Medical

A Portrait of Obstetrics & Gynecology

Central to the skillset of every physician is the differential diagnosis; this is the process by which new patients are evaluated to establish the most likely diagnosis. Similarly, the first clinical year of medical school is like a differential for each student, except instead of a medical diagnosis, students are seeking to determine which specialty they will choose. This column explores this differential: experiences from each rotation by a current third year student.
Having finished my first rotation, Women’s Health Clerkship, I’d like to offer a short look into the specialty, sharing some of my observations the last few weeks. As I have said often over the past two months, I believe this was the perfect rotation to kick off third year. OB/GYNs have a wide scope of practice, and their field contains elements of many other specialties. During this rotation I was exposed to clinical medicine, by which I mean the art of seeing patients in a clinical setting, spending a few minutes with each, and using history and physical exam skills to offer a diagnosis and treatment plan. I was also exposed to surgery. I hadn’t realized just how surgical of a specialty it is, or at least can be, depending on how a doctor chooses to practice. (More on that later.) I also saw some inpatient medicine, managing patients in a hospital setting and consulting with other specialties as needed. And of course, OB/GYNs have a very unique aspect of medicine that is theirs alone: the labor & delivery floor. This breadth of practice settings was an excellent introduction to many aspects of medicine that I’m only beginning to understand.
Despite all of this, an OB/GYN’s scope of practice is fairly narrow. Roughly half the population is immediately excluded by virtue of being male. Further, obstetricians deal for the most part with patients who are pregnant or would like to be. This excludes most children and most women over the age of 50. Expanding the scope to include gynecology widens the range of problems considerably, though still within the realm of problems unique to women. This encompasses many topics and many procedures and techniques to understand.
I thoroughly enjoyed this rotation, perhaps more than I expected to. One major reason for this: Nothing compares with the experience of seeing and helping with the birth of a child. I have tried to describe the experience in words and often find myself coming up short, feeling that my description fails to convey the sheer beauty and magic of the moment. I had the opportunity to see about fifteen vaginal deliveries and five Cesarean sections. Even by the end, the wonder I felt at the moment of birth hadn’t really worn off. I was also honored to be able to assist in many of these, including one in which the doctor let me do the delivery (under close supervision). It’s a moment that will stick with me forever – a moment of wonder and grace and yet another example of how humbling this profession can be.
There were other aspects of this rotation that I really enjoyed, like the fact that most of our patients were healthy and happy. Many patients were at the clinic for annual check-ups, taking an interest in their health. Most of the obstetrical visits were check-ups in which the patients were healthy and frequently happy as well. One of my attendings observed that obstetrical patients were the only ones happy to be admitted to the hospital and excited for their brief stay, at the end of which they would have a baby. The surgeries in gynecology, too, were generally routine. It is gratefully very rare for a patient to have serious complications or die from surgery, and especially so in gynecology. Further, most patients presenting for a surgery like a hysterectomy had suffered for years with bleeding, pain, and discomfort, and the surgery was a tangible, immediate fix to their problems. Understandably, these patients left satisfied and thankful.
Of course, there were some difficult aspects as well. One thing I noticed about this specialty, which is both challenging and rewarding, is that the doctors are present for the best parts of patients’ lives, but also for the worst. They have the opportunity to guide life into the world and give a healthy baby to new parents, but they also often deal with unimaginably hard situations – delivery of a stillborn infant, postpartum hemorrhages that are acutely life-threatening, or delivering the news of another miscarriage. The sheer joy of most patients must be taken with the dark pains of the others, and this is not always easy to balance. One nurse told me a story about a night where she had two patients, one delivering her first child and the other laboring with a stillborn. She described an incredible amount of emotional drainage trying to balance them, changing from happy and encouraging to consoling and grieving back and forth all night. There are other hard moments as well, not necessarily specific to this specialty but rather medicine as a whole: trying to balance the wishes of a patient with what is best and healthiest for the patient and her baby, trying to negotiate complex family dynamics, and working with noncompliant patients. Navigating these complex issues requires decisiveness, poise under pressure, and an ability to let go of difficult moments at the end of each day.
As with all specialties, there is the prospect of tailoring one’s practice as desired. I mentioned the broad scope of an OB/GYN – outpatient, inpatient, surgery, labor and delivery – but in reality, many doctors choose to focus their practice after residency. If a physician likes delivering babies, he/she can be an obstetrician and see healthy pregnant patients and do deliveries and C-sections; if he/she prefers surgery, he/she can do mostly gynecological surgeries. There is an array of fellowships to choose from as well. These typically include: Maternal & Fetal Medicine, Gynecologic Oncology, Reproductive Endocrinology and Infertility, and Female Pelvic Medicine and Reconstructive Surgery (Urogynecology). These fellowships give even further opportunity to focus and narrow one’s scope of practice.
I deeply enjoyed my experience on this rotation. I particularly liked how I was able to be involved – not all the time, and not always in the most central ways, but in little ways. This was especially true during labor, which often involves slow hours of waiting and affords time to talk with the patient and her family. I liked getting to know these people, and I look forward to doing this regardless of the specialty I choose. Compared to the long, slow hours studying for Step 1, the last several weeks have seemed some of the fastest of my life. Though my confidence and competence still have long way to go, I am already feeling more sure of myself than I was eight short weeks ago. I am more aware than ever of how much I have yet to learn, but I feel I at least have a better grasp on the structures and systems in which I will be learning it. I hope that many of the habits, skills, and knowledge I’ve developed in this first rotation will continue to expand as I move through the rest of this year – and the rest of my career. And now I am making the most natural transition – from the birth of children to watching them grow up – as I begin my next eight weeks in pediatrics!
About the Author
Brent Schnipke is a third year medical student at Wright State University Boonshoft School of Medicine in Beavercreek, OH. He is a graduate of Mount Vernon Nazarene University with a degree in Biology. His interests include medical education, writing, medical humanities, and bioethics. Brent is also active on social media and can be reached on Twitter @brentschnipke.

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Brent Schnipke, MD is a writer based in Dayton, OH. He graduated medical school in 2018 and is psychiatry resident at Wright State University Boonshof...