Monthly Archives: January 2008

An advantage to being a mom in med school

PhotobucketI have a dry erase easel available after the kids go to sleep. I am using it to diagram neural pathways as I study for neuroanatomy. Here is the epicritic pathway, the pathway of discriminative touch: two point tactile discrimination, vibration and proprioception (knowing where your body parts are).

Speaking of which, people with advanced syphilis have a harder time knowing where their feet are, since the spirochete chomps the fasciculus gracilus (which is labeled on the drawing – see?), the pathway that carries this information from the feet to the cerebral cortex. So, victims of advanced syphilis often have a wide stance. I’m just sayin’.

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Some musings about a specialty

My facilitator in my clinical practicum class in encouraging me to go into Ob-Gyn instead of family practice with an Ob-Gyn fellowship. She thinks I would be a great obstetrician (She is so sweet! She made a comment that she would love to use me if she got pregnant.) and that family practice would annoy me when I am so passionate about obstetrics.

And funny thing, we had this ultra suave gynecologic oncologist speak to our group last week. He said one of the reasons that he went into gynecology was that men are gross. (Ironic, since his dress and hygiene were impeccable). I thought about it, and I am weirded out by treating men. And probably older children, too. I am going to definitely give family medicine a good try in rotations. That way I can take care of a whole community like I plan to now. But, I am interested in Ob-Gyn, and maybe a women’s health fellowship, instead. Exciting!

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Speaking of protest songs

I was thinking that there are some others from this war that I like. Too bad they don’t get as much radio play as the ones from the Vietnam War did.

Faithless, Mass Destruction

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Wow

Dear Mr. President, by Pink

Thanks Tami.

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Blog for Choice Day

Blog for Choice DayI wasn’t sure that I was going to join the group Medical Students for Choice when I went to medical school. I knew that I wanted to provide abortions in my future practice, whether I was a family practitioner or an Ob/Gyn. But, I was afraid to sign up for the club. I was afraid of what it would “say” about me when I applied for elective rotations and residencies. I was afraid of what my fellow students would think of me. It was going to be hard enough to fit in, since I am ten years older than most of my classmates, with two kids. I felt like that was an obstacle enough, and that being labeled as a radical feminist would let my freak flag out of the closet, if my bad art school tattoos didn’t already give me away.

But, I found myself on their website before school even started, trying to find out if there was a chapter at our school. And today, I stood up, with my hands shaking, and asked my neuroanatomy professor if I could borrow the microphone to address the class, who was chattering away during one of our breaks.

“Today is the 35th Anniversary of Roe vs. Wade,” I said, and the classroom fell to a hush. I announced that medical Students for Choice would be having a lunch speaker, and invited the classes for “dialogue.”

We had a wonderful pair of speakers from a nearby abortion clinic. When the first one, the founder of the clinic, was done speaking, she asked us to speak about why we were so personally involved with choice, and why we were members of our organization. I had been excitedly discussing the NEJM article about antidepressant evidence suppression with the other club members while we ate our pizza, before the meeting started. “How about you?” she said brightly, and pointed right at me. She made a joke about how vocal I was, and I flinched. So much for hiding it!

“Unlike most of my classmates, I have two children. I know what it is like to carry two pregnancies to term, to give birth, to become a mother, and raise children. It is a big deal. I love my children and think motherhood is wonderful, and I don’t want that to be forced on any woman or child. A new life, a child, is too sacred to be a punishment for someone who doesn’t want to have a baby.” I also rattled off some numbers (I am a stats girl) about maternal mortality in countries where abortion is illegal, unplanned pregnancies, and how many women around us have had abortions, and complained about how easy it is to be lost in the discussion of abortion as it is now framed by anti-choicers, which mostly involves slut shaming.

What I didn’t do is say what I was screaming in my head. What I wanted to say in front of the class with the microphone. Which I want to say to my family and not be afraid or ashamed to say.

I had an abortion. I had an abortion when I was seventeen years old. I was a throwaway at the time – my mother kicked me out of the house after reading Tough Love a little too zealously. Ironically, she was upset that I was sleeping with my high school sweetheart. He treated me with respect, waited six months for me to have sex with him without ever pressuring me (well, not much anyway…) and always used a condom. She found out we slept together by reading his letters to me from college. I ended up bumming rides and sleeping at friends’ houses. One of the people I bummed a ride from was a friend of a friend. He did pressure me, he didn’t take no for an answer, and he didn’t use a condom.

Now, I would call it date rape. Then, I had never heard the term. I wasn’t drugged, I wasn’t beating him off, but I was crying and saying no. I stopped saying no after a while and just let him have his way. I had only been with my boyfriend before this, and he had always put on a condom first. When Chris was finished, I opened my eyes and said “You weren’t wearing a CONDOM??” and he said “You’re not on birth control?”

I could go on and on about what bad parents we would be, about how I was thrown out of the house and had no insurance or income, how I had great grades and a bright future. But all that really matters is that I was fully cognizant of the gravity of the situation when I finally figured out that my period wasn’t going to come, and I never once considered keeping the baby. There is no need test, no “bright future” test, no slut test anyone should have to pass.

I love my boys and feel incredibly lucky that I was given the opportunity to be their mother. Every pregnancy and event of a woman’s life time fertility is a total crap shoot. I have been pregnant four times, each of them unplanned. More than half of the pregnancies in the United States are unplanned, which is a ridiculously high number. The time with Chris was the only time that I wasn’t using birth control. It was also the only time I chose to have an abortion.

I cannot imagine what would have happened if I was forced to carry the pregnancy to term. There was no parental consent law at the time in Florida. There is one now. I would probably have gone to court to get a judicial bypass, but I didn’t even figure out that I was pregnant until I was almost a month along. My mother gave me books about Jerry Falwell’s maternity home when I was growing up, and I knew she would never consent to my having an abortion. As far as I know, she still doesn’t know, and neither does any other member of my fairly conservative family.

But, I don’t share that story. Because whores have abortions. And only stupid sluts get pregnant four times without meaning to. I hear it. I hear it every day from my classmates, from my family, from the media. No one says that they are one of the 40% who has had an abortion. They just talk about people they know who had them. That girl from high school. It is rarely a flattering story.

So the shame is still there. I will be a member of Medical Students for Choice. And all two people who read my blog now know that I have had an abortion, along with my husband an a few chosen friends. I don’t think any member of my family reads here, but we shall see.

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Sigh

Wish I could say I was surprised, but I was only disgusted.

According to the New England Journal of Medicine, several drug companies who sell antidepressants have misrepresented and covered up negative studies, including studies with deaths due to suicide. One study with suicides was done on NORMAL subjects, not depressive subjects.

Drug companies need to take the portion of their R & D budget that goes to clinical trials and give it to non profits and universities to conduct and release the results of the actual drug trials. They can still make every penny off of the drug if it is successful and sold.

On the Media had a great story on it. Every time the expert referred to a death as a “trade secret”, I wanted to barf. Oh wait, I forgot, it’s NATURAL medicine that is unregulated….right.

Don’t get me wrong, I am all for people getting the help they need when they are depressed. But, I am also all for accurate information and true informed consent. I have read research on antidepressants in which the results are very disappointing, studies that are secondary to the drugs being released. For example, studies on pregnant women who are depressed and taking antidepressants. I have often noticed that the efficacy rate in these studies, not conducted by the drug company, are often much much lower than claimed in the PDR and pharmaceutical literature.

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Giggle of the day

Today’s lowbrow giggle is brought to you by biochemistry. The very important part of the DNA sequence: the TATA box.

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Linkety dinkety doo

From the parenting front: The meanest mom on the planet

From the election front: The Star Wars Guide to the Candidates

From the depressing front: Uninsured and dying from it

I have a good friend with a heart condition. She works part time as a nanny for cash, and doesn’t make much. The public clinic has her jumping through hoops after a doctor ran an EKG and told her she needs to see a cardiologist. Even IF she could get her lawyer boss to sign an affadavit saying how much she pays her in cash (HA!), the clinic has told her they do not have a cardiologist. She would need to find one and pay out of pocket. Ummm, isn’t heart disease the leading cause of death?

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Speaking of HIV

I wanted to add that I am a trained HIV tester and counselor, and I will be running the free HIV testing clinic at the school next year. Just wanted to explain that I am definitely in support of HIV testing. Voluntary HIV testing.

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Mandatory HIV testing for during pregnancy

I have participated in a few discussions on New Jersey’s new opt-out policy regarding HIV testing of pregnant patients, such as here and here. When I saw Rachel talking about it here, I decided it would be easier to not start from scratch again on her thread. I had wanted to compile my thoughts on this issue in a complete essay, anyway. Some of it is in response to other comments, so sorry if it sounds like I am arguing with an invisible adversary. If you have any question as to what the arguments are for forcing HIV testing on pregnant women, follow any of the links.

New Jersey passed a law that is an opt out law. If it is like the one we have in Florida, it means if a woman refuses, she has to sign something stating that she is refusing. The part that bugs me is that they can apparently test the newborn if she refuses. This is a useless test for determining the HIV status of a child; a positive test would only reflect the HIV status of the mother. It would also set into motion, probably, a series of painful tests on the child for the first few years of its life if not longer to see if the antibodies clear.

The opt out part does not bug me as much – it means that they have to offer it to everyone. My experience at the birth center where I trained meant that not having opt out (it was instituted late in my training) means many practitioners do not offer HIV tests to people they don’t think are high risk. So, HIV tests got offered to poor women, single women, women of color, etc., and not to married women, white women, or women who dressed conservatively in the center where I worked. I would sit it the room with midwives who would say “We re-offer the HIV test at 34 weeks, but since you’re married…” and leave it at that. With the new “opt out” policy, they had to sign something saying they were refusing the test, but we had a sheet in every file with lists of tests they could refuse, and allowed many prenatal tests to be refused.

Now, this facility did require a mandatory HIV test upon admission to deliver with them or be treated with them. I do not think it would be legal for midwives to deliver an HIV positive woman in Florida, where out of hospital birth is highly regulated. I did not agree with the refusal of treatment, but it is the right of a private facility to screen and refer patients, and they can choose to go to another facility. I do not know of many facilities, private or public, that would allow you to refuse any and all HIV testing and still treat you, but I have not researched if there have been any showdowns over it in Florida. I suppose ultimately, a public hospital should treat you, but that would probably be if you came in in labor, not if you came in for prenatal care regularly as patient. Now that rapid testing is available, I see this as mainly a problem for women who come in with no prenatal care in labor, who can now be given a 20 minute test on the spot. I read recently that California is no longer going to require written consent for HIV testing, and I can only assume the abuses will start piling up.

I haven’t heard anyone arguing that HIV testing for pregnant women isn’t a good idea, in fact, a great idea. Forced testing or refusing care to someone who refuses testing is the issue.

I am a woman who has been pregnant, a parent, and also a medical student. I may not agree with many treatments or refusals of treatment, but I sure as hell don’t want state legislatures to decide which ones are allowed and which ones aren’t, especially when it comes to women, and doubly especially when it comes to pregnant women.

People die all the time by refusing screenings and treatment. Is it what I would want for my family member or for a future patient? No. Will I fight for their right to do so? Absolutely.

While I am no fan of “slut shaming”, I would assume the most common way a pregnant woman would get HIV would be from a cheating partner. That is what we heard in our Department of Health mandatory HIV training. What is important is to offer and encourage testing to all women during pregnancy and allow her to practice informed consent, which is more sacred to me than HIPAA any day.

It is typical and insulting to single out birthing moms and target them for mandatory policies. It treats them as a vessel, not an autonomous patient. Again, no one is arguing that screening and intervention are effective and may save lives. What we are arguing is that women still have the right to refuse.

The right to refuse screening or medical treatment is a fundamental right guaranteed by the bill of rights (prevention of search and seizure) and other significant legal precedence. I may think many medical procedures are valuable and/or necessary, and many aren’t. This makes a difference in what I choose for my family, screening and treatment wise, and what I refuse. I really like this right, and wish to have it extended to others. Including my patients. It is called informed consent.

Mothers should be told the benefits of the screening, the risk of HIV to the child, the reduction of risk of transmission if they are tested and treated and certain interventions are chosen (like cesarean section) and then should be allowed to make a very valid choice about their medical care. And if the practitioners do not know her HIV status, they should treat her as if she is infected (except for antiviral meds, of course) which would involve universal precautions, which they use for everybody anyway. What if she does get coerced into the test, finds out that she is HIV positive, and then is unwilling to take the antiviral meds or have a scheduled cesarean? How far do we go to we subjugate her desires to prevent transmission?

It is really easy to treat pregnant women as merely a vessel for their babies, and ignore their rights when someone, usually a doctor, judge, or legislator, decides that they “know better”. You may agree with them in this case, but don’t forget what this may do to your rights or other pregnant women’s rights down the slippery slope.

I went to a lecture recently on pediatric ethics. It was fascinating. There was a recent case in which a 12 year old (I think he was twelve – he was a younger teenager if not) refused cancer treatment and died. His parents had issues earlier in his life and gave him to an aunt to raise. An aunt who happened to be a Jehovah’s Witness. The parents took the aunt to court. They lost, and he died. People die from refusing care all the time. People infect people with HIV all the time too, not just through childbirth.

Again, no one is arguing that screening and intervention are effective and may save lives. What we are arguing is that women still have the right to refuse. Just like anyone else, just like the case I posted about the boy refusing blood transfusions. He died. People die from refusing care all the time. Men walking all over the world can infect other people and kill them eventually with the AIDS virus, but we do not pick one point in their lives (like childbirth) and say “Hey! You need an HIV test before you can get this vital care.” Men in prison infect other men in prison with HIV.

I am sure testing men when the are initially incarcerated and even coming up with an HIV prison and a non HIV prison would do SO much more in preventing the spread of HIV in America than testing moms in labor. Would it be ethical? Not sure. Do they do it? No. As far as I know, they are not testing when they show up or when they leave prison, and the HIV rates there can be in the double digits. So can the rape rates.

The 20 minute test (which I think is a rapid ELISA) and the tests that take longer (Western Blot, etc) are not true indicators of HIV status. I do encourage people to “know their status”, but it isn’t definitive. All HIV tests test antibodies, and only indicate if one has been exposed in a certain window. Someone who has regular exposures (unprotected sex, while pregnant, say…) with anyone, even a spouse they trust, can be exposed at any time. People have sex and lie to their spouse. People use drugs and lie to their spouse. Unless we start hauling in partners (ALL partners, needle sharing and sexual) and require them to submit, no true universal comprehensive testing could occur. A positive partner could infect a negative mother and she could pass it on to the baby, even after birth, if she is breastfeeding.

I think refusals will be extremely rare, and not necessarily among HIV positive individuals. The strong arguments about the effectiveness of preventing transmission would be more persuasive to me if I thought many HIV positive women would refuse.

I hope that people who think that women who are pregnant should lose their rights will always agree with what people who have control over them thinks is best for them and their families. If not, remember this.

I hope that people who disagree with me never have to go through a situation where someone who has control over their families’ health care does not agree with them about what is best. If that is the case, I hope they get the right to make an informed decision, and maybe they will remember this discussion at that time.

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