Need an OB? Paging Dr. Cummings.... not!

This semester I need to shadow a primary care physician, and I've been working with an OB/GYN, Dr. B., across the river in Jeffersonville. He's a really nice guy, with a solo practice, so I feel like I'm getting a taste for small-town medicine. I mean, really, when was the last time you went to a doctor's office where there was only one doctor? He has quite a busy practice, though, so I've seen numerous annual gynecological checkups and regular obstetrics visits on women over a large age range. I've also seen a number of older women being evaluated for incontinence, which the office screens for in every woman over the age of 35 with two or more children.

The first thing that strikes me is the number of women around my age who have had multiple pregnancies. It IS southern Indiana, I know, but it's still ... weird. At 25, these women are on their second or third pregnancy and look like they're in their 30s. I wonder about their lives -- what is it like to be a stay-at-home mom married to a blue-collar husband? Did they want to get pregnant? And why did they choose a male gynecologist? (That part really gets me... I think I wouldn't mind seeing a male obstetrician, but I wouldn't want to see a male gynecologist... not that you can really separate the two, I know. Therefore, I always choose female physicians. But I know my mom likes male doctors. Is it a generational thing?)

The second thing that strikes me is that staring at female genitalia all day is a little bizarre. I've now seen more vaginal canals and cervixes (cervices?) than I thought possible -- and I've only been working with him for 6 hours over two days! Women look surprisingly similar -- the only differences come with having had children -- whether your cervix shows signs of childbirth, and how stretched out you look. I've also noticed that Dr. B. doesn't put KY jelly on the speculum before inserting it. From personal experience, I thought using KY was the norm, but I don't know if his not using it is due to age (he's in his 60s at least, so he trained a long time ago), gender (maybe it wouldn't occur to him that having a speculum inserted is uncomfortable?), or training (I've only ever seen nurse practitioners for my annual exams, because I like their caring attitude in this area; maybe physicians really don't get that empathetic training?). Nevertheless, it's the cause of a lot of grimaces, which I don't think he notices, but I certainly do!

Anyway, a couple funny stories. Last week, we saw a woman in her 50s being evaluated for urinary incontinence. We were performing a urodynamic flow study, which consists of four parts. First, you spray a stream of water at the urethra to see how much pressure it takes to breach the sphincter from the outside. Second, you insert a small catheter and see how much urine is left in the bladder when the patient thinks she's emptied it (she urinates before the test begins). Third, you slowly fill the bladder through the catheter and record the volumes at which the patient reports sensing there's "urine" (really saline) in the bladder; sensing that she's going to need to pee sometime soon but she can still hold it; and sensing that she has to pee so badly that she'll drop trou on the side of the road in front of the president and the pope to do so (that was Dr. B's actual analogy, which I thought was hilarious). Fourth, you drain most of the saline out and then have the patient cough hard, and you record the pressures produced by coughing and see if she loses any urine while doing so. This woman, when she coughed, did lose a little bit of urine from around the catheter, but Dr. B had her keep coughing harder and harder, to see what the pressures would max out at. On the final cough, the lady coughed so hard, a huge stream of water flew out threw the catheter all over Dr. B, who was still sitting in front of her. How disgusting! And embarrassing! I was mortified just watching it happen.

The other story isn't so much funny as it is an illustration of my poorly developed ear. Dr. B is awesome in that he lets me evaluate the pregnant women myself first before he goes in. These are the women who are having their monthly or weekly OB visits to make sure the baby is growing appropriately and things like that. So I go in first and listen to the fetal heart tones using a small ultrasound machine, then measure the uterine fundal height (to get the baby's crown-rump length). I'm pretty good at finding the fundus (the top of the uterus), although it's definitely easier on thinner, more pregnant women than on heavier or less pregnant women. So this one lady asked me if I knew which way the baby was lying inside her. Every other pregnant woman I had examined so far, the baby was lying with its back (and therefore heart) on the left and butt up on the right (head at the bottom). On this lady, it didn't really feel that way, but she wasn't THAT pregnant, so it was hard for me to be sure. Plus, I don't really know anything about obstetrics -- if the 20 other babies had been lying that way, why wouldn't this one be? So I took a guess and said, "well, let's see if the heartbeat is on the left." And sure enough, there was the cute little woosh-woosh I had heard so many times before. So I said, "I think the back is here on the left, and the butt is on the right." Then Dr. B came in and examined her. "So, you felt the back over here on the right, right?" "Uh," I stammered, "I kind of thought I did, but then I found the heart beart on the left..." So he took out the doppler and found the heart beat -- on the right! I tried to maintain my cool, but I was dumbfounded by what I had heard myself. "So what's that on the left, then?" He found what I had found, and told me simply, "Placenta." Unfortunately, the patient didn't hear him clearly, and you could tell SHE was freaking out, because we were all hearing heart beats in two different locations. "Do I have twins??" she asked nervously. We explained it to her, and I realized her anxiety over the potential for twins was more called for than my embarrassment at not being able to tell the difference between placenta and baby, but still, I was pretty embarrassed. And dumbfounded. To tell you the truth, I still couldn't hear the difference. Thank god no one's depending on me yet!

Overall, I kind of like OB/GYN. You get to see women at all stages of their lives, and you get to do a very wide range of things. Counseling on healthy behaviors, obstetrics, gynecological surgery, oncology, and tons of other things. The environment is pretty bad for malpractice insurance, but I haven't had the chance to ask Dr. B about that yet. I'm spending next Friday in the OR with him all day, so I'll get to see some cool stuff -- there's a C-section, ovarian tumor, and bladder surgery scheduled so far that I know of. So far, I haven't crossed OB/GYN off my list. However, there IS that stereotypical aspect of it -- women going into OB to get to play with babies. Not really realistic, I know, but I hate fulfilling stereotypes, so that might be reason enough to avoid it as a career, a la "Scrubs," Season 1, Episode 11:

"Elliot: Dr. Kelso, I need to present a patient: Nineteen-year-old complaining of abdominal pain. Turns out she's at least eight months pregnant. I'm just gonna let one of the Family Practice people handle it.

Dr. Kelso: Well, that sounds like a wonderful idea, Sweetheart, except I heard your smart-alec remark a second ago, so why don't you just keep your little pregnant girl? It'll be good practice for you, since you'll probably end up in a female specialty anyway.

Elliot: What do you mean by that? I'm Internal Medicine.

Dr. Kelso: Well, of course you are. But numbers don't lie, and most women end up in OB/GYN, Family Practice, or Pediatrics. It's like a riptide, Sweetheart, pulling and pulling, and you can swim against the current all you want, but when Mr. Stork comes a-calling, you're not going to be thinking, "I'm Internal Medicine." Nope. It's gonna be, "Oohhh, look at the baaaby!"

Elliot: Sir, I have to say, I'm offended!

Dr. Kelso: Oh no. Now I have to go buy flowers to make it right."

At least I have the kittens to assault with my baby voice for the time being, and in a few months I'll have a friend's baby to coo at; then I can hope for awful Peds and OB/GYN rotations third year. :)

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In other news, we've gotten a couple pretty serious storms this week. Last Sunday, I missed Grey's Anatomy thanks to a tornado warning that had us holed up in the bathroom for 40 minutes. (I missed Grey's Anatomy because EVERY station was pre-empting for weather news.) Last night, we had another round of storms -- these actually did produce a tornado, in the southern part of the county. I'm not really sure how realistic it is that we would get hit with a tornado downtown -- we're in the middle of a lot of sort-of tall buildings, and don't tornadoes need wide, open spaces to develop? -- but we've prepared a tornado plan nonetheless. The disaster destination of choice is the hallway bathroom -- it's the only non-closet room that has no exterior walls. I've stashed some candles and matches in there, and I'm going to buy an extra flashlight to keep in there as well. Better safe than sorry! So far, I kind of like tornado coverage better than hurricane coverage: tornadoes come quickly and without warning, so the worst the media can do is cover it while it's hapenning. There's none of that dire, doomsday-approaching coverage for days beforehand, like there is with hurricanes. There's also not as much preparation needed: get into an interior room and stock some candles. No stocking up on canned food and bottled water or evacuating. If it hits, it hits, and then it's over. All the devastation, half the hassle!