Volume III Issue II
December 2012
Dr. Nancy Elliott carves a Thanksgiving turkey with surgical precision.
In This Issue of The Pitt Pulse... In The Last Issue...
Table of Contents
Answers to the “Are You Smarter Than A Pre-Med” Section:
Overeating During the Holiday Season p. 3 The Future of Medicare: What America Needs The Faulty House
Enhancing Practice with Cross-Cultural Experience
p. 4 p. 5 p. 7
Just for Fun Secret (and Not-So-Secret) Study Spots!
p. 8
A little bit of help studying for finals!
Vasopressin Luteinizing Hormone Aldosterone Insulin Atrial Natriuretic Peptide Calcitonin I. Olfactory II. Optic III. Oculomotor IV. Trochlear V. Trigeminal VI. Abducens VII. Facial VIII. Vestibulocochlear IX. Glossopharyngeal X. Vagus XI. Accessory XII. Hypoglossal
We apologize that, occasionally, errors in print will occur. Corrections to the last issue are below: p. 8, “Are You Smarter Than A Pre-Med?” matching section is missing a twelfth option for cranial nerves. The missing nerve is the Abducens.
Staff Writers Jessica Collins, Jessica Craig, Natalie Ernecoff, Lauren Hasek, Belinda Lao, Janine Talis, Rashmi Sagaram, Zaid Safiullah
Contributing Writers Rebecca Sponberg, Chase Moon
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Do you have an idea you’d like to contribute to The Pitt Pulse? Do you have any prehealth questions? Contact our editors at thepittpulse@gmail.com
Cover Photographer Beverly Hersh Cover Model Nancy Elliot, M.D.
Deborah Chen Editor in Chief Niaz Khan Assistant Editor
Beverly Hersh Assistant Editor
Overeating During the Holiday Season
By Jessica Craig Staff Writer We all know the feeling of the holiday food coma; the rush of exhaustion after a feast that sends us to the couch for the rest of the evening. What originated as a means of survival has transformed into a social activity and psychological behavior. We eat for entertainment, celebration, or to relieve stress or frustration. Many psychologists believe we eat for the wrong reasons, leading to unhealthy habits such as overeating, that become especially prevalent during the holidays. It is easy to get away with overeating during this time of year because food consumption is the central activity for people during the holiday season around the world. We don’t think twice about having three plates of turkey, mashed potatoes, corn, broccoli, cranberry sauce, stuffing, rolls, and enough gravy to fill a small lake – not to mention the desserts. The holidays are a time of indulgence and luxury, and many of us will stuff our faces with as much food as we can before our stomachs pop. Is this indulgence justified by the celebration of the holidays, or are we doing more harm than we think? What are the health risks of overeating? More importantly, how can we avoid overindulging while still enjoying the holidays? To understand the health risks of overeating, we must first understand how food is processed through our body and how eating is processed through our brains. Hunger and satiation are controlled by an array of hormones, neurotransmitters and signals in a part of the brain called the hypothalamus. Hunger is your body’s way of telling you that you need energy. The hungry sensation is generated in the hypothalamus, giving you the inclination to eat. As you consume food,
you begin to feel the sensation of being full or “satiated” as periphal signals that sense the consumption are sent back to and integrated in the hypothalamus. With this system in place, how is it possible to overat? Well, your body’s intuitive drive to keep eating can be traced back to hunting and gathering times when food was not always readily available, a striking contrast to most of our lives today. We evolved the ability to eat more when food was plentiful, despite being full, so our bodies could store energy in the form of fat, allowing us to survive during times when food was scarce. The abundance of food during the holidays makes it easy to get away having a second or third serving, even though your body most likely reaches its metabolic needs by the end of the first plate. Your brain registers the sight, smell, and taste of delicious holiday food, triggering your primal instinct to scoop more mashed potatoes and ladel on the gravy. So that’s it? We are biologically programmed to overeat and there’s nothing we can do? Wrong. We can train our bodies and our brain to control itself and its “hunger.” Researchers, dieticians and psychologists offer tons of free advice online, but how much of it is true, and can help limit how much we eat during the holiday season? The first tip to avoid overeating is to not skip meals before the Thanksgiving feast or Christmas dinner. Instead, eat healthy, low calorie meals throughout the day and drink plenty of water. In other words, don’t show up to your in-law’s house with a ravenous appetite because this will likely cause you to eat more than your body needs. Keep your digestive system working all day so when you do feast, your body can regulate itself and prevent a blood glucose spike that can lead to that food coma. Second, exercise in the days leading up to, the day of, and the day after feasting. Exercise helps to regulate your hormones levels, which in turn helps regulate your digestive system. And of course, exercise burns off some extra calories. Third, eat slowly; take breaks in between plates of food and in between dinner, dessert, and
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round two of dinner. Give your body a chance to digest your food properly. So why should you care about overeating once or twice during the holiday season? Does one instance of loosening your pants after eating too much do that much damage? Actually, yes. Overeating at just one meal can negatively affect your overall health. It can cause shortness of breath, heartburn, extreme fatigue, and temporary onset diabetes. Temporary onset diabetes is caused when one consumes so much glucose in a condensed period of time that your body cannot process it all. People experiencing temporary onset diabetes experience symptoms such as extreme fatigue, extreme thirst, blurred vision, and headaches. This is a serious condition that can cause long-term bodily harm, such as damaging your pancreas, a vital digestive organ that secretes insulin. Insulin is the hormone responsible for removing glucose from the bloodstream and into cells for energy use. A sudden increase of glucose in your blood can affect the sensitivity of your pancreas, causing an isolated insulin production spike. In an attempt to avoid future insulin spikes, your pancreas may react by becoming desensitized to future blood glucose levels, impacting insulin production for the rest of your life. So this holiday season, when you start to reach for a third slice of apple pie, stop and think about the damage you could be causing your body. Maybe take a break from eating, and go outside and play a game of flag football. Save your leftovers for lunch the next day and send some turkey home with your in-laws. Keep in mind the tips to prevent overeating and the health risks that overeating might bring. The holiday can still be a time of celebration, and you can still enjoy all the great food; just do so in moderation to avoid causing yourself bodily harm. v
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The Future of Medicare: What America Needs insurance, financed by the current working population. Today, Medicare has developed into a complex system with an array of coverage components for each individual. Basic Medicare, the traditional option, is composed of Part A and Part B:
By Belinda Lao Staff Writer The complex system of Medicare is currently undergoing a series of re-evaluations in anticipation of our population’s evolving needs. In fact, on November 8, this topic was the subject of Pitt Law School’s symposium, titled “The Future of Medicare.” But before we can join policymakers and citizens in discussion of Medicare’s future, we must first comprehend the current system. Congress created Medicare in 1965 under the Social Security Act to guarantee government-mediated health insurance for individuals 65 years and older. According to William McKendree, a symposium speaker and Pitt professor, medical insurance coverage was poorly represented within this population due to high costs and ineligibility because senior citizens often had pre-existing medical problems. Within five years of implementation, the Medicare program had increased the proportion of seniors with health insurance from less than 50 percent to nearly 97 percent, says McKendree. It was later expanded to cover the disabled and patients with end-stage renal disease, regardless of age. Rather than having to rely on community safety nets – or worse, paying out of pocket – older and sicker citizens now had an option to receive government-mediated health
•
Part A covers in-patient hospital care, skilled nursing, hospice, and some home health care.
•
Part B covers doctors’ services and outpatient care, outpatient surgery, lab work, diagnostic tests, therapy, and durable medical equipment.
These are fee-for-service programs in which medical facilities that accept Medicare will bill Medicare for a significant portion of an individual’s medical costs. The individual is then expected to cover the remaining cost, either through a supplemental medical insurance program or out-of-pocket. Beneficiaries of Medicare must share some of the coverage cost through additional payments such as premiums (as low as $0 for Part A, depending on how much the individual has paid into the Medicare system throughout their employed years), deductibles (the individual pays a certain amount and Medicare picks up the rest for a certain period of time), and co-pays (the insurance program designates a specific out-of-pocket payment that the beneficiary must pay each time a medical service is used). Since Basic Medicare does not cover certain services, such as dental and eye care, individuals are often motivated to
*Figure based on the work of William McKendree
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find other sources of medical coverage to supplement their current plan. • Part C, also known as Medicare Advantage Plans, are created and administered by private insurance plans and often offer additional coverage such as dental and vision care. Individuals must be enrolled in Part A and B before enrolling in Part C, which may include prescription drug coverage. These plans are much more variable than Parts A and B. •
Part D provides prescription drug coverage and is possibly the most-used type of Medicare coverage.
According to McKendree, one of the largest problems with Medicare today is the cost of prescription medications. Not only is the cost high, but the differing tiers of coverage create a volatile coverage gap for those whose monthly medications cost too much to qualify for partial coverage but not enough to qualify for catastrophic coverage. In an example he presented, an individual is only responsible for paying 25 percent of his drug coverage (the plan pays the rest). This continues until he reaches a month where he exceeds an “initial coverage limit” of $2,930. After that point, his plan switches to the coverage gap area, where he must now pay 50 percent of drug coverage. Until that individual pays a cumulative out-of-pocket total that meets the “out of pocket limit” of $4,700, he remains in this gap. If he can reach that limit, he is then eligible to pay only 5 percent of his drug cost and Medicare covers the remaining expenses. Although this cycle is reset at the start of each year, it is the cyclical nature that is problematic. High prescription drug costs lead people into the coverage gap, and the subsequent need to reach the high “out of pocket limit” to climb out of the gap puts a financial strain on many beneficiaries. For those who cannot climb out before the cycle resets, the costly cycle begins anew.
(Continued on pg. 6)
The Faulty House
By Natalie Ernecoff Staff Writer Treating illness is why we became doctors. Treating patients is what makes most doctors miserable. – Dr. Gregory House The above quote is from “House,” the television series that tells of the fictitious, narcissistic physician of the same name and his unconventional case-solving skills. Many medical and pre-medical students tune in each week to watch the out-of-line doctor take on a seemingly endless number of obscure cases at Princeton-Plainsboro Teaching Hospital. While entertaining, “House” is riddled with neglect for the patient as a person. Though many of his actions are uncalled for and meant for entertainment, one is still inclined to wonder if medical students and physicians are more like him than they are willing to admit. Granted, the vast majority of physicians surely care about their patients, unlike the disdain expressed above by Dr. Gregory House. Most people in medicine enter the field because they want to make the lives of others better. Physicians in the real world do not purposefully behave unethically or jeopardize the well-being of their patients to simply prove a point, but unfortunately that is not to say some of House’s less overt, deleterious behaviors are absent from medicine today. Is there a lesson to learn from House? Everybody lies. –House If everybody lies, then the media is a major culprit. Television series based on medical practice often misrepresent doctors and the hospital atmosphere. This includes physicians’ weak interactions with patients, frequent yelling, and inappropriate interactions with fellow staff members. The general population may perceive these behaviors as standard
practice, when they are often intended merely for entertainment value. Television designed for entertainment purposes can easily display misguided ethical principles. Not only might this influence the way medicine is perceived by the public, but it might also influence the way it is practiced. One can only hope that medical students do not apply many of the slippery lessons provided in their favorite television programs. I like being alone. At least I convince myself I’m better off that way. –House Although physicians want the best for their patients, some missteps are common with respect to bedside manner, and these patterns begin during medical education. Recent studies have indicated that students’ empathy levels drastically decrease during their time spent in medical school. Most of these changes occur at a critical time when students are transitioning from the academic setting to clinical practice. At the same time, many blatantly rude behaviors, like cursing, are common in the hospital setting; from observing their superiors, students may assume these behaviors are acceptable and justifiable. Several factors could contribute to this recoil of empathy for patients and their situations. Seeing real patients who have real families, illnesses and lifestyles can have a drastic effect on the emotions of medical students, which can in turn impact their mental and physical function. These effects can be a daunting reality to students who are accustomed to focusing primarily on hypothetical cases in their texts and lectures. In fact, students may overcompensate by trying to suppress their emotions entirely. Researchers hypothesize that inadequate empathy toward patients is a pre-emptive tool medical students use to protect against emotional attachment. Whether deliberate or subconscious, medical students may believe that building strong connections with their patients poses the risk of making them psychologically and emotionally taxed. They perhaps
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By Kristin Dos Santos (Hugh Laurie) [CC-BYSA-2.0 (http://creativecommons.org/licenses/bysa/2.0)], via Wikimedia Commons
feel distancing themselves from patients allows them to retain their own well-being in the long run. Though this may make intuitive sense, quite the opposite is true; research indicates a positive correlation between empathy, student well-being, and professionalism. Better a murder than a misdiagnosis. –House Though it may be true that empathy yields better outcomes for physicians and patients, sometimes students are too preoccupied with the biomedical information they need to recall in order to properly diagnose and treat people in real time. These added stressors have the potential to decrease students’ emphasis on empathy, which in turn negatively impacts the quality of the patient’s experience. Whatever the reason behind these decreasing empathy levels, simply being aware of the deficit gives students the opportunity to take actions to either conserve or expand their empathy and their ability to convey it to patients. In an attempt to help students do so, medical schools are beginning to offer courses intended to improve communication skills between future
(Continued on pg. 6)
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(Lao, pg. 4) In addition to these inherent structural problems, the landscape of Medicare demographics and changes in health policy are rapid and multifaceted, according to Dr. Edward F. Lawlor, the founding director of the Institute for Public Health at the University of Washington in St. Louis. Professionals who have followed the trends of Medicare have long predicted an explosion in the number of Medicare beneficiaries in the coming years, as American baby boomers reach eligibility criteria. Lawlor suggests that the current estimate of 48 million Medicare users will likely jump to 79 million by 2030, with the enrollment of the baby boomers. The increasing incidence of diagnosed chronic conditions will also require attention. This is especially apparent with the rising prevalence of diseases such as obesity and diabetes, which have many factors that complicate prevention and treatment. Mental illness, a sector which has previously garnered little attention, has also seen a boost in medical focus and treatment options. As the number of citizens eligible for Medicare and suffering from chronic conditions grows, the focus of our Medicare policy needs to shift to sustain a greater level of coverage. An increased focus on preventative and long-term care is only one factor necessary to keep up with our changing population. With all the current talk about Medicare and the American health system, it is important for us future health care professionals to understand what these programs entail. As we pursue our respective careers, we have the responsibility to educate ourselves. The Medicare system will surely contribute to the financial concerns of our patients and colleagues in the years to come. So what can we do? With the rising focus on preventative factors, our country needs individuals who are passionate and driven to answer the call for primary care. This will hopefully decrease the incidence of the chronic conditions that account for a large portion of Medicare spending. Primary care has often been pushed to the wayside because it offers less attractive lifestyle options and salaries than more specialized fields. Although institutions have yet to offer sufficient incentives for students to enter the primary care field, it remains one of the most short-handed areas of health care, especially in rural populations. Perhaps, this steadily growing need will instill a sense of urgency in policymakers and prompt them to take steps to improve the perceived quality of a career in primary care. v
(Ernecoff, pg. 5) physicians and their patients. Not only are they addressing communication issues explicitly, but many medical schools are also expanding their curricula to include a larger humanities base. One example includes teaching students to express themselves by utilizing creative methods such as painting, sculpture and poetry. While developing these skills helps the students directly, it can also benefit patients indirectly: when faced with adverse decisions or difficult medical situations, physicians with this training can help patients manage what they are feeling in an effective and comforting manner. I’m pretty sure I’m not going to like you. It’s nothing personal. I don’t like anybody. –House When physicians address their emotions explicitly, patients are not the only ones to benefit. Empathy-based care is correlated with good patient outcomes and adherence to treatment in the outpatient setting. When the physician indicates that he or she cares for a patient’s well-being, that patient is more likely to trust that the health care guidance he or she is receiving will be effective. This increases the likelihood that the patient will embrace treatments, which contributes to improved outcomes. Even if physicians are not intentionally following in House’s footsteps, his antics can offer a blunt reminder of practices to be avoided outside the realm of entertainment, especially those which eliminate even more humanity from the world of medicine. Medical schools are beginning to emphasize communication and allow for more exploration of the humanities because these subjects give students opportunities to express themselves, which in turn helps increase levels of empathy. Physicians currently improve patient outcomes biomedically, but by simply being more empathetic, they have the ability to improve psychological and emotional outcomes, as well. This empathy is something most patients could use a bit more of, whether their physician is House or not. v
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Enhancing Practice with Cross-Cultural Experience I was able to speak to my patients about topics ranging from the importance of completing their entire antibiotic regime to decreasing risk factors for acquiring parasitic infections in their homes. We were only able to offer medication for acute illnesses, but they were genuinely grateful for just a bottle of children’s Motrin or cough syrup. Although just a portion of the Costa Rican uninsured, the 220 patients I saw in two weeks provided me the opportunity to practice and perfect my head-to-toe examination and to reduce the time I needed to obtain a full set of vital signs. Their surprising patience and overwhelming curiosity made it easy for me to expand my questioning to gain a better understanding of their health knowledge and status. With each positive patient teaching experience, I gained more and more confidence. I cannot overstate the value of their gratitude on my psyche either: I will always remember the gigantic hug I received from a woman who reminded me of my grandma and I will always keep the crayon drawing one of my youngest patients gave me. Returning to nursing in the U.S. was a challenge, as I had become accustomed to the friendly acceptance my Costa Rican patients had displayed. With my enhanced patient assessment ability though, I have had improved success delivering health education because I now know how to ask pointed questions that more quickly identify deficits in patient knowledge. I approach each patient as a blank slate, and as a result, I have seen a general improvement in my clinical rotations this year. Since returning, I have realized that the Costa Ricans had a greater impact on making me a better health care professional than my temporary presence had on them. v
By Rebecca Sponberg Contributing Writer Ever since I was a junior in high school, I have been saving money towards the prospect of traveling abroad. Three years later, after my sophomore year in Pitt’s School of Nursing, I finally found the perfect opportunity to not only see a new part of the world, but also to gain my first international clinical experience: working with International Service Learning. Through this program, a group of American students helped provide health care and medical supplies to uninsured people in San Jose, Costa Rica. Until I took my first steps onto Costa Rican soil, I had never encountered such gracious people. Their ubiquitous hospitality was surprisingly prevalent in even the inner-city slums of San Jose. Although their homes consisted of only stark wooden frames and corrugated metal walls and roofs, our patients always welcomed us inside to meet their families and appreciated any amount of interaction with us. During one of these visits, I was touched to see the entire community of Los Diques share the task of watching Emanuel, a 2-year-old toddler diagnosed with Down syndrome. It was refreshing to see this community and shared responsibility for his protection. I could not conceive, then, how the Costa Ricans’ welcoming nature would profoundly impact my clinical practice back in the U.S. Despite a significant language barrier, I connected more on a human level with the ticos and ticas of Costa Rica than with some of the male and female patients that I have cared for in the U.S. Their eagerness to learn how to improve their health was so unlike the indifference I sometimes received in the states. Only equipped with my basic medical Spanish and the occasional help of a translator,
If you are interested in learning more about International Service Learning or want an ISL experience of your own, please email ISLpitt@gmail.com or visit www.ISLonline.org Visit us online at www.thepittpulse.com
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Secret (and Not-So-Secret) Study Spots! By Jessica Collins, Staff Writer With Hillman under construction during the day, and full to the brim at night, it can be stressful to find somewhere quiet to get work done. What students seem to forget is that there are places besides their rooms and this one library to get away and focus on school for a few hours. Finals are right around the corner, and everyone is feeling the pressure to make the grades. Here are a few of campus’s best-kept secrets to make your task a little easier …
Honors College Lounge Cathedral of Learning Floor 35
• Pro: Quiet place with very little foot traffic in the evenings and on the weekends • Con: No desks besides coffee tables; seating is mostly armchairs and sofas Frick Fine Arts Library Main Floor
Alumni Hall Floor 3
• Pro: Location is close to campus and a computer lab • Con: Well-known among students Study Lounge William Pitt Union Floor 9 • Pro: Location and quiet hours make it easy to study here between classes on weekdays • Con: Gets crowded at night as well as during midterms and finals weeks Business Library Mervis Hall Floor 1
• Pro: Very few students utilize the area • Con: Limited hours
Falk Library of the Health Sciences Scaife Hall
• Pro: Multiple places in the building to work • Con: Location is a little less accessible
• Pro: Multiple study areas, all of which are usually very quiet • Con: Closes at midnight during the week
Sennott Square Floor 2 • Pro: Plenty of seating Victoria Building • Con: Casual atmosphere allows Floor 1 daytime crowding and noise
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• Pro: Coffee cart is open on weekdays • Con: Busy during the day
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Law Library Barco Law Building Floors 3, 4, and 5 • Pro: Area kept completely silent • Con: Stiff atmosphere