Obstetrics and Gynecology: Of birthing, surgery, and nights

Whew, I just finished my OB/Gyn rotation. After those two months of medical exposure, I truly feel like I have only begun the marathon that is MS3/MS4. Both months were challenging in their own ways.

In November, I was introduced to the revered O.R. My inauguration was brief, and much of the mystique and wonder I had built up dissipated within the first week of my month of gynecological surgery. The surgeons and residents I was privileged to work with were focused and skilled, and I have the utmost respect for their craft. Surgery, I found, was demanding in ways I had not anticipated. The focus, diligence, and dynamic coordination required for the routine tasks of surgery was largely new to me in a medical setting. Internal medicine, to contrast, was steeped in speed, intellectual fastidiousness, and static coordination. The O.R. is the here and now; the floor is what was and what will be. The distinction is dramatic, and after experiencing both I can begin to understand the schism between the two disciplines. Moreover, I also can appreciate that while IM is more of a science (to some extent), surgery is an art. The control of every decision in IM guided by evidence cannot readily be replicated in the nuanced motions and subtleties of incisions, cautery, and knots.

“We are all fixing what is broken. It is the task of a lifetime. We’ll leave much unfinished for the next generation.”

Part of me finds dissatisfaction in this. There is an inner desire for certainty in the actions I take. The certainty in art of surgery stems from lifetimes of experience, against which my 25-year old self has comparatively paltry assuredness. And, really it’s a cop out. At its essence, I’m saying there are too many variables in surgery. That’s tantamount to saying there are too many variables in life. There are infinite aspects of in any situation, not simply surgery. I think it’s my engineering background that gives me this aspiration for an ideal action or solution at every turn.  Does medicine simplify many variables into digestible forms that are more interpretable? Blood pressure? Temperature? Possibly. I am not able to determine that. Maybe no one is.

In December, I was exposed to the practice of Obstetrics. In line with the discussion above, the field of OB has similarly a handful of cardinal variables that are critical to its practice – cervical thickness, dilation, contraction frequency, etc. Once mastered, the decision trees are fairly intuitive. Anyways, I was really tested on this rotation. Half of my month of OB was nights, one of the most demanding experiences I have had in medical school thus far. The nights were mixed – some were action packed, some were slow, some haphazard. The adjustment to a nocturnal lifestyle was not smooth, and I found myself craving sleep at times. The best part and the worst part of the rotation was its unabashed spontaneity – at moment’s notice, a C-section case could (and did, many times) step through the door. That readiness required was daunting, and often times, I found myself dreading action towards the end of my shift.

This dread stemmed from a very concrete (and mildly embarrassing) experience I had while on my first week of nights. A patient required a C-section at around 3AM and the team was notified. I had about an hour of sleep at that point, and also had not eaten dinner. I had a vasovagal episode and had to sit down on the floor of the OR in the middle of the case (in the middle of the night), later to be wheeled out against my requests. The ignominy of that event was replayed when the resident reenacted the scene in clinic.

As an aside: one particularly sad part of OB was being part of unsuccessful pregnancies. Intra-uterine fetal demise was unsettling and I cannot begin to fathom the feelings of the patients I saw that underwent such an ordeal.

This rotation was the one I learned the most from during the rotation. My basic science curriculum did not address the nuances of the management of pregnancy; I knew little of pregnancy and its clinical aspects. The hands-on experience I was afforded bridged much of that gap in my knowledge base, and I can say I appreciated it.

 

Second semester

Well, I completed my second semester of medical school a few days ago. The last exams, unsurprisingly, were a wild ride. The semester culminated in a 3-day mental marathon. We had two very specific exams on the final Monday of the term, and two comprehensive, board-style exams that were exhaustive in nature on the final Wednesday. During the final hour of the testing, I genuinely wondered to myself how I would be able to complete a grueling 8-hour examination with 100% mental clarity; here I was struggling to stay focused after a mere 4 and a half.

I realized that I still have 50+ examinations left under my belt before anyone even lets me register for the big one, so it’s an inevitability that I will adapt over time to the increasing stresses of medical academia, proving myself ultimately on the USMLE.

My second semester was rough, and overall I am slightly disappointed in the quality of instruction I received. The 2 exhaustive exams I mentioned were ‘Shelf’ exams written by the NBME, and while I was entirely comfortable taking one (Biochemistry), the other left me asking myself if I even knew the material being tested (Physiology).

Nevertheless, I passed, though not as spectacularly as I did in first semester. The takeaway message for me overall for this set of 15 weeks was simple: study hard, but not to death, and you will be fine. For me, it is not feasible to expect perfection every semester. My goal in studying on this island is to learn medicine and perform well on exams. I’d rather not burn out and be a husk of a human consciousness by going overboard in studying.

The name of this blog was chosen deliberately – “a toilsome peace” – because I need to remind myself that consistency and effort are the backbone of any endeavor I will ever undertake if I intend to undertake them properly. I cannot be impatient with things that matter. Originally, this line of thought – this impatience – stemmed from my frustrations with the medical admissions process and my fitness goals. Differentiating complacency and patience has been my large personal struggle, and it will be many years yet before I am entirely at one with my thoughts, goals and motivations fully. I know at certain points I certainly am at this peace I seek, and at others I am furiously displeased. I am happy that I have the wisdom to recognize that, and more often than not I find myself patient rather than complacent.

In other news, I’ve been thinking a bit more seriously about what I’d like to pursue professionally. I’ve been reading more about hematopoietic stem cell transplantation. It is a therapy that is maturing rapidly and, therapeutically, it has amazing potential. Like any therapy, there are risks and routine use, but what fascinates me is the plethora of applications HSC transplants have – I imagine gene therapy in its fullest form.

However, it is now that I exercise great patience, because, as of now, I am on this island, no labs or full-fledged oncologists anywhere. I will wait, but not complacently, and continue to educate myself so that once I have a real opportunity to research and treat, I will make the most of it.

He goes too fast or too slow for the conditions and when he talks his talk is forever about somewhere else, something else. He’s here but he’s not here. He rejects the here, is unhappy with it, wants to be farther up the trail but when he gets there will be just as unhappy because then it will be “here.” What he’s looking for, what he wants, is all around him, but he doesn’t want that because it is all around him. Every step’s an effort, both physically and spiritually, because he imagines his goal to be external and distant.

Zen and the Art of Motorcycle Maintenance, Robert M. Pirsig

Zen

Some thoughts

I have always heard that medical school involved copious studying, but as with all experiences, it’s impossible to understand a process through anecdote. The sheer volume of material that is presented to us as medical students is so great it is terrifying: a vast, mercurial ocean of correlations, causalities, and outright facts of human development and histology.

Every week the tide of the ocean rises and threatens to sweep me off my feet, but I manage to keep myself firmly planted to the earth and make connections between the information. When I see a term repeated and understand it in a completely different context, I flush with pride because I know I have properly internalized the material.

The subtlety of all this is that I’m only about a month and some into this herculean undertaking. I still have three and a half blocks left of this semester, let alone 4 other semesters.

The thing is, my motivations stem from my desire to be less ignorant about the entirety of human anatomy, microanatomy, and development. After I master these concepts – which are all universal truths – I can harness them to affect the human conditions of my future patients. It is with deep humility that I understand that I am entirely unqualified to hold the tenuous life of a dying patient in my hands. I want to reverse that notion and be able to confidently recreate a person’s life through my academic undertaking. Otherwise, my studying is moot, useless, and in vain. A degree is a piece of paper. Knowledge for knowledge’s sake is, in my opinion, a waste. There should always be some intention behind any academic pursuit. That is the mark of maturity.

The pursuit

In moments of weakness, I often think to myself, I wish I could do ‘X’ or have accomplished ‘X’ by now. Then I snap back to reality, realizing that if I truly wanted these things I would would either (A) already have accomplished them, (B) be working actively to accomplish them, or (C) not really want to accomplish these things.

For instance, I want to be an MD/PhD. No, I am not in such a program, but I am trying to secure a position that will lead me to such a place. If I fail, I will try again, exhausting all feasible options until I reach this goal. If I stop, it is because I did not actually want this. This is how the world works. People arrive at their destinations because they actually want to reach them, not by some wayward happenstance. People don’t get into these programs on a whim. To work on fulfilling projects or be accepted into a place that will let one do such, one must demonstrate that one has the foresight and scope and breadth of knowledge to be trusted in such a position. To do this, one must show it the actions and time-tested record one can show others (a good curriculum vitae)

I know I am whimsical (or as some say, ‘fickle’) about several things, but time will be the test to see how truly I want to persevere at my goals. Will I get an MD? Yes. A PhD? Yes. A muscle up? Yes. In time.

Above, I said exhaust all feasible options. By this, I mean never again having a year like I am having now. Sitting out. Biding my time and working on building my ‘character’ and killing my ego.