Motherhood, Women's Health

HOW I CAME TO BE AN OB/GYN

“You must have the grossest job in the world. Why on earth would anyone want to be a Gynecologist?” my twenty something patient asked, as I was examining her ‘nether regions’.

“Well, I do enjoy helping people” I lamely replied. I was doubtful she heard me, as she had already returned back to texting at this point.

I smiled as I left the room, remembering my surprisingly similar thoughts at her age.

I wanted to be doctor for as long as I could remember. But when I started medical school, the two specialties I knew I didn’t want anything to do with were OB/GYN and Pediatrics.

There was little doubt in my mind that Family Practice was my chosen path.  I chose Oklahoma State University because of its focus on primary care. I had shadowed several FPs and truly enjoyed the continuity of care and relationships that occurred in Family Practice.

When I started my rotations as a third year student, I excitedly picked FP as my first month. The practitioner I worked with was amazingly kind and knowledgeable.  He also had a passion for teaching and I was appreciative of the time he spent instructing me. Though we saw some interesting patients, there was also a lot of mundane colds and earaches. After about 3 weeks, I started to have doubts whether this was really what I wanted to do for the rest of my life. I was a little concerned, but knew I had a few (our school required 6 months of Family Practice) more months to decide.

The next month, I did an away rotation in internal medicine with a wise internist who had been in practice for 30 years. While I didn’t love internal medicine, I did love the doctor. I soaked up every bit of wisdom about life and medicine he sent my way. He inspired me to THINK and not just memorize facts. On my last day of the rotation he sat me down and said essentially that I had done well on the rotation, but he thought my personality was the most suited for OB/GYN.

I smiled on the outside, but internally I rolled my eyes.

My first thought was, “What a sexist!” I was sure he was saying that merely because I was a woman. OB was becoming a female dominated field, and it had been commonly suggested for me to consider it. However, the last thing I could possibly be interested in was doing PAP smears all day. Yuck. Child bearing had no interest to me whatsoever. It was WAY too messy.

I composed my initial thoughts and replied, with a simple, “I don’t think so.”

“When’s your OB/GYN rotation?” he asked.

“The last one of the year.” I replied, having postponed it to the end.

“You should seriously consider moving it up earlier” he encouraged me.

I thanked him for his advice as a courtesy. Then thanked him profusely for the other things he had taught me.

On the drive home I was still fuming about his remark. However, my thoughts began to wander. His wife and all 3 of his daughters were doctors, but none OB/GYNs. There were no other sexist things he had said or done the whole month.  I respected him greatly and had trusted all the other advice he had given me. Perhaps, I should listen and at least move my rotation up to earlier in the year. After all, I wasn’t loving FP nearly as much as I thought I would.

After several frantic phone calls, I managed to set up a rotation with a local private practice doctor, in desperate need of some CME’s.  I ‘did’ very little during this month, but what I observed was life changing.  I observed his daily practice: his rapport with his patients, interesting procedures and complex diseases.  He was able to practice preventative medicine in a real way (one of my passions) and also do fascinating surgeries.  I witnessed babies born then later the same day the removal of a giant ovary full of teeth and hair from another patient. It was thrilling. On my last day of the month, I broke down in tears on the way home. I couldn’t believe my month was over. I didn’t want it to end. I had fallen in love with the crazy life of being an OB/GYN.

Then began the soul searching and prayer. How could I have a family and be an OB/GYN? As much as I loved my month of OB, the hours were harsh, and I wasn’t sure I could hack it. Was being an OB really God’s plan for me or just a selfish whim? After months of pro’s and con lists and long discussions with my husband, I finally felt a peace from God that this was the path I should take.

Finishing my last 6 months of family practice rotation only confirmed my decision.

This life is NOT easy. The hours do get crazy. Yes, there are days when I do get tired of looking a vaginas all day long. But the longer I do this job the more I love it. So here I am, 8 years into private practice reflecting on how my life is nothing like I expected it to be when I began this crazy adventure in medicine. I realize that it is amazingly better.

Thank you Dr. Bruns for telling me I should be an OB/GYN. You were right.

pregnancy, Women's Health

WHEN IS IT “SAFE” TO TELL PEOPLE YOU ARE PREGNANT

I was at an end of the year kindergarten party this week. After consuming the usual amount of sugary snacks associated with such class parties, but before saying their dramatic goodbyes that also included full body hugs, each kindergartner circled up to say what they were looking forward to most this summer. Most announced various beach and Disney trips, but one little girl began jumping up and down and squealed, “I’m excited about summer because my mommy has a baby in her belly!” Based on the way her mom’s eyes widened and jaw dropped open in horror, I’m guessing this new baby news was not yet meant to be public knowledge.

It’s hard to know when it’s ‘safe’ to tell people you are expecting. In this age of social media, it is difficult to tell just family and close friends. Even when you try to keep it quiet, the news has a way of sneaking out like it did for my friend whose great aunt had recently joined “The Facebook” and accidentally posted her congratulations on her wall instead of a private message.

Everyone’s biggest fear is making a big public pregnancy announcement, only to have to sadly announce a loss a few weeks later. With my first pregnancy, we called all our friends and family the day we found out. We simply couldn’t contain our excitement. Sadly about a week later, we experienced a loss. It really stunk having to then tell everyone we had a miscarriage, but at least people knew why I was sad and could offer their sympathy and support, which was very helpful. With the next pregnancy I was very guarded and waited until after 12 weeks before I shared the news.

When I see a couple for their first pregnancy appointment, after we see the heart beating strongly on ultrasound and they breathe their initial sigh of relief, one of the first questions they ask is “Is it safe to tell people we are expecting?” I get a sense they feel that if I give them the blessing, all will be OK. While I can never offer a guarantee, I can offer statistics that provide some reassurance as to when it’s safe to let all their great aunts know the exciting news.

Chance of miscarriage after a normal first trimester ultrasound (maternal age <35):

  • At 5 weeks the risk of loss is 8%
  • At 6 weeks the risk of loss is 7%
  • At 8 weeks the risk of loss is 3%
  • After 12 weeks the risk of loss is < 1%

While many women choose to wait until after the first trimester to tell their news, if the baby has a normal heart beat at 8 weeks, their chance of a normal pregnancy is 97%.

Risk factor that might increase the chance of miscarriage:

  • Maternal age >40
  • History of >2 miscarriages
  • Diabetes
  • High blood pressure
  • Lupus
  • Untreated thyroid disease
  • Abnormally shaped uterus

Sadly, miscarriage is very common with up to 15% of pregnancies ending in loss. This rate can increase an additional 10- 25%  if you count “chemical pregnancies,” when a woman’s initial home test is positive only to have her cycle start a day or two late. Due to the high rate of chemical pregnancies, I encourage my patients not to rely on ultra sensitive home tests days before their period will normally start, but instead try to wait until they are at least a week late.

The decision of when to announce your pregnancy is a very personal one. I was initially horrified when I realized I was going to have to “unannounce” my first pregnancy after my loss, but eventually I was thankful I had the support of all my friends as my heart was healing. For those looking for the best time to share your news, know this: the risk of loss drops dramatically once you have seen a healthy heart beat, and then becomes extremely low after the first trimester. 

Motherhood, pregnancy

My Birth Story

When my alarm began blaring at 5:20 am on January 21, 2004; I immediately hit the snooze button. I am normally a morning person, but the last few weeks of my pregnancy were beyond exhausting. As I reluctantly climbed in the shower I purposefully avoided the mirror. I really didn’t want to catch a glimpse of my giant whale body. I had stopped feeling like a ‘cute pregnant lady’ long ago. My feet where still swollen from the night before; I noticed my sock indention from the previous day’s work.

I was lucky. My pregnancy was healthy and had gone quite smoothly, with the exception of one small hiccup: at 32 weeks I learned that my son was breech, and he never flipped. My c-section was scheduled for 39 weeks. If I am completely honest with you, I was more afraid of a vaginal delivery than a c-section. A small part of me was slightly relieved that things would be nicely scheduled and I would never have to face all the drama of labor.

My parents had their plane tickets to Ohio. It would all happen in 2 more days.

I was in my OB/GYN residency training during my pregnancy. I worked 80 hours a week, often 12 to 14 hour days. Residency was challenging enough when you weren’t carrying around 50 pounds of extra baby weight and having to pee every 5 minutes. However this was my final day of work. Tomorrow I would take an exam, then the baby would be here on Saturday. It was surreal to know exactly when the baby would come. I couldn’t wait to meet baby Ryan (we didn’t know if it was a boy or girl, but the name was to be Ryan either way).

My last day at work was not an easy one. I was assisting with several surgeries and it was during the first case that the headache started. As the afternoon progressed, I started seeing little spots. I knew these were the sign of preeclampsia, so I stopped by labor and delivery to have my blood pressure checked. It was dangerously high. I wanted to go home and get my things, but my fellow residents insisted I stay and get blood work. “Really, I’ll be fine” I said. I had no insight. Intellectually I realized I had preeclampsia, and shouldn’t leave the hospital when my blood pressure was sky high, but it didn’t compute emotionally. It was strange. There was also an element of denial at play. This could not be happening to me.

I had seen patients act this way many times and assumed they were non-compliant. I realize now when patients have an irrational response to an emergency that it is likely denial more than ignorance. So often we spend so much time picturing and planning how our special day is supposed to happen that when things go awry, it zaps the wind from our sails and leaves us stunned in disbelief.

My doctor arrived and decided the c-section should be done immediately and a magnesium drip would be started to treat the preeclampsia and help control my blood pressure. I attempted to argue that I really didn’t need it. Magnesium was a miserable drug. She just glared at me, “Of course you are getting magnesium.” I took a deep breath and complied.

After several blubbering phone calls to friends and family, they set me up for delivery. My mom didn’t get to be there, but my husband and friends (fellow residents) were there to support me.

As they wheeled me into the cold OR, I realized I was terrified of the “unknown” despite doing hundreds of c-sections myself. As I lay strapped to the OR table, I felt vulnerable and afraid. It was so awkward to be on the other side of the knife. As the surgery got underway, though I felt more calm; comforted by the familiar sounds of the instruments and operating room banter.

2004-01-21-0003

As he was born, the entire room cheered. “It’s a boy” someone said. My husband and I were overwhelmed with joy.

2004-01-21-0006

As the doctor held him up over the blue sheet for me to see him, I remember thinking that he looked blue and they should really get him to the warmer. Myself, my husband and my friends (who we’re running various cameras) we’re all crying and cheering. It was an amazing day.

As I held him in recovery and nursed him for the first time, I remember thinking how incredibly blessed I was. I couldn’t believe how deeply I could love this sweet little boy. What an amazing gift.

 

Women's Health

Why I am Giving my Kids the HPV Vaccine

An immunization that could prevent cancer? It seemed like far fetched science fiction when I first heard the rumors as a medical student, but fast forward 15 years and now I  give it to my patients almost every day.

HPV (Human papilloma virus) infects the skin of the genitals and the throat, potentially transforming normal cells into cancer. It is also the culprit for genital warts. There are 2 vaccines FDA approved to protect against HPV and thus prevent these types of cancer.  Cervarix protects against HPV types 16 and 18, which are responsible for 90% of cervical cancers. Gardsil protects against the cancer causing types 16 and 18, but also prevents types 6 and 11 which cause genital warts.

The current recommendation is for girls and boys to get the vaccine at age 11. The virus is sexually transmitted, so the idea is to give it before the kids even start thinking about sex. If they don’t get it in adolescence, the vaccine can be given up to age 26.

I’m often asked by patients and friends if I plan to give it to my kids. The answer is absolutely yes and here is why:

It’s safe.

With nearly 57 million vaccines already given worldwide, Gardasil is a well studied, safe vaccine. The most common side effects are pain at injection site {duh} and fainting.  After getting the vaccine, it is recommended to sit down for 15 minutes to prevent the fainting side effect. Other common side effects include headache and fever. Allergic reaction to vaccines are rare. The data does not show any severe or unexpected short or long term side effects with the HPV vaccine.

I don’t want them to get cancer.

The HPV virus causes 12,000 cases of cervical cancer; 3,000 cases of vulvar cancer; and 8,000 cases of throat cancer each year. The vaccine has been shown to be 100% effective in preventing HPV 16/18 related disease if given before kids become sexually active.  Throat cancers occur most commonly in men, who get the HPV from performing oral sex on women who have the virus. Anal cancer can also be caused by HPV, but it is rare.

I’m not naïve.

We are raising our kids in church, praying for them, and teaching them not to have sexual relations before marriage. But honestly, this is a fallen world and I know a lot of “good kids” who have made stupid decisions along the way. HPV is spread by vaginal, oral, and anal sex. Actually, any genital to genital contact can spread HPV.

Statistically 80% of women will contract HPV in their lifetime. Even if my kid manages to make it to marriage without HPV, odds are his mate will not.

I don’t want them to get genital warts.

Genital warts are not deadly, but they are painful and embarrassing. I’ve gone through many tissues in my office as I’ve comforted sobbing woman after telling them that what they thought was a mole on their labia was actually a genital wart. Genital warts are also commonly seen in pregnancy, as the lowered immune state can lead to the dormant virus suddenly popping up as “cauliflower like” bumps all over their lady regions as they approach the delivery suite {the one time in their life where their lady parts will literally be in the spotlight}.

I don’t want them to get pre-cancer.

The pap smear has become increasingly effective in preventing actual cancer, but the real gem of HPV immunization is the prevention of cervical dyplasia or “pre-cancer.” There are over 1 million abnormal pap smears in the United States each year. Each one requires a colposcopy, where the doctor looks at the cervix under the microscope and takes biopsies. The biopsy shows pre-cancer up to 35% of the time. A cone or LEEP is then performed which cuts out a portion of the cervix about the size of a thimble. Then the woman needs repeat pap smears 2-3 times a year for several years. If the pre-cancer returns, then another LEEP or even hysterectomy is warranted.  The LEEPs are painful and multiple LEEPs can lead to pregnancy complications like preterm delivery.

Abnormal pap smears would not be eliminated by universal vaccination, but would be reduced by 70%. That would save significant anxiety, pain, and money for a lot of women.

Perhaps it’s the misinformed apprehension that some parents currently have about vaccines in general, or maybe just the fact that HPV is associated with sex that throws them for a loop, but currently only 33% of adolescents have received the full vaccination series despite overwhelming safety and efficacy studies. I bet if you ask the 350,000 women a year who needed cone biopsies or even the many who have genital warts, if they wished they could have had the vaccine, the answer would be an overwhelming yes.

I’m a Christian, a doctor and a mom. I love my boys and yes they are getting the Gardasil/HPV vaccine. HPV is a nasty virus that causes a lot of harm and emotional grief.  I don’t wish for them or their future wives to have any type of unnecessary cancer or disease.

Motherhood, Women's Health

The Great Many Juxtapositions that are My Life as an OB/GYN

It was 9:35 pm and I found myself staring longingly at a trash can, salivating at the beautiful sandwich perched precariously on its rim. My hands were trembling from hunger. If you would have checked my blood sugar at that moment, it would have likely been critically low.

My day had started at 6am with a 5 mile run and I hadn’t stopped moving since. I got paged for a stat delivery while I was in the shower and the day had seemed to go down hill quickly. A full office and multiple laboring patients awaited me. My emergency protein bar served as my lunch and during the cafeteria’s dinner hours, I was in the OR on a hemorrhaging ectopic pregnancy. I was so tired I could feel every muscle in my body, and each one throbbed in their own unique way.

 

The sandwich is CLEARLY above the rim.
The sandwich is CLEARLY above the rim.

That is how I found myself in my real life Seinfeldian dilemma. After realizing the cafeteria was closed I had went back to my office in hopes of grabbing a leftover sandwich out of the refrigerator only to realize in horror that someone had thrown the precious salted meats in the trash. However one specimen had perched itself slightly above the rim, still on its original plastic tray.

Do I eat refuse or trek across campus to the doctors lounge for a poptart? If it is above the rim is it technically garbage?  Not to me in that moment. I wolfed down the cold cuts and said a little prayer against listeria and all other types of food poisoning. It tasted divine.

I thought about how very strange my life was, as I sat back and patted my full belly. A mere two weeks earlier I was dining at leisurely at cafes in Paris, now I was George Constanza, eating  out of the trash.

Beautiful gourmet meal from our trip to Paris.
Beautiful gourmet meal from our trip to Paris.

The next day  I ran into a casual acquaintance who remarked how glamorous my life seemed on social media. I laughed and told her my trash eating story. The incident made me think of the many other strange juxtapositions of my life.

There was the time I found myself in one of the messiest deliveries of my life a couple of hours before the hospital Christmas party. While birth is a beautiful moment of life, sometimes it can also be a giant hot mess. During this rather difficult birth I was initially pooped on quite extensively. Then as the baby delivered, I was hit with a tsunami wave of amniotic fluid that soaked me to the core, making a mockery of my ‘protective gear’. The patient then began hemorrhaging, so I performed an internal uterine massage to help stop the bleeding, which equals me inserting my entire arm into her uterus, making me feel a little bit like a large animal vet. The only bodily fluid missing from the event  was vomit. Hours later after a “Silkwood  shower” and a quick makeup application, I find myself at a country club in a little black dress having small talk about the weather.

Many times I’ve been at the playground with my kids only to sneak away a few steps to answer a call from the hospital about a STD or other topic that is definitely not a ‘playground friendly’. Bedtime stories or games of ‘hide and seek’ have often been interrupted with stat pages to the hospital. I’ve gone from reading Dr. Seuss to performing an emergency C-section in moments.

The worst juxtaposition is dealing with loss in the middle of a regular day. While OB/GYN is often a happy specialty, when it is sad it is heartbreakingly awful. I often have to deliver the worst of news: miscarriage, infidelity, cancer, infertility. There have been days where I have went from placing a lifeless baby in a mothers arms and with barely a moment to catch my breath and dry my eyes, to seeing a patient for a new pregnancy right down the hall. Death and life with only moments in between; the roller coaster of emotions is so strange.

I’m not complaining about my job. I’m well adjusted to the bodily fluids and tumultuous schedule. I simply find it intriguing how my life can go from one extreme to another so very quickly. I’m sure most other doctors would have similar stories (well maybe not the trash). Also this serves as a good reminder that if you see me looking semi-fancy in a picture, the special ingredient that made my hair extra shiny, might just have been amniotic fluid.

 

 

 

 

pregnancy

Baby Pictures: Illegal Privacy Breach or Adorable Tradition?

I write the Apgars and weight on a sticky note as I survey the delivery room one last time. The new mom is staring in awe at the baby in her arms while dad is nearby trying to dry up his tears before the extended family descends on the scene from the waiting room. I reassure myself with a glance at the monitor confirming that mom’s vital signs are stable, as I quietly make my way to the door.

“Wait Doctor! Don’t leave, yet. We need a picture of you with the baby!” They insist.
Internally, I cringe. It’s 3 am. My hair resembles that of a Dr. Seuss character due to hours of wearing a surgical hat and my eyes are a swollen mix sleep deprivation and caffeine overload. But outwardly, I smile. I realize this moment isn’t about me, it’s about the parents preserving the memory of the birth of their child.*

At mom’s six week postpartum visit, she—like most of my patients—proudly hands me a copy of the picture, requesting for me to put it on my “wall.”

My office is lined with baby pictures, like almost every OB/GYN office in America. After 10 years in private practice, walking down my hall is a virtual scrap book of my life. As I see the faces of the hundreds of babies I’ve delivered, I can’t help but smile.

Recently, more and more offices are removing the baby pictures from their walls over for concerns for patient privacy. A recent article in the NY Times notes how most large hospital corporations are requiring physicians to take down photos out of fear of HIPA noncompliance. The article quotes Rachel Seeger, a spokeswoman for the Office for Civil Rights of the Department of Health and Human Services as saying “A patient’s photograph that identifies him/her cannot be posted in public areas” unless there is “specific authorization from the patient or personal representative.” It states that unless written permission is obtained, the pictures are illegal.

Patient privacy should be taken very seriously. But is displaying a picture of baby, which was given to me specifically for that purpose, truly a breach of trust? Can there possibly be a small ounce of common sense left in this over-legislated world?

I adore the pictures as well. Some pictures make me laugh, as I remember the delivery of a baby that splashed me with a tidal wave of amniotic fluid, which sadly I’ve learned tastes like coconut water. Other faces are a reminder of a delivery tainted with tragedy; these evoke a silent prayer for patients with loss. Most of the pictures bring a simple smile and a moment of gratitude that I’ve been blessed to be a part of so many miracles.

But just as the birth isn’t really about me, neither are the baby boards. When women come back for their second and third pregnancy, I often see them hoisting up their tots to show them their own baby picture on the wall. “Look, there you are! That’s you with the doctor that delivered you!” they say with a grin. The toddler often responds with a squishy faced grimace of disbelief and a chuckle. If they can’t find their picture (we get so many, we actually have to rotate the photos) they are disappointed.

The purpose of the baby boards is to celebrate life and bring a small moment of joy to those walking by, not to expose someone’s private health information.

For now, my office walls will continue to display unflattering pictures of me at 3 am holding crying babies, fresh from the womb, still coated in coated in creamy vernix. These pictures bring us joy and my patients want me to display them. Some say it might be illegal, but surely that is not the spirit of the law. There are real problems in health care right now that need addressed, baby pictures on my wall isn’t one of them.

*any patient references are used with patient’s permission or are a fictions conglomerate of multiple patient encounters.