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.

Breaking the silence

I am happily coming down off the high of presenting at the Medical Students for Choice annual conference – I was part of a fantastic panel on Protecting Choice in Birth. I felt honored to be sharing the table with some brilliant people – two wonderful ob/gyns, two reproductive justice lawyers, and little old me. We talked about the legal and ethical underpinnings of patients’ rights and choice in birth: site of birth (e.g. out of hospital birth), VBAC, even use of a doula or refusal of certain interventions.

It was a wonderful experience. The director of MS4C told us the response was so overwhelming that the conference was buzzing about our panel, and we are definitely invited to return. I learned a lot from my co-panelists, and loved the enthusiastic response from the audience. One sweet medical student literally had his jaw agape when Farah Diaz-Tello, from the National Association for Pregnant Women, described a woman who had her baby taken away and put in foster care for simply wanting to postpone signing a blanket consent for any intervention or procedure during her labor and delivery. She had a healthy, spontaneous vaginal delivery with no complications during her SECOND psych consult (after the first psychiatrist deemed she was clearly mentally competent and allowed to refuse consenting to an unnecessary hypothetical cesarean), and apparently her six year old is still not in her care due to the red tape surrounding her case. Jaw dropping, indeed.

I talked about my journey, including being a patient, mother, midwifery student, doula and research fellow before becoming a doctor. I discussed the hostile-to-patient-autonomy atmosphere in South Florida, my fellowship research on labor interventions, and how to present risk to patients.

I almost burst into tears when my co-panelist, the lovely and dynamic Dr. Hanson, showed pictures of twins and breech births she has delivered all over the world. I did end up tearing up during lunch, not just because birth is moving and emotional, but because I am slowly accepting that I will most likely never be doing these difficult deliveries, and my wonderful copanelists innocently asked me about my residency plans. I may not be doing deliveries at all.

I got a decent amount of invitations to obstetrics residency programs. I am slowly canceling them, one by one. I simply cannot justify moving my two boys to a city where I don’t know anybody, then disappearing to work my ass off 80 hours a week at all times of day or night. I also don’t want to put them in public schools in the Deep South. When I got divorced during my third year of medical school I knew that would mean facing residency as a single mom. The divorce was worth it, but now that I have experienced the reality of how hard internship is, even with significant family support in my home town, I had to reconsider my options.

I will most likely be pursuing a family practice residency at a local residency program, probably at the hospital where I am doing my internship. Yes, obstetrics can fall under the family practice umbrella, but I would be the first family practitioner to get hospital privileges in the greater Miami area in recent or remote history. In other words, the chances of that happening falls between not likely and impossible. Yes, not even if I do an obstetrics fellowship, which would involve leaving town for a year. It’s just not the standard of care here, even if it’s normal in other parts of the country. And my custody arrangement stipulates that I practice here after training. So, even if I move for residency, I would have to uproot again and come back.

I can still do women’s health. I can still do prenatals. I can do lactation medicine, including the pediatrics portion. I can even be the medical director of a local freestanding birth center, just not their backup surgeon. Which, honestly, was never a huge draw for me. I want to be at the normal pregnancies, not a back up for the ones that go wrong. I can do family planning. I can still do academics, including medical ethics, which is an interest of mine.

So, most of the time I am ok with this. Most of the time. I have a lot to be happy about. I have great kids, good family support, a supportive director of my residency program, relatively good health, friends, a cute little house, a fuzzy loyal dog, and a blossoming (very tentative!) new relationship with a nice guy. And I’m a doctor, for Chrissakes. With a job in a shitty economy.

So, anyway, another permutation on the journey. Let’s see how it plays out.

Us vs. them (or a blog retrospective)

I cut down on my blogging a lot this past year. It was due to a combination of a different factors. It is harder to tell stories about clinical experiences without discussing my patients or attending physicians in a possibly sensitive way than it was to tell stories about studying or research. Also, I became a single mother, and blogging time is more negotiable than cooking dinner. Or cleaning muddy footprints up from the entire. fricking. house last night. After shower muddy trampolining and wooden sword fighting? Great idea!

But, another reason I stopped blogging has to do with the polarization and vilification that is so common in internet discussions of topics I find dear. Give me a nuanced discussion about breastfeeding, birth, contraception or abortion, please? Please?

I keep ending up writing posts like this one about the rhetoric surrounding “natural” birth, the how to present risks surrounding birth without freaking out post, the one about a death threat I got over a post about vaccination, abortion, fetal monitoring for chrissakes or posts one, two, three, four, five, six (OK that’s enough!) posts about polarizing breastfeeding if-you-can-call-it-conversation. I’m not going to start searching for my posts on race.

Let’s not forget Mommy Wars Bingo.

After one and two disappointing posts and comment sections on Skepchick about breastfeeding, I was tempted to post another plea on here. I want to like Skepchick because of posts like this about female genitalia self image, and a post about female body hair shaving that seems to have disappeared. I was going to beg, again, to please, please let a discussion of breastfeeding science go by without the “GUILT!!” hammer coming down, but I am starting to feel like I will be rating level five on the Professor Internet dick meter if I keep covering the same territory. Even though I’d rather fancy myself more like Jon Stewart preachin’ it on Crossfire.

Hell, I know I have “rant” as a tag on my blog, and I think I coined the term reply-turned-post, even though I hardly invented it. I replied on both Skepchick posts, but I didn’t even bother reposting it here. I am just tired of it. And, I have a sandwich, or a rank list, to get to.

By the way, this is apparently post #665. My next post will be from hell.

All board review and no play…

I have my USMLE Step II CK on Saturday, and my COMLEX Step II CK August 1st. So, sorry I haven’t had time or mental functionality to blog much. I have tons of stuff I have wanted to share. Let’s see if my medical fact clogged brain can remember a few of them.

NPR has been rockin’ lately. First, I heard Morocca say “hula doula” on Wait Wait, Don’t Tell Me” recently. They have been running a really great series on birth called “Beginnings: Pregnancy, Childbirth and Beyond”. It included a great piece on elective inductions that provoked a lot of comments when I shared it on my Facebook page.

NPR’s Facebook feed also tipped me off to a new report by the Institute of Medicine, “Clinical Preventative Medicine for Women: Closing the Gaps” which recommends mandating insurance coverage of contraception,” since it is preventative medicine. To quote Rachel from Women’s Health News, “Duh!”.

In addition to copay-free coverage of birth control, the Institute recommended:
screening for gestational diabetes:

*human papillomavirus (HPV) testing as part of cervical cancer screening for women over 30
*counseling on sexually transmitted infections
*counseling and screening for HIV
*lactation counseling and equipment to promote breast-feeding
*screening and counseling to detect and prevent interpersonal and domestic violence
*yearly well-woman preventive care visits to obtain recommended preventive services

Hear, hear.

Anyway, I should be studying. Wish me luck.

Hands on in the boondocks

Howdy. I have been busy, as usual. Not only working at a new rotation site, which has been wonderful, but driving more than three hours a day to get to and from this site.

Our medical school requires that we do three months of rural rotations. I am doing two at a community health center in the middle of the state. The surrounding town is a farming town, with a large migrant population.

I am absolutely loving it. I am starting off with the ob/gyn, and we do gynecology, family planning and obstetrics. It is a very hands on rotation with an attending physician who is eager to teach. I have done many pap smears, STD tests, contraception counseling, cervical checks on full term pregnant women, and I GOT TO INSERT AN IUD. That plus a journal club, a training on human trafficking and a training on contraception compliance. Not bad for the first week and a half!

Our first two days consisted of orientation, and the longest time slot was given to the lactation consultant, who I love. She is working on a “Men and Women’s Health Day.” When I gently pointed out to the Medical Coordinator of the site that it was trans exclusive, they took me seriously. I am going to be the point person for any individuals identifying as trans (or anyone else who has questions in that area) the day of the health fair. Apparently they had some there last year and were at a loss. I am going to start with the resources linked to by Rachel at Women’s Health News and go from there.

I’ll try to check in again. If I could type while I drove, I’d have a ton of posts. Instead I am listening to board review materials. And looking at the swamp wildlife. And trying to avoid a speeding ticket.

I can easily see myself working at a community health center. This is totally my bag.

Defending breastfeeding

I think I have been quiet on here longer than I have been for well, ever. I am doing a family practice rotation and trying to set up elective rotations and plan for applying to residency. I am also just busy and tired out in general. I can’t write about much of what I see day to day without discussing my patients or my attending physicians and residents in a way that might be ethically questionable.

But, I do want to write about something that happened today.

A patient came in with a complaint that wasn’t life threatening or earth shattering. My attending physician wanted to treat it empirically. The patient is breastfeeding exclusively. The physician, without even looking up the medication, told her to stop breastfeeding.

I usually don’t challenge what my attending physician recommends. The patient said she would do what she always does, and call her baby’s pediatrician. When we did look up the medication, it did not have a contraindication for breastfeeding, but had a typical “well, we just don’t know if this is safe” disclaimer. This wasn’t a book specifically dedicated to medications and lactation. There are books like this available.

I told the attending physician that the patient was exclusively breastfeeding, and breastfeeding is hard enough to pull off in this society as it is. I said that, barring a contraindication during breastfeeding, most medications are safe, and a little research on the topic and possible alternatives may be a good idea. The attending said that, in today’s litigious society (which is the topic of many lectures by many attendings), we just can’t take those kinds of chances these days. She apparently tells any breastfeeding patient to stop breastfeeding with any medication.

I hope I can take these kinds of chances one day. I respect my attending physician’s choices in balancing her medicolegal risk and the way she cares for her patients, but I hope to be able to strike my own balance one day that is more supportive of breastfeeding.

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.

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).

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.

Reply turned post, same old song about breastfeeding shame

On my Facebook page, I linked to this article asking the president of Facebook to change its policies on breastfeeding. In case you don’t know, Facebook considers photographs of breastfeeding to be obscene, and deletes them as pornography. Yet, they put underwear advertisements from American Apparel on my homepage.

The letter uses statistics from this recently publicized article from Pediatrics that enumerates the risks of our low breastfeeding rates in the United States in numbers of money spent and lives lost. This is a common way to discuss large scale public health issues. But, as usual, someone wants to hold breastfeeding to a different standard than other health issues.

A former friend of mine, who I thought I had blocked on Facebook, but I guess I hadn’t, replied with this comment:

i’m all for facebook changing its policies, but i don’t think that we need to demonize women who choose not to (or cannot) breastfeed.

*facepalm*

OK, I know the post took the mortality numbers and ran with them. I have to admit, they are startling numbers, and there is something about putting a mortality number on something to really drive home how policies can really affect public health. It’s all theory on the internet when we’re bloviating about whether breastfeeding in public is obscene, or whether being “pro-life” really can be reconciled with being against legal and safe abortion, but numbers of actual deaths per year are a powerful, powerful argument. There is nothing inherently different about breastfeeding that makes it somehow sacrosant, however, and therefore we cannot use our most powerful tools to promote it. There was not ONE word in this article that I thought demonized women who choose not to breastfeed. It acknowledged how breastfeeding successfully, even getting out of the hospital breastfeeding, needs a lot of support and education. It needs all the help it can get, and treating photos of breastfeeding like pornography on the most popular, incredibly pervasive social media outlet in the world may be a factor in the public perception of breastfeeding. Period. It wasn’t this post that linked breastfeeding to preventing almost 1000 deaths a year. It was the researchers who were published in Pediatrics, and then the article was publicized by outlets like CNN.

Here was my reply:

I don’t think that this post does that. It is a letter to the president of Facebook about its policy on breastfeeding photos being obscene, and draws attention to the fact that breastfeeding is important by using real epidemiological statistics on the public health effects of the low breastfeeding rates in the country.

I know that discussing breastfeeding’s very real health benefits may make women who don’t or can’t breastfeed feel bad, and that’s a shame. It’s hardly the most important point, however, as the statistics in the article clearly explain, and isn’t a reason to suppress real public health statistics on its benefits. It’s hard to discuss breastfeeding without talking about the true risks of low breastfeeding rates, and how these low rates may be related to how it is treated by various media sources, including social media.

One journal article on why women choose not to even initiate breastfeeding showed that the most prevalent reason was fear of what others, especially their partners, will think of them. The public shaming of breastfeeding is an important topic, even when discussing why some women choose not to breastfeed.

I didn’t see one line in this piece that said women who don’t or can’t breastfeed are wrong in any way. It’s an important health decision with important health consequences, and when I talk about it as a public health issue, I am not commenting on individual women’s health choices, which, when regarding many aspects of pregnancy, birth and parenting, are complicated and multi factorial. I don’t think this piece was, either.

In fact, in the comment section, I think the author answers this point rather well. Mothers, especially first time mothers, cannot make an informed health decision about breastfeeding when the behavior is shamed socially by prominent, pervasive outlets like Facebook. When mothers who don’t breastfeed have their bottle feeding pictures banned from Facebook for being pornographic, then we are talking about a similar issue. Otherwise, I don’t this article has anything to do with demonizing women who don’t breastfeed, but is rather about shaming women who do.

********************

I want to add, since this is my blog and not Facebook, that this is a major pet peeve of mine, and this person knows it. I hate that almost any internet discussion of breastfeeding is derailed by “Don’t hurt mothers’ FEELINGS!!!” and accuses me of being unsupportive.

I have a very good friend who had an awful struggle with breastfeeding who eventually had to give up and use formula, another who had to stop due to allergies that led to constant GI bleeding and anemia in her child, and a few cousin Susans who didn’t breastfeed after the first feeding or two in the hospital. I was a doula to a mother with MS that couldn’t breastfeed because she wanted to go back on her medications. I find it really insulting to be told that I am not supportive of mothers, since it is something I take very seriously. I have wiped tears off of a mother’s breast while helping her tape tubing of an supplemental lactation system to her breast, and I doubt any of these people who have accused me of that have ever been that supportive of mothers trying to breastfeed without judging them. And, I think crying “FOUL!” any time the subject comes up allows people to have an excuse to not consider the true risks to not breastfeeding, and casts it as a lifestyle decision rather than a health decision. And, I think this recasting of breastfeeding is a major reason why women choose not to do it.