Of Hospitals that Seem Otherwise

On Tuesday, February 26th, I will be going into work late because I will be listening in on a formal presentation that my mentor is giving at the Biltmore in Phoenix. The presentation is a lecture-type format, and will be discussing obesity, the causes of it, and the best way to deal with it.

Today, during lunch, I discussed the hospital with my mentor. If you have not visited the Phoenix Children's Hospital, I highly recommended you find some time to volunteer in it. The hospital is unlike any other hospital I have ever seen. To begin with, it is very easy to forget that you are in a hospital at all. This is partially due to the architecture, and partially due to the atmosphere the staff helps create.

Phoenix Children's is extremely well built. Everything is colorful, and serious efforts have been made to ensure that kids are not scared of it. Every wall is painted in a different color. The tiles are rainbow, and walking through the hospital to the emergency section, the tiles are colorful circles. There are giant windows everywhere which showcase a garden, and even a massive "laser wall" that consists of warped stained glass and moving projections of flowers and hearts that could easily belong in the Children's Museum of Phoenix. Each patient at Phoenix Children's has their own room. Some cases are extremely severe at the hospital, and there are notifications placed on the doors of each room which basically correspond to hazmat regulations (wear full body protections, refrain from contact, air controlled, etc.). However, the signs that indicate to doctors what to precautions to take consist of colorful laminated squares with pictures of smiling turtles, grinning rabbits, and cartoon figurines. Additionally, there are teddy bears that doctors put tiny IVs on to show kids exactly what will be done to them. There is even a tiny MRI machine that doctors but Barbie through to show kids how it works. Most impressively, all the medical equipment has been made to look, if not nice, then certainly less intimidating. sheets and pills are hid behind in-wall closets, and nurses wear bright scrubs often adorned with cartoon characters. The whole set-up of the place is really very impressive.

Additionally, the people that Phoenix Children's hires are just nice. Everyone smiles and is keen to have a quick conversation on how your day has been. Going up the elevators, a doctor on his way to do surgery was telling me about good hikes in the area. I have visited other hospitals to do volunteer work and sit in on surgeries before, and while the caliber of care and professionalism was of equal or greater caliber as Phoenix Children's, the general atmosphere of the Children's Hospital is much less stressful than at other places. It is not that there aren’t things to be stressed about--there certainly are-- it is that major precautions have been taken to make a family's stay as least awful as it can be.

 Hoping you all stay safe, healthy, and colorful,
Best,
Lior

Of Overcoming Ignorance

Today, day three at the hospital, I feel I am finally getting the hang of Hepatology!

Dr. Miloh sat down with me and had me sign off the skills I acquired on a, shocker, Skills Acquired worksheet that the hospital keeps for their records, and I was proud to be able to sign off on 'basic knowledge of Hepatology and Gastroenterology.'

Today, I was able to fly through three hundred more names, putting me at 500 out of 636. I also had time to get back to Scottsdale in time to hike Sunrise Peak before dark, which was absolutly gorgeous in the sunset.

With every case study I read, I become more used to the formatting the doctors use. I know exactly which ones use the dreaded One Paragraph Method, and which ones kindly break up the document into skimmable sections. The best MD though, is the Hepatologist. He writes all his diagnoses at the end of the page, so that it is extremely easy to find the right one once one gets accustomed to the usual diseases.

I can now discern most of the recurring Hepatological diagnoses, and can usually tell when a diagnosis does not pertain to a liver disease. I can now also quickly scan an entire study to find the diagnosis. I feel like a voyager slowly walking out of Plato's Cave. Ah, the feeling of ignorance being conquered is nice.

Here are some of the most common diseases I deal with:

NAFLD (Non-Alcoholic Fatty Liver Disease). This diagnosis is reserved for patients whose problems stem from obesity or extreme overweightedness. Often, their cases are sent in conjunction to the Psychology Department, where a licensed psychologist works with the patients to get them to change their habits, and explains to them the severity of their situation. These cases have similar "plans of attack" that seek first to help the patient loose weight through a strict diet and exercise plan. When asking Dr. Miloh if many patients loose enough weight to become healthy again through the hospital, he stated that though some seem insistent on staying the way they are, a much more significant amount lose enough weight to avoid surgery, and many acquire a healthy weight in the end.

Chron's Disease. This diagnosis often comes from the general Gastro department, and not the Hepatology department. The disease affects the intestines and the inner tube of the body that leads from the mouth to the rectum. It is basically an inflammatory disease that leads to liver complications, and treatment of Chrons will often remove any underlying liver problems.

Hepatitis, Hepatitis B (HBV) , Hepatitis C (HCV), and Autoimmune Hepatitis (AIH). Hepatis is the swelling and inflammation of the liver, and caused by a viral infection. Each type of Hepatitis comes in many flavors. The one I have dealt with have been Genotype 1, Genotype 1a and 1b, Genotype 2, Genotype 2a, and Genotype 2b. Hepatitis (in all its many flavors) is one of the main causes of lliver cancer, and consequentially many patients suffering from the disease get liver transplants. Some, however, especially those with "acute" and not "chronic" hepatitis, do get better without transplants. Additionally, I found one case study with states that there is a 50% spontaneous recovery rate amongst adolescents, which is quite impressive. While HBV and AIH originated mostly in the body, HCV often is transmitted via unclean needles, drug abuse, and through sexual transmission. This seems to be the most problematic flavor of this disease. However, HCV can also be simply a mutation in the body like HBV and AIH. There is no cure for Hepatistis currently. Looking at the case results, it seems most HBV patients get better or learn to live with their disease, while most HCV patients need a liver transplant, and it is heavily stressed that they discontinue any use of needles and make sure to cover all wounds in the skin, no matter how small.

Bilary Artesia. Most patients with this come to Phoenix Children's as a result of a liver transplant. From what I have encountered, Biliary Artesia seems to be one of the forefront reasons for patients to get a liver transplant. In this disease, the ducts that cary bile from the liver to the gallbladder become blacked. It is most often characterized my Jaundice (yellowing of the skin). In many cases, especially if the patients are diagnosed as infants, a Kasai procedure will be done to avoid a liver transplant. The Kasai procedure connects the liver to the small intestine, so to bypass the gallbladder completely.

Wilson's Disease. This is a very interesting and very rare disease, but it seems that pretty frequently patients visiting the GI will have (it was also featured on an episode of House if you are interested in some Med Drama). In Wilson's, copper builds up in the liver, as well as the brain, eyes, and other organs. It is a genetic disease, caused by a mutation in the ATP7B gene. The reason the copper (which in large amounts is poisonous) build up is because the liver becomes ineffective in removing it.

There are many more diagnosis’s I work with, but the above are the most common.

Hoping you are all keeping your livers in check! Best,

Lior

Of Sysophis and What Became of Him

Today, after reading and typing for nearly eight hours, I finished 284 names out of 636.

The reason this task is taking so long is because the case studies are written in a letter format. Each doctor has their own style of writing, and some are easier to understand than others. Additionally, there does not seem to be any standard for writing the case studies, except for a loose structure. One doctor may put the patients' diagnoses in the very last sentence of the letter; another may include it in a massive paragraph at the beginning; and yet still some will never explicitly state the diagnosis, but rather allude to it throughout the document. Additionally, some doctors clearly label the sections of the information (Assessment, Lab Work, etc.), some doctors do not label the sections, but only space them out into paragraphs, and still, most annoyingly, some doctors include the entirety of the information in one giant page-long paragraph.

The result is that skimming the studies for a diagnosis is not possible, because it is hard to know where it is located. Additionally, because a case study is written each time a patient meets with an MD, not all of the case studies contain explicit diagnoses or plans of attack. Some are follow ups, and some are referrals to other departments in the hospital if the MD feels the case no longer pertains to their speciality. This means that I often have to read multiple, if not all, case studies to discern the diagnosis.

Now, to the doctors' credit, the letter system is extremely efficient inside the hospital. The studies are easy to understand for the most part, and it is easy to see what the patient came in for from each one. It is also obvious that anyone with a degree in medicine would be able to understand the case studies. I think the hospital uses the letter system because it fits their patients best. It would be impossible and very inefficient to have the doctors fill out a set spreadsheet with all the patients information, because some patients simply do not fit into any mold. A lot of them suffer from problems that are interrelated amongst departments, and a "plug and chug" system would simply not be able to capture it.

So, the system works great, if your a doctor, and, well, educated. The biggest hurdle I am having to overcome is my ignorance. To begin with, I found out today that I would have to do some major personal research if I want to be able to stop googling every diagnosis I read to find out if it is a liver disease.

If this experience teaches me only one thing, it is that education is GOOD, and lack of it is utterly horrible. I want to be the person that can say, "Chron's Disease affects the intestines, and X% of the population has it," without having to look it up. Additionally, it is clear that even with an introductory level gastro course, I would be able to fly through these documents. The documents are not hard to understand, I simply lack the knowledge to process the most important part of the information.

Oh, the woes of a high school degree.

Finally!

I have finally gotten my official volunteer card! It is beautiful, and red, and oh so official. Today, after taking my very last physical exam, I started my first day!

Here is a background on what I will be doing:

Dr. Miloh is the only Pediatric Hepatologist in the state. He works in one of the biggest GI (gastrointerology) departments in Arizona. Additionally, Phoenix Children's Hospital is one of the only hospitals in the state to offer full GI/gastro/hepatology care for adolescents. Needless to say, this is an amazing opportunity.

As an intern, the more I do, the more I can do. Dr. Miloh wants me to start out small (ish) and then proceed from there. Today, I was surprised to find that when a patient visits the hospital, the doctor assigned to their case types up a Case Report at the end of each visit. Every time the patient walks into a hospital to get tested or to consult with a MD, it is recorded in a case study-like letter. The letters contain information on the patients. This information includes Reason for Visit, Physical Report (weight, height, etc.), Lab Work (if they have it done. This includes blood tests and cultures.), and, finally, the Assessment or Impression, which is the final diagnosis a doctor will give the patient and includes a Plan of Action for the patient to get better.

Each patient will often receive multiple diagnosis, especially in the Gastro department. The diagnosis actually reflects all the people the patient has seen. For example, if a patient admitted to Phoenix Children's saw a geneticist, a neurologist, and a general gastrologist, the doctor writing the report will write something along the lines of, "Today I had the pleasure of seeing XXXX, a fourteen year old girl who has Trisomy 21, numbness in her fingers, and abdominal pain." Please note that the above was a fictional example and does not reflect any real patient at the hospital.

At the hospital, the only way to get the diagnosis of a patient is to read through their case file. The files are on the computer, but they are scanned PDF documents, which means that it is impossible to search for one diagnosis without reading the entire case history of each patient. This, obviously, is  a problem. Dr. Miloh cannot do a research project on types of diseases because the information is not easily accessible.

My job is to read the case study, extract only the diagnosis that pertains to liver diseases (AKA Hepatology), and put the diagnosis on an Excell spreadsheet that contains only the Medical Record Number and the first and last name of each patient. When I am done, the entire Hepatology department will be able to conduct research, look up diagnoses for patients quickly, and compare treatment plans from one patient to another suffering from the same disease.

Phoenix Children's is a very efficient hospital, They are able to process hundreds of patients every day. The Gastro department has 636 patients. Therefore, I will be reading 636 case studies.

This task may seem Sisyphean in scope, but I have confidence I can do it in a timely manner!

Wishing you all the very best,
Lior

Of the Largest of Them All

Let us begin our discussion today on Mississippi, the only word in the English language that can be spelled with three sets of double letters.

Mississippi is also the only state in the United States to boast a 31% child obesity rate, the highest rate in the United States.According the the Mississippi Department of Health, 80% of children who are obese will suffer from obesity as adults.

And these adults are costing the state. Mississippi spends 757 million dollars on health care for adult obesity. It is estimated that Medicaid costs would be 11% lower in the absence of adult and child obesity, and Medicare costs would be 8% lower.

However, Mississippi has not stood idly by as its population expands. in 2004, the state implemented the Child Nutrition and WIC Reauthorization Act, forcing every public school to establish a Local School Wellness Policy, which included provisions to restrict vending machines, provide healthy options in school cafes, and other similar measures. Then in 2007, the state passed another major piece of legislation called the Mississippi Healthy Students Act. The law stipulated minimum requirements for physical education in public schools, required an official Physical Activity Coordinator in schools, required mandatory "health councils," required the State Board of Education to adopt measures to promote healthy food and beverage decisions, and, lastly, required every school to create a personalized Wellness Policy.

If it seems as though the state has passed extensive legislation to deal with the issue, it has. In fact, Mississippi passed so much legislation to deal with child obesity that in 2009 the Center for Disease Control and Prevention named Mississippi as one of the top states regarding school policy implementation.

Additionally, according to the MSDH, there are literally hundreds of grants to promote healthy living amongst school children-- everything from the Bower Foundation, which provides millions of dollars to make healthy options more attractive to students, to the Committed to Move grant, which provides over $ 9,000 to fund physical education teachers and top-of-the-line physical fitness equipment, has been showcased.

And yet,  Mississippi still has the highest child obesity rate, beating out second place by over 9%, though clearly not for lack of effort or funds. I believe that the problem lies in how the state is managing the millions of dollars it pours into the school systems. Perhaps, the solution to child obesity is not far-away government laws, no matter how well intentioned. Through my research, I have come to believe that the most effective solution lays in working directly with families, instead of forcing schools to change their ways. Perhaps with greater focused family attention, more productive change would come.

I have spent the bulk of this week researching Mississippi, and the more I read, the more I find out how much I do not know. However, I am fascinated by the states legal records, and the disparity between funding and results. Working with Mississippi first has proved invaluable, as I now feel I have a strong basis for understanding other states' policies.

I will post more research as I encounter it.

Thanks for reading! Please post any questions or comments you have! :)

Steps to Success!

Three easy steps to becoming a Phoenix Children's Hospital intern:

1) Attend, in order, a five hour Patient Care Orientation, an eight hour Online Hospital Orientation, a two and a half-hour Hospital Tour. Take two TB tests, three vaccinations, a blood test, and sign five forms. Attend a one hour interview, receive two official badges.

2) Receive a beautiful, new, red, official Hospital Volunteer t-shirt.

3) Love the t-shirt. It took you long enough to earn it. Also, red is a great color.

In ten short days, the results of the final medical exams will come in, and I will strut into the hospital in my official red t-shirt and badge. And it will be the best day ever.

As my blood sits in a petri dish in a doctors office, I have begun my research for my project. So far, I have looked through state laws and records of Mississippi, the state which has the highest child obesity rate in the US, and compared the enactment of state laws with the trend in child obesity in the state. I have found, surprisingly, that the rate has fluctuated slightly as some laws were passed, indicating that there is a strong response to changing policies. However, over time, the rates would go back to their original status. Clearly, taking action is making a positive difference, however, the problem seems to lie in getting the changes to stick. I plan to continue researching exactly which policies correlated to the greatest fluctuation in child obesity rate, and why they have not had a long-term effect.

Additionally, I have begun my research of the great umbrella that is "Affects of Child Obesity." I have decided to build a firm foundation for my research by first studying Hepatology, the science of liver diseases. Liver diseases are directly related to the levels of adipose tissue (fatty tissue) in one's body, so educating myself on them seems like a good starting point. Interestingly, the study of Hepatology is so much more than just understanding  liver diseases. Rather, Hepatology most directly deals with curing and preventing liver diseases. For example, nearly 80% of liver cancers can be attributed to the Hepatitis B or Hepatitis C virus. With this new knowledge, vaccines have been developed to limit the spread of the Hepatitis B virus. Additionally, new policies in blood and organ transfusion have drastically reduced the rates of liver cancer in the US.

The more I learn about the far reaching effects of Hepatology, the more I am becoming interested in it. Studying this is akin to learning Biology or Chemistry, in that it is a whole new science. However,  I am loving every bit of knowledge I gain on my research project, and cannot wait to apply it all in the lab.