Sick and leaning on the mute button
So, I am sick. Sick sick sick sick. I hurt everywhere. I have a fever and I am lightheaded. Runny nose, cough…the works. Blegh.
I am planted in front of the computer and the TV. I watched these Bill Nye videos about genetically modified foods. I just happened to get a link for them by being a fan of Slow Food USA on Facebook. It was interesting timing (not ironic, huh CableGirl?), since I just got in an annoying argument with commenters on on Dispatches from the Culture Wars. First of all, I am no fan of people who use snotty insults when they’re arguing on a site. Not necessary. Sarcasm is fine. But, if you’re going to go there, you better be right. I also don’t think blindly accepting technological advances is any more reasonable or educated than being blanketly afraid of all technology.
So, while I was tooling around on the internet, I had the Travel Channel on mute. Anthony Bourdain was visiting Ted Nugent. I could never listen to that much douchebaggy conversation, but I left it on in case there were any exciting gun accidents. Not that I wish that on anyone, but still, it’s exciting.
Now I am watching Birth Day. I wish I had the mute on here, too. I have heard “vertex position is NECESSARY” for a vaginal delivery. Also, I heard about a woman who had been in a long labor, and when her nurse introduced the next shift nurse, she said “And Amy has been with us forever.” Nice. She ended up with a fever after several hours of an epidural, and of course they discussed ZOMG infected baby!! but didn’t mention the link between epidurals an fever. The baby was born by “abdominal rescue” (wha??) and then was immediately taken to the well child nursery. Wait, I guess they don’t think there is a big risk this baby is infected. Then they talked about how it’s just great that she had a healthy baby.
I did get to see a successful external version (I cheered!) but I was surprised to see she got a neck down epidural for it, and then they induced labor immediately. I don’t know that much about external versions, however. The baby has distress now. They think it’s from the version. But, can it be from the Pit?
There is a woman who is one day past her due date (the horror) and was told her baby is “big” and she needs a cesarean. Oh, but she’s a hemophiliac. How does this sound safer? Her bleeding time test did not look good from my amateur eye. Why cut her without good indications?
Doublethink in health care
A four-month-old exclusively breastfed baby in the 99th percentile for its weight and height was refused health insurance because it has “obesity” as a preexisting condition.
*Shakes head in disbelief*
This story in the Denver Post is a perfect example of the sort of Orwellian doublethink that must exist for people to oppose health care reform because it will add a layer of evil government bureaucracy into medical decision making.
Here’s a great quote from the article:
Health insurance reform measures are trying to do away with such denials that come from a process called “underwriting.”
“If health care reform occurs, underwriting will go away. We do it because everybody else in the industry does it,” said Dr. Doug Speedie, medical director at Rocky Mountain Health Plans, the company that turned down Alex.
This kind of um, logic, for lack of a better term, is what these newly enraged self styled radical libertarians are advocating as a superior framework for guiding medical coverage than the government?
(A tip o’ the chapeau to Hoyden About Town)
Edited to add:
Here is a picture of Z when he was about that age:
I am sure he was in the 99th percentile, if I cared to measure it. Oh, yeah, and he has always been accident prone, like his mommy.
Race, race, race
I have had some frustrating encounters regarding race lately. First of all, there was racist display at a store at the touristy beach near my house. No word back from the newspaper about my letter to the editor. I may just have to write to the Ramada chain, since it is right outside their lobby and many people may associate it with the hotel.
Then, I got into it on a post on Alas, a Blog. It was a great post on many aspects of medical research, birth and race. Two commenters decided to take a whack at criticizing the research by taking random guesses about it without actually, you know, reading it.
A similar thing happened on Our Bodies, Our Blog. A link to an essay lamenting the shameful disparities between women of color and white, non Latino women in our country when it comes to perinatal outcomes prompted a commenter to say “But what about the white women?!” in the form of a weakly attempted criticism of a lack of inclusion of Caucasian women. It was an unfounded criticism of selection bias, and the essay wasn’t a study, it just referred to some epidemiological data. (Although I must say the comment was confusing in general. But, the “what about the white women?” part was crystal clear.)
These are two different types of issues. The first is the kind of situation that Jay Smooth so eloquently talks about here:
Someone, an individual, is doing something racist like putting up that display. This is what most people think of as classic racism. It’s also what many people would think may cause an ugly scene if someone wanted to talk about it. I took a quick photo and scampered out of that store.
However, the second and third example bug me on a different level. OK, maybe RonF on Alas has a history of making similar racism apologist arguments, as a commenter on here suggested. But why did the other commenter claim they were reluctantly jumping in to point out something they just had to correct me on, when they obviously didn’t have any actually knowledge about research or statistical analysis, and the point was just a random guess? Why did the commenter on Our Bodies, Our Blog feel the need to cry wolf about selection bias when the original post was talking about institutional racism and its effect on maternal and neonatal outcomes, not calling her a racist?
I am a pre-doctoral research fellow who researches birth. I am taking a Masters of Public Health class that involves analysis of the flaws of public health research studies with an M.D./Ph.D. who has been a reviewer for the CDC and worked for the government for decades conducting research and making public health decisions based on research. I am not trying to pull rank here. I am just saying it makes me really twitchy when people use baseless random hypothetical criticisms of research to justify denying the effects of racism. One of the most compelling issues for me when it comes to racism is the scary, overwhelming evidence of the pervasive negative health effects of institutional racism. (I could link to endless research here, so let’s just link to this and this. Their bibliographies offer a nice starting point if you’re hungry for more.)
There is a difference between the two situations. Obviously, I believe in calling out the former: blatant slurs or images or props that are symbols of racism.
But, the other is just as bad. Denying the very real effects of sometimes very subtle institutional and societal racism is just as bad, if not worse. The first study I link to above has this to say about denying institutional racism (emphasis mine):
Institutional racism occurs when seemingly innocuous policies and practices result in the disproportionate harm to particular race/ethnic groups. Institutional racism doesn’t require intent but is inherent in its outcome.13 Personal or individualized racism refers to personal prejudice resulting from negative attitudes and/or beliefs about a particular racial group’s motivations, abilities and intentions.14 It too does not require intent and as Jones states12 can be an act of either commission or omission. Internalized racism occurs when members of the stigmatized group accept or internalize the negative messages and stereotypes regarding their race/ethnic group that are perpetuated in society.12 This form of racism affects how one perceives himself/herself, including his or her self-worth and influences acceptance/tolerance of racially biased treatment or maltreatment by others.
Racism persists in American society because beliefs and attitudes that are not blatantly racist but result in racist behavior or outcomes are often not perceived to be racist. As Parks states, “racism thrives on denial“.15
People identify with these institutions. I am going to be a white obstetrician. Trust me, I am identifying with the people delivering the health care that is failing these women. It’s OK to have high standards. It’s OK to acknowledge where we are failing. It’s OK to admit that there are groups of people that many of us don’t belong to that have it worse than us in some ways. It is hard to discuss for some people, because they cannot admit that they have privilege. So they will make up imaginary flaws in statistical research to desperately deny there is institutional racism.
I write letters, racism style
I wrote a letter to the editor of my local newspaper. (Click to embiggen the picture)
It went a little something like this:
Jimmy Carter was right; there is confident, overt racism in much of the
opposition to Obama. It’s not just in isolated enclaves or in the Deep
South. I was using an ATM at a shop called “Sticks and Stones” in the
Ocenwalk Mall at the Ramada Inn in Hollywood Beach. The proprietor has a
display in a small enclave right inside the doorway, across from the ATM. I
attached a picture that I took with my iPhone. It has a cardboard cutout of
Obama, a stuffed baboon, and a book on Wild Chimapanzees.
I was disgusted, not only because this shop owner felt so confident in his
racism that he would put up a display like that, but also because there are
so many people who apologize for and deny similar situations and incidents.
Reply rurned post, pet peeve style
I get really annoyed when someone posts about some research, like this great post on Alas, a Blog on race and low birth weight, among other things, and someone who has no clue about research says “oh, but what about (insert obvious confounder that was obviously controlled for by the researchers here). Therefore, this study I didn’t even read must be total BS!”.
Some racism apologist commenter (RonF) decided to say that a study on the influence on racism on low birth weight is based on perceived racism, not real racism, and besides, he’d really like to see some research on poverty and low birth weight because that’s totally the real and only association with low birth weight.
Here is my reply:
Thanks for a great post.
Ron, you know, researchers who get published in major publications actually have to analyze their data for obvious confounders. (That’s a fancy statistics term for other variables that may be responsible for the outcome, like poverty instead of race being associated with low birth weight). I am sorry if I sound sarcastic, but this is a pet peeve of mine.
In fact, these same researchers wrote another entire study about poverty, race and low birth weight. You said you’d really like to see research on that topic. Do you actually believe you are the first person to consider this connection, and that you wouldn’t be able to find it? Or do you mean you’d like someone else to look it up for you, and in the meantime you’d just like to muse about the harms of racism being faked in published research by whiny black mothers who are mistakenly perceiving nonexistent racism and researchers with guilt and poor analysis skills?
It’s really frustrating when someone hasn’t bothered to read any of the abundant research that shows that race is an independent risk factor (independent from income and social economic status) for all sorts of health care outcomes, including low birth weight, but feels qualified to say the outcomes are incorrect and they have a much better theory, based on seeing no data and no research.
A simple search on the authors if you were trying to read the study before criticizing it, or on the topic of race, poverty and low birth weight before hypothesizing about it would find this:
Women’s Lifelong Exposure to Neighborhood Poverty and Low Birth Weight: A Population-Based Study
Here is the abstract:
Objective To determine whether women’s lifelong residential environment is associated with infant low birth weight. Methods We performed race-specific stratified and multivariate binomial regression analyses on an Illinois vital record dataset of non-Latino White and African-American infants (1989–1991) and their mothers (1956–1975) with appended United States census income information. Results Non-Latino White women (N = 267) with a lifelong residence in low-income neighborhoods had a low birth weight (< 2,500 g) incidence of 10.1% vs. 5.1% for White women (N = 10,647) with a lifelong residence in high-income neighborhoods; RR = 2.0 (1.4–2.9). African-American women (N = 18,297) with a lifelong residence in low-income neighborhoods had a low birth weight incidence of 17% vs. 11.7% for African-American women (N = 546) with a lifelong residence in high-income areas; RR = 1.5 (1.2–1.8). The adjusted population attributable risk (PAR) percent of LBW for lifelong residence in low-income neighborhoods was 1.6% for non-Latino White and 23.6% for African-American women. Conclusions Non-Latino White and African-American women’s lifelong residence in low-income neighborhoods is a risk factor for LBW; however, African-Americans experience a greater public health burden from this phenomenon.
Translation: African-American women who have lived in high-income neighborhoods had worse birth weight outcomes than white women who lived in low income neighborhoods.
There has been plenty of research that simply being a minority in this country is enough to affect you in many significant ways. It doesn’t matter if someone on a website hypothetically believes minorities have ever experienced “real” racism to make the measurable effects of racism true.
********
Edited with an update. The fool continues to defend institutional racism by grasping at straws in his effort to criticize the study, which he STILL HASN’T READ. Laughingly, he thinks there is a problem with the N (the number of subjects in the study.) I was forwarded research by a classmate yesterday of a gyn medical device that one of our professors is a fan of yesterday. The largest study had an N smaller than 30. The study I link to above? TENS OF THOUSANDS. Apparently this dipshit thinks researchers are supposed to misrepresent what happens in real life (like, more African American women live in persistent poverty in this sample, and lots more of them have low birth weight (LBW) infants) to make the numbers match exactly between groups (and therefore…prove nothing?) Then, Mr. Concern Troll says it is all well and good to talk about the lofty goals of eliminating racism, which he is not denying (except that he is) but realistically, what are we supposed to do about this?
Here is my reply:
RonF, you need to read more than an abstract to know what was controlled for. Also, in a multivariate analysis in which the researchers look for many risk factors, as this was, researchers may not even choose to publish risk factors that did not have clinical significance.
And, a disparity in the N numbers is not a problem with research, especially if one of the groups is a minority and is naturally present in lower numbers. In fact, the N numbers are NOT that disparate in this study, and just guessing that is true does not make it true. In fact, they clearly prove a higher prevalence of LBW in African Americans.
It’s amusing in a sick way, because the N is one of the strongest parts of this study. I am having a hard time having this discussion with you and not totally calling you out as a rabble rouser grasping at straws to apologize for and diminish racism.
If you want to discuss the fine points of statistical analysis, um, read a whole study first, and then take a biostats class.
What is important is the power of your N number. And, the power of this study is impressive. If you knew anything about research, or even read the full text of any of these studies, you would know that.
What else must be done? Well, first of all, we have to get ignorant white men to stop denying facts about the extent of the problem on websites so we can have a productive conversation about this.
*******
Edited again to add:
Someone came on to defend RonF, albeit she claims it is a reluctant defense. She also didn’t bother to read the original research or the other study by the authors I linked to, but thinks she is qualified to comment on their flaws. She criticizes the N and the “statistical analysis” of the original qualitative study. Here is my answer:
The statistical rigor I was referring to was of the quantitative research done by the same authors, which I link to in my very first post and from which I pasted the abstract. There is only one “N” in the qualitative interview, since there is only one group of subjects, so I assume RonF was also referring to the quantitative study when he claimed that there was a “disparity” between numbers in multiple groups.
You don’t control for confounders or variables in a qualitative study with interviews. It is not appropriate, for obvious reasons, other than in your subject selection. The qualitative research was done with a typical number of subjects for qualitative research, a small group, and is not set to the same “rigor” standards as quantitative research.
In other words, there is absolutely no statistic analysis in a qualitative study, so criticizing a qualitative study for its statistical analysis when there isn’t any, is, well, a sign you have no idea what you’re talking about. In fact, a qualitative study that tries to assign quantitative values to open ended interview answers is seriously flawed and should be criticized for even attempting statistical analysis, since the study method is not suited for statistical analysis.
Qualitative research is usually open ended interviews with a small group of subjects to get more nuanced information about complicated, multi factorial topics. Like racism, which is obviously sadly lacking in nuance in much of the discussions of the topic. It is a common technique in health issues that also involve power balance questions, such as pregnancy and birth.
As for “racial discrimination”, I am really missing the finer point here. If you show me flaws in so called statistical analysis of all of their background literature review, including the excellent quantitative study with the huge N, that point to simply being African American as being a risk factor, one that is greater than genetics or poverty or whatever other risk factors are examined, then we can talk.
It seems to me, yet again, as you are linking to the layperson’s news article that discusses the scientific article, that you, like RonF, have not bothered to read any of the original research. I would really think twice about discussing “rigor” when that is your method of looking into a study’s quality.
I know I am coming across as really pissy, and I apologize, but I would never go on a website and pretend to criticize something as technical as statistical analysis of medical research if I didn’t have a pretty good idea that I had an accurate criticism. It would be like me going on a website on engineering and start telling people their blueprints are messed up because I read some other person’s paragraph about their blueprints. It’s more complicated than all of that, and this armchair amateur hypothetical musing is one of my pet peeves.
Obama’s prepared remarks to students
Here is a preview of what President Obama will be saying to our nation’s schoolchildren this week. It is similar to speeches given by George H.W. Bush and Ronald Reagan.
Here is an excerpt:
No one’s born being good at things, you become good at things through hard work. You’re not a varsity athlete the first time you play a new sport. You don’t hit every note the first time you sing a song. You’ve got to practice. It’s the same with your schoolwork. You might have to do a math problem a few times before you get it right, or read something a few times before you understand it, or do a few drafts of a paper before it’s good enough to hand in.
Don’t be afraid to ask questions. Don’t be afraid to ask for help when you need it. I do that every day. Asking for help isn’t a sign of weakness, it’s a sign of strength. It shows you have the courage to admit when you don’t know something, and to learn something new. So find an adult you trust – a parent, grandparent or teacher; a coach or counselor – and ask them to help you stay on track to meet your goals.
And even when you’re struggling, even when you’re discouraged, and you feel like other people have given up on you – don’t ever give up on yourself. Because when you give up on yourself, you give up on your country.
The story of America isn’t about people who quit when things got tough. It’s about people who kept going, who tried harder, who loved their country too much to do anything less than their best.
It’s the story of students who sat where you sit 250 years ago, and went on to wage a revolution and found this nation. Students who sat where you sit 75 years ago who overcame a Depression and won a world war; who fought for civil rights and put a man on the moon. Students who sat where you sit 20 years ago who founded Google, Twitter and Facebook and changed the way we communicate with each other.
Some idiots, such as Florida GOP Chairman Jim Greer, think this is spreading socialist propaganda.
If that is socialist propaganda, I would hate to see what conservatives think should be taught in schools.
Oh, wait, this, and this, and all of this.
Reply turned post, othering style
I love the posts on Stork Stories. The blog author is an experienced, conscientious OB nurse and CLC. This week I was a little dismayed by the victim blaming tone of her post about having a run of racially and ethnically diverse, difficult patients. This part in particular bothered me:
“Is it too much to ask for a little bit of responsibility to understand at least a little something about what is involved in childbirth, postpartum, newborn care and the legal recording of birth in the facility, state and country in which they have chosen to give birth! Is it too much to ask that an individual try to learn what may be asked of them???” Not everything in the post was as clearly victim blaming, and I included a more reasonable statement of hers in my comment.
However, discussing problems with experiences with people of other races and ethnicities is really difficult, even with the most conscientious and progressive people. I hope I did OK:
I think this is the key:
“There are times when these situations unfortunately occur. Many times the individuals involved are Americans who are 2nd or 3rd generation of mixed ethnic background or are of no discernable ethnic or cultural background, have lived in this country all of their lives and still exhibit the same type difficult personality traits.”
Here is a good example of what happens in obstetrics when it is harder to relate to people who are “other” than us for some reason.
I know it is frustrating when there are language and cultural barriers, but I am not sure any of the people you described were necessarily fully choosing to be in the situation they were in. I don’t think many women want to be in a hospital in which their culture and language are not well understood or well received, and would prefer to be white, insured, from the United States, and would prefer not to be drug addicted or have aggressive men fighting outside of their room. But, since becoming privileged and safe is not in their control, let’s try to show a little empathy to people who need it more, not less.
I understand these situations are more trying since there are language and culture barriers, but think how much worse it is for the patients, too, and try to step back from making sweeping generalizations about anyone.
End of comment.
I wanted to add here that I had a very interesting discussion just yesterday with a black female ob/gyn at my medical school. She is a mother and is of Jamaican heritage, and wears her hair in dreadlocks. I am not fond of describing people as “black” or “dreadlocked” or other such adjectives if it is not relative to the conversation, but it is in this case. She was telling me about how you can pretend how it doesn’t matter what you do, but when one is from a less privileged position (a mother in medicine, black, female, and osteopath in an allopathic residency, etc.) you are representing whether you like it or not.
She had a cesarean delivery last year, and her child was born with a cleft lip and palate and had to undergo multiple surgeries in the past year. She is being pressured to finish up her MPH project, while still practicing as an ob/gyn full time and performing in her duties as a professor. When she brought up her surgery, delivery, and child’s health problems, the department head told her that if women are meant to be taken seriously in this day and age, they shouldn’t use those kinds of excuses.
WTF? If any man here had to undergo major abdominal surgery, a major life transition (new baby) and his child ALSO had to undergo multiple surgeries within an 8 month period, I think people would cut him a little slack. There is nothing wrong with acknowledging the realities of parenting, regardless of gender, or acknowledging the realities of health care issues. We are people. We are not just blacks, whites, moms, women, foreigners, whatever. We are real people with real needs. What’s wrong with a little nuance and empathy?
I write letters, activist style
A double hat tip to Shakesville, one tip for the title and another for the story.
CNN has a headline referring to Scott Roeder, the confessed assassin of Dr. Tiller, as an “anti-abortion activist.”
Here is my letter:
I was shocked to see Dr. Tiller’s assassin referred to as an “abortion activist” by your website (http://www.cnn.com/2009/CRIME/07/28/kansas.doctor.killed/index.html ) in a headline.
I am an abortion activist as a member of Medical Students for Choice. This man was many things: an assassin, a murderer, a terrorist, or simply “accused murderer” would have been accurate. He was not an activist.
Many people have complained that the popular media has normalized violent targeting of reproductive health care workers, and have theorized that this euphemization may embolden such “activists”. Please keep this in mind when covering this issue.
Signed,
A future provider of a legal, safe, necessary, common medical procedure who is sick of being maligned while violent nuts on the fringe’s feelings are coddled by the “most trusted name in journalism”.
Here is CNN’s Feedback form if you are so inclined.
