smells like teen spirit

as an ob/gyn, i know i'm supposed to be thrilled and wildly enthusiastic about the new HPV vaccine. HPV is a virus of many strains, some of which cause genital warts, and some of which are known to cause cervical cancer. most sexually active people are infected with at least one strain of HPV, even though most of them have neither genital warts nor cervical cancer--HPV is entirely asymptomatic in the vast majority of people.

the HPV vaccine, newly released by the FDA and widely advertised to the general public, can prevent infection when given to individuals not yet exposed to the virus. we think that this will prevent many cases of cervical cancer.

yay, right? nobody wants cancer, and most of us would be happy if told we could do something to prevent it.

still, i have a MAJOR problem with the new push to make the HPV vaccine mandatory to girls ages 9-13 years of age. people pushing for mandatory vaccination (namely a group of female lawmakers in Michigan, and of course, Merck, the drug company that makes it) are proposing that all females entering sixth grade should be required to be vaccinated against HPV. of course, the opposing group of conservatives are arguing that it infringes on parental rights and will encourage young people to have sex.

that's a load of crap, in my opinion. the fear of pregnancy is barely a deterrent for most kids who will start having sex, let alone a virtually symptom-less and usually consequence-less STD. i don't even think there are 3 teenagers in the entire united states who will say, "phew, now that i don't have to worry about HPV, i can start having sex."

as for parental rights, well, there are plenty of other mandatory vaccines, so i don't think the argument carries any more weight than for the others.

no, my problem is that making a vaccination MANDATORY should be reserved for diseases that are communicable with casual contact. after all, with those diseases it is as much a matter of protecting ME as it is YOU. epidemiologists refer to "herd immunity" when a certain percentage of the population is vaccinated against a communicable disease. if the critical threshold is reached, then even unvaccinated individuals are protected against infection because there is no source of communication. and when individuals decide not to vaccinate in greater numbers, then the entire population is at risk for outbreak. therefore, it is as much a matter of public as it is personal interest to require vaccinations for diseases such as smallpox and polio as EVERYBODY is at risk. but HPV is a different story--it requires intimate contact to spread. there are some people who will never ever ever be at risk for HPV no matter how many other people have it. people who are celibate or who are monogamous over a lifetime with a monogamous partner have ZERO percent change of catching it. granted, that group of people might be shrinking, but they still exist.

the first rule of medicine is "do no harm." it is non-hippocratic to force a group of people who are at zero risk of acquiring a disease to be given medication to prevent the disease. vaccines are very very safe--but they are not without risk.

the problem is, it is pretty difficult to tell who, at nine years old, will be at risk for the disease. and by the time risky sexual behavior (or let's face it, even "normal" sexual behavior) emerges, it is often too late for the vaccine. i don't have a good answer for this. but i don't think mandatory vaccination is the answer.

my second problem is with the push to vaccinate FEMALES. yes, women have cervixes and therefore get cervical cancer. but males can get genital warts, and, more importantly, males can spread HPV. actually, if all males were mandatorily vaccinated, then no female would ever have to be--the transmission of the virus would cease. (okay, i suppose there would be a certain amount of female-female spread, but i bet it would be pretty low).

and finally, i'm just sick of the government butting its head into my life at every turn. i am all for laws that protect the public from individuals. sure, drunk driving is illegal, not because we care so much if the drunk kills him/herself, but more because we know drunk drivers kill innocent people. we are protecting society from the drunk driver. but what's up with mandatory seat belt laws? if i, an adult, choose to drive without the protection of a belt, who will it hurt besides me?

and why should the government protect me against myself?

for that matter, why in some aspects but not others? 16-year-olds can go to tanning booths. 47,700 new cases of melanoma are diagnosed each year. 7,700 people will die of melanoma each year. compare that with cervical cancer: 9,700 new cases per year with 3,700 deaths. so while all of our young women are protected against cervical cancer with our snazzy new vaccine, we continue to let them grow melanomas one tan at a time (can you hear me, little sister?). where does it stop? smoking in public is illegal in many areas. good: protect MY lungs. but can we outlaw smoking at home? sure, but those donuts and fast food are next. soon exercise will be mandatory. so will multivitamins.

someone make it stop.

i will continue to encourage my patients to vaccinate their children against HPV. i spent quite a bit of time discussing it with parents during my adolescent gynecology clinic yesterday. luckily, most parents are quite open, realistic, and reasonable when discussing their child's current and future sexuality.

let's keep these decisions to be made between parents, children, and physicians.
government: butt out.


blah, blue, and things to look forward to

i'm in the library killing a little time while waiting to give a pelvic exam demonstration to a group of students traveling to the border to work in a free clinic.

it took me almost an hour to round up the older style of spatula/cytobrush/spray fixative cytology equipment that i knew they would probably be using. most modern clinics (including ours) use liquid base thin-preps, which are much simpler to use, but, of course, accordingly more expensive to process and interpret.

my life has settled into a nice routine of work, sleep, and work again. i'm not in a constant state of panic anymore, and i realize that i do have a few years yet to learn everything, so work is fine. but something is missing in my life, and i'm not quite sure what it is. i mean, it could be any of a number of things, none of which i have the time or energy to achieve. i'm spending a lot of free time reading journal advertisements for OB/GYN positions in alaska, montana, and maine and daydreaming about my future. not that there's anything wrong with planning ahead, but i'd like to enjoy my present life every once in awhile. i feel like all i've ever done is look ahead, and i think it might've caused me to miss out on some things.

right now i am looking forward to teaching the students. they are a bright spot in my otherwise rather boring life. they are youthful and excited and curious. i, on the other hand, am feeling blah. which isn't the same as blue, but isn't that great, either.

things to look forward to:
Ohio State football
sister and nephew visiting
Grey's Anatomy season premiere
Harper Lee's declawing
buying my red couch
finding a really great church (not a merely decent one)
new Bon Apetit and Backpacker magazines
last Harry Potter book
cooler temperatures
planning my 2007 Australia trip with Best Friend
baking Christmas cookies



as one of Texas' resident aliens, i have just one thing to say:




i love reproductive endocrinology.

now, let's clarify: i love REI, not for the patient contact, not for the medicine, and not even for the surgeries, which can be pretty cool. i heart REI because it is the most awesome schedule that i will see for the next FOUR YEARS. yesterday i went to the vet and the grocery store after work, and i still got home before 5 pm.

for those non-medical folks, reproductive endocrinology and infertility (REI) is the ob-gyn subspecialty that helps women with endocrinological (hormone) disorders and women who can't get (or stay) pregnant. it involves a lot of clinic work, and lots of nice little surgeries with hardly any blood loss. the patients are generally young and healthy, and as a group, extremely compliant with medical care. they also tend to have insurance. it doesn't get any better than this!

now, i find endocrinology as a medical subject rather dry, and i have personal objections to helping certain people get pregnant, so i would never explore this as a career option (plus the thought of finishing residency and than doing ANY more training makes me want to poke my eye out with a sharp stick). but i can see how the lifestyle would draw people in. you make loads of money with a normal human being's workhours. no call. no weekends. research if you want. or not. really, it has the makings of a fine career.

for all my enjoyment of a great schedule, it means i have plenty of time to go home and realize how lonely i am. i finally gave in to salinger's pitiful self-starvation and fur-biting depression and got a kitten for him. her name is harper lee. she is a cute little russian blue approximately 1/20th his size. i guess that makes her a mini-me. or mini-he. anyway, he hates her guts. but at least glaring and hissing at her gives him something to do all day, because i no longer come home to him meowing pitifully at the door. she is destroying my apartment and my reputation, as i have now officially become a single woman with cats. that is cat(s), as in plural. you know that old lady who died and left her house to 120 cats? one day, long long ago, she had a cat. then she got another one. and it snowballed from there.

i will try to restrain myself. in the meantime, i have three more weeks to enjoy my enviable schedule which has but one remaining 24-hr weekend call. i will store up the sleep and homemade meals and clean laundry like a squirrel before winter, because OB days, AKA 'the rotation from hell,' is next.

but i'm not going to think about that.



i'm back from a restful week of doing...nothing.

it was great.

now i'm going to take some of my readers' advice, lay low, and send happy thoughts to the ER in the hopes that they will not page me today.


the day i became a cynic

i don't know how you keep your soul in this business. maybe it grows back after residency. or maybe you can afford to buy a new one with your attending-level wages. whatever the case, i have found myself rapidly spiraling down the dark tunnel of bitchy intern.

so determined to stay "nice," i began the year all smiles and acquiescence. i was polite and friendly to everyone, never interrupted, went to see every patient the nurses called me for. when an order didn't get followed, or a mistake was made, i had the patience of Job. no temper tantrums here. and what did all this nice-intern attitude get me?


i firmly believe(d) that you catch more flies with honey than with vinegar--the nicer i was to all the nurses, techs, consultants, med students... the nicer they'd be to me. but i will tell you, that was not the case. instead, my agreeable nature got me about twelve times as much work. i should have realized what a stupid adage that is. i mean, who the heck wants to catch flies, anyway?

the nicer i was to the techs, the more they pushed my patients to the back of the line for x-rays and ultrasounds (one told me, "i knew you wouldn't yell, dr. midwife, so i put dr. meenypant's patient first). the more accommodating i was with the nurses, the more bullsh** pages i got at 4 am. "dr. midwife, this patient never got consented for blood. can you come up and do it?" i once made the EGREGIOUS mistake of discharging two patients for the day gyn team (chief calls me: oh dr. midwife, could you please please please do me this teensy favor...) turns out the patients had incredibly complex hospital stays requiring dozens of phone calls to arrange follow-up care, and yesterday i was unpleasantly surprised to discover that i will have the honor of dictating the charts of these two patients (in whose care i never even participated) simply because my name is all over the discharges. how convenient for my chief. and now i get asked to do it all the time.

last friday i arrived to find hours of work left over from the day gyn and gyn-onc teams (discharges, post-op notes, lab follow-ups) and this even before i got a single page for my "on call." and then, then there was the straw that broke this camel's back. i had to write a post-op note on this patient, but i found no record of the urine output (a very big deal in post-op patients, it gives us an idea of the patient's hemodynamic stability).

me: where can i find this patient's urine output?
RN, not even looking up: i don't do that. ask the PCT (patient care tech).
me: where can i find the PCT?
RN: out there. (waving with her hand as she doesn't even make eye contact).

me, wandering around: are you the PCT?
PCT: yes.
me: where can i find room 12's urine output?
PCT: i just got here. you'll have to go ask the nurse.

me: the PCT says you got debriefed, and she doesn't have the vitals.
RN: well go ask her again. i don't have them.

me, finally getting really really pissed off: no, i need you to stop checking your email, and find this patient's urine output.
RN, grumpily looking at the vitals sheet: i don't see it here.
me, sarcasm getting the best of me: really. i told you that 5 minutes ago. any idea where i can find it?
RN: if it's not here, it probably didn't get recorded.

extensive discussion with PCT and RN leads to conclusion that if urine output did get recorded, no one knows where it is. currently, the patient is 8 hours post-op, with less than 50 cc of urine in the foley bag, which is NOT GOOD. this is where i lose it.

me, in the hall, to the RN and PCT: it is UNACCEPTABLE to have a post-op patient with no urine output recorded. do you see this order? it says: RECORD URINE OUTPUT. not only is it unacceptable for it to have not been done, it is unacceptable for no one to have noticed that it was not done for EIGHT HOURS. now i have a patient who may or may not be oliguric, complaining of abdominal pain. could be normal post-op pain. could be ureteral obstruction. but there is no way to know, now is there?

i didn't exactly yell, but it's the loudest my voice has been since starting residency. i was pissed, and for once, other people knew about it. but i was amazed at the results it produced. RN and PCT suddenly sprang into action, apologizing and measuring urine and offering to search high and low for lost vitals sheets. it was a sobering moment, because i realized that maybe, just maybe my perfect plan to be so nice that everyone loves and respects me wasn't working. being nice has given people the idea that i can be dumped on and walked all over. over the next few days i was more curt on the phone. still polite, but more cut-to-the-chase "what do you want?" i refused to see a consult before the medicine resident did her own pelvic exam (i don't consult cardiology for my cardiovascular exam, now do i?) i told other residents to do their own discharges and post-op notes. i stopped feeling guilty for not answering pages on my way to the bathroom. it feels good to stand up for myself, even a little bit.

in a way, i'm sad that i have to leave that last shred of idealism behind. until i figure out how to be both firm and nice, i'm going to err on the side of firmness, because i can't keep up with nice intern's workload.

and so it has come down to this.

if anyone out there has any suggestions, any magic formulas for being friendly without getting stepped on, please pass them along. i'd like to resurrect nice glorified midwife, maybe for second year.



they said it would happen; i didn't believe them.

but here i am, mere weeks into my Tejas residency and i have mastered...

ta da!


i am actually really excited about this. i've spent weeks in foreign countries and never picked up a word of the native language. i took 3 years of german in high school and i only remember how to count to ten (minus the two. i can't remember two). my two closest friends are enviably proficient in spanish, and i am so jealous that they can carry on conversations with spanish-speaking people while i came home from guatemala knowing only how to ask someone if their bum itched (we were screening for pinworm). i have resigned myself to the fact that i am just not good at languages. i wish i was. i will be the first one to sign up for that brain chip implantation.

still, necessity is the mother of invention, and, i guess, language proficiency. when everyone around you is chattering away in spanish--nurses, doctors, patients, housekeeping, the computer tech...you manage to pick up the basics.

i am delighted to discover that i can now successfully introduce myself, evaluate a patient, describe findings of an ultrasound, deliver her baby, congratulate her, and follow-up her postpartum course, all in a really quite inventive combination of bio-linguistics i like to call sparades ("spanish charades"). this is also where my sign-language background comes in handy.

and i can tell i'm getting better, because more often patients are responding with 'si' or 'no' instead of puzzled (or worse, frightened) glances. my vocabulary is expanding to the point where i can actually ask a patient what she would like for post-partum contraceptives, a step-up from asking her what she wanted for "no mas bebes," which is what i was asking.

i could never go to mexico and have any sort of decent conversation with anyone, but stick me in a room with any spanish-speaking pregnant woman--i'd do all right.

Felicitaciones a mi!