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.
Tuesday, November 5, 2013
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.
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:
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.
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.
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.
Tuesday, August 7, 2012
Obesity
Despite what it might seem, "weight" is a four letter word.
Doctors don't bring it up as often as they should. Patients also rarely bring up how their weight bothers them - embarrassment, denial or other factors might cause them to sit quietly in the office chair. I will often talk to patients about it, if it factors easily into their disease - people with high blood pressure or diabetes, for example. Then, I feel I have a legitimate reason to call attention to their obesity. Even then, many patients do not want to engage in a conversation about it. They start making excuses about how they are too busy to work out, or about how things are really stressful right now, but they have a plan to fix things in the future.
I am not trying to make light of these very real scenarios. In my experience, patients usually do not take responsibility for their weight. Some external force is keeping them from being healthy. It is very difficult to talk to people about weight loss in a 15 minute office visit, when there are other things to talk about. I always like when patients make appoints to talk only about their weight. It gives me more time to find out about their eating habits. But, more often than not, I am the one trying to talk about their weight. It's actually very frustrating to see someone come in every few months and not see their weight drop. I end up not talking about it any more, because it doesn't seem to be helping. I understand that it's hard to lose weight. I don't think it's as expensive as people think. I do think it's easy to make small diet changes that can have a big impact. I need to not get frustrated with my patients when they struggle with their weight. Perhaps if I keep bringing it up, something will stick and they'll actually make some changes.
Doctors don't bring it up as often as they should. Patients also rarely bring up how their weight bothers them - embarrassment, denial or other factors might cause them to sit quietly in the office chair. I will often talk to patients about it, if it factors easily into their disease - people with high blood pressure or diabetes, for example. Then, I feel I have a legitimate reason to call attention to their obesity. Even then, many patients do not want to engage in a conversation about it. They start making excuses about how they are too busy to work out, or about how things are really stressful right now, but they have a plan to fix things in the future.
I am not trying to make light of these very real scenarios. In my experience, patients usually do not take responsibility for their weight. Some external force is keeping them from being healthy. It is very difficult to talk to people about weight loss in a 15 minute office visit, when there are other things to talk about. I always like when patients make appoints to talk only about their weight. It gives me more time to find out about their eating habits. But, more often than not, I am the one trying to talk about their weight. It's actually very frustrating to see someone come in every few months and not see their weight drop. I end up not talking about it any more, because it doesn't seem to be helping. I understand that it's hard to lose weight. I don't think it's as expensive as people think. I do think it's easy to make small diet changes that can have a big impact. I need to not get frustrated with my patients when they struggle with their weight. Perhaps if I keep bringing it up, something will stick and they'll actually make some changes.
Thursday, April 12, 2012
Babies
I've been seeing a lot of young patients recently with Hepatitis C. Kids in their 20s who have gotten into IV drug use, and who are now struggling with both sobriety and having Hepatitis C. That's a lot for a kid to deal with. I go in to the room, sit down and look over at them. More often that not, they come in with a parent. I mean, they're kids. They're not fully mentally developed. People who abuse drugs are in a sort of arrested development. They have poor coping skills. Thy have impulsivity issues. They don't do well with mental or physical pain. Babies.
I explain what Hepatitis C is, what the treatment is like, why it's important to try and cure it. I explain that the treatment is difficult, and I talk about the side effects: nausea, fatigue, muscle and joint aches, headaches, depression. I then explain that the most important thing they can do is stay sober. They are so eager to start treatment, that some are disappointed they can't start now. I explain that the treatment can drive them back to their drugs of choice. I explain that unless their depression is under control, the treatment might cause them to become suicidal. Some of them recognize that they are not ready, and they breathe a sigh of relief.
I have them come back in 6 months to talk again. Sometimes I think I'm too eager to start them on treatment as well. I've had 2 patients who have relapsed after starting meds. I feel a little responsible. Maybe I should asked more questions or listened to my gut. It's just hard to hold back treatment and explain how important that gut feeling is. I think I'll need to figure that out, so that I can help get people treated when it's really the right time.
I explain what Hepatitis C is, what the treatment is like, why it's important to try and cure it. I explain that the treatment is difficult, and I talk about the side effects: nausea, fatigue, muscle and joint aches, headaches, depression. I then explain that the most important thing they can do is stay sober. They are so eager to start treatment, that some are disappointed they can't start now. I explain that the treatment can drive them back to their drugs of choice. I explain that unless their depression is under control, the treatment might cause them to become suicidal. Some of them recognize that they are not ready, and they breathe a sigh of relief.
I have them come back in 6 months to talk again. Sometimes I think I'm too eager to start them on treatment as well. I've had 2 patients who have relapsed after starting meds. I feel a little responsible. Maybe I should asked more questions or listened to my gut. It's just hard to hold back treatment and explain how important that gut feeling is. I think I'll need to figure that out, so that I can help get people treated when it's really the right time.
Tuesday, January 31, 2012
Just Don't Lie to Me
Florence + the Machine has an awesome CD out. I love it. One song on there has a line, "I'm not calling you a liar, just don't lie to me." I find this very apropos to a patient I'm dealing with.
He has an infection in his knee. As I've mentioned here before, working in infectious diseases, I have to ask people a lot of personal questions. Where do you live, what do you eat, what drugs do you do, who do you sleep with, etc. I try to be very open and use nonjudgmental language. During my physical exam, I look at his hands and arms, trying to find other signs of infection. He has track marks on the backs of his hands and in the crooks of his elbows. These are scars from injection drug use. I already asked him about drug use, and he denied any. We don't make eye contact during my discovery, but he must have noticed that I saw them. He mumbled something about donating a lot of blood products in the past.
I sat down at the end of the exam to tell him my plan - antibiotics and such. I said again, "You know, in this job, I have to ask a lot of personal questions, and I'm sorry for that. However it's not to judge anyone or notify any one else. It's simply to help me do my job the best that I can." He said that he understands and that I shouldn't worry about it, ask whatever I want. Again I asked about drug use and told him why this is important. Again he denies it. I tell him that I'd like to test him for HIV and Hepatitis B and C, and he said ok. He doesn't seem concerned. He's been very pleasant through this whole interview, even if I don't very well believe much that he's told me.
I'll wait to get his labs back and make a plan for his treatment. He'll probably need a few weeks of IV antibiotics at home. I'm more than a little concerned that he'll go home with the nice IV we put in place and shoot whatever he'd like into it. I explained to him the dangers of this, and he shook it off and said he'd never do that. I smiled and said ok, as Florence's words rolled through my mind.
"I'm not calling you a liar..."
He has an infection in his knee. As I've mentioned here before, working in infectious diseases, I have to ask people a lot of personal questions. Where do you live, what do you eat, what drugs do you do, who do you sleep with, etc. I try to be very open and use nonjudgmental language. During my physical exam, I look at his hands and arms, trying to find other signs of infection. He has track marks on the backs of his hands and in the crooks of his elbows. These are scars from injection drug use. I already asked him about drug use, and he denied any. We don't make eye contact during my discovery, but he must have noticed that I saw them. He mumbled something about donating a lot of blood products in the past.
I sat down at the end of the exam to tell him my plan - antibiotics and such. I said again, "You know, in this job, I have to ask a lot of personal questions, and I'm sorry for that. However it's not to judge anyone or notify any one else. It's simply to help me do my job the best that I can." He said that he understands and that I shouldn't worry about it, ask whatever I want. Again I asked about drug use and told him why this is important. Again he denies it. I tell him that I'd like to test him for HIV and Hepatitis B and C, and he said ok. He doesn't seem concerned. He's been very pleasant through this whole interview, even if I don't very well believe much that he's told me.
I'll wait to get his labs back and make a plan for his treatment. He'll probably need a few weeks of IV antibiotics at home. I'm more than a little concerned that he'll go home with the nice IV we put in place and shoot whatever he'd like into it. I explained to him the dangers of this, and he shook it off and said he'd never do that. I smiled and said ok, as Florence's words rolled through my mind.
"I'm not calling you a liar..."
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