Tuesday, November 5, 2013

Life Changing

A few weeks ago I gave birth to a little girl.  People told me that everything would change.  I figured that, for the most part, these folks were right.  While on maternity leave, I have had some time to think about the whole experience.  Here are my thoughts right now.

1. I love this little person, and she can't even say "hello."  My heart nearly exploded when I first saw her.  She can't hug me or kiss me, she can't write "mommy" in shaky letters, and she can barely focus on my face, but I love her.

2. I have a new respect for my own parents.  As I have become an adult, I have realized that my parents are people - not just parents.  That's a weird realization, but it has helped me see them in a new - and more forgiving - light.  Now that I am a parent, I appreciate all that they have done for me even more than I did before.

3. I still want to work.  I love what I do, and even though I will be more anxious to come home at the end of the day, I can't imagine giving up my job.

4. I love my partner more and more each day.  To watch him with our daughter, my soul swells with pride and happiness.  It makes for some challenges for sure, but it also has brought us closer together.

5. I have a renewed commitment to the under-served and unheard.  I want more than anything for my daughter to see the struggles that many people have, to appreciate how blessed we are, and to have empathy for those around us.  I hope to be able to volunteer with her, travel with her, and teach her how to put the Golden Rule into practice.

I'm sure the next several years will be filled with more realizations and lessons.  I only hope I can be a good example for her, someone she is proud of, and someone she wants to emulate.

Sunday, September 15, 2013

A Moment of Clarity

I saw one of my HIV+ patients last week.  He has had a rough few months.  He ended up homeless, and he was staying with a "friend."  The friend's sons found out he was HIV+ and beat him up.  I had no idea this sort of thing still happened in America.

The rest of his difficulties have been self-inflicted.  He is an alcoholic, although he had not been willing to accept this diagnosis.  He kept surrounding himself with people who would take advantage of him.  He kept putting himself in situations where he'd end up losing his money or sometimes the shirt off his back (literally).  He would ride his bicycle drunk and break his arm.  He'd black out and have a seizure.  He'd lose his HIV meds and be without them for days a time.  He would talk about how he has bad luck or about how other people are terrible.  I would try to bring up that perhaps it was the choices he was making that was putting himself in these bad situations.  He never really saw it.  His eyes would glass over, and I could see that he wasn't getting it.

Last week he came in and said he recognized that he was an alcoholic.  He said he realized this after he spent 12 hours at a bar that he didn't want to go to with people he didn't want to see.  He spend $40 he didn't really have.  Some guy asked for his favorite hat, and he just gave it away.  He said he realized he was doing all of these things that he didn't really want to do, and the reason he was doing them was because of the alcohol.

I could see that he had a moment of clarity.  He was 2 weeks sober when I saw him, and he really seemed committed.  Whether he can stick with it remains to be seen, but I this is the first step in what could be his recovery.

Thursday, May 9, 2013

Human Papillomavirus Vaccine - why the controversy?

I have been preparing for an interview about Human Papillomavirus (HPV) and the HPV vaccine.  There has been some controversy around this vaccine, mostly as it relates to some state governments mandating the vaccine through schools (1).  I admit that as an Infectious Disease doctor, I am an advocate of vaccines, but I did a little research on the topic so as not to sound like a total fool in the interview.  

The quadravalant vaccine is Gardasil, from Merck.  It covers strains 6, 11, 16 and 18.  Strains 6 and 11 account for 90% of genital warts, and 16 and 18 account for 70% of cervical cancers.  Right now, the vaccine is recommended for girls and boys ages 11-12, but can be given in ages 13-26 if they haven't been vaccinated previously.  It is a 3 shot series given over 6 months (2).  

Genital warts are associated with depression, sexual dysfunction and a disruption in long-term relationships. 

HPV is associated with a lot of types of cancer:

-       Cervical cancer: Almost all are linked to HPV.  12,000 US women per year are diagnosed, 4,000 die per year.  
-       Vulvar cancer: 50% linked to HPV
-       Vaginal cancer: 65% linked to HPV
-       Penile cancer: 35% linked to HPV
-       Anal cancer: 95% linked to HPV
-       Oropharyngeal cancer*: 60% linked to HPV (3)

Now, it is important to note that not every women who gets a high risk strain of HPV (most commonly 16 and 18) will get cervical cancer.  One expert stated that 95% of women who have HPV will never have a malignant transformation - they will not get cancer (4).  The problem is that right now, we are not able to predict which women will, and which will not, get cancer.  

When I was in medical school, part of our obstetrics rotation was to do 2 weeks on Gyn-Onc, which was short hand for "gynecologic oncology."  This was an extremely sad rotation, where I helped to care for women with gynecologic cancers.  Most of them were too young to be battling cancer.  Most them had children.  Most of them did not do well.  When you have to watch a young mom die of cervical cancer, it influences your perspective on the cancer vaccine.  

I understand the controversy: we are recommending that girls who are too young to be having sex get a vaccine to prevent a sexual disease which might lead to cancer.  The point is to vaccinate these girls and boys before they start being sexually active.  And sexually active is more than just sex.  Noncoital contact (eg., oral-genital contact and hand-genital contact) can spread HPV.  One study looked at girls prior to their first vaginal intercourse, and found that of those who were positive for HPV, 10% had never had any sexual contact and 90% had at least one episode of noncoital contacts (Shrew ML et al. High Frequency of Human Papillomavirus Detection in the Vagina Before First Vaginal Intercourse Among Females Enrolled in a Longitudinal Cohort Study. J Infect Dis 2013;207:1012-15).  

Vaccination makes sense to me.  I agree with one parent who said that the repulsion to this vaccine is probably not due to the science behind or efficacy of the vaccine.  It's probably due to parents getting a little squeamish thinking about their 11 year old daughters some day (soon?) becoming sexually active.  It's probably a little unnerving to think about that messy-haired girl with dirty fingernails in sweatpants starting to come in to her own sexuality.  Unfortunately, saying no to the vaccine is not going to put the brakes on her development.  She will grow and find love - the puppy kind, the right kind and the wrong kind - and I think that parents should be willing to protect their daughters (and sons) from a potentially deadly, and very preventable, infection.

*I saw a young patient with HPV of the larynx, and he had multiple laser surgeries to remove the growths, but they kept coming back.  He couldn't breath and eventually couldn't talk.  His HPV spread to the lungs, and he was diagnosed with terminal lung cancer.

Sunday, January 27, 2013

When Empathy Fails

I consider myself an empathetic person.  In fact, according to a common personality test, I'm an INFJ - Introvert, iNtuitive, Feeling, Judging.  I place a lot of value in my ability to read people and understand where they are coming from.  However, I have a very difficult time relating to and understanding parents with sick children.

Most of the "children" I take care of are 16 years or older.  I have been consulted in these children for various infectious complications of their baseline situations.  These children have brain injuries, special needs, and congenital defects.  These parents remain very involved in their children's lives, even beyond the usual 18 years that define the normal years of parenthood.  These parents have to make difficult decisions, sometimes knowing that their child's underlying condition (eg, Down Syndrome) will not improve.  Most of these children are not capable of making decision on their own, so their parents have to determine whether or not to resuscitate their children if a heart stops or consent to a risky surgical procedure.  In the instance of brain injuries, these were usually fully functioning children prior to their accident.  These parents are very hopeful that their children will recover, even despite the dismal odds quoted to them. 

I find myself pitying them, becoming angry with them, and ultimately resigning myself to their unfounded optimism.  I have come to understand their feelings and their involvement, but I am as yet unable to empathize with the bond that a parent has with a child, especially a child with special needs or severe illness.  I am lucky enough to be an aunt, which is a sort of surrogate marker to parenthood.  I love my niece and nephew and would do anything for them, but it is a different bond than a parent has. 

I have to constantly work to maintain my patience and understand that they probably won't believe that the statistics I mention will apply to their child.  I will continue to try and give them the space and time necessary to process the situation, the information and hopefully realize the prognosis on their own.  I know that some parents will maintain an eternal optimism, and some will succumb to the unfortunate reality that their child is bound for a place of no more suffering and no more pain.  Hopefully their support network and their faith will help them transition from one extreme to the other.