Reply turned post, conscience clauses can be OK style

I am starting to grow weary of being the contrary voice. I duck out of many confrontations, believe it or not. But, sometimes I still speak up.

More than once, a liberal, pro-choice site has taken a stance against conscience clauses in general. Although I am a pretty vocal pro-choice commenter in the interwebs, I find myself defending conscience clauses in these conversations.

This time, I replied on a Feminists for Choice post asking if conscience clauses were ethical:

I am a medical student and a member of Medical Students for Choice.

I strongly believe in conscience clauses and plan on refusing to perform certain procedures and to dispense certain medications when I am a physician. I think every physician follows her conscience, and am afraid anti-choice activists are using this important part of medical ethics to refuse to provide services that are in the best interest of the patient.

I plan on refusing to perform unnecessary procedures that are requested all the time as an ob/gyn. I will not perform any genital mutilation, male or female. This includes any routine newborn male circumcision, or elective vaginoplasties. This of course does not extend to any medically indicated procedures, which would be in the patient’s best interest.

I will refuse to do labor inductions because a mother is sick of being pregnant or because I am going on vacation. I will refuse to do non medically indicated cesarean section because a mother is afraid of the birth process or wants to have her baby on a certain date, or because I want to get home in time to have dinner with my family on a day I am being paid to be on call.

I think practitioners that are truly ethical do not use conscience clauses as an excuse to deny medical treatments to their patients or clients because of some idea that premarital sex is immoral. It is easy to find work in an area that does not involve refusing to provide necessary medical care. Most of these people who are refusing reproductive health care want to make an issue out of their refusal to control women’s sexual autonomy, not to support their own ethics, and it’s a shame.

There are two students in my medical school class who have stated they will refuse to prescribe birth control. Both identify as Catholic. One was more than happy to take handfuls of condoms our club was passing out for when he has sex with strippers (I wish I was kidding). He said he is using them for disease prevention, not birth control, so he is not a hypocrite.

I hope he goes into radiology, or urology.

The other is a Jesuit priest. He is planning on going into psychiatry, so most likely won’t be in a position to be a birth control prescriber often. He is also honest and out in regards to his homosexuality, and is an activist to change the Catholic position on homosexuality. So, he thinks some rules are meant to be changed.

The point of these two stories is to say, ethics mean different things to different people. Physicians and other health care practitioners are too diverse a group to force into one group of practices. However, we can encourage responsible application of conscience clauses and try to make sure essential health care does not get refused in the process.

Reply turned post, failed induction style

I wrote a reply on Amy Romano’s Science & Sensibility blog for Lamaze International. (By the way, wish me luck. I am trying to finagle a way to go hear her speak at the Lamaze Annual Conference.) She wrote a post asking if there was any profession guidelines to determine when an induction has failed.

I didn’t find anything on how to determine if they are way too off the Friedman Curve (which is a pile of junk as a guideline anyway, but that’s a whole ‘nother post). The other reason I would think an induction would fail would be fetal intolerance to the augmentation or induction agents, due to hyperstimulation. This is associated with both Cytotec and Pitocin, from what I understand.

Here is my reply:

There is some information in ACOG’s Practice Bulletin #106 on Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General management Principals. But, I don’t think it is exactly what you are looking for or anywhere near adequate.

At some point in the bulletin, the authors state that the term “hyperstimulation” and “hypercontractility” should be abandoned (both would be used to describe one of the complications of an induced labor). They prefer the term “tachysystole”. This is first of two times there is even a sideways referral to induction / augmentation of labor. They write: “The term tachysystole applies to both spontaneous and stimulated labor. The clinical response to tachysystole may differ depending on whether contractions are spontaneous or stimulated.”

Well, spontaneous onset of labor can still lead to stimulated contractions, since there is a difference between induction and augmentation. Induction usually involves continuous augmentation, and both can lead to hypercontractility and/ or tachysystole, but they should not be grouped together as if they were synonymous. The terms “induction” and “augmentation” do not appear in the document.

In fact, it does not appear in the section on patients who are “high risk” and should be candidates for continuous external fetal monitoring as opposed to intermittent monitoring. As far as I know, almost every labor and delivery unit in hospitals, even ones that allow intermittent monitoring, say augmentation with Pitocin mandates continuous external fetal monitoring. Well, not in this practice bulletin.

Neither do the words “Pitocin”, “Oxytocin” or “Cytotec” or “Misoprostol” show up anywhere in the document, for that matter. Interestingly, the section on drugs that may influence fetal heart tones has a noticeable lack of any of these induction or augmentation agents.

But, even more interestingly, the very first recommendation under the section on what can be done with non-reassuring (Category II or Category III) tracings is “Discontinuation of any labor stimulating agent.”

Really? Why would that be? Because according to the list of agents we should suspect, none of those agents have a high index of suspicion for affecting fetal heart tones. But, someone seems to think they have enough of an effect that the very first recommendation is that they should be immediately suspended.

You are also supposed to check her labor progression (dilation, effacement, station, etc). What to do with this information? Not a word.

And then what? Has the stimulation (which may be an induction) failed? Do you proceed to cesarean? Do you allow the drug to wash out and hope the fetus will recover with other techniques of intrauterine resuscitation? They discuss using tocolytic agents and beta agonists and amnioinfusion. I would think amnioinfusion would not be done if a cesarean was imminent.

Anyway, they talked around failed induction a lot without ever actually discussing it.

Reply turned post, heart heavy but not too heavy style

I replied on Los Angelista’s post “How Do We Talk Productively About Racism On Blogs?” (h/t What Tami Said). It seemed relevant, considering what has been happening on this blog lately.

Here it is:

Great post that I really needed to read today.

I have had difficult conversations about race on two of my blog posts this week. One wasn’t even about race! The other ended up spilling onto other posts.

After a lot of really emotionally draining arguments and being called a racist at the end of both conversations (I am a white woman and both commenters are white women, by the way), I was reeling. But, I couldn’t help but think, hey, I can walk away from this. I can pretend racism isn’t my problem and ignore it. I don’t have to write about race on my blog.

I can only imagine how hard this is for someone of color. Someone who can’t choose to ignore racism. Someone who is expected to a patient educator who always takes the high road and watches her “angry” tone.

So, then I signed on Facebook and saw that my little brother, chairman of the local Young Republicans club, thought this chart was oh so funny and accurate. I didn’t comment, yet. The chart was posted on a third party’s page, one that I am not friends with. So, I am in limbo, thinking I have the valid option of “staying out of it.” And, I am feeling sorry for myself for walking around with arguments against it in my head, and my fingers itching to type them, and my heart heavy for the hatred in America and my stomach in knots because some of this hatred is coming from my own family.

But still, I can, to a certain extent, still be separate from the fray by choice. And all of this frustration and unease I am feeling, it is not anything compared to what people of color must be feeling in this culture of racism denialism.

Reply turned post, reverse racism style

This is a reply turned post of one of my recent posts. When I posted my picture of a racist display mocking President Obama and the letter I wrote to my local paper, a commenter started talking about reverse racism that she experienced living in “the ghetto”. Here is my reply:

IMO, that was ugliness and prejudice. I am sure it felt awful and I am sorry.

We can argue and disagree on this, but most people who study racism in a scholarly way say that the power differential occurs when you as a white person gets to go home, see the heroes and beautiful people in ads portrayed on TV who look like you, all of the pictures in magazines of people who are supposed to be beautiful who look like you, and go put money in the bank who most like has a white CEO who looks like you, and just live in a society in which you know that, regardless of your lower class upbringing, you have a lower maternal mortality rate than a rich black woman, you have a better chance at getting a job, and many, many other privileges.

When is the last time someone said a president or Supreme court justice who looked like you got their position did it only based on their race, not merit? See how ridiculous that sounds to a white person? Or that the health care plan that you’re proposing is really reparations?

Here is a great essay by a fellow white person, anti-racism activist Tim Wise, who discusses this:

The myth of reverse racism.

Here is an exercise that helps you look at this. I am sure many of these items, especially those in the beginning, you may be able to say …”See, we’re the same.” But wait until you dig a little further.

White privilege exercise.
(I have had trouble with this link. Right now it is set up for Firefox, since I can’t get to directly link to the .doc. If you do a google search on white privilege score, the exercise is the first link)

Once you leave that library or that situation with those black people and think about it, you know they are angry because of a LACK of power. They don’t think you’re lessor and use that to oppress you. They think you’re an oppressor and use that to attack you. They may make that judgment based on your race, but that does not give them racial power over you.

If an Iraqi soldier ends up alone and unarmed in a bunch of angry Iraqi insurgents and gets the crap beat out of him, that doesn’t change their power differential. Yes, the Iraqi soldier was “overpowered” by the Iraqis, but that doesn’t make it reverse racism.

I have lived in the “ghetto”, (that’s Racism Bingo card O2, by the way) and my husband grew up there. I did the white flight thing and moved from a neighborhood that was 90%+ African American in Miami Gardens Florida. If you want a trip in the police blotter, do a google search on “Miami Gardens” + the word “crime”. And, most of the crime is black on black. It’s unsafe to live there for them, too.

I felt afraid for my young, blond, pale white son there when I saw the kids at the playground glare at him and walk away when he asked to play, and was afraid of the gang bangers who tinkered on cars at the edge of the playground and jealously guarded their turf, cursing loudly enough for us to hear, every time we were there. I still feel extreme guilt for having the privilege and ability to move to a NICER neighborhood where more people look like me. I am proud of my multicultural neighborhood now.

But, can a black person do that? How often can a black person go to a safer place where more people look like them?

And, finally, the main problem I have with the term reverse racism is that it is used to deny that racism against people of color, especially African Americans, is a persistent, real problem with significant negative effects on a huge subpopulation of our country, and in the long run, negative effects on all of us. Your examples are a perfect illustration about how cultural and institutional racism against blacks can turn around and hurt white people. My last post linked to an article on how that racism denial, and I would like to add the competitiveness that lower class white people feel when people talk about racism, is what allows racism to thrive.

Edited to add: Kittywampus (with a little help from) Stephen Colbert does a great job discussing this here. Great minds think alike!

Reply turned post, religion and reproduction style

The blogosphere has been full of posts about a soon to be published study in Reproductive Health (one of my favorite journals!) about state teen birth rates and religiosity being correlated.

I posted a reply on one of the posts, the one on the New York Times parenting blog Motherlode.

What a shame.

I am proud to have a member of the Religious Coalition for Reproductive Choice speaking at our medical school next month. She is a Baptist minister and is a Doctor of Divinity. And she is adamantly pro-choice, provides condoms to teenagers at her inner city church, and also provides information about and promotes access to emergency contraception in her community.

There is nothing about religiosity or Christianity that inherently means that one cannot promote contraception, comprehensive sex education or safe and legal abortions. I am a member of Medical Students for Choice, and interact with many abortion providers and pro-choice activists whose faith has an important role in their lives and in their promotion of women’s health.

Dr. Tiller was assassinated while serving at his church. More pro-choice Christians need to stand up to the loud, reactionary ones who are trying to turn our country into a fundamentalist third world nation.

Reply turned post, guilt and pain style

This is a reply to a post on the post Builds Character at A Little Pregnant. Hers is one of many responses to an article by a male midwife about the benefits of unmedicated labor.

OK, birth researcher here. Please excuse the scientific language to follow.

I think this is a difficult topic, but there are some tools to measure bonding or attachment. It is not impossible to discuss parental bonding as an advantage to an intervention (or lack of an intervention). It is actually a subject I am interested in possibly researching. We could argue the merits or accuracy of such measurements, but that is a different topic. Such tools exist. So do tools on other “mushy” sociological and behavioral outcomes.

Is there a possible negative group impact to the discussion of parental bonding due to method of delivery,or presence of a doula, or breastfeeding (or going back to work or having a TV on etc. and ad nauseum)?

Absolutely. Saying that one method of delivery or related variable influence something with social desirability, like parental bonding, can make people who did not receive that intervention or have that method of delivery feel a sense of guilt or even a sense of societal shame.

(Can you tell I have been reading the Belmont Report?)

Keep in mind we are talking about risk here, not causality. If I do research, hypothetically, following mothers who participated in a recent program that provided doulas for women of low socioeconomic status and tracking parental attachment, am I acting unethically? First of all, if I identify women of low socioeconomic status as being less attached i.e. “worse parents” (not my judgment, but the implied judgment there), and then if my research shows a significant difference between the attachment between the women who had the doulas and some peer comparison, I could be doing harm to groups of women by association just by doing the research. Imagine if I racially stratify the results.

This would also apply to breastfeeding initiation and/or continuation, mode of delivery, use of anesthesia, etc. I did read the original article. I would have preferred a source when he discusses “emerging evidence” about bonding centers of the brain and pain medications in labor. It is very typical of mainstream media discussion of medical issues to lack sources.

To me, the bigger picture is yes, it is a valid point to say that groups of women may suffer by association by possible research outcomes. But, is the benefits of the research to future practitioners, researchers and parents worth it? I think it can be, depending on how it is performed and presented.

Reply turned post, fair fight style

I was inspired by Shakesville’s Quote of the Day yesterday, (sorry, been busy!) which was the always inspiring (laughter / horror / disgust ) Michelle Bachman complaining that the public option “would offer equal or better benefits than any plan—but cheaper.”

I was listening to NPR this morning, and they had an interview with one of the representatives from Tennessee who identifies as a “blue dog” democrat. He is in some group that is trying to work out a “bipartisan” bill with 2 other blue dogs and 3 republicans. According to the NY Times today, a similar group in the senate is most likely coming out with what will be the successful Senate version of the bill.

So, what we have, is bills written by groups shutting out the liberal democrats that were elected en masse to reflect the public’s will. 70 to 80% of the public want a public option. So….

…this Tennessee representative today said he is one of the few in the group who actually was OK with the public option (way to represent- snort) as long as it operated on a level playing field.

I’m sorry, sir, does this mean the public option has to be expensive, bureaucratic, confusing, and deliver few benefits with poor service? Is he agreeing with Michelle Bachman that a public plan that covers people and isn’t prohibitively expensive was somehow unfair or undesirable?

So, if it works, it’s bad. And if it doesn’t work, it’s good?

Reply turned post, COMLEX and USMLE style

A reader and fellow medical student who blogs at the Dark Autumn Hour asked me why I took both versions of the step I board exams. For most of my readers who are not medical students, especially osteopathic medical students, this question and corresponding blog post may sound like wah wah wah, but it is a huge issue in osteopathic medical schools, so I thought I would address it with an entire post.

Here is just a little background for those of you who aren’t osteopathic medical students and are reading anyway. There are two types of medical school and degree designations for physicians in the United States: D.O. (also called osteopathic) and M.D. (also called allopathic). (There are also two for dentistry: D.M.D. and D.D.S.). I am not going to get into the differences in training or controversies regarding the different designations now. Licensed D.O.’s and M.D.’s have the same practice rights in all 50 states and enter all fields of medicine.

Both medical designations have 3 parallel but separate board exams that one has to pass, step I and II in medical school and step III at the end of residency, in order to become a licensed physician. The osteopathic exam is called the COMLEX, and the allopathic exam is called the USMLE. I just took step I. I took both exams, allopathic and osteopathic.

There are many more allopathic medical schools and residency programs than there are osteopathic programs. Osteopathic students can and do apply to allopathic residencies. The opposite is not allowed. Again, not the topic of this post, but a controversy. When an osteopathic medical student is applying for a residency spot in a pool that includes mostly allopathic students at an allopathic institution, their measuring stick will be the USMLE. Some programs say they will consider COMLEX scores, and some osteopathic students have gotten residency spots with only a COMLEX score. But, in general, for many reasons, many allopathic institutions do not have any D.O. residents in their ranks. So, every osteopathic student in their second year has the option of taking the USMLE in addition to their COMLEX.

OK, here is the reply:

Isn’t that the question on everyone’s minds in the first few years of osteopathic medical school?

I took both for a few reasons. I had to take the COMLEX to finish my school’s academic requirements. However, there are no osteopathic obstetrics and gynecology residencies in my state. I find that especially pathetic, since we have no less than two osteopathic medical schools in Florida. When I first went to the ACOOG website to search residencies, I thought I was doing it wrong. But, no, unfortunately, osteopathic ob/gyn residencies are heavily concentrated in a few states, like Pennsylvania, Michigan, and New York. They might want to reconsider their search by state option, since the vast majority come up empty. (OK, I just checked out the site, and they may have removed this option.)

I am geographically limited. Severely. I have joint custody of my older son, and his father lives about one hour south of me in South Miami. There is only one ob/gyn residency within 6 hours of his house. It is allopathic, obviously. I have heard of D.O.s being accepted there in their internal med program with only a COMLEX score, but I wasn’t sure about the ob/gyn residency. I know of a D.O. student who wasn’t accepted there, and spent a year as a rotating intern, then accepted for this year. (He is probably starting this week. I need to get his contact info and pick his brain.) Another student from our school matched there, but I didn’t know her and have no idea if she took both exams.

According to APGO, 600 people applied for 9 slots there. I have also heard they grant a maximum of one D.O. slot per year, although, including the intern, there are two this year, both graduates from the osteopathic school I am attending. So, it’s going to be really competitive. I don’t want the lack of a USMLE score to hold me back. (Let’s hope a lousy USMLE score doesn’t hold me back!) I have shmoozed some of the attendings over there and plan to do some elective rotations there, so I hope I have a shot. I will unfortunately be competing with some friends from my school for what may be one or two D.O. slots.

There are a few other programs in Florida, and one in Asheville, NC, I may apply to (my husband’s folks have a house near there, but I may have to go to court to take my older son there). No matter what, anywhere I get in other than the Miami program will involve an alteration in our custody arrangement.

There are many arguments both ways about whether D.O. students should take the USMLE. Each exam costs $500 and takes about eight hours. D.O. students are educated slightly differently, and tend to do slightly worse on the USMLE than M.D. students, and a higher percentage will fail. I took both exams, and in my opinion, the USMLE questions were more difficult. The writing style, vocabulary, the question stems, and the amount of higher level thinking rather than rote memorization was dramatically different between the two exams.

Some of my classmates signed up for both exams. Some ended up taking both, and some changed their minds and didn’t take the USMLE even after paying the substantial fee. We got advice from former students emphatically pushing us in both directions.

In the end, I hope I chose best. I hope my score on the USMLE is adequate. I can always withhold my USMLE score and only present my COMLEX score, if I did better on the COMLEX, but the residency programs will see that I am withholding the score, which is pretty much saying I bombed.

Reply turned post, why not one more Tiller one style

Here is the original post talking about, you guessed it, late term abortion. You don’t necessarily have to read it, because many of the commenters didn’t read it. Ironic, because the post is all about how people don’t know what they are talking about when it comes to late term abortions. I saw yet another person say that their own, healthy, not very preterm babies (twins in her case) makes her against all late term abortions, and then she talked about a 23 week old baby that somehow survived somewhere.

My reply:

You are completely misrepresenting the chances of a 23 weeker to survive. The American Academy of Pediatrics (AAP) does not even recommend attempting resuscitation before 24 weeks.

Here is an entire scientific article that is a position statement on the debilitating health effects on the measly few who survive. This is from the AAP, the organization that is responsible for infant and child health in the entire country.

The resuscitative techniques and medical treatments can be torture, especially on a newborn who is only receiving futile treatment because its chances of surviving are miniscule, and its chances of being functional are even smaller.

The few women who get 32 week procedures do not get them just because their babies would be premature. Here are their stories. I don’t see why people can’t realize that this has NOTHING to do with their healthy premature babies. And, anyone can still choose to carry any pregnancy to term if they so desire, even if a 10 year old who was raped can still get an abortion, or a women with a fetus with anencephaly.

If you are uncomfortable with that choice, please exercise the freedom to not choose it. I would be uncomfortable with carrying a fetus that would never survive for 20 weeks while having to talk to every nosy stranger about my deformed, dashed hopes, and at the same time face greater health risks, because someone with healthy twins is uncomfortable about a medical procedure while commenting on a message board. If you don’t mind, I will ask physicians what they think about this instead.

Trying to get stuff done, and a reply turned post

I am trying to keep trucking with a semblance of normalcy. My entire house is either upside down, blocked by dehumidifiers, or packed into boxes. When they started packing my measuring cups, I almost cried. Don’t the workers know that I procrastinate by baking??

Anyway, I have had to be content with procrastinating by reading about the Tiller assassination on the web. Again, there are way too many great posts to link to. My blog roll has great links to many sites with great coverage.

I have tried to avoid the really bad sites, but I stumbled upon one that had a fairly ugly comment section. I guess I should have expected it, since the original post tries to link Tiller and Jeffrey Dahmer. I sort of feel bad even linking to posts and comments that encourage dehuminization of the few, unfortunate women who are put in the position of needing these procedures and the practitioners brave enough to help them. But, I figure, if you are reading at my site and would agree with the posters on that site, I’d rather you click and go there than stay here.

I posted two replies. Here is my second reply.

Tiller wasn’t a murderer, the man who assassinated him was a murderer. Language like this in this comment section emboldens assassins. Assassins who kill health care practitioners performing legal, compassionate procedures.

There are only 100 post viability abortions per year in the United States (less than 1% of all abortions), and these are done on fetuses that are not compatible with life (and, by definition, not yet alive, medically) or desperately sick, or done on rape victims who are 9 or 10 years old.

Anyone who ignores this and pretends Tiller was someone in the wrong is supporting terrorism. There is a reason why there is a new National Task Force on Violence Against Reproductive Health Workers. There is a reason why federal marshalls have been sent out to clinics. Because of proud, angry zealots like the ones on this thread.

There are plenty of ways to reduce all abortion. Support birth control access and affordability. Support comprehensive sex education. Support health care for women and their children. Support better maternity leave and public support of poor families.

Get to work, baby lovers. I’m waiting. You will affect a helluva lot more than 100 probably severely damaged or dead fetuses that way.

There isn’t much we can do to decrease late term abortions except prevent the rape of young girls and improve earlier detection of severe defects. Ranting about compassionate doctors being murderers online doesn’t. It just gives people who want to control women’s bodies (the chance to) feel power in front of their computer screen.

Go volunteer in a pediatric intensive care unit (PICU) sometime if you want to see some horrifying procedures. Physicians don’t throw fetuses in the trash. Tiller developed techniques specifically to help these women mourn and hold their sick, wanted fetuses after he compassionately ended the pregnancy. And all the reactionary commenters on here want to do is spit in their face and call them murderers.

I am almost happy that the silver lining of this brutal assassination is that the general public, who is horrified by this, sees the anti choice crowd for the raving, heartless bunch they are.