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.

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.

Reply turned post, that’s a nice welcome style

A reply to Own Worst Enemy, on Mothers in Medicine.

Here is my reply:

I think feminism has made us more supportive of women’s various choices and roles in life. I think women who work outside the home, go to medical school, get divorced, use birth control, have babies when unmarried, wear pants, etc. are judged a lot less now than they were a few decades ago, due to feminism.

I have been hurt by men and women alike. I think sexism and hurt in general isn’t doled out by a single gender.

Yes, women (and men) are very judgmental of women’s choices. Women definitely play along with the patriarchy and tear other women apart. “Female Chauvinist Pigs” by Ariel Levy is a really good book on the subject.

That’s why feminism has a lot more to do.

I am sorry I flounced away from your blog with a seething comment. I am just not a fan of Glenn Beck’s. You linked to a long letter of his I had serious problems with.

I think Glenn Beck is a destructive force in our country, one of those same fringe elements you seem to criticize in this post – like overly judgmental breastfeeders (most of us weren’t or aren’t) or stay at home moms who judge moms who work (most I know don’t). And he isn’t even a woman.

I hope it is less baffling to you now.

What do *I* think we should do?

I think we should be introspective and supportive. I think we shouldn’t give support to hostile fringe elements – whether it be med school friends who talk about someone’s eyebrows needing to be waxed or political pundits who stoke hatred.

I think we should support each other as best we can.

Advice to a mom starting her pre med

It’s advice time at the Tinfoil Hat!

A classmate of mine introduced me to a friend of hers who is a mother of three, is starting her pre reqs to apply to medical school, and is interested in ob/gyn. She connected us via a social networking site, and I wrote down came to mind as far as advice:

I haven’t found the mom thing to be a big obstacle for me in medical school. I learned how to juggle and prioritize my time when I became a mother.

Of course, I only have two kids, and I heard the transition from 2 to 3 can be a little rough. How old are they? Mine are 5 and 10, so they are both potty trained (whew!) and can both understand when mommy needs to study. Not that they won’t interrupt me, but still.

I was a little nervous about doing my post bacc pre reqs as an older student and a mother. I felt a little lonely in those classes, but I was pleasantly surprised when I got to medical school. There were other mothers and other older students there – one of my closest friends is a grandmother, and she found time to work 40 hours a week while in med school (I don’t recommend it, but she did. And she still does on her rotations).

I obviously don’t have the time nor the inclination to party as hard as many of my classmates. Nor do I get my nails done or go to the gym. But, I managed to be incredibly active in extracurricular activities in medical school. I found time to be involved in things that interested me (I was president of the ob/gyn club, for example, and helped run the Vagina Monologues and ran the HIV testing clinic) because I wouldn’t enjoy medical school otherwise. And, I could always give them up if I wasn’t happy with my grades, which I was.

What helped me:

1. Juggle and balance. I would go to school, try to make and eat dinner with my family, and then study in the later evenings when the kids were in bed and on weekends after spending breakfast with the family. That schedule worked for me.

2. During my pre med, I only took part time classes, but I was also working full time. Looking back, I wish I took out loans and did the school thing full time. My life course might have been different, since I got into ob/gyn late in my premed, but still, it was a longer journey than it had to be.

3. Find friends who know what’s going on and use them. (Not use them use them, but you know what I mean.) I am not the best person when it comes to knowing what paperwork is due when, etc. So, I find an organized, friendly classmate who is good at staying on top of this stuff, and remember to ask them for help when I need it. It’s also good to have a phone number or two in case a family issue comes up and you miss something.

I did not do this enough in my pre med, and entered the application process woefully underprepared. Do your research, ask for help if you aren’t informed. I didn’t have time to do all the pre med extra curricular stuff since I was working full time and my kids were younger. I blew it my first application round, because of stupid stuff (I didn’t wear a suit to my first interview. I wore professional clothes, like I would to a business interview. Wrong. Stood out like a sore sore thumb).

4. Don’t overestimate or underestimate the understanding of your classmates, professors or administrators when it comes to your kids. Some people who you think will be understanding won’t, and may treat it like a weakness. Some people who you wouldn’t expect to be an ally at all will surprise you. Don’t be afraid to bring up the kids, but don’t act like you automatically deserve a break or special treatment. If you try as hard as you can to be as good (or even better) than the childless students, you will hopefully get the support you need when you do need an accommodation.

5. Don’t put your education last in your house. I sometimes find myself having standards for myself as a parent that may be too high. For example, I love making home made valentines with my kids, and despise the commercial ones with the cartoon characters on them. Well, this year I had a major research presentation due this past Friday, and was working on it Thursday night when I realized that my younger son had to do the Valentine’s Day exchange Friday since the holiday occurred over the weekend. My husband bought some Batman valentines, I gritted my teeth and got over it.

6. Quality time is OK sometimes, as opposed to quantity time. I ave myself permission to leave the house to study if I had to, when shutting myself in a bedroom wasn’t working. I didn’t do it too much, but one day a week or so, more during board review, with strategic kid bonding time scheduled in, worked for me.

7. Remember, it could be worse. You could be looking for a husband and trying to plan kids during your residency.

8. As for ob/gyn, I wouldn’t obsess about a specialty now, but I am a huge fan of ob/gyn. Any specialty can be challenging, time wise. Neurosurgeries take 6 hours or more a piece. I talked to an ophthalmologist who loves her practice as a mom now, but she had a grueling residency, with three babies at home (she had twins during her residency!)

Hope that was helpful. Please feel free to contact me whenever you need to.

*****

Please feel free to add advice!

And it begins

I saw the first Focus on the Family ad by the Tebows. They direct them to the Focus on the Family website to learn more about their story. You know, the story about a privileged white American woman who had lots of choices. Now, people can go to the Focus on the Family Site and read how their team of doctors thinks birth control is a chemical assault on the unborn.

Nice. I wish they were directed toward these posts instead so they could learn about the 200,000 children whose mothers die each year due to groups like Focus on the Family.

Mammograms and the USPSTF: it’s the denominator, stupid

There has been a lot of brouhaha over the new mammography recommendations by the United States Preventative Services Task Force (USPSTF). Rachel at Women’s Health News has an excellent round up of posts on the issue, if you feel like you need to do some background reading.

I am also a big fan of Barbara Ehrenreich’s take on it.

Take your time if you need to check out those links, since I highly recommend it. Back? Good.

I have many thoughts on this issue. First of all, I am completely in support of the new recommendations. If you have been reading my blog for long, this may come as no surprise, since I tend to prefer using interventions only when absolutely necessary, and am a big fan of evidence based medicine.

Secondly, I don’t think it is anti-feminist to discuss the anxiety caused by false positive diagnoses, whether it be false positive mammography results or false positive prenatal genetic screening results. Not only is the anxiety potentially substantial to many, but, the false positives also lead to more invasive tests. My mother, who is as low risk as I am for breast cancer (white, has had children and has breastfed, non-smoker, not a heavy drinker, no first degree relatives who have had breast cancer, etc.) is also endowed with huge breasts, as I am. She had at least three biopsies and lots of ultrasounds in her 40′s. None of these came up with anything of concern, but there was plenty of anxiety leading into them. And, a biopsy is not comfortable or risk free. Come to think of it, neither is a mammogram. In fact, the radiation from repeated mammograms may actually cause breast cancer in some women. I know this is an anecdotal story, but my mother is the primo example of who this consensus opinion is talking about. These mammograms are not improving outcomes in typical low risk women in their 40′s, like my mom was when she started getting mammograms and subsequent biopsies.

Third, I had an argument with a fellow student today. He said that the public wants the extra mammograms, and they are too stupid to understand the nuance to the issue. He also said all they want is “the best care.” I said the best care is evidence based care, and that I plan on educating my patients. I do not believe in the can-I-have-fries-with-that-have-it-your-way approach to medicine. I do believe that patients’ values and opinions definitely matter. But, in the end, if a patient insists on a procedure I think will cause more harm than good, I will politely refuse and refer them to a practitioner that will accommodate them, if I know of one.

Fourth, and possibly coolest, I heard a discussion on Doctor Radio that made my nerdy day. The oncologist, Dr. Silvia Formenti, is fully supportive of the new recommendations. She also explained why there is an apparent discrepancy in breast cancer survival rates between the United States and United Kingdom, which is one of the few if only outcomes that appear better in the United States. She explained that this is a false comparison, since the denominator is different. My public health instructor has always harped about the denominator of any rate being key, but I thought it was just a nitpicky instructor thing – sure, you only include women of childbearing age in maternity rate stats, got it – but it’s more important than that. Dr. Formenti said that the reason our rates seem better is that we are currently overscreening younger women, and overtreating in situ cancers. So, our denominator is stacked with low risk women who are not really that sick. In fact, I spent too much time looking over the ACOG site for the article, but I read something recently in one of their publications that showed that a wait-and-see protocol for such cancers led to a shocking remission rate. I remember it being over 20%, but since I cannot find the article, please don’t quote me on it.

So, the denominator matters, and not just in a nit-picky way. Also, I was happy to see that the National Health Service, of which I am a fan, is not failing women with breast cancer, which was bugging me a little. What especially impressed me with her commentary was that not only is she a renowned oncologist and an attending at NYU Langone, but she practices in the United States. She could have easily said “Hooray for my team, hooray for my field, we’re kicking butt.” It’s really refreshing to hear someone value truth over seeming to be the best.

And, finally, I am a little chagrined by how many people are saying that these USPSTF recommendations are going to change the way the insurance companies reimburse mammography, and change medicine in the United States dramatically. I am still waiting for that to happen due to their recommendations of labor and delivery from November of 2008, in which many interventions are panned as inconclusively supported by evidence or detrimental to patients (such as third trimester estimation of fetal weight, denying nutrition p.o. to laboring patients, and episiotomy) and others are highlighted as extremely effective and highly recommended (e.g. upright positioning for pushing and the continuous support of a doula during labor.) I wish there was an uproar following those dramatic recommendations, but there was barely a peep. Hello, sweeping changes? Helloooooooo?

A banner day

Well, it’s been quite a day. My blog got over 1,000 hits in one day for the first time. Not bad for a part time venting project. That may sound like doodley-squat to some bloggers, but that is an avalanche for me.

Foul language warning – push the kiddies out of the room

Also, I got called a “racist cunt” on twitter solely based on this post. Right before that, the so-called feminist criticized me for attacking other bloggers, (project much?) and pointed out how stupid I was because she could see what I was saying about her, because she has a google alert on her name. Except that I already said it on the thread I linked to, (note the reply turned post nature of the post she is so incensed about) a thread she was a part of, not behind her back. And, my post only marginally dealt with her, but she has inflated that to mean it was a post obsessed with her, obviously. And, she linked to my blog (which I can see, duh!) on her twitter page.

Then she called me a racist cunt.

Way to prove a point.

I argue about racial privilege because I care about inequality. She argues about how her personal story about growing up poor is more important than all of these conversations, and twists all of these conversations to malign people of color (I’m not the only one who thinks this, she is even being accused of this by others on her own blog right now), and takes this fight to Facebook and twitter because…”It’s Personal”, according to her Facebook and twitter. It’s a shame that someone who calls herself a feminist would resort to such high school mean girls behavior, especially all in the name of denying racism and white privilege, because it’s not about her.

I am OK with the difference between these two positions. I am proud of why I am arguing what I am arguing, and I really doubt she is. It breaks my heart, a little, because we are both associated with the birth advocacy community, but there is room for both racist cunts and people who call people racist cunts in the community, and people who are both (ahem). I am officially done arguing with anyone who would resort to such tactics, however, and hope we never cross paths again.

OK, I can’t resist

I am supposed to be writing a lecture right now on anatomy and physiology during pregnancy. I learned some new terms:

souffle /souf·fle/ (soo´f’l) a soft, blowing auscultatory sound.
cardiac souffle: any cardiac or vascular murmur of a blowing quality.
funic souffle, funicular souffle: hissing souffle synchronous with fetal heart sounds, probably from the umbilical cord.
mammary souffle: a functional cardiac murmur with a blowing sound, heard over the breasts in late pregnancy and during lactation.
placental souffle: the sound supposed to be produced by the blood current in the placenta.
uterine souffle: a sound made by the blood within the arteries of the gravid uterus.

Huh. Who knew? A placental souffle. Since I heard about people eating their placentas and have cooked a few souffles (placenta free, I might add) before I heard this term used for the sound of the blowing murmur, I have an ewwww moment going on here.

And, I also just wanted to point out how problematic and difficult it is that most imagery for the medical discussion of the anatomy and physiology of pregnancy is really inconsiderate of the whole woman. I have given up trying to find images where the woman’s face and/or head and/or extremities are not severed and are either present or merely disregarded.

As it is nearly impossible and too time-consuming, I am giving up. I am using these kinds of images and discussing them in context, pointing out why they are problematic:

Mothering and feminism survey

There is a mothering and feminism survey available here.

Research progress

I have been hard at work coming up with my questionnaire for my survey of local obstetricians and gynecologists about birth interventions. I am planning on posting the completed survey when I am finished, unless there are some concerns with that. I don’t think any of my subjects read my blog, so I doubt it will add any bias to the results. Besides, it’s not like these issues are new to these practitioners. It’s not like a blog post with questions about these interventions will suddenly make them relevant to their practice.

The wording of some of the questions is based on the survey in this study by Reime et al, and many others are taken directly from ACOG position statements, USPSTF evidence based conclusions, and the like.

So far the interventions I will definitely be asking about are:

Doulas (Continuous Labor Support)
Episiotomy
Vaginal Birth After Cesarean (VBAC) and Trial of Labor (TOL) after Cesarean Section
Cesearean Section Without Medical Indication (CWMI) and Cesarean Delivery on Maternal Request (CDMR)
Upright Pushing Stage
Continuous External Fetal Monitoring (EFM) vs Intermittent
Restricting Oral Nutrition During Labor (Solid and/or Liquid)

Interventions that may be included in the survey include:

Estimation of Fetal Weight (EFW) (based on 3rd trimester ultrasound)
Routine Early Amniotomy (Artificial Rupture of Membranes (AROM) )
Oxytocin (Pitocin) Augmentation of Labor

I would like to ask about all of them. We need to make sure the survey is brief enough for the subjects to want to take the time to finish, and I plan on asking multiple questions on each intervention. I think the first list is more directly a balance of evidence based medicine and patient autonomy (which is a much more difficult concept to define than I thought, but that’s a whole ‘nother post). The second list is more practices that lead to the cascade of interventions. For example, oxytocin augmentation usually necessitates continuous EFM.

I didn’t include out of hospital births, even though I think they are an important and relevant point. I wanted to only cover practices under direct control of the obstetrician. That is also why I didn’t include skin to skin contact after delivery. I think that may more depend on the hospital policies and nursing / pediatrics team.

I just need to come up with a few questions about how they keep up with the current standards of care, and then it’s time to whittle it down.

Then, I need to work on my justification. I need to talk about patient empowerment and autonomy without sounding like too much of a militant feminist. Heh, wish me luck with that.