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FALL 2013

In This Issue

President's Letter

Resident Division Committee Updates

Advocacy: Women’s Advocacy

Research Spotlight

Global Health Updates: 

  *Mines and the Resettlement Issues, Columbia 
  *Experiences from the Field, Bolivia
  *The Time to Act is Now

Resident Voices:
  *You’re Fired!
  *On Surgery, Beauty, and Whistling
  *This Side of the Looking Glass: Clinical Cases

Publication Opportunity

AMWA Residency Division Awards

AMWA Residency Division Elections

AMWA National Meeting 2014 
Copyright © *|2013|* *|AMWA|*, All rights reserved.

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AMWA President Address to the Resident Division


A non-medical friend in NYC asked me how I was finding residency.  I uttered one word:  Relentless.

Residency is relentlessly intense.  Relentlessly engaging.  Relentlessly exciting.  Relentlessly tedious. Relentlessly exhausting.  Relentlessly empowering.  Relentlessly humbling.  Relentlessly fulfilling.  Relentlessly trying.  Relentlessly exhilarating.  Relentless. 

What’s your word to sum up residency?

And AMWA?  What is AMWA?  AMWA is productive. Encouraging.  Empowering.  As women of AMWA, we constantly lead our peers to new heights, new standards, new successes.  We challenge, applaud, and create.

We need your energy:  we will give it back to you in spades.  We need your ideas:  we can bring them to fruition.  We need your kindness:  we can share it with those who need encouragement.  Please email us your thoughts, photos, ideas, a few words to describe your residency experience… send to  Let us share these with others in our AMWA Resident Quarterly (ARQ).


Kanani Titchen, MD                                                                           
Jefferson/duPont-Nemours Pediatric Residency Program 
AMWA RD, President 2013-2014
image:  Relativity, by MC Escher

AMWA Resident Division Committee Updates

Welcome our newest committee member! 
Claire Roden, MD
ARQ Editor, AMWA National Residency Division
Pediatrics Resident, Cooper University Hospital


Rosemary Claire Roden, MD, is the third Dr. Roden MD, but the first to be a woman. Claire is a PGY-1 in Pediatrics at Cooper University Hospital in Camden, NJ. She recently left Philadelphia for scenic New Jersey with her brand-new state-sanctioned mate/husband, Matthew. In her spare time, Claire enjoys running, knitting, and the great outdoors, and she and her partner share a particular love of Ethiopian food.  When she’s done with this whole residency business, Claire will ultimately have to decide if she wants to specialize in Pediatric Emergency Medicine or Adolescent Medicine.
Women’s Advocacy

By Brittany Jackson, MD
Women's Advocacy Chair, AMWA National Residency Division
OgGyn Resident, George Washington University
Image by Michelle Chen
·         Ob/Gyns Join Together on Reproductive Rights: On August 23rd, 2013, Time Magazine featured an article regarding a statement by 100 Ob-Gyn physicians “condemning new state restrictions on abortion” and which “criticizes hospitals for relinquishing abortion to stand-alone clinics,” due for publication in the September issue of the American Journal of Obstetrics and Gynecology (AJOG).  The article cites some of these most recent restrictions by individual states, as well as examples of the monetary and political incentives accepted by particular hospitals in exchange for refusing to provide abortion services.  In addition, the piece offers interesting commentary on the changing make-up of the collective group of Ob-Gyn physicians in the U.S., and how the lack of hospitals providing abortion services affects career decisions of newly-trained Ob-Gyns entering the workforce.
·         Breastfeeding Goals: Moving in the Right Direction: On July 31st, 2013, the Centers for Disease Control (CDC) released a report outlining breastfeeding (and exclusive breastfeeding) rates in U.S. infants from 2000 to 2010.  Also included are break-downs of breastfeeding based on state and socio-demographic factors.   The good news is that, nationally, there has been notable improvement in multiple areas, including:

  2000 2003 2010
Any breastfeeding at 6 months 34.2±2.0%   49.0±1.9%
Any breastfeeding at 12 months 15.7±1.5%   27.0±1.8%
Exclusive breastfeeding at 3 months   29.6±1.5% 37.7±1.9%
Exclusive breastfeeding at 6 months   10.3±1.0% 16.4±1.5%
Source: “Breastfeeding Among U.S. Children Born 2000–2010, CDC National Immunization Survey,” Centers for Disease Control and Prevention.  2013 July 31.

In the past, breastfeeding rates struggled to reach the Healthy People 2010 goals, and the new Healthy People 2020 objectives outline higher goals including any breastfeeding at 6 months and 1 year as 60.6% and 34.1%, respectively.  Click here to see the remainder of the Healthy People 2020 breastfeeding goals.

·         How you can help!
o        The New York State Department of Health has developed a handy reference card for clinicians which provides helpful information including counseling new mothers on breastfeeding and the absolute (and presumed but not actual) contraindications to breastfeeding.
o        LactMed, a searchable database developed by NIH to help clinicians determine which medications are safe to use in breastfeeding mothers, also has a
FREE app available for both iPhone and Android!  You can download the app to your phone from either the iTunes App Store or Android Google Play.

Research Spotlight
Congratulations to new AMWA RD member Dr. Ilia Kritikou for publishing her abstract High Fat Intake Is Associated With Physiological Sleepiness In Healthy, Non-Obese Adults!  The abstract was in the Abstract Supplement, Vol.36 of the journal Sleep.  Ilia's research was guided by her mentor Dr. Alexandros Vgontzas (Professor of Psychiatry, Penn State Hershey), and agreed with previous studies showing that increased fat consumption - in contrast to carbohydrate consumption - increases sleepiness and negatively affects performace.  The mechanism remains elusive, perhaps involving cholecystokinin and proinflammatory cytokines.   The abstract was also featured in a recent issue of Glamour Magazine.    
Dr. Kritikou & mentor Dr. Vgontzas 

Congratulations to our AMWA Residency Division team Dr. Kanani Titchen, Dr. Mary Becker-Rasavy, and Dr. Dyani Loo, who -- along with Dr. Eliza Chin (Executive Director of AMWA) and Dr. Iman Sharif (duPont Children's Hospital) are presenting their preliminary data on domestic child sex trafficking this week!  Drs. Chin and Titchen will present the poster "Domestic Child Trafficking:  Educational Needs Assessment and Development of a Curriculum Targeting Physicians" at the Women's Healthcare Innovation & Leadership Showcase in Bridgewater, NJ.  They are still collecting data!  If you have not already completed the survey, please go to  The survey is IRB approved and takes just 2 minutes to complete.

Advocacy Action on Sex Trafficking In America

“What if a billion children were exposed to a disease that made them vulnerable to HIV, crime, mental health problems, substance abuse/addition, diabetes, and chronic diseases?  That disease is child sexual trafficking.”
-James A. Mercy, PhD,
National Center for Injury Prevention and Control, CDC
Global Health Updates

Mines and Resettlement Issues, Colombia
By Dyani Loo, MD
Global Health Co-Chair, AMWA National Residency Division
Psychiatry Resident, University of New Mexico
The communities located in the Cesar region of rural northeast Colombia are key players in a social, legal, health, environmental and political entanglement that has played out over the last several decades. The northern region of Colombia extracts some of the purest coal in the world.  Multinational companies, including two that are based in the United States, have been engaged in open pit mining, which has been largely unregulated for the last fifty years . The mines are massive in scale and the environmental impact results in complete restructuring of the local ecosystem that makes it inhospitable for animals and flora.   

Open pit mining is known to cause multiple long term problems, and the indigenous people living in this area have been directly affected. Generations of subsistence farmers and cattle herders no longer have enough useful land for subsistence farming.  Coal is extracted through use explosives to break up the top soil, and then mounds of earth are piled out onto the mine periphery in order to access coal rich veins. Particulate contamination from the explosions, the exhaust from service machinery, and the dust kicked up by fleets of mine vehicles remains at high levels and is known to cause significant respiratory and cardiac problems as well as increased mortality.  1,2,5,6  Because of high levels of particulate matter assessed and confirmed in a study done in 2011 by the Colombian government, the multinationals have been ordered to assist these communities in resettlement3,4.

I traveled to this area in order to understand respiratory health concerns which, to date, have not yet been formally assessed.  My team found , while the communities focus on increased respiratory problems, health concerns are also confounded by the problems of living in a rural area: people lack health care access, often find it necessary to use wood burning fires for cooking, and lack a central city census in order to track birth and mortality rates. One of the neighboring mine companies explained that they were aware of the respiratory concerns but that they feel these health problems are not related directly to mine contamination. 

The quality of life in these communities is very poor. Although we have yet to analyze the data , we observed decreases in physical, mental, and social health based on the Duke Health Profile, with the majority of focus group members screening positive for at least mild depressive.9 Respiratory infections were documented as the most commonly seen illness in the nearest clinic that serves this area.  Based on readings taken on site during our project, levels of air particulates with a diameter of 10 micrometers or less for our target sites were on par or higher when compared to the nearest city-- Baranquilla, and they were two to three times higher when compared to a rural site located away from the coal mines.

Community members report that conflict over the presence of the mines and contamination-related health effects has been detrimental to resettlement negotiations.  Communities going through the resettlement process in nearby La Guajira have been split.  Families have been asked to pay to relocate their burial grounds after mix-ups, are unhappy at being forced to relocate to new housing that is not culturally appropriate, and are overwhelmed by being forced to change too quickly from subsistence farming and cattle herding to urban projects.  Another nearby village was resettled before companies were held under more scrutiny:  These families were relocated into an area without water supply, without schools, and without transportation access. 

Although resettlement of the communities in Cesar was supposed to have been completed by June 2012, the communities and mines are still stalled in initial phases of planning, and the villagers now face recurring food shortages so severe that they were recently visited by the UN. While the problems facing the mines and the affected communities will not be solved overnight, resolving communication problems between the two parties would help reduce at least part of ongoing distress.  Improved mediation is needed in order to for both sides to begin instituting critical services.

1.        Fernandez-Navarro P, Garcia-Perez J, Ramis R, Boldo E, Lopez-Abente G; Proximity to mining industry and cancer mortality; Science of the Total Environment; 2012; 435-436, 66-73
2.        Ghose MK, Majee SR; Air pollution caused by opencast mining and its abatement measures in India; Journal of Environmental Management; 2001; 63, 193-202
3.        Huertas JI, Huertas ME, IZquierdo S, Gonzalez ED; Air quality impact assessment of multiple open pit coal mines in northern Colombia; Journal of Environmental Management; 2012; 93, 121-129
4.        Huertas Jim, Huertas ME, Solis, DA; Characterization of airborne particles in an open pit mining region; Science of the Total Environment; 2012; 423: 39-46
5.        Woodruff TJ, Parker JD, Schoendorf KC; Fine Particulate Matter (PM2.5) Air Pollution and Selected Causes of Postneonatal Infant Mortality in California; Environmental Health Perspectives; 2006; 114:5, 787-790
6.        Yang AC, Tsai S, Huang NE; Decomposing the association of completed suicide with air pollution, weather, and unemployment data at different time scales; Journal of Affective Disorders; 2010; 129, 275-281
7.        Zullig KJ, Hendryx M; A Comparative Analysis of Health-Related Quality of Life for Residents of US Counties with and without Coal Mining; Public Health Reports; 2010; 125, 548-555
8.        Peace Brigades

Experiences from the field: Bolivia

By Savitha Bonthala, DO, MPH
Global Health Co-Chair, AMWA National Residency Division
PMR Resident, Baylor College of Medicine; Intern, Manatee Memorial

During the summer of 2013, I had the privilege of completing my public health field study in Bolivia, South America. For five short weeks, I worked with the large umbrella NGO PROCOSI (Program de Coordinacion en Salud Integral), whose mission is to “improve the health of the neediest population, especially children and women, by means of inter-institutional coordination; the strengthening of member institutions; and advocating policies that influence health and quality of life of the Bolivian population.” I worked on their COMBI project. During my five weeks, I created a tool for COMBI to help them measure and evaluate their current system.

COMBI (Communication for Behavioral Impact) Malaria in Bolivia focuses on “Behavior change prioritizing sustainable solutions for early diagnosis, complete treatment and use of preventative measures [for malaria].” This project is aimed at targeting and changing the behaviors of Bolivian citizens to reduce the mortality and morbidity associated with malaria.

The highlight of my trip was my fourth weekend in Bolivia. I had the privilege to travel to Pando in the Bolivian Amazon with the director of COMBI to perform site visits on malaria education. The Bolivian Amazon has approximately 80% of malarial cases due to its tropical nature and the opportunity for mosquitoes to breed rampantly.

I was fascinated and excited about being part of this journey. To get to the actual location of our malarial education site, we had to travel deep into the Amazon. We crossed many rivers and drove into the jungle to reach our destinations. To ford the waterways, we drove our SUV onto a wooden raft that floated across the expansiveness of the waters.

Once we reached our destination, three members of Caritas, an NGO under PROCOSI, led an educational session for nursing students at the University of Pando. They displayed videos and power point slides across a white wall; detailing information about the pathophysiology, signs and symptoms and treatments of malaria. The nursing students also learned about personal development and governance. While the presentation of medical information was impressively thorough and exact, I was more deeply moved by the strong focus on youth leadership.

COMBI Malaria focuses both on education sessions tailored to meet the needs of health professionals, families, and communities; and also developed a systematic way to diagnose and treat affected individuals. Community health workers serve in each community as volunteers to help disseminate information about malaria. In addition, they stress the importance of going to the local health clinic if anyone in the household had fever or any other signs of illness. Once at the clinic, anyone testing positive received free treatment.

COMBI Malaria has also created several household items with images to help families remember the symptoms of malaria and the importance to follow through with the entire treatment course. These pictures were dawned on items ranging from notebooks, calendars, and mugs to bathtubs for small babies.
I had time to reflect about my experiences in the Amazon and the impact COMBI had on the Bolivian people when we travelled back to La Paz. As my time quickly drew to a close, I wondered if what I had done had been useful and if PROCOSI would be receptive to my work. I handed in my final report during my last week and hoped for the best.
On my final day in the office—which was also my final day in medical school—there was an announcement to meet in the cafeteria downstairs. I joined my colleagues and stood in a corner and listening to speeches for a dear co-worker who would be leaving PROCOSI. To my surprise, the attention shifted towards me and the head of PROCOSI, Dr. Carreno, started thanking me for my work. Then, Sergio, director of general services, also expressed gratitude for my work. Finally, Dr. Mirabal, who I had worked so closely and travelled with for five weeks, started speaking about my work -- how I helped COMBI Malaria and his appreciation for my time here. I could only stare at the floor as Dr. Mirabal spoke because if I made eye contact with him I knew I would start crying. I was handed a bouquet of flowers and given hugs by every member of the office.

Never in my life had I gotten this kind of recognition for my work. As I left the office I made the seven-block journey back to my homestay. I cried the entire way back; overwhelmed with gratitude and humbled by my experiences in Bolivia. I was inspired by Dr. Remen, who states, “We are all here for a single purpose: to grow in wisdom and to learn to love better. Life is the ultimate teacher, but it is usually through experience and not scientific research that we discover its deepest lessons.” The people I met were so dedicated and passionate about helping improve the lives of others that it inspired me to continue my path towards becoming a healer.

The Time to Act is Now

By Misty Richards, MD
Advisor, AMWA National Residency Division
Psychiatry Resident, UCLA
There has never been a more innovative time for the field of global psychiatry.  After the release of the 2010 Grand Challenges in Global Mental Health initiative, a surge in international efforts to address debilitating psychiatric conditions has emerged.  Through the efforts of powerhouse organizations such as the National Institutes of Mental Health and the Global Alliance for Chronic Disease, the world is realizing the necessity of addressing psychiatric disorders, as they occupy 13% of the global burden of disease (1). In fact, by 2020, an estimated 1.5 million people will die each year by suicide, and roughly 30 million will make an attempt (2). To address this state of affairs, the Grand Challenges in Global Mental Health initiative was born to identify barriers in accessing psychiatric care. Similar to the Grand Challenges in both Global Health and Chronic Non-Communicable Diseases initiated in 2003 and 2007 (3), respectively, the goal is to identify specific goals that may be collectively addressed by mental health providers throughout the world.
An international panel consisting of over 400 mental health researchers, advocates, and clinicians from over 60 countries was assembled to identify 25 grand challenges. These challenges were published in a pivotal Nature paper in 2011 (4), officially starting the clock on targeted, global mental health interventions. The challenges capture several broad themes distilled into four areas of focus (4): risk factors, families and communities, evidence-based approaches, and the impact of environmental factors on mental health. 
The first area emphasizes conducting research using a “life-course approach” which acknowledges the importance of identifying risk factors for mental illness.  Additionally, efforts by clinicians can be poured into building mental capital—the cognitive and emotional resources that influence how well an individual is able to contribute to society—in order to mitigate the risk of debilitating, chronic mental illness. 
The second area of focus is on families and communities of patients, as they are also affected.  Considering this, mental health system-wide changes are critical, along with attention to social stigma and discrimination. 
Thirdly, the challenges underscore the importance of evidence-based medicine when identifying treatment interventions, which may ultimately affect clinicians, policy makers, and program planners.
Finally, the panel’s responses emphasize the delicate balance between environmental exposure and organic mental illness.  Extreme poverty, natural disasters, war, and consequent despair plague many developing countries, and their causality in the timing and manifestation of mental illness is not abundantly clear.
Five top challenges were identified, ranked by disease burden reduction, impact on equity, immediacy of impact, and feasibility of implementation (4).   These five challenges are to:
1)  Integrate screening and core packages of services into routine primary health care
2)  Reduce the cost and improve the supply of effective medications
3)  Provide effective and affordable community-based care and rehabilitation
4)  Improve children’s access to evidence-based care by trained health providers in low- and middle-income countries
5)  Strengthen the mental-health component in the training of all healthcare personnel
These five goals are concretely identified to serve as a starting point for clinicians, policy makers, and educators so we may have measurable improvement within a decade.  By working to implement these sustainable, long-term solutions, significant economic and quality-of-life benefits will be reached that far outweigh the initial investment (5). The time is now to change the world of global mental health.

1.   World Health Organization. The Global Burden of Disease: 2004 Update (WHO, 2008)
2.   Bertolote J, Flieschmann A: Suicide and psychiatric diagnosis: a worldwide perspective. World Psychiatry 2002; 3:181-185
3.   Daar A, Singer P, Persad D, Pramming S, Matthews D, Beaglehole R, Bernstein A, Borysiewicz L, Colagiuri S, Ganguly N, Glass R, Finegood D, Koplan J, Nabel E, Sarna G, Sarrafzadegan N, Smith R, Yach D, Bell J: Grand challenges in chronic non-communicable diseases. Nature 2007; 450: 494-496
4.   Collins P, Patel V, Joestl S, March D, Insel T, Daar A, Scientific Advisory Board and the Executive Committee of the Grand Challenges on Global Mental Health, Anderson W, Dhansay M, Phillips A, Shurin S, Walport M, Ewart W, Savill S, Bordin I, Costello E, Durkin M, Fairburn C, Glass R, Hall W, Huang Y, Hyman S, Jamison K, Kaaya S, Kapur S, Kleinman A, Ogunniyi A, Otero-Ojeda A, Poo M, Ravindranath V, Sahakian B, Saxena S, Singer P, Stein D: Grand challenges in global mental health. Nature 2011; 475: 27-30
5.   Rupp A, Steinwachs D, Salkever D: The effect of hospital payment methods on the pattern and cost of mental health care. Hosp Community Psychiatry 1984; 35: 456-459

Resident Voices
You’re Fired!

By Tara A. Renna, MD
President-Elect, AMWA National Residency Division
ObGyn Resident, Albany Medical Center

Be it learning the fine-tuning of antibiotic regimens or the skill of knowing which patient needs to go to the OR, residents are in a program designed to prepare them for the future. Ideally, this time also gives new physicians the ability to learn the emotional, physical, and intellectual hardships of their chosen career in a controlled and supportive setting.

With that said, this past week I was fired. Not from my position as a resident and not from the hospital, but rather by a patient. I am sure that this is an event that has happened multiple times to residents and attendings alike, and if it had not happened to me on this particular day it likely would have occurred later. But when it happened it hit me, for lack of a better cliché, like a ton of bricks. The anger that resonated from the patient struck me to the core. I stayed in her room for a moment after she yelled the words “get out,” just long enough to have my emotions assemble into a giant ball in the center of my chest, where they made it difficult to breathe. I was so stunned that I did not even have the time to formulate a response; I simply turned around and left. 

My background with the patient started 8 days earlier. I had initially met her on postpartum rounds and as her situation began to deteriorate, I found myself spending extra time and staying after hours to make sure she was ok. So when she fired me I was, needless to say, shocked.

The logical explanation to her outburst was most likely projection. We learn about it in psychiatry coursework, never realizing that our patients can do this to us. She was mad that she was not getting better; she obviously was upset, frustrated, and disappointed all at the same time. I am sure that like me she had a little ball of emotion sitting in the middle of her chest, and simply projected this onto me. But in the moment, that’s not what it felt like. I felt betrayed, like she did not understand what I had been trying to do for her this entire time. I felt little, like I must have not come across as knowledgeable during my care for her. I felt anger that she was making me bear the burden of all of her emotions. I felt sadness that she was welcoming other residents into her care that had not previously been involved. And I felt embarrassed.

So what is the moral of the story? I came to realize, after some extensive processing and meditation, that in that moment, I was fulfilling the exact role that she needed me to; essentially helping her psychological self. She needed someone to blame: postoperative complications are difficult especially when you enter the hospital for what you think is going to be a normal vaginal delivery. She needed to yell, to release all of the anger and tension that had built up around the situation that had developed, and I was the only person she knew well enough to do this to.

Perhaps I am being selfish in thinking this. Perhaps I am completely wrong and she simply just did not like me. What I realized is that this is what I need to believe in order to cope with it.

When I was telling someone about this, they told me not to worry; eventually I will become hardened to things like this. But thinking further about it, I decided that I definitely do not want that to happen. One of the reasons I entered medicine was to care for people, and caring is the foundation of medicine. If we did not care for each other there would be no need to have the art of medicine. We would not spend time after hours researching to improve patient care. We would not wake up at four o’clock in the morning to spend extra time with our patients. Instead, we as a society strived to minimize pain and prolong life, because we care about each other. I hope to not lose this but at the same time I hope that my next “firing” does not have such an impact. I suppose there is a balance to achieve, and luckily I have the next 3 years to figure that out.

On Surgery, Beauty, and Whistling 

By Maya Bass, MD
Family Advocacy Chair, AMWA National Residency Division
Family Medicine Resident, Thomas Jefferson University Hospital

There is a joke in Medellin, Colombia: What did the girl get for her 15th birthday?
The answer: Breast implants or a nose job, depending on the audience.
I didn't think it was that funny either.
At first, I figured people were overselling the plastic surgery culture in Columbia, but by the end of my month in Medellin, I had to agree that it was commonplace. In 2010, 90,000 cosmetic procedures were done in Colombia alone. In addition, plastic surgery in Colombia is about 1/3 the price in the states (Conely, 2012). I was surprised to discover that -people from all walks of life were willing to go under the knife, and were also willing to discuss it openly. I worked in a respected hospital and many of my attending doctors were happy to talk about their implants. The consensus was that they wanted to look beautiful; surgery was relatively inexpensive and widely available so, why not?
In Columbia, beauty means large breasts, tiny waist, small nose, and a giant butt adorned with provocative clothing. Spandex is everywhere. One tour guide explained that this “narco-beauty” was a leftover from the days of drug cartels running the country. I asked a few women why they thought it was the norm. One woman in her 60’s, who opened her house as a homestay to the program I was interning with, said she loves the positive attention and it makes her feel pretty. She dresses up in high heels and tight clothing even to go to the supermarket.
What kind of attention? Well, men show their approval of women with a hiss or whistle. If you are having trouble imagining the sound, think of the sound one uses to get a cat’s attention or the sound produced by letting air slowly out of balloon.
Colombia is a beautiful country rich with culture and natural resources, struggling to recreate its image. Still, this cultural aspect resonated with an area of American culture that I distinctly dislike. The concept that, not only do women need to be visually appealing, but also that a woman’s body is fair game for male attention, or is somehow open to public commentary.

In Colombia, I was harassed every time I left my house, no matter what I was wearing. By the end of the month, I had taken to wearing my scrubs as armor against the hisses. When that didn’t work, I realized that I had taken the blame for the harassment on myself. It should not matter what I wear or how I walk, nobody has the right to comment on my image without invitation.  It is this harassment, “invited” or not, that leads women to make changes, to get surgery, to dress differently. We are professionals, mothers, and more but we are still being influenced by a simple whistle.

1.        Conley, Mikaela (April 25, 2012). Nip/Tuck Nations: 7 countries with most cosmetic surgery.

This Side of the Looking Glass: Clinical Cases

By Claire Roden, MD
Editor-In-Chief, AMWA National Residency Division
Pediatrics Resident, Cooper University Hospital

Illustration by Sir John Tenniel 

It was a humid day at the end of July when I walked into “Andy’s” room and started his four-year well child check with my standard question:
“What concerns do you have for me today?”

Andy’s mom looked at me with exasperated eyes and answered with a decidedly non-standard response. Her son was preternaturally smart, but he had a violent streak a mile wide that had gotten him expelled from multiple day care centers in the last six months. Andy liked to pick fights with his older brother, and he liked to fight dirty.  The final detail was that in a moment of impulsivity, Andy had picked up the family’s new puppy and pitched it down the stairs.

Most of the time, a “well-child check” is far less dramatic than this: every few months, I get to sit down with a family and chat about their lives, fill out some forms, give some shots, and do an exam. In the last month in clinic I had uncovered a vast array of issues families needed to discuss during a checkup, but I was not prepared for this mom’s concern of how to keep the rest of her family safe from her 30 pound, 3-foot-tall terror.

During the rest of our visit, Andy’s mom described his behavior as if she was reading the stem of a USMLE question about Conduct Disorder. That particular entity is “A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three [specific criteria] in the past 12 months, with at least one [criterion] present in the past six months.”1  It can sometimes coexist with Oppositional Defiant Disorder, though the latter is characterized more by excessive obstinance without frank disregard for the humanity of other people.2

A risk factor for both of these conditions, and the elephant in the room during Andy’s well child check, is a history of child abuse, in addition to family history of mental illness, domestic violence, and instability within the home.3 Estimates nationwide place child abuse, broadly, as having prevalence around 9.3% from 2007-2011.4 My program resides in a county with a particularly high prevalence of child abuse, within a state averaging 20 cases reported per 1000 in 2004 children and an increasing incidence.5  That knowledge rattled louder in my skull the longer I sat in that room.

While I took a history from his mother and stepfather, Andy turned and threatened his mother with a fist with every anecdote he didn’t like. Mom and Dad didn’t tell me anything that smelled like abuse or bad parenting, and Mom told me in a quiet voice about her own struggles with depression and suicide attempts. As they told me more about Andy’s specific story and past transgressions, it became more and more obvious what kind of toll their son’s hostility was taking on that mother and father.
Conduct disorder in a child is not a reason to remove the child from the home; neither is a family history of mental illness nor of poverty. I discussed Andy and his family at length with my clinic attendings, and we made a plan with them. Because Andy was not actively violent while visiting the clinic, there was relatively little that we could do at that moment to help. We made a strategy with Mom and Dad for what to do the next time Andy’s temper flared: if he had another violent outburst she should have no hesitation in calling the police or in carting her son to a crisis center, and we gave them a stack of phone numbers to call in case of emergency and for more long-term arrangements. We assured Mom that seeking care for Andy during one of these episodes would not make her a bad parent, nor would the state be forced to whisk her son away from her.

Andy taught me that thinking of a well-child check as a purely quotidian endeavor misses the opportunity to provide useful care. He showed me that the purpose of a well visit is to check in, and offer education, intervention, and reassurance. We ask “What concerns do you have for me today” on purpose: we want to form and strengthen relationships with families, and not put limits on what types of worries they are allowed to have.

1.        Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:90–1. Copyright 1994.
2.        Zahrt, DM and Melzer-Lange, MD. “Aggressive Behavior in Children and Adolescents.” Pediatrics in Review 2011;32;325.
3.        Sanders, Lee M and Schaechter, Judith. Conduct Disorder. Pediatrics in Review 2007:28:433.
4.        Child Maltreatment 2011, US Department of Health and Human Services; Administration of Children and Families; Administration of Children, Youth, and Families; Children’s Bureau, 2012.
5.        Child Abuse and Neglect In New Jersey: Statistical Report for Calendar Year 2004. New Jersey Department of Children and Families, Division of Youth and Family Services. John Corzine, Governor, September 2006.

Publication Opportunity

Let your voice be heard!

Have something to say? An experience to share? A unique perspective on research, residency, or healthcare? We’re all ears!

The AMWA Residency Division Quarterly is a journal for AMWA Residency Division members, and we want to hear your voice and publish your words. We are actively seeking submissions from our members on a range of topics, from your personal experiences in education to opinions about virtually anything connecting to medicine. This is a non-peer-reviewed publication, and we want to give you a place to publish your pieces. We are interested in short essays, poetry, photography, and illustrations.  Guidelines:

1) Deadline for the Winter ARQ Deadline is November 30.
2) Submit articles and pieces for publication to
3) Please make sure that anything submitted for publication includes the author’s name in both the file name and the body of the text.  Include a title.
4) Length: Limit is 500 words.
5) For articles that discuss AMWA-related policies, are more academic in nature, or that contain anything that required fact-checking, please include appropriate citations. Citations do not count towards your word count.
AMWA Residency Division Awards

Deadline is January 31, 2014, except as noted. All nominees must be AMWA RD members, except as noted. All winners will be notified by March 1, 2014, and will be honored at the National Meeting. For more details, visit
I.  Charlotte Edwards Maguire, MD Outstanding Resident Mentor Award
·         Demonstrated outstanding mentorship and guidance to AMWA national student members as judged by highest and most active ratings as determined by AMWA student evaluations
·         Must be nominated by an AMWA Student member
·         Applications are accepted on a rolling basis.
II.  AWHS Overseas Assistance Grant
The American Women's Hospitals Service (AWHS) provides small grants, up to $1,500, for assistance with transportation costs (airfare, train fare, etc.) connected with pursuing medical studies in an off-campus setting where the medically neglected will benefit.
·         Applicants should be spending a minimum of 6 weeks and no longer than one year in a sponsored program which will serve the needs of the medically underserved
·         Program must be sponsored by an accredited U.S. medical school or an outside agency (If there is no sponsor, it must be a program for which your school takes responsibility and provides academic credit).
·         Applicants should apply a minimum of three months prior to departure.
·         Please visit the website for more information regarding past recipients

III.  Young Woman in Science Award
·         Demonstrated exceptional contributions to medical science, especially in women's health, through her basic and/or clinical research, her publications and through leadership in her field.
·         Awardees will be honored during AMWA's Annual Meeting.
·         Posters will be judged at AMWA National Conference by a judging panel.
·         Online applications can be submitted to
IV.  Susan L. Ivey, MD Courage to Lead Award 
·         Demonstrated exceptional leadership skills through vision, inspiration, innovation, and coordination of projects that further the mission of AMWA by improving women's health and/or supporting women in medicine
·         Nominations should be submitted to:, please see website for further important details
V.  Elinor T. Christiansen, MD Altruism Award
·         Demonstrated altruism by acting unselfishly as an ambassador of the healing arts and AMWA for the continued promotion and success of healthcare and AMWA
·         Nominations should be submitted to:, please see website for further important details
·         AMWA's national Resident Board and Dr. Elinor T. Christiansen, MD will review all nominations in February. The recipient will be notified by March 1, 2014.

AMWA Residency Division Elections

Run for national office!  We know your time is limited.  Ours is, too!  We are looking for leadership, innovation, enthusiasm, and a commitment to women in medicine.  These look great on a CV and will help you to build a network of peer contacts and physician-mentors.  Positions are listed below.  For details, go to:


·         Serve as President the following year
·         Attend the Annual Meeting
·         Maintain communication with national, regional, and local leaders
·         Supervise maintenance of AMWA resident internet presence


·         Attend the AMWA Annual Meeting
·         Compile and send out the monthly AMWA Resident Quarterly (ARQ)
·         Schedule, set agendas, and take minutes for monthly conference calls

Editor-In-Chief, AMWA Resident Quarterly (ARQ)

·         Solicit written content for the AMWA Residency Division quarterly online publication. 
·         Organize, format, and edit content for ARQ.  Author content where needed.   
·         Work with the President and Secretary to update AMWA website content.   


·         Liaise with AMWA headquarters to track resident funds
·         Work with Awards Chair to disburse scholarships and grants

Advocacy Chair 

·         Serve on the physician Policy and Advocacy Committee
·         Identify relevant opportunities to lobby and raise awareness on behalf of AMWA and the issues            and policies supported by AMWA
·         Design and implement one annual advocacy project in conjunction with physician leadership
·         Maintain a close working relationship with the Treasurer 

Awards Chair 

·         Publicize, coordinate efforts to select, and notify recipients of AMWA awards, scholarships, and            branch and regional grants
·         Maintain a close working relationship with the Treasurer 

Global Health Chair (2)

·         Serve on the physician Global Outreach Committee
·         Contribute articles to the ARQ
·         Develop and identify international rotation opportunities for AMWA resident members with AWHS

Recruitment Chair

·         Coordinate all aspects of new membership recruitment each fall
·         Organize any AMWA promotional items; coordinate item distribution 
·         Nurture the development of new local branches and continue enrichment of existing local       branches

Conference Chair (2)

·         Serve on the physician Conference Planning Committee
·         Coordinate with AMWA headquarters to plan the Annual Meeting resident track content and logistics, as well as accommodations for resident attendees
·         Work with the Treasurer to coordinate grant-writing to subsidize costs

Regional Director (5)

·         Update and maintain region’s local leadership contact information
·         Reach out and recruit residents at residency programs that are under-represented
·         Generate and distribute a quarterly regional student newsletter

AMWA National Meeting 2014

You do NOT want to miss this!  If you love D.C., if you have a poster to present, if you’re running for national Residency Division office, or if you’re simply into creature comforts and a positive spirit, get yourself to this conference!  We are offering TEN $100 travel assistance grants for resident members who are running for office or presenting a poster.  Rooms will be set aside at a heavily discounted rate and can be split between 4 residents.  (Most residency programs reimburse cost of travel and the conference fee, especially if you run for office or present a poster.)  

More info can be found at

Email or