A Day In The Life: Gyne Oncology

I think had I gone the surgical route, gyne oncology would be a neat specialty to end up in. Gyne oncologists are OB/GYN graduates who have completed an additional two-year fellowship in gyne oncology. They perform surgeries to resect/debulk cervical, uterine, ovarian, fallopian tube, and vulvar cancers, and (I was surprised to learn) administer and oversee their own chemotherapy at the cancer institute. In addition, they run colposcopy clinics (to follow up on abnormal pap smears) and staff the hereditary breast and ovarian cancer (HBOC) clinic.

Gyne oncologists (in this city, at least) don't see any obstetrics or general gynecology cases. From my (perhaps naive) perspective that's pretty great -- they get to avoid the stress and urgency of delivering babies and the frustrations of managing non-specific pelvic symptoms. That's not to say they have it easy -- gyne oncologists do some of the toughest gyne surgeries out there. More than a few times this past month, mid-laparotomy, staring into an abdomen full of inflammation, adhesions, and fragile previously irradiated tissue, I've found myself doubting that the surgeon would be able to resect a massive ovarian cyst or bowel-adherent uterine cancer. But every time they've gotten it out. It takes a combination of skill, guts, and perseverance to get through these challenging cases, and I've certainly gained huge respect for these gyne oncologists.

Here's what a typical gyne oncology day looks like for me:

0530 h: I drive to the hospital, search around a bit in the residential streets for a parking spot, run up to the OR to change into scrubs, and head down to the ward to print a patient list.

I can tell how late I am by how far away I have to park. But not so late that the moon and a planet aren't still visible...

0600 h: The other residents and I pre-round on the ward, checking in on each patient and writing a progress note and orders.

0700 h: The staff gyne onc arrives and we run through the list, then round again as a team, usually accompanied by the nurse practitioner, pharmacist, and dietician.

0730 h: Once a week we have new patient rounds, where cases are discussed over videoconference with the gyne and radiation oncologists, radiologist, and pathologist present, to come to a consensus on management.

0800 h: Usually by 8 am the OR is paging us to come up for the first case. Generally two residents assist the gyne oncologist. I usually end up as the "bottom end" resident, which entails holding the uterine manipulator and pushing it up/down/left/right to "drive" the uterus as the surgeon requests.

Three times I've had to rescrub mid-case because I've fainted/nearly fainted...But hey, it happens. I'm so used to it I know exactly when it's coming and use those ten seconds to get well clear of the sterile field!

I've seen a good mix of open, laparoscopic, and robotic procedures; mostly ovarian cystectomies and hyst BSOs. The surgical robot, which I'd previously seen on urology, is neat technology -- the surgeon controls the robot's laparoscopic arms with pretty impressive dexterity from a 3-D viewing console in the corner of the OR. The residents assisting also get to sit down during robot cases, which is the best thing ever.

questionable sterile technique (in an actual case the robot would be covered in disposable plastic -- but that's not very sexy)
(http://www.arabiangazette.com/da-vinci-robotic-surgery-popular/)

On days when we're not needed in the OR, we spend time in the colposcopy clinic or new patient/follow-up clinics at the cancer institute. I hadn't ever seen a colposcope before, which is kind of like a microscope used to take a close look at the cervix. The patients get to follow along on a monitor.

colposcopy: acetic acid is applied to the cervix -- areas that turn white may represent VIN, HPV, or simply hyperkeratosis from trauma
(http://www.conceiveeasy.com/get-pregnant/can-a-colposcopy-interfere-with-my-fertility/)

Throughout the day we check back in on the ward, following up on bloodwork, investigations, and consults we'd ordered during rounds.

lots of walking up and down this (previously-featured-because-it-is-awesome) stairwell between the ward and OR

1730 - 2000 h: Depending on how smoothly the day goes, we can finish anytime from late afternoon to mid evening. After one last check on the ward it's time to head home.

And that's the day! I usually list some study resources at the end of these day-in-the-life posts, but waking up at 4:15 am and falling asleep pretty much the moment I finish dinner really hasn't left me too motivated to read these days. I'm embarrassed to admit that all I've done has been to browse the AHS Cancer Guidelines and skim-read my Hansen Evidence-Based Radiation Oncology book. I'll definitely have to dedicate more time to studying when I'm on gyne rad onc...and don't have 6 am rounds :)