BMI and Endometrial Cancer

I was surprised to learn recently that in contrast to decreasing incidence rates for lung and colorectal cancers, the rate of new uterine (endometrial) cancer cases has been increasing. Overall incidence rates have increased ~ 12% (0.7% per year on average) between 1999–2015 and death rates have increased 21% (1.1% per year) during a similar period.  The most recent data from 2015-2016 indicate a total of 53,911 new cases and 10,733 deaths from uterine cancer.  

In addition, closer inspection reveals significant racial and ethnic disparities.  For example, incidence among black women increased 46% (2.4% per year) and 32% (1.8% per year) among Hispanic women compared to 9% (0.5% per year) among white women.  Similarly, death rates among Hispanic (33%; 1.7%) and black (29%; 1.5%) women exceeded those among white women (18%; 1.0%).  Black women were more likely to present at a later stage and with more aggressive histologic types, which might in part account for their higher death rate.

One reason postulated for this observed increase may be elevated body mass index (BMI).  Women who are overweight (BMI = 25.0–29.9 kg/m2) or obese (BMI ≥30 kg/m2) are approximately two to four times more likely to develop endometrial cancer than those with normal weight.  According to the CDC, in recent years approximately 40% of women in the United States have been diagnosed as obese, including 56% of black women and 49% of Hispanic women.

So what can be done to reverse this trend?

• Health care providers need to promote awareness of the need for timely evaluation of abnormal vaginal bleeding.  This increases the chance for early detection and treatment. 
• Women can reduce their chances of developing uterine cancer by never taking estrogen-alone replacement therapy, maintaining a healthy weight, and being physically active.

  Judith Wolf, MD     Associate Director, WHEP

Uterine Cancer Incidence and Mortality — United States, 1999–2016                                                                                                   MMWR/ December 7, 2018 / 67(48);1333–1338

Cardiovascular Disease in Women: Exploring Clinical Signs and Risks Factors

Dr. Bernadine Healy, first female director of the National Institutes of Health (NIH), recognized that most of the research centered on the diagnosis and treatment of coronary artery disease in men, not women, thereby making men the normative standard.  Because of this, women’s symptoms became underappreciated or atypical, with fatigue being the most common complaint especially in older adult women with acute myocardial infarction. Women often present with nausea, jaw tightness, shortness of breath, muscle pain, dizziness, and chest pressure, although their symptoms are often milder than those of their male counterparts. Up to 30% of women may have no chest pain at all. This is important because heart disease is the leading cause of death for women in the United States, accounting for over 398,000 deaths per year (American Heart Association). This figure is greater than the next two leading causes of death in women, cancer and accidents, combined (American Heart Association). While it has been shown that men have myocardial infarctions at earlier ages than women, myocardial infarctions result in greater mortality in women than in men.

 

The pathophysiology and risk factors are also different in women. Women often exhibit coronary microvascular dysfunction, which is marked by smaller vessels and increased vascular stiffness with diabetes and hypertension being the most common risk factors in women. Many women with hypertension are undiagnosed or, if diagnosed, poorly controlled. Smoking increases heart disease risk significantly in women, raising it to the same level as in men. Interestingly, in women, the cardiovascular risk varies relative to menopause. Prior to menopause, protective high density lipoprotein levels, are elevated. After menopause, they decrease and women lose the protective advantage. Early induction of menopause has also been associated with increased cardiovascular risks.


Maureen Farrel   DUCOM 2021

 

https://www.goredforwomen.org/fight-heart-disease-women-go-red-women-official-site/share-your-story/

 

The Tainted White Coat: Realizing the Physician’s Role in Social Injustice

Stepping into the world of medicine, from the first time I took the oath to the first time I donned that crisp white coat, I was filled with an overwhelming sense that I was part of something so pure, so philanthropic, and so authentic in its passion to heal. Yes, on great days, I still remember that feeling and revel in it but that feeling can also be detrimental. Hospitals and physicians and healthcare in general, because of the philanthropic nature of the job and the difficulty it takes to attain the status of a physician, tend to be placed on a pedestal and celebrated as “all-knowing” when that is not the case. Black mothers have a three times higher maternal mortality rates than their white counterparts (1), African Americans are routinely under-treated for their pain compared with whites (2), heterosexual providers have been researched to favor heterosexuals over LGBTQIA+ patients while their explicit preference for heterosexuals over lesbians and gay men were “moderate to strong” (3). These are just a few examples how physicians not only practice medicine, but also practice social injustices like racism and homophobia. Because of the position of power that physicians have, issues like these do not garner enough dialogue. I urge the dismantling of the pedestal and the realization that our healing hands are also deadly.

It is significant to realize that though medicine is founded on science, it is also founded on a society that was and still is oppressive to marginalized groups, and because of that, we can become implicit to this injustice without realizing it. The lack of access to care in general, how fiscal disadvantages of low income folks inhibits them from getting the best care, insufficient cultural humility that may be present in a lot of providers, inadequate evaluation of health literacy, and the overall racism, sexism, homophobia, and classism embedded within implicit and explicit biases in providers and medicine as a whole makes it so often times the medical community contributes to the systemic oppression that vulnerable populations face. Nothing exists in a vacuum - we can rely on the scientific facts in order to treat patients, but our beliefs, decisions, and science ITSELF developed from a society that is oppressive, and thus yields, knowingly and unknowingly, practices that parallel with this oppression. We should be aware that our practices - how we treat Black patients versus white patients, misgendering our transgender patients, stressing reproductive and sexual health in women more than men - are not perfect, and in fact contribute to social injustice. We cannot sweep it into the rug, or hide under scientific evidence.

If we can think critically about pathophysiology and biochemical pathways, then we can think critically about our position and how, instead of being sources of justness and equity in a patient’s life, we might instead represent injustice. But realizing it is the first step. By doing so, we can start dismantling the ways in which we aid in the systems that abuse them and find ways to regain their trust. The best initial step, I think, is by knowing what we don’t know and to dive right into it. Physicians and health professions in training tend to practice their scientific mind, but it is just as important to study racism, sexism, homophobia, etc. Again, if we can think critically about enzymes and physiology, then we have the capacity to think critically about our patients as well - to realize the intersection of psychosocial factors rooted in institutionalized oppression that leads to toxic stress in our patients and ultimately produces the mental, emotional, and physical symptoms that they currently and will suffer from. Racism in the hands of medical professionals are killing patients, and if we don’t realize that these forms of oppression exist within the romanticized white walls of a hospital and actively explore them as intense as we explore the pathophysiology of a disease, more patients will suffer at the hands of our ignorance.

As hard as it is to hear: medicine is racist, it is homophobic, it is sexist. Once we realize this, the next step is asking oneself: How can I change how I practice medicine in order to make it as free from social injustice as possible? Serving vulnerable populations means having to navigate the social injustice that patients face on an everyday basis in order to treat them as a whole. Why should that injustice also exist within the exam room?

To put it simply, I urge the reframing of our narrative: that yes, physicians can be healers and advocates but to always, always, always include the caveat that we are just as capable of being agents of oppression. As I stand on the precipice of with my entire career in front of me, I ask myself: what am I going to do to change that?

Instead of doing no harm, why don’t we try doing good instead?

Candice Mazon   DUCOM 2019

 

References

1. https://www.npr.org/2017/12/07/568948782/black-mothers-keep-dying-after-giving-birth-shalon-irvings-story-explains-why
2. https://www.washingtonpost.com/news/to-your-health/wp/2016/04/04/do-blacks-feel-less-pain-than-whites-their-doctors-may-think-so/?noredirect=on&utm_term=.51b88adc7e59
3. https://www.advocate.com/commentary/2015/07/27/op-ed-how-we-can-address-homophobia-doctors-office
4. https://www.health.harvard.edu/blog/racism-discrimination-health-care-providers-patients-2017011611015

Weight Bias in Medicine

 

 

For one of my first patient encounters while on my elective I was waiting for her in the hallway as her vitals were recorded. We quietly moved through blood pressure, oxygen saturation, height, and then it became time to record her weight. As she stepped on the scale she playfully joked that she was going to close her eyes. She said “I’ve already had a bad day as it is, I don’t want this to make it worse”. We all agreed with her that being weighed at the doctor is one of the worst parts. Needless to say we went on our way with the visit and I didn’t think much about it.

It wasn’t until I noticed a trend, where when those patients who would be considered overweight or obese would step onto the scale they would often times close their eyes or appear visibly upset at the number on the scale. This typically only occurred with women and rarely if ever occurred with men. I started to think, was it something we as health care providers were doing to make these women feel so uncomfortable? At first I thought it was their own insecurities but then I soon realized that maybe the place where they were going for their health check-up was also adding to their feelings of dread when stepping on the scale.

I recently read an article about obesity bias in medical training. The article was eye opening while also being somewhat discouraging. It discussed how those in training for health care professions had witnessed bias against patients who were considered obese and overweight, but what I thought was most salient was that it looked into how your own self- worth influenced how you felt that others perceived you. Overall, the article found that individuals who scored higher on feelings of low self-esteem perceived greater bias towards obese patients.

I realized that how we view ourselves as health care providers and our own self esteem can greatly impact how we treat patients, even if we are doing so subconsciously. Women are particularly vulnerable to societal pressures of what is considered “normal” and “beautiful”. It’s easy to let our internal negative voice cloud how we see one another but I never realized how much it has been engrained into patient care, a place where there should be no bias when caring for individuals.

It’s impossible to eliminate bias in one fell swoop, but I feel that by acknowledging that bias against weight in medicine exists that the hardest part is now over. We can all do our part to ensure that we are not letting our own self-worth cloud the judgment of how we view others, especially patients. It’s important to empower patients and encourage them, not make them feel targeted or ashamed at their doctor’s appointments, even if it is unconscious bias that is occurring. Now that we are aware of the systemic bias that can exist around weight in medicine, we can consciously do our part to hopefully eliminate that bias for good.

 

Stephanie Tzarnas      DUCOM 2019

 

Swami V, Pietschnig J, Stieger S, et al. An investigation of weight bias against women and its associations with individual difference factors. Body Image 2010;7:194-199. 


 

Women in Surgery

I recently completed my general surgery residency interviews. General surgery has historically been a field dominated by men, and mainly white men, for a long time. On the interview trail, I noticed that most institutions invited an equal amount of men and women candidates. This observation prompted me to look into how much the surgery demographic has changed over the years. In the past, women were disguising themselves as men in order to receive medical education (1). Even when the first women were allowed into medical schools in North America, they were unable to find a residency position (1). It is humbling to reflect on the history of women in medicine and surgery in the context of current times when most medical school classes are 50% women.

 

We all know the stereotypical traits that women are labeled as. We are meant to be caring, nurturing, kind, and a home-maker. This played an important role in preventing women from accessing medical education and entering the surgical field. Dr. Mary Edwards Walker is considered to be the first female surgeon in the United States and the first female surgeon in the US Army.  She did not fit the stereotypical mold, as she did not change her last name when she married a medical school classmate (1). This act in combination with the mere fact of being a woman, caused her first surgical practice to fail (1). As of 2009, 21.3% of all surgical specialties are made up of women, according to the American College of Surgeons (2). This shows that times have progressed for the better, however there still remains inequity based on gender today, including personality characteristics and wage. Men are more likely to be perceived as dominant and alpha like when they exhibit confident or stern behaviors while women who exhibit the same behavior are perceived as emotional or abrasive. Also, women are less likely to receive full professorship and are paid less than their male counterparts (3). Women have also been discriminated against due to having a family or for the potential of bearing children (3).

 

While we are in an era where women do not need to disguise themselves as men to become physicians, and where medical school classes are half women, academic surgery and medicine in general still has a long way to go. It is important to acknowledge gender biases that may hinder a woman’s career and address them. Though surgery is still a male dominated field, my anecdotal observation of an even ratio of applicants gives me hope that this will no longer be a fact in the near future.

 

Shukri Dualeh

DUCOM 2019

 

References:

1. Wirtzfeld, Debrah A. “The History of Women in Surgery.” Canadian Journal of Surgery, Vol. 52, No. 4, August 2009.
   Link: https://search-proquest-com.ezproxy2.library.drexel.edu/docview/195955342?pq-origsite=summon
    
2. American College of Surgeons (2010, April), “The Surgical Workforce in the United States: Profile and Recent Trends.” http://www.acshpri.org/documents/ACSHPRI_Surgical_Workforce_in_US_apr2010.pdf
    
3. Dossa, F., Baxter, N. “Reducing Gender Bias in Surgery.” British Journal of Surgery 105: 1707-1709, November 2018
   Link: https://onlinelibrary-wiley-com.ezproxy2.library.drexel.edu/doi/full/10.1002/bjs.11042
    
    

 

Improving Healthcare Encounters of Patients with Autism Spectrum Disorder: Deciding on a Care Plan

Finally, after working through our history, physical exam, and initial evaluation of our patient throughout this series; we have finally come to a diagnosis! No matter what the diagnosis, it is very important that we keep certain things in mind when determining a management plan. The first thing to keep in mind is that these patients may require more education than most patients.¹ This makes sense as the barriers to communication these patients have along with their need for predictability and routine require more information regarding the treatment, whether it is a procedure or a medication, before the treatment is implemented. For this reason, the treatment modality and the explanation of its implementation must be tailored to suit the needs and abilities of the patient.¹ Taking certain sensory sensitivities into account during this process may be needed in addition to the use of different resources and treatment modalities in order to help inform the patient as to what the treatment is going to look like may be needed.

                When it comes to care plans that involve the use of procedures, it may be especially important for the patient to become familiar with the tools that will be used and with an illustration of what the procedure will look like when performed. Specifically showing the patient the materials that will be used (for splinting and bandaging for example) and allowing them to feel the material has been shown to be a good way to better inform the patient as to what the procedure entails.² In addition to this, modeling the intervention with said materials on a caregiver or volunteer can give these patients the predictability they need in order to brace themselves for the procedure.²  

                Meanwhile, for management care plans that involve the use of medication, the taste of the medication should be taken into account. This makes sense as, given that many individuals on the spectrum have sensory sensitivities, aversive taste of a medication could be enough to scare the patient out of taking the medication, causing the intervention to have an aversive effect on treatment compliance. For this reason, pediatric formulations should still be considered for adult patients on the spectrum that might have sensory sensitivities related to taste that could have this effect on their adherence to the medication.²

                As with any patient, the provider should always keep in mind the financial aspect of the management options they provide. For the provider that serves the ASD population, it may be helpful to familiarize oneself with programs like Supplemental Security Income or Medical Assistance that many individuals on the spectrum are eligible for in order to obtain more affordable care.³ Doing this allows the provider to advocate for and implement affordable care plans for these patients.

                Lastly, many of these individuals on the spectrum have many different specialists that they see for different aspects of their care including physical therapy, occupational therapy, case management, psychiatry, etc. In order for a given care plan to be effective, it is important that these other members of this patient’s care team are aware of the treatment plan being used³ so that it can be supported an encouraged in a variety of contexts by each of the team members. This interdisciplinary communication ensures better treatment adherence as the patient is being encouraged by multiple people to stick to their current regimen. Although this is done increasingly more through the use of medical home models established for the patient, it can still be done by the single provider that cares for a patient by simply communicating and coordinating with the different specialists and professionals that the patient currently seeks care and services from.

                It is with these revelations that we now can take a moment and look back on everything that we have discussed in this series. No matter what locations and institutions we end up in throughout our training, we as future medical providers in training are bound to come across these individuals as our patients, as the overall prevalence of ASD within the United States is steadily increasing. For this reason, I hope that the “toolbox” of skills introduced in this series may be helpful to the soon-to-be healthcare provider in serving these patients and other patients with similar barriers to care, so that the healthcare encounters we share with these individuals yield positive outcomes.

                                                                                                               Alexis Matarangas   DUCOM 2019

REFERENCES:

1. Jain S. Teaching learners to care for children and youth with special healthcare needs. Fam Med 39, 85-87 (2007).
2. Venkat A, Jauch E, Russel WS, Crist CR, & Farrell R. Care of the Patient with an autism spectrum disorder by the general physician. Postgrad Med J 88, 472-481 (2012).
3. Bultas MW, Mcmillin SE, & Zand, DH. Reducing Barriers to Care in the Office-Based Health Care Setting for Children with Autism. J Pediatr Health Care 30, 5-14 (2016).