Year 4: Obstetrics/Gynecology BOOK UPDATE

High Yield Obstetrics and Gynecology by Elmar P. Sakala:

I forgot to add this book to the OBG post. This book partially saved my life. Its name is descriptive of its content. It gives you the important information you need to know for the exams (written & DOCEE). 

It may not be up to date, but that is what you have UpToDate.com for. Take the main guidelines and outlines from the book and update the information from new sources (which is first line management and which is second; what are updated drugs and doses).

It is particularly useful to have on rounds or in clinics when you free time is abundant, quickly reviewing topics and memorizing on the go from this book.

Year 4: Obstetrics/Gynecology Clerkship - Part 4

Books
Most read from Kaplan Obstetrics & Gynecology USMLE Step 2CK Lecture Notes.
Many also read from Blueprints Obstetrics & Gynecology for covering the more important topics.

However, I like to read important topics in a full-rounded way - and this has been satisfying during exams for me. Meaning cover every aspect of them as you will be quizzed in detail in the DOCEE on common problems. Therefore I have done the following:

1. Kaplan Obstetrics & Gynecology USMLE Step 2CK Lecture Notes for getting a general idea about the topic and as the only source for low-yield uncommon problems
2. Combined Blueprints Obstetrics & Gynecology + Obstetrics by Ten Teachers + Gynecology by Ten Teachers for the high-yield topics I need to know in detail.
3. UpToDate for the most recent information I need to know on important topics: management, drugs, lab result numbers

How to study
Most students say the last 2 weeks are enough to study for OBG. This is somewhat true. Here was my routine:

1. In the first 6-7 weeks, you can study lightly. When you have free time during the hospital use them to study the high-yield topics. 
2. At home, you will have A LOT of free time. Spend it wisely. During this time, you can spend an hour or so watching some Kaplan videos at home. Or go over the low yield topics. Both only take about an hour.
3. In the last 2 weeks, you need to be studious. They will be more than enough to cover the high-yield topics in detail. You will most probably be revising them as you would have read them during the days in the hospital or adding in missing points.
4. You may study the important topics for the first time in these 2 weeks. It is still enough.
5. These high-yield topics are important for all exams, but mostly the DOCEE.

Hospitals
Qassimi:

• You will not learn much. This hospital is only for exposure to a variety of cases as well as exposure to many operations. 
• You can make use of self-directed learning here as it is the only kind you can get. Find willing patients, take history from them and examine them. You may observe women in labor (there are MANY!).
• Clinics:
• Attend clinics as they are a golden opportunity to see patient communication and learn about the elements of OBG ultrasound.
• Clinics are also great for seeing the elements of a history. It is only from the clinics that we were able to understand how organize a proper history.
• Labor suites: you can get many hands on experience here from the mid-wives.
• OT gets you exposure to D&Cs, uterine prolapse repairs and C-sections.

Baraha:

• Clinics with Dr Nabeela, Dr Mansoura and Dr Wafaa are quite useful - matter of fact, the most beneficial learning you will do.
• Labor suites: beneficial for learning and observing, not hands-on training

Dhaid:

• Clinics get you lots of exposure, hands-on practice and learning
• Labor suites (which are empty most of the time) are great for hands-on delivery by guidance of the doctor herself.
• OT gets you exposure to D&Cs, uterine prolapse repairs and C-sections.

OSCE

1. Know the uses and names of OBG instruments as you may have a station on them
2. Histories:
1. Discharge
2. PV bleeding
3. Pelvic Pain
4. Infertility
3. Physical examination:
1. Pap smear
2. Pelvic exam

DOCEE

1. High-yield topics will be given to you by the doctors at the hospital (ask them)
2. You will be taken to one patient for history-taking. You will not be doing a full history because it is too long. Only chief complaint and history of presenting illness. Other parts of the history will only be asked if necessary to the illness. If you are a girl, you WILL be asked to do physical examination.

Written

1. Important and low-yield topics in the practical exams are of equal importance here. You would therefore already have studied them from previous exams and daily training.
2. It is also important to study the blueprint from previous years.

Boys, This One's For You
Many of you will be reluctant to train. Many of you will stay home most days because of the conservative female culture here. Many of you won't care because you believe OBG is useless to your training. Ultimately, the decision is based on your conscience and circumstances.

If you do not attend because you believe you won't be able to do anything anyway, that is not always true. Doctors try their best to get you learning opportunities if you show your enthusiasm.

If however you choose not to attend, you will graduate with absolutely no practical knowledge in this field. Remember the amount of money you are paying to learn. You will not get another opportunity to learn like this in the future should you need it. Also if you are planning internship outside the country, your gender would not matter in OBG and you would not want to look incompetent.

Year 4: To be on-call or not to be? - Part 2

This was a confusing post for me to write because being "on-call" has no concrete rules.
Being "on-call" is really not what it sounds like. You just need to be in the hospital from say 3pm-8pm. It is not an all-nighter thing like the future will be. The purpose of this is to help you gain extra hours to train and practice. I know there are many questions in your head, most answered below I promise!

Each rotation, you have 10 nights, where you need to go to a hospital and stay there for a few hours to learn.

1. You can choose any day you desire.
2. You can stay any time you desire at any hour of the day. You can stay for 3 hours, 4 hours or even a whole night (some people are over-enthusiastic in this regard. Don't push it. You'll have plenty sleepless nights in the future. Stock up on energy now and do your 'calls' during the evening.)
   To give you an example: I used to stay after university depending on what time I finish either 3 pm or 6pm till 8-11pm depending on when I started. Sometimes, I'd be too tired during the week, so I go during the weekend.
3. Generally they tell you to stick to the hospital you are training at.
   Surgery and Internal medicine: preferable to do so. However, people in Dhaid Hospital have the option of choosing where. People in other hospitals who do not like to follow rules will probably also choose.
   OBG and pediatrics: there is only one hospital to be on-call at --> Qassimi and Baraha.
4. If you decide not to follow university rules, you can choose the hospital. Choosing the hospital really depends on personal preference and ease of access. Qassimi offers many cases and varied patients and is usually the best to learn from. Kuwaiti has a small variety of cases but you may still pick up a few things here and there. As for Baraha, I have never been on-call there so I cannot advise you. Dhaid....does anyone want to be on-call in the end of the universe...unless you live nearby.
5. Many/most students opt not to be on-call as they believe it to be a waste of time that they can use to study to increase their grades. However, you should not be influenced by others. You must do what fits into your goals and criteria. Do you need extra practice outside of regular hospital hours? Or do you feel you are more deficient in information and need to spend time reading?

Year 4: How to behave in hospitals - Part 3

1. First week: You will need to revise physical examinations and history taking as you may be doing them alone and then asked to present your findings to the doctor before they start teaching you things on your first week and before you start remembering them as they teach you. So get a head-start by freshening up your memory.
2. Be punctual. ALWAYS be on time (or before time)!
3. Have your white coat neatly on you (crinkled white coats and splotched ones make for an unsightly disheveled look. Patients already do not want to see your faces, us being students and all. Add an unkempt look to the list and you may not be welcome anywhere.)
4. Have your stethoscope on you, a quick reference guidebook or ipad, a notepad and pen (and a measuring tape if OBG). Make sure you have an ID tag on you at all times (certain hospitals are strict about this).
5. Be confident NOT COCKY! Be polite and respectful to ALL staff. Doctors. Nurses (are your best buddies in a hospital ya hear me! Make good friends with them. They run the place.). Janitors (good possible translators).
6. Do not talk to each other in ward rounds. Only talk to ask the doctor/nurse a pertinent question that absolutely cannot wait or when they are not utterly busy.
7. You can tell the doctor at the beginning of the rotation/week what your group goals are for that time period so he can help you achieve them. Is there a certain something you want to learn? Haven't learned something yet? Doctors are there to help you.
8. When you are not given a task, do not sit in a room and wait. Follow the doctor around and observe him, do not wait for him/her in a room until they tell you to do something (unless he/she tells you so). That way you miss out on many things you could be learning by observing. 
9. If a doctor says something you find contradictory to something you read, bring it up in a gentle manner. Doctors may feel challenged when you do that and few may get offended enough to get angry (I've seen it happen...). You may start with a: I would like to ask a question regarding this point, I read in this so [site reliable reference], that so-and-so is supposed to be like this-and-that....you get the hang of it.
10. Make educated guesses. Say "I don't know" when you don't know something. Doctors respect someone who is honest and not conceited in their own knowledge. Most doctors do not like random guessing of answers (the ones who do will let you know). Many a time have I witnessed students being berated for uneducated guesses.
11. Do not be afraid to ask questions that seem stupid. Do not be afraid of looking inexperienced. You are. Do not be afraid to try new things in order to learn. At this stage, everyone knows we are at the beginning of learning and expect us to be idiots anyhow. No matter the geniuses we were at university academically, this is clinical life. A person's life is either renewed or taken here. Allow yourself to make mistakes now - because that is truly the only way to learn - when you do not have a person's life hanging on your hands. When you are under the care and protection of the people responsible. Learning is done now, or in the future you would be too shy to admit inexperience as a full-fledged doctor. So seize the opportunity and learn to become great later!

    
    

    

    No those are not flowered diapers! But that is us now and for another few years...or maybe even till we retire!

Anything I missed out on?

Year 4: Clerkship Starts Here! - Part 1

That is the general outline of your year! Yes those are back to back 10 weeks...get used to this life :D

You will have 4 rotations, each rotation is 10 weeks long. Absolutely no vacations in between. 9 weeks in the hospital and the 10^th week is exam week.

BUT YOU ALREADY KNEW THAT!!

The 9 weeks:

• 8 weeks in the hospital
• Usually the entire 9^th week or half of it are taken as study-break. You must take the permission of your responsible doctor to go on this study break (sometimes it may require begging depending on the doctor. And 1 doctor in specific may give you only 1 day – Thursday – as a study break from this 9^th week). I'm not sure if the university is aware of this trend among students.....

The exam week usually starts with the DOCEE followed by the OSCE and finally the written is always on Thursday for all rotations together. (The DOCEE and OSCE may be interchangeable in OBG and Pediatrics.)

DOCEE: (I still don’t know if it is with a double ‘E’ or one ‘E’ -_-) is a hospital based exam. In surgery and internal medicine, the doctor will usually ask you to choose a day in the 9^th week or 10^th week that you would like to do your exam (some doctors may decide on their own). Certain doctors do this differently. However, generally, you come at the designated time to the hospital and are taken in turns to the same/different patients. Usually each student has 1 patient (certain doctors put multiple patients where you do history on one and physical exam on the next…etc.). You are told to take a full history, do a relevant physical exam on the patient. It is not as hard as it sounds as you would have had 8-9  weeks of experience in observing the doctors and doing it yourself. They allot you a time, however it is not as strict a timing as the DOCEE. They are lenient with it. Doctors may pause you to ask about why you are asking such or why you are doing such. The key is confidence. You either know or you confidently can say: I don’t know. I will consult with my senior doctor or read up on this matter and let you know.

Then they will ask you about your differential/provisional diagnosis. After which you will be asked to plan a management line for the patient along with investigations. Basics. Basics. Basics. Vague. Vague. Vague. That is all I can say with management. Eg.: Do not jump to MRIs and CTs before doing the easy stuff (or unless it is absolutely indicated). Another eg.: Do not say “metronidazole” for a disease unless you are prepared to answer the array of questions that will be fired at you when you could have easily said “antibiotics” and breezed by the answer without the teacher second-guessing you. Then you may or may not be asked to exclude the differentials based on the investigation results they provide you with. Your diagnosis is the least important part of the exam. I assure you. Do well on the history and physical exam parts and that is a big chunk of your grade. What they want you to learn during clerkship is how to be a good historian and examiner. The rest (management, diagnosis) comes with experience and reading.

OSCE: unlike the pre-clerkship phase, there are no longer merely 2-3 stations in the OSCE with 15-20 minutes each. That was the honeymoon phase dearest. Now it’s reality time. 10-12 stations with 5-6minutes each and 2-3 break stations between. 6-8 stations are a focused task that can definitely be completed in time. You will either be asked to do a focused abdominal exam, or peripheral vascular exam….etc. They do not teach you in previous years how to be focused in history or physical exams. I cannot predict all the scenarios you will get, so I can’t post any help here (I will try). Therefore what you need to do is to make sure you inform your hospital doctors of this at the start of your rotation. Let them know, you want to “learn how to take focused histories and do focused exams in 6 minutes tops”.

Along with history taking and physical examinations, you may have stations with:

•        Breaking bad news
•        Counseling on:

o   How to use a device

o   Major/minor operation

o   Contraceptives (for OBG)

3-4 stations will be computerized unmanned stations. 

FOR THE LOVE OF GOD WHAT DOES THAT MEAN?! You will go inside the room but instead of a doctor testing you, there is a computer with a picture and a paper in front of you with questions you have to answer about the picture on the computer. It could be a disease case, imaging, devices…etc. Sort of like OSPE.

Written: need I say anything? >70 questions: MCQs + EMQs.