endometriosis, hysterectomy, OB GYN, Uncategorized

Not Everyone with Endometriosis Should Get a Hysterectomy Like Lena Dunham

The internet is aflame with people suffering from endometriosis wondering if they should be getting a hysterectomy after Lena Dunham revealed she had one at the age of 31.

Best wishes to Lena Dunham in her future health, it sounds like she has been through so much the past few years. I would not presume to know all the details behind her medical condition. She is quoted regarding her recent health battles here , and she has an article coming out in Vogue in March detailing her personal experience.

However, it is important for people to understand that not everyone with endometriosis or chronic pelvic pain should get a hysterectomy- in fact, the overwhelming majority should not. The truth of the matter is that it’s the ovaries that cause the problem with endometriosis and therefore you cannot be cured from endometriosis if the ovaries remain. A hysterectomy means simply taking out the uterus (typically with cervix too) but leaving the ovaries behind.

The simple fact is that endometriosis pain is tied to the estrogen provided by the ovaries. Therefore, even if the uterus is removed, the pain may continue if even just one ovary remains.

So, why don’t we just take out the ovaries too?

It’s complicated. You need the ovaries for more than just the obvious ability to produce an egg to allow for the ability to get pregnant and conceive a child. While the sole purpose of the uterus is for childbearing, the ovaries involve much, much more.

The estrogen produced by ovaries is protective to our bones and cardiovascular health as well, amongst many other things. Taking out the ovaries prematurely would cause an instant menopause in a woman in her 20’s or 30’s which has serious ramifications on long term health.

This is the reason why many physicians are reluctant to do such a major surgery as hysterectomy and/or removing of the ovaries in a woman in her 30’s. Your reproductive choices are absolutely your right. However, it is important to understand that simply removing a uterus will not cure a patient of endometriosis. Knowing this fact, it makes little sense to go through a major surgery to remove an organ which is not directly causing endometriosis.

Endometriosis implants can be found throughout the abdominal cavity. During surgical procedures, I’ve personally seen implants on bowel (intestines), pelvic sidewall, bladder, and even in the skin of the abdominal wall. Therefore, you can see how taking out the uterus may relive some pain, but it is not a cure.

Is there ever a time for removing both the uterus and ovaries in someone at a young age with debilitating pain from endometriosis? The answer is yes, rarely.

This is only after a multitude of other less risky and effective measures have been attempted and failed. It is exceedingly rare that a patient would not benefit from other methods of suppressing estrogen for short periods of time. Therefore, the case where a hysterectomy is needed for endometriosis alone is very rare and should never be a first treatment for endometriosis.

A hysterectomy alone may be considered for other reasons such as excessive bleeding not responding to less invasive treatments, large fibroids, uterine abnormalities, and even cancer. We may never know all the reasons behind Lena Dunham’s decision to have her uterus removed- that is between her and her doctor. However, given the fact the ovaries remain tells me it’s about more than endometriosis.

So, to any patients suffering with endometriosis, please know there is always more to t story and discuss all options with your doctor.

This article should not be taken as medical advice, but each patient should explore options with their own physician regarding treatment options for this painful and sometimes debilitating condition called endometriosis (there are many!).

 

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OB GYN, Parenting

8 Things Your Doctor Wants You to Know About Your Miscarriage

Miscarriage is one of the hardest (and most common) challenges women face. If you have not had a miscarriage yourself, you most certainly have a best friend, sister, or daughter who has. There are many myths floating around the internet, however there are a few important truths everyone should know about miscarriage.

1. You aren’t alone. Miscarriage is common and occurs more frequently than you might think. Often, a miscarriage occurs before a woman even knows she is pregnant. If you include these cases in statistics, up to 50% all pregnancies end in miscarriage. However, the number is closer to 15-20% for recognized pregnancies.

2.  Most miscarriages occur in the first trimester, but they can also happen later too. Luckily this is rare after 13 weeks. It is often more traumatic emotionally and physically in later trimesters. Women who experience late second trimester or 3rd trimester fetal losses (the term used when occurs later in pregnancy) will have physiologic responses from their bodies that think they just had a child. Their breasts may engorge with milk, a painful reminder of what was lost.

3.  It’s not your fault.

4.  It’s not your fault. Bears repeating. Also, its okay to grieve an early pregnancy loss. You likely had hopes, expectations, and dreams already wrapped up around this pregnancy. It may take a while to recover.

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5. Up to 80% of pregnancy tissue from first trimester miscarriage is chromosomally abnormal- meaning that there was a genetic problem with the developing baby.

6. There has been debate over the amount of time you should wait after a miscarriage before trying again, but newer research shows that in most cases you can start trying again with the next cycle. Although, 3 months is a commonly quoted and may give you more time to heal physically and emotionally.

7. The fact that you got pregnant is a good sign that you will be able to get pregnant again.

8. You have 3 options when a miscarriage occurs- make sure you discuss all 3 with your doctor to determine the best course of option for you.

Expectant: this means waiting for your body to complete the miscarriage on its own. It may include moments of severe cramping and bleeding. The timing can be unpredictable, but you may be able to avoid a procedure if this is important to you. However, if the bleeding is severe you may still need medical intervention.

Medication: If you haven’t started bleeding yet, a pill can help your body to start the process once miscarriage is confirmed. This gives you a measure of control over when the process will start. It is successful in most cases, but sometimes you may still ultimately need a procedure if everything does not pass on its own.

Surgical: The procedure is called Dilation and Curettage “D & C”. This is a minor procedure to remove the contents of the uterus (failed pregnancy). Some women prefer this option as bleeding and cramping time is limited after the procedure. The process is over sooner and may cause less interruption for women who may need to be back at work, or have other children at home dependent on their care. There are risks with any surgical procedure, and although minor, must also be considered.

Since many people wait to tell family and friends about a new pregnancy until safely out of the first trimester, it can be a lonely experience if you go through a miscarriage without the support of your loved ones. In recent years, women have become more vocal about miscarriage and this has helped women feel less alone when it occurs. Don’t be afraid to reach out to others during this time. Be sure to discuss any concerns with your doctor and don’t lose hope about what the future may bring.

 

 

Investing, physician, Physician Training, retirement, Uncategorized

Why Physicians Make Big Financial Mistakes….and Should They be “Firing Their Financial Advisor”?

I am not a financial advisor, so please do not make any financial decisions based on anything I write. However, I am a physician who retired early after achieving financial independence and many readers have reached out to know more about this.  In the latter half of this article I also review a popular new online financial literacy course geared for physicians from the “White Coat Investor”  “Fire Your Financial Advisor”

Probably like you, I remember having an investment firm invited to speak at our residency program. They discussed the benefits of own occupation disability and offered a discount to residents wanting to sign up with their firm. I also remember them talking about managing portfolios. I opted to sign up for the disability coverage and continued with this for a few years until I had adequate coverage through my attending job. At this time, I canceled the plan. I never did use them to manage my money.

I since found out that this same group speaks to many residency programs/hospitals in the surrounding area. Makes me wonder, how did they get this monopoly of a captive audience of fledgling physicians?  Is there some incentive to the programs for allowing them to speak to their residents?  I don’t know the answer to that.  Regardless, it makes me nervous that many physicians aren’t getting good/fair advice relating to finance.

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Why are we talking about finances again? Its important to everyone, and it doesn’t get enough attention with physicians who are more focused on patient care and family time with little left for anything else. With medical student loans, yet also high income potential, every physician should care about finance.

My goal in discussing these topics is NOT to have physicians leave medicine early by retiring early. However, a benefit of financial success is the ability to have control over your time- and I have found time to be the most precious commodity after a health scare read more here

You may be hearing about the massive rally going on in the stock market and wondering if you are missing out. You may have worries about student loans and whether you should agree to a “doctor loan” when buying your first home.

There are so many financial topics that are specific to physicians but, yet as a group, we do not have the training or interest in managing our own finances to allow us to pay off our loans, fund our kid’s college education, or book the vacation that provides the life experience with our families that we value so much.

Most of us don’t have time to learn in depth analysis of stocks or to research different real estate investment opportunities. Unless you have a specific interest in this, I wouldn’t recommend it.

However, as high income earners,  we make big mistakes by leaving an enormous amount of money on the table by not having a basic understanding of retirement savings plans, and the importance of a financial plan for your family.  It is dry, and sometimes painful, to get a better understanding of these things but I promise its worth it.

You may be investing in CME conferences for your career, reading new journal articles, and paying for an “Uptodate” subscription every year. These are all good things to continue advance knowledge in your medical career. Just don’t forget to invest in yourself and family too.

I wish I could say I was able to retire based on my physician income alone. Its just not true. Unless I had completely maxed out all retirement vehicles early (including while a resident), minimized loans (both student and mortgage), lived modestly, and invested in the stock market, it just wouldn’t be possible. However, your income as a physician puts you in a place where you should absolutely be able to retire when you want to if you make prudent financial decisions.

Take the time to make a financial plan. Read a few books or take a course. It will be worth so much to you over the years and well worth your time investment. Its not fun, but crucial. And no one in medicine will tell you to do this.
End of rant.

In full and complete disclosure, I was approached by the creator of the “White Coat Investor” to give feedback and take his new online course to see if this was something I thought would appeal to my readers. If you end up buying the course through my link, I will get a small portion of the cost for the course (without any additional cost to you- the price is the same regardless).  You can take as long as 7 days to determine if you find it worthwhile, refund is available if not.  WCI “Fire Your Financial Advisor” Course

 

WCI Course _4

I am definitely not running this website as a principle means to make money. This is a hobby for me, but it does have administrative costs. So, if you are going to buy the course for the same price anyway and my review/link helped you decide to do it, I feel it is a win for us both.

All that being said, I did the course. Here is my honest feedback:

1. It is boring, and dry. (Perhaps mostly just a function of the material itself, but some variation in how the information is presented would be nice).

2. It is incredibly useful for physicians.

It deals specifically with topics that are unique and pertinent to physicians. If you have tried to read about finance and found books incredibly boring, or if you don’t know where to find all the important information for physicians in one place, it is likely a good fit. Its all done on videos that you can start and stop when you want. I don’t recommend doing more than a few hours at a time as you will start to lose focus.

Some topics (many more available) with their own video segments that I found to have very good coverage that you might also be interested in:

  • What an advisor can do for you
  • What to look for in an advisor
  • Disability Insurance
  • Physician Mortgage Loans
  • Refinancing During Residency
  • Paying off Debt Quickly
  • How Much You Need to Retire
  • Investing in a Taxable Account
  • 529 Plans
  • The Backdoor Roth IRA
  • Stocks, Bonds, and Mutual Funds
  • Why You Need a Will

This course is perfect for people who don’t have time or desire to hang out on investing sites/forums or read tons of books on investing. Can you find all of the information somewhere else (perhaps even free) or other websites/books/lectures? Yes, but you would have to spend an enormous amount of time to track all the information down and compile it. If you want the information highly geared to physicians and spoon fed through videos, this may be a great tool to help you build wealth. The impact over many years can be incredible vs. staying in a static situation where you are doing nothing for your finances.

In the end, my recommendation is to do something. Buy a finance book, hire a financial advisor (after at least understanding the basics of how their fees are collected), write up a financial plan, or lastly buy this course if it fits your learning style. You need to at least know what you don’t know.

This course is expensive at $499. However, if you think about the yearly amount you would pay to an advisor or the amount over the years that you could accumulate by having a better understanding of personal finance, the cost is pretty nominal. In addition, if you are like me, you may be more likely to actually do (and finish the course) since you invested some real money into it. It gives you motivation to complete it as you don’t want to waste that money! Lastly, you can get a refund within 7 days if you don’t find it useful.  I would suggest doing 2 hours every weekend for a month.  If you commit to that you will have a huge improvement over where you are today.

If you are interested here is the link to check it out:

WCI Course _2

White Coat Investor: “Fire Your Financial Advisor” Online Course

By the way, I think financial advisors are generally good people. I even have a close family member who is one, and their expertise cannot be replaced with a single course. The title is a little provocative and misleading because you very well may still benefit from using a financial advisor, but you should know how to pick one and determine how they can best help you. You will get advice on this in the course too, and it may save you a lot in the long run. Ultimately, even if you use an advisor you should have a basic understanding of how things work so that you aren’t taken advantage of by a small minority of bad ones (especially those trying to sell you whole life insurance policies)!

I hope you don’t mind me telling you about this course, but I truly do feel it could be very beneficial to many physicians- especially those in medical school, residency, or 5-10 years into their career. And to answer whether you should be getting into the stock market, the answer is yes! But don’t do it blindly. Whether that is through a 401K, taxable brokerage account, 529 for your kids, etc. depends on your financial situation but you should be making your money work for you instead of relying solely on your paycheck.

If anyone else has tried the course, help our other readers out and let us know what you thought in comments below!

OB GYN, physician, Physician Training, work hours

The Wrist Band Challenge: A Safe “Strike” Against Unsafe Working Conditions That Can Harm Patients (and Physicians)

My shift had finally ended. As a second- year resident, I was driving home after 30 hours awake straight. During this time, I delivered several babies, performed a cesarean section or two, a couple of circumcisions, rounded on many patients the following morning, triaged new patients, and taught medical students. Never during that 30 hours was a 5- minute nap possible; clinical load would not permit this.

I couldn’t wait to get home at the end of the shift as I was completely exhausted. So, I buckled up and prepared to drive the 20 minutes home on interstate 95 so that I could finally get some rest before my next shift started less than 24 hours later.

I could feel my eyes starting to droop as I was driving. I turned the radio up loud, drank a big gulp of my hot coffee, and rolled down the window. I had done this many times previously after these long shifts and had figured out all the tricks to make it home safely, or so I thought.

I must have not been able to fight off my increasingly heavy eyelids, because I woke up suddenly to the jarring bumps on the side of the road- intelligently placed to wake up drivers such as myself who may be drifting out of the lane. This startled me, and I turned the wheel hard to get back on the road. However, I overcompensated, confused, and dazed from no sleep, and spun around 180 degrees so that I was facing the opposite direction of traffic on the interstate. I slammed into the wall of an overpass and my car came to a sudden and jolting stand still.

 

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My heart was racing, my hands were shaking, and I tried to get my bearings to understand if I hit someone, or if I was still in danger and needed to get out of my car. I quickly got out, unbelievably unharmed (and miraculously no one else either) and called my husband with trembling hands. I was only 5 minutes from home.

A man with his wife and children in the car quickly pulled over to see if I was ok. He could see how shaken I was an offered to sit with me until the police and my husband could make it.

My car was totaled. I walked away fine, without a scratch, but with a new understanding of the inhumane conditions expected of physicians.

Ultimately, I believe patients have the right to know if they are receiving care in optimal situations that promote safety and decrease preventable medical errors. Physicians have an incredibly strong, important and powerful ally in our quest for humane working conditions- our patients.

We’ll call it the wristband challenge. It works like this:
Physicians take call for any varying amounts of time. I propose physicians start wearing rubber wristbands (like those commonly seen promoting the “LIVE STRONG” campaign) signifying to their patients how many hours straight they have been responsible for patient care without a break

 

Green: 0-24 hours
Yellow: 24-30 hours 
Red: 30+ hours

                                                                                                                      
Think this could never work, or that nobody would do this? Guess what, its already been done. Please see how the South African Medical Association came to bring this project to fruition in their country. https://www.samedical.org/campaign “The SAMA campaign makes it easier to identify doctors who have worked longer hours. It is also a visible reminder that South Africa should employ more doctors to manage their workload”.

wristband

This is a way to promote transparency with patients. They should have a right to know if their obstetrician is on their 30th hour awake and about to deliver their first born child. Or if their physician is admitting their father with congestive heart failure and writing detailed medication orders without sleep for over 24 hours.

Physicians want to have humane working conditions that promote patient safety, but it is complicated for a profession such as ours. We have been told it is illegal to form a union. We are threatened that going on strike puts patients at risk. We can’t just all walk out of an ER at the same time, and therefore we don’t, out of respect for our patients and concern for their well-being. However, this puts us in a trap of beneficence where “do no harm” compels us to continue working in unsafe conditions not only for our patients but for ourselves.

A physician can wear their wristband and not have to fear speaking out or arguing with an employer or worry about being labeled a “trouble maker”. If the bands become standard, hospitals who are employing safe practices can use this as a bragging tool that their physicians are well rested and rightfully claim to be advocates for their patients. It is a silent tool of protest for physicians who will continue working without going on physical strike and allow our patients to do the fighting. In the end, it is the collective voices of our patients that matters most and will get the most promise for change to a dysfunctional system.

As a patient you may ask, “well, why don’t you just not schedule yourself for more than 24 hours on call”? If you are a physician in private practice you can. However, the trajectory of medicine now has more physicians employed through a hospital or HMO. The loss of autonomy in these positions does not allow a practicing physician to dictate the amount of time on call thought to be “reasonable” or “safe”. This is especially true for resident physicians and medical students who are bound by their teaching programs rules. Importantly, the number of residency spots has not sufficiently increased each year to allow for enough doctors to fill in the patient needs that continue to increase in number.

Up until now, no hospital or CEO of an organization wants their patients to know how long their doctors have been working straight. It isn’t posted on websites like C-section rates, repeat hospitalization rates, or complication rates. The government isn’t mandating reporting this statistic that directly impacts the safety of patients AND physicians. Perhaps if the public knew and could see first-hand, in real time, the types of hours the doctors caring for their family members were working, they would demand change.

It would no longer be an abstract concept. I don’t blame current residency programs- they are simply trying to meet patient needs with the limited number of physicians employed to fulfill this demand. This would mean increasing the number of residency positions so that we have enough doctors to provide required care. This in turns means there needs to be increased funding for residency positions from the government.

we can seek meaningful change in our profession without going on “strike”. Patients will see wristbands turn from green to orange, and ultimately red. Patients will begin to speak up. Not only out of concern for themselves, but out of care for their physicians.

We remain a team, with health and healing at the core of our mission. With enough help from our patients I do believe we can see a change in the culture of medicine. I believe this should start with our teaching institutions and residency programs that are treating our most vulnerable of patients.