Grand Rounds Recap 2.14.18

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Guest Lecture Series : Gender Bias in medicine WITH DR. Esther Choo

GOALS:

  • Discuss existing gender disparities within medicine
  • Examine why they matter
  • Consider biases and mechanisms underlying these disparities

Existing Gender Disparities:

  • SALARY
    • Multiple studies have examined wage gap within medicine (JAMA, Academic Emergency Medicine, etc)
    • Seem to consistently demonstrate a wage gap between male and female physicians
    • Wage gap persists despite adjusting for multiple factors including:
      • Speacialty
      • Years of practice/training
      • Age
      • Race
      • Hours worked
      • State of employment
      • Leadership positions
      • Administrative roles
    • Multiple studies showing wage gap ranging between $19,000-21,000 annually
  • ADVANCEMENT
    • Studies show that men and women seek advancement at similar rates
    • However
      • Women are less likely to receive full professorship
      • Women comprise 13% of leadership rolls in >1000 departments surveyed
  • RECOGNITION
    • ACEP award winners between 1970-2010 predominantly male
    • Recently more women have been represented, however, has not seemed to penetrate into the more prestigious award categories
  • ASSESSMENT
    • Studies have shown discrepancies on how male and female residents are evaluated
    • Large study examined milestone evaluations by faculty for residents at 8 different centers
      • >33,000 evaluations were reviewed for > 359 residents
      • Study demonstrated that evaluations were roughly even at R1 year
      • By R3 year
        • Men were generally scored higher
        • Women were evaluated lower on all 23 EM competencies, both procedural and non-procedural
    • Such discrepancy is extremely suggestive of underlying gender bias

Effects of Gender Disparities (Why These Disparities Matter):

  • Apart from being inherently unfair
  • Gender diversity / equality is good for patient care
    • Large study comparing mortality rates for medicare patients treated by male and female physicians
      • End points included morality, cardiac outcomes
      • Women hospitalists had better outcomes
  •  Good for business
    • Multiple studies show better performance, earnings, returns with more diverse leadership
      • Reviews have shown board of directors with more equal female and male representation results in increased revenue and more customers on average
      • More diverse companies have been shown to have better financial returns compared to national means
        • More diverse companies shown to be 15% more likely to have financial returns above national means
        • Less diverse companies were less likely to have returns greater than the national mean

Mechanisms Underlying Disparities:

  • Multi-factorial and complicated (Some examples listed below)
    • Lack of mentorship
    • Part time work
    • Maternity leave
    • Gender discordant expectations
    • Group dynamics
    • Stereotype susceptibility
    • Group dynamics
    • Children
    • Unequal domestic responsibilities
    • Gender Bias
  • In general, men are more associated with agentic traits, women more associated with communal traits
    • Agentic traits:  Assertiveness, competitiveness, independence, courageous, mastery
    • Communal traits:  Caring, sensitive, compassionate, sympathetic
    • Can lead to vicious cycle
      • Women penalized for more agentic behaviors (Perceived negatively)
      • Women then over-correct by behaving more communally
      • Less likely to advance because they then do not exhibit more desirable agentic traits
  • Examples demonstrating gender bias
    • Harvard test for inherent bias
      • Pool of results demonstrate strong associations / ingrained idea of gender roles
      • Women associated with family,  men with career
    • Study examining how science faculty bias favors male students
      • Nationwide sample of science professionals (Biology, chemistry, physics, etc)
        • Found that men were generally rated as more hireable, competent
        • Bias was found in ALL takers of the survey (Young and older faculty, male and female faculty)
    • Yale studies demonstrate that being vocal is perceived differently according to gender
      • Male executives who spoke more in meetings were rated higher in competence
      • Women executives who spoke more in meetings were rated as less competent
    • Study from UT Southwestern examined how suggestions for change/feedback was received coming from men and women
    • Motherhood penalty
      • Participants in large study were asked to review hypothetical applications for mid-level marketing position
      • Hobbies, interests, activities were geared to suggest whether or not the applicant was a parent (ex, participates in PTA)
      • Participants scored each theoretical applicant.
      • Findings
        • When comparing mothers to non-mothers
          • Mothers perceived as less competent
          • Perceived to have lower commitment
          • Generally scored lower
        • Also compared fathers and non-fathers
          • Fathers scored higher relative to non-fathers

How Bias Plays Out in the Workplace:

  • Individual interactions
    • Professional introductions
      • Men less likely to introduce women professionally as "Dr." (~50% of the time)
  • Verbal and written language
    • Letter of recommendation content tends to vary
      • Men > Women
        • Emphasize research
        • Emphasize accomplishment > Effort
        • Use more superlatives
        • Generally 16% longer
      • Women > Men
        • Emphasize effort > accomplishment
        • Mention personal life more often
        • Greater emphasis on "soft qualities"
        • More likely to contain negative comments
  • Opportunity
    • Scientific collaboration
      • Women found to collaborate equally with men and women
      • Men tend to include proportionally more men 
  • Group dynamics

Approach to Improving Gender Disparities/Gender Bias

  • Non-Solutions
    • Telling women to behave more like men
    • Placing the onus solely on women to fix
    • Token representation
    • Benevolent sexism
  • Key Solutions
    • Target change at an early level:  Cannot change pervasive problem in an interconnected system with an isolated intervention
      • Recruitment
      • Hiring
      • Retention
      • Promotion
    • Track Transparency
      • Salary and other forms of compensation
      • Improve formal recognition
      • Monitor time to promotion
      • Examine how leadership positions are offered / filled
    • Micro-equity goals
      • Create / be cognizant of having a standardized approach
        • Feedback and assessment
        • Inclusion in teams and projects
        • Mentorship
        • Language in formal and informal communication
    • Normalize family responsibilities for men and women
      • Normalize procreation within medicine
      • Create equity within policies for parental leave
    • EM IS A GREAT PLACE TO START
      • Early adopters
      • Young specialty without entrenched behavior

QI/KT : Atrial Fibrillation WITH DRs. Owens and Ventura

Review of Evidence Behind A-Fib Protocol

Rate Vs. Rhythm Control:

  • RACE Trial (NEJM 2002)
    • Compared rate control to rhythm control
    • Determined rate control was not inferior to rhythm control for prevention of death and morbidity from cardiovascular disease
  • RACE II Trial (NEJM 2010)
    • Compared strict vs. lenient rate control (80bpm vs. 110bpm goal)
    • Examined several outcomes
      • Mortality
      • Risk of bleeding
      • Risk of dysrhythmia
    • Results
      • No difference in significant outcomes between strict and lenient group
      • Lenient group were able to be discharged faster and required fewer resources
  • However, Canada recommending more rhythm control
    • Ottawa Aggressive Protocol
      • Promotes sequential pharmacologic and or electrical cardioversion by the ED physician
      • Goal is to avoid hospitalization and prolonged ED stay
        • Protocol gives 1 hour for each step, then move to next intervention
      • Evaluation:  Multiple studies, all performed largely by 1 author
        • Essentially, 99% able to be discharged
        • No adverse events in 7 day follow up in initial study
          • No deaths
          • No strokes
          • No heart attacks
        • More recent study
          • 91% Discharge rate
          • 30 Day adverse events examined
            • No deaths
            • 1 Stroke
  • Given effectiveness of Ottawa Aggressive Protocol, as well as efficiency in terms of avoiding admits and decreasing ED times, new protocol will encourage rhythm control in the setting of A-Fib with onset < 48 hours

Approach to Rhythm Control:

  • Limitations
    • Applicability may depend on local cardiology practice patterns
    • Drug availability in the ED for certain anti-arrhythmics
    • Patient population
    • Patient access to follow up
  • Methods of rhythm control
    • Pharmacologic
      • Procainamide
        • Class 1a
        • Good for WPW and A-Fib
        • Efficacy 50-60% in 1 houe
        • Dose:  1g over 1 hour
        • When to stop:
          • Rhythm conversion
          • Hypotension
          • Bradycardia
          • A-Flutter with RVR
      • Flecanide
        • Class 1c
        • Good for acute onset A-Fib
        • Efficacy roughly 50-60%
        • Dose:  2mg/kg over 10-30 minutes
        • When to stop:
          • Hypotension
          • A-Flutter
      • Ibutalide
        • Class III
        • Preferred agent in A-Flutter
        • 9% Risk of V Fib or V Tach
        • However, risk is reduced if appropriately pre-managed
          • Assess and correct potassium
          • Review medical history
        • Dose:  1mg over 10 minutes.  Can repeat X1
    • Electrical
      • Synchronized cardio-version
      • Generally recommend starting higher (200 J)
      • Lower for A-Flutter (50-100J)
      • Downsides of electrical
        • Requires sedation
        • More money and resources than pharmacologic

Approach to Rate Control:

  • 1st Line (Calcium Channel Blockers or Beta Blockers)
    • Once rate is controlled with IV, give subsequent oral dose
    • Both somewhat discouraged in acute CHF exacerbations
  • 2nd Line 
    • Amiodarone
    • Digoxin

Approach to Anticoagulation:

  • Assess stroke risk with CHA2DS2VASc score
  • Assess bleeding risk with "HASBLED"
  • Verify time of onset
  • Select appropriate anti-coagulant
    • RELY Trial:  Showed dabigatran was non-inferior to warfarin
      • Increased GI bleeds and MI
      • 80% Renal metabolism
    • ROCKET AF:  Showed rivaroxaban non-inferior to warfarin
      • Decreased rates of ICH
      • No increased rates of hemorrhage
    • ARISTOTLE:  Compared apixiban to warfarin
      • Non- inferior
      • Decreased rate of stroke
      • Has lower renal metabolism
  • Starting anti-coagulation in ED has been shown to be beneficial
    • If medications given in ED, more likely to remain compliant at 6 months-1 year
    • Script filled faster

Approach to Disposition:

  • Successful cardioversion
    • If in sinus rhythm, may discharge to home
  • Persistent A-Fib / Rate controlled
    • Goal HR < 100 - can be discharged
  • Persistent A-Fib / Not controlled
    • Admission to cardiology
  • Arrange follow up with cardiology
    • Improved mortality at 90 days and 1 year for patients who receive cardiology follow up
    • Decreased stroke and CV mortality in patients who receive cardiology follow up
    • However, leads to increased hospitalizations (Regional practice variation)

***NEW PROTOCOL TO BE POSTED SOON TO TAMINGTHESRU.COM

PEM Lecture Series : The Febrile Infant WITH DR. VALENTINO

Objectives:

  • Define fever
  • Discuss approach to the workup of a febrile infant
  • Discuss how to talk to families
  • Determining disposition

Fever in an Infant:

  • Accepted fever threshold is >38C or 100.4 F
  • Reason for treating
    • Comfort
      • HR increases by 10 bpm for every 1 degree C
      • RR increases by 5 breaths per minute for every 1 degree C
  • Approach to treatment
    • Tylenol:  15mg/Kg
    • Ibuprofen:  (> 6 months old)
  • Importance
    • May suggest Serious Bacterial Infection (SBI)
    • Prevalence of SBI in infants < 3 months
      • 9.4% overall
        • 25% in infants < 2 weeks
        • 12% in infants < 1 month
        • 7.1% in infants 1-3 months
    • Common causes
      • UTI most common
      • Bacteremia less common
      • Meningitis is rare
      • Other causes to consider
        • Pneumonia
        • Renal infection / pyelo
        • Abdominal infection
        • Abscess
        • Cellulitis
        • Osteo
        • Septic arthritis

Approach to the Febrile Infant:

  • < 28 days old
    • Gets full septic workup (Blood, urine, CSF)
    • Empiric antibiotics and admission
    • Assess for HSV
      • Risk factors
        • Maternal HSV
        • Active outbreak during delivery?
        • Premature or immune-suppressed?
        • Any operative delivery?
        • Intra-uterine monitoring
      • Diagnosis
        • Neonatal surface culture
        • Eyes => Nose => Mouth => Bottom
    • 28 days to 90 days
      • Risk stratification
        • Several approaches exist
          • Boston
          • Rochester
          • Philadelphia
          • Step by Step
        • Best to get to know 1, and know what inclusion and exclusion criteria are
        • Step By Step (used largely in Europe)
          • Compared to Rochester had better sensitivity (Better screening)
          • Better negative likelihood ratio
      • Pursue workup based on pretest probability and risk stratification
        • CSF
          • May consider avoiding CSF if low risk for meningitis
          • Reassuring findings
            • Full term
            • Well appearing
            • Easily consolable
            • Exam benign
            • Reassuring blood workup
        • Chest X Ray
          • Clinical suspicion for bronchiolitis => Do not pursue
          • Clinical suspicion for pneumonia => Pursue CXR

Management of Febrile Infant:

  • Empiric treatment
    • <21 days:  Amp/Cefotax/Acyclovir
    • 21-28 days:  Amp/Cefotax
    • 29-56 days:  Cefotax or ceftriaxone
  •   Disposition
    • Consider home if
      • Family's concerns have been met
      • Patient has rapid follow up
      • PCP comfortable with outpatient workup
      • Tachycardia and fever improved with ED management

R1 Clinical Diagnostics : Rashes WITH DR. Iparraguirre

Approach to Management of Unknown Rash:

  • History
    • Time of onset
      • Primary lesions
      • Secondary lesions
    • Distribution
    • Nature of spread
    • Concomitant symptoms
    • Medical history
  • Physical exam
    • Knowing terminology / descriptors can help narrow down etiology
    • Examples
      • Scaly plaques and patches (Often fungal)
        • Tinea corporis
          • Superficial dermatophyte (Skin, hair, nails)
          • Usually trichophyton or microsporum 
          • Management
            • Topical antifungals
        • Tinea capitis
          • Affects the scalp
          • Usually accompanied by hair loss
          • Management
            • Often oral anifungals
        • Tinea versicolor
          • Malassezia furfur
          • Usually characterized by skin color changes that may persist
          • Management
            • Topical antifungal agent
        • Candida Albicans
          • Usually occurs in skin folds/moist areas
      • Scaly papules
        • Pityriasis rosea
          • Unknown etiology, likely viral
          • Herald patch followed by Christmas tree distribution of papules
          • Management
            • Oral antihistamines
            • Supportive care
        • Eczema
          • Associated with allergic disease/asthma
          • Diagnosis
            • Itchy skin
            • PLUS
              • Flexor surface involvement, Hx of asthma, dry skin for 1 year, or presence before 2 years old
          • Management
            • Topical corticosteroids
              • Lowest potency for shortest amount of time
                • Start with low-moderate potency
                • High potency if refractory and not in high risk area (Face, groin)
              • Influenced by vehicle and method of delivery
      • Vesicular/Papular Lesions
        • Contact dermatitis (poison ivy, sumac, oak, etc)
          • Toxicodendron
          • Usually results in oozing vesicles
          • Management
            • Steroids
              • Topical if small area
              • Consider systemic if larger area affected
            • Supportive care
              • Cold compresses
              • Burow's solution
      • Vesicular lesions
        • Shingles
          • Herpes zoster
          • Peaks in 50-70 yo patients
          • Commonly involves thorax or trigeminal nerve
          • Management
            • Valacyclovir
            • Analgesia

Overview:

  • General management
    • Diagnosis
      • History and physical exam are key
    • Management
      • General principles
        • If it's wet, make it dry
        • If it's dry, make it wet
        • Consider which vector according to type of rash/location
        • Treat etiology and symptoms

R4 Clinical Soap Box : Medical Marijuana WITH DR. Maika Dang

Cannabis Overview:

  • 3 species of cannabis:  Sativa, indica, and ruderalis
  • Contain 2 main active components
    • THC
      • Euphoria
      • Anti-nausea
      • Some analgesia
    • CBD (Cannabidiol)
      • Possible anti-inflammatory
      • Possible anti-cancer
  • Routes of ingestion
    • Inhaled
      • 50% is absorbed in smoke
      • Rapid onset
    • Ingested
      • 6% absorbed
      • Peak onset after 30 minutes

History of Medical Cannabis/marijuana:

  • William Oshaughnessy
    • Irish physician
    • Studied cannabis in India for its use in muscle spasms, rheumatism, and stilling infant convulsions
    • Subsequently listed in contemporary pharmacopoeia from 1850-1942
  • Removed from medical pharmacopoeia in 1942
    • Thought to be due to the Mexican Revolution in 1910
    • Associate cannabis with violence associated with small sects
    • Demonized in media
    • Became incorrectly associated with violent behavior in men and promiscuity in women (Reefer madness)
  • Harry Asinger:  Commissioner of Federal Bureau of Narcotics from 1930-1962
    • Took over around time of prohibition
    • Feared the bureau would become obsolete with legalization of alcohol
    • Targeted marijuana
      • Associated violence, racially based themes to marijuana
      • Imposed Marijuana tax of 1937
  • Nixon
    • Made marijuana a schedule I drug despite not meeting all 3 requirements of schedule 1 classification
      • Criteria for schedule 1
        • Lack of medical uses (Incorrect)
        • High potential for abuse (Possible)
        • Lack of safety under medical supervision (Incorrect)

Evidence Behind Medical Cannabis:

  • Large review/meta-analysis in JAMA in 2015
    • Compiled best evidence regarding medical marijuana usage
    • Evidence is scarce
      • Difficult to study due to legal status
      • Most focus on isolating one active component (ex. THC)
  • National Academy of Sciences came out with a paper in 2017 examining evidence as well.  Findings included:
    • Found some use in chronic pain
    • Found to reduce muscle spasticity
    • Benefit as anti-emetic in chemotherapy
    • Moderate evidence showing benefit improving short term sleep
    • Limited functionality as appetite stimulant
    • Insufficient evidence to support use as:
      • Anti-epileptic
      • IBS

Risks to Consider

  • Increased pediatric exposure
    • Legalization and increased medical use will increase accidental pediatric exposure, especially with edibles
    • Ingestions carry risk in peds
      • Airway compromise
      • Ataxia
      • Nystagmus
      • Tremor
      • Labile affect
    • May have downstream psychiatric effects
  • Possible negative long term cannabis effects
    • Abdominal pain
    • Cyclic vomiting
  • Intoxication while driving
    • Difficult to test/level
    • Metabolites detectable in 1 hour, but may persist for 3 months
    • Spot testing is difficult

Summary:

  • Marijuana is becoming increasingly common for both medical and recreational use
  • More research is needed
    • Determination of efficacy
    • Exploration of different uses
    • Increased research might be easier once legalized
  • Legal landscape is changing