During my OB-Gyn rotation, I’ve been working with the great staff of our local Planned Parenthood , and let me just say: Planned Parenthood rocks.

I will admit, fully ignorant of Planned Parenthood beforehand, I thought I’d be doing abortion evaluations. Planned Parenthood equals abortions. That was the extent of my knowledge. I spoke with friends–well-educated, public health-type friends, and that was their same response. “So, did you do any abortions today?”

I was so far, far off base it’s not even funny. * In fact, it may sound ironic, but I’m pretty confident when I say this: No matter what your feelings are about the subject, there would be more abortions performed in this country if Planned Parenthood didn’t exist. Let me explain.

The patients I’ve seen have been, in general, young, healthy women, ages 12 to 26. They come in primarily for three things:

1. annual exams (pap smears, breast exams, etc.),
2. sexually-transmitted infection (STIs) diagnosis and treatment,
3. and birth control.

I see patients of all socio-economic statuses, but most are immigrants or lower-middle class women. Their health knowledge runs the gamut, from the highly educated 12 year-old I saw today, who curiously asked “how exactly do the birth control pills work ?” to the 23 year-old who shrugs and answers questions with a dull, empty look on her face. Almost every single one uses some form of birth control.

This makes sense. Over 90% of women of childbearing age use some sort of contraception method. I quickly became aware that my male gender has allowed me to pass through medical school (and life!) totally ignorant of all of this. My patients came in using almost everything–condoms, the pill, the patch, Nuvaring, Depo–and I was left perplexed. What a humbling role reversal–this was one of the first times it’s been so painfully obvious that my patients are more informed about their health and medicines than me. (This also made me realize that I generally assume I generally know more about medicine than my patients.) Not that the pharmacology or physiology is at all complex or difficult–just that the topics had never really come up before. Birth control was birth control was birth control.

I’ve been having a fantastic time at Planned Parenthood–I’m able to perform a number of pelvic exams and get a good sampling of “normal variation,” and probably the harder part–I’m able to talk very candidly with my patients about their sexual health. It’s great practice just to get used to figuring out how to talk about “sexual activity” and “sexual intercourse,” because it certainly takes practice. You have to unlearn (or at least disengage) the typical social cues in your head that encourage you to avoid the subject or the word, especially since almost none of my patients have had any complaints or concerns with their sexual health. It’s great to see patients in an environment where discussing sexual health is the norm, as it also helps bring a level of normalcy to the encounter.

We give out a ton of contraceptives every day. Condoms, pills, patches, rings, shots. And none of the patients I’ve seen are taking these medications for anything other than preventing pregnancy. They are sexually active, almost always with one, monogamous partner, and they do not want to get pregnant. And by enrolling these largely uninsured teens and young women in California’s Family PACT program , we’re able to provide them with free contraceptives and reproductive health services.

55% of pregnancies in the US are unintended, and of these, 43% are live births, 43% are terminated electively, and 13% end in miscarriage.

All the women I see in clinic are sexually active. And most are working or middle class at best by income standards (the average 2 bedroom apartment in the area runs you at least $1400 a month), most are uninsured, and most do not have another source of medical or reproductive care. And none want to get pregnant.

Now just take away Planned Parenthood, add in the costs to see a health care provider and pay for contraceptives, and imagine how many more of my patients would become pregnant. Keeping everything else the same, you’d find many more women in the difficult position of considering an elective termination of pregnancy.

I am far from zealot or activist–as I said before, I knew nothing before a few weeks ago–but I’ve been incredibly impressed with my short time there, and I’m hoping I’ve educated you as to what Planned Parenthood does in your community, since I was woefully ignorant myself.

*Planned Parenthood provides reproductive health services, annual female gynecologic evaluations, breast exams, pap smears (and management and followup of abnormal pap smears), the HPV vaccine, STI testing including HIV, emergency contraception, vasectomies, patient education–the list goes on and on.

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The dreaded standardized patient pelvic exam was much less dreaded this time around. In contrast to Boobies , written three and a half years ago (seems much longer than that), the breast, genital, and rectal exams are no longer cause for alarm for me. They’re no longer mysterious, frightening territories full of stigma and social awkwardness, amazingly.

Six weeks of OB-Gyn started with a refresher on the female pelvic exam–which was greatly appreciated–and the nervousness I’d previously felt with prior genital exams just wasn’t there. I kept searching for it internally, waiting, expecting at some point to become shaky, laughing as to reveal my discomfort, but it never really happened. Maybe it was that the “patient educator” was a nurse practitioner, and so I felt more comfortable with another health care professional–that this was strictly education, passing information from one generation to another. Maybe it was her 2 foot long, plush, purple model of the female anatomy (Violet the Vulva, of course) that broke the awkwardness. I’m not really sure.

More than anything, I think, it’s just my level of maturity and comfort with patients. It’s a part of the exam that needs to be done for certain complaints, and I need to know how to do it. Step up to the plate, assume the responsibility, and get it done. It’s this new-found attitude and outlook–rapidly advancing especially during last month’s sub-internship–that I think is making me a more assertive, competent medical student (soon-to-be-physician). It’s this same outlook that probably also makes physicians sometimes appear cold or impatient to our patients. While we’re trained to always be emotionally, mentally, and physically ready to perform a potentially emotionally, mentally, and physically uncomfortable portion of the exam, patients aren’t. They often want and need time to “get ready” for it, especially when it’s unexpected. (Sometimes that time isn’t readily available.)

The attitude overall, however, probably makes the exam less awkward. Projecting confidence and normalcy to the exam–that you’ve done it many times, and that it’s pretty much standard operating procedures–helps alleviate some of the potential anxiety a patient may feel. Communication is key. I find using medical terminology to be helpful–asking patients to move their “buttocks” toward the end of the bed, instead of their “butt” just makes it at least sound much more objective–that I am simply the doctor asking a female patient to do something, nothing more. Telling the patient beforehand what will happen, and explaining what he or she may feel helps, too. Body language I think is also key. I often close my eyes and lower my head when listening to heart sounds to help me concentrate on them, but I believe it has the added benefit of ensuring patients that I am touching them for medical purposes only. You never know what prior experiences a patient has had that may make them uncomfortable.

It’s fun to go back and read old blog entries–one of the reasons I’m thrilled I’ve documented this experience–to see where I’ve been, and where I think I may be headed. (Oh, and by the way, Boobies still gets a ridiculous number of hits–it’s listed on the 14th page of Google search results for the word. I can’t possibly imagine what people are actually looking for.)

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The rumors of my demise have been greatly exaggerated, even though my first night of call as a sub-intern was incredibly, incredibly painful . It’s scary to actually admit it, but I… kind of enjoyed my Internal Medicine sub-internship. Yes, I know, this is crazy talk, especially having found my prior medicine months a bit slow, but the constant hypervigilance required to make sure all your patients’ labs get drawn and studies get done is, in a small, small way, similar to the constant nature of the ED.

I enjoyed it so much, and felt so comfortable managing the patients there that I even wondered for a few minutes, “Am I going into the wrong field?” Of course all my medicine colleagues asked me the same thing, and always had their own opinions about Emergency Medicine (I’m used to getting ragged on by pretty much every service by now, so it’s fine).

Calls went incredibly smoothly–probably another reason I enjoyed the month so much. We only capped (received the full number of patients we’re allowed to have) twice in the entire month, once on our first day, and the other we’d capped by 11am, since most of our patients came in overnight and were already tucked in by a fantastic night float resident (thank you, Cheryl!). Taking a note from the ED playbook, I was king of dispo, able to discharge half of my patients by post-call time! (Which often makes you wonder if they needed to be admitted in the first place.)

I definitely learned a ton, and feel comfortable writing diet and DVT prophylaxis orders now. Overall, a really great month.

I think the deal-breaker, however, is summed up today in clinic. I was reading the latest ACEP Newsletter . In the Tricks of the Trade session (written by an awesome mentor of mine, Dr. Michelle Lin!), she mentions unique uses for wall vacuum suction, including how to remove a foreign rectal vegetable using vacuum tubing and bulb suction. What other specialty talks about that in their monthly newsletter?

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The short white coats are all over the hospital these past several months*: the visiting sub-interns are here, hoping to get a leg-up on interview season in their chosen specialties.

*We’re spoiled here at Stanford, as we as medical students get to wear long coats, too. (Our residents sometimes give us crap, saying we never went through the humiliation of a short white coat. We don’t miss them.)

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Maybe this is just a west coast thing, but here’s essentially the only times residents refer to themselves as “Dr. Suchandsuch:”

1. With patients. “Hey there, I’m Dr. Kim. Tell me what brings you to the Emergency Department today?”
2. On the phone, when asking/telling someone to do something. “This is Dr. Brenner, could you connect me to the Hematology lab, please?”
3. On the phone, returning a page, because often the person that paged you only knows your last name. “This is Dr. Serfass, returning a page?”
4. Resident to intern, implying that the intern is qualified as a doctor to make a decision. “I don’t know, Dr. Walker, what antibiotic would you like to give?”
5. Resident to resident, using the term friendly and jokingly because of its importance. “I’m good, how are you today, Doctor Kea?

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Well, that was much better than last time . I went into call with one patient, came out of call with… one patient. Our team went into call with 7 patients, and came out with… 6 patients.

Thank you, gods of call. (And I got most of my ERAS application done wasting my beautiful Saturday away in the hospital!) Now just that damn personal statement.

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Pronounced my first patient just now. The hospice unit called down to our team room, so my resident and I put on our white coats, buttoned them up to look presentable, and headed upstairs.

Luckily there was no family in the room–I’m sure it would have been much more uncomfortable if there had been. Felt the patient: warm; checked for a pulse: none; saw no reaction of the pupils to light. It was very strange, putting a stethoscope to a warm, lifeless chest wall. You’re so used to hearing the rhythmic whooshing of the breath sounds or the lub-dub of the heart that it’s a little un-nerving when there’s nothing there. I moved my stethoscope to a few other places– wait, did I hear something? –but there was simply nothing there.

After a quick confirmation by the resident, we turned turned around to the nurse, looking at the clock on the wall. “Okay, we’ll call it Eight Thirty-Seven. Thanks.”

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Had my first night of subintern call last night. We capped; I admitted 4 patients.

Man it sucked.

I fully recognize it will get easier: that I will get more efficient at entering orders, more comfortable with how detailed my H&P’s need to be, and more able to focus with less sleep. But still, it sucked, and will probably continue to suck.

Now, it wasn’t particularly difficult or anything, and wasn’t far from what I was doing as a medical student on my Medicine clerkship–I was seeing patients on my own, coming up with a differential, assessment/plan, writing the H&P, deciding management, etc. But man, it’s different as a sub-I. I’m essentially being treated as another intern on the team by my attending, resident, and co-interns–which is how I should be treated, and I’m glad it’s that way. But boy, just the slight upgrade in my status and responsibility has made me a wreck: being fully responsible for a patient’s orders, making sure they’re getting the right meds at the right doses, making sure the labs that I ordered get drawn, and the studies I ordered get done is a nightmare. Especially at 2 in the morning.

Things I am sadly but quickly learning:

1. Take nothing for granted. Assume nothing. Even though they’re called “orders,” not “suggestions” or “pretty please requests,” it’s amazing how most of the ORDERS I wrote for (mostly labs that weren’t at scheduled lab draw times) didn’t get done, were completely just ignored, and I wasn’t even called about it. (It doesn’t help that labs on the computer system that have been drawn are described as “active,” whereas ones that are being ignored are labeled as “pending.”) So I wake up this morning, expecting my patients to have finished their rule-outs, since I scheduled their troponins x3 q8hr, and hey, they were never even drawn.
2. If you don’t do it, it’s not going to get done. Sure, I have a fantastic resident who’s standing on the sidelines making sure I’m not forgetting anything, but it’s not like I have an intern co-following like you do as a medical student. If you meant to write for the daily chest xrays, or the stress test, and you just forgot, it probably won’t get done, and that means another day in the hospital for your patient (which is good incentive for you to not forget these things in the first place).
3. It’s much easier to remember what we did for a patient when I’m writing the orders. When co-following, you’re kind of out of the loop on things. There’s this big stream of information that’s constantly going over your head, and when you go off to class for an hour or two as a med student, things can greatly change and you don’t really know about it until the next morning. But when you’re the one thinking, “Okay, what all do I need to do for this patient,” and you actually think it through and write or click which orders you want, it helps. A lot.
4. My team is really trusting me with these patients. I know it’s just a month trial run, but when you look up on the floor whiteboard with patients names and the assigned intern name and pager number after it, it’s “Walker p11028,” not my resident or another intern. Yes, it’s annoying that I still need to call my resident to sign/co-sign any orders that I get called about, and that I can’t just give verbal orders, but while it’s still a Medicine rotation, it’s markedly different from the one you do as a non-sub-intern.

I think I hated mostly the fact that I didn’t feel like I was doing a very good job, on account of my lack of sleep. I really pride myself on the fact that I really try to do my best, and that I’m almost always on top of everything. But during call, I just felt the constant onslaught of work prevented me from having a chance to really think about the patients, read up about them in detail, or even really go through the differential. Most of my patients were pretty straightforward, so it wasn’t much of a problem, but I felt so pushed to constantly be getting orders in, and then seeing the next patient that I wasn’t able to really solidify patients’ stories in my head like I normally am. My presentations the next morning weren’t where I’d have liked them to be, forgetting small bits and pieces and having to go back. Perfectionist, guilty as charged, but I don’t like the feeling of being unsure if I’m providing the 100% best care to my patients, only providing good enough care to get them admitted, stable, and start initial treatments. (Maybe this is just the way call days work, I’m not sure.)

Old school docs and your ragging on the 80-hour work week be damned: interns on little sleep who’ve admitted patients all night, who are writing orders at 2 or 3 in the morning is, in the best of worlds, sub-optimal, and in the worst of worlds, dangerous. Having run around all day and night long, with patients’ stories and allergies and medications confused in your head, and then trying to write orders on them is awful. The mental poop that was coming from my brain was so foul and uncontrollable that it took easily twice as long for me to focus and concentrate to think through my patients. After 3 hours of sleep, the fog and haze was truly no better: I would sit down at a phone, desk, or computer and stare blankly, trying to remember what I was supposed to be doing. I wasn’t particularly sleepy or tired, just with a profound inability to focus. I hated being so out of control of my head, since it’s normally so easy for me to power through things.

It’s not the workload of the resident that’s the taxing part–all of us have pulled our all-nighters, with diminishing returns as the night carries on–it’s the frequent interruptions and constant shifting of attention. If you could just focus on admitting one patient at a time, it’d be great. But at the same time you’re admitting one patient, you’re gearing up, overhearing that your next one has just arrived in the ED; you’re getting a page that a patient needs pain medications when he’s already written for them; you’re trying to ignore your stomach that’s asking to please find something to feed it, while trying to concentrate and remember which is the antibiotic that covers urinary tract infections and which is the one that doesn’t.

I think I can see where Panda is coming from sometimes now. He writes about his frustration with patients, hospitals, and residency training, and from my N of 1 call night, I kind of get it. (Now, this does not mean that I agree with his solutions or placing of blame, of course–it’s not a patient’s fault that the system is messed up, or that they got sick at 4am–but you go through this and think, “God, there has to be a better way.”)

Enough bitching and ranting, as I’ve already talked several people’s heads off today, and now yours, too. Time for bed, and to hopefully work on getting my two other patients discharged: I’m on call again on Saturday.

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Now that I’ve survived my month of ICU (and actually enjoyed it–love that high acuity stuff), I should clear up some misconceptions about the ICU that I definitely had coming in (and that likely most people have about ICUs).

You walk through an Intensive Care Unit and see almost everyone totally sedated and out of it: on a ventilator, with lines going in their arms, legs, necks, urethras, and rectums, and lines of plastic tubing entrapping them, and you think, My God, why are we keeping these poor people alive on a ventilator? They’re too sick to make it, just let them go already! Americans don’t know how to let their loved ones go!

So it turns out: while most people in the ICU at any one time are really sick and totally out of it, every day there’s at least a few people who are getting better, getting various tubes removed from them, and actually getting out of the ICU. I had this big impression that few people make it out of an ICU–that most people die, and the ICU is some sort of “last ditch” effort. While it’s true that we can’t save everyone, and some people are just too sick for us to save, the vast majority of our patients did really well after suffering some seriously major insults to their bodies. It’s truly miraculous what people’s bodies can deal with with some support during the really bad times from the ICU.

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Started my Medicine Sub-I today; anyone have advice for the sub-intern (or intern, for that matter)? Tips and tricks appreciated.

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