Medical School 2020, Year 3, Week 17 (Outpatient Gyn)

Outpatient gynecology week begins at a clinic with two nurse practitioners. Two-thirds of appointments are routine obstetric visits; one-third are gynecology visits (annuals and acute problems). Sixty percent of patients are enrolled in Medicaid; the remaining 40 percent are typically uninsured, but a social worker employed by the hospital is tasked with signing them up for Medicaid. The office runs like a typical doctor’s office… except there is no doctor. In theory, the NPs can call the inpatient gynecology attending who will drive over (20 minutes) from the hospital, but this didn’t happen during my two days.

My first patient is an outgoing postmenopausal 54-year-old botoxed blonde presenting for vaginal itching. She divorced her husband six months ago and co-founded a rental business with her handyman, with whom she now files. Their first property on the market was the ex-husband’s former house. She reports that during the early phase of her relationship with the handyman, she had sex with her ex-husband “a few times, huge mistake”. She emphasizes that for the past month she has been faithful to her new lover, but reports vaginal itchiness and discharge. She is concerned that she may have an STD. “I just pray I don’t have to tell my ex-husband. The bastard would tell my [teenage] children to turn them against me.” The NP supervises while I perform a speculum exam. I swap the cervix then prepare a wet (saline) and KOH slides to analyze under the microscope. Urine sample tests negative for chlamydia and gonorrhea. We reassure her that she does not have an STD, just bacterial vaginosis (multiple clue cells under microscope are diagnostic) and prescribe a seven-day course of Flagyl (metronidazole) 500mg BID (twice daily).

The NP schedules me for all three gynecology visits so I can practice speculum exams (nurse chaperone in room) while she keeps on time with the short routine OB. I see two OB visits on my own before she comes in. The last patient I see jointly with the NP. She is a withdrawn 17-year-old G2P1 at 16 weeks presenting for her initial OB visit. She is accompanied by an older sister. I communicate the schedule of upcoming OB visits (e.g., 20-week anatomy scan, glucose tolerance test, bacteriuria screening, Rhogam at 28 weeks, etc.). “I’ll have to make sure I can get out of school and that my sister can drive me.” The older sister says that she hopes the soon-to-be-mother-of-two will stay in high school and graduate. “Is the father aware of the child?”  The older sister responds, “Yes, he’s in school, but isn’t going to be involved. Our parents are going to take care of the new baby.”

After the visit, the NP recounted her experience as a nurse on the obstetrics triage floor. “We had a 12-year-old come in for a missed period. We asked the patient if she was having sex. No. Intercourse? No. Then a resident finally comes up and says: ‘Are you doing it?’ ‘Well yeah, I’m doing it.’ We immediately started to get worried about incest. Back in the day you’d get worried about a 12-year-old having sex. Now we don’t even bat an eyelid.”

I leave at 3:00 pm for the afternoon gynecologic oncology lecture. Our attending goes over the common gynecologic cancers: ovarian, endometrial, and cervical. She summarizes: “Ovarian cancer patients die of malnutrition, endometrial cancer patient die of a heart attack [patients are generally  obese with multiple comorbidities].” She continues: “Does cervical cancer run in families?  After a pause, Nervous Nancy responds, “No, it’s not a genetic disease, it’s about behavioral risk factors — HPV exposure and smoking.” The attending answers: “You’re correct about the risk factors, but cervical cancer does end up clustered in families because failure to access the health care system runs in families. My cervical cancer patients have not been to the doctor in over 10 years, or at least haven’t gotten a pelvic exam in 10 years. Sometimes they have been seen by an internist a few times who just have given up performing pelvic exams in their practice. Cervical cancer patients die of renal failure, that’s a good death. Uremia, you just fall asleep. The patients are young, typically 50 years old but it’s a good death unlike ovarian cancer.” (The working lower middle class are in the worst shape for access, suffering from massive insurance co-pays and being ineligible for the various free care options.)

She describes the challenges of patients consuming online information and the Power of the Pink Ribbon. “I had a sister who sent me an article saying OCP [oral contraceptive pills] increase the risk of breast cancer. I followed the link and it cited a 2014 article assessing high-dose estrogen-only pills, which are never used now. It just shows you how much false information is online. This stuff can impact your health. OCPs actually prevent breast and gynecologic cancers.” She continues: “Now keep in mind the vast majority of women who get breast cancer do not have ANY of the risk factors we talk about.  There is a high enough baseline risk that every woman over 45 should be getting a mammogram.”

[Editor: See “National expenditure for false-positive mammograms and breast cancer overdiagnoses estimated at $4 billion a year.” (2015), a study done using the insurance claim database that we have at Harvard Medical School. “Populationwide mammography screening has been associated with a substantial rise in false-positive mammography findings and breast cancer overdiagnosis.” Many of the lives saved from cancer that have been chalked up to mammograms were in women who did not actually have cancer. It turns out that waiting for a lump is as reliable a way of finding true cancers as mammography. Switzerland, which spends much less on health care and enjoys longer life expectancy, has eliminated routine screening mammography. The U.S. meanwhile, is doubling down on medical interventions. The government issued a February 11, 2019 recommendation to put all higher-risk women on aromatase inhibitors.]

On Wednesday, I am in a different outpatient clinic: the “resident clinic” for high-risk OB. This one is led by a 5’4″ no-nonsense PGY4. My first patient is an uncontrolled obese T2DM G3P2002 (type 2 diabetes; third pregnancy; two babies delivered at term; zero pre-term; zero miscarriages; two living children) presenting for her initial OB visit at 8 weeks. I go in first to get a history and complete a basic physical with doptone heart rate, waiting for the resident before beginning the pelvic exam. The unkempt diabetic single mom does not check her sugars. She hasn’t followed up with her endocrinologist because she owes $150 (she should be eligible for Medicaid, but hasn’t jumped through all of the paperwork hoops). 

The patient describes vaginal discharge. We perform a speculum exam. I have to hold up several abdominal folds leading to a foul smell from candidiasis (yeast infection) while the resident performs the exam. We explain that she needs to use contraception if she doesn’t want to get pregnant again. “Those pills bad for the body.” (She may be correct; her uncontrolled hypertension is a contraindication for oral contraception.) The resident: “Yes, but it’s also unhealthy to keep having unwanted pregnancies, especially when you are overweight and have uncontrolled blood sugar.” She says she will consider contraception, but rejects the offer of an IUD insertion after delivery. The resident gets frustrated when her lecture on risks to the baby from uncontrolled diabetes is interrupted by incoming calls and texts on the Medicaid-eligible patient’s unsilenced iPhone X.

After several obese women described by the resident as  “simply refusing to take care of themselves, let alone their multiple kids,” I see a young immigrant couple. They earn too much to qualify for Medicaid, but found that insurance was unaffordable. The 24-year-old Indian 26-week nullip has a normal BMI, but was diagnosed with gestational diabetes at screening.  The husband brings a notebook of sugar logs. I circle two fasting and one 2-hr postprandial sugar value that were elevated within the past two weeks. Wow! I present the patient to my resident. “If they are tracking their sugars, they have good sugars,” the resident explains. “For every five terrible patients, many of whom have several children in foster care, you see a couple like this one. I’m glad you were able to see them. They can’t afford private practice so they come here, and they will be terrific parents.”

The outpatient clinic employs a full-time Spanish-language medically certified interpreter and she is present for roughly 50 percent of the visits. Visits with a Mandarin-speaking patient and an Arabic-speaking patient are cumbersome. Within the hospital, full-time Mandarin and Arabic interpreters are available in person. From the clinic, however, we use a phone-based service for interpretation, but it isn’t nearly as efficient as having a live interpreter in the room.

[Career tip from the Editor: the typical certified interpreter earns about $35/hour, or $70,000 per year working full time.]

Jane is on inpatient pediatrics. “After rounds we sit at a table finishing notes on our laptops. After a while, she does UWorld questions. She is partnered with Awkward Arthur, a 5’5” Asian 28-year-old who has had to remediate following most clinical skills exams. “He keeps looking over my shoulder. I eventually ask if he wants to do questions with me. And he starts trying to show me up. He does this in rounds too. He seems innocent, but he is a total gunner.”

Statistics for the week… Study: 4 hours. Sleep: 7 hours/night (showtime for outpatient work is 8:00 am); Fun: 2 nights. We see an Americana jam-band at a church turned into a concert hall by a local foundation with Sarcastic Samantha and Lanky Luke.

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