medicine | DOS

you gotta be bad/ you gotta be bold/ you gotta be wiser

you gotta be hard/ you gotta be tough/ you gotta be stronger

you gotta be cool/ you gotta be calm/ you gotta stay together

all I know all I know is love will save the day

(lyrics from des'ree, you gotta be)

...and somehow I became a second year.

spring time // a first time

1. spring time
this is my first spring in DC and it is just STUNNING.  never mind the fact that I've been on nights for 7 weeks straight and that my family has had a grief-ridden first quarter of the year; I LOVE SPRING IN DC. The heat and humidity of the summer hasn't yet set in but the cold has gone for good (I think!) and being outside feels great, the perfect remedy for my exhausted body and soul. I can't believe I'm just a few short months from finishing intern year.

PS: that is an elephant jump suit you see right there. spring present to myself and probably my favorite clothing item I own.  I literally want to wear it ALL THE TIME.

2. a first time
sometime in the past few months I was called to the ED for a gyn consult for vaginal bleeding.  This is probably the most common consult that the ED calls us for, so I didn't think much of it. But  this patient experience reminded me why I became an ob-gyn.  She was a 20-something year old woman who had just had her first experience with sex and had a vaginal laceration.  We ended up packing the vagina - or creating a pressure dressing but in the vagina - and then we just had to wait to see if the bleeding stopped.

The waiting ended up being the best part, because she and I just talked.  It was clear while I was taking my history that she really did not have a lot of information - and even less accurate information - about sex.  So when I explained that normally when women have vaginal bleeding after their first intercourse, it's not this heavy because usually it's from tearing the hymenal ring - the ring of tissue that is at the opening of the vaginal introitus.  however, many if not most women have already "broken" this ring through movement or tampons so many women do not bleed at all after their first intercourse.  A laceration or deep cut in the vagina is never normal after intercourse.  Then I asked her if she had other questions.  She paused and then asked me about the different holes in a woman's bottom - she wanted to be sure he went in the "correct" one.  So I drew her a picture (and gave it to her to keep) and labeled the urethra, the vaginal opening, and the anus.  I asked if she had more questions.  She did.  We ended up talking for about 45 minutes - her asking questions, me answering them.  They ranged from what were normal emotions after a first sexual encounter (anything, I answered, can be normal), to whether or not she should talk to the guy and tell him what happened after she left (communication is probably the most important component of healthy sex, I answered, if you don't think you can talk with someone, it's a pretty good indication that it's not a great idea to have sex with them) to anatomy including the location of this elusive g-spot (I drew more for her).   Those 45 minutes were such a luxury in a time when my job emphasizes speed and efficiency, but I felt like even more than fixing her laceration, I was hopefully affecting her entire sexual life and hopefully for the better.  Moments like this, of helping women understand themselves and their bodies better, especially in vulnerable and potentially scary times, remind me why I do what I do.

magical moments

While biking home from clinic a few days ago (yes, the bike commute is the best!) I was thinking about how I wanted to go into this field because I like being able to offer support, guidance, and skills at women's most vulnerable moments - but that these moments don't always take the form of delivering a beautiful baby or removing a breast mass or uterus and curing someone's cancer, they are not always helping someone get pregnant after years of trying.  Often they are much less magical and women feel much more ambivalent about how helpful I'm being, and more frustrated or scared about their situations -

they're a woman who comes in from clinic after being told she has an intrauterine fetal demise (IUFD) for induction, a woman who thought she was coming in for a regular prenatal visit who is told she is in preterm labor and going to deliver her baby months sooner than she had planned, a woman in her 40s with symptomatic fibroids (pain, bleeding) who has never had sex, but doesn't want to have a hysterectomy because she doesn't want to give up on the idea that someday she could be pregnant, another woman in her 50s with vaginal bleeding for years who has never had a pelvic exam or a pap smear who you have to counsel about her high risk of cancer, a woman who fled her abusive family to come to a new country only to live with abusive "friends" here with few other options because she is still undocumented, another woman trying to figure out what she is going to do with her young child in labor because she has no one to watch him, or the woman with a urinary infection during pregnancy who refuses to leave the hospital, even after her antibiotics, because she is so afraid of the pain she isn't sure she can go through with labor, a woman spending her pregnancy in prison who hasn't slept for days because she cannot figure out a comfortable position for her growing abdomen on her one allowed mattress and built-in pillow.

** 

but I guess those ARE the moments why I went into this field: to explain what's happening with her body, to explain that it's not her fault, to explain what we are going to do to try to make it better or easier, to write prescriptions for extra mattresses, to talk to the other people in their lives with the authority of someone with knowledge and skills, to counsel about her options, to hold her hand and tell her that 

I'm just so sorry this is happening to her.

~~~~

"the wound is the place where the light enters you"

-Rumi

work I must do

"the best way to predict the future is to create it"

- by one of the doctors at the conference I attended

(I'm going to look up who and correct this soon)

2013 is the year of big decisions and a big transition for me, with the start of residency about half way through the year.  The process of interviewing has been an introspective experience about the doctor I want to become, the service I want to provide, what are the roles I want to emphasize as a physician, and talking with Chris about the best decisions for our life together.

I also had the opportunity this past week to present at a national conference about the medical education of obstetrician-gynecologists.  It was an incredible experience - not just because my presentation was so well received - but also because I was surrounded by people who are really passionate about teaching adults to be phenomenal physicians.  As part of the conference, the participants reflected on the physician they thought they were going to become when they were in medical school and how that compares to their reality.  For me, this was less reflection and more thinking forward about the type of physician I want to become.  In many ways, the writing of a personal statement as part of my application was a laying out of those aspects of the field that are fascinating and compelling to me, but this conference inspired me to be a bit more specific.

Here's the mission statement I've come up with so far.

*To be healer and promoter of health to my patients and in my community

*To be an advocate for women's access to health care and reproductive rights

*To be an educator and mentor, improving how we train the next generation of women's health physicians

*To be a researcher of best practices - determining how to better maintain and restore women's health

I've also been thinking a lot about the environment I train in, and thinking how important it is for me to be surrounded by people who inspire me, who challenge me, and who make me want to be a better doctor and person.

As part of my thinking about how I want to live my life and what's important to include in it, I read about this guy, Scott Dinsmore, and his company, Live Your Legend, on a great blog that I follow.   Check out his Tedtalk about finding your passion and doing the work you love.  It's definitely inspiring.

the turnaway study

*according to this new study, this woman is very wrong.

One of the hypotheticals that is always touched on in reproductive rights discussions is what would happen if we simply did not allow women to have abortions?  Well, the Turnaway study from San Francisco-based research group Advancing New Standards in Reproductive Health (ANSIRH), investigated that question and just presented their first results.  

There's a great overview on the Slate XX blog to check out.

In brief, the group followed over 1000 women across the country who went to have abortions.  Most were able to obtain abortions (97% had no regret), but almost 200 women were not able to have abortions, usually because they were farther along in their pregnancies than the places they went to have abortions would perform the procedure.  The researchers interviewed these women extensively and compared them with the group who was able to obtain abortions.  

A few (of the many) things worth mentioning:

1. women not able to have abortions were more likely to be financially struggling a year later.

Compared to the group who did have abortions, a year later (the study is ongoing) those who were "turned away" were more likely to be on government assistance, living beneath the poverty line, and less likely to be working full time.  

2. women not able to have abortions were more stressed.

They also reported more stress and were equally as likely to be depressed as the other group of women (as in, no happier).  

3. women not able to have abortions had more medical problems.

Including pregnancy complications and postpartum complications (abortion is almost always safer than pregnancy, as is birth control).  

4. women not able to have abortions were more likely to be victims of domestic abuse.

The researchers attribute this not to the "turn-aways" being more likely to enter into abusive relationships, but being less able to get out of them while pregnant/with a new baby.  But this didn't mean that men were more likely to stick around - they found that "men were no more likely to live with a turnaway who'd borne their children than they were to live with a woman who had an abortion".

This study is excellent data to add to the discussion of women's reproductive rights - showing that the consequences of our reproductive choices are far-reaching and longer lasting than just 9 months.

~~~~

"As women's access to abortion care...becomes increasingly restricted, it is extremely important to document the effect of unintended pregnancy on women and their families.  The Turnaway Study is an effort to capture women's stories, understand the role of abortion in women's lives, and contribute to the ongoing public policy debate on the mental health and life course consequences of abortion and unwanted childbearing for women."

- taken from the Turnaway study website, under Why this study is Important

(*I copied this image from the Slate XX blog review of the turnaway study, because it was just so good)

believing the whole concept

Back to Sarah* (*obviously not her real name) and our counseling session.  Sarah started the session by listing quickly - before we could even ask her any questions - all the reasons why terminating her pregnancy was the right thing.  Reasons that she - and many other woman- have cited included that her "life is a mess" and she could not responsibly bring a new life into it.  Sarah* was living with an on again/off again boyfriend who she loved, but struggled with uncontrolled and unpredictable bipolar disorder.  The two of them had been living in a van under a bridge for the past several months.  They were both having a hard time finding work.  Neither one of them had any support from or connection to family in the area, nor did they have any other resources to draw on.

She went on for several minutes listing these reasons and more.  We listened.  Then she stopped and paused, looking at us to see if we had anything to say, almost looking for our agreement with her reasoning.  But the very wise and experienced counselor said nothing, just waited.  I wasn't sure what to do, so I said nothing, and waited.  Then Sarah* said, "but the truth is, I want to be a mother more than anything else in the whole world.  Even though it doesn't make sense.  Even though it's not responsible.".

And that's when the counseling began, as the counselor started asking questions to help Sarah* work out what she thought and felt.  To help her see her situation in the truest light - without judgement, but without rose colored glasses either.

Sarah* said that she was concerned that if she terminated her pregnancy, that in several months - when the baby that would have been actually would have been - what if her life was better?  What if it was now responsible for her to bring a new life into it? What if she and her boyfriend had figured out jobs, had found an apartment, had organized their lives - would she then feel incredibly guilty and regretful that she had ended the pregnancy?

The wise counselor listened and finally said, "You know, Sarah*, no matter what you decide to do in this situation, your life will be different in several months.  And if you decide to end the pregnancy and your life is better in several months, how will you know that this decision didn't help you to make your life better? And if you decide not to end the pregnancy and your life is better in several months, how will you know that this decision didn't help you make your life better?  We just have no way of knowing how our lives would have turned out if we made other decisions, but I can tell you that this decision you are making now will absolutely affect your life over the next few months - because it will be very different if you are pregnant and expecting a baby than if you are not.  Only you can make this decision, but once you have made it, don't judge yourself for it, or think of all the other possibilities that could have been - because it will be different."

Later, after Sarah* left, without terminating her pregnancy, to think more about her decision, the wise counselor and I debriefed.  We talked about how even though her reasons for why she should not be a mother right now make logical sense to us - that if we really believe in a woman's right to choose, a woman's right to make decisions about her own body, then we cannot judge her decision, we cannot think to ourselves that she should make one decision over the other.  Our role is to help her make the best decision for her, in a non-judging, non-assuming way.

It's definitely hard, but feels incredibly important.

~~~~~~~~~~~~~~~~~~~~~~~~~~~

"A woman's life can really be a succession of lives, each revolving around some emotionally compelling situation or challenge, and each marked off by some intense experience"

-Wallis Simpson, Duchess of Windsor (1896-1986)

Choosing What We Show

Recently, I interacted with a woman around my age who had come to the clinic where I was working with the intention of terminating her pregnancy.  It's been so long I can't remember how many weeks along she was, but not far.  Women enter these difficult and emotionally wrought visits with a clinician in all styles.  Some openly weep, some list all the reasons why this is the right decision - as if convincing themselves, some are silent and refuse to make eye contact, many are curious - about the pregnancy, about their options, about what they might see or not see, how their lives may be different depending on how they choose.

I feel so lucky to live in a country, in a time, when women get to make these decisions - though saddened that their decisions were not instead the less emotionally draining one of choosing effective birth control or choosing not to have sex in the first place.  I feel even more lucky to have worked in a clinic that allowed women the space to feel, think, and process whatever they needed.

This woman, let's call her Sarah* (*obviously not her real name), knew she was pregnant but was not sure how many weeks - so we did an abdominal (on the belly) ultrasound to take measurements to date her pregnancy.  There has been a good deal research on interactions with ultrasound technicians by women considering termination and the data is surprising.  But first, because ultrasound is a tricky subject these days, let me set the facts straight: everyone who is seeking or considering a termination usually has an ultrasound to date the pregnancy, because this determines many things about the possible procedures and counseling.  In the vast majority of cases, this ultrasound is done abdominally (on the belly) and is only done transvaginally (in the vagina) if the pregnancy is too early, and therefore the uterus too low in the pelvis and too small to see through the abdomen.  There are some people trying to pass laws about ultrasound and pregnancy termination that require very different things, including transvaginal ultrasounds, narration of ultrasounds, listening to heart beats, seeing moving images, etc.  This has not been my experience.  

In research investigating how to interact with a woman considering termination when conducting an abdominal (on the belly) ultrasound, the results are surprising in that many women are interested in seeing the image, many would even like an image printed to take home.  Even more fascinating is that there does not seem to be a pattern with the choices women make (in terms of keeping the pregnancy or terminating the pregnancy).  Additionally, when ultrasonographers (the people who do the ultrasounds) and clinicians are interviewed, they largely believe that women should not see the ultrasound if they are considering or have decided to terminate a pregnancy.  There are still many questions to be answered - including if the age of gestation matters (many of these papers were only involving women who were intending to have first trimester terminations), larger sample sizes, longer term effects, correlation with other factors such as parity and reasons for termination.

Planned Parenthood has a national policy where every woman is asked, before stepping into the ultrasound room, if she would like to know if she has more than one pregnancy (twins, triplets, etc), and if she would like to see any images.  Anecdotally, I have been told that most other clinics don't ask and do not offer unless the woman asks explicitly to see a picture.  

As I have had more experience with this, and after hearing an amazing presentation on some soon to be published data on women's experiences of ultrasound before a termination, I decided that I am going to ask women if there is anything they would like to see or not see, know or not know.  And I have been fascinated by the results.  

Which brings me back - finally - to Sarah*.  Sarah was very quiet when I brought her to the ultrsound room.  I had already asked Sarah the same question I ask everyone and she had said she would like to see an image.  Again, based on experience, the teaching I have received, and the data I have seen, whenever I show anyone an image, I zoom out so that there's slightly more realistic perspective of the size of the pregnancy, and I point out the abdominal wall, the uterus, and the pregnancy, as well as any other obvious structures.  When I did this for Sarah, she started crying.  In my desire to comfort her, I quickly turned the ultrasound away from her and sat in a chair next to her.  I asked her what was going on her in head at that moment, and if there was anything I could help with.  When she shook her head No, I put my hand on her back and reminded her that the next step at our clinic is to talk in depth with a counselor.  I asked her if she wanted to see any other images, and when she said No, I walked with her to the counselor's office, where the three of us sat and talked for a long time.

To be continued in the next post, as it takes this thought in a slightly different direction.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

"I pointed out that she was, by definition, pro-choice.  In its simplest form all it means is that the woman gets to decide".

-Susan Wicklund, Physician and Author of This Common Secret

(click the link to see a NYT review of her book)

just like owning a dog

I love how the process of having a baby, especially the last really tricky labor part brings out so much of a couple and you really get such an intimate view of their relationship.  I love when people laugh in labor (because if you can laugh in labor...)  Even the couples who are clearly so nervous, you can tell how much they love each other.  being surrounded by all this love and new beginnings and creating of families is amazing - but also reminds me on a daily (nightly?) basis how little I'm seeing my own family, including the manfriend.  so today, when I got out early at 6:45 and it was beautiful out, I practically ran home in order to see the manfriend for a good 30 minutes of alert and awake time together (as in, I was alert and awake - he was mostly mumbling but smiling).  It's funny how we've learned how to tend to our relationship - how we've learned that even those 30 minutes, however tired and grumpy and hungry we are.  And it reminded me of this amazing poem by the def poet Taylor Mali, which I think fits in with a lot of conversations I've been having with friends lately about their own relationships, it's called:

Falling in Love is Like Owning a Dog
first of all, it's a big responsibility,
especially in a city (like New York)
So think long and hard before deciding on love.
On the other hand, love gives you a sense of security:
when you're walking down a street late at night
and you have a leash on love
ain't no one going to mess with you.
because crooks and muggers think love is unpredictable.
who knows what love could do in its own defense?
On cold winter nights, love is warm.
it lies between you and lives and breathes
and makes funny noises.
Love wakes you up all hours of the night with its needs.
it needs to be fed so it will grow and stay healthy.
Love doesn't like being left alone for long.
But come home and love is always happy to see you.
It may break a few things accidentally in its passion for life,
but you can never be mad at love for long.
Is love good all the time? No! No!
Love can be bad. Bad, love, bad.  Very bad love.
Love makes messes.
Love leaves you little surprises here and there.
Love needs lots of cleaning up after.
Sometimes you just want to get love fixed.
Sometimes you want to roll up a piece of newspaper
and swat love on the nose.
not so much to cause pain,
just to let love know, Don't you ever do that again!
Sometimes love just wants to go for a nice long walk.
Because love loves exercise.
it runs you around the block and leaves you panting.
it pulls you in several different directions at once,
or winds around and around you
until you're all wound up and can't move.
But love makes you meet people wherever you go.
People who have nothing in common but love
stop and talk to each other on the street
throw things away and love will bring them back,
again and again and again.
but most of all, love needs love, lots of it.
And in return, love loves you and never stops.

night float

so I started my month of night float on labor and delivery two weeks ago (or was it three?  the days sort of blur together when you leave work, sleep for a few hours and come back to work and it's the same day)  you'd think wishing so many new people their first birthday I'd at least know what day it is, but usually I don't.

what is night float?, you may ask -
well I go in around 5:30 pm, change and get ready for sign-out at 6pm, take over patients from the residents who have been there during the day and then manage all patients who are already on the floor or who come in laboring over night, then I sign out around 7am the next morning back over to the day team.  Usually this is followed by a lecture or a didactic session until about 8:30 or 9, after which I bike home, shower, maybe eat something, and crawl into bed to sleep for a few hours before heading back in later that night.

it's a total shock to the system, to say the least, but it's also pretty amazing.  babies are definitely meant to be born at night.  if you take an evolution view, if you're going to be in a state where you are pretty unaware of your surroundings and spending all your energy on something that leaves you pretty defenseless - best to do it when it's easier to hide and there's less going on in the forest.

it's been an amazing few weeks of actually getting to deliver babies, managing women in labor - and learning what's normal and what's not, how to follow the heart tracing of a baby about to be born, how to check the cervix as it gets ready to open and let a baby out, and getting the honor of supporting women in some pretty vulnerable - but also incredibly powerful moments, it's truly awe inspiring and even though I'm exhausted, I don't know if there's anything cooler or more exciting than helping a new life come into being.

some tips I have for anyone working nights (this is also so when I'm a resident on months of night float I can look back and remember what I did to make it through):

1. first thing you do when you get home is shower.  I don't care how tired you are, [other people's] amniotic fluid should not be on your sheets.
2. bring lots of healthy snacks - especially water-heavy snacks (fruits, veggies, just plain old water)
3. when you wake up (or if you feel alert before heading to sleep): work out.  even if it's short, ugly, traumatic - there's not a day when it will feel good so if you start using that as your measure if you should go work out, it'll never happen.
4. make your off days count - get in a good run, go on a good date, take some lazy slow moments
5. have easy to prepare delicious food at the ready - it's good to still try to eat meals, even if you don't know what meal you're eating (otherwise you're just snacking, literally 24 hours).
6. make sure everyone around you knows that you're on nights, and that they should lower their expectations of you temporarily as a friend, partner, roommate, daughter, etc.
7. drink coffee when you wake up.  not too much, not to often, but just enough. (stop at palpitations)

that's all for now.  gotta grab some healthy snacks and head out for another night of birth!

choice

All the battles over contraception coverage that have older men inappropriately talking about the reasons women use contraception, as well as the heated debates about new laws that humiliate and isolate women while they are making these very difficult decisions.

A recent study from the Guttmacher Institute showed that HALF of all reproductive age women now live in states that are hostile to abortion!  This map below shows the change over time in states hostility to policies related to contraception and terminations. 

It may also be a map of where I am applying to residencies next year.

and just in case you haven't been following along - Doonesbury is running a series on the new laws surrounding a woman's right to make reproductive decisions that is obviously now being censored.  Check out the censored strips on Slate blog.

Contraception

"It comes down to this: if the issue is contraception, Republicans lose. The polls are clear enough about that. But the numbers do move a bit depending on how you ask the question: if it’s framed in part as an issue of religious liberty, the picture looks better for opponents of the rule. There, Republicans have an opening—if they can shift the debate away from contraception, and instead make it about the President attacking religion and the religious (and throw in a few winking hints about his personal beliefs), then they have a chance to turn this into a winning issue come November."

Oh goodness, I hope note.
Read more of this New Yorker article here.

It's Complicated

After having a few too many not-so-enthusiastic responses to my starting to tell people that I'm going to be an ob/gyn (YES it's true!  And that's short for obstetrician gynecologist for anyone who is thinking how in the world do I pronounce that) I decided that I needed to write a letter to myself about why I want to do it.  Not because I'm not sure, but so I can reflect back on it whenever I want a reminder in clear, honest words instead of a jumbled, messy "well I don't want to do what you do either!" knee jerk response which is not necessarily the greatest.

As I was groping for the right words I read this awesome post by an ob/gyn from her fabulous blog that I just stumbled upon and thought: SO RIGHT.  I like it because it's complicated.  Because women are complicated.  Because women talk through everything they are thinking and feeling about their health.  Because for women, health isn't just about them but about the people in their lives, the people they love.  Because women's bodies are changing and morphing throughout life in ways that are fascinating to me and aren't just getting older or getting diseases that can benefit from explanations of the inner-workings of medicine.  Because I want to be on the same page as my patients (and while I wish I felt that way with male patients, I just don't).  Because I want to be able to take my patients into their C-sections if that's what's necessary, into their hysterectomies, to catch breast cancer early and explain what happens next, to talk about safe and empowering sex, to deliver a baby and then deliver her baby many years later, to talk about how hormonal changes can affect even the most powerful woman - but how they don't have to be debilitating, to help women make their lives healthy with exercise and good nutrition and screening tests and asking questions.  Because I want to be an advocate for women's health and while I could do that from other fields, it would be only so that I could say I didn't JUST go into women's medicine - when in fact all I want is to go into women's medicine.

phew.  this might need some editing later, but for now I just want it out there in the world.

Stereotypes and Tents

A friend of mine just sent me this awesome article written by Mindy Kaling, one of the writers of the office, about female stereotypes in film that are absolutely ridiculous - but we love them, and maybe crazier, start to aspire to be like them or think we are like them.  For example:

The Woman Who Is Obsessed with Her Career and Is No Fun at All

I regularly work sixteen hours a day. Yet, like most people I know who are similarly busy, I’m a pleasant, pretty normal person. But that’s not how working women are depicted in movies. I’m not always barking orders into my hands-free phone device and yelling, “I have no time for this!” Often, a script calls for this uptight career woman to “relearn” how to seduce a man, and she has to do all sorts of crazy degrading crap, like eat a hot dog in a sexy way or something. And since when does holding a job necessitate that a woman pull her hair back in a severe, tight bun? Do screenwriters think that loose hair makes it hard to concentrate?

Other gems include "The forty-year old mother of a thirty-year old male lead", the "ethereal weirdo" (think juno or the female lead in garden state), and "the skinny woman who is beautiful and toned but also gluttonous and disgusting" (think skinny girl stuffing her face with cake).  I've been on my own sort of stereotype smashing spree because, sparing you the details, I've been getting some pretty awful reactions to my telling people that I am strongly considering the field of ob-gyn. 

the consensus generally seems to be that I'm not going to be a very good mother, a very good surgeon, very good at diagnosing things other than pregnancy, surrounded by mean awful people, and overall pretty miserable with my life.  The field itself is sometimes perceived as being "too estrogen heavy" (helllloooo it's birth, it REQUIRES estrogen) which inevitably results in catty gossip, backstabbing, and comparing who has cuter dansko clogs, right?  NO.  From what I've seen, ob-gyn is not a field of just women, and the women and men in the field are serious, smart, competent doctors who went into ob-gyn because the physiology of pregnancy is like nothing else, because we still haven't figured out fertility, or menopause, and the reproductive cycle of a woman is one of the only topics in health vital to the continuance of our species, so it's been pretty fine-tuned by evolution and involves tons of genes, messaging cascades, and signals.  And  while some of my very favorite ob-gyn attendings were men and many of the people I love and respect in my life are men, I feel a different kind of energy in groups of just women.  It's not catty or gossipy or back-stabbing energy, but strong, calm, nurturing power.  Especially with pregnancy, it feels like going back to our tribal roots, when the birthing process was a tent filled of the women of the tribe who each had been through it or would soon, who had felt twinges in their own bodies that resembled this sensation, who empathized with the feeling of looking at your child for the first time, of the power of that bond, the implications of how the rest of your life will change, that's a lot to hold and I think there's something programmed in women to understand that in a different way.

And if we can bring medical knowledge and skills to the tent, well then, all the better.  

10 Things I Learned in Ob-Gyn

1. body language matters.  for ob-gyn's, where you stand before, during, and after an exam makes a huge difference in the comfort of the patient. Pushing your naked butt forward while your feet are in stirrups towards someone you can't see who you know is about to use a speculum is so much more nerve-racking than someone standing beside you and saying, please scootch down until you feel like you're about to fall off the table - THEN going to the bottom of the table.

2. my body does strange things when it has to be awake for too many hours.

3. no one fully understands menopause.  It's one of the great frontiers of women's health that we have only barely begun to brush the surface of - but the good news is that there is a ton of interest in topics in  menopause because women are living at least 1/3 of their lives after menopause now.
4. women are not just like men.  for example, when women have heart attacks, they rarely get chest pain.  they are much more likely to get jaw pain.  science and medicine are just barely adjusting.
5. women are not so different from men.
6. say what you want, seeing a baby be born and especially helping a baby be born is one of the most incredible magical miraculous things in the entirety of existence.
7. if birth control access were truly universal - meaning that women would come in to get it, would be able to take it well (so we would be able to give them whatever kind they would actually use), and that women would follow-up regularly, there would be fewer unintended pregnancies, fewer women who have children when it's not a good time for them to have children or when they really can't handle having children, fewer abortions, and that would translate into everything being just a little bit better.
8. we have to talk about sex.  it's too much of a health issue to have your doctor not talk about it.
9. lots of cancer is preventable, yet people are either embarrassed or too busy to do the things.  Get pap smears. Get mammograms.  If you are a guy, encourage your mother/sister/friends/wife/girlfriend to get regular screening tests.
10. surgery is freaking cool.

"Hello babies.  Welcome to the Earth.  It's hot in the summer and cold in the winter.  It's round and wet and crowded.  At the outside, babies, you've got about a hundred years here.  There's only one rule that I know of, babies -- God damn it, you've got to be kind"

-Kurt Vonnegut, in Thanks You Mrs. Rosewater

controlling birth

we just had two of the most excellent lectures in medical school so far on Friday - one, on birth control and one on abortion - strikingly and unfortunately related as access to one decreases the amount we have to see the other. it made me realize that while I've touched on lots of women's health issues, I haven't talked about either one on this blog.

BIRTH CONTROL first (because I have to be a little less careful about how I explain everything):

From the beginning - birth control is anything that is designed to prevent a pregnancy. Some also prevent STIs (sexually transmitted infections), some do not. To see a full list of birth control options available in the US and some of the pros/cons, check out the CDC website. If you are considering a particular type of birth control, I'd definitely talk to your doctor about the pros/cons of each type and how that fits with your life.

Some factors to consider when choosing a form of birth control:

1. how much do you not want to be pregnant? as in, how good does your birth control method need to be? For example, if you are not willing to make some decisions about an actual pregnancy, the withdrawal method (where the penis is removed before ejaculation) is not a good method for you, because it's not very effective. On the other hand, IUDs are more effective than tubal ligation.

2. would you rather use something only at the time of sexual intercourse? OR

3. how good are you at remembering something consistently? If taken correctly, birth control pills are 98% effective, if taken incorrectly (like missing them, taking them at different times, taking other medications that interfere with them), they are only about 80% effective, meaning 1 in 5 women who takes them incorrectly gets pregnant.

4. how much money are you willing to spend on birth control? Many people like the hormonal ring because it can be put in for the whole month but is otherwise much like the birth control pill, but it's pretty expensive. On the other hand, condom charges can add up pretty fast. An IUD is expensive up front, but then you don't have to pay anything for the next 5-10 years.

5. is there any reason why you shouldn't use a particular type of birth control? do you have a clotting disorder in your family or a family history of breast cancer? then maybe birth control involving estrogen is not the best for you. If you have a male partner who refuses to wear condoms, well - THAT's not going to work (also, probably worth a conversation about why)

6. Is there an added benefit to using any type of birth control? for example, estrogen-containing pills often also help clear up skin, the progesterone-secreting IUD can make your periods lighter.

7. Do you need to get period every month? Or do you NOT want to get a period every month? depending on your own neuroses, it might be important that you see "proof" that you're not pregnant every month. On the other hand, menstruation might really interfere with your day to day life. Hormonal methods like the pill, the patch, and the ring allow for you to choose if you want to have a withdrawal (of progesterone) bleed, whereas with the progesterone IUD (the Mirena), 1/5 of women stop bleeding altogether.

8. What kind of access do you have? If your job takes you traveling all over the world, you might not be able to get your pills refilled every month. Depending on where you are, it's easier or harder to undergo any procedural birth control like tubal ligation (tubes tied), vasectomy (where the male vas deferens or the tube the sperm swim from the testes to the penis in, gets cut), or even IUD placement (though this is much more widely available).

9. What do you like? If you really don't like the feeling of anything in your vagina, the ring might not be the best option for you. If you're not into condoms, chances are, you won't use them or they'll make sex less enjoyable. If you hate trying to remember your pills, they aren't the best option for you.

10. What does your partner like (or rather, not mind)? male condoms definitely require some male partner consent, especially if he's going to be buying them. There are also those wonderful male partners that help pay for birth control pills or IUDs because he knows he's benefiting too. But there are also male partners who can feel the IUD strings so are less wild about those. Definitely a factor to consider, but I put it last for a reason. YOU are the person who should feel comfortable with your birth control because you are the one who will be pregnant if it doesn't work out.

My one plug is that recently a lot of my classmates have gotten IUDs because with night call and 24 hour shifts and generally unpredictable schedules, not to mention moving around, it became harder to remember any type of birth control (pills, patches, rings). Generally, people are very satisfied - less bleeding, no estrogen meaning no water weight but also no acne control, and best of all: no having to think about it.

The most important thing about a birth control option is that it works for your lifestyle because none are good if not actually used.

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"Birth control is a woman's right to decide when she is ready to be a mother"

-Julie Hebert

"I got a pocket full of rubbers and my homeboys do too"

-Snoop Dogg, in his song Gin and Juice

promoting the use of safe birth control methods

Where are all the grown-ups?

Today I had two surgeries (by "I had" I mean I generally watched and held things): one was a dramatic robotic surgery that was more difficult than they thought it would be so they converted to an open surgery. The second surgery was a suction evacuation of a woman who had had a failed termination of a 9 week pregnancy 3 weeks before and subsequently developed an infection along with not actually terminating the pregnancy. It was one of the most interesting cases I've had yet, not because of the procedure but because of all the ethics and emotion tied up in the case. For starters, it was hard to find staff for the case. It ended up being one attending who did not want it known that she performed terminations and two residents (A first year and a second year) along with a first year anesthesia attending and a circulating nurse who was about my age.

I definitely had a thought before we started like, "but where are all the grown-ups that are usually in the OR with us?" but everything went really well and obviously the OB attending was there, mostly teaching me and confirming what the residents were doing/finding.

After the procedure, we have to confirm that the "products of conception" have been removed from the uterus. This involves piecing through the specimen to find evidence of a gestational sac and organs/structures. It felt very strange but oddly similar to my undergraduate research lab to be searching through bloody mush to find specific parts.

I ended up sitting with the patient a long time afterward because she was so emotional and so scared. It was the one moment this rotation that I've been glad to be a medical student - because I didn't have to run off anywhere to do all sorts of other things and could just answer all her questions whenever she had them. (because otherwise, it's been infuriating to be a medical student and mostly observing...)

Ob-gyn is still going well - I'm done with q2 (every other day) 24 hour shifts on OB and have moved on to the "gyn" section which is a lot of surgery and outpatient clinics, but still requires me to be at the hospital before 5am. A few days ago I had a complete scraping-the-bottom-of-my-barrel-of-energy day where everything felt overwhelming and I felt incompetent. Then I remembered that the last time I got more than 5 hours of sleep at one time was about 3 weeks ago and that I still don't know what meal my body feels like it should be eating. After a run, a good dinner, a glass of wine, and an early bed time (6hours last night, hooray!)

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"self preservation is a full time occupation"

-ani defranco

first test of motherhood

around 4am last night, on the 26th hour of my 28 hour call day, I was standing at the side of the bed of a 29 year old woman who was trying to push out her first baby and screaming "help me, help me, help me. I can't do it. I can't do it" and I was thinking (amidst telling her she was safe, her baby was safe, that she was doing a great job, to KEEP. FREAKING. PUSHING.) that birth is really the first test of a mother. I have yet to see one first vaginal birth where the mother didn't actually tear through her vaginal opening. Not like, it happened to tear. Like, she pushed so hard to get that baby out that she is actually TEARING HER OWN SKIN. It seems like a pretty good test of what's to come: are you willing to tear yourself from the inside out in order to give life, air, comfort to this brand new baby that you aren't even sure what it will be like, but you already know you love it enough to rip yourself open.

The best part is that after the big, (often) tearing push, the baby goes on the mom's chest, the partner leans over and pushes her sweaty hair back from her face, they gaze at their new, crying baby who is covered in white vernix together and glow. They all glow.

Terrifying and amazing.

oh, yeah. so I started my ob-gyn rotation and freaking love it.

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"a healthy woman is much like a wolf: robust, chock full, strong life force, life-giving, territorially aware, inventive, loyal, roving".

-Clarissa Pinkola Estes, author of Women Who Run with the Wolves