msrj.chm.msu.edu · emergency medicine, carolina’s medical center ‘14 executive editor...

Winter, 2015

Michigan State University College of Human Medicine

Vol: 4, Issue: Winter, 2015

The Medical Student Research Journal (MSRJ) is the longest-running international academic journal in the United States authored, reviewed, edited, and published by medical students for medical students. It is dedicated to promoting the scientific achievements of medical students,

teaching principles of peer and article review, and providing editorial, publishing and leadership learning experiences. Medical students worldwide are invited to submit manuscripts and serve as trained reviewers. The MSRJ publishes original research, case studies, editorials,

research letters, reviews, and reflections that meet required standards, are authored by a medical student, and advance science. It is sponsored by the Michigan State University College of Human Medicine. Visit www.msrj.org and www.facebook.com/msrjchm for more information.

EDITORIAL BOARDEXECUTIVE EDITORS

Jessica Wummel - MS4 and Jack Mettler - MS4

FOUNDING FACULTY ADVISORClare Luz, Ph.D. (2007 – Present)

ADVISOR, OFFICE OF RESEARCHMark Trottier, Ph.D. (2012 – Present)

SENIOR EDITORS JUNIOR EDITORS

EDITORIAL STAFFSTUDENT REVIEWERS FACULTY REVIEWERS

Faculty reviewer credits will be published once per volume (year) to protect the double-blind reviews. The next recognition of faculty reviewers will be in the Fall issue of Volume 4.

EXECUTIVE EDITOR ALUMNI

Andrew Wyman, M.D. Emergency Medicine, Carolina’s Medical Center ‘14Executive Editor Emeritus, Founder (2007–2011)

Steven Plato, M.D.Integrated Vascular Surgery, UH/Case Western Reserve ‘17Executive Editor Emeritus, Founder (2007–2011)

Marissa Baca, M.D.Plastic Surgery, GRMEP/MSU ‘18Executive Editor (2011–2012)

Chad Klochko, M.S., M.D.Diagnostic Radiology, Henry Ford Health System ‘18Executive Editor (2012–2013)

David Ortiz, M.D.Neurology, University of Minnesota ‘17Executive Editor (2012–2013)

Kevin C. Patterson, M.D.Internal Medicine, Ohio State University Wexner Medical Center ‘17Executive Editor (2013–2014)

EDITOR ALUMNI

David Hobbs, M.D. (2011–2012)Jon Zande, M.D. (2011–2014)

Skyler Johnson, M.D. (2011–2014)

SPECIAL THANKS

Marsha Rappley, M.D., Dean, College of Human MedicineAron Sousa, M.D., Senior Associate Dean for Academic AffairsJeffrey Dwyer, Ph.D., Senior Associate Dean for Research and Community EngagementDavid Solomon, Ph.D., Professor, Office of Medical Education Research and DevelopmentGeri Kelley, Communications Director Michigan State University, College of Human Medicine, Office of ResearchJincy Joby at Datapage.ie

MSRJ —Vol: 4, Issue: Winter, 2015ISSN: 2159-3647

Andrew BenintendeTrevor CarleJoseph JacobsonAnupama Joseph

Tyler JunttilaMarissa MartzJames PolegaRobert Zondervan

David Carr - MS4Margaret Chi - MS4Michelle Dwyer - MS4Sahil Bobby Gambhir - MS4Liza Gill - MS4Caela Hesano - MS4Patrick Roach - MS4Kailyne Van Stavern - MS4

Tina Chaalan - MS3Alexander Golec - MS3Romina Kim - MS3Ghadear Shukr - MS3Timothy Smith - MS3Kaitlyn Vitale - MS3Mey Yip - MS3

Johnathan Kao - MS3Rama Salhi - MS3Apoorva Aekka - MS2Toomas Arusoo - MS2Andrew Benintende - MS2Trevor Carle - MS2Tyler Junttila - MS2Michael Klinger - MS2Regina Matar - MS2Jennifer Monacelli - MS2

Masaki Nagamine - MS2Amir Pakray - MS2James Polega - MS2Mahnoor Rehman - MS2Garrett Roe - MS2Joginder Singh - MS2Nadine Talia - MS2BG TenBrink- MS2Samantha Wu - MS2Daniel Ziazadeh - MS2

Michigan State University College of Human Medicine

Vol: 4, Issue: Winter, 2015 Pages 51–70

Winter, 2015

Letter from the Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .051Jessica L. WummeL, Jack c. mettLer

REFLECTIONS

White Coat Sparty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .052carter anderson

In Situ Thrombosis of the Pulmonary Arteries: An Emerging New Perspective on Pulmonary Embolism . . . . . . . . . . . . . .054Virginia corbett, Houria Hassouna, reda girgis

ORIGINAL RESEARCH

Sticking to the Plan: Patient Preferences for Epidural Use During Labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .059Lauren ann gambLe, asHLey Hesson, tiffany burns

Care for Laotian Ethnic Minorities: A Cross-National Study of Medical Students in Laos and California . . . . . . . . . . . . . . . .066katHerine crabtree

he editors of MSRJ are excited to announce ourWinter 2015 issue. As always, we were incredibly

impressed by the caliber of submissions. This issueincludes interesting articles written by medical studentsfrom UC Davis College of Medicine and Michigan StateUniversity College of Human Medicine.

Since the release of our last issue, we have beenastounded by the number of submissions received. Weare always honored when medical students choose ourjournal to showcase their work, and we are very thankfulto all of our authors. Because we want to ensure promptpublications to our authors, we have made the decisionto modify our submission and publishing process. Thechanges are as follows: removal of submission dead-lines, implementation of rolling submissions, and start-ing an e-publication process. What does this mean?Manuscripts submitted to our journal will be reviewedin the order in which they are received, *as has alwaysbeen our policy. However, now, they will be electro-nically published as soon as they are ready. These onlinepublications will then be combined into a full issueat our normal publication dates. We believe this willallow articles that are polished when submitted to gothrough the process more quickly and prevent articlesthat may need more time in the reviewing/editingprocess from holding up any particular issue. We hopethat this solution will satisfy our authors and provide ourreaders with a steadier stream of articles to enjoy.

As this issue goes to print, our annual Spring studentelective has come to a close. We hold this studentelective every year to cater to students interested inbeing part of the MSRJ editorial staff and for thosewho wish to familiarize with the reviewing and publish-ing process. The elective continues to grow in popularityand we are always excited to meet a new group ofstudents interested in the MSRJ. This year, we wereimpressed with all those who completed the course,many of whom will be joining our editorial staff for theupcoming year.

In addition, we will be making the transition to our

new executive leadership staff within the coming month.

Jessica Wummel and Jack Mettler will be graduating

this year and moving on to residency. They were honored

to serve as Executive Editors for the past year and will

continue to be involved in MSRJ as much as they can.

Jessica will be moving on to complete a residency in

medicine/pediatrics at the University of Michigan, and

Jack will be starting his residency in radiology at

Beaumont Hospital in Royal Oak, Michigan. Kailyn

Vitale, an incoming fourth year, has been elected as

the new Executive Editor-In-Chief and James Polega,

an incoming third year, and Rama Salhi, an incoming

fourth year, have been elected as Executive Editors. We

are very excited for these outstanding students to take

over leadership of the journal. They have shown tremen-

dous commitment over the years in working with MSRJ

and we cannot wait to see where they take the journal.As always, we would like to thank the Michigan State

University College of Human Medicine for their con-

tinued support. In addition, we would like to acknowl-

edge the hard work of our talented staff; without them,

this journal’s success would not be possible. We hope

that our readers will continue to follow the progress

of the MSRJ both on Facebook and Twitter, and on our

website at http://www.MSRJ.org. Please continue to

send your manuscripts to us; we welcome reading all

of the amazing work from our fellow colleagues.

Sincerely,

Jessica WummelExecutive Editor � MSRJ 2014�2015

Jack MettlerExecutive Editor � MSRJ 2014�2015

Letter from the Editors

MSRJ # 2015 VOL: 04. Issue: Winter

epub January 2015; www.msrj.org

Medical Student Research Journal 051

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White Coat Sparty

Carter Anderson*

College of Human Medicine, Michigan State University, East Lansing, MI, USA

*Corresponding Author: Carter Anderson; [email protected]

rofessional responsibility, compassion, honesty,respect for others, competence, and social re-

sponsibility are the characteristics that the MichiganState University College of Human Medicine strives toinstill in every student. The characteristics that thecollege aims to imprint on the student population areextraordinarily evident in the faculty. For instance, mypregnant wife recently had blood work done that cameback as high risk for Angelman syndrome. I emailed thegenetics professor that night and by the time I wokethe next morning I had two emails from her. She wascompassionate; she reassured me in my time of need.She was open and honest; she spoke frankly about the

situation and what would be involved. She showed

respect for me; she took time out of her schedule toaddress my concerns. She showed competence; she

not only discussed follow-up procedures but actuallycontacted a geneticist working for the company who

performed the test so that she could best serve ourneeds. She showed both professional and social re-

sponsibility; she used her expertise as a doctor and her

position as a teacher to encourage and help a memberof her community. With such role models it is inevitable

that CHM graduates will embody these ideals.These ideals are represented by two iconic symbols

in our college. These symbols are the ‘Clinical Sparty’

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logo and our white coats. The Clinical Sparty logo isa Spartan helmet that prominently features a stetho-scope. This image shows not only our school’s pridein its Spartan heritage but its pride in its Spartanphysicians. The white coat represents the years of hardwork each and every incoming medical student has putforth to get to this point in our lives. It is a badge ofhonor, signifying our place in not only a professionbut also a family of medical personnel across the world.For this project I decided to bring these two iconstogether into a single display. With permission fromthe college, I utilized photographs from the 2014 WhiteCoat Ceremony and the Clinical Sparty logo to make aphoto mosaic of the logo.This project was not only meant to highlight the

previously mentioned ideals, but also to highlightother aspects of our education and future professionalcareers. To me, the most important aspect of this pro-ject is the representation of so many people, of differentages, genders, ethnicities, religions, sexual identities

and backgrounds coming together to form one cohe-sive whole. The diversity and inclusion present inthese individuals, working together to become doctors,is amazing and inspiring. The fact that this collagewould not look like the Spartan logo without each andevery physician, faculty member, mentor and studentin the picture hammers this point home. Of the limitedtraining we have had as first-year medical students, avery significant portion has been dedicated to culturalsensitivity. We have learned through empathy, accep-tance and understanding that we have the abilityto treat every patient in a way that they desire. It isamazing to me that the many cultures and beliefsrepresented by my classmates will ultimately mesh toprovide positive care for an even more diverse patientpopulation. I hope that I have captured this diver-sity and have shown in some small way that despiteour differences we form something so much biggerand better than our individual selves when we worktogether.

Carter Anderson White Coat Sparty




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In Situ Thrombosis of the Pulmonary Arteries: An Emerging

New Perspective on Pulmonary Embolism

Virginia Corbett1*, Houria Hassouna2, Reda Girgis3

1College of Human Medicine, Michigan State University, East Lansing, MI, USA2Division of Thrombosis, Department of Internal Medicine, College of Human Medicine, Michigan State University,

East Lansing, MI, USA3Department of Pulmonary Medicine, College of Human Medicine, Michigan State University, Grand Rapids, MI, USA

*Corresponding author: Virginia Corbett; [email protected]

Keywords: pulmonary embolism; in situ pulmonary artery thrombosis; deep vein thrombosis (DVT); pulmonary circulation;

Virchow’s triad

INTRODUCTIONhe annual incidence of pulmonary embolism(PE) in the United States is reported to be 0.69 per

1,000 persons with mortality of up to 30% dependingupon the size of the emboli.1 PE and deep venousthrombosis (DVT) are both considered manifestations ofthe same disease of venous thromboembolism. Virchowpostulated that dysfunction of vessel walls, alterna-tions in blood flow and hypercoagulability of theblood triggered inappropriate thrombus formation.2

DVT most commonly occurs as local clot formation inthe deep calf veins. PE arises when clots break off froma peripheral DVT and become lodged within the pul-monary arterial vasculature. PE is routinely diagnosedwhen filling defects are found in the pulmonary arterieson computed tomography angiogram (CTA). Amongthe general population of patients presenting to emer-gency rooms, absence of DVT may occur in up to 57% ofthose diagnosed with PE.3 A high prevalence of isolatedPE may suggest localized thrombus formation in thepulmonary arteries instead of embolization from per-ipheral clots. In situ thrombosis is not differentiatedfrom emboli on CTA. However, despite evidence formultiple possible origins for clots within the pulmonaryarteries, PE is the default diagnosis for filling defectsdetected by CTA in clinical practice.4 The goal of thisarticle is to present a new model suggesting that asubset of what is currently labeled as PE is actuallya localized thrombus within the pulmonary arteries.We review the following topics: (1) the unique featuresof the lung vasculature that contribute to hemostasis,(2) disruption of hemostasis and localized pulmonary

artery thrombosis, (3) a possible role for inflammation inthrombosis, (4) clinical implications of in situ pulmonaryartery thrombosis, and (5) future directions for research.

HEMOSTASIS IN THE PULMONARY ARTERIESThe pulmonary circulation is a uniquely fibrinolytic

environment. Expression of mediators of fibrinolysisare increased in pulmonary arteries when comparedto peripheral veins in response to an inflammatorystimulus.5 Blood fluidity in the pulmonary arteries andtheir branches is promoted by a high ratio of tissueplasminogen activator (t-PA) to plasminogen activator-inhibitor 1 (PAI-1) and endogenous heparin-like proteo-glycans that provide a non-thrombogenic surface in thevasculature endothelium.6,7 One model suggests thatthe pulmonary vascular system is ideally suited to be amechanical sieve for venous drainage from the body.With the ubiquitous nature of spiral CT angiography,an increasing incidence of incidental isolated small PEshas been reported.8 These small clots may representthe critical role of the pulmonary vasculature in filteringout small emboli from the systemic circulation, whichsubsequently undergo fibrinolysis.9 If the pulmonaryvasculature is highly fibrinolytic, how can localizedthrombosis occur within the pulmonary arteries?

MECHANISMS OF THROMBUS FORMATIONSystemically, clotting occurs when initiated by a stimu-

lus, which transforms tissue factor from an encrypted FVIIcell membrane receptor to a functional receptor.10 Injuryto endothelial cells from trauma, ischemia, inflammation,

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or activation of the complement system exposes tissuefactor receptor activity. Disruptions to endothelial cellmechanisms that maintain blood fluidity in the pul-monary vasculature may result in localized thrombus for-mation. Localized thrombosis is the most common typeof thrombosis and has been documented throughoutthe body including cerebral, retinal, upper and lowerextremity, and abdominal veins.11 Case studies havedescribed in situ pulmonary artery thrombosis inpatients who have disruption of hemostasis includ-ing patients with pulmonary hypertension, chronicobstructive pulmonary disease (COPD), and with apast history of pulmonary wedge resection surgery.12�

14 Despite this evidence, local thrombus formation is notroutinely considered in patients with obstruction of thepulmonary artery.

The strongest support for a model of in situ pulmo-nary artery thrombosis has come from trauma surgeryliterature. Several large retrospective studies of patientswith chest trauma and PE report that up to 80% ofpatients have isolated PE without DVT and these authorssuggest these findings are due to localized thrombior ‘acute peritraumatic pulmonary thrombus’ ratherthan emboli.15,16 In this model, direct damage to thepulmonary vasculature and visceral tissue from chesttrauma leads to activation of tissue factor and de novolocalized thrombus formation.

INFLAMMATION AND THROMBOSIS FORMATIONLocal inflammation is associated with a procoagulant

state. One proposed explanation for this associationis that activated coagulation in acute infection wasevolutionarily advantageous to capture circulating mi-crobes in localized thrombi to limit pathogenesis andspread of infection.17 Infection, inflammation, sepsis,and immune dysregulation cause release of tissue factorreceptor activity from macrophages. Alveolar macro-phages also express tissue factor.18 Tissue factor ex-pressed by inflammatory cells promotes conversionof prothrombin to thrombin leading to a shift from afibrinolytic environment to a thrombotic state.19 Localinflammation in the lung parenchyma might also beexpected to lead to increased thrombosis in the lungs.

Risk factors for isolated PE differ from the risks ofPE with DVT, which may be expected if isolated PErepresents in situ thrombosis originating from a dif-ferent pathophysiologic mechanism. PE without DVTis associated with a younger age, recent surgery andhospitalization without being bedridden.20 Mortality forPE without DVT was 4.6% compared to 12.9% in patientswith PE and DVT. In a recent retrospective review study,

Van Langevelde et al. examined risk factors for DVTand PE. They found diseases that cause pulmonaryinflammation such as COPD, pneumonia, and sicklecell disease were associated with a high incidence ofPE but not DVT. In the paper’s discussion, they suggestthat pulmonary inflammation may contribute to loca-lized in situ thrombosis.21

Multiple recent studies support a connection betweenpulmonary inflammation and PEs. New research sug-gests clotting factors and tissue factor can pass betweenblood vessels into the airways of patients with asthma.22

In a large population-based study of 31,000 patients,asthma was associated with an increased hazard ratioof 3.24 for PE when compared to patients withoutasthma.23 In another recent study of 648 patients withasthma, Majoor et al. found that patients with severe asthma

had an increased risk of PE but not DVT.24 Similarly,patients with COPD have an increased incidence ofPE; up to 25% of patients have concurrent PE duringexacerbations.25,26 This evidence suggests physicianscan no longer consider diseases of the pulmonary cir-culation separately from diseases of the airways.27

LIMITATIONS TO A MODEL OF IN SITU PULMONARYARTERY THROMBOSIS

Although recent studies suggest a connection be-tween local pulmonary inflammation and pulmonarythrombus, there are also several significant limitations tothe theory of in situ thrombosis. Many of these limita-tions were first laid out by Velmahos et al. in their2009 paper introducing a model of in situ thrombus intrauma patients.28 The first limitation is the possibilitythat when PEs are being detected without peripheralDVTs, the entire clot dislodges instead of a part ofthe clot breaking off, and so DVTs are not detectedon ultrasound scans of the extremities. Another possibleexplanation is that current compression ultrasoundtechniques are not sensitive enough to detect all pe-ripheral DVTs in the extremities and so they may bepresent and contributing to PEs but remain undetected.A third possible explanation is that a subset of PEsoriginates from clots in the upper extremities or pelvicveins, which are not routinely scanned by compressionultrasound.

To address these limitations, Van Langevelde et al.completed a prospective study of 100 patients with CTAdiagnosed PE and used full body MRI scans to look forperipheral thrombosis in the upper extremities, pelvis,and abdomen in addition to the lower extremities.They found that 56% of patients had isolated PE with-out any peripheral thrombus.29 This study did not

Virginia Corbett et al. In Situ Thrombosis of the Pulmonary Arteries




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address the possibility that these findings were due tocases where the entire clot dislodged from the periph-eral vein. Other limitations include the fact that MRI maynot be highly sensitive for thrombus and thus may notbe detecting all peripheral clots. Van Langevelde et al.also suggested that thrombi in the pulmonary arterycould originate from thrombi right atrium in patientswith atrial fibrillation.

CLINICAL IMPLICATIONSTreatments are not likely to change for in situ

thrombosis when compared to those for PE. Currentresearch shows that patients should receive 3 monthsof anticoagulation for venous thromboembolism withreversible, provoked etiologies and indefinite anticoagu-lation for patients with unprovoked, or persistent andprogressive etiologies.30 Case studies suggest localizedthrombus does not undergo fibrinolysis in the 3 monthspatients with idiopathic PE receive anticoagulation foractive disease.14 Due to ongoing disruption of smoothblood flow and the pulmonary fibrinolytic environment,patients with in situ pulmonary artery thrombosis likelyrequire indefinite anticoagulation. Treatment of patientswith placement of inferior vena cava filters (VCFs) is likelyto differ in patients with in situ thrombosis as com-pared with PE. VCFs are placed in patients with PE withcontradictions to anticoagulation to prevent recurrentemboli from traveling from the pelvic veins and lowerextremities up the inferior vena cava to the pulmo-nary arteries.31 If the thrombosis originates in thelung, VCFs would be unnecessary in patients receivinganticoagulation.

The most serious consequence of in situ thrombo-sis is likely pulmonary hypertension and right heartstrain. Chronic thromboembolic pulmonary hyperten-sion (CTEPH) develops in 4.6% of patients with acutePE, resulting in considerable morbidity and mortality.32

Patients with in situ pulmonary artery thrombosis arelikely at increased risk for development of CTEPH dueto retained residual clots and disrupted blood flow.Due to concern for right heart strain and potentiallyCTEPH, frequent echocardiography may be warrantedin patients with in situ thrombosis.

FUTURE INVESTIGATIONSAlthough there is evidence of localized thrombosis

in the pulmonary arteries, there are few studies thatinvestigate the pathophysiology of these phenomena.Currently, research in this area is focused on in situthrombosis in trauma patients. One group, Kumar et al.5

recently published a study examining the response of

pulmonary artery endothelium to inflammatory media-

tors to explore the molecular origins of in situ throm-

bosis in trauma patients. Future directions could focus

on autopsy studies to determine if in situ pulmonary

artery thrombosis can be differentiated from pulmonary

embolus based on histology. There is no current data

available on treatment outcomes for patients with in situ

thrombosis, and future research should also examine

whether treatment for in situ thrombosis should include

surgical therapy to reduce clot burden in patients with

right heart strain or CTEPH.Thus far, investigations of in situ thrombosis have

focused on diagnosis by CTA.Transesophageal echocardiogram (TEE) is also poten-

tially a useful way to examine the pulmonary arteries.

Future research should focus on identifying thrombus

formation and examining if it is possible to differentiate

thrombus from emboli with TEE. Due to increased risk

of PE and likely in situ thrombosis in patients with COPD

and asthma, a study of TEEs in this patient population

to screen for PEs, thrombosis, and possible right heart

strain may yield additional information about the role of

venous thromboembolism in pulmonary diseases.

CONCLUSIONPE is a common disease with significant mortality.

When filling defects are found on CTA, they are almost

universally assumed to be emboli from a peripheral DVT.

However, new studies have found that half of all PEs

are found without evidence of a peripheral thrombus.

These findings have led to the theory that localized

inflammation, endothelial cell damage, and disruption

of blood flow cause de novo formation of clots within

the pulmonary artery or in situ thrombosis. Although

treatment with anticoagulation would likely not change

for patients with in situ thrombosis as compared to

PE, patients with in situ thrombosis would likely not

benefit from placement of VCFs. Patients with COPD

and asthma are at increased risk for PE and are also likely

at risk for in situ thrombosis. The theory of in situ

thrombosis presents a new perspective on the tradi-

tional understanding of the pathophysiology of PE.

Further research needs to be done to truly understand

the clinical implications of this new model in terms of

treatment, patient outcomes, and prevention.

Conflict of interest and funding: The authors have notreceived any funding or benefits from industry or elsewhere

to conduct this study.

In Situ Thrombosis of the Pulmonary Arteries Virginia Corbett et al.

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doi: 10.1161/01.CIR.100.17.180814. Wechsler RJ, Salazar AM, Gessner AJ, Spirn PW, Shah RM,

Steiner RM. CT of in situ vascular stump thrombosis after

pulmonary resection for cancer. AJR Am J Roentgenol 2001;176(6): 1423�5. doi: 10.2214/ajr.176.6.176142315. Lundy JB, Oh JS, Chung KK, Ritter JL, Gibb I, NordmannGR, et al. Frequency and relevance of acute peritraumaticpulmonary thrombus diagnosed by computed tomographicimaging in combat casualties. J Trauma Acute Care Surg2013; 75(2 Suppl 2): S215�20. doi: 10.1097/TA.0b013e318299da6616. Knudson MM, Gomez D, Haas B, Cohen MJ, Nathens AB.Three thousand seven hundred thirty-eight posttraumaticpulmonary emboli: a new look at an old disease. Ann Surg2011; 254(4): 625�32. doi: 10.1097/SLA.0b013e318230020917. Schulz C, Engelmann B, Massberg S. Crossroads ofcoagulation and innate immunity: the case of deep veinthrombosis. J Thromb Haemost 2013; 11 (Suppl 1): 233�41.doi: 10.1111/jth.1226118. Drake TA, Morrissey JH, Edgington TS. Selective cellularexpression of tissue factor in human tissues. Implications fordisorders of hemostasis and thrombosis. Am J Pathol 1989;134(5): 1087�97.19. Polgar J, Matuskova J, Wagner DD. The P-selectin, tissuefactor, coagulation triad. J Thromb Haemost 2005; 3(8):1590�6. doi: 10.1111/j.1538-7836.2005.01373.x20. Sevestre MA, Quashie C, Genty C, Rolland C, Quere I,Bosson JL, et al. Clinical presentation and mortality inpulmonary embolism: the Optimev study. J Mal Vasc 2010;35(4): 242�9. doi: 10.1016/j.jmv.2010.05.00421. Van langevelde K, Flinterman LE, Van hylckama vlieg A,Rosendaal FR, Cannegieter SC. Broadening the factor VLeiden paradox: pulmonary embolism and deep-veinthrombosis as 2 sides of the spectrum. Blood 2012; 120(5):933�46. doi: 10.1182/blood-2012-02-40755122. De boer JD, Majoor CJ, Van’t veer C, Bel EH, Van der poll T.Asthma and coagulation. Blood 2012; 119(14): 3236�44. doi:10.1182/blood-2011-11-39153223. Chung WS, Lin CL, Ho FM, Li RY, Sung FC, Kao CH, et al.Asthma increases pulmonary thromboembolism risk: a na-tionwide population cohort study. Eur Respir J 2014; 43(3):801�7. doi: 10.1183/09031936.0004331324. Majoor CJ, Kamphuisen PW, Zwinderman AH, Ten BrinkeA, Amelink M, Rijssenbeek-Nouwens L, et al. Risk of deep veinthrombosis and pulmonary embolism in asthma. Eur Respir J2013; 42(3): 655�61. doi: 10.1183/09031936.0015031225. Bertoletti L, Quenet S, Laporte S, Sahuquillo JC, Conget F,Pedrajas JM, et al. Pulmonary embolism and 3-monthoutcomes in 4036 patients with venous thromboembolismand chronic obstructive pulmonary disease: data from theRIETE registry. Respir Res 2013; 14: 75. doi: 10.1186/1465-9921-14-7526. Rizkallah J, Man SF, Sin DD. Prevalence of pulmonaryembolism in acute exacerbations of COPD: a systematicreview and metaanalysis. Chest 2009; 135(3): 786�93. doi:10.1378/chest.08-151627. Konstantinides SV. Asthma and pulmonary embolism:bringing airways and vessels closer together. Eur Respir J2014; 43(3): 694�6. doi: 10.1183/09031936.00009414

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28. Velmahos GC, Spaniolas K, Tabbara M, Abujudeh HH,de Moya M, Gervasini A, et al. Pulmonary embolism and deepvenous thrombosis in trauma: are they related? Arch Surg2009; 144(10): 928�32. doi: 10.1001/archsurg.2009.9729. Van langevelde K, Sramek A, Vincken PW, Van rooden JK,Rosendaal FR, Cannegieter SC. Finding the origin of pul-monary emboli with a total-body magnetic resonance directthrombus imaging technique. Haematologica 2013; 98(2):309�15. doi: 10.3324/haematol.2012.06919530. Kearon C, Akl EA. Duration of anticoagulant therapy fordeep vein thrombosis and pulmonary embolism. Blood 2014;123(12): 1794�1801. doi: 10.1182/blood-2013-12-512681

31. PREPIC Study Group. Eight-year follow-up of patients with

permanent vena cava filters in the prevention of pulmonary

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Pulmonaire par Interruption Cave) randomized study.

Circulation 2005; 112(3): 416�22. doi: 10.1161/

CIRCULATIONAHA.104.51283432. Korkmaz A, Ozlu T, Ozsu S, Kazaz Z, Bulbul Y. Long-term

outcomes in acute pulmonary thromboembolism: the inci-

dence of chronic thromboembolic pulmonary hypertension

and associated risk factors. Clin Appl Thromb Hemost 2012;

18(3): 281�8. doi: 10.1177/1076029611431956

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Sticking to the Plan: Patient Preferences for Epidural Use

During Labor

Lauren Ann Gamble1*, Ashley Hesson1, Tiffany Burns2

1Michigan State University, College of Human Medicine, East Lansing, MI, USA2Department of Family Medicine, Michigan State University, East Lansing, MI, USA

*Corresponding author: Lauren Ann Gamble; [email protected]

Background: Women have been shown to value control in the labor experience, a desire that is often formalized into an explicit birth

plan. Epidural preferences are a primary component of this plan. Despite this specification, women’s plans are not always carried

out. This may be due to patient factors (e.g., dissatisfaction with labor), provider behaviors (e.g., frequent epidural offers), or

situational variables (e.g., prolonged labor).

Purpose: The current study investigates the relative impact of patient preference for epidural use as compared to provider

suggestion and circumstances of labor. It hypothesizes that providing an epidural preference in a birth plan and receiving frequent

epidural offers will predict epidural administration.

Methods: Adult, postpartum women were surveyed about their labor experience at a high-volume obstetrics unit in a medium-sized

community hospital. Responses to a structured survey instrument focused on prelabor preferences and labor characteristics.

Descriptive statistics and multiple logistic regression modeling were used to analyze participant responses.

Results: Eighty-three postlaboring women completed surveys, of which 79 surveys were analyzed. Eighty-four percent (N�66)

received an epidural during their labor process, while 73% (N�58) desired an epidural as a part of their birth plan. Women were

offered an epidural at a mean frequency of 0.2790.48 times per hour (median�0.14). The significant predictors of epidural

administration were desire for an epidural in the birth plan (pB0.01) and the frequency of epidural offers (pB0.01). Wanting an

epidural was associated with receiving an epidural. Conversely, increased frequency of being offered an epidural negatively

correlated with epidural administration.

Conclusions: Our findings indicate that personal preference is the most influential factor in determining whether or not a laboring

woman will receive an epidural. Increasing provider attempts to offer an epidural � as represented by increased frequency of queries

� decreased the likelihood that an epidural would be received.

Keywords: epidural; birth plan; labor analgesia; patient preference; decision making.

INTRODUCTIONhough few would deny the value of shareddecision making in obstetric management, the

extent to which patient preferences should dictatecare still remains a controversial issue. The inherentlyasymmetric patient�provider relationship1 has beenforced to evolve in this particular setting, accommodat-ing shifts in cultural values pertaining to women’sinvolvement in and control over the birth experience.Birth plans, written documentation or explicit verbali-zation of women’s preferences prior to the onset oflabor, have played a major role in empowering patientsin the labor process. In addition to specifying whatprocedures women desire or hope to avoid, birth plansare currently seen as a tool for improving communica-tion2 in that they provide an organized set of talkingpoints, educational objectives, and guiding principlesfor the healthcare team. A ‘good’ birth plan, one that is

satisfactory to the patient, is largely concerned withwomen’s control in the labor process,3 meaning thatthese plans represent personal expressions of patientvalues and expectations.4 Despite their clarifying intent,these patient-centered plans generally make specificreference to interventions that have traditionally beenrecommended under the discretion of healthcare pro-fessionals, creating the potential for interpersonallychallenging negotiations as labor proceeds.

Epidural administration is a particularly meaningfulaspect of labor management from the patient perspec-tive, one that has been subject to changing professionalopinion over the last decades. In surveying a group ofpostpartum women (N�63), Pennell et al. found thatpreferences for pain control (including epidural use)were the most common element of birth plans, followeddistantly by preferences regarding invasive interventions

Original Research




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for vaginal delivery, cesarean delivery, and ‘naturalchildbirth’ not otherwise specified.5 Accordingly, epi-dural analgesia use is increasing for laboring women.Patient requests for epidural pain relief have trendedupward from 1995 to 2001, rising from 57 to 66.5% ofwomen interested in having an epidural. Opioid use andmedication-free birth have both undergone a compen-satory decrease in popularity.6 Fluctuating patient andprovider views on epidural pain control are likely to beimplicated in the shift towards its use. Of the commonobstetric procedures, epidurals have the largest percen-tage of patient participation in the decision-makingprocess compared to ultrasound scans, blood tests,fetal monitoring, and cesarean sections.7 Relatedly,patients subjectively reported feeling informed on therisks and benefits of the epidural procedure. Their levelof confidence in epidural knowledge is second onlyto cesarean section (inclusive of pre- and postlaborprocedures).7

Patients’ apparent comfort in engaging with epiduraldecision making does not imply that they have anobjective understanding of the procedure’s indicationsand maternal�fetal risks. Studies suggest that patientsoften espouse inaccurate information about epiduraluse.8 Multiple surveys indicate that physicians are theleast common source of information on epidurals.Family members, friends, and midwives tend to bethe primary overall information sources for womenconstructing a birth plan,9 where similar sources areconsulted specifically on epidural use.5 Though physi-cians are not the primary source of patient knowledge,it is their ultimate choice as to whether or not anepidural is placed, a decision that is based on their ex-pertise and preference. The overarching role of phy-sicians in alleviating pain undoubtedly impacts theirstandpoint on this issue. The inherent tension to respectpatient preferences and to offer pain relief is illustratedin the guidelines of the American College of Obste-tricians and Gynecologists:

. . . [With the exception of labor] there is no othercircumstance where it is considered acceptable for anindividual to experience untreated severe pain, amenableto safe intervention, while under a physician’s care.10

As both patients and physicians are major stakeholdersand active participants in the epidural decision-makingprocess, the rationale behind any given epidural place-ment is likely to be multifactorial, representing prio-rities of both parties. However, to the best of ourknowledge, no study has rigorously investigated the

determinants of epidural use in the context ofuncomplicated labor processes taking place in a UScommunity-based teaching hospital. The current studyconsiders women’s epidural preferences (i.e., birthplans), providers’ encouragement, and features ofthe labor process as potential predictors of epidu-ral use. Our objective is to determine the extent towhich women retain control over their pre- and peri-natal analgesic experience through their birth planspecifications.

The central question of our study is as follows: arewomen’s preferences for epidural use (as expressed bytheir birth plans) the primary predictors of whetheror not they receive epidural analgesia during the laborprocess?

Hypothesis 1: The inclusion of an epidural in apredetermined birth plan is a significant positivepredictor of receiving an epidural during labor.

Hypothesis 2: There is a significant direct relation-ship between the number of times per hour a laboringwoman is queried about receiving an epidural andthe likelihood of actually receiving an epidural duringlabor.

By exploring the factors that influence whether ornot a laboring woman will receive an epidural, wehoped to determine the degree to which women’spreferences are being respected in the labor process.

METHODS

Selection and Description of ParticipantsParticipants were recruited as a convenience sample

of postpartum patients admitted in spring 2011 tothe 34-bed postpartum Mother�Baby unit of a high-volume obstetrics hospital in central/mid Michigan.The patient population of this community hospital’sobstetrics ward is notable for its diversity � a greatvariety of socioeconomic and cultural backgroundsare represented. Among these are groups for whomsharing de-identified demographic information isan especially sensitive issue (e.g., refugees). Thoughparticipants were required to be at least 18 yearsof age to participate in the study, we chose not tocollect specific demographics on individual patientsas it may have discouraged certain patients fromparticipating.

Potential participants were asked if they wouldlike to complete a brief questionnaire regarding theirlabor experience. Medical students on the researchteam obtained informed consent from participants andread them the questionnaire, transcribing their verbalresponses to each item. The environment for survey

Patient Preferences for Epidural Use During Labor Lauren Ann Gamble et al.



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administration varied between patients in terms of thepresence or absence of family members and the exactdelivery to interview time interval. All surveys werecompleted within 48 hours of delivery. The MichiganState University institutional review board (IRB) ex-empted this methodology after reviewing our proce-dures and instrument (IRB x11-1135Se).

Eighty-three participants were recruited for thestudy. Four subjects were subsequently excludedfrom the analysis because they did not report anepidural preference before entering the active stage oflabor. They reported that they were ‘unsure’ regardingtheir preferences for receiving an epidural, reducingthe number of subjects from 83 to 79. By definition,the participants that were retained all had some formof birth plan, as characterized in the Introduction sectionabove. The vast majority of the patients surveyed herepresented their birth plans as a set of verbal instruc-tions to a healthcare provider. For some, this wasrealized in general terms (e.g., ‘I would like as natural ofa birth process as possible’), while others were morespecific (e.g., ‘I want an epidural’). All of these variantswere considered birth plans for the purposes of thisstudy, as long as they gave a clear indication of patientpreferences for pain management.

Survey InstrumentThe survey consisted of eight closed-ended ques-

tions (Table 1) that covered participant intentions onepidural use, evaluation of their current labor experi-ence, and their reflections regarding possible futurelabor.

StatisticsIn order to test the hypotheses given above, we

constructed one multiple logistic regression model

predicting whether or not our subjects received epi-durals. Wanting an epidural as indicated in one’s birthplan (Hypothesis 1) and the number of times onewas offered an epidural per hour (Hypothesis 2) wereincluded as potential predictors. Number of offerswas treated as a rate, meaning that these occurrenceswere relativized to the length of each woman’s laborprocess (henceforth discussed as ‘frequency’ of queries).Overall satisfaction with the labor process was alsoincorporated as a possible mediator of the aforemen-tioned predictors. Number of hours in labor and ad-ministration of oxytocin were not integrated into thisanalysis due to overly skewed distribution of thevariants of these factors with respect to each otherand our dependent variable. The final multiple logisticregression model was generated using model build-ing techniques supported by Rbrul11 in the R statisticalenvironment.12

RESULTSOur subjects’ survey responses are summarized in

Table 2. The majority of our subjects (84%, N�66)received an epidural during their current labor process.Approximately three quarters (73%, N�58) of oursubjects specified that they wanted an epidural beforegoing into labor. A relative minority of subjects receivedoxytocin for their current labor process (43%, N�34).More than half of the subject pool had previouslyreceived an epidural in a prior episode of labor (73%,N�58).

There was very little variation in women’s satisfactionratings for their current labor processes. Furthermore,there was a clear ceiling effect whereby the vastmajority of respondents rated their labor process as9 or 10 of 10. The mean satisfaction was 9.3291.07.

Table 1. Survey instrument. Question wording is reproduced verbatim as read by the research team

Question Answer options

Did you intend on having an epidural prior to onset of labor? Yes, no, undecidedDid you receive an epidural as part of your labor and delivery process? Yes, no, unsureHow many times do you recall being asked if you wanted an epidural? 0, 1�2, 3�5, �5How long was your labor from time of arrival to Sparrow Hospital until birth?Was your labor induced or augmented with pitocin? Yes, no, unsureRate the satisfaction of your labor delivery experience at [Hospital] on a scale of 1�10 (1 being extremely

dissatisfied and 10 being extremely satisfied).1�10

If you received an epidural rate the level of pain relief you received from it on a scale of 1�10 (1 beingno relief at all and 10 being complete relief of pain).

1�10

Would you choose to have an epidural with a subsequent pregnancy? Yes, no, unsure

Answer options were communicated to the patient, but not displayed visually.

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By contrast, hours of labor varied greatly from subjectto subject. The mean was 11.16911.59 (median�8.5).The skew in this parameter is due to a handful of laborslasting longer than 24 hours, notably including 48 and72 hours labor durations.

Similarly, the frequency with which women wereasked whether or not they wanted an epidural duringtheir labor process exhibited substantial variability, witha mean of 0.2790.48 times per hour (median�0.14times per hour). Again, a few women experienced amuch higher than average rate of queries.

Subdividing the data into women who receivedepidurals versus those who did not, additional trendsemerge (Table 3 and Fig. 1). As demonstrated in Fig. 1,when compared to women who did not receive anepidural, a greater proportion of subjects who receivedan epidural had expressed a desire for an epidural in theirbirth plan. Other factors that may have contributed to

whether or not an epidural was received include havinghad an epidural in a prior pregnancy, having moreopportunities to receive an epidural in the current laborprocess, and administration of oxytocin to augmentthe present labor process (Table 3). With respect to priorepidural administration, most women who received anepidural in the current pregnancy also had one duringa previous pregnancy (80%, N�53). Focusing on thenumber of times women were offered an epidural duringlabor, the most substantive jump in receiving an epiduraloccurred between 0 and 1�2 queries. Sixty-three per-cent of subjects who were not specifically offered anepidural received one (N�7). In contrast, greater than85% of women who were asked 1�2, 3�5, or greaterthan five times received an epidural (N�37 for 1�2queries, N�16 for 3�5, N�6 for �5; see Fig. 2). Lastly,an overwhelming majority of the subjects who receivedoxytocin also received an epidural (99%, N�33).

Wanting an epidural, frequency of epidural offers(as distinguished from number of offers), and overallsatisfaction with labor were incorporated as predictorsinto a multiple logistic regression model of present epi-dural administration. Table 4 displays only those factorsretained in the output of the Rbrul analysis as signifi-cantly predicting the distribution of epidural adminis-tration. Two significant predictors were retained in ourmodel of receiving an epidural: desire for an epiduralin the birth plan (pB0.01) and frequency of epiduraloffers (pB0.01). As predicted in Hypothesis 1, wantingan epidural was associated with receiving an epidural.Contrary to Hypothesis 2, however, frequency of queriesnegatively correlated with administration of an epidu-ral. These results are summarized in Table 4 and illus-trated in Fig. 2.

Table 2. Counts and descriptive statistics for participant responses

Factor Variants Nsubjects Proportion Mean Standard deviation

Received epidural Yes 66 0.84No 13 0.16

Prior epidural Yes 58 0.73No 21 0.27

Wanted epidural Yes 58 0.73No 21 0.27

Oxytocin received* Yes 34 0.43No 45 0.57

Satisfaction 1�10 9.32 1.07Hours in labor* 1�72 11.16 11.59Frequency of queries 0�3 0.27 0.48

Factors marked with an asterisk (*) were not included in the multiple logistic regression model due to their skewed distribution with respect toother factors.

Table 3. Distribution of response counts with respect tosubjects receiving or not receiving an epidural

Factor Variants Received epidural No epidural

Prior epidural Yes 53 5No 13 8

Times queried 0 7 41 to 2 37 63 to 5 16 2�5 6 1

Oxytocin received Yes 33 1No 33 12

Epidural preference is excluded from this table as it is displayed in

Fig. 1. Note that ‘Times queried’ as shown here is differentiated from‘Frequency of queries’ (the rate of queries per hour in labor) reported

in Table 2.




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Figure 1. Women who received an epidural (Y) compared to those who did not receive an epidural (N) subdivided by those whowanted to receive an epidural (Y) compared to those who did not want to receive an epidural (N).

Figure 2. Frequency of epidural offers (times asked per hour) plotted against hours in labor. Women who received an epidural (Y)are distinguished from those who did not (N).





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DISCUSSIONOverall our findings suggest that women’s prefer-

ences for epidural administration are major influenceson whether or not they receive an epidural. This is par-ticularly evident in the results of our regression analysis,which selected patient desire for an epidural as one oftwo significant predictors for epidural administration.Increasing frequency of provider epidural offers, the othersignificant factor in our model, actually had a negativepredictive effect on epidural use. In other words, womenwho did not plan on having an epidural were less likelyto receive one and, furthermore, multiple offers per hourdecreased their likelihood of accepting an epidural. Itmay be the case that iterative offers reinforce women’sdesires to adhere to their original birth plans.

The dominant effect of patient preference in ourmodel of epidural administration is consistent with priorliterature indicating that women’s opinions on epiduraluse are adequately expressed5 and generally respected.Though reported rates of birth plan follow-through vary,our research corroborates previous suggestions thatthis variability is patient-mediated.13 A qualitative studyby Hidaka et al. following primigravid women into laborprovides context for this observation.14 They describea transition from envisioning an ideal labor processto confronting the reality of extreme pain, beyond theexpectations they had while constructing birth plans.Most of the women in this study elected to deviatefrom their initial intent of medication-free birth basedon their own re-evaluation of the experience, yet re-mained satisfied with their labor processes.14

Satisfaction with the labor process in general did notpredict whether or not an epidural was given. This is

counterintuitive insomuch that prior studies reportedan association between labor dissatisfaction and epi-dural use in women who did not want an epidural aspart of their birth plans.15 The high rate of satisfactionin our study suggests, however, that this apparentdiscrepancy may be a methodological artifact. As ourstudy surveyed women with uncomplicated births inthe immediate postpartum period, our satisfactionresults may be less indicative of concordance betweenlabor process and birth plan and more reflective ofwomen’s successful pregnancy outcomes. Hodnett’scommentary on a meta-analysis of satisfaction withchildbirth supports this possibility.16 She notes that ran-domized control trials (RCTs) for pre- and peripartuminterventions often fail to demonstrate the inverserelationship between medications/procedures and satis-faction shown in observational studies. She interpretsthis discrepancy as an effect of the necessary inclusionof complicated births in prospectively recruited RCTs,where said complications and their sequelae (e.g., pro-longed labor, anxiety, and pain) mediate the relation-ship between intervention and satisfaction.16

Integrating across the variables considered here, ourresults generally emphasize a high degree of patientcontrol exerted over epidural administration. Patientsappear to be directing their analgesia experience bothprior to and during the onset of labor. Whatever conflictmay arise between patient and provider views on epi-dural use, they seem to be resolved in a way that issatisfactory to the patient and reflective of her desires,given that her opinion on pain control is subject tochange as labor proceeds. Thus, current practice asobserved in our study seems to be in accordance withpublished guidelines for management of pain reliefduring labor: ‘decisions about interventions shouldincorporate the woman’s personal values and prefer-ences and should be made only after she has hadenough information to make an informed choice, inpartnership with her care team’.17

Though our study highlights the relative autonomythat women seem to enjoy in intrapartum epiduraldecision making, it has several key limitations thatshould be addressed in future work. Most importantly,our sample size was small and potentially under-representative of the population of laboring womenin our setting of interest. Factors that may have provensignificant in a larger study of epidural administra-tion may not have been selected in our analysis due toour limited sample size. Furthermore, a variety of demo-graphic and pregnancy-related variables were not col-lected in our survey. Age, marital status, socioeconomic

Table 4. Significant predictors of epidural administration

Receiving an epidural(vs. not receiving an epidural)

Grand mean ‘receiving’ 0.835Total N 79Deviance 52.246

Log odds % N

Wanting pB0.01Yes 1.17 91.4 58No �1.17 61.9 21

Frequency pB0.01Continuous �1.87 N/A N/A

Results are in the direction of receiving an epidural. Factors includedin the analysis: wanting an epidural (wanting), frequency of epidural

offers (frequency), and patient satisfaction.




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class, education level, etc. might have played a role indetermining epidural use, but these factors were notrecorded here (see Methods for a discussion of thisissue). For example, Miller et al. explores the culturalaspect of a woman’s preferences and how they competewith economic position and birth option availability,concluding that labor process is ultimately shaped byeconomic position and resource access.4 Similarly, wedid not survey any women with complicated preg-nancies or stratify the labor processes of our surveyedwomen based on relative complexity (e.g., hours spentin labor, oxytocin administration). Though the latervariables were recorded, they could not be modeledbased on their distribution with respect to epidural use,suggesting that they might prove significant in a largerdata pool where they might be included in statisticalmodeling processes. Hodnett’s 2002 meta-analysis, dis-cussed above, is consistent with this prediction.16

CONCLUSIONThere are many ethical and practical concerns

regarding laboring women’s contribution to the epi-dural decision-making process. Our findings indicatethat a woman’s preference is the most influential factorin determining whether or not she receives an epiduralfor perinatal analgesia. Practitioners should be awarethat the frequency of offers for an epidural has littleor negative impact on a woman’s acceptance of thisintervention.

Conflict of interest and funding: The authors have notreceived any funding or benefits from industry or elsewhereto conduct this study.

Disclaimers: The author has no disclosures.

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4. Miller AC, Shriver TE. Women’s childbirth preferences and

practices in the United States. Soc Sci Med 2012; 75(4):

709�16.5. Pennell A, Salo-Coombs V, Herring A, Spielman F, Fecho K.

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of women who have birth plans. J Midwifery Women’s Health

2011; 56(4): 376�81.6. Horowitz ER, Yogev Y, Ben-Haroush A, Kaplan B. Women’s

attitude toward analgesia during labor � a comparison

between 1995 and 2001. Eur J Obstet Gynecol Reprod Biol

2004; 117(1): 30�32.7. Thompson R, Miller YD. Birth control: to what extent do

women report being informed and involved in decisions

about pregnancy and birth procedures? BMC Pregnancy

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Hasnain-Wynia R. A qualitative analysis of parturients’ per-

spectives on neuraxial labor analgesia. Int J Obstet Anesth

2013; 22(2): 119�23.9. Frohlich S, Tan T, Walsh A, Carey M. Epidural analgesia for

labour: maternal knowledge, preferences and informed

consent. Irish Med J 2012; 104(10): 300�2.10. Pain relief during labor. ACOG committee opinion No 295.

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Gynecol 2004; 104: 213.11. Johnson DE. Getting off the GoldVarb standard: introdu-

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Linguist Compass 2009; 3: 359�83.12. R Development Core Team. R: A language and environ-

ment for statistical computing [Computer program]. Vienna,

Austria: R Foundation for Statistical Computing; 2012.13. Hadar E, Raban O, Gal B, Yogev Y, Melamed N. Obstetrical

outcome in women with self-prepared birth plan. J Matern

Fetal Neonatal Med 2012; 25(10): 2055�7.14. Hidaka R, Callister LC. Giving birth with epidural analgesia:

the experience of first-time mothers. J Perinat Educ 2012;

21: 24.15. Kannan S, Jamison RN, Datta S. Maternal satisfaction and

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Pain Med 2001; 26(5): 468�72.16. Hodnett ED. Pain and women’s satisfaction with the

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147�8.





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Care for Laotian Ethnic Minorities: A Cross-National

Study of Medical Students in Laos and California

Katherine Crabtree*

UC Davis College of Medicine, Sacramento, CA, USA

*Corresponding author: Katherine Crabtree; [email protected]

Background: In both the United States and Laos, Lao ethnic minority patients face cultural and linguistic challenges to adequate

medical care. We may be able to learn from Lao experiences to improve care for patients in the United States. This study explored

Laotian and American medical students’ experiences in care for these patients.

Methods: Laotian and American medical students (n�19) participated in five interview groups discussing barriers to health care and

strategies for addressing barriers for Laotian ethnic minority patients.

Results: The students identified similar barriers to care. Laotian students identified unique strategies to address barriers to care.

American students focused on general approaches to cross-cultural care.

Discussion: The strategies that Laotian medical students learn in their training reflect their extensive exposure to Hmong and other

Laotian ethnic minority patients, while American students learn broad strategies to care for many minority groups. Further work is

needed to determine if their experience can be translated into the domestic context.

Keywords: Hmong; Mien; Laos; refugees; cross-cultural healthcare; medical education.

BACKGROUNDfter fighting alongside American forces againstthe North Vietnamese military in Laos, large

numbers of Hmong and Mien Laotian refugees cameto the United States in the 1970s.1,2 Since 1975, anestimated 30,000 Mien3 and over 130,000 Hmong4 havesettled mostly in California, Minnesota and Colorado.5

The Hmong and Mien are also minorities in Laos6 andin both the United States and Laos, these groups facebarriers to healthcare including language discordantcare, culture-based belief differences and distrust ofthe system.7�19 These groups make up 100 times moreof the population in Laos than in the United States, andthe majority Lao Loum population has lived alongsidethem for centuries,20 theoretically narrowing the cul-tural gap. With these differences noted, this studyexplored the experience of both Laotian and Americanstudents in caring for Hmong and other Lao ethnicminority patients.

METHODSInterviews were conducted with a convenience

sample of 10 students at the National University ofLaos College of Medical Sciences in Vientiane, Laos,and 9 students at the UC Davis School of Medicine inSacramento, CA, home to the third highest population

of Hmong residents in the United States.21 Interview

groups were conducted between May and August 2011.

The structure of these groups is described in Table 1.

The interviewer (KC) opened the discussion with

two patient care examples from the literature22,23 and

continued with a question guide that was developed

through literature review (see Table 2). Interviews

ranged from 2.25 to 3.5 hours and were conducted in

English. To protect student anonymity, interviews were

not audio or video recorded but the interviewer took

copious notes using shorthand and transcribed the

notes for analysis. Participants were compensated with

refreshments.

The University of California Institutional Review Board

(IRB) approved the study. Interviews conducted in Laos

conformed to United States IRB standards due to the

absence of an IRB equivalent in Laos.

Two authors (KC and OM) reviewed transcripts

independently, generated codes and identified salient

themes,24 collaborating to determine major themes

around barriers to care and strategies to improve

care. Coding categories were applied to transcripts

using Dedoose (Los Angeles, CA) qualitative analysis

software.25

Original Research




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RESULTS

Common BarriersAmerican and Laotian students both raised concerns

about cultural barriers to healthcare for Laotian ethnicminority patients. Identified barriers in both Laos andthe United States included language, religious differ-ences, expectation of involvement of elders in caredecisions, limited health literacy and preference forherbal medicine rather than Western medicine. Otherbarriers that were more specific to the Laotian experi-ence included access problems such as cost of care anddistance to care facilities, and barriers at the level of thehealth care provider such as concerns about providershortages and inadequate compensation.

Despite their agreement that significant barriers tocare exist for Laotian ethnic minority patients, the stu-dents were similarly optimistic about the patients thatsought care. A Laotian student said, ‘If they [Hmongpatients] are coming to you [the physician], somewherein them they’re open even if they don’t think so. Itwas their choice to come in’. In an American group,a student echoed this sentiment; ‘The fact that the

patient came to see the doctor is because they havesome small part of belief in the doctor’.

US Approach to BarriersUS students offered general solutions rather than

specific strategies for overcoming barriers, includingbroad concepts such as community empowerment,improving trust and patient-centered care. Studentssuggested that providers could address barriers tocare by having knowledge of available communityresources, working as a team with other healthcareproviders and employing ‘cultural humility’ but wereunable to provide specific strategy examples based ontheir preclinical exposure to the hospital setting. Forinstance, they believed it would be useful to employmore interpreters and cultural brokers, but after speak-ing about cultural brokers used in Hispanic popula-tions, an American student was asked if this kind ofsolution existed for Hmong patients. He responded,‘Not to my knowledge, I’m just envisioning a perfectsystem’. They also felt conflicted about some specificapproaches, such as their ability to discuss herbalmedicine use with patients in the absence of supportfrom attending physicians. One student explained, ‘Ifwe ask, ‘‘Hey, can they take herbal?’’ and [the attend-ing] won’t discuss, over time the more likely we are tobe that way ourselves’.

American students drew from their knowledge ofdiverse groups in discussing barriers faced by Laoethnic minority patients, referencing experiences withAIDS patients in Africa, Jehovah’s Witnesses and bloodtransfusion, Ayurvedic medicine, the history of theTuskegee experiment, traditional medicine use amongAsian and Russian patients, and cultural brokers withHispanic patients.

Table 1. Interview groups and participant characteristics

nInterviewlength (h)

Gender(% female)

Age range,average Ethnicity

Training level lastpreclinical year (%)a

Lao group 1 4 3 75 20�23, 21 Lao Loum, 100% 100Lao group 2 6 3 83 21�32, 24.5 Lao Loum, 100% 100US group 1 3 2.25 100 22�27, 24.7 African American, 33% 66b

Caucasian, 66%US group 2 3 2.5 33 23�24, 23.7 Chinese, 66% 100

Taiwanese, 33%US group 3 3 2.5 33 22�25, 23.3 Chinese, 33% 100

Caucasian, 66%

aAll students interviewed were in their last preclinical year, that is, the second year (total 4 years) for American students, and the third year

(total 5 years) for Lao students.bOther statements from a phlebotomy student were excluded in Dedoose analysis for themes.

Table 2. Discussion guide

Question stem: ‘Based on your current level of education andexperience . . .’

1) What barriers to health care face the Lao ethnic minoritycommunity?

2) What steps can be taken to overcome these barriers forLao patients?

3) How is the Lao patient’s perspective addressed?4) What approach do you take when the problem is

discomfort with Western medicine?5) What kind of practice do you get with these situations

in school?

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Lao Approach to BarriersLaotian students discussed specific approaches

to learning about care for Lao ethnic minorities (seeTable 3). They discussed a month-long rotation duringtheir first clinical year requiring students to live in arural village providing care for a Laotian ethnic minor-ity group, including both Hmong and others. Theexperience involved teaching the village about Westernmedicine and learning about traditional medicine,cultural practices and recipes for herbal remedies fromthe villages. One student summarized, ‘First, the team[that] go to the village should know about how theylive, not ‘‘talk talk talk’’ then come straight back . . . orelse it is like the man who went to give a speech to acrowd, and he talked and talked but didn’t look aroundhim, and when he finished he looked out and only oneperson was left standing in the crowd’.

In the hospital, Laotian students reported that inpreclinical shadowing, it was standard practice for aneducated Hmong layperson to be available to explainhealth problems and decisions to Hmong patients.According to one student, ‘If a Lao person tells some-thing to a Hmong patient, they don’t believe as theywould if a Hmong person tells a Hmong person’. Theyalso reported education on herbal remedies in theircourse work and a willingness to use herbal medication

for minor illnesses. They described using that asleverage to persuade patients to use Western medicinewhen needed. ‘For simple disease(s), like fever, we canlet them take [herbs] and they get less side effects,but for severe disease(s) they have to take the correctmedication’.

Finally, Laotian students reported that during theirpreclinical years they had often seen an entire ex-tended family come to the hospital with a sick Hmongpatient. The students assumed that the decision totreat the sick person did not lie with the parents or thepatient only, but with the clan elders and family. Theynoted discordance with Western medicine practice inwhich patients were expected to make health-relateddecisions immediately, whereas for Hmong patients,these decisions often could not be made quickly orindividually and depended on the opinion of the elder.One student summarized, ‘. . . they always have oneperson they respect the most. The doctor needs to goto that family member to explain what they have to doand if they don’t what could happen to the patient’.

LIMITATIONSOur study has some limitations. First, students were

chosen via convenience sampling, which biased thesample to include only Lao students who were able to

Table 3. Summary of Lao medical educational strategies for improving care for Laotian ethnic minority patients, per students

Strategies to improve care Examples from medical education Possible applications for American students

Provide systematic, ideallyimmersive, opportunities forstudents to learn aboutcommunities

Laotian students spend a month in ruralminority villages during clinical training todevelop an understanding of culture andtraditional medicine

Elective time in refugee clinic

Incorporation of education aboutuse of traditional and herbalmedicines

Laotian students learn to integratetraditional medicine into patient care, forinstance, negotiating use of herbal medicinesfor minor illnesses in exchange for usingWestern medicine in the event of majorillness suchas malaria

Curriculum on herbal medication usedin relevant patient populations

Allow for students to learn aboutfamily and elder involvementin care

Laotian students learn to allow elders to beinvolved in decision making for patients

Students should be trained to schedulefamily meetings with Laotian patients assoon as possible in hospital course

Increase opportunities for studentsto work with cultural brokers

Laotian students observed systematic use ofnot only a translator but also a transculturalmediator for care of Hmong patients

System-level endorsement of use oftranscultural mediators in teachinghospitals

Build a conceptual frameworkaround cross-cultural care

American students discussed need forcultural humility

Provide students with practical examplesof community resources

Incorporate learning from othercross-cultural experiences

American students drew on their experiencewith diverse minority patient groups

Require in depth of relevant culturalgroups during preclinical curriculum

Care for Laotian Ethnic Minorities Katherine Crabtree



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speak English, a subset of students who may be differentfrom their peers. Second, interviews were not recordedwhich could have resulted in some errors of omission;however, the pace of interviews was amenable towritten transcription, and this method was chosen tominimize Lao students’ concern of being identifiedas participants. Third, our small sample size could over-or underestimate students’ exposure to Hmong pa-tients. Finally, our study involved preclinical studentswith limited clinical experience. More clinical experiencemay improve student knowledge about cross-culturalcare in the United States.

DISCUSSIONMedical school preparation to care for Lao ethnic

minority patients differs greatly between Laos andthe United States. Lao students reported receiving aneducation on Hmong and other minority patients thatinvolved extensive interaction with them both insideand outside the hospital. Their educational experiencegives them specific resources to apply to while caringfor these patients. American students’ education pre-pares them to care for different cultures in a moretheoretical manner. Perhaps because American stu-dents are more likely to care for multinational patients,their education is less focused on specific minoritygroups. However, students would be well-served by acurriculum which introduces not only concepts andtheories but also gives them an idea of what resourcesare available to assist them in caring for minoritypatients. Further studies should attempt to answer thequestion of how specific strategies used in Laos couldbe translated into the American context.

In a broader sense, the United States is culturallydiverse, and refugees make up a particularly vulnerablepatient population. Given that students will likely en-counter a large number of refugees from around theglobe,26,27 who face various barriers to healthcare,28

it is important to consider this as part of their medicaleducation curriculum. As noted here with Lao students,the doctors in refugees’ home countries naturally workwith them more extensively than American physicians.American physicians therefore could potentially learnspecific strategies from international providers for ad-dressing shortfalls in health outcomes, for instance, inthe case of Hmong patients, incorporating families intocare and flexibility in use of herbal medicine.29

Future studies could attempt to implement specificstrategies from refugee countries of origin, measuringeffects on specific health outcomes and patient satis-faction. Implementation of strategies from the home

country need to be considered within the context ofthe US healthcare system and will require innovation ininternational collaboration.

Conflict of interest and funding: The author has not re-ceived any funding or benefits from industry or elsewhere toconduct this study.

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