Tik Tok Board Doc

This month has been awesome.  I'm what is called board doc which means I run the labor and delivery board making sure everybody has been examined, monitors are placed and all of them are delivered.  It's been a blast but it's probably the most crazy experience of my entire life.  There is no time for sitting, or eating, or thinking.  In honor of board doc, I have re-written the words to a favorite pop song, Tik Tok by Kesha.  In medical school we used to have a show Doc Opera with a very similar feel to it, and I used to direct the band.  Since there's no Doc Opera in residency, I've spent my few minutes of free time re-crafting the song.  So here ya go!




Wake up in the morning feeling oh so S%ty
I got my glasses, I’m out the door, I’m lookin oh so gritty
Before I leave, brush my teeth and I pull my hair back
Cause when I leave for the night, I ain’t coming back

I’m talking danskos on our toes toes
Scrubs instead of clothes, clothes
Blood all over ourselves, selves
Pulling out all the babies
Sewing up all the ladies
Trying to get a little bit messy

Don’t stop, make her pop
Nurse will you run my pit up high
Tonight, push it right
Till that baby sees the light
Tick tock on the clock
But the babies don’t stop, no-oh-oh no-oh-oh-oh

Don’t stop, make her pop
Turn the epidural up to high
Tonight, imma write
Notes til I see the sunlight
Tick tock on the clock
But the pager don’t stop, no-oh oh oh

Ain’t got no sense in the world but got plenty of fear
Ain’t got no food in my belly but nobody cares
Now the tasks are lining up, can I work any faster?
There are 8 million things I’m not sure I can master

I’m talking about everyone running around round
Feet never leave the ground ground
Gonna pit her if she’s moving too slow
Decels so she can’t no second miso-so
Can’t wait until she crowns crowns
Wait until she crowns crowns
Wait until she—

Don’t stop, make her pop
Nurse will you run my pit up high
Tonight, push it right
Till that baby sees the light
Tick tock on the clock
But the babies don’t stop, no-oh-oh no-oh-oh-oh

Don’t stop, make her pop
Turn the epidural up to high
Tonight, imma write
Notes til I see the sunlight
Tick tock on the clock
But the pager don’t stop, no-oh oh oh

I’m cramping up
I might break down
The heart, it pounds
FSE
With my hands in
I got it through
I think we’ll know
IUPC
Let’s build it up
Head come on down
We’re hoping for
Adequacy
With my hand in
With my hand in
Get your hand in

No the party don’t stop when I walk in

Cool as a cucumber—refreshing my Spanish on the job

A word to the squeamish or vaginally offended, this post is really about gynecology

I came to Texas for residency because I love taking care of Spanish speaking women.  For good reason, I’ve discovered.  There couldn’t be a more caring, kind, respectful and fun group of people to take care of than the Mexican and Central American patients that we take care of in clinic and on the wards.   Although I have spent multiple months perfecting conversational and party Spanish all over Latin America, my gynecologic castellano wasn’t quite all there when I started residency.  

It’s kind of funny to try and communicate clearly but still be professional and culturally sensitive when talking about private parts in another language.   Whereas in English I might just come straight out and ask patients about sexual activity, in Spanish, I seem to have better reception and communication if I ask about “relaciones”.    While I could literally translate the questions I ask in my history the same way I normally would, I have noticed that in Spanish, phrasing is more modest and more nuanced.   So, here below I have a list of common words and phrases used in OB/GYN that I have picked up over the past few weeks. 

Basic gynecologic Spanish, patient friendly edition:

Pain—dolor

Blood—sangre

To examine—examinar

My vagina—mi parte (or mi vagina)

Cervix—cuello de matrix (literally neck of the uterus)

Itching—comezón

Discharge—flujo

Pads—toallas

Contractions—contracciones

Cramps—cólicos

Pap smear—Papanicolaou

Speculum—especulo

IUD—dispositivo

Clots—coágulos

D+C—legrado (pretty awesome that there is one short word instead of dilatation and curettage)

Vaginal delivery—parto natural

You probably don’t want to eat after that, but hey, I do it everyday.   Even though my patients might be modest about their private lives, they certainly eat some very bold food.   The other amazing part about living in Texas besides fantastic patients is the fantastic food, and the large Hispanic grocery stores.  Limes are 20 for a dollar and the produce is fresh, diverse and abundant. 

One of my favorite Mexican inspired treats couldn’t be easier.  It’s a simple dressing put on all fruits, including cucumbers consisting of chile powder, salt and lime.  Just makes anything taste better.  Keeps me cool as a cucumber!

Mexican cukes

1 cucumber

chili powder

sprinkle salt

juice of 2 limes

Combine and enjoy

The July Phenomenon

While July 1 might just be another hot summer Thursday for most of America, for the world of medicine, it is the traditional day in which every teaching hospital in America initiates interns into the start their residency and all current residents move on to be higher levels.  July 1 signifies a new iteration of hierarchy within medicine and another year gone by. 

Internship, as I had suspected, and have confirmed during orientation, will be a lot of responsibility.   My pager is to be on my person, turned on, at all times so I can be reached in case of an emergency.  Just keeping my pager with batteries and on me is hard enough. There are an incredible amount of sick women to be taken care of and a vast amount of procedures to learn.  Mastering a system, especially a complex, extremely busy, county system, is seemingly impossible even without the massive patient load.

My greatest concern however, is not for my own sanity or vanity (I’m sure I’ll recover), but for the safety and health of the patients.  My friends in medical school frequently joked during graduation week as we had parties and slept late that they hope “nobody gets sick in July”.   We all wonder how we won’t make people sicker when we really don’t know what we’re doing and feel even less knowledgeable and accountable than we did a year ago. 

Fascinatingly, the “July Phenomenon” as it’s so referred to, has actually been studied in depth in a number of specialties, referring to the frequency of medical errors and patient outcomes throughout the calendar year in teaching hospitals.  While some studies show that morbidity and mortality within teaching hospitals is much greater in the beginning of the academic year, some show no difference.  A study recently published from the University of California San Diego reviewed all death certificates in the US for the past 30 years (n=62 million!) and found that deaths from medication errors were much more likely to occur in July than other months [1]. 

Fortunately, there are a few large studies in the labor and delivery suite which found no difference in adverse outcomes between July and other months.  One nationwide study of about 300,000 women between 1998 and 2002 showed no difference between important complications like chorioamnionitis, C-sections, 3^rd or 4^th degree lacerations, or shoulder dystocia  [2].  Another smaller study showed a higher rate of infection during the July months, but other outcomes were similar [3].

How can we, as doctors and as broader society members, reconcile the fact that in some cases we may be putting patients at risk by allowing residents to truly “practice” medicine?  I recently read Atul Gawande’s excellent book “Complications” where he discusses this very quandary.   He suggests that there is no other solution to the problem of training new physicians without human experimentation, under supervision of course, and putting some people at risk.  He concludes, therefore, that training residents ultimately is for the good of everybody. 

The July phenomenon, in a more positive light, I think also refers to the burst of fresh veggies and eggs available as summer comes into full bloom.  I was blessed to be given freshly laid eggs by my new friend and classmate who has four lovely hens.  The beauty of an eggy tart like this is that even though it takes a bit more time than many dinners, it can be eaten for breakfast, lunch or dinner and can really have any fresh veggies, meat and cheese that you choose.  I list below what I used, but substituting almost anything appealing would be just as wonderful.  The whole meal comes together in a snap with a food processor but can just as easily be done the old fashioned way.  It’s the perfect meal to gear up for an insane week (WISH ME LUCK!)

Eggy veggie tart

In 9 inch tart pan or 8 inch pie pan

For crust

1 cup flour

1 stick ice cold butter

¼ cup ice cold water

½ tsp salt

Filling

5 eggs

¼ cup cream

Cut up cooked sausage

1 large shallot or half of onion

½ red pepper

4 oz goat cheese

Whole tomato thinly sliced

Chiffonade basil

To make crust.  Preheat oven to 425.  In food processor pulse flour and butter until butter is pea shaped about 5-6 times.  Add water and pulse a few more times.  Alternatively, you could use a pastry cutter or 2 knives.  Take dough out and bring together with hands.  Do not overmix.  Ideally, refridgerate for 2 hours, but I just rolled it out.  Put in tart pan and cover with foil.  On top of foil use beans, weights or another pan to weigh down.  Bake for 15 minutes.  Take off foil and allow to brown for another 2-3 minutes.  Remove from oven.  Turn oven temp down to 375

For filling, clean out the food processor, pulse eggs and cream with pinch of salt until foamy.  Over medium heat with 1 tbsp olive oil, cook shallot/onion and pepper with salt until shallot starts to brown, about 15-20 minutes.  In pastry shell, add sausage, onion/peppers, then tomatoes.  Add egg mixture, top with cheese and herbs, bake for 15-20 minutes until custard is set.  (sorry the picture is ugly)

1. Phillips, DP.; Barker, GE. “A July Spike in Fatal Medication Errors: A Possible Effect of New Medical Residents.” Journal of General Internal Medicine,, 2010.

2. Ford, AA.; Bateman, BT.; Simpson, LL.; Ratan, RB. “Nationwide data confirms absence of 'July phenomenon' in obstetrics: it's safe to deliver in July.” Journal of perinatology : official journal of the California Perinatal Association, v. 27 issue 2, 2007, p. 73-6.

3. Myles, TD. “Is there an obstetric July phenomenon?.” Obstetrics and Gynecology, v. 102 issue 5 Pt 1, 2003, p. 1080-4.

Contraceptive Confections—IUDs, you are so sweet

Disclaimer: These cookies do not prevent pregnancy.

In my last post I celebrated the birth of oral contraceptives.  Today I will salute another favorite form of birth control, the intrauterine device, or IUD.  IUDs have an interesting history of their own.  They have a very bad reputation among many of the lay population, but in fact, they are an extremely effective and safe form of birth control.  I would say that IUDs are a great form of contraception because they are very popular for OB/GYN docs [1].  If that doesn’t speak for itself!

The bad reputation of the IUD comes from a previous form of the IUD called the Dalkon Shield released in the 1970s.  The Dalkon shield caused a lot of controversy because it was blamed for causing an increased rate of pelvic inflammatory disease and infertility. A 1981 study showed that woman were 5 times more likely to have pelvic inflammatory disease from the Dalkon Shield than from other IUDs [2,3]. The Dalkon Shield is banned, but won’t be forgotten because it’s also a band.  Although, not a very good band.

In the US currently, there are two FDA approved IUDs--the Mirena and the Paragaurd.  The Mirena is impregnated with progesterone and is effective for five years, and the Paraguard, the more traditional device wound with copper wire, is effective for ten years.  The Mirena works by secreting progesterone into the uterine cavity and makes the uterus inhospitable to implantation as well as thickening cervical mucus (yeah I know, cervical mucus…kind of gross to some).  The copper in the Paraguard reacts with the uterine cavity to inhibit implantation.

The IUD is an highly effective form of contraception, more effective than birth control pills, with a pregnancy rate of <0.5% over 5 years [4].  The side effect profile is low; women are at a minimally increased risk of PID if they have an STD at the time of insertion [5,6].  Women can experience cramping, abnormal bleeding, and expulsion. The IUD does not affect fertility, and fertility returns once the device is removed [7]. 

Along with the birth control cake for my contraceptive confections series, I made IUD cookies.  What could be more delicious than a simple sugar cookie decorated to look like a plastic device inserted into the uterus?  Nothing really.  My fiancé ate them all.  I used my favorite childhood sugar cookie recipe straight from nothing else but the Betty Crocker Cookbook.  I fashioned up some simple royal icing and with my two surgeon gal pals, we delicately iced the ladylike cookies.  So thanks girls and I’m so proud of you!

IUD Cookies
Sugar Cookies from The Betty Crocker Cookbook
Makes about 50 IUD cookies

T shaped cookie cutter (purchased at Sur La Table and the only thing in the ENTIRE store that costs $1)

Cookie dough
1 ½ cups powdered sugar
1 cup (2 sticks) butter softened
1 tsp vanilla
½ tsp almond extract
1 large egg
2 ½ cups all purpose flour
1 tsp baking soda
1 tsp cream of tartar

Royal icing
4 cups powdered sugar
6 tbsp heavy cream or 4 egg whites

Beat powdered sugar, butter, vanilla, almond extract and egg in large bowl.  Stir in remaining ingredients, cover and refrigerate for at least 2 hours.  Heat oven to 375.  Roll dough to ¼ inch thick on floured surface, cut into T shape.  Bake 7-8 minute or until edges are light brown. 

Combine icing ingredients until smooth.  Color some and leave some icing white.  Pipe shape with pastry tube.

If you are interested in an IUD, please discuss with your doctor.  I might be a doctor soon, but I’m not yours.  There are other risks and side effects not discussed above. 

1. 2003 ACOG News Release. Gallup Survey of Women
OB/GYNs. Available at: http://www.acog.org/from_home/
publications/press_releases/nr12-09-03.cfm. Retrieved February
2. http://www.cdc.gov/mmwr/preview/mmwrhtml/00000072.htm
3 Burkman RT. Association between intrauterine device and pelvic inflammatory disease. Obstet Gynecol 1981;57(3):269-76.
4. Thonneau, PF.; Almont, T. “Contraceptive efficacy of intrauterine devices.” American Journal of Obstetrics & Gynecology, v. 198 issue 3, 2008, p. 248-53.
5. Mohllajee, AP.; Curtis, KM.; Peterson, HB. “Does insertion and use of an intrauterine device increase the risk of pelvic inflammatory disease among women with sexually transmitted infection? A systematic review.” Contraception, v. 73 issue 2, 2006, p. 145-53.
6. Shelton, JD. “Risk of clinical pelvic inflammatory disease attributable to an intrauterine device.” The Lancet, v. 357 issue 9254, 2001, p. 443.
7.  Hubacher, D., et al. “Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women.” New England journal of medicine, v. 345 issue 8, 2001, p. 561-7.

Contraceptive Confections—Happy Birthday Birth Control! I Made You a Cake

Disclaimer: This cake contains no contraceptive properties and does not prevent pregnancy

Ladies and gentlemen, let’s all give a big happy birthday to a very special someone today, THE PILL!  Today marks the birth control pill’s fiftieth birthday.  You’ve probably seen a lot of press coverage of this anniversary in important publications such as The New York Times and Time Magazine.  Well, I’d like to give oral contraceptives my own little commendation.

Birth control pills are certainly not perfect.  They are not 100% effective at preventing pregnancy and they require excellent compliance.  They put women at increased risk of blood clots, especially those who are older or who smoke.  They can cause high blood pressure.  They do not prevent sexually transmitted diseases or HIV. 

However, oral contraceptives are an incredible drug and we should celebrate them.  Not only have they revolutionized a woman’s ability to control her reproductive fate, but they also have peripheral benefits.  They are effective at resolving painful or heavy periods, they can help resolve acne, and they reduce a woman’s risk for ovarian cancer.  A recently released cohort study from the UK following 40,000 women over 40 years found that women who had ever taken the pill had lower mortality than those who had never taken the pill, controlling for age, smoking status, and socioeconomic status. [1]

When birth control pills were introduced on May 9, 1960, there was only one pill, called Enovid. Enovid contained very high levels of progestins which caused multiple undue side effects.  The dose was lowered fairly quickly as a lower amount of hormone was shown to be equally effective at suppressing ovulation.  Now there are over 30 different formulations of pills approved by the FDA, as well as shots, vaginal rings, patches and hormone laced intra-uterine devices which are all derivatives of the original birth control pills. 

It is impossible to dispute that the pill has had a tremendous impact on our society.  Analysis by political economists suggests that the Pill allowed women to pursue higher education and prolonged the average age of marriage [2].  Regardless of each woman’s individual contraceptive choices and intimate practices, I do think that we as women can at least indirectly thank birth control for our ability to realize our personal and professional dreams, whatever they might be, in this crazy, uncontrollable world. 

So, happy birthday The Pill.  I made you a birthday cake.  It was another baking disaster day, but the beauty about making cake with frosting is that frosting covers all scars.  I had to make the cake twice because I broke one half of it, and then when I re-baked it I took it out while it was still gooey so part of the cake is undercooked.  The white chocolate ganache, which I still can’t figure out for the life of me how to whip up right, got kind of grainy and then I put part of it on a hot cake so it melted everywhere.  But, the cake itself which I layered with kiwis and strawberries with a white chocolate filling, is delicious and I can only thank James Peterson’s Baking for his beautiful vanilla butter cake.  I made a simple buttercream frosting to coat the outside and cover the disaster, and I think it turned out beautifully.

Birth Control Cake (they're all sugar pills)

Vanilla Butter Cake from James Peterson’s Baking
2 9” by 1” round cake pans
Butter an flour for the cake pans
2 ½ cups cake flour (all purpose will work fine)
1 ½ cups sugar
½ tsp salt
1 tbsp plus 1 tsp baking powder
2 eggs
3 egg yolks
1 ½ cups milk
2 tsp vanilla
¾ cup plus 2 tbsp softened butter, sliced

Preheat oven to 350.  Butter and flour cake pans.  In a mixing bowl, whisk together flour, sugar, salt and baking powder.  Add 1 cup milk and butter.
In a second bowl, whisk together eggs, egg yolks, ½ cup of the milk, and vanilla.
In bowl with flour, mix with wooden spoon or mixer for about 2 minutes, until well combined.  Add ¼ egg mixture, work until smooth, then work in half of remaining egg mixture.  Add last of egg mixture.  Transfer to cake pans and bake until toothpick inserted in center comes out clean, about 25 minutes.  Remove from oven, let cool in cake pans for 5 minutes and then invert onto cake rack.

For white chocolate Ganache
From James Patterson’s Baking
8 oz white chocolate chopped
1 cup heavy cream

Place the chocolate in a heatproof bowl.  Bring cream to simmer and pour it over chocolate.  Let mixture sit for about 10 minutes.  To whip, put the bowl in a bowl of ice water to cool it and beat until fluffy and stiff, like beaten egg whites.

For buttercream frosting
From Betty Crocker Cookbook
2/3 cup butter softened
3 cups powdered sugar
1 tsp vanilla
1 tbsp milk

With mixer, beat butter and sugar until a paste, add vanilla and milk slowly and whip until desired consistency. 

For cake assembly
1 kiwi thinly sliced
5 strawberries, thinly sliced
2 packs Giant Smarties for pills

Put first layer of cake down, cover with layer of ganache and fruit.  Add other layer of cake, if ganache remains put on top.  Coat with frosting and arrange smarties to look like pills.

Update: A special thanks to Dr. Charles of the blog The Examining Room of Dr. Charles.  He hosted Grand Rounds this week, a carnival of medical blog posts, and the birth control cake post was the editors choice.

1. Hannaford, PC., et al. “Mortality among contraceptive pill users: cohort evidence from Royal College of General Practitioners' Oral Contraception Study.” BMJ: British Medical Journal, v. 340, 2010, p. c927
2. Claudia Goldin and Lawrence F. Katz. The Power of the Pill: Oral Contraceptives and Women's Career and Marriage Decisions.  The Journal of Political Economy, Vol. 110, No. 4 (Aug., 2002), pp. 730-770.

Torte Reform

Unfailingly, each time I tell somebody that I’m doing OB/GYN, the first thing that they tell me is either, “Ooh babies” or “You’re brave--the malpractice insurance.” I’m naïve. I chose OB/GYN because I am passionate about the field, and because of my love, I feel willing to pay the high insurance and face the threat of lawsuits. Because the only obstetricians I know are part of an academic practice that covers malpractice insurance, they don’t openly discuss, at least with me, their fear of lawsuits. Even so, I think the dread of bad obstetrical outcomes is palpable in each decision that is made on a labor and delivery unit.

I know next to nothing about the legal system. However, I think as a physician I should learn some basics as lawsuits will most likely, unfortunately, be part of my life. Many healthcare practitioners have told me “tort reform is the answer” and I just nodded my head. I have no clue what tort reform is. According to the Agency for Healthcare Research and Quality, “torts are civil wrongs where the injured person asks for monetary damages from an individual in a situation where there is no contractual relationship.” Thus, tort reform includes legislation that caps payments for non-economic damages when a patient sues a doctor and wins.

As of 2003, 23 states had some tort reform legislated into their government. There is evidence to suggest that tort reform is effective at curbing malpractice fees. For example, in California, legislation was passed in 1975 to lower malpractice costs; by 2000 their insurance premiums increased by 167% whereas in the rest of the nation, fees increased tremendously by 505% [1]. It has also been shown that in California, defensive medicine is less employed and that health care costs are 5-9% lower without significant change in patient outcomes [2].

One of my favorite blogs, Academic OB/GYN, written by Dr. Nicholas Fogelson, recently discussed the importance of change within the country’s legal system in order to produce better obstetrical outcomes over the long term. This is in response to the recent National Institute of Health’s Vaginal Birth After Caesarian (VBAC) Consensus that convened this week. VBAC is a highly contended subject; having a vaginal delivery after a previous caesarian puts a woman at a low but existing risk of the uterus rupturing from the C-section scar being stressed during labor.

Many obstetricians refuse to do VBAC because of fear of litigation due to the risk of uterine rupture. The consensus concluded that VBAC trial was shown to be a safe option for most women [3]. Dr. Fogelson suggests that the apprehension to perform VBAC might be assuaged by “mini-tort reform” in which patients sign a release that in case of a uterine rupture during VBAC, they waive their right to sue. While this is a provocative idea, requiring unlikely consensus and collaboration among a highly divided obstetrical profession, I am not informed or experienced enough to have my own personal convictions on the topic.

I am so protected and coddled as a medical student. I have no concept of what it feels like to be the final decision maker in stressful or liable situations. It is easy to be idealistically devoted to vaginal delivery for every woman who desires it, but to take a stance on the complex and heavily weighted decisions that obstetricians make would be unfair. I do feel with full fervor, however, that it is important to do what is safest and best for our patients. Letting the terror of litigation overrun an entire field of medicine is expensive and can potentially produce worse patient outcomes.

What I am certain about and can propose however, is TORTE reform. As a rich intermediary between a pie and a cookie, this is one topic that there is only one right answer: YES! Tortes are traditionally made with eggs, sugar and nuts. In this recipe, which I very loosely based on a linzertorte, I’ve reformed the composition to have a Southern tinge as a dedication to the pecan pie. The dough is made from chopped pecans and almonds, as is the filling in a pecan pie with mixed nuts spiked with brandy, and it is topped with a gooey chocolate ganache. This is one torte reform we can all agree on (unless you don’t like nuts or chocolate; nobody will ever completely agree).

Nutty Torte Reform with Chocolate on Top

For the crust
½ cup blanched almonds
½ cup pecans
6 tbsp butter cut into cubes, kept cold
1/8 tsp salt
¾ cup cake flour
½ cup powdered sugar
1 egg yolk

For the filling
2 eggs
¼ cup walnuts
¼ cup pecans
¼ cup blanched almonds
(or you could do ¾ cup pecans or use other nuts such as macadamia nuts or hazelnuts)
1/3 cup brown sugar
1/3 cup corn syrup
2 tbsp brandy
2 tsp vanilla
Pinch of salt
Pinch of cinnamon
1 tbsp heavy cream

10 inch tart pan

For the chocolate ganache
1 cup chocolate chips
¾ cup heavy cream
Splash of brandy

Preheat oven to 400 degrees. Toast almonds and pecans for crust in oven for 7 minutes or until golden and fragrant. Toast the nuts for the filling on a separate baking sheet. Allow to cool. Blend in food processor for 30 seconds or until mealy but don’t overwork or it will start to look more like nut butter. Add flour, sugar and salt, pulse a couple of times to blend. Add egg and butter, pulse until blended. With hands, gently bring dough into ball and press into disc, don’t overwork, refrigerate for at least an hour.

Preheat the oven to 300 degrees. On a floured surface with parchment paper, roll out dough. If the dough becomes too sticky, you can press it into the tart pan with your fingers. Prick dough with fork and bake for about 15 minutes. While baking, whisk together filling ingredients. Once crust has started to brown, remove from oven, add filling and bake for another 25 minutes until filling has solidified and crust is brown. Allow to cool.

Over simmering double boiler, whisk together chocolate and cream until blended, add splash of brandy and pour over top of torte while cooling. Refrigerate for a few hours and eat!









1. Hellinger F et al. Malpractice Awards on the Geographic Distribution of Physicians. 2003. US Department of Health and Human Services Agency for Healthcare Research and Qualtiy. http://www.ahrq.gov/research/tortcaps/tortcaps.pdf
2. Kessler, David and McClellan, Mark “Do Doctors Practice Defensive Medicine?” The
Quarterly Journal of Economics, vol. 111, Issue 2, May 1996, pp. 353-390.
3. http://consensus.nih.gov/2010/vbacstatement.htm

Pregnancy Pudding

I love to eat (clearly). And, I love working with pregnant women and delivering babies. Unfortunately, these two passions do not coincide. Sure, pregnant women love to pack on the pounds and devour thousands of calories of delicious treats everyday. But, the second they go into labor, they are banned from consuming anything but clear liquids in almost every labor and delivery suite in America.

Why?

The story goes back to 1946 when Mendelson wrote a ground-breaking paper showing that pregnant women are at high risk of aspirating their stomach contents into their lungs if they required emergency surgery and intubation (when a breathing tube is placed in the airway for safety during anesthesia) ¹. Since the time that Mendelson’s groundbreaking paper was published, the fear of aspiration has permeated the minds of all OB/GYNs and anesthesiologists, banning food from the labor suite. Aspiration is an absolutely devastating outcome which can cause significant morbidity and can be fatal. Aspiration rarely occurs in the modern day L&D ward, but it should be prevented at all costs.

Can prohibiting oral intake actually prevent aspiration? This has never been proven, and is extremely difficult to study based on the rare occurrences of aspiration. In order to study this properly, there is a need for a very high study volume to detect a difference in aspiration rates for those that eat versus those that don’t. Even so, there is limited data on the effects of labor outcomes for fasting versus eating women.

Recently, an article was written in the NY Times discussing an analysis by the Cochrane Review². The Cochrane Review is a database of meta-analyses of randomized control trials of high quality, and is an excellent, unbiased source of information. This particular review compiled 5 studies looking at studies of eating or consuming sports drinks during labor. They concluded that “there is no justification for the restriction of fluids and food in labor for women at low risk of complications.”

The analysis is complemented by a study recently published in the British Medical Journal³. This study was a randomized trial of 2426 low-risk, non diabetic subjects randomized to clear liquids or a low residue diet. The low residue diet group did not have a statistically significant difference in Cesarean rate, APGAR scores, or vomiting, and thus seemingly did not greatly affect birth outcomes. 

 

I do NOT make any recommendations to eat during labor. The American College of Obstetrician Gynecologists recently published guidelines recommend to not change any rules⁴. Thus, we will continue to fast. Even so, this is an area that needs more well designed, strongly powered studies, especially since many women are so miserable during labor and simply want something to eat. Anesthesiology has advanced incredibly since 1946 and has many new techniques and medicines to prevent aspiration. Beyond this, less than 1% of people require intubation for emergency surgery because epidural and spinal anesthesia are used for C-sections the majority of the time. 

Hopefully, for my sake and the sake of everyone around me, by the time I get pregnant and have babies, the rules will have changed and I can gobble it up. (I didn’t eat during my triathlon, and pooped out in the run coming in 5^th from last!) In preparation, I will make some pregnancy pudding, because what could be better to eat during labor than homemade chocolate peanut butter pudding (maybe toast, but I can dream)? It’s filling, delicious, and easy on the stomach, with carbohydrates and proteins to give you energy for the long push. Most homemade puddings have raw eggs in them (not good for the pregnant ladies), but you can make a great pudding with just milk and cornstarch (and peanut butter and chocolate). And if you’re not gestating currently, feel free to partake as well.

Recipe adopted from Bon Appétit January 2009:

Chocolate peanut butter pregnancy pudding

½ cup sugar

5 teaspoons cornstarch

1/8 teaspoon salt

2 ¼ cups whole milk (honestly, you can do it with skim or 1% and I eliminated the heavy whipping cream from the recipe and replaced it with milk. This is not meant to give you massive indigestion)

1/2 cup creamy peanut butter

4 oz (about 2/3 cups) semi-sweet chocolate chips

1 tsp vanilla

Whisk first 3 ingredients in large saucepan to blend.

Gradually whisk in milk. Whisk over medium heat until mixture comes to boil.

Then boil until thick, whisking constantly about 30 seconds (this step can sometimes take longer, but you’ll be able to see it thickening).

Whisk in peanut butter; boil until thick again, whisking often, about 1 minute.

Remove from heat, add chocolate chips and stir until melted, add vanilla.

Cover and chill at least a few hours ahead of time.

1. Mendelson CL. The aspiration of stomach contents into the lungs

during obstetric anesthesia. Am J Obstet Gynecol 1946;52:191-206.

2. Singata M et al. Restricting oral fluid and food intake during labour. Cochrane Database Syst Rev 2010; 1:CD003930.

3. O'Sullivan, G., et al. Effect of food intake during labour on obstetric outcome: randomised controlled trial. BMJ: British Medical Journal 2009; 338:784.

3. ACOG Committee Opinion No. 441: Oral intake during labor. Obstetrics and Gynecology 2009. 114(3): 714.

the match

Oh my oh my! 2010 Match is upon us. For those of you that don't know, it's the gut-wrenching, terrifying process of trying to streamline/cram all 10-thousand something American medical school graduates into residency positions all over the country in all but a select few of the specialties. The idea seems ludicrous. The process begins as a 3rd year medical student (or before) when a medical student picks her specialty. Herein begins the compilation of board scores, grades, research, extracurricular activities, and letters of recommendation, not unlike any of the thousand other applications somebody with too much education has thrown together.

Not unlike any other CV compilation and job application, one applies and is invited for interviews. The BENEFIT of the match, and the ERAS (electronic residency application system or whatever), is that one CV is sufficient. No other essays, cover letters, nothing! And, applying is surprisingly affordable, comparing at least to medical school apps which were insanely expensive. It's something like 60 bucks for the initial fee, which includes 10 applications, then 10 dollars for each additional program, and after 20, then it's 12. Well, this part is cheap...just wait. The most fun part about the ERAS is that all of the programs are just a click away. Dreamed of moving to California? Well, click away! Thought you might want to build an igloo in Alaska as a family medicine resident? it's just one button. Click, click, click, click! Speaks one that only applied to 10 medical schools, I applied to 23 residency programs, even though I am probably way more qualified coming out of med school than into it. This makes it easy to OVER apply (as does the hysteria of the whole match process and the disbelief that you could possibly be as qualified as all those OTHER medical students at even FANCIER medical schools than yours).

Next comes the most stressful, or second most behind match, part. Awaiting interviews. You will get interviews. More than you thought. That's what everybody said to me, and I didn't believe them. Well, out of the 23 places I applied, I got 20. Way more than I could go on. And then you get to schedule them all. My medical school gives us tons of vacation time, so scheduling was only hard because I was going to various parts of the country and needed to try and get to them all in the middle of winter. Why?! WHY do they schedule interviews in the middle of blizzard season! This is not logical and adds to the stress AND fun of the whole process. I did not get stuck once. I am very lucky. Oklahoma had a blizzard this year. Nothing is guaranteed.

You buy plane tickets on your own dollar. What dollar? Yeah, who knows. Med school is expensive and demanding and demeaning, but you love it! You buy plane tickets and rental cars and call people you haven't seen for 5 years to sleep on their couch. You lose 15 lbs to fit into the suit you wore interviewing for medical school (or buy a new one). Then go! There's always a party the night before with Indian food, or so seemed the case for the obstetrical world this year, where there are residents and maybe faculty that want to "get to know you" (make sure you aren't really weird). The interview day is usually fairly long and at least 3 people will talk to you although at least in OB they want to pretend to be nice so most interviews are fairly relaxed. You'll get pretty good at talking about yourself. In fact, when you're done interviewing, you might be in a little you withdrawal.

Then, after smiling and asking the same STUPID questions 1000 times that you don't care about the answer to, eating way too many airplane peanuts, spitting a green bean over a chief resident, denting a resident's car at the dinner, almost missing your connecting flight in Vegas because you were playing the penny slots, and buying a plane ticket for the wrong day entirely and almost getting stuck in Atlanta, you're done. You make your rank list, write emails to your favorite people begging them to employ you, go on second looks if you have time/money/energy. And you're done! Phew. Wasn't that bad. Submit your list to NRMP or whatever the letters are... and certify it.

Here comes the sheer terror. The waiting. The hoping SOMEBODY liked you of the over 100 people you met enough to want to enslave you into the drudges of the hospital spending half of your life with your shoes soaked in blood and amniotic fluid. You spent about $3000 of your Uncle-Sam earned cash to land a job that pays 47 grand a year, which if you average over the 80 hour work week is about 10 bucks an hour. Yep! I'm honestly so excited.

The match seems like an archaic process. And guess what, it is! Only after a little of research, this excellent article published in JAMA (Roth, A. The Origins, History, and Design of the Resident Match. JAMA. 2003;289(7):909-912) discusses the history of the match process. It was first established in 1952: "That selection [of interns] has now been advanced on the school calendar to the beginning of the junior year and, indeed, inquiries now come to me even from sophomores. The dates of examinations and selection have been pushed farther and farther back, through the efforts of some hospitals to get ahead of others in the choice of candidates, for hospitals can exercise pressure on the selected candidates by requiring acceptance of offers of internship at once or within a short time. The student’s dilemma is understandable; if the first offer of this kind comes from a hospital of his second or third choice, he loses out entirely if he declines and is not selected later by the hospital of his first choice" (Joseph Turner 1945). This presented a significant problem to both programs and applicants as they were not making informed decisions and there was too much pressure on medical students.

The current algorithm has been the same since 1952, with few minor changes including the couples match. The algorithm, which is well explained by the NMRP is in the applicants favor. HA! Finally. This is the other awesome thing about applying to residency. The programs, for the first and last time ever, do not have the upper hand. They can rank you and recruit you, but only YOU have the final say if you rank a program or not. Well, I guess this is always the case, but as little control as you have in the match process, the programs are just as terrified that they won't match. Remember, they need you! You are the future slaves of Hospital X, the pride and joy of the hospital that will do all the scut work for the attendings. You are a valuable asset.

Between now and match day, the computer does it's little beep beep beep, 0101010101111000, a little cinnamon, a little sugar, no cream, and concocts the match list for all the programs. Supposedly it takes mere seconds for the algorithm to run. That's why you have to wait 3 weeks. I swear it's just for the NRMP to f&*# with your head in their diabolical plan to control the minds of 15,000 doctors for just a few weeks of the year. And when it spits out the hospital of your dreams and prints it on a plain white piece of paper, this functions as a contract. WHY DID YOU APPLY TO ALASKA?! You thought it would be fun. You'll know soon enough.

Match day. This year it's March 18th. So, now I just have to wait. But as I tear that envelope open and read choice #13 on the letter and start crying, I'll still be employed. In the end, that's what matters. As long as I match, I get to be a doctor, take care of people, learn how to operate, and deliver babies.

The most amazing thing about medicine is that as much as it changes, it really is the same as it was in 1952. It's a bunch of neurotic 20 somethings, waiting for the opportunity to learn from the people before them. It's being taught a beloved and semi-secret set of skills and to seek knowledge. It's to take care of people and improve the health of those around them. It's an opportunity to be at the forefront of medicine, "in the trenches" as they say, and get your hands dirty, just like they did 50 years ago. Match day is nothing more than gaining a little control on something, like medicine, that nobody can truly control. And that little morsel of order in a world of complete chaos, blood, sweat, birth and death truly stands for what gets us (or at least me) out of bed everyday.