Tag Archives: Ally

Happy birthday, ADA

Today is the twentieth anniversary of the Americans with Disabilities Act! *blows party horn*

I didn’t know that earlier today. But, I did a little personal ally work in support of accommodation, so I am proud of myself.

The student who is sharing the surgery rotation with me is disabled. She was in a terrible car accident about five years ago, and shattered her ankle and heel. She has some difficulties walking and standing for long periods of time. She has been very successful when assisting on alternating surgeries, but she has asked our attending if she can sit when it’s my turn to scrub in at assist. My attending is fine with her sitting, but occasionally, the OR staff gives her a hard time.

Today, a nurse anesthetist started making really sarcastic comments to her when she sat before the procedure started. “Do you want me to get you a pipe and a smoking jacket?” he sniped. He turned to the one of the other people in the room and said “Is that what it was like when you were in medical school?” He made a few more rude comments. My classmate just glared at him from behind her mask, and didn’t say anything. She feels really put on the spot when those sorts of things happen, and doesn’t choose to make excuses.

After the procedure was mostly over, the surgeon took my classmate to go to pathology to check to see if the sentinel lymph nodes that were removed were negative, and the assistant and I remained to close the mastectomy. Once the incision was closed, and we knew the nodes were negative, I told the whole OR team that was assembled that I had something to say.

“I heard someone saying something to (classmate) earlier about her sitting down. I wanted to let you know that she is disabled. She was in a really bad car accident and her ankle was shattered. She has trouble standing for long periods of time. She has asked to be able to sit in the OR if she is not assisting, and Dr. (Attending) has told her it’s OK. She’s really self-conscious about it, and won’t say anything to anyone who asks her about it. I just thought it was important for you all to know.”

There were some mumbles and grumbles, but no other comments. There were two anesthetists and one anesthetist student there when the comments were made in the beginning of the procedure, and they all kind of look the same with their caps and masks on. One of the anesthetists left before the procedure. I am not sure if the one who made the comments heard what I said, but I hope his buddies go back and tell him what I said if he was the one who left. I wasn’t necessarily trying to teach him a lesson in particular, but I wanted to let everyone on the staff to know that people may sit because they need a disability accommodation, since this isn’t the first time someone has given her a hard time.

Maybe the next time someone sits down, they won’t automatically assume they are being lazy.

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Nothing like bad news to drive a message home

(Trigger warning for poor obstetrical outcome)

Less than one week after I blogged about the maternal mortality crisis among black women in our country, I lost a friend. She was of Haitian descent, a fellow medical student, an aspiring ob/gyn, and a kind and wonderful person. She was eight months pregnant with her first baby, and newly married. We talked for a while last week about her taking time off, breastfeeding, and pumping when she got back to rotations. She was incredibly happy about becoming a mother.

She went into premature labor this weekend. She had a hemorrhagic stroke. She died. The baby is doing fine.

This was not an underprivileged woman by most definitions, at least not currently. She may have been raised in an impoverished home. The Haitian population in South Florida in general is devastatingly poor. She was well educated. She was not “advanced maternal age”. She was not a teen mother. She was not obese. She had good prenatal care and insurance. She had family support and was happy about her pregnancy. As far as I know, she had no health conditions, didn’t smoke, and didn’t do any drugs.

But, she was a black woman in America, which puts her at much higher risk of premature labor and death. In recent years, the maternal mortality rate for black women in Miami has been up to 10 times that of white women. We don’t completely understand why. Different delivery of care, early life malnutrition or lack of health care, the stress of racism, biological or genetic differences…these all may play a role.

But, right now what we do know is that a baby is born without a mother, and a husband is welcoming a new baby in his life with a dead wife, and no mother to help raise it. That is a horrible shame.

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Proud to be an American

Happy birthday, USA!

When I say I am proud to be an American, (a USian, really, but I am quoting a song title), I am proud of what we have done that is progressive, such as women’s suffrage, and the civil rights movement. I am also optimistic of the potential we have to improve ourselves. I do not think that means we have to ignore problems that we have, or not admit mistakes, as many people mistakenly consider patriotism to be. I think having low standards and ignoring our issues is the opposite of patriotism.

Anyway, despite the partially successful civil rights movement of the 60’s, there is still glaring racism and racial inequalities in our country. Please check out this blog carnival at the Uneccesarean. It’s a round up of posts discussing the shockingly and depressingly high rates of infant and maternal mortality suffered by black women and infants in our country.

And, before someone goes there (which has happened before on this blog and on others so often it’s on racism bingo cards), it’s not a class issue. These inequalities still exist even when the mother is college educated, compared to white mothers who don’t even have a high school degree. This is more pervasive and deeper than class. Not that poverty isn’t important, but there is no quota for issues we should address to make this country even greater.

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Excellent article on female sexual dysfunction

Please go check out part one of a series on female sexual dysfunction on K’s Feminists with FSD site. Like me, stay tuned for part 2. This post covers the history of statistics on female (and male) sexual dysfunction, as defined and discussed in a landmark article in JAMA, Sexual Dysfunction in the United States.

One of the good points she makes is:

According to Sexual Dysfunction in America, there are seven symptoms of sexual dysfunction. Keep in mind though, the authors did not factor in the degree of symptom severity, and did not factor in how individuals felt about their sexual problems. (Some people have difficulty maintaining an erection or researching orgasm, and are comfortable with that.)

Go read the whole thing!

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Resources from ACOG

I am going through my papers from the conference. I wanted to throw up some links while I did it, since I am coming across some cool stuff.

First of all, I am excited about ordering powerpoints synced with the audio from some of the presentations I missed because they were sold out, or they conflicted with medical student activities. There was one on VBAC I definitely plan on ordering, and will see how much money I can spare on the some of the other interesting topics.

I wish I could buy lots of books, too. Such as Special Issues in Women’s Health, or Evaluation of Cesarean Delivery.

I heard about the Maternal and Child Health Library out of Georgetown. Time to sign up for another newsletter. Hmm, maybe another one. Here’s a flyer from the North American Society for Psychosocial Obstetrics and Gynecology, and I think they have a newsletter. Phew, they seem to be on a newsletter hiatus.

I grabbed a flyer on NIH Loan Repayment Programs. Interesting. I am keen on doing disparities research eventually.

The President’s Program focused on perinatal depression. I liked that he had a spectrum of speakers: one patient / activist, one psychologist, and one physician. I learned about the Perinatal Depression Information Network, which I don’t know much about, but sounds like it could be a good resource. One of the biggest issues with depression (and other mental illness) is that it can be isolating, and I am a firm believer in support networks and information for patients to counteract this sense of isolation. I noticed that one of the Presidential Program posters mentioned dyadic assessment and intervention for mothers and infants aimed at improving attachment for women with a history of trauma. This was from the University of Michigan. Sounds like some great research.

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Reply turned post, I’m Mom f*cking TFH round up style

I don’t know how many of you have read this awesome post at Shapely Prose, but if you haven’t, please do. I am loving this wave of posts in which bloggers are proudly taking a stand on being good at what they do, and having high standards and authority. (Not like Technorati authority or Eric Cartman’s authori-tay. Wink wink, Rachel. Stay dry!)

Here is another great post by a blogger I have added to my out-of-control blog reader, That Post on Natural Childbirth on The Feminist Agenda.

And, this bit of awesomeness at Fugitivus. The post is pretty specific to a recent post she wrote about adoption, and how she is sick of putting up disclaimers and catering to reactionary commenters who derail these conversations. But, it is similar to what a lot of these posts are saying. She says:

I’m not catering to anybody else, and I’ve never felt any shame over that, despite how many trolls have tried to make me feel shame by screeching about free speech and limited perspective and your tone is too angry and oh my god she’s using swears.

The whole post, and all of the other ones I link to, are all worth a read. Here is my reply on harriet’s post at Fugitivus:

Wowza. Love it.

Sorry, I am about to go off.

I forwarded your recent adoption post to a friend of mine. She is someone who had a relatively successful adoption, but is so in tune with the major flaws in the whole adoption industry. I am incredibly lucky to have learned about adoption on a deeper level, and been shown the issues of adoptive parent privilege and birth mother (and adoptee) silencing prevailing media and cultural dialogue. The barriers to being able to discover one’s genetic identity and familial history as an adoptee.

I learned what I have learned by listening to the people in my life that are part of the adoption triad, and through my interaction with birth mothers (and adoptive parents, and adoptee infants) as a health care practitioner-to-be. I still feel like I need to tread lightly before I start bloviating on this subject.

One of my pet peeves is when people stumble on to a very technical conversation that involves a layered understanding of privilege just to broach the specific topic, and starts crapping all over it. This happened on Alas A Blog when talking about research on maternal mortality and racism. If you can’t even acknowledge there has been good research on racism and its real effects on health care outcomes, then don’t come crapping on the conversation with a hypothetical “Well, has anyone ever looked into how CLASS plays into this? Hmmmm?” thinking you are coming up with a brilliant new angle that us researchers have NEVER thought of doing multifactorial analysis on, and if you don’t even know what the word “confounder” means and you didn’t even read the article you are bloviating about, I am not interested in having a conversation with you, and I may sound sarcastic when I call you out.

You’re completely right that there is a learning curve to this, and this is not a 101 site. You cannot get into a deep discussion about these topics if you have to put up with derails. It has happened on my site. I am not going to stop a discussion about the intricacies of health care reform because one commenter is spouting off Glenn Beck quotes at me about how taxation is like stealing from your neighbor. I am not going to stop a discussion about pregnancy or breastfeeding because one commenter is saying their experience is more important than the real barriers and layers of privileged fucked up ness and loss of autonomy surrounding that whole experience for millions of people.

There is a conversation going on in the genfemblogosphere about taking a stand on the importance of what you are writing about, and having high standards, and not taking any shit from people who want to say you’re not authoritative on what you really are pretty authoritative on, in your own space, to boot.

There’s nothing wrong with having high standards for the conversation you are hosting.

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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, advice on VBAC in rural New Mexico?

I replied to a post on Shakesville in which a community member who is pregnant after a prior cesarean asks for advice in seeking a VBAC in rural New Mexico, when the nearby hospitals have a no VBAC policy.

This is my reply:

You can contact me at hilseb at gmail dot com, if you’d like. I know a bit about this. I am in medical school, and am planning to be an ob/gyn. I am doing a research fellowship on obstetrics right now. I am a big proponent of evidence based medicine, which means I am a big proponent of VBAC.

Here is a link to all the blog entries at my blog I have written on VBAC. That’s just the first page. Click on older entries, and the list goes on. Just to give myself some cred, if my alleged bio doesn’t.

Here (pdf) is the incredibly recent, like published last month, and very thorough NIH evidence report on VBACs, which concludes “This report adds stronger evidence that VBAC is a reasonable and safe choice for the majority of women with prior cesarean. Moreover, there is emerging evidence of serious harms relating to multiple cesareans.”

Here is an excellent academic article on risk and pregnancy written by the American College of Obstetrics and Gynecology risk task force that has some very supportive language on offering VBAC and how to present risk to obstetric patients. According to this article, “Although rates of delivery-related perinatal death are indistinguishable between VBAC and primary vaginal delivery, there is a genuine differential in the rate of uterine rupture–related hypoxicischemic encephalopathy. Such perinatal morbidity is indeed devastating. It is also extremely rare. In a recent large prospective study, the probability of this outcome was 0.00046 in infants whose mothers underwent a VBAC trial at term compared with no cases in infants whose mothers underwent repeat cesarean delivery.” (emphasis mine)

Here is the website for ICAN, the International Cesarean Awareness Network. Here is their page on VBAC. Here is their VBAC reading list. Here is their database on hospital policies on VBAC. Here is their FAQ on how to face a VBAC ban. Unfortunately, there is no New Mexico chapter listed on their site, but there is a national group, an AZ group, and lots of resources available.

Here is a link to my buddy Jill’s incredible blog, the Unnecessarean.

I have been to many, many beautiful VBACs, most of which were successful, safe vaginal deliveries, which goes with the 75% to 80% “success” rate numbers abundant in the literature. Even the ones that ended in a cesarean were happy, healthy births that fit the informed consent of the pregnant person.

Please, please, don’t hesitate to contact me, if this post hasn’t overwhelmed you.

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If anyone else has any advice, please comment at the original post at Shakesville.

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Reply turned post, Dr. Amy’s “egregious” post on KevinMD style

KevinMD invited Dr. Amy to write a post about offering VBAC, simply entitled “VBAC should not be a woman’s right”. Keep in mind on both my blog and on Academic Ob/Gyn, she has agreed the evidence supports offering VBAC. But, on this post, she mocks people who support offering VBAC, using no evidence or data, but links to blog posts and, of all things, an ad on the site of a medical malpractice firm.

The reply:

Why don’t you link to scientific evidence instead of blogs and websites of malpractice lawyers? Using inflammatory words like “bizarre” and pretending women don’t have the right to be active decision makers in their medical care is doing nothing to improve communication between physicians and their patients.

Here is the evidence report of the NIH conference on VBACs. VBAC activists are not a small group of blog writers. This is a mainstream medical cause.

Also, the pattern of obstetricians not offering VBAC has a lot more to do with the wording of a specific ACOG position statement and less to do with real medicolegal pressures. I am in Miami, which has one of if not the highest cesarean rates in the country, one of the lowest if not the lowest VBAC rates in the country, some of the worst malpractice rates and payouts in obstetrics, some of the highest malpractice insurance premiums, and really revolutionary tort reform, in that obstetricians can and mostly do “go bare”, which means that they don’t carry malpractice insurance, and effectively limit awards $250,000.

So, the only thing these docs have in common with obs throughout the country is the rocketing trend to refuse VBAC since the ACOG position statement change in 1999. They have their tort reform. They have their low VBAC rates. Their malpractice premiums haven’t gone down. Their malpractice awards and frequency of being sued hasn’t gone down. Our maternal mortality is horrendous. I can provide citations for any of that, by the way. ACOG does a yearly survey on malpractice, and they print numbers for Florida every year.

Here are two scholarly articles one and two that indicate that refusing VBAC isn’t the key to malpractice. It’s proper documentation (including during VBAC, yes I have read the first article, so don’t try to misrepresent what it says about VBAC) and evidence based standards of care. And, the AHRQ statement out of the NIH conference is the most recent, comprehensive evidence review on VBAC.

There is already good literature on risk and decision making during pregnancy if you want to talk about the rights of the pregnant patient. It reads: “These tendencies in the perception, communication, and management of risk can lead to care that is neither evidence-based nor patient-centered, often to the detriment of both women and infants.” The section on VBAC is enlightening, and calls your type of scare tactics unethical. Do you have a similarly well documented discussion published in an equally reputable journal written by practicing obstetricians that takes your point of view, that women don’t have the right to refuse elective repeat cesarean, when the most recent evidence review calls it perfectly reasonable?

I think we all know you don’t, because I have been linking to the Lyerly et al article for about a year now, and you have yet to come up with anything other than your own writing to support your point of view. Why don’t you use well established bioethical principles, and quote ACOG committee opinions on balancing the rights of women to refuse surgeries? Because they support the fundamental bioethical principles of non-malfeasance, beneficence, and autonomy of the patient. I don’t remember seeing CYA listed as a bioethical principle on weighing the rights of patients.

Calling people who are consistent with ACOG bioethics teams and the NIH “irrelevant”, “bizarre”, “Inane”, “egregious” and and “committed to resentment” is, well, bizarre, egregious, inane and committed to resentment. And, it completely ignores the basic fact that a repeat cesarean IS a procedure, and a trial of labor is the REFUSAL of a procedure. That basic inarguable “semantic” fact is the center of why women DO have the right to refuse an elective repeat cesarean. Using inflammatory insulting words doesn’t make your reasoning right NOR ethical, and when discussing rights, that is what is key.

The NIH report concludes “This report adds stronger evidence that VBAC is a reasonable and safe choice for the majority of women with prior cesarean. Moreover, there is emerging evidence of serious harms relating to multiple cesareans.”

Why don’t you work with activists AND the medical establishment to get the ACOG position statement on this, and the presentation of risks, both TO obstetricians about malpractice and TO patients about all risks in pregnancy and delivery in line with evidence and bioethics?

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Commenting policy: I am committed to keeping my comment sections civil. If I criticize Dr. Amy for using verbally abusive, inflammatory tactics, I cannot ethically abide by people using the same in my comments. I am also not interested in people insulting people living with mental health diagnoses by using “crazy” or “forgot to take her meds” as insults for anyone, including me and Dr. Amy.

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Exciting things a-brewin’

I am going to be in a production of Eve Ensler’s The Vagina Monologues tomorrow night. This is my third year being involved with our medical school V Day production. I was the narrator for the past two years. This year I am performing the poem at the end, a poem about birth called “I Was There in the Room”. It ends with:

The heart is capable of sacrifice
So is the vagina
The heart can forgive and repair
It can change its shape to let us in
It can expand to let us out
So can the vagina
It can ache for us and stretch for us, die for us
And bleed and bleed us into this difficult, wondrous world
I was there in the room
I remember

I also was selected to be a delegation coordinator for Amnesty International’s lobbying effort to bring attention to maternal mortality, including lack of prenatal care and racial disparities.

So, I know I am supposed to write up my cousin Susan’s birth story (which will probably be my first non guest post at Mothers in Medicine), and talk about the whole NIH VBAC conference thing, and recruit more doctors for my survey, but I’m a little busy right now. I’ll get to them soon, I swear.

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