Race, Racism, and Medicine: Featuring @TheBlackOBGYNProject

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Today we’re thrilled to welcome to the show two folks in the #FOAMed #FOAMob space we admire greatly: Dr. Tamandra Morgan, a current PGY-2 in OB/GYN at UCSF; and Dr. Rachel Berell, who did her intern year in OB/GYN at UC-Irvine and is continuing her training in family medicine, with a focus on obstetrics and public health, at Boston Medical Center.

Together, they run the Instagram page @TheBlackObGynProject, which at the time of our recording has 16,700+ followers. They have created this as a space dedicated to educating and promoting anti-racism, equity, and inclusion within OB/GYN, women’s health, and reproductive health care.

We had a lovely interview with them about their work and their experiences.

The Black OB/GYN Project: Learning, Celebrating, Advocating, Healing.

On their Instagram, they have remarkably well-referenced posts about various instances of racism in the history of medicine, as well as how racism and other biases continue to be a factor today.

The Black OB/Gyn Project, 9/17/20

The Black OB/Gyn Project, 9/17/20

The Black OB/Gyn Project, 9/17/20

The Black OB/Gyn Project, 9/17/20

On the show, we mention in particular their September 17, 2020 post on the history of racism in obstetrics and gynecology as an excellent primer to the troubled past of our specialty and its link to today. Other posts include more history of the legacy of James Marion Sims and the impact of racism on postpartum care and hypertension, in particular.

The Black OB/GYN Project, 12/31/20

The Black OB/GYN Project, 12/31/20

The Black OB/GYN Project also celebrates Black lives, past and present, and provides a mentoring and celebratory space for folks in the BIPOC community.

And if that weren’t enough, they have provided exhaustive resources on allyship and antiracism, including choices for books and movies. Be sure to check out their posts from 6/4/20, 8/2/20, 9/11/20, and 10/26/20 for their recommendations to date.

The Black OB/GYN Project, 8/2/20

The Black OB/GYN Project, 8/2/20

Finally, from the podcast, Tamandra and Rachel share some thoughts for a personal plan to grow as an antiracist:

  • LEARN: read, watch, listen, and immerse yourself in the history and the present of injustice towards Black / non-white lives and bodies.

  • PRACTICE: anti-racism daily. It’s not an overnight thing! Be aware of your language, your preconceived notions, and even the patterns of thought you were trained to use becoming a doctor in order to recognize when race plays an inappropriate role in your own work.

  • BE CRITICAL: look at the scientific literature as you grow as an anti-racist, and ask when race is used as a variable why it was used, how it was obtained, and what significance (if any) racism may have in the true, interpretable results.

    • After our podcast, a phenomenal blog post/paper in Health Affairs was published, demonstrating a complete lack of focus on racism in the major journals over the last 30 years, while there was plenty to say on “racial differences.”

  • ADVOCATE: find opportunities locally, regionally, and nationally to bring the best care for your patients of color, and the best treatment for your colleagues of color. Attention has been brought towards the VBAC calculator and the impact of race, for instance. There are many other opportunities where work needs to be done, including in genetic screening and testing, gynecologic surgery, abortion care, and infertility.

Informed Consent

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What is informed consent and shared decision making? 

Informed consent is a part of both medical ethics and law (though exact wording and definition may vary based on locality). It entails that a medical provider must tell a patient about all potential benefits, risks, alternatives, etc to a medical procedure or course of treatment.

In order to be able to obtain informed consent, we need a few things:

  • Patient who is able to give consent 

  • Presentation of accurate information that includes: 

    • Diagnosis (if it is known) 

    • Nature and purpose of the recommended interventions 

    • The risks, benefits, and alternatives of all options 

  • Documentation of the conversion and the ultimate decision 

Shared decision making is similar, and is also a key component of patient-centered healthcare. It is a process in which clinicians and patients work together to make decisions, selection treatments, that is based both on evidence and balances risks/benefits and patient values 

  • It is not a menu of everything that is available!

Some special situations:

  • Patient that lacks decision-making capacity

    1. Any physician can determine if a patient has capacity!

    2. A brief aside on capacity/competency:

      1. Capacity: a person’s ability to use information they are given and make a choice that is congruent with their own choices and preferences. Law and ethics have settled on four decision-making abilities that constitute it, which are:

        1. Understanding

        2. Expressing a choice

        3. Appreciation

        4. Reasoning.

      2. Competency: a legal judgement that is informed by an assessment of capacity. Basically, whether an individual has the legal right to make their own decisions.

    3.  Times to assess capacity:

      1. Presence of cognitive impairment from any cause.

      2. Circumstance where patient’s decision is inconsistent with prior decision.

    4. How to assess capacity:

      1. Should be done with open-ended questions to basically understand if patient has understanding, expressing a choice, appreciation (recognizing facts and how they are relevant to themselves), and reasoning for their decision 

      2.  There are a few validated instruments out there:

        1. MacArthur Competency Assessment Tool for Treatment 

        2. Assessment of Capacity for Everyday Decisions

        3. Capacity to Consent to Treatment Interview 

    5. Even if the patient is not deemed to have adequate capacity, they should still be engaged in their care as much as possible!

      1. Identify an appropriate surrogate on the patient’s behalf - either through durable power of attorney or through family members.

      2. Sometimes, if there is question to capacity or to a surrogate, or any other questions, may be a reason to consult an ethics board. 

  • Minors

    1. Not considered to have capacity to make healthcare decisions on their own except for a few cases. This varies by situation and by state.

      1. Minors who become pregnant in some states can be considered capable of making their own decisions regarding their care (ie. abortion, epidurals, etc).

    2. Emancipated minors may make their own healthcare decisions in most jursidictions.

  •  Situation that does not require informed consent

    1. Usually: 

      1. Emergency - person is unconscious or in danger of death or serious outcomes (loss of limb) if medical care is not given, then informed consent may not be required 

      2. If there is an advanced directive stating that patient refuses certain types of care 

      3. If there is decision by a court that overrides the patient’s decision 

Hidradenitis Suppuritiva

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  • Admittedly we are not dermatologists… but hydradenitis suppuritiva (HS) affects a substantial number of our patients and because of the locations it affects, OB/GYNs are often the first to see it.

What is HS?

  • Chronic, recurrent inflammatory disease of apocrine sweat glands

    • Also known as acne inversa 

    • Located usually in axillae, groin, genitals, perineal, buttocks, and inframammary areas 

    • Women tend to be more affected than men  

  • Prevalence 

    • 1%-4%, onset usually between puberty - 40 years of age, usually in second or third decade of life 

  • Why do we care?

    • Can cause significant pain, issues with scarring 

    • May have huge impact on self-esteem and quality of life can be severe, thus importance of early diagnosis and treatment 

    • Very rarely, squamous cell carcinomas develop within sites of HS 

How do we recognize it and diagnose it? 

JAAD 5/2020

Pathogenesis 

  • Follicular occlusion is most likely the even that is responsible for the initial development of HS lesions; may be due to ductal keratinocyte proliferation  → hyperkeratosis and plugging 

  • There is then follicular rupture → formation of sinus tracts

  • Associated factors

    • Genetics

    • Mechanical stress (ie. pressure, friction, etc.),

    • Obesity (maybe...but it’s also present in those without obesity),

    • Smoking (strong correlation; majority of affected patients are smokers),

    • Hormones (some people may experience perimenstrual flares)  

  • History and Physical exam 

    • Typical lesions, typical locations, relapses and chronicity 

    • Inflammatory nodules - first lesion is single, painful, deep-seated inflamed nodule in the intertriginous area; diagnosis is usually missed at his stage; can be diagnosed as a “boil” or furunculosis 

      • After some time, the nodule can progress to form an abscess → may open to skin surface spontaneously 

      • Pain usually improves after drainage 

    • Sinus tracts - skin tunnels; can happen if HS is persistent for months or years; can release blood-stained, seropurulent, malodorous discharge periodically 

    • Comedones - can appear with longstanding HS 

    • Scarring - healed areas can have individual, pitted, acneiform scars; may be atrophic or keloidal 

  • Lab studies - usually not needed, but if you’re uncertain, can do skin biopsy → r/o squamous cell carcinoma 

  • Differential Diagnosis 

    • Folliculitis, acne vulgaris, pilonidal disease, Crohn disease 

Stage II disease — image courtesy of Wikimedia commons.

Stage II disease — image courtesy of Wikimedia commons.

Stage III disease with active infection ongoing -- image courtesy of Wikimedia Commons.

Stage III disease with active infection ongoing -- image courtesy of Wikimedia Commons.

What is the Hurley Staging System? - divides patients with HS into three disease severity groups:

  • Stage I: Abscess formation (single or multiple) without sinus tracts and cicatrization/scarring 

  • Stage II: Recurrent abscesses with sinuses tracts and scarring, single or multiple widely separated lesions 

  • Stage III: Diffuse or almost diffuse involvement, or multiple interconnected sinus tracts and abscesses across the entire area.

How do we manage HS, and when should we refer out? 

  • Goals

    • Reduce formation of new areas, sinus tracts, and scarring 

    • Treat existing lesions and reduce symptoms 

    • Minimize psychological morbidity 

  • For all patients 

    • Education, psychological support if needed - it’s a chronic disease, not due to poor hygiene. Course can vary from person to person 

    • Wound and skin care techniques 

    • Pain management - NSAIDS usually, but discuss opioid analgesia if needed 

    • Treat associated symptoms and conditions 

    • Encourage smoking cessation if they smoke 

  • Stage I - Aim is to reduce burden of disease  

    • Topical clindamycin - can reduce inflammatory lesions; usually applied 2x/day 

    • If fail topical therapy → oral therapy

      • Oral tetracyclines: 100 mg doxycycline daily or BID

        • If oral antibiotic therapy achieves good disease control, patients can stop and continue with topical clindamycin for maintenance

      • Antiandrogenic agents - spironolactone and finasteride; can be used, but they should NOT be given if there is possibility patient is pregnant  

      • Oral contraceptives - very small study that showed some improvement 

      • Metformin - can help promote weight loss, which can help HS

    • For acute symptomatic lesions - warm compress 

      • May want to refer out for this: possibility of intralesional corticosteroid injections 

      • Unroofing the area over the nodule 

      • I&D - not advised for routine treatment. It can lead to immediate relief, but can promote lesion recurrence and scarring 

  • Stage II and III - Can try everything above, but if not working, usually this is when we would say you should refer out for other treatments 

    • If they don’t achieve good control with antibiotics, metformin or antiandrogenic therapy, may require oral retinoids, dapsone and biologics 

      • We’ll mention some, but we won’t go into detail, since we don’t really do this stuff as Ob/Gyns 

    • Oral retinoids - may only have limited benefit 

    • Oral dapsone - sulfone drug with immunomodulatory and antibacterial properties 

    • Adalimumab - FDA approved treatment for moderate to severe HS 

    • Acute symptomatic lesions: oral glucocorticoids may also be used 

    • For severe, refractory disease 

      • Wide excision - extensive surgical intervention can get to greatest likelihood for resolution of active inflammation, but can be disfiguring and involve a prolonged recovery time.

Espresso: Local Anesthetic Systemic Toxicity (LAST)

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In follow up to last week’s episode, this week we have a quick episode on local anesthetic systemic toxicity (LAST), a classic CREOG question.

First, a bit about how local anesthetics work:

  • Medications like lidocaine reversibly block sodium channels → these meds vary in lipid solubility, potency, time to onset, and duration of activity.

  • You can imagine that some of these medications will be absorbed systemically, especially if you inject it directly into a blood vessel, and can go to other places in the body and block sodium channels in far away places.

    • Organs that we generally care about in this sense are the CNS and the heart.

    • The CNS is more sensitive than the heart to effects of local anesthetics, so will generally manifest signs/symptoms of toxicity first.

To prevent systemic toxicity, there is a max dose for various forms of local anesthetics. If injected with epinephrine, these doses are higher due to epinephrine’s vasoconstriction activity (thus preventing systemic absorption by constricting local blood vessels):

ACOG PB 209

  • Effect on CNS system 

    • Initial = Tinnitus, blurred vision, dizziness, circumoral numbness

    • After can have nervousness, agitation, muscle twitching due to blockage of inhibitory pathways → seizures 

    • You can also have CNS depression like slurred speech, drowsiness, unconsciousness, and even respiratory arrest  

  • Effect on CV system

    • Local anesthetics can block fast sodium channels in the Purkinje fibers of the heart → decreased rate of depolarization 

    • Can lead to prolonged PR intervals and widened QRS complexes 

    • Can lead to sinus bradycardia or even ventricular arrhythmias, especially with bupivacaine 

  • Treatment

    • Stop injecting the local anesthetic!

    • Call for help - definitely call your anesthesia colleagues.

      • Also alert cardiopulmonary bypass team because resuscitation may be prolonged.

      • Some hospitals may have a LAST rescue kit.

    • Airway management - ventilate, and get advanced airway device if necessary 

    • Control seizures 

      • Benzodiazepines preferred 

      • Avoid large doses of propofol 

    • Treat hypotension and bradycardia - if pulseless, start CPR 

    • Give lipid emulsion therapy - lipid emulsion 20% 

      • If >70kg, bolus 100 mL Lipid emulsion over 2-3 min, then 200-250mL over 15-20 minutes 

      • If <70kg, bolus 1.5 ml/kg lipid emulsion over 2-3 min, then 0.25ml/kg/min of ideal body weight 

    • Continue monitoring - at least 4-6 hours after a cardiovascular event or at least 2 hours after a limited CNS event.

COVID-19 for the OB/GYN

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Today’s episode is an audio summary of the CDC and SMFM guidelines for COVID-19, focusing on the virus, identification, containment, and considerations for pregnancy and postpartum care. We do not explore treatments or any intricacies in either outpatient or inpatient care.

Rather than posting those guidelines here verbatim, we have gone through and identified a lot of reputable sources with factual, up-to-date information for healthcare providers:

We also mention in the episode a registry being established for pregnant patients with COVID-19. Please listen to learn more about how you can be involved.