Friday, September 25, 2009

Boys to Men

By Shawn Vuong

In the current society, men and boys are having a hard time defining themselves and fitting into their gender role.  What does it mean to be a man?  

It is said that nearly one fourth of all American children live in mother-only families.  At school they are more than likely taught by a female teacher.  Boys are growing up without a solid male role model.  This is a problem, as research shows that fathers tend to be more tend to be more challenging, prodding, loud, playful, encourage risk taking, and physical when compared to mothers.  This is important for children, and especially boys who are looking to their father for what it means to be a man.

In a world where being a woman is celebrated, it may be difficult for boys to figure out their gender role.  Women these days do a great job banding together, groups such as Women At Work, Women In Medicine, Women's Health Group, YWCA, and the many many organizations are devoted to celebrating what it means to be a woman.  Yet, you do not see similar things for men.  This could be that men only groups seem sexist and are discouraged, or that men just do a poorer job defining their gender role.  Either way, this lack of men groups in conjunction with a lack of male-role models may be making it hard for boys to understand what it means to be a man.  


By Richard P. Holm MD

For men, there is always something about our Fathers.  I heard it today in my office coming from a very hurt, yet extremely successful businessman how his father had always told him that he was too soft and would never amount to anything.  His Dad always expected way too much.  He could never do enough… never do it right.  His Father was never satisfied with anything he did…  Never!

On the other end of it, some would suggest that much of what is wrong in our society comes as a result of inner-city boys growing up without Fathers, or Grandfathers, or male role-models.  Without mentoring, these angry boys make the world a very dangerous place.

Robert Bly, a Minnesota poet, is one of the leaders of what has been called "the expressive men's movement," and he tells us that a “man’s work” is to not deny his inner suppressed “wild man”, and at the same time learn from older men principles such as the work ethic, honesty, justice, and especially respect.

They say that a boy growing up needs to experience, from older men, a ritualistic initiation, a robust challenging physical experience with nature.  This could be at basic training, at a work setting, or during a football or sports experience.  There should be a separating time from Mama when a boy becomes a mature man and learns about his responsibility to protect, not harm.  He needs to learn that virtue and justice is the goal, never violence, betrayal, or abandonment.

My own Dad had been a Sergeant in the Army during WWII, and if I dropped the ball on something, I learned to say, “No excuse, Sir.”  He challenged me to work hard, and demanded the truth from me always, calling me on it big time when I deceived him. 

Certainly he had his failings, and every son sees these things in his Father, but my Dad taught me the “golden rule” and proved it by the way he treated others.  And somehow I always sensed that I was safer from whatever bad there was, when he was around. 

He has been gone for seventeen years this month, but I still feel him protecting me.

An Old Dog’s Computer Quest

By Shawn Vuong

Technology.  I love it.  

I am a proud member of the millennial generation (aka Generation Y).  While we aren't known for our humility or strong work ethic, we are known for our extreme integration with technology.  As time goes on and more of the Generation Y hits the workforce, we will be expecting businesses to be updating to fully integrated all digital business schemes.  In medicine this means the adoption of the electronic medical record.  

While this seems like a huge step for older physicians still in practice (the baby boomer generation), this is hardly what we (as the Generation Y) envision as our ideal digital medical record.  As time goes on, and our generation starts becoming the majority of the medical work force I for see the trend digital medical record becoming much more than some doctors could ever imagine.  Fully integrated, international, digitally accessible and protected medical records.   If I go to vacation in California and get hurt, I expect the ER doctor to be able to read my full history since my birth on his EMR at his/her hospital.  If my child gets a test done at Mayo, I want to see the results online as soon as my physician gets them.  We may have a long way to go before we get to this kind of integration.  But I believe this is the future of medicine.  


By Richard P. Holm MD

They say you can’t teach an old dog new tricks.  Yet today I found myself in front of a Brookings Health System computer with a personal nurse tutor trudging through our new test version of an electronic medical record. 

Indeed, for about a year we have been gradually getting used to seeing parts of the hospital record on computer screen.   Finally this month we are about to take the leap of dropping our paper orders and progress notes, and going entirely paperless in the hospital. 

We have to be prepared so that no patient is harmed by this transformation.  That is why the physicians and PA/NPs have spent many meetings this spring developing orders sets, which are pre-defined orders for specific illnesses.  That is why we have been having two hours a week of educational meetings all summer long on the topic.

It will be difficult for many of us to make this change, especially since we have been doing things on paper for so many years.  At first it will take us all a lot more time.  But the whole process is not only taking time, it means our hospital has to make 
 a significant commitment both in personnel and money.

So why would we spend this kind of time and effort?  Along with many who are so capably helping us through this, are two RN experts.  Today I asked them both just what will result from all this effort, and their answers were straightforward.  “It’s all about patient safety and accessing information.”  Safety, for example means avoiding dangerous medication allergies and interactions.  Access, for example means seeing the patient’s Problem List, prior test results, and medication list whenever needed.

Still, the electronic medical record cannot look into the eyes of a frightened person in pain, listen for a clue to solve a problem, provide for relief of suffering, and then find a way to healing and better health.  That’s something this old dog better not forget.

Impossible To Fix

By Shawn Vuong

Medicine demands perfection. Nobody wants their loved one to die of something that could have been caught earlier on a blood test or CT scan.

So, a lady with a headache comes into the ER. The ER doctor knows that this headache is probably a tension headache or a migraine headache. The ER doctor also knows that the odds of this lady having a brain tumor are low, very low. Although every other ER doctor in the state would order a CT scan for every headache case that comes to the ER (due to the fact that they are scared of litigation brought against them, not because they think every headache warrants a CT), this ER doctor decides it is close to the end of his shift and he doesn't want to waste time ordering the CT scan this lady probably doesn't even need. So, he sends her home with some migraine medication.

Well, thanks to Murphy's Law this lady ends up permanently injured due to a malignant brain tumor. So because of this devastating turn of events, the family files a malpractice claim against the ER doctor.

Thanks to the teachings of a very wise law professor with significant expertise in tort law, I know what's coming next.
The doctor will be asked if it is the 'Standard of Care' to order a CT scan for a headache patient. Although medical literature may say that it is not the best practice to order a CT for every headache patient, and although every other ER doctor in the nation is ordering CT scans for fear of medical malpractice litigation, it IS considered the 'Standard of Care' just because every other ER physician is doing it. Right or wrong. Thus, this ER doctor will likely lose this malpractice case.

How do we as a profession change this? Obviously, a group of ER doctors cannot just follow the medical literature and stop ordering CT scans for every headache. This will just increase the chance that they will be successfully sued in a malpractice case. So, in reality, no ER doctor will stop ordering unnecessary scans. The more the 'Standard of Care' deviates from what the medical literature considers the best medical practices, the more of a disservice physicians are providing to patients. Yet, the legal climate prevents the doctors from changing the way they practice from the 'Standard of Care' due to fear of litigation.

This sounds impossible to fix.

-- Please note that this article is not trying to say ER doctors should not order CT scans for headaches. I have no idea if you should or not, I am not a licensed physician. This hypothetical scenario was merely thought up to help illustrate the problem with defensive medicine.


By Shawn Vuong

Failing leg veins are also known as varicose veins.  In this post, Dr. Holm describes how people develop varicose veins, why they are a health risk, and how best to treat them.  

Some times conservative treatment can fail, but one should not worry.  Many other treatment options exists for varicose veins, although they are usually more invasive and expensive.  Some of these options include sclerotherapy, laser surgery, vein stripping, ambulatory phlebectomy, and endoscope vein surgery.  If you are having problems with varicose veins, it is best to see your physician to discuss the best treatment option for you.


By Richard P. Holm MD

I’ve heard failing leg veins called everything from “spider veins”, or “a bag of worms,” to “very-close-veins.”  Affecting more than fifty percent of people over fifty, these gnarled, distended, varicose veins represent a problem that, generally, only gets worse.

Arteries take blood out away from the heart, like a steel pipeline from a powerful pump station.  On the other hand, veins bring blood back like a lazy river that works because of locks or valves located to prevent back flow.  But there is nothing lazy about the job of returning all that blood up hill, against gravity, all the way back to the heart.

The trouble with leg veins usually starts during pregnancy, or with a job which requires lots of standing in one spot without walking, or with the increased venous pressure associated with obesity.  Of course, some people inherit better veins than others.

When a few valves begin to fail, then veins gradually become distended and dilated, which makes more valves fail, and the problem swells.  Common signs of failing veins include edema, redness, rash, fever, pain, and even hard to heal sores.  What’s worse, when blood movement slows down, clotting can happen, and when clots spread the result can be life-threatening clots to the lung.

What can we do to prevent varicose veins?  Muscles surround most veins within the leg, so when we walk or use our legs, the muscles contract and squeeze, acting like pumps.  If the one-way valves are still working, walking and leg movement makes blood flow upward and in this way regular walking or rocking back and forth while we stand helps prevent varicose veins.  And don’t forget to put the feet up whenever possible.

The next best solution is to wear compression stockings.  Although they can be hard to put on and many people are hesitant to use them, the lower, knee-high stockings are easier to use, do the lion’s share of the job, are relatively cheap, and the results are well worth the effort.  Some people absolutely swear by them since they prevent so many problems and feel so good.

There is a lot you can do if you stand to inherit those very-close-veins.  Left alone, they only get worse.

Surprise Death

By Shawn Vuong

In the light of the current healthcare reform debates and all of the craziness that has come with it (the infamous 'death panel'), let us not forget what this debate is truly about, the patients.  

As Dr. Holm reminds us, eventually we will all come to our death.  The important thing is that we must let our loved ones pass away with a little dignity and pride.  To do this we must talk to our family members about their death wishes, as well as our own.  This is an important and often ignored piece of medicine that never gets the attention it deserves until it is too late.  

By Richard P. Holm MD

The late physician poet John Stone wrote of Death… I have seen come on/ slowly as rust/ sand/ or suddenly as when/ someone leaving/ a room/ finds the doorknob/ come loose in his hand.

This is not a topic about which anyone likes to talk.  The poignant truth, however, is that all of us will die one day, so we should go there every once in a while.  Many say they would like to die quickly and unexpectedly.  Let me go at ninety, shot by a jealous lover.  Or more realistically, let it happen in the night during sleep, after a joyful day, as a very old person, still with all my faculties.

As a physician, I have seen death occur in many ways.  Certainly, no one wants to die slowly while suffering, or after a long period without the capacity to know what is going on.  In these cases I have grown to appreciate the hospice attitude of comfort care, instead of medically trying to prolong an un-enjoyable life.  Perhaps our ability to keep someone alive has gone past our ethical understanding about how to know when to allow a natural death.

But here we are talking sudden death.  The kind of end that is unexpected.  When we lose someone and we have to say “Why?”

I have often wondered what the ghosts of those who die so abruptly must think.  Is it, “That wasn’t so bad!” or “Wow, that caught me off guard!” or “I wish I could have told my family one more time that I love them.” Or “That was a better way to go than that long and drawn out suffering way!”

I have had too much opportunity watching people hear and react to words like, “We have found cancer, and your condition is terminal.”  We are simply not built as human beings to handle the hopeless sound of a phrase like that.

It is better to live our lives with hope for a reasonable future, but still knowing that at any moment this could be our last.  One friend told me that when it’s his time to go, “Surprise me.”

Take home message:
   1. Talk to your family about your own death wishes;
   2. Finish your business and say what you should say everyday.