Medical School 2020, Year 3, Week 16 (Inpatient Gyn)

Gynecology rotation starts at 7:30 am in the outpatient surgery center. The chief texted the previous night to skip hospital rounds and just meet the team at the outpatient surgery center for the first 8:00 am case (this is an inpatient week, but if there are no scheduled surgeries at the hospital we go with an attending to the outpatient center). I appreciate the extra sleep! Our first patient is a 27-year-old who had an unfortunate uterine perforation after IUD placement by a Planned Parenthood Nurse Practitioner. “I think it was her first IUD placement. Looking back, she was so nervous.” After a brief physical, we have about 30 minutes before the OR is ready.

Did it hurt getting the IUD placed? “It hurt so bad, but they told me that’s expected. Over the next week, the intense pain got better, but I just kept having these sharp lightning bolts of pain once or twice a day.” She saw an Ob/Gyn for a regular check up three months later who ordered an abdominal x-ray that showed a “T”-shaped device in the right upper quadrant. 

The 70-year-old attending arrives. She meets the patient and confirms the consent is signed. I grab gloves for the attending, intern and myself. We perform a laparoscopic removal of the IUD. It was lodged in the omentum requiring three port placements (three holes in the belly). Throughout the entire procedure, the 60-year-old anesthesiologist, a former dentist, tried to convince me that anesthesia is the best route. “Hospitalists are miserable,” he began. “They have 80 patients, they work 12-hour shifts. It’s not good for the patient, but it’s the way medicine has gone. In anesthesia, we have only one patient at a time, and we are done after you leave the office. And the physiology is just awesome.”

As the OR is prepared by the nurse, surgical tech, and OR tech,s for the next case, we head to post-op to talk to our recovering patient. After a brief conversation with the patient and her mother, we head to the nurse’s station where the intern is instructed to prescribe 10 OxyContin 5 mg. “It’s crazy how much opioid pills we still give out. Epic defaults to 30 pills for a prescription,” says the attending. “I still have dozens of narco left over from my breast cancer surgery. Everyone is talking about the opioid problem and how doctors created this monster, perhaps, but I still blame the government. They started to adjust reimbursement rates based on patient-reported pain scales. No wonder the ED gave out Oxy like candy.”

Before our next procedure (hysteroscopy, camera through the cervix into the uterus to look for, and possibly biopsy, cancerous polyps), I chat with the attending about the future of Ob/Gyn: “Ob/Gyn was a beautiful field because it combines surgery with long-term patient relationships. I am the primary care provider for a lot of my patients. We’re succumbing to the specialization tsunami. I’ve been grandfathered in, but most hospitals require you to choose a track: gynecology or obstetrics.” She continued, “The days of having clinic in the morning with two afternoons of gyn surgeries alternating with a week of obstetrics are ending. Administration is chipping away at the scope of practice for every field.”

After a total of three procedures, I leave the outpatient OR at noon to attend lectures at the hospital on urinary incontinence by a “UroGyn” (Urogynecologist, 4-year OB/Gyn residency followed by 3-year fellowship). 

The next day starts with hospital rounds before surgery at 6:30 am in the main hospital OR. We have two laparoscopic fibroid removals and a hysterectomy scheduled. Dr. McSteamy is the attending. He is a 37-year-old whose recent marriage occasioned despair among the residents (all female, except for one gay guy, a junior resident, who shared their grief). The chief, now four years out of medical school, struggles with basic laparoscopic techniques, incorrectly locating the ureters, a critical item given the risk of damage during the procedure. She also has a six-month-old at home, which might explain some of her deficiencies, but her parents have moved here to assist the software engineer husband in taking care of the baby. She is trying to find a job next year as a general practitioner in a smaller hospital setting. 

During the second hysterectomy, the junior resident gets a page for two ED admits. He and I step out to evaluate a 24-year-old bartender with a three-day history of excruciating labial pain. She had a similar episode several years ago. Her right labia majora is swollen, erythematous (reddened), and extremely painful when she walks or moves. As I prepare to present the findings to Dr. McSteamy, I look up management of Bartholin abscess in my trusted Comprehensive Handbook of Obstetrics and Gynecology by Zheng, a $30 book that fits into a scrubs pocket. The bartholin glands, located at 4 and 8 o’clock in the vaginal introitus, secrete lubricating fluid through a small duct. Some women develop a blockage in the duct leading to an enlarging cyst that becomes infected. Once McSteamy is out of surgery, we head down as a team to examine the patient. We then gather supplies (numbing medication, Wort catheter, scalpel, iodine prep) to drain the abscess. Before we go in, the ED attending asks if the resident has performed one of these. No. Dr. McSteamy then describes the procedure. The ED attending also wants to watch as she has never seen one performed. We transfer the patient into an ED procedure room with stirrups. The resident injects lidocaine in the 3 cm labial abscess and she cries out in pain. After 5 minutes, the resident makes a small incision in the labia, which results in screams and “sorry, sorry.” He then slips a 3 mm-diameter drainage catheter into the abscess. She is supposed to leave this in for 2-4 weeks, but the attending admits that most will fall out within a week. If this happens again she might consider getting a bartholin gland excision or marsupialization surgery (turns the gland inside-out) to maintain duct patency. 

Friday morning: round on two post-op patients and then am sent off to study before a mandatory class meeting at 1:00 pm. Nervous Nancy is in the student lounge watching Grey’s Anatomy on her phone. She is on outpatient Ob/Gyn week and was told not to bother driving to the clinic today. “Whenever I get nervous before exams, I instinctively watch Grey’s Anatomy. My excuse is I might learn something from it while calming my nerves by binge-watching.” We talk about her experience on Obstetrics. “I sometimes think, screw I am going to have a baby even though I am vastly irresponsible and underprepared. Look at these moms. Then I remember that they are terrible people.” I recount my experience with the G9P8 having the ninth baby. When asked why she keeps having babies, she responds: “Well all my children are in foster care so I need to have another one to actually keep one.” Nervous Nancy laughs, and says, “I’ve seen those too. Maybe your children are in foster care because you are a crack addict.”

We head over to the school for confessions of a medical student. We were instructed to prepare by writing a two-paragraph anonymous confession from this year. We are divided into 10-person groups, each led by a physician who shuffles them and hands them out for presentation: 

1. Dear patient, I know everything about you. I know your STD history, I know you have had more children than reported to your husband, and I know your mother died from colon cancer. But as I walk through the door I realized I forgot your name. Unnamed patient, I am sorry.
2. We were so rushed one day on rounding that we didn’t not explain to a patient why we were performing a digital rectal exam. I felt we violated his dignity. We were trying to rule out colon cancer.
3. I resent when doctors say “we have it so much easier than you did”. They don’t understand the stresses we are under from residency competitiveness and financial costs.
4. It is such a relief to see bad doctors practicing. The imperfection reminds me that I don’t have to be perfect to become a doctor. Being a doctor is human, and humans are imperfect. Some are even bad at their job.
5. I learn more from watching bad doctors make mistakes than from good doctors.
6. We had a patient whose biopsy was delayed because of another patient requiring a more urgent read. We joked how annoying he was. He started to yell that he was going to sue the hospital so the team disliked him even more for him being so difficult. He started to have delirium. When I went in alone to check on him in the morning he was clam and present. He confided in me: “I don’t care about myself, my wife is not strong enough to handle another day of not knowing.” The wife broke down in the room. He then got delirious and started asking philosophical questions, “Where are you going?”, “Are you content?”, “What happens next?” It gave me chills.
7. I can never do pediatrics. An anti-vaxxer mom and her three kids came to the pediatric clinic for a first visit after getting thrown by of their prior pediciatrian. The kids asked me why they can’t go to normal school instead of being homeschooled. It was terrifying seeing a crazy woman make decisions that will impact these kids’ lives with no one to stop her.
8. We don’t do much good in the hospital or in medicine. So much waste, discharging patients for them to come back in a week. We just use all this expensive technology that prolongs a miserable life. The best care I’ve seen so far was when a surgeon decided to not operate and recommended comfort care.
9. I kept telling my team that a patient had a certain diagnosis, albeit atypical presentation. They kept saying how it could never be that, and made fun of me. After a few days and it turned out I was right, but they never acknowledged what I had told them. In my evaluation they mentioned only trivial stuff: on time, attentive, knows patients.
10. I feel disillusioned. Despite all this training I feel worthless and unable to manage any real problems my friends and family ask me about. Barbara Freiderson helped me: “The negative screams at you, but the positive only whispers.”

Nervous Nancy: “I just feel like I am always in the way. That no one is grateful for us, and the people that actually care for the patient would have it easier without us present.” The physician leader asks, “Do any of you wish you were invisible?” Every student grinned, and nodded. Gigolo Giorgio, who sports a beer belly after gaining several pounds on psychiatry comments: “I think you mean we all want to be flatter against the wall.” 

Statistics for the week… Study: 10 hours. Sleep: 6 hours/night; Fun: 1 night. Halloween celebration. Gigolo Giorgio hosts a pregame before the class Halloween party downtown. We reminisce about our rotation experiences. Buff Brad and his girlfriend dress up as Gamora and Warlock from Guardians of the Galaxy, Adrenaline Andrew and his girlfriend win first prize with homemade jellyfish costumes out of christmas lights and clear umbrellas. Classmates are downing shots and beer. Once we arrive at the rented out bar’s upstairs room, students dance Top 25 Pop hits while a line grows at the private bar for $5 mixed drinks. Gigolo Giorgio jokes: “[Put-Together Pete] is on his 24-hour night shift for surgery, we should all get blackout and visit him in the ED.”

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