What I Learned on my OB/GYN Rotation

OB/GYN happened a few months back, but I haven’t blogged about it yet. Area medical student discovers blogging difficult to schedule during third year. Story on page 12. Ahem. Anyway, here are some more lessons learned:
saying-vaginas-could-save-your-life

  1. The human body is freakin’ amazing, and female bodies are amazing in specific ways. I mean, the human ovary, man. This is an organ that ruptures and heals itself once a month for like thirty years. The first time I saw an ovarian cyst removed, I was confused about why we were closing up when the de-cysted ovary still looked like a frittata, but the attending told me, “In a month or two it will have completely remodeled and repaired itself, like you never know we were here.” That’s pretty wild.
  2. I am not a future surgeon. Yeah I could have told you that before, but I am so strongly interested in reproductive health (this is the one rotation during which I actually looked forward to studying for the stupid SHELF exam) that part of me thought maybe, just maybe. I liked my residents, I loved the patient population, I was interested in the diseases, but I just don’t love the OR. I really like to talk to my patients, which is less fulfilling when they’re unconscious. And I can’t get used to the practice of avoiding contamination by resting my hands on an anesthetized patient as though they were a table.
  3. Here is a list of surgery-adjacent activities that are acutely physically painful: Standing for hours, sitting for hours, holding retractors in the same position for hours, keeping ones hands sterile for hours by folding them over ones thorax as though preparing to break into a chorus of How do you Solve a Problem Like Maria?, being the first person awake in your whole neighborhood (mediated by emotional pain). Have I mentioned I’m about to start my surgery rotation?Miranda
  4. Ovarian cancer really sucks. I’ve made a pest of my self on every rotation since OB/GYN trying to get my superiors to test for ovarian cancer in patients who are in the hospital for, say, psychiatric disorders. As you probably know, the biggest challenge is getting a diagnosis early, because the symptoms are not very specific and are often ignored. If you haven’t yet, tell your gal pals, your girlfriends, your wives, your sisters, and your moms over 40(ish), not to ignore digestive, urinary, or abdominal symptoms. Meanwhile I’ll try to work on their doctors (not the OB/GYNs, though, they’re on it).
  5. Spanish skills are in short supply around here (see the photo below, taken in the surgeon’s lounge, of the cup of soup that had been reserved for a chief resident). Because of cost, interpreters were sometimes only requested on the L&D floor when there were at least three Spanish-speaking patients. The thought of going through labor surrounded by people who can’t understand you gives me chills. As far as my education went, having enough Spanish to hang got me a lot of opportunities to work with patients. But I also found out the hard way while rounding on a patient the morning after her c-section that I didn’t know how to say “pass gas”–I racked my brains unsuccessfully for a Spanish translation of “fart,” and finally wound up acting it out. I figure there’s about a 30% chance the patient in question just wanted to see what I would do. IMG_0421
  6. Among OB/GYNs, gender was a weaker predictor of awesomeness than I expected. The only clinician I observed exhibiting true indifference to patients’ comfort was female. There were certainly some male OB/GYNs who truly believed themselves to be the victims of discrimination, and that was, ahem, frustrating. As one of my female colleagues put it–and in order to honor her original wording while preserving this blog’s PG rating I will be making use of the French word for seal–“Oh, they’re at a disadvantage in one field? Boo Phoque3-ing hoo.”  On the other hand, one of my awesomest male colleagues really clicked with this rotation, and I’m psyched about it, because of things like this: When one of the attendings found out he was considering OB, she encouraged him to talk to some of the male doctors about their experience. “Why would I need to do that?” he answered. “I already talked to the female doctors.” Basically a doctor with humility trumps a doctor whose genitals and/or gender identity matches your own.
Advertisements

Six Times Psychiatry was Accurately Represented in TV or Film

This post was brought to you by my psych rotation. I won’t be telling you anything, really, about my experiences on the psych unit, because these are some of the most vulnerable patients in all of medicine and it doesn’t feel appropriate. Media representations of psychiatry, on the other hand, I will talk about all day. It’s been on my mind ever since the morning I got to sit in on some ECT sessions. ECT, if you’re not familiar, is Electroconvulsive Therapy, colloquially called shock treatments, and if you are familiar it’s probably because you’ve had some. Otherwise chances are you’ve been exposed to some wildly inaccurate conceptions of this medical procedure.

I haven’t experienced ECT as a patient, and wouldn’t presume to speak for those who have. As a rule, however, modern ECT is not represented in media from the patient’s perspective, and for good reason: that would be hard to film, and boring, because patients go through this procedure under anesthesia. In fact it’s kind of boring to watch IRL, in the best possible sense. ECT is performed with the patient 1) asleep and 2) medically prevented from having muscle spasms associated with some types of naturally occurring seizure. The patient points their foot, and makes a face (caused by involuntary muscle contractions, not pain, see above asleepness), and that’s the whole show. Well I guess the machine also makes an inoffensive beep to make sure everyone knows the shock is being administered. But there’s just…not much to see. Do these important details come through in the way ECT is represented in, say, Homeland?

HomelandECT

Haha, not likely! No, Homeland wants you to know that mental health treatment not only ruins careers, it looks and sounds like a living nightmare. At least that’s how it seems by the end of Season 1; I stopped watching after that because of this scene. Also because of the more than slightly exploitative approach to its protagonist (as this blogger put it, “It says a lot that for the most part the obsequious wannabe terrorist was a more sympathetic character than the mentally ill woman he was conning”), because of its casual islamophobia, and because it is a major pet peeve of mine when supposedly hardened, CIA-employed characters say nonsarcastic lines like, “My god. You’re in love with him!”

Look ECT isn’t magic, though TBH it can feel that way when a really sick patient who isn’t responding to medications or therapies starts to get better after having this treatment. This isn’t going to be a summary of the evidence base surrounding its use, though please feel free to post one on your own blog. I raise this issue because I think it typifies the representations of psychiatry and mental health care in popular culture. In contrast to the way medical doctor characters are so often written as relatable heroes (Grey’s Anatomy, E.R.), or at worst as lovable scamps even when their behavior is sociopathic (Scrubs, House), our baseline cultural understanding of psychiatry is pretty different. I object to the double standard. There are deep historical reasons for the mistrust between the public and psychiatrists, but yo, there are deep historical reasons to distrust anyone remotely connected to medicine (paging Dr. J. Marion Sims). I don’t believe the double standard is fair or accurate. The stigma attached to mental illness is bad enough–do we have to stigmatize the treatment of those illnesses too?

And so, by way of counteracting the trope of the sadistic power-mad and also just vanilla-mad shrink, I have assembled a collection of representations that I believe give a more realistic picture of psychiatrists. They’re not hero-healers, they’re just folks, and sometimes they help their patients live with incurable and potentially life-ruining diseases. This is list is by no means comprehensive–hello, I’m in medical school, I don’t have time to watch good TV, much less shows I hate like The Sopranos–but let me know if you’d like to do an updated content analysis some day. Here is a link to an out-of-date scholarly analysis if that’s your bag.

Below the jump the entire post is spoilers. Continue reading

What I Learned on my Radiology Rotation

1. Radiologists are, on average, pretty chill, happy people. They also, on average, swear a lot, which relaxes me and frees up the 25% of my mental effort that usually goes toward not dropping F-bombs, for learning.

2. Most kinds of images are not taken by radiologists themselves, they’re done by radiology technicians. I already knew that, but I’d never thought about it before. An experienced and knowledgeable tech makes all the difference in the world. Incidentally it takes them a buttload of time to train, and they’re highly specialized to the kind of images they take. Most of the techs I asked said that good communication with the doctors was everything. Also they would like the doctors to appreciate that some pictures are just really hard to take, and that they are doing their best.

3. Imaging is a consultation, not an order. The x-ray doesn’t spit out an answer; what you get is another doctor’s assessment of the patient’s condition.

4. Therefore, radiologists really, really, really, really, really, want clinicians to provide a clinical history when they order imaging. What they are looking for and how they interpret what they find are both influenced by the patient’s story. You know, like, everything else in medicine. And no, they can’t look it up in the patient’s chart. Another med student on this rotation with me ran the numbers and figured out that if the radiologists at UW took two minutes for each patient to look into their charts, it would add 7 hours to their day.

5. MRA can stand for Magnetic Resonance Angiography. I now plan to imagine the uglier corners of the internet as arteries.

MRA-Kidneys

6. The experience that trained me the best for reading images is taking Art Humanities in college. In case you were looking for another reason why premeds should get a liberal arts education.

7. ALARA, as you may know, stands for As Low as Reasonably Achievable, and it is the principle that guides exposure to radiation from medical imaging (and other things). I checked, and the number of US babies named Alara is on the rise. How many of their parents are radiologists, and how many are teenagers that are into Magic the Gathering? We’ll never know.

AlaraBabies

One Scholarly Article and One Comic about Talking Pills

First, the serious. One of the papers that came out of my dissertation work has just been published at Annals of Epidemiology (wide grin) and is available here. The paper takes advantage of a historical event, which is the halting of on arm of the Women’s Health Initiative Trial in 2002, after the trial found that the use of estrogen and progesterone in midlife women modestly increased risk of coronary heart disease. After that announcement a lot of women quit their hormonal medications cold turkey, and if you happen to be hooked up with a study that was following a cohort of midlife women before and after that date (which I am), that abrupt shift in prescribing and use of medications creates a natural experiment. My adviser said I can’t call it that but I’m doing it anyway cause I already have my PhD and they can’t take it back. Anyway, point is, we used these conditions to look at an outcome that has never been examined well in a large randomized trial of hormonal medications: sleep apnea. We found that up until the Women’s Health Initiative made its announcement, hormone use was associated with less sleep apnea. After that date, though, the association disappeared. The biology of the medications didn’t change, but its social context did. We argue that is evidence for what we epidemiologists call a Healthy User Bias; in the early period, hormonal medications were a marker for healthiness, and created a spurious association between the meds and lower risk of sleep apnea. So if this is your kind of thing, feel free to check it out at the link above.

And now, the silly.

PillAuditions

[click on comic to see it larger]

I’ve been doing a lot of book learnin’ lately, and I keep getting hung up on this phrase that I see a lot. “This medication/procedure/practice has no role in the treatment of this disease,” is how it goes. It’s code for, “I don’t care how they taught it when you were in med school, stop doing this now before you hurt someone.” It’s always struck me as a sort of odd euphemism. So I made a comic about it.

Why I Don’t Need a Mirror

Like a lot of things that have made my life better, this one started by accident. When we moved into our current apartment, we decided to take the doors off the closets, and the closet doors happened to be where the full length mirrors were installed. I fully intended to put them back up, but in the time it took us to unpack, I began to notice that not having mirrors was changing my behavior. And it was good.

I’m not sure I was fully aware of the Socially Acceptable Outfit Vortex until I was well out of it. But it would go something like this. I would get dressed. I would stop to check myself in the mirror. Something about what I saw made me unhappy–the look I thought was classic turned out to be dowdy, the color combination was too hard to pull off, the length of the hem made my knees look wide. So I would change my top. Back to the mirror. This combination looks weird. Go change into different pants. Back to the mirror. Pretty soon I was just looping between the dresser and the mirror, rejected clothes piling up on the bed. I have been late to work because of this behavior. I have lost so many hours I could have spent doing literally anything else. The cycle never ended in my leaving the house feeling like I had nailed the right outfit, and was ready to take on the world. In fact it almost never left me feeling okay.

SleepingBeauty

When we moved my mirrors to the basement, this behavior essentially ceased. The frankly pretty nutbars routine I’d been performing since early adolescence just fell out of my life. And I did not miss it. In place of the “how do I look” ritual, I was checking in with how the clothes felt. Over time I proved to myself that I could trust my own judgment. It turns out I am sufficiently competent at getting dressed that it’s not usually necessary to check my work.

Life without a full length mirror requires some changes, but some of them I had already made. For example I had gotten rid of the clothes that didn’t fit me. The range of possible sartorial disasters is actually pretty limited when all your clothes fit. On two or three occasions, I got to the office and found that my bike shorts were a tad too long for my skirt. And one time I wore my shirt inside out until 2 in the afternoon. But nothing bad happened because of those mistakes. I turned my shirt right side out and moved on with my life. Eventually I stopped wearing that skirt, and I didn’t miss that either. I began to gravitate to really reliable, low-maintenance garments that required no thought because I knew I liked how they looked on me. Then I went further.

One day I was complaining to my husband about the unfair double standard in professional dress for women and men. I pointed out that his entire process for getting dressed in the morning was 1) Grab the shirt on top of the shirt stack 2) Grab the pants on top of the pants stack. And he has never once tried something on and then come to me for an opinion on whether looks too masculine, or not masculine enough. I told him I just wanted what he had. “Well,” he asked me, “What’s stopping you?”

I took that question seriously. The double standard is real, but it’s up to me how much I choose to bend to it. I started asking myself what, actually, was the point of getting dressed. I’m not using clothes to attract a mate or make a best-dressed list. If I want to intimidate my enemies, I have a better weapons.
Gloria

My work clothes in particular only have one job, which is to perform professionalism. I resent that I am graded on my ability to dress preppy (see also this important piece by Jacob Tobia), but that’s a post for another day. Point is, I do not work at Vogue. Nobody cares if I curate a tasteful capsule wardrobe in a variety of neutrals, or wear a giraffe-print jumpsuit to clinic every day, as long as my cleavage is covered and I don’t wear jeans. If there is a professional advantage to looking trendy, or having a varied and creative wardrobe, the payoff is pretty small proportionate to the amount of time, money, and stress that it requires. I think it’s awesome when other people express themselves creatively through their clothing, but when I looked at it hard I had to admit that most of the time I wasn’t expressing myself, I was just trying to pass for acceptable. So I opted out.

I now wear a black sweater and a black pencil skirt pretty much every day (sub in black jeans on the weekend). Every now and then I have the urge to change things up, but I usually regret it. I can now get ready for work in under ten minutes, and usually don’t have to think about my clothes for the rest of the day unless a baby barfs on me. I don’t wonder how I look cause I know my clothes really well, and I also know my own body.

I always thought of people who didn’t have full-length mirrors as people who couldn’t stand to look at themselves. But I’m pretty sure there are a lot of people with mirrors who also can’t stand to look. I can’t speak for anyone else, but I find I treat my body with more respect when I skip the daily appraisal. I don’t need a mirror to tell me how I look if I know how I see myself.

What I Learned on my Primary Care Rotation

The astute readers among you will have noticed a little change to the header of this blog a few months back. As many of you know I indeed recently finished my PhD, and have returned to medical school, where I have been thrown in with a group of people, some of them 10 years my junior, who have not taken a five-year hiatus from their clinical studies. This afternoon I finished my first of the third-year rotations, the clinical courses in which we are sent out to clinics and hospitals around the state to learn from practicing doctors and try not to get in anyone’s way. I was lucky to be assigned to begin with primary care. Lucky because it is a broad overview which I sorely needed, and lucky because it’s the part of med school I had been waiting for, ever since I started back when Bush II was in office. I got to split my time this summer between a rural family practice clinic, a pediatric clinic here in Madison, and a super-cool nonprofit, and frankly, I loved the whole thing. I started my third year wanting to go into primary care, and nothing that has happened in the past eight weeks has changed my mind. In fact I have quaffed deeply of the primary care kool-aid.

Now, mind you, none of this means I expect a good grade in the course. My performance on my first practical exam of the year can’t really be summarized by one gif alone, but perhaps in combination you’ll get some of the feel of it:

6-Dancing-on-Breads

Titanic

PoopingHippo

Whereas the national board exam was more like:

classic_game_over_screen_by_el_tortuga-d5eeh9l

But in the clinic I was really content. I’m not saying I put my best foot forward with every patient or enjoyed every interaction, cause it’s med school and not The Nexus. Like any other time of my life, the rotation had its highs–like watching a patient and their parent go from “I don’t want to see a med student” to “thank you, that was really helpful.” And it had its lows, like when the earpiece of my stethoscope caught on the hem of my skirt and I accidentally flashed my (male) preceptor–a situation mitigated only by my loyalty to the world’s comfiest and most conservative undies, albeit in flamingo pink.

What I am saying is that I feel more strongly than ever that this is the work I want to do. And I’ve been lucky enough to spend the summer learning from people I really respect, who seem to think I could be good at it some day. I’ve learned a lot in a short time.

So here, in summary, is a list (not exhaustive, thank you very much) of lessons I have learned, and in many cases re-learned, this summer. Some I learned right away, and some I had to mess up repeatedly. Some I didn’t really put together until the rotation was over, and my poor beleaguered preceptors were probably thinking, “How is she not getting this yet?”  Anyway…

  • At this point in my career, my job is to learn how to form an assessment. Even though I’ll pretty much always be wrong.
  • A lot of the job is communication. As much as certain representatives of the medical school have treated my humanities background as an unfortunate handicap, it’s what’s taught me to listen analytically, write, teach, and make an argument. Which is kind of what I do all day now.
  • Before you talk to the patient about anything else, establish the identities of the people they brought with them.
  • My teenage hijinks, though bad decisions at the time, are coming in handy in peds clinic. Apparently, as med students go, I’m hard to shock.
  • I really suck, however, at using tongue depressors. I’ve seen so few oropharynxes that for or all I know 50% of children are born without them.
  • I like working with seniors. The demographic with which I have had the best luck establishing rapport is women over fifty, especially if they are “non-compliant,” and/or believe they are psychic.
  • It is possible for a moth to get stuck inside a human ear canal.
  • Rural medicine is for badasses.
  • With respect to rural populations, my cultural competence has a long way to go. I literally do not understand one sentence on this magazine cover.OutdoorLife
  • It’s on me to recognize the limits of my Spanish. I’m most likely to get in trouble when I’m feeling awkward about making someone repeat themselves.
  • That being said, a lot of patients are pretty stoked to find someone who speaks Spanish at all.
  • People who see the world very differently can be very much in sync when it comes to what they value in medicine
  • A lot of medical students are really excellent people. I have always held my colleagues to a pretty high standard, and sometimes my disappointments have dominated my feelings to the point where I almost forgot just how many fantastic people I had the privilege of knowing in med school. I’ve now met about 20 members of my new class, and I’ve liked all of them. When was the last time you met 20 people in a row in any context and liked them all? I’ve met young people with a lot of wisdom, men who care about women, people who respect their patients not because of some higher calling but just because they basically like people. They’re going to be great doctors.
  • Some doctors are really excellent people, too. My colleagues and myself are in danger of having the compassion ground out of us by a tough and often irrational medical education system, before we ever get out and to practice independently. But I’m beginning to believe most of us will be ok.