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Teaching Hospital Update - February 20-24, 2012


Email Alert

February 24, 2012

By C. Elizabeth O'Keeffe*

Pregnant Surgeons: An Issue for the Profession?

A study published this week in Archives of Surgery offers the first large-scale examination of attitudes toward pregnant surgeons. Researchers from the University of Maryland School of Medicine in Baltimore sent questionnaires to more than 5,000 female surgeons who were in various stages of their careers, asking them about attitudes toward pregnant surgeons. Roughly half of the women responded. A vast majority reported a significant stigma attached to being pregnant, particularly during training. While younger respondents felt significantly less stigma than those who had trained a generation or two earlier, a sizable majority of the young womenover two-thirds of themstill believed that being pregnant during training could negatively affect or even jeopardize a surgical career.

And although female surgeons tended to be more supportive of their pregnant colleagues than men, they were also capable of being just as dismissive as their male colleagues. While women now make up almost half of all medical school graduates, only 30% of surgeons-in-training are female, a discrepancy that may be related at least in part to the fact that the most intense period of surgical training, which sometimes stretches over an entire decade, correlates to a woman's most fertile years, her 20s and 30s. "You cannot not look at the impact of such training on childbearing and career decisions," noted the study's lead author. Although many women also wrote about what they deemed to be positive experiences, these were not recollections of festive baby showers and congratulatory cigars. One respondent, for example, wrote about hiding her pregnancy for several months before finally approaching the senior surgeon in charge of the residency program. His response was matter-of-fact; he would rearrange the on-call schedule and her schedule to make it possible for her to take time off to have her baby. "The fact that it was handled like a non-issue and without screaming, yelling, or threatening to kick her out of the program was perceived by this surgeon as amazingly positive," the study author said.

There have been official efforts in recent years to improve the work-life balance of surgeons-in-training. Residency programs across the country have been working to limit duty hours to no more than eighty a week; and the American Board of Surgery, the organization that defines surgical training standards, has made some of its requirements more flexible. Trainees now, for example, can apply to take up to six weeks off for maternity leave or medical reasons without penalty.

Still, it probably will not be until those in the youngest generation of surgeons become well established in their careers that significant changes will occur. "Thirty years ago, people didn't have the words to say 'work-life balance,' let alone say it was a priority in their career," said the lead author of the study. "But younger surgeons, female and male, aren't afraid to articulate that that's important to them." "We are going to have to figure out how to mesh our training with the dreams this generation has for the other parts of their lives," she continued. "Especially if we still want the best people to keep going into surgery."

Pauline W. Chen, MD, The Plight of the Pregnant Surgeon, The New York Times (Feb. 23, 2012).

Mental Health Stigma for Some

A new study suggests old problems continue to limit mental health services for minority groups. In the article, published in the journal Psychological Services, researchers determined that African-American young adults, especially those with higher levels of education, were significantly less likely to seek mental health services than their white counterparts. "Past research has indicated people with higher education levels are more likely to seek out and receive mental health services. While that may be true for whites, it appears the opposite is true for young adult blacks," said the study author, a sociologist.

Stigma, lack of knowledge, trust, and cultural understanding were key barriers to using mental health services, according to previous research with focus groups of blacks, the author said. Researchers determined the desire to seek additional mental healthcare varied among whites and blacks. They discovered whites who had previously used mental health services were more likely to receive additional services, while the opposite was true for blacks. The finding may be correlated to previous research that suggested blacks receive a lower quality of care when using mental health services. Earlier studies also discovered that blacks often report unpleasant experiences and unfavorable attitudes after receiving care. "Practitioners need to address the concerns of black clients in a culturally sensitive and appropriate manner, and during exit interviews, they should ask what is appropriate and what didn't work," said the author.

Rick Nauert, PhD, Better Educated Blacks Shun Mental Health Care, (Feb. 23, 2012).

U.S. Supreme Court Punts Medi-Cal Suit: Foreshadowing the Battle for Healthcare Reform?

The U.S. Supreme Court has declined to rule on a case challenging cuts in California Medicaid reimbursements, instead sending it back to a lower court for new arguments. In a five-to-four vote won by the high Court's liberal wing, the majority decided that recent moves by federal and California state officialsmade after the justices had heard oral argumentshad altered the situation enough that the case should be reheard by the Ninth Circuit Court of Appeals, which earlier had thrown out the cuts.

Five suits challenged a 2008 order by the California legislature to impose 10% reductions in reimbursements to providers who participate in Medi-Cal, the state's Medicaid plan. The providers filed suit, seeking a preliminary injunction against the rate cut. The three suits were eventually joined together under the name Douglas v. Independent Living Center of Southern California et al. A federal district court denied the injunction and the providers then took their case to the Ninth Circuit Court of Appeals, which ruled in their favor. The California state government appealed that decision to the Supreme Court.

Writing for the majority in the opinion issued Wednesday, Justice Stephen Breyer noted that after the Supreme Court heard oral arguments, the Centers for Medicare & Medicaid Services (CMS) had approved parts of the state legislation as consistent with federal law. In the wake of that decision, moreover, the state withdrew its requests for approval of other parts. "CMS'[s] approval does not make these cases moot, but it does put them in a different posture, since the federal agency charged with administering Medicaid has now found that the rate reductions comply with federal law," Breyer wrote. "That decision does not change the substantive question whether California's statutes are consistent with federal law, but it may change the answer." Breyer was joined by Justices Sonia Sotomayor, Ruth Bader Ginsburg, Elena Kagan, and Anthony Kennedy.

Chief Justice John Roberts Jr. wrote a dissent, joined by the Court's other conservatives: Antonin Scalia, Clarence Thomas, and Samuel Alito Jr. In it, Roberts argued that the justices had enough information to rule on the case's basic merits, irrespective of the subsequent CMS and state decisions. "I am not sure what a remand without answering the preliminary question is meant to accomplish," Roberts wrote. Indeed, he indicated, it should have been clear that, since the federal Medicaid statute did not explicitly give private partiessuch as doctorsthe right to sue to have it enforced, the suits should have been thrown out by the lower courts. "The Ninth Circuit's decisions to the contrary should be reversed," Roberts concluded.

John Gever, High Court Punts Medi-Cal Suit, MedPage Today (Feb. 22, 2012).

Do-It-Yourself Medicine Apps

Dr. Eric Topol is only half joking when he says the smartphone is the future of medicinebecause most of his patients already seem "surgically connected" to one. For example, a blood glucose monitor works with an iPhone app. A blood pressure cuff works with an iPhone or iPad to track blood pressure over time and can send the data to a website. But he says in all seriousness that the smartphone will act as a sensor that will help people take better control of their health by tracking it with increasing precision.

His book, "The Creative Destruction of Medicine," lays out his vision for how people will start running common medical tests, skipping office visits, and sharing their data with people other than their physicians. Dr. Topol, a cardiologist at the Scripps Medical Institute in La Jolla, CA, is already seeing signs of this as companies find ways to hook medical devices to the computing power of smartphones. Devices to measure blood pressure, monitor blood sugar, hear heartbeats, and chart heart activity are already in the hands of patients. More are coming. He acknowledges that some doctors are skeptical of these devices. "Of course, the medical profession doesn't like D.I.Y. anything," he said. "There are some really progressive digital doctors who are recognizing the opportunities here for better care and prevention, but most are resistant to change."

Dr. Topol may be right about the caution in the industry, but he is far from the only person with this vision. An entire marketplace is evolving that marries the can-do attitude of hacking devices with the fervor of the wellness movement. Smartphones make taking care of yourself more of a game, Dr. Topol said. "I recommend these devices because it makes it more fun and I get more readings than if I ask them to do it manually." The enthusiasm for this vision of do-it-yourself medicine with a smartphone, though, must be balanced with the cold reality that all of the experimenters should consult with their physicians.

The most prevalent diseases and the biggest markets are getting the tools first. Devices to monitor heart disease are already available. The growing incidence of diabetes is, by many estimates, the biggest public health challenge today, so companies are developing tools to help people with the disease manage their blood sugar. Tom Xu, the founder of SkyHealth in El Cerrito, CA, created the website to help people keep track of the sugar in their blood. The numbers must be entered manually. The site works with an app for the iPhone to gather the blood glucose level and some information about when it was taken. "Our main goal of glucosebuddy is not to just record numbers. That's the boring part," he said. "Once you know how your diet affects your blood sugar, you take your health more seriously."

Peter Wayner, Monitoring Your Mobile Health with Mobile Devices, The New York Times (Feb. 22, 2012).

"Jelly-on-the-Belly": Controversial Legislation in Virginia

A controversial bill that would require women to get an ultrasound before an abortion is now in doubt after Virginia Governor Robert McDonnell (R) diluted the measure Wednesday by making it optional in many cases. The legislation initially sought to require ultrasounds, which, early last week, prompted opponents to raise concerns over the procedures' potentially invasive nature. In many cases the ultrasounds would require a vaginal probe to establish gestational age. On Wednesday of this week, citing concerns over that intrusiveness, McDonnell, an abortion opponent who had repeatedly said he would sign the bill, asked state lawmakers to amend the measure. House members approved the governor's amendments, but the bill's Republican sponsor in the Senate said she would try to pull the measure for the session.

"Mandating an invasive procedure in order to give informed consent is not a proper role for the state," McDonnell said in a statement. "No person should be directed to undergo an invasive procedure by the state, without their consent, as a precondition to another medical procedure." He did not comment further.

Confusion over the legislation and ultrasoundsand considerable national media attentionpreceded the unraveling of the bill. The original measure stated, simply, that a woman needed an ultrasound before an abortion. Many lawmakers did not understand that at the young fetal age abortions usually occur, the invasive vaginal ultrasound would be needed to establish gestational age, as required by the bill. Republican lawmakers on Wednesday in essence said that an abdominalor "jelly-on-the-belly"ultrasound before an abortion would still be required but that vaginal ultrasounds would be voluntary. McDonnell's announcement came a day after legislators and governor's staff members, including Chief of Staff Martin Kent and Secretary of Health Bill Hazel, huddled in his office Tuesday night to hash out a compromise after learning that some ultrasounds could be more invasive than first thought. "I think these amendments . . . will resolve much of the controversy in the bill," said Delegate David Albo (R-Fairfax), chairman of the House Courts of Justice Committee, who introduced the amendment on McDonnell's behalf. The bill has been derided on television, including "The Daily Show with Jon Stewart" and "Saturday Night Live," and was the subject of protests on Capitol Square on Monday. The House and Senate have already approved versions of the bill, even after lawmakers spent weeks arguing that it would subject women to unnecessary tests, invade their privacy, and cost them money.

It wasn't until opponents of the bill recently began to graphically detail the invasive nature of ultrasounds in early pregnancies that McDonnell took a second look.

The news spread across Capitol Square and across the nation with news shows reporting on the Virginia General Assembly and 1,200 protesters converging on the state Capitol. The language grew more explicit as more commentators and comedians picked up on the controversy of the probe. Until Saturday, McDonnell and his aides have said the governor would sign the measure if it made it to his desk. But the governor, who, as a legislator, authored the state's informed-consent law, said he began to take a harder look. He said he took a few days to discuss the specific language of the proposed legislation with other governors, doctors, lawyers, legislators, advocacy groups, and others before announcing his decision Wednesday.

Anita Kumar and Laura Vozella, McDonnell, Virginia Republicans Back Off Mandatory Invasive Ultrasounds, The Washington Post (Feb. 24, 2012).

Alcohol Abuse a Significant Issue for Surgeons

Alcohol abuse is a "significant problem" for surgeons in the United States, with more than 15% of respondents in a nationwide survey signaling that they may have dependency issues, the American College of Surgeons reports. The survey in the February issue of Archives of Surgery found that the rate of alcohol use disorders among the 7,197 responding surgeons is slightly higher than that of the general U.S. population. For surgeons reporting dependency issues, the survey found there was a "strong association" with problems in personal and professional relationships that included burnout, depression, and medical errors. In fact, the study found that nearly 78% of surgeons reporting a medical error in the previous three months also had issues with alcohol abuse or dependence.

"Our goal is not to scare the public. That is the last thing we want to do. But we also want to say that people are paying a really high price," says a co-author of the survey, Prevalence of Alcohol Use Disorders Among American Surgeons.

The study recommends that healthcare organizations and professional associations, including the American College of Surgeons, develop early warning and intervention programs that identify problem drinkers and provide treatment and therapy options. "These findings should also decrease the shame and stigma associated with alcohol abuse or dependence and encourage surgeons to pursue treatment and rehabilitation to promote patient safety and personal well-being," the study said. "We want people to be aware of this because we want to be able to honestly look at ourselves and say here is the issue we need to support people," said the study co-author, who is chair of the American College of Surgeons Governors Committee on Physician Competency and Health.

The co-author says substance abuse problems may be particularly insidious and difficult for surgeons to admit. "There is the idea that 'I can take care of crazies and disasters, so I am in control. The alcohol is just to take the edge off because I deal with enough things,'" she says. "We also know that in general, the characteristics we value in our professional lives, things like perfectionism, commitment to patients, those things put people at risk of burnout as well." Alcohol disorders target female surgeons particularly hard. The survey found that 25.6% of female surgeons indicated that they have alcohol use issues, compared with 13.9% of their male colleagues. By contrast, in the general population, 9.4% meet the criteria for alcohol and substance abuse, including 10.5% of men and 5.1% of women.

The anonymous online survey is the latest in a series of studies the American College of Surgeons has undertaken recently to assess members' stress, burnout, and other job pressures. The co-author of the study says failure to address these problems could have significant repercussions for patient safety and access. "We have people who are not functioning at their best in terms of taking care of patients optimally," she says. "We find people who are struggling with these issues are less likely to stay in practice. We have a workforce shortage already so we have to figure out how to allow people to function at their best and continue in practice."

John Commins, Alcohol Dependence Among Surgeons a 'Significant Problem', HealthLeaders Media (Feb. 23, 2012).

*We would like to thank C. Elizabeth O'Keeffe, Esquire (University of Mississippi Medical Center, Jackson, MS), for providing this week's update.

AHLA Teaching Hospital Updates are intended to provide quick summaries of cutting-edge issues of interest to teaching hospitals and their counsel. Additional information and more in-depth coverage on these topics may be available from AHLA Health Lawyers Weekly and appropriate AHLA Practice Groups.

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