Monthly Archives: March 2011

When the doctor is sick

Well, I’m not the doctor yet. I’m a mere medical student. I got hit pretty hard with a GI bug my younger son brought home from school. I never get sick. I mean it. I am one of those parents who didn’t get every little bug my kids brought home. Well, the kids rarely get sick, too. I made it through my entire pediatrics outpatient rotation without catching one upper respiratory infection.

But, when my 6 year old woke up barfing profusely into his bed, I hugged him, rubbed his back, and changed his sheets without scrubbing my hands immediately after. OK, it was the middle of the night. Half of his class was out the next day. I am guessing this is the Norwalk virus. Two evenings later, I was throwing up in a friend’s bathroom. One of the few social events I have attended all month, and I threw up and had to leave. Nice! Classy!

I had to miss my ob/gyn shelf exam. I am being allowed to make it up and can still (hopefully) try to pass with honors. Sigh. I am a dork and hate missing anything. But, it was not going to happen.

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Catching Babies Blog Series: Refusal, Rights and Balance

This is an entry in the Catching Babies Blog Series, a conversation with medical economist and author J.D. Kleinke about his new novel, which focuses on ob/gyn residents at the end of residency and the beginning of private practice.

Hilary: Hi J.D.,

I am a medical student who is currently on her obstetrics and gynecology (ob/gyn) rotation. I hope to be an ob/gyn resident in just over a year, and after that, a private practitioner, hopefully in an academic practice.

When I first heard about your book, I thought it would be more like Peggy Vincent’s Baby Catcher: Chronicles of a Modern Midwife than Grey’s Anatomy. But, as I read it, I was reminded of life in the call room, listening to the residents at my core rotation site talking about their engagements, their breakups, their exercise routines and their more difficult patients, in that order.

I was enthralled and moved by the dramatic medical and ethical issues in the beginning of the book: a resident so tired he is hallucinating, a vaginal birth after cesarean (VBAC ) patient with a ruptured uterus bleeding out in a snowstorm, and a twin to twin transfusion vaginal delivery with head entrapment. At first I thought, well, these are all extremes. But, the easy births don’t make good literature. And, the easy births don’t form residents’ practice patterns for years to come.

When I was doing my research on labor and delivery interventions, I asked an obstetrician in his late 60’s about VBAC. He said he saw a traumatic uterine rupture during his residency, and he would never let that happen to one of his patients. This same physician said he thought breech deliveries were fine, as long as they met certain conditions. He had never had a case of head entrapment, obviously, so his attitude and practice patterns reflected this.

How do you feel, as a medical economist and as a patient, about physicians practicing based on clinical experience and attitude as opposed to evidence? As much as I try to base my attitudes toward my future clinical decision making on evidence, I have a constant barrage from everyone around me, telling me I will only have one license and thousands of births, that obstetricians have to be “right” all of the time, that I need to protect my lifestyle as much as I need to advocate for my patients, and evidence is flawed, anyway.

This doesn’t even take into consideration the emotional and physical strain the particular practitioner is experiencing on that particular day. If a physician is practicing late on a Friday night, after not eating since breakfast, has already had two gynecological procedures go badly that day, hasn’t seen his family and has a chance to make it home just before bedtime, and will have to pay his weekend coverage physician for any births that he leaves behind, how does that factor into his decision making toward the women he has admitted in labor, if at all? We do hold physicians to much higher standards. We are not supposed to make any mistakes, ever, at all, and we are not supposed to let hunger, sadness, exhaustion, or pain affect our skills and our judgment. But they do. How can we balance this?

I am happy that there are new work hour rules in effect as of July of this year. (Link to new rules) Residents can still work 24 hours straight, and can still work up to 80 hours in one week. But, there are more limits on unsupervised practice and excessive work loads on first year residents. Catching Babies focused on graduating residents, who are presumably ready to practice on their own. Some people, mostly older physicians who walked uphill both ways during their residencies, criticize limits on resident work hours as limiting continuity of care and preventing residents from being trained adequately for private practice. As someone who once worked more than 100 hours in a so-called “Hell Week” at my midwifery training, I can tell you that you don’t learn very well once you are hallucinating, and your patients don’t have good continuity of care at that point, either.

I would also like to touch on the part of the book that dealt with anti-abortion protestors. I am glad you chose a religious resident who was struggling with his perspective on abortion as the victim of this violence. The real abortion debate is not black and white. It is very, very gray. As a co-president of our local Medical Students for Choice chapter, I found that most medical students who had qualms about performing abortions due to their religion were not in support of making all abortion illegal, and did not think all future practitioners should not be trained on how to do an abortion. I had many good discussions with them on what it means to be pro-choice, and how practitioners can separate their own values and choices from what they recommend or even force on their patients.

We had a Maternal Fetal Medicine specialist talk to our chapter of the obstetrics and gynecology interest group once. She was Catholic and self identified as “pro-life”. She said she was put in the position of having a mom almost die on her as an attending physician because she had refused to be trained on how to treat a ruptured ectopic pregnancy, which inevitably involves removing the embryo. She told us that she will never be in that position again, and neither should we.

It was very important in Catching Babies for Dan, despite his religious beliefs, to be well trained in second trimester abortion. He paid for it dearly. It’s easy for a fervent protestor to be behind a sign or a brick, and easy for me to walk past their bullhorns and pictures of gruesome products of conception blown up to billboard size with a glare when I attend the American College of Obstetrician and Gynecology Annual Clinical Meeting, but I am not sure how I will feel when I am on my Family Planning rotation when I, like Dan, have to face those very real, very tiny body parts in the stainless steel bowl. Or how I will feel if a brick comes through my window or my family is threatened when I am an abortion provider. I do know that I will never face a teenager who has been date raped, like I was in high school, and tell her that there is nothing I can do. And I will never let a woman die from an ectopic pregnancy because of a philosophical argument.

Anyway, I guess I am commenting on the amorphous line where the private life of the practitioner ends and the needs and rights of the patient begins. I think work hour rules, oversight, some sort of protection against frivolous lawsuits and consideration of the physician as a human being is important. But I also think the autonomy and informed consent of the patient, along with the practice of evidence based medicine, is just as important. I am wondering how you think this interplay can be balanced.

J.D. Kleinke: Thanks for your comments, Hilary.

These are great observations and important questions. If I am teasing out your questions properly, I’ll respond as follows.

The recent movement across all medical residency programs toward reduced work hours is decades overdue. There is no clinical rationale for the brutality, on providers or patients, of any OB/GYN shift lasting longer than 12, let alone 16, 18 or 20 hours. 24 hours is a reform? You want someone cutting past YOUR uterine artery in hour 23? Into a uterus holding your baby? Around your bladder or clitoris? I wouldn’t want them cutting my bagel at that point, for fear of what they could do to themselves with the knife, let alone me. The OB/GYN residency, like most residency programs, is hazing, plain and simple, more frat house than boot camp – because boot camp is actually a workplace-relevant culling – and it is incredibly dangerous. It is also an incomprehensibly stupid way to compensate for the dysfunctional economics of federal residency funding, academic medicine generally, and our operation of a major part of the safety net we have woven over the years to care for the poor and uninsured and lost. As a gruesome physical, psychological and emotional endurance race, OB/GYN residency selects for and rewards physicians based less on sheer clinical skill and commitment, but on irrelevant criteria like stamina and the ability to think without sleep. It probably weeds out, before match or during residency, God knows how many gifted physicians who do not have these characteristics, or do not want to endure their mobilization. Not only does this bizarre gauntlet-based acculturation process NOT yield for society the best of all possible OB/GYN workforce – it probably yields a subset of people with a special capacity for detachment, indifference, masochism, self-denial, and/or dissociation. Is this who we want to deliver our babies? Is this who we want making emotionally gut-wrenching decisions about medically indicated termination, oopherectomy, hysterectomy? People chronically overstimulated from adrenaline, exhaustion and stress? When they themselves are so compromised, they have lost all sense of wonder, joy, and pathos? Let’s speak plainly: sleep deprivation is a method of torture. And it’s a great one for a secretive regime, because it leaves no visible marks. But prolonged sleep deprivation is how you break people, get them to compromise their most deeply held beliefs, sell out their own friends and families. Is this really how we want to acculturate those attending our childbirths?

Medical evidence and clinical experience are equally valid and equally important. This is not an either/or question, though the loudest voices on both sides of this debate make it sound like it is. All medical fields need more and better data, data-driven protocols, richer informatics at the point of care, and real feedback loops. But we also need human beings at the helm. And we need human beings – both OBs and midwives – who are willing to answer AND follow through on the toughest, most frequent, most important question that patients ask: if this were you, or if this were your wife, what would YOU do? As with that VBAC-averse veteran OB, when one provider’s negative experience with a difficult case diverges with the best known evidence on that case, they have a profound ethical responsibility to turf the case to somebody, anybody. Because no human being can be expected to repress their own terror about a clinical pathway that, even though they know the numbers and the evidence in support of that pathway, they can no longer go down it for their patient. That’s their right as a provider, and as a patient, I’d much rather be warned about it and turfed. And if that weren’t possible, and the potential divergence in outcomes were not that great, I might also prefer the less evidence-backed approach, if my provider were completely comfortable with that pathway and terrified of the evidence-backed pathway. This is the damnable reality of evidence – it works for the study group, but study groups are made up of thousands of little clinical realities, each of which are multi-factorial and, at rock bottom, ultimately human, not machine. Medical evidence is like snow, and every patient is a snowflake.

Much of the clinical practice of abortion is indeed gray, despite deeply held beliefs in this country that abortion is a black-and-white issue. This is why the book takes the abortion problem head-on, as it rears it hydra-headed self in residency, no matter what the protesters out in front of the clinic want to believe. The clinical case I chose in Catching Babies runs right down the middle of the line, for both the devoutly Catholic OB and the desperately ill teenager he is trying to help. All OB/GYNs, no matter how deeply held their views against abortion, run up against these ugly, clinically ambiguous realities in their training, and they have to decide, often with heartbreaking angst, how they are going to navigate them. Ectopic pregnancies do rupture, women do miscarry and need D&Cs, fetuses do develop fatal in utero anomalies in the middle of the pregnancy that will erupt and kill the woman if they are not terminated. These are the gruesome facts of nature, no matter how many laws we pass, providers we harrass, or patients we terrorize outside clinics. All OB/GYNs need to be trained adequately to deal with these clinical situations. And with equal force, I’ll say that all OB/GYNs need to have complete freedom to decide for themselves what they are willing to do, and under what circumstances. Most importantly, they need to be honest with themselves and their patients. Finally, all women and their families need to understand that their OB/GYNs are also human beings, people with hopes, dreams, frustrations, beliefs, fears and political agendas, who are bringing their own souls into every exam room, labor deck, and OR. This is probably the key impulse for my writing the book. I wanted people to understand how the culture of the OB/GYN is formed, informed, mal-formed, and where it can and should be re-formed.

*******

Other posts in the Catching Babies Blog Series:

Consider the Source: A new voice for maternity care reform
Tolerating Risk in the U.S. Maternity Care System
Catching Babies Blog Series: Fear, Faith and Perverse Incentives

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Halfway through obstetrics!

I am pretty much halfway through my obstetrics and gynecology rotation. I am loving it! I especially like clinic. I love talking to women about pregnancy, birth, reproduction, their bodies, and sex. I can’t believe I still have to do rotations in other specialties. I want to do only ob/gyn from now on.

Even though I am loving it, sometimes it’s still really frustrating. There was a patient who came in for an initial prenatal visit who had a shocking obstetrics history – several miscarriages, many more than the three required to be considered a “habitual aborter”, and one live birth. She is in her second trimester now.

What was even more frustrating to me is that she seemed to have no clue about her past work ups or treatment during this pregnancy. She has been treated by another practice, including a perinatologist whose name she couldn’t quite remember. She doesn’t know if she has been given any medicine to help her carry this pregnancy. She doesn’t know the names of the medicines she was given when she was hospitalized during her only successful pregnancy. Oh, and she had an unexplained heart attack last year that got her admitted to the hospital. She seemed most concerned with whether the doctor could give her a tummy tuck with her cesarean, and was proud that she had been so sick this pregnancy that she hadn’t gained any weight.

Sigh.

I strongly suspected, with that history, that she may be abusing cocaine. I treated her with respect, and tried to glean as much information from her as I could. I did ask her if she used cocaine, and explained it is linked to heart attacks in young adults and pregnancy losses. She denied it. Or, she could have a clotting disorder, or one of many other issues. I asked her if she had ever had a work up to see why she had such trouble maintaining a pregnancy, especially to see if she had a clotting disorder. A factor V Leiden disorder could cause repeated losses and heart attack. She wasn’t sure.

Speaking of which, according to my blog dashboard, someone found my blog by using this search string:

“does a fetus withdrawl in the whom”

Sigh.

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Catching Babies and Match Day

Go check out Jill’s post Catching Babies Blog Series: Fear, Faith and Perverse Incentives at the Unnecesarean.

To all of my former classmates who are finding out where they match for residency tomorrow, and all of their medical school cohorts in the same boat: may the luck of the Irish be with them.

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Catching Babies Blog Series

I am participating in a blog series on Catching Babies, a novel about obstetrics and gynecology training by health economist J.D. Kleinke. As a medical student on her obstetrics and gynecology rotation who is (hopefully!) staring down an obstetrics and gynecology residency soon, it really resonated with me.

Amy Romano kicked it off with an interview with the author on Science and Sensibility, and Kristen Oganowski followed up with a great back and forth with him on Birthing Beautiful Ideas.

Stay tuned for more great posts!

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Reply turned post, yes, I’m worried

I haven’t done a reply turned post in a while. I used to do them quite often, but my blog reader is currently burgeoning at over 1000 unread posts, and I don’t have time to read, much less post, on other sites, as evidenced by my lack of writing on my own blog. But, sometimes I get moved.

Juliaink wrote a wonderful post on Mothers in Medicine called “Anybody Worried?”, in which she says:

Choice about childbearing comes in many forms. In my own case, it was because I came through training at a time when professional women had trouble finding men who valued us–or maybe it was my evil temper. In any case, I married quite late and had my last child at age 39. This is not necessarily the path I recommend, but I do think that if we support women’s professional aspirations, we should be committed to the proposition that all women should have access to reproductive health services. If Congress prevails, many women who might otherwise make up the next generations of mothers in medicine are going to be instead mothers who lack education, income and the privilege of being able to care for others as well as their own children, in the ways we all do.

I was upset but not surprised by the comments that referred to termination of pregnancy as choosing to “end the life of a child”, and said “A child is a blessing and a privilege from the moment of conception. If you had a problem keeping your legs closed or your birth control method actually failed, it is not the child’s fault or problem – it is yours.”

Sigh.

Here are my two replies:

Reply #1, in response to “Kelley”, a mother and an aspiring physician, who kept an unplanned pregnancy and thinks an abortion is choosing to “end the life of a child” for convenience:

I object to calling terminating a pregnancy ending the life of a child. Neither my first trimester abortion nor my miscarriage was killing a living child, and I am not a murderer. 1/3 of women in this country have an abortion at some point in their reproductive years, and we really should watch the tone of our rhetoric. Calling 30% of women murderers is pretty harsh, and out of step with most of America’s attitudes toward abortion and miscarriage.

One of the leading causes of maternal death in the world is complications following illegal abortion. Most of these women were already mothers, and leave behind real living, breathing orphans who are four times more likely to die once their moms are dead. In these countries, where making abortion goes hand in hand with reducing access to contraception, just like it does here, abortion rates actually increase.

I am not sure what these other options are other than Planned Parenthood, especially with the same politicians trying to cut Title X funding for contraception in general, and wanting to cut social programs to pay for these children once they’re really alive. If we are talking about Crisis Pregnancy Centers, most do not provide any health care and are not run with any licensed health care workers. Only 2% of Planned Parenthood’s services involve termination of pregnancy, and they serve poor communities where unplanned pregnancies and STDs are more prevalent.

It’s all fine and dandy to sit in a privileged seat and call yourself pro-life, but there’s rhetoric and then there’s reality. Cutting funding to Planned Parenthood will increase unplanned pregnancy and abortion, and possibly maternal and child death in the long run.

Reply #2, in response to Ernest, who earnestly believes us sluts just have “a problem keeping our legs closed”, and it’s not the child’s fault, it’s ours. How surprising that Ernest, who is presumably male if I can make assumption based on his moniker, makes no mention of the man who pried those legs open as sharing in the blame responsibility. He thinks a “child” is a “blessing and a privilege” from the moment of conception, but doesn’t think any of these comments actually count as getting into a heated debate. Oh, and anyone who gets an abortion is a murderer. Period. But, he’s not getting into the debate or anything.

Saying a child is a blessing and a privilege from the moment of conception ignores the reality of the 50% of pregnancies in this country that are unplanned, the 30% of women who choose termination at some point, and the 50% or more of pregnancies (some say up to 80%) that spontaneously abort in the first trimester.

Villfying women who choose abortion as not being able to keep their legs together and only choosing abortion as a convenience is speaking from a very privileged viewpoint. The man who date raped me in high school did not give me the option of using birth control as I cried and said no to him. I have been in an abusive relationship, and it was hard enough to leave with the one child we had together that I decided to keep when I got pregnant, unplanned, while using contraception. If I got pregnant again, I might be still living with him with a new “blessing”, if I was forced to keep the baby. And before any lovely judgmental people say I shouldn’t have had sex with an abuser in the first place, most abusers don’t start abusing until their partner gets pregnant, and that is what happened with me. He seemed like a fine, upstanding member of society before that point.

Thank goodness I found a midwife who was willing to put in an IUD after the baby, after I was denied one by a physician because I was divorced when I first started the relationship with the abuser. (No I’m not kidding. This is why we need Planned Parenthood, and we need to step back from judging women for not having effective birth contol). Being judgmental has NO PLACE in medicine, especially not in reproductive issues.

Anyone who mistakenly thinks an embryo is a living child can personally choose to keep any unplanned pregnancy. But your rights end where mine begin. The only alternative is forced pregnancy. I believe children are far too sacred, important blessings to be forced on a woman because her rights were taken away by someone who will never, ever have to raise them and will probably vote for politicians who will defund health care and social services for them.

As others have said, I think bombing civilians is murder. I think capital punishment is murder. No one can argue that the victims of these acts are not living, breathing human beings instead of one inch long bundles of cells completely dependent on another human being who has to risk her life for them for the better part of a year. Save the philosophical conversations for church and around the dinner table. Otherwise, you be the physician in Nicaragua who has to stand there while a woman dies with a ruptured ectopic pregnancy, and tell her surviving orphaned children that well, technically, that embryo’s “life” was worth more than the convenience of them having a mother, and she should have just kept her legs together if she didn’t want to take that risk.

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A day in the life of a single mom med student

I have been really busy on my ob/gyn rotation. Loving it at times, cringing at it at times, and spending almost every waking minute either there or stuck in traffic trying to get there.

Sorry about the lack of posting here. I put up a post on Mothers in Medicine about a day in my life as a single mother and medical student on her obstetrics rotation.

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Happy birthday to meeeeeeee

Happy birthday to meeee
Happy birthday to meeee
I am going to be in the Vagina Monologues tonight, I settled my divorce case, and I am on ob/gyn this month
Happy birthday to meeee!

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The March of the Vaginas

This month is an exciting month. I am starting my obstetrics and gynecology rotation today. I am performing in the Vagina Monologues on Saturday, which is also my birthday. I will be participating in a blogging book club of Catching Babies, about which I will provide more links and info soon.

I sense a theme.

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