On the third day of our Ob-Gyn rotation, we got to see Dr. Tung perform a cone biopsy--also known as conization. The patient was a 44 year old female who had an abnormal pap smear result. The pap smear revealed high grade squamous intraepithelial lesions (HSIL) and Dr. Tung decided to do a biopsy as these lesions may indicate an increased risk of squamous cervical cancer. There are a few ways to perform a cone biopsy, but Dr. Tun focused on the 3 main methods:
1) Direct scalpel sample removal
2) CO2 laser
3) LEEP= loop electrosurgical excision procedure.
During the biopsy procedure, Dr. Tung removed 3 samples, one from the cervix, one from the endocervix region, and one from the endometrial layer. The patient started to regain consciousness during the procedure and had to be put under again because the procedure was taking too long. Dr. Tung explained that as she was cutting with the loop, she realized the cervix was not thick enough for the sample she originally planned to take so she had to switch to scalpel excision which required extra careful maneuvering.
Another interesting case we saw today was that of a 23 year old female who presented with a chief complaint of dysmenorrhea. It wasn't the clinical part of the case that was interesting, but rather the interactions of this case that caught my attention. This 23 year old female came in to the office with her parents. Her father was a doctor in the hospital also, so I suspect there were special arrangements made for her to move up the extremely long list of patients. Dr. Tung also spent 40 minutes with this patient alone trying to cover all her bases and explaining everything multiple times. This patient, though she was an adult already and recently married, sat in the seat and barely said anything. Her mother spoke on her behalf, claiming her daughter did not speak Chinese well. However, it was apparent she both understood and spoke Chinese. It was really strange for me to see her mother answer questions such as "are you sexually active?" and "how long have you been sexually active?" for her daughter. I feel this may cause difficulty in helping the doctor diagnose the patient since all the information she is receiving may or may not be true. Over the 4 days I shadowed in the OB-Gyn department, I saw several mother daughter duos, so I believe it could be a cultural thing for mothers to come with their adult daughters to the doctor and answering questions for them. In the US, it is common practice for the doctors to ask the family members or significant others to leave the room when asking such intimate questions. Here, on the other hand, the doctors often allow family members to stay while taking history and would allow the family to answer and speak for the patient even if the patient was capable of answering herself.
In the afternoon, we shadowed Dr. Cao in OPD. We saw a 45 year old woman who came in complaining of a mass in her vagina. Upon examination, Dr. Cao found a large cervical polyp that was visible even before inserting the vaginal dilator. Dr. Cao asked the patient if she wanted it removed, and when she said yes, he immediately scheduled for a same day removal. An hour later, we were in the surgery room watching Dr. Cao perform a polypectomy. He proceeded to excise the polyp without using any anesthesia. He explained it was because there are few nerve endings in the cervix so she would not feel much pain. A few simple zaps with the electrocauterizing device and a few twists with a forceps later, the polyp was out. It took less than 20 minutes and the patient was able to go home polyp free. The polyp was sent to pathology to determine its cytology. Though they are mostly benign, it was still sent as a precaution.
On the 4th and last day of my rotation, we once again went to outpatient. We shadowed Dr. Cao in the morning and saw several pap smears and cases of amenorrhea. Dr. Cao discusses a little about what it's like to be an Ob-Gyn in Taiwan with us during a short break. He had very unfavorable opinions about the profession in Taiwan. He explained that in the past, OB-Gyn was a highly esteemed specialty and only the top students were able to compete for the residencies. However, with changes in the health insurance system and declines in the economy, there are less and less children being born and the salaries of the Ob-gyn physicians are decreasing steadily. In addition, there is a high lawsuit rate in the profession and it often costs the physician at least 2-3 years of salary if he were to lose a malpractice suit. Also, Ob-Gyns do everything from pap smears, outpatient visits, ultrasound, X-ray procedures, delivering babies to surgical procedures. Overall, it is risky and tiring profession for these physicians in Taiwan. In the US, Ob-Gyn is also a specialty that is becoming more and more unpopular due to the unpredictable hours and demanding nature of the profession. I believe Ob-Gyns are crucial and easily one of the most important physicians in medicine. If the trends continue in Taiwan with which few to none of the students want to go into this specialty, Taiwan may face an extreme shortage of Ob-Gyn doctors and more patients would suffer the consequences of the shortage.
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