Another marriage equality win – in Wyoming

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U.S. District Court Judge Scott Skavdahl ruled today against Wyoming’s law banning marriage equality for same-sex couples.  Judge Skavdahl granted a temporary stay and the ruling will not go into effect until October 23 or until state government officials say they are not appealing the decision. In his ruling, Judge Skavdahl wrote, “The court understands that every day where same-sex couples are denied their constitutional rights is another day filled with irreparable harm.”

Wyoming’s Governor Matt Meade has previously said that the state should not appeal the district court’s decision if the ban is struck down.

Judge Skavdahl’s ruling came hours after a similar ruling in Arizona, although the judge in Arizona refused to issue a stay.  If Governor Meade’s statement is any indication, marriage equality will be swiftly coming to Wyoming.

Wyoming Marriage Equality Win

Marriage Equality in the Grand Canyon

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Today, October 17, U.S. District Court Judge John Sedgwick ruled in favor of the freedom to marry in Arizona in a federal legal case that challenged the state’s anti-marriage constitutional amendment.

Judge Sedgwick also refused to place a stay on his decision, meaning marriages could begin almost immediately.

Arizona geographically falls under the U.S. Court of Appeals for the 9th Circuit, which recently ruled in favor of mariage equality in both Idaho and Nevada.  Arizona’s Attorney General has said that he will decide on Monday, October 20 whether or not he will appeal the ruling.  Given the 9th Circuit’s prior rulings, it is highly unlikely that any appeal would be successful.

ArizonaRuling marriage equality

seriously people…

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Marriage equality marches forward

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While I was away for the long weekend, several key victories occurred for marriage equality.  In case you missed them as well – a quick little wrap up for you.

North Carolina – On Friday, October 10, a federal judge in North Carolina agreed that the ruling in favor of the freedom to marry in the 4th Circuit also applies to North Carolina’s state constitutional Amendment 1, which bans same-sex couples from marrying.  In the ruling, Judge Cogburn wrote:

The issue before this court is neither a political issue nor a moral issue. It is a legal issue and it is clear as a matter of what is now settled law in the Fourth Circuit that North Carolina laws prohibiting same sex marriage, refusing to recognize same sex marriages originating elsewhere, and/or threating to penalize those who would solemnize such marriages, are unconstitutional.

Same-sex couples were immediately issued marriage licenses on Friday.

Alaska -  On Sunday evening, a federal judge struck down Alaska’s ban on same-sex marriage.

The U.S. District Court for the District of Alaska ruled that the state’s ban was unconstitutional under the Due Process and Equal Protection Clauses of the U.S. Constitution.  U.S. District Judge Timothy M. Burgess wrote that any relationship between the ban and government interests was “either nonexistent or purely speculative.”  In the ruling, he states,

Alaska’s same-sex marriage laws are a prime example of how ‘the varying treatment of different groups or persons is so unrelated to the achievement of any combination of legitimate purposes that we can only conclude that the legislature’s actions were irrational.  [...] Refusing the rights and responsibilities afforded by legal marriage sends the public a government-sponsored message that same-sex couples and their familial relationships do not warrant the status, benefits, and dignity given to couples of the opposite sex.

Alaska’s governor has already announced plans to appeal the ruling to the 9th U.S. Circuit Court of Appeals, although that court ruled against similar bans in Nevada and Idaho.  You can already hear Sarah Palin having a coronary.

Idaho - The 9th Circuit Court of Appeals has dissolved the stay blocking same-sex marriage in Idaho, announcing that couples may begin marrying on Wednesday morning.

On Oct. 7, the 9th Circuit Court struck down both Idaho and Nevada’s gay marriage bans.  Marriages were allowed to begin immediately in Nevada, but the U.S. Supreme Court issued a stay after a last-minute appeal by Idaho officials, temporarily putting same-sex marriages on hold in the state. On Oct. 10, the nation’s highest court said Idaho could proceed with same-sex marriages.

marriage equality marriage momentum hrc

hilarious blogger

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Every once in a while on slow days at work, I peruse the internet looking for newsworthy articles to blog about or the latest funny blog.

Well, today I found one.

It’s titled Where Am I? and it’s hilarious.  Kristin’s musings on co-ed gyms are funny as hell.  And her post “Why Pinterest is Ruining Weddings” begins as follows:

I like Pinterest. I have many boards that keep me humble including “Foods That I’ll Never Make” and “Crafts I have No Time For,” because let’s be serious for a minute. Yes, that 5 layered dessert with about 50 ingredients looks amazing but in reality I have no patience to make something like that and will show up at a cookout with a box of cookies (store bought!).

Check it out – you might get a laugh or two.

Marriage Equality meets Appalachia

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The West Virginia Attorney General announced today that his office will no longer fight a court challenge to West Virginia’s ban on same-sex marriages.  West Virginia Attorney General Patrick Morrisey issued a statement Thursday that his office “will respect” the recent U.S. Supreme Court declining to review the 4th Circuit Court’s ruling in July striking down Virginia’s ban on same-sex marriages.

U.S. District Judge Robert Chambers in Huntington had previously put West Virginia’s case on hold. On Tuesday, Chamber ordered the state and clerks in Kanawha and Cabell counties to respond to a motion by plaintiffs by Oct. 21.

West Virginia’s Governor Earl Ray Tomblin added:

I do not plan to take any actions that would seek to overturn the courts’ decisions. West Virginia will uphold the law according to these rulings, and I have directed state agencies to take appropriate action to make that possible. Our state is known for its kindness and hospitality to residents and visitors alike. I encourage all West Virginians—regardless of their personal beliefs—to uphold our statewide tradition of treating one another with dignity and respect.

west virginia marriage equality

Marriage Equality in the Silver State and Potato State

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The 9th U.S. Circuit Court of Appeals in San Francisco ruled today in pending appeals on marriage equality bans in Idaho and Nevada.  The court, led by Judge Stephen Reinhardt, struck down the gay marriage bans in Idaho and Nevada.  The ruling comes a day after the Supreme Court effectively legalized gay marriage in 5 more states and opened the door in 6 other states when it rejected a set of appeals.

The appeals court ruled that gay couples’ equal protection rights were violated by the bans. Judge Stephen Reinhardt said during oral arguments in September that he expects the Supreme Court ultimately will decide whether gay marriage bans are constitutional.

The opinion, issued by Judge Reinhardt, reads:

We hold that the Idaho and Nevada laws at issue violate the Equal Protection Clause of the Fourteenth Amendment because they deny lesbians and gays who wish to marry persons of the same sex a right they afford to individuals who wish to marry persons of the opposite sex.

9thCircuitVictory marriage equality

Prepared to play doctor?

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I’m not sure how I missed the article, but one of my favorite New York Times bloggers wrote a piece in April titled “Are Med School Grads Prepared to Practice Medicine?”  I applaud Dr Pauline Chen’s attempt to discuss the variability of medical education across the United States and the need for more uniform standards and testing, but the resounding answer to this question is obvious and is absolutely no.  Reading the comments on this article (something I keep telling myself not to do but somehow cant avoid) would make you think that every young doctor out there is completely incompetent and therefore is not ready to practice medicine.  My opinion might be unpopular, but I would argue that not being prepared to practice medicine out of medical school isn’t necessarily a bad thing.

I’ve often commented that medical school is the time for learning how to act like a doctor, while internship is for learning how to actually be a doctor.  Part of the problem with preparing medical students to be physicians is that no amount of training can fully prepare you for internship.  As one of the chief residents this year, it has become all to clear how “preparing students to be doctors” is almost an insurmountable challenge.  Throughout their “clinical training”, third and fourth year students struggle with the tremendous amount of factual information they must learn in the chaotic environment of the hospital, while preparing for exams at the end of their rotations that are a test of knowledge rather than skill.  Additionally, students are often observing residents and attendings interact with patients, and rather than being the lead are often at the bottom of the totem pole, a situation that makes acquiring clinical knowledge much more difficult.  As it is, medical school still focuses on education for factual knowledge instead of clinical knowledge.

Interns are no different, and their learning curve is particularly steep.  Surgical interns start out particularly handicapped – not only must they conquer the knowledge base of a medical doctor, but they must also acquire the skills necessary to be a young surgeon.  But a solid knowledge base of medical facts does not ensure that a student will be prepared to be an intern; the critically important part of intern year is learning accurate clinical judgments.  Learning that skill that takes variable amounts of time to acquire from resident to resident, and among attending physicians, some will always be better than others.  Interns are also charged with taking care of far more patients than their student counterparts, and while the amount of responsibility students have varies across medical schools, interns are directly involved and responsible for patient care.  Part of learning to be a physician is well… actually being a physician.  If students came in fully prepared to practice, what would we need residency for?

I firmly believe that nothing can fully prepare you for the first time your pager goes off as an intern and an emergency in one of your patients awaits you on the other end of the line.  But perhaps there is room to do better in training medical students.

Marriage Equality Monday

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Last week, the US Supreme Court announced its 2014-2015 case docket, and much to the dismay of LGBT advocates, the Court revealed they had yet to add a marriage equality case to their calender.  In a a supreme move (see what I did there), the Court announced that they would not hear an appeal from five states seeking to prohibit same-sex marriages, paving the way for an immediate expansion of marriage equality.

The justices on Monday did not comment in rejecting appeals from Indiana, Oklahoma, Utah, Virginia and Wisconsin, immediately ending delays on marriage in those states.  The decision also makes appeals court decisions in the 4th, 7th, and 10th circuit courts the law of the land, making marriage equality likely to come in 6 more states for a total of 30 states and the District of Columbia.

Huge.  Epic.  Monumental.

marriage equality

National Breast Cancer Awareness Month

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I will undoubtedly get into trouble for this post.  So be it.

October 1st marks the beginning of National Breast Cancer Awareness month, an annual international health campaign organized by major breast cancer charities every October to increase awareness of the disease and to raise funds for research into its cause, prevention, diagnosis, treatment and cure.  Unless you’ve been living under a rock, you’ve undoubtedly seen pink colored products in mass quantities over the past few years.  It seems like everyone “goes pink” for October.

I don’t want to trivialize breast cancer with the remainder of the post.  As a physician and a surgeon, I recognize the critical importance of mammograms and the devastation that breast cancer causes to thousands of women each year.  I also do not want to downplay the important work that is done by some breast cancer charities to support research toward ending breast cancer as well as screening and treatment.  But  before you go buying pink products this October, I want to add a word of caution to everyone out there, particularly women.

First, despite all the charity events, the “awareness”, and the funding, breast cancer is NOT the leading cause of death among women.  As far as a woman’s individual health is concerned, a good diet, exercise, and avoiding smoking are far more important to prevent heart disease – which happens to be the overall leading cause of death for women.  Avoiding smoking is doubly important because it’s highly associated with lung cancer, which happens to be the overall leading cause of cancer deaths among women.

Second, people should be aware of the term “pinkwashing” – the outrageous corporate practice of selling products linked to an increased risk of breast cancer while claiming to care about (and profiting from) breast cancer.  I encourage everyone to visit the website for “Think Before You Pink“, because it highlights a lot of the hypocrisy in pink products.  One of the more striking examples may be the NFL, which started “going pink” in October 2009 to support women and breast cancer.  Given recent events surrounding the NFL and domestic violence, one might question how much the NFL really supports women.  Of note, domestic violence affects more women annually than does breast cancer, and October also happens to be National Domestic Violence Awareness Month.  Additionally, an analysis by Business Insider found that only 8% of the money spent on the plethora of pink gear sold by the NFL ended up going to research at the American Cancer Society, the supposed beneficiary of the league’s efforts. Since 2009, when pink first appeared on the field, the NFL has donated a grand total of $7 million towards the cause, while the league made $9 billion in revenue in 2012.

Third – be very critical of which charity you are supporting.  Susan G Komen Foundation is one of the most widely recognized breast cancer charity, yet only 15% of its donations in 2011 went toward breast cancer research, with less going toward screening and only 5% toward treatment.  For a charity that claims to be “for the cure”, spending nearly 43% of your donations on “public health awareness” seems a little suspect.  I’m not claiming that others are any better, but just be aware of where your money is going.  Donating directly to research institutions like Dana Farber or Memorial Sloan Kettering or to breast cancer survivor support groups might be more beneficial.

And finally, As the association Breast Cancer Awarness notes, pink ribbon products spread empty awareness – awareness that has failed to address and end the breast cancer epidemic. Pink ribbon trinkets on store shelves that promote “awareness” ultimately change nothing. We have more than enough awareness, but not nearly enough action that will make a significant difference to whether women get breast cancer or survive it. Awareness shouldn’t be the end goal; unfortunately, pink ribbon culture defuses anger about breast cancer and its devastating impact and distracts us from the meaningful actions that will achieve health justice.

Ultrasound – the new stethoscope?

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If you walk around most hospitals, you’re likely to find a stethoscope hanging around the neck of a number of medical professionals.  It’s probably safe to say that no other instrument has had such a lasting impact on medicine as the stethoscope, and no other single piece of equipment has come to symbolize “physician” quite like it.

The stethoscope first debuted in 1816 in France, when physician Rene-Theophile-Hyacinthe-Laennec rolled a piece of paper into a cylinder and pressed it to the chest of a sick patient.  Almost 200 years later, the stethoscope is used by almost every medical provider and has changed minimally from its humble beginnings.  In addition to symbolizing the profession of medicine, it has come to represent an intimate part of the physical exam – when is the last time your primary care physician didn’t listen to your heart and lungs?

But as Drs  Soloman and Saldana point out in their article in the New England Journal of Medicine, ultrasound may prove to be the new stethoscope of health care.  Over the past 50 years, ultrasonography has increasingly worked its way into different parts of medicine.  Much like the stethoscope – the ultrasound is employed by a wide variety of physicians; long a standard tool in obstetrics and gynecology, ultrasound has become the most widely used and cost-effective imaging modality for cardiologist.  ED physicians use ultrasound to perform basic abdominal, cardiac, and obstetric evaluations, and even surgeons use ultrasound during trauma scenarios.  Ultrasound can be used to evaluate the heart, the blood supply, the uterus and ovaries, the liver and biliary systems, and the kidneys.  Ultrasound has become the preferred imaging method for investigating intraabdominal pathology in children (such as appendicities) and pregnant women given the lack of radiation, as opposed to xrays and CT scans.

And much like most emerging technology, ultrasound machines have become smaller, more portable, and cheaper over time.  I’ve even seen ultrasound apps for smartphones – perfect for use in the field or in developing countries with less medical infrastructure.  It’s not too hard to imagine a future where instead of listening to the heart and lungs with a stethoscope, primary care physicians examine the heart with a portable, hand-held ultrasound machine – thus providing a more accurate picture of the patient’s cardiac function as well as a potential billing opportunity and source of income for primary care physicians.

Ultrasound’s advantages – low cost, no radiation, portability – are precisely why the technology has expanded so rapidly in medicine.  Yet ultrasound has a few drawbacks to further implementation, the first of which is accurately interpreting the images (a drawback inherent in all imaging modalities).  Inherent in in the first drawback is the other drawbacks – ultrasound is a skill that needs to be learned.  Currently, ultrasound education occurs mostly during residency, where Emergency Medicine, OB/GYN, surgery and medicine residents learn to use ultrasound targeted toward their own specialties.  Surgical residents are taught how to perform ultrasound exams in trauma scenarios and for certain procedures, while OB/GYN residents focus specifically on gynecologic and obstetric procedures.  More detailed examination of the heart and vasculature often occurs during fellowship training in cardiology or vascular surgery.  And ultrasound technology is extensively taught during residency training in radiology.

In order for ultrasound to become the “new stethoscope” and gain wider implementation, education in the proper use of ultrasonography must begin at the same point where physicians learn how to use a stethoscope – in medical school.  Undergraduate medical education must routine incorporate training in ultrasound in order for the technology to become “point of care”.  We cannot expect all of our physicians to be facile in using ultrasound if we don’t teach all of our “physicians in training” how to properly use the technology.  As Soloman and Saldana point out, a generation of physicians will need to be trained to view ultrasound “technology as an extension of their senses, just as many generations have viewed the stethoscope.  That development will require the medical education community to embrace and incorporate the technology throughout the curriculum.”