Surviving Residency: The Professional Socialization of Family Physicians (Addison 4/20/2022)

Many many thanks to Dr. Ritch Addison for his wonderful Grand Rounds this morning (and his 40+ years of teaching and mentorship at Santa Rosa Family Medicine Residency. It felt like a warm cup of perfectly brewed tea to sit and listen to Ritch share his observations from the professional socialization of family physicians. 

For those of you who missed it, the recorded presentation is available HERE and is definitely worth watching!

I have jotted down just a few notes. The talk is definitely best absorbed by listening/watching.

To start, Ritch asked us to consider what resonates with you?

• How do physicians get trained?
• How is residency a process of habit formation?
• How is residency a "stress test" of emotional capacity?

A long time ago (40+ years) in a galaxy (not so) far far away, Dr. Ritch Addison followed nine family medicine interns around for three years-- "I wanted to see what they did." His notebook always in hand, Ritch took call with them, observed them delivering babies, suturing folks in the ER, race to clinic, etc. For three years, he watched them live and process their entire residency training experience.

Today's talk was a summary of observations and models derived from that research. Ritch highlighted a number of important themes:

Surviving residency involves  a TON of immediate issues that new R1s are confronted with

• information overload
• work overload
• dying patients
• control
• time pressures
• sleep deprivation
• inexperience
• responsibility

Working relationships are a complex piece of residency identify formation. Relationships with:

• patients
• nurses
• providers
• attendings
• private doctors
• faculty
• other residents
• AND. . . family (which often takes a back seat because residency can be totalizing)

Asking for help >> too late, too early

When?

Who?

How?

Learning the ropes>> equates to decoding local customs

where to sleep 

when to cry

who to ask

how to put in orders

how to write notes

Spheres of existence evolve over time

                                         work                                    education                        life outside

initial purpose/weight        take care of patient           learn family medicine    maintain some QOL

evolves into                        GET done                        do procedures                whatever is left

There is an inherent conflict and contradiction between a resident's ideals/goals/visions (expectations) and the everyday practices of being a resident. 

Ritch finished off with his assessment of the "modes of surviving" 

Over-reflecting: too much self reflection (favorite patient dies, yelled at by attending, make a mistake)

Covering over: using little self-reflection, so focused on what you are doing you cannot see what is happening to you 

Moving between these two takes wide movements and is extremely jarring. How do residents learn to move between these modes? Ritch said clearly that it's really NOT about finding the sweet spot of reflection, but rather being able to smooth out the space and integrate these two forms of being. 

Finally, Ritch introduced the birth of the Personal and Professional Development groups (P&PD) that really were birthed from the desire of residents to facilitate the movement between these two spaces-- to smooth it out. After all, everybody feels the same way. What happens when we talk about our experiences? We start to resolve the two modes. . . 

Ritch ended with an excerpt from The Heroes Walk, by Anita Rau Badami on the physician-patient relationship. Listen to him read it at the end of the recording. That is what family medicine is all about, right? The most meaningful way we can bring health to people. 

Skin Cancer Reconstruction (Pourtaheri 4/13/2022)

Many thanks to Dr.  Navid Pourtaheri, new-to-our-community plastic surgeon, on Skin Cancer and Skin Cancer Reconstruction. This is a great summary of skin cancer findings and some specific indications and recommendations of when to involve plastic surgery. 

A recording is available HERE 

Skin cancer types: basal cell (BCC) squamous cell (SCC) keratoacanthoma, melanoma

Basal cell cancer (~4 million cases/year in US)

• variable in appearance, "can look like anything"-- don't know what it is until you remove it
• always slow growing (even high risk ones)
• primarily occur on sun-exposed areas (hand, ears, face)
• do sometimes spontaneous bleed or ulcerate
• can be locally invasive
• very rarely metastasize

Squamous cell cancer (SCC), 1.5 million cases/year in US

• variable appearance, but more commonly dry and scaly, also can be rough/thickened, wart-like, can ulcerate and form open sores
• more accelerated growth with local invasion than BCC (tend to progress more quickly)
• lower lips more common with SCC 
• can be locally invasive, can metastasize
• curable if treated early
• actinic keratoses (AK) is pre-squamous cell lesion

Keratoacanthoma, 275K cases/year in US

• once considered subset of SCC
• dome-shaped lesion with central keratin plug
• almost always in sun exposed areas (face, ears, nose, hands)
• quite rapidly growing (faster than SCC), can be locally destructive
• unpredictable, can spontaneously regress
• less likely to metastasize

Melanoma, 197K cases/year in US

• most costly type of skin cancer
• 25% found in existing moles, 75% spontaneously occur on normal looking skin
• 50% are melanoma in situ>> high cure rate (90-100%)
• can be found ANYWHERE
  
• most common form is superficial spreading
• when goes deeper, called lentigo maligna
• 10-15% of cases are nodular melanoma, most aggressive, tends to be found invading
• remember ABCDE (see below) with special attention to "E" (evolving-- that is a changing mole)
• Breslow thickness correlates with 5-year survival

Treatment options for skin cancer

• Moh's surgery 
• most commonly used in BCC and SCC (often contraindicated for melanoma)
• high risk areas (H zone)
• cosmetically sensitive areas, over joint surfaces
• decreases amount of tissue excised, maintaining the same cure rate
• Excision with margins and simple closure also acceptable
• Curettage (EDC)
• scrape the abnormal tissue, then burn it
• Cryotherapy more common in older patients, people who don't want a procedure, on blood thinners, large number (e.g. on face)
• Melanoma best excised w/margins, possible lymph node biopsy (plastic surgery, general surgery)
• sentinel node biopsy not indicated for melanoma in situ

When to refer to plastic surgeon?

• skin cancer not indicated for Mohs
• post dermatology resection, cannot close
• melanoma

Biopsy options

• shave: get full epidermis but only part of dermis (this is good because it won't form scar)
• always inappropriate for c/f melanoma because need full thickness
• punch: takes full thickness of skin
• incisional biopsy: get piece of abnormal with normal adjacent, done with scalpel
• excision: preferred for lesion is <1cm (cut the whole thing out with margin, 1mm of normal tissue is acceptable margin 
• FNA not used for skin, but for clinically positive nodes
• Sentinel lymph node biopsy (SLNB) after melanoma diagnosis, after lymphoscintigraphy (radioactive dye that drains to the lymph node)

Imaging

• Always needed in >Stage 3 melanoma, definitely NOT indicated in stage 1 (stage 2, use your judgement, may be indicated)
• Most common: PET CT for assessing for metastases
• Chest CT also good modality b/c melanoma so often goes to lungs (chest xray not sufficient)

LGBTQ+ Fertility and Preconception Counseling (Lopez 4/5/2022)

Many thanks to Dr. Julissa Lopez for her important Grand Rounds presentation on LGBQT+ Fertility and Preconception Counseling. Key take home message up front: primary care physicians SHOULD be helping LGBQT+ patients pursue the families they desire. It's definitely within our scope.

If you would like to watch, the presentation is available HERE. 

Dr. Lopez started with a reminder of the wide range of gender and gender identities that we may encounter. Refer to the Flying Gender Unicorn graphic below as often as you need to to remind you of the range of gender identity, gender expression, gender expression at birth, sexual identity, etc (and to help your patients and you better understand themselves). 

Dr. Lopez' 3-part framework for gender identity considerations

• Biology>>sex>>chromosomes and anatomy
• Psyche>>gender>> identity and expression
• Interpersonal>>sexuality, sexual orientation, attraction

Important reminder for all of us who care for childbearing age patients of all genders and gender identities: Do NOT assume that LGBQT+ do not desire pregnancy. 

In fact, since the early 2000s, there has been a "Gayby Boom"

• 2002: 41% of Lesbians and 52% of gay men expressed an interest in having children
• 2013: 51% of LGBT are parents or want to be
• 2017: 49% of lesbians and bisexual women have had a child (through previous relationship, reproductive technology, adoption, etc)

There is growing consensus that LGBTQ+ community have a right to pathways to parenthood. This includes an increasing number of state laws that protect fostering and adoptive parents. Information on state laws and protections are available HERE via the Movement Advancement Project, where maps like this live:

https://www.lgbtmap.org/equality-maps/foster_and_adoption_laws

The remainder of Dr. Lopez' presentation focused on ways in which primary care clinicians care for persons with ovaries not on gender affirming hormone therapy (GAHT) and persons with testicles not on GAHT achieve biologic parenthood.

1) Preconception care: this is similar to care for any patient who desires children. Goal is to plan for family building: optimize fertility and minimize pregnancy complications

• Risk assessment and counseling
• Cost: home insemination w/fresh semen (cheapest), genetic and STI testing can cost updwards of $3-4K, sperm is $700-$1500/vial
• Optimize health: routine screening, alcohol and substance use screening, prenatal vitamins, medical conditions (DM, BMI, stress)
• Social and legal considerations (depending on state of residence)
• Outcomes counseling: typically families achieve pregnancy with 3 cycles of IUI (this is much higher than other IUI populations because you are not dealing with someone with fertility challenges), increased rates when both (vs. one) partner attempt pregnancy

2) Deciding origin of sperm

• known vs. anonymous donor
• frozen vs. fresh (more effective)
• sperm banks provide STI and genetic testing (could be more desirable but more expensive)
• washed vs. unwashed (i.e. processed-- removing prostaglandins for IUI)
• West Cost sperm banks have online donor searches vs. direct contact
• differences in $$
• Local sperm banks: California Cryobank (LA), The Sperm Bank of California (Berkeley), California Sperm Bank (SF), Seattle Sperm Bank (Seattle, Tempe, San Diego)

3) Preparation for insemination: mapping out reproductive cycle (we definitely know how to do this)

• 28 day cycle: ovulation occurs 14 days before first day of menses
• educate on use of home ovulation kit: LH surge, cycles day 10-12
• frozen sperm has a short life span, so should be inserted 24 ours after LH surge (right before ovulation); there is no benefit to repeated insemination

4) Assisted Reproductive technology i.e. intrauterine insemination (IUI) in the office

IUI is more effective than transvaginal (home syringe method) and can (and should) be done by PCP in the office. Using the reproductive cycle above.

• 1cc syringe
• 18cm polyethylene catheter (available online)
• Speculum
• No other medications needed
• Patient lies down for 10-15 minutes after insemination

https://www.obgynofatlanta.com/iui

***

In contrast with above, for persons contributing sperm (i.e. men), the needs are different and always require a fertility clinic/specialist (i.e. cannot be managed by PCP alone) because they must involve an ovum donor and a surrogate (or both in one)

Things to consider in discussions as you refer folks to fertility centers:

• intentional unknowing (mixing sperm to fertilize ovum)
• genetic fatherhood in turns
• genetic vs. gestational surrogacy (different ovum donor from who carries the pregnancy)

Local Fertility Centers: Southern California Reproductive Center, CCRM Fertility (SF and Orange County)