Medical School 2020, Year 3, Week 15 (Gyn Onc)

As part of our OB/Gyn rotation, we selected a week-long surgical subspeciality, either urologic oncology (“UroGyn”) or gynecologic oncology (“GynOnc”). GynOnc is known to be an intense rotation featuring surgery hours with operations that frequently last more than four hours and extend well into the night. Lanky Luke responds to hearing that I chose GynOnc: “I loved UroGyn last week. It’s all old ladies with urinary incontinence, but the surgeries are really neat.”

GynOnc begins at 6:30 am on the oncology floor. My Chief, Marvelous Martha, is a big and tall 34-year-old who loves talking about her adventures on the Bumble dating application. The residents and my classmates adore her. Nervous Nancy: “All her patients are taken care of, even the small details about nausea, ambulation, pain. I don’t know how she stays so on top of all the patients on the floor.” The intern is a short, 45-year-old mother of two college-age kids. She worked as a project manager for GE before going to medical school. Nervous Nancy was shocked to hear about the two kids in college: “She looks so young!”

[Editor: How long would a 34-year-old guy talking about his Tinder adventures last at this hospital?]

The case load is light so I go to the medical student lounge and meet Lanky Luke and Particular Patrick. Particular Patrick says that he misses the “intensity of surgery” and is “bored out of [his] mind on Family Medicine.” Lanky Luke is not enjoying L&D nights. “I have to watch what I say around my team. They were complaining that Medicaid would pay for the Mirena IUD, but would not pay to remove the IUD unless medically indicated. I wanted to say, ‘Maybe we shouldn’t be taking it out. If you can’t pay the $100 fee to have it removed, maybe you’re not able to afford a child. Taxpayers paid for five years of contraception. They’ll pay for 18 years of housing, health care, and food if a baby is pushed out. Why can’t the Medicaid customer scratch up $100 in the middle?'”

Luke’s team was not entirely humorless. “This hippie couple brought in an eight page labor plan document. The [male] resident showed me a cartoon in his locker in which a sheet of paper labeled ‘labor plan’ was being shoved up someone’s butthole.” Proving the old adage “no plan survives contact with the enemy,” labor was prolonged and the fetal heart rate was “nonreassuring.” They got a C-section. The father took his shirt off in the middle of the OR and had the newborn placed on his chest (“kangaroo care”) while the mother was getting sewn back up. A nurse joked: “It’ll latch onto you if you’re not careful.” The father was excited. “Really!?” Should I let him?” Luke fought the urge to add “No, no you should not. You want that baby to suck on your hairy nipple? He’ll never latch onto another one after that traumatizing experience.”

Our weekly afternoon lecture begins at 1:30 pm and is on contraception and miscarriages. The generalist OB/Gyn describes the different techniques for an abortion (medical versus surgical). “Most states limit abortions beyond 24 or 26 weeks and some as early as 22 weeks. Most women do not get results for their fetal anatomy ultrasound until 22 weeks. Whether or not you support abortion, it’s important for everyone to understand the harrowing choice some women have to make, sometimes in a matter of days to get an appointment.” We also go over the various types of birth control and the uses of OCPs [oral contraceptive pills] beyond contraception per se. For example, patients with BRCA1 mutations have a 60 percent chance of getting breast cancer by age of 70, and a 50 percent chance of getting ovarian cancer by the age of 70. Every year that a patient takes COCs (combined oral contraceptive) decreases the risk of ovarian cancer by 5 percent.” We get out at 4:45 pm and are done for the day.

Tuesday is more typical. I get to the hospital at 5:45 am to pre-round on two patients. Both  were admitted for intractable nausea and vomiting. The first was admitted two days after getting her first cycle of carboplatin/paclitaxol chemotherapy for stage IV endometrial cancer. She’s about 55. My other patient is a 57-year-old with ascites (fluid in her belly, in this case over 20 liters) that has led to the classic protuberant “beer belly” that suggests ovarian cancer (stage IV in her case).

We have four cases today: two “majors”, both TLH/BSO (total laparoscopic hysterectomy with bilateral salpingo-oophorectomy); two “minors”, a laser ablation and a cervical stenosis repair. The attending is a 55-year-old gyn onc surgeon. She’s sarcastic, but quite patient. 

I run to meet the first two patients in pre-op before heading to the OR for gown and gloves. Our first case is a robot-assisted TLH/BSO with lymph node removal and an omentectomy (removal of a fatty lining) for ovarian cancer staging. The 53-year-old patient underwent neoadjuvant chemotherapy before this surgery. “Ovarian cancer responds well to chemotherapy,” says the attending. “Sixty percent of ovarian cancer will go into remission. That’s why we need to be thorough and not leave any protected spaces of tumor that the chemo can’t access. Unfortunately, 90 percent of our patients will have recurrence and over time the cancer develops resistance. The big ticket item in ovarian cancer research is finding a maintenance therapy that prolongs remission.”

Two of the OR technicians have been on staff for only a couple of months. It takes 90 minutes before we get the robot docked, and the arms attached to the laparoscopic port sites. The attending and Martha head to the robot control panels, about 15 feet away. They’re still in the OR, but they’ve scrubbed out for comfort. I hold the uterine manipulator and the mid-level resident uses a grasper under direction from the attending. The attending sounds frustrated as she coaches Martha: “Never buzz with the scissors open.”; “Angle the scissors. Use your point of strength!”

We begin to remove the omentum from its connections to the gut tube. “This is the biggest omentum ever!” says the attending. “I just don’t know.” After more came out: “This is unreal how big this omentum is.”; “This is a really fucking big omentum.” After 3.5 hours with the robot, we give up and perform a laparotomy (conventional opening of the belly with a large incision; the opposite of laparoscopic) to finish the removal. The da Vinci Xi robot ($2 million base price; accessories additional; $10,000 in disposables for each operation) turned out to be useless.

It is nearly time for a UroGyn lecture covering content easily found with UpToDate or OnlineMedEd.com.

I tell Martha that I will skip the lecture because the surgery is far more interesting. “Sorry we can’t let you do that,” she responds. “We’ve gotten in so much trouble for students being late to lecture. Appreciate the enthusiasm.”

The next case is a laser ablation of the cervix to prevent cervical cancer. The OR staff lug in a giant CO2 laser. The attending commands, “Arm the laser beam”. Just as in Austin Powers, the nurse responds, “Laser armed and ready.” The attending lets each of us have a quick experience looking through the microscope and aiming the laser. The nurses made the surgeon insert a wet 4×4 gauze into the anus to prevent the release of any methane gas that might be ignited by the laser.

Thursday features two hysterectomies and a fibroid removal. We use the robot (da Vinci) for the first two cases, and opt against it for the more challenging third case. Our attending is relatively new and extremely cautious, so each case takes at least three hours (one hour would be normal). The residents are not afraid to express their frustration in the OB lounge. “I hate working with him. Everything takes three times as long as it should.” The second case is removal of a two-centimeter fibroid at a patient’s insistence. The 40-year-old Eastern European is convinced that all of her problems stem from this benign tumor. The intern ungratefully complains about the attending to another OB/Gyn team: “No one should ever remove a fibroid that small.” The Gyn Chief adds: “I cannot believe [the attending] went ahead with that surgery. Either do a hysterectomy or tell her we’re not removing it.”

The third case, removal of a uterus with a 10 cm fibroid, starts at 3:30 pm, right when we would ordinarily be heading home. The chief is driving with the laparoscopic graspers while I wield the uterine manipulator. By the time we get the fibroid dislodged, it is 8:30 pm. Then the fibroid won’t fit through the vagina. We then have to do a laparotomy (open the belly with a knife, thus rendering all of the laparoscopic work and extra time pointless). On the bright side, the attending allows me to make the incision with the scalpel. It feels heavy. The attending sends us home at 10:15 pm while he closes up. He felt bad for keeping the chief from her 14-month-old. 

We sit in the OR lounge and chat with another OB/Gyn attending. He explained to the young team members that our medical education and experience would transform us into superior beings with respect to uncovering microaggressions and revealing implicit bias: “Doctors are more in tune with bias than other people in society because we deal with the consequences of bias all the time. A patient comes in for the 10th time in two months for the same nonsense problem, we are prone to blow it off and send them out. The patient comes back to the ED in crisis because of what we missed. Every doctor in practice for more than twenty years has had this experience.”

[Editor: “Your Surgeon Is Probably a Republican, Your Psychiatrist Probably a Democrat” (nytimes, October 6, 2016) lends some credence to this theory. Surgeons, notorious for not doing any long-term follow-up with their patients (so they would never learn about the consequence of holding a bias), are much more likely to be Republican than Internal Medicine docs.]

I leave early for lecture on Friday. I chat with Nervous Nancy in our medical student lounge. Nervous Nancy, age 31, confided: “After going through L&D, I sometimes think to myself, screw it I am going to have a baby. I am vastly irresponsible, and underprepared. But look at some of these mothers. Then I remember that they are terrible people. They’ll have a child without batting an eye when the kid is going to the NICU because of the mother’s unrepentant cocaine use.”

[Editor: In the 1990s, a social worker friend in her mid-30s said that she had been agonizing over whether she was sufficiently prepared to take on the responsibility of caring for a child. She then reflected that one of her clients was 15 years old, pregnant with her second child, and living, without apparent health impacts to mother or child, almost exclusively on a diet of Coca Cola and Doritos.]

Statistics for the week… Study: 2 hours. Sleep: 5 hours/night; Fun: 0 nights. I leave the hospital early on Friday afternoon to catch a flight to a college classmate’s wedding. We chatted with the groom’s cousin the morning after the wedding. My best friend, also a third year medical student at a different school, asked, “Did you notice something about him?” I quickly responded, “Yep, pinpoint pupils.” He grins back, “Yep, must have been partying all night with some opioids.”

The rest of the book: http://fifthchance.com/MedicalSchool2020