New story: Matching Rings

One of my pieces was published in Pulse Magazine. It is about an experience I had with a young patient on the cancer wards. Click here to read Matching Rings.

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The tattoo

During a late-night emergency room shift, I took care of a cranky but high-spirited woman with back pain. A CT scan revealed a new compression fracture, and despite my attempts to persuade her to stay pain management and physical therapy, she declared in a thick French accent that she was going home. She was elderly and had had multiple falls in the past year, but insisted on living in her own apartment and paying for home aide service.

I was about to finish explaining her discharge care when I noticed the tattoo. It was so faint that it looked grey, but there the numbers were, on the inside of her right arm.

To my knowledge, there is only one scenario in which an almost-ninety year old French Jewish woman would have such a unique tattoo: Auschwitz. In light of the political upheaval in the United States and, in fact, the world, our situation struck me as somewhat of a miracle: a Chinese-American female doctor treating a Holocaust survivor cared for by Haitian health aides, without regard for cost or resources.

Medicine is a rare neutral ground in which everyone—patients and providers—is entitled to dignity and respect. We do not deny care because we don’t agree with our patients’ politics or background; we should treat patients with the same level of care whether they are CEOs or immigrants who just landed at the airport. In the troubling current political environment, will we be able to say to future generations of doctors who treat the children of Syrian refugees, DACA Dreamers, or had two mothers or two fathers, we upheld our professional responsibility by taking civic responsibility? Will we be able to say, we were not complicit, but practiced advocacy to ensure better health for our patients?

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Time to act: advocacy for medical professionals

Given the current political climate in the US and abroad, friends and I have been brainstorming ways that providers at all levels can continue to provide equal access to care and advocate for disadvantaged populations.Advocacy includes procedures, prescriptions, counseling, networking, and speaking out about legislation. I’m sharing this here to broadcast the message as widely as possible: be the change you want to see in the world. If you have ideas, please add them in the comments section. Feel free to repost or share this.

 

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Introduction

As health care professionals we have a responsibility to support our patients and speak out against policies that would do them harm. We have the privilege to be heard when others may be ignored. This document was created by medical residents, with input from lawyers and advanced practice nurses to provide suggestions for action in response to potential changes in healthcare at the federal level, or issues pertaining to health next year. We have tried to keep our focus narrow with an audience of other health professionals in mind.

We have put our summary points first and then divided this document into sections organized by demographic group and issue (the Affordable Care Act, reproductive rights, attending protests and rallies). The last section, “Ways to be Heard” offers suggestions for lobbying and greater participation. For the sake of brevity, much background information that may provide context to our suggestions is included under a “More Info” section at the end of the document and we recommend taking a look.

Live in Boston and want to continue the discussion? The Boston chapter of the CIR/SEIU (resident/fellow union) is holding Health Justice Subcommittee meetings: Tues 12/20 @ 6:30p at Boston Medical Center (Yawkey Basement Conf Room B) and Wed 12/21 @ 6:30p at Cambridge Health Alliance (Learning Center C/D)

A huge thank you to the more than 40 medical professionals and health advocates who were a part of this!

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SUMMARY POINTS

Affordable Care Act and Health Insurance

  • Support national efforts to decrease drug costs
  • Learn to code (ICD-10) accurately to ensure that patients pay as little as possible under their healthcare plans
  • Encourage patients to get insurance now -> it is harder to take insurance away
  • Consider organizing street clinics  – triage patients to ED/urgent care/primary care

Reproductive Rights

  • Discuss contraception coverage with all of your patients within the next two months, including long acting reversible contraceptives (LARCs)
  • Prescribe emergency contraception in advance to reduce cost
  • Learn and teach procedures: IUD, implants, first trimester abortions (all physicians; midwives and NPs in some states), second trimester (Ob/Gyns)

LGBTQ Rights and Health Care

  • Expedite care before policy change: work shifts at local LGBTQ health clinics: some clinics and resources are available on the CDC website

Trans Health Care

  • Know local resources – where you refer patients for hormones, surgeries, etc
  • Consider using different billing codes for medical visits/hormone prescriptions
  • Prescribe syringes for hormone injections
  • Expedite document changes – trans patients need a letter from a physician to allow them to change the gender marker on government documents such as passports, birth certificates

Responding to Hate Crimes

  • Document events and physical exam as accurately as possible
  • Document psychological sequelae
  • Connect your patient with legal resources and referrals to counseling

Immigration

  • Network with local immigrant/refugee communities. Professional interpreters living locally can discuss issues affecting the population they work with
  • Write letters describing the specific medical effects of deportation for individuals who have family or are personally facing immigration issues. These letters are more effective than submitting medical records.
  • Contact patient’s immigration attorney for examples of these letters

Refugee health

  • Consider joining Physicians for Human Rights and participating in asylum clinics to do initial intake for refugees.
  • Document physical, psychological, and emotional trauma and injuries carefully, and talk with the attorney handling the case if possible.

Healthcare for individuals who use drugs:

  • Prescribe naloxone (Narcan) to all patients at risk for opioid overdose in the outpatient setting

Patients with limited English proficiency

  • Advocate for increasing access to interpreters whether by telephone or in-person
  • Use professional interpreters and avoid using family members if possible

Support People of Color

  • Practice sensitivity: take time to reflect on your own implicit biases and actively ask your patients about discrimination or harassment
  • Consider joining White Coats for Black Lives and volunteering your time
  • In cases of reported police brutality, document carefully as this may be used as court evidence
  • Participate in minority health professional organizations and advocate for increased medical education about health disparities

Support Indigenous Peoples  

Support People with Disabilities:

  • Lobby against removal of the ACA provision that protects against insurance discrimination for people with pre-existing conditions
  • Ensure that patients are receiving all necessary accommodations, which may include parking, school, housing, and therapy animals.

Protests and Rallies

  • Bring a portable medical kit and offer first aid
  • Familiarize yourself with common scenarios: tear gas/pepper spray exposure, dehydration, effects of not taking home medications.

Ways to be Heard

  • Take part in your representative bodies! Join your council, union, hospital committee, or student organization.
  • Consider attending a protest or rally to educate yourself or show solidarity. If you do so, make a safety plan for yourself.
  • Testify as a medical professional for issues you care about, whether locally at town meetings, your state house, or Congress.

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MEDICAL ADVOCACY

Rationale

President-elect Trump has called for policy changes that would negatively impact our patients:

  • Repeal of the ACA which currently provides insurance to millions. The ACA includes:
    • Coverage regardless of pre-existing conditions
    • Age <26 clause
    • Birth control mandate
    • Expanded Medicaid eligibility
  • Efforts to defund/attack Planned Parenthood
  • Overturning Roe v. Wade
  • Increased enforcement of deportations
  • Defunding the NIH

Affordable Care Act and Health Insurance

  • Support national efforts to decrease drug costs
    • The GoodRX app and website offers coupons/discounts on prescriptions, and shows the costs for different pharmacies around you. You can use this for patients who don’t have insurance or very high co-pays. This resource requires a prescription. It works with all types of prescriptions.
    • Order from overseas online / mail-order pharmacies:
  • Urge your patients who are around 24 or 25 years old to look into health insurance options. It is harder to take away health insurance that someone already has.
  • Learn to code more accurately to ensure that patients pay as little as possible under their healthcare plans
  • Consider organizing street clinics. It is possible to triage patients and direct them to an urgent care/ED or recommend primary care follow up, or write one-time prescriptions if needed as long as you have established a provider-patient relationship and have keep some form of documentation.
  • Assault: steps to take in event of a hate crime. For medical professionals, most important is to document events and physical exam as accurately as possible.

Reproductive Rights

  • Discuss contraception coverage with all of your patients who have a uterus within the next two months. Consider LARCs including IUDs and implants that can provide coverage for up to 10 years (copper IUD). These are especially important for patients who may lose coverage and not be able to pay out of pocket. Use a shared-decision making approach in contraceptive counseling.
  • Prescribe emergency contraception (Plan B, Ella, the copper IUD) – the American College of Obstetrics and Gynecologists recommends prescribing emergency contraception to patients in advance.
    • Patients should be counseled on how to take EC (within 72 hours of unprotected intercourse and up to 5 days). Patients should not take Plan B if they are already pregnant.
  • Learn procedures: IUD and Nexplanon placement
    • Merck requires a training to place Nexplanons. Request a training here.
  • Abortion:
  • Teach procedures:
    • Schedule training sessions on IUD placement, implants, abortion care for your residency or medical school
  • Lobbying
    • Contact local chapters of advocacy organizations such as Physicians for Reproductive Rights, Medical Students for Choice, Nursing Students for Sexual and Reproductive Health, Planned Parenthood
    • Attend legislative hearings and speak as a clinician against anti-choice legislation
    • Keep aware of the laws pertaining to reproductive health in your state: the Guttmacher Institute  and ACLU are excellent resources
    • Support legislation to expand access to abortion by legalizing advanced practice nurses, including nurse-midwives, as abortion providers
    • If you are an Ob/Gyn/surgical resident consider training in second trimester abortions
  • Build partnerships and quality referrals with reproductive health and justice care workers
  • Intimate Partner Violence (IPV)/Domestic Violence (DV)
    • The USPSTF recommends screening all women of childbearing age for IPV. Women who present for recurrent STIs may be at greater risk.
    • If your patient is a victim of IPV, create a safety plan and ensure social work followup.

LGBTQ Rights and Health Care

  • Affirm patients of all sexual orientations and patients who report gender fluidity; discredit ineffective “therapies”
  • LGBTQ children and teens face higher rates or harassment and bullying, depression, anxiety, and suicidality – ask your patients about these issues specifically
  • Work shifts at local LGBTQ health clinics: some clinics and resources are available on the CDC website
  • Free Clinician-to-Clinician Consultation and advice on PrEP management
  • Trans-specific health care:
    • Any primary care provider has the capacity to provide primary care and cross-sex hormones to transgender patients. You do not need to be an endocrinologist. Work shifts for physicians who work with trans patients to help expedite care for trans patients.
    • Know where to refer if you work in a clinic that doesn’t offer trans services:
    • Caring for Trans Youth:
      • Research has consistently shown that family support of transgender individuals acts as a significant protective factor against adverse health risks and outcomes. Advocate for trans youth by educating parents about the difference between sex and gender, including the biological basis for gender identity, and urging them to accept and support their child.
      • Counsel your patients and their parents on the risks and benefits of starting pubertal blockers (GnRH agonists). The Endocrine Society guidelines and WPATH Standards of Care endorse the use of pubertal blockers (GnRH agonists) starting at Tanner 2/3 in youth experiencing a significant increase in gender dysphoria with onset of puberty.
    • Gender Marker Changes
      • Make sure your patient have the necessary documentation to apply for gender marker changes on their legal documents (e.g. driver’s license, birth certificate, passport).
    • Cross-Sex Hormone Therapy (see More Info section for details)
      • If you do not prescribe hormone therapy, refer your patients to Planned Parenthood (see their website and scroll down to see a list of which Planned Parenthoods offer trans care.) Many states have health centers which prescribe hormones:
      • Most trans women and transfeminine patients take spironolactone and 1-8 mg of estradiol/day. Trans men take testosterone. Some of your patients may give away their prescriptions to support their trans friends. Listen with empathy; we would encourage you to keep the dialogue open and keep prescribing.
      • Consider prescribing syringes to patients who will need hormone injections.
    • Silicone & “Pumping Parties” (see “More Info” section for details)
      • Non-surgical-grade silicone and other substances (e.g. airplane oil) are injected into soft tissue for body modification (e.g. face contouring, lip enhancement, breast augmentation, hip and buttock accentuation). Educate your patient on the serious, potentially fatal risks of injecting silicone and encourage to pursue body modification with hormones +/- surgery under medical supervision
        • Teach anticipatory harm reduction techniques to reduce risk of infection and complications in case they pursue silicone injection.
      • For patients interested in surgery, counsel about expected outcomes and possible adverse effects of surgery and help to expedite that process. Ten states currently cover surgery and but coverage is at risk.
  • Lobbying: testify at legislative hearings against anti-LGBTQ legislation, including:

Immigration

  • For reference: AMA’s pro-DACA resolution. This resolution, which supports healthcare professionals who are DACA recipients, passed on 11/14/16.
  • Deportation and immigration benefits (edited by Lily S. Axelrod, immigration attorney LAxelrod@visalaw.com; see the “More Info” section to learn about the legislation that protects refugee):
    • Ask your patients if they are experiencing harassment, discrimination, violence
    • Network with local immigrant/refugee communities – what specific needs and barriers to care they are encountering? Professional interpreters who live locally can be a great source of information about issues affecting the population they work with.
    • For patients and their family members facing deportation or requiring special waivers when applying for visas or green cards, medical history of the immigrant, or a US citizen family member, is a key part of a successful application
      • Any doctor who treated problems arising from an injury, even years later or any mental health professional, can write a letter explaining how the patient was harmed physically or psychologically.
      • Attorneys can give you guidelines/samples of how to write a letter
    • A letter from a physician/medical professional is key to helping the immigration judge or officer understand why it’s important for someone to remain in the US, why someone would not be able to get appropriate medical treatment abroad, the level of seriousness of injury that someone suffered as a result of domestic violence or other crime, why a trauma survivor may have memory problems, etc.  A letter from a medical professional is often much more valuable than just submitting a pile of medical records.
    • Examples of when medical documentation is useful:
      • There are several waiver applications available to people who would otherwise be unable to get visas or green cards, which use a similar standard of “extreme hardship.” For example, a child has cancer or autism, and appropriate treatment would be unavailable in her immigrant mother’s country of origin.  Or a woman is a trauma survivor and suffers severe anxiety, which she is only able to manage with the help and support of her immigrant wife who brings her to appointments and makes sure she regularly takes her medication.
      • A letter from any doctor providing evaluation or treatment of a medical problem can provide an explanation of what the problem is, what ongoing treatment is required, and why the treatment would likely not be sufficient in the immigrant’s home country OR why separation from the immigrant would make treatment in the US more challenging.  

Refugee and Asylee Health

  • Asylum is for people who have arrived in the US and cannot return to their country of origin because they fear persecution for their race, religion, nationality, political opinion, or membership in a particular social group (such as trans women).  Asylum cases often require us to show that despite lack of corroborating evidence, the client is giving truthful testimony about the trauma she survived.
  • Refugees are required to apply for a green card within a year of being admitted to the United States.
  • You may participate in clinics for initial forensic evaluations (consider joining Physicians for Human Rights, see the PHR website)
    • Sometimes you’ll be more of an evaluator than actual provider of medical services, to build the legal case.
    • Documentation is the key: letters from doctors documenting physical injuries and scars are helpful to show that a client was beaten, tortured, raped, etc. How “consistent” are the physical evidence with reported events? (This can address skepticism about “lack of evidence” of abuse).
    • Letters from mental health professionals help us show why a traumatized client may not have been able to come forward with her story right away, or why memory problems may make her testimony inconsistent. It is important to document cognitive deficits and psychological findings as well. There may be “invisible” signs of abuse such as PTSD, depression, and anxiety.
    • Always talk with the attorney handling the case before you submit the affidavit. You can do a dress rehearsal with the attorney beforehand if you are going to testify.
    • Do not include anything that could not be proved under oath. Don’t videotape or audio record interviews, tend to shred notes after you’re done because those could be requested by the court.

Health Care for People Who Use Drugs

  • Familiarize yourself with this philosophy and practice of harm reduction
  • Support the training and hiring of specialized addiction social workers and counselors
  • Drug overdose and prevention:
    • Access to naloxone/narcan (opiate reversal agent):
      • Become trained in narcan administration so you can teach your patients
      • Integrate naloxone as a standard prescription for patients/clients who use drugs – every person should have access to this and every clinician can prescribe it
      • Prescribe naloxone for patients/clients who have family members and/or friends who use drugs – typically the people who are the first-first-responders
      • Prescribe to Prevent – has everything you need to know about prescribing naloxone, including sample prescriptions, descriptions of different products, prescribing recommendations, etc.
      • Carry naloxone yourself as a provider if you live in a community with active substance use
    • Great resource on naloxone: The D.O.P.E. Project – Drug Overdose and Prevention Education
  • Advocate in your city for Supervised Injection Facilities (SIFs)
    • SIFs have been shown to increase utilization of harm reduction strategies, improve access to primary care, and decrease frequency of overdose

Patients with Limited English proficiency

  • Patients with limited English proficiency are entitled to a professional interpreter (either in-person or via telephone) in most patient’s rights documents. Providing patients with interpreters improves understanding and increases delivery of healthcare.
  • Does your hospital/clinic/office provide adequate translation services for the major languages spoken in your catchment area? Are these services working? What is the average waiting time for those services?

Support People of Color

  • White Coats for Black Lives – excellent resource for activism. Sign up on their website for more information – the sign-up asks for amount of time you can spend (ranging for 1 hour/week- 1 hour/month)
  • Police violence
    • Carefully describe and document all injuries in cases where police brutality is suspected- medical records may be used as evidence in court cases
    • Work with local organizations for civilian oversight of police accountability. If you would like to learn more about the role of civilian oversight committees, this brief from Fullerton University is a good place to start.
    • Do No Harm Coalition is a great resource. Contact for information on holding police accountable as healthcare providers
  • Ask your patients about harassment, discrimination, violence
    • Patients have rights and responsibilities within the healthcare setting, whether that is inpatient or ambulatory. In cases where there is concern that a patient’s rights may have been violated, intervene if it is safe to do so. Follow up with the patient: how to file a civil rights complaint and encourage them to seek legal counsel with a civil right attorney. Follow up with your institution to ensure similar violations do not occur again–some institutions may have patient safety committees that may be able to make recommendations.
  • If you work in an under-resourced hospital or clinic serving an under-resourced patient population, identify missing resources and address these deficiencies:
    • Compare health outcomes at your hospital to monitor for racial disparities in health care – these need to be addressed locally as well as nationally
    • Work with community organizations to identify ways in which the health system is not meeting the needs of the community
    • Many residency programs staff hospitals serving communities of color – when you finish your training, consider working as an attending in these communities.
  • Be aware of implicit bias in medicine. This systematic review may be helpful in providing a background on how implicit bias contributes to health disparities.
    • Comments about how some patients “deserve” to get sick or “do this to themselves” are actively harmful to patients and need to be eliminated from the workplace. Challenging the culture of bias is part of patient advocacy.
  • Health provider education
    • Take a preclinical elective on health disparities. If one does not exist, start one. Many examples of curricula exist online (see below).
    • Work with school administration to include programming on health disparities. Here is a paper describing implementation of such a curriculum.
    • Encourage your extracurricular groups to do service-related projects in communities of color. This could include health screenings (screening for hypertension, diabetes, hyperlipidemia, and glaucoma) that might encourage participants to follow up with a primary care doctor.

Support Indigenous Peoples

Support People with Disabilities

Protests and Rallies

  • Consider attending a protest or rally (no matter your political affiliation) as a way to understand issues affecting communities that you serve.
    • You do not have to be arrested to make a difference. We do not encourage getting arrested. Call your state licensing board to understand what happens if you are arrested so that you can make an informed decision about engaging in action.
    • Work with local activist organizations as a street medic and teach attendees basic first aid.
    • Make a safety plan for each protest. Inform friends of where you will be and have a few phone numbers memorized in case you need to call a friend.
  • Seek out trainings to become a street medic
  • Offer trainings to become a street medic
  • Bring a portable medical kit to protests and rallies.
    • Street Medic Kit content suggestions: gauze, ACE wrap, Maalox-water 1:1 mixture in bottle with squirt top, bandaids, bandana and vinegar for tear gas exposure, non-latex gloves, sunblock, water, ibuprofen and/or Tylenol, Benadryl
  • Common scenarios that may require first aid:
    • Dehydration
    • Side effects from not taking home medications for long periods of time (example: a protester leaves their insulin at home and becomes hyperglycemic)
    • Bruising from nonlethal canisters and weaponized beanbags
    • Pepper spray exposure:
      • Evacuate area, flush eyes with water, remove contaminated clothing
      • Liquid antacid and water – Unfortunately there is not strong evidence to recommend one particular regimen. One treatment proposed by Street Medics is a 1:1 mixture of maalox and water. It is recommended this solution does not contain potassium.
      • Encourage all attendees to carry rescue inhalers if history of asthma as pepper spray may cause asthma attacks.
  • Treating protesters in the ED:
    • Carefully describe and document all injuries – medical records may be used as evidence in court cases about police brutality
  • Get training on how to handle medical emergencies without calling the police

Ways to be Heard

  • The ACGME encourages residents to have an “institutional form or other mechanism to give residents the opportunity to raise questions about and discuss educational and working conditions … the standards acknowledge that a resident association (which could be a union) is one way to accomplish this.” It is reasonable to apply this statement to all other working medical professionals as well.
    • We encourage participation in representative bodies no matter what form those take: unions, housestaff councils, senates, class representative positions, sitting on hospital committees, etc. The focus should be on enacting changes that are beneficial for our patients and supporting our peers.
    • Organize a meeting with your hospital or practice to determine which funding streams are most vulnerable.
    • Consider calling businesses that do business with the Trump family and/or boycotting their products. Their business interests continue to represent a major conflict of interest.  
  • Consider getting involved in professional organizations such as the AMA to advocate for specific issues that you would like to see addressed. At the medical student level, consider joining the AMSA, SNMA, LMSA, APAMSA, AMWA.
    • To engage with the AMA: Each state has delegates from the AMA that are listed on the AMA Website. If needed, use this link to find their contact info.
    • Doctors for America – national organization of doctors and medical students advocating for increased health care access.
  • Testify for issues important to you. Anecdotally, it will involve preparing a 1-2 minute statement, wearing a white coat, and speaking to your legislators.
  • Contact your state representatives. Follow the advice of this former staffer.

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MORE INFORMATION

Reproductive rights:

 

 

LGBTQ+ and Trans patients:

  • Don’t be afraid to ask children for about their gender identity. You can phrase it as “Are you a girl, a boy, or are you not sure?” Trans youth are “consistent, persistent, and insistent” in their gender identity, dysphoria, and pursuit of social acceptance of their identity.
  • Resources:
    • If your institution does not currently have experience in trans-specific care for children and adolescents:
    • Great resource for transgender patients/clients:
    • Practice discussing reproductive health care options without tying them to gender, and offer options as appropriate
    • Make sure your trans patients with a uterus and sexual contact with semen are encouraged to start a long-acting contraceptive
    • If you lack mentors experienced in hormone therapy at your institution:
      • TransLine – a free online resources and consultation for physicians to receive support from experienced providers
      • Advocate for your institution to make transgender health a priority
      • Identify a local provider in your community who is familiar with caring for trans patients and organize a workshop
      • Attend a trans healthcare conference
      • Invite Fenway Health or Transgender Law Center (CA only) to run a workshop at your institution
    • WPATH – sets the Standard of Care for Trans-specific Care
    • Cardea Services – Free educational tutorials, CME credits, and CNE credits on topics such as Providing Care for Transgender or Gender Nonconforming Patients (including cross-sex hormone regimens, labs to draw, etc.)
    • UCSF Center of Excellence for Transgender Health
    • Fenway Health
    • Testosterone (T) is a tightly controlled substance and, as such, is hard to get prescribed without direct reason. Cis men may be able to get a prescription for testosterone for hypogonadism (not producing as much testosterone as is considered “normal” for men), and some doctors will also prescribe testosterone to AMAB (assigned male at birth) people who are aging and experiencing a related drop in testosterone, and to AMAB youth who have not experienced puberty as early as expected. If you can get a prescription for T and do not need to use it yourself, please consider doing so. Trans men use T in a variety of forms, including injectable and transdermal.
      • Most trans women and transfeminine folks who take hormones use 25-200mg of spironolactone per day and 1- 8mg of estradiol per day. Cis women and AFAB (assigned female at birth) trans people can consider getting a prescription for spironolactone for acne or blood pressure. It is not recommended to get a combination birth control prescription for trans women and other transfeminine folks due to the increased health risks associated with such pills for them.
        • Hormone medications frequently used by trans women:
          • Estradiol 2 mg tablets, as many as you can get
          • Spironolactone 50 mg or 100 mg tablets
          • Micronized progesterone 100 mg or 200 mg capsules
          • Finasteride 1 mg or 5 mg tablets
          • Depo-provera 150 mg injection syringes
  • More commonly used among patients with:
    • Low health care access to hormone therapy
    • Low economic resources for gender-affirming surgery
    • Patients already on hormone therapy but seeking to expedite body modification.
    • Transwomen more so than Transmen
  • Non-surgical-grade silicone is often injected by non-medical persons in non-medical environments (e.g. homes, salons) at events known as “pumping parties.”
  • Do not stigmatize or intimidate if a patient discloses history of silicone use or intent to use. For trans individuals, passing as their gender and avoiding being “clocked” is a matter of safety & survival (physical +/- economic). Understand that waiting for body modification may create anxiety and legitimate concern. Provide reassurance and resources to enhance social safety.  
  • Insurance coverage of gender affirming surgeries under Medicare and Medicaid may change under a Trump administration.

PrEP:

Immigration

  • The U visa is for undocumented victims of crime who come forward and participate in investigation or prosecution. It requires proof that the person suffered “substantial harm” as a result of the crime.  Sometimes ER visit records are sufficient for this, but sometimes the injury is less obvious.
  • The T visa is specifically for victims of human trafficking who come forward to participate in investigation or prosecution.  
  • The Violence Against Women Act offers protection for immigrants who have suffered physical abuse or extreme cruelty by their US citizen or lawful permanent resident partners.
  • Cancellation of Removal is a path to a green card for undocumented people in deportation proceedings.  It requires showing that the person’s removal would cause “extreme and exceptionally unusual hardship” to her “qualifying relative” (US citizen or lawful permanent resident child, spouse, or parent).  

People of Color:

    • Look for implicit bias in your own interactions and make this analysis an active part of your internal assessment in every patient encounter. Project Implicit allows you to take a self-assessment of implicit bias. Learn about the movement to promote “structural competency” in healthcare, and the ways that inequality is naturalized within medicine.

Protests/rallies:

Ways to be Heard:

  • Pertaining to medical professionals in the military: Article 88 of the Uniform Code of Military Justice, which states, “Any commissioned officer who uses contemptuous words against the President, the Vice President, Congress, the Secretary of Defense, the Secretary of a military department, the Secretary of Transportation, or the Governor or legislature of any State, Territory, Commonwealth, or possession in which he is on duty or present shall be punished as a court-martial may direct.” This is to say, medical professionals in the military may face pressure to not speak out about restrictions in healthcare due to their position in the US government. Be understanding of this.

Local Resources – By State

National Directory of Free Clinics: http://www.freeclinics.com/

Massachusetts:

Michigan

California:

New York:

  • Q Clinic: medical student-run clinic for LGBTQIA (particularly homeless youths), 7:30pm-10pm Wednesday nights at MCCNY on 36th St betw 9th and 10th Ave,
  • Asylum Clinic: medical students and law students perform asylum interviews and evaluations in conjunction with PHR
  • CHHMP: medical student-run clinic for under-insured/homeless based in Harlem, W 126th St and Amsterdam at St. Mary’s Church, 6pm-9pm Tuesday nights, Spanish-speaking and many ancillary services to offer (including psych and dental)
  • Callen-Lourde: the original NYC LGBTQIA clinic

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Versatile Blogger Award

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Thank you to ItsNotWhatItsWhy for nominating me! I am honored.

Award Rules: 

Thank the person who nominated you
Share the award on your blog
Share seven random facts about yourself
Tag 15 fellow bloggers and let them know that they have been nominated.

Seven random facts:

  1. I survived my first year of residency (whoo!)
  2. I now own the world’s weirdest piggy bank
  3. I have done Nanowrimo 3 years running, and am planning to win this year, too
  4. I have heard Billy Joel sing live from my apartment for the past 2 years
  5. Chocolate chip cookies are still my favorite
  6. Any cookie from Momofuku is also acceptable
  7. I recently joined a Facebook group called Dogspotting, and you should, too

Alas, my reading sphere is small (but mighty), and so here are 7 bloggers I would like to recognize as improving the quality of the blogosphere:

  1. The Weekly Sift
  2. Nursing Clio
  3. Kristin Lamb’s Blog
  4. The Chirugeon’s Apprentice
  5. The Daily Medical Examiner
  6. The Insatiable Traveler 
  7. Florida Behind the Scenes 

 

 

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Hiatus

Dear readers-

I will be taking an extended hiatus to focus on other projects such as The Friendly Intern, my ever-growing collection of practical Q&A for medical students/residents, and Silkeater Stories, my fiction writing blog.

Please feel free to continue to leave comments! Good luck on your own journeys.

-Joy

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Dialysis: a case study in medical ethics

When I was a medical student, I had a renal small-group leader who had practiced in the time before dialysis. He talked about what it was like to use this new technology. “It was life-changing, literally,” he said. “And hard work. We had to manually filter patients’ blood to keep them alive long enough to be dialyzed.”

This reminded me of Seattle’s “god squad,” a case which was a crucial mover in the American bioethics movement. Dialysis was very limited in the 1960s; demand exceeded supply. In Seattle, one hospital created a selection committee composed of laypeople, including housewives, a reverend, and local community leaders, who sat around a table and checked off certain names and not others, making life and death decisions.

The selection committee chose dialysis candidates based on not only their medical history (so who would most gain the most years of life from receiving dialysis) but also social factors like financial stability, church attendance, standing in the community. The rationale for choosing a married churchgoer with kids over a convicted felon seems implicit: choose the person who has the better compliance and is more likely to contribute to society. And to a certain extent, it is satisfying. If you have been good, you get good treatment.

But when this treatment comes at the expense of “bad” people, we must question if being “bad” means that you don’t deserve the same medical treatment as others. Are all poor people “bad?” All felons? People who dropped out of high school? Drug addicts? Sex workers? The uninsured?

This goes back to the basic principle that everyone, regardless of who they are or what they’ve done, must receive the same level of medical treatment. Many people cannot control the financial situation that they’re in, what neighborhood they’re born in, or whether they get physically or mentally sick. But the dominant groups in society may see these people as undesirables, unfit. As the Seattle case shows, if we do not have a medically sound system for evaluating patients, a eugenics-like situation based on ugly social biases is a very real possibility.

Although dialysis is much more widespread now, there are still ethical dilemmas that basically determine whether someone lives or dies (and how they choose to live or die). This is a moving paper about the emotional turmoil that dialysis may cause to doctors. How do you present dialysis to a patient who will eventually die of end-stage renal disease? What is the benefit of keeping someone alive on dialysis if they don’t have a certain quality of life? What if the patient’s wishes and the family’s wishes are not the same?

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Is sex ed still taught like this? Historical Disney video

Because Disney doesn’t own enough of my childhood already, I sometimes go looking for some of their less well-known videos. Given that we’re learning about the menstrual cycle now, I thought this 1949 educational video was timely. It’s interesting to contrast how periods were presented to students then versus how they are presented now in science textbooks. Also interesting to note how the Disney production urges girls to not get emotionally overwhelmed and continue to be their cheery, perky self.

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