Much has been made of the fact that technology now makes it extremely easy for teenagers to send pictures of their genitalia to one another. I, for one, think this is fantastic. Sending fully or partially nude pictures to your boyfriend or girlfriend, or "sexting," represents the ultimate in safe sex. There is virtually no other sexual activity that incurs a literally 0% risk of pregnancy or transmitting sexually transmitted diseases.
Unfortunately, our current laws have not yet caught up with the technology and teenagers around the country are being hit with child pornography charges. This makes no sense whatsoever. The point of child pornography laws is to prevent children from sexual abuse and exploitation. Clearly, there need to be laws protect children from being used in child pornography. But, let's think clearly about this. The bad thing that we are preventing is not the production of any image containing the nude bodies of teenagers. What we are preventing is child abuse. By prosecuting teenagers who send each other naked photos, we are criminalizing normal sexual behavior.
Adolescents are quite skilled at getting themselves into all kinds of trouble and need our help in so many ways. We don't need to further mess up their lives by punishing them for what is normal, healthy activity.
The American Academy of Pediatrics issued a policy statement yesterday that outlined a new set of guidelines for welding safety in the pediatric population. The AAP subcommittee for prevention of welding related injury and death issued the statement in response to what they call a "Growing trend towards children and teens engaging in welding and welding related activities at younger and younger ages."
According to pediatrician Dr. Arlene Miller, spokesperson for the committee, "In 1970, the average age of first welding experience was 21. Today it is 17. This includes welding of everything from steel and aluminum to iron and often occurs as early as age 14. In the past decade alone we have seen a 50% increase in welding related injuries such as burns, hearing loss, vision loss and metal fume fever. These injuries are all the more tragic in that they are entirely preventable."
The AAP statement offers 25 recommendations for parents on how to prevent welding related injury, or WRI, in their children including keeping welding equipment securely locked, placing a minimum eight foot fence with appropriate warning signs around any areas where welding is occurring and wearing suitable safety gear if the child or teen does decide to engage in welding. The statement also stresses the importance of early education and the endorses the strengthening of school programs that teach safe welding practices. Dr. Miller also went on to report that, "Studies show that children and teens in communities where safe welding techniques are taught in school are less likely to suffer WRI than similarly matched children and teens who are taught only to refrain from welding."
Charles Davis is the principle of Xavier middle school in Charlotte, NC where one such so-called "welding abstinence" program has been taught for 30 years. "Welding is an activity that should only be performed by licensed professionals, or by trainees in an accredited program under close supervision," Davis spoke with reporters. "By teaching our kids how to weld 'safely' we send the message that it's ok for anyone to do welding. It's the wrong message."
This, in sharp contrast to the AAP's Dr. Miller. "It's time we acknowledge the high prevalence of welding among children and teens in our society and of subsequent WRI. Prevention of WRI begins in the home. Parents, please, talk to your kids about welding. Be involved in their lives. Ask them where they go and what they do after school. And, if your kids are going to weld, make sure they get proper training and use proper safety gear. There is nothing more tragic than when I see a welding related injury in child who says 'I only wish somebody had showed me how.'"
Ok, I realize this is long overdue. But, I did promise a review of Watchmen and, wanting this blog to retain some semblance of credibility, I now fulfill my obligation to the reader.
I love the source material that the movie came from. Anyone who loves the material the way I do and who will buy the special edition DVD in order to watch the movie with director commentary (as I surely will) will enjoy this movie. However, those unfamiliar with the source material are likely to find the movie dull and plodding. The problem is that it follows the graphic novel too closely - almost frame for frame. The result is a series of beautiful and gratifying scenes for those of us who know what's coming and a series of well crafed, highly digitalized but emotionally unengaging scenes for those who are trying to figure out what the point of the story is.
Nevertheless, I really liked this movie. I'm not sure if the PG-13 version that was to be more loosely based on the graphic novel would've been the better choice or not. On a scale of 1-10, I give this movie a solid score 'read-the-book.'
Have I written about this before? It seems like I must have. I certainly have been bombarded with the idea that doctors should screen their patients for relationship/domestic violence during these last several weeks. And the idea continues to appear no less ill-conceived.
As any good epidemiologist knows, if you are going to screen for some condition, that condition should meet two basic criteria:
1. the condition you are screening for should be asymptomatic
2. intervening earlier should have some effect on the disease process in terms decreasing morbidity and mortality.
There is also the issue of cost-effectiveness which it only makes sense to talk about once criteria 1 and 2 are met. Domestic violence fails to meet the first criteria - it is not asymptomatic. Getting hit, kicked or raped by your partner are all symptoms of domestic violence. By screening for it, we are not using our medical expertise to identify a condition for which we can intervene, thereby helping our patients live longer and healthier. What we are doing is identifying a condition that our patients already know that they have (because the only way we know they have it is by asking them) and then telling them that it's a problem. Telling patients what is or is not a problem rather than letting them decide for themselves is pretty much the definition of paternalism.
I don't deny that the prevalence of domestic and relationship violence is huge. Nor that there are thousands of women out there in very bad situations. And I'm glad that there are some resources that these women have available to tap into. But, I don't believe that there is anything about medical school or residency training that confers the expectation upon doctors that they identify ALL of their patient's problems and try to solve them. Patient's may have a whole host of problems which doctors are equally unqualified to deal with. Should we screen our patients for excessive credit card debt? Excessive debt can cause huge emotional distress, bankrupcy and can ruin lives. But, I've never heard of any doctors advocating that we should screen for excessive credit card debt. Why is domestic violence different?
Now, if a person comes in complaining that they're being abused by their domestic partner, I'm more than happy to put her in touch with appropriate resources. But this is not the same as screening. This is a case of the patient having identified a problem and asking for help. And, as a doctor, I will provide whatever help I can. But seeking out patients via screening in whom you try to identify an additional problem? This is fine for conditions like diabetes, hypertension and cervical cancer - conditions for which our medical training has supplied us with privileged information about how much of a problem the condition may or may not be for the patient. But we have no privileged information about how much of a problem the behavior of our patient's boyfriend is for her. She is much more qualified to make that determination than we are. Therefore, in the final analysis, it simply is not a doctor's place to screen for domestic violence.
And, in yet another exciting edition of, "What they taught me in medical school turned out to be completely and utterly wrong:" open ended questions.
I was listening to the medical students talk about a patient interviewing class that they take every year. It's a pretty standard kind of thing. The student interviews a standardized patient (actor) is videotaped and receives feedback from an experienced physician. The biggest thing they always used to press us on - and still continue to impress upon the next generation of medical professionals - is that we should ask open ended questions. For example, questions like "how do you feel about your pregnancy" allow the patient the opportunity to give you much more information than "for how many days have you had a cough." As a resident, I quickly learned that asking open ended questions is absolutely the wrong way to go about things.
In my office, the patient gets asked exactly two open ended questions: 1) what brings you here? (asked at the very beginning of the visit) and 2) do you have any other concerns? (asked at the very end of the visit). If your goal for the visit is to address your patient's complaint and to do it efficiently, it doesn't benefit anyone to allow the patient to go off talking about random, irrelevant nonsense. Once you understand what their complaint is, you - the doctor - should have some ideas about what specific bits of information are important for you to know about. That's what medical school is supposed to teach you. You obtain those specific bits of information by making your questions as pointed and direct as possible. Your goal is not to identify every single problem the patient may possibly have. Your goal is to address the current problem that they're coming to your office with (hence, question #1). I believe it is then prudent to make sure that doctor and patient are both on the same page and that everyone understands everyone else (hence, question #2).
The students are lucky that they have me around to preempt some of the harm that might otherwise be done to their education.
I sometimes get myself into this rut where I find myself completely unmotivated to read. When there is such a vast ocean of knowledge out there, what can a few drops of knowledge possibly do to improve my ability to give good patient care? That's how we learn, though...drop by drop, taking a good sized gulp here or there. Put myself on a steady diet of 5-10 cc's of knowledge per day and, in two years, I just might be able to learn everything I need to know.
I continue to struggle with the concept behind the combined MD/PhD degree. For that matter, I continue to struggle with the concept of physicians doing research in the first place - even though it's considered pretty standard practice in academic medicine. If you want to keep your faculty position at Big University Hospital, you had better be writing grants and publishing. Why?
With the persistent, pervasive culture of publish, publish, publish pressing down upon me, I can't help but feel that I've been the victim of a 'bait and switch' somewhere along the line. I went to medical school specifically because I did not want to do research, write grants or publish. If I had wanted to do any of these things, I would have gone for a PhD rather than the MD which I very specifically remember checking on my med school application. The skills and knowledge required to do medicine versus the skills and knowledge required to do academics are not the same. Yet somehow, the medical community finds it natural that doctors should do research and, if you're already doing the research, hell, why not follow that to its logical conclusion - a PhD?
The way I see it, physicians and researchers are charged with very different tasks. Physicians are in the business of helping you. Physicians are interested in mastering as large body of knowledge as they can in the shortest amount of time possible and in applying that knowledge in such a way as to cure or help manage your medical condition. Researchers aren't interested in you. Researchers are interested in furthering scientific knowledge. People who do research and get PhD's spend huge quantities of time investigating an extremely narrow question, the answer to which is probably completely irrelevant to any medical condition that you have or ever will have. The whole point of being a physician is that we get to enjoy the fruits of this labor. Thousands of hours spent writing grants, controlling variables, running PCR reactions, taking x-rays and whatever else eventually does result in real and useful knowledge that we physicians have the pleasure of using in the course of patient care.
To me, a physician who studies, say chemotherapy drugs, is like an auto mechanic who studies structural engineering. And, I have nothing at all against structural engineers or cancer researchers. Quite the contrary. Only, it's not what I signed up for.
