Four Decades of Change

Even though my flights last Saturday night all came with first-class upgrades and early arrivals, snuggling under the covers still presented the most attractive option Sunday morning. My husband had other ideas – we were going to church on Palm Sunday.

I am truly grateful that he dragged my ample butt out of that bed.

When I was 11, the ordination of women caused much controversy within the national Episcopal church. The controversy divided my own church which had never allowed female acolytes (alter girls). Hours of coffee- and beer-fueled debate ensued. Ultimately, practicality won the day. The upcoming confirmation class included no male children, and the parish needed new acolytes. They trained two girls.

Lightening did not strike. The sanctuary walls remained upright.

Today it is difficult to remember that ordaining women was controversial, especially since the head of the American Episcopal church is a woman.

The Most Rev. Dr. Katharine Jefferts Schori presided at Palm Sunday services at Trinity Cathedral in Omaha. She delivered a beautiful sermon about helping others in the world as the route to peace.

In my lifetime we have advanced from ordination of women being “illegal” to a woman running the church. More than any passage in the bible, this gives me hope.

So thanks, honey. It’s retrospective, but sincere.

Sleeping woman photo courtesy of PhotoXpress.

More On Personal Branding and Platform

Once again, my daily email from Pink Magazine proved timely and informative. Today’s topic, personal branding, fits well with all the talk about platform development in last week’s workshop.

One informative link was to an online identity calculator. This short query uses a Google search of your name to determine your digital distinctness.

It helps to be “Pascale Lane” and not “Jane Doe.” It also helps to be online actively managing what people associate with you. Owning your own domain, blogging, and other digital interactions will help increase your digital brand immensely. Most importantly, you can move your brand in the direction you desire rather than passively allowing others to determine your image.

In this day and age, when a Google search about you may make or break a job search, overlooking your online brand would be short-sided. I encourage everyone to use the link and determine their online identity score.

Think it doesn’t matter? Better think again.

Then Color Me Pinko

I have friends and relatives living in terror. They fear that they will lose their health care coverage to “Obama’s socialist agenda.”

Of course, their primary coverage is via Medicare, a government program. One could say a socialist program.

What is socialism? According to Wikipedia:

various theories of economic organization which advocate either public or direct worker ownership and administration of the means of production and allocation of resources.

In short, public ownership constitutes socialism. I live in Nebraska, a generally red state, where “socialist” is considered a major insult, yet I purchase my water, gas, and electricity from publically-owned utilities with elected boards. Looks like socialism to me.

My children attend excellent public schools and universities. An educated electorate is essential to democracy, and most education in the US is subsidized by the public one way or another. More socialism in action.

Early intervention is  another service readily available through our socialist education system. Every state in the union put these programs into place during the 1990’s to target children with special needs. Their development improves with programs implemented before the traditional school age, sometimes during the first year of life. Most parents would not be able to afford the intensive behavioral and occupational therapy provided by these publically-funded programs.

Yup, early intervention programs are another example of pooling public resources to provide a public good. More of that “S” word.

Sarah Palin denounces socialism every chance she gets. She attended several public universities, though, and has thus benefitted from educational socialism. Yes, you pay to go to university, but it is highly subsidized via tax dollars, even for out-of-state students. State universities are big-government at work.

Palin claims to have turned down government handouts. Will she become even more suspect of public and government funding as the tea-party movement gathers steam? I hope not; for the sake of her son, Trig, I hope she accepts those socialist early intervention services.

Just say thanks- the American public does this because it is the right correct thing to do. We all want Trig to have the best life he possibly can. I personally want every child to have nutritious food, educational opportunities, vaccinations, and adequate healthcare, even though it means higher taxes for me. Even though it means a larger government. I would like every US citizen to have guaranteed health care, whether or not they are employed or have pre-existing medical conditions. I do not see how these changes to healthcare threaten individual freedoms in any way.

Guess that makes me a socialist. Please don’t shoot me.

Increasing Sensations of Incompetence

I am learning to write creative nonfiction.

I have this book idea. I finally “gave” myself this conference to try and get my act together and WRITE THE DAMN BOOK!

Among this group of mostly middle-aged healthcare workers, I am way ahead of the online media curve. I have a blog (no link because you’re reading it right now). I am on FaceBook. I am on LinkedIn. I even Tweet!

The first day of the conference discussed preparing the book proposal and pitching it. I felt smug then because I had began developing “platform” with my traditional and social media work (see Thursday’s post).

Yesterday we talked about actual writing. Michael Palmer presented his insights from the beginning and growth of his writing career.

This morning focuses on public relations for budding authors. And I feel so far behind. I just now registered my domain name. I just signed up for HARO (help a reporter out). I have bought my Flip videocamera, but have yet to upload to my YouTube Channel (no link because THERE IS NOTHING THERE YET). So much to do… and I haven’t yet factored in the book proposal! Or actually writing THE DAMN BOOK! Or my day jobs.

Sigh!

The good news is I have a lot of new blog fodder. And I have to write; I don’t know why. It is part of who I am. So hang on- it may be a bumpy ride, but it won’t be boring. At least not every day…

Building a Platform

When I hear the word platform, something like these Madden Girl beauties comes to mind.

So why was I listening to “Platform: What It Is and Why You Need One” in a writers workshop this morning? Would hot shoes and a taller appearance make publishers like me better? If so, then my decision to bring a single pair of low wedges might bring me down, and  not merely in physical stature!

Turns out that one’s platform consists of professional credentials, media work, and other writing; the stuff that lifts you above the waves of others out there, sort of like an oil platform in the ocean (once I came up with the analogy I had to use it).

Turns out that blogging, podcasting, twittering, facebooking, and other social media help build that platform.

Now when my husband asks me if I’m screwing around on the computer/Blackberry/iPod again, I can honestly tell him no; I’m building my platform!

APS vs. Isis Slam-Down

No, the above photo is not a depiction of this year’s Experimental Biology meeting in Anaheim. It is labeled on Flickr as a Biker Mud Wrestling Party.

As of today, EB is one month away. I am awaiting official updates from the training camps of Dr. Isis, the Domestic and Laboratory Goddess, and Marty Frank, Executive Director of the American Physiologic Society. The contest will see which of these icons of physiology can enroll the most new Twitter followers during the meeting. The rules and other details are outlined here.

Dr. Isis recently acquired an iPhone; her daily tweets show increasing proficiency with the touch-screen keypad. The Frank camp is maintaining silence on his training regimen.

Only one month till EB; let the shenanigans begin!

Trip Time

Tomorrow I leave the homestead in the heartland for a workshop in Boston.

I have wanted to attend one of these writing courses since I first saw the brochure. I am finally making it happen. Maybe, just maybe, I will write my book one of these days.

So tonight I will pack 3 days worth of clothing in a carry-on bag. And I know my readers are asking, “What will you pack?”

• 2 pairs of dress trousers in wrinkle-resistant blends
• 3 tops
• 1 jacket
• Undies and accessories and other necessities
• PJs

I will wear my best pair of jeans with another top and jacket; the jeans will make the trip home as well. I have a pair of neutral metallic 1.5” wedges, that will serve me well through airports and along city streets, as well as complimenting every outfit in the suitcase.

The usual electronic devices want to come along for the ride: BlackBerry, Netbook, iPod, and Kindle.

It is time to do those things I love, travel and write.

I am so glad I gave myself this trip!

Making and Breaking Rules

A couple of weeks ago I posted on neonatal hypertension. In the course of that piece I commented that I had made a rule about when I would recommend treatment for this condition. A commenter, Dr. Isis, asked the following:

I am interested in the "I decided to make a rule..." part of it. Can you tell us more about how you made this decision?

I posted an answer about my review of the literature and other considerations, but that really does not address the root of the issue; why did I feel the need to make a rule?

So I reviewed a relatively recent book, How Doctors Think. This read from 2007 examines the ways physicians deal with uncertainty in medicine. We learn to recognize patterns, and respond to them accordingly. Neonatal hypertension bothered me because of the uncertainty, the lack of data to drive decisions. We usually cannot identify a cause, we cannot determine which tiny minority of patients will not do well, and yet we hope to do no harm using drugs not approved for use in infancy.

In my case, I wanted a rational approach to the common neonatal hypertension patient who had no evidence of kidney or vascular problems to explain the hypertension. I picked a level of blood pressure that seemed significant, and I decided to treat at that level.

Physicians deal with uncertainty on a daily basis. We rarely know everything about a patient (not until the autopsy, anyway), and our patients rarely fit the textbook completely. Recognizing patterns and responding to them makes practice possible, although numerous examples in Jerome Groopman’s book illustrate the dangers of these thought processes.

Lots of doctors proclaim that they do not practice “cookbook medicine.” In other words, they treat each patient individually rather than relying on rules, flowcharts, and other “cookbooks.” Of course, they all do rely on rules to some extent- the important thing is to realize when the pattern and response to treatment vary in some important way that will influence the patient’s outcome.

As I noted at the end of my earlier post, my rule seems to be serving me well. I spent far more time considering why I formulated it than I took to create it.

Fuzzy Women

First, I am pre-menopausal. Still cycling, thank you very much.

Peri-menopausal? Can’t deny that. I mean, you expect that when your next birthday puts you at the half-century mark.

But I have had excessive facial hair for a long time. Since puberty. A mustache. It’s been bleached, dissolved, shaved, and waxed.

I put patients, including teen-age girls, on medications that increase hair growth. I am able to discuss various forms of hair removal with them from my own personal experience.

So when this video showed up in my twitter feed this morning, I really appreciated it:

H/T to @dikeough via @RebeccaSkloot.

By the way, my husband is an endocrinologist. The Gland Man. He thinks facial hair on a woman is a good thing because it means the androgens are working, pushing our sex drives. He probably just says that to make me feel better, but feel free to quote him if you need to put a positive spin on facial hair sometime.

Remember: You are not alone.

A Major Award and a Major Headache

Last night, my husband won Specialty Physician of Distinction for The Nebraska Medical Center. He poses with his plaque and Beth Pfeffer, the nurse manager of the Diabetes Center and Service Line who nominated him.

One bonus of the evening was the keynote address by J. D. Kleinke, medical economist extradordinaire. His views on healthcare reform provided further support for my own, and one of his books sounds like a must-read: Oxymorons: The Myth of U.S. Health Care System (2001).

I hoped to post this morning so my husband’s achievement could be easily shared with friends and family; unfortunately, my patients did not allow it. When I finally got to a computer, I skimmed one of my regular reads, White Coat Underground. The post today raised an interesting question: would health care reform cause physicians to leave medical practice?

I will let you read the original post, because the question (and supposed answer) are not, well, real.

I do know something that will make physicians consider leaving medical practice, though: Maintenance of Certification (MOC).

In the old days (before 1985), a medical student graduated and took one of two courses of action. After 1 or 2 years of rotating internship, most states would license an MD for general practice. Alternatively, one could pursue residency training for a number of years and then sit for board certification examinations in specialties. These specialties included primary care (Internal Medicine, Pediatrics) and more specialized fields (Endocrinology and Pediatric Nephrology for my household). Once you passed the test, you were board certified forever.

A few years back, someone decided that certification should not be forever. Boards should have processes to certify that a physician’s knowledge and skills remained current. I was in the first group in pediatrics that could not get permanent certification (we became board eligible in 1988).

It sounds reasonable to require continuing medical education (CME), and state licensing boards have required documentation of such coursework for years. Sitting through a lecture did not insure learning, though. This new process would assure specialty-specific CME, along with the examination to document the accomplishment. So far, so good.

But then the powers that be decided that knowledge alone does not a physician make. Practicing medicine requires skills not tested by traditional multiple choice exams. Thus, MOC was born.

MOC includes (1)maintaining unrestricted medical licensure; (2)completing qualified education modules; (3)practice improvement projects and patient surveys; and (4)secure examination.

My husband is currently performing a practice improvement module. A quality measure has to be first defined, and then measured via a chart audit. Once measurements are made, an improvement project can then be implemented. This takes time and person-power to accomplish. In academia, he has time to pursue this, along with support staff to help carry it out. Those in private practice will have to clear patient schedules to perform these tasks (loss of revenue), and/or hire personnel to perform them (increased costs). Either way, these requirements have negative economic impact on a practice.

Will physicians continue to practice after a couple of rounds of MOC? I believe most will; after all, taking care of patients drives most doctors to “doctor.” Will doctors maintain certification? A number of insurers require MOC for reimbursement of specialty services, so I suspect many will. I guess a fair number will not, especially in primary care. Once your patient base is set, they are unlikely to ask if you have maintained certification. Many doctors may find that patients prefer to have them more available, rather than working on MOC.

I recertified in general pediatrics once. At the time recertification was an open-book exam via personal computer. I learned a lot of things that I had missed while devoting myself strictly to my subspecialty. It was a great experience, and I had no ill will about doing it (not even the cost). I will no longer be maintaining this certification for a number of reasons, especially the fact that I have no general pediatric patients for the required survey. I am enrolled in the Pediatric Nephrology MOC program.

MOC looks good on paper, but it will not be easy to complete, especially in a clinical practice environment. Only time will tell if physicians maintain certification and if MOC makes any difference in physician performance or patient satisfaction.

Lack of data never stopped anyone from enforcing a course of action.

Qualitative Quap

The blogosphere has been buzzing about a recent publication on science blogging. The study by Inna Kouper is “an attempt to understand current practices of science blogging and to provide insight into the role of blogging in the promotion of more interactive forms of science communication.”

She examined eleven blogs.

I must admit I have trouble getting my brain around qualitative research. To my mind, research should provide information that can be generalized or applied in some way. Many forms of qualitative research cannot be used this way.

I asked one of my colleagues who really likes this sort of analysis what he thought of a sample size of 11 for this study. He said that was a reasonable number depending on the goals and methodology of the study. A qualitative study would not necessarily require a random sample of a certain percentage of blogs; that’s quantitative research thinking!

So I sent him the paper.

He was not impressed.

[One] disturbing part of this is that the methods do not mention how or why the particular blogs were chosen.  There is no consistency and no specific criteria that is detailed.  That is important for any qualitative analysis because there should be a specific phenomenon that is being analyzed.  This author very loosely commented that the purpose was to look at science-related blogs and the responses. That is very broad and does not guide one to believe looking at only 11 blogs is useful data....even in qualitative studies.

He also comments that the qualitative analysis theory the study used was exceedingly difficult to find within the manuscript. His most damning criticism:

[More detail is needed on the] data reduction that was done.  Yes, the author details how items were coded.  However, this coding process was not validated by an independent reviewer to ensure they were coding in a similar manner.  That is the one way to ensure reliability and credibility of the data collection and data analysis process.  This was not done at all from what I read.

Qualitative research is a different world, but even in that world there are problems with this work.

For earlier posts on this study see:

A Blog Around The Clock

DrugMonkey

On Becoming a Domestic and Laboratory Goddess

I realize I have not credited my qualitative statistics expert; I will let him “out” himself, if he desires, in the comments section.

Membership Has Its Benefits

I remember joining a sorority in high school. After pledging, we had secrets to learn. Rules, colors, and goals were memorized and recited, the exact texts never to be shared outside of our sisterhood. OR ELSE…

Dan Brown makes a pretty good living writing about secret societies. People keep joining these groups, even though death seems to be the price of holding their secrets.

Biomedical and scientific societies are not quite this secretive. Or dangerous.

In an email on March 10, The Scientist linked to an essay on membership in scientific societies. Steven Wiley briefly discusses the origins of scientific societies and their vanishing benefits. Most journals are readily available online or through a university library. Opportunities to present work flourish. Groups can be powerful advocates for funding as the NIH budget seems to be driven and targeted more and more by special interests. Networking and career advice also provide value.

Some of these groups have trouble:

many of the larger societies are struggling with stagnant or declining memberships, especially among young scientists. Although it is the youngest scientists who potentially have the most to gain from a scientific society because of networking opportunities, they are the ones who usually are most poorly served by those societies. This is because scientific societies generally cater to the status quo…

It does not have to be this way.

As a nephrologist, my strongest allegiance is to the American Society of Nephrology. I joined after completing fellowship because it was the “thing to do.” It got me a bit of a discount on registration for the annual meeting, and I could submit my abstracts without having to track down a sponsor to sign the submission form (yes, it was that long ago). Over the years, ASN has published two journals (JASN has the highest impact-factor of nephrology journals; CJASN has grown into a monthly publication), an update and self-assessment program publication (NephSAP), and a newsmagazine (which I edit).  The society maintains several grant programs for research funding, and it leads advocacy efforts to maintain adequate federal funding for kidney disease research and treatment. Full benefits of membership can be found here.

ASN maintains relevancy with some less traditional output as well. Highlights of the annual meeting become RenalWeekends for members unable to attend RenalWeek, the big annual meeting. Members also work closely with the certification boards on the development of Maintenance of Certification (MOC) coursework and criteria. Board Review Courses provide another membership benefit. In the last few years, web-based learning and podcasts added to the society’s offerings.

The American Physiologic Society also impresses with their efforts to provide relevant services to members (click here for the full benefits page). For example, students and young investigators awarded travel grants for Experimental Biology are paired with “meeting mentors.” Mentors and mentees (is that a real word?) are corralled together during EB. Advice imparted includes getting the most out of a huge meeting and the power of networking. APS provides much needed career support for those pursuing careers in academia or industry, research or teaching. Advocacy and public relations on a number of topics are another service provided by the organization that make my dues worthwhile.

One reason I feel these are value-added organizations is that I have been behind-the-scenes working on committees and projects. I have seen the effort that goes into making the world, at least from the members’ perspective, a better place. Their offices are not just a clearinghouse to process membership fees.

Some of the groups that get my dues do not impress me that much, and I maintain membership because I should. Others, like ASN and APS, are making a difference. If you belong to a group that is underperforming in your eyes, perhaps you need to get involved and make something happen. Most big organizations seem to need volunteers for committees and advocacy (what they call unpaid lobbying), and they welcome junior member participation, at least in my experience.

When you come right down to it, organizations are their members.

Happy World Kidney Day 2010!

Once again the second Thursday in March has rolled around, bringing celebrations of all things kidney with it! World Kidney Day, for ye of little faith, is a real event (go ahead and click the link if you don’t believe me), but it really needs better PR.

This year’s theme reminds folks to protect their kidneys by preventing and controlling diabetes, a disease near and dear to my heart both personally and professionally. Today should be doubly festive in my household.

And that is the problem. We have no generally recognized festivities for World Kidney Day.

No songs.

No gifts or cards.

No activities or foods.

In the spirit of the day, I invite people to suggest ways to make the second Thursday in March more festive. Christmas has candy canes and cookies. Easter has Cadbury eggs and Peeps. What special foods should we have for World Kidney Day? Please do not suggest anything containing actual kidney; that would be (1)too literal to be clever and (2)something I do not like (and yes, I have tried steak and kidney pie; IMHO, a waste of steak).

Next week a whole bunch of people will become Irish for a day; beer would be an appropriate beverage for today without even dying it!

Come on! We have a year to make World Kidney Day 2011 unforgettable!

Pee on Earth, Goodwill to Urine!

Top image created by Pascale Hammond Lane.

Other images courtesy of PhotoXpress.

del.icio.us Tags: world kidney day

Primer on NICUs

Last week I posted on neonatal hypertension. This week I am reminded that not everyone appreciates the level of care some newborn infants require, nor that nurseries are rated for the level of care that they may provide.

The American Academy of Pediatrics describes 3 major levels of newborn nursery care, with 4 sublevels for those serving the sickest infants as outlined below:

Basic neonatal care (level I)

    Well-newborn nursery

    Evaluation and postnatal care of healthy newborns

    Neonatal resuscitation

    Stabilization of ill newborns until transfer to a facility at which specialty neonatal care is provided

Specialty neonatal care (level II)

    Special care nursery

    Care of preterm infants with birth weight at least 1500 g

    Resuscitation and stabilization of preterm and/or ill infants before transfer to a facility at which newborn intensive care is provided

Subspecialty neonatal intensive care (level III)

Level IIIA

        Hospital or state-mandated restriction on type and/or duration of mechanical ventilation

Level IIIB

        No restrictions on type or duration of mechanical ventilation

        No major surgery

Level IIIC

        Major surgery performed on site (eg, omphalocele repair, tracheoesophageal fistula or esophageal atresia repair, bowel resection, myelomeningocele repair, ventriculoperitoneal shunt)

        No surgical repair of serious congenital heart anomalies that require cardiopulmonary bypass and /or ECMO for medical conditions

Level IIID

        Major surgery, surgical repair of serious congenital heart anomalies that require cardiopulmonary bypass, and/or ECMO for medical conditions

I visited a shopping center yesterday that was plastered with posters about a new Women’s Hospital nearing completion in Omaha. According to these posters, this place will provide comprehensive service for mothers and infants, including the first level III NICU in west Omaha. On their website they describe the design and engineering that will make their facilities wonderful:

Unfortunately, the subtlety of “virtually all” critically ill neonates may be lost on a lot of laypeople. Many of them will see the following still on the landing page and assume that “everything” means, well, everything:

I am one of two Pediatric Nephrologists in this region. We currently see patients, including sick newborns, at 3 hospitals in the Omaha area, all with level III NICUs (2 are IIID; the other is IIIC or D). I also have a lab and a bunch of other job responsibilities, so I am seeing patients about one-third of the time. Essentially, a single kidney specialist serves the state of Nebraska and other nearby areas (western Iowa and the Dakotas). Covering the hospitals we currently serve is difficult at best. Another level III NICU in Omaha (covered by our neonatologists) wants us to provide services, but we do not have the personnel to do it. They show similar ads for their NICU around town, and I shudder when I see the billboards.

Adding yet another NICU to our coverage is not in the cards right now. In other words, if your baby encounters problems with its kidneys, pediatric subspecialty care will not be available at this shiny new neonatal unit. I am sure it is a beautiful unit, with everything new parents could want. But not a nephrologist.

I cannot speak for all pediatric subspecialists in Omaha, but it is not clear which, if any, of them will be covering the new hospital.

Parents need to understand these issues (if they are not having an absolutely uncomplicated pregnancy) and discuss the best place to deliver with their perinatologist. Ask if the appropriate pediatric specialists will be available immediately, if needed, or if the baby will have to be transferred to get all the care it (probably) needs. Ask if you can talk to these specialists before planning your delivery. Some abnormalities may not require immediate care, allowing mom and dad more choices about where baby is born. Other conditions will limit options; transporting the baby in a uterus is generally easier than moving a critically ill newborn in an ambulance.

del.icio.us Tags: Clinical,Medicine,NICU,Omaha

More On Money

A few days ago I posted a query about raises with promotions in academia. I queried some other sites as well, ones with readers with experience in the whole promotion thing.

I am dismayed.

Most of those who answered pointed to educational salary sites. One can presume, based on the increase in median salary from rank-to-rank, that there is that level of increase. Some schools have rules, generally a set amount based on the tabular data from AAMC or other standard sites.

Many schools have no increase in salary with rank. Promotion occurs through acquisition of grants or clinical work. These activities may make one eligible for incentives that increase salary as well as resulting in promotion.

But no increase in base pay.

So even though one gets promoted with tenure, and a guaranteed salary line, the amount guaranteed remains low. Many who have responded report never receiving any raise to base pay besides small cost-of-living  boosts.

I expect more answers will be coming in, and I will update if I get any novel information.

I didn’t realize how good I had it.

del.icio.us Tags: academia,promotion,salary

Ignore or Engage?

Last night my daughter called to talk to her brother with an unusual question:

Who were those people dressed like fairies outside of your high  school?

Seems Westboro Baptist Church has been making the rounds in Omaha. Yup, the “god hates fags” people targeted a high school for the unforgiveable sin of putting on the school edition of Rent (last month) and having a Gay-Straight Student Alliance. My daughter was in the group of students that put together that alliance. I am pretty proud of that.

Other high schools in the area have been targeted recently. The schools know when the protesters are due, since they are “kind” enough to post a schedule online (Academy Awards, you have the next one). The local schools have not engaged the protests; I guess fairies are like trolls and go away if you withhold food. Or publicity.

No mention made of the activity on the local news or in the paper this morning. Maybe if we ignore them they will go away. Maybe the schools have it right. I just hate to do that; when we do not actively fight hate and ignorance, I feel like we give it approval. Writing this blog may be the wrong thing in the eyes of some, but I feel better letting the world know that at least one family at our high school disagrees with these bigots.

Note: I included the link to the church’s website above, but I don’t recommend clicking on it unless you want to see a whole lot of offensive ignorance in full-color html.

How Much To Request, How Much To Expect

A question arose in discussion earlier today:

When being promoted in academia, what sort of performance raise should one request or expect?

In biomedical specialties in centers that include medical schools, there are standards for salary by region and rank available through the Association of American Medical Colleges. There are a couple of problems with relying on these data to determine your salary goals.

First, they report median and various percentiles for your department, rank and administrative title, and region of the country. Years in rank generally are not filtered in, so knowing an appropriate “starting salary” is more difficult. Second, these are lag data, reported after the fact. Salaries (should) already be higher than what is reported.

Some institutions use the median for rank and region as a base, adding in fudge factors for years in rank, productivity, and other variables. While this approach seems fair, it means there is really no market working in academic medicine. Basing salaries on regional medians works to keep everyone in the same range, even in short-supply specialties like my own.

The only guide I have ever received was 10%. If you get a promotion or tenure, you should receive at least a 10% raise. If you change institutions, even without change in rank, you should get at least 10% more in salary than in your old position.

Since most of my promotions occurred within a single institution, there was no “request” for a raise with promotion; I knew my chair would make it 10% since he gave me the above guidelines. However, what if you have the opportunity to request a performance raise. How much should you request? Is there a limit to how high you can go without looking like a greedy, ungrateful wretch?

I am looking for experiences. Please leave your comments, opinions, gripes, etc, along with your general area (basic science department, clinical science, whatever). I realize this is an extremely unscientific survey, but we have to start somewhere.

Photo courtesy of PhotoXpress.

Hyper-what? In the NICU!

I get consulted a lot for neonatal hypertension.

In actuality, most cases I see are not really neonates but premature infants who are nearing their due dates. They often have chronic lung problems or other major health issues and a history of umbilical vessel catheterizations.

Because of issues with measuring and confirming blood pressures in this age group, our practice is to rely on the systolic measurement (SBp). A variety of studies address normal blood pressure in neonates, with most showing a value of approximately 110 mmHg as the 95th percentile after the first 2 weeks of life. Elevated blood pressures in these infants rarely cause detectable end-organ damage such as cardiac enlargement. Virtually all infants with blood pressures above the 95th percentile have complete resolution of this condition by 2 years of age. Risks and benefits of treatment or non-treatment remain unclear.

Values repeated greater than the 95th percentile for age warrant a work-up that includes estimated glomerular filtration rate via serum creatinine measurement; a urinalysis and culture; and a renal ultrasound with doppler bloodflow studies. Echocardiogram may show a cause for the SBp elevation, or may indicate end-organ damage. We rarely find a secondary cause for the blood pressure elevation. 

The question remains whether to treat or not to treat. No studies provide concrete evidence of benefit of treatment. Major risks of medications include dropping the blood pressure too low. Occasional reports of death, heart failure, and encephalopathy associated with high blood pressure warrant careful consideration of treatment benefits, though.

About 10 years ago, I decided to make a “rule” about how I would handle these babies. SBp of 110 seemed the critical value. Since most of these infants were still in neonatal units, we generally had access to multiple readings over several days. If the SBp were greater than 110 on more than half of the readings, treatment with an angiotensin-coverting enzyme inhibitor was recommended. Otherwise, ongoing observation of SBp occurred.

My last call week included several infants with SBp elevations, so I pulled more recent articles on this topic. While no definitive randomized trials or other evidence-based studies have been published, the overall recommendations remain consistent with those I created a decade ago, as far as I can tell.

I feel better now. But I wish we knew more.

References:

Arch Dis Child Fetal Neonatal Ed 2002;86:F78-F81 doi:10.1136/fn.86.2.F78

Pediatr Nephrol. 2009 Jan;24(1):141-6. Epub 2008 Jul 9 doi:10.1007/s00467-008-0916-9

del.icio.us Tags: Clinical,medicine

When Kidneys Fail: A Brief Glossary

One of my current projects centers on the rebuilding of the continuous renal replacement therapy (CRRT) program at Children’s Hospital and Medical Center in Omaha, NE. Last week I blogged from a CRRT meeting on Coronado Island, and more posts will include these topics as the project progresses. Definitions seem in order.

When kidneys fail, some form of dialysis must be performed to replace their function. Most people have heard about hemodialysis, illustrated in the photo, in which blood is pumped out of the body, run through an artificial kidney, and then returned to the circulation. Another form, peritoneal dialysis, uses the blood vessels that run through membranes in the bowels to filter blood. A tube inserted into the abdomen allows fluid to surround the bowels. After time for wastes to enter the fluid, it is drained and replaced.

CRRT is a continuous form of hemodialysis.  Some forms of CRRT use primarily hemofiltration to remove water and wastes from the body. Blood passes through the dialysis cartridge as in hemodialysis, but no dialysate passes around the blood filters. Instead, large amounts of filtrate are removed and then replaced with an appropriate sterile solution. In many cases, patients require both this type of clearance as well as dialysis to maintain appropriate biochemical balance; these therapies are collectively called hemodiafiltration.

CRRT removes fluid and wastes continuously, thus providing gentler shifts in balance than traditional hemodialysis. This therapy class most frequently benefits unstable intensive care patients who would not be able to tolerate hemodialysis and in whom peritoneal dialysis may not be feasible.

A pediatric CRRT program faces special challenges. First, virtually none of the devices have been FDA-approved for use in children; pediatric CRRT is not a huge market. Second, we are dealing with a much wider range of patient size than the adult market, with weights ranging from 5 to 300 pounds. Scalability becomes much more of an issue.

The process of rebuilding a program can be tedious, but we will develop state-of-the-art capabilities. Next step? Reviewing hardware.

Stay tuned!