Old people and Sex

I recently had a series of lectures on geriatric patients including what kinds of foods they eat, delirium, and sex. I was surprised at home many seniors still have sex and even more surprised at the amount of STDs these people have! About 12% of people with HIV are over the age of 50! And most of these people would be new cases because the treatments have not been around that long to increase longevity of those infected in the 70s and early 80s. Because normally men die younger than women the population in a nursing home or senior apartment complex can be 7 women:1 man! So it is assumed that guys will have multiple partners. And since most of these people probably have never had the "safe sex" talk diseases like chlamydia and syphilis are way too common. I just recently came to terms with having to give the awkward sex talk to teenagers, but now it seems like at some point I will have to talk to everyone over the age of 10 about sex!

Dead bodies

I just had my first anatomy lab recently and became acquainted with my own personal corpse. I was extremely worried that I would pass out or cry when I saw a dead person because I have never seen one before. None of that happened though. They were careful to cover up the person's face for now, which helped a lot. Someone they didn't look human though. The skin was a grayish color and all the parts just seemed a bit alien. I am definitely grateful for all the people who donated their bodies to help us learn, but it is a much weirder feeling cutting into a person than a mouse for research!

My first "patient"

I had my first pretend patient interview the other day, and boy am I glad it was pretend! I volunteered to go first because I figured the expectations would be low and I kind of wanted to fail spectacularly so I could learn from my mistakes. Well all of these things happened. I’ll admit that failing horribly in front of everyone was embarrassing but I feel like I have learned so much more by getting a hard case from the start, trying to run with it, and falling flat on my face. The second person to interview a patient that day did remarkably well, but I don’t think they will learn nearly as much from their success as I did from my failure. The goal of this interview was NOT to diagnose anything, but simply to communicate with the “patient,” and figure out why they were at the doctor’s office and try and get a history. Basically I was talking to a young girl who was thinking about going into medical school and she wanted to talk to the doctor about “other things” but was too uncomfortable to say them at first (it turns out she wanted birth control). It took me a long time to work it out of her.

So here is what I learned, briefly…

• Just because a patient’s concern has nothing to do with medicine, does not mean it isn’t important. (I was talking to the standardizes patient (SP) about school and friends and hobbies but in the back of my mind I kept thinking ‘when do I get to the medicine part of this’ – I was so busy trying to do everything I thought I should do that I forgot to listen to the SP and talk about what was on their agenda)

• Interviews should proceed in a logical fashion (I jumped around a lot and asked some very random questions out of the blue, when I should have been asking good follow up questions to get more specific information) Ex. If a patient says they have a boyfriend you should find out more relevant information like how many relationships they have had in the past, what is the boyfriend like, how old is he, etc – this is very important for teenage patients when it might be their first sexually active relationship. I missed a lot of golden opportunities to ask really probing questions because I wasn’t taking the next logical step
• It’s ok to talk to a patient like you would a friend ( I was so wrapped up in trying to be a professional that I missed opportunities to share some of my own relevant life experiences like how I got into med school! – I mistakenly thought that the only advice I could give a person had to be based on statistics)
• Let the patient tell their story
• Reassure the patient that you will not judge them and will keep everything confidential (this can help people open up more and talk about uncomfortable issues especially when it comes to teenagers and sex!)
• Don’t make assumptions! (I made the mistake of skipping a lot of simple questions because I thought I knew what the answers would be already, sometimes I was right but I was also guessing wrong a lot of the time)
• Relax!

I have learned so much from this experience and I am so excited to tackle my next “patient.” Interviewing is a lot harder in practice than it is in theory. Hopefully by the time I talk to real people I will feel less like a fake and more like I know what I am doing.

Prenatal Screening and Myths

I have been learning a lot about the different types of prenatal screening and diagnostic tools available to Canadian women lately and many of the topics featured corrected a lot of myths I used to believe. So I am writing this post to help eliminate some of the widely held beliefs about screening and tests.

First of all I will talk about the different types of screens available:
1. IPS (Integrated Prenatal Testing): What is it? Two blood tests (at 11-13 weeks and 15-16 weeks) plus an ultrasound. What does it test for? Down Syndrome, Trisomy 18, and neural tube defects. Pro: high detection rate for Down Syndrome. Con: 2 tests and results received later than other methods

2. FTS (First Trimester Screening): What is it? Blood test (11-13 weeks) plus an ultrasound. What does it test for? Down Syndrome. Pro: earlier results than IPS. Con: Does not check for neural tube defects.

3. MSS (Maternal Serum Screening): What is it? Blood test (16 weeks plus). What does it test for? Down Syndrome, trisomy 18 and neural tube defects. Pro: Can be used if IPS and FTS were not done. Con: Lower detection rate for Down Syndrome.

MYTH: A good prenatal screen means the baby will be perfect
TRUTH: Prenatal screening is not perfect and 2-3% of all babies have a major abnormality at birth.

MYTH: A positive screen means the baby definitely has a defect
TRUTH: A positive result means the baby is at a higher risk of having a defect, but special diagnostic tests are still needed. The false positive rate of screening tests is about 5% which means that 5% of positive results are wrong.

MYTH: Prenatal testing is just for people who would have an abortion
TRUTH: Prenatal testing can be good for couples because if a defect is found then parents can prepare for a special needs child, and doctors can prepare for the best way to plan the birth and neonatal management once the child is born

After prenatal testing, if a positive result is obtained there are a few more options for couples who want diagnostic testing to determine what is potentially wrong with the child.

Types of Diagnostic Tests:
1. Amniocentesis: This is performed around 15-18 weeks. A needle is used to remove about 20 mL of fluid from the amniotic sac surrounding the baby. This can be used to determine if the baby has chromosome abnormalities (Down syndrome), neural tube defects, blood type, blood disorders (like sickle cell anemia), and infection. Risks: The biggest risk is miscarriage which is 0.5% or 1 in 200 pregnancies. (Note: background risk at this time is 2%)

2. Chorionic Villus Sampling (CVS): A catheter is used to obtain cells samples from the placenta. This can test for chromosome abnormalities, single gene defects (like cycstic fibrosis), and gender. It is usually performed between 10-12 weeks. There is a 1% risk of miscarriage or 1 in 100 pregnancies. (Note: background miscarriage risk is also a bit higher earlier in the pregnancy and risk depends greatly on the physician who is performing the procedure)

I learned a lot while researching all the different prenatal options women have today. I was surprised how inexact some testing is, and how despite the best efforts of medical professionals, not all birth defects can be detected. But I think the key with any medical decisions people have to make is the information they receive. I did not realize how common birth defects actually are, and I think that is how the majority of other people think as well. Knowing the limits of testing is important for setting expectations, both for yourself and patients.

Clinical Skills

I have already learned a few invaluable skills that every doctor should know. I learned how to take a blood pressure using a sphygmomanometer (blood pressure cuff) and how to look in ears to see the eardrum. I learned how to make a half cast and how to tie a square surgical knot as well. The knot tying was a bit complicated but I feel like with a bit of practice I will be able to do this knot blindfolded! Luckily I spent a lot of time when I was younger making friendship bracelets and hemp jewelery so I was a bit ahead of the game. I also learned how to insert an IV, some people got to practice on each other but I just practiced on a plastic arm. It went really well and I hit the vein on my first time. I also learned how to intubate people and did really well on that too. I am excited at the possibilities of learning "real" doctor skills but I realize I have a very very long way to go. I can't wait to go shadow doctors and learn even more.

Miscarriage

I did an intense science degree for my undergrad but I am still feeling overwhelmed after the first week of classes. Right now we are just learning about the general science we need to learn the rest of the body systems. We have learned a bit about genetic diseases and I was surprised how many pregnancies end in miscarriage, aka spontaneous abortion. About 1 in 6 pregnancies end in miscarriage and of those about half are due to genetic diseases. This was really surprising to me and I could not believe how hard it was to carry a child to term, especially once women age. There are so many extenuating factors that influence pregnancy like too much exercise that I didn't even realize. This is especially relevant because I am in that age group where most of my friends will soon be getting married and having children and miscarriages can happen to even the youngest and healthiest women. There is a lot of conflicting evidence available about the affect of caffeine of pregnancy (despite popular belief that any caffeine is bad) and there don't seem to be many reputable online resources that tell women what to do/not to do during pregnancy. I am very interested in learning more about this topic, so if anyone has any interesting articles on miscarriage or pregnancy tell me!