#MedEd: Transitioning to Residency

Today we’re joined for a special #MedEd episode by a few guests: Halley Staples, MD, who is a PGY-3 in OB/GYN at WashU in St. Louis; Helen Morgan, MD, who is a clinical professor at U Michigan; and Anita Malone, MD, associate residency program director and assistant professor at U Michigan.

This team in part recently published a narrative experience study of students transitioning into residency in OB/GYN which was fascinating. We talk to them a bit about their experiences and takeaways from their work, as well as their thoughts on the challenging transition time.

Retirement and Investing, feat. Michael Foley

Today we welcome back Michael Foley for another episode in our financial series alongside SMFM. We talk through retirement accounts and the most important ways to set up your savings.

How to get in touch if other questions come up?

·         Michael.foley@northstarfinancial.com

·         Can offer you a complimentary, no obligation, initial review and more in-depth financial consultations available for those who might have more in depth questions.

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. 

North Star Resource Group is independently owned and operated. 6720 N Scottsdale Rd Ste 290, Scottsdale, AZ 85253.

Separate from the financial plan and his role as financial planner, Michael may recommend the purchase of specific investment or insurance products or accounts. These product recommendations are not part of the financial plan and you are under no obligation to follow them. Financial Professionals do not provide specific tax/legal advice and this information should not be considered as such. You should always consult your tax/legal advisor regarding your own specific tax/legal situation.

Perinatal Mental Health, feat. Dr. Tiffany Moore-Simas and Dr. Nancy Byatt

Today on the podcast, we’re addressing perinatal mental health. While we’ve talked about depression on the show before, there’s so much more in this sphere as we’ll discuss today.

Joining us are two experts in this field who share their passion for this work with us. Dr. Tiffany Moore Simas is Chair and Professor of OB/GYN at UMass Memorial Health and UMass Chan Medical School as well as co-Chair of the ACOG Maternal Mental Health Expert Work Group. And Dr. Nancy Byatt is a tenured Professor of Psychiatry and OB/GYN at UMass Memorial Health and UMass Chan Medical School. Both serve as senior leaders with the Massachusetts Perinatal Psychiatry Access Program, MCPAP for Moms, and Lifeline For Moms.

Importance of Perinatal Mental Health

• Mental health conditions are the most common complications of pregnancy – 1 in 5!

  • More common in adolescents, veterans, marginalized populations (BIPOC, poverty).

• Untreated mental health conditions carry both short- and long-term consequences that can affect whole family:

  • o   Less engagement in medical care

  • o   Smoking, substance use

  • o   Preterm delivery, low birth weight, NICU admission

  • o   Lactation challenges, bonding issues

    • Parent with untreated mental health disorder is considered an Adverse Childhood Experience (ACE) for the infant.

  • o   Adverse partner relationships

• Mortality: leading cause of preventable maternal mortality.

  • 100% of maternal deaths due to mental health, including suicide, overdose, are preventable!

• Underdetected and undertreated

  • o   Of women who screened positive for depression, less than 25% had at least one mental health visit.

• OB/GYNs can screen and help manage mental health conditions. The majority (80%) of depression, for example, is managed by primary care providers, not psychiatrists. As obstetric care clinicians, we are the primary care providers to pregnant and postpartum individuals and thus, we should be providing mental health care!

Screening for Perinatal Mood and Anxiety Disorders

• In this context, perinatal refers to during pregnancy and the first year after pregnancy ends

• Perinatal Mood and Anxiety Disorders primarily include depression, bipolar disorder, and anxiety or anxiety-related conditions (generalized anxiety disorder, PTSD, OCD).

• Screens should be performed with validated tools that query the last 7-14 days of symptoms for anxiety and depression.

  • o   Validated tools:

    • PHQ-9, EPDS (depression)

    • GAD-7 (generalized anxiety)

  • o   ACOG recommends screening patients at least once during the perinatal period for depression and anxiety symptoms. If a patient is screened during pregnancy, additional screening should occur during the comprehensive postpartum visit.

    • We recommend screening: new OB visit, later in pregnancy (i.e., 3rd trimester) and postpartum given the almost even distribution of onset predating pregnancy, onset in pregnancy, and onset postpartum.

  • o   Data suggests that early detection and treatment improves outcomes.

• Bipolar disorder screening:

  • o   In one study, 1 in 5 patients screening positive for postpartum depression actually had bipolar disorder.

    • Recall: bipolar disorder can worsen with antidepressant treatment (unopposed SSRIs) – thus, need to screen for bipolar before initiating pharmacotherapy and ideally universally to prevent harm!

  • o   Patients with bipolar disorder have higher risk of postpartum psychosis

    • Rare: 1-2/1000 perinatal individuals; but 70% have bipolar disorder!

    • 4% risk of infanticide with postpartum psychosis

    • This is a psychiatric emergency.

      • Often occurs within the first days of delivery and most cases occur within the first 3 weeks.

  • o   Screening options:

    • Mood Disorder Question (MDQ) – self administered

    • CIDI – clinician administered with branching logic

  • o   Appropriate to refer to psychiatry if bipolar disorder is suspected – more on resources to help later!

Positive Screening   General Principles of Treatment

• Just like a glucola, our questionnaires for mental health concerns are screening tests. Subsequent assessment is critical to confirm diagnosis.

  • o   See resources collection at the end of these notes for help!

• For depression and anxiety, there are three pillars of treatment:

  • o   Psychotherapy

  • o   Pharmacotherapy or medication

    • o   Adjunctive interventions

• Treat based on level of severity. For information on assessing and treating perinatal mental health conditions, visit the ACOG website.

• If pharmacotherapy is indicated/started, patients may have some concerns:

  • o   Provide reassurance

  • o   Frame risk/benefit discussion in treated disease vs. untreated disease as not treating is associated with risks - just like any other disease!

  • o   Use lowest effective dose and monotherapy when able

• Find more information on educating patients about treatment on ACOG’s website.

Concerns for Suicidality or Harm To Baby

• These can represent urgent clinical scenarios and further assessment and response is critical:

  • o   Thoughts of harming self or baby are common yet not all are necessarily a psychiatric emergency.

  • o   When assessing for risk of harm to self or others it is important to assess:

    • Ideation – Do they have thoughts of harming themselves or someone else?  Are the thoughts fleeting or do they persist?

    • Intent – Are they intending to act on it? Have they thought of how they could do harm themselves or someone else or die by suicide?

    • Plan - Are they planning to act on it?  Have they developed a plan for how to die by suicide or to harm someone else?

  • o   If you are concerned that the patient is at risk of harm to self or others, then it is important to obtain further assessment which includes an evaluation for whether the patient may need psychiatric hospitalization

  • o   Regardless of whether these are a psychiatric emergency, the presence of thoughts of harming self or baby are indicative of higher illness severity.

• More information on ACOG’s website.

 Resources for Integrating Perinatal Mental Health Care into Your Practice

• ACOG Practice Bulletins  Clinical Practice Guidelines, Committee Opinions – updates coming soon!

• Toolkits for OB/GYNs with screening tools and patient and provider resources:

  • o   https://escholarship.umassmed.edu/cgi/viewcontent.cgi?article=1140&context=pib

  • o   https://www.acog.org/programs/perinatal-mental-health

• Lifeline for Moms – https://www.umassmed.edu/lifeline4moms/products-resources/

• Perinatal Psychiatry Access Programs – Clinician-facing resources on state-by-state basis and a national warmline for over-the-phone assistance and referrals:

  • o   https://www.umassmed.edu/lifeline4moms/Access-Programs/network-members-us/

  • o   National: https://www.postpartum.net/professionals/perinatal-psychiatric-consult-line/

• AIM PMH Patient Safety Bundle and Implementation Resources – updates coming soon!

• NEW resources coming soon:

  • o   Lifeline for Moms eModule

  • o   Self-paced implementation guide to integrate mental health into obstetric practices, accompanied by recorded trainings

• National Hotlines – Patient-facing:

  • o   1-833-9-HELP4MOMS (1-833-943-5746): National Maternal Mental Health Hotline

  • o   Text HOME to 741741: Crisis Text Line

  • o   9-8-8: National Suicide Prevention Hotline

Budgeting, feat. Mike Foley

We’re back with another special Wednesday episode this week, again brought to you in part by the SMFM Thrive Initiative! SMFM Thrive is a wellness program for MFMs - but we hope that this week’s podcast will be helpful even to those outside of MFM land!

Michael Foley rejoins us today to talk budgeting!

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. Separate from the financial plan and his role as financial planner, Michael may recommend the purchase of specific investment or insurance products or accounts. These product recommendations are not part of the financial plan and you are under no obligation to follow them. Financial Professionals do not provide specific tax/legal advice and this information should not be considered as such. You should always consult your tax/legal advisor regarding your own specific tax/legal situation.

How to build a budget

• Spreadsheet or app to identify normal and regular expenses and regular income to identify surplus income.

  • What comes in?

  • What goes out?

  • What is left over?

Research for budgeting hacks

• Brain scan study https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2656877/

  • Same cognitive energy to save for our future self as it does to give money to someone else.

• Make the decision once and then automate, automate, automate.

• Setting up hurdles

  • We tend to see better results when there is a separation between your everyday checking account and your emergency reserve.

  • Look at a separate high yield online savings account at a separate bank

    • Takes 1-2 business days to transfer

    • Enough time to feel a bit guilty but it is there if you need it.

• Positive psychology research

  • Identify those things that actually bring you happiness and fulfillment

  • Some may cost less than you think.

    • Get the most bang for your buck from a fulfillment standpoint.

• PERMA exercise

  • Positive Emotion, Engagement, Relationships, Meaning, Accomplishment.

  • These are your real goals... not a dollar amount in your bank account!

Triaging your surplus income in residency vs in practice.

• Establish the basics- like checking basic vitals – if a patient tells you that they want to start to train for a marathon, but they have high blood pressure, knee issues, and they have no training plan. Can you go out there and start running? Absolutely. But you might want to address some other issues first.

  • Emergency reserve

  • Cash ready for upcoming expenses

  • Insurances- DI, Life, Umbrella

  • Debt repayment plan

  • Then preventative care- like starting to work out, eat healthy, etc.

  • Retirement savings

  • Medium term savings- nonretirement

  • Once maxed out all other retirement options, then look towards other tax advantaged accounts as a business owner or through 7702 max funded life insurance contracts.

• How to know if you can afford something?

  • Are you on track for your short and long term goals and have savings automated, then you can spend the rest and not feel guilty about it?

Common mistakes

• Only focusing on your student loans: I’m going to continue living like a resident and pay off all of my loans”

• Building up fixed expenses right out of training before working with an advisor to help you identify some of your longer-term goals.

• Raising fixed expenses can limit your surplus income very quickly

• Not able to hit goals? Make more money or spend less money. Going backwards in lifestyle expenses is rough.

Need some budgeting help?

• Michael’s Bio: https://www.northstarfinancial.com/advisors/michael-foley/

• To schedule an initial consultation with Michael click here.

#MedEd: Applying into Pediatric and Adolescent Gynecology (PAG)

Today we welcome back Dr. Aimee Morrison, a current resident in OB/GYN at UPenn heading into specialization in Pediatric and Adolescent Gynecology (PAG). She shares with us some tips on the application experience and getting set up optimally to pursue this specialty — which is wonderful given it’s a smaller specialization with fewer mentors available.

Some highlights from the episode:

• PAG is a two-year fellowship typically; some one-year programs do exist.

• There’s a wide variety in care, which is often multidisciplinary in nature. There’s a good amount of endocrine issues (PCOS, CAH), as well as disorders or delays in sexual development; surgical care in Mullein anomalies and congenital malformations; and trans care, menstrual problem management, and contraception.

• Aimee suggests getting involved with some exposure in years I and II, and often times this might be through an REI with a specific PAG interest, given the limited number of PAG specialists currently in existence.

  • Starting a research project or two is also helpful for applications - and in PAG, because of small numbers, case reports/series, literature reviews, and retrospective chart reviews are very normal and typical.

• If you can, get involved with and go to NASPAG!

  • Can even open you up to mentoring opportunities from far away!