History and Physicals:

Journal Article Summary:

The article I chose was related to a patient case I had in my OBGYN rotation, which I also wrote one of my H&Ps about. We had a patient who had an ectopic pregnancy while having a fundal IUD. I wanted to look further into the use of methotrexate to treat ectopic pregnancies. At the clinic, the typical protocol was to administer methotrexate, and then evaluate the changes in HCG levels. If they didn’t decrease in the appropriate amount of time, additional methotrexate would be administered. The study I looked into was a systematic review and meta analysis from 2017 that evaluated multiple and double-dose administration of methotrexate (MTX) compared to single-dose administration for treatment of ectopic pregnancies. The pregnancies included were unruptured tubal pregnancies, and the outcome measured was higher than 15% reduction in serum HCG in 48 hours after administration of MTX. This study found that the success rates between multi-dose protocol and single-dose protocol were similar. However, the side effects were significantly higher with the multi-dose administration.  They concluded that single-dose MTX administration had fewer side effects and a similar success rate to multi-dose MTX. Double-dose MTX had similar outcomes to the single-dose protocol, and was recommended when the pretreatment serum HCG level was 3600-5500 IU/L or the ectopic mass was 2.7-3.5cm in diameter. It was interesting for me to see that the multi-dose, which I expected to be better, was actually not noticeably better and led to worse adverse effects in patients. Thus, continuing the traditional protocol of a single-dose of methotrexate seems like the best option, and it may be worth considering a double-dose in specific situations.

Site Visit Summary:

For my site visit, I initially presented on bacterial vaginosis. While a fairly straightforward diagnosis, it was something that I saw almost every day in my time working in the clinic. Talking through the patient case I presented with Professor Melendez really helped me get a better idea of this diagnosis and how it can typically present. We discussed whether the diagnosis should be a clinical diagnosis or confirmed with specific testing. While textbooks often mention clue cells and a KOH whiff test, that is not always feasible in a clinic, and adds additional time to the patient while awaiting treatment. It’s critical to rule out other more serious differentials, including things like gonorrhea, chlamydia, or candidiasis, but after that, we concluded it is best to make a clinical diagnosis and begin treatment when there is a high suspicion. While you can still test and confirm your suspicion, it’s best to begin treatment for the patient. We also discussed different medications, including topical metronidazole, which was one of my pharmacology cards. Another thing I realized from my site visits and presentations is that while the patient may be presenting with one complaint, it is critical in OBGYN to address other things, especially patient education. While my patient may just be there for treatment of bacterial vaginosis, it’s also critical to discuss contraceptive options, for example. 

Typhon Case Log Totals:

Reflection:

Overall, this rotation was my absolute favorite so far. I went into this rotation unsure how I would feel about OBGYN as a whole, and I was pretty hesitant about it. However, I enjoyed it so much! Everything I did this rotation felt pretty new – while I had been exposed to some OBGYN in other rotations, this was completely different. I was so nervous initially to use the speculums, and I found it difficult to explain and keep patients informed (which is critical for something like a speculum exam) while I felt so unsure of my own technique. However, I had some really great teachers who were patient and showed me different techniques or little tricks that they used that really helped. By the end of my rotation, I felt completely confident at pap smears, speculum exams, and making the patient comfortable while doing all the necessary tests needed. It was a huge accomplishment for me, as it was something I found daunting initially. 

One thing I found challenging this rotation was working with patients who spoke other languages that I was unable to speak. For example, there were a lot of Spanish speaking patients that I wished I could better communicate with. While there was access to interpreters, I could tell how comforting it was for patients to speak with a provider who was fluent in the language they preferred. It allowed for better communication and I noticed patients were more comfortable opening up to those providers. While I can’t just learn a new language overnight, it helped me realize that wherever I end up working, I want to be as prepared as possible to do what I can to help patients receive care in their own language, and make sure their questions and concerns are heard. 

One memorable experience I’ll carry with me – it’s hard to narrow it down, because every day I was in labor and delivery was utterly amazing. I had so many great moments with families there. There was one midwife who let me help deliver the baby, and being able to help catch the baby and be part of that experience was so wonderful. In labor and delivery, you grow close with the mothers and the families there in such a short time, because you’re there for a life-changing experience for them. I absolutely loved being there for those births and doing whatever I could to help- whether it was getting ice chips, holding legs, or even just fanning moms. It was so wonderful to be a part of. 

For my last two rotations, I want to continue doing what I can to provide patient education and support in whatever aspect the patients need. I was so impressed by the patient education happening in OBGYN, and I want to continue to make sure I am teaching my patients their options, whether it’s for treatment or generall healthcare information. It’s critical for patients to understand everything in order to make the best healthcare decisions for themselves, so I want to do what I can to provide that understanding. I will try to check for understanding when teaching patients, ask patients if they have questions about things we’ve discussed, and check in on general health care maintenance to make sure they are receiving adequate care. But on top of all that, I saw this rotation how just being a warm provider who makes patients comfortable leads to so many opportunities to discuss concerns patients may have and provide further education on things they have questions about. I want to continue to listen closely to patients and provide a comfortable environment where they feel they can bring up concerns they have.