The end of OB

24 02 2012

Today was my last day on the Obstetrics service – I start Gyn next week..  After the past week, all I can think is “thank goodness.”  For the most part, I’m a pretty cheerful person, but the last few days have been full of downers. It’s mostly been little things, but you know as well as I do that they can accumulate quickly.

We’ll start with Wednesday.

Out of everything we do on OB, I like being on the Labor and Delivery service the most.  It’s so fun, I love interacting with the moms-to-be in triage and when they are admitted for labor—they are not all the fanatical, shrieking, hot messes that the media portrays; in fact, many of them are happy, others are too zonked on pain meds to express any emotion other than indifference.  Point being, I like taking care of mostly young, healthy people for a change. I like deliveries a lot (though admittedly I was a little nauseated watching my first-ever vaginal delivery), and you might like to know that I can now deliver a placenta without making a mess.

Usually, my “blah days” are the ones where I sit up on L&D and nothing happens.  Wednesday sucked because there were interesting things happening left and right, but I didn’t get to see any of it.  I got there early afternoon only to find all of the residents had disappeared from their usual hangout on the L&D floor.  The only remaining nurse at the station told me one of the women was delivering, and so I went to the room.  Before I got in, though, the attending on call that afternoon rushed by, told me not to go in—which is appalling coming from an attending—and slipped into the room herself.  So I sat by myself for almost 45 minutes while everyone else was at a delivery.

I was pumped for that afternoon because there were 4 c-sections scheduled, and I like being in the OR.  I figured I would get to see at least 2 of them.  False.  When my intern returned from her delivery, she told me to go write an H&P (a giant long interview and chart review) on the patient she had just delivered.   Just as I was standing to leave, the nurse came up to the intern and said “oh, by the way, while I was holding her hand I’m pretty sure something crawled out of her hair.”  The two of them had the “You tell her,” “No, you tell her” conversation for a solid 3 minutes until my intern was like, “Oh, my student can do it.”

And so added to my list of responsibilities was doing a complete fine-toothed comb exam of the patient for lice, not to mention breaking that news to her.  Because, as it turned out, her head was a crawlin’ with critters.

Lice really don’t give me the heebie-jeebies, so I didn’t mind too much.  Frankly, I liked having something to do.  What was irritating that it took several extra minutes and by the time I got back and started to write up the H&P, it was time to go to a C-section.  I asked the intern to scrub in, and she said “I’d like you to finish the H&P.”  Which means “No,” even though I would have finished it later.  It was also irritated because on my midterm eval, the same intern had said that her only criticism was that I wasn’t aggressive enough about doing things in the OR (I have only scrubbed into surgery 3 times), so that particular chance to improve circled the drain.

After H&P #1 was finished, C-sections were still going on and I was assigned H&P #2 by the R4, and then H&P #3 by the R3 (which was never used because it turned out the patient didn’t need to be admitted).  I don’t mind writing them, but after a certain number, these stop being a useful learning experience.  By the time I had finished, it was just after 4 and there was only one more C-section left that afternoon.  I was ticked about the missed opportunities, and the fact that resident after resident had refused to let me tag along for the deliveries.

So around 4:20 everyone started to filter into the nurses’ station, and I was so sure I’d get to go the C-section. Then, at 4:25, who should show up but a first-year med student.  Now, don’t get me wrong, I was one once.  I like my fellow MS1s and MS2s, and I know that it’s important to have them do shadowing in the hospital.  But the thing is that everyone just seems to be kinder to the first- and second-years, and so when she showed up and all of the doctors introduced themselves, and were super nice about including her in things, after being largely ignored for most of the afternoon myself, I was a little jealous.

But when one of the attendings looked at her and said “Ok, let’s get you back to the OR, there’s a C-section soon that would be awesome for you to see,” I was so incredulous that it took me a second to process that I wasn’t about to see the C-section, and my jaw actually dropped a little.  Now I’m partially to blame for this, I know, because I was operating under the delusion that maybe if I busted my butt doing all of the other menial crap that they had asked me to do that day, and had missed 4 other deliveries because of it, that I would somehow be rewarded with the opportunity to scrub in.  In retrospect, this was kind of a stupid and illogical line of thinking, but I believed it at the time because that’s what every “How to be a 3rd year med student” book, handout, and lecture had said.

Legitimately, it felt like I was robbed.  Or stepped on.  Maybe both.

20 minutes later when my intern asked if I’d had fun on L&D that afternoon, I looked at her and said “No, I didn’t.”  She didn’t ask me to elaborate, and I’m glad, because I just felt so frustrated and dejected that I was at the edge of tears.  So she just said thanks for the help, that I’d done a great job, and she used the phrase, “you’ve been thoroughly abused today.”  And I never volunteer to leave early, but when she offered, I thanked her and was out of there ASAP.

And that was my last L&D experience.  Yeah.

A note to the medical students still in B1:  yes, your clinical experience is important, Lord knows that was one of the only things that kept me motivated through those years.  But if there’s ever a time where a resident or attending says “only one student” and the other student is a 3rd or 4th year, let them go.  Your experience right now is for funsies, ours is necessary, and you will get another chance when you do your clinical rotations.  I will be honest, though, even though it wasn’t her fault, I wanted to throttle that first-year a little on Wednesday.  Obviously, I can’t really be angry with you because 90% of the time y’all are clueless. (I was on night call recently and there was a 2nd year shadowing.  The resident ended up having to tell a patient she had Hep C, and even though she knew this would be a good opportunity, she only could have one student in the room.  Instead of saying “decide who’s going,” she ended up deciding that neither of us should because—she told me after the other  student had left— she didn’t want either of us to not feel included. It’s not the MS2’s fault, but like I said, I don’t like missing out on things).  Maybe this sounds petty and selfish, but once you get there, you’ll understand.

[This cartoon is the stereotype.  It’s not always true, only for the female residents at the times when they haven’t eaten, haven’t slept, haven’t showered, or hate life.  On the upside, I’ve only seen a resident treat a patient this way once.  They usually only cop attitudes with the students.  And I have never seen an attending interact this way with anyone]

I said that there were 2 bad days this week, and the other was today.  The morning was a bona-fide train wreck, and because I’m not in the business of throwing my peers under the bus, all I will say about that was that it was a series of miscommunications combined with a number of adverse events and an imbalanced workload.  By the time morning rounds began, though, everything had been pulled together and I don’t think our higher-ups ever knew about our cluster of a morning.  There were only two signs that showed through, one of which was the attending asking my whether I had researched cholestasis of pregnancy (which one of my patients had), and of course I had not because I’d run out of time.  The other was a colleague inadvertently stumbling on a presentation.  No biggie.

After a very short morning in clinic (during which I got to see one of my favorite patients), we had midterm eval meetings, an hour and a half worth of student talks, and a terribly written quiz.  And then the obstetrics portion of the rotation was over.

One last update:   Many of the readers are interested in knowing how the baby that was the subject of my previous post was doing.  The little one has passed away.  I have no idea what her parents are up to, but I’m sure they are devastated.  My initial hatred towards them has dissipated and has been replaced by a strange combination of grief, anger, and pity.  I’m sure that, over time, that will fade, too, and when the emotions no longer taint the memory of those events I will be able to draw from that experience in the future and hopefully will be a better doctor for it.

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5 responses

24 02 2012
Amy

I had cholestasis of pregnancy with my second of three pregnancies. What do you want to know? 🙂

26 02 2012
Anonymous

as you finish OB, so I enter tomorrow.. I *really* hope my experience is happier than your has been

1 03 2012
oldmdgirl

Sounds a lot like my experience on OB. I remember being furious that the M1 “watch a birth” student got to catch a baby, and I’d been there all week and I hadn’t been permitted to yet. The worst is when the resident yells at you in front of them. It makes you feel even dumber than usual.

7 03 2012
Ad2b

My sympathy to all on the team who tried to save the infant. I can’t fathom the anger, sorrow, and other emotions filtering through the group.

18 03 2012
CanDoc

1) Thanks very much for the update from the Saddest post. Sounds like you’re processing this the way most of us do. I’m so sorry that you’ll be haunted by this one for a long time.
2) A pragmatic suggestion (that you can totally ignore). The “history and physical” is seen by the 1st and 2nd year medical student as a thesis-length tome designed to elicit every item of past and current medical history of the patient, their neighborhood, and the entire family tree back to Adam, or at least to the first migration of ancestors to North America, requiring at least 30-60 minutes. Clerkship is the time to refine the H&P to a 10-to-12-minute review of the highlights and pertinent positives and negatives, with examination of only the relevant systems. I know they suck (they REALLY suck), but the truth is that the more you do, the smoother, faster, and better they get (and the more you know what symptoms you’re really aiming for the in the review of systems, rather than just a checklist of, well, everything). Occasionally watching a really skilled clinician do an H&P is also helpful exercise because it provides some modeling about how to make your own more efficient. (And I don’t say this as someone far removed – I’ve been in private practice for almost a decade and I do all my own H&Ps, unless I have an elective learner who is actually “working up” the patient first.) I’m having flashbacks to all the worst parts of clerkship, including the service where I was the only house staff and EVERY pre-op patient required a full pre-op H&P – for cystoscopy, which were booked EVERY 15 minutes ALL DAY from 7:30 am til 4 pm (and seemed to be always done on elderly men with prostate symptoms and a buffet table of medical problems and medications). Oh my. Anyway, like I said in a different post, hang in there. And thanks for sharing your experiences with us in cyberspace.

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