Compassionate Care for Non-Conforming Teens

I take care of non-conforming teens, but I have many colleagues who are “uncomfortable” with what they call the “new” issues of sexuality. I am convinced it’s because they don’t know the science, the vocabulary and how to speak to non-conforming teens.

This presentation was put together for my pediatric surgery colleagues as a project for a course I’m taking, but several of them asked me to make it more available so they could share it, which is why I’m posting it here.

Research has demonstrated that most aspects of sexuality are far from binary (either-or). We now understand that sex, gender, identity, expression and attraction are separate aspects of sexuality – and that they can be quite varied and fluid (i.e. can differ over time or in different situations).

Pediatric surgeons are among the professionals who care for babies who are born with ambiguous genitalia or, more correctly, what is known as “disorders of sexual development“. For pediatric surgeons, it’s been clear for a very long time that there are three categories for “sex” – male, female and intersex. Almost 2% of children are intersex (which, by the way is the same percentage as the number of people who have red hair).

Gender refers to the identity we hold as an individual. I love this particular diagram with “Barbie” on the left and “GI Joe” on the right. What a delight that we have people all along this spectrum!  It’s also true that there may be days you are a 5 and other days your are an 8… whether your sex is male, female or intersex.

Because it’s such a spectrum, there are different ways to describe someone’s identity. This chart represents the most common words used.  Cis-gender may or may not be familiar to you, because it is the correct way to describe what is usually (but sometimes not correctly) assumed – i.e. that a person’s gender is the same as their sex.

When we have patients, friends or colleagues who are non-conforming, it is our responsibility to address them in a way that affirms them as human beings.  For those who have a clear gender identity (whether its cis-gender or transgender) it is fairly straight forward. When addressing non-binary folks, the correct pronouns to use are they/them/theirs. This is hard for most people because it’s new. It’s perfectly ok to tell them it’s hard but that you are going to try your best. The other important take home message is that if you aren’t sure, it’s ok to ask.

To add even more to the amazing diversity of human beings, how you express your gender is also completely separate from your sex and your gender identity!  So, you can be born with female genitalia (sex = female), identify as a girl (cis-gender) but still choose a gender expression that is more typically “male” in terms of behavior and dress. Gender expression is also amazingly fluid, since there are other times this same individual may prefer to express as “Barbie”, somewhere in the middle, or “GI Joe”.

Although most people are familiar with bisexual, homosexual and heterosexual as concepts, the fact that there are people who are asexual may be a new concept to many.

The Genderbread person is a wonderful visual representation that sex, gender, expression and attraction can all be independent of each other.

So what prompted this presentation and now this blog post? Gender dysphoria is real, although not common, and it is a state of suffering. There is so much stigma in our society around sexuality that these children and young adults feel ostracized and isolated.  As professionals who care for children and young adults, it is important that we understand these issues, learn to speak openly with patients and families experiencing the effects of gender dysphoria and refer them for appropriate medical and psychological care.

It’s hard to know what to say, but it’s so important to say it. Being open – even admitting that you don’t know much about sexual fluidity – is key. More importantly, caring enough to ask and learn may save a life.

BTW – if you are teen reading this and I’ve messed up, please contact me!

Study Tips for First Year Medical Students

Yesterday was my first embryology lecture of the year to the new MS1s at Baylor College of Medicine, as well as the PA, DNP and Genetic Counseling students. For years, I’ve been including a few slides at the end of each lecture to help with the transition to medical school. Yesterday’s lecture ended with tips on how to study. I promised the students I’d share these slides in a written formate. I realized sharing them here might be the most appropriate way to do that!

Medical school (or any high volume graduate school) involves a dramatic change from what students have previously experienced. As you know, if you read this blog, I believe there are a lot of “tools” that can help students “thrive, not just survive

The biggest change for many students is it really isn’t about the grades anymore. It’s about studying for the patients you will be caring for in the future. That means really learning the material, not just knowing it for a test.

Even though there is still a lot unknown about how the brain works to learn material, what is certain is that it is a physical process. You create new synapses when you experience or learn new things. As they are repeated, these synapses get stronger and stronger.

So, to organize the advice, I’ll share some basics, some specifics and then a little refinement.

Learning this volume of material at this level of complexity is about consistency. You can’t run a marathon by running 20 miles every weekend. This is no different. You need to study every day (except one). One of our great teachers at Baylor, Dr. Clay Goodman, tells our students that they have signed on for a 60 hour a week job. (which roughly means 1-2 hours of studying for every hour in the classroom). If you map out your week as a 60 hour job, it will work a lot better than ever trying to “catch up.”

The SQ3R system is the best system I know to learn what you need to know during the basic sciences. So, how do you translate the SQ3R system into practice?

The night before lectures, spend 30-40 minutes skimming the lectures. No “studying”. Be curious. What questions are going to be answered during the lecture? How is it organized?  (BTW “Mike” is a fictitious patient with muscular dystrophy that Dr. Goodman uses in an introductory lecture to show how everything you learn in medical school matters – from the DNA to the psychosocial context of the family)

This 30-40 minutes is basically the “S” and “Q” of the SQR3 system.

  • SURVEY to get the big picture
  • QUESTION = what questions are going to be answered during the lecture? What else do you want to know to really understand this? (write them down!). Do not try to look up anything now.

During the lecture stay ACTIVE. Don’t sit in the back row and look at FaceBook – even if the professor is reading the slides.* You’ll need to take notes for this to be really active. Put the questions you want answered on an outline you prepare the night before lecture and fill it in during the lecture. Use mind maps or other powerful visual aids to learn. Click here to get to my post on taking notes during basic sciences.

*(If you are a lecturer who does this, stop it! – otherwise you are guilty of “death by PowerPoint.” Find someone who is a good lecturer and ask them to coach you.)

After the lecture, you move on to the 3Rs. Now you get down to the real studying. Read through the printed notes (or slides). Did everything get answered? MAKE NOTES that synthesize what you learned.

Review. Review. Review. Here’s the deal. Medical school is a lot like learning a new language.  The first part of basic sciences (anatomy, physiology, embryology, etc) is learning the vocabulary. The second part of basic sciences (diseases, pharmacology, etc) is learning the grammar. When you get to the clinics, you are practicing the language until you are fluent. “Flash cards” such as Anki are great at learning “vocabulary”. They are terrible at synthesizing and learning connections and concepts.  That’s why you need a single page summary of every lecture. The summary is the “forest”, your notes (plus or minus flash cards) are the “trees”. If you really want to succeed, you need both. BTW, I made the class repeat (out loud) after me (twice) – “You cannot learn medicine from Anki alone.” (It’s on tape. I really did this.)

Here’s an example of a single page summary of the embryology lecture I gave the class yesterday. I spent time to make this really look nice – more time than you will want to spend. It doesn’t need to be typed, it doesn’t need to be particularly legible to anyone but you, but take the time to do these summaries!

Did I already mention that you need to review?

This is probably the single most important slide I show when explaining how to best study in medical school. It’s the basis of many apps in medical learning, including the NEJM Knowledge+ courses. There are two really important points in this graph.  First, it takes at least 5 repetitions to really learn something. Second, they have to be spread out in a logarithmic fashion over time.

Here’s how to do it. The first three repetitions should be same day, next day and 2-3 days later. The more times you review it, the better, but it should at least be 1 week later and 3 weeks later.  More is better.  Plan another review a month later and three months later, too. For the Type A folks in medical school (i.e. all of you), make a spread sheet!

 

Another thing about our brains and learning.  Pushing through for hours without rest is as stupid as thinking you can build up your biceps by doing an hour of uninterrupted reps. Speaking of reps… use “study reps”. Get an app if you think it will help. 50 minutes of studying.

Stop studying for 10 minutes (no matter how engrossed you are) when the alarm goes. Repeat.

People sitting next to you in your study areas are going to look like they have it more together than you do.  It might be true… but it probably isn’t.  If someone has a study technique that looks like it will work for you, by all means try it!  Just don’t change too often. I was a liberal arts major in college. If you come from a non-science background, the first 6 months are going to be a little tougher on you because you have more “vocabulary” to learn but don’t worry, after that you’ll be caught up,

Read this slide. Believe this slide. The most important point on this slide is the last line. You cannot make those physical synapses you need to really learn without 8 hours of sleep.

Keep notes about what works for you and what doesn’t. Everyone is a little different, but you will find a system that works best for you through conscious effort.

It’s like running. Some of this is just “time on feet”. Remember the 60 hours a week job concept and you’ll do fine.

I end with this slide to remind my students that there has to be balance for this to work. Most of what I tell my students about finding and keeping that balance is in this blog, so feel free to use the word cloud to the right or search for what you might need. Please contact me if you have a specific question I can answer or if you have an idea for a new blog post.

Welcome to the best career in the world! We are all happy you are here!

 

 

 

 

 

The Ripple Effect

Dr. Marc Rowe is one of the truly great pediatric surgeons of our era. His work in newborn physiology profoundly changed how babies were and are taken care of in intensive care units. His prolific research, along with the many people he trained, has unquestionably affected the lives of hundreds of thousands of newborns.  He has taken on creative work as a writer and wood carver in his retirement. Dr. Rowe is one of my personal heroes and, when I read this essay he recently posted, I asked his permission to post it here to be able to share it with you.

Photo credit and link to video

I am troubled by what is happening to our Country. Principles and ideals – truth, honor, kindness, diversity compassion and love and protection for the people, the creatures and the environment we share has been replaced by selfishness, prejudice, lies and a willingness to compromise in order to gain material wealth and power. What is particularly frightening is the effect the current leadership may have on our greatest gift, our children- the message sent – that you can be dishonest, unfaithful to your loved ones, lie, be a racist, a bully and a braggart and still become the most powerful person in the world and be supported by many of our religious and political leaders. I am confused – does this mean that these political and religous leaders would choose our current president to be a role model for their children and grandchildren?

As I watched this sad period in the history of our country unfold I was overtaken with a sense of powerlessness. I then remembered two lessons I learned during my career as a pediatric surgeon. The first occurred during my first job as an assistant professor of surgery. I was incensed by an episode of academic politics and was tempted to speak out but realized if I did I would pay a price. I vented my frustration to my wise and famous boss, Dr. Mark Ravitch, a battle scarred warrior of the political and academic world. He said – “before Socrates drank the hemlock he began his defense by saying –never let it be said that I had a podium and failed to speak. – You have a big mouth use it”.

The second lesson came later when I became depressed realizing the huge number of children suffering from potentially correctable diseases and abnormalities and how little one person could do. I then began to think about the ripple effect – the ever-expanding effect that even one person can have by teaching and striving to be a role model. I realized that young people are astute observers and learn not by what their teachers say but by the way they act, how true they are to the principles they teach and most important by not selling out when being principled becomes painful and dangerous. Kids spot phonies a mile away.

Three people I have greatly admired, Mother Teresa, the Dalai Lama and Robert Kennedy all have spoken of the ripple effect. To quote Robert Kennedy who spoke of the ripple effect during the tumultuous civil rights strife – “Each time a man stands up for an ideal, or acts to improve the lot of others, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current that can sweep down the mightiest walls of oppression and resistance.”

This carving I call the Ripple. The pond and thrower is carved from a branch and cross-section of bass wood, the shoreline is made from Sanibel sand and the stone in the pond is a small piece of river rock.

Scientifically Superstitious

There is a longstanding superstition in medicine that you never wish someone a quiet call night, sort of the medical equivalent of never wishing an actor a good show. We are trained in science, so all physicians know this is silly…and yet…

There are many theories in psychology about why human beings are superstitious, but the one that I think best explains the superstitions of doctors is that superstitious rituals decrease stress and can improve performance during stressful work.

So, don’t make fun of me when I wear my green socks for Kasai procedures… or when I feign horror if someone wishes me a quiet call night!

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Take the Stairs

When I was an intern, I had an attending who always took the stairs.

Twelve flights.

Fast.

Multiple times a day.

We’d be on the second floor and he’d announce “Let’s go see Mr. Smith.” He would take off to the 12th floor with a trail of panting residents and students spread out behind him. Here’s the punch line: Every summer he would take a vacation to climb a mountain. To get ready for the climb he did…nothing. Climbing the stairs was enough.

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Why you should take the stairs

It is a great way to keep from gaining weight during med school and residency since it burns three times the calories of a brisk walk (even at a slow pace)

As little as two flights of stairs climbed per day can lead to losing 5-6 lbs of weight in a year.

You burn 8-11 kcals per minute climbing stairs.

Climbing stairs is essentially a series of vertical lunges.  You’ll tone your leg muscles – good for both strength and appearance.

55 flights of stairs/week = overall decreased risk of mortality.

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Tips on taking the stairs instead of the elevator

Even if you are fit, you’ll be out of breath climbing stairs. It’s normal.

Make sure you don’t overuse your calf muscles to power up the stairs – use your quads, hamstrings and gluts to protect your knees.

It’s ok to take the elevator down if you want to. Walking down stairs is actually much harder on your joints than taking the stairs up.  If you choose to walk down, use the rails (it’s stupid to fall).

It’s ok to use the rails going up the stairs. It provides a little upper body workout and doesn’t really diminish the advantages of climbing stairs.

Want to add more?  Find a more isolated stairwell and do additional exercises on the landings (e.g. crunches, burpees, pushups). Do “ladders” – up and down one flight, then two, then three, etc.

Want to go to the next level? There are actually “races” to climb the stairs of tall buildings.

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The Tools We Hold: The Senn Retractor

The Senn retractor is a small, relatively delicate retractor that is used extensively in hand surgery, vascular surgery, plastic surgery and other procedures involving the skin and soft tissue.  I hold this instrument most days I am in the OR and yesterday found myself wondering about this beautiful tool.

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Nicholas Senn was an early adopter of Listerism and performed his operations under a fog of carbolic acid spray. He felt that smooth surfaces on surgical instruments were important to help prevent infection.1  That, plus the need for retraction in superficial wounds undoubtedly led to developing the Senn retractor.

Surgery being performed under carbolic acid spray

 

Nicolas Senn was born in 1844 and emigrated to the Fond du Lac, Wisconsin from St. Gaul, Switzerland  in 1852.  He graduated from Chicago Medical School in 1868, completed his residency at Cook County, started his academic career at the Medical College of Wisconsin, studied in Europe at the University of Munich and then returned as Professor at the University of Illinois. He served as president of the American Surgical Association in 1892, and was named president of the AMA in 19872, Dr.Senn was a military surgeon who served in the Spanish-American war and the Russo-Japanese war. Importantly, he founded the Association of Military Surgeons.2,3 He died in 1908 at the age of 64, five years before the American College of Surgeons was founded.  There is little doubt that he would have been a founding member of the American College of Surgeons as he was the first Editor-In-Chief of SGO, which later became the Journal of the American College of Surgeons.4

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In addition to his truly extraordinary resume, there are other facts and stories about Dr. Senn worth knowing.   So, the next time you find yourself handing a student, resident, or assistant a Senn retractor you might want to share some of this history.

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  • Dr. Seen taught elementary school for a year and then studied with a local GP in Fond du Lac before entering medical school. 1
  • There is a high school in Chicago named for him. He was known as an outstanding educator, so this is a particularly appropriate tribute.
  • He was a collector of historical medical documents which resulted in a collection of over 10,000 volumes and 14,000 pamphlets and articles now stored in the John Crerar Library.2
  • One of his most famous quotes is “The fate of the wounded rests with the one who applies the first dressing”2
  • In 1904 he wrote a beautiful tribute to Father Damien who lived in the leper colony of Molokai which can be read here.
  • He strongly supported early operation for appendicitis, which was not the practice of the time. “The principal object in writing this paper is to call the attention of the profession to the necessity of treating the primary disease of the appendix by radical measures before the advent of incurable complications, that is, before disease due to perforation has occurred.”5
  • He was probably best known for his studies on intestinal perforation. To set the stage, Dr. Senn was a military surgeon in an era of transition. This was literally the time that it was finally “proved” that suturing a bowel perforation resulted in a better outcome.  Senn used an animal model to instill hydrogen via the anus to see what kinds of pressure would result in bowel perforation.6  (The full text of Dr. Picher’s article, published in 1888, can be found here and is a fascinating read). He went beyond animal studies to show that this could be applied to humans by doing the same experiment on himself (short of the perforation we assume!).  “Senn used a rubber balloon connected to a rubber tube inserted in his anus to pump 4 US gallons (15 L) of hydrogen gas into his intestinal tract. An assistant sealed the tube by squeezing the anus against it. The hydrogen was inserted by squeezing the balloon while monitoring the pressure on a manometer.” 2 This technique was subsequently used in soldiers who had been shot to determine if bullets had punctured the bowel.7
  • Many of his experiments were carried out in the Nicholas Senn Building. He had this building serve as a place where students and medical professionals would gather to learn from one another. In the basement of the building he experimented with medical procedures that he would later carry out on patients.”8

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  1. El-Sedfy A, Chamberlain RS. Surgeons and their tools: a history of surgical instruments and their innovators. Part III: the medical student’s best friend-retractors. Am Surg 2015;81:16-8.
  2. Nicholas Senn. Wikipedia. (Accessed May 5, 2018, at https://en.wikipedia.org/wiki/Nicholas_Senn.)
  3. Smith DC. Nicholas Senn and the origins of the Association of Military Surgeons of the United States. Mil Med 1999;164:243-6.
  4. . (Accessed May 5, 2018, at https://www.facs.org/about acs/archives/pasthighlights/sennclubdinner.)
  5. Senn N. A plea in favor of early laparotomy for catarrhal and ulcerative appendicitis, with the report of two cases. JAMA 1889;13:630-6.
  6. Pilcher JE. Senn on the Diagnosis of Gastro-Intestinal Perforation by the Rectal Insufflation of Hydrogen Gas. Ann Surg 1888;8:190-204.
  7. Senn N. The Modern Treatment of Gunshot Wounds in Miliatary Practice. JAMA 1898;31.
  8. Nicholas Senn Building. 2009. at http://genealogytrails.com/wis/milwaukee/nicholassennbuilding.html.)

 

If you are starting the think you might be depressed, or that your brain is out to kill you, here’s what you do…

The following is an “unrolled” Twitter feed from Mark Reid, MD on depression.  It’s solid, important advice that I thought should be shared. Dr. Reid  is an internist from Denver, who is very active on Twitter as @medicalaxioms. He is also the author of Medical Axioms, a delightful book of medical wisdom

Interview with Dr. Reid about @medicalaxioms

If you are starting the think you might be depressed, or that your brain is out to kill you, here’s what you do:

1. Find or call your primary care IM of family MD. When you call for an appointment and they ask what for, say “depression.” Notice how the scheduler doesn’t flinch. They get this call 4 times a day!

2. When you get to the doctor, and they ask what’s wrong, just say, “I want you to do those screening tools on me to see if I’m depressed.” Let them do their thing. If they say you’ve got it, let them tell you how meds and counseling work. Let them tell you what they know about pills and which one might help you. Decide together if pills are worth a shot. Tablets really work for some people.

3. You also need a counselor. Ask the MD for a referral. That might work. If not,

4. Go to your insurance and find out their preferred providers for counseling. I suggest you pick someone your same gender. Counterintuitive for some but works better for many.

5.  If that doesn’t work, go in the internet and type in counselor or therapist and the name of your town or city. Read ratings and reviews. Cross reference them with yelp. Look for someone nearby who writes a bio that sounds okay. Figure you’ll see them once a week and it will cost $100. Give them 4 tries. If you don’t feel like you are getting anywhere, ditch them and try again. I’ve seen 3 people in the last 10 years and in retrospect I can rank them.

6. With tablets and shrinks, the trick is resolve. If they aren’t working or give side effects, don’t just quit. Try again. Different shrink. Go back and try a different tablet with your MD.

You can feel better and you are worth it. You deserve it.

There’s lots of other stuff that helps some people: support groups, sobriety, exercise, sleep hygiene, self help books, spiritual practice, ALANON. If your shrink is any good they will recommend this stuff and know something about it.

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To add a few more comments to Dr. Reid’s advice….

  • Depression is a disease, not a failing. You wouldn’t judge yourself for a sprained ankle.  This is the same…. except for one thing.  The disease of depression includes not being able to objectively see what’s going on.  That’s why it’s so important to get started on treatment.
  • If you are a medical student or resident, counseling is available for you and it’s free. The same rules hold, though.  If the first person you see isn’t helping after 3 or 4 visits, it’s ok to make an appointment with someone else.  This is not personal and you don’t have to worry about “hurting their feelings” any other consequences.
  • The National Suicide hotline is 1-800-273-8255. You are loved.  You matter.  This is a disease not a failure.  Please seek help.

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#BanTheBouffant

If you don’t work in an operating room, you may not be aware of the controversy going on about OR caps.  To get right to the point – the surgeons think they should be allowed to wear the cloth hats they have worn forever.  The Association of Operating Room Nurses (AORN) developed guidelines which included covering the ears and all hair (which means a bouffant paper hat). These guidelines were then implemented by JACHO which means they became “law” in every hospital in the United States.

Anonymous surgeons demonstrating extremely effective covering of all hair with bouffant hats.

I’m a real believer in evidence based medicine (and policies) so I decided, like others, to look into what is really known about the issue.  Because it is a conflict of interest, I need to disclose that I can’t stand the bouffant hats and I really, really miss my (clean and washed) cloth hats. (which BTW cover all my hair!)

What do the data say about the use of bouffant hats and infection rates?  

 

Why don’t surgeons like bouffant hats?

It’s harder to keep them in place when wearing loupes or headlamps. If the goal is to keep the hair covered, this is a real problem.  When moving headlamps, operating microscopes or loupes, the bouffant hat often moves substantially – or even comes off entirely.

They are hot. Many surgeons feel (me included) that the bouffant hats are uncomfortable and are hot.  One can argue that anything that increases surgeon discomfort could affect concentration, which might be reflected in less focus on the operation.

Bouffant hats are expensive and bad for the environment.  On Amazon, 100 bouffant hats cost $7.45.  There were 48 million inpatient operations performed in 2009.  When you add the 48 million outpatient procedures performed, that means there are roughly 100 million operations performed per year.  (Mind you, these data are almost 10 years old, so it’s likely to be more now).  If we assume an average of 4 cases/day by an average surgical team (nurses, CRNA, anesthesiologist, assistants/resident) and they all wear their hat for the day, the number of hats needed per year would be 100 million cases x 6 members of the team = 600 million hats/yr. 600 million hats divided by 100/box = 6 million boxes x $7.45 = $44,700, 000.  Over 44 million dollars a year for the bouffant hats… all of which (600 million/year) end up in a land fill or are incinerated.  p.s. Given that hats are often changed during the day, this number is probably on the low side.

It affects morale.  In a survey of young (<45 years of age) surgeons, 71.2% stated that the new rules had affected surgeon morale.

They are inferior in blocking bacteria when compared to other caps.  In a study of bouffant hats, disposable skull caps and cloth hats, the bouffant hat was the worst in preventing airborne bacterial contamination in the operating room.  “I expect our findings may be used to inform surgical headgear policy in the United States,” he said. “Based on these experiments, surgeons should be allowed to wear either a bouffant hat or a skullcap, although cloth skull caps are the thickest and have the lowest permeability of the three types we tested.” Troy A. Markel, MD, FACS

 

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I’m confident that in the very near future we will be back to wearing our clean, cloth hats.   When you look at the data, and weigh the pros and cons, it seems pretty obvious what needs to be done….