Monthly Archives: April 2010

Where real life and future practitioner life meet

So, I got to hang out in the weird interface of being a future practitioner and being a patient recently. I have been getting some tests done because of a weird skin thing I have. Whenever I think I have it figured out, I don’t. If it is all one condition, it has been going on since I was 16, so, it is obviously not an acutely dangerous condition. I have gone though, in my head, diagnoses from being dirty -> fungal infection -> systemic candida -> inverse psoriasis -> something…else? Like maybe erythema annulare centrifugum? Erythema gyratum repens? Granulomatous dermatitis? Mycosis fungoides?

Med studentitis?

Ack. Well, I just got a biopsy done, which was inconclusive, and I also had to go and get my (*ahem*) supposed-to-be-annual gynecological exam, and get various vaccines and tests to prepare for rotations. On my way in the get the check under the hood, I passed a group of what I assume were either physical therapy or occupation therapy students traversing the perimeter of the school, including the parking lot near the handicapped spaces. Many of them were using assisted mobility devices (not sure if that is the correct term) such as different types of crutches, wheelchairs and walkers. I do not think any of these students needed these devices to ambulate themselves, but were using them to see what it was like for their future patients. And, at the same time, testing out the accessibility of our building, which not only houses a huge health professions graduate school, but employs a large number of support faculty and staff. We also share the site with our clinic, which has various medical specialties, a dental clinic, an optometry clinic, and physical and occupational therapy offices.

I was running late, but I had to stop and ask their professor how they were finding the accessibility. She seemed like a great professor (from my 2 minute interaction while we were both negotiating a parking garage with lots of traffic and no sidewalk) and said it seemed to be poor in many areas, including the one we were in. The front parking and front of the building were better, but the majority of the students and patients will be in the garage.

I was so happy to see this particular group doing an excursion like this. I have seen members of these programs on our elevators and on different floors of the building with assistive devices. Sometimes they have real live people with them who have mobility barriers, but not on this particular trip. I heard students complaining about how difficult it was to use a walker for a long distance, and was happy to see them getting real empathetic experience, even if they were not getting direct input from someone who has to deal with this every day. They will get a lot of that in their careers, and I hope this helps them think about mobility and accessibility more holistically.

I also hope the professor and/ or students submit an accessibility report to the powers that be at the university. All facilities should strive to be accessible, but I have an ever higher standard for a location that serves and trains people to serve people who have different accessibility and mobility needs.

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Reply turned post, VBAC consent form style

Jill has a great post up at The Unnecesarean that is a great example of the interactive nature of the internet birth advocacy community that Amy Romano talks about at Science and Sensibility. The post is almost a wiki of a VBAC consent form. A doctor who reads the site and its comments says he has changed the way he interacts with patients (!!) based on the voices there. He also has submitted a VBAC consent form he cannot edit but can add to. The comments and suggestions are fantastic and I recommend reading them all. I put up a small suggestion, then posted again almost immediately, musing about ACOG’s Practice Bulletin on VBAC:

Sorry for the double post here, but my comment made me think. I just read over the ACOG practice bulletin on VBAC last night (after getting into an annoying “devil’s advocate” conversation with a fellow medical student who was studying for his women’s health final) and the recommendation I posted above (which is a recommendation to offer a trial of labor to all eligible patients) is a highest level (level A) recommendation.

There are two interesting points. One, the suggestion that a physician be immediately available is a level C (the lowest level). I think ACOG is clear in saying this should be offered, and that is more important than the immediately available issue. Language about physicians being available for emergency cesarean also appear in their bulletin on inductions, but that is rarely mentioned. Finally, under “Intrapartum Management”, it says:

“Once labor has begun, a patient attempting VBAC should be evaluated promptly. Most authorities recommend continuous electronic monitoring. However, no data suggest monitoring with intrauterine pressure catheters is superior to external monitoring. Personnel who are familiar with the potential complications of VBAC should be present to watch for nonreassuring fetal heart rate patterns and inadequate progress in labor.”

I think this is a much lower standard than many people say this bulletin warrants.

Also, under delivery: (emphasis mine)

There is nothing unique about the delivery of the fetus during a trial of labor. The need to explore the uterus after a successful vaginal delivery is controversial. Most asymptomatic scar dehiscences heal well, and there are no data to suggest that future pregnancy outcome is better if the dehiscence is surgically repaired. Excessive vaginal bleeding or signs of hypovolemia at delivery require prompt and complete assessment of the previous scar and the entire genital tract.”

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Reply turned post, the liberation of motherhood style

I don’t normally do much of the mommy blogger stuff (I save that for Facebook!) but I can’t resist linking to blue milk’s post about motherhood with a wonderful Toni Morrison photo and quote. Please go read it, it is a sentimental (and not revolutionary, but in a way, revolutionary) perspective on motherhood as liberating and self actualizing.

Here is my reply:

“Thank you so much for this. I absolutely agree. There is nothing more liberating than making huge decisions that involve shepherding a new life into the world, and helping shape that individual to be a member of society. It radically changed my interaction with the world in a macro way, and with individuals in my life.

Although I was a bleeding heart liberal since I could remember consciously rejecting my parents’ conservativism, it completely changed my perspective on social justice issues. Not only was police brutality wrong on a philosophical level, but that victim who was being hit was SOMEONE’S CHILD.

And yes, I do strive to be a better person as a parent. I used to be oblivious about my physical belongings. Really irresponsible about appointments and being on time. I would replace my driver’s license once a year. I would constantly lose my keys, and usually didn’t even own a purse. I don’t think I have lost my wallet once since becoming a mother 11 years ago. I actually hold on to sunglasses for a little while! I am a firm believer in leading by example, so I tend to be very reflective on my behavior, especially in front of my children.”

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What I read for fun

Look what I stumbled across: Substance P, the science and perception of food. (Thanks, Gizabeth!)

I am really enjoying his presentation Chemosensory Sorcery. As someone who gives presentations (I did a review for med students yesterday, and plan to be in academics), I love great quotes and cool pictures. He quotes the Walrus from Through the Looking Glass! It doesn’t hurt to have such a great topic, too.

When I talked about my alternate fantasy careers at Mothers in Medicine, I forgot to mention food scientist. Oh, and medical librarian.

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Reply turned post, did someone say breastfeeding?

I wasn’t the only one talking about the recent Pediatrics article on breastfeeding. Well, Annie at PhD in Parenting had a post up about the constant refrain that talking about breastfeeding’s benefits is somehow judgmental. People in the comment section kept saying it was a “personal decision”, as it that made it somehow a non-discussable topic. I had to reply:

Sorry I’m late to the conversation, but I am just caching up on my blog reader!

First of all, a lot of these comments are hitting on a key issue I have with these conversations. Every decision one makes, important or unimportant, affecting others or not, is a “personal” decision, so that’s a moot point.

However, here is my favorite explanation of breastfeeding, and it isn’t an analogy. Breastfeeding (or switching to the intervention of formula feeding) is a HEALTH DECISION. It’s not a lifestyle decision, it’s not merely a personal decision (whatever that is supposed to mean – done by a person?), it is a health decision.

Health decisions involve social and cultural aspects, and feelings of guilt, and controversy. But, they also invoke a certain level of scientific conversation and (hopefully!) proper weighing of health benefits and risks along with the discussions of lifestyle, emotions, barriers, etc. Some people may choose to weigh their religion, or some cultural factor when making a health decision, more than the health risks and benefits. That’s OK, and it happens. Also, all people are not able to do operate physiologically equally or able to avail themselves of all interventions equally. This doesn’t just apply to breastfeeding.

Breastfeeding is a physiological state, like a vaginal delivery, and formula feeding is an intervention, like a cesarean section. (Or breathing without asthma medication, or supplemental oxygen). Sometimes the intervention is necessary. Sometimes the intervention is coerced by caregivers. Sometimes the intervention is chosen for lifestyle or cultural reasons, not health reasons. That doesn’t mean the very real health effects are not the key issue. Sometimes people will say hurtful or insensitive things about people who have the intervention, whether they really needed it or not. Sometimes people will look back at when the decision was made, and think the decision was wrong or could have been avoided, and feel regret, or guilt, or judged. Sometimes people who have had the intervention think that no one can talk about the intervention but people who have had it, and when people say it is just that, an intervention with risks and indications, and will say “No, stop talking about those facts, and just listen to what women want to choose, you big meanie!”

It can be a cesarean section, a vaccine, a gastric bypass, circumcision, medication for mental illness (especially during pregnancy or breastfeeding, or behavioral modifying meds for children) etc. Health decisions. Also with major societal and cultural influences. Major gender, misogyny, and other privilege issues tied in there, too. Overblowing of risks to the fetus or baby, but also over exaggerating the strength of the evidence that the intervention is effective and risk free happens, a lot.

So, let it be complicated and nuanced. But don’t silence the fact that first, and foremost, it is a health decision, and needs to be discussed with the true risks and benefits to morbidity (health) and mortality (life).

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Ugh x 2

(Trigger warning)

Pregnant woman is told she must have a cesarean for her fourth birth, even though her third birth at that hospital was a successful VBAC.

Raped ten year old is refused an abortion in Mexico

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Reply turned post, Cox really showed J.D. this time, zing!

Do you remember when KevinMD gave Dr. Amy a chance to guest post about VBAC?

Well, there was another post about VBAC up simultaneously. Its comment section has devolved into an argument about external fetal monitoring and whether it reduces perinatal mortality.

I am subscribed to the comments on this post, and every few days I get an email telling me these two commenters are still arguing about this, and instead of looking up the evidence, they are trading sarcastic insults and puffing up themselves like Doctor Cox on Scrubs. I finally couldn’t take it anymore and replied:

Oh my MAUDE this is not an episode of Scrubs, you two. It is not hard to look up what you two are fighting around. As witty as your banter may be, it doesn’t change the state of the evidence on external fetal monitoring during labor, which isn’t even the point of the original post.

Here is the ACOG practice bulletin on continuous external fetal monitoring. If you can’t access it (you may need to be a member of ACOG), let me sum it up for you.

In the introduction, it says: (emphasis mine)

Despite its widespread use, there is controversy about the efficacy of EFM, interobserver and intraobserver variability, nomenclature, systems for interpretation, and management algorithms. Moreover, there is evidence that the use of EFM increases the rate of cesarean deliveries and operative vaginal deliveries. The purpose of this document is to review nomenclature for fetal heart rate assessment, review the data on the efficacy of EFM, delineate the strengths and shortcomings of EFM, and describe a system for EFM classification.

Here is what they have to say about its efficacy:

” * The use of EFM compared with intermittent auscultation increased the overall cesarean delivery rate (relative risk [RR], 1.66; 95% confidence interval [CI], 1.30–2.13) and the cesarean delivery rate for abnormal FHR or acidosis or both (RR, 2.37; 95% CI, 1.88–3.00).
* The use of EFM increased the risk of both vacuum and forceps operative vaginal delivery (RR, 1.16; 95% CI, 1.01–1.32).
* The use of EFM did not reduce perinatal mortality (RR, 0.85; 95% CI, 0.59–1.23).
* The use of EFM reduced the risk of neonatal seizures (RR, 0.50; 95% CI, 0.31–0.80).
* The use of EFM did not reduce the risk of cerebral palsy (RR, 1.74; 95% CI, 0.97–3.11). “

And, their complete, unedited conclusions:

Conclusions

The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):

* The false-positive rate of EFM for predicting cerebral palsy is high, at greater than 99%.
* The use of EFM is associated with an increased rate of both vacuum and forceps operative vaginal delivery, and cesarean delivery for abnormal FHR patterns or acidosis or both.
* When the FHR tracing includes recurrent variable decelerations, amnioinfusion to relieve umbilical cord compression should be considered.
* Pulse oximetry has not been demonstrated to be a clinically useful test in evaluating fetal status.

The following conclusions are based on limited or inconsistent scientific evidence (Level B):

* There is high interobserver and intraobserver variability in interpretation of FHR tracing.
* Reinterpretation of the FHR tracing, especially if the neonatal outcome is known, may not be reliable.
* The use of EFM does not result in a reduction of cerebral palsy.

The following recommendations are based on expert opinion (Level C):

* A three-tiered system for the categorization of FHR patterns is recommended.
* The labor of women with high-risk conditions should be monitored with continuous FHR monitoring.
* The terms hyperstimulation and hypercontractility should be abandoned.

Not really a glowing recommendation.

Hmm, well, maybe ACOG doesn’t like EFM because it is used to sue physicians. Maybe the Cochrane Database has something on it. Oh, wow, it does!

The unedited conclusions:

Authors’ conclusions: Continuous cardiotocography during labour is associated with a reduction in neonatal seizures, but no significant differences in cerebral palsy, infant mortality or other standard measures of neonatal well-being. However, continuous cardiotocography was associated with an increase in caesarean sections and instrumental vaginal births. The real challenge is how best to convey this uncertainty to women to enable them to make an informed choice without compromising the normality of labour.

Continuous external fetal monitoring, as it is being applied as the most common obstetrical intervention used in birth in the United States, has not been proven to improve neonatal outcomes significantly other than a small reduction in neonatal seizures, which are uncommon and transient. It does free up labor nurses to monitor laboring mothers from a nursing station, and it provides a continuous metric that has a false positive rate of about 99%, and is being used to sue physicians. I am sure it is involved in many more malpractice cases against ob/gyns than a trial of labor for VBAC.

It is amazing to me that it is not condemned with the same vehemence as VBACs. It has definite drawbacks that limit the mother’s autonomy and mobility, and I have never met a woman who thought they were comfortable.

That is one of the reasons I included the use of continuous external fetal monitoring in my research, because I am honestly confused about why some interventions and practices are utilized and supported, while others are not.

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