Dr Kimberly Manning joins to discuss imposter syndrome, how vacations affect health, and an update on the pneumonia vaccine, PCV13. Plus, hot takes on the dangers of vaping, and using procalcitonin and CRP to determine need for antibiotics.
Howdy, gentle listeners! It’s that special time of year when the school doors reopen, classrooms are awash in ‘new pencil’ smell, and FOAMed fans grab their trays and head to the cafeteria for some tasty knowledge food. Rest assured your Curbsiders friends have saved you a seat at the lunch table for this very special September 2019 episode!
Today we are joined by Dr. Kimberly Manning MD, FACP, FAAP, who is an Associate Professor of Medicine at Emory University School of Medicine. Dr. Manning authors a blog (“Reflections of a Grady Doctor”) that was named in 2010 by ‘O’ The Oprah Magazine as one of “four top medical blogs you should read.” She can also be found on Twitter, @gradydoctor. Thanks for listening!
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Written and Produced by: Sarah Phoebe Roberts MPH, Christopher Chiu MD, FACP, FAAP
Hosts: Matthew Watto MD, FACP; Sarah Phoebe Roberts MPH, Paul Williams MD, FACP; and Christopher Chiu MD, FACP, FAAP
Editor: Christopher Chiu MD, FACP, FAAP; Emi Okamoto MD
Cover-Art: Christopher Chiu MD, FACP, FAAP
Guest: Kimberly Manning MD, FACP, FAAP
In this opinion piece, Dr. Samyukta Mullangi and Dr. Reshma Jagsi (featured on Curbsiders episode #162, Gender & Sexual Harassment in Medicine) discuss the roots of ‘imposter syndrome’–the erroneous belief that one’s successes are a result of luck or chance, and not fully deserved. Imposter syndrome is commonly endorsed by women and minorities, and is a common affliction among those pursuing careers in academic medicine.
The authors note that imposter syndrome is not simply a self-imposed insecurity that can be easily overcome by changing one’s way of thinking or by modifying professional behavior. Rather, it is related to other structural barriers that women and minorities in medicine face, such as lack of representation in leadership, inadequate resources dedicated to identifying and supporting diverse candidates, and insufficient follow-through from administrators in regards to building an equitable work environment.
Remember that imposter syndrome is common. It’s not just you and is likely part of the bigger system. Be a better bystander by accepting differences and understand the societal pressures. And be your authentic self!
Metabolic syndrome is a constellation of symptoms/conditions such as hypertension and obesity that can lead to elevated chronic disease risk (e.g. diabetes, heart disease, stroke). Although most employed adults have vacation days they can take each year, only half of this time is typically used. Recent research suggests that workers who use more of their allotted vacation days are less likely to meet criteria for metabolic syndrome, suggesting the benefits of taking vacation time may yield an overall positive effect on workers’ health and well being.
Hruska B, Pressman SD, Bendinskas K, Gump BB. Vacation frequency is associated with metabolic syndrome and symptoms. Psychology & Health. June 2019:1-15. Doi: 10.1080/08870446.2019.1628962
The researchers sought to explore the relationship between past-year use of vacation time, and symptoms of metabolic syndrome among adult workers.
A total of 63 adult workers were recruited for the study, and took part in surveys and interviews to assess past-year use of vacation time. Participants were evaluated for metabolic syndrome through tests including measures of waist circumference, blood sugar, blood pressure and cholesterol. About half of all participants were employed in the fields of healthcare or education, and most were white women (mean age: 43).
The study has some important limitations (retrospective design, limited study sample, generalizability of participant characteristics) but overall lends support to the notion that using one’s vacation time may reduce risk factors for metabolic syndrome.
Zuger A. How Should We Use Conjugate Pneumococcal Vaccine in Immunocompetent Older Adults? NEJM Journal Watch. 2019.
Ampel N. Childhood Pneumococcal Conjugate Vaccination Benefits Adults. NEJM Journal Watch. 2019.
See the deliberation on YouTube: https://www.youtube.com/watch?v=wlb59e4bcSM
In the United States, there are two FDA-approved vaccines for the prevention of pneumococcal infection: the Pneumococcal conjugate vaccine (PCV13 or Prevnar 13®) and the Pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax23®). PCV13 is routinely administered to children, and since 2014 the CDC has recommended it be provided to healthy adults aged 65+ as well. Immunocompetent adults ages 65+ are also advised to receive PPSV23.
However, the CDC’s Advisory Committee on Immunization Practices recently revisited the recommendations regarding administration of PCV13 to healthy older adults, and is now advising that clinicians (in consultation with their patients) determine its appropriateness on a case-by-case basis. The change in position appears to be driven by data suggesting PCV13, while safe and potentially helpful to select patients, is very expensive with a high ‘number needed to vaccinate’ annually in order to prevent one case of invasive pneumococcal disease (26,000 patients) or pneumonia (range: 2,600-14,000 patients). The recommendation for provision of PPSV23 to healthy adults ages 65+ has not changed.
Additionally, recent research suggests that vaccinating children with PCV13 provides ancillary protection to adults, reducing the likelihood of contracting invasive pneumococcal disease (IPD) by 28% (further reduced to 40% when considering IPD caused by the strains PCV13 prevents). However, the study also found adults aged 65+ faced a 20% increase in risk of IPD infection from a pneumococcal virus strain not covered by PCV13.
The number of e-cigarette associated lung illnesses continues rising, latest updates (after show recording) are 450 cases as of September 6, 2019 (CDC report). In August, the CDC released a Clinician Outreach and Communication Activity statement urging all providers to report cases of vaping related illness. Also, vaping pens have exploded! –see this NBC News story
A meta-analysis of 12 trials found procalcitonin had a sensitivity of 0.55 and specificity of 0.76 (Kamat, 2019) for distinguishing bacterial from viral community-acquired pneumonia. An ACP Hospitalist Weekly article warned procalcitonin may not be reliable enough to use for guiding treatment.
A recent randomized control trial involving outpatients with COPD presenting with an exacerbation found that using C-reactive protein (CRP) to guide antibiotic use resulted in 22% less patients getting antibiotics, without evidence of harms (Butler, 2019). The guidance given was a low CRP level (<20mg/L) was unlikely to benefit from antibiotics, a moderate level (20-40mg/L) may benefit particularly if purulent sputum is present, and high level (>40mg/L) is likely to benefit from antibiotics.
Listeners will learn about relevant medical literature, with an emphasis on breaking news and recently published research.
After listening to this episode listeners will…
Dr. Manning reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Roberts SP, Chiu C, Okamoto E, Williams PN, Watto MF, Manning K. “Hotcakes: Imposter syndrome, the perks of vacation time, and a pneumonia vaccine update.” The Curbsiders Internal Medicine Podcast http://thecurbsiders.com/episode-list. August 26, 2019.
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Thank you again, Curbsiders! I have had the imposter feeling many times in my career. I had attributed it the fact that I started out in the "mail room" and worked my way up. I was an ED clerk and switch board operator at 16, diploma RN at 22, and then NP at 41. I never attended med school and was often the first NP and only NP in a practice. I have made it worse by trying a new field of medicine every 2 years or so, but I like the challenges and the variety of experiences. But, after listening to your podcast, I can see that my soft style of leadership is a factor and that I was mostly surrounded by male doctors in my practices. It was very helpful to hear that doctors, including male doctors, have this feeling. And, as I write I think that our clinical experiences add to this. You can do everything right in a case and the results are not what you wanted or expected. Conversely, you can do the same with another patient, and they do well and as you expected. I think we are often humbled that even when we do our best, some things cannot be explained and are out of our mortal hands, for better or worse. I do agree with the idea of authenticity, bringing your true self to your work which increases emotional connection and empathy with/for the patient. In all my work, caring is core, and helps with the "imposter" feeling. When people know you care the workplace becomes "safer" for all. I appreciate Dr. Manning's "reflecting about reflecting" and am very familiar with this kind of loop processing. I did speculate that the "imposter" feeling might have to do with the journey from "novice" to "expert" and that there really is no end to medical education as new information becomes available daily. This podcast was so helpful in that it validated many of my feelings in medicine as a female nurse practitioner. I am much more accepted today, compared to when I first graduated with with my NP degree in 1997. And, I now have a long history of contributions which help to reinforce my "place in the sun" when I am feeling a tinge of "imposter". As always, I love your delivery with humor, laughter, quirkiness, and humility. You feel like good "friends" in the work. Terry Forbes, CRNP-Family
Very good point about our clinical experiences in some ways reinforcing imposters syndrome! The more we know and see the more we know we don’t know!