O&G: a rotation of fingering vaginas and covering my ass.

So, I am coming to the end of my rotation on O&G. I have exactly 5 shifts left, and that is 5 shifts too many. O&G is essentially A&E but more stressful, and with exclusively hysterical women, babies coming out of teeny tiny holes, and various permutations of bleeding and diseased vaginas. You aren’t really taught much of the theory at medical school, so starting as an SHO on Gynae basically entails feeling like a moron 100% of the time. You are put in a position of authority, asked to examine and assess patients for conditions, most of which you have never even heard of. Dr Google has legitimately been my best friend. It is ludicrous. There is a baseline expectation of competency.  You are a SENIOR house officer now; you must know shit. Clearly somewhere in the small print of my contract it told me how to pull knowledge about complex gynaecological presentations out of my ass but I must have missed it.

The pressure is immense. There is a culture of litigation, and as such I would say that 70% of all decisions made in the specialty are about covering the clinician’s behind. Everything has to happen immediately. With no prior training you are expected to juggle women in dangerous pre-term labour, women hosing litres of blood from their uteruses (uteri?), women potentially unstable due to ectopic pregnancies, to distinguish between idiotic and urgent referrals, and do all of this calmly and competently, all the while smiling sweetly at the midwife who was called you to perform an urgent ECG that has been waiting all day because for some reason no one thought it necessary to train midwives how to use the machine, or to print off a discharge summary STAT because the patient absolutely has to go home immediately and midwives don’t have access to the discharge system, or to come and take blood cultures off of someone who has spiked a temperature because instead of re-cannulating them the nurse decided to switch their IV drugs to oral because, they’re the same thing, right?

This leads me to a side rant about the ridiculous lack of competency assessment we have as doctors. I have lost track of the number of times I have been asked to administer a drug because a nurse hasn’t been trained how to, or perform a procedure that a midwife isn’t competent to do, that I myself have had no training in. As doctors, we are expected to be able to just get on and do things. There is very little sympathy for the line “but I don’t know how”. And this is insane. If anyone asked me to produce evidence of competency in giving calcium gluconate, or administering methotrexate, or misoprostol, I would be screwed. Yet I do it frequently. 

O&G though, is on a whole different level. There is a guideline for EVERYTHING, but it is never exactly followed. You can assess a patient, make a correct diagnosis, initiate management according to the guideline, and be entirely decimated by a Consultant who has decided, on a whim, that it is not appropriate to give this particular pre-term labourer steroids. And that will be your fault. Acceptance of incompetence, and acceptance of culpability even when it is not your fault are necessary attributes for a successful rotation.Oh, and skin as thick as a rhinoceros.

So, I have compiled a list of possibly helpful, hopefully amusing tips for anyone who may be about to enter an O&G rotation. 

Top tips for anyone doing O&G as an SHO:

  1. ALWAYS put in the biggest possible cannula – when these women bleed, they lose their entire circulating volume in minutes. Plus, its so satisfying doing locum shifts in ED, waltzing into resus and placing a grey cannula without batting an eyelid. SKILLS.
  2. Regardless how young, virginal, or skanky a woman is, she is pregnant until the labs have excluded it.
  3. Following on from this, it is an ectopic pregnancy until proven otherwise.
  4. You will be referred at least one woman who is legitimately on her period. A&E will inevitably want you to admit her.
  5. Speculums are things we are ALL taught to do in medical school. The line from ED/UCC/Surgical/Medical Docs of “you’ll only repeat it anyway” is pure laziness, and their impression will be at least as good as yours. Whether you fight this one is personal choice. Frankly, it is irritating but not worth your breath.
  6. “Asian Pain Syndrome” is multiplied exponentially in pregnancy. 
  7. Headaches in pregnant people = NIGHTMARE. Even if it is definitely a migraine, you will go home convinced they have a thrombus and are going to die.
  8. Specialty tennis between surgeons and gynae for the women with abdominal pain helps no one. Gynae is seen as the easier option, which can be frustrating, but remember that there is a woman, possibly in agony, probably scared out of her mind, sat somewhere waiting for answers. Accept the patient. Get an USS. Yell at the surgeons later. 
  9. Secondarily to the above: Right Iliac Fossa pain in someone who still has their appendix is appendicitis until a surgeon has written that it is not. Regardless of how snarky they are on the phone. No one likes appendicitis because it is a difficult clinical rule-out, but that does not make it an ovarian cyst. Sort your shit out.
  10. “Gynae pathology” is NOT a diagnosis. I have had a lot of fun with this one. If they cannot give you a legitimate differential, then you don’t see the patient.
  11. Run absolutely EVERY decision by someone senior. Even prescribing antibiotics. Even following a guideline. They will look at you like a moron, but you get used to that pretty fast. There is no room for autonomous decisions in O&G, unless you want to be on the receiving end of a court case. Better to look like a moron than be proven one in court. 
  12. Remember this rotation is temporary. This is not your life. Soon you can be back doing something you enjoy, unless, of course, you are an O&G trainee, in which case, I salute you, and am getting you a psych evaluation.