So, in the midst of all the madness sweeping through the world, I’ve just finished the Obstetrics and Gynecology rotation — I finished my first rotation. I received some of my feedback from the interns, residents, and attendings; I was told that I made it to honors level if my shelf grade pans out (or a high pass at worse case).
Schedule and Experience
It was a 6-week rotation, 3-weeks on Gynecology and 3-weeks on Obstetrics. My hours of patient care, not counting charting, ranged from 12-17 hours a day, a typical day was around 14 hours with charting. After 6 weeks, I’ve seen and interacted with about 170 patients. Usually, once a week I had call. Interspersed within the rotations are ambulatory clinics. Once a week we had didactic days (lots of workshops about patient care and disease management), conferences, and one M&M meeting.
- Student run clinic (we saw patients, diagnosed, and formulated treatment to be signed off by a physician or NP)
- Clinic for high risk pregnancies (gestational diabetes, mothers with risk of heart failure, etc)
- Substance abuse pregnancies (methadone, heroine, cocaine, etc)
- Gynecological Oncology
- Urology/Gynecology (usually pelvic floor dysfunction)
By the end of ambulatory Ob/Gyn, you’ll be a master of unsavory vaginal secretions, and you’ll feel unusually comfortable talking to women about their nether-regions. I’ve heard males have it rough, because some women don’t want their Gynecology care from them. Sure, there were a few patients who didn’t want me to do their vaginal exam. But, for the most part, after about two minutes of us talking and building up a relationship most women were very comfortable with me asking them questions and performing their exam. I only had one awkward experience that made me very happy I had a chaperone in the room. There was also an opportunity to an abortion. I was warned that seeing the fetus (at 10 weeks they’re rather human-like in form) could be traumatizing. After the abortion, you have to take the products of the abortion and identify the fetal parts: arms, legs, trunk, and head. Although, it may offend some people, this was actually less remarkable than I expected. The only thing that bothered me was the intense sucking sound during the procedure. On the other side of the spectrum, I’ll never forget using sonography to allow the mom to hear her baby’s heart beat for the first time — though, I’m not sure who was more giddy her or I, because it was my first time to do it.
Prior to this rotation, I was rather ignorant to the fact that gynecology is principally a surgical specialty. As such, you end up seeing a lot of procedures. In our program, you just signed up for whatever surgery you wanted to see. You’d follow that patient throughout their stay: do post-op checks, get to know their nurse, pre-round on them in the morning, present them during rounds, and make the occasional friendly visit just to see how they’re doing. When there’s downtime, you can study if you want, because it’s easier to remember a person than anything else I prefer to read up on the patient I have.
Pre-rounding: everyday, there are rounds, the most succinct description is people get together and talk about patients. Prior to rounds, because you’re expected to be an expert on your patient, you may (or must) pre-round on your patients. A lot of times, this involves getting in a little earlier to talk to the nurse that was with the patient overnight, waking the patient up to hear their subjective experience, doing a physical (including checking their wound healing, urine output, and overall disposition). Without a doubt, a lot of your conversation with the patient will revolve around you being excited that the patient had a bowel movement or passed gas. My biggest advice for pre-rounding is to get there very early, earlier the better, have your note down and practice it with your Sub-I or resident, then use your polished note as the basis of your presentation for rounds.
Surgeries: we could sign up for any surgery we wanted, as it was ‘required’ that a medical student is present for every surgery. Most people signed up for a variety of surgeries, hoping to never see the same procedure twice. Personally, after working with several surgeons, I signed up for the same surgeon repeatedly. This worked out for me, because there was a trust progression: first I was allowed to scrub in and successfully not touch anything, then I was allowed to assist in retraction, then I was allowed to suction and place a few stitches, and by the end allowed to diddle around with the laparoscope and help close with subcutaneous stitching. You learn a lot during the surgery, a lot of it applies to the shelf exam and to clinic (I’ll never forget that fibroid are a common cause of bleeding after my scrubs were soaked in blood during a surgery from the fibroid, even with the gown protection). My biggest advice for surgery, “Unless you know exactly what you’re doing, resist the urge to help”.
This is exactly what you imagine it’ll be: pregnant moms, babies being flung into the cold hard world, and lots of fluids splattering on you. Child birth, at least the result, is rather beautiful. However, it shouldn’t be forgotten that for most women it’s the most dangerous and precarious event in their life. This is reinforced by the fact that in many countries, without modern facilities, labor and delvery is still one of the leading causes of death and morbidity.
Labor and Delivery: now I’ve seen a few vaginal births, I’d almost feel like a war criminal if I got a women pregnant — shout out to all the ladies who take one for the team and keep humanity going. But, I digress. This part of the rotation requires a lot of you, few things will inspire you to read-up than having to answer questions from anxious parents about their progress into labor. Labor and delivery was a mixture of organized chaos, calm (time to chart), and extreme organized chaos. Here, I’ve learned a few things:
- Holding a woman’s hand during contractions is helpful, but beware of women with long nails that dig into your skin.
- Babies either stubbornly are delivered cm by cm or rocket out like a cannon ball, it’s hard to predict which it will be.
- During delivery most fathers are rather useless, but them being there is usually better than not.
- Delivering the placenta is your job, as the medical student, it’s actually rather easy if you follow instructions but if you screw it up then the patient may exsanguinate — follow instructions
- A lot of people tacitly assume you know what you’re talking about, even if you don’t, so try to know what you’re talking about.
- Every women who chooses to give birth is gambling her life and such owns their experience, whether that be the decision to refuse an epidural or to refuse a c-section.
- Always have gloves in your pockets and also know where to find sterile gloves in a hurry.
Cesarean section: c-sections get a lot of bad press. Some think of it as ‘unnatural’, or a procedure overused by mothers too inconvenienced by vaginal births. But, I’d wager that if you’re fervently against c-sections you’ve 1) never given birth, 2) if you have, things ended without complications for you so you have biased perceptions, or 3) judging people is just your past time. It is true that the rates c-sections have risen, but so have the indications for c-sections: mothers at risk of maternal or fetal demise and/or morbidity. Though, it is disappointing when a mother who didn’t want a c-section ends up needing an emergent one to save their and/or their baby’s life. C-sections are a messy procedure, because birthing is a messy process: you’ll be squirted by amniotic fluid (fancy way to say baby pee), covered in blood, and bathing in your own sweat (the ORs are heated for the comfort of the soon to be delivered baby). Besides that, I’ll never forget reaching into a patients abdomen to manually contract an incompetent uterus with my bare hands, a uterus that wouldn’t have had the power to give birth vaginally. Nor will I ever forget seeing the umbilical cord tied in a knot and hence the indication for the c-section.
The most rewarding experience of any means of delivery is seeing the baby be put with the mom for immediate skin-to-skin contact. I still find it amazing to see the look on each mothers’ exhausted face, that look of relief and proud joy.
Grades will come out in a few weeks, hope I get honors. But, above all else, I’m really pleased with the experience and opportunity I was afforded. It was the first time nurses asked me for orders of what to do next, the first time I was thanked by a patient who referred to me as her doctor even though I told her I’m a medical student repeatedly, and it was the first time I’ve felt marginally competent in the entirety of medical school.
Next, onto Pediatrics (I see germs in my future).