Today I sat in the infection control committee at Grady Memorial hospital and listened to two sales pitches for products meant to decrease surgical site infection. I am a tough sell at these meetings. Some might even say that I am the asshole in the room. But really the issue is that I say what everyone else is thinking but are too polite to say.
The first pitch was from Ethicon, who was marketing their antimicrobial impregnated suture. The presentation shows convincing evidence that the suture, placed in a petri dish surrounded by bacteria, does in fact inhibit bacterial growth. There were many claims made that it also decreased the rates of wound infections in comparison to using typical suture. When I questioned what data there were to suggest this, I was told that the data was all in my handouts.
I looked down at my handouts and found no data whatsoever. I found a bibliography of about thirty articles that investigated the product. I pointed out that there is no data, just a list of articles. I was reassured that these data support everything that they are saying.
At this point I was kind of pissed.
A warning to all – this post is really for the docs out there. If you are not in the medical profession, you might find this humorous, or you might find it completely unintelligible – so read on with that warning.
When I was a medical student and resident, we routinely presented obstetrical patients in a common format:
Age – Gravity (how many times pregnant) – Parity (how many children delivered) – gestational age extra information.
For example, this patient is a 24 year old (age) G2 (gravity) P1 (Parity) at 29 6/7 weeks with a history of a preterm delivery in her first pregnancy (extra information).
To me, this format makes sense and when I am listening to a presentation it is easy to hear and process.
Unfortunately, things have changed. We seem to have adopted a new system that incorporates all the extra information into a numerical abbreviation system. Now we do this:
Age – Gravity – Parity Full Term – Parity Preterm – Miscarriages/Abortions – Live Children – gestational age – extra information ( which may not be required any more)
For example, the previous presentation would be “this is a 24 year old G2P0101 at 29 6/7 weeks”.
For some reason, this just doesn’t work for me. Inevitably what happens is that the resident quickly says all of these numbers and my brain freezes. I now have to spend the next 3 or 4 seconds of my attention processing these numbers into some actual meaning that I can interpret. During those 3 or 4 seconds the resident has continued their presentation, but I have not heard what they said because I was trying to figure out what they said before meant.
The problem here is over-abreviation. Abreviation is good when it improves efficiency, but there can be too much of a good thing, and I think we have that right here.
And so to all you med students, residents, and docs, I encourage you to set an example by extinguishing this extended numerology from your obstetrical presentations. Just say it in plain English. We will all understand you better.
Last night I had the pleasure to watch an HBO special documenting a masterclass given by singer Josh Groban to three young music students. Over the course the show, Groban coached the students through composition of an original song, and it culminated with their performance of a song that had not existed a week previously at his concert in Chicago. It was a great show that I quite enjoyed, and if you like Groban or music, you should check it out.
The show also made me think quite a bit about how my job teaching residents is quite a bit different than the job most teachers have.
Medicine is a strange career, in comparison to most, in that a doctor does not go on their first true job interview until they are nearly 30 years old. Prior to that, its really just trying to get into college, then trying to get into medical school, then trying to get into the right residency…. but never really interviewing for a job, per se. My first job interview was with Dr Kenneth Ward, then the chair of the University of Hawai’i department of obstetrics and gynecology. I was interviewing for an academic position, and the interview seemed to be going pretty well. We both liked technology, and were both Apple fans, so there was a fair bit to talk about other than just the job. Overall, we seemed to hit it off. Then he asked me a serious question. “So Nick, what was your greatest accomplishment in residency?” Read more…
This is an edited video of a robotic hysterectomy and salpingoopherectomy in a patient with stage IV endometriosis, with bilateral endometrioma, cul de sac obliteration, and severe retroperitoneal fibrosis. The video demonstrates ureterolysis, dissection of ovarian vessels from the ureter, and management of colpotomy in the setting of dense adhesions.
For clinical consultation with Dr Fogelson, call Emory University Department of Obstetrics and Gynecology (404) 778-3401
This week in the news there have been a number of articles about a new technology that has allowed the creation of an embryo from three parents, and boy it is creating controversy.
Three parents you say?
Yes. Of a sort.
The case in point regards a woman who unfortunately had a child with a deadly mitochondrial disease. Mitochondria are organelles (“small organs”) inside each of our cells where ATP, our primary energy source, is made. Mitochondria are special in that unlike other organelles, they carry their own DNA. In the case of this woman’s tragically afflicted baby, defective DNA that could not support much life.
Geneticists have developed technology to create an healthy embryo without the defective mitochondria by placing a nuclei from the woman’s mitochondrially defective egg into a donor egg, after removing that egg’s nuclei. They then fertilized the new proto-egg with the husband’s sperm to create a new embryo. In essence, the egg had three parents – two in the nuclei, and a third one in the mitochondria.
And the world shuddered.
From all corners were cries of “we’re playing GOD!!!”. “We are altering the human race!!” “We’re no better than Mengele!!”
Most of this comes from a bright line we have put around genetics research that says we will not genetically engineer human beings. Legitimate bioethicists have felt that this is something we should not do, because of a ‘slippery slope’ towards eugenics. Religious radicals are just uncomfortable with advancement in science in any kind. They say it is because it is against God, but I think it is because a true understanding of how the universe works deprecates the validity of their religion, and thus sparks a crisis of faith.
But either way, most people think that manipulating human DNA is unethical.
I, for some reason, don’t see it this way. In fact, I couldn’t be happier that we have made this leap, and hope we keep leaping. We are coming to understand how we are put together, and in such we are coming to understand how to manipulate that process. That is exciting, not concerning.
We are not “Playing God”. For us to be “Playing God”, a “God” would have to have been the reason we came to be on this earth. And unequivocally, it is not. The evidence for evolution is so unbreakably strong that to claim that we are here because of “God” is purely ignorant. Humans are on this earth because our genes were selected for over millions of years, not because somebody put us here. If you believe in God, fine. But please don’t hold humanity back from our future by claiming that we are breaking your religious rules.
Even worse is the claim that to genetically engineer a human is akin to Nazi experiments. True, Hitler wanted to manipulate the future of humanity. But he didn’t want to do it by changing the genetic information of the future. He did it by murdering the people who were already here. To claim these are the same thing is an affront to geneticists, and is too good for Hitler.
In truth, I am absolutely head over heels excited to hear that we were able to eliminate a deadly genetic disease from a family through genetic means. What this means to me is that we are actually CURING disease, not just treating the symptoms that it produces.
Evolution is something that is terribly misunderstood. Its detractors really don’t get how it works. People who don’t understand it think it is about the selection of individuals over others, and thus don’t believe it could ever have ended up in us, but that is not really how it works. It is the selection of GENES that drives evolution, not the selection of individuals.
The problem in this case is that mitochondrial genes do not reproduce sexually, but are rather copied directly from their parent mitochondira, and as such they do not evolve. As such, problems in the mitochondria are passed on forever, never changing except by random mutation.
But now, for the first time, mitochondrial DNA is evolving. Perhaps not by natural selection, but it is evolving nonetheless. And that is exciting.
Don’t take this to believe that I am ignorant of the potential problems. But they are technical, not ethical. Obviously we can not open the doors to unlimited human experimentation, but this is a first step, and it is a good one.