Future OB/GYN?

Before I started this rotation I thought that by the end of it I would have decided that I didn't want to specialize in OB/GYN. On the contrary, I haven't rule out this specialty. This fact really surprises me.

OB/GYN rotation ended almost two weeks ago. At that time, I jotted down some things I liked and disliked about the rotation.

Relevant medspeak:
obstetrics: branch of medicine that deals with pregnant women during pregnancy, delivery, and the postpartum period. 
gynecology: the branch of medicine that deals with diseases of the female reproductive organs. 

Likes:

• I'd be okay if I only saw female patients for the rest of my career. 
• I like asking people about their gynecologic history. Yup, this includes all the awkward questions we had to practice asking in pre-clinical years. 
• I like gynecologic surgeries. Some common ones I saw were ovarian cystectomy, dilation and curettage, salpingoophorectomy, hysterectomy, different types of tubal ligation, endometrial ablation, diagnostic laparascopy, salpingectomy for ectopic pregnancy. I think it's the coolest thing that I get to see the inside of someone's body. 
• I like doing a speculum exam and finding the cervix. 
• I like palpating uteruses.
• I like checking cervical dilation even though 80% of the time I can't find the internal os of the cervix. 
• OB/GYN residents are nice. But so far I haven't worked with any other residents so I'm not sure how they compare.
• Getting dirty in blood and amniotic fluid. 
• It's the medical application of my longstanding interest in reproductive health and reproductive rights. I've learned a lot more about reproductive medicine, which is someone I always wanted to learn about. I feel like I'm being true to my values and beliefs. I guess I'm still telling people to use birth control, just in a different setting. 

Dislikes:

• Ridiculous work schedule in residency and as an attending. What other physicians or working person would feel fortunate to have to work every fourth weekend and every fourth weeknight? Really, this is considered a cushy schedule for a full time OB/GYN.
• So... I kind of don't like obstetrics. I know this is half of OB/GYN... If I could do a residency that only consisted of gynecology, I would be ready to commit to that now. Unfortunately, it doesn't work like that. I could do a fellowship after an OB/GYN residency in an gynecologic field so that I'd pretty much only see gynecologic cases. But I'm not sure I'll have the energy to do a fellowship by the time I'm through one of the most difficult residencies so I can't make that decision right now. 

The typical patient on L&D

I have finished my clinical duties on OB/GYN rotation. This week we have exams and presentations. So I think this is a perfect time to procrastinate by blogging.

In preclinical years there were rare instances where we saw real patients in hospitals, not hired actors playing the part of patients. One time we were seeing patients on the pediatrics unit. A classmate of mine said something when addressing the parents of an infant that implied the parents were married. But they weren't married and the student felt really awkward.

Now that I've been at this hospital for about two months, the image I have of a typical parent is completely different. The typical obstetric patient at this urban safety-net hospital:
-Teenager or early 20s African American girl.
-The standard age to have a baby is in your late teens or early twenties. I'd say that most of the pregnant patients we see are between 16-22. This means that they're younger than I am. I'm a little bit taken back when I see a date of birth on the chart that's in the mid nineties. I remember the mid nineties! But now I'm not that surprised.
-The baby daddy (terminology is per patient) is minimally involved, if at all. At her delivery are usually her mother, her aunt. A few times I saw the baby daddy cry when the child was born and I was touched by that. But this is pretty rare.
A few days ago I saw a 28 year old patient who was pregnant for the first time. Reflexively I thought that she was old.

Then I saw a pregnant patient in her late thirties so by definition was AMA. Advanced maternal age: 35 years or older at the due date. I thought she was really old. She was starting to have grey hair.

First rotation!

An attending I worked with yesterday asked what specialty I wanted to do. I was honest and said that I wasn't sure. I probably won't decide until the end of my third year, which is as late as possible. He suggested that I write down notes from my rotations so that I can look back on them when making a decision on choosing a specialty.

That is a very good idea, I thought.

Also a couple friends inquired about my blog recently even though it had been on hiatus for months.

So I'm blogging again!

Quick recap:
I'm a third year student now. My first and current rotation is OB/GYN.
Passed USMLE Step 1!
My score was pretty good and I'm pretty happy with it. (Though I really wanted five more points. That's how it always is, isn't.) Good or bad, that uncertainty is over.

A doctor explained Bartholin's gland to a patient this way:
When you are about to eat delicious food, the glands in your cheek produce saliva to lubricate your mouth. Bartholin's glands have a similar function. When you have foreplay, these two gland on each side of the vagina that secrete fluid to lubricate.

I thought that that was a fitting analogy but I think about it every time my mouth waters.

One of the many ways med school irritates me

Medical schools really want to humanize the patients to their students. One method my school has adopted is including a photo of the patient to go with each case we get in PBL.

(PBL is problem-based learning. Each session we get a new patient case where the information is presented to us as if the patient came to see the doctor. I'm sure I'll rant talk about PBL a lot this year so you should remember this.)

I generally like the photos when they fit the description of the patient because they help me remember the patient's symptoms and their diagnosis. But many photos do not fit the description of the patient. One common problem is that the photo does not fit the description of the patient. For example, the woman in this case is 5'3" and weighs 157 lbs.

This is the photo:

http://www.flickr.com/photos/sharon_love/4154466098/

This woman does not weigh 157 lbs! Even if you're a smartass and tell me that people with large muscle mass weight more, blah blah blah, this woman does not look like a bodybuilder. She probably weighs 110 lbs.

It annoys me so much that this is such a simple thing but the school can't get it right! I'm pretty sure it's not that hard to find on flickr a photo of a woman who is 5'3" weighs closer to 157 lbs. Whoever is finding these photos is doing a terrible job of making these patient cases more realistic. This defeats the purpose of including photos!

8-year-old African American...

IT'S SICKLE CELL!

http://www.flickr.com/photos/snapeverything/4158509106/

A fellow classmate would blurt this out every time an clinical vignette featured an African-American patient. It become a joke that if there was a sick African-American man, woman, or child, that person had sickle cell disease before we even got to his or her symptoms. Every time we learn about diseases with an ethnic predisposition, sickle cell disease is always the prime example. While it is a fact that sickle cell trait and disease is more prevalent in people of African descent, it's troubling that sickle cell disease and thalassemia seem to be the only two diseases that people of African descent according to clinical vignettes we get in medical school. Caucasian patients are the default in most other clinical scenarios.

Oh every Jewish baby has Tay-Sachs.

3/3 of the depressing future: Attendings tell us about their lives

(attending: a physician who has finished all training. So actually a doctor.) 

So we've learned about how terrible Step 1 is, how terrible clerkships are, and how we've learned how terrible it is even after we're actually doctors.*

There was a panel of docs, one of whom was a doctor in his last year of orthopedics residency. They told us the following things:

"If you stand still, you will get passed over." - 5th year orthopedic surgery resident

"When I was a resident (in internal medicine) at one point all the attendings I worked with had been divorced. I'm now divorced." - pulmonologist

"I have four kids and just went through a divorce." - urogynecological surgeon

"I get home around 10pm every day and get up around 5am." - either the urogynecological surgeon or the orthopedic surgery resident, I can't remember which

"I leave work at 5:30 every day." - a radiologist. At this point all the students decided they want to be radiologists.

At the end of the panel, the career services coordinator sensed the mood of the event and had to beg the panel for encouraging closing thoughts.

*unless you're a radiologist and leave work at 5:30pm every day.

Part 2 of 3: Ethical Issues during clerkships

One of our classes this semester is ethics. The first day of ethics class was a panel that all students were required to attend. There were a few third and fourth year students who shared with us some "ethical dilemmas" they faced during their clerkships. (Clerkships are rotations. You follow around a resident (usually), wake up at ridiculous hours, and get asked questions to which you don't know the answer.)

Basically three of the four stories had this moral:
Don't say anything if you think you're resident or attending is wrong or is just acting like a jerk. 

(The last one wasn't about the attending or resident being wrong or a jerk. It was about a teenage patient who feigned pain in order to be admitted and then her boyfriend tried to sneak onto the floor during the night or something. It was weird.)