Tag Archives: Medical Establishment

Reply turned post, Trisomy 18 and mental masturbation style

I can get really frustrated by people who enter into philosophical arguments about serious medical ethics questions online. Many of these people have a definite agenda, often controlling access to abortion, but try to couch it as some sort of intellectual exercise. Many of these commenters are men who toss around large words like “autonomy” and “qualitative determination.” This happens all over the interwebs, and I know better than to spend my time hunting down every blowhard that litters a comment section with his ideas on viability and fetal rights.

However, I clicked through a link on my Washington Post headline newsletter on Trisomy 18, since it is a topic that genuinely interests me. Presidential candidate and notorious crusader against contraception and abortion Rick Santorum has a daughter with Trisomy 18, one who is questionably lucky to have survived the few years she has, and has been hospitalized yet again. I was generally pleased with the accuracy and tone of the article. I hesitantly stumbled into the comments section, and then happened upon a perfect example of what I like to refer to as mental masturbation, from a commenter named “johnbmadwis”, which he wrote in response to a comment drawing the logical connection between the suffering and medical expense of Santorum’s daughter, and his position on the ability of other families to choose this road for themselves:

But haven’t you just made Santorum’s point and fueled the fire of the pro-life proponents? That is, the pro life advocate’s long held belief that abortion rights advocates are not really talking about rape and incest, but rather personal evaluations of the quality of life of the fetus or externalities such as heartache and expense. Regardless of the condition of the fetus, pro life advocates would say society has a moral interest, they’d say imperative, in preserving the life of such a fetus from individuals such as yourself, who may want to terminate that life due to such condition. At what point, if any, does that societal interest give way to individual autonomy? Would you truly advocate for the ability to terminate that life after birth? in the last weeks of pregnancy? 3rd trimester? viability? Whatever the point, what is the guiding principle? Individual autonomy? Quality of life? (determined, assuredly, by one other than the one whose life is at stake – so, whose individual autonomy?) at what point does one achieve individual autonomy? Does a fetus have individual autonomy At some point the life of the fetus does, presumably, outweigh the individual’s autonomy, right? When? Is individual autonomy equally valid if it were exercised for clearly base purposes such as mere inconvenience or desire, say, to have a boy instead of a girl? Who should make that qualitative determination? Society? The individual carrying the fetus. The affected fetus? The personal choice of a couple does affect the life of another human being in your scenario, so, it is reasonable to ask you when, if ever, do you believe that personal choice must give way to other principles or interests?

My reply, which was thankfully limited by a character limit, is here (I added a few hyperlinks to this version, but otherwise it is unchanged):

@johnbmadwis, these questions have been answered by courts and medical ethicists. There is an obvious glaring difference in autonomy between a child who is already born and a fetus, whose existence depends entirely on the mother, whose life is intimately affected and at risk by carrying a pregnancy. Late term abortions (post viability) are extremely rare, and most states have strict limits on the conditions under which such procedures can be performed.

If you are worried about a slippery slope, it is pretty obvious the slope has been tilting towards restrictive legislation limiting all abortion, not just the dramatic but rare cases you bring up. More than 400 bills have been proposed recently in state legislatures seeking to place barriers on access to abortion, from extended waiting periods for all terminations, overreaching excessive requirements for providers and facilities that don’t extend to other, riskier outpatient surgeries, to personhood bills for fertilized eggs.

Trisomy 18 is a serious condition that is considered mostly “incompatible with life.” Not only is the fetus likely to die in utero, but if it survives, it is likely to die as newborn. The article (mostly) covered this really well. (We do know the “cause” of most trisomy 18 – nondisjunction during meiosis II – which is much more common the longer the egg has been in a suspended state of meisosis, i.e. in older mothers).

Santorum’s daughter is lucky in some ways to be a 1% in more ways than one, but this is more than just some sort of ethical masturbation in a comment section of a blog. This issue involves the emotional and physical challenges to the mother. Have you ever carried a fetus, commenter with a male sounding handle? Have you ever had a stranger put their hand on your belly and ask when you were due, when you knew the fetus would most likely die before birth, or soon after? Then there’s the suffering of the baby if it survives, and the emotional toll such care takes on caregivers – do you have any idea what it is like to work in a NICU on suffering, terminal infants? With major cutbacks in personnel in public hospitals, too.

Not to mention the health care dollars arguably misproportioned here. I got to tell pregnant mothers with no insurance yesterday that they had to pay full price, cash up front for necessary basic lab tests. These are mothers who don’t have husbands flying around the country campaigning for president. These are mothers who may and do skip important labs, or prenatal visits, because they have to choose between knowing if they have hepatitis B or food for their existing children. We got to tell a mother who was having her fourth baby and desired a tubal ligation that there was no funding anymore for it. She could pay $1400 up front to the clinic then pay more in hospital fees. Maybe she could google birth control – oh, wait, she probably doesn’t have a computer.

Enjoy wringing your hands about the autonomy of a trisomy 18 fetus. It’s a luxury.

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When good care isn’t emotionally driven care

Hello, folks! I am slowly getting over not matching. Slowly. I am trying to strategize for the next match. And, I’m trying to take care of myself, emotionally and physically, in the aftermath.

In the meantime, I am on my last rotation for medical school. It is a “rural selective”, which is a required elective at a rural or underserved location. I am fulfilling it at a local community health center in the women’s health department. Fun!

I am taking part in a day long orientation today. In one of the presentations, the speaker had a point on one of the slides about mandatory reporting, and included all domestic violence as falling under that category. I rose my hand and suggested that we had been trained that elder abuse and child abuse fell under that category, but other domestic violence did not. I couched that statement by saying it was controversial and I didn’t say I necessarily agreed (although I do).

One of the other attendees got very perturbed by my correction, and said I was wrong. I said I disagreed, politely. The speaker and several other attendees said they thought I was correct, and one pointed out that other vulnerable adults, such as someone with a disability, also fell under the mandatory reporting group. At the end of the speaker’s presentation, the offended woman called me out specifically, and again told me I was incorrect, but again, had nothing to back herself up other than her strong emotional response. Since this was a training on legal requirements of the job and privacy, and this population definitely would include adult victims of domestic violence, I decided to look up the law.

When I located the appropriate information, I read it out loud to the group. This nursing CEU was the first good site I found, and it had very complete information. I read this part:

Intimate Partner Abuse

Florida statute 790.24 requires healthcare providers to report gunshot or life-threatening wounds or injuries. Obviously, this does not cover the majority of injuries sustained in IPV. However, reporting suspected domestic violence without the informed consent of the victim is unethical and may cause the abuser to retaliate.

She interrupted me and said “SEE? You have to report gunshot wounds!” and I continued to read the rest of the quote. Then she angrily said “Well OF COURSE you need their informed consent!”, and I countered “Well, then that’s not mandatory reporting, is it?” She got more agitated, and started pacing the room, telling me I am saying to send these women home to get killed. I said no, and tried to explain, again, the rationale of establishing trust with the patient, many of whom are not at a place where they are ready to leave or press charges. She said she would definitely report ANY case she saw of suspected intimate partner violence, and said she didn’t want these women killed. I said that they may not press charges, and then may not trust health care practitioners again, and still get killed.

I know that IPV is a sensitive, triggering topic for many, including me. I was in a relationship with verbal and emotional abuse, and trust me, if people came on too strong about me leaving him when I wasn’t ready to, I avoided them in the future. I would not come to them when there was an incident, because I didn’t want a lecture of how it was my fault for staying. When we went over this in medical school (and I was still in my abusive relationship), one member of my small group said she was a victim of physical violence in a past relationship, and she would absolutely never press charges, she would lie to any health care practitioner or official about it, and defend him under any circumstances, when she was still in the relationship.

These victims already feel an enormous lack of control. It is not our job to control them or act for them. It is our job to be there for them on their terms. Even if it gets us emotional.

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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.

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Lamentations

Please, run, don’t walk, to the series called Lamenting the System at the Unnecesarean. It is a series of responses from practicing ob/gyns to an article called “An Obstetrician’s Lament” by Annette E. Fineberg, MD, which was published in the Green Journal (ACOG’s Obstetrics and Gynecology) this month. The Navelgazing Midwife reproduced the article in its entirety here.

Jill, blogmistress (I love that word!) at the Unnecesarean sent me a copy of the original article right before she started the series. It couldn’t have been better timing. My attending physician (in my pediatric ER rotation) was giving me a similar lecture to one I have gotten from almost every physician I have worked with – a lecture about what the “real world” was like, and how, in the “real world”, you couldn’t afford to offer VBACs. I argued about how VBACs were no riskier than primary vaginal deliveries, and how refusing to allow them flies in the face of expert consensus and ethical responsibility to the autonomy of the patient.

Then, I got the email from Jill. I eagerly read passages aloud to the intern sharing the service with me. She is a good friend and is leaving to start an ob/gyn residency in July. She is kind and open minded, but she did not have the benefit of training in a freestanding birth center with lots of spontaneous, natural births and plenty of successful VBACs, like I did. She has been subjected to as many if not more lectures on the “real world” as I have, and has probably only seen conventional hospital births with all of the constraints and interventions of modern obstetrics.

I read many passages, to her, including this one:

Each of these women deserves an honest discussion about the fetal and maternal risks of each birthing option. However, our lack of experience as obstetricians colored by our fear of liability is narrowing women’s choices, and sometimes motivating them to ignore fetal and maternal safety in an effort not to be coerced into unnecessary interventions. I sense a mounting tension, because many obstetricians do not have the willingness, time, or skills to provide maternal choices.

All of the articles in the series are good, but I especially love An Obstetrician’s Hope, the last one in the series, by David Hayes, MD. Every word in his piece spoke to me and to the type of practitioner I want to be. On the one hand, I am overjoyed to read of a physician supporting and attending homebirths, and even happy to see more obstetricians who support and attend homebirths in the comments. I am saddened, though, that he is leaving his practice here (although joining Doctors Without Borders is fantastic for him and the people he will help).

Here is an excerpt:

A woman choosing to have a home VBAC rather than be forced to have a repeat C/S in her local hospital is making a rational decision given the data we have available, a decision which we should be prepared to support if we cannot offer her a better alternative. I have delivered several hundred VBACs in the past several years without incident. In the same time frame, my local hospital has lost at least 3 mothers during or shortly following cesarean deliveries.

U.S. obstetricians have already come to the crossroads and have taken the wrong path. It can be fixed, but they need to start having honest and open discussions among themselves about the real maternal and fetal risks, about the rampant rate of unnecessary induction which leads to unneeded cesarean delivery, about the continued use of continuous fetal monitoring, restricted movement, withholding of nutrition, unneeded augmentation of labor, artificial rupture of membranes, epidural anesthesia and even multiple cervical exams, none of which have any proven benefit and all of which contribute to increased morbidity and even mortality.

Please go read the whole article, and the rest in the series.

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When routine care is not evidence based care

I am studying for my shelf exam (my end of rotation exam, for those of you not well versed in the jargon) on ob/gyn. I am using one of a popular series of board review books. Every single question in the chapter on intrapartum fetal monitoring had the use of an intrauterine pressure catheter (IUPC), and most mentioned a fetal scalp electrode.

Shudder.

I am not sure what the prevalence is of IUPC use. I have not seen it in most of the labors I have been to, but I have definitely seen them used. In one labor I went to, the IUPC and/or fetal scalp electrode had to be replaced three times because of problems.

As far as I know, there is no evidence supporting their use. I found this article, which is a rare randomized trial with a significant number of subjects. There seems to be no advantage to using them. When that is the case, I think it is only ethical to use the less invasive intervention, which would be external monitoring.

There are a few quotes I find interesting in this article. Here’s one:

“The American College of Obstetricians and Gynecologists (ACOG) and the Society of Obstetricians and Gynaecologists of Canada (SOGC) advise the use of internal tocodynamometry in selected circumstances, such as when the mother is obese, when one-on-one nursing care is not available, or when the response to oxytocin is limited. The Dutch Society of Obstetrics and Gynaecology recommends its use in all cases of induction or augmentation of labor.2″

Well, I have never seen one to one nursing in labor and delivery in a hospital. Never.

Also, here’s another one:

Induction or augmentation is necessary in approximately 20% of all deliveries, and internal monitoring is thought to quantify the frequency, duration, and magnitude of uterine activity more accurately than does external tocography.1-3″ (Emphasis mine)

Wow, really? Unfortunately, there are poor statistics on the prevalence of interventions in labor, but Listening to Mothers cites an induction rate of 48% for first time moms, and “Only 41% of the women had a labor that began on its own.” This link didn’t have the statistic for augmentation, but from what I remember, more than 70% of labors were augmented by oxytocin.

So, 20% of that is necessary, and what does that make the rest? Depends on who you ask. Some practitioners will say it is active management, aka “doing what we can to get the baby out…that’s what you’re here for.” I call it excessive interventions that lead to possible iatrogenic risk.

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Catching Babies Blog Series: Refusal, Rights and Balance

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

Hilary: Hi J.D.,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

*******

Other posts in the Catching Babies Blog Series:

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

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Catching Babies and Match Day

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

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

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