What Happened to Informed Consent?

I guess for some people this is old news, but this morning I read this article about medical students doing pelvic and rectal exams on patients who are under general anesthesia for surgery. These patients, in many cases, did not consent to such exams, and may not ever even know it was done to them. Apparently this issue has come up a few times over the years (see the references section of this article) without ever really being resolved. And men, this includes you too... Imagine going in for a routine knee surgery and having 4 or 5 med students practice rectal exams on you while you're out cold.

If a woman goes out to a bar and a man spikes her drink with roofies and then has sex with her while she's unconscious, is it not rape if she can't remember it? Of course it is. How is this significantly different?

Any procedure performed on a patient requires informed consent. It is a legal right and an ethical obligation. The fact that this continues to go on is abhorrent. Of course med students need to learn somehow, but this is not the way.

Studies and surveys have shown that people will, when asked, consent to med students performing such exams. There are also some programs in place that pay volunteers for undergoing examinations in order to teach med students. Both are better alternatives than simply probing people's orifices without their knowledge or consent. More importantly, performing pelvic and rectal exams with a conscious patient have the advantage of allowing the patient to give feedback (as in, "Hey that HURTS!"). The student can better learn to conduct such exams so as not to hurt the patient.

If you are having surgery or any other treatment at a university or teaching hospital, ASK if they have med students learning pelvic and rectal exams on anesthetized patients. If you are ok with simply knowing in advance, you can feel free to consent at that time. Or you can tell your attending physician you do not consent, as well as write it on your consent form that you specifically do not consent to such exams.

If you are a student doctor or nurse, please refuse to check your ethics at the hospital door. Just because "this is the way it's always been done" doesn't mean it has to continue to be done that way. Tell your resident, your attending, your supervisor, or your preceptor that you won't participate in exams of anyone who hasn't given explicit consent.


Hat tip to The Unnecesarean for the topic of this post.
Further reading here

In Florida, A Pregnant Woman is Nothing But A Womb Pod

I encourage people to follow this case in Florida, where a woman was court-ordered to be held against her will on hospital bedrest. She was 25 weeks pregnant and having some issues in her pregnancy, so it was recommended she remain on bedrest. However, with a job and two other young children at home, she did not feel that would be possible. So the hospital sought a court order to keep her hospitalized, claiming it was in the "best interests of the fetus." Never mind what might be in the best interests of her other two children! The court order required her to submit to any and all treatments during her stay. Three days later, she had no choice but to undergo a c-section, and during the surgery it was determined that the fetus had already died. (Which, as an aside, could have easily been determined by an ultrasound rather than major abdominal surgery.)

In the past, courts have always upheld patient autonomy in making medical decisions, even for pregnant women, even when it might endanger a fetus. The Florida courts, however, have summarily stripped this woman of her constitutional rights. Fortunately, a lawyer has agreed to appeal her case pro bono, and the ACLU has (rightfully) stepped in as well.

Let this case be a warning to women everywhere: The Pregnancy Police are watching. You think it's bad that people give you the stinkeye in Starbucks when you don't order a decaf latte? Just wait til they imprison you in the hospital until delivery for it.

Are You a Disaster Waiting to Happen?

A couple of weeks ago, I came across a blog post that combines two of my main interests: Teaching group ex and birthin' babies. The analogy quoted from Mother's Intention: How Belief Shapes Birth by Kim Wildner is great:

"Heart disease is the leading cause of death in the US. 873 per 100,000 die of heart disease (CDC). (Remember, natural birth is between 6 and 14 per 100,000 in the US, depending on the population.)... Using the logic of obstetrics, all health clubs should be in hospitals and all fitness trainers should be cardiac surgeons. Any independent health club with 'lay' trainers would be 'practicing medicine without a license,' subject to prosecution. It's for your own good."

Exercise is dangerous business! Go for a workout and it could end in catastrophe! Let's not forget that Pheidippides DIED running the first marathon. But don't worry, Wildner has the solution for all of us exercisers out there:

"...in order to know if a problem is developing, close monitoring and 'management' is required. We will need to place straps on the muscles to measure the intensity of the workout. of course, it will be restrictive, but we need to know how hard the muscles are working to know if the heart can take it. We'll need to monitor heart rate, blood pressure, fluid output. We'll need to give an IV because with sweat excreted, you could dehydrate, and of course, we simply can't take the risk of letting you drink anything lest you need emergency surgery..."

Does any of this sound faintly ridiculous? Is your health, your life, so precarious that a workout could kill you? Is your body so defective it can't handle a natural function like physical exertion? Unless you're in a risk category- such as a heart problem, an autoimmune disease, or chronic illness- the answer is no.

So why are we so quick to believe that a mother's body can't birth her baby without all the monitoring and the technology and the machine that goes ping? Why do I keep meeting women who were told their baby was too big, their pelvis too small, their bodies just "not able to do it on its own"? I think that's just sad. It can't be true that so many women's bodies function normally in every other way... except this one. Having a baby is not an emergency or a condition from which women need to be rescued. Pregnancy and birth are not a disaster waiting to happen. But unfortunately that doesn't seem to be the prevailing attitude, least of all among most obstetricians.

I leave you with one of my favorite quotes, from midwife Ina May Gaskin:

"Remember this, for it is as true and true gets: Your body is not a lemon. You are not a machine. The Creator is not a careless mechanic... Even if it has not been your habit throughout your life so far, I recommend that you learn to think positively about your body."

Resolution Time

For a lot of people, the new year is a time to pledge change. Some people try to break old habits and some try to create new (healthier) habits. One of the most common resolutions is to get in better shape, whether that means losing weight, exercising more, or both. Maybe you've made that resolution in the past. Maybe you made it this year.

It should come as no surprise then, that January is the busiest month of the year at gyms and health clubs. (Second is September- when kids go back to school and routines that petered out over the summer start anew.) I've watched each January as the gym fills with "New Year's Resolution People" who are gone by the time Valentine's Day rolls around. And you should know, that we as instructors and trainers, are talking about you. We love to see new faces in class, really we do. But when you start out during the month of January, we are skeptical. And truthfully, though I can't speak for all instructors, there are some of us guilty of complaining about our gym regulars getting shut out of classes by overexuberant newbies during the month of January. Sorry.

Here is where I have seen a lot of people go wrong. Let's take a hypothetical woman named Jane. Jane has made a resolution to lose weight through diet and exercise. So on January 2, she signs up at the gym and vows to go every day. I would bet my last dollar that Jane will fail.

Why?

Well, for a couple of reasons. First, Jane is likely to burn herself out quickly. I see this more with men, but women do it too. Jane literally hits the ground running, going 4, 5, 6 days in a row to the gym and pushing herself hard. And then she is overtaken by fatigue and muscle soreness... And then she thinks, "Ugh, this is why working out sucks. It makes me tired and sore." And pretty soon that gym membership is nothing more than an automatic monthly charge on her credit card. Second, Jane set herself up for failure before she even began by setting a vague goal of "losing weight" through diet and exercise.

But Jane doesn't have to be one of the New Year's Resolution People that instructors and trainers sigh about. She can do one simple thing to help herself succeed. She can set a SMART goal. SMART stands for Specific, Measurable, Attainable, Relevant, and Time-bound.

Specific- "Losing weight" or "getting in shape" are not specific goals. Losing 20 lbs. or being able to run for 30 minutes without stopping is specific.
Measurable- There should be no doubt about whether a goal has been achieved. Progress towards a goal can be measured- losing 5 lbs. out of 20, or running 10 out of 30 minutes without stopping.
Attainable- Losing 20 lbs. or training for a marathon in 2 weeks is not attainable (and even if it were, it certainly wouldn't be healthy). Be realistic when setting a goal.
Relevant- It may seem obvious, but it doesn't make sense to train for a 5k run by riding a bike. And "training" for a competitive eating event is probably not a good method of weight loss. (That's a joke people!)
Time-bound- Assigning a deadline keeps goals on track. Set both short-term or interim goals to mark progress towards a long-term goal.

For Jane, a SMART goal might be: Fit into her size 6 jeans (specific) by losing 20 lbs. (measurable) in the next 4 months (time-bound). To do this she will count calories and go to the gym 3 days a week (attainable and relevant).

Finally, my personal opinion for people who haven't been working out regularly is to start off slow. Yes, we should all work out about 5 days a week, but for those just starting out, 2-3 days a week is enough. Carve out that time and cement it into a weekly schedule, the same way meetings or appointments are scheduled. Once those couple of days become a habit, add another day, and eventually another. Trying to do it all at once can be too overwhelming and discouraging, and I think that's why a lot of people can't stick with a routine for more than a few weeks.

Have you made a resolution to get in better shape in the past? How did it work out for you? Are you resolving that this is the year you'll get fit?

A Bit of History That Gives Me Chills

Yesterday one of my favorite bloggers, The Unnecesarean, posted an excerpt from a history text about birth in the early 20th century. The excerpt presents the practice of putting women under "twilight sleep" for labor and delivery as a way to convince WASP women to have more babies because "modern" birth practices render it painless-- or at least without the memory of pain. I had never heard of this racist/classist perspective of twilight sleep before. But it got me thinking, especially since I recently read that the tv show Mad Men featured a character giving birth within the haze of twilight sleep.

I can't remember the first time I heard about women being "put under" to have their babies- it was probably as a child or teen. Until a few years ago, I guess I thought it was a benign but clumsy attempt to spare women the pain of birth. No big deal. But then I happened to see "The Business of Being Born, " a documentary by Ricki Lake that covers a little bit of the history of birth in the US. The historical aspect was eye-opening, to say the least. When you start to think about the fact that this is the way many of our parents came into the world (and maybe even some of us, considering twilight sleep was prevalent well into the 60s and even the 70s in some hospitals), it can be downright scary.

Beginning in the 1900s, a combination of scopolamine and morphine was administered to all women entering the hospital for birth. Women had no recollection of the birth, and certainly no recollection of any pain. Feminists heralded this as a fantastic medical breakthrough, and demanded its widespread availability for birthing women. As word spread of this wonderful new pain-free way to give birth, women across the country chose to deliver in hospitals offering twilight sleep. In fact, there are reports of women being put under for delivery whether they wanted it or not, even against their own explicit refusal. But since women had no recollection what actually happened during their births, and husbands at that time were not part of the birth process, it was years before the true horror of twilight sleep was exposed.

Since the women were not fully sedated, and not fully relieved of the pain of labor, they had to be placed in restraints in their hospital beds so as not to thrash themselves onto the floor. When husbands started questioning the marks on their wives' wrists and ankles left behind by the leather restraints, the practice of restraining was not abandoned. Instead new restraints made of lambswool were designed so as not to leave any marks. Women were left, tied down, to writhe through their labors until the doctor arrived with forceps to extract the baby. (See photo at top.)

When the effects of the medicine wore off, women were presented with a freshly bathed, blanketed bundle of baby. Some women complained of feeling detached from their babies, like they weren't even sure it was their own child. The drugs also crossed the placenta and often sedated the baby, resulting in breathing problems. Over time the method was eventually abandoned, as a result of the negative side effects and the second wave of feminism. As women reclaimed control of their reproductive lives, including access to birth control pills, they also began increasingly demanding unmedicated births and fathers' involvement in births. The development of epidural anesthesia also played a role in the demise of twilight sleep.

Maybe it's my own personal bias against hospitals, but the thought of literally being dropped at the door of the maternity ward by my husband and literally having no recollection of anything else until being handed a baby two days later utterly horrifies me. I don't think the method would have taken off if husbands had been allowed in- I cannot imagine any man permitting such barbaric practices to be visited upon his wife. But they didn't know, so they couldn't help.

There was (and I think there still is) a certain mystique around birth: We don't know exactly how labor starts, and can't predict when it will happen. Regardless of a mother's weight gain or belly size, we don't know the size of the baby until it's born-- even ultrasound measurement can be off by a pound or more in either direction. This mystique allowed generations past, and still allows many people today, to maintain a certain degree of ignorance about birth. It's very easy to assume that the doctor has all the knowledge, the hospital has all the equipment, so all the expectant parents need to do is show up when it's time. I think that is a dangerous attitude. The same people who wouldn't hesitate to seek a second opinion from a doctor who said they need a heart transplant... the same people who would consult with three different orthopedic surgeons about a knee replacement... don't think twice about their choice of care provider, birth place, or pain management options. I could write a whole other post on the topic of informed birth choices... But suffice to say for now, If you don't know your options, you don't have any.

Vitamin D Confusion

Until recently, I'd never given vitamin D much thought. I mean, rickets? Isn't that a disease that pirates and other seafarers got, along with scurvy and beriberi? It seems like every time I turn on the news lately, vitamin D deficiency is linked with other health conditions, such as cardiovascular disease, prostate cancer, diabetes, depression, even H1N1 influenza. The problem isn't limited to adults, either. New research has indicated that children are vitamin D deficient as well.

It's possible we've taken the "safe sun" message too much to heart. We've become so accustomed to slathering on sunscreen every time we step outside that we're blocking our bodies' natural vitamin D production from the UV light of the sun. Ironic that by trying to prevent one disease, skin cancer, we've potentially put ourselves in the path of other diseases.

The NIH recommends 400 IU of vitamin D supplementation for adults, assuming an individual is not synthesizing any vitamin D from sunlight. But is that enough? Recent evidence makes the case for higher amounts, up to 5000 IU per day. There is also a case for modest sun exposure, 5-10 minutes of full sun (without sunscreen) on the arms/legs/face, 2-3 times per week. But the amount each individual needs varies based on age, race, time of year, and latitude. So how to know if you're getting enough?

I was surprised to learn recently that a simple blood test can tell you if you're getting enough vitamin D. (And with my annual physical coming up in a couple of weeks, I'm definitely asking for my D to be tested as part of my labs.) If you'd like to ask for it too, it's the 25-hydroxyvitamin D test, also known as the 25(OH)D test. Note: This is different from the 1,25-dihydroxyvitamin D test [1,25(OH)2 D], which will not give an accurate portrayal of vitamin D status. According to the Vitamin D Council, a healthy level is 50-80 ng/ml, which should be maintained year-round.

Another bit of information of note: Athletes may need more vitamin D than the general population. This is an area of research that needs more study, but initial recommendations are on the upper end of the intake range. One writer chronicled her experience with D deficiency and its effects on her athletic performance. If your performance has been lagging for no apparent reason, it might be time to check your D level.

I think this is as good a reason as any for me to pack it in and move to the Caribbean. "Sunshine Vitamin" anyone?

Exercise and Breastfeeding

A new study from the University of North Carolina-Greensboro concludes that breastfeeding mothers who exercise lose less bone density and less lean body mass than non-exercising women. Although the study is small and the topic warrants further exploration, the results are promising. Bone loss is normal during pregnancy and lactation, as the baby depletes some of the mother's calcium stores for skeletal development. Bone density generally rebounds, at least partially, after a woman ceases breastfeeding. But concern over osteoporosis could lead some women to decide (or be convinced) to wean prematurely.

The UNC study demonstrates that moderate exercise, in addition to its many other benefits, can mitigate the effects of breastfeeding on a mother's bone density. It is important to note that the women in the study did not have a gym membership or attend group exercise classes- they performed a combination aerobic/strength-training routine 3 times a week in their own homes. In other words, the benefits of exercise are not out of reach to women unable to join a health club. For women who worry that exercise will affect their milk supply, there is no research that supports this myth. Furthermore, the additional caloric expenditure associated with both exercise and lactation (along with healthy eating habits) may help mothers shed their pregnancy pounds more easily.