Still tired as stink, but I'm so excited about being a gynecologist one day, I can hardly stand it.
First of all, "adjective as stink" is an expression I've started to use more often recently, because a lot of the residents and attendings I'm working with use it. I'm such a verbal sheep. I should blaze my own trail, go my own way (and...song stuck in head). I should start trying to work "like gangbusters" into my vocabulary again.
Another week of urogynecology is drawing to a close. I've seen a ton of vaginal operations, which, as I've said, seem really cool to do. Luckily because there's both a fellow and a resident operating, I get a pretty good view of the operative field over everybody's shoulders. Most of the time. Other times, I was staring at a wall of other people's heads. It was during those times that I got some negative feedback, in the form of exasperated "Come on"s and the like, about my admittedly poor lighting of the field. After that happened a few times, it was only self-control in its purest form that kept me from blurting out, "Wear head lamps, FOR CRYING OUT LOUD." I've seen surgeons wear head lamps for big open cases with everything laid out before them, why wouldn't you wear one when operating in a dark recess of the body? Yet nobody does... I must be missing something. Maybe there's some study comparing the use of head lamps to the use of medical students who can't even see the field, showing that the students are 40% more effective. I don't know. Maybe I'll ask a resident. I'll let you know what I find out.
I have my mock interview coming up with a peds critical care attending-- none of the ob/gyn attendings volunteered to do the mock interviews, and I'm not sure it would be the best idea to practice with them anyway (since, hopefully, I'd be interviewing with them for real at a later date). I almost signed up for a mock interview with one of my former surgery attendings who always pimped the living daylights out of me. I thought that would accurately evoke the feeling of fear and terror that shall surely be present during at least my first interview. However, I'm just not that courageous. Just thinking about a mock interview with that attending has made me tachycardic (current heart rate = 108). Anyway, the attending I will be practicing with is a "tell-it-like-it-is" kind of guy, so I hope to get some accurate feedback about things I need to fix.
As far as real interviews go, I have three scheduled so far. One in New Orleans, one in Houston, and today, I scheduled an interview at Seattle Grace Hospital. Just kidding, Seattle Grace isn't real. But it is in Seattle, and I can't promise I won't blurt out lines of dialogue from "Grey's Anatomy" starting the moment I enter the University of Washington Medical Center. I am, after all, the same person who can't come within twenty miles of the city of Memphis without singing "Walking in Memphis" at the top of my lungs.
One more day before a lovely weekend off!
I forgot to mention that I had to go back to Gyn Oncology tumor conference last week, after moving on to my next rotation. One of the attendings (also the department chair) had wanted me to give an oral presentation as the culmination of my time on the service. Since there wasn't time during my final week, he had me come back to give it. My topic was gestational trophoblastic disease, and I think it went well. Hopefully nobody noticed that I was shaking throughout. Maybe it wasn't as obviously visible as it felt. I've got to get me some propranolol.
I forgot to mention that in addition to submitting my residency application, I also registered for my second licensing exam, also known as Step 2. This one comes in two parts. Clinical Knowledge (or CK) is a computer-based multiple-choice test, much like Step 1 which I took after second year. Clinical Skills (or CS) is already the bane of my existence. It's a full day of standardized patient encounters, in which I'll have to take a history, perform a physical exam, and write a note in which I come up with a differential diagnosis. I've already discussed how awkwardly forced and completely unrealistic standardized patient exercises are. To make things worse, the test is only given in a handful of cities across the country. I signed up for the Houston location, then found out that the family members I plan to stay with live a good 45 minutes from the testing center. Curse you Houston, why must you be so big???? But worst of all, I paid over fifteen hundred dollars for the "privilege" of taking these two exams. It's highway robbery.
I forgot to mention that in addition to paying for the exams, and for my residency application, I had to pay a separate fee to register for "the Match," the process that will actually assign me to a residency. Ridiculous. And all this is happening to thousands of senior medical students across the country, most of whom have already paid tens if not hundreds of thousands in tuition just to get to this point.
Anyway. That explains why my facebook status says I'll be living on saltines and peanut butter for a while.
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I forgot to mention that college football season began last week! I am pleased that my teams of choice (Vandy, LSU, GA Tech) were all victorious. I went to the Vandy game, which was fun. However, as I was standing there, surrounded by freshmen (seven years my junior) in various states of drunk (ranging from "very" to "extremely"), all I could think was "This smells bad" and "My feet hurt; I should've worn Merrells instead of sneakers." I might be getting a little too old for the student section.
I think that's all. Coming up in future entries: more tales of pelvic surgery!!
In other news, as of Monday I was able to review my Dean's Letter and suggest any changes I'd like to have made. I was fine with the content. The only change I asked for were a couple of grammatical errors in my Medicine evaluation, which have been bothering me for about a year now. I have to say, it's kind of sobering to see my entire medical school career summed up in a few pages. Speaking of which, I need to do some serious work on my residency application, also known as ERAS. The most important things I have to do are polish my personal statement and write little blurbs about all my extracurricular activities. Since, you know, I've had oh so much time for extracurriculars. It's like AMCAS all over again, and we all know how much fun I had with that one.
Another sobering thing about the application process is putting together an actual list of programs to apply to. Previously, I could always say, "I could end up anywhere in the country!" I don't normally consider myself adventurous, but there was a certain thrill in thinking that I had a huge number of possibilities when it came to the place I'll end up. Once my application is finalized, those possibilities are limited. Of course, applying to all the programs out there would be ridiculous. According to most people I've talked to, twenty is bordering on ridiculous. But that's the number I set for myself. I'd rather leave myself with more options now. I can always turn down interviews later, if I feel I have too many.
--Helped take out the ovaries of a patient who has a BRCA gene mutation. They're known as the Breast Cancer genes, but mutations increase your risk of other cancers, too. I don't know what the specific stats for breast cancer are, but this lady had a 40% chance of getting ovarian cancer at some point in her life. As opposed to the 1-2% chance of a "normal" person. So she got a double mastectomy and had her ovaries taken out to reduce her risk. It was specifically pointed out to me that this was not a prophylactic procedure, but rather risk-reducing, since there's still a chance the patient could get ovarian cancer. My thought is, patients can still get clots on low-dose heparin, but that doesn't stop anyone from calling it DVT prophylaxis. But that is a battle I choose not to fight.
--Helped take out the ovaries of a patient with endometriosis. No cancer, but a combination of body habitus and previous surgical history that classified her operation as "complex pelvic surgery." Many gyn oncologists get referrals for such cases due to their operative expertise. This was a really tough case and lasted about five hours longer than was originally planned.
--Presented a patient at tumor board, along with a quick summary of a paper I'd read.
--We got two new third years on the service. I've been trying to help them out without being that annoying fourth-year who's always dispensing unwanted advice. I thought presenting patients as a third year was nervewracking. It's nothing compared to listening to third years present after being given twenty minutes to practice with them and being told, "They better be good." Every verbal misstep was like a knife in my gut.
--A solid six hours of clinic in one afternoon/evening. I saw mostly followup visits after the various female cancers. One of the attendings lets me go see patients by myself; I like that. And after clinic, that same attending and I realized we'd both gone to Emory, so we spent some time talking about that.
--Took out the ovaries of an 85 year old who'd known she had masses for a while, but hadn't wanted surgery previously. She finally came in for an operation when she started to have pain. Both her ovaries were huge, but the attending felt pretty sure that they looked and felt benign. So they got sent to Pathology for a quick diagnosis, which came back as mostly benign, with some metastatic cells from a GI tract cancer. Yikes. So we inspected her bowels, found the offending tumor, and called in general surgery to do a bowel resection. Actually, my attending asked, "Do we call Colorectal or Surg Onc?" and before I could stop myself I'd said "NOT Colorectal." So Surg Onc it was!!
Yesterday, I willingly gave up a day off to hang out at the hospital, in the hopes of getting to do some OB stuff. My reward was a twin c-section. Both babies were breech, and there was a slight possibility of one of them coming out umbilcal cord first (A Very Bad Thing™) had a vaginal birth been attempted. They both did splendidly. Afterward, the GUMP* and I talked about how doing a delivery was much, much happier than spending time on the gyn oncology service.
I'm spending a lot of time with residents who are in their second year or beyond, which means they've had plenty of time to become burnt out. I've been around for multiple bitch sessions, which usually end with one of the residents saying, "Stop, we're going to scare LaKedra away!" It's too late. I'm sucked in. Besides, it's not as if the Medicine residents complained any less.
*When a second-year resident is rotating through the Gyn Oncology service (they do two months at a time), she or he is known is the GUMP**. That stands for Gynecologist Under Maximum Pressure. Basically, it's not a whole lot of fun to be the GUMP. There's no intern on the service, so the second year takes care of all the floor patients. If she's lucky, she gets to operate a couple of times a week. It's like being an intern all over again. If, like the current GUMP, you're on Gyn Oncology during the first two months of second year, it's like being an intern still. When I'm not in the OR or in clinic I'm helping the GUMP with discharges, following up labs, and the like.
**This is not an informal nickname. I once answered the phone with "GYN Oncology," only to have the department chair respond, "I thought I was calling the GUMP office."
Second week on Gyn Onc has been a bit more difficult than the first. On Monday I did a case that didn't leave the OR until almost 9PM. Yesterday, I had clinic all morning, then a case in the afternoon (with the ob/gyn department chair). Because of that case, I was six whole minutes late for the tumor pathology conference at which I was supposed to present a patient. By the time I got there, they had already presented the patient and were discussing her pathology. I have to wonder why they couldn't wait even a few minutes, considering only about a dozen people attend the conference and half of them were still in the OR. It wasn't a big deal, though, since my "presenting the patient" would have only involved reading from the note I'd already put in StarPanel. (I hope they at least noticed that I wrote it!) And I was still able to present the article I'd read for the occasion, if only because I forced my way into the discussion. I might have used the phrase "If I may interject, I found an interesting article..." It's not something I'm proud of, but you just have to do things like that sometimes. You're supposed to gun your sub-I(s), it's the rule.
So this week has gotten off to a pretty hectic start. I think it was pretty obvious that I was Le Tired™ at trivia last night; I almost fell asleep in my fried pickles. .Happily, I got seven hours, forty-eight minutes of sleep last night. That might not seem like anything special, especially to you people who must have eight hours or more every night. But, at baseline, I usually function on six to seven hours. Usually closer to six. Usually more like five to six. Like I'm going to get tonight!!
Percival clearly wasn't happy that I was getting so much sleep, as he decided to have a meowfest early this morning. This has been happening between 4am and 5am with increasing frequency. I don't know what to do with that cat when he's like that. I try to ignore him, but he just goes on forever. I could let him out of my room, but then he'd just go to Liz's door and wake her up. I could throw him out of my window, but that type of action is generally frowned upon. Any tips, cat owners?
My Medicine sub-I ended last Friday, and I spent the following weekend dreading Gyn Onc and seriously doubting my life choices. I really enjoyed Medicine, and could definitely see myself functioning as a Medicine resident. I was even giving some serious thought to which career paths might appeal to me. It's funny, top of the list was pulm/critical care, and we all know how much I hated that rotation when I was a brand new third year and hadn't seen many really sick people before.
Then I started my Gyn Oncology sub-I. Long story short, I'm not doubting my career choice anymore. On day 1, I got to help take care of some hyperthyroidism and some acute renal failure, AND helped remove a big ol' tumor from a woman's body. As my friend Hannah would say, it was the best of both worlds.
On day 3 the team was short on residents, so I scrubbed out of the tumor debulking I was helping with, to go "drive" a hysteroscope (camera used to look inside a uterus). With close supervision from an attending of course. That pretty much made my day. Also day-making was the fact that the staff's scrambling for assistants to help with all the cases ended when the chief said "I'll send my sub-intern." Do you know the feeling of walking into an OR where you are wanted and expected and being waited for so the case can start?? No, you probably don't!! I can't even describe it. I never knew such a thing existed.
Yesterday I scrubbed in on a vaginal hysterectomy. That means the whole operation was done through the vagina. I'm not going to lie, that's no fun as the medical student. I understand that it's the most minimally invasive way to do the operation, which is good for the patient. But I couldn't see jack, and it was uncomfortable to boot. It did seem like it was a pretty cool operation to do, though. Phenomenal surgical powers...itty bitty operating space. I'll have to let you know how cool it is when I actually do one in a few years. For now, I definitely prefer open bellies.
Coming up in my next entry: More stuff about med school! Get excited.
Third year is half over.
Unbelievable.
My Ob-Gyn rotation ended with both a bang and a whimper.
The "bang" happened just this past Monday. I had MFM rounds, and then was assigned to outpatient clinic in both the morning and afternoon. I went in upset that I wouldn't be getting home until 6pm, when otherwise I could've left right after rounds ended at 8am. But once I actually got to clinic, it was fine. It was great. The very last patient of the day ended up getting sent to L&D for possible preterm labor. I wanted to go with her, despite being free to go home...bang. I realized that for the first time this year, I've loved every single thing I did during a rotation. I loved being in the OR on gyn onc. I loved L&D, from actual deliveries to just watching the monitors and doing mag checks. I loved c-sections. I loved MFM, even with the personality conflict, because it had a nice component of Internal Medicine. And I loved outpatient clinic.
That leads to the "whimper," which was the sound I made several times throughout the rest of the week. It happened whenever I thought about how this whole loving Ob-Gyn thing is not according to plan. Going into this year, I thought I would love Medicine and Peds, choose the one I loved slightly more, and then just tolerate Ob-Gyn with my career decision already made. I feel blindsided by this turn of events. But, just like I gave myself a few weeks after the rotation to say for sure that I don't want to do pediatrics, I'm not going to declare myself a future obstetrician just yet.
Since I haven't yet, this is a fine time to explain Maternal Fetal Medicine, also known as high-risk OB. I like to think of it as Internal Medicine for pregnant ladies. If somebody with a medical condition like diabetes or lupus gets pregnant, then their pregnancy is managed by a specially-trained obstetrician. For example, we had a patient with a condition called Osler-Weber-Rendu syndrome. She and her baby ended up doing perfectly well, but IF something had gone wrong, the normal obstetricians didn't want to be the ones managing her. MFM doctors also handle pregnancies in which the fetus has anomalies. Finally, MFM handles the inpatient courses of patients with preterm labor, premature rupture of membranes, etc. Some of those poor ladies can end up in the hospital on bedrest for weeks and weeks!
Okay, back to the present. I felt like there was a lot of teaching done on rounds today. I liked that. I don't mind getting pimped and looking dumb, if the end result is my learning something. I do mind being pimped and looking dumb if it seems like the whole purpose is just making me look and feel dumb.
Because it's my space, to do with as I please, here's a breakdown of how I classify the type of rounds I've participated in, in the order of my personal preference:
1) Rounds that involve a lot of teaching, with useful information. Even if they last for hours, I don't feel like my time is being wasted. I've had four attendings run rounds like this since I've started third year.
2) Rounds that involve very little teaching and are short. I figure if I'm not getting any knowledge out of the experience, at least don't waste my time. This was standard procedure on GI, where the attendings had procedures to run off to, and most of the teaching was done by the residents after rounds. Also on gyn onc, where most of the learning went on in the OR.
3) Rounds that involve a lot of "teaching" (translation: very little teaching) and last forever. A waste of everybody's time. I've had one attending who preferred this method. I hated my life most of the time. In hindsight though, I learned quite a lot, possibly from fact-checking whatever was being blathered on about.
4) Rounds that involve no attempt to teach, only a hearty game of "insult the med students!!!" Boooo. I guess this could actually be a subset of #2. I've never had an attending like this. It seems to happen when the attending runs rounds and jets, giving residents more time to do what they want. When what they want is not having to teach med students, it sucks to be the VMS III!
5) Table rounds. Still the worst!! I guess I think even being treated rudely is ok if, at some point during the experience, I get to see a real live patient.
That's about it! In other news, I might actually become an ob-gyn. Seriously.
My second short call was Tuesday, and there were enough cases to make up for my slow Friday. Things I saw:
1) cerclage placement. Some women may have repeated miscarriages because their cervix just won't stay closed and hold the baby in. A cerclage is basically a suture that holds the cervix shut, so the pregnancy can make it to term.
2) two regular, planned c-sections. To plan to have a c-section instead of a vaginal delivery, there has to be some indication. None of this "I don't want to push" foolishness. The first woman had a section because her baby was breech, the second because she'd had a previous c-section. (Trying to push against a repaired uterus isn't always the best option, especially if you're having a 10-pound baby.)
3) An emergency c-section. This happened because while Mom was trying to push the baby out, the baby's heart rate was doing very troubling things. Because the goal is GET BABY OUT RIGHT NOW, there wasn't a whole lot to see. Incision to baby out was like three minutes. Baby ended up doing fine.
That's it! That's plenty, I know. I enjoyed the day, though it was tiring. I'm currently on Maternal-Fetal Medicine, or high-risk OB. More on that later.
Anyway, I'd only been on the L&D floor about 4 hours when one of the patients was ready to deliver, and they let me do it. I was pretty nervous! As I was getting ready, I yanked on one of my gloves so hard that I ripped it. And once I sat down, I was shaking pretty hard. My knees were literally knocking together. But the resident and midwife guided me through the steps and I successfully caught the baby. It was a bloody, slimy, gross-but-awesome experience. People joke about dropping babies, but that would be really really hard to do. There was a 3rd year resident standing at my right shoulder and a nurse midwife at my left. Between them, my body and lap, and the place he had just come from, the little guy literally had nowhere to go. I ended up delivering three babies myself, and helping out with quite a few others.
Unfortunately, the whole afternoon/evening/night/morning spent on L&D call isn't as exciting as delivering babies. I spent a lot of time doing triage assesments. That means, examining pregnant women who came in sick or possibly in labor. Most of the women I saw were not actually in labor. A couple were, and they required multiple checkups throughout the night. The residents actually switched out at 6pm, making me the ONLY person on the floor who'd been following the patients all along. That was kinda cool.
I didn't get to sleep Tuesday night, but Saturday night was a little slower so I got about two hours of shuteye. To be honest, I felt better the night I was too busy for sleep. When I got to nap, I woke up feeling really groggy and out of it. not to mention stiff and freezing cold.
Tomorrow, I finish L&D with short call. That means I get to scrub in on any c-sections that happen. I haven't seen any of those yet, so I hope there's some action.
Well, it turns out that passing up that caffeine was a big, BIG mistake. I found that out during our next case, when I became super postprandial. I might not have mentioned this earlier, but during robotic cases, I don't get to sit. So as I stood there, theoretically staring at monitors that showed the action in our patient's abdomen and pelvis... I fell asleep. As in,there were multiple times when I woke up just as my knees were buckling and I was about to pitch forward or sideways. I never actually fell down or contaminated anything, but I think it was pretty obvious that I was sleeping. Luckily, nobody pays attention to the students during robotic cases.
This afternoon, I went to colposcopy clinic. A colposcopy is basically just a zoomed-in pelvic exam, done as followup for an abnormal Pap smear. The clinic wasn't very busy, but I got some good experience taking gyn histories and doing exams.
Only a few days to go until Thanksgiving! I'm excited to go home, see my family, and get some tasty food.
No cases today, so it was just rounding. I was home by 9AM. Instead of using all that glorious time to study, I instead made beer brat chili, which I've wanted to try and do for a while. The main obstacle between me and cooking is the fact that I don't usually think about food until I'm already hungry. By that point, I don't want to spend any time preparing food. I tend to just heat and eat. But this time, I actually planned ahead, bought stuff, and was ready to get cooking today. I think it turned out well, but I'll change a few things the next time I make it.
We had two hours of lecture this afternoon, from 4 to 6. I've already forgotten it all.
At least three cases tomorrow, two of them robotic. If we finish early enough, I will try to get my student ID validated before tomorrow night's basketball game. And if we go late, I'll just watch the game on TV.
Well, today was my fourth day in the OR, and so far I love it. Like gangbusters, even. Instead of fearing the bizarre rules and hierarchy of the OR, I should have seen it as the perfect haven for my OCD tendencies. I've only been in for ten cases, so for now I am still blaming this OR-love on novelty. I won't be changing any career plans, yet.
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