Hey, good lookin’

Howdy. I’ve been busy doing residency stuff, family stuff, house stuff. I passed my Step 3 boards (woo hoo!) so now I just need to scrape enough money together to get licensed.

Anyway, I posted about Thanksgiving on my mostly dormant food blog, Almost Healthy, if you’re so inclined.

Here’s a taste (see what I did there!)

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I love this time of year. I cook. A lot. Not all of it is holiday themed. My garden is going, and I try to get time off with my family. It’s been relaxed and good.

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Reply turned post, I reject your reality! style

OK for Mythbusters, not for health advocacy

I have been participating in the Facebook group VBAC Facts Community for a little while now, ever since meeting the wonderful community founder Jen Kamel at the VBAC Summit last year. It is a supportive group, and Jen runs the site well with the help of moderators and a good foundation of evidence.

This group, at times, can be a good example at how distorted internet microcosms can make uncommon opinions seem much more accepted. In this community, using midwives and having a home birth comes up in almost every thread, it seems. I have seen using a midwife treated like a hipster fashion choice recently on Jezebel and other sites. However, midwife attended births still make up less than 10% of births in the United States. Hardly a huge trend. Midwives are underutilized here compared to many other countries with better maternity and neonatal outcomes than we have. But, depending on your source, midwife attended and/or out of hospital births may seem to be common or even a glorified standard. However, in the circles I travel in my daily grind as a physician, choosing out of hospital birth is fringe, reckless behavior.

So, it’s like entering a portal in another world when I participate on a thread in the VBAC group, and the commenters have a heated argument about epidurals, and many participants did not get one. On our labor and delivery floor, it is a rare to never occurrence that someone wouldn’t get one. Because out of hospital birth, choosing not to have an epidural even if you deliver in a hospital, and VBAC are such rarely available, rarely supported choices, I am usually on the side of defending people who advocate for such choices as underdogs, not the holier than thou bullies that many paint them to be.

It’s also a really strange place for me to be in when I gently try to correct medical inaccuracies, and I sometimes get painted as a brainwashed surgico-technocrat physician. I correct fellow physicians when they say all VBAC is dangerous. For real, even my attending physicians. I also have corrected fellow physicians who state episiotomies are preferable to tearing. But, I also correct women in the VBAC group who state things that are medically inaccurate, like that worsening hypertension in pregnancy is not serious and does not warrant an induction or cesarean unless the fetus is in distress, or that leaving the hospital midlabor is a reasonable course of action if one is faced with unwanted interventions (in one particular thread in which I was painted as a typical brainwashed South Florida cesarean happy physician, the intervention that warranted attempting to leave midlabor was continuous external monitoring).

These are not the majority opinions even in this microcosm. But, they are often aggressively defended positions. One that has come up repeatedly, recently, is an insistence that tubal ligation is linked to “post tubal ligation syndrome”, which leads, according to some posters, to the majority of women needing hormonal interventions to control heavy menstrual bleeding, and / or hysterectomy to control intractable post procedure pain.

I think these communities are incredibly valuable, not just because of the sharing of strictly evidence based facts. I think a lot, even the majority of the benefit is the support and stories from other women who have experienced similar choices and situations, or share similar priorities and stories. I think in the VBAC community, and in pregnancy and mothering as a whole, there is so much value to support, empathy and stories. However, there is a big difference between asnwering an original poster who says “what was your experience with tubal ligation?” and someone answering “geez, I had pain and menstrual irregularity after” and an original poster saying “I am planning on a tubal ligation” and a slew of commenters saying “NO! This is PROVEN to cause a, b and c horrible side effects to the majority of women who get it!” and usually a touch of “Have you considered Natural Family Planning?”

Sigh.

I have reluctantly been the heavy in many of these conversations, but it is triggering a bunch of pet peeves of mine. 1. Medical inaccuracies masquerading as facts. 2. Ignoring the expressed informed choice and priorities of the woman posting and substituting the commenters’ own priorities and (often faulty or anecdotal at best) information

So, this coalesced into a recent thread, and here is the reply I posted:

“This is the best article I have found on post tubal ligation syndrome:

http://www.nejm.org/doi/full/10.1056/nejm200012073432303#t=articleResults

It is a good article because it compares women who have had tubals with women whose partners have had vasectomies. It is also a good study because it has an N number of over 9,000 subjects who had the tubal ligation. It is also authored by a group from the Centers of Disease Control (the CDC). There is no economic conflict, and the New England Journal of Medicine is about as high quality a publication as it gets. Here are the results:

“The original concern about sterilization involved the risk of heavy bleeding and intermenstrual bleeding, but we found no evidence of either problem. Furthermore, we found that women who underwent sterilization were likely to have decreases in the amount of bleeding, the number of days of bleeding, and the amount of menstrual pain and an increase in cycle irregularity. We know of no biologic explanation for these changes, most of which were beneficial, in women after tubal ligation.”

I don’t think there’s any evidence of widespread issues post tubal. In fact, this high quality study seems to indicate the opposite. I am not saying a tubal ligation is right for everybody, but I do think it is inappropriate for every thread on here in which tubal ligation is mentioned to devolve into a pronouncement that tubals are PROVEN to cause these problems, often with alarming figures like half of all women who get tubals end up with hysterectomies, etc.

As I have also said, it is inappropriate at best and borderline bullying at worst for women on here to disregard a woman’s stated informed choice and substitute their own priorities, especially if they are coming from a place of anecdote and questionable information. It is also inappropriate to ignore a woman’s expressed desire for a highly effective form of birth control (like a tubal or IUD) and to tell them to try NFP* instead, when it has a typical failure rate much higher. I hold a woman’s right to make informed decisions about her reproduction to include highly effective birth control if desired as well as safe options for trial of labor after cesarean.

I am not a surgery lovin’ medicoindustrial defending brainwashed doctor. I trained as a midwife, had both of my kids unmedicated** with midwives, and have never used hormonal birth control myself due to my own priorities and reasons. I support low intervention birth and VBAC for two main reasons which may seem contradictory, but are wonderfully not. 1. It’s a woman-centered approach and 2. It is an evidence based approach. Bullying women into avoiding their choice of safe contraception is neither.”

*I love this site for comparison of contraceptive methods: http://www.birth-control-comparison.info/
**The first labor was augmented with pitocin without my informed consent, but was otherwise unmedicated

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The past, present and future

Howdy, blogland. Long time no see. Oh, and happy Mother’s Day.

It’s been a rough string of months. I had personal changes, a 40th birthday, a malignant rotation, a psoriatic arthritis flare, the stinking IRS is holding my refund for some sort of random review, a struggle with the black dog, and now I topped it off with a nasty viral infection that doesn’t want to leave my lungs.

But, things are looking up. Or, I have to start looking at the positive. I got my schedule for next year. Most rotations, I will be doing two days a week of clinic, which I am really looking forward to. I have zero nights, zero swing shift for the year. I’ll get to do some rotations I am looking forward to, like radiology (I hope I get to focus a lot on ultrasound) and hematology. I also will get to do a full four week block of clinic and one block in a community health center, so I’ll get my share of outpatient medicine. Hooray! I also have a block of NICU and a block of obstetrics, among other hospital based blocks.

I went to a social event with a lot of members of the local natural birth community, and everyone seems to be eager to work with me in the future. I see a lot of possibilities. I have always kept myself motivated by imagining what my future would look like. I am imagining a future with a practice in a freestanding birth center, doing women’s health, prenatals, family planning, lactation medicine, pediatrics, and possibly even some births. One of the local obstetricians said she would welcome me into her solo practice to see her clinic patients. This may be a more compatible future than doing hysterectomies and cesareans.

So, the future is bright. I just have to free myself from the gloom of the recent past.

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Overheard at work

1. Two elevator repairmen in the lobby this morning: “I don’t know how those Seaman systems work.” I snickered, because I am really mature.

2. A medical student: “What’s water boarding?” I overreacted. “Are you SERIOUS? You have never heard of waterboarding?!” I gave her a two minute synopsis on so-called advanced interrogation techniques vs. torture, the Geneva convention.

3. A patient: “Someone is taking medications out of my purse!” I rocked this one. No ableism intended, but I am known as the “crazy whisperer” at my site. I didn’t come up with that name. A lot of practitioners / caregivers take an adversarial communication style with patients that are combative, delusional, or simply question or want to refuse treatments. I try as hard as I can to meet them where they are. The patient is intermittently in florid psychosis, is paranoid, and is refusing treatments, tests, meds and food. She is sick, in many ways, and some of her meds can literally be a matter of life and death. I had a good, long conversation with her. I am going to let her use her home inhaler if she informs us, instead of confiscating it and making respiratory document every administration. I am ordering sealed cans of dietary supplements to her bedside to accommodate her fear of “dirty hands” contaminating her food. I told her that her 1:1 sitter will help keep track of her belongings, trying to establish trust with her sitter and to help her feel more secure. I let her know some of her meds are refuseable, even though she has been involuntary committed and deemed confused and inappropriate. I find that when patients feel like the have some respect and control, they are more secure and cooperative. She immediately agreed to her most critical meds, and is much more calm.

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I know what I’m going to be when I grow up

I am going to be a family practice physician.

 

I have mixed feelings about this. I think I will make the best of it, and I can have a rewarding (and hopefully successful) career in family medicine. I can still do a lot of women’s health, and even possibly some obstetric care of sorts.

 

Anyway, here’s to the future.

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Should I go to medical school? An advice column.

Check out my post over at Mothers in Medicine:

Should I go to medical school?

It is an answer to a series of emails I have received over time asking me advice about the whole single parent medical school doctor used to be in the natural birth community thing.

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Working during the holidays

Happy holidays!

I have had the dubious honor of being on what our residency calls the “swing shift” during most of December and early January. That’s 4 pm to midnight, Monday through Friday, and one of those nights I stay until 7 am to relieve a member of the night float team.

In other words, I worked Christmas Eve and Christmas Day, and I will be working New Year’s Eve and New Year’s Day.

In some ways it’s been rough. It was hard during the kids’ last week of school. I didn’t see them much. I was up until 3 am making treats for their teachers after getting off at midnight, but then I did have the freedom to drop off the treats at their schools before going into work. I also got to spend Christmas morning with them.

It’s fun, in a weird way, being in the hospital on Christmas. Everyone is in a good mood. People bring in treats, including me. The whole hospital is decorated. Usually, there are less BS admissions because people tend to want to be home with their family.

Anyway, hope you all get to spend time with your loved ones. I need to do another admission!

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