Board scores, driving, public health and applications

Sorry I have been so scarce. I have been doing a rotation at a community health center that is 90 miles from my house. I commute most days. The kids started school last Monday, and I have started doing doing ERAS, the electronic residency application.

I got my USMLE Step II scores back. (I am a DO student. I took both the COMLEX and the USMLE because I will be doing the MD match. If you want to read more about this, I wrote about it here) Since I talked about my scores for Step I to of how well I did, I guess I’m going to this time around.

I did really well. Very well. Much better than I thought I did. It should make it a bit easier to get interviews at MD programs, I hope. Now I am going through the application process and getting ready for elective rotations.

One more board exam

Tomorrow I am taking the Step II COMLEX. Then, I am done with board exams until I am a doctor.

I would feel some relief, but that just means I need to get my applications to residency in, and then start the interview process.

Eep.

Wish me luck, please, for all of the above.

All board review and no play…

I have my USMLE Step II CK on Saturday, and my COMLEX Step II CK August 1st. So, sorry I haven’t had time or mental functionality to blog much. I have tons of stuff I have wanted to share. Let’s see if my medical fact clogged brain can remember a few of them.

NPR has been rockin’ lately. First, I heard Morocca say “hula doula” on Wait Wait, Don’t Tell Me” recently. They have been running a really great series on birth called “Beginnings: Pregnancy, Childbirth and Beyond”. It included a great piece on elective inductions that provoked a lot of comments when I shared it on my Facebook page.

NPR’s Facebook feed also tipped me off to a new report by the Institute of Medicine, “Clinical Preventative Medicine for Women: Closing the Gaps” which recommends mandating insurance coverage of contraception,” since it is preventative medicine. To quote Rachel from Women’s Health News, “Duh!”.

In addition to copay-free coverage of birth control, the Institute recommended:
screening for gestational diabetes:

*human papillomavirus (HPV) testing as part of cervical cancer screening for women over 30
*counseling on sexually transmitted infections
*counseling and screening for HIV
*lactation counseling and equipment to promote breast-feeding
*screening and counseling to detect and prevent interpersonal and domestic violence
*yearly well-woman preventive care visits to obtain recommended preventive services

Hear, hear.

Anyway, I should be studying. Wish me luck.

Sorta studying

I am doing daily board review. Today I did most of it in front of a Mystery Diagnosis marathon. That counts as review, right? I got a few of the diagnoses correct. And, I will remember the signs, symptoms and work up for the others.

Night of the fourth year medical student

Yes, I am rising from the great beyond of rural rotations. I am, as of July first, a fourth year medical student. Hello, senioritis! I am doing a board review month. I am taking the MD and the DO boards. Soon. Eek.

I have a lot of posts jumbled around in my head. They may show up in one way or another soon, since I will want to procrastinate while studying.

Oh, and good luck to all of my former classmates who are starting their residencies. Double eek!

Hands on in the boondocks

Howdy. I have been busy, as usual. Not only working at a new rotation site, which has been wonderful, but driving more than three hours a day to get to and from this site.

Our medical school requires that we do three months of rural rotations. I am doing two at a community health center in the middle of the state. The surrounding town is a farming town, with a large migrant population.

I am absolutely loving it. I am starting off with the ob/gyn, and we do gynecology, family planning and obstetrics. It is a very hands on rotation with an attending physician who is eager to teach. I have done many pap smears, STD tests, contraception counseling, cervical checks on full term pregnant women, and I GOT TO INSERT AN IUD. That plus a journal club, a training on human trafficking and a training on contraception compliance. Not bad for the first week and a half!

Our first two days consisted of orientation, and the longest time slot was given to the lactation consultant, who I love. She is working on a “Men and Women’s Health Day.” When I gently pointed out to the Medical Coordinator of the site that it was trans exclusive, they took me seriously. I am going to be the point person for any individuals identifying as trans (or anyone else who has questions in that area) the day of the health fair. Apparently they had some there last year and were at a loss. I am going to start with the resources linked to by Rachel at Women’s Health News and go from there.

I’ll try to check in again. If I could type while I drove, I’d have a ton of posts. Instead I am listening to board review materials. And looking at the swamp wildlife. And trying to avoid a speeding ticket.

I can easily see myself working at a community health center. This is totally my bag.

Back from ACOG

I am back from the American College of Obstetricians and Gynecologists Annual Clinical Meeting in Washington DC. It was wonderful. I mostly stuck to the medical student track again.

Some highlights – I thought the lecture on Misogyny and Women’s Health by Dr. David Grimes was brilliant, and sad and hopeful at the same time. I was impressed that ACOG chose that topic for the presidential program, which meant it was on the main stage on the main day. Although many people walked out (I am hoping it was because the program was a little bit behind schedule and the exhibit hall was opening rather than people uninterested or challenged by the material), he still had a good sized audience, and received the only standing ovation I witnessed at the convention.

Stump the Professors was fun, as usual. The medical student program was well run and helpful. My favorite part, however, was when I decided to leave the residency fair early and head to the poster sessions. I got to talk to someone who did research on publicly funded community doulas for poor women, among other topics. I also got to interact more with people from programs I wish to apply to than there were present at the residency fair.

I was also really happy to talk to more than one practitioner about episiotomy, including a maternal fetal medicine specialist who does a lot of research, and have them say it is to be avoided, even when applying forceps.

Now I am trying to get back into the swing of life, and working on elective rotations and other school stuff. Ugh.

When routine care is not evidence based care

I am studying for my shelf exam (my end of rotation exam, for those of you not well versed in the jargon) on ob/gyn. I am using one of a popular series of board review books. Every single question in the chapter on intrapartum fetal monitoring had the use of an intrauterine pressure catheter (IUPC), and most mentioned a fetal scalp electrode.

Shudder.

I am not sure what the prevalence is of IUPC use. I have not seen it in most of the labors I have been to, but I have definitely seen them used. In one labor I went to, the IUPC and/or fetal scalp electrode had to be replaced three times because of problems.

As far as I know, there is no evidence supporting their use. I found this article, which is a rare randomized trial with a significant number of subjects. There seems to be no advantage to using them. When that is the case, I think it is only ethical to use the less invasive intervention, which would be external monitoring.

There are a few quotes I find interesting in this article. Here’s one:

“The American College of Obstetricians and Gynecologists (ACOG) and the Society of Obstetricians and Gynaecologists of Canada (SOGC) advise the use of internal tocodynamometry in selected circumstances, such as when the mother is obese, when one-on-one nursing care is not available, or when the response to oxytocin is limited. The Dutch Society of Obstetrics and Gynaecology recommends its use in all cases of induction or augmentation of labor.2″

Well, I have never seen one to one nursing in labor and delivery in a hospital. Never.

Also, here’s another one:

“Induction or augmentation is necessary in approximately 20% of all deliveries, and internal monitoring is thought to quantify the frequency, duration, and magnitude of uterine activity more accurately than does external tocography.1-3″ (Emphasis mine)

Wow, really? Unfortunately, there are poor statistics on the prevalence of interventions in labor, but Listening to Mothers cites an induction rate of 48% for first time moms, and “Only 41% of the women had a labor that began on its own.” This link didn’t have the statistic for augmentation, but from what I remember, more than 70% of labors were augmented by oxytocin.

So, 20% of that is necessary, and what does that make the rest? Depends on who you ask. Some practitioners will say it is active management, aka “doing what we can to get the baby out…that’s what you’re here for.” I call it excessive interventions that lead to possible iatrogenic risk.

Defending breastfeeding

I think I have been quiet on here longer than I have been for well, ever. I am doing a family practice rotation and trying to set up elective rotations and plan for applying to residency. I am also just busy and tired out in general. I can’t write about much of what I see day to day without discussing my patients or my attending physicians and residents in a way that might be ethically questionable.

But, I do want to write about something that happened today.

A patient came in with a complaint that wasn’t life threatening or earth shattering. My attending physician wanted to treat it empirically. The patient is breastfeeding exclusively. The physician, without even looking up the medication, told her to stop breastfeeding.

I usually don’t challenge what my attending physician recommends. The patient said she would do what she always does, and call her baby’s pediatrician. When we did look up the medication, it did not have a contraindication for breastfeeding, but had a typical “well, we just don’t know if this is safe” disclaimer. This wasn’t a book specifically dedicated to medications and lactation. There are books like this available.

I told the attending physician that the patient was exclusively breastfeeding, and breastfeeding is hard enough to pull off in this society as it is. I said that, barring a contraindication during breastfeeding, most medications are safe, and a little research on the topic and possible alternatives may be a good idea. The attending said that, in today’s litigious society (which is the topic of many lectures by many attendings), we just can’t take those kinds of chances these days. She apparently tells any breastfeeding patient to stop breastfeeding with any medication.

I hope I can take these kinds of chances one day. I respect my attending physician’s choices in balancing her medicolegal risk and the way she cares for her patients, but I hope to be able to strike my own balance one day that is more supportive of breastfeeding.

Done with ob/gyn

I am done with ob/gyn, at least for now. I absolutely loved it. I loved the births, which I knew I would already. I loved the OR. I got to close a cesarean! Squeeeeee! I loved the procedures. Most of all, I loved clinic, especially prenatals. I have no qualms about the field I have chosen. The hours were long, but I loved it.

I can’t believe I have to go back to doing other rotations before I can be all ob/gyn, all the time. I still have two months of family medicine and two months of rural rotations, which will both luckily involve a lot of ob/gyn, pediatric ER and regular ER, and then it’s all electives. Whoooo!