Dr Jerry Kruse's Seussian rhyme

The following Seussian rhyme was imagined and written by Dr Jerry Kruse, Professor and Chair, Department of Family & Community Medicine, Southern Illinois University School of Medicine.
It was given during the final plenary session at the 2011 STFM Conference on Medical Student Education.

The Saga of Michael Klein

Or…..

 Ein Kleiner Schnitt

Or…..

The Triumph of Reason Over Power, Finally!

By Dr. Kreuss*

In that faraway land to the North, in Quebec,

Lived a doctor whose practice was very low tech.

A family doc, accoucher Michael Klein,

Who didn’t like forceps or women supine

Or ‘lectronic monitors, stirrups or sections

Or enemas, shaving or IV injections.

He hated electrodes and IUPC’s

And treatment of labor as if a disease.

And one of the worst – epidural blockade –

A stab in the back to start the cascade

Of catheters, tubing, Nubain and pit

And Sulfate of Mag so she won’t have a fit.

Blood pressure cuffs and punctures of veins,

Cesarean Sections and Tucker-McLains

Retained placenta, post partum metritis

I’ll bet you a buck she’ll come down with mastitis.

“I don’t like these women to all be strapped down.

Stand up and walk!”  he cried with a frown.

Michael knew in his heart, way deep down inside

That obstetrical knowledge was not well applied. 

“Technology’s great, for those who are ill,

But for those who are healthy it’s really no thrill

To be strapped down and poked, and scared stiff as a board.

This just isn’t right!”, his fervent voice roared.

One thing more than others, did gnaw at his heart,

Made his blood boil, and stung like a dart

He just couldn’t stand it, to see a long slice,

A cut, an epis - what a terrible vice,

Disruption of skin for no reason at all,

A snip with the scissors that starts very small

But rips and extends as the baby comes through

Tears into the sphincter and up the wazoo.

A third, then a fourth, oh my what a mess

“They must like to sew, is my only guess.”

So Michael jumped up, and he raised his right hand

And opened his mouth, and he took a firm stand

“I’ll study this problem,” he said with a shout

“And when I am finished there won’t be a doubt

That these cuts are no good…the whole world will see….

This idea’s a good one, they’ll have to agree.

I’ll start up a randomized, single blind study

And I’ll work with Michel who’s my very good buddy

And we’ll put ole’ McGill right here on the map.

This study of perineal trauma’s a snap.

“We’ll put in a grant, we’ll get recognition.

We send all this stuff to a good statistician.

Our alpha will be less than point zero five

And beta point two will let us derive

The number of women we’ll need.  It’s a slew.

We’ll enroll ‘bout a thousand five hundred and two.”

He worked and he toiled, he felt quite convicted—

The results were exactly the ones he predicted.

“Midline epis, when routinely done

For women in labor, is not very fun.

Our EMG’s show that sliced muscles get weak,

They heal up quite slowly and let urine leak.

And that isn’t all that comes out that should not.

She’ll find our real quick when she sits on the pot.

“The relative risk for a fourth degree rip

Is greater than twenty, with each little snip.

And all of us know, if the rectum is torn

That a permanent hole will often be born

That connects the vagina and rectal mucosa

And where it comes out then will make you nervosa.

So my warning to you, who practice OB

Is to use the epis quite conservatively.

Don’t be in a rush, and don’t interfere

Throw down the scissors, they’re not needed here.”

Now Michael was proud, and really excited

With his results he was very delighted.

He wanted to spread the good news he had found

He wanted to broadcast this stuff all around,

But a funny thing happened.  He couldn’t believe it

No one would listen, they just couldn’t perceive it.

The doctors in charge of the medical journal

The ones who are experts in issues maternal

Did not want to hear about data that’s new.

It was hard to convince that conservative crew.

“No one will believe it,” the editors cried

And they wrote down “REJECTED” with feelings of pride

And one after another they all did the same.

They suppressed this great knowledge – oh my what a shame!

But this story’s not over, he didn’t back down

He battled the towers who sport cap and gown.

Then once, then again and a third time, it’s true

His papers were granted another review.

And though eight years late and quite overdue

All three ended up in the publishing queue.

And now the world knew, both up in the North

And in states to the South, the new message went forth.

The paradigm shifted, the good word was this:

“The epis is archaic, and you’ll be remiss

To ignore this great knowledge that newly exists

And to squander this chance to cause perineal bliss!”

The rēsearch of Michael had ended the reign

Of procedure and practice we all thought mundane,

Of cuts and incisions most surely inane

And the scissors were thrown to the floor with disdain.

In just over a decade, the rate of epis,

Of pelvic dysfunction and fourth gaping degrees

Had tumbled to levels that went far below

The figures observed just a few years ago.

From sixty percent of all getting cleaved

To just nine in a hundred a cut to receive.

“Never give up!”  Michael’s voice still rings clear.

The moral today is to be of good cheer

To persistently fight, in the face of all the odds.

To battle ideas of conventional gods

To fight for new facts, and new evidence find

To give power to reason and sight to the blind.  (THE END).

*Dr. Kreuss                 Jerry Kruse, MD, MSPH

                                    Professor & Chair

                                    Department of Family & Community Medicine

                                    Southern Illinois University School of Medicine

                                    Springfield, Quincy, Carbondale and Decatur, Illinois

Bibliography:

1.      Klein MC, Gauthier RC, Jorgensen SH, Robbins JM, Kaczorowski J, Johnson B, et al.  Does episiotomy prevent perineal trauma and pelvic floor relaxation?  Online J Curr Clin Trials, Doc 10, July 1, 1992.

2.      KIein MC, Gauthier RJ, Robbins JM, Kaczorowski J, Jorgensen SH, Franco ED, et al.  Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation.  Am J Obstet Gynecol 1994; 171:591-8.

3.      Klein MC, Kaczorowski J, Robbins JM, Gauthier RJ, Jorgensen SH, Joshi AK.  Physician beliefs and behavior within a randomized controlled trial of episiotomy; consequences for women under their care.  Can Med Assoc J 1995; 153:769-79

4.      Huston P.  The pursuit of objectivity [editorial].  Can Med Assoc J 1995; 153:735.

5.      Schultz KF.  Unbiased research and the human spirit: the challenges of randomized controlled trials [editorial].  Can Med Assoc J 1995; 153:783-6.

6.      Klein MC.  Studying episiotomy:  When beliefs conflict with science.  J Fam Pract 1995; 41:483-8.

7.      Frankman EA, Wang L, Bunker CH, Lowder JL.  Episiotomy in the United States:  has anything changed?.  Am J Obstet Gynecol 2009; 200: 573.e1-573.e7

8.      Hyer R.  ACOG 2009:  Steep decline in episiotomy rates credited to research, peer pressure.  ACOG 57^th Annual Clinical Meeting, Medscape Medical News.  http://www.medscape.com/viewarticle/702541

The rhyme contained in this blog is the intellectual property of Dr. Kruse and cannot be copied without his express consent.  Thanks. JED

The STFM Conference on Medical Student Education

Last week I had the privilege of chairing the 37th annual STFM Conference on Medical Student Education. Until 2010, the conference was known as the STFM Predoctoral Education Conference. We changed the name to the Conference on Medical Student Education. You may not know much about STFM. The Society of Teachers of Family Medicine is my academic and professional home. All of my mentors, my teachers, my peers, and my colleagues are in STFM. It is a great organization. The Conference on Medical Student Education is a premier educational meeting that includes most of the family medicine educators from around the country. 

Let me give you some highlights of the meeting. 

We started the meeting with an amazing plenary speaker. Dr Kevin Eva, Senior Scientist from the Centre for Health Education Scholarship (CHES) at the University of British Columbia in Vancouver, Canada. Dr Eva gave an invigorating talk about medical decision making. My favorite concept from the talk was that we have to make errors in order to get better, and maybe more importantly, we as educators have to provide safe environments that allow students to make those mistakes. His talk is posted on FMDRL.

There was a great talk by Stacy Brungardt, CAE (Executive Director of STFM) about the alphabet soup of family medicine. She described several of the organizations that make up the "family" of family medicine (AAFP, CAFM, COGME, etc...). There was an excellent peer session describing a study of teaching students about the Four Habits model of patient-centered communication, by Dr Hannah Maxfield and colleagues. (full disclosure here, Drs. Maxfield, Zaudke and Chumley are my colleaguesy at KU)

Dr. Chumley and I presented some of our data about using Artificial Neural Networks to classify students' information gathering patterns to make a diagnosis. We looked at 200 students' performance on a standardized patient case, with a 22 item checklist. We used the first 100 patients to train the ANN, and then we tested the neural network with the second 100 cases.  We found that the ANN was able to predict whether the student got the right or wrong answer/diagnosis with a 85% accuracy.  This was better than two other standard classifiers called Bayesian and KNN (K Nearest Neighbor).

There was an awesome dance party on Friday night that brought together faculty (old and young) with medical students.  

The Saturday morning plenary was by Dr Cathy Pipas from the Dartmouth medical college. Dr. Pipas is the Vice Chair of Community and Medicine. She gave a stimulating talk about the transformation of the Dartmouth practices to patient centered medical homes. The scary part of that talk was that the senior administration at Dartmouth have still not aligned the financial incentives with the clinical practices that are transforming to PCMHs.

Drs. Jana Zaudke and Hannah Maxfield presented an interesting randomized trial of giving feedback about the Four Habits model of communication after watching the students perform on a standardized patient.

On Sunday morning Dr. Joshua Freeman moderated a special session on social justice and family medicine. There's were several medical students at the session and we had a great discussion after his talk.

The final plenary for Sunday morning was Dr. Jerry Kruse. Dr. Kruse is the Chair of the Department of Family and Community Medicine at Southern Illinois University School of Medicine. I asked Dr. Kruse to talk about his views of health care reform. He said that there are two different and divergent views of healthcare reform and its importance to the nation's progress toward the future.  He called the passage of the health care reform bill last year, "the triumph of reason over power". Dr Kruse is famous amongst his friends for his poetry. He gave the most amazing Seussian rhyme describing the saga of Dr Michael Klein, the Canadian doctor that studied the routine use of episiotomy. Dr. Kruse gave me permission to post the lyrics of this poem for your edification. Look for it coming in a couple of days.

Dr. Kruse also presented the new COGME report, "Advancing Primary Care" and its recommendations. The most important recommendation from COGME was that the percentage of primary care physicians should be at least 40% of all physicians.

Overall, this was a great meeting.  Thanks to all of the presenters for your great work. Thanks to all the attendees, including over 200 students attending the national student-run free clinic forum. Thanks to the STFM staff for your hard work, in particular Ray Rosetta, the hardest workin' man in the conference business.  Next year, the meeting will be February 2-5, 2012 in sunny Long Beach, California. The Call for Papers opens in March, so get ready!