OB/GYN Rotation coming up? - Maximize your productivity!
Dec 9, 2014
Myles McKittrick, Medical Scholar at Osmosis & Medical Student at the National University of Ireland Galway.
Obstetrics and gynecology (‘OB/GYN’) are two subjects every student must study before he or she can graduate with a medical degree. It is the study of the female reproductive system, all the areas surrounding pregnancy and depending on the tutor may also involve some urology as well. Whilst starting my first rotation of study in this field, I was asked by the consultant obstetrician to take a history and perform an obstetric examination on one of her patients. I obliged happily and set about introducing myself as a medical student and set out to gain full consent before proceeding to take the patient’s history and complete the appropriate examination. Despite feeling I had built some rapport with this patient I was not given consent to proceed. My heart sank as I heard the words ‘Sorry, I just wouldn't be comfortable with that’. I thanked the patient for her time and asked her if there was anything I could get her such as a glass of water – she didn't want water so I left to try and find a consenting patient.
We, as professional students, must have complete respect for the rights of patients and at this point I would like to emphasize that the patient has the right to refuse to consent a history or examination and this is how it should be.
As a fourth year male medical student I am acutely aware of the situations where patients are more likely to refuse to grant consent for both history taking and examinations. Throughout my first day in the clinic it became quite apparent that if I was going to get any clinical experience in gynecology or indeed obstetrics I would have to improve on my introduction. The first day, with regard to history taking and examinations, was an unmitigated disaster. I had never been ‘rejected’ so many times in such a short period of time – in medicine. I knew I had to change my approach and introduction. I had been paired with a female medical student and it had been obvious from the beginning the patients (all of whom were female) trusted my colleague much more. When I checked with other male medical students they were having a similar experience, i.e. the female students could successfully consent for a history and examination and the male students found it difficult to consent a history. When my colleague would start to take the history, the patient would ask me if I wouldn't mind leaving the room. Something had to change, and I had to make the change as quickly as possible. I excused myself early from the clinic.
Upon arriving back to my accommodation I immediately set out to determine what had gone wrong. (The first 20 seconds after meeting the patient, i.e. your first impression, is vital to your success on the wards). I studied my appearance in the mirror – neatly pressed trousers, polished and shined black leather shoes, matching black socks, crisp clean ironed shirt, shaved stubble and my hair was neatly cut and styled with product. Surely the extra few pounds I was now carrying around my mid-line, after a very enjoyable summer vacation, had not discredited me as a professional trustworthy person? I reassured myself – ‘If you’re still getting dates, you’re not looking too bad’. Dismissing the weight gain I moved to check my personal hygiene. While I had showered and shaved etc. earlier that morning, as is my routine. My teeth had been brushed, flossed and I had used mouthwash. I had used antiperspirant and aftershave that morning. My hands and nails were impeccably clean. I decided that I could relax on this issue as the problem was not related to my personal hygiene or appearance.
I now knew the problem was related to the development of rapport with each patient and I realized I would have to focus on this area, but what could have gone wrong?
Having observed my colleague introduce herself and gain consent for history and examination on every attempt – I set about trying to mimic her approach. I copied her word for word: ‘Hi, I am a medical student; I would like to take your history and perform an examination on you, is this acceptable for you?’ This opening line was very similar to what I had always used: ‘Hello my name is Myles, I am a medical student from Galway, I was hoping to talk to you for a while with regard to why you are in hospital and perhaps perform a brief examination on you today. Would that be OK?’
Another factor that will play a major role for consenting patients for examinations is your timing. Patients are people and if it was you or I, would we want a student asking to palpate our abdomen when it’s lunch time? I found the best time to approach patients is between meal times and my most successful times are roughly about 30 minutes to 90 minutes after meal times. This will improve your success rates and will also mean you are less likely to aggravate the ward sisters.
The end result was that, despite spending more hours than normal (many 16 hour days) in the hospital during this rotation, I only took a few histories and I performed even fewer examinations – compared to other rotations. In medicine, as in life, I think you should always try your best and endeavor to complete every task as effectively as you can. Having said that, there may be some circumstances where you do all the preparation possible and put everything you can into your task at hand and still come out with very little to show for it. In my personal opinion, these are the times when we can look forward to the easy and the mundane duties that we know we can complete effectively. If you find yourself in the same situation as me – perhaps obstetrics and gynecology is not the place for you!
To summarize, if you want to get the best results and take as many histories as possible make a checklist before you go into the hospital and tick each item off as you have checked it is completed. You should ensure your personal hygiene and appearance are up to the mark including shaved stubble, pressed trousers and ironed shirt and nothing worn below the elbow (including jewelry). You should definitely pay extra attention to the parts of your body the patient will see; your nails for example should be visibly clean and trimmed. In the event of consenting for an examination you should have a plan of action in mind. I personally find it useful to break each history and examination down into different bullet points as follows:
History and Examination Checklist:
- Have your approach mapped out in your mind;
- What side of bed to initiate?
- What to say and when to say it?
- Where will you place your hands at introduction? Adopting a ‘hands-in-pockets’ or a ‘folded arm’ approach tend not to make the best first impression. A more neutral positioning of your hands e.g. by your side, will make you appear professional and interested.
- How will you stand?
- Eye contact? (It is useful to use eye contact to establish rapport with the patient but be careful not to overdo this – you don’t want to scare your patient!)
- Tone and pitch of voice. Be careful to speak clearly and in language that the patient will understand. You should use a minimal amount of medical jargon and if you do decide to use these terms be sure to check patient understanding.
- How good is your body language and will you use any hand gestures and if so, when?
- What questions will you ask for the history?
- How will you perform the examination?
PS: I have reverted back to my previous introduction and it is proving successful on all of my rotations. I have put my failures down as learning experiences and look forward to my second rotation in obstetrics and gynecology – I love a challenge!