No Wonder

A recent patient, all of 16, told her story in what we call the "history". It was clear that her problem was a gynecological infection and it was just a matter of getting to the final diagnosis and treatment through some easy, in office testing.

But I found myself hung up on the social history and explored that deeper than usual. How'd it come to this, I probed. What resulted was a scenario that left me with the feeling of "no wonder."

No competent family, parents or friends available or present. No one being attentive to education and social issues. No kindness, fun or light-hearted playing. No one to be playful when possible or serious when needed. No real love, forgiveness, honesty or truth around her. No appropriate feedback, critique, direction or guidance. Mostly hurtful words, being ignored, emails and texts not returned. No real genuine interest from others for her well being or needs. Nobody to share concerns with or speak the truth with. No respect, and no hellos, "how was your day." No open hearted love or trust, but plenty of vulnerability, people walking out or away, grudges, pride and ego. Most of all, nobody walking in, when everyone else was walking out and no unconditional acceptance, love or support.

 

This bout of a STD may not be the worst of her problems in life. The foundation has been cast, mostly on shifting sand dunes, empty promises, unkept responsibility and unattainable dreams. Pretty sure she'll be back, maybe pregnant next time.

Epiphany

There comes a moment of recognition on rotations that is hard to ignore and likely the core reason why we do this. It's that moment in time that I realized that I really enjoy learning, I've learned a lot, but I couldn't see myself doing this specialty full time. I really hope to help kick out a few babies in my career, but I'm certain I won't be doing OB/Gyn full time. That is both a relief and a hallmark moment on any rotation.

Still I need to learn all I can since I know with great certainty that while babies and vaginas are not my career passion, I will see this content on the boards I'm certain. And it has been a GREAT experience in many ways.

Case point: When 19 year old smokers come in 27 weeks pregnant with no history of pre-natal care, folic acid, nutrition / vitamin / supplement support, is it any wonder there are complications? The world of medicine if faced with very tough decisions indeed.

Open Mouth, Insert Foot

There I was left alone in the office with a woman seeking care while the attending walked down the hallway. You'd think that every disproportionately overweight woman (stomach bigger than the rest of her body) would be pregnant in an obstetric practice. At least that's what I thought.

"How's your pregnancy going?" I asked to try to break the uncomfortable silence and be the caring young professional that I am.

A look of sheer horror filled her face and I knew that I had done the un-done-able. "I'm not pregnant..." she said indignantly with wide and a 40 yard stare that filled in the rest of the sentence (...you asshole).

Rule #234 of OB/Gyn:

Every overweight woman who walks into an OB/Gyn clinic setting is not pregnant.

Scowl

It happened again. That scowl of judgement and prejudice. The FMG/IMG scowl from American trained physician and medical students. I'm getting used to it. But should I have to? It's amazing how it feels and how it looks, but it is my reality. There are no American born/bred IMG/FMG students in the world today (and there are many 1000's of us) that wouldn't have liked to attend a U.S. school, but there simply are not the opportunities. So out of country is the only way for us. Why the scowl?

The truth is that International medical graduates fill many of the gaps in the U.S. system of medicine, as well as those gaps in other Westernized countries. But for many reasons that is seen as a lesser calling than say Orthopaedic Surgery or Dermatology. Foreign school provide opportunities for the student and help fill those gaps. And IMG's have had a very positive effect on the U.S. system by providing care in extraordinary ways, in places that most U.S. grads can't or won't go.

There is an increasing number of U.S. citizens attending international medical schools. We are the U.S.I.M.Gs. we are the many Americans who attend schools in the Caribe, Central and South America, Mexico, Asia and Europe. We work hard to prove ourselves and return to practice in the states. We sit for the same school exams and NBME boards as our U.S. trained colleagues. We do rotations for the most part, in U.S. clinics and hospitals.  We know that we want medicine, but sometimes we are not sure that medicine wants us. Yet we continue. And we endure the scowl.

Almost 300,000 IMGs, 25% of the American physician population, have entered the practice of medicine in the U.S. And about 1/4 of them are U.S. born and bred. Another 1/4 are from the Philippines, India and Pakistan. And while the history has meandered, we now all (U.S. and foreign students) take the same Step 1, 2CS, 2CK and 3 exams to gain license and practice privilege in the U.S. 

The American health care system relies on IMGs to supplement an ever-increasing demand for health care, particularly in light of the baby-boomer generation entering their geriatric years.  Only 40% of primary care positions (internal medicine, pediatrics and family medicine) are filled by U.S. grads. But that tide may change as the number of slots for medical students in U.S. school is rising (up to 30% increase over the next years). For the recent past and future, IMGs will continue to fill those gaps.

So the scowls continue, but seem to based on an old system of prejudices that hang on for dear life. Discrimination has been felt by many in my position as we are seen as less competent or able to practice medicine. And I'll do whatever it takes to counter that old argument.

Not A Great Way to Start the Day

"And the baby was born dead"

I can't imagine a worse way to start the day in obstetrics. Over the past few days, while we were out, one of our near delivery patients discovered that her baby wasn't moving. For two days she worried, and hesitated to contact the doctor or the hospital. And when she did, she was instructed to immediately go to the emergency room. Immediately it was recognized that the baby was at least in trouble, at worst wasn't alive, and an emergency C-section was performed. Too late. The baby was born deceased; 37 weeks gestation. A full grown human baby.

This teaching moment, this tragedy, became the topic of our morning rounds discussion. What exactly would you say to the mother? How would you deliver the news? What would your pre-caesarian "informed consent" sound like? I really struggled for the words, but "passed" the test in theory. But the mother wasn't there to hear my answers.

The loss of a child in the peri-natal period is considered to be one of the greatest losses a mother can experience. There is profound feeling of loss, lack of control, and totally being unprepared. Compound that with the feelings of responsibility and of blame, and the loss becomes magnified. In the Kubler-Ross Death and Dying model of recovery, all of the emotions of anger, denial, etc can be felt. The hardship and difficulties psychosocially have been described but are immeasurable.  The remarkable thing is that the literature recognizes no real difference in the grief process or response between mothers losing a baby by stillbirth (as this was), miscarriage, or pre-term death.

As providers we are aware that patients who suffer such losses need for us to acknowledge the loss and express the consideration, sensitivity and compassion they yearn for. We need to provide the support services personally and arranged. Most of all we need to avoid any tendency to blame, chastise or lecture. And it is remarkable how easy it is to slip into this thinking when in your gut you know you could have saved the baby if the mother had done as she should have.

Today my gut reminded me of my own struggle with death and dying...and loss. I flashed back to the teenage blonde lying still, in pieces, on a gurney at a Spring Break city after attempting to jump into a swimming pool from a 4th story hotel balcony. I saw a vision of a 10 year old boy draped across the hood of a car after an accident when I was playing paramedic. And there were way too many others. It just doesn't get any easier to contemplate. But I seem to be getting better at generating the mechanics of dealing with the issues surrounding the events. At least when pimped for the verbal answers to the questions. I wonder how I'll do in real life.  I hope I never have to face that situation.

And then the clinic day went on. Future mother's were waiting to be seen.

“For death begins with life's first breath And life begins at touch of death” - John Oxenham

From Vaginas to Interaction

I got bored with studying the nuances of gynecology, speculum exam and the various presentations of vaginas & cervices in clinical practice. While potentially an exciting subject and surely one to be on the boards and in clinical practice, I guess being cooped up for these days awaiting "thaw" has over-drenched my brain with the subject.  I think too I inherently fear any content that has so much focus on estrogen, vagina and babies.

So I moved on to read some journals and stumbled upon one related to the psychosocial aspects of clinical care. And phrase caught my attention: "judging days"; Those days and times when we are too busy analyzing our own actions or the actions of others instead of just focusing on doing good, what's best and what's right.

Seems like such a subtle perspective, but it's really a dramatic one I think. From judgmental to just providing the best care possible. The system seems to train into young minds being judgmental because inherently the system is such. Every action we take is assessed, graded, scrutinized, commented on and judged by others in some way. It would be difficult to assume that new providers wouldn't be the same with each other, staff and patients.

But in the system comes the choice. And that may be the greatest advantage of being an older dude in this educational process; making the choice to do what's right, and just serving...thinking less about the judgement of others, and more about doing the right thing. It means abandoning the "what about me" mentality that seems so pervasive in medicine and the world in general. It's about abandoning a core selfishness that seeks to provide personal gratification and satisfaction over the needs of others.

But then I've always tried to do that even in my private life. And I hope that it extended to my practice life so that the "judging days" are way less than the just "doing the right thing" days. It's a daily, even moment by moment, choice. And just knowing that makes the choice easier and more clear. Even if it makes navigating the process of medical education more challenging. In this case it may be more beneficial not to "go with the flow."

 

“Everything that irritates us about others can lead us to an understanding of ourselves.” - Carl Jung

Rotation Success

There really is no magic to doing well on rotations and getting through with minimal trauma imposed by attendings, coordinators and residents. There are some things that one can do (and I have to constantly remind myself of these often neglected facts) to insure success on rotations in the 3rd and 4th years of medical school.

• Exclaim loudly, "This is my favorite rotation/specialty and what I want to do when I grow up." Without that gut wrenching enthusiasm, you look as if you aren't interested. Enthusiasm goes a LONG way.
• No bitching about anything. Indirectly you are commenting about the environment that your superiors have chosen to work (and thus commenting on their mental capacity). Besides, does complaining help? Moreover, there is nothing they can do to you in 4, 6, 8 or 12 weeks that you can't get over.
• Lead, don't wait to be lead. Figure out on your own what needs to be done and do it. Short of practicing medicine, try to anticipate the scut work that needs to be done and just do it!
• Help your fellow students, interns and residents SHINE! If they look good, you look good. Nothing off your back if you help them succeed. Keep them up to date about their patients. That's your job.
• Be inquisitive and ask good, thought out questions. Your curiosity stimulates teaching, and your own learning. But don't ask questions that are easily searched on your smart phone. Ask questions that are about the how and why things are done in the mind of the attending or instructing physician.
• If you don't know, say "I don't know". It'll likely stimulate a conversation or explanation...or at worst, a "go look it up and tell us about it tomorrow. BTW, more chances than not, they'll forget to ask you about it tomorrow.
• Make the nurses, techs and other clinic and hospital staff love you. Alienating a trusted staff member of the attending/physician is rotation suicide. They'll be there long after you are gone and are more likely to be defended as "family" by others working with them.
• Show up early, stay late. This shows your respect, interest, dedication, and ability to organize your life around the most important things at this time...the rotation, your attending, and your learning.
• Try stuff you are frightened of within the parameters of your learning. Sit down and create a treatment plan based on your assessment and run it by you supervising doc. Test your knowledge regularly without waiting for the doc to do it.

Focus on the success pathways in rotations.

Avoid the potholes.

Where Do Lonely Ex-Professors of Medicine Go?

This week was an exciting re-entry into the world of medical education. Lots of great highs and very few lows as the drug of education entered my veins again.

One of the more interesting events was being corralled at the hospital by a former professor of medicine, now retired, who seemingly was just "hanging out" and l;kely interested in the free breakfast. Before I knew it, he was sharing his expertise on everything from IUD's to hospital politics...before I could even say a word.

So many teachers of medicine, who spend way too many hours at the hospital during their careers. They lose their families to the effort and have only hospital based friendships. They end up hanging on and around way too long. This guy obviously had no place to go except to the hospital, dressed in his sparkling whites. He carried a briefcase filled with articles for instant access to hand to any unsuspecting "short coat" student of medicine like me.

Fact is, I didn't know him and he didn't know me. He barely allowed me enough time to recite my name. But in my zeal and zest to be early (or at least on time) I had some time to kill before rounds one morning. And there I was trapped with Dr. Retired.

He began discussing his history, and it slowly progressed to his expertise. I wasn't allowed to say a word, so it appeared. He droned on about the subject matter as if imparting the great wisdom of the Pharaoh's upon me. It was filled with history, inaccurate assumptions, and pharmacy company rhetoric. And while I learned some things about the subject matter, I learned more about the ego, loneliness, and pomposity of retired pseudo-Ivy professors who spent way too much time proving himself to students, residents, fellows, chairmen, promotion committees, curriculum directors, research boards/IRB's, deans and pharmacy sales folk.  He repeated his appointment title at least 10 times during the conversation as if to emphasize his height and weight over me. And while I appreciate his interest in me and my education, this was nothing more than sad.

But such is the mental challenge of academic medicine and the individuals in it. There are great teachers, researchers and mentors, and then there are the others. At the end of week one, I remain humble, open to learning, and eager to create value in my education for me and my future patient's. I've been exposed to amazing minds this week and I know this is where I belong once again.

 

And as for my brush with Dr. Retired? I'm on this side of the lectern now. And I know I won't ever go to the hospital, free breakfast or not, when I'm retired. Mostly because I may run into some nudnik like me.

First rotation bleeding

It was just a matter of time before I was assigned a topic to review for the attendings and learn-lings on the service. It's sort of an apprentice right of passage to be able to present a topic in a concise manner and defend or support the information when questions are asked. I've seen this before and presented a ton, but somehow this first one feels different.

The topic? Bleeding in the first part of pregnancy, also known as "first trimester bleeding". First trimester bleeding is any bleeding during the first 12 weeks of pregnancy, and it is one of the most common symptoms to send a woman to her obstetrician and is never really considered to be a "normal" thing. And while bleeding is frightening at any time for any reason, most of the time it's nothing serious for the newly pregnant woman.  It is reported that ~1/4 of all women who deliver healthy babies experience some bleeding in the first trimester.

Some causes:

• Cervicitis / Vaginitis: any inflammation of the cervix or vagina, usually from trauma or infection causing bleeding from the inner lining of the mouth leading to the uterus (womb);
• Infections of the vagina or cervix: yeast, gonorrhea, chlamdia, trichomonas, Gardnerella
• Cervical polyps
• Tissue dislodgement from uterine lining (must r/out tissue from pregnancy)
• Miscarriage: doomed genetic mismatch or similar genetic reason (blighted ovum, etc); 1 in 5 chances; Mostly associated with cramping pain; Can be complete, incomplete or threatened.
• Ectopic pregnancy (outside of uterus implantation of fetus)
• Embryo (future fetus) implantation bleeding when ovum initially implants into uterine wall
• Hormonal changes
• Aggressive placenta growth & implantation with trapping/release of blood from behind placenta
• Intrauterine fetal demise
• Molar pregnancy (a type of cancer)
• Post coital bleeding from having sex during pregnancy
• Other "trauma" to vagina, vaginal wall or cervix

I've got lots of work to do to be sure I understand that topic completely, but just the act of this cursory research has me more aware of the work up for bleeding in the first trimester. And that may be the greatest value of this exercise...my awareness. We'll just see how much I impart on my fellow learners in the process and how I avoid death by questions I can't answer. I've got the weekend for that, the gym and study for boards.

Preparation is the key. Preparation it'll be.

 

 

 

Blighted ovum

What do you want to be?

"When I come back, I want to come back as a vagina or uterus. It's the center of life"

After today I sort of agree with Dr. G about his wanting to come back as a female body part. For my moment in time, they are royalty. Today the female organs were elevated to new heights of medical science and clinical applications. The full gamut of discussion from CD36 markers on macrophages of the peritoneal cavity and their role in endometriosis to family planning with IUD's making a come back. Deeper discussions in the politics of female health capped with social commentary about single young females getting pregnant and cutting off their lives at the knees ensued.

The uterus and vagina were, at least today, the center of my life and universe. Seems that it will be my life for the next several weeks.

Day #2 - It's all about what you give

"Let me introduce you to 3 of my students. Two of them are smart. Can you guess which one?"

It doesn't matter how smart or accomplished you are in this field. Teacher's of medicine can find ways to "pimp you" into submission and the recognition that you don't know squat. And that seems so easy in my case. Even simple questions seem to throw those willing to work hard to prove themselves in clinical education.

"What is the single factor in determining specialty choice by student physicians?" he asked. "Passionate interest" M said. "And you?", the instructor asked pointing to me. "I was going to say passion", I said. Did that really come out of my almost a doctor mouth? And with that, I moved to the top of the shit list and received a public lashing. Of the 1000's of words in the English dictionary, I couldn't think of one additional reason? What a maroon!

I must be the dumb one. At least I know where I stand, sit or mutter. My position on the lowest wrung of the scut dog ladder is insured. And it doesn't help that I stick out like a sore thumb in this sea of youth, dark hair and essence of "smart as hell". But then, I did know the breast cancer contraindication to the use of estrogen/progesterone in women. And the other reasons likely to show up on some board exam in the future?

hypersensitivity to the drug

pregnancy, known or suspected

undiagnosed vaginal bleeding

thromboembolic disorders

cerebrovascular disease

hepatic tumors, benign or malignant

hepatic disease, active

papilledema

retinal vascular lesions

sudden onset vision loss or changes

 

I do have lots to learn, and I'm sure there will be many more "dumbass" moments in my clinical education. I think that's why they make us wear the short coats.

Day #1- Babies and Insight

Today was the first day of my first rotation and it started like most days of a new job filled with anticipation, fear and trying to figure out how to beat the traffic. Luckily school is not back from holiday break yet, so the traffic was relatively good and I made it to the clinic for our first meeting with plenty of time. Before I knew it, the orientation meeting was over and I had new friends in the 6 of us students starting today.

By noon, I thought the day would be over. There were no patients in clinic, the doc was on call and exhausted from overnight, and we had finished what we needed to finish. The clinical coordinator in the clinic had us finish the last paperwork, handed us our paperwork for hospital badges, and that seemed to be it...until she said three of us would be on call. Guess who was one of the three?

Call? First day, first night, first rotations? Really? My consciousness had to suck it all in and up, and my id wrestled with my ego for a bit, but then I realized I've done this before. And as a medical professional, I've sort of kind of done this stuff before.

I had 4 hours to kill before the shift started at 6 PM. I ran to the hospital, got my picture ID done and headed "home" (or at least my temporary corporate housing home). At least I could get a short work out and something to eat before I had to be back. I did both. And before I knew it, I was back at the hospital, searching for parking.

Meeting the doc for the first time was not without some advance preparation. I'd heard about Dr. G but nothing could prepare me for his energy, insight, stories and calling to teach. I think I am the 1900th or so student he has "mentored" and it shows. His interest in students is amazing. He genuinely cares, and said so in no uncertain terms and his discussion on the practice of medicine not being about him, but about his patience, was truly inspiring. I can see already, this is going to be an amazing learning experience as long as I keep open, present, eager and not worry about the infrastructure that is living in a new city, with new staff etc. But then, I've done that before too.

And just when I thought the day would dash my anticipation, nervousness and excitement with fairly routine, "It" happened...

One of the patients on the floor birthed a baby human. And even though I've seen 100's of babies being born, participated in many myself including emergency, life saving C-sections, this still felt amazing, and very new. And in a small way... 5 lbs, 6 ozs small...reminded me what this is really all about. And it's not about me at all. But then, it never was.

Rotations Begin

It's hard to believe that it's actually here, but I am firmly geographically implanted and ready to start OB/Gynecology in the AM. I've not really been involved in OB since the birth of my child, but it's an area that I've enjoyed, learned about, and worked in in the past. Setting my mind in gear and pre-reading the content is a bit frightening, but I realize that nobody has ever died from "first day of rotations" either.

And so it begins in the morning. I've got my instructions. And beyond handling any emergencies that may come up tomorrow and the future in patient care (although highly unlikely I'll have to worry about that), I'm more concerned about the traffic, parking and finding the clinic. Then the daily experience of the work and schedule will begin to take over and I'll start the steadfast move to the end of rotations and school. Ready to learn!

Note to self: Don't drop babies. They don't like it. Or at least, catch them on the first bounce.