This morning we got to observe Dr. Tung perform a conization (cone biopsy), which is an extensive form of a cervical biopsy in the operating room. A cone-shaped wedge of tissue is removed from the cervix, which includes the transformation zone and all or a part of the endocervical canal. There are 3 methods to perform this procedure:
1) scalpel (cold knife conization)
2) laser
3) electrosurgical loop (Loop Electrosurgical Excision Procedure, LEEP)
At first, Dr. Tung tried to use the LEEP method, but the tissue was too thin, so she had to switch to the cold knife method. The whole procedure took about 20 minutes.
After the conization, we returned to the OPD where Dr. Tung saw many patients. Most patients came in for Pap smears and others needed an ultrasound (aka transabdominal sonography). One patient that stood out to me was a 23 year old who came in with a chief complaint of dysmenorrhea. She has had dysmenorrhea since menarche, which was at 11 years of age. Additionally, she has been on hormone treatment with lower dose oral hormone contraceptive since the age of 13 and for the past 3 years has been taking Norethindrone/Ethinyl estradiol (oral contraceptive with iron supplement). This patient came in with her mother and father (who may have been a physician at this hospital). It seemed as if the patient's primary language was English, as she conversed with her mother in a mixture of Mandarin and English. However, what struck me was that during the majority of the visit (which lasted about 30-40 minutes, much longer than other visits, which were 5-10 minutes), the mother spoke for the patient. The mother told the doctor that the patient was recently married and wanted continuous oral contraceptive for menstrual cycle control. The mother spoke for the patient and even answered questions regarding sexual activity and sexual activity prior to marriage. When another person answers for the patient, there is always the possibility of pertinent information not being disclosed and affecting the care of the patient. If the patient is capable, then who would know the history and health status of a patient better than herself? Also, I feel that in the US, the mother and father would have been asked to leave the exam room, unless the patient requested that they be present. Then, after the patient was given an ultrasound and Pap smear, the mother sat on the stool intended for patients, and discussed contraceptive options with the doctor, while the patient herself stood close by and listened to the discussion, but did not really participate. This struck me as quite odd. This interaction between the doctor, the parents, and the adult patient made it seem as if the patient was not in control of her own health care and was unable to advocate for herself. And this was not the first time I have witnessed mothers answering all the doctor's questions in the OB/GYN outpatient clinic for their adult daughters (all in their 20's). I believe that the age of majority in Taiwan is 18 years of age. (Age of majority is the threshold of adulthood as it is recognized by law), so why do these mothers play such a large role in their adult children's health care, particularly gynecological care? At what point in their lives do these adult children get to talk to the doctor on their own? Is this an aspect of Taiwanese culture that is difficult to understand based on our ideas of adulthood, patient confidentiality and privacy, and gynecological care in the United States?
Then, in the afternoon, we observed Dr. Cao in the OPD. One interesting case was a 45 year old patient who reported having a palpable mass in the vulvar region. The doctor's examination revealed a large cervical polyp that protruded into the vagina (it was about the size of my thumb). Dr. Cao called the operating room and scheduled a polypectomy. After about 20 minutes we headed into the operating room to watch Dr. Cao perform the procedure. He explained to us that twisting the polyp would be enough to remove it and sure enough, it did not take very long to remove the polyp via the twisting method.
In only 3 days with the OB/GYN department, we have seen several interesting cases and procedures as well as many common gynecological diseases . And although it is unlikely that I will want to pursue an OB/GYN specialty, I have enjoyed learning from Dr. Cao and Dr. Tung and look forward to continuing this week with them.
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