The intangibles of medical training: No benchmark established

Dr. Afshar is a third-year resident in the Department of Obstetrics and Gynecology at Cedars-Sinai Medical Center in Los Angeles, CA. 

Dr. Zakhour is a second-year gynecologic oncology fellow at UC Los Angeles / Cedars-Sinai Medical Center. 

In this era of highly regulated medical training, most residency and fellowship programs establish rigorous educational objectives and procedural curricula for their trainees. Guided by the expectations set by ACOG and ABOG, Ob/Gyn training programs rely upon structured didactic sessions and guided reading recommendations to keep their residents in compliance with these benchmarks. Residents and fellows track their case and procedure counts in order to meet the minimum thresholds set by ACGME, and all of these criteria must be met within an 80-hour work week, with 10 hours off between each shift, and with at least one 24-hour period off per week.

With these objectives, rules, and regulations in place, some of the most meaningful lessons learned in our medical training cannot be found in an educational syllabus. Many of the invaluable pearls that we learn in residency and fellowship cannot be measured, quantified, or evaluated by any reasonable metric. These are the nuances hidden amidst the daily interactions with patients and their families. Some are lessons we must learn on our own, by virtue of showing up to work, engaging in the lives of our patients, and going home at the end of the day with the weight of what we have experienced.

Obstetrics is a unique field in that it involves the concomitant care of two (or more) patients, not one. Shared decision making still stems directly from discussions between the patient and the physician; however, the fetus must also be placed within the algorithm of care. Most often, the interests of the pregnant woman and her fetus converge, and optimizing the maternal condition will provide for the best interest of both parties – mother and fetus. Sometimes this mantra does not stand.

Of late, we’ve had the privilege of taking care of two young women, both with second trimester pregnancies. Philosophically, no environment exists in the absence of organisms; rather, organisms construct the environment. In obstetrics, this milieu is the gravid uterus, which is dynamic and often reflects the array of internal and external forces upon it at any given moment.

Our first patient presented with unilateral upper extremity pain and weakness and a large intracranial soft tissue mass. During her work up, a biopsy was consistent with diffuse large B-cell lymphoma. The second patient presented to us with nausea and vomiting in the setting of headaches and ataxia. She was found to have a high-grade glioma, and prognosis was deemed poor even with the most aggressive chemo-radiation.

In the absence of a pregnancy, the treatment algorithms for these women are straightforward and standardized. In the first case, we would proceed with systemic chemotherapy, which includes methotrexate. In the latter case, aggressive radiation therapy and chemotherapy would be recommended. Clearly, the maternal and fetal interests have diverged. Now that these fetuses are viable, do we optimize maternal or fetal outcomes? We must appreciate a grave 6-12 month prognosis for the mothers, as well as the risks of prematurity and subsequent hematologic malignancies to the fetuses. Do the mothers' partners have a say? Do we move toward delivery so the mother can proceed with treatment? Over and over, we are humbled by the insight of patients to make these seemingly impossible decisions when they are provided data, algorithms, and autonomous decision-making. These are the lessons not learned in textbooks.

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In gynecology, we have the privilege to care for women beyond their reproductive years. Particularly, on our gynecologic oncology rotations, we learn the importance of caring for patients at the end of life. We are taught the technicalities of hospice care, the meaning of palliative care, and the value of establishing advanced directives for patients before they are incapable of making decisions for themselves. While these issues are more commonly encountered in oncology, the ability to deliver bad news and to establish patients' wishes for their own care traverses all realms of obstetrics and gynecology.

A few weeks ago, a patient well known to our service passed away from complications of metastatic uterine cancer. In a conversation with her husband after her passing, condolences were expressed, as we had done with many patients' families in the past. But we were taken aback by his response. Rather than thanking us for taking care of his wife, or for the phone call, he thanked us for facilitating their comfort in changing her code status to DNR/DNI. He explained that, in our prior conversations, he began to understand his wife's prognosis and felt grateful that she was allowed a peaceful death, free of chest compressions and intubation, at home.

No other field of medicine allows the physician the ability to be an integral part of both the first moments of human life as well the final moments prior to death. Most days, we leave the hospital feeling rewarded. Other days, we head home heavy-hearted, unable to separate ourselves from the grief of our patients or their families. Empowering women to live and die with dignity underlies our entire profession. These are the intangibles of medicine.