I am seeing patients again. My partners are slowing phasing into maternity leave. This week I’m seeing patients from 7am to 6pm and then rounding at the hospital. For the next seven days I am the on call Ob-Gyn, the last three days of the seven I am covering the ER as well. This hell schedule was only to meant to last for a week. But Covid is once again taking off here in Alberta and we are down two doctors so I am in week two of utter exhaustion. Today is day 13 or 14. I am not sure.
I stupidly had my bivalent Covid shot 12 days ago today. Not good planning. I had a spectacular reaction which made last week more about aching and less about doctoring.
Currently, I am sitting at the front desk in admitting trying to decide if I am going to go home and sleep or drink 5 or 6 cups of coffee and stay up all night. I have a patient who is here on bed rest and not due for a week but I just bet the charge nurse in the maternity ward $20 that the patient will go into labor tonight. That is a guess but it is a very high risk pregnancy and with experience you start to see patterns.
I am having a run of obstetric and gynecological emergencies. I am choosing to accentuate the positive and am thinking at least I am two thirds of the way through the crisis. I am also finding joy in the odd little things that keep coming up during my work day. I am practicing mindfulness.
I will be thinking about my first patient of the day for a long time to come. Jolie and I have an easy rapport. She gave me permission to use her name and tell her story but I have opted to alter her name but stick to the exact details of what she told me.
We are on the same swim team. Jolie is a near world class free styler and I am the world’s slowest distance swimmer. We spend a lot of time swimming together as she passes me over and over again. Every 25 meters I swim she passes me twice. If she is really pushing it she passes me 3 times. She is my wake machine.
Jolie wants me to take her IUD out. The removal can be done in the office but I have had two previous near disasters with Jolie. So we both think she needs a hysteroscopy. If you are unfamiliar with this procedure Jolie will be under anesthesia and I will widen her cervix and insert a hysteroscope into the uterus. This allows me to see what I am doing and insert instruments. With Jolie the two previous procedures have taken me over 30 minutes instead of the five to ten that is normal. The IUDs form adhesions with her uterine wall.
When I asked Jolie why she wants the Mirena, which is a hormonal IUD, out after only 3 of the 5 years it should last she asked me, “what is wrong with boys?” I so wanted to respond with, “what isn’t?” But I restrained myself.
”All boys want is to hook up. I want to find a guy I can have a relationship with. You know date, have sex, travel, have sex, shack up with, have sex with all the time, have a baby, never have sex again.”
”I seem to remember helping your mom have two healthy baby boys after she had you.”
”I know you can’t say it because she is your patient but I am aware my parents have a very active sex live, even after having the three of us. But there aren’t any guys like my Dad out there, or like Jim Bob.” My son in law, married to my oldest daughter, is 29 years into his marriage and still in the honeymoon stage. He is Jolie’s Godfather, her Dad Alvin’s best friend.
Alvin and Jim Bob are hybrid men. Out in the world they are really manly men. In private, even with each other they are funny, supportive, kind, and goofy. They have very high emotional intelligence.
”I decided I am best off to just go ahead and have my kids now while I am young.”
”You’ve met somebody?” I asked.
”No. I want to do artificial insemination,” Jolie said.
Now what do you say to that? “None of the guys I am meeting would be worth shit as Fathers. They would just be another baby for me to look after.”
Right in that moment I was very defensive of my gender. But none of those thoughts escaped my lips. I was quite surprised by what I actually did say. When I am this tired I often have the feeling I am watching myself from outside my body.
“Look at the burnout among Obstetricians, Gynecologists, and Pediatricians during the pandemic,” I said. “Emergency and Critical Care Doctors had the highest burnout rates but Ob-Gyns and Pediatricians were close behind. Want to guess why?”
Jolie thought for about ten seconds and then asked, “what percentage of Ob-Gyns and Pediatricians are women?
“85% and 73%.”
”I bet they worked a lot of extra hours during the height of the pandemic, teaching their kids at home, looking after their parents. While their boyfriends and husbands did fuck all,” Jolie guessed.
”You got it. More than 8 hours a week for doctors with some of the highest hours and the most erratic hours of any speciality.”
I was torn. I wanted to urge Jolie to give flesh and blood men another chance. But she wasn’t asking for advice. She wanted her IUD out and to know if I would do the Artificial Insemination. So I am taking out her IUD and helping her get pregnant using donor sperm. Her mother is going to kill me.
As I was walking Jolie out there was another young women sitting in the waiting room. She looked lost and alone. A tiny child. Then she stood up walked toward me. That is when I noticed the Vanderbilt University jacket. My heart skipped a beat.
The little girl walked up to me, hit me with a 1,000 watt smile and said, “I was wondering if I could start work early.”
Dr. Elfesya Ahmadi is our newest partner. A not pregnant one. She recruited herself. She just phoned up one day and asked if we were looking for additional partners. Until August 25th, Elfesya (which means fairy Princess) was scheduled to join a practice in Nashville, Tennessee September 1st. Then all abortions were banned in Tennessee. September 10th, she found us.
It wasn’t all that surprising she knew about us I guess. She was born and raised less than 45 minutes from here. Then she went to Vanderbilt on a track and cross country scholarship. But she did med school in Edmonton where her parents now live. Then she matched with Vanderbilt for her residency. Elfesya is from an Iranian Kurdish family. She really wanted to be part of something new, building a new practice, a new kind of practice. But she couldn’t survive Tennessee’s idiotic total ban on abortions.
There is already a shortage of Ob-Gyns in America. The shortage isn’t trivial. America needs 10,000 more Ob-Gyns. Well, that was before Dobbs. It is 20th on the list of highest paid specialities and can have horrible hours. The average retirement age is 59 because delivering babies is such a demanding career. The average age of Obstetrician-Gynecologists in the United States is around 51.
In the United States in regions where large numbers of pregnant women are on Medicaid or uninsured Ob-Gyns are older, more are male, and income levels are much lower versus areas where most pregnant women are insured. In these areas the Ob-Gyns are younger, far more are women, and incomes are higher. It is estimated that the Northeastern US has 179% of the needed Ob-Gyns. Meanwhile well over half of all counties in the United States have no Obstetrician-Gynecologists at all.
Not only is there a shortage of Ob-Gyns but resistance from doctors and healthcare administrators has prevented the wide spread use of Midwifes and Nurse Practitioners in Obstetrics. In Canada it is very different. In so many ways.
First, the average Canadian Obstetrician delivers far more babies than her American counterpart. The highest state average in the United States is 192 babies in a year. In Canada it is 325.
Secondly, the typical family doctor delivers about 40 babies a year, Midwifes and Nurse Practitioners do another 80. They also assist with most of the deliveries done by Obstetricians. I work with a team as do most Canadian Ob-Gyns.
Third, I get paid to provide prenatal care, postnatal care, and well baby and toddler clinics. I also have gotten paid to take additional training in treating the health problems of peri menopausal and menopausal women. I am paid well enough I can take as long with each patient as I like, or at least I can when I am not covering three practices by myself.
I will say this, Elfesya jumped right in and started seeing patients. Tonight she is sleeping here in the hospital, available to deal with emergencies. She insisted. Then while she looks for a place to live she will stay with Gabby, Butch, and I. Patients are already calling her Dr. Elf. She suggested it knowing all the doctors here use a diminutive of their first names to help us build rapport and trust with our patients.
Elfesya is the tip of a very large iceberg. What forced her out of Tennessee, the final straw, was learning what her new insurance premiums were going to be post August 25th, 2022. In the US insurance premiums for Obstetrician-Gynecologists were already high but post Dobbs the insurance companies had to change their actuarial tables and include a new risk premium and that premium is much higher in places like Tennessee. She couldn’t pay that premium, her student debt payments, rent a small apartment and still eat.
Their loss, our gain. But I keep thinking that there is an entire generation of young women (younger millennials and Gen Z) who may have no access to an Obstetrician-Gynecologist at all. I really hope Republicans get there heads out of their butts and let Ob-Gyns do their jobs. But I am not holding my breath.