Archive for June, 2011

On the Surgical Consent Process

Today I saw a patient for a preoperative visit and went through the ritual of “informed consent” and the signing of the surgical permit.   We had decided to do a hysterectomy to treat her problematic fibroids, and she very much wanted to proceed.  Having discussed the alternatives, we now had to go through the legal ritual of the surgical consent.

As usual, I discussed what we could expect to gain from the hysterectomy.   There was a 100% chance that she would no longer have any bleeding, and a very strong chance that any pain that originated in her central pelvis would get entirely or mostly better.  Anemia that resulted from the bleeding would improve. Other symptoms, like urinary pressure and frequency, and lateralized pelvic pain, would likely improve though it is not as strong a likelihood as the other symptoms.

We also discussed the risks.   “You could have bleeding during the surgery, potentially enough to need a blood transfusion before or after surgery.  You could get a communicable disease from a blood transfusion.  You could develop a wound  infection or abscess, which sometimes is easy to treat and other times quite complicated.  Anything in the abdomen could be damaged during the surgery, such as the bowel, bladder, ureters (“which carry urine from the kidneys to the bladder” I always say), blood vessels, or other structures.  Anything damaged can be fixed at the time by myself or a consultant.  There is a possibility something could be damaged but we do not recognize it at the time, or that there is a delayed injury.  If this occurs you might need further surgery, antibiotics, or hospitalization.  Though extremely rare, you could die or be injured from an unforeseen surgical complication or complication of anesthesia.”

At this point she looked white as a sheet, as usual, and then I tempered with “but all of this is extremely unlikely, less than 1% of cases for major issues, and I have to explain it all for legal reasons.  I am well trained to do this surgery and will do my absolute best for you.”  I answered her questions, the consent is signed, and we had our pre-op.
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One for the medical students – on presenting

I have the pleasure of working with our resident GYN team for several weeks every few months, rounding on their patients and teaching each morning.  One of the best parts of this is hearing our medical students present their cases.

Presenting patients is a skill that takes a great deal of time to master.  Each student is taught the basic form of a medical presentation at an early ‘age’ – Subjective, Objective, Assessment, and Plan.  Each of these bits can be broken down into many subareas, such a Past Medical History or Social History (part of the subjective usually), Chest Exam or Labs (parts of the objective), or individually listed problems (each parts of the assessment and plan.)

This sort of structure is both an aid to great presenting and a hinderance.  It helps because it gives the presentation a structure that is easy to follow, and over the years of hearing such presentations the listener has created little boxes in their mind, and had developed the expectation that these boxes will be filled in a specific order.  By following this structure, the student fills those boxes and thus creates a structured narrative that fits the listener’s expectations.  This can be very functional and efficient.  The downside is that if the student follows that structure too tightly, the presentation sounds stilted, like a person reading a spreadsheet.  This creates a presentation that is technically correct, but lacks grace.

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Academic OB/GYN Podcast Episode 33 – Journals for April and May 2011

Drs Browne and Fogelson discuss articles from April and May of 2011.  Antibiotics in Obesity (use more), Inpatient vs Outpatient Hysterectomy (hospital beds are nice), Homebirth Ethics a la Chervenak (not so much), Generalists in Academics (shrinking), MOC vs CME (MOC winning), Duration of Hot Flashes (long time).

Academic OB/GYN Podcast Episode 33 – Journals for April and May 2011

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