Influenza

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What is flu, and why do we care about it in pregnancy? 

  1. We reviewed the flu vaccine in pregnancy previously, but we have never talked specifically about flu itself! 

    1. Flu is a contagious respiratory illness caused by the influenza virus 

    2. The virus is a negative sense RNA virus 

    3. There are multiple strains, including A, B, C, D

      1. We have probably heard about A and B, but C and D also can infect people 

        1. A and B are known to cause more severe illness, while C can cause can cause a mild infection 

        2. D can infect humans, but is not known to cause illness 

    4. Transmission is through aerosols and contaminated surfaces 

  2. Why do we care about flu so much? 

    1. In typical years, as much as 5-15% of the population will contract flu

    2. This leads to 3-5 million severe cases annually and up to 650,000 flu deaths a year in the world 

    3. In the US, on average, 8% of the population gets sick from the flu, per the CDC 

  3. Who is most likely to get sick? 

    1. Children are most likely to get sick from flu and people 65 and older are least likely to get sick 

    2. However, pregnant and postpartum individuals are at significantly higher risk of serious complications related to seasonal and pandemic influenza infections compared to non pregnant people 


How is flu prevented? 

  1. Vaccination 

    1. The CDC recommends that all adults receive an annual influenza vaccine and that individuals who are pregnant during the season receive an inactivated or recombinant influenza vaccine as soon as possible 

    2. Timing: end of October is ideal, but any time during flu season vaccination should be encouraged 

    3. Remember that it is safe to give the flu vaccine with other inactivated vaccines that may be needed in pregnancy (ie. Tdap, RSV, or COVID vaccines) 

    4. It is also safe for lactating individuals to receive the flu vaccine 

    5. Of note, the vaccine also benefits the newborn when it is given during pregnancy 

      1. Randomized controlled trials and observational studies have shown neonatal protection from maternal influenza vaccination 

    6. Importantly, studies show that when recommendations for the flue vaccine during pregnancy come from the patient’s Ob/Gyn or other obstetric health professional, and the vaccine was available in the office, the odds of vaccine acceptance and receipt are 5x-50x higher! 

    7. For more information on the flu vaccine, check out our previous episode: https://creogsovercoffee.com/notes/2019/5/26/vaccines-i-tdap-and-influenza

  2. Masks 

    1. This is probably familiar to all of us now with the COVID-19 pandemic 

    2. Mask wearing can help prevent transmission of many respiratory infections, particularly when community levels of circulating viruses are elevated 

    3. When to wear a mask 

      1. Local public health guidance and recommendations based on community-centered risks 

      2. Individual’s specific vulnerability due to health conditions 

      3. Clinical and health care professional recommendations 

  3. Other methods 

    1. Hand washing 

    2. Cleaning surfaces regularly 

    3. Make sure to to use usual techniques to minimize contamination/spread of disease 


How should we evaluate for influenza in pregnancy? 

  1. Assess for symptoms 

    1. Fever >100.4 F (38 C) and one of the following 

      1. Cough, runny nose, sore throat, headache or body aches, fatigue, difficulty breathing or SOB 

    2. If these symptoms are present, test for COVID and flu 

    3. Also assess for illness severity 

      1. Difficulty breathing or shortness of breath 

      2. Chest pain/pressure 

      3. Unable to keep down liquids 

      4. Dehydration signs and symptoms 

      5. Less responsive, confused

      6. Symptoms are worsening 

    4. If yes to any of the above, then encourage patient to go to emergency room or equivalent location to be treated 

    5. If no, if there are other morbidities (ie. cardiovascular or pulmonary issues, immunosuppression, obstetric issues like preterm labor) → should be seen in a clinical setting as moderate risk 

    6. Otherwise, patient is considered low risk and patient can be treated outpatient or even over the phone, with follow up in 24-48 hours 


How to Treat Respiratory Infection in Pregnancy 

  1. Empiric treatment 

    1. Oseltamivir is the preferred treatment for pregnant individuals 

      1. Dosing: 75 mg orally twice a day for 5 days 

    2. Zanamivir can also be used (two 5 mg inhalations twice daily for 5 days) 

    3. Peramivir can also be given, but is 1 dose IV for 15-30 min 

    4. Do not delay treatment while respiratory infection test is running

  2. If suspected to have both COVID and flu, oseltamivir and Paxlovid can be prescribed and taken together 

  3. Post Exposure chemoprophylaxis for flu 

    1. Due to high potential for morbidity and mortality related to flu in pregnant and postpartum individuals, post exposure chemoprophylaxis can be considered for those who are pregnant and for those who are up to 2 weeks postpartum 

    2. Recommendation: oseltamivir 75 mg 1x/day for 7 days 

    3. Should be started within 48 hours of most recent exposure 

    4. At risk family members of patients with flu should be referred to health care professionals for consideration of chemoprophylaxis 


Medical Ethics

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What is medical ethics, and why do we need them? 

  • What is ethics? 

    • Covers the study of the nature of morals and specific moral choices to be made 

    • It can attempt to answer the question: which general moral norms for the guidance and evaluation of conducts should we accept and why? (Beauchamp TL, Childress JF. Principles of bioethics. 7th ed. Oxford University Press; 2013.)

      • Some moral norms for correct conduct are common to everyone despite differences in culture, religion, etc. = common morality 

      • Some are norms that only exist within a certain group = particular morality 

    • Bioethics and Clinical ethics are two examples of particular morality that should govern physician professional standards 

    So why do we need them? 

    • The best example of why we need medical ethics is to look at history and when medical ethics was ignored 

    • There have been multiple times in history when there have been medical abuse of human subjects in research and medical interventions without informed consent

      • Examples: Tuskegee syphilis study, Henrietta Lacks and the use of HeLa cells, World War II etc. 

    • To avoid repeating history, we should follow the following principles of medical ethics 

    • And of course, there is always 1-2 questions on CREOGs and your written boards about medical ethics, so this is a good time to review them!

The Fundamental Principles of Medical Ethics 

  • Beneficence 

    • Obligation of the physician to act for the benefit of the patient and help protect and defend the rights of others, prevent harm, remove conditions that will cause harm, help persons with disabilities, and rescue persons in danger 

    • This is distinct from the next principle of “nonmaleficence” in that beneficence has positive requirements (actually doing something to promote benefit to others) 

    • Some examples: providing vaccines, speaking at an event to discuss STI prevention, encouraging a patient to stop smoking 

  • Nonmaleficence 

    • The obligation of a physician not to harm the patient 

    • Obvious examples - do not kill, do not cause pain and suffering, do not incapacitate, etc.

    • Practical application is more difficult – this is when the physician needs to weigh the benefits against risks/burdens of all interventions and treatments 

    • This can especially come into play in things like end of life care decisions and pain/symptom control 

  • Autonomy

    • Patients have the power to make rational decisions and moral choices for themselves, and each person should be allowed to exercise their capacity for self-determination 

    • Like other principles, autonomy does need to be weighed against other competing moral principles 

    • Sometimes, autonomy needs to be overridden in the cases where patients are not deemed to have decision-making capacity 

      • Capacity: person’s ability to use information they are given and make a choice that is congruent with their own choices and preferences 

      • This is different from competency = legal judgment that is informed by assessment of capacity 

      • See our previous episode on informed consent where we talk about how to assess capacity!

    • Autonomy can also at times be in conflict with certain social norms depending on culture/religion etc 

      • Example: in some cultures, full disclosure of medical status, end-of-life status, etc. is frowned upon and some cultures may prefer a family-centered approach where these statuses are hidden from the patient 

    • As the definition currently stands, respecting the principle of autonomy obliges physician to disclose medical information and treatment options that are necessary for the patient to exercise self-determination

  • Justice 

    • The fair, equitable and appropriate treatment of persons 

    • The thing that is important to take away, especially in the US for this principle is “distributive justice” 

      • Fair, equitable, and appropriate distribution of health-care resources

      • There are different principles of distributive justice, and can be based on equal share, according to need, according to effort, according to contribution, according to merit, and according to free-market exchanges 

        • Each principle is not exclusive and these principles are often combined in application

        • However, this does increase the difficulty in choosing, balancing, and refining these principles  

    • Examples of justice: rules for allotment of scarce resources, allotment of time for outpatient visits

Three Other Principles Derived from the Original Four

  • Informed Consent

    •  In order to obtain informed consent, things that are required: 

    • Patient who is able to give consent 

    • Presentation of accurate information that includes: 

      • Diagnosis (if it is known) 

      • Nature and purpose of the recommended interventions 

      • The risks, benefits, and alternatives of all options 

    • Documentation of the conversion and the ultimate decision 

    • We won’t go into this too much because we have a whole episode! 

  • Truth-Telling 

    • This is a vital component of the physician-patient relationship – full disclosure of disease process is the normal in the US 

    • However, this may be variable in other countries 

  • Confidentiality 

    • Physicians are obligated not to disclose confidential information given by a patient to another party without the patient’s authorization 

    • Primary exemption would be disclosure of necessary medical information for care of patient to other health-teams 

Some examples of conflicts between principles

  • Paternalism 

    • When beneficence and autonomy collide 

    • The physician may be trying to do what he/she thinks is best for the patient, but patient autonomy suggests that patients have the right to refuse treatment 

    • Paternalism happens when physician takes away patient autonomy by nondisclosure, manipulation, deception, or coercion 

  • Consumerism 

    • Extreme form of patient autonomy where the physician’s role becomes limited to providing all the medical information and available choices and letting the patient select; ie. a menu of choices  

    • This does not permit the physician full use of his/her knowledge and skill for beneficence

Student Loan Update After Supreme Court - with Mike Foley

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We’re back once more with Mike Foley, CFP, CSLP, to bring us another update on the student loan saga. Unfortunately that forgiveness isn’t going to happen, but there are a lot of other changes upcoming… including returning to payments! Mike lays it out for us:

What are the major updates?

  • Student loans are back on - interest returning in September, with payments likely resuming in October.

  • No Biden forgiveness.

    • But no impact to PSLF rules, either.

  • New PSLF rules are active.

  • No more interest capitalization when changing repayment plans or enrolling.

  • New “SAVE” plan.

    • Replacing the REPAYE

    • Lowers the monthly payment by changing the discretionary income calculation.

      • No unpaid interest!

      • Able to file taxes separately from spouse.

      • Weighted average calculatoion for undergraduate and graduate loans:

        • 5% for undergrad

        • 10% for graduate

    • Will start later this summer.

      • Those on REPAYE will automatically switch over to SAVE

      • Married borrowers can file separately — unsure if this will recalculate payment adversely for some married borrowers.

        • Some spouses with higher loan balances could see increase in payments.

  • PAYE and ICR programs going away.

    • Tough break for those going for long-term taxable forgiveness and have loans pre-2014.

    • Also tough for those with high incomes and just a few years away from PSLF.

  • New “On Ramp” program

    • No defaults until Sept. 2024 — interest will still accrue, though.

  • Losing out on REPAYE, and then switching to IBR or PAYE strategy:

    • Limited to just 5 years on REPAYE/SAVE to get interest subsidies before losing out on being able to switch to a plan that can be done in 20 years like the new IBR or PAYE.

    • Those who have loans pre-2014 — need to switch to PAYE or forever hold your peace!

What should we do before loans turn back on?

  • Update your contact info at student aid.gov and with your loan servicer.

  • Link your bank account to your new loan servicer — likely changed during COVID.

  • Check your payment amount due on your loan servicer website.

    • Don’t just automatically rectify your income — earliest you need to rectify if already enrolled in a program would be 6 months after payments resume — so you may be able to make payments still based on your 2019 income!

Any loopholes to look out for?

  • Are you unemployed during the summer between residency/fellowship and your job?

    • May be a good time to re-certify while you’re unemployed.

  • Are you looking to pay off your loans?

    • May want to consider reporting lower income for a few years while you can, to take advantage of interest subsidies through new SAVE program.

  • Did you work for a qualifying PSLF institution prior to med school while you had undergrad loans outstanding?

    • Potentially able to consolidate loans and get PSLF or IDR credits, if you complete before end of year.

Getting in touch:

More info:

Disclosure:

Michael is a comprehensive financial advisor who runs his practice out of Scottsdale, Arizona, under North Star Resource Group. Michael was trained at Duke University and holds his Certified Financial Planner designation alongside his Certified Student Loan Professional designation. Although Michael serves a diverse group of clients with their financial and student loan needs, with two physician parents, Michael has found a specialty in working with those in the healthcare space.  Michael is a registered representative and investment advisor representative of Securian Financial Services. Securities and investment advisory services offered through Securian Financial Services, Inc. Member FINRA/SIPC. North Star Resource Group is independently owned and operated. 6720 N Scottsdale Rd Ste 290, Scottsdale, AZ 85253. Financial Professionals do not provide tax or legal advice and this should not be considered as such. Please consult a tax or legal professional for advice regarding your specific situation.

A Critical Examination of Abortion Terminology

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Today we are reviewing a new document from SMFM’s Reproductive Health Committee regarding the vocabulary surrounding abortion. Joining us are two of the paper’s lead authors: Dr. Cara Heuser, an associate professor of OB/GYN at University of Utah; and Dr. Sarah Horvath, an assistant professor of OB/GYN at Penn State University.

Their paper and their comments in today’s podcasts are really worth listening to. We also recommend some additional resources or guides for reproductive health advocacy:

SMFM: a number of resources and ways to get involved are here.

ACOG: the ACOG IMPACT project on abortion care training can be reviewed here.

SFP: SFP regularly updates clinical guidance and educational material surrounding abortion care, best practices, and data.

Espresso: Sign Out

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Read on with ACOG Committee Opinion: Sign Out

Sign Out: A Critical Moment

  • Sign out or hand off – transferring of patient knowledge and plan between two physicians or care teams. 

  • Patient care transitions represent a potential challenge to all of us:

    • Communication is challenging - different styles and preferences

    • External dynamics (interruptions, emergencies, home-life demands)

    • Internal dynamics (power differential, hierarchy, fatigue)

    • Interpersonal characteristics (defensiveness, minimizing, conflict-averse or conflict-prone)

  • Communication errors are frequently identified as pain points or root causes of safety events.

  • Three primary focuses to improve sign out:

    • Setting the stage

    • Being a good (and thorough) “giver” of sign out.

    • Being a good (and vigilant) “receiver” of sign out.

Setting The Stage for Effective Handoff

  • Preparation

    • The “giver” of signout should organize and update information to be prepared for handoff.

      • Updating any signout template or process used at your institution.

      • Reviewing daily updates to ensure most salient points are reviewed during verbal discussion.

      • Identify any tasks or specific guidance for the receiving team to complete.

        • Consider organizing sign out order by acuity/urgency or timely completion of these tasks.

  • Physical Environment

    • The environment should be set appropriately. Ideal physical environments are:

      • Quiet, and ideally away from distractions; i.e., a quiet conference room vs at nursing station.

      • Areas where patient confidentiality is preserved.

      • “Warm hand off” in a patient room as appropriate for particularly significant cases. 

      • Paper forms for hand-off should be legible and organized.

        • Fortunately many EMRs are incorporating sign-out templates, but don’t be afraid to ask your institution to modify things if needed to apply to your environment.

    • Sufficient time should be set aside to protect effective handoff.

      • Consider assigning someone specifically to address acute patient concerns during sign out - this keeps a significant amount of the team intact to focus on information exchange. 

      • This requires redundancy in those who are aware of patients on the service - sign out is a team responsibility, not an individual one!

  • Communication Environment

    • Use of medical terminology

      • Try to stick to understood medical language: i.e., “Category II for repetitive variable decelerations” instead of “this baby’s been a little naughty.” 

        • Standardized terminology allows for conveyance of the appropriate message and plan of care; colloquialisms may leave significant room for error due to being inexact.

      • Also consider language importance with respect to professional communication - attention to terms that may be culturally or personally insensitive, or the use of judgment statements rather than objective facts.

  • Culture and Hierarchy

    • Many times in OB/GYN residency, sign out is predicated on a structural hierarchy. 

      • Certainly, all patients should have a primary individual or team responsible for them, but a back-up system should be in place in case the primary contact is unavailable.

    • These hierarchies may lead to communication challenges in patient care:

      • I.e.,A student, first year resident, or RN should all be as comfortable to communicate in sign out as the senior resident or attending regarding a concern. 

        • Senior residents and attendings should role model effective communication and elicit team member concerns.

        • Senior residents sign out should strive to serve as a role model for junior team members to demonstrate communication style, active listening, and prioritization.

      • At the same time, sign out should be recognized as a patient safety event and treated the same:

        • Unique learning points for safety may be raised

        • However, sign-out is not a time to do an in-depth review on basic topics - lengthy interruptions should be avoided.

Sign Out Time: The Verbal Discussion

  • “Giver” of signout should ideally follow a standardized presentation strategy for each patient.

    • Common frameworks:

      • IPASS - Illness severity, Patient summary, Action list, Situational awareness, Synthesis by receiver.

      • SBAR - Situation, Background, Assessment, Recommendation

        • Use of a structure for sign out has been shown in some studies to reduce preventable adverse event rates by as much as 30%.

    • Verbal hand-off should focus on the most important items, and ensure your communication is structured to make those points stick for the receiver.

      • Even in optimal conditions, studies have shown that in those not using structured communication strategies, the receiver fails to identify the main concern 60% of the time! 

      • You as a giver of hand-off should prioritize issues to help the receiver, who is new to the patient - don’t make them prioritize and learn the patient simultaneously!

        • Critical to relay tasks to be done, and anticipatory guidance for events that may occur:

          • I.e., “The tracing was previously category II for some variable decelerations. If it occurs again, I would recommend an IUPC and amnioinfusion.” or 

          • “She is known to have CHF and received 2L IVF intraoperatively. If she is short of breath, she should be evaluated for pulmonary edema and if suspected, start with 60mg IV lasix per cardiology.” 

    • Giver should likewise use strategies to check receiver understanding, like read-back and interactive questioning. More on those momentarily!

  • “Receiver” of sign out has an equally important role in comprehending sign out and actively listening:

    • Read-back communication allows the sender to check that information is received by a recipient. It is rarely employed in hand-offs, but it is one of the most effective strategies to effective communication.

      • I.e., last example – “Got it. She’s at high risk for pulmonary edema. If I suspect it, I will give 60mg IV lasix.” 

    • Active listening should also be employed - that’s more than just head-nodding or uh-huh-ing!

      • Take notes

      • Ask questions

      • Clarify the plan when needed

    • If for a patient you do not hear any “critical events” or “tasks” - take that as a signal to ask!

  • Giver and receiver should both be aware that there are high risk scenarios for sign-out failure:

    • When a patient is physically moving locations

    • When a patient is clinically unstable

    • If the hand off is permanent, i.e., a service change, transfer to another facility, or a patient who is newly being admitted at sign out.

      • In these scenarios, there is evidence for higher risk of a patient safety event due to hand-off concerns.

      • Both should be acutely aware of importance of thorough sign-out in these scenarios.