September 27th, 2009 by Kenneth Trofatter, M.D., Ph.D. in Better Health Network, Health Tips
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The following recent query requested my opinion regarding the safety of metformin during the periconceptual period and throughout pregnancy. Although there are not many large or comprehensive studies addressing these concerns, the bulk of the data available to us is encouraging…
Dr. T,
Quick opinion if you don’t mind. As you may recall, I miscarried on 9/12. I have since seen my PCP for a regular check-up. He prescribed me Metformin….he believes based on my history, weight, blood work and family history, my body may have issues with the breakdown of sugars (i.e., type 2 diabetes but I’m not diagnosed with that). He said that it also may have some positive side effects for me including weight loss and assistance in helping me to conceive (although that doesn’t appear to be a problem since I WAS able to get pregnant even though I miscarried). He says it is completely safe.
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This post, Is It Safe To Use Metformin During Conception and Pregnancy?, was originally published on
Healthine.com by Kenneth Trofatter, M.D., Ph.D..
September 8th, 2009 by KerriSparling in Better Health Network, True Stories
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I did it.
I started my mission while we were on vacation in Barcelona, because between the time change and our eating schedule and the fact that sleep was a hot commodity, it was a good time to let go of the caffeine addiction. No real withdrawal, no extreme headaches, and no unrighteously sassy moments where I can’t function “WITHOUT MY CUP OF COFFEE DAMNIT!”
This is a big step for me, because coffee and I were buddies.
Bestest pals.
Friends all day long.
But now, I have a new pal. Someone who can still be part of the collection of stupid iPhotos that the editorial team snaps every few days. (These photos are known as the Friday Face-Off, where we take one photo to emulate, like this one (my version) or this one, and we all recreate it ourselves, then paste them together as a college. My favorite so far was when we all tried to look like my chubby-cheeked niece. But I’ve once again digressed. Ignore me.)
My new pal is decaf, and I have embraced the change. The coffee shop downstairs makes a mean iced decaf coffee, and just a short walk away from my office is a fabulous graham cracker flavored coffee that comes in delicious decaf. I am finally weaned off the caffeine, but I still get to enjoy the taste and the “coffee runs” that are part of the social routine in my office.
It’s nice to feel free.
It’s also nice to not drink so much coffee that my fingertips actually jitter to the point where I can’t type a sentence without mangling most of the words.
FutureBaby, I hope you appreciate this. Because it was HAAARD. But I know it was worth it.
*This blog post was originally published at Six Until Me.*
August 9th, 2009 by KerriSparling in Better Health Network, True Stories
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I stood there with my best friend as she rubbed her pregnant belly. The whole waiting room was filled with these lovely women and their round beachball bellies of varying sizes.
And I felt oddly self-conscious with my lack of roundness.
Last Friday was my first official appointment at the Joslin pregnancy clinic. It’s located at Beth Israel in Boston and is a beautiful hospital, different from the Joslin Clinic across the street that feels like home at this point. I’m not pregnant, and we aren’t trying to become pregnant YET, but this appointment puts things into full swing to bring me to a safe level of pre-pregnancy health.
Sigh. This all sounds redundant, even to me. I’ve talked the Big Talk before. “Oooh, look at me! I’m going to really wrangle in my numbers and have an A1C you can bounce a quarter off!” And I’m all gung-ho for a week or two, armed with my little log book and my good intentions, but within a few days, Other Things start to creep in. Like work. And stress. And getting to the gym. And social stuff, like hanging out with my friends and going to RI on weekends. Eventually my good intentions end up in the spin cycle, and my log book starts to gather dust. My workload piles up. And my stress levels skyrocket.
I’m so frustrated because I want to have a career. And I want to have a baby. (I’d also love some tight control of my diabetes, too.) These things would be excellent, but it feels like tightly managing type 1 diabetes is a full time job unto itself. Slacking off is easy, and frustrating, and not healthy for me or any baby I’d like to have.
But I also realize this is one of my biggest hurdles when it comes to pregnancy planning – the whole “sticking with the pre-program.” This becomes more and more obvious to me when I go back and re-read old blog posts where I’m so excited to get back into better control, only to be derailed by those Other Things. So during the course of my appointments on Friday with the endocrinologist, the registered dietician, and the certified diabetes educator, I admitted my faults freely.
“I need help being held accountable.”
They didn’t quite hear me at first. “We can do some tweaking, and in a month or two, we can revisit your A1C and see if it’s lower and then we can give you the green light for pregnancy.”
I knew I needed more than that. I had to be completely honest.
“Guys, I really need to be held accountable. I know this sounds crazy and I seem very compliant, but I have trouble following through. I’m great out of the gate, but I lose steam after a few weeks and I’m at the point where it isn’t good enough anymore. I’m out of excuses. And I’d really like to join the ranks of those pretty pregnant ladies out there. Please help me?”
And they listened. We spent the rest of the day working out a plan for me. One that will actually make a difference. One that will get me there.
I’ll be in Boston every three weeks until I’m pregnant. This is a huge commitment but I need to make diabetes a priority without fail. I want this. I want to succeed at this more than anything else. I’ll have my blood sugars logged for those three weeks and we (my husband and my diabetes team and I) will all review them together. Chris is in charge of my meals, in that he’ll be helping me plan my day, food-wise, and he’ll be counting carbs and measuring things for me. I’ll be eating relatively similar items every day so I can manage the trends and control them. I’ll continue to test all the live long day and wear the pump and the CGM, but I’ll actually use these devices to their fullest potential, instead of just going through the motions.
With these appointments spaced just a few weeks from one another, I hope I can stay tuned in to intense diabetes management for three week stints. Being sent out for three or four months is too much for me. Obviously, because I burn out well before my follow-up appointments. I just plain can’t pay rapt attention for that long. But three weeks? Can I do that?
I have to do that.
I will do that.
*This blog post was originally published at Six Until Me.*
June 23rd, 2009 by Gwenn Schurgin O'Keeffe, M.D. in Better Health Network, Opinion
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With health care reform being the talk of the week – a top priority for President Obama and for the AMA, who wants to be sure that America’s physicians are not just talked about in the reform process but included – I can’t help but wonder if the entire system will be reevaluated or if we will end up with just another band aid.
What worries me is that it’s not just the practical end of medicine that is broken. It is not just the billing end that is unhealthy. It’s not just the reimbursement and billing end that is broken. The overall culture of how we practice medicine is broken as well as the educational system in which and through which our next generation of physicians are being trained.
In this Spring’s issue of the Tufts University Medical School Alumni Magazine, my medical school Alma Mater, resident life style issues were at the core of their headline article. Reading the article, Pressure Drop, by Susan Clinton Martin, M.D., M.P.H, ’04, a pediatrics resident, I was at times propelled back in time to my pediatrics residency at the same institution in the early 1990’s have discussions with my adviser and residency director about whether I wanted to go part time. As I was in my junior year of my pediatrics’ residency and expecting my first child, this was not an easy decision to make and I had seen mixed results with other residents who had attempted this path before me.
In the end, I opted to not go part-time and for the reasons stated in the article for most residents not opting for this path:
1. longer length of overall residency
2. decreased pay and benefits (not ideal with a baby at home!)
3. resentment of colleagues for fear of extra work on their plates
4. lack of support of the program
The honest truth is all of these issues were at play back in the 90’s with me and my colleagues and still exist today. I opted to just forge ahead and deal with having a baby and being a full time resident. I don’t regret that decision. I had the support of some attending physicians and colleagues, friends, my husband and a wonderful nanny who a PICU (Pediatric Intensive Care Unit) Attending introduced me to. It wasn’t easy but is there ever a great time to have a baby in the medical profession? Let’s be honest – residency is one of the most challenging times for a physician and adding any stress to the plate makes it worse.
Balancing work and family is never easy for any career but particularly challenging as a doctor and incredibly challenging as a resident physician where you don’t control your time. Residency programs have rather rigid schedules and even the most thought through back up systems don’t accommodate the last minute life issues that can occur unexpectedly when you are a new parent and have a new baby at home. Residencies try to be reasonable when life issues emerge but it isn’t always easy and there is always some sort of “pay back”. Even when unexpected life issues emerge – daycare crises, infant illness, or a family crisis, it’s almost easier to find a way to get to your shift. That’s how intense the pressure is on you at the time. I recall seeing an Attending pregnant with her 3rd child in tears one day because some small issue had unraveled at home. I asked a mentor about it and she told me “You’ll see when your baby comes. Some days the pressure just gets to you. Just come talk to one of us. There are a few who understand and can help.”
Reading that Dr. Martin was brave enough to go part time was like seeing a rose among weeds. The benefit to her and her family was enormous. When working her “on” months, she can focus and feel less guilty, knowing her time with her family is coming. When she has her “off” months, she’s refreshed “emotionally accessible” to her family.
A recent study by Martin’s program director Dr. Robert Vinci showed that today’s medical students value part time options in residency programs, yet few residents are utilizing those options when they do exist and the majority of programs are still very traditional. According to the article, only 25% of US residencies have part time options with only 10% of residents in those programs utilizing the part time paths.
So, there’s a big disconnect in medical education between desire for better lifestyle and what is available, no different than what those of us who have completed our education and training have experienced within the health care system for years. While it’s discouraging that our caring profession doesn’t have a system that allows us to care for ourselves and our families, it’s encouraging that we are all finally speaking up that balance between work and home isn’t a frill but a necessity – even for physicians.
This is why it is so crucial that doctors at every level of today’s health care system not only have a voice in the health care system discussions under way but be the key players in crafting the new system. This is our career, our life’s work. We would never tell the Government how to do their jobs…what makes them think they call tell us how to do ours?
*This blog post was originally published at Dr. Gwenn Is In*
June 8th, 2009 by Dr. Val Jones in Health Policy, Opinion
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The abortion “issue” is such a hot topic that I have never written about it on this blog until today. I hope I won’t regret that decision but I felt it was appropriate to respond to this medical student’s essay – and the ~560+ comments that follow it – as a physician who has witnessed (but never performed) about 100 abortions. Let me explain.
During my Emergency Medicine training I was required to perform a certain number of intubations and abdominal ultrasound scans. My residency training program offered rotations in Ob/Gyn and at a local Planned Parenthood center. The senior residents told me that the best way to fulfill my intubation requirements was to assist with the Ob/Gyn OR procedures because the patients were young, healthy, and generally uncomplicated. At the time I was really excited by the opportunity to get the experience I needed – in as short a time as possible. I used to hang out in an Ob/Gyn operating room asking if I could assist the anesthesiologist with the intubations. Once they got to know and trust me, I could intubate about 6 patients in a day – an opportunity otherwise hard to come by as all the new anesthesiology residents were vying to practice intubation themselves.
One of the Ob/Gyns who used the OR (where I got my intubation experience) scheduled some abortions of fetuses that were at the border of viable – as old as 23 weeks. That made me quite uncomfortable, and I know that there were other staff (and several nurses) who refused to work with that physician. However, as squirmy as I felt, I thought it was important for me to see first hand what the procedure entailed… because otherwise I’d have to rely on anecdotes and second-hand opinions to draw my own conclusions. I wanted to see this for myself.
I’ll never forget the day I witnessed the first late-ish term abortion. I was preparing my intubation equipment – fidgeting with the Mac size 4 blade, making sure the light worked, when the physician brought the patient into the room on a gurney. The woman’s abdomen was very pregnant, and the Ob/Gyn was stroking her hair and whispering reassuring things to her. The anesthesiologist made small talk with the patient, explaining the nuts and bolts of the anesthesia – the oxygen mask – the propofol – the intubation. I stayed out of the patient’s line of sight and allowed the Ob/Gyn and her resident to spend some final moments with her. The scene was both tense, and yet supportive of the patient.
I initiated rapid sequence intubation with the assistance of the anesthesiologist, and then moved to get the ultrasound machine to visualize the uterus and its contents. Much to my discomfort the fetus was fairly large – and was moving around normally, even sucking its thumb at one point. I asked the Ob/Gyn resident why the fetus was being aborted since it didn’t appear to have any structural abnormalities. She responded that the mother simply didn’t want to have the baby, and had wrestled with the idea of abortion for a long time before she made her final decision.
The rest of the procedure is a bit of a blur – with details too graphic to describe here. But suffice it to say that the resident performing the dilatation and curettage had a fairly difficult time removing the fetus through the cervix, and had to resort to eliminating it in smaller parts, rather than a whole. It was very sad and it took a long time to make sure that the uterus was fully evacuated. I decided that I couldn’t watch another one of these procedures.
The rest of my female abdominal ultrasound experience was obtained at a Planned Parenthood center where very early abortions were performed. Generally, this consisted of suctioning out a tiny yolk sac (and “products of conception”) – without much of a recognizable fetus in the midst. Although these procedures were certainly emotional, they were somewhat less troubling than the later term dilatation and curettage.
What I didn’t expect, however, was that of the approximately 100 abortions I witnessed – none (to my knowledge) of the women requesting them were rape victims, nor was there a life-threatening birth defect in the fetus. Usually the reason they gave was psychological, emotional, or financial – “I just can’t afford to raise a child” or “This is not a good time for me to be pregnant” or “I don’t want this baby” or “I don’t want another baby” or “This was an accident, and I don’t want it to ruin my life.”
I did my very best to adopt an attitude much like the one that the author of the Washington Post article did – “It’s not for me to judge the validity of someone else’s reasons for wanting an abortion… They’re going to do it anyway so physicians need to make sure they’re safe… Women have the right to choose…”
But the reality was that those attitudes didn’t prepare me for the emotional turmoil inherent in the process of abortion. It’s sadder than I thought, more difficult than I thought… and the impact is farther reaching than I imagined. Studies estimate that about 1/3 of US women have an abortion at some point in their lives – that’s a heavy emotional burden that many women carry in silence.
In my opinion women should have the right to choose to have an abortion, but I’d hope that they also consider their right to choose to give their baby up for adoption as well. Some believe that an abortion is “easier” than giving up a baby for adoption – but I’m not so sure that’s the case from an emotional perspective. As far as rape victims or women who are carrying a moribund fetus – the decision to abort may well be emotionally less damaging. But for the majority of women who have abortions for less clear reasons (reasons like the ones I witnessed), I’d really encourage them to consider adoption as an option. Obviously, these decisions are intensely personal and have to be made on a case-by-case basis – and women should be supported either way.
As scientific and rational as I wanted to be about the procedure, I am still troubled by what I experienced as a witness to various abortions. Though I might have “entered the abortion conversation” as the third-year medical student did – after witnessing quite a few, I have a deeper appreciation for the emotional complexity of abortion, and a desire to help women avoid them if at all possible. I wonder if the author of the Washington Post article will change her perspective after she’s witnessed a few of the procedures?
