Career Exploration – Gynecologic Oncology

Another reflective piece I needed to write for school below.  It's talking about my week elective I did in gyn onc back in early November.  It was fun.  But not for me I think.  I'm taking picking my specialty more serious all of the time.  I spent a day of break focusing on looking into specialties.  Right now my tops are Urology and ENT.  And if I decide against those (#1 negatives- Urology- working with all those darn genitals. and I was thinking I'd like to avoid the pelvis period, ENT- bitches too competitive! :( ), you can bet I'll just do general.  But surgery, I'm coming for you, baby!

            The nature of gynecologic oncology consists of working with women who are either diagnosed with female cancer or suspected of a diagnosis.  One of the most important things I learned with this broad description is that the Gyn Onc surgeons are truly primary caretakers of their cancer patients.  Aside from radiation oncology, gynecological oncology surgeons are not just surgeons.  They are diagnosticians, surgeons, and chemotherapy caretakers.

gyn surgery = watching a boob tube for a few hours.  that's an ovary getting bovied off a ligament...

             The training involves the Ob/Gyn 4-year residency plus a two-plus year fellowship focusing on oncology.  I only spent a week in the exploration, but a typical academic gyn onc surgeon would operate 2-3 days a week, have 2 days a week for clinic, and an administrative day.  Hours seemed very comparable to typical general surgeons, with early mornings starting at 5 for residents and days ending with the ending of procedures, which could vary from 5pm to 8pm on any particular day of procedures.  Many of the surgeons seemed to like having marathon surgery days, consisting of 3 or more surgeries one after the next.  None of this was overwhelming after just having completed my surgery rotation.   In fact I enjoyed the similarity.

            I mentioned that understanding the composition of gyn onc work was one of the most important things I learned in my week of exploration.  I did not know that gyn onc spent so much time in clinic following up with long term patients and making major treatment plans beyond surgery.  I had spent a 3-4 weeks before this exploration following surgical oncologists, and had always enjoyed their clinic.  In Surg onc, clinic usually consisted of new patients looking for a positive or negative diagnosis, patients ready to undergo surgical treatment decisions, patients coming to hear their pathology results, and beyond that, long term follow-up of already “cured” surgical patients.  In gyn onc clinic, I was distressed at the amount of bad news and difficult decision-making advice I watched the surgeons give.  These solemn encounters were oddly out of proportion to what I had considered routine in cancer surgery work.  I couldn’t help but get the impression from this that it meant that gyn onc’s had to deal with some of the worst and most incurable cancer seen in medicine.  But I knew that this assumption couldn’t be correct.  

Da Vinci! concept kind of cool.  but laparascopy in general can't ever seriously be fun unless your behind the electronic arms :)  Not to mention pretty much 80% of the surgeries I saw were hysterectomies.  shoo.

            It didn’t take me long to realize that the lack of comparison to surg onc was due to the fact that surgical oncologists have the convenience of turning away cases that are inoperable, and thus are able to turn away situations doomed for bad outcomes.

            I have long thought to myself that I like sick patients.  But I have also thought that I like sick patients that can and are going to get better with a physician.  The typical excuse some people use when they go into surgery comes to my mind: a desire to cure patients in a expeditious fashion [with surgery]. 

            I know I want to work with cancer.  This may sound counterintuitive in the opinion of the typical person, but those who go into cancer work dooming themselves to the struggle of dealing with failure and death (and likely desensitizing themselves to death in the meantime)…. are the medical oncologists.  I want to go into a field of oncology that has been shown to be capable of truly curing cancer patients.  Surgeons may not cure all, but the rate of disappointment is statistically much better than those who have to depend on chemotherapy.

            After getting my peak into gyn onc, I do wonder if I still may like regular OB/GYN.  But I am running out of time to decide, and after my experiences in my surgery rotation and my enjoyment of my cancer research, I like the path I’ve already started trailing down.  Cancer surgery!

Reflective Writing Experience – Psychiatry, Fall 2011

I had to write a reflective piece on a patient encounter for psychiatry, and I had a great subject to work with.  So I enjoyed the patient, enjoyed writing the paper, and wanted to share.  I probably could've gone on and on about the patient story and my thoughts, but we had a 3 page limit.  And yeah I know the ending isn't good.  I've never been good at concluding summaries.

                My first week on inpatient psychiatry, I anxiously awaited my first intimidating experiences with the mentally ill.  One morning later in the week, I thought I’d finally get that perfect opportunity to practice keeping myself between the patient and the door.  My resident had taken assignment of AB, a 23-year old white male, with a past diagnosis of paranoid schizophrenia.

                An MIW had been filed by his mother for bizarre behavior after he had neglected his medications for 9 months.  He had been making threats regarding his mother, sister and self. Specifically, he threatened to hang himself, his mother, or make bombs and blow up their house. In the EPS report at admission, it was noted that he had over “10 hospitalizations” in the past 2 years including at Central state. In addition, as a minor he had hospitalizations in OLOP, and a facility in Florida.

                On our first visit to him, he was non-threatening but somewhat agitated, denying cooperating with the interview, and criticizing his mandatory hold in the unit.  He was often sarcastic and scrutinizing.  On questioning of his homicidal threats, he denied, calling himself a “prince of peace.”

                His toxicology screen was negative, but he claimed that he had used cocaine, marijuana, and hallucinogens in the past.  He stated that he had “tried it all.”  He claimed to use marijuana and alcohol both “once in a blue moon,” with last uses within the past month.  He claimed that he had tried unheard-of hallucinogenic drugs around the time of his first hospitalizations.

                On further questioning of how he got his schizophrenia diagnosis, he denied memory of the events which led up to it, other than the drug use.  He also claimed to have little memory of the sequence and timing of his past hospitalizations.  AB denied he had schizophrenia.  He denied experiencing auditory or visual hallucinations, suicidal ideations, homicidal ideations, and past suicide attempts.  We did not have any documentation from previous hospitalizations to support his diagnosis.

                He had held a job as a waiter for 7 months, which he lost a month before because he decided to “no call no show” and stop going after getting involved romantically with a girlfriend.  He lived at home.  He claimed to have an active social life, involving music, dancing, and bar scenes.  When not living at home, he stayed with friends for days at a time.  On questioning about his relationship with his mother, he said they do not get along because she “pushes her beliefs on me.”  His family is Jehovah’s Witness.

                He frequently referred to his distrust of doctors, including us, calling them “representatives of the pharmaceutical industry.”  On questioning of his orientation to location, he stated he was “in a restricted area.”  He cooperated with a urine tox screen taken in EPS but refused further labs.  When asked about his mood, he stated it was “like Thomas Jefferson,” with a blunted affect.

                During his admission, AB appeared slightly disorganized.  He was unkempt with long hair, and his body odor was noticeable on occasion.  He refused to take a shower because he only used organic soaps.  His excuse was the same whenever he denied food and medicine.  He did eat vegetarian diet foods when offered.  He never took his scheduled Seroquel in his 5 days inpatient.  During the day, he would often stand in hallways, looking around at the other patients, occasionally laughing at the bizarre behaviors of other patients.  On one occasion, AB was given an intramuscular dose of Geodon because he would not remove himself from an area where another patient was displaying aggressive behavior.  

                 AB often stood facing the nursing station, staring off but doing rhythmic movements, especially hand gestures.  When asked about his movements, he responded about his interest in magnetic healing powers, and also that they were movements he enjoyed for raving and glow stick dancing.  He would say that he was “magnetizing the air.”

                Even with his slight disorganization, bizarre and magical beliefs, he was able to give a clear, concise, goal-directed, and daresay convincing argument about his current situation at his mental inquest hearing.  His mother attended the hearing, but was unable to provide testimony due to English language struggles without an interpreter.  Regardless, the judge determined that a de novo would be needed to begin forced medications.  This could only be done at Central state hospital, leading to his transfer out of the unit on day 5.

                In the 6 weeks on psychiatry, it did become very clear to me how common it is for schizophrenics to deny their diagnosis.  I noticed this early on, but even in the end I still wish I understood more about why this is the case.  Most of the patients who exhibited this seemed to be aware that they were not being honest.  I also got the impression that those that denied their diagnosis were more at threat for future suicide, which worries me about patients like AB.

                I had a lot of doubts about AB and his diagnosis while he was in the hospital.  Compared to the other schizophrenics I had the chance to observe, he seemed so calm and aware of reality.  He was never caught talking to himself or responding to other internal stimuli.  Most of his out-of-the-ordinary beliefs were not unheard of.  He agreed in one conversation that he was definitely anti-establishment.  He seemed immature for his age, and not well educated… but I would argue that if he was schizophrenic, he was in a residual state.  I know that as a student, I am inexperienced and probably naïve in regards to psych, but as an attending I will hope to maintain an open mind with every patient.

                If I hadn’t felt as limited by my role as a student, I would have wanted to interview him more to gain more insight about his thought processes, and to look for clear signs of positive or negative symptoms.  I did get the opportunity to have a last conversation with him on his last day.  I knew I wasn’t going to see him again.  I wanted to tell him that I thought he seemed fine, but of course I couldn’t.  Instead, I warned him that if he wanted to stay out of the hospital, he needed to avoid arguments with his family.  And that when does argue, he could never threaten, or he would be back.