This is my first week on the gynecological service within the OB/GYN rotation. To most people, gynecology means awkward, invasive exams every couple years (either for yourself, or someone close to you). We do have one week on clinic that's something like that, but the bulk of our inpatient gynecological experience turns out to actually be managing patients before, during, and after gynecological surgeries and other procedures. In just my first two days on the team, I've spent nearly 5 hours in the OR. In my opinion, this is significantly more fun than fumbling with a speculum and warning that "you might feel some pressure."
That being said, even on day-one I ran into some of the more ethically complicated aspects of this field. My first observed procedure was an elective abortion. We are always given the option to opt out of these types of procedures if it would make us uncomfortable and I respect those classmates that do just that. But the way I look at it for myself, I'm here to learn and I'm not squeamish about graphic surgeries, so, in what might be one of the only chances in my career to get this experience, I wanted to see what it really means to be a pro-choice OB/GYN doctor. I think that's as far into this topic I want to go here, but it was an interesting experience.
Next, longtime readers might remember an ethics case I discussed way back in my first year. The crux was whether it was ethically permissible to do a pelvic exam as a medical student on an anesthetized hysterectomy patient. Well, the other day, that's exactly what I did. I think the program at our hospital does a pretty good job of taking proper precautions to respect our patients. Generally, only one medical student works closely on each case and they must ask for permission from the patient to participate in the procedure beforehand. Now, do we explicitly get consent to do a pelvic exam? No. But as we are the least experienced part of the 3-4 person physician team, it seems reasonable that we might be involved in a relatively noninvasive part of the operation (and not wielding the scalpel, say). If we ever feel uncomfortable or think that the patient's autonomy has indeed been violated (e.g. many unnecessary exams are being done without any clinical indication), we are encouraged to speak up and pass on participating.
Next, longtime readers might remember an ethics case I discussed way back in my first year. The crux was whether it was ethically permissible to do a pelvic exam as a medical student on an anesthetized hysterectomy patient. Well, the other day, that's exactly what I did. I think the program at our hospital does a pretty good job of taking proper precautions to respect our patients. Generally, only one medical student works closely on each case and they must ask for permission from the patient to participate in the procedure beforehand. Now, do we explicitly get consent to do a pelvic exam? No. But as we are the least experienced part of the 3-4 person physician team, it seems reasonable that we might be involved in a relatively noninvasive part of the operation (and not wielding the scalpel, say). If we ever feel uncomfortable or think that the patient's autonomy has indeed been violated (e.g. many unnecessary exams are being done without any clinical indication), we are encouraged to speak up and pass on participating.
The last experience that surprised me in the past couple days was when I tagged along on an ER consult with one of the residents and a 4th year medical student (a sub-intern or "sub-I"). The resident in question mumbles a bit and was talking quietly to protect patient privacy. And since the sub-I was the real audience of his discussion, I was just happy to pick up anything that I could. We briefly looked at a pelvic ultrasound and, from the little I heard and saw, I understood that something wasn't right with this barely pregnant woman. Finally, we headed over to the patient's bed in the ER and introduced ourselves to find that she only speaks Spanish.
Lacking any foresight in high school, I never took Spanish and so, ten years later, I was immediately cut out of the conversation with this patient. The resident had a limited grasp of the language and asked a few simple questions before having the sub-I grab the three-way interpreter phone. Thanks to the phone, I suddenly had a window into the resident's half of the conversation, even if the patient's side of things remained stubbornly opaque. It dawned on me at that point that I was entering into this interaction nearly as uninformed as the patient about her diagnosis and treatment.
I, meanwhile, suddenly realize the impact that our seemingly innocuous little conversation is likely to have. It's like eating dinner at a new restaurant, only to find that the couple at the next table is actively going through a breakup.After clarifying some of his previous routine questions with the help of the interpreter, the doctor asked, "When did you find out that you were pregnant?"Through context I could see that the answer was "this afternoon during this ER visit.""Has anyone talked to you about the results of the ultrasound?" asked the doctor, hesitantly."No," said the patient, which thankfully translates in many languages."The ultrasound showed that something is wrong and the pregnancy is probably not viable." He waits for the translator to repeat his sentence over the phone, but quickly sees that she isn't understanding.
This whole interaction took me by surprise. Given the awkwardness of the language barrier, I think it was handled as best as could be suspected, but it was a powerfully emotional moment for everyone nonetheless. Part of what makes medicine so captivating as a career is that our interactions with patients often happen at life-changing moments in people's lives. OB/GYN adds another layer of cultural and emotional meaning to that sentiment."I'm sorry to tell you, but the baby is not growing," he rephrases. Now she understands and quietly starts to cry. The doctor touches her shoulder consolingly. "I'm sorry, this must be a lot to go through in one day."
TuesdayIL: Marsupialization is the term for surgically creating a pouch - and no, not a pouch to carry your young in. We do not create human kangaroos. The technique is usually used to open up a cyst or abscess and keep it open so that it can drain freely.
TIL: The two most common causes of an enlarged uterus are adenomyosis (when the uterine lining grows into the uterine muscle layer) and leiomyomas (aka fibroids, benign tumors in or on the layers of the uterine wall). The chief difference between the presentation of the two is that adenomyosis usually causes a pretty uniform growth and fibroids cause heterogenous lumps.
