Academic OB/GYN

Some Cancer Humor

I saw a patient today who presented with a large vaginal cancer.  I was discussing her care with my intern, and that it would make a big difference if the cancer were localized or if it had already spread to the lymph nodes.  Based on her exam, I thought there was a pretty good chance it had already spread.

“The toothpaste is already out of the tube”, said the intern.

I replied “I suppose… but usually we say ‘the horse is already out of the barn‘   After all, like cancer, the horse wants to leave the barn and run.  The toothpaste doesn’t want to leave the tube.  It will stay there forever until you squeeze it out.”

A look of understanding hit the intern’s face…. then puzzlement.

“But Dr. Fogelson, it seems like its a lot easier to put a horse back into the barn than it is to put toothpaste back into the tube.  If cancer was like the horse it would be much easier to cure once was spread.”

So there you have it.

Cancer acts like a horse at first, but then becomes toothpaste.

As a physician formally trained in computer science, I have the opportunity to look at today’s computerized medical record systems both from the perspective of a end user and as a software designer.  It is perhaps because of this that I have been so persistently disappointed with the current state of clinical record software.  

I am disappointed because despite all the fancy hardware and expensive software, our clinical records systems aren’t that much better than paper.  We would think that a patient could go to any doctor and present their medical records the doctor could read them, but they can’t.  We would think that it would be easy for me to get a CT scan report that was done at an outside hospital, but no.  It actually has to be printed out and faxed, requiring not only human intervention and time, but if reentered into the receiving provider’s system actually converts a digitally stored report into a picture of a piece of paper, completely breaking the idea of an electronic record system.  While information can be digital in one system, if it ever is passed on to someone working in another system, it becomes just another piece of digital paper.  The sad truth is that despite our incredible investment in EMR systems, we have only created a massive collection of information silos, and have almost no way to transfer information between them – a system little better than the paper charts we sought to eliminate.  And sadly, because these silos are hard coded and massive, innovation is stifled.

There is a very specific reason why our system operates like this, and it is that EMRs as a whole lack a common way to represent information.  Each system represents medical records in its own proprietary format, and thus lack the ability to speak to each other.  An thus no matter how wonderfully a EMR system represents information to its users, if information has to get out of the system, it can only be through pictures of pieces of paper.

So is there a solution to these problems?  I would argue yes.   But it requires a fundamental change in our paradigm – a change to a common “Model” for representing data.
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Two years ago, I penned a post entitled “Delayed Cord Clamping Should be Standard Practice in Obstetrics”, which was read by many.  Later I gave a grand rounds on the topic, which was viewed by many.  In doing so, I contributed to a growing movement towards delaying cord clamping after the birth of preterm and term neonates.  This was all well and good.  But something else happened as well.

In the eyes of many, I became an “Expert in Delayed Cord Clamping”, worth quoting to others, and even name dropped as some sort of trump card – “Well, Dr Fogelson says….”  So let me set the record straight.  I am not an expert in delayed cord clamping, if such a person even exists.   I am certainly not an activist for the idea, not am I sure that such activism could be justified in the literature.

What I am is this:

1. An educated person with access to the literature and training in interpretation of medical research.
2. A physician with intellectual expertise in maternal health, and first hand experience in its practice
3. A person with a platform where his opinion would be heard.

and

4. A person who chose to express said opinion on that platform.

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One of the interesting things about running a semi-popular blog is that from time to time the blog community decides to take up a topic and run with it, completely without any stimulation from me.  This happened recently on the Academic OB/GYN Facebook page, where a group of concerned individuals carried on a serious and passionate discussion about the merits of circumcision.   As such discussions tend to be, this one was dominated by the anti-circumcision activists, with occasional interjections by those that were less concerned about the issue, including myself.

Circumcision is an interesting issue because it crosses multiple boundaries.  It is a social tradition in many cultures, and in some cases considered a religious mandate.  It is also an ethical issue for many, with some feeling that it is an assault on an infant with long term negative impact on their psychosocial health.  For some it is just cosmetic.

As a young person, I always thought that my penis looked like penises were supposed to look. It looked like my father’s and my brother’s, and anyone else’s I had ever seen.  For the most part, I was blissfully unaware that a penis could look any other way, until one day in high school when my world completely changed.  I happened to see a friend’s penis we were showering after wrestling practice, and in that flash of a moment all kinds of things went through my mind.  Did he have some kind of growth on his penis?  Could he pee out of that thing?  A few other choice thoughts.  I can still remember the shock to this day.  All I had ever seen looked like mine, and in that moment what I saw was foreign, revolting even.  You see, from my frame of reference he looked like an alien.  It took me a few minutes and SNAP! it came to me like a ton of bricks – he has a foreskin.  He probably doesn’t have an alien death ray then.   I can relax about that one.

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Last year I wrote about a few strategies for decreasing costs in the operating room.  Since being in fellowship operating many days per week, I’ve come up with a new idea, this time a bit more radical.

In Freakonomics, Leavitt and Dubner posit that in all things, human beings respond to incentives.  If you want to understand human behavior, all you have to do is identify the incentives that drive them, be they emotional, financial, or social.  In that vein, I wonder what incentives drive us to spend so much money on healthcare, and to waste resources when they need not be wasted.

I found a potential answer in another book, Chris Anderson’s “Free: The Future of a Radical Price”  In this work Anderson investigates how an economy is affected when the marginal cost of production of a good approaches zero.  Specifically, he investigates the economy surround digital goods, that while costing resources to develop, have a marginal cost of zero to produce and distribute.  He proposes that in such a system, it is quite natural that the price of such goods will eventually approach zero, and if it doesn’t, the goods will be routinely stolen rather than paid for.

The corollary to this idea is the concept of optimal use of a resource when its cost is zero.  That is, if one gets a real benefit from the use of a resource but it costs nothing whatsoever to use it, what is the right way to use that resource?  Anderson suggests that the correct course is to use that resource to its maximal extent, and even to waste it without thinking despite diminishing returns. Read more…

This month I started a fellowship that predominantly involves taking care of women with cancer.  Through surgery, chemotherapy, and other medications we do our best to cure or hold back malignancies of many kinds.  In these past weeks, I have taken care of several patients who are Jehovah Witnesses, an experience that has been quite interesting.

In most cases, what religion a person subscribes to has little to no impact on their clinical outcome.  We have an exception, however, when it comes to a Jehovah’s Witness with cancer.  JHW patients to a rule will not accept blood products of any kind, which greatly limits their ability to be effectively treated for cancer.  In some cases they cannot have surgery the surgery they need is unsafe without the possibility of blood transfusion.  In some cases they cannot take chemotherapy because blood transfusion is required to survive the associated myelosuppression.  As surgery and chemotherapy are our two best treatment, they are at a major disadvantage.

When I was a resident, I had a pretty hard opinion about this.  I heard a lot of different view on the topic, but the position of one of my attendings resonated best with me.  He felt that his job as a physician was to protect the health of his patients, and that if a JHW was dying in front of him he was going to transfuse them whether they liked it or not.  He was quite clear about this upfront, and told JHW patients that if they were not happy about this they should find another doctor.  He even arranged for attending coverage for emergent issues if need be.  He felt that the preventable death of a patient was an emotional trauma he didn’t want to be exposed to, almost as if the patient, through refusal of blood, was exposing him to unnecessary emotional violence.  While this was a very hard line, I respected the boldness of  it, and that he was being true to his internal values.  I held a similar feeling for the first few years of my attendinghood, though I never had to test it until my third year out of residency.

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I wish I could say that when I’m done doing a little impromptu lecture on pelvic anatomy that there is something on paper worth saving, but well, there isn’t.  Wish you could have been there.

Drs Browne and Fogelson discuss Cesarean Delivery Rates, VBAC Guidelines, Placenta Accreta, and the critical role of Flash the Cat in the Academic OB/GYN Podcast.

Academic OB/GYN Podcast 34 – Journals for June through August 2011

Today I had the pleasure of talking shop with my brother’s mother in law, Joni Dawning, a very experienced direct entry midwife in Eugene, OR.  Joni has been attending births for over twenty years, and she has been a great resource to me over the years I have known her.  I hold her in great respect, as she is the kind of midwife that I think is a great resource to her community.  She provides a service to her clients that is greatly desired, but at the same time sees herself as a part of a larger system of birth service provision that includes hospitals and obstetricians.  Unlike some direct entry midwives (or CPMs in some communities), she respects the limits of what she can offer, and does not see a hospital transfer as a failure in any way.

Recently in Oregon there have been some deaths during attempted breech deliveries at home, all attended by various home midwives of varying skill.  Following this there was a discussion in the legislature about whether or not licensed midwives should be completely banned from intentionally attending breech births at home.  Joanie wrote a passionate letter about the topic.  She shared this letter with me, and to my surprise the letter was not in support of breech birth at home, but rather a plea that the legislature ban breech homebirth.  She felt that too may midwives believed that they understood how to deliver breeches, not because they had experience, but because they were just ignorant of the potential risks and the techniques required to succeed.  I some cases they just “believed in birth” and felt that the baby would deliver if one would just stand by and watch. Read more…

Academic OB/GYN, and I, Nicholas Fogelson, are honored to have so many great twitter followers.  Over time it has come to pass that there are two populations of followers – 1) people that are interested in the Academic OB/GYN blog, podcast, and related educational materials and 2) people that are interested in the unrelated musings of myself.  At present, @academicobgyn is a combination of those two things.

So things are getting separated:

If you want to hear about things related to the blog, the podcast, and other things of medical interest, continue to follow @academicobgyn.

If you want to hear from me on a more personal level, follow @nickfogelson.

Or follow both.