White fat, black art

A Canadian friend recommended the show White Coat, Black Art from CBC Radio. I have enjoyed several of the shows. There’s one on burnout, which is supposedly worst in ob/gyn. She wanted me to listen to the show on obesity. (Link to mp3 of “Fat Doctors”.)

I was kind of napping while I listened, but I played it twice and I think I got most of it. I think they thought they were showing “both sides of the issues” by having advocates for bariatric surgery, and someone who lost weight through diet and exercise. But, it was a very judgmental show. No one argued that not all obese people need to be fixed, either with surgery (which they started the show with) or diet and exercise, which the other two segments suggested.

I was struck by some of the people in the support group. Like, the one who was talking about how you could never tell a heroin addict to just take it 3 times a day in small amounts, but we expect people with food issues to self regulate food consumption. I am happy the doctor at the bariatric center emphasized that no one chooses to be morbidly obese, and no one gets morbidly obese by making poor choices.

I also kind of related to the doctor at the end who talks about being overweight and struggling with weight loss and her self image, which I am sorry to say. I feel a lot of self hate and guilt (and I have gained even more weight. I am afraid to weigh myself.)

I loved it when she said she secretly thinks “I would hate to live like that” when people give her weight loss advice and discuss strict, boring diets. I admit, people tell me about getting their “butts kicked” by their spinning instructor, and it makes me wonder if sedentary life isn’t worth it. But, I felt better about myself when I was in better shape. I like many types of exercise. It doesn’t hurt to fit in my clothes, either.

I guess it made me feel a lot of self hate, but I didn’t realize it at the time, because I am surrounded by that attitude constantly. I was just reading a maternal mortality review (pdf) today, and they were analyzing trends of BMI and maternal complications. But, I know this is a multi faceted issue. Obese women get more unnecessary interventions, including more inductions and more cesarean sections. And, the maternal mortality rate is much higher for African American women, who are more likely to be obese when of childbearing age.

I am afraid I may get passed over for a residency spot because I am obese. Spots are competitive, and are based on interviews and personal interactions with people on the team at the site. I know some people don’t think obese people make good doctors, some people think a person who is forty and obese may not be a good investment for four years, since I may succumb to some sort of fat complication, die young, and be a waste of their training. And even more people have unconscious negative reactions to fat people. We do worse in interviews, period.

Anyway, thanks for the recommendation. It was definitely worth the listen and gave me a lot to think about.

Newest, bestest KALI questionnaire, annotated

Here is the annotated survey, with an attempt at dividing the questions into domains and scaling them. So, the domains so far are K=Knowledge, A=Attitude, B= Barrier, P=Practice pattern, and Y=Autonomy of the patient. If a question says “Reversed” after it, then it is phrased in the reverse or negative compared to the evidence cited.

Sorry about the messed up formatting; I swear it looks OK in Word. I will try to edit it later today when I have more time.

The KALI Project Survey

Thank you for agreeing to participate in the Knowledge and Attitudes of Labor Interventions (KALI) survey. This survey is intended to gather information about obstetrical practice patterns. The survey is anonymous, and should take about fifteen minutes. By completing this survey, you are giving consent to be part of this study.

First, we would like to gather some information about you and your practice. Please answer these questions by either circling your answers or writing your answers in blanks provided. This information will be kept confidential.

1. You are:
[1] Male [2] Female

2. Age:
[1] 20 – 29 [5] 60 – 69
[2] 30 – 39 [6] 70 – 79
[3] 40 – 49 [7] 80 – 89
[4] 50 – 59 [8] 90 or older

3. Do you have children?
[1] Yes [2] No

4. Ethnicity:
[1] Hispanic or Latino
[2] Haitian
[3] Neither Hispanic nor Haitian

5. Race (choose as many as apply):
[1] White / Caucasian [4] Native Hawaiian / Pacific Islander
[2] African American / Black [5] Native American Indian /Alaskan
[3] Asian or Asian American [6] Other:_______________________

6. How would you describe the location of your ob/gyn residency?
[1] University
[2] University affiliated
[3] Community
[4] Other: ____________________________

7. Year of residency completion _____________

8. Which of the following most accurately describes your practice type?
[1] Public hospital
[2] Community health center
[3] University based practice
[4] Private practice
If private –
[a] Large partnership (four or more partners)
[b] Small partnership (two or three partners)
[c] Solo practice
[5] Military / government
[6] Other:____________________________________________

9. Do you currently practice obstetrics?
[1] Yes
If yes:
[a] Average clinical time spent with prenatal clients:______________(%)
[b] Average number of deliveries per year:________________
[2] No

10. Which of the following most accurately describes your personal practice scope?
[1] General obstetrics and gynecology
[2] General gynecology only
[3] Obstetrics only
[4] Laborist
[5] Maternal Fetal Medicine
[6] Reproductive Endocrinologist
[7] Gynecologic Oncology
[8] Urogynecology
[9] Other: ______________________________

11. Which of the following most accurately describes your current malpractice coverage?
[1] None / I “go bare”
[2] I pay for individual malpractice insurance
[3] My practice pays my malpractice premiums
[4] I am an employee of an institution that pays my malpractice premiums
[5] I am an employee of an organization or institution that provides legal defense but
not malpractice insurance
[6] Other: __________________________________________________

Please rate the following statements about obstetrics as accurately as possible. All questions will have this scale available for you. Please choose whether you:

[1] Strongly agree
[2] Agree
[3] Neither agree nor disagree
[4] Disagree
[5] Strongly disagree

1. _____Restricting maternal intake of all nutrition by mouth during labor prevents serious adverse maternal outcomes.(K)1 Reversed

2. _____Elective cesarean section should not be performed on a woman desiring several children.(K)2

3. _____Doulas (i.e. private labor coaches, or trained labor companions) improve maternal and newborn outcomes.(K)3, 4

4. _____Episiotomy should be avoided if at all possible. (K, A, P)1, 5

5. _____The use of continuous external fetal monitoring (EFM) increases the risk for cesarean delivery. (K)6

6. _____In the absence of maternal and fetal medical indications, vaginal deliveries confer more risk than cesarean deliveries. (K)7, 8 Reversed

7. _____Insurance should not reimburse use of doulas for labor and delivery.9 (A,B)Reversed

8. _____I employ episiotomy routinely, because it is easier to repair than lacerations that result when an episiotomy is not used. (K,P,B) 3, 10 Reversed

9. _____Fear of liability claims limit the options I present to my obstetrical patients.(B,Y,P)11, 12 Reversed

10. _____Liability insurance company policies forbid me from performing VBACs. (B,P) Reversed

11. _____Use of upright (non lithotomy) positions during the pushing and birth has no positive impact on perinatal outcomes. (K)1, 13 Reversed

12. _____The use of continuous EFM does not result in a reduction of cerebral palsy. (K)6

[1] Strongly agree [2] Agree [3] Neither agree nor disagree [4] Disagree [5] Strongly disagree

13. _____All women in early active labor should have an amniotomy (i.e. artificial rupture of membranes or AROM ) if they present with their membranes intact. (A,P,K)1, 14 Reversed
14. _____Few women would choose to have a vaginal birth after cesarean (VBAC) if they knew the consequences of uterine rupture.(Y,A,K)3 Reversed

15. _____I regularly employ episiotomy to shorten the second stage of labor and delivery. (B,P,A)15 Reversed

16. _____Low risk labor patients should be offered the option of intermittent fetal heart rate monitoring in labor.(K,A,Y)6

17. _____Elective cesarean section should only be performed after accurately determining 39 weeks of gestation.(K)2, 8

18. _____Mediolateral episiotomies result in less postpartum pain than median episiotomies. (K)16, 17 Reversed
19. _____Prior to an induction, patients should be counseled about the possible need for reinduction or cesarean delivery.(K,Y)18

20. _____The hospitals in which I attend births do not have sufficient staff to support intermittent fetal heart rate monitoring during labor.(B)6 Reversed

21. _____Most patients attempting vaginal delivery benefit from oxytocin (Pitocin) augmentation of their labor.(K,P)1, 19Reversed

22. _____I regularly employ episiotomy to prevent pelvic floor relaxation.(K,P) 3, 5, 16, 17Reversed
23. _____Hospital policies forbid me from performing VBACs.(B)20-22Reversed

24. _____If my partner or I were pregnant for the first time, I would recommend an elective cesarean delivery in the absence of any medical or obstetrical indication.(A)7, 23, 24 Reversed
25. ¬_____I have made changes to my practice because of the risk or fear of liability claims. (B)11, 12 Reversed
26. _____Childbirth is only normal in retrospect.(A)3Reversed

27. _____Clinical guidelines are useful tools for me in daily clinical practice.(A,P)25

28. _____I regularly employ episiotomy to prevent perineal trauma.(K,P)5, 15, 17Reversed

29. _____The use of continuous EFM reduces perinatal mortality.(K)6Reversed
[1] Strongly agree [2] Agree [3] Neither agree nor disagree [4] Disagree [5] Strongly disagree

30. _____ Labor induction for non-medical indications (psychosocial or logistical) should only be attempted after establishing a gestational age of 39 weeks. (K,P)18

31. _____I encourage my patients to try alternative or upright positions during the pushing stage.(A,B,P)1, 13, 26, 27

32. _____Physicians should initiate discussion of elective cesarean delivery as part of routine prenatal care. (A,P)28 Reversed

33. _____I refer patients who want to attempt a trial of labor after a prior cesarean delivery to another practitioner.(B,P,K)29, 30 Reversed

34. _____Women should have the right to refuse an episiotomy.(Y)12, 29, 31, 32

35. _____I recommend that most patients use a doula for their labor and delivery.(A,P,K)1, 9

36. _____I feel that it is a woman’s right to elect to have a caesarean section even if there are no clear maternal or fetal indications.(A)3, 28 Reversed

37. _____There is high interobserver and intraobserver variability in interpretation of fetal heart rate tracing.(K)6

38. _____Hospital standards of care or policies sometimes get in the way of optimal management of individual patients.(B)33 Reversed

39. _____I discuss the risks and benefits of episiotomies with my patients prior to delivery.(Y)31, 32

40. _____Routine artificial rupture of membranes (AROM) increases the risk of cesarean delivery. (K)1, 14

41. _____If a patient asks if she could use a doula for her delivery, I would encourage her.(Y,A)1, 4
42. _____ Time and scheduling pressures affect the way I manage labor and delivery.(B) Reversed
43. _____Most women with one previous cesarean delivery with a low-transverse incision should be counseled about VBAC and offered a trial of labor.(K)34

44. _____Episiotomies increase the risk of third and fourth degree tears.(K)5, 16, 17

45. _____Clinical guidelines are overly rigid and difficult to adapt to individual patients.(B)25 Reversed

How often do you consult the following sources regarding obstetrical practice?

[1] Never
[2] Rarely
[3] Sometimes
[4] Often
[5] Always

1. _____ACOG Practice Bulletins
2. _____ACOG Committee Opinions
3. _____Obstetrics and Gynecology Journals (e.g. the Green Journal, the Grey Journal)
4. _____Cochrane Database
5. _____Electronic evidence-based services (e.g. Epocrates, UptoDate)
6. _____Books and/or textbooks
7. _____Professional conferences
8. _____Physicians in my practice
9. _____Physicians in my local community
10. _____Physicians I trained with in residency
11. _____Physicians I consider experts in the field
12. Other sources: ______________________________________________________

Have you ever been the subject of a professional liability claim or litigation?
[1] Yes
If yes – Did the liability claim involve an obstetrical claim?
[a] Yes
[b] No
[2] No

Thank you for your time and participation!

Reference List

(1) Berghella V, Baxter JK, Chauhan SP. Evidence-based labor and delivery management. Am J Obstet Gynecol 2008 November;199(5):445-54.
(2) ACOG Committee Opinion No. 394, December 2007. Cesarean delivery on maternal request. Obstet Gynecol 2007 December;110(6):1501.
(3) Reime B, Klein MC, Kelly A et al. Do maternity care provider groups have different attitudes towards birth? BJOG 2004 December;111(12):1388-93.
(4) Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2007;(3):CD003766.
(5) Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J, Jr., Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA 2005 May 4;293(17):2141-8.
(6) ACOG Practice Bulletin. Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles. Obstet Gynecol 9 A.D. July.
(7) Gunnervik C, Sydsjo G, Sydsjo A, Selling KE, Josefsson A. Attitudes towards cesarean section in a nationwide sample of obstetricians and gynecologists. Acta Obstet Gynecol Scand 2008;87(4):438-44.
(8) NIH State-of-the-Science Conference Statement on cesarean delivery on maternal request. NIH Consens State Sci Statements 2006 March 27;23(1):1-29.
(9) Green J, Amis D, Hotelling BA. Care practice #3: continuous labor support. J Perinat Educ 2007;16(3):25-8.
(10) Klein MC, Kaczorowski J, Robbins JM, Gauthier RJ, Jorgensen SH, Joshi AK. Physicians’ beliefs and behaviour during a randomized controlled trial of episiotomy: consequences for women in their care. CMAJ 1995 September 15;153(6):769-79.
(11) Hyer R. ACOG 2009: Liability Fears May Be Linked to Rise in Cesarean Rates. MedScape Medical News 2009 May 9.
(12) Florida Liability Lowdown. American College of Obstetricians and Gynecologists; 2009 Aug.
(13) Gupta JK, Hofmeyr GJ. Position for women during second stage of labour. Cochrane Database Syst Rev 2004;(1):CD002006.
(14) Smyth RM, Alldred SK, Markham C. Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev 2007;(4):CD006167.
(15) Low LK, Seng JS, Murtland TL, Oakley D. Clinician-specific episiotomy rates: impact on perineal outcomes. J Midwifery Womens Health 2000 March;45(2):87-93.
(16) ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006. Obstet Gynecol 2006 April;107(4):957-62.
(17) Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev 2009;(1):CD000081.
(18) ACOG Practice Bulletin No. 107: Induction of Labor. Obstet Gynecol 2009 August;114(2 Pt 1):386-97.
(19) Wei SQ, Luo ZC, Xu H, Fraser WD. The effect of early oxytocin augmentation in labor: a meta-analysis. Obstet Gynecol 2009 September;114(3):641-9.
(20) Lyerly AD, Mitchell LM, Armstrong EM et al. Risks, values, and decision making surrounding pregnancy. Obstet Gynecol 2007 April;109(4):979-84.
(21) Roberts RG, Deutchman M, King VJ, Fryer GE, Miyoshi TJ. Changing policies on vaginal birth after cesarean: impact on access. Birth 2007 December;34(4):316-22.
(22) Coleman VH, Erickson K, Schulkin J, Zinberg S, Sachs BP. Vaginal birth after cesarean delivery: practice patterns of obstetrician-gynecologists. J Reprod Med 2005 April;50(4):261-6.
(23) Bettes BA, Coleman VH, Zinberg S et al. Cesarean delivery on maternal request: obstetrician-gynecologists’ knowledge, perception, and practice patterns. Obstet Gynecol 2007 January;109(1):57-66.
(24) Wu JM, Hundley AF, Visco AG. Elective primary cesarean delivery: attitudes of urogynecology and maternal-fetal medicine specialists. Obstet Gynecol 2005 February;105(2):301-6.
(25) Vinker S, Nakar S, Rosenberg E, Bero-Aloni T, Kitai E. Attitudes of Israeli family physicians toward clinical guidelines. Arch Fam Med 2000 September;9(9):835-40.
(26) Difranco JT, Romano AM, Keen R. Care Practice #5: Spontaneous Pushing in Upright or Gravity-Neutral Positions. J Perinat Educ 2007;16(3):35-8.
(27) Gilder K, Mayberry LJ, Gennaro S, Clemmens D. Maternal positioning in labor with epidural analgesia. Results from a multi-site survey. AWHONN Lifelines 2002 February;6(1):40-5.
(28) ACOG Committee Opinion No. 395. Surgery and patient choice. Obstet Gynecol 2008 January;111(1):243-7.
(29) Fenwick J, Gamble J, Hauck Y. Reframing birth: a consequence of cesarean section. J Adv Nurs 2006 October;56(2):121-30.
(30) Goodall KE, McVittie C, Magill M. Birth choice following primary Caesarean section: mothers’ perceptions of the influence of health professionals on decision-making. Journal of Reproductive and Infant Psychology 2009 February;27(1):4-14.
(31) Simpson KR, Thorman KE. Obstetric “conveniences”: elective induction of labor, cesarean birth on demand, and other potentially unnecessary interventions. J Perinat Neonatal Nurs 2005 April;19(2):134-44.
(32) Helewa ME. Episiotomy and severe perineal trauma. Of science and fiction. CMAJ 1997 March 15;156(6):811-3.
(33) Block J. Pushed: The Painful Truth About Childbirth and Modern Maternity Care. New York: Da Capo Press; 2007.
(34) ACOG Practice Bulletin #54: vaginal birth after previous cesarean. Obstet Gynecol 2004 July;104(1):203-12.

My structures list for the anatomy review

I am exhausted, folks. An old friend got married yesterday, and my 10 year old son S was in the ceremony. We have been going nonstop since Thursday. I finally crashed after the post wedding breakfast this morning, and I am almost recovered after a nap and dinner.

This week is pretty busy, too. Wednesday night I am doing a gross anatomy review tutorial for our surgical interest group. I wasn’t thrilled with gross anatomy and wasn’t sure if I would ever go back. Well, this is my second year teaching the female pelvic cavity.

Here is my structures list:

Vagina
Fornices (anterior, posterior, lateral)

Broad ligament
Round ligament /ligamentum teres
Uterus
Cervix-external & internal os, endometrium, myometrium, isthmus, & fundus,
Uterine/Fallopian tubes
Infundibulum w/ fimbriae, isthmus, ampulla

Ovarian ligament
Suspensory ligament
Vesicouterine pouch
Rectouterine pouch (of douglas)
Retropubic space
Rectum, external anal sphincter, anal canal
Vaginal artery

Doing a presentation on autism

Considering autism is something I read a lot about, whether it be scholarly research on the autism spectrum, talking with parents of autistic spectrum children, or reading the writing of adults on the autism spectrum, I am surprisingly intimidated by doing a presentation on it to my “Epidemiology of Diseases of Public Health Importance” class.

I am going to try to cover the swiss cheese that is the history of diagnosis and epidemiology of the disease, the current state of diagnostic criteria, the controversies over treatments and “cure” discussions, the controversies over the etiology, and the controversies over insurance coverage (or lack thereof) for educational settings, treatment, etc.

Ulp.

New, improved KALI questionnaire

Here is the new, improved KALI (Knowledge and Attitudes of Labor Interventions) questionnaire. Thanks for all the input. I think everyone who gave suggestions will see them reflected in the questions.

I included the demographics this time. I struggled a lot with this section, and still have a lot of guilt. I want to say I feel like I am part of the problem currently, since “gender” is a binary in my study. I wanted to include “transsexual” and “intersexed” or even “other” and a blank as an option, but my mentors nixed it. They say this is not the purpose of the study, and isn’t relevant to my study population. I have no idea if there are no ob/gyns in the tri-county area who don’t strictly identify as “male” or “female”, but I guess they are assuming there aren’t any. I caved. I did hold out for allowing people to pick more than one race. Geez.

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

The KALI Project Survey

Thank you for agreeing to participate in the Knowledge and Attitudes of Labor Interventions (KALI) survey. This survey is intended to gather information about obstetrical practice patterns. The survey is anonymous, and should take about fifteen minutes. By completing this survey, you are giving consent to be part of this study.

First, we would like to gather some information about you and your practice. Please answer these questions by either circling your answers or writing your answers in blanks provided. This information will be kept confidential.

1. What is your gender?
Male       Female

2. Age:
20 – 29      60 – 69
30 – 39      70 – 79
40 – 49      80 – 89
50 – 59      90 or older

3. Do you have children?
Yes       No

4. Race (choose as many as apply):
White / Caucasian          Native Hawaiian / Pacific Islander
African American / Black         Native American Indian /Alaskan Native
Asian or Asian American           Other:________

5. Ethnicity:
Hispanic or Latino
Haitian
Neither Hispanic nor Haitian

6. How would you describe the location of your ob/gyn residency?
University
University affiliated
Community
Other: ________________

7. Year of residency completion ______

8. Which of the following most accurately describes your practice type?
Public hospital
Community health center
University based practice
Private practice
If private –
Large partnership (four or more partners)
Small partnership (two or three partners)
Solo practice
Military / government
Other:____________________________________________

9. Do you currently practice obstetrics?
Yes
If yes:
Average clinical time spent with prenatal clients:______________(%)
Average number of deliveries per year:________________
No

10. Which of the following most accurately describes your personal practice scope?
General obstetrics and gynecology
General gynecology only
Obstetrics only
Laborist
Maternal Fetal Medicine
Reproductive Endocrinologist
Gynecologic Oncology
Urogynecology
Other: ______________________________

11. Which of the following most accurately describes your current malpractice coverage?
_____None / I “go bare”
_____I pay for individual malpractice insurance
_____My practice pays my malpractice premiums
_____I am an employee of an institution that pays my malpractice premiums
_____I am an employee of an organization or institution that provides legal defense but
not malpractice insurance
Other: ___________________

Please rate the following statements about obstetrics as accurately as possible. All questions will have this scale available for you. Please choose whether you:

1. Strongly agree
2. Agree
3. Neither agree nor disagree
4. Disagree
5. Strongly disagree

1. _____Restricting maternal intake of all nutrition by mouth during labor prevents serious adverse maternal outcomes.

2. _____Elective cesarean section should not be performed on a woman desiring several children.

3. _____Doulas (i.e. private labor coaches, or trained labor companions) improve maternal and newborn outcomes.

4. _____Episiotomy should be avoided if at all possible.

5. _____The use of continuous external fetal monitoring (EFM) increases the risk for cesarean delivery.

6. _____In the absence of maternal and fetal medical indications, vaginal deliveries confer more risk than cesarean deliveries.

7. _____Insurance should not reimburse use of doulas for labor and delivery.

8. _____I employ episiotomy routinely, because it is easier to repair than lacerations that result when an episiotomy is not used.

9. _____Fear of liability claims limit the options I present to my obstetrical patients.

10. _____Liability insurance company policies forbid me from performing VBACs.

11. _____Use of upright (non lithotomy) positions during the pushing and birth has no positive impact on perinatal outcomes.

12. _____The use of continuous EFM does not result in a reduction of cerebral palsy.

13. _____All women in early active labor should have an amniotomy (i.e. artificial rupture of membranes or AROM ) if they present with their membranes intact.

14. _____Few women would choose to have a vaginal birth after cesarean (VBAC) if they knew the consequences of uterine rupture.

15. _____I regularly employ episiotomy to shorten the second stage of labor and delivery.

16. _____Low risk labor patients should be offered the option of intermittent fetal heart rate monitoring in labor.

17. _____Elective cesarean section should only be performed after accurately determining 39 weeks of gestation.

18. _____Mediolateral episiotomies result in less postpartum pain than median episiotomies.

19. _____The hospitals in which I attend births do not have sufficient staff to support intermittent fetal heart rate monitoring during labor.

20. _____Most patients attempting vaginal delivery benefit from oxytocin (Pitocin) augmentation of their labor.

21. _____I regularly employ episiotomy to prevent pelvic floor relaxation.

22. _____Hospital policies forbid me from performing VBACs.

23. _____If my partner or I were pregnant for the first time, I would recommend an elective cesarean delivery in the absence of any medical or obstetrical indication.

24. _____I have made changes to my practice because of the risk or fear of liability claims.

25. _____Childbirth is only normal in retrospect.

26. _____Clinical guidelines are useful tools for me in daily clinical practice.

27. _____I regularly employ episiotomy to prevent perineal trauma.

28. _____The use of continuous EFM reduces perinatal mortality.

29. _____I encourage my patients to try alternative or upright positions during the pushing stage.

30. _____Physicians should initiate discussion of elective cesarean delivery as part of routine prenatal care.

31. _____I refer patients who want to attempt a trial of labor after a prior cesarean delivery to another practitioner.

32. _____Women should have the right to refuse an episiotomy.

33. _____I recommend that most patients use a doula for their labor and delivery.

34. _____I feel that it is a woman’s right to elect to have a caesarean section even if there are no clear maternal or fetal indications.

35. _____There is high interobserver and intraobserver variability in interpretation of fetal heart rate tracing.

36. _____Hospital standards of care or policies sometimes get in the way of optimal management of individual patients.

37. _____I discuss the risks and benefits of episiotomies with my patients prior to delivery.

38. _____Routine artificial rupture of membranes (AROM) increases the risk of cesarean delivery.

39. _____If a patient asks if she could use a doula for her delivery, I would encourage her.

40. _____Most women with one previous cesarean delivery with a low-transverse incision should be counseled about VBAC and offered a trial of labor.

41. _____Episiotomies increase the risk of third and fourth degree tears.

42. _____Clinical guidelines are overly rigid and difficult to adapt to individual patients.

How often do you consult the following sources regarding obstetrical practice?

1= Never 2= Rarely 3 = Sometimes 4 = Often 5 = Always

1. _____ACOG Practice Bulletins
2. _____ACOG Committee Opinions
3. _____Obstetrics and Gynecology Journals (e.g. the Green Journal, the Grey Journal)
4. _____Cochrane Database
5. _____PubMed/MEDLINE
6. _____Electronic evidence-based services (e.g. Epocrates, UptoDate)
7. _____Books and/or textbooks
8. _____Professional conferences
9. _____Physicians in my practice
10. _____Physicians in my local community
11. _____Physicians I trained with in residency
12. _____Physicians I consider experts in the field
Other sources: ____________________________

Have you ever been the subject of a professional liability claim or litigation?
Yes
If yes – Did the liability claim involve an obstetrical claim? Yes No
No

Thank you for your time and participation!

IRB ups and downs

So, my research project got approved by expedited review yesterday by a representative of our Institutional Review Board (IRB). I am fond of this particular reviewer. He is an M.D./J.D., which is impressive in itself. He has a bronze star. He fought in Vietnam. He was a sheriff. He was a state legislator. He was a head and neck surgeon. He ran the correctional medical system in Florida for a while. Now he’s a professor at our school on many surgical topics, on Medical Ethics (he wasn’t the one who I had issues with) and on Medical Jurisprudence. I like to joke around that he’s training to be an astronaut next.

Well, he read through my IRB application. Since my project is a simple survey with no compromising or legally sensitive questions of physicians, who are not a vulnerable population, it qualified for an expedited review. But, the reviewer warned me that even though the IRB committee should not override his approval, it was still a possibility. I got hints of political undercurrents in his explanation.

Well, apparently they were warranted. I got an email telling me to not perform my study on any human subjects yet! I need to go talk to the chairman of the IRB, since my mentor is on the IRB and is one of my coinvestigators. Even though she isn’t the one who performed the expedited review. Even though the same situation is true for the other research fellow (my fellow fellow), who was approved last week by the same reviewer performing a similar expedited review. So, I am going to keep my head low, and forward the information on to the reviewer and my mentor and see what happens.

I don’t anticipate there will be any major problems in getting my study approved, since it really is a low risk study with a focus well within the normal boundaries of medical academic research. I think this is the typical kind of static one encounters when dealing with anything with the term “institutional” right in the name.

So, I’m treading water. I did take all of the suggestions on my questionnaire that were offered, and I want to thank everyone for their time and good ideas. I think my questionnaire was unquestionably improved. I will post an updated version soon.

The KALI questionnaire

This is the survey on labor interventions that will be my research project for my fellowship. Many of these are taken from other studies, position statements, practice bulletins, and meta-analysis conclusions. There is also a demographics and practice description portion of the questionnaire, which I did not include in this post. The target population will be practicing ob/gyns in a certain geographical area. Please let me know what you think.

Keep in mind that the question are supposed to be mixed to prevent bias based on how they ordered are in conjunction with other questions on the same topic, and they are mixed in positive and negative phrasing, and mixed in whether they are talking about practice, knowledge, attitudes or future intentions.

Here it is:

Please rate the following statements about obstetrics as accurately as possible. All questions will have this scale available for you to choose to most appropriate response:

1. Strongly agree
2. Agree
3. Neither agree nor disagree
4. Disagree
5. Strongly disagree

1. Restricting maternal intake of all nutrition by mouth during labor prevents serious adverse maternal outcomes.

2. Elective cesarean section should not be performed on a woman desiring several children.

3. Doulas (i.e. private labor coaches, or trained labor companions) improve maternal and newborn outcomes.

4. Episiotomy should be avoided if at all possible.

5. The use of continuous external fetal monitoring (EFM) increases the risk for cesarean delivery.

6. In the absence of maternal and fetal medical indications, vaginal deliveries confer more risk than cesarean deliveries.

7. Insurance should not reimburse use of doulas for labor and delivery.

8. I employ episiotomy routinely, because it is easier to repair than lacerations that result when an episiotomy is not used.

9. Fear of liability claims limit the options I present to my obstetrical patients.

10. Use of upright (non lithotomy) positions during the pushing and birth has no positive impact on perinatal outcomes.

11. The use of continuous EFM does not result in a reduction of cerebral palsy.

12. All women in labor should have an amniotomy (i.e. artificial rupture of membranes or AROM ) if they present with their membranes intact.

13. Few women would choose to have a vaginal birth after cesarean (VBAC) if they knew the consequences of uterine rupture.

14. I regularly employ episiotomy to shorten the second stage of labor and delivery.

15. Low risk labor patients should be offered the option of intermittent fetal heart rate monitoring in labor.

16. Elective cesarean section should only be performed after accurately determining 39 weeks of gestation.

17. The hospitals in which I attend births do not have sufficient staff to support intermittent fetal heart rate monitoring during labor.

18. Most patients attempting vaginal delivery benefit from oxytocin (Pitocin) augmentation of their labor.

19. I regularly employ episiotomy to prevent pelvic floor relaxation.

20. If you or your partner were pregnant for the first time, would you choose / recommend an elective cesarean delivery for yourself or your partner in the absence of any medical or obstetrical indication?

21. I have made changes to my practice because of the risk or fear of liability claims.

22. Childbirth is only normal in retrospect.

23. I regularly employ episiotomy to prevent perineal trauma.

24. The use of continuous EFM reduces perinatal mortality.

25. I encourage my patients to try alternative or upright positions during the pushing stage.

26. Physicians should initiate discussion of elective cesarean delivery as part of routine prenatal care.

27. I refer patients who want to attempt a trial of labor after a prior cesarean delivery to another practitioner.

28. Women should have the right to refuse an episiotomy.

29. I encourage patients to use a doula for their labor and delivery.

30. I feel that it is a woman’s right to elect to have a caesarean section even if there are no clear maternal or fetal indications.

31. There is high interobserver and intraobserver variability in interpretation of fetal heart rate tracing.

32. Hospital standards of care or policies sometimes get in the way of optimal management of individual patients.

33. I discuss the risks and benefits of episiotomies with my patients prior to delivery.

34. Routine artificial rupture of membranes (AROM) increases the risk of cesarean delivery.

35. Most women with one previous cesarean delivery with a low-transverse incision should be counseled about VBAC and offered a trial of labor.

36. Episiotomies increase the risk of third and fourth degree tears.

37. Clinical guidelines are useful tools for me in daily clinical practice.

38. Clinical guidelines are overly rigid and difficult to adapt to individual patients.

How often do you consult the following sources regarding obstetrical practice?

1= Never 2= Rarely 3 = Sometimes 4 = Often 5 = Always

1. ACOG Practice Bulletins
2. ACOG Committee Opinions
3. Obstetrics and Gynecology Journals (e.g. the Green Journal, the Grey Journal)
4. Cochrane Database
5. Electronic evidence-based services (e.g. Epocrates, UptoDate)
6. Books and/or textbooks
7. Professional conferences
8. Physicians in my practice
9. Physicians in my local community
10. Physicians I trained with in residency
11. Physicians I consider experts in the field
12. Other ____________________________

My head hurts

Today was a long day back under the fluorescent lights and in front of a computer screen. I like this fellowship because it allows me to do research, and I am confirming that I like academia. But, I definitely know I want to have a clinical practice. I am not liking being back in an office all day, every day.

So, after having to deal with defending Obama from being called a Nazi and a socialist, and helping with an ob/gyn interest club meeting, and being filmed for a promotional video for the medical school, I was trying to sit at my desk and fight my headache when I got a message from a friend of mine who is on his ob/gyn rotation.

He is rotating with a team of our professors, one of which I have already complained about. Well, everything he told me about what he has learned so far made my head explode message by message. I will give you a play by play:

He got to see a woman have a cesarean for a 4,300 g baby. He called the baby “macrosomic”. ACOG recommends that macrosomia should be defined as 4,500 g and up.

The physicians told him they cut episiotomies for every vaginal delivery. They told him “She’ll tear anyway.”

They do cesareans on whoever they can convince and then call it an “elective cesarean.”

The female ob/gyn told my classmate that in the 80’s the “trend” was toward cesarean section, and in the 90’s the “trend” was toward vaginal delivery because people wanted to get “back to nature.” Yeah, because anyone who wants to avoid major abdominal surgery with worse outcomes for the mother and the baby obviously is a crunchy hippie who is just following the latest trend. Evidenced based what?

She also told him that African American women (she is one, by the way) do not have adequate pelvises (pelvii?) to deliver vaginally. I know anthropoid pelvises (pelves?) are more likely in African American women, but they seem to have reproduced and delivered for millions of years without having a race wide dystocia.

That’s all I can remember. I better not have to do a rotation with them. I will switch, mainly because they have a very light practice and I want to see a lot more deliveries. But, I would also spend the entire time arguing with them or biting my tongue as my head exploded, and would probably fail the rotation when I need to pass my ob/gyn rotation with honors.

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.

USMLE and COMLEX

OK, I’ll do another post for the medical students out there.

I took both the USMLE and COMLEX board exams. I went through the decision making process behind that choice, if you’re interested and missed it.

I figured I would follow up and post how I did. Unlike the posters on studentdoctor.net, I decided I would post about my performance even if I didn’t knock them out of the park. I passed both exams. I did better on the COMLEX than on the USMLE. I scored above the mean on the COMLEX and below the mean on the USMLE. Only 60% or so of osteopathic medical students pass the USMLE, so on one level, I guess I should be relieved. I still wish I had done better.

I have many excuses and regrets about my board prep. I wish my house hadn’t flooded, I wish I had spent more time on the high yield, I wish I had taken a Sudafed the morning of the USMLE. I can only look forward to the Step II and hope I ace it. According to an OMS IV I know, as long as I scored above 200 on the USMLE, I will make the cut off for most residencies. I checked APGO.org’s ob/gyn residency database, and it can be hard to tell. Some residencies post the average Step I score of their residents, but don’t publish a minimum score to be considered for interview. Some publish a minimum score but no average. I haven’t seen a program that posts both yet, and some have neither. One program I am interested has a cut off of 190, so I would be fine. Another program that I am not really interested in, but is closer to my home than many other programs, has a cut off just above my score, and wants you to be ranked in the top half of the class. As of right now I am just under that. Close to both, but no cigar.

I am doing a research fellowship, I was the president of our ob/gyn interest club, and had leadership positions in other related clubs. I hope to kick butt on rotations, including electives at sites where I want to apply, and on my Step II. I have never failed a class or had to remediate.

But, I look at these residency info pages at APGO and get nervous. 600 medical students applied for 9 slots at my first choice Their average USMLE score posted, which is the 220 mean I scored just below, and no minimum score is posted for interview. 200 people applied for 4 slots my second choice. Their minimum USMLE Step I is 200, which I beat, and minimum GPA is passing. No average score for current residents. My third choice (which is my heart’s first choice but is the most geographically undesirable, family wise) had 480 applicants for 7 slots. They don’t post an average score, and their cut off for interviewing is 190.