sDiagnosis of mental retardation = IQ >2 Standard Deviations below the mean + impairment of function.
To get a sense of patitent’s IQ, ask about their education, ask about their parents education.
“socializing is like skiing, the better you get the better it gets”
average attention span 22 minutes.
ADHD is the #1 reason for pediatric outpatient referrals!!!!
Referrals – school, parents, pediatricians in that order
30-50% of cases of ADHD are co-morbid w/LD
First thing to do when kid has delayed language development – hearing test.
FAQ – Is my kid manipulative because s/he won't sit still for math homework but has perfect attention for the Xbox/nintendo video game?
No - ADHD kids are understimulated. Paper and pencil mathhomework sitting stil is not stimulating enough, but the lights and colors of video games are far more stimulating. This also underlies the reason the stimulant is given as treatment.
Children manifest psychological disorders uniquely to adults. School is normally the major stress in a child's life. When you think about what is going on with a kid, you have to always think in developmental terms as the kids change so rapidly, also think Family Context!! Family Context!! It effects children much more significantly. A child can either internalize or externalize a trauma/mental illness/medical condition. Internalizing results in depression and anxiety and is egodystonic whereas externalizing disorders manifest as conduct disorders and tend to be egosyntonic. The major externalizing disorders are:
ADHD, conduct disorder (this is typified by an absence of remorse), oppositional defiantdisorder
Pediatrics can commit suicide, it has been found that the single greatest risk factor for suicide in a depressed child is a feeling of hopelessness.
From the mouth of a borderline, "I came here depressed and I'll be leaving suicidal" -individuals with borderline personality disorder often threaten suicide as way of leveraging, have to set limits!! w/borderline
ZyprexaZydis - an olanzapine wafer that dissolves instantly in your mouth, helps with compliance.
Suicide in Chinese vs US
US suicide rate 11.5/10^6, in '07 ~35,900 completed suicides
males 4x females for successful suicides
females 3x males for attempts
3rd leading cause of death for 15-24 year old, most common means FIREARM
90% of those who have committed suicide have some sort of psychological disorder
Risk Factors for suicide: past suicide attempt, having a specific plan, making an attempt without others being able to know (doing it in secret)
Chinese suicide statistics
China has 1/3 of global suicides. Rate is 23/10^6 people.
there are decreased rates of mental illness in China
Chinese male suicides much much more common than female suicide
Rural citizen has 3x the suicide rate than urban citizen
low plan suicides (impulsive) more common among the young
most frequent means, pesticide poisoning
risk factors: low social status, lack of social support
1. Connect (anyway, find anything to agree on, even agreeing on nothing)
2. Listen!
3. Have list of diagnosis in head - Achilles heel is not having a framework in place to pull from.
Do not interrupt!!! If you interrupt to clarify, sure you get your answers, but you won't see how they think!!
Psychoanalysis Metaphor:
Anatomy is what the person thinks
Physiology is how the person thinks
Hallucination- real sensory event in absence of stimuli
Hallucinosis - patient hallucinating but knows it, almost always a form of organic brain injury. Acute!! probably an emergency
Illusion - incorrect conclusion about real sensory stimulus, the chair in the dark looks like a monster
Attitude- a persons attitude is a reflection of their way of organizing social information into a theme.
Psychosis - loss of reality testing involves two categories
-ideas (reference, religiosity, grandeur...)
-sensations (bugs crawling on skin)
Near delusion - almost completely fixed false belief, a little room for doubt (e.g. - i am willing to entertain the notion that the CIA may not be controlling my mind from my microwave)
Overvalued idea - on the same spectrum as a near delusion, a little less fixed.
Somatic delusion - a healthy body w/subjective pain symptoms (back pain w/no medical explanation)
Panic disorder - SSRI 1st line treatment, can have paradoxical response so start extra low and uptitrate, if you're gonna prescribe meds for panic disorder patient will have to be on them longer, clinically looking for "1 year of feeling good"
Panic disorder - cognitive behavior therapy, psychodynamic therapy - just don't harp on physical symptoms (if present)
Buspirone: non benzo anxiolytic, an adjunct - big plus: NO SIDE F/X, takes time to work
Tricyclics can be very sedating, start low. They can also create a conduction block so clear an EKG. The most sedating is amitriptyline (Elavil), lots of anticholinergic side F/X, dry mouth, constipation, urinary retention, vision problems
üTD hyperkinetic movement disorder from prolonged dopamine block
oCaused by antipsychotics and metoclopramide
o“Tardive” latin tardus –slow (delayed onset) history of >3months don’t confuse w/acute and EPS (although associated)
oInvoluntary movements –
§Choreiform (greek khoreia: to dance– rapid, jerky, nonrepetitive
§Athetoid (greek athetos: without position)– slow, sinuous
§Rhythmic (stereotypies)
üTD manifestations
oOral, facial, lingual dyskinesia (3/4 of patients, typical in older patients)– protruding/twisting tongue, pouting, puckering, smacking, bulging of cheeks, chewing, blepharospasm
oLimb dyskinesia (~1/2 of patients, more typical in younger patients) – “piano playing” finger movements, foot tapping, toe extension, akathisia (subjective motor restlessness; occur both early and late in AP tx)
§Tardive akathisia – inability to sit still, crossing/uncrossing, marching in place, rubbing hair or face w/hand
oRespiratory dyskinesia – cause tachypnea, grunting
oTremor/tics/myoclonus – uncommon
üSUBTYPES
oTransient TD – brief, limited only during treatment
oWithdrawal Emergent TD – described in pediatrics following discontinuation! Common for TD to appear after a reduction in dose or switch to less potent AP. Called “unmasking”. Withdrawal TD normally resolves within several weeks.
§Manifested by reducing dose or coming off drug which unmask the disorders (in fact last resort treatment to resume AP)
üPathophysiology
oUnknown – working theories include
§Dopamine receptor supersensitivity (evidence of striatal dopamine receptor upregulation)
§Decreased GABA inhibitory interneuron firing in basal ganglia leads to excitotoxicity (ev -chronic AP treatment in primates leads to reduced GABA/glutamic decarboxylase)
·D2 block (inhibitory) increase glutamate firing in striatum and subthalamic nucleus
oLeading theory – imbalance between D1/D2 firing b/c of preferential block of D2 (supported by increased atypical EPS threshold)
üPrevalance – AIMS (12 item inventory) difficult to assess accurately b/c AP both cause and mask the clinical manifest, fluctuates based on emotional arousal, orofacial dyskinesia common in age 65
oThus, current point prevalence has range from 3-77%
oDSM-IV – 20-30%
ü1st Generation -1982 analysis of 35K cases put prevalence @ 20%
ocontrols had prevalence of spont dyskinesias @5%
§therefore – estimated prevalence at 15%
ü2nd Generation – less D2 block, more 5-HT2A block
oCase reports -Clozapine – almost no risk of EPS
oCase reports – risp/olanz have greater risk for TD than other atypical
oassociated w/akathisia and NMS
ostill better than 1st gen, but not as safe as previously thought
§short term studies
§very few patients are AP naïve, this is a risk factor for TD
§In reviews earlier patients had schizo later had dementia
üRisk factors -
oOlder age, length of exposure, female, brain damage, affective disorder, history of ECT, use of anti-cholinergics, African American ethnicity
üPREVENTION – early detection!
o>3months treatment should be limited
ometoclopramide should not be used >12months
oshould inform patient of risk, possibly obtain consent given medicolegal implications
üTreatment guidelines – only give when absolutely necessary, if the psychosis is controlled, attempt to reduce dosage or eliminate
oLong term use is discouraged in neurosis, anxiety, Axis II, chronic pain
oMonitor patient using AIMS scale (abnormal involuntary movement)
üTREATING TD – few therapies (lower, change, stop)
oDiscontinue drug – within 3 months ~1/3 remit, 12-18months 50%, as late as 3 years
oswitch to atypical antipsychotic – may just be masking, or gradual improvement w/weaker drug
§clozapine - @least 8 studies since 1991, all uncontrolled, effective at reducing tardive dystonia
oBenzodiazepine- mixed results in trials: DBRCT 19 patients: clonazepam- start 0.5mg and titrate max 3-4mg/day
oBotulinum: multicenter 29/34 shown to help cervical dystonia/blepharospasm
§Contraindicated in Myasthenia Gravis
oTetrabenazine (approved Aug08 for HD)/mirtazapine – deplete dopamine storage used for Huntington’s chorea and debilitating TD
oAnticholinergics - benztropine (*anticholinergics exacerbate choreiform disorders but good for acute/tardive dystonias/EPS)
PANDAS - pediatric autoimmune neuropsychiatric disorder associated w/strep A
Bedwetting aka nocturnal enuresis most likely to happen in first third of the night
Garlic breath - could also be arsenic poisoning
Lifetime prevalence of psych disorders (chiefly anxiety and depression) in epileptic patients - 20-30%
How to differentiate a generalized tonic-clonic from a non epileptic seizure?
check prolactin levels - they are elevated in the epileptic form, but have to get sample within 20minutes
postcardiotomy delirium is differentiate from delirium tremens of alcohol withdrawal because the former does not have the autonomic activation. The prevalence of postcardiotomy delirium has remained constant at 32% over the years!!!!
Mental retardation
IQ:
50-70 mild retardation - 90% (6th grade level)
35-55 moderate ret... - 7% (preschool level)
25-40 severely ret...- 3%
20-25 profoundly ret - less than 1% (death in early 20's)
prevalence of schizophrenia in siblings - 10%
which antipsychotics treat negative symptoms of schiz? olanzepine/clozapine
uneven pigmentation after exposure to sun - which antipsychotic? chlorpromazine
delusions -fixed false belief not culturally shared is a dysfunction of thought content
suicide rate for schizophrenic patients- 10%
concordance rate in homozygotic twins for mood disorders - 70%!!!
which cancer most likely to manifest w/depressive symptoms? pancreatic adenocarcinoma
prevalence of depression in post stroke patients estimated to be 30-50%
post stroke depression risk extends for approximately 2 years
Heinz Kohut - his theory was all psychopathology comes from bad parenting. neglectful, unempathetic
Beck - depression results from cognitive distortions in depression prone people
Bowlby - attachment
Mahler - separation/individuation (rapprochement - kid comes back to mom for check in supports)
ECT improves motor symptoms associated with Parkinson's
Lithium, thyroid, stimulants, estrogens can all augment anti-depressants
Prevalence of alcoholism in bipolar is 60%
REM latency is shortened in depression and narcolepsy
Treatments for panic disorder - SSRI, TCA, benzos
OCD tx - ssri, clomipramine,
GAD tx - buspirone, SSRI, imipramine
Causes of restless leg syndrome - pregnancy, anemia, renal failure
Symptoms of meperidine intoxication - resp. depression, stupor, coma and seizure!
Hypnosis is contraindicated in paranoid personality disorder (it just won't work)
Important to remember that when living with a schizophrenic the emotional environment of the home is very important- keep fights, arguing etc to a minimum
Freudian concept of abstinence -refrain from making an major life decisions while receiving psychoanalytic treatment.
Akathisia occurs early during neuroleptic treatment, treat it w/beta blocker
Want to knock down both ADHD and depression in a 16 year old? tx with bupropion
Trazodone priapism risk is highest with LOW doses (50-150mg/day)
How to treat sexual side effects of SSRI (decreased libido, anorgasmia) without changing medication? add cyproheptadine
treatment for involuntary tics, grunts, and coproalia (obscene outbursts) - haloperidol
Person being treated with disulfiram presents with facial flushing, tachycardia, hypotension, N?V - denies alcohol use what else could do it? Cough syrup has 40% alcohol.
Lithium treatment begins to work after roughly 7-14 days.
treatment of cataplexy? SSRI, MAOi, TCA
The drug of choice to knock down both bedwetting and ADHD is imipramine.
Going to be sued for malpractice? Plaintiff has to prove the 4 D's
Duty - you had a duty to act and didn't
Deviation from the standard of care
Direct - harm was directly caused by physician's actions
Damages - there were actual damages as a result
Tarasoff v. Regents of California - provider has to warn the potential victim of a violent patient if identity becomes known
Two most common cause of malpractice claims?
1. maltreatment
2. suicide
Principles
Beneficence - promote well being
Nonmaleficence - do no harm
mens rea - state of mind that indicates criminal intent at the time of the crime
Durham rule - defendant is criminally liable if it can be shown the unlawful act was a result of mental disease
Olanzapine!! A commonly used antipsychotic that is commercially known as Zyprexa. This compound can eliminate psychotic symptoms by competitively blocking overactive serotonin receptors in the basal forebrain in psychotic individuals. However significant side effects to this medication are metabolic derangements, obesity, and edema. Instances of extrapyramidal symptoms are rare with Zyprexa because it is not a strong blocker of dopamine.
Here is my mnemonic for the DSM criteria for diagnosing substance dependence"
L U/R Ng Q W T Time
aka "learning quit time"
L- longer/larger periods using substance than originally planned
U/R - use despite repercussions
Ng - neglect of obligations, work, relationships...
Q - unsuccessful attempts at quitting
W - withdrawal
T - tolerance
Time - inordinate amount of time/energy/expense used to acquire substance
in psychotherapy here are three things to say when you don't know what to say next-
1. that must have been hard
2. tell me more
3. how are you feeling?
The full-proof parenting algorithm:
1. Hungry? Feed em
2. Wet? Change em
3. Upset? Soothe em
When inquiring about history of trauma or abuse during an interview one way to ask is, "Do you have any history of trauma or abuse?"
The signs and symptoms of PTSD revolve around three primary clusters:
1. Reliving the experience in some way
2. Hyperarousal/hypervigilance
3. Avoidance, numbing, shutting out/down/off
Substance abuse clinical points-
ethanol disinhibits the behavior regulating prefrontal cortex- it inhibits the inhibitor, most drugs don't do this. -"Have you ever heard of a crack house brawl?"
Heard in rounds- "when the going gets tough, the borderlines get using"
-substance abusers are ambivalent about change, remember- ITS DOING SOMETHING GOOD FOR THEM!!! - so don't finger wag, it will get you nowhere, instead try asking about their goals? do they want to control their using, cut down, switch whatever but find out- this can reveal flawed thinking and assumptions. And if you feel as though whatever reasons are not in line with treatment, reality or your own moral compass simply state - , "I can't join you in that goal"
Think a person in a hospital for detox is lying about use? Ask him/her what are their goals? What are you hoping to get out of this hospital visit?
Heard in rounds regarding borderline personality - "They love beyond measure whom they will soon hate without reason."
"what is learned with pleasure is learned full measure"
the key to motivational interviewing is get the patient to tell you why they should quit
Food for thought:
During a discharge plan one day we were discussing the private psychiatrist fees for an office in a suburb of Washington, DC. The office does not take insurance and the following rates are out-of-pocket.
Initial consult - $350
20 minute med check - $135
1 hour psychotherapy - $270
Child psychiatry pearls
Kids deal with trauma by either internalizing or externalizing.
IF they internalize there are two chief symptoms: depression and anxiety. This is ego-dystonic, i.e. - it causes conflict with the child's sense of self or ego.
IF they externalize then you get conduct disorder, oppositional defiant disorder, disruptive behavior disorder. Conduct disorder presents with two chief behaviors - fire setting and animal harming. It is oftentimes a prelude to antisocial personality disorder as an adult.
The 4 P's for diagnosing and understanding psychological illness
Predisposing factors - family history, genetics, environment
Precipitating events - trauma, deaths, life events
Perpetuating circumstances - psychosocial issues, persons, places, things
here is another source comparing first generation antipsychotic and atypical - notice the reduction in dopamine blockade
7.07.2010
for billing and insurance be sure to include two GAF scores, the most recent GAF and the highest that the patient has experienced in the past year.
the proper order of a presentation for morning rounds on psych
-ID 1-2 sentences
-reason for presentation, why on psych now?
-Axis dx
-meds + doses, organize the polypharmacy, don't care about prn
-clinical update on case, what's new
don't discharge anyone without a follow up appointment
getting a parallel history is crucial for establishing the history of present illness, but many patients don't want anyone talking to their families. in order to get consent try asking in this way, "who would you like us to contact?", in this way you kind of "assume" talking to family is part of the care, if patient still refuses, well then the trick didn't work
heard on the floor - "for now, she's going to marinate in zyprexa"
heard on the floor - "we once had a fireman try and crawl through the ceiling in an attempt to elope from the ward, patients can be inventive"
many personality defenses arise in psychotherapy, regarding anger vs. apathy - "it is easier to calm the wild than raise the dead"
in psychotherapy don't interrupt - goal is not to get the answers but to see how patient thinks, if you interrupt - sure you'll get the answers but you won't see how they think!
the act of worrying about having a panic attack strongly suggests panic disorder
SSRI first line treatment for panic disorder
buspirone - non benzo anxiolytic, takes time to work but no side f/x!
thinking about using tricyclic antidepressant? don't forget to get an ekg, these drugs can cause conduction blocks
end point of using meds for panic disorder? "1 year of feeling good"
clomipramine is the only TCA that can be used for OCD
patient comes in with major depression, you treat with antidepressants, patient gets better with a very quick response - you should start to suspect bipolar disorder
sleep deprivation can trigger manic episode
patient on lithium sudden develops polyuria? check levels, they may have taken NSAIDS decrease renal clearance of lithium
"even if you don't go into psychiatry, you will be treating depression, in fact most provider's that treat depression are not pscyhiatrists. but if you see these 3 things you need to get a pscyh eval, 1. suicide/homicide 2. psychosis 3. mania
transference - displacement of emotions, thoughts, behaviors toward the therapist derived from earlier emotionally significant relationships
e.g. - patient comes in late, therapist asks "what's the deal?" patient says - "stop treating me like a child!"
countertransference (two types)
- true: thoughts feelings behavior directed toward patient from therapist that come from significant emotional relationships in past
- general: the ability of a patient to call out a similar response from all persons he/she interacts with,
how do you tell if its just you who has a problem w/patient? ask around about how others feel
are you a highly sensitive person? do you want to find out?
PTSD patients have different neurobiology -
hippocampus is decreased in size
emotion responsive areas (insula etc) are hyperactive
prefrontal executive dampening is decreased
PTSD - use of morphine good because lessens memory formation
beta blockers were a bust for treating autonomic hyperarousal in PTSD
-when taking an interview in the ER, for the HPI try to find out why now? why here? what happened this time that brought patient to ER
-unless absolutely necessary never use family member as interpreter, especially children
-patient on edge? glance over the EMS report before doing the interview to get a better sense of whats up
remember you need patient consent to give the family details about the patient, but you don't need consent to get details from the family
while getting a parallel history, if the family etc start to inquire about patient, just reply, "there in a safe place"
tremor and tongue fasciculations? could be EtOH withdrawal
mental health therapy aides, "nurses aides", have been around the longest and have the best subjective sense about patients
stress comes from emotionally draining patients.
whats a delusion? fixed, false belief not culturally shared.
an arkow pearl: limit setting with a borderline patient is imperative, "i don't care if you have the chainsaw gassed up and ready to kill yourself if you have to leave, than we can just go the state hospital and you can figure it out over the next few months"
the pronouns are screwed up with borderline patients, you should be I, (patient)- I have the problem, I have issue, its my fault
clozapine is different - it never crosses the threshold for extrapyramidal symptoms, good for negative symptoms
axis I diagnosis will trump adjustment disorder
fluoxetine takes ~5 weeks to washout, paroxetine has the most DDI
when diagnosing depression, don't say "major depressive episode, or major depression", instead say you have "a depression", educate about symptoms
SSRI side effects
1. anorgasmia
2. tend to be activating
3. loose bowel movements/GI symptomes
4. black box for under 25yo
end point with SSRI's is "six months of feeling good"
stay away from benadryl and anti-cholinergic
help projecting complainer i.e. - gimme help please, no thanks don't need it.
when choosing residency don't go to a place where you have to drive far to work
check and see if the residency is unionized
risperdal consta can lead to retrograde ejaculation in young men
-regarding psychopathology - "if its not affecting you, its affecting someone else..."
-arkow pearl: "we once had a patient who was a fireman try to crawl through the ceiling tile trying to escape out of here"
-is there a giant fight going on over a patient in the nurses station? look for the patient quietly reading a magazine nearby, that's who there fighting over
Two years of med school have come and gone, and as I hit the hospital tomorrow I thought it was appropriate to stop and take stock of what has happened since matriculation. It is a great feeling to be done with "class". Personally being done with the classroom is an exciting milestone in my education, I like to think that I'm never going to back to the classroom. Through my post-bac program and two years med school (age 26-30), it seemed as though I would never get out of the deathgrip of the classroom theoretical and lecture (picture the difference between reading books on flight and actually opening the throttle on the runway). I like to think that from this point forward the life long learning will be done in the framework of the practical- and real life. Finally, I get to practice a skill in the world, I couldn't be more eager. Looking back on all my big plans and ideas one central theme has become very apparent - there was a wide gulf between what I hoped to accomplish and what was accomplished. Still, a lot got done. Here are some of the key lessons and insights I have gained regarding med school- things that worked, things that didn't, things I'm glad I did, things I wish I would have.
The underlying assumption directing my conduct in the first two years was, "Given that our classes are graded as pass/fail the only reliable marker of preclinical knowledge used by residency directors to discriminate candidates will be the USMLE Step 1 performance." Moving forward from this, all my activities revolved around trying to score high. So right from the first day I read all that was assigned, always, and until the very last day of class. And right from the first day I never missed a day of class, never, and was front and center in lecture. However what I didn't anticipate was twofold
-the shear amount of medical knowledge is completely and totally overwhelming.
-the difference between what was being taught and what was on the step 1 was substantial
This first point is best illustrated by a simple algebraic word problem.
Person X has to approximately 35,000 facts to learn. Person X has two years in which to do it. Given that completing this task would require an average fact acquisition rate of 96 facts per day for two years duration, what should person X do when they realize that at best they could only learn 0.5k (where k is the minimum necessary fact acquisition rate)? Next, how should person X differentiate which facts belong to the set of 35,000 necessary facts when, over two years duration they are presented with a >250,000 fact pool? Finally, how the hell should person X remember all those facts?
Evenso, I loved every minute of it. I gladly traded in my social life. I gladly pawned my outside interest reading. I sold my weekends to the first bidder, so that I had time to spend sorting through all these facts.
But...
I would have shadowed more, I would have gotten more involved in the hospital during those years. I shadowed only neurology and emergency medicine to any significant extent, that was to my detriment.
Also - I would have studied in pairs, or three at the most, not solo. Sometimes it got lonely, and I missed many things that other eyes don't, and I go slower than if other people were there. But - you have to police the screwing around and distraction with groups.
Specifically - I would have bought a subscription to usmle world qbank step1 right on the first day of med school and started doing board style questions. 25 here, 25 there, it adds up, and this addition would have by increased repetition greatly eased the task of rote memorization that was to occur later the following year in pathophysiology. Also this would have focused my studying because too much time was used sub-optimally during first year addressing obscure science that is central only to the researcher and could easily be referenced when needed. As it turned out -the lead up to the boards was slightly tight, even for me the unequivocally non cramming ramper-umper timeline dependent studier.
Thus going forward to third year, I'm getting a jumpstart on step2 by starting the qbank well well well in advance of test day. As well the qbank will double help me on shelf exams and hammer home clinical management.
Other points
-I had the opportunity to travel internationally with friends, that was the right decision, and money well spent.
-Summer of first year I returned home to Rockford, IL to spend time w/family & old friends, learn to fly, and garden. I maybe should have pursued other options - hearing stories of a number of classmates who traveled to Africa and beyond makes me go hmmmm. I would need to return to flying and get my license in order to have made that summer worthwhile.
-I didn't spend the time to write about valuable experiences much beyond the first few months of first year. I never found the time to write. Instead I would put reading and studying marginally yielding subject matter before archiving my experiences. This was a major mistake. Going into third year, much learning will happen on my feet, so I'm going to do a better job of jotting down the medical wisdom that is thrown my way.
- Playing rugby was a lot fun, good decision. However, I sprained my knee in the second to last game of this past season, reminded me that getting older, it is more important at this point to be injury free- makes me think maybe more squash and basketball next year.
- Being in Bard Hall Players theatre group and having the med school band Sister Chromatid was a lot of fun, lots of time but many good friends, good decision.
I have learned this a least by my experiment: that if one advances confidently in the direction of his dreams and endeavors to live the life which he has imagnined, he will meet with a success unexpected in common hours.
Michelle and I were talking about the factors complicating family life, in particular- how to start a family with both mom and dad in residency. We decided the central issue was women who want to have children are stretched too thin between professional and family obligations during residency. We have observed a huge demand for a type of residency track that is more accommodating to those female physicians with preserved maternal instinct from both anecdotal and online sources. In keeping with the longstanding medical tradition of change, we have invented the: Family Medicine Residency - Maternal Track, designed for the physician who would like to procreate during their younger years but also not throw in the towel professionally while doing so. We envision the residency, specifically oriented toward Family Medicine - will be of extended length with lighter hours/call to help moms be moms. A Family Medicine Residency program is a perfect candidate for this type idea because it has a shorter length, (normally 3 years would be extended to 5 or 6 years), but more importantly the residency is named in the spirit of the endeavor- Family Medicine. Ultimately we are hoping to create a more balanced work/family life during residency where in the past intense hours have shown to skew these obligations for women with children. We believe that it takes more than a residency to create a competent physician, instead years of clinical decision making will bear out who the good doctors are. In light of the lifetime commitment that medicine obliges, we see no logical reason to forgo prime reproductive years when family planning is more optimally suited for this time. To that end we have begun to create a custom extended residency curriculum with the aforementioned goals in mind. We also expect the demand for this type of program to be significant!! OK- time to plan.
