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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“Blog partnership request”

This is at least the third time I have received a “blog partnership request” from someone named Eashwar at ExpedientInfoMedia.com, and he wants me to put up a link for one of the blogs in his network called “The Pregnancy Zone”. I am not going to link to them, but they aren’t too hard to find with a simple search.

I actually went and checked out the site when I was invited the first time, and sent dear Eashwar a detailed critique of the first article I read, which happened to be on ectopic pregnancy. I thought it was incredibly poorly written, and had obviously not been fact checked by a practitioner. I never received a reply.

I ignored the second invite, and began to read about other bloggers being offered a similar link exchange deal with the same form letter.

I received a third email from him today. Just for fun, I decided to check out the site, to see if there was any improvement in the quality of information.

Here is the information that is available for “39 weeks gestation” as physical signs before labor starts:
* You will lose the mucus plug sometime before the labor sets in.
* The water will break down.
* Before you feel the contractions, you will observe some brown-red colored discharge from your vagina.

“The water will break down”? What does that even mean? If it means the water will break, not break down, that happens only in 20% of women before the onset of labor. As for the water breaking “down”, that sounds to me like it is losing quality or falling apart before the baby is even full term at 40 weeks, which is entirely inaccurate.

Even worse, at the bottom of the entry, it reads:

“Do you know about the procedure named as episiotomy? Basically, this is the method in which an incision is made between your vagina and anus. Most of the practitioners claim that the procedure helps to avoid severe splitting when the baby comes into the world.”

Me: head exploding. Them: no citations or academic sources for the article.

I am providing some references here, in case anyone wants to read why episiotomy will NOT help to “avoid severe splitting”, but is actually the leading risk factor for “severe splitting”, if that includes third and fourth degree tears.

(1) ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006. Obstet Gynecol 2006 April;107(4):957-62.
(2) Althabe F, Buekens P, Bergel E et al. A behavioral intervention to improve obstetrical care. N Engl J Med 2008 May 1;358(18):1929-40.
(3) Berghella V, Baxter JK, Chauhan SP. Evidence-based labor and delivery management. Am J Obstet Gynecol 2008 November;199(5):445-54.
(4) Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev 2009;(1):CD000081.
(5) Costa ML, Cecatti JG, Milanez HM, Souza JP, Gulmezoglu M. Audit and feedback: effects on professional obstetrical practice and healthcare outcomes in a university hospital. Acta Obstet Gynecol Scand 2009;88(7):793-800.
(6) Drew NC, Salmon P, Webb L. Mothers’, midwives’ and obstetricians’ views on the features of obstetric care which influence satisfaction with childbirth. Br J Obstet Gynaecol 1989 September;96(9):1084-8.
(7) Goer H, Sagady LM, Romano A. Step 6: Does Not Routinely Employ Practices, Procedures Unsupported by Scientific Evidence: The Coalition for Improving Maternity Services. J Perinat Educ 2007;16(Suppl 1):32S-64S.
(8) Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J, Jr., Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA 2005 May 4;293(17):2141-8.
(9) Helewa ME. Episiotomy and severe perineal trauma. Of science and fiction. CMAJ 1997 March 15;156(6):811-3.
(10) Klein MC. Studying episiotomy: when beliefs conflict with science. J Fam Pract 1995 November;41(5):483-8.
(11) Klein MC, Kaczorowski J, Robbins JM, Gauthier RJ, Jorgensen SH, Joshi AK. Physicians’ beliefs and behaviour during a randomized controlled trial of episiotomy: consequences for women in their care. CMAJ 1995 September 15;153(6):769-79.
(12) Lothian JA, Amis D, Crenshaw J. Care Practice #4: No Routine Interventions. J Perinat Educ 2007;16(3):29-34.
(13) Low LK, Seng JS, Murtland TL, Oakley D. Clinician-specific episiotomy rates: impact on perineal outcomes. J Midwifery Womens Health 2000 March;45(2):87-93.

Needless to say, I will not be adding this site to my blogroll, and I hope they don’t add me to theirs. I hope than any other birthy blogger who receives invites from The Pregnancy Zone, or any other site for that matter, actually goes and looks at the quality of the information on the site before deciding to add them to the blogroll.

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I get mail!

I got two emails on the same day, asking me for advice! I feel like mighty Isis. I’m not going to start call you “my little muffins”, but I am going to answer them on the blog, like she does.

Since the letters are so similar, I am going to answer them both together.

Letter writer #1 writes:

I’m just curious what made you decide to move from an education in midwifery to medical school. I’m at a bit of a crossroads. I’m about to finish my MPH and had been planning on applying to medical school this summer. I already have the MCAT and all prerequisites under my belt. However, I recently became really interested maternity care and midwifery. Now I’m confused about whether I should pursue an education in midwifery or go into medicine as an OB and support natural birth practices and midwives.

Letter writer #2 writes

I am currently a doula and CBE and the more I get involved with birthwork, the more I see that overall we need way more options out there for respectful, compassionate, Care Providers who practice evidence based medicine.

So naturally I thought, OK go be a midwife. … There’s a great program in Chicago for those of us with generic Bachelor’s degrees to jump right in get the RN and then do a master´s in midwifery in 2-3 years after that. So with another year of pre-reqs at a community college, it will take me 6 more years (at least) to finish.

Now we are moving to Oregon which opens up the CPM route if I wanted (just means I can’t move back to IL and practice legally if that’s what I choose)….

I see how regulated and pushed around midwives are here in IL. There are only about 5 in the Chicago area who will do home births and even then b/c they work all over the Chicago area it’s difficult for the to build up a rapport with the staff at the hospitals b/c there are so many and a necessary transport can be difficult which puts moms and babies at risk.

So then I was thinking about medical school to go the OB or the GP who also delivers babies route. But then that means at least 2 more years of pre- reqs before I can even apply for medical school. And then med school plus residency. (And I haven’t even mentioned the loans I’d have to take out).

One other option my aunt threw out there was a Physician’s assistant. I have never heard of them delivering babies, but she seemed to think that might be a possibility…I know this has been a huge ramble, and I guess I’m writing b/c I’d like to get some slightly objective input. What factors influenced you to dive all-in to med school instead of midwifery? What kind of practice do you think you’d like to be part of?

Ha, well, I don’t know if I am a good example when it comes to planning a career in medicine. Not unless you want to be the non-traditional student everyone else seems to think they are. (Not that there aren’t other non-trads, but most students seem to think they are non-trads even when many of them seem really trad to me).

I didn’t choose to train as a midwife. It is one of the best things I ever did, but it kind of happened to me. I had my first son with a CNM at a hospital. I was not a birth activist at the time. I was the first of my friends to become pregnant. It wasn’t a particularly great birth, and it certainly didn’t make me want to be a midwife.

I was interested in natural medicine originally, after helping diabetics in the health food store where I worked right after art school. I originally considered going to Bastyr University to its naturopathic physician program, but, much like the CPM dilemma mentioned in letter #2, an NP can only get licensed in a dozen states, which is even less than a CPM/LM. Considering how tenuous that seemed, I decided going for a conventional medical degree would be more safe, and then I would be able to practice as holistically as I chose, while also able to be the primary care physician, regardless of where I ended up living.

I had both of my children during my pre-medical journey. I had to take a significant amount of prerequisites, and I only went to school part time. If I had it to do over again, I would have taken more classes and taken out loans. I was five months pregnant with my second son when I interviewed for medical school for the first time. I had no clinical experience, and talked about using natural supplements for diabetes in my interview. I also was wearing a much more casual suit than the other applicants, and stood out like a sore thumb in many regards. I didn’t get a spot.

I was devastated. For my pregnancy, I was seeing a direct entry midwife practice (in Florida, they are licensed as LMs, in other states, they are often licensed as CPMs) associated with a freestanding birth center and midwifery education program. I loved the atmosphere and the women-centered medical practice there. I was also adrift, not sure if I could or should reapply to medical school with an infant. I had planned on having two potty trained children by this point in my training, but a miscarriage, divorce, and remarriage postponed that a bit. I remember asking the director of the program if she would hire me as a physician’s assistant. She asked me why I wouldn’t just apply to the midwifery program.

I laughed and told her no. Honestly, and this will probably sound funny coming from people who know me now, I thought “Vagina and screaming all the time – who needs that??” Then, I went home, and reconsidered. Becoming a PA would leave my scope of practice very limited. Becoming a ARNP (or CNM) would take almost as many years as medical school, and I would have to be a disrespected and overworked nurse first. Becoming an LM would take 3 yrs, and the director told me I could bring my baby until he was crawling. I signed up for the midwifery program.

Studying to be a direct entry midwife was one of the best and most trying experiences of my life. I can’t and won’t go into all the details. I was attended more than 50 births, five of which were my own catches. Many of these were VBACs. I finished two of the three years of classes. I was trained and worked as a doula and as a lactation consultant. I loved the holistic atmosphere, the (usually) woman-centered care, the wonderful patients, the normalization and success of breastfeeding. I did not love cleaning the toilets and floors, doing “hell week”, or witnessing the ethical issues when it came to the gray areas of what was safe care within the legal limits of midwifery practice. I also wanted to be an abortion provider, which would not be legal under a direct entry midwifery license.

Amy Romano does a good job of describing what the legal and collaborative climate can be like for midwives. I replied on her post (and here), and described what it was like to be at a legally scrutinized birth center with problems getting doctor back up. One night, the director faced having five years of her records pulled, including all of her active clients, because of a compassionate delivery of a known intrauterine fetal demise (IUFD) because it was, technically, out of her scope of practice, based on the letter of the law. I know how hard it was for her and every midwife and student to stare at those 700 charts and wonder how many other technicalities could be found in them. I left that night knowing I couldn’t continue at the center, risk it being closed down, risk being implicated in any findings, and face being a marginalized and severely limited practitioner.

I had already been thinking about returning to medical school. The midwives and students had remarked how I seemed like I should be a physician and not a midwife, mostly due to my love of clinical research and academic journals, and my cynicism towards some of the more “woo” aspects of the midwifery community. I didn’t want to have to transfer every stalled labor. I didn’t want to have to have a physician back up my practice. I didn’t want to find out that a patient that I referred to a physician because she was risked out of my practice for something minor had been pressured into a non-medically indicated induction, episiotomy, or cesarean. I wanted to be able to deliver twins, and breech babies. I wanted to be able to practice like the physicians I observed in the hospitals and in the community – they seemed to have a wide level of autonomy, authority, respect, and freedom of practice.

I was afraid, and still joke about having a “midwife crisis” and “crossing over to the dark side.” It is hard not to adopt the paradigm of the system in which you are completely immersed. I am desperately searching out progressive residency sites. I am terrified of being stuck at a program in which I am ostracized or constantly in confrontations about standards of care and evidence based practices. I have to bite my tongue when interacting with some members of the medical establishment. But, I had to do that with some midwives. I adore some members of the medical establishment, and adore some midwives, too. I hope I can go to or even attend a homebirth every once in a while, but I can survive with just backing up midwives and working with midwives. There are physicians who attend homebirths. I have never heard of a PA delivering a baby, but I am not an expert.

Anyway, I ended up having to take the MCAT again. It had been 2 years and 3 months since I had taken it, and one of the schools, the closest one I applied to and the one I am now attending, wanted a score within two years (I have since heard of people getting around this, but I wasn’t able to, even though my score was more than decent for the program’s admission standards). Medical school has been challenging but doable. It has been far more enjoyable and varied than I thought it would be. I am only half way through, and would be a practicing midwife by now if I stuck with the midwifery program. A midwife who graduated after I would have has moved and opened a birthing center. I will not be practicing on my own, out of residency, for at least another six years.

I hope I would have made a damn good endocrinologist, or a damn good midwife. But, I have to say, despite how much of a runaround my training has been so far, I love having the direct entry midwifery experience and doula experience and think it is a definite advantage to me in medical school. I have had more than one physician look over his glasses at me and say “Aren’t you the one who was a doula?”, with a not exactly favorable expression, but for the most part, my knowledge and comfort with the subject, and experience with patient contact and basic skills has been nothing but a boon to my training.

Well, this post is about as long as it can be. I hope this helps! Please keep me up to date, letter writers!

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So that’s what the IRB is for

I spent most of today editing and tweaking three institutional review board (IRB) new project applications today. If you are not familiar with the loveliness that is the IRB process, it is a bureaucratic pile of red tape and paperwork that you have to navigate through in order to do research at an institution.

I decided to break away from my computer and help S, my eleven year old, with his science fair project. He is going to a science magnet program next year, and supposedly loves science. But, I was disappointed with his proposal – something about stretching chewing gum after chewing it – and came up with a physiology project idea for him. I suggested that he get some friends together, take their resting heart rates, then compare it to their heart rates after various different activities. He and his friends had fun learning how to take their pulses, and then walking three mailboxes down and back, taking it again, then running three mailboxes down and back, then taking it again. We decided to do a bike ride, too.

I am usually really strict about bikes. I don’t let the kids in the neighborhood jump on each others’ bikes, and am a stickler for helmets. But, it didn’t even cross my mind. I thought briefly how maybe I should get permission from their parents, but these kids play football in the street and climb trees every day. I thought running and riding a bike back and forth a few hundred feet, activities they do every afternoon, wouldn’t be a big deal.

Until one of the kids wiped out on the bike, and banged his head on the pavement pretty hard. I ran inside, told my husband to call 911, and called his mom right away.

Well, I went with them to the hospital. The CT scan was negative, but he has a pretty nasty knot on his head. And, he has a broken wrist. Argh. I feel terrible.

I think I’m sticking with surveys.

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