If I've said it once, I've said it a hundred times, but clinical rotations are crazy. The schedule changes every 5 weeks, if not weekly or daily, and free time tends to be a precious commodity. After all, if you're not actually at your rotation site, sleeping, or commuting, you're expected to be studying and learning. There really are times when you sort of have to tell friends and family that they won't see you for a while. Despite the craziness though, you really do need to take time for yourself. It's not healthy to live constantly on the go, and without any time to do the things you enjoy, be with the people you love, or even have time for self-reflection. So you have to learn to make the time, and to seize the opportunities that arise.
My last rotation was in the emergency department, and I had a schedule of 3 days on, 3 days off. It was so amazing to actually know from the first day of rotation exactly what my schedule would be for the next 5 weeks, and I tried to make the most of it. Sometimes this meant catching up on more "grown-up" tasks, which is why most of my Halloween was spent cleaning my apartment, doing laundry, making pie and apple butter, paying bills, and listening to podcasts and audiobooks all the while. You can make time for fun though too. October is the time of peak fall foliage for New England, so I took walks on my days off, scheduled in some activities with friends, and when my parents came to visit, I'd already arranged my schedule in the ED so that I had time to spend with them. I love both photography and poetry, and since this month I actually had time to indulge both those loves, the rest of today's posts will simply be pictures from the last month or so, with poems about autumn interspersed between.
Salem Woods
Thompson's Meadow
The morns are meeker than they were,
The nuts are getting brown;
The berry's cheek is plumper,
The rose is out of town.
The maple wears a gayer scarf,
The field a scarlet gown.
Lest I should be old-fashioned,
I'll put a trinket on.
-Autumn by Emily Dickinson
Willowdale State Forest
October turned my maple's leaves to gold; The most are gone now; here and there one lingers: Soon these will slip from out the twigs' weak hold, Like coins between a dying miser's fingers -Maple Leaves by Thomas Bailey Aldrich
Harmony Grove Cemetery
Willowdale State Forest
The autumn's a gorgeous golden cup, With a warm, empurpled rim; The sunset lavishly fills it up With rosy wine to the brim. And while the wind so wearily grieves Through the grasses parched and dead, It spills the wine on trembling leaves And turns them yellow and red. -A Cup of Nature by Richard Kendall Munkittrick
Willowdale State Forest
Harmony Grove Cemetery
As dyed in blood the streaming vines appear. While long and long the wind about them grieves: The heart of Autumn must have broken here. And poured its treasure out upon the leaves. -Woodbines in October by Charlotte Fiske Bates
Greenlawn Cemetery
Oh, Autumn! why so soon Depart the hues that make thy forests glad; Thy gentle wind and thy fair sunny noon, And leave thee wild and sad? Ah! 'twere a lot too blest For ever in thy colored shades to stray; Amid the kisses of the soft south-west To rove and dream for aye; And leave the vain low strife That makes men mad-the tug for wealth and power- The passions and the cares that wither life, And waste its little hour. -Excerpt from Autumn Woods by William Cullen Bryant
Greenlawn Cemetery
Willowdale State Forest
Now in golden glory goes Autumn toward the time of snows: Ere white winter come indeed, Speed the hours, with music speed. Heed not winter's mournful breath, Sighing at the thought of death: Make but music, dearly sad; Make but music, gravely glad. Music is a king of kings, Mightiest of immortal things: Music is a lord of lords, Ruling all with royal chords. Though the woodland ways be chill, Though the woodland choirs be still: Music moves the starry choir, Music sets the soul on fire. -Song I by Lionel Johnson
Before starting my surgical rotation, I was both very excited, and very nervous. I knew from my time in Kenya that I enjoyed observing and assisting with surgeries, so I was looking forward to the chance to do it again. Plus, it's a rare thing in medicine to be able to cure a patient's problem with one procedure, but this is a real possibility in surgery. If a person's issue is an inflamed and infected appendix, we can just take it out. Boom. Problem solved. However, I knew from my women's health rotation that surgery can also be stressful, and I was all too aware that we had not spent much time covering suturing and surgical knot tying in lab during my didactic years, so I was a bit terrified of screwing something up. I also wasn't too thrilled about the ice box ORs (60 or 62 degrees was the norm) or long days (shifts were could be as short as 8 hours, but typically lasted 12-14 hours, depending on how many operations were scheduled) or all the procedures that hadn't been covered in depth during didactic ("treatment: surgery" doesn't cut it as an answer when you're actually in the surgery), but I prepared myself to try to learn as fast as possible. There was definitely much to learn.
One thing I learned right away on the surgical rotation is that, in surgery, more than in any other of my rotations, the hierarchy and divisions of medicine are clear. As a student (whether PA or MD), you are at the bottom of the totem pole. Above you are attendings, PAs, NPs, residents, interns, nurses, and basically everyone else. When you're actually in the OR, there are even more people, like the anesthesiologist or nurse anesthetist, circulating nurse, and, of course, the scrub tech or scrub nurse (a quick note on the scrub tech/nurse: you do not mess with them. You give their table a wide berth, you follow all their commands, and if they say you broke sterile field, whether or not you think you did, you had better apologize, make it right, and then promise never to do it again. Some scrubs are nice and friendly and will ease you into everything if you seem unsure. Others will watch you for signs of weakness and will put the fear of God into you if they sense you have the potential to screw something up, which is necessary since a patient's life could be on the line. You just have to figure out how to live and learn with both, and focus on doing the best you can do.). In short, there are a million people who can, and likely will, order you around. That's part of being a student, just like coming in at 5AM to do pre-rounds before actual rounds, or having the freakish 24+ hours overnight shift. Some students hated this, but everyone had to deal with it.
Beyond the hierarchy, I also learned to recognize the other divisions in the medical fields, specifically the divisions between providers who chose to go into surgical specialties, and those who chose to go into medical (aka non-surgical) specialties. Anyone who has watched the TV show "Scrubs" knows that the surgical people (typically portrayed in green scrubs) are known as the jocks, and the medical people (typically portrayed in blue scrubs) are known as the nerds. This is a stereotype actually perpetuated in real life as many of the surgeons would jokingly refer to themselves as "dumb surgeons" who just knew how to take things out of people. Obviously, this was a gross misrepresentation, but it was funny to actually hear them say it. It was even funnier to hear the general surgeons talk about the orthopedic surgeons, because the general surgeons often referred to their compatriots in orthopedics as being the true "jocks" of medicine. However, I will admit that it is true that orthopedic surgery is in a different class from general surgery.
The Todd... jock surgeon extraordinaire
Orthopedic surgery sometimes felt like a workout as I stood there holding up a limb for what seemed like an interminable time (fact: unless you look like a pathetic weakling, this is the student's job and, fact: whether it's an arm or a leg, they get very heavy, very quickly, especially when you can only support them with one hand lest you accidentally touch a sterile area while not yet scrubbed in yourself), and it is also more violent then general surgery. There is truly elegance to any surgery, and sometimes I loved simply watching the surgeons as they deftly made incisions, tied off vessels, etc., all while making it seem like a dance. The dance is just rougher in orthopedic surgery. It's hard not to be when a typical set up for an orthopedic procedure includes mallets and saws. Yes. Mallets and saws. I enjoyed scrubbing in for any surgery, but I am not sure I'll go into orthopedic surgery in the future as I have learned that the sound of bone crunching kind of freaks me out. Go figure.
In case I wasn't sure before, this rotation reminded me that it's ok to have fun in surgery. I could give multiple examples of this, but the one that comes to mind right now is from my time in orthopedic surgery. There was a patient with shoulder pain because calcium deposits had built up in the tendons of their rotator cuff, and they needed to be removed. We did that by inserting a camera, finding the deposits, making a small hole, expressing (aka squeezing out) the deposits, and then stitching up the hole. It turned out that this procedure is surprisingly satisfying and entertaining. This might weird some people out, but it's a bit like squeezing a zit, only you're squeezing out calcium deposits (which can either be hard as a rock or more like toothpaste) rather than pus, and there's much more to squeeze out. During the surgery I observed, nurses from other rooms came to tell my room to quiet down because everyone was laughing too much and getting too excited whenever we found another deposit. It was very, very weird, yet also very fun. I guess you could say I learned to embrace the weirdness.
The coffees of my overnight shift
I talked in a previous post about how much of clinical rotations is just learning to be flexible. This is another part of the weirdness, especially as you have to learn to handle a schedule that changes daily. My schedule for this rotation was divided into four sections, each lasting just over a week. These sections were general surgery (primarily gastrointestinal surgeries, each time with a different surgeon), orthopedic surgery (we found out our assigned surgeries in the morning on the way to the OR), orthopedic office (each day was spent seeing patients in the office of a different orthopedic surgeon), and general surgery office, which I actually spent in the weight loss clinic. This last section involved the unexpected realization that there's quite a bit of psychiatry in surgery, at least in bariatric surgery. I'm not sure about other weight loss clinics, but if someone wanted to have bariatric surgery done at my site, they were required to meet not just with the surgeon, but also with a nutritionist/dietician and psychiatric nurse, as well as attend meetings held by other people who had undergone the surgery. The goal was to make sure that the surgical candidates were really prepared for the operation, that they understood what life changes the operation required, and that they would actually be able to stick to those changes. I learned that it is possible for someone to "fail" a gastric bypass or gastric sleeve (i.e. still gain weight), and that there were good indicators of who those patients would be. Specifically, any patient suffering from an uncontrolled psychiatric illness was told to wait on their operation until they were mentally healthy, patients who had been obese since childhood did worse, and patients were reminded over and over how important it was that their family supported their decision since the lack of encouragement (or even downright enabling of bad habits) from family members was often a major deciding factor in whether or not a bariatric surgery had the desired long-term effects. On that note, patients were also counseled that their family not only had an effect on them, but that they also had an effect on their families. Overweight parents in particular were reminded that much (some might even argue most or all) of a person's future eating habits are set by the time they turn 8, and thus the importance of developing healthy eating habits in children could not be overemphasized. If you want to see a video that makes this point in a vivid way, I present this ad:
On the subject of making life choices, I should mention that I was tempted to title this post "Lose Weight, Stop Smoking, and Exercise: Primary Care Part 2" because it seemed like much of my rotation was simply spent dealing with the consequences of people ignoring the advice of their primary care doctors. Orthopedic surgeons would lose much of their business if people were not carrying around extra weight that wore and pounded on their joints. Cardiac surgeons would have less to do if people exercised and kept their hearts fit. All surgeons would have easier jobs if people just stopped smoking because (contrary to the popular notion that smoking just affects your lungs) smoking affects every organ system in the body. I have a post on smoking in the works because it comes up so frequently, but right now I'd like to mention one aspect of smoking closely tied to this rotation: there are surgeons who will refuse to perform surgery on a smoker, and they have good reason for this. Smoking causes narrowing of the small blood vessels all throughout the body (vasoconstriction), which means that those vessels are no longer delivering much needed nutrients and oxygen. After a surgery, this can mean an increase in both healing times and failure rates for the procedures. Now if a patient comes in with acute appendicitis and they need an appendectomy before the appendix ruptures, of course they will get the surgery, whether or not they are a smoker. For more elective or less emergent procedures though, there's a good chance that surgeons will require that patients quit before they'll operate. Orthopedic, cosmetic, and bariatric surgeons in particular are strict about this, and some will even test their patients for nicotine before the operation to ensure that the patient has been compliant. So please, just quit smoking now. Soapbox over (for now).
Some advice for PA students preparing for their surgical rotation:
Knot tying on my overnight.
Sometimes residents bribe you with chips and a cookie to stay late and assist with a surgery. This is completely ok. Take the food and eat it while you can.
This follows the last point, but please eat. You might have very weird hours, but grab at least a snack, even if it isn't a full meal, between surgeries because you do not want to pass out in the middle of a surgery. That being said, if you do feel light-headed in the OR, tell someone ASAP.
If you know ahead of time what surgeries you'll be assisting with, look them up the night before and become very familiar with the anatomy you'll be seeing.
Practice your suturing and knot-tying whenever you can. Keep string on your keys, your steering wheel, your scrubs, wherever.
Be flexible. Different rotations are set up differently, but chances are good that there will be a lot of uncertainty. You might work with a different surgeon each day (or even each case), or surgeries might run late or be added on, or complications might arise intraoperatively. No matter what happens, you have to be prepared to roll with it.
Embrace the experience. Even if you hate surgery, this might be your only chance to actually see the inside of a person while they're still alive, or to cure a problem with a single procedure. You can acknowledge the difficult aspects of the rotation, but take time to recognize the incredible things you are witnessing and enjoy them.
Always go with your patient to the recovery room. You should also introduce yourself to them before procedures.
Realize that sometimes you will feel like an idiot. Some surgeons are jerks. Some residents enjoy hazing. Sometimes people just don't explain everything and yes, there really is a purpose to you rubbing a woman's breast for 5 minutes while everyone else leaves.* You just have to do your best, ask questions when you don't understand, and not let the jerks get to you.
Surgeons like to quote the saying, "all bleeding stops eventually." This is 100% true. It is also 100% terrifying. Bodies are complicated, and everyone is a bit different, so chances are good that, no matter how careful everyone is, at some point during your surgical rotation an artery or vein will accidentally be nicked. The most important thing is to remain calm. If you can take a deep breath and continue retracting, or whatever it is you are supposed to do, this will allow the surgeon to find and fix the bleeding vessel that much sooner, and a crisis can be averted.
Elf ears happen
Surgical caps can make your ears point out and turn you into an elf. Deal with that, or settle for the silly bouffant. It's your choice.
Keep the safety of the patient foremost. If a patient has a penicillin allergy, yet you hear the anesthesiologist say they're going to give prophylactic cefazolin, speak up. You might have misunderstood about the patient's allergy, or the anesthesiologist might have missed it, but no one will fault you for double-checking, especially if you do it respectfully. You should also make sure the patient is safe on the operating table, especially in the times right before and after the procedure when they're half-conscious and possibly not always surrounded by nurses and doctors. I saw big patients who we had to make sure didn't drop or roll off the table, and I helped with another patient who tried to fight his way off the table as the anesthesia was wearing off.
Know GI! My rotation was predominantly GI and ortho, and I think that's pretty typical. Any neurosurgery usually has to be done as an elective, OB/GYN surgery is saved for the women's health rotation, and most thoracic surgery is reserved for students who know that's what they want to go into, so it's not typically an option for the general clinical year.
Enjoy the scrubs. Scrubs are basically professional pajamas and they are wonderful. Your surgery (and possibly ED) rotation might be the only time you get to wear scrubs during the clinical year, and you might never wear them again unless you go into surgery or emergency medicine, so enjoy them while you can.
In case anyone is still bummed by the dire consequences of poor eating* or smoking (and also just because I love Scrubs), I have decided to close this post with this cheerful gif and video compilation to celebrate the beautiful friendship that is JD and Turk.
*I had to do this before a breast lumpectomy and biopsy. The resident had injected blue dye that we hoped would drain to the sentinel lymph node so we'd know which node to remove. Even though I was pretty sure I knew why I was doing it and that it was actually an important part of the procedure, it still felt very weird to be massaging an unconscious woman's breast while everyone else left the room to scrub in.
*When we talked to patients about simple ways to lose weight, the doctor I was with always shared the same four principles: 1. Don't drink your calories (i.e. cut out sodas, iced coffees, cocktails, etc.). 2. Have protein in all your meals and eat it first. 3. Don't eat processed foods (i.e. go for whole foods and avoid junk foods, even the healthy-sounding crackers). 4. Don't skip meals. Another thing that also came up all the time was that exercise is great for improving the health of your body as a whole, but the deciding factor in losing weight is simply eating fewer calories. In fact, many times people GAIN weight when they exercise, not because (as so many people believe) they are gaining muscle, but because they use their exercise to justify eating more, and they end up consuming more calories than they burned. The more you know.
Today's post is just a super quick update on my previous post PSA: Donating. The first thing I have to say is that the Red Cross seems to have taken a cue from Sweden, and are now letting donors know when their blood is used, which I think is pretty excellent. I feels like a much better way to motivate people to donate again than to call them every. single. day. When it comes to donating your body to science, this recent podcast from Stuff You Should Know provides a lot of information about just what that means and the different ways you can do it: How to Donate Your Body to Science. Lastly, even if you can't, or don't want to, donate blood, marrow, or organs, there's still another way to donate your body while you're still alive: let medical students (no matter whether they're future PAs, MDs, NPs, RNs, etc.) examine you or be present during your exams. I cannot express enough just how valuable it is for me to practice examining real patients or even simply observe as my preceptor examines them and explains their findings and the patient's conditions. For an example, Charcot-Marie-Tooth is no longer a vague concept in my head, but a disease whose symptoms and treatments I can easily remember because I can associate them with the kind woman who said yes when my preceptor asked if he could use her as a teaching tool. Yes, it can be awkward, yes, students will make mistakes, and yes, your appointment might go a bit longer, but the experience you give to future healthcare providers is invaluable. Really, in the long run you're helping yourself, and everyone else, by helping make tomorrow's clinicians the best they can be. There's an added benefit for you as well since things are less likely to be missed if two people are covering your history and exam, and there's also a decent chance that you'll understand your own condition better once you hear it explained to someone else. Consider it.
Primary care is an odd duck. It's certainly not the most glamorous part of medicine. Patients come in complaining of colds and acid reflux, not trauma wounds and surgical emergencies. It's not exactly the stuff of primetime medical TV shows. It can be tedious and monotonous, and it's no wonder that many primary care doctors become burned out over time. A large part of the burn out is the feeling of repeating yourself over and over without being heard. Much of primary care deals with treating chronic conditions and, more importantly, using preventive medicine to prevent these conditions in the first place. The focus on preventive medicine means that the same topics (e.g. exercise, healthy eating, safe sex, smoking cessation etc.) are covered with almost every patient, yet it can feel like an exercise in futility. It can seem like the patients who are doing well already know and follow the advice you're giving them, and the others have heard it all before and have ignored it. You can't help but ask why they would suddenly listen to you now.
A big part of the problem is that primary care battles against silent killers. The diabetic doesn't see the importance of keeping their blood sugars under tight control until they discover the foot ulcer they couldn't feel and suddenly face losing their toe. The patient with high blood pressure doesn't take their medications consistently until they have a hypertensive emergency. The alcoholic doesn't cut back on their drinking until they develop cirrhosis. The patient with high cholesterol doesn't change their diet until they have their first heart attack. The morbidly obese patient doesn't try to exercise until they realize it hurts too much too move. When you try to prevent problems rather than treat known issues, it's easy for patients underestimate their risks or think that they will be the exception. There are some tricks to get your message across, such explaining to the man with high cholesterol that his eating choices and smoking habit not only increase his risk of a heart attack but also decrease his ability to achieve and maintain an erection, yet all too often primary care can feel like an uphill battle, fraught with frustration.
This is not good.
PA-Cat Bob approves of PCPs
Here's the thing though: primary care might not seem like the most interesting or the most glamorous, but it is arguably the most important specialty in medicine. A primary care provider (PCP) might not be using their fingers to plug lacerated arteries and they might not be compressing a chest just to keep someone's blood pumping, but they are saving lives. They're helping to prevent patients from ever getting to that point of crisis. PCPs are the gatekeepers, responsible for recognizing the difference between when a patient has a common or manageable condition, and when they need to seek a specialist's help. They are the providers who are there for their patients at all stages of life, who get to see their patients in sickness and in health, and who have a truly awesome opportunity to get to see the whole picture of their patients rather than simply how a patient presents in a crisis. And who knows? PCPs might just make that once in a lifetime save after all. The man a PCP works up for iron deficiency anemia might turn out to have esophageal cancer causing an upper GI bleed (and thus the low iron levels). The young guy with pneumonia might have a carcinoid tumor that no one else caught before because they treated the immediate problem and didn't notice the suspicious recurrences of lung issues. The PCP who actually takes time to listen to his female patient and not be biased by the opinion of previous providers might recognize that her malnutrition and frequent bouts of vomiting are actually due to celiac sprue and not an eating disorder.* I don't know whether or not I'll end up in primary care, but I do know that after my rotation I appreciate it, and the potential impact it can have, more than I did before. With this in mind, I have some suggestions now for anyone who will ever be a primary care patient (aka everyone).
Find a provider you like -I'm not saying you have to be picky and find the best clinician ever, but this is a potentially lifelong relationship you're starting, and there are certain characteristics you should look for. You should find a PCP who listens to you, addresses your concerns, and takes the time to make sure you understand any conditions you might have. Find a provider who is open and honest with you, and is willing to let you seek a second opinion if you're not sure about their advice. If a provider spends less than a minute with you, that's a bad sign. If they spend more time with drug reps than patients, that's a bad sign. If you feel like you're nothing but a nuisance to your PCP, that's a bad sign (unless you are being a nuisance; don't be that guy). You should know what your conditions are, what your medications treat, and why tests are ordered. Now, this last statement certainly requires you, as the patient, to actually pay attention when your PCP explains everything, but if you still have questions, you should feel safe asking them.
Get screened -A large part of preventive medicine is screening for certain conditions before they become a problem. While some PCPs may differ slightly in some of their screening techniques (e.g. getting blood work on all patients annually at any age vs. periodic checks after age 40), there are standard guidelines for many conditions which are continually reviewed and revised if necessary. For example, in general, sexually active women should be getting pap smears, women over 40 should be getting mammograms, and adults over 50 should get colonoscopies. The exact timing of these screenings might vary somewhat from person to person based on each individual's risk factors, but your PCP should know the guidelines and how to apply them to each patient. While I know that many people are afraid to be screened for medical conditions because some screening methods are uncomfortable and because sometimes it seems like ignorance is bliss, but the truth is that even if a screening test comes back with an unpleasant result, it's far better to detect conditions early when they're asymptomatic and there's hope of potential prevention or treatment, than later once they've become symptomatic and treatment is much more difficult or merely palliative.
Show up on time to your appointments, and call if you're not going to make it -This isn't some huge, life-shattering advice; it's just a courtesy that can be easy to forget. Both in my women's health and primary care rotations I experienced time after time of waiting at an office with all the MAs, nurses, and the PCP because a patient ran late or didn't call to say they wouldn't be coming. If there's limited time for lunch, or if it's at the end of a long day, you can bet most of the people in the office are pleased as punch to have patients who show up right on time (or even a little early), or who call to say when they're running late or can't come.
There's more that I can (and probably will at some point) say about primary care, but tomorrow starts my week in orthopedic surgery, which means I'm back to a 3:15 AM wake-up call rather than my leisurely 5 AM alarm for my weeks in the surgical offices, so it's time for me to go to bed. *These are all true examples, by the way. The first two come from a PA and an MD I know, and the third comes from the book How Doctors Thinkby Dr. Jerome Groopman.
When you start clinical rotations, you’re prepared (at least in
theory) for certain difficulties. You don’t know your schedule ahead of time,
though you know that it will change every five weeks, the emergency medicine
rotation will likely have odd hours, and you will probably have to wake up very
early for the surgery rotation. You’re told that you will likely feel like you
know nothing at first and that any time not actually spent at your rotation
site will probably be consumed by studying. You know that some rotations will be
better than others, but that even the worst ones will end. Then the first day
comes, you take a deep breath, and you step into a new realm of uncertainty. It’s
not just for the first rotation either; each rotation is different from the
last and while you may quiz your peers on what to expect, you still face each
first day of each rotation with a blank slate and lots of questions. What does
your preceptor expect from you? What are the typical hours? Are there typical
hours? Will I be quizzed constantly? What will the other students be like? Will
patients refuse to be seen by me? What if I completely botch a procedure? What
if I forget all the medications I ever learned? And on, and on, and on... The
truth is, the questions never really stop, they just change into new questions.
By the time you finally start to feel comfortable at one rotation, time’s up
and it’s time to go some place new.
Before going into an appendectomy at 11 AM, and then later at
midnight, with at least 7 hours still left to my overnight shift.
The key to keeping sane
sometimes is to just be flexible. Some rotations will never give you a clearly
defined schedule and you just have to live day by day. For some rotations your
preceptor changes daily, so you’re constantly adjusting to new and different
personalities. For some rotations you realize that the experience of your peers
might vary vastly from yours, sometimes based on what seem like tiny details.
For example, I am currently on my surgical rotation, which includes an
overnight shift during the week of general surgery. The thing is, because I’m
in general surgery first, my “week” is actually one day longer than the other
weeks of this rotation, so there is a definite possibility that I may have to
do one more overnight shift tomorrow, even though I already did one last week.
I will admit right now that I am not thrilled about this prospect, particularly
since the “overnight” shift actually goes from pre-rounds (5 AM) of one day to
post-rounds (approx. 7:30 AM) of the next and sleeping rarely happens, but if
it has to happen, it has to happen. Rolling with the punches and adjusting expectations is just part of the clinical year. I’ll
probably do a post in the future about some of the other difficulties of the
clinical year that don’t often get discussed (What if your preceptor is a bad
teacher, or worse, a bad clinician? What if the preceptor for your next
rotation decides to reture? What about all the non-rotation related things that
can cause problems, like cars or living situations?), but right now I need to
grab some lunch, read up on laparoscopic cholecystectomies, and attempt to get
the electricity account transferred from one roommate to the next, so it's time for me to sign off. UPDATE: a kind medical student volunteered to take the overnight shift so I didn't have to do another one. It was only later that the chief resident informed us that a student wasn't necessary for every overnight shift anyway.
I started my June post remarking how surprising it felt that yet another month was over and that I was already in another rotation, and I could repeat those exact same thoughts now as July ends. Even though graduation next May still seems years away, the days have flown by ever since I started my clinical rotations. Since my last post I've completed my time in women's health, and I'm already done with two weeks in primary care. Leaving women's health was even more difficult than leaving my psych rotation, so before I move into full general medicine mode, I have some reflections from my time there.
This has nothing to do with WH, I'm just
proud of my first batch of cold brew
that I made with my coffee sock.
The first is that you learn to get over awkwardness in women's health. I'd say you get over it quickly, but that's not 100% true. There were still days toward the end of the rotation when it felt odd to ask a woman about her bathroom habits or if she had any discharge, not to mention all the times I said, "you're going to feel me touching you" or "do you have any irritation in the vagina?" Asking about a woman's sexual habits was pretty awkward at the beginning as well, especially if you started realizing those women were the same ages as some of your female relatives. That being said, my classmate and I needed to get over the awkwardness quickly. All these questions weren't asked just for kicks and giggles. They were necessary to get to the bottom of a diagnosis, determine if treatment was working, and figure out how a patient's issues were affecting their life. Plus, I quickly realized that the answers were not ones I could just guess or assume, especially when it came to sexual activity. A 50-year-old might look at me as if it was was crazy to imagine she might still be interested in sex, whereas a 79-year-old might answer "yes" so emphatically that it would seem crazy that I could think a woman might ever lose interest. There were a few women who asked why I needed to know, and at the beginning I might have wondered myself, but it was amazing how asking such simple questions could lead to important diagnostic information. I think of the women who'd given up sex because it had become painful or uncomfortable, but who had never mentioned it to a clinician because they were too embarrassed or because they thought nothing could be done, and then how elated they were when we could tell them that there was in fact a treatment for their interstitial cystitis, or vaginal atrophy, or pelvic organ prolapse, or whatever their particular problem was. It was pretty rewarding to be able to give someone back a part of their life.
The second reflection is a bit of a long one. It began with how we joked frequently during my rotation that being a woman sucks. Sometimes it was the playful joking of saying that women go through the awfulness of periods just so we can go through the agonizing pain of childbirth, or that once you hit menopause everything starts falling out (at least one kind of prolapse was found in 14-34% of women in the WHI study, and some studies think this is closer to 50%). At times though it was a rather dark sort of joking, especially when you looked at statistics. For example, 1 in 8 U.S. women will develop breast cancer in their lifetime. That sucks. Cancer of reproductive organs in general has the potential to be more deadly for women than for men because the reproductive organs of men are more easily examined, whereas the reproductive organs of females are primarily hidden inside the body. To often this means that symptoms of a cancer are not detected until the cancer has progressed and spread, a primary reason why ovarian cancer is the fifth leading cause of cancer death in women, even though only 1-3% of women will ever get ovarian cancer. Looking at younger females, 1 in 15 sexually active young women (ages 14-19) will have chlamydia at some point. This is can be quite tragic since chlamydia is most commonly asymptomatic in females (possibly as few as 5% have symptoms) so it's not treated, but left untreated chlamydia can lead to pelvic inflammatory disease (PID) in at least 10-15% of women. PID in turn can have drastic effects on a women's fertility: 1 in 8 women with a history of PID will have a hard time becoming pregnant, and the rates of infertility increase dramatically with each incidence of PID. For any woman who does become pregnant, she then faces the possible heartbreak of a miscarriage. Depending on which study you look at, miscarriages happen in 31% to 70% of pregnancies, though most of these occur early in a pregnancy, often before the woman even knows she's pregnant. Still, 15-20% of confirmed pregnancies end in a miscarriage, a rate much higher than many people realize, which can lead many women who miscarry to believe that the miscarriage was their fault or that they must suffer alone because they think no one else knows their pain.
The hardest statistics to look at are the ones where a woman's suffering is not related to purely medical causes, but to what other people do to her. For example, there's the disturbing statistic that the rate of abuse of women INCREASES during pregnancy. In the UK it's estimated that 30% of domestic abuses begins when a woman becomes pregnant, and in the US almost 1 in 6 pregnant women have been abused by their partner. The fact is that I need to be more concerned about screening pregnant patients for abuse than for preeclampsia or gestational diabetes because the rate of abuse for pregnant women is higher than the rate of both those conditions combined. That's absurd. Even if a woman is not abused during pregnancy, chances are she has already been abused in her life because studies show that 1 in 4 women in the US were sexually abused as children. While I may not have statistics for it, there also seems to be an alarming number of women being sterilized against their will. I saw 3 such patients over the course of 4 weeks. Three! That's a lot in such a short time frame. These weren't old women either; all three had been sterilized by force or without their knowledge within the last 5-20 years, so this is a current problem. While all 3 were from countries other than the U.S., this is not solely a foreign problem. California didn't pass a ban on forced sterilization of prisoners until last September, and that only after an investigation had revealed over 140 females patients were coercively sterilized between 2006 and 2010, at least 39 of those without legal consent. This doesn't just suck; it's horrifying.
Shout-out to the woman who first introduced me to the
beauty and strength of being a woman: my mom
I could leave this post right here. I could end with the conclusion that women have horrible lives due to their own anatomy and the injustices of society. I could do that, but I won't, mostly because I disagree with that as a universal statement, and also because that's just not the conclusion I got from my rotation in women's health. Over and over again I was presented with the sheer strength of women. Sometimes it was the forceful strength of the woman in labor, pushing with all her might. Sometimes it was the quiet strength of the woman who'd suffered in silence, simply plugging away with her life despite lasting discomfort. Sometimes it was the plucky strength of the older woman who'd wink while reminding me and my classmate that "it's a terrible thing to grow old." Sometimes it was the resilient strength of the woman who'd faced injustice after injustice and hadn't let it break her. I've never really used the term "girl power" (at least not seriously), but there was something about working with women every day that grew in you the feeling of sisterhood and camaraderie. Yes, sometimes my patients convinced me that women were completely crazy (especially during my first week), but they also convinced me that I could work in women's health and really enjoy it, even the parts that aren't all pregnancy and babies (though there is something simply magical about locating a fetal heartbeat on your own for the first time... and every time after). Is women's health where I'll end up? I don't know yet, but I'm so very grateful that I was able to spend 5 weeks there. And now as I close, some last few bullet point thoughts*:
KEGELS! No matter your age, women, you should be doing these. They might not be the most effective treatment once a problem like prolapse develops, but starting them early might help prevent some problems from developing in the first place.
Uteruses are overrated. They're good for growing babies but after that they're more of a nuisance.
If you are menopausal or postmenopausal, a local estrogen (either a ring or a cream) is something you might want to talk to your gynecologist about.
Coconut oil has a surprising number of uses.
If you're being abused, or you think someone you know might be, do not keep quiet. There are always ways out and always ways to help. Obviously this post was focused on women, but this point applies to anyone, male or female. Oh, and while we're at it, instead of just helping someone who is being abused, let's work on creating the kind of society where abuse is neither tolerated nor encouraged.
Don't rule out a male gynecologist. My preceptor was a man and he was one of the best doctors I've ever seen. My classmate and I both talked about how we want to be clinicians like him one day, and you could tell his patients loved him. Sure, some women admitted being nervous about seeing a male gynecologist, but it was well worth it for such excellent care.
On a similar note to the last point: Ladies, be nice to the male students. It's always going to be awkward to have a student in the room for these kind of examinations (and a few patients did turn away me and my female classmate), and it can seem even worse if the student is some young, attractive fellow, but if your clinician asks if you mind having a student in the room, please consider saying yes. The practical experience is invaluable and many of my male classmates have left their women's health rotations frustrated because no patients would let them see them. Just think about it.
Turtles know the proper way to enjoy sunshine.
If you've made it all the way to the end of the post, congrats! It was a bit longer than my usual posts, and somewhat lacking in photos or catchy songs (I was unable to find a song that adequately conveyed the idea of "if you're a girl there's a good chance you'll face societal injustice, multiple forms of abuse, the pain of your own body working against you, and when you' go through menopause everything will go to pot and/or fall out, but it's ok because girls are awe-inspiring and amazing," so if anyone knows of one, let me know), but I had a lot to say after this rotation. Who knows what I'll have to say after my time in primary care. For now though, it's back to the books to review all the intricacies of diabetes, coronary artery disease, hypothyroidism, and basically everything else in medicine. Hopefully I'll emerge from my study cave to get at least a little vitamin D this weekend. :)
*I'm not a licensed or certified PA yet, so any medical advice is simply a suggestion. Talk to your own healthcare provider further if you have questions.
Two summers ago I did a short PSA on drowning because many people don't know how to recognize the signs, which are often subtle (not the thrashing and yelling that Hollywood teaches us to expect). Today I present another PSA on a topic that has the potential to save even more lives: CPR.
First, I have some quick background info. CPR is used to treat cardiac arrest (also called sudden cardiac arrest or SCA). While a heart attack can lead to SCA, the two are not the same. In a heart attack, a blockage in the heart's blood vessels deprives areas of the heart of oxygen, which causes the affected cells to die, resulting in pain. The heart will usually continue to beat though. In a SCA it's the electricity of the heart that is affected. The normal electrical systems of the heart that control heart rate and rhythm stop working, and thus the heart stops beating completely, often without warning. There are many possible causes of SCA, everything from coronary artery disease to inherited heart defects (e.g. hypertrophic cardiomyopathy, valve diseases, Brugada syndrome) to stress to drowning to simply being hit in the chest by a baseball at the exact moment that the heart's electrical system is vulnerable (i.e. commotio cordis). If a heart attack is left untreated, it can also lead to a SCA once enough cells die or enough scar tissue forms. Because it is the electrical system of the heart that is failing, victims of SCAs require immediate defibrillation to "jump start" (so to speak) the heart and get it to beat properly again. If the heart is not beating, oxygen is not being delivered to the rest of the body, including the brain, and permanent brain damage can occur within 4 minutes, and death typically follows by 8 or 10 minutes. This is especially concerning because, as their name implies, SCAs often happen without any warning (the first sign is typically when a victim loses consciousness) and 88% occur while a victim is at home, away from the immediate help of emergency services.
About right now you might be asking how all this affects you. If you're not a healthcare professional, you might never be trained in how to use a defibrillator, which is what a person suffering from an SCA most needs. However, anyone can be trained to perform cardiopulmonary resuscitation (CPR). While CPR typically does not cure an SCA, it buys valuable time. By keeping the heart pumping, CPR ensures that oxygen is still delivered to the rest of the body and thus staves off the death of other cells until defibrillation can be performed and the heart can resume pumping on its own. According to the American Heart Association (AHA), CPR can double or triple a victim's chance of survival, but in the US it is performed in only 32% of cases. So what can you do?
The simplest answer is to take a CPR class. The AHA and Red Cross regularly offer classes in Basic Life Support (BLS), which includes training in the performance of CPR and the use of a defibrillator, and often includes training in the Heimlich maneuver as well. Classes do not cost much, last a couple hours, and are offered in different versions for laypersons and healthcare professionals. If you don't have the time or money for that, at least learn the basic steps. They've been simplified over the years to encourage more people to learn them and they're rather easy now. As depicted in the graphic to the right, the first step is check a person for responsiveness. You can yell at them or rub their sternum with your knuckles, and then check for breathing. If they don't respond at all and/or they're not breathing, move to the next step. If you're by yourself, call 9-1-1. If someone else is with you have them make the call and send them to find an automatic external defibrillator (AED) as well. Next, begin CPR. The AHA currently recommends that laypeople do what they call "compressions only" CPR, which means that you don't have to stop to give the victim breaths. You simply need to "push hard, push fast" in the center of the victim's chest. Ideally you're pushing at a rate of 100 bpm, and you're allowing for full recoil of the chest, but the fact of the matter is that poorly performed CPR is still going to be better than no CPR at all. Even if you are incredibly nervous (and that's normal), it's far better to start compressions than to sit around wringing your hands waiting for EMS to arrive. If you're scared of hurting the victim the fact is that they are already dead (at least in a cardiopulmonary sense), and your attempts to provide CPR can only help. The bottom line: just try. Still nervous? Here's a 90-second video explaining how to perform CPR, complete with cheesiness and the Bee Gees.
Lastly, I'll conclude this PSA with some encouraging news about CPR from Sweden. Almost one third of Sweden's population of 9.6 million is trained in CPR. That fact in and of itself is pretty amazing and worth celebrating, but the Swedes continue to go above and beyond to find ways to help their citizens survive a cardiac arrest. In The New England Journal of Medicine published June 11, 2015 Swedish researchers published two articles back-to-back that explored the effects of early CPR (before EMS services arrived) and on how to dispatch laypersons to the scene of an out-of-hospital cardiac arrest. The first study showed that when CPR was initiated before EMS services arrived, a victim's chances of surviving increased from 4.0% to 10.5%, a significant increase. The second study looked at the use of a new app for people trained in CPR. When a call is made that someone has just suffered a cardiac arrest, the app will notify any users within 500 m of the incident and dispatch them to perform CPR until EMS arrives. This study found that the app resulted in bystander-initiated CPR in 62% of the incidents, as opposed to 46% in the control group (still better than the US average of 32%) when the app was not used. Already some cities and counties across the US are trying to create their own similar apps. Who knows? In a few years or a decade, maybe bystander-initiated CPR will occur in 75% or 80% of cardiac arrest cases, and maybe we can bring the survival rate higher than the dismal 4% or 10.5%.
