Tag Archives: Musings

Floating

backyardAlmost seven years ago, I was sitting in a dive bar* with some friends from college. We had moved to different cities after our various undergraduate experiences, and rarely got to see each other. I sat across from them and another mutual friend and coasted on bliss. I relished the comfort and joy of having beer in a bar playing punk music with people who shared so many touchstones with me – concerts, people, places, parties. People with whom I could talk in shorthand. I felt connected in a way I hadn’t in years, years that seemed brimming with pregnancy, parenthood, divorce, work, classes, exams, but not a lot of effortless connection.

But, underlying that social happiness was a buzz of elation because I had just found out that I got accepted into medical school. It was an unexpected, against the odds, fantastic dream fulfilling surprise. I applied late in the application cycle, and had to fight to even get my application considered. I was told to retake the MCAT due to the scores being just too stale to count, even though it was safely within range to be considered. I crammed for the exam in 6 weeks. I hadn’t had a physics class in 5 years. I somehow even improved my score, but was told the application window had just closed. I begged my plight to the young chipper voice at the other side of the phone line who told me just to wait until the next cycle, and I would surely be invited to interview. “Please,” I pleaded. “I’m 34.” I got the interview. I brought the application administrative staff home baked cookies. No joke. And I make awesome cookies.

So, I sat there in the bar with a stupid grin on my face, and I was hyper aware of everything. The delicious beer, the laughter, the music, the horrible overpriced art in the decor, and the strange elation in my chest of a scary dream coming true at that brief, delicious moment in time that the dream is true, but isn’t reality yet. Medical school was just a bunch of fantasy and hopes, not grueling hours of studying and gross anatomy. I was able to spend a night out with my friends on a Saturday still, without the endless string of Monday exams to come for the two years. I promised myself to hold on to that moment, and to never take for granted how wonderful it was to have a dream come true.

Today, I am sitting in my back yard. I recently moved. My house is finally mostly settled. I have a lovely little spot just outside my kitchen on my tiny patio under the awning, with my fragrant potted rosemary bush and subtle wind chimes. The breeze still has a touch of that gorgeous March coolness to it that lingers every year in Miami just a few weeks longer than my cranky cynical mind thinks it should. There are birds and butterflies and bustling neighbors in the background. I have things to do – dishes, laundry, shopping, even more unpacking, but I have time. I don’t have the kids this part of spring break. I am on a light outpatient rotation. I was able to sleep in. I took a deep swig of my coffee and closed my eyes, and felt the breeze. I felt elated. Yes, it’s wonderful to relish these last lovely mornings before Miami gets unbearably hot and muggy. But, I have an underlying elation in my chest.

I got accepted into a brand new obstetrics and gynecology residency. I found out during the shortest and most wonderful interview of my life this Friday afternoon. I am more than halfway through my second year of a family practice residency. I applied to a very geographically limited number of obstetrics programs when I was finishing medical school. I interviewed at several, but didn’t match at any. There’s only one program within 500 miles of where I live and share custody of my boys. The next year, I applied again, and got invited to more interviews. These interviews were at wonderful programs in places where I didn’t know a living soul, like Macon Georgia and West Virginia. In the meantime, I was struggling through 80 hour workweeks that included 6 night shifts in a row. I rarely saw my kids. I rarely saw my friends. I rarely saw daylight. I slowly cancelled all of my out of town interviews, one at a time, as they approached, because I couldn’t see surviving an intern year in an obstetrics and gynecology residency, which would be more grueling than the one I was in, and not have the family support I did here. I also wasn’t willing to move and leave my boys behind. Again, I interviewed at the only local obstetrics and gynecology program. Again, I didn’t match there.

I worked through my second year of family practice residency this year without thinking of reapplying to obstetrics. A new program opened up in Kissimmee, which is about 4 hours north of here, and my oldest son said he wouldn’t move with me if I applied and got in there. This is the first time he said he wouldn’t even go. The interview season came and went, merely a wistful blip on my radar. The osteopathic match drifted by, and the allopathic match started releasing results this week.

Except, I just found out a week ago that a new program got approved. I have heard rumors and rumbles of new at least six new obstetrics programs being opened for over seven years of medical school, fellowship and residency, and none of them had materialized. I never heard a whisper about this program. What’s even more bizarre, I had done a 4th year rotation with the director of obstetrics there, and she must not have known of the possibility yet, and I just finished a four week rotation in their family medicine department with one of their medical directors, who didn’t mention it. Oh, and one more thing. THIS SITE IS LESS THAN A MILE FROM MY HOUSE.

After a flurry of emails, research and phone calls on my part, I procured a phone interview with the new obstetrics residency director and graduate medical education director. It was a five minute interview with two of the nicest people I’ve ever known for five minutes. They had my CV. They had been told about me by the director of obstetrics at the site, by the clinical education director at my medical school, and others. They wanted me, I wanted them, and the match already happened, so they could recruit me directly.

I was ecstatic. My dream came true, again. In fact, my dream from that night 7 years ago included my eventually becoming an obstetrician. That was the promised land at the end of my reverie that night at the bar. It was becoming harder and hard to access that place of joy and thankfulness when I struggled as a family practice resident. Part of the dream had not materialized. I hated to say “Sob, woe is me! I’m going to be a family practice physician!” and realized how stupid and obliviously privileged and ungrateful that sounded.

But today, the dream is realized. It’s still sinking in. And I still have a day well rested and quiet to sit and relish in the fantasy of getting my dream job.

“My goal in life is to unite my avocation with my vocation,
As my two eyes make one in sight.” – Robert Frost

So, one more cup of coffee. One more pause before I get to the dishes in the sink. Because this is the feeling I will be tapping into when I’m exhausted on the labor floor, when I’m struggling with learning a new surgery, when my kids and I are fighting because I’m exhausted and they are resentful because I don’t seem to have quality or quantity time with them. The breeze, the calm, the sounds, and the elation.

*I love that when I googled the name of the bar, a box popped up with information about the hormone prolactin.

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Apology accepted…I guess?

Howdy, interwebs. I have been blogging a lot less than I used to. For those of you that haven’t been around for the long haul, I used to post a lot, and I would dive in to controversial topics often. But, I cut down on my blogging for many reasons, not the least of which is how divisive and angry people can get online, and how annoying it gets to rehash the same arguments over and over.

Well, every now and then I get pulled back in. Here is where I should warn the more sensitive of my readers that there will be some four letter words coming, because of the, um, writing style of the person involved. Today, when I woke up, one of my Facebook friends posted a link to this post about white privilege by a certain contentious blogger. It starts with “Years ago, some feminist on the internet told me I was “Privileged”. “THE FUCK!?!?” I said.”

Sigh.

Let’s hop on the wayback machine. I was that feminist. Here is the original post, if anyone wants to follow the sordid path. It wasn’t even a touchy post about white privilege, with nuance about class. It was a post about a blatantly racist display in which Obama was compared to a monkey. She still couldn’t handle it, and wanted to make the discussion about how she was poor as a child, and how mean black people were to her. She didn’t say “THE FUCK?!?!”. She accused me of reverse racism, and proceeded to call me a “cunt” who was “stalking” her (when she was posting on my blog, not to mention the cognitive dissonance of being a feminist who uses either term in that way…huh?) on twitter. She also used my real name and location on twitter, even though she was well aware that I was blogging anonymously at the time. This led me to “coming out” and subtly changing the way I discussed my patients, friends and medical school -> doctoring on here.

Here is where I was a “good feminist” as she called me in the post I saw on Facebook, and linked to many resources for her to learn about the concept of white privilege, and the BS that is so-called reverse racism.

She still hadn’t learned the lesson when we interacted here on the Unnecesarean, which all you old timers will remember was a hugely popular blog at the time in the natural birthy circles.

Now, on the one hand I am happy that she has at least woken up to the reality of white privilege, including her own. I am happy that she has spent the past few years working on her blog readership, while I have spent that time becoming a doctor and letting my blog languish, and she is getting the information out to many people. I may not agree with her, often, and honestly avoid her like the plague, as do many old timers from the natural birth blogosphere. I didn’t even find out about this post from November until today. I definitely have a problem with her lack of civility. She has gone from saying that I’m a cunt to saying “Lord help me, if I have to explain Privileged one more F*CK*NG time today. Seriously? LOOK IT UP. White? Privileged. Straight? Privileged. Man? Privileged. Got food? Privileged. American? Privileged. Health Insurance? Privileged. Please for the love of god if you think you’re a feminist, LEARN ABOUT PRIVILEGE.” I guess that’s an improvement?

So, I can’t comment on the latest post in which she has promoted me from a “stalking cunt” to a “good feminist” who introduced her to intersectionality and white privilege. I’m not a paying member, and I doubt my comment would get through her cadre of moderators. She is not well known for allowing any negative comments about her, at all, on any site she has control over. Please note I did not ban her from my site or moderate her comments. I politely asked her to, in my own nice way, to “Seriously? LOOK IT UP.” (her words now) before she came back to discuss the topic.

I still want to remind her of the concept of white women’s tears, which I explained to her back when this all started. She still spends almost the entire post about white privilege talking about her poor upbringing. Listen, I am sorry about every time she was cold and hungry. Poverty = horrible. I am a class warrior with the best of them, trust me. But, if you still spend every discussion of white privilege talking about how poor you were when you were a little white girl, you are still missing the point.

This poem is by a Native American poet named Chrystos

Those Tears

of a white woman who came to the group for Women of Color
only
her grief cut us into guilt while we clutched the straw
of this tiny square inch we have which we need
so desperately when we need so much more
We talked her into leaving
which took 10 minutes of our precious 60
Those legion white Lesbians whose feelings are hurt
because we have a Lesbians of Color Potluck
once a month for 2 hours
without them
Those tears of the straight woman
because we kicked out her boyfriend at the Lesbians only
poetry reading where no microphone was provided
& the room was much too small for all of us
shouting that we were imperialists
though I had spent 8 minutes trying to explain
to her that an oppressed people
cannot oppress their oppressor
She ignored me
charged into the room weeping & storming
taking up 9 minutes of our precious tiny square inch
Ah those tears
which could be jails, graves, rapists, thieves, thugs
those tears which are so puffed up with inappropriate grief
Those women who are used to having their tears work
rage at us
when they don’t
We are not real Feminists they say
We do not love women
I yell back with a wet face
_Where are our jobs? Our apartments?_
_Our voices in parliament or congress?_
_Where is our safety from beatings, from murder?_
_You cannot even respect us to allow us_
_60 uninterrupted minutes for ourselves_

Your tears are chains
Feminism is the right of each woman
to claim her own life her own time
her own interrupted 60 hours
60 days
60 years
No matter how sensitive you are
if you are white
you are
No matter how sensitive you are
if you are a man
you are
We who are not allowed to speak have the right
to define our terms our turf
These facts are not debatable
Give us our inch
& we’ll hand you a hanky

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Should I go to medical school? An advice column.

Check out my post over at Mothers in Medicine:

Should I go to medical school?

It is an answer to a series of emails I have received over time asking me advice about the whole single parent medical school doctor used to be in the natural birth community thing.

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Breaking the silence

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

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

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

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

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

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

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

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

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

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“Life” as a single mom in internship

It’s life, Jim, but not as we know it…

I am blowing the cobwebs off of the blog once again. I have a rare moment to write. Well, it’s not like I don’t have a lot of other things I could or should be doing, but I can’t pass up this quiet pause.

I am just over two weeks into my intern year. I am doing a traditional rotating internship at a local hospital. I volunteered to be on nights first. For the night float, I am working 6 nights a week, and an average of about 10 hours a night. Our team does admissions into the hospital from the ER, handles house calls, and helps run rapid response codes and code blues. As busy and frustrating as the job can be, it is not horrible. I love the people I work with. We have a great team, and I really like the people in the graduate medical program in general.

I am happy because I have gotten to handle a few emergency night gynecology admissions for my favorite attending physician in the hospital, a gynecologic oncologist. I also have gotten to handle a few psych admissions. Psych is my second love. The other members of the team gladly let me handle these cases. I know what to do on a lot of basic house calls now. I got to help save a woman’s life, a patient who coded and ended up having a massive heart attack.

I am naturally nocturnal, so the nights thing isn’t killing me so much. It is really difficult to have a life outside of the night float, however. One of my sons is mostly traveling with his father, and my other son is in camp and is spending nights at his grandmother’s house. That is why I volunteered to do my 4 weeks of nights now. I try to see them every day that I can. Sometimes it is only for a brief visit, after I wake up and before I head in for my next shift. I have one day off a week. The last one I spent dozing off on the couch. I had to spend the day today at an excruciating orientation. I had to flip my schedule to days for two days in order to attend it. As my friend and fellow expert in scatolgical therapy told me, this kind of sleep deprivation would turn her into a “drooling turd sandwich”. I am officially there.

I am gearing up for the match again. I am not looking forward to going through the whole process again, except with less spare time and optimism. I am also facing the harsh reality of residency as a single mom, without the benefit of doing what I love – ob/gyn. So, the application process is especially horrible.

Today, after orientation, I stopped by to see an old friend whose brain cancer is, unfortunately, messing with him again. He is now suddenly mostly blind, and will find out soon if he will be having his fourth brain surgery, and will most likely be starting chemo again for the umpteenth time. I picked up the kids, and made it all the way to the grocery store parking lot. I looked around in my wallet and purse for a Visa gift card I had been saving for such rainy days. It is pouring, my friends. I am waiting for a check to clear, and a deposit to show up in my account. My cushion between the two is $10. I couldn’t find the Visa card, so I took the kids home.

When I got there, I was so emotionally, mentally and physically exhausted, I couldn’t even bear the thought of looking through my cluttered, dirty house for the gift card. I, luckily, am quite a food person. Even though I have not done a decent food shopping trip in more than a month, I have a kick ass pantry and reserves. I had defrosted catfish nuggets (yeah, mama is buying cheap) already, and had hoped to buy the ingredients for the beer batter today. I also haven’t had any bread for over a week, and I have to make breakfast tomorrow for the kids, and Seb needs a lunch for camp.

I put together a breading for the catfish out of flour, cornmeal and plain yogurt. I had vegetable oil for frying. I had half a bag of onions, so I made onion rings with the rest of the breading and oil. I also had half a packet of yeast, and just enough flour and milk to make dough for bread. After the kids and I ate the interesting, slightly tart but definitely edible dinner, I passed out on the couch at about 8 pm. I am officially a drooling turd sandwich, and am on the exact opposite schedule I need to be on to resume a stretch of seven night shits in a row as of tomorrow night.

I didn’t clean the kitchen, which was wrecked. I didn’t bake the bread. I didn’t dry the laundry, which included stuff that S needs for camp tomorrow. I did manage to wake up intermittently to tell the kids to shower and brush teeth. I got Z into bed, and eventually got myself from the couch into bed.

I woke up at 4 am. Initially I was annoyed, since, as I said, this is the exact opposite schedule I need to be on. But, now I am grateful. Even with only half a packet of yeast, the bread dough rose beautifully. I kneaded it and put it in the oven. I put the wet clothes in the dryer and started a new load of laundry. I tackled the oily, breading-y mess of a kitchen. I started a load of dishes, cleaned all the pots and pans, I swept the floor, wiped down the counters and some surfaces, and I am now on the couch, enjoying a cup of delicious coffee and the aroma of freshly baked bread.

S made me a pot of French press before he went to bed last night, and it was waiting, full and gorgeous, on the kitchen counter amid the oily mess this morning. It was quite a love letter from a thirteen year old. He and I share a love of French press. He offered to try to help me out, since my fancy coffee maker decided to finally die about a week into my internship, by making me pots of French press when he was home. But, we got in a big argument about it the other day. I was exhausted, he was feeling very thirteen and had been juggled from his grandma’s to his dad’s and then back to my house. We got in one of our worst arguments in a while over him making me a pot of coffee. It was the first hour I had seen him in three days (his dad had him for the whole weekend), it was the first time he had spent with his brother in a few weeks. We spent it fighting about him plunging the coffee, and he was reduced to tears. So, it meant a lot to me to wake up to a fresh, full pot waiting for me, unbidden.

So, the kids are still sleeping. The washer, dryer and dish washer are humming. The sun is coming up. My coffee cup is empty, and I am going to pour myself another love offering and I’m going to walk the dog to the lake and drink it and the sunrise in. The bread is cooling and will be ready to enjoy for breakfast. I may even get to my presentation for the VBAC Summit.

Could be worse

Could be worse.

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Heavy music

Despite my hippy crunch tendencies and tie-dye banner, believe it or not, I don’t listen to a lot of classic rock anymore. I got supersaturated with it in my youth, and have heard just about every classic rock song enough times already to last me forever. But, today I had reasons to want to listen to two moldy oldy favorites of mine, both about carrying a heavy load.

Levon Helm of The Band died. My favorite song of theirs is “The Weight”:

And, Molly at First the Egg published her birth playlist, which contains a lot of songs I like. It includes another of my favorite older songs, a version of George Harrison’s “Give Me Love”:

It’s been a hard month. Hell, it’s been a hard couple of years. These songs are great because I love them, and I guess I kind of need them right now.

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Autism and obesity, a confounder

The journal Pediatrics released a study recently claiming an association between autism and maternal obesity during pregnancy. As soon as I heard this study being splashed all over the media, I winced. As much as the journalists point out “correlation, not causation”, they also throw out vague warnings about obesity. On NPR this morning, the story was covered as being another casualty of the “rather striking epidemic of obesity”, and, in this article in the Washington Post, despite the lack of causation, the author warns “[s]ince more than one-third of U.S. women of child-bearing age are obese, the results are potentially worrisome and add yet another incentive for maintaining a normal weight, said researcher Paula Krakowiak, a study co-author and scientist at the University of California, Davis.”

Because, it’s all just our fault because of our behavior, right moms?

I don’t think so.

I was already pondering autism and causation recently. It has been an interest of mine for quite some time. Before I knew that I was going to go to medical school, when I got my first job at the first health food store, I was intrigued by the parents of children on the autism spectrum who would come into the store, desperately seeking anything to help. Many were trying gluten-free, casein-free diets, long before the recent gluten-free craze. Many were buying supplements. I was surprised at how many children on the autism spectrum there were. This was in the mid 90′s, and my first glimpse at the burgeoning numbers of children living with this diagnosis. I decided I wanted to work in the field, and help unravel this mystery for these parents.

Since then, my focus has obviously shifted. However, I have two cousin Susans with two sons each on the autism spectrum or with related developmental delays, which were also included along with autism in the study. One is closely related to my younger son’s father, and one is closely related to me. They are not related to each other at all. I know it is just anecdote, but I was already trying to look for a pattern – something they had in common. Why were their children affected, and mine not? I was overweight, possibly obese according to BMI, during both pregnancies. One of my cousins was, and one wasn’t.

Well, this study made things click in my head. There is a confounder strongly associated with obesity that was not looked at in the study. It is also associated with high circulating androgen levels, which have a known association with autism spectrum disorders. And, interestingly enough, both of my cousin Susans have this condition, and I don’t. It’s polycystic ovarian syndrome (PCOS). It is a lot less common than obesity, and would probably make more sense as a causation, both prevalence-wise, and physiology wise. I did a quick literature search, and couldn’t find anything on it.

I am not sure how difficult it would be to do a case-control study on this. It would be easy if I was at Kaiser. It was probably easier to look at weight and height at delivery than delve into gynecologic histories to find if there was any diagnosis of PCOS in the subjects of the study.

Well, trying to do some research on this is a definite possibility. Hopefully in the near future.

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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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The empathy toggle switch

In our clinical years, our medical school has instituted a program in which we do learning modules along with our in hospital experience and didactics. I was happy to see a module on empathy for my second month of surgery. The last question to be answered in this module was: “Although the studies on empathy are very consistent other authors have indicated that medical students are really not losing cognitive empathy, rather they are learning to engage in a “toggle switch” approach to patients where one side of the switch is “associated with the patient” and the other is “disassociated from the patient” which is necessary in order to perform medical procedures. Please discuss this and use example which you have seen or in which you have been involved.”

Here is my answer:

I am not sure if I agree with this. Yes, there is a certain amount of disassociation that may have to happen in order to get through the day, and I guess I felt a “toggle switch” moment when I was first in the OR, and the patient was not a patient but more of a sterile field surrounded by drapes. But, I think there are complex layers of desensitization, not just an on/off switch situation that happens.

I participated in a dilation and curettage on a woman who was experiencing an incomplete abortion. I was in the room before the procedure and the OR nurse offered to let me do a pelvic exam on her, since the patient was already anesthetized. Although I was fascinated by the opportunity, and initially was tempted by the learning experience, I didn’t want to do it without her permission, and made myself consider her as a patient and a person, not as a pathology or anatomy in front of me. Yes, I knew she was going to have a pelvic procedure that she already consented to, and I even had the opportunity to introduce myself to her before she was anesthetized, but I knew it wasn’t diagnostic for me to do a pelvic on her in this situation, wouldn’t change the course of her treatment, and questioned the ethics of it. I knew I would have plenty of opportunities to do pelvic exams on awake and aware patients whose humanity I would face directly and whose informed consent I would be able to directly assess, and I was willing to wait for that opportunity.

I did promptly forget about the patient and what she was going through when I was observing the procedure with the physician. I was more fascinated by the tools I had seen used in other applications and in workshops, but never used in a real D & C. I was eager to listen to the physician and thrilled that he was a willing and excellent instructor, and wanted to explain everything he was doing in great detail. I suppose there must have been some sort of toggle-switch moment where the patient was no longer a patient, and I was only cognitively aware of dilators and an os, and the integrity of a previously scarred uterine wall that was attached to a nameless, faceless body.

After the procedure, I happened to come across the patient in the holding room immediately post op. She was not doing well. She was feeling incredibly nauseous, and felt like the room was spinning. I was saddened that she was alone. I summoned the nurse, and the nurse tended to her needs medically by getting some anti-emetics on board. Still, I stayed with her and talked to her about how she felt, emotionally, about what she was going through. It is hard enough to feel nauseous and dizzy, but it has to be even harder when one just definitively ended a much desired pregnancy. Also, her family was not with her in this recovery area, and I felt bad for her for being so alone. I guess if I was ever switched off, I was definitely empathetically switched back on at this point.

I hope that if I do get my career in ob/gyn, I do continue to consider my patients as patients. I know there is a crisis in ob/gyn in which obstetrics is turning more into a game of avoiding liability and “moving meat”, and I hope my switch won’t get flipped to the point where my nameless, faceless patient is just a medicolegal liability or a long labor to be avoided by an unnecessary surgery.

Edited to add: RH+, a contributor on Mothers in Medicine, where this was cross posted, pointed out that a pelvic exam would be necessary in the D & C to determine the position of the uterus. She was right, and the physician did do a pelvic exam when he came in, and explained to me why he was doing it. In that scenario, if he asked me to perform one and tell him what I thought the position of the uterus was, with instruction, I would have thought it was ethical. He did not ask me to perform one. When the OR nurse (who is not part of our teaching faculty) offered the opportunity to me, it was more as an opportunity to perform one on an anesthetized patient just because the opportunity was there, not as a specific learning experience. I guess it is a fine line, but it’s there.

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Another music post

Time for another music post. I have been putting it off, but I got triggered by the blogiversary at The Unnecesarean. Whenever I say “Happy anniversary”, I always think of “I Think I Need a New Heart” by the Magnetic Fields, which isn’t really a cheerful song and wouldn’t be appropriate for a blogiversary comment. But, it fits in with my life right now pretty well.

So, since I felt like posting that, I am going to post a few more songs that have been bopping around in my head:

I love her voice, and her melodies are so catchy. Nothing in particular about that song that made me want to post it.

I’ve decided what the next song will be whenever I get to do karaoke:

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