doc w/ Pen

journalist + medical student + artist

Tag: ob/gyn

The one thing I can do as a medical student: listen

Show me a medical student who only triples my work and I will kiss his feet.

This is one of the “laws” from the satirical novel The House of God, by Samuel Shem. Now that I’m a medical student, I can see the truth in what that fictional medical resident said. It does take extra time to involve the medical student. And the scope of what I can do as a student is very limited. Of course, being included is the only way I’m going to learn — it’s the only way any doctor has ever learned. But when there’s so much to be done, I know there are moments of frustration for the nurses, residents, and attendings.

What I’ve discovered in the last few weeks, though, is that there is one job I can always do: listen. I’m in a unique position to do this. Most of the time the doctors and nurses simply don’t have time to sit there with a patient for very long. They have other patients to attend to, other more pressing tasks.

As I saw during my time rotating through ob/gyn, patients are often scared or upset. Just being present in the moment, hearing a woman’s concerns and holding her hand, makes a huge difference. Two encounters where this happened stand out in my mind.

One woman had presented to labor and delivery after falling. Trauma in pregnancy can induce labor or potentially cause a placental abruption (where the placenta prematurely separates from the uterus, resulting in painful, dangerous bleeding). She didn’t have any worrisome signs or symptoms, but was there for monitoring. I was the one to initially take her history, and noticed right away how anxious she was. Women who come in to triage, which is the emergency department for pregnant women, are all put on electronic fetal monitoring. She kept asking me how her baby was doing. After taking her history, I left to present the case to the resident. We returned together to see the patient. A little while later, my gut told me I should go back to check on the patient. She was still frightened. My reassurances that the baby was doing fine didn’t seem to help. So I went for the distraction technique. I asked whether she had a name picked out, whether she had a nursery ready. Almost immediately, the woman’s demeanor changed. For a few minutes at least, rather than concentrating on the angst of the moment, she focused on how excited she was to welcome this baby into the world in a few short weeks. Clearly wanting to share her excitement, she urged me to feel the baby kicking against her bare belly. It was obvious that a deep love for this unborn child was driving this woman’s fear. My heart went out to her. I know I didn’t take away the anxiety. But for the time I was there, I think she felt understood, cared for, and listened to. I believe that made some sort of difference — if only temporarily.

While on labor and delivery, I was also involved in many births. Some went smoothly, others less so. One woman in particular had a rough labor. This was during one of my night shifts. She’d been in the hospital for hours and hours, accompanied by her very supportive husband. She was exhausted. Her labor was not progressing well. I had been in the room for about two hours, helping her push. When the attending physician came into the room and recommended a C-section, the woman was devastated. The husband and I listened to her frustration. He held her hand, and I put my palm on her shoulder. The next morning, after the surgery, I ran into the husband as I left the unit. I was headed home after my 14-hour overnight shift for much-needed sleep. I walked up to congratulate him on the birth of his child. He dodged my outstretched hand and engulfed me in a hug. He thanked me for being there for his wife. He told me I had a marvelous bedside manner, and that I would make an excellent doctor. Suddenly every moment of my brutal night shift was worth it: I had really helped these people in their time of need. I walked the few blocks home exhausted, but on an emotional high.

Spending time with patients like these, listening to their life stories, jokes, or concerns, may not lessen anyone else’s work load. But I think it does help the patients. And that’s what I’m here for.

An altered attitude about studying

In the flurry of ob/gyn, I neglected to share this news:

That image comes from my score report for USMLE Step 1. I have never been so happy to pass a test in my life. The six weeks of studying for Step 1 were brutal and often demoralizing. The amount of content tested is more than anyone could ever possibly learn. Much of it is clinically irrelevant, which made it harder for me to motivate. But I slogged through. And thankfully, I never have to think about Step 1 again. Later I will take Step 2 and Step 3, but my understanding is that these exams aren’t so bad.

Medical school, you see, is full of tests. This includes clerkships. At the conclusion of each rotation, we take a comprehensive, multiple choice exam called the “shelf.” My ob/gyn test is tomorrow. It covers everything I’m expected to have learned during these six weeks. Everything from delivering a baby (and all the possible complications that entails) to diagnosing uterine cancer to dispensing appropriate contraception to dealing with sexually transmitted infections — and all manner of women’s health issues in between. Some of this, we learn during our actual time in the clinic or hospital. But there is still book learning to be done.

In the last six weeks, I have spent many weeknight and weekend hours poring over ob/gyn review books and doing practice questions. In doing so, I realized that my attitude about this kind of studying — clinically applicable studying — is markedly different from how I felt while studying for Step 1. I’m finally learning real medicine. I don’t just want to pass. I want to surpass. My future patients are counting on it.

Getting back up

In addition to sharing my experiences here on this blog, I write a monthly column for the online magazine The American In Italia. This month’s piece, published yesterday, is about how humbling medicine is — in more ways than I expected. Here’s the link: Getting back up.

Becoming my own advocate

The first day of my ob/gyn rotation, I remember the clerkship director telling us one way in which pre-clinical and clinical experiences are different. In the classroom, she said, the focus is on you the student. In the hospital, the focus is on the patient. That seems obvious. I quickly learned what that means, though, is that I need to be a constant, assertive advocate for my education.

While on labor and delivery, for example, I’ve discovered that keeping my eyes and ears open is the best way to stay involved. When I overhear a nurse saying that the patient in room 5 is fully dilated and starting to push, I rush to the room so I can help — and learn. When I see on the patient list that someone new has just arrived in the triage area, I quickly tell the nearest resident that I can go see her. I pull up her outpatient chart to review and start a note with our triage template so we can easily add the information from the patient interview. When I hear a resident mention that she needs to do an EKG on a patient with an irregular heartbeat but our machine is broken, I offer to run to the SICU (surgical intensive care unit) the next floor up and borrow theirs. Then I finish the EKG myself.

There are certainly times when someone specifically invites me to participate. One night, for example, a resident told me they were removing a cerclage (a stitch that holds the cervix closed), took the time to briefly describe the case to me, and suggested I go watch. But often, it’s up to me to insert myself. Then once I’m in the room, the resident or attending will explain what’s going on. It’s not that the doctors and nurses are trying to withhold information from us medical students. It’s that they’re busy taking care of patients — that’s their priority, and understandably so.

Assertive self-advocacy wasn’t necessarily a skill I expected to strengthen in medical school. I’m realizing, though, that while medical education entails learning about medicine, it’s also about so much more.

Learning to adjust, and keeping the faith

I made scrambled eggs for myself today around 8. Making eggs isn’t unusual for me. I do it almost every day. What’s odd is that I made them at 8 p.m., not 8 a.m. I’ll tell you, it’s disorienting to eat breakfast after the sun has gone down rather than after it has come up. But that’s what you do when you’re working the night shift.

I’m so glad to finally be working in the hospital rather than sitting in a lecture hall. Like every transition though, there are elements that take some getting used to — like being awake when it’s dark outside.

One aspect of clerkships I’m adjusting to is how little time I spend in one place. Every team has a rhythm and it takes a while to fall into sync. My first two weeks of ob/gyn, I was on the gynecology service. As my first clerkship, there was lots of generalized adjusting. Then there was learning the gyn team’s workflow, figuring out where to find things (I have a horrible sense of direction so this probably took me longer than the average person), and developing a better understanding of gynecologic surgery. Just as the two weeks were ending, I finally felt like I’d gotten a better grasp of it all. And then I moved on to rotate through maternal fetal medicine, with a completely different schedule, team, workflow, and fund of knowledge. I’ve never worked as a temp, but I imagine this is similar. You walk into a new situation, cold, every few weeks. You rush to get up to speed, then head somewhere else to do it all over again. I’m not sure there is a solution for this in medical education, since medical students do need to rotate through so many fields. My goal is to do my best, to be as useful and helpful as possible, but also to give myself grace when I fall short of that goal.

Maybe as much as anything, this constant merry-go-round teaches us medical students to be flexible. In medicine, as I’ve learned so many times already, things often do not go as planned. You need to think on your feet, to be creative, to work with what you have and where you are. With that in mind, I’m trying to use these periods of disorientation to learn how to adapt to new and challenging situations. That can only help me as a physician.

Once I started thinking that way, focusing on how this frustration could actually teach me something useful, I started to feel better. This reminded me that attitude plays such an important role in education, as with anything else. You truly get out of it what you put into it — mindset included.

It also helps to know that I’m not the only one who feels like I’m flailing. Yesterday I was chatting with an anesthesiology resident shortly before a minor procedure on labor and delivery. He acknowledged that as a medical student, he too felt like he was in the way much of the time. He also said, with a wry smile, that he hoped my transition to feeling useful would be shorter than his was.

That would be nice. But I’ve realized that it’s not all about feeling useful. It’s great to be helpful, and I aim to be as much as I can. The truth is, though, that I just don’t know much of anything yet. That will slowly change, I’m sure. For right now, I want to go in every day with a smile, to be as valuable a team member as possible, and to keep an open, curious, passionate mind so that I can take it all in.

The pieces will fall together eventually. No matter how disoriented I feel in the moment, I have faith in that.

Nocturnal on demand

I’m hoping a pot of strong coffee will help prepare me for my first night shift on labor and delivery.

I can count the number of all-nighters I’ve pulled on one hand. All were in college. Tonight I will add to that number. Tonight, I start working nights on labor and delivery (L&D). It’s only for four shifts. But it will definitely be a growing experience.

I’m simply not a night person — morning is when I shine. Some people will stay up late to finish their work, then crash when they’re done. Not me. Back when I was in journalism, with a newspaper deadline looming, I would go to bed at 10 p.m., sleep for a few hours, then wake up at 2 or 3 a.m. to finish writing my stories.

But babies are born around the clock. So being a medical student on L&D means both learning what goes into a delivery and developing the stamina to work these long and sometimes awkward hours. The same principle is true for many other specialties too.

There doesn’t seem to be any good way to shift your schedule from days to nights. I got up as usual this morning, and then after lunch took a 2-hour nap. I made a pot of French press coffee around 4 p.m., which I’m drinking now. I’ve got lunch (if you can call your midnight meal that) and snacks packed, and more caffeine if needed.

Here goes …

Observations from ob/gyn

I’ve almost finished my fourth week (out of six) on ob/gyn. What a refreshing change from sitting in a lecture hall. I keep meaning to sit down and write about what I’m seeing and learning, but I’m always … So. Tired. Many of the days are long. Regardless of the number of hours, I come home exhausted. That’s not a complaint, it’s merely a statement of fact. And it’s exactly what I expected. I’m gradually adjusting. Some moments are stressful (like the few seconds before I launch into presenting a patient’s case to my resident); others are absolutely thrilling (like watching a baby being born, and then helping deliver the placenta). But it’s a roller coaster I’m glad to be on.

So far I’ve had two weeks on gynecology (mainly observing surgeries), a week of maternal fetal medicine (high-risk obstetrics), and four days of labor and delivery (assisting with births and covering “triage,” which is essentially the emergency room for pregnant women).

In brief, before I dash off, here are a few observations of my time so far.

I really like talking to patients. That might sound silly, like it should be obvious. I’ve gone into medicine, of course I should like talking to patients. But I really do. When I was on the gynecology service, rounds — when the doctors and students go see each patient first thing in the morning — were usually between 6:30 and 7 a.m. As medical students, it was our job to “pre-round” — to go see each patient before rounds, to see how they were doing, what happened overnight, to do a brief physical exam. Then we presented each patient to the residents. The first morning I went to pre-round, as I stood outside the patient’s door, I was terrified. But once I walked in the room and started talking to her, it felt so right. I felt at home asking, listening, answering, and examining. I quickly discovered that if you’re wearing a white coat, people think you know things, and so they ask you questions in return. And I do know a few things. But I’m careful to always acknowledge my limitations as a student.

Medicine is a humbling profession. During these few weeks, I’ve shared some of people’s happiest — and most tragic — moments. Watching a baby escape the uterus during a C-section, and then seeing the parents hold their new child for the first time … I felt a slice of their joy. While on my maternal fetal medicine elective, I also saw the other end of the spectrum. Several times, I stood beside the physician as she told a couple that their pregnancy was not viable. In those instances, I felt a sliver of their pain. It’s a privilege to share these moments with people, to celebrate with them in their happiness, or to stand in solidarity with them in their sorrow: “Rejoice with those who rejoice, weep with those who weep.”

Clinicals are a real bonding time for us medical students. On both gynecology and labor and delivery, I’ve spent hours upon hours with fellow students I barely knew at the onset of the rotation. That quickly changed. We’d share bits of information we’d gathered — how to find the template for writing notes in the convoluted electronic medical records system, for example. Or even simpler things — where the closest bathroom is, where to find surgical gowns in the supply room. In moments of doubt, we’d huddle and confer, united in our uncertainty. These people were near-strangers to me initially. But I witnessed so many times when someone bent over backwards for a classmate. I’ve heard that it can go the other way, that some people will throw you under the bus. But I’ve never seen anything like that. More than ever, I deeply respect my classmates, and feel honored to be working with them.