lundi 31 août 2015

Caregiver Nation: Snapshot Of 43 Million Americans Who Give Unpaid Care

Caregiver Nation: Snapshot Of 43 Million Americans Who Give Unpaid Care

(Photo: a4gpa/Flickr Creative Commons)

(Photo: a4gpa/Flickr Creative Commons)

By Marina Renton
CommonHealth intern

A high-stress job that requires a full-time commitment for no pay.

What kind of work fits that description? The answer should resonate with more than 43 million Americans: unpaid family caregiving.

As the population ages and more people need care, the ratio of available family caregivers to care recipients is declining, and efforts to support family caregivers are beginning to make headway in the political sphere.

Among those who need that support most: “higher-hour” caregivers, who spend more than 21 hours a week on caregiving, according to Caregiving in the U.S. 2015, a report released this summer by the National Alliance for Caregiving and the AARP Public Policy Institute.

Ask Massachusetts resident Diane Gwynne, 56. After her mother’s sudden death this past December, Gwynne found herself trying to balance her career and household responsibilities with caring for her 92-year-old father, who has dementia.

“I was so overwhelmed,” Gwynne said of when she first started caring for her father. “It was so sudden. I didn’t even know where to turn.”

Diane Gwynne of Andover with her 92-year-old father.

Diane Gwynne of Andover with her 92-year-old father.

Last year, Gwynne’s mother had an intuition that the Christmas of 2014 would be the family’s last. Gwynne’s mother was in her eighties and her father was seven years older, in his nineties. Both were feeling the effects of age.

“My mother said, ‘I want to put all the decorations up, because I think this is going to be our last year all together,’” Gwynne recalls. Her mother, it turned out, was unknowingly predicting her own death: She passed away just before the New Year.

Suddenly, her bereaved children found themselves managing the estate, taking their father to medical appointments, and making arrangements for his day-to-day care.

Caregivers by the numbers

Caregiving in the U.S. 2015, a report that comes out every few years and aims to profile the nation’s family caregivers, looks at the demographics of family caregivers, along with the emotional, physical, and financial challenges they face.

Based on the results of online interviews with 1,248 adult caregivers who provide care to adults, the report offers a quantitative snapshot of the country’s caregivers. Among its findings:

• Approximately 43.5 million adults in the country have provided some form of unpaid care to an adult or child with special needs in the past year.

• About 39.8 million Americans have cared for an adult (over 18 years old), and 34.2 million an adult over 50, in the past year. In other words, about 18 percent of U.S. adults have shouldered some unpaid caregiving responsibilities in the past year.

• The average caregiver is a 49-year-old woman caring for a relative. (Eighty-five percent of caregivers look after a relative, 49 percent a parent or in-law.)

The average caregiver is a 49-year-old woman caring for a parent or parent-in-law.

• Less than a third of unpaid caregivers retain some kind of paid help.

While she had helped out both her parents in recent years, it wasn’t until her mother’s death that Gwynne and her sister became the primary caregivers for their father.

“For many caregivers, they’re thrust into this job through some crisis,” said Gail Gibson Hunt, president of the National Alliance for Caregiving. “We need to provide resources for the caregiver who’s going to be facing an enormous amount of stress and responsibilities…They’re going to be faced with all kinds of decisions, and we need to support them when they’re first starting out.”

Gwynne’s childhood home in Andover, Massachusetts, where her parents had lived for nearly half a century, was not adapted to senior living — it had multiple sets of stairs, required upkeep, and the bathrooms weren’t handicapped-accessible.

Plus, her father needed 24/7 help to ensure that his personal care needs — like shaving and showering — were taken care of, he got his meals and medications, and he didn’t wander out at night. So, his children had to make the “heart-wrenching” decision to move him into a nursing home, Gwynne said.

‘Higher-Hour Caregivers’

Being a caregiver is often a major time commitment, requiring an average of about 24 hours a week. (Twenty-three percent of caregivers spend 41 or more hours a week on caregiving, Caregiving in the U.S. 2015 found.)

Caregivers who provide care for more than 20 hours a week are classified as “higher-hour caregivers,” Hunt said, and tend to face more challenges.

“You could see the difference in how the stress levels, for example, were greater among those caregivers who were doing more hours of caregiving,” she said. “There was a greater impact on their work. There was a greater impact on their health. Financially, there were greater impacts with those people. And, if you were one of the higher-hour caregivers, you were doing more intense caregiving, as in personal care: bathing, dressing, feeding, toileting, transferring.”

Gwynne fits into that higher-hour category, estimating that her caregiving responsibilities take up at least 20 hours a week. She helps her father with his finances, brings him to church and the Senior Center or arranges for his transportation, and takes him to and from his medical appointments.

“We make sure that he feels like he has a life, and we make sure that he’s cared for,” she said.

Even though her father’s personal care needs are managed by his nursing home, Gwynne finds herself responsible for making sure they are all consistently met.

“Even if they are in a facility, you still have to be their advocate,” she said. “If somebody were to go into a hospital or somebody were to go into a nursing home — even if it’s the Ritz-Carlton of nursing homes — the only person who’s going to make sure he has his nails cut and that he’s showered frequently and that his hair is cut is someone who’s a family member. You have to watch them.”

“Now that I think about it, 20 hours per week is probably too short,” Gwynne said.

The sorts of tasks seniors need help with can be broadly classed into two categories: personal care tasks like feeding, dressing, and bathing, and tasks that support independent living, like balancing a checkbook, driving, and grocery shopping.

More than half of all caregivers help with at least one personal-care task, and all help with at least one independent-living task. Plus, like Gwynne, they often act as advocates for the care recipient, keeping an eye on their medical condition and interfacing with health professionals.

Nearly 60 percent of caregivers also help with “medical/nursing tasks,” jobs that are traditionally the responsibility of a nurse, like giving injections, providing wound care, or working equipment like a hospital bed.

“The higher-hour caregiver group are doing many more hours of medical/nursing tasks,” Hunt said. “And that’s also a stressor.”

Career and money

When she started caring for her father, one of Gwynne’s first thoughts was, “Should I quit my job?” She works full-time in Boston as a finance director, and her career has “absolutely” been affected by her added family responsibilities, she said, although her workplace has made efforts to accommodate her.

“When I used to be always on top of stuff, I feel like I’m just holding it together, and I’ve had to learn to deal with that,” she said.

Gwynne’s experience is typical, according to Caregiving in the U.S. 2015. A majority of caregivers reported making changes to their work schedule — taking a leave of absence, decreasing their hours, retiring early — to balance their caregiving responsibilities.

A 2011 study found that, on average, the total amount of lost wages, lost Social Security benefits, and lost pension for a caregiver who alters his or her work schedule is more than $300,000.

So being a caregiver can bring physical, emotional, and financial strain, Caregiving in the U.S. 2015 found. Thirty-eight percent of all caregivers reported high levels of emotional stress, and around 20 percent reported significant physical strain. Nearly 20 percent of caregivers reported major financial challenges stemming from caregiving.

In this, Gwynne counts herself lucky, because her parents saved in preparation for their retirement years. “As a caregiver, I think I have it pretty easy compared to some other people,” she said. “The financial issue is big.”

Joy and choice

This snapshot may be looking pretty grim so far, but there are upsides for caregivers as well. Studies have found that caregivers might live longer, and some caregivers report having an overall positive experience.

Gwynne has had the opportunity to deepen her relationship with her father by caring for him, she said: “He really is a total joy. He always says thank you; he enjoys your presence; he’s never grumpy; he never complains.”

About half of caregivers reported that they did not have a choice in whether or not to become a caregiver, according to Caregiving in the U.S. 2015.

For Gwynne, it was a question of duty.

“I love my dad,” she said. “And I have been blessed with two great parents. So there was not really a choice.”

The lack of choice can be challenging for caregivers, Hunt said. “They had greater stress; they feel psychologically like this is more of a burden for them.” Other stressful circumstances include living with the care recipient and caring for someone with dementia, she added.

Even though it’s very stressful, “I feel good because I’m doing my job,” Gwynne said.

Where to turn (in Massachusetts)

There are resources available for caregivers “if you know where to turn,” Gwynne said. The Center at Punchard, Andover’s senior center, has been “a great resource…The more you get into it, the more you learn.”

Her father frequently visits the center, where he is able to spend time and socialize.

Gwynne knows there are support groups out there for family caregivers, which she said she should go to, “but I have no time.”

That’s a challenge that the Massachusetts Executive Office of Elder Affairs is trying to combat.

“We certainly want more people to be able to be at home and living and aging in their own communities, but that’s a burden on caregivers if we don’t have the right resources in the community to support caregiving,” said Alice Bonner, secretary of the Executive Office of Elder Affairs.

“Massachusetts’ network of aging services is anchored by Aging Services Access Points, which offer a range of programs, including some for caregivers, Bonner said. Massachusetts is the only state in the nation with these access points.

It might be hard for a caregiver to access services like support groups because it would mean  leaving the care recipient home alone, Bonner said. So certain programs encourage the caregiver and recipient to attend together.

When caring for someone with dementia, it can be challenging to communicate and keep your cool, Bonner said. How do you help manage the mood of someone with Alzheimer’s or dementia who becomes agitated or distressed?

“If you haven’t trained as a health-care professional, families can very often benefit from some sort of formal training,” Bonner said. Some programs are designed to help build communication skills, while others might help caregivers with medical tasks.

While the training can be web-based, in-person training tends to be particularly effective, Bonner said, because “you get a group of folks who can be a sort of support group for one another.”

Community members are also vital to caregivers.

“Sometimes people get very isolated because their friends and neighbors stop coming, Bonner said. “That isolation is a real problem for caregivers…Even if it’s just for half an hour, go have a cup of coffee, offer to go buy groceries, or go for a walk with the caregiver. These are simple things and they can really make a big difference.”

There’s room to do more to support family caregivers, Bonner said. Respite care could use expansion, along with building ties with community organizations not devoted to aging, like schools or the clergy.

“There’s not really a one-size-fits-all model,” she said.

Fewer caregivers, doing more

Caregiver demographics are evolving, Hunt said. “It appears that there are fewer family caregivers, but they are doing more intense caregiving.”

Almost 10 percent of caregivers are 75 years old or older, according to Caregiving in the U.S. 2015.

“You think of the physical strain that caregiving could put on the 75-to-80-year-old caregiver who’s trying to lift someone, or transfer them, or just deal with all the day-to-day issues,” Hunt said.

Gwynne’s mother was one of those older caregivers, Gwynne said, and she had to manage her usual household responsibilities while taking on her husband’s. “It was very, very hard. She was exhausted all the time.”

“She was having to make sure he shaved, make sure he showered,” Gwynne said. “That changes everything in a relationship.”

Caregiving in the U.S. 2015 found that about 40 percent of caregivers are male, a significant increase from previous decades.

“When I first started working in caregiving, the rule of thumb which you always heard in surveys was 25/75 [male/female]. As we move closer to a 50/50 split, caregiving becomes somewhat less of a ‘women’s issue,’ and it becomes an issue for everybody. And that could have political consequences.” [[who said this??]]

National strategies

Indeed, there is some legislative movement on supporting family caregivers. In July, the Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregivers Act was introduced in the U.S. House of Representatives.

It would require the federal Department of Health and Human Services to create a National Family Caregiving Strategy and a Family Caregiving Advisory Council. (The AARP support statement for the act is here.)

Caregiving in the U.S. 2015 also made several recommendations to improve the caregiver experience:
• Target the caregivers with the highest risk of burning out.
• Help family caregivers who are struggling with balancing work and family – “Employers need to play a greater role in offering caregiver support to employed caregivers,” Hunt said.
• Give caregivers resources when they’re first starting out and struggling with the transition.
• Increase training available for caregivers. “An alarming number of people who are doing these medical/nursing tasks never had any training at all,” Hunt said. “We need to give caregivers training in in specific tasks like wound care, but also tasks around behavioral issues.”
• Encourage families to make plans for what happens if the caregiver stops being able to provide care

“Caregivers typically don’t self-identify,” Hunt said. “They’re just doing what every good daughter would do, or what every good husband would do. It’s not easy to identify then and reach them.”

When Gwynne tells friends and co-workers that she cares for her father, many of them say they don’t know if they could do what she does.

“But you never think you’re going to have to, or that you could,” she said. “Then all of a sudden you might have to give your father a shower.”

————————————————————————————————

Resources for family caregivers – A starting point:

If you live in Massachusetts, consult your local Council on Aging, Area Agency on Aging, Senior Center, or ASAP.

The Alzheimer’s Association Alzheimer’s and Dementia Caregiver Center

The Mass. Executive Office of Elder Affairs would like to hear from family caregivers statewide. If you have questions or suggestions, contact the office via its website.

vendredi 28 août 2015

I Never Expected To Love My Kids’ Sex Ed Course, But I Do

I Never Expected To Love My Kids’ Sex Ed Course, But I Do

Oh boy... (Romana Klee/Flickr)

Oh boy… (Romana Klee/Flickr)

Truth is, I dreaded my children’s sexual education.

I’d read that parents can be a powerful force for smarts about sex, so I’d tried to script imaginary heart-to-hearts. But in my head, they all sounded like this: “Please don’t do these incredibly stupid things that I did when I was young.”

So I procrastinated, abetted by the younger generation’s point-blank refusal to let me even broach this most awkward of topics. Then, last year, word came home that middle-school health class would use a curriculum called “Get Real” that involved extensive family homework activities.

“Now I’m in for it,” I thought.

But in fact, I was in for a shockingly pleasant surprise — one that more and more parents may experience in the coming years if Get Real’s popularity continues to grow. As of this year, it has been adopted by 200 schools in seven states — 175 of them in Massachusetts. That’s up from 132 schools in 2012.

And in recent months, Get Real has scored two victories: An analysis by the Wellesley Centers for Women reported that students who go through Get Real do become likelier to delay sex, and the federal government put it on a list of “evidence-based” sex-ed programs.

No way is Get Real, which was created by the Planned Parenthood League of Massachusetts, for everybody. It strongly promotes abstinence as the healthiest choice for young people, but it’s not the sort of “abstinence-only” program that many parents and schools seek; it also includes teachings on birth control and preventing infection.

But perhaps more than any other curriculum out there, it pulls parents into the sex-ed endeavor, and here’s my pleasant surprise: It wasn’t awkward.

The Get Real homework prompted conversations about friendships, about feelings, about life lessons. I got to reminisce about my first crush, and talk about how important I think it is to stand up for yourself with a boyfriend or girlfriend. I even got to vent about how perniciously relationships are portrayed in that detestable high-school-girl series, “Pretty Little Liars.”

Sure, the course teaches intimate anatomy and the changes of puberty, but the body part it seemed to focus on most was the heart. It was teaching — well, love. Or rather, the skills that can make love better. Healthier. Skills like self-awareness and communication — useful in their own right, and also in service of sex-ed goals like preventing pregnancy and infections.

“We believe that if young people are able to develop healthy relationships in all aspects of their lives, they’re going to be that much better able to negotiate healthy sexual relationships,” says Jen Slonaker, vice president of education and training at the Planned Parenthood League of Massachusetts.

At this national moment of rising discussion about campus rape — from “Missoula” to this week’s New Hampshire prep school trial — the need for such skills has never seemed more urgent. And they take time to develop, says Nicole Cushman, executive director of Answer, a national sex-education organization based at Rutgers University.

“When people talk about sexual assault and rape prevention on college campuses,” she says, “the sad truth is that by the time young people get to college, it may be too late, because we haven’t really laid the groundwork by teaching them these basic concepts about communication and relationships from a younger age. So I really believe that comprehensive sex education is sexual assault prevention.”

‘Red Flags’

Ashley, a Boston high school senior who is on the Get Real Teen Council, went through the curriculum beginning in middle school but says she really started seeing its effects when she got to high school.

“I know that what I learned in Get Real classes made me see certain red flags in my friends’ relationships and my own relationships, and helped me solve what I need to do in order to get away from the red flags,” she says.

One friend who took the class with her drew on it to resist sexual pressure, Ashley says: “She didn’t know if she was ready to have sex, and she touched upon the consent part — she was like, ‘I don’t have to do this, necessarily. It’s like — consent. It’s not fair. I don’t have to engage.’ “

Get Real not only teaches principles like consent, it actually has the students practice them in role-plays — even if they likely won’t face certain situations for years.

For example, Slonaker says, one scenario might portray a couple in which one partner “wants to try some sort of sexual behavior and the other person isn’t ready for that. And so how do they have that conversation? Because it’s absolutely a conversation, and it’s a continuous conversation.”

Also key, she says, is that after such role-play scenarios, the teachers help the students process what happened, asking questions like, “What was challenging about that? How do you think someone might feel in that situation?”

“It’s all about the development of the skills we want our kids to have when they go out in the world on their own,” Slonaker says. “It gives them the chance to practice something, stretch or strengthen that particular muscle in their brains that they’re really just developing in eighth grade, and have that safe place to fail so they can do it differently and better the next time.”

Sign Of The Times

Get Real is not unique among sex-ed courses in teaching relationship skills, but Slonaker says that emphasis has contributed to its success, aligning nicely with the rise of “Social Emotional Learning” in schools.

Its growing popularity also jibes with two other sex-ed trends, Cushman says:

1. Federal support

Historically, the federal government tended to invest mainly in “abstinence-only” sex education, she says, but the Obama administration has shifted toward funding “evidence-based” programs that prove their effectiveness.

Though the actual decisions on which sex-ed program to use happen at the local level, Cushman says, that federal support has helped developers of “comprehensive” programs like Get Real, which encourage kids to delay sex but also include information about contraception and preventing disease, along with relationship skills.

(Given the recent news stories about Planned Parenthood and fetal tissue, I asked Slonaker what Get Real teaches about abortion. She emailed: “Abortion and other pregnancy options are not included in the Get Real curriculum. If a student asks a question regarding abortion, the educator answers in a factual manner. As in any other discussion in Get Real, the school staff encourages students to talk to parents and other caring adults regarding their values related to the subject.”)

2. What works

Back in the early days of AIDS, Cushman says, educators thought it would be enough just to provide basic information — about condoms, for example. Since then, “we’ve come a long way in understanding what it really takes to impact young people’s behaviors,” she says, and “not just their behaviors but their skills, their attitudes, that all contribute to lifelong healthy behavior. It takes a lot more than just providing a plumbing lesson on reproductive anatomy.”

These days, she says, it’s known that effective sex ed has to be based on sound theory, has to be suited to the student’s culture and age, has to be highly interactive, and needs to go beyond sharing knowledge. It has to actually build skills.

Get Real fits nicely into those trends; where it may be unique, Cushman says, is in the extent of its family involvement. And that, too, is evidence-based, she says: Research finds that parent communication can make kids likelier to delay sex and practice safer sex.

All that communication is not always easy, of course. Slonaker says Get Real teachers report that one of their biggest challenges is how to encourage families to complete all the activities. “Some kids feel too embarrassed to bring them up at home,” she says. “Some parents don’t want to engage in the conversation, some parents are too busy with jobs and other commitments, some kids are unable to identify a caring adult in their life with whom they can have these conversations.”

But even if not all 27 of Get Real’s family activities get done, she says, even a little parent conversation can make an impact.

The Wellesley analysis on Get Real found that by the end of eighth grade, 16 percent fewer boys and 15 percent fewer girls had sex compared to their peers who had a different curriculum.

I Never Have To Tell Them!

I’m filing this under “what I learned today:” The sort of parent-child talk that can help teenagers make better sexual choices does not have to revolve around our past idiocy at all.

“A fear we often hear from parents,” Slonaker says, is, “‘Wait a second, you’re talking about family activities? Are you going to have my kid ask me about my sexual activities?’ And that is absolutely not what the family activities are designed to do.

“It’s up to the parent to make the decision of when or if they share information about their own sexual experience,” she says. “And so the conversations are much more guided around relationships, or, ‘Tell me about the first relationship you had — what was really great about that relationship? What do you remember about that relationship?’ ”

So in other words, I pressed Slonaker, I never have to tell my kids about my past mistakes?

“No, you don’t,” she reassured me. “It’s really about articulating the values and beliefs that you want your children to carry around sexual health.”

Joy! I can articulate my values, I think — they’re pretty golden-rule-based. And I have Ashley’s experience to spur me on. The Boston high school senior says the Get Real activities really helped open up channels of communication with her mother, including discussions of her mother’s relationship with her father.

“I was blown out my mind when she said certain things,” Ashley recalls. “I said, ‘My father did that? Really?’ It shows how we’re alike, sort of, and what she went through, I can go through as well, or have her help me avoid those same issues.”

Now, Ashley says, she’d be able to say, “‘Ma, I need you to come to the hospital with me to get this checked.’ And it’s much easier to be able to talk relationships, because moms and parents know best. They always do. And you might not want to talk with them because oh, this is awkward, but at the end of the day, they will always be there for you.”

Related:

jeudi 27 août 2015

Bright Screens May Be More Disruptive For Young Adolescents’ Sleep, Study Finds

Bright Screens May Be More Disruptive For Young Adolescents’ Sleep, Study Finds

If you’re the parent of a school age child, you are probably thinking about sleep these days. More specifically, you may be wondering how you will possibly get your child back on a sleep schedule for school after a summer of late nights and mornings sleeping in.

Here’s one tip, based on a recent study on sleep led by researchers at Brown University: get rid of bright screens at night. Especially if your child is a young teen or tween.

(Photo: Robin Lubbock/WBUR)

(Photo: Robin Lubbock/WBUR)

The study, published online in the Journal of Clinical Endocrinology & Metabolism, found that children between the ages of 9 and 15 in the early stages of puberty were particularly sensitive to light at night compared to older teens. Researchers conclude: “The increased sensitivity to light in younger adolescents suggests that exposure to evening light could be particularly disruptive to sleep regulation for this group.”

From the Brown news release:

In lab experiments, an hour of nighttime light exposure suppressed their production of the sleep-timing hormone melatonin significantly more than the same light exposure did for teens aged 11 to 16 who were farther into puberty.

The brighter the light in the experiments, the more melatonin was suppressed.

Among 38 children in early to middle puberty an hour of 15 lux of light (think dim “mood” lighting) suppressed melatonin by 9.2 percent, 150 lux (normal room light) reduced it by 26 percent, and 500 lux (as bright as in a supermarket) reduced it by 36.9 percent. The 29 teens in the late or post-puberty stage were also affected, but not as much. Exposure to 15 lux did not suppress melatonin at all, 150 lux reduced it 12.5 percent, and 500 lux reduced it by 23.9 percent.The effects were the same for boys and girls.

“Small amounts of light at night, such as light from screens, can be enough to affect sleep patterns,” said study senior author Mary Carskadon, professor of psychiatry and human behavior in the Alpert Medical School of Brown University and director of chronobiology and sleep research at the E.P. Bradley Hospital in East Providence, R.I. “Students who have tablets or TVs or computers — even an ‘old-school’ flashlight under the covers to read — are pushing their circadian clocks to a later timing. This makes it harder to go to sleep and wake up at times early the next morning for school.”

I asked Carskadon what parents can do to help. Here’s her emailed response:

- Make a plan for sleep: Set a bedtime for that will provide enough time to sleep—and keep as close to it as you can

– Get bright light every morning upon wake up to help move the internal clock stay at an earlier time that can help enhance sleep onset

– Avoid light at night before bedtime to keep the internal clock from moving later

– Avoid “arousing” activities in the evening; have a wind-down time to relax for about 30 minutes before bedtime

– Don’t sleep with cell phone on, nor the computer, TV, or any other technology (including lights) in the bedroom

– Stick as closely as you can to the sleep schedule on weekends

– Avoid caffeine after school

– Do not nap after 4 pm

– Allow for some fun every day and enjoy life!

Good luck.

mercredi 26 août 2015

Study: Kids Are Dumping Fruits And Veggies Offered At School — But Don’t Give Up Yet

Study: Kids Are Dumping Fruits And Veggies Offered At School — But Don’t Give Up Yet

A study found that students put more fruits and vegetables on their trays, as required, but consumed fewer of them and increased waste by approximately 56 percent. (Courtesy of Sally McCay/UVM Photography)

A study found that students put more fruits and vegetables on their trays, as required, but consumed fewer of them and increased waste by approximately 56 percent. (Courtesy of Sally McCay/UVM Photography)

File this one under: You can lead a horse to water…

Researchers at the University of Vermont report what they characterize as a “heartbreaking” finding: Many schoolkids are trashing the fruits and vegetables they are now served as part of a federal law that was supposed to nudge the kids toward healthier food choices.

The study, published online in the journal Public Health, concludes that kids are putting more fruits and vegetables on their trays, as required by the Healthy, Hunger-Free Kids Act of 2010 (which took effect in 2012 and was championed by First Lady Michelle Obama). However, the children ate fewer of these items after the law took effect and often dumped the produce straight into the trash.

“It was heartbreaking to see so many students toss fruits and vegetables into the trash right after exiting the lunch line,” Sarah Amin, Ph.D, a UVM researcher in nutrition and food sciences and the study’s lead author, said in an interview.

For the study, researchers captured before-and-after images of school lunches. (Courtesy)

For the study, researchers captured before-and-after images of school lunches. (Courtesy)

As part of the study, researchers captured images of kids’ school lunches before they ate and then again right before they dumped uneaten foods into the trash. So, for instance, the child might choose a school lunch (pictured on the left) of chicken nuggets, mac and cheese, green beans and milk. But, when the child is done eating, it’s clear the greens beens remain untouched.

The study concludes:

Children consumed fewer (fruits and vegetables) FVs and wasted more FVs during the school year immediately following implementation of the USDA rule that required them to take one fruit or vegetable at lunch. Average waste increased from one-quarter cup to more than one-third of a cup/tray, with about one-eighth cup/tray more FVs discarded, or a total of about 56 cups/day/school (based on an average of 400 lunches served/day).

Researcher Amin, who will soon begin a post doctorate fellowship at Tufts, said that while the initial findings might seem disheartening and show some unintended consequences of the federal law, it’s worth remaining hopeful.

She pointed out that “this was the first update to these regulations in 15 years and kids were really acclimated to how the environment was before,” and not used to choosing either one fruit or one vegetable with lunch.

“Maybe you can’t just put these foods in front of them and expect them to eat,” she said. “But it may just be too soon.”

For younger kids entering kindergarten, for example, “this may work,” Amin said, because it’s all the children know. “But for older kids used to the old system, this may rock their world because they’re just not used to it.

“I still think the guidelines [which are up for reauthorization next month] are necessary,” she said. “We have a childhood obesity epidemic and the guidelines were put in place to address it. … A little bit of waste at the get go may be a sacrifice we have to make for the health and well being of children in the long term.”

Amin added that the guidelines need to be supplemented with other strategies both in the school cafeteria and at home. Those strategies range from serving veggies with dip, cutting fruits up into smaller chunks and, more broadly, incorporating farm-to-school programs into the curriculum.

For more positive school meal ideas, Amin pointed to the website School Meals That Rock, which depicts images of beautiful, healthy school meals, debunks myths and, in general, tries to show that school meals can be cool and delicious.

Here’s more from the UVM news release:

Less than a month before Congress votes on whether to reauthorize a controversial program mandating healthier school lunches, a new study confirms the suspicions of school officials – many students are putting the fruits and vegetables they’re now required to take straight into the trash, consuming fewer than they did before the law took effect.

The new study…is also one of the first to compare fruit and vegetable consumption before and after the controversial legislation – the Healthy, Hunger-Free Kids Act of 2010 – was passed.

After passage of the legislation and the USDA mandates it put in place 2012, the study found that students put more fruits and vegetables on their trays, as required, but consumed fewer of them and increased waste by approximately 56 percent.

“The basic question we wanted to explore was: does requiring a child to select a fruit or vegetable actually correspond with consumption,” says Sarah Amin, Ph.D.

“The answer was clearly no,” she said…

Digital imaging produces fast, accurate data

Amin and her co-authors documented almost 500 tray observations over 10 visits to two elementary schools in the Northeast before implementation of the USDA guideline and almost twice as many observations afterwards.

Forty to 60 percent percent of the students at the schools qualified for free or reduced lunch, a marker for low socioeconomic status.

The research team used a digital imaging method that they validated three years ago in the Journal of the Academy of Nutrition and Dietetics to measure consumption.

The new methodology, which involved visual estimations and calculations based on digital photographs of trays as students reached the cashier and again after they passed the food disposal area, was faster and more accurate than conventional methodologies that simply weighed food waste.

“The beauty of this method is that you have the data to store and code to indicate what was selected, what was consumed, and what was wasted as opposed to weighed plate waste, where everything needs to be done on site,” said Amin, who hopes to develop an online training tutorial that could be used by schools across the country to measure consumption and waste.

Revisiting past practices part of answer to increasing consumption

In an earlier study published in the Journal of Child Nutrition and Management, Amin and colleagues looked at what types of fruits and vegetables children selected prior to the new guideline.

They found that children preferred processed fruits and vegetables such as the tomato paste on pizza or 100 percent fruit juice rather than whole varieties.

In addition to making sure those options are available, Amin and her colleagues offer these additional strategies in the paper for increasing fruit and vegetable consumption in school lunch programs:

  • Cutting up vegetables and serving them with dip or mixing them in with other parts of the meal;
  • Slicing fruits like oranges or apples, rather than serving them whole;
  • Adopting promising strategies targeting school settings such as Farm-to-School programs and school gardens, which can encourage fruit and vegetable consumption in addition to what the cafeteria is providing
  • Putting public health programs in place that encourage fruit and vegetable consumption in the home, which could carry over to school.

Related:

mardi 25 août 2015

Performance Enhancing Supplements: Does Overuse Signal An Eating Disorder Among Men?

Performance Enhancing Supplements: Does Overuse Signal An Eating Disorder Among Men?

By Marina Renton
CommonHealth Intern

You’ve seen them at the gym: extremely body conscious men, driven to achieve a level of physical perfection through grueling workouts.

Well, new research suggests that overusing popular supplements like whey protein and creatine to improve workout performance may signal an emerging eating disorder.

Researchers presented their findings at the American Psychological Association’s annual convention in Toronto earlier this month.

Almost 200 18-to-65-year-old men who consumed legal appearance- and performance-enhancing drugs (APEDs) and worked out at least twice a week participated in the study, led by co-authors Richard Achiro and Peter Theodore, both from the California School of Professional Psychology at Alliant International University, Los Angeles. In addition to asking about their supplement use and eating habits, researchers surveyed the participants about their psychological well-being, asking about their body image, self-esteem, and gender role conflicts.

(Wikimedia Commons)

(Wikimedia Commons)

Almost 30 percent of the people surveyed said they were worried about their supplement use. Over 40 percent had increased their supplement intake over time. Twenty-two percent said they consumed the supplements instead of a meal, even when that wasn’t their intended use. Eight percent had been advised by their doctor to curb their use of supplements, and three percent had been hospitalized for kidney or liver problems stemming from their supplement intake.

Risky behaviors were influenced by how much participants had internalized what the study authors called “cultural standards of attractiveness,” their self-esteem, gender role conflict, and body dissatisfaction. (For more details, see NPR’s coverage here.)

“Our findings suggest that misuses [over the counter] workout supplements is a type of eating disorder among gym-active men,” Achiro wrote in an email. “This is a critical finding because we have been overlooking this form of eating disorder based on our conventional understanding of eating disorders being directed toward a drive for thinness (which predominates among women) rather than considering that men are more likely to strive for a body that is both lean and muscular — exactly the type of physique many of these supplements purport to foster.”

I spoke with Dr. Jacques Carter, an attending physician at Beth Israel Deaconess Medical Center and assistant professor at Harvard Medical School, about the research and the use of legal APEDs. He said a surprisingly high number of his patients use the workout supplements. Below is our conversation, lightly edited:

MR: What was your reaction to the research?

JC: I had never looked at legal supplement use as being an issue related to an eating disorder in men. I have lots of male patients who take supplements — more than you would imagine, actually. And they often come in with their supplement in hand to inquire as to whether I think they’re okay to take.

In most of those cases, these are guys who I think are eating well, not skimping on meals, and not using these supplements as some kind of snack. I think they use them to help build muscle tone and muscle mass, and not so much for any other reasons.

But, maybe now I’ll ask some of these guys, do you have any problems with eating, do you skip meals when you take this stuff? I’d like to know that because it’s not something that immediately comes to mind. These guys who seem healthy and work on their overall health and bodies, you don’t tend to think about them having eating issues. They don’t fit the typical profile.

So, your patients often come to you with questions about the appropriate use of supplements?

Absolutely. The main reason that they come in with the supplements, actually, is to make sure that they’re okay to take, that there’s nothing harmful in them. I’ll look at the label and I’ll go through the ingredients on the label and say, this will raise your blood pressure, this will do this, this will do that. Most of these products are quite safe if used in moderation, as long as they don’t have a lot of stimulants in them. But some of them have stimulants in them, and that can cause some problems.

What are some of the most common products you see?

Creatine is a big one, and a lot of my patients come in with products with amino acids in them. A lot of claims are made for these products that don’t have to be backed up scientifically. And they get marketed that way, and consumers have no idea, they just read the label and say this is going to help me build more muscle, or have more energy, or blow off more fat. So that’s why they use these products, but there is absolutely no way to know for sure. And you can’t put stock in those advertisements because they don’t have to be backed up scientifically at all.

Would you advise people consult their doctors if they’re considering taking supplements?

If it’s more than just a simple multivitamin, I would suggest a telephone call about the product’s safety. Especially if you have some underlying health issues, such as hypertension, diabetes, high cholesterol, or kidney disease. You have to be careful of your renal function, especially with some of these products like creatine and other protein products.

How can they damage your kidneys or liver?

When you take these products, you have to eliminate them somehow. And they have to be broken down, and they go through the liver. Some of them are excreted through the bowels and some are excreted through the urine, through the kidneys. If you’re prone to some renal problems, sometimes it doesn’t take very much of an overload to make that worse.

You have to be very careful with some of these products, especially if you’re taking them in some mega doses. A lot of these folks take these things in multiple pills. You have to know your health history and how well you are, how well your kidneys and heart are functioning.

A lot of my patients who use these supplements are in their 50s and 60s. They’re health-conscious, that’s why they take some of these products, but they especially have to be careful if they have tenuous renal function.

What about the relationship between supplement use and body image issues?

People who are taking legal supplements to build up their bodies, I guess they might have some body image issues, but I’m not sure if that falls into the category of eating disorder.

lundi 24 août 2015

Cut Your Risk Of Alzheimer’s? Growing Evidence Says Maybe You Can — Modestly

Cut Your Risk Of Alzheimer’s? Growing Evidence Says Maybe You Can — Modestly

Alexis McKenzie, right, executive director of The Methodist Home of the District of Columbia Forest Side, an Alzheimer’s assisted-living facility, puts her hand on the arm of resident Catherine Peake, in Washington, Feb. 6, 2012. (Charles Dharapak/AP)

Alexis McKenzie, right, executive director of The Methodist Home of the District of Columbia Forest Side, an Alzheimer’s assisted-living facility, puts her hand on the arm of resident Catherine Peake, in Washington, Feb. 6, 2012. (Charles Dharapak/AP)

It was the “two-thirds” in the press release headline that grabbed me: “Nine risk factors may contribute to two thirds of Alzheimer’s cases worldwide.”

So of course I read more about the new study:

Nine potentially modifiable risk factors may contribute to up to two thirds of Alzheimer’s disease cases worldwide, suggests an analysis of the available evidence, published online in the Journal of Neurology Neurosurgery & Psychiatry.

The analysis indicates the complexity of Alzheimer’s disease development and just how varied the risk factors for it are. But the researchers suggest that preventive strategies, targeting diet, drugs, body chemistry, mental health, pre-existing disease, and lifestyle may help to stave off dementia. This could be particularly important, given that, as yet, there is no cure, they say.

How I wish this meant that we can reduce our risk of Alzheimer’s by two-thirds. But no matter how I mangle the statistics, it doesn’t. Here’s what it does suggest, according to Dr. James Hendrix, director of global science initiatives for the Alzheimer’s Association: that for up to two-thirds of people who have Alzheimer’s, these modifiable risk factors may have contributed to it, and probably to when they got it.

“So,” he says, “if you were going to get Alzheimer’s, because maybe you had a genetic predisposition, and you take very good care of yourself, maybe you don’t get it until you’re 85 or 95. But if you smoke or you’re overweight or don’t exercise, maybe you get Alzheimer’s at 75. That’s really what this says — these could be contributing factors to if you get Alzheimer’s or when you get Alzheimer’s. It increases your risk.”

Of course, we’ve been hearing for years — at least since those smart Minnesota nuns got famous in 2001 — about how mental challenges like crossword puzzles could be linked to lower Alzheimer’s risk. But this latest paper seems part of a broad shift based on growing evidence about a far greater array of “modifiable risk factors.”

Exhibit Number 1: This summer, the Alzheimer’s Association ran a campaign on “10 Ways to Love Your Brain,” encouraging people to exercise, keep learning and quit smoking, among other advice. Exhibit Number 2: A round-up paper in the journal Alzheimer’s & Dementia laying out the levels of evidence on which lifestyle and health changes could protect people against Alzheimer’s.

The findings are relentlessly commonsensical: Many of the usual suspects that we already know are good for our health — exercise, heart-healthy diet, sleep, weight and blood pressure control — also appear to help fend off Alzheimer’s.

I asked Dr. Gad Marshall — a neurologist and associate medical director of clinical trials at the Center for Alzheimer Research and Treatment at Brigham and Women’s Hospital — how he’d respond to a neighbor who says, “Hey, I hear I can really move the needle on my risk of Alzheimer’s!”

“The answer is yes, you can,” he responded. “It’s not a huge difference, but it is a difference, and you do give yourself a better chance of reducing the risk of Alzheimer’s disease and other dementias by doing what makes sense: Being physically active, eating a healthy diet. For these two elements, yes, we have good evidence, including some clinical trials.”

“To a lesser degree, we have some evidence on cognitively stimulating activities or socializing,” as being protective, he says, and still weaker evidence for the potential benefits of supplements like antioxidants or omega-3 fatty acids.

Preventive measures could stave off Alzheimer’s disease by perhaps a couple of years, he says, and “right now, that’s better than any medication we can prescribe. There’s no medication approved for this purpose, for preventing Alzheimer’s disease. And so it’s no guarantee but it does improve your chances.”

Which factors matter most? At this point, Dr. Hendrix says, exercise has the strongest data behind it.

“We saw some of that data at our Alzheimer’s Association international conference last month,” he says. “Not only have we seen it in terms of prevention and improving overall cognition as we age, but we also saw data looking at people who already had early stages of Alzheimer’s disease — and it appeared to have benefit even within that population.”

One important point: No blame here. All these risk factors have turned up in broad population studies, but there’s no way of knowing which factors contribute to any particular individual’s Alzheimer’s disease.

The question arises, if we already know that most of these healthful measures help fend off the No. 1 cause of death — heart disease — and people still resist healthy lifestyles, why would they care about data on Alzheimer’s?

Dr. Hendrix says he’s often asked that question, and “all I can say is, I’m a scientist and this is the data that we have and we’ve seen — and we want to get that information out. And maybe this will be enough to scare people to start making those changes.”

Personally, I find Alzheimer’s scarier than heart disease; at least heart disease can be treated. Dr. Marshall says that while there are studies of Alzheimer’s drugs under way and more expected, the drugs are all still considered experimental. Studies are also under way — though more are needed — to tease out the effects of lifestyle factors. But those, too, take time.

For now, these recent papers can give us a snapshot of the state of the data on many possible Alzheimer’s risk factors; the “two-thirds” paper notes that the previous studies it encompassed included 93 possible factors. More from the press release:

They found grade 1 level evidence in favour of a protective effect for the female hormone oestrogen, cholesterol lowering drugs (statins), drugs to lower high blood pressure, and anti-inflammatory drugs (NSAIDs).

They found the same level of evidence for folate, vitamins C and E, and coffee, all of which were associated with helping to stave off the disease.

Similarly, the pooled data indicated a strong association between high levels of homocysteine—an amino acid manufactured in the body—and depression and a significantly heightened risk of developing Alzheimer’s disease.

The evidence also strongly pointed to the complex roles of pre-existing conditions as either heightening or lowering the risk.

The factors associated with a heightened risk included frailty, carotid artery narrowing, high and low blood pressure, and type 2 diabetes (in the Asian population). Those associated with a lowered risk included a history of arthritis, heart disease, metabolic syndrome, and cancer.

Certain factors seemed to be linked to altered risk, depending on the time of life and ethnic background.

For example, high or low body mass index (BMI) in mid-life and low educational attainment were associated with increased risk, whereas high BMI in later life, exercising one’s brain, current smoking (excluding the Asian population), light to moderate drinking, and stress were associated with lowered risk.

The nine risk factors included obesity, current smoking (in the Asian population), carotid artery narrowing, type 2 diabetes (in the Asian population), low educational attainment, high levels of homocysteine, depression, high blood pressure and frailty.

This is an observational study, so no definitive conclusions can be drawn about cause and effect, but the researchers suggest that preventive strategies, targeting diet, prescription drugs, body chemistry, mental health, underlying disease, and lifestyle might help curb the number of new cases of Alzheimer’s disease.

Readers? Enough to change anything you do?

Further reading:

vendredi 21 août 2015

Shameful Operating Room Moments: Medical Journal On Calling Out ‘Dirtball’ Doctors

Shameful Operating Room Moments: Medical Journal On Calling Out ‘Dirtball’ Doctors

Imagine this scene:

A female patient under general anesthesia is being prepped for a vaginal hysterectomy. As the attending doctor washes and scrubs her labia and inner thighs, he turns to a medical student and says: ‘I bet she’s enjoying this.’ Then he winks and laughs.

No, this account doesn’t come from a racy British tabloid. It was published this week in a reputable medical journal, Annals of Internal Medicine.

The account, written by an anonymous doctor and titled “Our Family Secrets,” also describes this incident involving an obstetric patient, Mrs. Lopez, who experienced hemorrhaging and other complications after childbirth:

“…something happened that I’ll never forget. Dr. Canby raises his right hand into the air. He starts to sing ‘La Cucaracha.’ He sings, ‘La Cucaracha, la cucaracha, dada, dada, dada-daaa.’ It looks like he is dancing with her. He stomps his feet, twists his body, and waves his right arm above his head. All the while, he holds her, his whole hand still inside her vagina. He starts laughing. He keeps dancing. And then he looks at me. I begin to sway to his beat. My feet shuffle. I hum and laugh along with him. Moments later, the anesthesiologist yells, ‘Knock it off, assholes!’ And we stop.”

Stomach Churning

Dr. Christine Laine, Editor in Chief of Annals of Internal Medicine, said this is the first time in her tenure that such a profanity has been printed in the journal. But, she said in an interview, it seemed appropriate in this case. When she first read the essay she says it made her “stomach churn,” and it made her angry. “Angry for the patients…angry for the younger physicians who encountered this behavior, angry at myself and others who have witnessed colleagues being disrespectful to patients but were too timid to speak out.”

(Truthout.org/Flickr)

(Truthout.org/Flickr)

In an accompanying editorial condemning the doctors’ behavior, Laine and her colleagues wrote: “The first incident reeked of misogyny and disrespect — the second reeked of all that plus heavy overtones of sexual assault and racism.”

So how did this series of unfortunate medical events unfold?

Here’s the backstory: The anonymous author of the essay, (the journal decided to keep the doctor’s identity a secret) was leading a course on medical humanities for senior medical students. The topic was “the virtue of forgiveness.” At one point the doctor put a question to the class: “Do any of you have someone to forgive from your clinical experiences? Did anything ever happen that you need to forgive or perhaps still can’t forgive?”

Did You Laugh Too?

The room went silent. Finally, a student named David spoke out: “Something unforgivable happened to me.”

David then told the story. Here’s the full account from the piece:

“I was scrubbed into a vaginal hysterectomy. The patient was under general anesthesia. My attending was prepping the patient’s vagina. He picked up a clamp holding sterile cotton balls and dipped them into Betadine. While he was cleansing and scrubbing her labia and inner thighs, he looked at me and said, ‘I bet she’s enjoying this.’ My attending winked at me and laughed.”

Someone gasped. I stared at David. He shifted in his seat and crossed his arms on his chest. A splotchy red rash appeared on his neck. Staring down at the table, he murmured, “Man, I was just standing there trying to learn. The guy was a dirtball. It still pisses me off.”

David glanced at me. I asked, “When your attending said that and laughed, did you laugh, too?”

My question touched a nerve; perhaps my tone was accusatory. David snapped back, “Yeah, I laughed, but what was I supposed to do? Have you ever been in a situation like that?”

I looked down at the table in front of me and saw my black ballpoint pen. I focused on its gold clip for a moment. I placed my index finger and thumb beside the pen and spun it in place. It twirled and clicked as it spun around and around… I looked up at David. “Yes, I have.”

“So, what happened?” David asked.

Then the instructor recounts his own story when he was a third year medical school working in obstetrics/gynecology. The patient, Mrs. Lopez, delivered her baby but then started hemorrhaging. That’s when Dr. Canby takes charge.

From the essay:

I look at Mrs. Lopez—her eyes are half-closed and vacant. Dr. Canby instructs me to hold her knee. A fellow medical student holds her other knee. Our job is to keep her legs spread. Canby then performs an internal bimanual uterine massage. He places his left hand inside her vagina, makes a fist, and presses it against her uterus. I look down and see only his wrist; his entire hand is inside her. Canby puts his right hand on her abdomen and then massages her uterus between his hands. After a few minutes, he feels the uterus contract and harden. He says something like, ‘Atta girl. That’s what I like. A nice, tight uterus.’ And the bleeding stops. The guy saved her life. I was blown away.”

“But then something happened that I’ll never forget. Dr. Canby raises his right hand into the air. He starts to sing ‘La Cucaracha.’ He sings, ‘La Cucaracha, la cucaracha, dada, dada, dada-daaa.’ It looks like he is dancing with her. He stomps his feet, twists his body, and waves his right arm above his head. All the while, he holds her, his whole hand still inside her vagina. He starts laughing. He keeps dancing. And then he looks at me. I begin to sway to his beat. My feet shuffle. I hum and laugh along with him. Moments later, the anesthesiologist yells, ‘Knock it off, assholes!’ And we stop.”

After I finish my story, I glance at the students; some gaze down at the table in front of them, while a few others look at me with blank stares. They are all quiet.

I know this is my silence to break.

So, the doctor does save Mrs. Lopez’s life. And she likely knows nothing of the event. But the entire essay begs the question: How many of us are being mocked and crudely taunted when we’re at our most vulnerable — exposed, under anesthesia or not watching what the doctor is doing?

The answer: Who knows?

Dissing Patients

The essay brings to mind the recent case of a man who inadvertently recorded his own colonoscopy and discovered the anesthesiologist and other doctors mocked and insulted him while he was sedated: among other things, doctors made fun of certain body parts and noted on his chart that he had hemorrhoids, which was untrue, according to reports.

Laine, the journal editor, who is also a general internist at Jefferson Medical College in Philadelphia, said that while the awful behavior outlined in the essay is extreme, doctors show disrespect toward patients all too often.

“The incidents described in the essay are clearly abhorrent and at the far end of the spectrum,” she said. “But do these things happen? They do on occasion happen, and even if they happen rarely, that’s too often. And there are far less extreme examples, and those shouldn’t happen either.”

She added that for physicians who witness such behavior, there are three options: to play along, to be quiet, “and the third is to call them [the offensive doctors] out and try to stop it.. we need more physicians willing to tell people to knock it off.”

Emotional Harm

In some medical circles, efforts are underway to address such “emotional harm” in a more systematic manner.

At Beth Israel Deaconess Medical Center in Boston, for instance, emotional harm is beginning to be addressed with “the same rigor that we’ve traditionally applied to physical harms — such as falls, infections or wrong site procedures,” emails Dr. Lauge Sokol-Hessner, associate director of inpatient quality at Beth Israel and lead author of a recent article published in the journal BMJ Quality and Safety, titled “Emotional Harm from Disrespect: The Neglected Preventable Harm.”

Ken Sands, a co-author of the emotional harm paper and chief quality officer at Beth Israel Deaconess, adds in an email:

Currently most hospitals are rigorous about tracking physical harm events. There are definitions to refer to, methods for counting, models for doing root cause analysis, and reporting on findings and corrective actions.  Emotional harm lacks the same rigor, often goes unreported (as the Annals paper illustrates) and if it is reported, there is likely to be anxiety, handwringing, and perhaps individual follow-up but nothing resembling formal cause analysis, reporting, and corrective action. We have put systems in place to 1) encourage our staff to consider these as adverse events that need to be reported; 2) come up with definitions and a classification scheme so that we can track events; 3) subject serious events to analysis and corrective action planning;  4) formally report on occurrences to hospital leaders and the Board.

And Laine says that by publishing the essay, she hopes to spark more discussion about how to prevent such behavior and change the culture from which it stems.

Squelch This

Here’s more from the editorial:

It is our hope that the essay will gnaw on the consciences of readers who may recall an instance of their own repugnant behavior. The story is an opportunity to see what this behavior looks like to others and starkly shows that it is anything but funny. After finishing it, readers guilty of previous offense will hopefully think twice before acting in a manner that demeans patients and makes trainees and colleagues squirm. Again, if the essay squelches such behavior even once, then it was well worth publishing…

Multiple interpretations of the piece are valid and lend insight. They were reflected in the lengthy and heated discussion that occurred among our editorial team when considering whether to publish the story. The discussion was so impassioned and opinions so disparate that we needed a “time-out” and came back to it a week later after we had ample time to contemplate the issues raised. We all agreed that the piece was disgusting and scandalous and could damage the profession’s reputation. Some believed that this was reason not to publish the story. Others believed that it was precisely why we should publish it.

When we finally decided to publish the essay, we did so under the condition that the author would remain anonymous. We have done this in only one other instance. Then, as now, we did so to protect the identity of any person who might be identified, most importantly the patients.

We hope that medical educators and others will use this essay as a jumping-off point for discussions that explore the reasons why physicians sometimes behave badly and brainstorm strategies for handling these ugly situations in real time. By shining a light on this dark side of the profession, we emphasize to physicians young and old that this behavior is unacceptable—we should not only refrain from personally acting in such a manner but also call out our colleagues who do. We all need the strength to act like the anesthesiologist in this story and call our colleagues “assholes” when that label is appropriate. We owe it to ourselves, to our profession, and especially to our patients.

jeudi 20 août 2015

Carter’s Cancer: Melanoma Is ‘Bad’ Skin Cancer, But Better To Have Now Than Past

Carter’s Cancer: Melanoma Is ‘Bad’ Skin Cancer, But Better To Have Now Than Past

Former President Jimmy Carter discusses his cancer diagnosis at the Carter Center in Atlanta, on Thursday. Carter, 90, said the cancer has spread to his brain, and he will undergo radiation treatment at Emory University Hospital. (Phil Skinner/AP)

Former President Jimmy Carter discusses his cancer diagnosis at the Carter Center in Atlanta, on Thursday. Carter, 90, said the cancer has spread to his brain, and he will undergo radiation treatment at Emory University Hospital. (Phil Skinner/AP)

Ninety-year-old former President Jimmy Carter announced Thursday morning that he’s being treated for melanoma, and the cancer has been found in his brain and liver.

My reaction: “Melanoma? Isn’t that supposed to start with weird spots on your skin?”

I turned to Dr. Elizabeth Buchbinder, melanoma expert at Dana-Farber Cancer Institute. Our conversation, lightly edited:

So is our popular conception of melanoma — odd, mole-like things on sun-hit skin — not consonant with reality?

So often, when people think of skin cancer, they think of the more traditional basal cell, squamous cell, where you go in to the dermatologist, they cut it off, maybe you need to get a little bit of liquid nitrogen, or something else, but really, once they’ve done that, the risk in terms of it affecting your survival or anything else is very low. They’re really very controllable cancers.

Melanoma is kind of the exact opposite of that. It’s the real bad actor among the skin cancers, because melanoma likes to get into the blood and spread. It likes to go anywhere it wants in the body. Some of the places it likes to particularly go are the liver and the brain. It can also go into the lungs and other areas of the body. It’s kind of the ‘bad boy’ of the skin cancers; it’s definitely a bad actor in terms of cancers in general, but then also in terms of skin cancers as a group.

And you can have melanoma without ever having seen a spot?

First of all, melanomas predominantly arise on the skin and are most commonly associated with sun or UV exposure. However, they can arise in areas of the skin that never see the sun. They can also arise on other membranes that are not visible; for example, the inside of the mouth or the inside of the intestine. They can also arise within the eye.

Although most of them arise on skin that are seen, some melanomas may arise on the skin and never necessarily be detected. We have a fair rate of what’s called ‘unknown primary,’ where we never find that skin spot, and one of the thoughts is that that skin spot either has been attacked by the person’s own immune system and kind of gotten rid of, or that something else has happened; it’s been scraped off or itched, or who knows? It just never was found. So there’s some rate of that.

And so what is the cutting-edge of melanoma research and treatment now?

Melanoma treatment is so exciting right now. The real, real cutting-edge is basically using the immune system to fight the cancer itself. What we’ve known for a long time is that the immune system has a relationship with cancer, and sometimes can keep it from growing or prevent new cancers from forming, but often the cancer kind of overcomes that somehow. And what’s happened with new treatments and with new research and understanding of how the immune system works is we’ve been able to use medications to make the immune system attack the cancer.

What’s so exciting about that is once the immune system starts attacking the cancer, it continues to do so. So just like as a kid when you’re vaccinated against mumps you’re not going to get mumps for the rest of your life, if you get that immunity going, there’s a chance that the cancer can be controlled not just for a brief amount of time, but for five years, 10 years, ongoing. And so what we’re seeing with some of these new immune therapies is what are called ‘durable responses,’ where people respond well to the treatment initially, but then continue responding without the cancer coming back. So very, very exciting.

So have you actually moved the dial on what could be called a cure rate?

In cancer, we’re always afraid to say cure, because we always think it could come back and then we really haven’t cured it.

But we definitely have. A lot of people ask about the prognosis in cases like former President Carter’s, and it’s very hard to say, because if he has a great response to immune therapy, there’s the potential that he could go on to live many, many more years. And so it’s really changed the landscape for melanoma, and we’re hoping, as these treatments are tested more and more, for cancer as a whole. Because they’re seeing success in other cancers, like lung cancer and bladder cancer, which is really exciting as well.

So melanoma is a little bit like the poster child for the new immune therapies?

It really is. I think it has the highest rates in terms of response. We’ve actually been doing immune therapy for many years in melanoma, even before these newer agents came along, partly because there weren’t a lot of other option in melanoma treatment.

So maybe that could also be an effect of Carter’s announcement, that it will bring even more attention to the very promising nature of these immune therapies. I know you can’t comment on his case directly, but we can assume he’s going to be getting them, right?

I think I read in one of the reports that he is getting something that is enhancing his immune system.

I think the other area of melanoma treatment that’s also very exciting — but these days is kind of falling to the second tier in a way — is the targeted therapies, where we actually look at genetic changes in the cancer itself and use drugs that attack those genetic changes. But the immune therapy, because of those long-term responses, is really what people tend to be starting as front-line. So it makes sense that that would be exactly where they start in terms of his treatment.

Related:

mercredi 19 août 2015

Possible Key To Weight Loss? Researchers Find ‘Master Switch’ To Crank Up Fat-Burning

Possible Key To Weight Loss? Researchers Find ‘Master Switch’ To Crank Up Fat-Burning

(Source: UConn Rudd Center for Food Policy & Obesity.)

(Source: UConn Rudd Center for Food Policy & Obesity.)

Here’s my fantasy: I’ve overindulged — let’s say, purely theoretically, on Cape Cod fried clams, french fries and beer — and would normally face the greasy regret and resign myself to extra carrots and cardio in the days to come.

But no. Instead, I simply pop a pill that cranks up my metabolism for a few hours so that I burn the extra calories instead of storing them as fat. I don’t gain an ounce.

That’s a very distant prospect. But new science on a “metabolic master switch,” just out in the New England Journal of Medicine, brings my dream one step closer to reality — and, researchers say, may hold the promise of someday making a dent in the obesity epidemic.

Until now, weight-loss treatments have focused on altering appetite and exercise, says MIT computer science professor Manolis Kellis, senior author on the paper. Now, “what we have in our hands is a third knob, if you wish, for controlling body fat,” he says. “It’s working directly on your fat cells to reprogram them to burn more energy rather than to store it as fat.”

In normal-weight mice, Kellis says, the effects of turning that knob are dramatic: “By changing the expression of one gene in these mice, they lose 50 percent of their body weight. You can feed them all the fat you want and they will not take on weight. They do not exercise more and they do not eat less, what they do is simply burn more energy when they’re awake, or even in their sleep.”

Dr. Melina Claussnitzer is lead author on the fat-burning paper just out in the New England Journal of Medicine. (Courtesy of Lovely Valentine)

Dr. Melina Claussnitzer is lead author on the fat-burning paper just out in the New England Journal of Medicine. (Courtesy of Lovely Valentine)

But mice are not men, of course. Could this work in humans?

“We experimented on human fat cells,” says Melina Claussnitzer, first author of the paper, a visiting professor at MIT and faculty member at Beth Israel Deaconess Medical Center. “And we found that we could flip them from energy-storing to energy-burning by altering the expression of a single gene — and, even more remarkably, by altering a single letter from our 3-billion-letter genome. And we could flip that switch back in either direction.”

Still, it’s a very long way from genetically editing human cells in a Petri dish to altering the metabolism of a breathing human, the researchers caution. The team has filed patents on their switch-flipping manipulations and are seeking to commercialize the approach and lead it into human clinical trials, Kellis says, but cannot speculate on a time frame.

So meanwhile, there’s no such thing as a free fried clam. But we can at least savor the story of how this cutting-edge science came to be.

Let’s begin in 2007, when researchers turned up the first genetic link to obesity, a region of the genome called FTO. To this day, it remains the strongest genome-obesity link: Some 44 percent of Europeans, it turns out, have a version that predisposes them to weigh more, on average five to seven pounds.

The natural next question was: How does it work? Does it make people eat more? Move less? Both?

Or neither, says Claussnitzer. “Despite seven years of intense efforts to hunt down a mechanism, no link has been made between the genetic differences in the region and altered functions in the brain.”

Rather, she says, FTO appears to affect the precursors of fat cells: “Our results indicate that the obesity-associated region acts primarily in adipocyte progenitor cells in a brain-independent way. When we lifted up the hood, we found a master control switchboard that works independently of the brain, and flips between storing energy as lipids versus burning energy as heat.”

“Our story,” Kellis says, “is that we shouldn’t make assumptions about how something works until we’ve connected the dots between the genetic differences and the ultimate mechanism. In the end, connecting these dots uncovered a previously unknown metabolic master switch and this has major implications for how we can actually begin treating obesity.”

It’s Complicated

This has long been the promise of the Human Genome Project: that the genetic insights it yielded would lead to better understanding of biology and hence to treatments. But of course, life is always more complicated than you think.

The quest to understand the FTO region was particularly difficult because the genetic variants do not affect a protein, Kellis says; rather, they affect a “control region.”

“Control switches are much harder to understand than the genes themselves,” Kellis says. “Imagine yourself in a dark factory with 20,000 machines, 2 million control switches and hundreds of factory workers, that makes thousands of different products. Genetics may suggest that a switch is broken, but you still need to find which one, and you need to trace its wires to the machines it controls, the products that are ultimately affected, the factory workers responsible for the switch, and also to understand the schedule of when that switch is normally flipped on or off.”

In obesity, the FTO genetic mutation doesn’t affect the FTO protein, either directly or indirectly. Instead, Kellis says, it breaks a genetic switch, which can no longer be turned off, leading to the activation of two faraway genes more than a million letters away.

Those genes then instruct fat cell precursors to differentiate into fat-storing white fat cells instead of fat-burning beige fat cells, leading to more body fat.

Manolis Kellis (courtesy)

Manolis Kellis (courtesy)

Kellis and Claussnitzer see the New England Journal paper as a model for what’s now possible with genomic research, they say. “Because this study has now connected all the dots,” Kellis says. “From the region of association; to figuring out what the cell type is where that region acts; what is the driver nucleotide” — or bit of DNA — “that is responsible for the genetic signal; who is the upstream regulator — the finger that flips the switch; what nucleotide has broken the switch; who are the lightbulbs that turn on when you flip that switch; and what are all the intermediate processes that are the consequences of flipping that switch.”

Lots of dots, combining into an impressive picture. Kellis believes the treatments that eventually emerge from it could help people regardless of their genetic makeup.

“There’s a huge environment component” to the obesity epidemic,” he says, “but perhaps by flipping that switch in people of both risk and non-risk genotype, we could help solve the obesity equation.”

Obesity Experts: ‘Tour-De-Force’ Science But No Quick Pill

This is “wow science,” says Dr. Caroline Apovian, director of the Center for Nutrition and Weight Management at Boston Medical Center. At the same time, “This is not going to turn into a new obesity drug tomorrow.”

So what might she tell a patient who comes in asking about this new study?

“I would tell them to go out and exercise like crazy,” she says.

The New England Journal study may add still more impetus to exercise, because earlier research suggests that exercise may help turn white fat into brown or beige fat, Apovian says.

Similarly, Dr. Sam Klein, director of the Center for Human Nutrition at Washington University School of Medicine in St. Louis, calls the new paper “a scientific tour de force.” He, too, focused on new insights into brown fat.

The study found, he says, that the weight-promoting FTO mutations “result in more fat cells being white fat cells, which store fat, versus beige fat cells, which burn energy and burn up fat.”

“So this tells us that having more brown or beige fat might be an important regulator in body weight, which has never really been shown before in humans.” And it naturally suggests a possible target for treatment, Klein says: “By trying to make more beige and brown fat cells in people, you may be able to help regulate body weight and obesity.”

Let’s hope. But obesity research is littered with attempts to get around the the tight control systems our bodies evolved to hang on to weight when times are lean. Past drugs aimed at ramping up energy expenditure have turned out to be toxic, Apovian noted.

Obesity is such a complex disease, Klein says, involving everything from brain to gut to environment, that “there won’t be any one single magic gene or magic bullet that will address this problem.”

Related:

Women’s Health World Abuzz On Pink Viagra Approval: But Are Expectations Realistic?

Women’s Health World Abuzz On Pink Viagra Approval: But Are Expectations Realistic?

Everyone, it seems, has an opinion on the FDA’s approval this week of the drug Flibanserin, aka “pink viagra,” to boost women’s sexual desire.

“This is the biggest breakthrough for women’s sexual health since the pill,” Sally Greenberg, executive director of the National Consumers League told The New York Times.

Others have their doubts. Cindy Pearson of the National Women’s Health Network told NPR that approval of the drug “is a triumph of marketing over science” and added: “To have any chance of benefit from this drug they’re going to have to take it every day for months on end, years…We just don’t know what the long-term effects will be of changing brain chemistry in this way.”

Janet Woodcock, M.D., director of the FDA’s Center for Drug Evaluation and Research (CDER) said the approval “provides women distressed by their low sexual desire with an approved treatment option…The FDA strives to protect and advance the health of women, and we are committed to supporting the development of safe and effective treatments for female sexual dysfunction.”

Day Donaldson/Flickr

Day Donaldson/Flickr

The drug, which will be sold under the brand name Addyi, is expected to go on sale Oct. 17, according to its maker, Sprout Pharmaceuticals.  And along with the potential to ignite a low (or non-existent) libido among some women, the drug comes with a boxed warning, the strongest kind, on contraindications and potential side effects, including low blood pressure, fainting, nausea, dizziness and sleepiness.

Here’s more on the site Throb, about how the drug actually works.

Still others have extreme doubts.

Emily Nagoski, a feminist sex educator and author of the book “Come As You Are” wrote a smart, thoughtful piece on the site, Medium, about why Flibanserin isn’t addressing the true nature of women’s sexual desires. Here’s a bit of that piece, called: “Pleasure is the Measure:”

I believe that the folks at Sprout Pharmaceuticals — the company that owns Flibanserin, the so-called “pink viagra” — have good intentions. I believe that they want to help women who are struggling with sexual desire.

And I believe that they feel sure — as most people do— that lack of spontaneous, out-of-the-blue desire for sex is a problem. A disease.

They are wrong — as you now know.

It’s not their fault, really, that they’re wrong. Cindy Whitehead, Sprout CEO, isn’t a sex researcher, educator, or therapist. She’s a marketing professional, and she’s darn good at her job. But why would she believe anything except what mainstream culture taught her?

In fact the drug is designed — they’ve said explicitly — as though responsive desire were a disease, as though spontaneous desire were the only “normal” way to experience desire.

And that’s a problem.

The drug is designed to create spontaneous desire — and it doesn’t even work for the vast, overwhelming majority of women, even within the highly selective group it was tested on: it was only tested on pre-menopausal cisgender women in monogamous heterosexual relationships, who had not given birth or breast fed in the last six months and had not had depression or other mental health issues that can interfere with sexuality in the last 12 months, among other exclusions. Also 90% of them were white…

But millions of women will want it, because the very fact of the drug’s existence reinforces the myth that lack of spontaneous desire is an illness that requires medical intervention — that is: It makes women focus on whether or not they “CRAVE” sex,
distracting them from whether or not they ENJOY sex.

In another Medium piece written by Nagoski just before regulators approved the drug, she envisions two possible scenarios for women who don’t always feel instantly the mood:

Imagine one year from now.

Imagine you’re a premenopausal woman in a long-term, monogamous heterosexual relationship (the only people included in the drug trial). Previously in your relationship, you experienced spontaneous, out-of-the-blue desire for sex, but these days you’re not experiencing that. Your relationship is strong, your health is good, and when you can get yourself into a sexy scenario, it goes well — you’re not just going through the motions, you actually enjoy sex with your partner — but you aren’t experiencing that urge.

So you ask your doctor about it. Is there anything she can offer to help you experience that out-of-the-blue desire?

What if your doctor says: “Yes there’s a drug that you take every day, indefinitely, that could possibly increase your sexual frequency by approximately one ‘sexually satisfying event’ per month above placebo. Also, about 10% of women experience side effects like dizziness, fainting, somnolence or nausea.”

And then she holds up her prescription pad and says, “Want it?”

How do you feel? What do you do next?

Okay. Now imagine a different scenario.

What if your doctor says: “Actually, though spontaneous desire is lots of fun and most of us grew up learning that it’s the only ‘normal’ kind of desire, it turns out that responsive desire is also normal. Responsive desire is when you don’t get that urge, but if you put your body in a sex positive scenario — for most people that means low stress and high affection — your body experiences pleasure, and desire emerges from there. Most people experience both styles at different points in their lives. Spontaneous desire isn’t a measure of sexual wellbeing. Pleasure is the measure.”

And then she holds up a booklet called something like 10 Tips for Making the Most of Responsive Desire, and she says, “Want it?”
Women are struggling. They want to feel normal and healthy in their sexual functioning, and they deserve safe, effective treatments. Fortunately, an expanding body of research has shown that sex therapy, couples therapy, bibliotherapy, mindfulness, and sex education can improve sexual satisfaction. They work more effectively, for more women, with less health risk, than any drug.

By approving Addyi, it seems, the FDA is ensuring Option 1 will become a reality for more women. But maybe along with it, we can gain some knowledge about the non-drug options for sexual pleasure.

Readers, chime in and share your thoughts. Are you running out to get a prescription today, or will you stay away from Addyi?

mardi 18 août 2015

Where Does Life Begin, And Other Tough Abortion Questions For Doctors In Training

Where Does Life Begin, And Other Tough Abortion Questions For Doctors In Training

Our recent post on how residents training to be ob-gyns think about providing abortions (or not providing them) went viral earlier this month and triggered a broader conversation among readers. The topic was also featured on Radio Boston and WBUR’s All Things Considered.

I asked Janet Singer, a nurse midwife on the faculty of Brown University’s obstetrics-gynecology residency program, and the person who organized the initial discussion among the residents, to follow up. She, in turn, ​asked Jennifer Villavicencio, a third-year resident​, to lead a discussion digging even more deeply into the topic.

Two of the residents ​in the discussion ​perform abortions, two have chosen not to do so. ​But they are colleagues and friends who have found a way to talk about this divisive issue in a respectful and productive way. ​Here, edited, is ​a transcript of ​their discussion, which gets to the heart of a particularly fraught question: When does life truly begin? ​Three of the residents have asked to not include their names for fear of hostility or violence aimed at abortion providers.

Jennifer Villavicencio (Resident 3): Let’s talk about a woman who comes in, has broken her water and is about 20-21 weeks pregnant and after counseling from both her obstetricians and the neonatologist [a special pediatrician who takes care of very sick newborns] has opted for an abortion. Let’s talk about how we each approach these patients.

Resident 2: As a non-abortion provider I will start just by saying that a patient of this nature in some ways is on one extreme of the spectrum. As an obstetrician, I view the loss of her pregnancy as an inevitability. I think we would all agree with that. So, taking part in the termination [another word for abortion] of her pregnancy is different to me than doing that for someone whose pregnancy, but for my involvement, would continue in a healthy and normal fashion.

Opponents and supporters of an abortion bill hold signs outside the Texas Capitol on July 9 in Austin. (Eric Gay/AP)

Opponents and supporters of an abortion bill hold signs outside the Texas Capitol on July 9 in Austin. (Eric Gay/AP)

JV: Would your opinion change if she were 22 or 23 weeks and theoretically could make it to viability [the concept that a fetus could survive outside of the mother. Currently, in the U.S., the generally accepted definition of viability is 24 weeks gestation or approximately six months pregnant]?

Resident 2: Personally, it wouldn’t, because I feel there is a very slim chance of an intact survival [refers to an infant not having significant mental or disabilities] of an infant. If she were 22 or 23 weeks gestation and could potentially make it to the point of a survivable child, that likelihood is so rare. But for my involvement, she will still lose this pregnancy. My point is, if I help terminate this pregnancy, I am not playing an integral role in the loss of this pregnancy. I feel that supporting her in proceeding in the safest possible way, protecting her while accepting the loss of her pregnancy, is my job.

Future Health Of The Child

JV: … Does the future health of the child really play a role in it for you?

Resident 2: Yes it does, it absolutely does, and it’s kind of on a case-by-case scenario. Theoretically, the goal of every pregnancy is a healthy outcome for mom and baby, and if one of those is in jeopardy my perspective changes.

JV: What do you think Resident No. 4?

Resident 4: I think as you get closer to viability, it becomes a more complicated question.  We know from literature [the current known facts from research done in the area] involving breaking waters that the gestational age at which it happens is very important for the prognosis of the newborn. Unlike Resident No. 3, I think my involvement would weigh on me more greatly as the fetus approaches viability, because at 23 weeks our neonatal intensive care unit (NICU) would be resuscitating this baby if it was something that was important to the parents. We are in a very privileged position to work in a hospital with many doctors, so if you don’t actually do the termination yourself, chances are you have many other providers in the hospital who are able to do so. We have the luxury of opting out. I wonder how my answer to this question would be different had I not been working in this environment.

JV: So, what if you were in a place where you were the only person able to provide the termination?

Resident 4: I would have a hard time with that. I don’t know the answer to that question. Because I’ve not been there, I can say honestly, I don’t know what I would do.

JV: And how about you Resident No. 1?

Resident 1: In my opinion, that’s her decision. I feel very comfortable providing her with that healthcare service.

Two Patients At Once?

JV: Resident No. 1, it sounds like you are talking a lot about the woman, and Resident No. 4, you are talking about where the fetus would be if the fetus was delivered right at that point in time. So, how do we, as OB/GYN’s, who take care of two patients at the exact same time, reconcile that? I know for me in this particular situation I have no qualms whatsoever about providing this termination. Whatever the woman desires is what I am willing to do. I do not think that my personal feelings, ethics or politics should be involved in that. It’s hard as a provider who takes care of two patients in a situation in which one might not survive to reconcile that, but I almost always land on the side of the mother.

Resident No. 1: It is easier for me when I think about the poor outcomes that we see. I feel that a lot of people who are not in medicine do not see …[pause]

Resident 2: …what the alternative is.

Resident 1: Right … which is a severely premature delivery or a newborn with a serious infection being admitted into the NICU [intensive care unit for newborns] for months and months and months and the amount of emotional and financial strife that might bring upon the family. I think she can decide that that is not the choice that she wants.

JV: I think abortion is really an interesting place to discuss life – what life is – where it begins. Even in this scenario how much of a life is that 24-week fetus going to have in the NICU after it’s delivered versus not having a life if the pregnancy was terminated.

Resident 1: Even if it were to make it through the first six months to a year, what kind of life is that infant going to have. Especially in the patients we take care of; they do not have the resources to take care of a child like that, with so many medical issues.

JV: I think it is interesting too because in talking about this situation in which the outcomes are very, very likely, upwards of 95 percent, to be very, very poor, some of us are less certain of our positions on termination. But it seems to me like we, the four of us, (because we have talked about this before) are much clearer about an elective 16-week termination – two of us would do it and two of us wouldn’t. There seems to be a much more clean line, which is interesting, because ethically, I don’t know if it is a much more clear line when you think about the fetus.

One Patient Talking, One With No Voice

Resident 4: Well, I can speak to that. My central conflict in not providing terminations is that we are talking about two patients – one of whom is looking at you talking to you, interacting with you – the other one has no voice, is only seen by a black and white two-dimensional picture and who, I hesitate to say, doesn’t have anyone to advocate for them, because that makes me sound like a crazy person. But if you really accept the fact that we have two different patients whose needs are not one in the same, then you have to consider the possibility that [pause]… anyhow, my tension is that it is such an intellectual distinction to think about a fetus as its own entity, because you can’t do things like talk to it and consent it. That’s been a very big tension for me, not hearing from the fetus, but also wanting to respect it as something that I consider to be alive.

Resident 1: I don’t think that a pre-viable [before 24 weeks, the time a fetus can survive outside the womb] fetus has wants. And that may make me a different kind of person. I’m sure there are biological needs of a pre-viable fetus, but I don’t think of it as a human entity with a conscience and capable of making complex decisions.

Defining ‘Personhood’

Resident 2: I think that’s an interesting point, and one that I struggle with. I agree with you that a very early first trimester fetus likely doesn’t have a conscience, although I will never actually know if that’s true or not. It certainly isn’t capable of making complex decisions. But the same could be said for a 9-month-old, or even a 9-year-old. Clearly there is a difference between an in-utero fetus (in the womb) and an ex-utero (outside the womb) child, but I don’t totally know where that line crosses over into personhood. I have a hard time moving past the fact that 24 weeks is an arbitrary line created by medicine and technology; I think that personhood is a more mystical and innate quality than one that should or can be determined by technology.

Resident 3: I used to be pro-life, very much anti-abortion, and since I have grown and changed and studied science and become a provider of care to women, my opinion has changed a lot. A couple of different things come in to play. I agree with Resident 1 – a pre-viable fetus at 16 weeks is alive in name and heartbeat only. If it cannot survive outside the mother, then it is part of the mother. At that point I don’t have two patients. I have one patient who is pregnant. Even if I sit down and think about the potential life, I think that Mom, my patient, has still lived and learned and earned a lot more, as Resident 4 mentioned, respect than that potential baby has. My allegiance will always lie with the mother, because she is the one going through all of this.

Resident 4 – Would you perform an elective termination for a viable gestational age?

Pregnancy: A State Of ‘Caughtness’

JV: That’s a really good question. For me, if there is something wrong with the pregnancy, if the pregnancy is unlikely to survive, absolutely. Pregnancy scares me – a lot – I think it is a state of “caughtness” – women are, once they become pregnant, they are stuck – and they can perceive being stuck in a great way or a bad way. But, regardless of how they feel about the pregnancy, those women have no control over what’s going on. They are growing this pregnancy inside their body, and they can become extraordinarily ill, can lose their life. They can lose this child that they have dreamed about since they were themselves a child. They can lose that in an instant. That is a very scary thing to me. To make a woman be in that state of “caughtness,” to be trapped that way when she doesn’t want to be, seems very wrong to me. And that very much motivates how I think about these things.

Resident 1: Doesn’t that make you want to be able to prevent women from ever having to be in this state of being “caught”?

JV: Absolutely.

Resident 1: I think about abortion providers, there are certain ideas about them. I think one we can all, at least Resident 3 and I, agree on is that we work very hard to prevent women ever having to be in that situation.

Resident 4: And me too!

Resident 1: Yeah! Sorry, you too, you too. You know what I mean. All of us.

JV: For me, speaking for myself, I am not just pro-choice, I am pro-abortion. I think it is a medical procedure that should be a part of every woman’s care should she want it. If she was on birth control, if she wasn’t on birth control, if she got pregnant and didn’t want to be pregnant anymore. I don’t think it matters what the circumstance is. If a woman doesn’t want to be pregnant anymore, she shouldn’t have to be. I feel very, very strongly about that.

Resident 1: I think Resident 3, that both of us were raised very pro-life … I like the idea of what you said about “allegiance.” I feel the responsibility to defend a similar idea that you just described because of all the anti-abortion things we were taught.

Resident 2: … There are gray areas here for each of us; I think it’s so crucial to acknowledge that our opinions are far more complex than being just “pro-life” and “pro-choice.” I consider myself pro-choice in that I think it’s not my job to make decisions about other women’s bodies or lives. But supporting a woman’s right to make that decision and actually performing abortions are entirely different issues to me. I need to make peace with my own values and choices, and every pregnant woman in the world needs the ability to also make peace with hers, whatever that may mean.

Opting In, Opting Out

Resident 4: I’m caught between feeling like someone who really cares about women’s health, the empowerment of women, and was drawn to this field because of that and recognizing that not providing terminations has basically been cast as the opposite of empowering women. So, you know, so there’s that. I can tell you I feel I would lose sleep at night if I did terminations, and I do know that people who do terminations do sometimes lose sleep, and we have talked about it. I wonder if I am just one of the weaklings who can’t do it at the expense of everyone else who has to pick up my slack. That’s what I think in my moments of doubt.

JV: But don’t you lose sleep over other things too?

Resident 4: Well I lose sleep over lots of things, but with abortion we have a choice — we can either opt in or opt out. We can’t opt in or out of performing surgery for anything else. But I wonder if I’ve just overly intellectualized this question in the convenient setting of being able to opt out. That contrasts starkly with how I view myself as a physician, which is as an advocate for women.

JV: I think that you can be an advocate for women and not be an abortion provider.

Resident 1: I agree.

Resident 2: I have very similar feelings to Resident 4’s. I also consider it a luxury to work in a place where I know that women will have other options, that me not providing abortions is in no way a barrier to access to abortions. If I end up moving back home to some rural town in the West, I may end up changing my stance. It’s very different when I am someone with the appropriate training available to serve a population who are otherwise un-served with abortion services, and I choose not to do it. Now, back to the “but-for” rule, but for my provision of abortions, women are back to being “caught,” as you said before, and all of the sudden I’m standing in the way of their autonomy. That might be enough to tip the cost-benefit analysis I do in my head, when I think of my personal cost of violating my beliefs against the benefit of empowering women. It’s tough, and I don’t know for sure what I would do, but I know I would struggle with that choice.