Life is like a Speculum Exam

For those of you (men) who are unfamiliar, a speculum is a much feared medical device used to visualize a woman's cervix during a pelvic exam. You put it in and then crank it open. Women hate them, and medical students don't really know how to handle them (biggest challenge: finding the cervix!). These devices are actually genius, and save women's lives by allowing us to diagnose cervical cancer (among many other diseases). But having had a few pelvic exams in my life, I have to say that no woman loves a speculum.

During second year, we were taught how to do speculum / pelvic exams on standardized patients. Women who demonstrated how to do the exams on their own bodies. They were able to tell us when we were doing something incorrectly, and if we were making them uncomfortable - verbally, emotionally, or physically. They could kindly inform us when we said something stupid, or worse, something insensitive. I distinctly remember one of my male classmates accidentally saying "I am going to enter you now." (We all laughed, including the standardized patient.) Using a speculum isn't just about placing it correctly, or maneuvering the different pieces of the device. It is also about language, attitude, and respect. A lot like my life right now.

The past two weeks I have done at least 15 pelvic exams with at least ten different supervising doctors / nurses / midwives / medical assistants. And to my frustration, every single supervisor wanted me to use the speculum in a different way. My first preceptor, Dr. Bay, showed me how she used the speculum - the correct placement, sequence of events, etc. With my second preceptor, Dr. State, I followed those same instructions exactly. After the physical exam, despite following every step described by Dr. Bay, Dr. State took me back to his office and informed me that I was "doing it wrong." This happened ten times. Every supervisor that I worked with wanted me to use the speculum in a different way. After all of those exams, I feel like healthcare providers need to conform the pelvic exam based on each patient's personality, anatomy, medical history, and one specific technique won't work on every single woman.

Like the speculum exam, being a third year medical student is all about conforming to the wants and needs of the people around me. The needs of my patients, but also those of the residents, doctors, and other healthcare providers that I encounter. Like a speculum exam, my success depends not only on knowing the facts and the technical aspects of physical exam but also on the way I interact with each team that I work with.

I have definitely learned a lot from each pelvic exam. I am  still somewhat confused by the number of ways a speculum can be placed and which is least unpleasant for my patients (because honestly, there is no way for this exam to be pleasant). A midwife told me I should borrow a speculum and see what feels the best on myself. I am not sure if I am that committed to mastering the speculum exam, or if there is really one superior way to use a speculum. I guess (also similar to my medical school life) I just need more practice to get the hang of it!

Chosing my Fluids and Night Float on L&D

I'm adapting well to my bottom-of-the-totem-pole role. I have shed my title of M15 back at the library of Tufts and am now referred to as an MS3 at Baystate Medical Center, otherwise known as a clumsy, know-nothing, overly-enthusiastic, in-the-way annoyance to any part of the healthcare team. I know so much, but I know nothing about the true ins and outs of the hospital.

Last week, after completing my Family Medicine clerkship, I started my journey into the awesome and powerful world of Obstetrics & Gynecology - OB/GYN.

I LOVE IT. As one of the most outspoken reproductive justice activists in my class (and Boston), nobody should be all that shocked... And soooo much oxytocin!!!

A few weeks ago at a dinner function, Dr. Wiczyk, the OB/GYN Clerkship Director of Baystate, mentioned to a group of MS3s that when considering our future, we need to "Chose our Fluids." She went on to explain that she can't stand mucus, sputum, earwax, nasal discharge, or saliva, but has no problem with feces, semen, vaginal discharge, blood, or urine. Dr. Piccioni, the Medicine Clerkship Director chirped in that he had to get friendly with all of the bodily fluids, and Dr. W. smiled and responded, "Exactly, you chose ALL of the fluids!" After Family Medicine I was so sure that I wanted to do Family Medicine. But now I am back in the land of ambivalence. And I feel like I am sitting in a big bucket of fluids that I don't know what to do with... ew! Medical professionals sure know how to chose great dinner conversations.

(I hope that the title of this post was warning enough of the graphic nature of my ramblings this evening.)

So last week I started with Night Float on Labor & Delivery (L&D). I spent my nights checking fetal heart tracings; playing with newborns; estimating fetal weights; guessing cervical dilation; chatting about post-partum contraception, baby names, and breastfeeding; scrubbing into cesarean sections; and of course CATCHING BABIES! I saw 7 vaginal births and 3 cesarean sections (2 were emergencies!). I pulled babies' heads out of vaginas and suture Pfanensteil incisions closed with subcuticular stitching. I drew cord blood, inspected placentas, and learned how to stitch women back together again. The residents, nurses, scrub techs, and even the cleaning staff were incredible to work with - patient, fun, friendly, helpful. I could not have had a better experience.

I think my favorite moments were spent with mothers and their babies during post-partum checks, when we got to chat about the delivery, discuss the bright future for their newborn, and get to know each other. No matter what age, what background, what expletives these women used during labor - during the post-partum checks all of the mothers looked at their newborns gushing with love (and oxytocin). A few of them even brought me to tears. I may not EVER want to have a vaginal delivery of my own, but it absolutely seems worth it when I catch a new mom and new baby staring at each other.


------

Other topics not covered in this post that need to be mentioned:
1. I saw one of those "I didn't know I was pregnant" patients. It is real.
2. Saw a lot of teen pregnancies. Although I loved my teen moms (they are so strong!) we as a society need to do better at sexual education, and teens should use long-acting reversible contraceptives (Nexplenon, Mirena, or ParaGard), not daily or weekly methods that they are likely to misuse or forget!
3. OB/GYNs only take care of the pregnancy until birth - once the baby is born, they hand him/her off and the nurses do everything or call Peds. There is one exception - OB/GYNs do circumcisions!

MI in NoHo and other Fam Med Adventures

I love to talk in abbrevs. IMO*, its NBD* to shorten the way you speak. Medically, acronyms and abbreviations save lives by saving doctors' time.

So this entry is dedicated to all my abbrevs lovers out there. XOXO I'll use as many abbrevs as poss.

I am currently in my Fam Med clerkship. I was supposed to be in Boston rotating with a diff provider, but luckily I ended up rotating at Pioneer Valley Family Medicine (PVFM), a primary care branch of my fave hospital (Baystate, of course, see my last post...)

At one of my four desks in our new office!

PVFM is located in the beattiful town of Northampton, or as we like to call it, NoHo. In our Fam Med clerkship, we talk a lot about what "patient population" we get to work with. Some students are working in "underserved," or "hispanic," or "suburban" sites. My site's patient population is lesbian. According to my reliable source (Wikipedia), NoHo has the highest number of lesbian couples per capita than any other US city. Go NoHo! In my explorations and patient encounters, I would definitely believe Wikipedia's claim. I also spent two days with Spanish-speaking patients in Springfield. Between NoHo and Springfield I have seen people of all ages, genders, and sexual orientations, including a plump 9 month old baby boy and a sassy 94 year old woman.

Because I have been on this whole "becoming a doctor" path forever, one of my least favorite questions is "What do you want to be when you grow up?" When you are five, it's cute to say "a doctor." In college, people think (and say) that you'll never make it. In medical school, you start getting asked "What specialty do you want to do when you grow up?" This question is even worse, because I have no idea, and have to decide really soon. Also, depending on who you are talking to, and what your answer is, you get a lot of advice (or judgement) that you didn't ask for. I was with a good friend and classmate of mine last year, who, when asked what specialty he wants to go into, replied with, "I'm not sure, what is your suggestion?" I loved his strategy, and have used that answer a lot, but usually I say, "Probably Family Medicine with a focus on family planning."

PVFM put my face on the wall!

So as a probable yet undecided future family doctor, I obviously love my Family Medicine clerkship. It has a little bit of everything. In two and a half weeks, I have talked to patients about erotica novels, the color of their poop, what depression feels like, how their herbal medicines work, unexpected pregnancies, why they should quit smoking, the weirdest foods they ate in China, their biggest health goals, their end of life plans. Not to mention what they actually came to the office for... I like learning how to prevent disease, how to treat disease, and how to manage and distribute patients to the specialists they need to see. I also like to talk, and boy do we talk.

I lost my abbrevs for a bit, but they are back. In medical school, MI means myocardial infarction which means heart attack which means PANIC, BAD STUFF HAPPENING. In my Fam Med clerkship, however, there is another more positive and equally important MI: Motivational Interviewing.

MI means no nagging or lecturing. MI means letting your patient talk, and empowering them come up with their own reasons to make positive behavior changes that will benefit their health. MI means listening and reflecting the patient's ambivalence. For example, today, I helped a patient chose a day that he will quit smoking. It is not easy to get people to put down the cigs. How did I do it? MI.

It wasn't easy, but I listened and I listened and I listened, and then I summarized what the patient had said. "Sounds like you want to quit, and know it would help your health if you quit, but quitting seems like a pretty big challenge right now. What would it take for you to feel ready to quit?" And then the patient said, "You know what, I'm just being lazy. I quit before, and I can do it again. I already know how." So we set a date. BAM. He was MI'ed.

MI doesn't mean that my patient will actually quit on June 8th. But science says that the more doctors talk to patients about healthy behavior changes, the more likely they will make them. Tobacco use, diet and physical activity, and misuse of alcohol are the top modifiable risk factors for death and disease in the US. Taking the time to MI some patients is well worth it.

To wrap up my particularly non-sequitor discussion of Fam Med, MI, NoHo, and abbrevs, I want to share the way my supervising doctors write their notes.

Instead of writing (excuse the medspeak):
Head, Eyes, Ears, Nose, and Throat: Normocephalic atraumatic, mucous membranes moist, extraocular muscles intact, pupils equally round and reactive to light and accommodation bilaterally, bilateral tympanic membrane intact and reactive to light, bilateral sclera anicteric, no conjunctival injection

They write this: 
HEENT: NCAT, MMM, EOMI, PEERLA, b/l TM intact, b/l sclera anicteric, no conjunctival injection

I am also slowly getting better at writing notes about patient interactions, and I am rapidly getting better at translating my medspeak into medabbrevs. Good thing I came in with a strong background in the art of abbrevs.

(I meant to discuss public health and joy in practice, too, but got carried away with the abbrevs. Maybe next time?)







*This is for you, Mom: IMO = in my opinion, and NBD = no big deal

Baystate Pride

Time for a major update. I have MOVED to Springfield, Massachusetts for my third year of medical school.

So what is third year? Honestly, until it started I wasn't so sure myself. I've heard a lot of rumors about what it is like, and have seen former third year students wandering around hospitals like zombies in white coats. When I moved into my beautiful and humungous apartment in Chicopee with my new and awesome roommates, Nicole and Falafel (the cat, not the food), I got a peek of what third year might be like. The guy who lived here before us just finished third year. When we moved in he pulled a dusty dry erase board with a message for us down and smacked it onto the front of our fridge. He told us it was a message he got from the third years who lived here before he did, and that he felt the same way and saved the board for us. I hope that this wont be "the worst year of our lives," but just in case, we changed the dry erase board to something a bit more positive.

Yep, third year is supposedly "challenging." We rotate through 2-4 electives and 6 core clerkships of Family Medicine, Obstetrics and Gynecology (OB/GYN), Internal Medicine, Pediatrics, Psychiatry, and Surgery. Depending on the rotation, we work between 40 and at maximum 80 hours a week with doctors caring for patients, and then go home and do homework and read about everything we treated. We are expected to know everything, and to speed up health care. In reality, we know close to nothing and slow everyone down (or at least that is how I feel a lot of the time).

Luckily for us, Tufts had their first ever Orientation for third year this year, to make us feel just a little bit more prepared. We practiced placing catheters, drawing blood, suturing (photo of some of my first stitches - other than the ones I did on the Thanksgiving turkey this year...), and went over how to communicate with busy doctors. They like to call this communication style "presenting," and it involves using as many big jargony medical terms as possible in the shortest amount of time needed to convey the most important information about a patient to their doctor.

I. Love. Baystate. Ok, it may be really early, and I may not exactly be rotating INSIDE the hospital, but I love the mission (to improve the health of the people in our communities every day, with quality and compassion), the culture, the people, the ambiance, the je ne sais quoi. I just love it.

Lets talk Baystate. Baystate has won too many awards for me to keep track of, but if you want to see them (Mom, this is for you), dig into the Baystate Trophy Closet. I found the picture to the left in a Consumer Reports magazine - Leapfrog rated Baystate in the Top 10 teaching hospitals based on five key safety and quality metrics (readmission rates, complications, communication, CT scan overuse, and infections). TOP TEN!

Of equal importance to me (AKA a medical / public health student, not a patient) is that the doctors and educators and medical teams love having students here. They love to teach, and they take pride in the quality care they provide to their patients and the quality education that they provide to us. And that pride is clearly contageous. 

Pathologically Delicious

I am taking Step One tomorrow. Not to be a super dork, but I actually enjoyed studying for boards. Obviously not all of it, let me explain.

Studying for boards is life consuming. I spent about 12-15 hours a day pouring over facts and drug names, side effects and pathology slides. And doing HORRIBLY on a question bank. It was exhausting, frustrating, mind numbing, but I learned a ridiculous amount of information. Some of it was SO CRAZY!!! Like Lichtenburg figures (Google that NOW - lightning tattoos, anyone?).

And between the hours of learning and endless question answering, I got to spend time with my amazing and hilarious family. Not to mention my new family here at Tufts. Studying with everyone at Sackler for the last time for a long time was, as usual, super goofy. Pictures on whiteboards. Headstands. Quests to find the free food before everyone else. Freak outs. Sackleritis. Lots of memories to look back on fondly. Hopefully I will remember not only the facts and signs and symptoms, but also the amazing memories I made on Harrison Ave.

Also - because I not so secretly love pathology (and super obviously am obsessed with food), I entertained myself during the studying by keeping track of all pathology that was described in the literature with culinary terms. I did a lot of Google image searches. Maybe someday I'll make a coffee table / cookbook with pictures and recipes to go along with the craziest diseases (don't steal this idea - I will NEVER forgive you). Gross? Maybe. Either way, here is my final list. Enjoy!

Sample of my list: 
 

• Anchovy paste exudate - entamoeba histolytic
• Berry aneurism
• Chocolate cyst - endometriosis
• Drumstick bodies – Barr bodies in neutrophils
• Eggshell calcifications on CXR – silicosis
• Fish-mouth valve - mitral stenosis from chronic rheumatic fever
• Green apple birefringence - amylodosis
• Honey crusted vesicles – herpes, impetigo
• Ice cream cone sign – malleus and incus on HRCT
• Jelly belly - pseudomyxoma peritoneus
• Kidney-bean nucleus - histiocytes
• Lemon sign - concave frontal bones on fetal ultrasound indicating spina bifida
• Milk leg - phlegmasia alba dolens
• Onion skin bone - Ewing sarcoma
• Prune belly syndrome - lack of abdominal musculature
• Rice-water diarrhea - cholera
• Scrambled eggs and ketchup - Cmv retinitis
• Tea-colored urine - porphyria cutanea tarda

• Vegetation - fibrin and bacteria collection on a heart valve
• Watermelon stomach - gastric antral vascular ectasia

The full list will be released someday - work in progress!

Sources: Goljan Path, First Aid, Pathoma,Terry SI, Hanchard B, Gastrology: the use of culinary terms in medicine. Br Med J 1979;ii:1636-9,  foodmedicaleponyms.blogspot.com,  the internet, random friends, professors, etc.

Guest blogger: Hanka

My little sister is my first guest blogger!

Hannah missed two days of her hippie dippie private school (to go to the Bahamas with my parents - not fair) so her teacher, who she calls Jake..., told her to write a paper rather than do the easy assignment all her friends got to do. Her mission: write a paper in the style of Kafka. She was not happy about the assignment and didn't know what to do, but she eventually figured it out and came up with this. I am super proud of her and super entertained by her screw you attitude. Enjoy!

Part 1:

The girl opens her computer. An email from him entitled “Your Mission” is at the top of her inbox. As she reads over the requirements of her assignment, her heart sinks. Her brain has already begun its futile attempt at finding ideas, it searches and searches but nothing surfaces. She begins to accept that this is not a task she will be able to accomplish easily. Her fate is in his hands, and she knows if she does not accomplish this task, there will be consequences.

                She looks outside for some type of inspiration. There is no sun. Only dark grey clouds and a light mist falling from the sky. It’s as if the sky is a reflection of what is inside her brain, no light, not even the slightest glimmer of an idea shining through the dark clouds of doubt.

She stares at the blank page in front of her and begins to write, the feeling of complete failure already prevalent in every word she scribbles. The words sound even duller on paper than they did in her head. She crumples the paper as tears of frustration fall from her eyes. The words “I’m not good enough” repeat over and over in her head.

                Suddenly the girl realizes that she has time. “This assignment does not need to be completed until later,” she tells herself. She decides to carry on with her everyday activities. She goes to school and work and volunteering, she spends time with her friends and her family. But no matter where she goes, whom she’s with, or what she’s doing, the thought of her assignment follows her like a shadow, its dark and ominous presence intruding on her every thought.

                Every night before she goes to bed, she runs over what she must do in her mind and prays that she will wake up with some idea of how to accomplish this overbearing assignment.

Part 2:

It is the day before the deadline. Her assignment is due tomorrow. How will she accomplish it? Who can she ask for help? Does anybody even care if she fails? All these questions and more race through her mind. And then suddenly she realizes that nobody can help her. Nobody can do this assignment for her. It is completely up to her to come up with something, anything to write. Feelings of helplessness, abandonment and frustration cloud her every thought making it impossible for her to come up with an idea. Her mind is going in circles, as if she is having a conversation with herself inside her head.

“Do I really have to do this?”

 “It has to be done. There is no question.”

“ Who can help me?”

“Nobody. This is up to you”

“What do I do now?”

“Write something, anything, just get it over with.”

                As she begins to write embarrassment creeps up on her making her feel insecure and incapable of continuing. She knows it sounds stupid. She knows that he will think she’s dumb as he reads what she’s turned in to him.

                Once again she crumples the paper in front of her. She hates how unproductive she is being. She hates how dumb every word that comes from her pencil sounds. She hates this assignment, everything about it. Once again, frustrated tears fall from her eyes as she picks up her phone. It rings.

“Hello?”

“Help me.”

“What’s up?”

“I can’t do this assignment. I can’t.”

“Just be creative, let your creative juices flow.”

                 Creativity. The one subject her brain has yet to develop. Or probably will never develop all together. This exact thing is what is inhibiting her ability to complete this assignment. She realizes her friend will be no help.

“Okay, thanks.”

“Good luck!”

“Bye.”

                Suddenly she realizes she has spent the past week agonizing over this assignment and it has gotten her nowhere. She knows what she has to do. She will write something, anything and follow the guidelines no matter how stupid it sounds. She must turn something into him, to avoid the horrible consequences she’d be facing if she didn’t.

Part 3:

                She is once again sitting at her desk with a piece of paper in front of her. Hours have passed. It is close to midnight and her eyelids are beginning to feel heavier and heavier with every tick of the clock on her wall.

                Three pages. She has written three pages and only has two more to go. She begins her writing at the top of the fourth page. That’s when she feels it, the subtle shaking of the ground beneath her feet.

                She looks up from her paper, alarmed.

                The shaking becomes stronger and more violent; pictures are falling from the walls, furniture crashing to the floor around her. She stands up from the desk and runs to the door but trips on a pair of shoes, as she’s falling to the ground she hits her head on her dresser, pain coursing through her as she hits the floor.

                She can no longer tell if it’s the earthquake making the room around her shake and spin, or if it’s a result of the impact.

                “My assignment. I didn’t finish my assignment.” She thinks to herself.

                Stars are creeping into her field of vision. The fan on the ceiling above her head is shaking vigorously. If she weren’t so preoccupied with the thought of her unfinished assignment she may have noticed that it was beginning to come loose.

                Her last thought before slipping completely under is of how she spent the last week agonizing over this project and she didn’t even finish it.

                As the house continues to shake, the fan falls from the ceiling onto her head.

                “Hannah!!! Are you okay?!” Her mom calls out to her and runs up the stairs.

                There is no response, and as her mom turns the corner into her room she begins to scream. She screams and screams until the shaking stops and lies down next to her daughter as she sobs. The papers with the unfinished assignment written in Hannah’s neat handwriting float silently to the ground next to their bodies.

Blog for Choice 2013: Roe vs. Wade Anniversary Cake

This post is part of Blog for Choice 2013, launched by Boston Students for Sexual and Reproductive Justice (BSSRJ).

Find this post and more Blog for Choice 2013 entries at blogforchoice.blogspot.com.

Last week I bought a cake, had the baker write "Roe vs. Wade" on it, lit some candles, and sang an anniversary song with friends from multiple graduate programs across the city of Boston who love reproductive justice as much as I do.

Roe v. Wade means that women can make their own decisions about their sex, their reproduction, their health, their families, their lives. Definitely deserves a cake. But to most of my peers, it doesn't even deserve an opened email. Here in Massachusetts we have a surplus of abortion providers and insurance-covered abortions for women on state-run health insurance. Women feel safe. But that safety has lowered our defenses. It seems to me that the people of Massachusetts have stopped fighting for reproductive justice, probably because they feel like the fight is over. That we won.

In my medical school ethics class, more than 90% of my classmates, when anonymously polled, identified as "pro-choice." As president of our Medical Students for Choice (MSFC) chapter, I can tell you that we don't even have 25% of my medical school class on our email list. And probably less than 10% of my class attend MSFC events. I often wonder - where is this mysterious pro-choice majority?

Well, pro-choice ladies and gentlemen of my class, Massachusetts, and the world - show yourselves! The fight is not over. Not here, not anywhere. Here in the liberally blue and fabulous Massachusetts that we all love, there are plenty of laws restricting women's access to abortions (click HERE or HERE for more information), and dozens more being proposed in our state house and senate each year. Not to mention any of the crazy and mind-bogglingly backwards things going on in our country's red states. Not to mention other countries where abortion is often out of the question, completely illegal, never, no way, don't even think about it. Where women die because they have no other choice.

Peers, fellow millenials, women, men, everyone - my only request is that you care. Care that we have a lot of rights, but we still have a long way to go as a global community. Don't sit around waiting for someone to poll you anonymously or for a funny meme to catch your eye or for something really bad to happen before you put on your reprohttp://www.lawlib.state.ma.us/index.htmlductive justice hat. Wear that hat all the time. Don't be part of the silent pro-choice majority. Share your stories. Blog. React. Write letters to representatives. Discuss the current issues in your state. Volunteer.

And today, celebrate that it is the 40th Anniversary of Roe v. Wade. Light candles, sing a song and eat some Roe vs. Wade cake! Celebrate that we have come a long way. Celebrate our victories. Just don't forget that we still have a lot left to fight for.

This blog post is part of a number of different Blog for Choice initiatives.

• Boston Students for Sexual and Reproductive Justice Blog for Choice
  bostonreprojustice.blogspot.com
• NARAL Pro-Choice America Blog for Choice Day 2013
  blogforchoice.com
• Law Students (and friends) for Reproductive Justice National
  reporepro.lsrj.org