The biggest setback of O&G is how to study for it. I have borrowed about 6 textbooks and only one has been quite useful with the remainder collecting dust on my desk. I got told by one of the Residents today that I had currently been studying for it incorrectly - the majority of the assessment workload is clinical rather than theoretical. That pretty much meant that about 90% of my work was 'irrelevant' to the assessments. But hey, I shouldn't let assessments guide my learning. However, if I am to prove that I am 'competent'.. I might just have to.
My last rotation was in General Practice and being back in hospital was a relief until yesterday. I was reminded of how little of my brain I was using at any given time. Of course, who else to prove that than my hero: Dr. ML - the man who tucks my tail in between my legs and sends me off into a spiral of insecurity after long case presentations.
So I organised to see him yesterday for an O&G long case. Before that, I had a morning in the Antenatal Clinic with an Obstetrician & Gynaecologist Dr. CR. There was a moment of opportunity for me to give her my long case presentation and she agreed to hear it. After my presentation, which was ill-prepared, she was completely lost in the case. In fact, the question at the end was so explain to me why she presented in the first place?
My opening statement was: Courtney is a 24-year-old female of 22 weeks gestation transferred from Victoria Hospital with epigastric pain associated with copious biliary vomiting on a background of congenital vesicoureteric reflux and myelomeningocele.
Dr. CR's response was No no no! You haven't told me anything about her pregnancy other than gestational age!
She was right and then the comment was this case is very complicated for your first. When I discussed the patient's social history and menstrual cycle, I was told it's not relevant, I don't care.
After this, I went out to have a short break and caught up with a 2nd year colleague Anna. It was great speaking to her and catching up. We definitely have mutual respect and I enjoy her company. Then I looked at my watch and it was time to present Dr. ML my long case tailored by Dr. CR.
I enjoyed catching up with him. He told me about his experience last week as a College Examiner - I cannot understand how people know so much. I really don't. Finally the catalyst: what have you got for me?
I introduced him to the case: Courtney is a 24-year-old female of 22+1 gestation complicated by recurrent urinary tract infections and pyelonephritis with G2P0 who presents today with epigastric pain and copious biliary vomiting on a background of 1 miscarriage at 6 weeks gestation.
Dr. ML looked at me calmly and gestured to continue.
This patient presented with what she described as epigastric pain as well as biliary vomiting, however there were no other associated thoracic symptoms such as cough, angina or dyspnoea. The pain was not radiating to any location, nor was it deep-seated. Vomiting occurred in a post-prandial pattern and may or may not be associated with a past medical history of pregnancy-related gastro-oesophageal reflux.
There is a background of recurrent pyelonephritis secondary to vesico-ureteric reflux. The patient is being assessed by the Nephrologist for renal scarring annually. In addition, this patient was recently admitted to hospital for an obstruction of a ventriculo-peritoneal shunt, which was introduced shortly after partuition indicated by Arnold-Chiari Malformation secondary to myelomeningocele.
I identified a few things that I thought could be explaining her presentation. But the list stopped short of about 3 differentials. I felt level with the ground again. He disliked my presentation structure.
But this is what I was taught by Dr. CR.
That made me realise that my initial presentation structure was appropriate, especially because it was a Physician's template - the wholistic view. Dr. ML realised this: You better get used to it. You want to be a surgeon, you will have to get used to talking their language, regardless of how you feel. Just never forget that there is a person attached to that appendix you're removing that must be managed as much as the appendicitis.
The wholistic view must never be forgotten. The patient, regardless of their presentation, must be considered a whole person - not an appendix, hernia or myocardial infarct. It's sad to see that most of medicine is becoming this way.
I am (slowly) reading Atul Gawande's 'The Checklist Manifesto', and one of the things he talks about is the increasing superspecialisation of medicine, prompted by the huge increases in knowledge over the past century.
ReplyDeleteWhile I agree with you that the holistic view is crucial for our patients, it doesn't surprise me that some of your supervisors tend to hone in on their 'own' organ system. I imagine they don't see many patients with myelomeningoceles! I'm glad to know that there are still doctors out there who ascribe to the former view, though.