i’m not making this up.

A few months ago I was at dinner with friends, one of whom is pregnant. The topic of drinking in pregnancy came up and someone said to me “you just tell people not to drink because you have to, not because it’s really harmful right?” Um…I made that face. That face.  You know. The one where  you couldn’t possibly believe what you heard but, then again, you heard it.  The one where your eyes are big and your mouth is open.  After a pregnant pause I explained that national and now international guidelines recommend against any alcohol consumption in pregnancy.

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We all know that you are never going to get more unsolicited advice than when you are pregnant.  What you can and can’t do including raising your hands above your head or eating peanut butter in the bathtub along with what your baby should eat, how it should sleep, what it should wear and where it should go to college.  Whether or not you should consume alcohol in pregnancy is among that advice.  However, drinking during pregnancy is the most common cause of birth defects in the United States. And while these birth defects are most common among women who drink heavily, there is no safe amount of alcohol consumption for a pregnant woman.  Alcohol use in pregnancy is associated with low birth weight, preterm birth, birth defects and developmental disabilities.  Health care providers are encouraged to discuss discontinuation of alcohol for women who are pregnant and those actively trying to get pregnant.

April is alcohol awareness month. It was established to reduce the stigma associated with alcoholism and increase awareness about alcohol abuse, treatment and recovery.  Excess alcohol use costs the United States about 250 billion dollars per year.  About 5 billion of that is related to alcohol use in pregnancy.  So no, as gynecologists we don’t just say these things because “we have to.”  We say them because we truly want the best outcome for you and your baby.  So if you should find yourself with two lines on that pregnancy test, congrats!  It’s time to take a break from alcohol.  If you are already pregnant and haven’t stopped drinking I would urge you to do so now.  You can tell your grandmother, your best friend, the lady at the grocery store and the dude at the gas station that you are doing everything you can to take care of yourself and your baby.  Really.  We’re not making this up.

march madness.

Talking to patients about disease prevention and improving their health isn’t always easy. It’s like when your mom told you to eat your fruits and vegetables and you would roll your eyes…or was that just me?  Every day doctors are faced with the challenge of not only caring for the patient’s immediate issues but reminding them to exercise, nudging them to lose weight and recommending appropriate screening tests. For me, I often get to recommend the ultimate trifecta: a mammogram, pap test and colonoscopy.  Patients look at me like I have offered them a few hours locked in a small room with screaming children.  Seriously.

March is colorectal cancer awareness month. Despite being a preventable disease, it is the second leading cause of cancer death in our country.  Colon cancer screening is recommended for everyone age 50 and above. The polyps that become colon cancer usually don’t have symptoms which means you need a colonoscopy to find them and remove them.  Some patients are at an increased risk of colorectal cancer above the rest of the population.  Patients with inflammatory bowel diseases or a family history of colon cancer are at increased risk. About 5% of patients with colorectal cancer will have a genetic predisposition for the disease, such as Lynch syndrome, which is a genetic condition associated with an increased risk of colon, uterine and other cancers. Patients who are overweight or have poor diets may be at increased risk.

Therefore, your favorite gynecologist gets to recommend such tests and you get to roll your eyes at me.  See the pattern here? In all seriousness, about 1/3 of adults who need colon cancer screening don’t get it.  And I understand the eye rolling, I really do. It’s not like IMG_6422people look forward to having a colonoscopy.  Or going to the gynecologist at that.  I tell my patients that at least when I go to the dentist I feel like I’m a bright, cleaner person at the end of the visit.  I’m not sure anyone leaves my office, or their mammogram or colonoscopy with the same thoughts. So I get it.

But here’s the deal.  We don’t recommend these uncomfortable tests because we like seeing you squirm around on the exam table.  We do it because cancer screening saves lives.  March for myself and the pastor means lots of basketball and brackets and yelling at the tv. We love the madness. But when you think of march, think about reducing your risk of cancer.  Know your family history.  Eat your fruits and veggies and go to the gym. See your doctor.  And get your colorectal cancer screening. It won’t be the best day of your life, but it just might be the day that saves it.

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stay in your own lane people.

We’ve all done it, right?  Veered into another lane of traffic.  Oh, you haven’t?  Yeah right. Anyhoo, moving into another lane of traffic can be no big deal or a giant disaster.  And while I hope we all can agree that we should put down our phones and ignore our children in the backseat and pay attention to the road I’m not really here to discuss actual driving habits.  To stay in your own lane is to stick to what you know.

For the past 3 Sundays I have awoken to the desperate need for a cinnamon roll.  Not the kind you can get at a donut shop on a Sunday morning but a warm iced homemade cinnamon roll.  Guess how many weeks I happened upon said delicious breakfast treat?  ZERO.  So this weekend I decided I would make my own cinnamon rolls.  That’s right. I can perform surgery so certainly I should be able to follow a recipe and make these rolls. With great pride I proceeded to gather all my ingredients from the grocery store along with three other food projects I decided to create for our Super Bowl party.  Yes, you read that correctly.  Not only did I decide to make cinnamon rolls from scratch I figured adding a few img_7732other new recipes in the kitchen certainly wouldn’t add to my angst.  Um, oops.  Moving on, I made those cinnamon rolls.  I mixed up the dough and let it rise and put it in the fridge ready to complete my creation.  It was only then that I noticed the recipe I was using said clearly at the top: “Makes 40-50 Cinnamon Rolls.”  You have got to be kidding me. What am I going to do with 50 cinnamon rolls?  At this point I panicked and frantically phoned one of my best church girls who also happens to whip up homemade cakes and pies and other fancies in her kitchen on a daily basis.  My exact text: “WHAT HAVE I GOTTEN MYSELF IN TO?”  Clearly I had veered from my own lane. Fortunately for me cinnamon rolls can be made ahead of time, they can be frozen and they can be shared with those you are lucky enough to attend Sunday School with.

In this case moving out of my comfort zone, my lane, didn’t turn out so bad. It could have turned out worse.  Sometimes we decide to swiftly move into territory in which we have no education or experience. This has the potential to be disastrous. I won’t be trying my hand at teaching kindergarten, flying a plane or operating any heavy machinery.  Our culture too often tells us we know as much as the experts. And why not? We have access to all sorts of information through the power of the internet. Exactly.  All sorts of information.  The good, the bad, the ugly.  It’s too much. In my arena we use what we call “evidence based medicine” as best we can to direct patient care and research efforts.  We are taught to examine the evidence and decide what the full body of research has concluded, if anything, on a subject. And while I have a good deal of experience reviewing medical literature it doesn’t mean I can easily read the law, interpret scripture or solve complex math problems. At other times knowledge in one area transfers easily to another. Take surgery, for example. When we plan for a gynecologic surgery our team anticipates possible deviations from the norm we might encounter based on the patient’s problem, their medical and surgical history and the procedure being performed.  We create a plan to minimize risk and maximize benefit to the patient.  Does being a gynecologic surgeon mean I should volunteer to operate on your brain or in your nose?  Well, first of all, gross. Secondly, while some principles of surgery carry over from one specialty to another like sterile technique or attempting to minimize blood loss and restore normal anatomy, a gyn surgeon does not have the expert knowledge and experience a neurosurgeon might have. If you ask me the best treatment for say, your eye disease, I’m going to tell you to go to your ophthalmologist, ask some questions about the risks and benefits of each treatment and some others on success rates, etc and then make an informed choice on what to do with the help of your physician.  On the other hand, many more of the techniques used in general surgery would apply in gynecology and vice versa.  So, should natural disaster strike, general surgeons and gynecologists would operate side by side to save life and limb.  But let’s hope it doesn’t come to that.  There are lots of other examples.  Have kids in school?  Swerve into the other lane because you must know how education works!  Voted? Swerve into the other lane because you can run the government.  Been going to church awhile?  You probably know the Bible better than most. The truth is we are all stakeholders in these issues: whether it’s our own health, education, the government or theology.

So what is the best way to change lanes?  Well, we check our blind spot, we put on our signal and then deliberately move over.  Life should be much the same. How do we improve education?  We find our best educators and the best available evidence on education and then create your best practices.  I know exactly who I would approach if I want to figure out how to make low income kids succeed in the classroom.  How about government?  Well, until about 4 months ago I didn’t actually know how the electoral college works.  Or really much else about government.  Who knew those things would matter when I was ignoring them to focus on my science and math classes way back when? So I find those whom I trust who have done their homework and who will, more importantly, discuss all sides of the issue with me. And when it comes to theology, well, I’ve been learning from the Pastor for almost 16 years.  And trust me when I say he knows what he is doing people.  So let’s check our blind spots.  Let’s figure out where we have assumed we know best and admit that we don’t know best.

Here’s another “if you know me” moment.  If you know me, you know I love being right. But I’ve learned that being loud and persistent doesn’t mean you’re right.  So now I’m learning to signal to the people around me and learn about what they have to offer.  So join me in checking our blind spots. Let’s figure out where we have assumed we know best and admit we don’t know best. Otherwise we should just stay in our own lane people.

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deeply rooted pain.

Most gynecologists will tell you that one of the most difficult patient encounters they will have in their clinic is someone with pelvic pain.   Pain comes in many forms and is different for every individual.  Sometimes pain is straightforward.  If I were to give you a generous throat punch (a hollow threat I often use) you will be able to precisely locate your pain and know its cause.  Some painful events are less straightforward.  Let’s say your img_4091appendix has decided to become inflamed, infected and will try to  rupture in an attempt to ruin your life.  That pain will usually start around your belly button before it moves to the lower right side of your belly which is home to the offending organ.  Pelvic pain is often like the latter.  It is difficult to find the cause and can present in a variety of different ways.

About 15% of women will experience chronic pelvic pain at least once in their lifetime.  Chronic pelvic pain is pain that lasts 6 months or more in duration.  It could be daily or constant pain or it could come and go inconsistently.  About 5 to 8% of women will struggle with chronic pelvic pain for a large portion of their life.  When I see patients who have pain in my clinic I remind them that I can list probably a dozen things that might be causing their pain.  Usually we can narrow down what we call the differential diagnosis (list of potential causes) to a few most likely causes or maybe even the exact reason for the pain.  In other circumstances we have no answer.  Nothing.  A list of maybes, a list of treatments, but no name, no diagnosis for the face that sits in front of us.

Most women with pelvic pain have endometriosis.  Endometriosis occurs in less than 10% of women but is the diagnosis for at least 70% of patients who present with pelvic pain. The American College of Obstetricians and Gynecologists state in their practice bulletin on the topic that “the clinical manifestations of endometriosis are variable and unpredictable in both presentation and course.”  No sentence could be more true.  Endometriosis is, to put it too simply, when the lining of the uterus is implanted inside the body, usually in the pelvis.  When visualized during surgery it can appear red, black, white, clear or even be difficult to see.  Harder than finding it is getting rid of it.  Many women with endometriosis have infertility from their disease.  We have few medications and surgery is often not curative.

Some other women with chronic pelvic pain have muscle spasms that are often long-standing and difficult to reverse. These women often have a difficult time being diagnosed and once they are, the road back to health is quite long.  Still others have gastrointestinal disease, inflammation of their bladder, scarring from previous surgery or pain caused by previous trauma or abuse.  Even depression and anxiety are known to cause pelvic pain. Can you have pain without a cause?  Sure.  Just like you can be sad and not know why or be upset and not exactly know what you are upset about.

If you know someone with pelvic pain, know their pain is real.  If you are someone who has been diagnosed with chronic pelvic pain, please know that your doctor wants to help you get better.  My best advice for you is to find a provider you trust; to know the road will be long and will require patience and strength; and to find someone who will support you on the journey back to health.

 

the measure of success.

How do we measure success?

The Pastor and I were discussing the events of the last few months and upcoming events. Elections, the national title game, the end of the church year, the end of the calendar year, the NFL playoffs, the Super Bowl, the upcoming year.  Each of these events has many ways in which those involved can measure success.  For some, success is equal to winning.  For others, success is equal to just being present in something greater than yourself. Success can be measured on a personal level, a team level, a national level.  And not all those measurements will come up with the same answer in the same situation.  Let’s take employment, for example.  If the unemployment rate goes down then, on the national level, it will be counted as a success.  But, if you lost your job in that same timeframe and are yet to find new employment I am guessing you would not agree that there was major success in reducing unemployment.

 

In medicine we measure success in many ways. One of the most common ways is morbidity and mortality.  Morbidity refers to disease or worsening health and mortality refers to death.  We view morbidity as complications or poor outcomes related to disease or surgical or medical interventions. Mortality is easy to measure.  Did the patient live or die?

How does our own nation do?  When we look at comparable countries (those with total and per capital GDP rates above average in the last 10 years) we find that we have worse mortality rates for almost all diseases than in those other countries.  The US spends more on healthcare than any of these nations.  Why the difference? Some of it falls on the healthcare system itself.  We have issues that lead to difficulty in accessing healthcare; we have a complex system that contributes to cost, and for many Americans a significant portion of that cost will be spent in their last year of life.  But there are also social determinants that impact our health.  We have more obesity, a more sedentary lifestyle, and more disease caused by environmental factors.  When we evaluate morbidity, or disease burden, we see that despite having a lower rate of smoking and alcohol consumption, we have higher rates of lung cancer, alcoholic abuse and alcohol related liver disease than comparable countries.

Now those are all national statistics.  Measuring outcomes in a large scale view.  It is not the only way to measure success.  A patient might measure the success of their surgery based on when they are able to get back to their yoga class or weekly run and their surgeon might be measuring success based on the time it took to complete the surgery, or by minimizing blood loss or the patient’s hospital stay. Your primary care doctor may img_5778measure success by looking at vaccination rates, patient satisfaction, personal job satisfaction or seeing that long time patient achieve their weight loss goals or quit smoking.  Your OB might measure success by lowering their c-section rate, improving quality of life in the women they care for or when that patient who has long-suffered with infertility or pregnancy loss finally gives birth.

How will you measure success in 2017? Maybe you will set a personal goal for your health, your business, your family.  Maybe you will look at national data like the unemployment rate or what the Dow Jones does.  Maybe you will measure success by what your own state does for its own citizens.  Hopefully many of us will measure success in ways that are much less “measurable” but in ways that have much more meaning.  May we measure success by how we treat our neighbors, how much our children know that they are loved, by how the widow and orphan are cared for and by how we have given away from ourselves in 2017.

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the worst part.

I got my flu shot on Friday.  The worst part?  My office nurse made me weigh and take my blood pressure before she would give me the vaccination.  Talk about ouch!

“Should I get my flu shot?” is one of the most frequently encountered questions I answer between the months of October and February.  My answer; almost always a resounding “yes.”  Why?  Not only because the flu is terrible to have, it kills people.  And I’m not talking about the “my husband has the flu and now he acts like he’s dying but I might kill him instead” kills people.  Like it really kills people.  While the current reporting systems don’t allow us to know exactly how many people die from the flu in the US annually it is likely to be somewhere around 20,000 people including about 150 children.  The young, the old, the pregnant and the immunocompromised are the most at risk.

So why would anyone question getting their flu vaccine?  Oh, let me count the ways.

Many of my patients think the influenza vaccine can give them the flu.  Wrong.  It does create an immune reaction and you develop antibodies in about 2 weeks that should be protective against the flu.  Most patients receive either the trivalent (traditional) or quadrivalent flu vaccine. Trivalent vaccines protect against an influenza A (H1N1) virus, an influenza A (H3N2) virus, and an influenza B virus. The quadrivalent vaccine (what my nurse was giving me in the above photo) has protection against an additional B virus.  These are inactivated or recombinant immunizations which means, in short, they won’t give you the flu.  And remember, it takes 2 weeks to be immune, so if you get the flu 2 days after you get your shot don’t blame the vaccine.  Blame the person who exposed you to the flu virus before you were protected.

Some patients just don’t think they need the vaccine.  Maybe they have never had the flu.  Well, trust me that it only takes one week of feeling incredibly ill with the flu to convince most people they never want to skip out on vaccination again.  I also tell my patients that even worse than getting the flu is giving it to someone else.  If you have a child, a pregnant woman or a person over the age of 65 you care about then the influenza vaccine is for you.  If you have friends or a family member who has cancer, asthma, diabetes or another immune disease then the flu vaccine is for you.  Giving the flu to someone who is at high risk of hospitalization or death is not nice.  Pregnant?  Pregnant women who get the flu are more likely to have severe illness, be hospitalized or die from the flu.  Scary much?  Trust me, I repeat that line on a weekly basis.  Plus, the infants of pregnant women who are vaccinated for influenza in pregnancy have protection that can last up to 6 months.

So what do I say when asked by someone if they should get the flu shot?

Yes.  You’re pregnant and I don’t want to risk seeing you in the ICU with the flu.  Plus your baby can’t receive a flu vaccine until 6 months of age and you want to protect your infant until they can protect themselves.  You can be vaccinated in any trimester so trust me when I say if you don’t do it today I will ask you again at your next visit.

Yes.  Immunizations carry much less risk than the diseases they protect you from.  Does the flu vaccine guarantee that you will not get the flu?  No.  But it does significantly reduce your risk.  You still need to wash your hands, avoid sick people, cover your mouth when you cough and all those good things your grandma has been telling you since you were small.

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Yes.  Getting a flu vaccine is more than just about protecting you.  It’s about avoiding the flu so you don’t spread a virus to someone who can’t get vaccinated.  Or spreading the illness to someone who could get very sick and hasn’t had time for their vaccine to be fully protected.  Or your wife.  Husbands, get your flu shot.  If you give the flu to your wife no one will be happy.  The Pastor had the flu last year and I literally locked him in one room of the house until he was no longer contagious.

Yes.  Because you care about your kids and your family.  My kids will be disappointed to learn the nasal spray isn’t recommended this year.  The needle stick will be the worst part for them.  But the good news is this…first, they get excited when they get on the scale at Dr. Melissa’s office (unlike me!) Second, they think doctors and nurses are awesome and trust that they will be protected.  Finally, there are stickers…and probably treats on the way home.

So go get vaccinated.  There are about 150 million doses available so I’m sure you can find one.  Some more news for those of you still skeptical.  Now you can be vaccinated if you are allergic to eggs.  There is even an intradermal version: which means the needle is about 90% smaller for those adults in the group who are afraid of sharp things seen above.   No matter if the weight or the blood pressure measurement or the waiting in line to get it done or the actual needle stick is the worst part.  This gynecologist and pastor’s wife thinks it will be worth it.

(photo credit my arm, Heather’s hands and Erika for being the photog.)

 

red hair…don’t care.

I got the “red hair…don’t care” award from my residents a couple years ago.  I loved it.  They decided this award was best for me because I shoot pretty straight on most things; especially when it comes to the residents and medical students I work with.  I say things like “here’s a great way NOT to impress your attending.”  Or  “how about we try not to say that in front of the patient.”   I also have a thousand funny memes and sayings and have been known to let loose with my sarcasm at times.

In the spirit of all things “don’t care” I thought I would share with you what myself and my fellow OBGYN’s don’t care about that our patients seem to be all worked up over.

That your legs are not shaved.  No seriously.  I’m not giving you a leg massage.  It really doesn’t bother us.  We usually don’t even notice unless you bring it up.  Confession: our legs probably aren’t freshly shaved either since most of us prefer to use that extra few minutes for sleep instead of time in the shower.

That you are on your period.  I’m sure you hate it but we signed up to deal with it.  Like every day.  Remember we deliver babies and perform surgeries and see hundreds of women who are bleeding.  We got this.  Thanks for worrying about us but we will be fine.

That your socks don’t match or your toes aren’t manicured or you aren’t wearing your cutest undies.  For the most part we get dressed in the dark.  We come into the hospital in the middle of the night.  Our socks might not match.  Wearing underwear is considered enough.  Please do wear it.  You don’t have to wad it up and hide it from us under your other clothes, we don’t care what it looks like.

That you might see me in public.  One time I saw someone bolting down the aisle at Target to avoid me.  It’s OK if you see us at the grocery store or the gym or the PTO meeting (who am I kidding we are always at work during the PTO meetings) we will do our best to remember your name correctly and say hello but it won’t be awkward for us because we take very seriously protecting your privacy and honestly we don’t remember every detail from every patient…that’s why we take good notes!

That you have a ‘weird’ question.  Trust me.  Patients often say “I have a weird question” followed by something that is totally normal/common/not weird at all.  There is not much we haven’t seen or heard.  Not much we haven’t dealt with, walked patients through or bailed someone out of.  What might seem weird to you is probably routine for us.  So hit us up with your ‘weird’ questions.

What the internet (or your bestie) told you.  If you come to the doctor with a plan in place for yourself then it makes our job harder.  Instead of focusing on listening to your problem and making decisions on the best available evidence we spend time re-educating you about what you have read or heard.  We are happy to provide you with that information but we really want to spend our time helping you get better.

So, here’s what we DO care about.

That you are honest with us.  We can’t take care of you if we don’t know what is really going on.  While most OBGYN’s are friendly and inquisitive by nature, we ask about who you are sleeping with and what medications you are taking because we want you to be safe and healthy, not just because we are nosy.

That you know we want what’s best for you.  If you are honest with us we will listen, we will empathize and we will be honest with you.  Sometimes that means we might tell you something that is hard to hear.  Or give you bad news.  But through it all we are doing are best to do what is best….for you.  For your health and for your family.  Try to remember that when the answer we give you isn’t necessarily what you wanted to hear or involves hard work.  We want you to be safe so we are going to ask about any history of violence or dangerous behavior.  We want you to be healthy so we are going to ask you about your diet and exercise habits.  We don’t want to harm you so we might not be able to give you a medication you want or perform a procedure you would like to have.

That you know we are doing our best.   Sometimes we run behind, we get stuck at the hospital or are dealing with a difficult situation.  I can’t promise you won’t have to wait in our waiting rooms or that your surgery won’t be delayed or even that everything will turn out perfect, but know that we are doing our best to make sure you are taken care of as best we can.  We are mothers, fathers, husbands, wives and most importantly, human beings.

screen-shot-2016-09-25-at-6-38-08-pmSo there you have it.  The truth from blonde covering gray hair who don’t care and will tell you how it is.  Go ahead, don’t shave your legs. (Please note that my obgyn friends do ask that you please have clean feet when you arrive.)  Ask the embarrassing question without even saying it’s ‘weird’.  Say hello when you see us at the grocery store with our screaming children and sweat pants. And come to your physician with honesty and an open mind.  Grace and peace, friends!