues’, wellbeing.  How?  Well, I have plenty of ideas.  Whether I can bring them to fruition is a good question, but I’m ready to try.

How can you help?  Can you help?  Can anyone?  I think so.  Here’s an idea.

Next time you’re in the emergency department, or your family doctor’s office, or visiting a specialist in clinic, try to think about how hard those individuals are working for your benefit.

Put yourselves in our shoes, for a moment, and see through our eyes.  See the way we have to hide our own emotions in order to help you get through yours.  See how we stay late to take care of your children, while our own children miss us at home.  See the glassy look in our eyes when we try not to cry as we tell your mom she will die within the year of a cancer we discovered by accident when we did a CT scan for kidney stones.  Look at my hands clasped tight, white, before me as I break the news that your brother did not make it after I worked for hours to the best of my ability, to save his life.

Physician burnout - a condition in which physicians lose
satisfaction and sense of efficacy in their work - has become
widespread in the medical profession, according to a recent report.
Look at all of us, stretched far beyond what we ever thought we signed up for, in a system where more and more sick people come to our door but we can’t hire more physicians to help see all of you faster.  When you have waited six hours and it’s 4 a.m., and I finally walk into the room with an exhausted look on my face and a droop in my shoulders, but I put on a smile and say “Hi, I’m Dr. A., how can I help you today” – please don’t crush me with your anger and your frustration.  Please understand we do our best and work our hardest to navigate fear, exhaustion, panic, sorrow; that we search to balance these with moments of joy of a new pregnancy diagnosis, or a hard-fought save in the resuscitation room.  We try so hard to give you good news, or break the bad news with empathy; to see you faster, more efficiently, without skimping on the care we give to each of you.

Please, look at me and see my heart, see my humanity, treat me as you would like me to treat you, with kindness.  Just because I am a doctor, wearing scrubs and a stethoscope and a messy ponytail with pens sticking out from all pockets and phones ringing every few minutes, just because of this garb I put on when I come to work, don’t decide I am any less of a person than you.  I feel what you feel.  I hurt as you hurt.  I bring your stories and your pain home, and I feel it over and over with you as you lie in the stretcher where I left you, and feel it yourself.  We feel this together.  You are not alone.  But when I go home, I am alone; no one knows your stories, no one sees the tears you cried when I told you the awful things I had to tell you. Those moments we had together, that changed your life, don’t think they haven’t changed mine.  They have. I am changed, by you, and you by me.  And it hurts.

So please, be kind to your doctor.  We need it.  We need kindness and compassion.  From you, from each other, from ourselves.  Help us heal, the way we try to heal you.

Sara R. Ahronheim is an emergency physician.

Wednesday, June 12, 2019

Your Phone Can Wait – The Dangers of Distracted Driving





By Katrin Lichtsinn, MD
Pediatric Resident at The University of Texas at Austin Dell Medical School
Member, Texas Medical Association

One of the biggest milestones in a teenager’s life is getting a driver’s license, but with this newfound freedom also comes a lot of responsibility. A big danger facing teenagers behind the wheel is distracted driving, which is defined as any activity that takes a driver’s attention away from driving. According to the Centers for Disease Control and Prevention (CDC), drivers under age 20 are more likely than any other age group to be involved in a distraction-related fatal crash. One in 10 (9%) of all teenage motor vehicle crash deaths in 2017 involved distracted driving. We physicians would much prefer our young patients stay safe. Otherwise, the consequences are just too tragic.

There are three main types of driving distractions: visual (eyes off the road), manual (hands off the wheel), and cognitive (not focused on driving). Texting is one of the most dangerous driving distractions, because it involves all three elements. According to CDC, in the five seconds it takes the driver to send or read a text, a car going 55 mph could drive more than the length of a football field (120 yards, or 360 feet). In that distance, a deadly crash could easily occur. According to recent studies, as many as four out of five (84%) teenagers have sent a text while driving in the last 30 days. In addition, adolescents who frequently text and drive have a high risk of other dangerous driving behaviors, including not wearing a seatbelt, driving under the influence of alcohol, and riding in a car with a driver who has been drinking alcohol.

Many states are fighting this growing problem by implementing bans on cell phone use while driving. As of this spring, 48 states and the District of Columbia had banned texting while driving, and 18 states and the District of Columbia had banned drivers from using a phone hand-held while behind the wheel. Texas has such a law: In 2017, Texas passed a statewide ban on using wireless communication devices for electronic messaging while driving. If caught reading, writing, or sending electronic messages via a wireless communication device while driving, first-time offenders can be fined up to $99 and repeat offenders can be fined up to $200. In addition, it is illegal for drivers under 18 years old to text or make any telephone calls while driving, even with a hands-free device.

So, what can teens and their parents do to make driving as safe as possible? First, parents need to model safe driving habits by always wearing a seatbelt and obeying traffic laws. Second, the American Academy of Pediatrics recommends creating a teen driving contract, which can start a discussion about expectations, the rules of the road, staying focused on driving, avoiding drugs and alcohol while driving or riding in a car, and being a responsible driver. By focusing their eyes, hands, and minds on driving, teenagers can more safely enjoy the freedom of being behind the wheel.

My physician colleagues and I want to keep our teenage patients safe and out of the emergency department, so I hope teens heed this advice.

Monday, June 10, 2019

Potentially Deadly Meningococcal Disease is Preventable

Editor's Note: This video is part of a monthly Texas Medical Association series highlighting infectious diseases that childhood and adult vaccinations can prevent. MeAndMyDoctor.com will post a video about a different disease each month. Some of the diseases featured will include: FluMeaslesPneumococcal diseaseHuman papillomavirus (HPV)Chickenpox and shinglesPertussis (whooping cough), Hepatitis ARubella (also known as German measles), RotavirusPolioMumps, Tetanus, and Hepatitis B.

TMA designed the series to inform people of the facts about these diseases and to help them understand the benefits of vaccinations to prevent illness. Visit the TMA website to see news releases and more information about these diseases, as well as physicians' efforts to raise immunization awareness.



In the video above, Maria Monge, MD, an Austin pediatrician/adolescent medicine specialist and Texas Medical Association (TMA) physician leader, talks about Meningococcal disease, its different strains, symptoms patients can experience, and the vaccines available to prevent it.

Meningococcal disease can refer to any illness caused by a bacteria called Neisseria meningitidis, also known as meningococcus. These illnesses include meningitis, an infection of the lining of the brain and spinal cord most commonly caused by the B strain of the bacteria; and bacteremia and septicemia, bloodstream-related infections. People are at risk of contracting these diseases if they are in close personal contact with anyone infected - including sharing drinks,and kissing- or if they live in close quarters such as college dormitories or military barracks.

Symptoms of meningococcal B infection include a sudden fever, headache, stiff neck, nausea, vomiting, and confusion. Patients might also develop a rash. According the National Foundation for Infectious Diseases, one in 10 people who contract the disease (even with treatment) will die; two in 10 will suffer serious and permanent complications. Long-term effects include learning difficulties, hearing loss, or limb amputation.

Although overall meningococcal disease is rare in the U.S., meningococcal B accounts for more than half of all meningitis cases nationwide. The Centers for Disease Control and Prevention (CDC) reported 10 meningococcal B outbreaks at universities located in seven states between 2013 to 2018, resulting in 39 cases and two deaths.

Meningococcal disease can be prevented with vaccines. The CDC advises people age 10 or older at risk for meningococcal disease, including those with a weakened immune system or living in close quarters, get vaccinated against serogroup (type) B. The CDC recommends the shots be given between ages 16 to 18. More than one dose is recommended to ensure best protections. Different meningococcal vaccines against serogroups A, C, W, and Y are also recommended for all adolescents.

Tuesday, June 4, 2019

Staying Safe When Traveling With Children

TMA staff member Erin Behncke and her family explore Tokyo, Japan. Courtesy of Erin Behncke.

By Mark Shelton, MD
Pediatric Infectious Diseases and Pediatrics, Fort Worth
Member, Texas Medical Association Committee on Infectious Diseases
Summer’s here, school’s out, and it’s a great time to hit the road.

Traveling is fun, and with children, it can be a great time to make lasting family memories. However, nothing spoils a trip like an accident or illness. With a few easy precautions, your trip need not turn into a disaster for you or your kids. 

The first step to safe travel is to know where you are going, what health risks may await you, and how to best minimize those risks. Map out your destination and find out such things as: what medical care may be available, what the vaccine requirements are, and the safety of the drinking water. The Centers for Disease Control and Prevention (CDC) has an excellent website, Travelers’ Health, and a mobile app version, TravWell, that lists CDC recommended vaccines, medicines, and potential health advisories for most destinations.

Avoiding Accidents
Believe it or not, the laws of physics apply to Texans on vacation! If not properly restrained, momentum will carry an adult or child traveling in a car through the windshield. Wear your seatbelts – even in a cab or a ride-sharing vehicle.

Just as your mother told you when you were little, look both ways before crossing the street – particularly if the drivers in the country you’re visiting drive on the left side of the road. This applies to people coming to the U.S. as well. There is a famous story about Winston Churchill looking the wrong way when crossing a street in New York City and spending months in a hospital.  

TMA staff member Debra Heater and her family at the
beach in Destin, Florida. Courtesy of Debra Heater
Accidents are one of the biggest health risks to Americans abroad. So, heads up, eyes open, and buckle up. Don’t forget car seats if appropriate for your child’s age and weight. Be smart and think before you do something you will regret later – especially on those popular new electric scooters!

Drowning is a leading cause of death among children and teens worldwide, so even on vacation, be sure to practice good water and swimming safety. Never leave children unattended near bodies of water (including small pools and spas), even for a moment, and be sure to put life jackets on children while on a boat. Choose swimming locations with a lifeguard on duty, and never allow children to swim alone in open water.

Food (and Drink) For Thought
Watch what you eat and drink. Nothing can spoil a trip abroad like five days of diarrhea. Be cautious in buying foods from street vendors and restaurants that appear to be unsanitary. The old adage of “cook it, peel it, or boil it, or forget it” is still great advice. This goes for water as well.

Bottled water and bottled drinks may be safer than public water supplies, but that is not always the case. Check the seal of your purchased bottled drinks. It is also important to make sure that if traveling with an infant and mixing formula, that a safe supply of water is available. If unsure, boil the water first. The CDC’s Can I Eat This? mobile app allows travelers to input the foreign food and drink they may be considering to help determine whether or not it’s safe for consumption.

A travel physician (a physician specialized in travel-related medicine) may prescribe antibiotics for diarrhea, depending on your trip. Mild diarrhea can be treated with bismuth salts like Pepto-Bismol, but prevention is best.


Be Wise, Immunize

TMA staff member Helen Kent Davis with her husband and
son in Spain. Courtesy of Helen Kent Davis
The most important travel vaccines for children are their routine vaccines. For the most part, and for most destinations, if children are up-to-date on their routine schedule, they may not need any additional vaccines. Depending upon where you are traveling and the child’s age, they may need vaccines for yellow fever, typhoid, hepatitis A, or meningitis. There may also be a resurgence of vaccine-preventable diseases at your destination, such as the recent measles outbreak in different states in the U.S. and other countries. This requires travelers to check that they are fully vaccinated against these highly-infectious diseases.

Most countries in the world do not have any vaccine requirements to visit. However, there are numerous countries that require yellow fever vaccine and a certificate when traveling from another country where yellow fever exists.

TMA staff member Amy Sorrel and her
husband in Byblos, Lebanon.
Courtesy of Amy Sorrel
Check with your travel medicine physician to determine what out of the ordinary vaccines might be needed depending on your destination. It is best to do this at least one or two months prior to travel, in order to have enough time to obtain an appointment, receive the vaccines, and for the vaccines to take effect – which usually occurs about two weeks after immunization.

If travel takes you to an area of the world where there is endemic malaria (mostly Central America and central Africa), it is important to take malaria prophylaxis. Multiple medication options are available. It is also important to have protection against mosquitoes, such as topical sprays or lotions which contain an EPA-approved repellant such as DEET.

Plan ahead, be prepared, and have a safe trip. When in doubt, consult your primary care or travel medicine physician.

Monday, June 3, 2019

Maternal Mental Health: Where Family Well-being Begins

Editor's Note: The following podcast episode, featuring interviews with Kaitlyn Doerge of Texas Pediatric Society  (a former Hogg Foundation Policy Fellow) and Adriana Kohler of Texans Care for Children, is part of the Hogg Foundation for Mental Health's podcast series Into the Fold: Issues on Mental Health.  They describe recent legislation, best practices, and resources for women to care for themselves and their children. The episode was previously published on the foundation's website.



As the Texas Medical Association's Healthy Vision 2025 campaign states, postpartum depression is not the "baby blues" that 50 to 60 percent of mothers experience in the first few months after delivering a baby. As many as one in seven new mothers acquire the serious psychiatric disorder known as postpartum depression. It's the tipping point where the physical, emotional, hormonal, and psychological changes surrounding pregnancy and birth gang up to create a dangerous mental illness in the mother.

"It is so overwhelming to the individual with the multitude of changes going on in every bit of their being that you've got to watch them," Eugene Hunt, MD, Dallas obstetrician-gynecologist, said. "We must address every lady who has a baby, when we're discharging them from the hospital, we better talk about postpartum depression. It's recognized. This is real. And you can save lives when it's talked about properly."

The Office on Women's Health at the U.S. Department of Health and Human Services advises new mothers to contact their doctor, nurse, midwife, or pediatrician if symptoms of depression begin within one year of delivery and last more than two weeks, tasks are difficult to complete.

For more information on postpartum depression, click here.

Thursday, May 30, 2019

VIDEO: Hepatitis B Infection Can Cause Liver Damage, Cancer

Editor's Note: This video is part of a monthly Texas Medical Association series highlighting infectious diseases that childhood and adult vaccinations can prevent. MeAndMyDoctor.com will post a video about a different disease each month. Some of the diseases featured will include: FluMeaslesPneumococcal diseaseHuman papillomavirus (HPV)Chickenpox and shingles, Pertussis (whooping cough), Hepatitis ARubella (also known as German measles), RotavirusPolioMumps, and Tetanus.

TMA designed the series to inform people of the facts about these diseases and to help them understand the benefits of vaccinations to prevent illness. Visit the TMA website to see news releases and more information about these diseases, as well as physicians' efforts to raise immunization awareness.



In this short video, Marilyn M. Doyle, MD, an Austin pediatrician and Texas Medical Association (TMA) physician leader, breaks down the severity of Hepatitis B, the age groups most affected by the infection, and why vaccinating is the best form of prevention.

Hepatitis B is a serious liver infection caused by the hepatitis B virus. Anyone can contract the virus if any bodily fluid from a person infected with the virus - like blood or semen - enters another person's body. This can happen through sexual contact, sharing needles, or an infected mother passing it to her baby at birth. Hepatitis B can either be short-term (acute) or long term (chronic). Those suffering from the acute stage often don't show symptoms, so they can spread the disease unknowingly. Infected people who do have symptoms can experience fever, fatigue, loss of appetite, stomach pain, nausea and vomiting, dark urine, a light-colored stool, or yellowish skin. Whether a person experiences symptoms or not, the acute stage of hepatitis B lasts about six months.

Age plays a factor on whether a case of hepatitis B becomes long-term. Nearly 90% of infected infants suffer chronic infection, compared to 2% to 6 % of adults. In many cases, chronic hepatitis B can lead to liver cancer or cirrhosis of the liver (scarring of the liver) or liver failure. It can even be deadly.

According to the Centers for Disease Control and Prevention (CDC), the rate of new hepatitis B infections dropped by 89% from 1991, when routine vaccination of children was first recommended. The number of reported cases dropped from approximately 8,000 cases in 2000 to nearly 3,200 cases in 2016. However, thvideoe CDC reports an increase in injection drug use is causing the rate of new infections to rise once again.

Vaccination is the most effective way to avoid hepatitis B. Infants are recommended to receive a three-dose series: one at birth, another at 1-2 months, and again at 6 months. The CDC recommends unvaccinated adults and adolescents receive a two-or three-dose series depending on the vaccine. Currently, there are six different vaccines in the U.S. against this disease.

Tuesday, May 14, 2019

Suicide: More common than ever

By Sid Roberts, MD
Lufkin Radiation Oncologist
Member, Texas Medical Association

Editor's Note: This article was originally published May 12 at The Lufkin Daily News and on Dr. Roberts' blog.

A Rice University classmate and friend of mine — a 57-year-old woman and mother of two — committed suicide on Easter Sunday. She was going through a divorce, but many of her college friends had been in contact with her one way or another in the weeks (and even the day) before she died. She seemed strong, resilient. Defiant, even. None of us saw it coming. Maybe we should have.

The suicide in 2018 of 55-year-old fashion designer Kate Spade captured our collective attention, because here was a wildly successful woman who, by outward appearances, appeared to have everything going for her. Yet, according to her husband, she suffered from depression and anxiety (others report bipolar disorder) for years. Even so, her death came as a surprise.

Suicide in middle-aged women is on the rise. Kate Spade is not the only celebrity woman to kill herself. Actress Margot Kidder, film producer Jill Messick, model L’Wren Scott and Mary Richardson Kennedy, estranged wife of Robert F. Kennedy Jr., have committed suicide in recent years. In fact, the suicide rate among middle age women (age 45-64) has jumped by an astounding 60% since 2000. The increase for women is more than double the increase for men. No one knows why.

Mental illness, substance abuse, loneliness and financial and relationship problems have all been linked to rising suicide rates. In a 2018 Wall Street Journal article, psychiatrist Samantha Boardman is quoted, saying, “Life satisfaction hits an all-time low in middle age,” and, “Depression and stress are particularly high in this age group. Juggling responsibilities and managing multiple roles takes a toll and can lead to feeling overwhelmed, a loss of control and despair.” But why are people less able to cope today?

Of course, with any one suicide you don’t always know the reason(s). Did the person leave a note? (My friend didn’t, but in retrospect, some of her communications signaled a finality.) Was the suicide planned, or was it an accident? (My friend’s appears intentional.) And as the recent uptick in suicides after the Netflix series ‘‘13 Reasons Why’’ is reported to demonstrate, suicide may be suggestible. For the survivors, questions are inevitable and often unanswerable. (Support groups are available for suicide loss survivors and can be of great benefit.)

According to the National Institute of Mental Health, there are multiple risk factors for suicide, and interventions and treatment will of necessity vary depending on individual circumstances. Medical therapies are most appropriate when the risk of suicide is related to underlying depression, anxiety or other mental illness. As much as we are a society that likes to medicate our problems away, medication is only a part of the solution for some, but not all, patients at risk for suicide. There is no magic bullet — or pill — for suicide prevention.

Psychiatrist Amy Barnhorst, writing in the New York Times, warned that suicide prevention is often difficult because family members rarely know someone they love is about to attempt suicide. Often that person doesn’t know herself. She advocated “tried-and-true” strategies for working with people at risk of suicide, like limiting access to what she called “lethal tools” (drugs and firearms primarily) and working as a society to improve access to resources like alcohol and drug treatment and individual therapy. “Antidepressants can’t supply employment or affordable housing, repair relationships with family members or bring on sobriety,” she wrote.

Knowing how to gauge how overwhelmed a person is, or the point beyond which there is no return, is hardly a scientific enterprise. And yet we must try, individually, as family and as a society. Lots of people think about suicide, as it turns out (I did, as a teen). Thankfully, most never act on those thoughts (I didn’t). Common teaching is that if we think someone is depressed, we should talk to them specifically about their emotions, not judgmentally or dismissively, and even ask if they are thinking of hurting or killing themselves. That can open the door to getting professional help.

But data are conflicting about how open people are with their feelings and intentions. One study said nearly 80% of suicide victims deny suicidal thoughts before killing themselves. Others say that one-half to two-thirds of people who attempt suicide express thoughts about committing suicide, even if only one-third of those ever make an attempt. How do we identify and screen for those at risk for suicide? We must be willing to have an open conversation on multiple levels. Patricia Todd, a licensed professional counselor and mental health advocate who is herself the mother of a suicide victim, believes we have a moral obligation to educate the minds and hearts of those around us about all things mental health. Only then can we begin to eradicate the debilitating stigma that is too often attached to suicide.

Our primary care providers are on the front line of mental health care in this country. Reportedly, three-quarters of those who commit suicide have been seen by a primary care provider in the year prior to their suicide. One might conclude that our PCPs would know patients the best and could screen patients for suicide risk. Knowing how busy PCPs are — and how little face time they have with each patient they see — it is unrealistic to expect that mental health screening questions be a routine part of every visit or intake history and physical exam on every patient. Indeed, the U.S. Preventive Services Task Force, an independent panel of experts that makes evidence-based recommendations about clinical preventive services, looked into this and concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in adolescents, adults, and older adults in primary care. Nonetheless, all physicians should be willing and ready to dig deeper when patients express feelings of depression, despair, and hopelessness.

Facebook, after all, is looking. Businessinsider.com reported that Facebook has been monitoring users’ posts since 2017 for warning signs that they might be at risk of suicide, and has even sent emergency responders to users’ houses more than 3,500 times. Who knew? And based on what criteria? My friend who committed suicide was a regular Facebook poster, and Facebook apparently didn’t tag her as being at risk.

Radiologists and researchers in Pittsburgh believe they have found a way to distinguish between individuals with and without suicidal thoughts with a brain imaging technique known as functional MRI. Even if this proves to be accurate, this is hardly a practical or cost-efficient method to screen people. It is a provocative idea nonetheless. It makes sense that suicidal brains think differently.

The bottom line is we cannot — yet — rely on computer algorithms or brain scans to identify those at risk of committing suicide. Until we have a better understanding as to why more people are killing themselves — and how to identify those at risk — every one of us must be vigilant.

What can you do? First, know what to look for. NIMH warns that suicidal thoughts or actions are a sign of extreme distress, not a harmless bid for attention, and should not be ignored. The Centers for Disease Control and Prevention lists 12 suicide warning signs: feeling like a burden; being isolated; increased anxiety; feeling trapped or in unbearable pain; increased substance use; looking for a way to access lethal means; increased anger or rage; extreme mood swings; expressing hopelessness; sleeping too little or too much; talking or posting about wanting to die; making plans for suicide. The National Alliance on Mental Illness urges that any person exhibiting these behaviors should get care immediately: putting their affairs in order and giving away their possessions; saying goodbye to friends and family; mood shifts from despair to calm; planning, possibly by looking around to buy, steal or borrow the tools they need to complete suicide, such as a firearm or prescription medication.

Communities are starting to put together Crisis Intervention Team programs, working with law enforcement, mental health experts and community and religious leaders to respond more effectively to those experiencing a mental health crisis. Communities that don’t have this type of formal program should get one started.

If you know someone exhibiting these warning signs, take action. The CDC lists five simple steps to help someone at risk: 1. Ask; 2. Keep them safe; 3. Be there; 4. Help them connect; 5. Follow up. If you or someone you know is in crisis, call the toll-free National Suicide Prevention Lifeline at (800) 273-TALK (8255), 24 hours a day, seven days a week. Another option is to chat online with someone at suicidepreventionlifeline.org. These services are free and confidential.

Dr. Sid Roberts is a radiation oncologist at the Temple Cancer Center in Lufkin. He can be reached at sroberts@memorialhealth.org. Previous columns may be found at angelinaradiation.com/blog.
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