Monthly Archives: April 2010

“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 masterĀ“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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Fantasizing about residency sites

I have been doing more research on residency sites. I have been searching the far corners of the intertubes, from sites as divergent as the dreaded SDN to the dreaded MDC, with a little help from FREIDA and APGO.

I have three top sites identified right now. One is an old favorite, one is an old favorite that fell out of favor, but further research has given it a renewed shine. And, a new up and coming favorite.

The old stalwart: OHSU in Portland, OR.

The old favorite that is back in favor: MAHEC in Asheville, NC.

And, my new love: St. Luke’s / Roosevelt in New York City.

New York City. Ulp!

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Reply turned post, Mothers in Medicine specialty style

There is a new post up at Mothers in Medicine. It’s a letter from the mailbag, from an ambitious high school junior named Taj, who knows that zie wants to go to medical school, and will be starting an accelerated BS/MD program soon.

Taj writes:

I am really interested in anesthesiology and cardiology so my question is really for MommyDoctor and JC. I wanted to know how and when did you ladies juggle and decide when to have kids and also what do you both love about your careers?

Taj goes on to say that zie is also interested in ob/gyn and thoracic surgery. I was surprised to see such a wide range of specialties that I see as really, really different from each other.

I wrote a reply that I wanted to reproduce here, since it’s about how I ended up where I am. But, please go check out the original post, especially to see if the contributors that Taj asked talk about their choices and paths, too.

Here is my reply:

I know I wasn’t specifically addressed, but I just wanted to jump in and say something. Hope that’s OK.

I have a different perspective than the contributors you asked, and I hope they weigh in from the point of view as someone who is living with their career choices. I am sure they all have really good things to say about the specialties you are interested in. I am halfway there, and you sparked some thoughts.

Congrats on knowing that you want to do something in the medical field, and good for you for planning and thinking in advance. I am a big advocate for dreaming and planning ahead, because the shlep to the light at the end of the tunnel in medicine is a long one.

I noticed that the three areas you are interested in are quite different types of medicine. Anesthesiology is a completely different life, not just lifestyle, than ob/gyn, with a completely different type of interaction with patients (asleep vs. awake, acute vs. long term).

A thoracic surgeon (9 years of training, general surgery (6)–>thoracic surgery (3) ) is much different that going into internal medicine (3 years) then a cardiology fellowship (another 2 t0 3).

I think you will see which specialty and training requirements suits your temperament and interests the best. I was convinced during my premed that I wanted to be an endocrinologist. But, after spending just a little bit of time with pregnant women, I was sold on ob/gyn and have never looked back. That was after swearing I would never be interested in ob/gyn. But, I haven’t done my clinical rotations yet.

I think I could never do anesthesiology, because I love patient interaction and continuity of care (and, frankly, I wouldn’t have the grades to go gas if I wanted to). I couldn’t do orthopedics because it seems like bicycle repair to me, and I would be miserable. I couldn’t do pediatrics, because I would cry all the time. I can barely make it through a lecture about a sick toddler without tearing up.

I am thrilled there are people who are attracted to these other specialties, and hope they love their careers. I would hate for anyone who is ill-suited for ob/gyn to end up there, also. It is a unique area in which you interact with people who are on a wide spectrum of well to sick in a lot of important and highly emotional times in their lives. It is a great balance between surgery and medicine.

I tell people to sign up for email table of contents of the main journals in each field, and glance over them once a month. If the titles excite you, and you want to click through and read the abstracts of at least a few of the articles, then that may be a good field for you. If all else fails, you can try out Fizzy’s handy guide to choosing a specialty.

Good luck!

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Hellooooooooo?

I am in a childless house. S is with his dad, and Z is spending the night at a friend’s.

I am not sure what to do with myself! Should I read? I have quite a few books to read, including Pollan’s In Defense of Food and Atwood’s The Flood. I could read some of the 1572 posts in my Bloglines Reader. I could do some yoga. I could cook.

I think I am going to put on this podcast on “Listening Generously” that was recommended to me by a friend. I may listen to it in bed. And if I fall asleep, so be it.

I live in the fast lane.

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Things to read

I have a new post up at Mothers in Medicine, my first official post as a contributor, not a guest. Exciting! Please check it out.

There is also some interesting discussion going on in the comments of this post about breastfeeding and shame. I am not as involved in discussions online about breastfeeding as I was when I was breastfeeding. It is still a difficult topic, and I only want to delve into it occasionally, for reasons that are pretty obvious in the comments.

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