Month: March 2021

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

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