Remember to Screen All Your Patients for Eating Disorders

My cousin died during the Coronavirus pandemic for reasons unrelated to COVID-19. When I first heard my cousin had been hospitalized, I immediately attributed it to the virus. She would get through it, I was sure – she was young, healthy, and strong. But slowly, as her brother entrusted me with more information, I realized that wasn’t the case. “You’re a doctor,” he said, knowing full well I was just a medical student. In hindsight, it was more than that. I was a source of support. Someone to share the burden with. But even with this relay of information, I struggled to make the pieces fit. My uncle was forced to unhinge her bedroom door when she failed to answer his calls. Inside, he found her listless and unresponsive. I was told she weighed a meager 89 pounds on admission and her glucose level was 10. Rumors drifted through the family, born of disbelief. She was suffering from depression and anorexia. I could not understand how we could have collectively let it get to the point of required intubation. To the point of total parenteral nutrition. To the point where she coded twice and required dialysis. 

Eventually, her body failed her. And in many ways, it felt like we did too. 

As someone training to be in the medical field, I found myself fraught with grief and regret. I should have seen the signs. I should have asked. Eating disorders have the potential to be life threatening. Often, they’re a source of jokes in mainstream media and I didn’t understand the full impact it could have until it truly hit close to home. As someone who wants to go into primary care this motivates me to do proper screening and aim for early intervention if possible. The American Academy of Family Physician (AAFP) suggests reviewing not only clinical factors but also psychosocial factors because there are additional things to work on such as self-worth and coping with emotions and stressors (Klein, 2021). Though eating disorders are often diagnosed in teenagers and young adults, it’s important to keep in mind that it can occur in people of all ages. My cousin was in her thirties when she passed.

Treatment options include cognitive behavior therapy, family-based therapy, and pharmacotherapy such as antidepressants like fluoxetine. What’s important is that health related goals be emphasized and not strictly weight. The AAFP defines some markers of recovery as eliminating harmful behaviors, reducing body dissatisfaction and valuing actual health more than weight and numbers (Klein, 2020). I wish there was less of a stigma on talking about mental health and eating disorders and a wider air of acceptance that fostered an environment where people felt comfortable talking about their troubles and maybe my cousin would still be here today. This experience further fueled my desire for better follow up, screenings, and preventative measures for patients. 

Hinal Patel, MS4

Drexel University College of Medicine

Klein DA, Sylvester JE, Schvey NA. Eating Disorders in Primary Care: Diagnosis and Management. Am Fam Physician. 2021 Jan 1;103(1):22-32. PMID: 33382560. 

Why aren't there more Filipino-American Doctors?

 

Why aren’t there more Filipino American doctors?

A few weeks ago, a good friend texted me saying that she was asked a really thoughtful question during one of her residency interviews. The interviewer noted that my friend is Filipino and asked her, “I noticed there aren’t a lot of Filipino doctors, so how has your cultural background influenced your approach to patient care?”

It is true that we have an abundance of Filipino nurses in our healthcare system, but what about doctors? Filipinos fall under the larger umbrella of Asian Americans, who are not considered to be underrepresented in medicine, but Filipinos are an absent minority. According to AAMC’s 2019 Diversity in Medicine report, 17.1% of active U.S. physicians identify as Asian. However, only 4.6% of Asian physicians in the U.S. identify as Filipino. This underrepresentation is also evident in medical education. Filipinos consisted of 4.3% of Asian applicants to U.S. medical schools during the 2018-2019 academic year. This means that less than 1% of total applicants identified as Filipino.

This is the truth we face, even though Filipino Americans are the third largest Asian subpopulation and one of the fastest growing ethnic minorities in the United States. In fact, Filipino Americans make up nearly a quarter of California’s Asian American population, but only about 6% of the UC’s medical school matriculants. The majority of Filipino physicians in California are international medical graduates.

It is incredibly important for Filipino patients to have access to more physicians who look like them and understand their culture, language, and traditions. The world of medicine is extraordinarily difficult for patients to navigate but having a provider who identifies with their specific cultural needs can greatly improve healthcare outcomes. This is especially crucial since Filipinos suffer from diabetes at higher rates than non-Hispanic whites and have a higher prevalence of cardiovascular risk factors such as hypertension and obesity compared to other Asian Americans.

I’m proud to identify as a Filipino American woman who will be entering the workforce as a pediatric resident physician in a few months. I wish I could say that I had inspiring Filipino faculty or attendings who guided me along the way, but I didn’t. However, I’m thankful that I found a group of intelligent, kind, and like-minded classmates in medical school who also shared the goal of wanting to become culturally competent Filipino American physicians.

As for my friend, she effortlessly answered her interviewer’s question by talking about applying her parents’ immigrant values towards advocating for her patients and wanting to serve as representation for Filipino youth who may be interested in pursuing a career in medicine. I recognize that we have a long way to go, but I can’t help but be excited and hopeful for future nanays and tatays to see doctors who look just like them.

Briana Mancenido, M.D. Candidate
Drexel University College of Medicine Class of 2021

Sources:

https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018

https://www.aamcdiversityfactsandfigures.org/section-ii-current-status-of-us-physician-workforce/index.html#fig2

https://www.aamc.org/data-reports/workforce/interactive-data/figure-3-percentage-asian-alone-applicants-us-medical-schools-asian-subgroups-academic-year-2018

http://greenlining.org/wp-content/uploads/2013/02/ClosingDataGapsAANHPIUCMedicalSchoolDiversity.pdf

  Fuller-Thomson, R. (2017). Diabetes among non-obese Filipino Americans: Findings from a large population-based study. Canadian Journal of Public Health, 108(1), e36–e42. https://doi.org/10.17269/CJPH.108.5761

  Borja‐Hart, G. (2019). Atherosclerotic cardiovascular disease risk assessment and predictors of statin use in Filipino‐American Women. Journal of Clinical Pharmacy and Therapeutics, 44(4), 632–639. https://doi.org/10.1111/jcpt.12837

Postpartum Depression in the COVID Pandemic

In the advent of the Coronavirus pandemic, new and expecting mothers are facing increased levels of fear, anxiety, and stress on top of overwhelming social isolation. Postpartum depression cases, in particular, are rising globally as mothers are now navigating unanticipated challenges of delivering without a support person, being physically separated from loved ones (including newborns), managing their newborns without help, and grieving loss during a moment that was meant to be cherished.

Postpartum depression is a perinatal mood disorder that develops within four to six weeks of delivering a newborn due to neurobiological factors and environmental stressors. The disorder is characterized by at least two weeks of severe depressive symptoms and must be differentiated from postpartum blues, which is known to self-resolve. Unlike postpartum blues, postpartum depression requires a combination of antidepressant medication, psychotherapy, and a significant amount of planning. Postpartum depression is associated with an increased risk of preterm delivery, reduced mother-infant bonding, and delays in cognitive development of the infant; it is crucial to recognize and manage symptoms early on. These symptoms include depressed mood, excessive crying, difficulty bonding with the newborn, withdrawing from family and friends, fatigue, insomnia or hypersomnia, irritability, hopelessness, or feelings of worthlessness, shame, guilt, or inadequacy.

Prior to the recent pandemic, approximately 14 percent of women have suffered from pregnancy-related anxiety and 20 percent of women are said to experience postpartum depression. Those most at risk are women who have a history of depression, bipolar disorder, postpartum depression from a previous pregnancy, difficulty breastfeeding, weak support systems, or financial troubles. Unfortunately, despite the prevalence, postpartum depression cases are often underdiagnosed and undertreated – especially in the African American patient population who are more likely to be infected or die from the virus compared to the Caucasian population.

Perinatal psychiatrists are working towards creating COVID-19 maternal well-being groups, which allow patients to share their concerns, seek support, and grieve together. These groups are particularly helpful as affected women are forced to also think about specific scenarios that may not have medical guidelines. For instance, if a patient or her partner is a health care worker, what precautions should she take? If she is balancing other kids at home, can she send them to day care? If she has a limited support system, can she rely on help from her own parent who is at high risk? These decisions can cause added stress for mothers and are difficult to make without the guidance of medical professionals and the availability of social support. Additionally, a public health intervention to battle postpartum depression includes reaching out to families with prior mental health concerns to address issues proactively.

The pandemic unveils a new mental health crisis and has been shown to disproportionately impact women. For this reason, it is crucial for new mothers to monitor symptoms and seek medical support during these challenging and uncertain times.

Sitara Soundararajan

M.D. Candidate

Drexel University School of Medicine

Class of 2021

Reducing Teen Pregnancy with Comprehensive Sex Education

Sex education in the United States is currently regulated on a state level. Each state has funding and resources from the federal government but has the autonomy to make its own policies and curriculum. Some state curriculum teaches abstinence only while others combine abstinence with comprehensive sexual education that includes medically accurate information on contraception and STDs. A study in 2005 showed that states with abstinence only education average 73.24 per 1,000 teen pregnancies per year for girls aged 14-19 and states that promoted comprehensive sex education in conjunction with promoting abstinence averaged 56.36 per 1,000 teen pregnancies per year. Additionally, this data accounts for confounding factors such as socio-economic status, education level, and ethnic differences. 

Currently, a bill titled The Real Education for Healthy Youth Act (REHYA) proposed by Senator Cory Booker and Congresswoman Barbara Lee has been introduced in House. The goal of the bill is to create a holistic approach to sexual health and provide adolescents with accurate information to make healthy decisions. The bill includes topics such as: basic anatomy and physiology, growth and development, pregnancy prevention, STI prevention, dating violence and sexual assault, and bullying and harassment. Research has shown that students exposed to a safe dating curriculum were 60% less likely to perpetrate forms of dating violence against a partner. Overall, preventing teen pregnancies can help expand communities by empowering teens and allowing these youths to become stronger contributors. It is most important to introduce accurate information and allow young minds to make their own informed decisions. Evidence-based data should be the driving point of all medically related education taught in schools, and the teachers should be up to date, bias-free, and have appropriate training and education themselves. In order to implement changes in each state, there must be change on the federal level.

Kristy Hou

Drexel University College of Medicine

Class of 2021

Sources: 

Philip, J., & Marr, A. (2016) The Real Education for Healthy Youth Act. Advocates for Youth. Retrieved from: https://advocatesforyouth.org/resources/policy-advocacy/the-real-education-for-healthy-youth-act/ The Real Education for Healthy Youth Act (REHYA) (2017, Sept) 

Sex Ed for Social Change (SIECUS). Retrieved from: https://siecus.org/resources/the-real-education-for-healthy-youth-act-rehya/ Stanger-Hall, K. F., & Hall, D. W. (2011). 

Abstinence-only education and teen pregnancy rates: why we need comprehensive sex education in the U.S. PloS one, 6(10), e24658. https://doi.org/10.1371/journal.pone.0024658

Remembering Ruth

This morning I began the day with a cup of tea, drinking out of one of my favorite mugs with a quote on it from an inspirational woman: Women belong in all places where decisions are being made. I am reading this quote on the morning of one week after the passing of Ruth Bader Ginsburg, originator of this quote, trailblazer and consistent champion for reproductive rights and gender equality. Stories of her life and memory have flooded news outlets, being laid bare for us to get the chance to say thank you for her work and acknowledge where we must all pick up and continue the fight for gender equality.

I wanted to reflect on some of the ways that her civil rights work has made life more equitable for women and girls. Even before she joined the Supreme Court in 1993 and established important precedents and decisions regarding reproductive rights, she co-founded the Women’s Rights Project at the ACLU, an initiative that was devoted entirely to gender equality. She fought fiercely to make sure women’s rights were seen as an essential part of human rights. She may not have gone into law school intending to fight gender discrimination, but her experiences as one of only nine women at Harvard Law School in 1956, being turned down for law jobs despite graduating tied for first place in her class from Columbia Law, and facing unequal pay for equal work while serving as faculty at Rutgers Law School in 1963 set the stage for laws she would help create and cases she would bring to justice.

During her time on the Women’s Rights Project with the ACLU, Ginsburg pushed to have pregnancy discrimination recognized as a form of sex discrimination, fighting against an Air Force policy in 1972 that automatically discharged pregnant officers unless they terminated their pregnancy. Ruth Bader Ginsburg believed that, "The decision whether or not to bear a child is central to a woman's life, to her well-being and dignity. It is a decision she must make for herself. When the government controls that decision for her, she is being treated as less than a full adult human responsible for her own choices." In cases such as Whole Woman’s Health v Hellerstedt (2016) and June Medical Services v Russo (2020) she reinforced the essential nature of abortion and reproductive care as part of healthcare and protective of women’s bodily autonomy and equal status as citizens in this country. She expressed in multiple dissents the need for separation of church and state with regard to contraception coverage, a logical response since numerous studies show decreases in STIs, teen pregnancy, and abortions with comprehensive sexual health education and access to contraception over abstinence only education and restrictions placed on access to contraception and abortion. Ginsburg paved the way for women to obtain financial independence through the Equal Credit Opportunity Act passed in 1974, having downstream effects of everything from decreasing their risk for being trapped in abusive relationships to realizing their talents and dreams. Finally, she helped the world see that sex discrimination is damaging for both men and women through representing Charles Moritz in 1968, ultimately proving that men are entitled to the same caregiving and social security rights as women.

Ruth Bader Ginsburg made space for women to be in all places where decisions are being made building on the work of other trailblazing women before her, and I am grateful for all the ways that she has shaped my ability to be in my final year of medical school irrespective of my sex. In medical school, we learn about social determinants of health and how they affect our patient’s wellbeing and overall physical and mental health. Societies inequalities, gender based discrimination included, have many implications on health and I am happy to continue working toward gender equality alongside the generations of feminists Ruth Bader Ginsburg has inspired.

Anna Braginskaya M.D. Candidate, Class of 2021 Drexel University College of Medicine