hpv, OB GYN, Parenting, vaccine

This Mom (and OB/GYN Doctor) Sounds Off on Whether Your Daughter Should Get the HPV Vaccine

My young daughter will be entering middle school in another year. However, she still likes coloring books. If she watches a scary movie, I have to lay with her in bed until she falls asleep.

She is still just a kid. Should I really be worried about HPV? Is this something you should consider for your daughter?

Most people know that the HPV virus is sexually transmitted. However, most people don’t think it could happen to their daughter. Unfortunately, more than 80% of the population has been exposed to the HPV virus during their lifetime. How is that possible?

Well, let’s assume your daughter has 1 lifetime sexual partner. Let’s pretend her future husband only had 1 girlfriend prior to meeting your daughter. However, maybe his previous girlfriend had 5 partners- and who knows how many exposures those 5 partners had.

Now it’s easy to see that you don’t have to be sexually promiscuous to be exposed to HPV. It could happen to anyone and often does. HPV is silent (there are often NO symptoms), and people don’t know they have it and therefore pass it on to others unknowingly.

As an ob-gyn doctor, I know about the HPV virus and have seen so many patients affected by this virus that can cause cervical cancer if left untreated. I have seen women die from cervical cancer caused by this virus. I have seen pregnant women who are newly diagnosed with cervical cancer have to decide whether to delay treatment or potentially risk their pregnancy by treating the disease.

Luckily, most of the time we can monitor the HPV virus through pap smears/hpv testing and never have to intervene as the body will often clear the virus on its own. Occasionally, treatment in the form of excisional procedures on the cervix are necessary to prevent progression to cervical cancer. If you have never seen a LEEP procedure done in the office, trust me, you want to spare your daughter from this if at all possible.

By the time a girl visits her ob-gyn’s office she may have already been exposed to HPV and we potentially missed an important opportunity to give the vaccine. This is due to the fact that we typically don’t see teens in the office unless they are having a problem, and we don’t start pap smear screening until age 21 (appropriately so).

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Pediatricians (and family practitioners) do a fantastic job of making sure our young girls are getting the vaccine when indicated. Currently, the vaccine can be given to girls between the ages of 9-26 years old. Most girls are vaccinated with the series at age 11 or 12. Remember, the point is to vaccinate far PRIOR to sexual activity. We don’t expect your 11 year old daughter to be sexually active.

On the other hand, I have had to do numerous procedures on patients in their 20’s who have precancerous lesions from the HPV virus. Most are shocked and terrified and don’t understand how this could have happened to them.

As a mother, I am just like any other parent who would do anything to prevent my child from suffering. I worry about risks and benefits of treatments (even preventative) and how they will affect my daughter. I feel lucky to have had the opportunity to truly understand the research and risks behind this vaccine through extensive training in obstetrics and gynecology.

It is empowering to have access to a vaccine that can actually prevent cancer.

So, while the physician in me appreciates and understands the research and clinical implications this vaccine portends, when I counsel patients I find the mother in me also weighing in.

Since I do have a young daughter who I would do anything to protect, I can assuredly say that she will be getting her HPV vaccine when she turns 11. I want to know that I did my job as her mother to protect her when she can’t yet understand how this may impact her life down the road.

 

Maternity Leave, Parenting, Physician Training, Uncategorized

Best Time to Have a Baby as a Physician? It Depends.

Is there truly a best time to be pregnant, have a baby, and care for a newborn during a medical career? I’ve done the groundwork by having a baby in residency and two more as an attending. Here is what I found out along the way.

 

Is it even possible to have a baby during residency?

It was the end of a 24-hour call – I’m guessing similar to the ones most physicians in residency experience. Zero sleep, several high-intensity and stressful patient care situations, and a few graham crackers and ginger ale from patient waiting areas throughout the day to keep you going. When the call ended, the right thing to do was to lay down and get a few hours of sleep prior to driving home. However, your baby is waiting, and you haven’t seen her in 24 hours. You pumped milk in between admitting patients from the ER and a quick add-on surgery. You are desperate to get it home to see your child, so you rush out the hospital doors after carefully signing out to your oncoming resident.

 

Once home, you can’t wait to see your baby, your everything. Instantly, all stress evaporates and her belly laughs melt away the last 24 hours. Your husband gives you a quick kiss, hands off the baby that kept him up all night teething, and immediately heads out to the gym for an hour of his own much-needed downtime before starting his workday.

 

You lay on the floor to play with her and arrange pillows and toys surrounding her while you rest your head…just for a moment. The 24 hours of no sleep catches you and you realize you fell asleep on the floor next to your baby with no one else around. It scares you. Luckily, she hasn’t learned to crawl yet and is still content playing with toys. Exhaustion and exhilaration fill your days as a new parent/resident physician.

 

Time is lacking. Love is not. You will likely have to put your baby into childcare sooner than you would like. Six weeks maternity leave is pretty standard (but expect to use all of your vacation time for the year to cover it). You will also need to factor in additional calls before or after your baby is born to make up for the call you miss during leave. Your fellow residents will help by picking up the extra calls in your absence and will appreciate your reciprocity. As uncomfortable and painful as it is to take additional 24-hour calls while you’re pregnant, I highly recommend this instead of waiting until after the baby is born. Until maternity leave policies change in the US, this is what can be expected with having a baby during residency. More than six weeks off will likely involve adding time to your residency training. I actually agree with this as the high-yield information/learning obtained during residency will sustain your whole career; missing a large portion of it may put you at a disadvantage.

 

In the end, you will miss a few of the early milestones but will be reassured knowing that you will be available more in the future as an attending physician as your child grows older and is able to form memories of your time together. Plus, the days fly by as you are invigorated by your interesting days as a resident, while also knowing your life outside of the hospital is quite rich.

 

Your child will not suffer long-term consequences from you not being the one giving all the bottles during the day and tucking in for naps. You will be able to finish your training on time and have colleagues and program directors to help you cover the patients who need to be cared for in your absence.

 

The one person who may suffer a little bit is you. It’s hard to be away from your newborn while working 80 hours per week. So, why not wait until later to have a baby? Well, read on…

 

Yes, it is acceptable to plan your life and think about money

You may think this is backwards, but it actually makes more financial sense to have a child during residency than as an attending. I definitely don’t recommend finances to be the sole reason for having a baby during residency, but if you were thinking it didn’t make financial sense to do so, it may give you something to consider. We’re getting practical now. I personally didn’t factor in any of this when starting my family but realized the impact looking back.

 

You will be getting paid while on leave as a resident (covered through your accrued vacation time). You will have access to excellent health insurance coverage. It is not uncommon for your entire pregnancy and delivery to be covered by a $20 copay as a resident. Don’t expect this as an attending; if you aren’t seeing patients, you aren’t getting paid. It may also be difficult to find enough colleagues to help you cover your patients if you are in private practice. Most large employers will have some type of leave policy, but few will pay your salary while out.

 

As an attending I was able to take 12 weeks of leave, but it was unpaid. If you evaluate lost wages and earning potentials pragmatically, you actually come out far ahead by having a baby during residency. As an attending, you may be making 5x the amount of a resident, and 12 weeks unpaid leave is quite different than when a resident. When you don’t work as an attending, you don’t get paid. Why does this matter? Well, most of us right out of residency have six-figure medical school loans we need to repay as quickly as possible. Of course we don’t want money to be a factor in family planning, but sometimes it is, and it’s better to understand the consequences upfront.

 

The flip side to this is that, as an attending, you will have more income at your discretion. That income could provide a higher quality of childcare, and as mentioned earlier, help you enjoy more time with your newborn.

 

Why do we hate the term “advanced maternal age”?

 

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Lastly, but perhaps most importantly, is age. In a recent discussion with other physician moms, more than half had gone through costly infertility treatments to complete their families. Some spend close to $100,000 for these treatments. Most of us in medicine are very driven people, who enjoy the rigors and challenges of our careers. We work diligently to make it through to the “light at the end of the tunnel” once the 8+ years of medical education is complete. However, once we can finally start to focus on family, children, and an existence outside of the hospital, we may have lost more than realized.

 

Far too many women may have missed out on their prime years of fertility by putting off childbearing. By the time medical school and residency is complete, most of us are approaching 30; add on a few years if fellowship is considered.

 

While 30 years old is likely not an age-related fertility concern for most, if you plan to have more than one child, it definitely could be. Around age 35, fertility starts to decline. In addition, if you do get pregnant, you are considered “advanced maternal age.” There is a higher risk for gestational diabetes, hypertension, chromosomal abnormalities, and miscarriage. Suddenly, you may find yourself longing for a second child, a sibling for your growing toddler, or a much-anticipated first child, but the answer may not come so easily. Physicians are fortunate to have stable incomes that allow us the opportunity to seek fertility treatments when needed. Ultimately, you will likely be able to complete your family, but it may be a long, financially, and emotionally exhausting journey through fertility treatments – and not the route you expected.

 

What really matters most?

Ultimately, the decision whether or not to have a child is very personal, and not every female physician desires this. However, the majority of female physicians do eventually become mothers. Our lives may become busier, but the dedication to medicine and our patients does not waver from the act of having a child. In some ways, I became a better physician after my own childbirth experiences.

 

The right time to have a child will be different based on personal values, support systems in place, and emotional readiness. But, perhaps we can help each other by being honest and open about what it is like to have children during a medical career. This way we can each determine the right time to expand our family, independent of pressures and expectations from outside influences.

hospital birth, Parenting, Physician Training, Uncategorized

Mother’s Day on Labor and Delivery

Mother’s Day weekend is a great time to be the ob-gyn on call for deliveries at the hospital.  Of course, we physicians would love to be snuggled up next to our little ones on this special day.  However, the next best place to be is bedside with a woman about to become a first time mom.

The new mom is unaware how her life will change. Sure she has had countless advice from well-meaning friends and family. What diapers, breast pumps, sleep sacs, and toys are essential and how to handle the sleepless nights and messy house are all topics of endless conversations these days.

Labor stories abound and she has heard 50 different versions of what could happen during the process and how it didn’t always go the way it was expected.  Everyone has their own struggles and triumphs to share but most of the stories end with a healthy baby and a physically exhausted mom who may be hurting from delivery or surgical wounds but exhilarated in the way only a new mom can understand.

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Little does she know, she will never be the same person.  Her body will never be the same.  Her heart learns to expand to be able to love exponentially more with each child she has. Her needs now become secondary to those of another, and she will gladly have it this way.  She experiences life with a different view and understanding of others and thinks of random strangers as “someone’s son or daughter”.  She finally has a better appreciation for her own mother and understands her love in a much deeper way.  To help deliver her baby and be a very small part of this transformation is a unique gift.  Watching it unfold as her newborn is placed in her arms for the first time is one of the most gratifying experiences as an ob-gyn, and for a moment everything is blissful.

But there is also a different group of women that are sometimes forgotten on mother’s day.

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On Mother’s Day, many other patients are also on my mind.  The patients who have struggled with infertility for years. The patients who have suffered miscarriage, possibly multiple times. The patients who have lost an infant shortly after birth, or many years down the road. This day weighs especially heavy on them.  It forces them to deal with their hurt.  It resurfaces pain and brings memories to the front of their mind that are always lurking in the background. I have been on this journey with many of them.

While celebrating the wonderful women in my own life and the people who are getting to experience the world of motherhood for the first time, I stop to remember and include the women who are forever changed by the short life of a child, pregnancy that ended too soon, or the indescribable desire to become a mother.

 

hospital birth, Maternity Leave, Parenting, Physician Training

Open Letter to a Child of a Doctor: To My Daughter on Her 9th Birthday

It was the end of my 3rd year in ob-gyn residency.  I was 39 weeks pregnant with you and doing a hysterectomy, my gravid abdomen being utilized as an “extra hand” to displace the large clamp nicely to the side as I pressed my belly gently against the table. I was doing surgery all day and loved operating and feeling your occasional gentle movements when in the quiet operating room as I was working. I knew my days were limited with us being one. 

It was sometimes hard to breathe with the mask covering my face from the natural air hunger that can sometimes accompany pregnancy. I would have the OR nurse gently loosen my mask and take a deep breath.  Worried about you, I wanted to make sure you were getting enough oxygen.  After my last case was finished, it felt so good to drive home and rest sitting down after standing all day.  This was my favorite time of day as you moved the most on my way to and from work while I was still and I could concentrate on just you.

Later that same day I went into labor and your Dad drove us back to the same hospital where I was operating earlier that afternoon.  He was nervous but I knew you were safe and we had a long journey ahead of us.

When you finally made it into my arms 19 hours later I was exhausted and exhilarated all at the same time.  Looking at you, I finally understood what it meant to feel like your own heart was outside of your body. You were perfection and I didn’t know how I could make something so beautiful. I still feel that way.

I spent a precious 6 weeks at home with you but had to return to work and help other women bring their own miracles into the world.  I hoped you would grow to understand that I of course always wanted to be with you, but also felt a pull to continue my path as a doctor.

That first year was tough.  I was working 80 hours a week and there were some days when I only got to see you an hour a day, or when on call not at all. Those days were torture. You were often asleep for the night before I got home. There may have been more than one occasion when I sneakily scooped you out of your crib while you were still asleep and rocked you in the middle of the night so that I could have that precious time with you.  I knew you were well cared for during the day, and it was me who needed this snuggling more than you.  I missed you so much during those times.

It got better over the years as my work load became manageable and I got to feed you breakfast in the morning and dinner at night. We would play before bedtime and I could see that you were thriving and my guilt for leaving you during the day lessened.  Your pictures covered my desk at work and your smiling face was plastered all over my bulletin board along with the babies I have delivered.

After you were born, I was also changed as a doctor.  Delivering a baby wasn’t the same.  I empathized more with my patient in pain, begging for an epidural. I understood the fear before a C-section.  The first cry from a baby I delivered brought me back to hearing your first cry every time.  Unfortunately, the losses my patient’s experienced also hit me 5x harder as I felt their pain as only a parent could.  I think you made me a better doctor.

 I’m sorry I missed your field trips at school.  I so wanted to be there but work requires 6 month notice for a day off and schools don’t often understand this.  I’m sorry I would forget to send you in with crazy hair on “crazy hair day” or miss a deadline for a book fair.  I was doing the best I could juggling surgeries, being up all night at the hospital delivering babies, and seeing patients in the office all day. Despite all that, you were always in my thoughts.

I hope when you are older you will understand the sacrifices and more importantly how much I love you.  You will know a different mother than your much younger brother and sister.  You will remember me coming home in scrubs exhausted after a 30 hour call.  You will remember me leaving your soccer game early to go to the hospital to deliver a baby.

However, I also hope this will help you to see that you can do it too.  Maybe not a career in medicine, but whatever you want to do.  I could see you as an artist, singer, scientist, entrepreneur… the list goes on.  Knowing what a fantastic person you are turning out to be lets me know that it is possible to be a good doctor and also raise a wonderful child. To have a career and also give your children the love they need.  I am fortunate that I will have more time with you moving forward, and I am so happy for that, but I don’t regret our past.  It has made us both who we are today and I couldn’t be more proud.

hospital birth, Parenting, Physician Training

When Dads Cry During the Delivery

He is pacing. He is nervous. This is his first baby and he is scared to death. His wife is getting settled into the delivery room with fetal monitors being applied.  The nurse is asking health history questions in between her painful contractions and quickly places an IV and draws labs. The soon-to-be new Dad pretends to busy himself with setting up pillows and figuring out how to work the fold out chair that will serve as his bed if he can even consider sleeping at some point during the process.

I start to discuss the routine hospital consent for delivery.  We review the real risks of possible maternal injury: blood loss, infection, or need for surgery or other medical interventions.  We also talk about fetal risks.  He is listening attentively and his wife looks to him for reassurance before she signs the papers.  He gives a quick nod and places his hand on her back.  For a second he feels useful, she needs him to be her advocate and he is grateful to have this role.

We talk about the actual delivery and any preferences.  He looks a little squeamish when I ask him if he wants to cut the umbilical cord at delivery and he politely declines.

Over the next few hours an epidural is placed and the labor progresses quickly.  She is ready to begin pushing.  He stands by her side, holding her hand and applying a cool cloth to her forehead.   She is getting exhausted after over 2 hours of pushing and he is starting to fidget.  Concern is evident on his face as he keeps looking at my eyes behind my mask for reassurance.  I tell them both she is doing great.  Baby is fine.  All is well.

He is her protector, but presently is left feeling utterly helpless.  His entire life, and all things that ultimately matter to him in this world, are out of his control.  He starts pacing again, breathing a little more rapidly but keeping it together to appear calm for his wife.  She needs him to believe everything is fine. She needs him to be her rock at this moment. She grips his hand with all her strength and finally the baby delivers.  The umbilical cord is wrapped tightly around the baby’s neck twice.  I calmly ask the mother to stop pushing and untangle and quickly remove the cord from around the baby’s neck.  The rest of the baby’s body delivers and a small squeak emerges from the baby boy right before his loud bellowing cry.  The mother realized she has been holding her own breath while waiting to see if her baby is ok and she inhales deeply with relief, gratitude, and amazement at what just happened. 

I look over to Dad.  He is crying.  Actually sobbing.  The experience is like nothing he could ever have imagined. He clenches his wife’s hand so tightly that it turns white.  He kisses her sweaty forehead and leans his head into the crook of her neck.  His love for his wife and newborn baby is palpable.

My own eyes are welling with tears.  It is not lost on me the utter importance of this moment in their lives.  It also comforts me to know how much this baby will be loved.  I ask one more time if Dad would like to cut the umbilical cord, a second chance to take part in this tradition.  This time, Dad shakes his head yes.  He walks over and his trembling hands grab the scissors and cut through the surprisingly tough and gummy umbilical cord. I quietly complete my routine assessments of blood loss, deliver the placenta, and help to make sure Mom is now comfortable. 

Before parting, I give Mom a hug as we have become close over the past 9 months with frequent visits and I have come to know her very well.  I shake Dad’s hand and congratulate him one last time.  His eyes meet mine and he holds my grasp an extra second.  He doesn’t say an additional word but his unspoken gratitude speaks volumes to me.