Saturday, July 15, 2017

Third party reproduction

This post conforms to the blog rules.About a year ago, a gestational carrier of twins was admitted to our antepartum wing. Her condition required a long-term stay and she was not in her home state. To make matters more complicated, the presenting twin was not vertex. There was heated disagreement between the intended parents and the gestational carrier about mode of delivery because my attendings recommended a cesarean section for the twins. The carrier did not want a C-section. The physicians' hands were tied: we couldn't do a C-section on a non-consenting woman without committing assault and battery. But the agreement signed (while not designed for this state) did specify that the gestational carrier was to comply with physician recommendations on mode of delivery.

To translate into colloquial terms: about a year ago, a surrogate carrying twins for a gay couple came to our hospital while out of her home state. Because the first twin was not head-down and for a few other reasons, my attendings recommended a C-section for delivery. There was a painful, days-long disagreement between the surrogate and the couple, because the surrogate didn't want to have a surgery. We couldn't do a C-section without the surrogate's consent, but the contract signed by the surrogate and the couple said we should have been able to. ("Surrogate" is not a term preferred by the ASRM or third party reproduction lawyers.)

The ethics committee was, as I recall, rather unhelpful. No member of the healthcare team ever saw the agreement signed between the intended mothers and the gestational carrier. All residents whose names were not already in the chart were encouraged not to open the chart or see the patient out of concern for legal repercussions. The intended mothers of the children became rather forceful, asking that the healthcare team discuss matters with them before discussing them with the patient and lurking around the floor to catch any healthcare providers who might be discussing the case of their children. When it once appeared that the twins might suffer some adverse neurologic outcomes because of the disagreement, one of the mothers stated she did not want the child if there was brain damage.

All of this was a rather unpleasant ethical case that ended as well as it could, since the gestational carrier agreed to a C-section eventually and both babies were born. I have many dissatisfied feelings about the way all five people's lives changed during this pregnancy episode. I began to wonder whether the true nature of things (a contract about goods belonging to the adults) came out in the unpleasantness.

Recently my program has been adding more IVF experience for us. A few months ago I drove out to the IVF clinic of the new professor we'll be working with. As luck would have it, there wasn't much on the schedule and I didn't have to explain much. Although I've written about being "inside IVF" before, this one afternoon included actual experience of ARTs (two IUIs and an embryo transfer). Since I know how these procedures are done, in a way it wasn't earth shattering. But in another way, it was painful. By the end of the morning I felt nauseous and had to talk aloud with the Lord in the car about the experience.

Unfortunately, this isn't the end of this topic. I haven't covered it much on my blog, as I've mostly focused on contraception and sterilization. But now that I'm becoming a third year resident, who will spend two consecutive months on the REI service, it will become a topic of much more discussion.

Friday, June 30, 2017

Residency pre-Fellowship is Different (A Rant)

You know I work an average of 70 hours per week, and you can guess that making time to study is hard. You might not know how much there is to study. And did you also know that I'm expected to go to one conference per year and publish 1.5 peer-reviewed publications per year?

Let's start with the stuff that ACOG puts out. There are 79 Practice Bulletins and 236 Committee Opinions. Those are usually three- to fifteen-page documents, including references and tables. That sounds almost manageable, but then the Guidelines for Women's Health Care is 907 pages long and the Guidelines for Perinatal Care is 599 pages long. There are also seven Task Force documents, only one of which I've even opened (the Hypertension in Pregnancy report, which is a hundred pages long). Te Linde's is 1300 pages, Gabbe's is 1200, as is Creasy's. And then there are landmark papers that we are supposed to know.

Our program recently started giving us "homework" because our CREOG scores went down. I do not think this is the right answer for me. The answer is no more wasted lecture time, let me privately study and read. Don't give me extra materials, let me work through what I'm responsible for first.

And I'm also supposed to study obstetrics and gynecology while researching and furthering the field. This seems stupid in several ways, and I suppose the old way of doing it was that attendings did research and used medical students and residents as peons so that they could learn how to do it. I can't memorize study designs and statistical tests while also trying to memorize pelvic anatomy! In fellowship you have to do your own statistics and are usually responsible for higher-level study types (e.g. randomized controlled trials, bench science, etc), but you get a year without clinical responsibilities to do it. This week I clocked 70 hours and I presented a poster and submitted a manuscript.

Time spent researching is time not spent studying. Time spent reading a practice bulletin is time not spent reading a textbook (viewed by my program as better). Time spent reading a textbook is time not spent praying. This truth goes on and on for cleaning the house, sleeping, cooking, exercising, and recreating.

Recently I had a mentor meeting and we talked about the juggling act. "Residency is a different animal for you, compared to your peers who don't want to do fellowship," she said. "It's a fundamentally different thing." In my opinion it's fundamentally crazy. </rant>