Thursday, November 26, 2009

Next patient, please

One of my patients tonight is an immature 19 years old. In fact, I am shocked at her immaturity, though it is something I frequently see in teenage mothers. I met her in the mists of a seizure caused by eclampsia, a condition which strikes pregnant women. She has two risk factors: She is young and this is her first pregnancy.

While 19 is older than most first time mothers I encounter in this population for which I provide medical care, I believe her sexual experience began at a much younger age. Why do I think this? For starters she has 4 sexually transmitted diseases. Five if you count her pregnancy. These diseases are herpes, syphilis, gonorrhea, and HIV. Yes, HIV at nineteen. I suspect she has been working as a prostitute. She is not a run away. Both her mother and an older sister have been to the hospital to see her. The records from the county hospital show her mother accompanied her to the prenatal visits she made there.

It is hard for me to imagine what kind of life has been handed to this young woman. The facts I learned as spent most of the morning trying to fill in the gaps social work and CPS left were shocking. The stories from family members differ. "She been livin' with a relative in another state." "The baby daddy 's in jail." I can't help but think she needed multiple sexual partners to contract all these diseases and the variety of explanations from the family seem to confirm my suspicion about prostitution. Though nineteen is old enough for her to be living on her own, it seems she has been on her own for some time.

Yet I am at a loss as to what to do. Child protective services came to make sure the baby would have care. Social work has little to offer. She will leave the hospital with her mother. I am not at all sure she will continue the medications she needs to prevent her from developing full blown AIDS. I can not think to much more about the situation. She is scheduled for discharge in just a few hours and I need to move on the other, more pressing problems today.
Next patient, pleaseSocialTwist Tell-a-Friend

Friday, November 20, 2009

Evidenced based medicine

Evidenced based medicine is the terminology physicians use when we talk about medical practice which is based on studies large enough to have statistical significance. If you are not a physician it is difficult to understand how much of medical practice is based on dogma. This makes one of the best things about medicine one of the worst things about medicine, a patient's trust in their own individual physician.

Several years ago when remodeling our house the electrician gave us an estimate based on the plans which were drawn for the remodeling project. The demolition crew came and went. The electrician returned. He carefully went through the wiring again, ask to meet with me and my husband, and gave us the bad news. Wiring uncovered in the tear out was not code. It had probably been done by the previous owner and was in fact, a fire hazard. If we wanted him to do the wiring he would have to increase his bid by 20%.

My husband had a fit and was ready to fire the guy on the spot. I one the other hand reasoned the following: This man has a license. The city is going to inspect his work. We don't want to have a fire. I am going to trust him. I told my husband if he was that upset by the price increase we would get a second opinion from another licensed electrician. We went ahead, finished the remodeling project and twenty-five years later, everything in that kitchen is working fine.

Standing there with the electrician that day, I remember thinking, "I don't know electricity. I know medicine. I can trust this guy or I can get someone else I trust but I am never going to know electricity. Someone, hopefully an electrician, is going to give me the correct information."
(Also understand we did not yet own a personal computer nor was the Internet a household word so maybe my position was made a bit simpler by these two facts.)

Ever since that incident, I have hoped my patients trust me as much as I trusted that electrician. Over the years my patients have brought me newspaper articles, magazine clippings, and yes, websites to view. I have been given books, DVDs and tapes from the lay press. One patient offered to pay me to watch a thirty minute video about natural hormonal replacement therapy in hopes I would write the prescriptions she desired.

Through it all, I have tried to stay abreast of both what The New York Times and The New England Journal print along with Cosmopolitan, Glamour, and O. In these later years, I have even given in to watching television advertising by the pharmaceutical industry to try and hear what my patients seem to hear and believe will make their lives better.

So you can imagine I have been all eyes and ears these past several days as the new recommendations for breast and cervical cancer screening are released. I sat down this morning to write Diane Ream and the editor of my local paper but instead chose to put my thoughts down here.

First, both the Preventative Services Task Force and the American College of Obstetricians and Gynecologist are made up of excellent physicians much more knowledgeable than I about statistical analysis and evidenced based medicine. It is true, many of them have not spent their lives as I have holding patients hands and advising individuals on health care decisions. But these women and men did look at the evidence. They did not sit around as we practioners often do speaking only of their individual experiences. That is the kind of stuff which led to the dogma that every woman should begin hormonal therapy at menopause.

Second, I have two patients I can name, one now dead, which were low risk for breast cancer and normal routine screening mammograms DELAYED the diagnosis of their breast cancer. At the risk of being long, I will tell you the story of one of them.

At forty Barbara did what most obedient, health conscience, American women do. She had her baseline screening mammogram. It was totally normal. Three months later she felt a lump. She surmised it was normal since her mammogram had been. Just a function of the normal monthly ebb and flow of her hormones, she told me later. She forgot about it. Until nine months later when I felt it on her yearly examination. Not only could I feel that lump but I could feel a lump under her arm, the early metastasis of her disease. A disease that did not show up on her mammogram even on retrospective inspection by multiple radiologists (the case has been through several attorneys and expert witnesses.) She delayed seeking care because of a routine mammogram which was negative. Today, despite aggressive treatment, she is dead of her disease. I often wonder, what if she would have come in when she first felt the lump, which was solid and would have been biopsied regardless of mammogram findings, would she be alive today? She had no family history. She was in a low risk group. I can't help but believe that screening mammography contributed to her death by giving her a false sense of security.

This is a long piece incorporating many of the thoughts I have developed over the last twenty seven years of practicing medicine. The practice of medicine is not an easy task which is probably one of the reasons I was drawn to it in the first place. I believe the recommendation from these two groups have much merit (and a good bit of wiggle room.) American medicine has long been in love with and dependent on technology. Prehaps the best to come of these recommendations (besides an increase in the sale of newspapers) will be some serious discussion between women and their physicians.
Evidenced based medicineSocialTwist Tell-a-Friend

Thursday, November 19, 2009


I sat at the labor room desk staring at the form. DOB 4/18/96. Thirteen. 13. Any way I looked at it Morgan Whitney Nabors* is thirteen years old. And this is her second pregnancy. The first ended in a miscarriage but still, she had been pregnant before. I searched the form for other clues. The responsible party was Olive May Warren, a medical assistant, and her employer was blank. Emergency notification listed Arthur Warren. All the telephone numbers and social security numbers were filled in.

I imagined this mother sitting in the emergency room filling out the form. How long had she know her daughter was pregnant? Who is the father of the baby? They have not yet applied for Medicaid. Who is the father of this baby? Why hadn't she gotten her daughter contraception after the miscarriage? Who is the father of the baby? Which baby? What is going on here? Who is the father of the baby? How does a thirteen year old begin having sex? Who is the father of the baby?

I have a headache from the swirling questions. Some of the nurses have told me I just don't understand the culture. Which culture? I have lived right here in this city for the last 27 years. I understand motherhood. I have raised children. I don't understand how a thirteen year old gets pregnant. Who is the father of the baby? Here I go. I am about to dive into this with CPS and social work right behind me. Who is the father of the baby? I am sure the first answer I will get to this questions is "her thirteen year old boyfriend."

There seems to be a sea of inertia in which we are swimming. Despite my strong strokes to stop these teen pregnancies, they are coming faster and younger, with the resources of prevention occasional life preserves usually just out of reach. And who is this baby's father? I will probably never know.

*all names are changed
ThirteenSocialTwist Tell-a-Friend

Tuesday, November 10, 2009

The future

I stand very quietly watching the tiny form wiggle his toes, the whole foot not much larger than my thumb. "No name yet," the nurse informs me as she adjusts the ventalator. She is reading my mind, "We are coming down on the ventolator settings. He is doing better."

I always go up to the NICU or neonatal intensive care unit to see the babies I have delivered. Many make it through to the step down unit, grow to be 5 or more pounds and go home. As with this baby, I always wonder what kind of home that will be.

I know this baby's mother better than most. She was in the hospital 5 weeks before he was born. Her drug screen was positive and after a few days of "drying out" she ask me to terminate the pregnancy. When I told her this was not only against hospital policy but at her stage in gestation, it was illegal as well, she refused all subsequent care and left against medical advice.

She returned via ambulance, again in a drug induced stupor, and I delivered this two pound baby boy on the stretcher just inside the doors to labor and delivery. At delivery I thought he was dead but the NICU team was there and revived him. Now we are here. He is two days old and getting stronger.

From the mother's previous hospitalization I know there are two other children. One in the custody of her mother, the other her sister. The patient asked to have her tubes tied and if it were up to me that would already be done. I have no illusions of rehabiliation. Sterilization is at least part of the solution. I am just wondering about this baby, with feet the size of my thumb. Who will care for him? What does his future hold?

How many more like him are in this city, state, country? Where does it stop? I fear we will run out of resources sooner than we will run out of babies with feet smaller than my thumb.
The futureSocialTwist Tell-a-Friend

Sunday, November 8, 2009

My office

With my change in positions several people have ask, "Where is your office?"

The short answer and probably the most truthful is, "I don't have one."

Oh, I have an eight by eleven foot call room complete with bed, desk, and chair. I have grow so tired of this space in the last 6 months that I now only go there to sleep. I share a conference room, complete with two computers, monitors for all the beds in labor and delivery, and cable TV with any other obstetrician who happens to have a patient in labor. There is a common workspace I use in labor and delivery, again with monitors and computers to scan what is happening in each room or access medical records. Similar accommodations exist for my use in the emergency department.

Yet, it dawned on me one morning last week, as I slogged around a park south of my home, that my office is there also. On my non-call days, when I am not chained to the hospital by my contract which states I will be physically present to care for any obstetrical or gynecologic emergency, I head for this park. It has a one mile dirt trail, beautiful oak and pecan trees, a creek bed, and several grassy areas. Set back from the roadway, the sounds are birds, squirrels, and the rustle of the leaves.

The peace of this place passes any understanding. I can feel very beaten down when I arrive but I leave refreshed, physically spent, and believing I can make it at least one more day. And, lest you doubt, it is my office, my beeper is strapped to my side and my cell phone is in my pocket. Some days I spend more than one of the five miles I attempt to traverse talking with a young doctor about how to care for a patient. My counterpart, the person who is now captive in the hospital, will have to be the physical presence when one is needed. I am fine with talking for a few minutes as I sweat and struggle to make it around the trail again or as I simply sit and admire what a fine piece of work the interior designer of this space has done.

My officeSocialTwist Tell-a-Friend