Surviving an Ob/Gyn Rotation

30 Oct

Ob/Gyn Rotations have notoriously gone down in history for medical students as a “Love it or Hate it” rotation.  As an ob/gyn resident, now the witness of this phenomenon, it’s true.  Students usually join our service not quite knowing what to expect but may have a curious interest, may be extra excited or may be full of disgust and may exit our service with feelings reflecting 180 degrees opposite of their initial thoughts. An Ob/Gyn rotation can be quite an experience depending on what students are exposed to and the type of practice/hospital setting the rotation is set up in. 

Unfortunately, Ob/Gyn residents, attending physicians and nurses are well known for their cat-i-ness. It’s not true everywhere, but a lot of Ob/Gyn involves long hours, lots of patient calls and pages, high risk procedures and unhappy patients which makes the field pretty stressful – until they deliver and then they’re the happiest people in the hospital!  Keep this in mind while you navigate through your ob/gyn rotation and try not to take anything personal… and as a plus one of my favorite blogs “Gomerblog” posted a tongue-in-cheek case report of a friendly Ob/Gyn – they do exist!

Rotation Do’s & Don’ts: 

  • Be early! Ob/Gyn’s round on their patients fairly early because they have surgical cases booked in the morning typically that they need to see before going to the OR with them.  You should pre-round on your patient’s earlier than the attending or resident and be prepared to present them. 
  • If you are on service with a junior and senior resident, the junior resident is probably going to be working all the time; follow this resident unless told otherwise.  It may be more fun to sit at the desk and chat with the senior resident or nurses but as a student, you’re there to get the most patient/learning exposure as possible.  The more you look involved and help out your residents or attendings the more they’ll let you do for patient care typically.
  • When you go into a patient’s room always be cautious if the patient is in stirrups or otherwise exposed. Always make sure to shut the door behind you if it was closed when you walked through it. You can also mute or turn off the TV as a courtesy if you are rounding with your attending and need to have a discussion with the patient.
  • If the resident or attending is doing a procedure (like a cervical check), you can help position the patient, get gel/lube out, etc. If the patient has an epidural it may be an opportunity to ask the resident/attending if you can do a cervical check also. If you are going in for a delivery you can always help hold legs if you’re not scrubbed in and get a closer view of what’s going on.
  • Save the computer work stations for the residents/attending.  They will eventually need to use that space and it’s nice to just start from where you left off, e.g. logged on and not having to ask for their spot back.
  • Try to sit in the front row at a conference or teaching didactic session (this is really important to some residents – they use students to deflect questions from them…)
  • Try not to ask an attending questions when a resident is nearby. The attending almost always asks the resident your question and if they don’t know the answer it puts them on the spot and they may feel like they look bad in front of their attending. Instead, just ask the resident the question later.
  • Which leads to, always make the resident/attending look good.  They will usually take all the credit for whatever you do to help them but again, the more you help your preceptors the more they’ll involve you usually.
  • Sometimes you’ll find yourself doing nothing on rotations, usually you can find little ways to be helpful.  I always had my Epocrates app available on my phone to look up diseases and medication names and dosing, Shots app for immunization schedules, Mediquations for various disease scoring calculators, and gUnit for unit conversions. I also had ob/gyn specific apps such as Perfect OB Wheel to help with gestational age dating.  You can also help by taking notes on patients if you hear something that needs to be done in case it gets forgotten.
  • If you’re starving but know the resident is starving too and you can get away – offer to go get them something (and you can get something too). It’s never really nice to have your food out when everyone else hasn’t gotten away to lunch yet.  Typically, if you offer to get something for the resident they’ll often give you their money or cafeteria card and pay for your lunch too.
  • Always having something to read, a small reference book, up-to-date article or journal article work great. (for Ob/Gyn the American Congress of Obstetricians and Gynecologists (ACOG) publishes Practice Bulletins that work great for this since they’re small and can fold up in your white coat pocket.  If you’re interested in Ob/Gyn you can get a free membership to  the specialty college’s website here: ACOG student membership.
  • There is a lot of surgery in Ob/Gyn – practice and be ready to tie knots and suture, with instruments, right handed, left handed, one-handed, two-handed.

When The Medical Student Asks a Million Questions in Sign-Out

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OR Specific:

  • Read about the patient and surgery before going in to the surgery, know your anatomy and have a general understanding of how the surgery will go.
  • Meet the patient in pre-op or you may not be allowed into the surgery at many residency programs.
  • In any OR it’s usually a medical student and resident’s job to help position the patient, make sure the lights aren’t all tangled (elbows out) – let the resident take the lead on this – if it’s something they do at their program then help out.
  • Always bring a pen and scratch paper in your pocket as I can’t even count the number of times I’ve been the only person in the room with a pen.
  • It never hurts to ask if you can just observe the surgery if there are too many people scrubbing.  For c-sections, depending on the complexity of the case a senior resident, junior resident and attending will scrub so sometimes 3 is enough at the table.  If it’s a 3rd or 4th year resident as surgeon you’re more likely to be able to scrub for that one and most likely just retract and get asked questions.
  • At the end of the case – help clean up the patient, move the patient to their bed, etc.  Do not leave the room until all of the residents/attendings leave; if a resident is still helping do something you should be helping too.

OB Specific:

  • Meet the patient, introduce yourself at the beginning of your shift. Never walk in to a delivery or cervical check if you haven’t met the patient.  If she is up in stirrups or actively pushing that is NEVER the time to meet a patient and ask if it’s okay you’re in the delivery, you will have to wait for the next delivery.
  • Be available, don’t expect people to tell you when a delivery is happening. A lot of students think that their residents will page or find them when someone is about to deliver, but that’s not always possible. L&D moves so quickly, things can happen fast so it’s hard to remember to page someone else if this is happening.
  • Also, never ask if you can do a procedure when you’re in the actual delivery room or OR.  Ask the resident or attending before the delivery/surgery if you can do part of the procedure, e.g. deliver the placenta, etc.
  • When you do history and physicals on Ob/Gyn patients as a student, do everything up to the pelvic exam/cervical exam. The pelvic/cerivical exam must be done with the resident/attending.
    • Ask and know your patient’s OB and GYN related history!
    • Get a pregnancy wheel app (or the real deal) from somewhere and USE IT. Knowing your patient’s G’s P’s, due date and how they are dated (LMP/sono/what trimester) will make you look smart.
    • Be on top of triage… beat your intern/resident to the triage patients and get started with their H&P. Try to learn the basics of what needs to be done to triage a patient and see if you can help your resident gather the supplies they need (portable light, culture swabs, ultrasound, towels, gloves, etc).
  • Review fetal heart monitoring strips frequently; report your findings to your residents and try to write a progress note every 2 hours on patients that are actively laboring. Follow patients on magnesium and write notes every 2-4 hours.
  • If you’re in a delivery that turns into a stat C-Section there’s usually so many people around that it’s difficult to say if you’ll actually scrub.  There are things you can do to be helpful though in an OR then like grabbing surgical hats and masks for everyone, tying gowns, etc – just make sure to watch your sterile field extra closely in this case as this is probably the worst possible time ever to break sterile field. This stuff shows that you’re not just going to be someone in the way and will probably not get kicked out of the room… then you can remain a fly on the wall for the rest of the time.
  • If you find your self in a spot where you don’t know what you’re supposed to do: always ask!  

GYN Specific:

  • Be mindful of the variety of cases on ob/gyn.  Obstetrical cases are usually happy moments for new mothers but gynecological procedures are often scary or sad for women if they just had a miscarriage or if they have a new cancer diagnosis.  Keep this in mind when approaching a surgical case when you are greeting a patient.
  • Ob/Gyn is a great place to practice asking about topics that are often very sensitive for most women such as miscarriage, abortion, sexually transmitted diseases, sex, sexual partners, rape, etc. These are all topics that will come up and you need to be careful about how you ask questions, who you’re asking them in front of (learn how to ask permission to ask medical histories in front of patient’s family), etc.
  • There is a lot of retracting in GYN surgery, like most surgery as a student. Remember, if you are retracting or operating in the vagina it is considered “dirty” even though you are in sterile garb. Never move from pelvis to abdomen without changing gloves.
  • Pelvic exams & Pap smears are often very frightening for a student to perform.  Make sure to have your preceptor walk you through an exam before doing one if you are not comfortable with your pelvic exams.  There are many tips and tricks to make the exam more comfortable and it can really make or break your confidence depending on the success of your examination skills. Check out the link below for a ton of cervix photos.  The cervix is hard to miss so if you’re asking yourself “is that the cervix?” you probably should keep looking for it. 

I very much like the APGO Ob/Gyn Clerkship Guide to Success for advice on ob/gyn rotations and recommend reading it. 

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