On The Criticism of Papers We Don’t Agree With, and How Endometriosis is More Common Than Many Doctors Think
As academics, we are all about evidence based medicine. We practice 100% based on what we read, and often change our method of practice when new evidence comes out that shows us the right path. Right?
Of course not…. In reality, most of us slowly integrate new data into our practice over many years, and only when there is a preponderance of evidence do we really change from what we previously thought was right. Until that time, we hold up the papers we like and attack the methodologies of papers we don’t.
Today a bill passed the Oklahoma State House making it a felony for a physician to perform an abortion. Are you serious?
I assume that the governor will veto this bill. At least I hope she does. Because when she was sworn in as governor, despite being a conservative, she swore to uphold the constitution the United States of America. And I have never seen an anti-abortion bill so obviously unconstitutional. Roe V Wade protected women from laws that made abortion unduly difficult to obtain, and putting doctors in jail for doing an abortion certainly fits that description.
It saddens me that states continue to pass laws that don’t even pass the sniff test for unconstitutionality. It means that the legislators in the state have completely abdicated their responsibility towards our country. Even the most anti-abortion legislator should stand up and say ‘sounds good to me, but since this is obviously against our country’s constitution, I am voting no’. Instead they jam up the legislature and the judicial system with challenges, and eventually the law gets ruled out by the courts.
Can’t we just skip that step? I’d love to see a system where a state is punished for passing a law that is obviously unconstitutional. The court system could decide when that has happened, and do something bad to the state. Maybe the governor gets a dock in pay, or has to pay for the court costs out of their own pocket.
Want to make abortion illegal in this country? You suck, for the first thing. But after you finished sucking, then you have to get to the business of amending the Constitution of the United States. And given than 1 in 3 women in this country has had an abortion in their life, and it remains the most common procedure performed for humans on the planet, I think you’re going to have a hard time getting that one through. And until you do, stop trying to get around that requirement by passing bills that are just going to get reversed. Its a waste of this country’s time. Worse, its black mark on our entire society that so many people care so little about a woman’s right to control what happens in her own body. Shiver me timbers.
I am happy to announce a new partnership with a great new sponsor, TrueLearn. TrueLearn is a web based platform for learning material to improve performance on standardized medical exams, with platforms for specific specialties as well as general medical boards. In OB/GYN TrueLearn offers question banks for CREOGS, ABOG boards, as well as general OB/GYN question banks. In each case, the online questions exactly simulate the computer environment you will see when you actually take the test as well.
TrueLearn also allows you to track your performance over time, as well as compare you performance to other doctors and students preparing for the same exam, both on a global level and specific to each question. It’s a great too that will no doubt be of tremendous use to the thousands of students and physicians who take OB/GYN related exams each year.
Each month, we will be doing TrueLearn Question of the Month, both on the blog and on the soon to relaunch Academic OB/GYN Podcast.
Academic OB/GYN readers and listeners can also get a 10% discount on the product by using the promo code “ACADEMICOBGYN” when they order.
This month’s question, from the CREOG Test Bank:
A 24 year old G4P2012 Jehova’s Witness and is undergoing emergent cesarean hysterectomy secondary to hemorrhage. She clearly stated prior to the procedure her refusal of foreign blood products. Despite receiving 2 liters of lactated ringers, her pulse has increased to 155 bpm and blood pressure is 60/40 mmHg. The cell saver is unavailable and she is losing consciousness. Which of the following is the MOST appropriate infusion for this patient to receive?
- Fresh Frozen Plasma
- Packed red blood cells
I recently was looking into whether or not you should place a paracervical block before placing an intrauterine device, after a particular patient had a difficult time with a placement. Over my career, I generally haven’t done so, as the vast majority of patients don’t seem to have a significant amount of pain, and the literature I have read has not been very supportive of the practice.
Today I looked at the literature again, and was a little irritated at what I found. One particular study was Mody et al, which concluded “Compared with no anesthetic, a 1% lidocaine paracervical block did not result in a statistically significant decrease in perceived pain with IUD insertion.”
So clearly most would read this and say that it doesn’t matter if you put in a paracervical block or not.
But’s here’s the kicker; the summary of their data is the following: ” Twenty-six women received the paracervical block before IUD insertion, and 24 received no local anesthesia. Groups were similar in age, parity, ethnicity, education and complications. Women who received the paracervical block reported a median VAS score of 24.0 mm with IUD insertion, and women who did not receive local anesthetic reported a median VAS score of 62.0 mm with IUD insertion; p=.09.”
So patients who got a block had pain of 2 on a scale of 2 to 10, and patinets who did not have a block had pain of 6 on the same scale. So did the paracervical block really not work?
I would say it did. What didn’t work was the study, or at least most likely so. The p value, or likelihood that the outcome was do to statistical chance alone, was 0.09. In translation, there was a 9% chance that the difference between the groups was due to chance alone, and a 91% chance that it was due to an actual effect of the paracervical block. Since we arbitrarily say that a p of 0.05 is statistically significant, the authors say that the study was negative.
But isn’t this quite misleading? It is 10 to 1 likely that the paracervical block actually made the procedure less painful, and we just didn’t reach a p of < 0.05 because there weren’t enough patients in the study to adequately separate the groups mathematically (lack of power).
P values are important, but we can’t consider them to be everything. Statistical significance is a continuous variable, not a nominal one. If we say that p=0.049 means that the study shows a difference and p=0.051 means there was no difference, we are just being foolish, and in the end quite ignorant of the actual mathematics that goes into how the p value was created.
Here’s how I would like to see such a study concluded : “Compared with no anesthetic, a 1% lidocaine paracervical block showed a strong trend towards decreasing pain with IUD insertion, that did not reach statistical significance. Further study with a greater number of patients is warranted.”
If you read their conclusion, you would probably take from that that paracervical blocks don’t work. But if you read mine, you take a different message, which is actually supported by the data, which would be “It is very likely that paracervical blocks decrease pain with IUD insertion”, which of course makes sense
Mody SK; Kiley J; Rademaker A; Gawron L; Stika C; Hammon C. Pain control for intrauterine device insertion: a randomized trial of 1% lidocaine paracervical block. Contraception. 2012; 86(6): 704-9.
This video demonstrates and discussed technique for performance of a supracervical hysterectomy in a massive fibroid uterus, 2 kilograms in size. This procedure was performed in the Pearl Surgicenter in Portland, OR by Drs. Nicholas Fogelson and Richard Rosenfield.
Please call us at 503-771-1883 for clinical consultation for any gynecologic concern, including complex laparoscopy as well as complex endometriosis management.
As many of my readers know, I spend a fair amount of time online. I love interacting with other docs that do what I do, and even more so, I love interacting with women that have the conditions that I treat. Even though I have left academics, I am a teacher at heart, and enjoy the opportunity to pass on what I have learned when I can.
One of the biggest questions I see is about how endometriosis care is paid for.
Unlike typical care, many endometriosis physicians are not under contract with insurers for care. This creates a whole different system for payment of medical care that is confusing to many patients – so let me explain it here. Read more…
Recently I read an article by Lena Dunham, describing her life with endometriosis, treatment she has undergone, and how her life has been since. Its a very poignant article about a successful woman who has been held back by her condition, yet also a story of incredible perseverance despite tremendous barriers. Ms Dunham is a successful actress, producer, writer, and director, having created multiple films and the wildly successful (and awesome!) HBO series Girls, both as writer/director/producer and as principal actress. She is also a woman who did these things despite tremendous pain from endometriosis.