Better support for women

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If you’ve worked in global health, you’ve seen it happening: the steady trickle of smart, talented women out of the field. The 34-year-old fellow whose young marriage comes under strain from long stints in Cambodia. The junior faculty member who can’t manage a pregnancy or a new baby in the least developed parts of the developing world. The assistant professor, who has already put family plans on hold for her career, struggling to conceive or follow a fertility treatment regimen while spending months away from home.

Women constitute more than 80 percent of medical students seriously considering global health careers. These problems seem small to them when they start out as first year medical students at a median age of 24. Four years later, however, women disproportionately abandon these aspirations, largely because of concerns about how to balance a global health career and family life. As they finish their residency training, they are in their early 30s. If they sub-specialize, they get uncomfortably close to 35 – the much-feared “advanced maternal age.”

Where can they turn for advice? There are few female role models to inspire them. Less than 25 percent of leadership positions in global health at the 50 top US medical schools are held by women.

This is not unique to global health; there is dramatic attrition of women as you go up the career ladder in most fields of science. But women who dedicate their careers to improving healthcare in some of the poorest countries in the world face added challenges that their US-based colleagues mostly do not. The biggest of these is personal safety. More than one-in-four female trainees conducting international fieldwork have been sexually assaulted in the field, most often by their superiors. Once again, they have nowhere to turn. The mechanisms for reporting these incidents are inadequate or nonexistent in many research sites abroad.

During Sunday’s Grammy Awards, President Obama asked all Americans to make a personal commitment to help keep women and men safe from sexual assault through the “It’s on us” campaign. The pledge has four parts: (1) to recognize that non-consensual sex is sexual assault; (2) to identify situations in which sexual assault may occur; (3) to intervene in situations where consent has not been given; and (4) to create an environment in which sexual assault is unacceptable and survivors are supported. Nowhere is this message more urgent than in global health.

When conducting work in international settings, the usual support networks are absent. Your friends and family are thousands of miles away. The lack of fellow women makes solidarity – such an important asset in an environment where sexual harassment and assault are common – all but impossible. Even with supportive and understanding mentors, they are located on a different continent. A garbled Skype connection is not the optimal medium to discuss these sensitive issues.

These challenges are manageable. Targeted efforts to increase female leadership in business and politics have produced successes. [Barsh McKinsey 2012, UN Entity for Gender Equality and Empowerment of Women 1995, Interparliamentary Union 2012]. A network of mentors, including both US and international female colleagues, could provide a woman with someone to turn to, no matter where she is in the world. We must develop pathways for those based abroad to report sexual harassment or health and safety issues – a process that their domestic colleagues may take for granted. We have identified the problem and now we must take action on a personal, institutional, and governmental level to support these women who work to improve the lives of those in need around the world. It’s on us.

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A patients legacy

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As physicians, we have the unique privilege of meeting and interacting with thousands of people throughout our careers. Every once in a while, though, there are certain patients who really make a lasting impact and forever change us – as caregivers and as human beings. Ed was one of those patients. He also became one of my dearest friends.

Ed, a Korean War veteran, was an amazing man. He was a dedicated father, a devoted spouse, and lived a life that was an example of faith and service to others. I first met him years ago through his daughter. He had moved to my area in order to live near his children and needed a new cardiologist. Fortunately for me, his daughter asked me to take him on as a patient.

Ed had an ischemic cardiomyopathy and suffered from complications of congestive heart failure (CHF). He was fairly well compensated on medical therapy but continued to have worsening CHF. During the course of his illness, we eventually implanted a biventricular ICD and his symptoms improved significantly. As with most patients with CHF, over the years, he began to have more frequent hospitalizations for CHF exacerbations.

Through it all, Ed was always cheerful and never complained – in fact, it was sometimes difficult to monitor his symptoms due to his demeanor. Ed always put others before himself. His wife, suffering from her own chronic illness, was the focus of his final days. He loved her deeply and wanted to be sure that she was comfortable and well cared for.

Men like Ed are few and far between – I was honored to care for him. My professional role as his cardiologist is what provided me with the fortunate opportunity to be a part of his life and develop a relationship with him and his wonderful family. Medicine is best practiced when relationships and tight bonds are formed between doctor and patient.

As I left the chapel where the Catholic Mass celebrating Ed’s life was held, I could only wonder if I would ever have the chance to meet another “Ed.” Many patients are experiencing access issues, and many doctors are spending more time typing and glaring at computer screens. Connections like I had with Ed are becoming harder to form. I fear sometimes that medicine is becoming more about the system than it is about listening and caring for those who suffer from disease.

Ed taught me many things during the time that I cared for him. He taught me humility, kindness, and selflessness. I have never met anyone quite like him. Most importantly, he taught me the value of relationships and time. Even in death, he inspires me to be more to each of my patients. Ed never stopped caring for others; he never wavered in his commitments to his God, his wife, and his children. It is my hope that I can stand firm and continue to fight for my patients and their right to receive exceptional care. That is how Ed would see it – of that I am sure.

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Treating the patient, not the X-Ray

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A dignified man, mentally sharp with clear blue eyes, sat before me. Next to him, his wife of 51 years, and next to her, their three children. His voice – surprisingly soft, and muted – offered the probability that he was nervous. Yet his attention was unwavering. He appeared to be waiting for me to speak. Mr. Meyers (not his real name) was in my office for a fourth opinion regarding his ailing, aching legs – or so his intake paperwork said. The first portion of the paperwork was filled out in a quivering manner, often illegible. The latter part was neat, perfectly written, and precisely poised on the lines provided. Clearly, someone had felt he needed some assistance. His medication list was a mile long.

The X-rays on the computer were awful. Those knees and hips had seen far better days. They hurled him forward as a college ball player, and helped him retreat from trouble during the times he served to protect our nation. Still, you cannot predict who will or won’t have surgery – or who should or shouldn’t have in based on an X-ray alone. “Treat the patient, not the X-ray,” I said, turning to the resident in the room. It wasn’t the first time I’d said this. The resident had heard my “personality of an injury” talk many times before.

Mr. Meyers struggled to get to the examining room table, but he seemed more unstable then uncomfortable. His family reached to assist him; he brushed them away. The exam was brief. But telling.

“How can I help you, Mr. Meyers? What brought you here today?”

He seemed taken aback. He wasn’t sure what to say. He glanced at his wife and his children in the cramped, now humid room.

“Mr. Meyers, there are times when patients come in to my office with a very clear understanding of what they wish to accomplish on that day. And there are other times when they are looking for me to help them reach a conclusion. I sense that you have something to ask.”

“Doc, I’ve lived a long and wonderful life. I’m not well, and I’m not long for this earth. I want to be able to get around without being a trouble or burden to my family. I’m not in terrible pain, and I’m not willing to have the surgery everyone wants me to have.”

 

Mr Meyers’s issue was not unique. As a matter of fact it is all too common. He’s from a generation that often defers to the physician for advice and often follows that advice, perhaps against personal judgements or desires.

“Sir, you do not need surgery – you might not even survive it,” I began. “Mr. Meyers, we are going to work with a hospice agency and a physical therapist to get you the assistance you desire.”

His eyes, if that were possible, became sharper. I believe he even had a little more determination as he reached out for his wife’s hand, gathered his children, and left the office.

And I was once again reminded of how deeply a patient’s own expectations and desires matter.

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How to avoid injuries

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We exercise for a myriad of reasons. Many of these reasons are obvious such as  reduction of body fat, weight management, mental health, to feel better, or just for the overall positive health benefits.  However, there are certain injury prevention protocols that should be followed.  The last thing any of us wants is prolonged downtime in the form of a preventable injury.

 

Here are a few protocols to follow;

Always warm up prior to any exercise activity.  Warming up is important as it prepares the body and the mind for physical exertion.  Warming up the body increases circulation, helps ligaments, tendons and muscles loosen up and slowly connects the mind and body  into unison with the mindset of  “Okay now it’s time to work out”.

I always suggest light stretching immediately after the warm-up with more prolonged or intense stretching at the end of a good workout.  Again it is important to get the body ready for exercise.  Light stretching at the outset does this.  Include stretches for the entire body with more emphasis on injury prone areas such as the hamstrings, groin area and the lower back.  At the end of each workout, when your muscles are warmer and more pliable, you can move into deeper stretching, while focusing on lengthening by holding stretches longer.

It’s important to know the difference between muscles soreness, a minor twinge or strain, and a more serious injury.  Typical muscle soreness is normal and a condition you really want to try to work through.  You do this by warming up, light stretching and participating in your workout with maybe light modifications to sore muscle group areas.

If you feel a minor twinge or strain during your workout or during physical activity know that this is a common occurrence.  Almost everyone strains or pulls a muscle or one time or another. Typically, you will feel a sharp pain followed by a dull ache.  When this happens stop whatever you are doing and end your workout for the day.  Use the PRICE acronym; prevention, rest, ice, compression, elevation are the typical protocol for most minor strains or pulls.

 

Here is the PRICE protocol;

Prevention: Protect an injury from further damage.  Do not put excess strain on the injured area until the pain is completely gone.

Rest:  Give an injury time to heal.  This is very important as many people try to return to their normal routine before the injury has healed properly and end up re injuring the area, which in turn creates longer downtime.

Ice: Use ice (ice packs) to reduce the pain and inflammation for the first 3 to 5 days after an injury.  A top orthopedist once told me if everyone of his patients would ice an injury he would be out of business.

Compression: Wrap the injured area if need be to reduce swelling.

Elevation: Elevate the injury above the heart to reduce the flow of blood to the injured area and reduce the swelling as well.

 

A more serious injury such as a sharp, excruciating snap or pop with continued, localized pain requires greater attention.  Injuries like a pulled groin muscle, bad ankle sprain or severe tendinitis need to be addressed immediately by a medical professional.  Stop all exercise that affects an injured area and see a qualified orthopedist or medical doctor immediately.  A qualified medical professional can advise you on the extent of the injury and the proper protocol to follow, and provide  exercise guidelines and restrictions.

Stay away from weekend warrior mania! I know it’s a blast to go out with the buddies on the weekends for that pickup game of hoops, flag football, tennis or mountain biking.  It feels great to go back in time and participate in sporting activities you did in your youth.  You can still imbibe in these activities,  just keep in mind your current age and fitness condition.  Don’t try to turn back the clock in one day!   There is nothing wrong with participating in sports; however, as you get older it becomes even more important to warm-up properly and to do some light stretching before any sport or exercise activity.  Injuries can and do happen so you don’t need to encourage them.

Lastly, make sure you always cool-down after any exercise session or sporting event.  Rehydrate and give your body some recuperation time.  Improper cool down can result in greater lactic acid build up and onset muscle soreness.  Dehydration and insufficient rest saps you of needed energy.

So go out and have fun! Be active, but also be smart about it!

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