Monthly Archives: December 2009

Happy New Year’s Eve!!

I have had a history of throwing New Year’s Eve parties. They have changed, a bit, over the years.

I am planning a fondue party tonight. If anyone is interested in my other side, my ever-so-slightly domestic side, I have a mostly defunct food blog. I have been posting pictures and updates. If it’s your thang, check in and I may even keep up the posting until it gets too hectic.

Happy New Year’s, everybody!!

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Still working

I am still reviewing and contributing stuff for the new Our Bodies, Ourselves. I am learning a lot more about breast cancer and screening, in the process.

If anyone has any breast cancer or breast screening stories, please feel free to share. Even thought my mother has had several biopsies and ultrasounds, our family has been thankfully free from breast cancer.

In the meantime, I will try to stay on task.

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Reply turned post, parenting judgment style

I used to write more about mom on mom judgment than I do now. But, every now and then I see a conversation online, and it brings me back into the common discussion of what is acceptable to “judge” and what is not.

On PhD in Parenting, this conversation comes up every once and again, and it did on this post on parenting styles on vacation.

Here is my reply to the cries of “don’t be so judgmental!”:

I think there is a fat line between mommy judgment and deciding which parenting tactics aren’t for you.

I hate it when I see parents yelling at their kids, repeatedly, for doing something when they could get up and do more effective disciplining up close, but are too busy with their own texting or book or conversation that they don’t want to bother. Know where it’s worse? On a school playground. With both of my kids, I observed the playground first before choosing a preschool. If the adults huddled in a corner and yelled at the kids from afar, and missed acts of aggression, you betcha my kid didn’t go to preschool there.

But, I am not condemning parents who I see do that once as “bad parents”. I am not condemning the adults (teachers, teacher’s assistants, whatever) at the preschool [where] I saw this as awful teachers. In fact, I use this “judgment call” “opinion” or whatever you want to call it to catch myself, too. If I am doing something similar, like yelling at my kids repeatedly from my keyboard (who me? never…), I will think “You’re doing that thing you hate” and hopefully get off my tuchus and discipline more kindly AND effectively.

Are we really defending screeching at children from afar? Of course, a parent may have a hurt foot or a disability. Of course, a child may have an immune disorder, and may need stuff wiped down. I am the type of person to travel with snacks, but mostly because 1. the food at resort style places is obnoxiously expensive and 2. it’s usually pure crap. Do I judge parents who let their kids eat it? No, when I can afford it, I splurge a little and relax my standards for my kids. Are we talking about kids with severe allergies here who need their own food? No. And, again, I would never use that as some sort of end-all-be-all judgment of the quality of parenting.

We aren’t talking about exceptions, we’re talking about parenting choices, here. Screeching from afar = poor discipline, and I don’t feel overly judgmental saying that.

I was stuck in a long line at DisneyWorld once next to a mom who had just gotten out of a tour in Iraq. She was with her young son, who was the same age as my older son at the time. I still remember to this day the nasty and sarcastic way she talked to her son the whole time we stood next to each other, and it was the good part of an hour.

I have no idea what it is like to leave your child for a tour of duty in a war. Just thinking about it, and I do often, because I am a ruminating bleeding heart like that, makes me want to weep for our society. I cannot imagine what it would be like coming home and having to reconnect with a child, while dealing with all of the complex feelings and guilt. I am not judging this woman as a parent. What I do know is that the experience in the line for a mere 45 minutes of their life was excruciating to me, and it broke my heart for the boy.

She could be a great parent. I am not saying I am a better parent. I am not saying that I haven’t been bitingly sarcastic or nasty to my children, or that you couldn’t play back a recording of some things I’ve said that would make me cringe. Or that could easily be torn apart on a blog.

There may have been some problematic points in the original post in which she seemed to be guessing at motivations for the behavior, and I can see how that could rub someone the wrong way. But, criticizing screeching, or valuing a scheduled feeding for an infant who is howling on an airplane over just feeding the poor thing, is just looking at a snapshot of an action and reacting. It’s not mommy wars, in my book, and leaves room for a defense of such choices without name calling.

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Open call, please share and repost

I am busy reviewing and contributing to the second chapter of Our Bodies, Ourselves that was assigned to me. It is called “Unique to Women” and is about screening tests and medical procedures. I am trying to get through the technical side of writing this: checking on new screening guidelines, new screening tools, and such scientific type things. But, I really want to take into account the needs and points of view of many women, including disabled women, women of color, women from different cultural and religious backgrounds, women who are trans, men who are trans, women who are survivors of sexual abuse and/or assault, women who work in the sex industry, women who are polyamorous, women who are gay, women with piercings and tattoos, women of size, etc.

I am going to jot down items to look up. I already have some ideas. I know of many blogs out there for people with different disabilities, so I can search them for the easy to find encounters-with-medical-personnel horror stories. I know I can find plenty of health care practitioner bloggers out there (you know who you are) and submit something about a code green.

I am going to try to search out other stories on outlets available to me, but considering my short deadline, I would LOVE any voluntary submissions. The deadline is New Year’s Eve. I would love to continue the conversation past that point, but may not be able to submit anything to the publication. I am not a final decision maker editor, just a reviewer and contributor, but I will be happy to link to posts or publish them on here as comments, if people like. Or, you can email them to hilseb at gmail dot com.

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Reply turned post, participatory medical education style

I have had the benefit of communicating to physicians who like to teach on the internet, not just in the real world. DoctorJen was really helpful with my KALI questionnaire. I have communicated with Dr. Fogelson of Academic Ob/Gyn, whose blog has inspired a reply turned post of its own.

Dr. Onyeije, a Maternal Fetal Medicine specialist, is also communicating with me about ethics, risk presentation and paternalistic (or not) obstetrics.

Here was his comment on reply turned post, Academic thought on VBAC style.

Just wanted to chime in and echo your comments regarding how risk is communicated and how it is received. What I’ve found is that there are multiple different ways to communicate risk and (perhaps just as many ways) to receive such information. It’s a two way street and problems can occur when the recipient and communicator are not on the same wavelength.

I certainly see this when counseling patients regarding all types of screening tests.

I’ll be interested to read your thoughts on risk perception.

I answered:

I have thoughts! I wrote a little bit about it here, but that is just the tip of the iceberg. Prenatal screening can be really problematic. High false positives in some screening tests can be emotionally devastating to a patient, especially if the physician and staff communicate risk poorly.

I know of a couple who called off their baby shower and told everyone they were getting a 20 wk termination over a “positive” quad screen – a high AFP level. And this was AFTER I personally warned them about the poor specificity of the test. Then, this couple who had told me they weren’t going to get amnio (prior to the quad screen) got an amnio, and of course, the amnio results were within normal range.

I have heard of a woman passing out at work and hitting her head on the desk because someone from her OB office called and told her her fetus has tested positive for Down’s syndrome. Not only was this incorrect, it was, again, just a quad screen result, not a diagnostic result, but they hadn’t even told the patient what the test was screening for until they called with the results. Every subsequent pregnancy she got the same low AFP, and then a “normal” amnio. Every pregnancy she got the amnio anyway.

Same thing with gestational diabetes screening. UpToDate is currently full of information about how unreproducible the results are for the initial challenge test screening and the GTT, and how there aren’t universally adopted thresholds. But, how many women have been bumped up to “high risk” by a GTT test, and then possibly even sectioned due to possible fetal macrosomia? I don’t even want a baby getting unnecessary heel sticks after every feeding, which is protocol in some places if the mother had GD. Especially if it subtly tells a new mother that her child will be hurt every time she attempts breastfeeding. It’s not worth it if it’s due to an imprecise diagnosis. I have another set of friends, the mother is a medical student, and the father has a PhD in psychology. She got a positive challenge test screen, and had a “freak out” (their words, not mine).

These are anecdotal studies, but I have read research about the anxiety these screening tests cause women.

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Itching to write, but tooooo busy (and clitoris)

I have a post brewing about reproductive health care and enlisted women, but right now I am up to my eyeballs in stuff to do.

I am catching up on reviewing the chapters I am assigned for the new Our Bodies, Ourselves. It’s been really exciting. I have been researching the anatomy of the clitoris for the last two days. (Hello, weird search engine hits to my blog). I am having trouble finding a consistent, comprehensive description in one source. I was watching Rachel Maddow interview Ana Marie Cox while reading about the clitoris last night – I feel like I earned an honorary lesbian card. (OK, now I’m asking for the weird search engine hits. But, it’s better than being caught by surprise by even weirder ones. You have no idea.)

My Essential Clinical Anatomy is passable, but not detailed enough. I can’t find my Netter’s, and I feel sorry for whoever has it, because it stank of formaldehyde and had some very questionable stains on some of the pages. I wish my library has access to the Journal of Urology, since it has what appears to be a good article on it. In fact, I am kind of surprised it doesn’t. I did find an interesting article in the Australian Nursing Journal by Helen O’Connell, who is the author of the unavailable J. of Urology article, in which she complains of the, ahem, shortcomings (her word) of the treatment of the clitors in anatomy texts, including Grey’s Anatomy.

Anyway, as usual, my “I’m too busy to post” post has gotten long. Two reviewed chapters, one eggnog Bundt cake, a few batches of spiced nuts and Christmas cookies, and a roasted chicken from now, I hope to be writing about military reproductive health care.

Edited to add: I had no idea the clitoris was so complicated! (Insert joke here). I think I get it. Well, as much as I can when the sources aren’t consistent with their terminology.

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Thank you, Shark fu

What she said.

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Reply turned post, Academic thoughts on VBAC style

One of my favorite new blogs, Academic OB/GYN, has an interesting post up called Ten Thoughts on VBAC. I encourage you to read the entire post and comment thread. I was especially interested in #7 and #10, which said:

The single most important thing we can do to deal with VBAC issues is to not have them at all, by avoiding the first cesarean section. Many cesareans are absolutely necessary, but when possible we should achieve vaginal deliveries. I’m willing to push some grey cases that others might deliver by cesarean. Sometimes that means being more patients with a slow labor. Sometimes that means operative vaginal delivery. Because of that, more of my patients will have easy multiparous second labors rather than having to worry about VBAC issues. There is a receiver operator curve for cesarean necessity. Most OBs should push their needle a little towards “specificity”.

Here is my reply:

Thanks for a thoughtful post on a controversial issue.

When I selected an article on VBAC for our medical school ob/gyn interest group journal club, our faculty sponsor said we shouldn’t even waste our time, since no one is doing them any more. That is certainly true for our area, where most practices and hospitals refuse to allow trial of labor attempts for VBACs. We are hardly rural. I know of an ophthalmologist who had to hire a concierge obstetrician and pay $10,000 up front to get any obsterician to attend her VBAC. She had one prior successful spontaneous vaginal delivery and a cesarean for twins. Practice patterns are obviously not the same everywhere, especially when it comes to obstetrics. She had her cesarean in another part of the country, and was assured by her obstetrician that she would be a fine candidate for a future VBAC attempt. If she hadn’t moved, it probably wouldn’t have been an issue.

I have another local friend whose physician refused to attend a VBAC attempt she requested (her prior pregnancy ended in preeclampsia, a failed induction and a cesarean at full term). When she showed up a few days before her scheduled cesarean in spontaneous labor, they sectioned her anyway, even though an article in that month’s Green Journal found that emergent cesarean after onset of labor to be the most expensive choice in their study of VBAC with the worst maternal and fetal morbidity. Why not let her attempt the trial of labor, especially since she expressly asked to be able to do so, and prominent medical opinion found it to be not only a reasonable choice, but an easily defensible one?

And, the area primary cesarean rate, which is above 45% in most hospitals, means that less of our primips are “successful” at an attempted vaginal delivery (I put “success” in quotes because I think a safe delivery, even if by cesarean section, is still “successful”) than even the conservative estimates you quote as “success” rates for VBAC attempts in the original post in point #7. (I have usually read of a “success” rate of about 75% in several articles, but outcomes vary.)

But, ACOG’s Practice Bulletin on VBAC says women who are good candidates should be offered a trial of labor. And, practice patterns vary in different parts of the country, and many physicians and hospitals still offer VBACs, and the current literature seems to consider it to be a reasonable option and continues to publish articles on VBAC. But, when I did a history on a woman switching care to a midwife in her third trimester, she said her doctor told her he’d refer her to a psychiatrist before he’d let her attempt a VBAC. So, there’s obviously a wide range in opinions on how to interpret the risks.

This article on explaining obstetrical risk by Lyerly et al is one of my favorite articles I have read on the topic. It states that “Although rates of delivery-related perinatal death are indistinguishable between VBAC and primary vaginal delivery, there is a genuine differential in the rate of uterine rupture–related hypoxicischemic encephalopathy. Such perinatal morbidity is indeed devastating. It is also extremely rare. In a recent large prospective study, the probability of this outcome was 0.00046 in infants whose mothers underwent a VBAC trial at term compared with no cases in infants whose mothers underwent repeat cesarean delivery.” (Emphasis mine)

I think that indicated that there is some validity to the argument that anywhere that it is safe to allow a premip to labor and deliver, it should be safe to allow a good candidate to attempt a VBAC. However, some may disagree about where it is safe to deliver at all. Some may find the risk of a home birth not only acceptable but preferable to a medicalized birth experience. Others may only be comfortable with a delivery at a facility with on site 24 hour anesthesia and obstetricians, and a Level IIIC NICU.

I don’t want to paint all obstetricians with one brush, but neither do I want to disregard the possibility that out of hospital births can be safe. Well managed out of hospital births may have risks similar to real obstetrical care in many hospitals, which unfortunately is not always evidence based care optimizing good outcomes. But, women are not always given an unbiased view of true risk, whether it be the risks of a HBAC or the risks of an induced, augmented VBAC attempt or the risks of repeat cesareans. The Lyerly article concludes that “[T]hese tendencies in the perception, communication, and management of risk can lead to care that is neither evidence-based nor patient-centered, often to the detriment of both women and infants” when discussing the way obstetricians present these risks. I think the natural birth community can probably be equally possible of have members on the fringes who would de-emphasize the risks of a home birth VBAC or an unassisted VBAC.

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Hop into a tub of Cialis

Cialis ad with a white hetero couple in two tubs somewhere pictureque outdoors

Do you know what I hate? Pharmaceutical commercials.

Cialis has a new ad campaign I keep seeing on the T.V. machine, that goes something like “When is it time to get out of the tub?” as far as I could hear as I was fumbling toward the mute button. I came up with some answers:

When the water gets cold.
When my toes and fingers get really wrinkled.
When I’m done washing myself.
When I’m falling asleep. (I only get to take baths late at night, after the kids are asleep.)
When the wine glass is empty.

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Another banner day

I saw on my blog stats page that I had two incoming links from Technorati. When I clicked through, I found my little blog on their top 100 health blogs list! In fact, I’m at number 30.

Well, whaddya know?

It’s a nice end to a crap week. It started with my ten year old getting hurt at a local kids’ expensive fun place, and ended with my husband in the hospital with an infected cat bite on his hand. Throw in witnessing some obstetrics in practice that made me want to consider maybe doing endocrinology as a specialty, a take home final exam I had to turn in two days late, only to find out the email didn’t send, and every other minor annoyance from stepping in cat vomit with my bare feet and hitting every. red. light. when I was running late for my brother’s birthday party and low on gas.

So, Technorati. Better be the sign of good things to come.

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