Ob/gyn rotation problems

Discussion in 'Clinical Rotations' started by plainolerichie, Jul 22, 2008.

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  1. plainolerichie

    plainolerichie Senior Member 5+ Year Member

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    May 3, 2006
    Okay, so I am on my Ob/Gyn rotation as a third year and it is my first rotation.

    Just a little about me, I am a 24 year old YOUNG looking (18 yo or so looking) male. Point is, I don't look like someone a year or two from being a "doctor" doctor.

    Well since Ob/Gyn deals with a very sensitive area of the body and subjects, some of the residents and doctors I follow would always ask patients if they mind if I come in or stay and watch. They would usually say something short like "POR is a medical school student, is it okay if he comes in?" (of even worse, leave out the "medical" part and just call me a "student." But literally more than half the time they ask, the patients say no to even me watching the most basic things, let alone doing anything, which I really need and am supposed to be doing. Especially today at one clinic, I spent more than half the time outside the room sitting in the nurses station than actually watching learning how to be a ob doctor, like I'm supposed to be doing! It was supposed to be my big "first Ob" visit clinic day, but I was not able to see any! 0 for 8 new mothers today!

    And the same goes to some of the residents on my L and D shifts when they do various procedures, like pap, pelvic exams, GBS, FFN's, cervidil etc, I cannot even go in the room (the other person on my team is a female and she has no problem seeing and doing everything of course!).

    The thing is, some of the doctors and residents (especially older ones) I get to follow in clinic or on L and D don't really even ask and I just go in and watch. For example, this one who would say once I have a glove on and a lubricated speculum in hand "POR is going to do the Pap smear." And that's the only time I get to do anything.

    I understand the July thing with residents, but that shouldn't have much to do with me being in the room and watching/learning. My question is, I feel that the way the doctors and residents I follow ask the patients by just saying "he's a student, can he stay" really is just asking for the patients to say "no." I really feel that they should at least tell them WHY I should be there and how soon I am to becoming a doctor so they don't think I'm just some high schooler or premed shadowing or something. I don't think most patients really know what "third year medical school student" really means "2 years until doctor." Even some people in my family do not know that I'll be a "doctor" in two years, so why would patients?

    I honestly feel that if I were to go into Ob/gyn (which I'm thinking about since I like the medicine, surgery, and patient follow up aspect of it), I would have little experience with sensitive issues like Pap smear and anything like that to really know if I want to go in the field.

    What should I do to get more experience, or at least not kicked out of every room for observing procedures and learning? Would you think it would be cool if I go up to the residents and ask them to give a little blurb to the patients for me, or do what the old doctors tend to do (not really even asking, but more or less telling the patients I'll be there and letting the patients object)? How should I ask them to introduce me to inspire confidence, age, and to project the "I'm supposed to be there to learn" aspect in patients? Or what should I try to say myself to patients?

    Also, any good ways to look older? I have glasses that I do not usually wear (they are black/Indie or Weezer-esque, so I don't think they'd help much, but they do look kinda nerdy). Should I grow facial hair, which I'm not sure I even can? Any suggestions?

    Thanks!

    Edit: Note, I took out the mention of being black from the post description of myself, just to avoid making it stick out like a sore thumb! Maybe it's an issue, maybe not. Either way, race and internet discussion boards don't mix well, so forget I mentioned it.

    EDIT: PLEASE JUST LET THIS THREAD DIE!!!
     
    Last edited: Aug 7, 2008
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  3. futuredo32

    futuredo32 Senior Member 10+ Year Member

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    I'm a Caucasian female and on every outpatient rotation I've had (except a mobile medical clinic for indigent patients), the attending or the MA always asked the patients if I could go in the room. I did a two week outpatient OB/Gyn rotation in a private clinic and didn't do a single pap in two weeks, so if you've actually done one, you're ahead of me. I observed many of them(and I really didn't consider that much of a learning experience.) I did have many occasions where the patient said that I could not enter the exam room as well. I do have another four week OB/Gyn rotation scheduled and part of it is in the resident clinic, so I assume I'll get to do some paps and pelvic exams.

    As a female medical student who knows that you will be a doctor in two years and understands that you need to learn, I wouldn't let students of any gender in the room if I were getting a pelvic exam. Personally, I wouldn't ask the attendings to stop asking the patients if it's ok if you observe or practice pelvic exams on them. Though it's a time for you to be learning, it's more important, IMO, that the patients are comfortable. If Ob/Gyn is something you think you may be interested in, try scheduling an elective at a resident clinic where the patients are used to being subjected to students.
     
  4. I am sorry you are having this problem, and I hope that you come up w/ a good solution. But you should consider that some patients are just uncomfortable w/ any extra people being present during a pretty personal doctor's visit, be that extra person a man or a woman...sorry.
     
  5. docjolly

    docjolly On Cloud Nine, Once Again 10+ Year Member

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    i definitely agree with this, although i suspect that your issue is primarily due to patient preference with your gender (and less so because of any other factors...e.g. you looking young, you being black).

    during my ob/gyn clerkship when i was an MSIII, i felt badly for my male classmates because many of the patients did not feel comfortable...often times, they(the male students), as a whole, were asked to leave the examination room..

    my suggestion to you is to remain optimistic and keep a positive attitude. there isn't much that you can do, in terms how much you are able to see and do...some female patients simply don't want additional people (especially male students) present in the room.

    i wish you all the best :)
     
  6. plainolerichie

    plainolerichie Senior Member 5+ Year Member

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    Yeah, I understand that it is about the patient's wishes ultimately, but I still feel that there is a way the doctors can ask the patient that makes it seem there is a purpose for me to be there I'm not just a random kid in the room, in which they are not.
     
  7. It seems like you are on the right track, i.e. talking the situation out w/ the residents to make sure that they introduce you in a way that gives you more credibility w/ the patient. And chances are, if the residents are more assertive about your role during the visit, you would get to have more hands on experience.
    My guess is that they might not be very comfortable w/ taking responsibility for you and your experience (or lack thereof), and they prefer to let the patients make the "no, thanks" choice.
    From a female perspective, if a doctor asks me if I would consent to a student observing my visit, I would say "no" (sorry, but that's the way it's gotta be). However, if a doctor says something like "This is Richard, the medical student doing his Ob/Gyn rotation w/ us, and he will be doing blah, blah, blah (all procedures that the doctor has already deemed necessary)", I would be less likely to object. It might be a little manipulative, but...
    Good luck to you.
     
  8. LadyWolverine

    LadyWolverine 10+ Year Member

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    I am female, and while on my FM rotation I have never encountered a problem with patients refusing my presence during pelvics/gyn exams. I attribute this to my preceptor's approach: she enters the room like she's on a mission and very busy (which is not stretching the truth in the least) and time is of the essence. Then she tells the patient, "LadyWolverine is my student, and she will be performing your exam while I am in the room. OK?" The patient invariably responds, "Sure."

    I think that much of this comfort stems from the fact that I am also female - I know that I would be very reluctant to let a young male student perform a pelvic exam on me. But I think that a significant chunk of my luck with patients so far has to do with my preceptor's demeanor and attitude while asking her patients for "permission" for me to perform the exam. The patient has the right to speak up and say "No, I would rather have you do it," but so far, it hasn't even come up. Perhaps you and your preceptor(s) could work on a script like this? Even if it only works a fraction of the time, at least you'll be doing more than you are now.
     
  9. plainolerichie

    plainolerichie Senior Member 5+ Year Member

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    But about the whole "politics of third year and residency" do you think it would be a bad idea to ask preceptors and residents, especially preceptors, to spend an extra few seconds to explain or to change the way they introduce me or ask the patients. I think the residents would understand, but the preceptors in clinics may not. If they are annoyed and see me as whining or critical, or slowing everything down, well they write my evals and that could be bad.

    Maybe they don't because they feel like they need to do all the procedures, maybe they really would rather me be out of the room because they know the patient would rather that be the case whether they say so or not. I don't want to be that annoying whining medical school student complaining about not getting to do or see anything, but I feel left out if I were going into Ob/Gyn, especially when I cannot go into the room for anything other than a history.
     
  10. LadyWolverine

    LadyWolverine 10+ Year Member

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    They shouldn't penalize you for asking for a more clearly-defined role on the team. You could explain that your clerkship director has a list of objectives or a checklist of specific experiences that he/she wants you to accomplish by the end of the rotation. I don't think that your superiors are "out to get you." Odds are that they simply are so busy that they sometimes forget what it was like to be a student. It's easy to push the MSIII to the back-burner when there are 20 patients to see.

    Remember that your preceptors agree to participate as your instructors, but not all of them realize what the objectives are for your specific clerkship. An initiative taken on your part to further your educational experience cannot be construed as whining or complaining (as long as you aren't actually whining and complaining)! I think that it's better to rock the boat and risk making a few waves than to sit back and let the rotation and its opportunities pass you by. You will probably get an equally poor grade on a clerkship where you didn't see/learn anything as the one where you were penalized for speaking up for yourself. You need to be proactive in your learning experience and not live in fear of pissing off your superiors. It's not all or nothing - there is a tactful and gentle way to approach your preceptors/attendings/residents and ask for more experience while still remaining on their "good side." Don't whine, complain, or accuse - just state the facts: you are not learning what you need to know, and that you need some help in fixing the situation (the checklist idea is good for that, in my experience - concrete examples of stuff you "should be" doing is helpful to give to superiors an idea of what you are expected to learn).

    At any rate, this has been my approach so far. I admit that I have limited experience, so don't just take my word for it. But I have gotten to do quite a bit by asking/reminding/listing things I need to know, and my current preceptor is still speaking to me :)
     
  11. DarthNeurology

    DarthNeurology 5+ Year Member

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    I think it is O.K. that the attending asks the patients if they want so and so a student examining them. They are the attending and may deliver multiple babies for this patient or do their pap smear every year for decades, the viability of their practice depends on being sensitive. I think it is too much to ask for an attending to just say the student will do the procedure and trample the patient's rights.

    Now, I have taken step 2 CK and the end-of clerkship ob/gyn examination and no where did they ask about how to do a pap smear. More important is evaluating the results of the pap smear and what to do next, these are management issues that make doctors different from midwives who do a ton of pap smears. Because once you see one you can do the next one yourself, I think the hard part is that different patients are different and you need to look around for the cervix, obviously ob/gyn residents are pros.

    Many (most?) internists don't do pap smears and refer patients out to ob/gyns. If you do go into ob/gyn then you will be a pro at them, likewise I would think for family practice residencies, especially those that deal with ob/gyn related stuff. Otherwise I think having seen a couple pap smears and doing a couple is sufficient for internal medicine. I did maybe two dozen pap smears as a student and don't feel that I should have done more. Regardless, ob/gyn residents can be really mean and some ob/gyn attendings have a foul mouth towards and I wouldn't want more abuse by asking to do more paps and change how their office works.

    I think if a physician respects a patient enough to ask them if a student should go in then they won't change "their ways" for you, and asking could possibly make you look insensitive.

    In the end realize that seeing 40 versus 4 pap smears is almost insignificant part of your medical education and that really the issue with you is POWER, i.e. you are the lowly third year medical student and patient's comfort takes priority about giving you access to everything and you just realized how low down on the totem pole you are. I.e. you are more upset about being "locked out" of the room than any true loss of education . . .

    Realize that clinical care comes before medical student education, and in ob/gyn there is a huge sensitivity issue that has to be dealt with well or presumably an ob/gyn doc will get a bad rep. Realize also that as a male ob/gyn attending you will need to beg and ask female nurses/nurse's aides/midwives etc . . . to be your "chaperone" every single time you examine a patient and furthermore many women want a female ob/gyn
     
  12. plainolerichie

    plainolerichie Senior Member 5+ Year Member

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    Firstly, it really is not about power as you assumed! I could see if I were talking about not being able to perform C-section alone but about not being in the room for most gyn patients who I am technically supposed to be seeing and writing up as a student on rotation.

    My problem is not about Step 2, the shelfs, power, my main reason for feeling that I need more experience with gyn patients and pelvic exams is the need for more clinical experience in general. Everything about pelvic exams makes me very uncomfortable now and I am sure many of my patients will have some issues in the future in which I will have to competently (and confidently) perform some exams. If I only see and do a very few pelvic or gyn exams during my Ob/gyn rotation and I am still as insanely uncomfortable then as I am now, I will likely always be very uncomfortable and be a much less competent doctor with any female ob/gyn issue in the future (e.g. gyn referrals). You become more competent and comfortable with exams and diagnoses with experience from something as simple as reflexes to doing open heart surgery. That is why I am worried. Nothing else in medical school will be as sensitive, so I was wondering what I should do. And I am NOT just talking about pap smears!

    And I do need to learn from the many gyn patients for my education. Remember, I'M NOT EVEN IN THE ROOMS. I would like to be more knowledgeable about the exams and how this vs. that infection's discharge looks, different presentations, etc. You do learn from seeing patients, not sitting at the nursing station, and it is hard to see patients if you're not in the room! I thought that's why we even have third year.

    That and one a more current practical problem. By Monday, I supposed to have seen, worked up, and present a gyn patient for a 10 minute presentation. According to the director of our rotation, the clinics are supposed to be our chances to see gyn patients. The mentors and the doctors in charge with our rotations say we should have at least 8 paps minimum (and "easily" as they told us), 5 breast exams. We have a "must see" checklist and most it for me is almost empty in gyn and we are almost half-way through! (And it's a "see" list, but not "do," so I'm not seeing much).

    I am not asking them not to ask the patients, but to explain WHY I am there when they do ask. I feel doing that is still very sensitive, professional, and reasonable. It is very sensitive issue and patient care above all else, but nobody would WANT or prefer some random young guy with little experience in there, either doing the exam or watching without knowing their reason to be there. I just want to make sure the patients know my reason being to learn so that I could be a doctor, and I really don't feel that idea is projected with usual four second intro and my experience suffers.

    Main point, it's not some power trip!
     
    Last edited: Jul 22, 2008
  13. DarthNeurology

    DarthNeurology 5+ Year Member

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    All I can say is that you have to do your best in third year and, no you won't see even 1/4 of what you will have to be competent with, that is why you have to sort of paste things together with duct-tape to make third year work. All I can say is that I am a guy and my residents would maybe 50% of the time ask the patient if it was ok if I was in the room. I would smile at the patient and nod my head in a dorky way and it was fine with them 90% of the time, maybe two patients in all the six weeks said no, but guess what they also didn't want female students. Point being is that you feel that the resident and patients are doing you a diservice by:

    1. Not asking the patient in the right way. Please. Residents are busy and my residents never asked the "right way". Doesn't matter, the patient always looked me over and said yes and I said thank you. You have to make eye contact with the patient.

    2. The patient doesn't like you because you are young, male or black. Please. If you already feel the patient is against you then you have lost. I always smiled at the patient when she entered, put her bag on a stool for her and acted like a gentleman doctor. Even when I was kicked out, maybe two times?? I would tell the patient that "That was ok" and once the patient changed her mind.

    3. You persist to believe that you have some huge wrong done against you. If you do in the future become an ob/gyn then you will gain far better experience in residency and you may do a ob/gyn subI. Residents, even male one, always get enough ob/gyn experience so the smallest violin in the world is playing for you in this scenario.

    4. I volunteered to see extra patients in my ob/gyn rotation, and I saw probably 5 papsmears a day, did some pelvic examinations. Is any third year supposed to tell the difference between a 5 cm and a 4 cm ovary?? Residency is when you learn how to become a doctor.

    When a patient does say it is OK then you work her up on the spot, I always did my workups at the *begining* of the rotation so again if you don't have the workup I would be in the camp to blame you, sorry, you have to get the job done no matter what. If the resident asks a patient if it is ok, you could even politely mention that you need the experience for a write up and would like to ask the patient afterwards more questions, i.e H and P. . .
     
  14. futuredo32

    futuredo32 Senior Member 10+ Year Member

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    It's really great that you want to learn, see, do. But your posts are all about your needs and don't really take into account what the patient wants. If you feel the need for more exposure to gyn than you are getting, it's your issue and not the patient's problem. Patient comfort with the exam trumps your need or desire to see more patients , your comfort levels, and your checklist. You are not the priority in that room, the patient is. If you take your level of discomfort and multiply it by 1,000- that's how uncomfortable many of the female patients are without even having a student in the room.

    Patients may not understand all of the details of medical education, but they generally get the concept of students in a private doctors office/hospital/clinic. Some patients are happy to help educate future physicians, some would rather just see the attending and it's their perogative. Personally, I wouldn't want an attending to coerce a patient into allowing me to perform an exam or even stand in the room.

    As others have said, if paps and pelvic exams are something you need to do well in your particular specialty, you will have more than enough opportunity to learn to do them well during residency. For now, while you are sitting in the hall, outside the patient's room, open whatever book you are using for this rotation and use those minutes to read. Yeast infections in a patient look like those you will see in a book. You are doing rotations to see patients, but there will be down time when you aren't allowed to see patients during other rotations as well. Use your time wisely. See patients who allow you to see them, and make the best of it when you are sitting in the hall.

    This is your first rotation. You will probably go through many of your rotations feeling that you aren't competent in particular areas when the rotation is over and you're not supposed to be. You may go through surgery and feel that you aren't suturing as well as residents or you may go through anesthesia and feel that you aren't proficient at intubating patients. Students aren't supposed to be proficient at everything. Things you will need to do well as a physician will be learned, relearned, and practiced during residency.
     
    Last edited: Jul 23, 2008
  15. plainolerichie

    plainolerichie Senior Member 5+ Year Member

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    Smiling at patients, politely introducing myself and shaking hands, saying "thank you" and "I understand, it is okay" even when kicked out, I've been doing that. I actually think that's the one part of gyn I am competent at it!

    And if you say only two of your patients kicked you out in your ob/gyn rotation, I honestly do not believe you know how I feel. You say patients "looked" you over and said you could stay. They "look me over" and tell me to leave. There must be something I can do and something you did or just who you are that meant they did not kick you out. You sound fairly confident, which could help (I am not and very timid). I don't know what it could be for me, age, general appearance, gender, race, demeanor, etc. I was asking is for suggestions on what I could do or say to avoid missing most gyn patients. If I feel the need for more exposure to gyn patients, then that is why I am asking what "I" should do to get more exposure, and not getting kicked out!

    As far as the sensitivity of the issue for women, I think I mentioned I believe it was one of the more (or dare I say most) sensitive routine issues in medicine. I just feel that's obvious. I could not imagine any women would want me or any third year in the room but most (male and female) students seem not to have as dramatic of my problem of being kicked out of most all rooms.
     
    Last edited: Jul 23, 2008
  16. lil pook

    lil pook Senior Member 7+ Year Member

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    not to make light of your situation, but seriously...

    WHY would you want to stick your fingers inside some nasty, smelly, last cleaned god knows when nether-regions of some chick?

    seriously, dude, i had the opposite experience from you..:(

    yeah, i am a small non-intimidating female, but i had no intentions of going into ob/gyn, and from your post, it sounds like neither do you...

    what i would have given to have your experience on that rotation

    if only
     
  17. vtucci

    vtucci Attending in Emergency Medicine Moderator Emeritus 10+ Year Member

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    It is not just you and it is not just about your gender (I agree with former posters race has likely nothing to do with it and I suspect your appearance with respect to age is not as much of an issue either).

    I got kicked out of my fair share of rooms and I know a lot of my male classmates had much worse luck. I did not do any pap smears during my OB rotation. I did 2 or so during GYN and had way more in my ER rotation.

    Many women do not want anyone but a very trained ob/gyn doing their pap smears and exams. Residents and the newer generation of docs are trained to make sure that the patient's comfort is a top priority (one reason I suspect it has not been an issue with those older docs who state things matter-of-factly) I have classmates who thought I was nuts when I said I would not care if a male student did my exam. But then I do not have modesty issues and understand the importance of education.

    If you really want to learn, see if you can do a shift in a rural or free clinic. Patients there are less likely to object because they are grateful for the care. likewise, as I mentioned, I do way more in emergency medicine. When someone comes in with vaginal bleeding, they do not seem to be as concerned with who does the pap, pelvic as when it is an annual exam.
     
  18. LadyWolverine

    LadyWolverine 10+ Year Member

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    This is definitely part of the reason that I have never been kicked out of a room or had a patient refuse to let me perform the pelvic exam - most of my preceptors' patients have been extremely poor and therefore happy to be getting their problems taken care of. Additionally, many of them have significant Gyn histories and are therefore less squeamish about letting a student examine their more private parts. Ask your clerkship director if there are any attendings/preceptors available who work at clinics that serve this demographic.
     
  19. plainolerichie

    plainolerichie Senior Member 5+ Year Member

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    Just to clarify, I "mentioned" I was black but PLEASE don't think I believe race was my main or only concern as to why, just possibly contributing, maybe, maybe not. But race can and does play a role in the way patients perceive you in medicine (let's not start that flame war :)), so I felt it should have been included in my description of me. I really think how young I look and gender is probably the most important thing in this issue or something else I cannot think of.

    But about free clinics, ALL of my rotations and clinics are in free/walk-in clinics and public hospitals. Most are places for free (or at least for the uninsured, pay for service) prenatal care. They are all in downtown and South Central LA. And most of the women kicking me out the room are young and BLACK like me!!! So I'm not saying it is racism, I don't know why I get kicked out so much. I am just wondering for any suggestions people have to help with the apparent discomfort our patients have towards me in sensitive issues. Ways to introduce myself better, things I should say, ask the residents to say, etc.
     
    Last edited: Jul 26, 2008
  20. QofQuimica

    QofQuimica Seriously, dude, I think you're overreacting.... Lifetime Donor SDN Administrator 10+ Year Member

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    Two things:

    1) This awkwardness works both ways. There are plenty of men who are not comfortable discussing urogenital problems with a female student. I am a white, 33-year-old woman, and I have had a few male patients ask me to leave during the urogenital part of the physical. This is more common with the older generation; many younger guys don't seem to care as much.

    2) Changing your technique to approaching patients can make a huge difference, IMO. If you go in there and start out by asking to do a Pap, sure, lots of women will say no. You are a perfect stranger, and yeah, you being a guy makes that even worse. What I generally do is start by asking a pt if they would mind speaking to me for a few minutes about why they came in today and to go over their meds and allergies. I have never had a pt say no to this. Try to also find out something about her personally (ex. her kids, her hobbies, etc.). If you take ten minutes to try to build up a rapport with the patient during the hx, you can then ask to listen to her heart and lungs. You shouldn't ever be doing a female exam unchaperoned anyway (more for your own protection, not for the patient's), so after performing the rest of your exam (heart, lungs, abdominal, etc.), you go get your preceptor and *then* s/he or you can ask if you can stay for the Pap and breast exam. Some pts will still say no. But if they have just had 20 minutes to get to know you during your H & P first, and you have used that time to build some rapport with them, I think you will have at least some of them say yes. This method has been working very well for me. :)
     
  21. thedrjojo

    thedrjojo Devout follower 7+ Year Member

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    Here is another idea (and i didn't read all the responses so I appologize if someone else said this): Ask the resident/attending if YOU could do the introducing of yourself... I am sure if you go in and start talking being like, I'm the medical student working with Dr. So and so today, would it be alright if I do the exam, or would it be alright if I am here when the doctor does the exam, it makes them a little less likely to shoot you down right away... not always, but if one person says ok to that, you've already done better than last time
     
  22. persia

    persia Member 7+ Year Member

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    Hey plainole,

    You sound like a thoughtful and intelligent person. Even sensitive - in the right ways!

    Ob can have difficult dynamics on many levels but you seem to have hit on one thing - that some preceptors just tell the patient a student will be doing an exam and others 'ask' the patient.

    I can see both sides of the issues, but then again this is not a private hospital. You are working with patients in (I assume) a teaching hospital setting and so they must understand that part of their receiving care there means that they will have to work with a student. Period. That doesn't mean forcing a student on them if they are unwilling, but then they should at least be willing to some extent. Believe me, I was an ugrad at a very private and prestigous university and all of us poor students were subjected to their medical students and residents crowding into the small, curtained booths to look at our various medical conditions and be talked about in the third person. Yeah, it was great. But, I only paid peanuts for the excellent medical care. :D

    As for people who say the burden falls on your student shoulders to rectify this situation - I say that you are not in a position to ultimately change the course of this dynamic. You need a superior like a resident or attending to change the tide. As a student you are too vulnerable and not in a position to take charge. You need someone to enter the room and say "student doctor plainole will be doing part of your exam today, is that ok with you?" but of course, they say it in a way that means this is how it's going to be. Sure it's no choice for the pt but then they have the option of going down the street to the private clinics. Sorry but that's how it is in a teaching hospital.

    See if you can glom onto one of the preceptors who seems to understand that this is your education here. Also, can you politely talk to the course director? Put it in the light of 'really! I want to learn how to do this!' and stress the neutral, positive aspects of the situation. ;)

    Good luck -
     
    Last edited: Jul 23, 2008
  23. bjackrian

    bjackrian Senior Member 10+ Year Member

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    This thread brings up an interesting ethical question: should patients who benefit from having highly trained doctors be ethically obligated to participate in their training? The consensus among the replies seems to be that patient comfort trumps other concerns, so whatever the attending needs to do to make the patient comfortable is right. I think that ethically, the patient is obligated to contribute to medical education by allowing students to participate in her care. Otherwise, we end up with a system where well-informed, confident people will refuse to have students participate in their care and all the training will be done on poorly-informed or unconfident people, which does not seem just.

    In practice, this means that I have no problems with attendings saying that "Medical student X will be doing your exam today" and not explicitly presenting a choice to the patient. I think this is even more true if the patient has chosen to go to an academic hospital/clinic. I got very frustrated at our academic hospital where patients went because they could have the "best" care, but refused to let anyone other than the attending touch them. That seems to me to be exploiting the system to take advantage of the benefits of academic medicine without subjecting themselves to the downsides.

    My $.02.
     
  24. QofQuimica

    QofQuimica Seriously, dude, I think you're overreacting.... Lifetime Donor SDN Administrator 10+ Year Member

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    I disagree that the patient ought to be *forced* to contribute to the medical student's education, even if I accept your argument that s/he is behaving unethically by not doing so. This is about patient autonomy, not patient comfort. No person ever has the right to take away another competent person's ability to make decisions about their medical care. In clinical research, patients must give signed, informed consent to participate. However, if a patient decides to withdraw from a study at any time, s/he is always free to do so with no repercussions, even if it screws up my experiment and inconveniences me. In the clinical realm, poor, uneducated women should not be denied their autonomy just because they can't afford to get healthcare elsewhere. Rich, educated women should not be denied their autonomy just because they know that the hospital is a teaching hospital. In fact, a patient must always be free to change his/her mind and withdraw consent at any time even after having given it, or else the whole concept of autonomy is meaningless.

    When people talk about the art of medicine, this is exactly the kind of thing that they are talking about. Learning how to do a Pap smear is easy. It's a technical procedure; you do a few of them, and then you can do them for the rest of your career. But gaining a perfect stranger's trust to the point where they voluntarily agree to tell you about their sexual history and permit you to examine their genitals is not something that can be learned by rote practice. To put it more bluntly, you have to treat the whole patient, not just her crotch. This starts by respecting her as a fellow human being.
     
  25. villa

    villa all thrilla, no filla 2+ Year Member

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    2 more suggestions...hopefully not toooootally redundant

    I agree with what many of the previous posters have said. Some of your problem is obviously due to gender (as you mentioned your female co-student not having this problem), but of course it may likely have to do with race as well. Those are the two things you can't change.

    1. agreed with QofQ. if at all possible, can you take the history before your preceptor sees the patient? That way you introduce yourself, (as a 3rd medical student interested in ob/gyn), and ideally even listen to heart and lungs (with confidence!) before going back out and presenting the patient. There were a few times when I would walk into a room, and the patient would say, "Oh, no, I only want to see the doctor," and I'd respond, "Of course; do you mind if I just ask some questions before she does the exam?" If the patient said yes, I would take her history then say, "Obviously Dr. - will be doing the exam, but do you mind if I'm in the room?" It was less than doing the exam myself, but it often got me in the room at least.

    2. If you don't take histories first, then approaching the docs who introduce you could be done in a diplomatic way: "I'm actually really interested in this field, and hey look at this checklist of things I haven't done. Do you have any suggestions of how I can get more experience?" (opens the door for discussion on patients asking you to leave the room) Or, "would it be okay if I took histories on my own before you see the patient--I'd like the practice" etc, whatever is true for you. It seems like you're a a thoughtful person and perhaps once patients talked to you they'd be more open to the exam. Or at least your observation of it.

    Either way, even though it is unfortunate to not have a ton of hands-on experience during this rotation, do trust that you will get more. Like some previous posters, I performed more pelvic exams in the ER, it seemed, than any other rotation.
    Unlike previous posters, I do actually find that the more exams I do the more comfortable I feel, even if I know exactly what's going on and what to look for. So it's totally understandable (to me) to want more experience from the beginning. Good luck.
     
  26. Law2Doc

    Law2Doc 5K+ Member Moderator Emeritus 10+ Year Member

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    Agreed. A good resident/attending/preceptor will "ask" in a way that is really just "telling" the patient what's going to go down. If actually phrased as "do you mind if", no males would ever get to do a pelvic exam. If phrased, "student DOCTOR XYZ is going to do the exam. Ok?" It's all about being matter of fact about it, and working doctor into the title. Hopefully all of us will take this approach when residents, rather than the wimpy approach that gets students like the OP kicked out of the room. It's very hard to learn when you are outside of that room.
     
  27. njbmd

    njbmd Guest Moderator Emeritus 5+ Year Member

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    Here are some things to think about:

    If you are rotating through a private hospital (not university), the patients there are the patients of the attending who is allowing you to rotate with them. This means that you are on their license and part of their practice. If their patients do not wish for you to participate in their care, then you can't.

    If you are in a university hospital, and your attending is one of the teaching attendings or part of the teaching service, you are part of their team. In this case, you are not an "extra observer" but an intergral part of that team. This means that you particpate in the care of those patients. When they sign admission papers to be treated by the teaching service, they have already given permission for you to treat them.

    When you go through a required rotation during third year, you have specific things that you must master. You can't master them by standing outside of a room while the rest of the team goes in. If you continue to have these problems, you need to speak to the clerkship director so that your rotation location can be changed.

    Every patient has the right to refuse to be treated by a medical student but you can't learn OB-Gyn outside of a door. If you are not getting a good experience, you need to make sure that you are moved to a place where you can get an good experience.

    I can tell you that at my medical school, none of the places that third year medical students rotate for OB-Gyn clerkship have private patients (patients that are not on the teaching service). The attendings do not ask if male medical students can enter the rooms. If a patient refuses to be seen by a male medical student, they are not seen by any medical students period.

    Attending to the health of female patients is not the sole right of female physicians or medical students. As a competent physician period, you have to know how to perform a thorough exam and evaluation of the female reproductive tract (same as with any organ system). Your sex or race is not part of this equation. If the experience is not adequate, you (as the consumer) have to find a way to make it adequate. This is best done by having a discussion first with your resident and attending and then with the clerkship director.
     
  28. plainolerichie

    plainolerichie Senior Member 5+ Year Member

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    Thanks for your replies! But I think part of my limited gyn/pelvic experience is due to the location and schedule, and the main gyn preceptor is on vacation so I haven't gone to his clinics and the gyn here is WEAK already! I think it should be better the last three weeks (I added more clinic days with good experiences to my schedule today, talking to the director).

    I think the post came on the crux of my frustration of what was supposed to be one of my two days at a gyn clinic thus far in the rotation (since the other doctor's on vacation), but it was a TERRIBLE day! The doctor who I was supposed to be following was in a rush and a complete jerk! It was his first year, first rotation he had med students with him, as I learned today. Well, after I was following him to 3 patients for about 20 min, and getting two doors shut in my face in only 20 min by him, he told me to follow a nurse practitioner/midwife and left 20 minutes later for some meeting. And she really did not know about nor was she involved in medical student training, etc. She was pretty much doing Paps all day and made me sit outside the room after 3 or so patients in a row kicked me out when she asked if I could be in the room (one kinda rudely).
     
  29. Law2Doc

    Law2Doc 5K+ Member Moderator Emeritus 10+ Year Member

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    The fact that teaching hospitals don't regularly remind their employees (particularly the non-physicians) that they work in a teaching hospital kind of irks me. More than a few times I've seen nurses complaining to each other or their supervisors that a patient was having a procedure/crisis and the resident/attending actually allowed med students to "stand around, in the room" and (god forbid) "just watch". As a third year you frequently find yourself a pawn in a battle of wills, with your resident telling you "go see" and the nurses telling you "get out".

    If it were up to some folks at the hospital, all doctors would learn everything they know from a safe distance beyond a drawn curtain, far away from the poor sick patients. It doesn't work that way and the hospital is complicit in this foolishness by not reminding its nonphysicians (the physicians hopefully are aware of this) regularly to participate in education whereever possible.

    I've learned quite a bit from those NPs, PAs, midwives and scrub nurses who have understood that they can play a useful role in student education. But these experiences have unfortunately been dwarfed by the numerous other nonphysicians who are appalled by the notion that students are allowed to bother or watch their patients.

    While patients have a say in exams, the folks working with the med student bear the burden of actually getting that med student to be allowed to stay in the room. Shouldn't matter if it is a new physician or an NP or whatever. If the place takes on students, it's mission becomes one of teaching and it better allow for opportunities for learning.
     
  30. Tired

    Tired Fading away 7+ Year Member

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    Actually, it's about them waddling themselves out the door to a private hospital if they don't like it.
     
  31. burlypie

    burlypie Senior Member 10+ Year Member

    I'm completely appalled that any student could get through third year and not do a pap or pelvis, as one poster shared! And the OP's situation!! You need to talk to your course directors, curriculum committee, dean etc. immediately. This has to be some kind of LCME violation.
    Ridiculous.
     
  32. WayChanger

    WayChanger Senior Member 7+ Year Member

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    Richard -

    I'm trying to preserve my anonymity as best as I can (pm me if you wanna talk in private!) but suffice to say we're in the same class at Keck and I'm on OB/GYN right now as well. And to be honest, I'm flabbergasted that you've had this experience. Where are you doing your rotation at? I haven't heard of anything similar happening at any of the rotation sites so far. I'm sorry your experience has been so limited! You really need to bring it up with the MSE and the clerkship director, because it sounds like you're having a really substandard experience. I can try to help out some more once I figure out where you are =]
     
  33. Law2Doc

    Law2Doc 5K+ Member Moderator Emeritus 10+ Year Member

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    A lot of schools definitely do ask students to document having done at least one of each of those. I suppose students/schools could lie, though.
    I'm kind of surprised too since I don't think I got through a DAY of not doing both of those during clinic days, let alone a whole rotation. I'm not sure why someone wouldn't speak up if they didn't get to do this experience somewhere along the line.
     
  34. getunconcsious

    getunconcsious Very tired PGY1 7+ Year Member

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    So I know this is a strange suggestion, but it really did help me a lot. If you can push yourself to take on a somewhat more effeminate persona (which will be easier for the patients to buy if your young looking actually), it might put the patients more at ease. This was easier for me cuz i'm gay irl, but I saw some very manly type of guys learn to soften up enough to ingratiate themselves on this rotation. The more masculine you are the more uncomfortable they seem to be. Of course if you have a voice like the brother on Everybody Loves Raymond then you're probably just screwed.

    Every rotation will require you to do a bit of acting. In addition to this lil' act, I pulled the opposite one on surgery, acting butch and speaking very little and using a voice deeper than my normal one. On pediatrics I dropped my usual flat, neutral affect and became enthusiastic and smily with the kids (not hard, since kids are fun IMO). It's important to be true to yourself, sort of, but try to mold yourself to the culture of each service to the extent possible. In OB/Gyn this typically requires behaving as "one of the girls", at least as much as you can. The guys who insisted on being manly, acting butch, and refusing to soften up their image at all persistently got kicked out of the room and treated badly by residents. Ditto for the unfriendly or cold types on peds. Ditto for those who insisted on talking too much and being touchy-feely on surgery. It's all about fitting in and acting.
     
    Last edited: Jul 31, 2008
  35. indo

    indo Feed me a stray cat 7+ Year Member

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    jeezus h...sell your soul and your testicles for the ob/gyn clerkship.
     

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