2019 Physician Writing Contest: Back to basics

“Dr. M is terrifying.”

I was less than two weeks into my intern year, clutching the lapels of my white coat like my program director might rip it from me at any moment and banish me back to medical school. I didn’t think I could get any more terrified, and yet, I did at the brief words of my seniors. Without ever having met her, I was terrified. I had managed to avoid her during my weekdays on the inpatient gynecology service, but had no such luck on call.

My chief that day saw the tightness of my morning smile, patted me comfortingly on the back, and then sent me upstairs with her to postpartum rounds.

Dr. M has closely cropped black hair, neatly kept dark nail polish, and a line of silver earrings up the shell of her ears. When she looks at you, you’re a butterfly pinned under bright lights, and she definitely knows that you spent your free hour yesterday evening watching Netflix instead of reading that week’s journal club article on the use of misoprostol for induction of labor. When we got to the door of our first patient, I started with, “So, um, this lady…” and then meandered, focusing all of my strength on simultaneously not stuttering and not forgetting who this patient was out of the fifteen I had seen this morning.

Dr. M quickly put me out of my misery. “Tracy, how are you structuring your presentations?” My terror rapidly peaked. She waved aside my jumbled answer. “Start with the subjective and the patient’s history. Then vitals, exam, labs, imaging. Your assessment and plan. When you do it the same way every time, you’re less likely to forget anything. Okay? Now start over.” That day, postpartum rounds must have taken three times as long as it usually did, but by the end, I was presenting the same way every time.

Subjective. History. Vitals. Exam. Labs. Imaging. My assessment and plan. It became my mantra as I weaved around OR carts to present a new finding from a patient on the floor to my chief wedged next to the attending during a vaginal hysterectomy, as I tapped my foot waiting for an elevator up from the emergency department, as I typed up my fifth history and physical from triage on labor and delivery. Do things the same way each time, and you’ll be less likely to forget anything.

As I’ve gotten farther along in residency, the pace has only picked up and the patients have only gotten more  complex. The amount of detail I’m liable to forget has only accumulated. OBGYN is unique in the vastness of our field; we are the vanguard of women’s medicine and women’s surgery, despite receiving less surgical experience than any of our surgical counterparts and having to master the field of obstetrics in addition to women’s primary care.

Little wonder that talks about splitting the residency back into obstetrics and gynecology, extending the residency beyond four years, and general hand-wringing about the number of residents that graduate feeling that they are ill-equipped to practice, have become more than a rumble in the field.

As a new third-year resident, I’m no stranger to the feeling of opening up a patient’s chart after an extensive tumor debulking for ovarian cancer and being crushed by the anxiety of, “How am I possibly going to take care of her?”

Whenever I get overwhelmed, I go back to the basics. I talk to the patient. I review their history. I look at their vitals, their incisions, and touch their abdomen. I check that their labs are up to date, and that the final read from the radiologist is in for all their imaging.

I form my assessment and plan, and if I’m stumped, I ask my chief (right now I’m steadfastly ignoring the question of what I’m going to do when I’m the chief). This rigorous approach to organizing how I think about patients and how I present these patients to others has grounded me during times of panic. I know that as long as I do things the same way every time, I’m less likely to forget things and more likely to be a better doctor.

On one of my calls halfway through my second year as a resident, as my chief was joking that I might as well be a third-year resident now, I got a call from the ED that one of our GYN oncology patients had arrived for us to see. She was a lovely, sweet lady, who was a few months postoperative from a hysterectomy; she had called in earlier because when she went to the bathroom that morning, she felt like something had “fallen out of her vagina.”

Just yesterday, she had gone to a local tulip festival and had done a fair bit of walking. She wondered if that was what was causing her problem today.

Her problem was a vaginal cuff dehiscence. As I slowly withdrew my gloved hand after her pelvic exam, my stomach having plummeted off the cliff as soon as my index finger ran over the stitch at the edge of her cuff, I said weakly to the ED nurse next to me, “Can we get her in some Trendelenburg position please.”

Subjective. History. Vitals. Exam. Labs. Imaging. My assessment and plan. I repeated those words to myself through the panic ringing in my ears.

That mantra steadied my voice as I systematically laid out her story to my attending over the phone, as I texted my chief to let her know about my add-on case, and as I communicated to the patient that she was not likely  to be leaving the hospital  that night. I was absolutely terrified, but because I stuck to the basics, because Dr. M made sure I knew them well, the patient got the care she needed in a timely fashion.

I’m terrified of fewer things now. Every summer that rolls by, I’m reminded of how much less as I look into my new intern’s eyes as they bravely fight against the urge to hyperventilate. After we settle them down with the note templates they need for labor and delivery and where all the bathrooms are located, talk turns to their new co-residents and attendings. We try not to sugarcoat it.

“Dr. M is terrifying.” I say. “But she’s the reason I’m a better doctor.”