Reflections on Observing a Medical Professional

These are a collections of reflections, outlining my learning and thoughts from the knowledge I am gaining from observing a doctor.

Background:

The premise of this experience is to gain an understanding of a specialist’s role in the hospital, acquire knowledge about a speciality, and utilise my learning to improve my extended essay. I am taking guidance from Dr. Chaitali Trivedi, a laparoscopic and hysteroscopic gynaecology surgeon (with a role in cosmetic gynaecology), who holds the world record for removing the largest uterus weighing 4.1 kg, laparoscopically. I go to the hospital she works at, Nanavati Max; Super Speciality Hospital, for 1-2 hours to learn from her and become accustomed to a medical work environment.

04.05.22

We began our session at 4:10 pm and ended at 5:40 pm.

Our discussion commenced when I asked her about the patients she talked to in the morning and the types of issues she sees daily. She began discussing a patient who was diagnosed with polycystic ovaries. A notable point Dr. Trivedi mentioned, was the effect of this disease is elevated by an unhealthy lifestyle ergo she recommended daily exercise to the patient (28 years, female). She also included that it is not a major complication for the patient and they can stop it early. For context, polycystic ovary syndrome (PCOS) is a condition caused by hormonal imbalance leading to irregular menstrual periods, excessive hair growth and infertility. Patients with PCOS produce high levels of androgens, causing the reproductive hormones to become ‘deranged.’ Cysts may develop on the ovaries because of the lack of ovulation occurring.

Next, she starting talking about a patient she interacted with in 2013 where Dr. Trivedi was involved in removing 6 fibroids from the uterus. Fibroids are tutors developed in the uterus also known as leiomyomas and myomas. Fibroids consist of muscle cells and connective tissue and are found to develop when estrogen is higher. Evident symptoms of fibroids are heavy periods (menorrhagia) which may lead to anaemia, painful periods and discomfort.

(Medical News Today, 2020)

Dr. Trivedi went on to say that in 2022 (present year) the patient again experienced fibroids which caused her heavy bleeding; in fact, causing her to faint twice given that the brain wasn’t receiving enough blood. Moreover, she also suffered from a seizure because of the same. Dr. Trivedi explained that when other doctors operated on the patient to remove the fibroids, they did not restore the haemoglobin that was lost due to the heavy bleeding (which would be standard procedure). This caused the wounds to open because of the less oxygenated tissue. The vessels opening is known as secondary inflection and usually haemoglobin is built-up first to avoid this. During our discussion Dr Trevedi noted, “morbidity is prolonged because of low haemoglobin.”

Another case we discussed was a patient with a polyp in the uterine cavity, size of 4 x 5mm, causing excessive bleeding and vaginal discharge. The position of the polyp is indicative that it is in fact the cause of the excessive bleeding. From this case, I was able to deduce how females are susceptible to anaemia as the haemoglobin levels would continue to drop until the polyp is removed.

To better understand Dr Chaitali’s role, I asked her about her title as: laparoscopic and hysteroscopic gynaecology surgeon (with a role in cosmetic gynaecology). She first explained what an endoscopy is and divided this definition into laparoscopy and hysteroscopy. An endoscopy is surgery performed with an endoscope; a long, thin tube with a small camera attached. A laparoscopy (done with a laparoscope) allows the surgeon to operate through small incisions, unlike in open surgery where a large cut is made. It is known as minimally invasive. A hysterectomy is performed without incisions as surgery is performed from the birth passage itself. Towards the end of the session, she showed me a presentation she had made on the advantages of laparoscopy such as:

• Less pain and bleeding

• An early return to work for the patient

• Only a one-day hospital stay

I then inquired more about terms like fibroids and polyps and she informed me that “they feed off estrogen”. Estrogen, mostly produced by the ovaries, helps maintain the female reproductive system and characteristics such as pubic hair and breasts. Moreover, it also contributes to cognitive health, bone health, and the healthy functioning of the cardiovascular system. Other factors impacting the development of fibroids and polyps include; smoking, delayed marriages, genetics and late child bearing. Dr. Trivedi mentioned that other conditions that we could explore are prolapse and endometriosis.

Another condition would be the formation of cysts. She talked about a patient case, 47 years old, where the patient had a cyst (a fluid collection). The patient expressed that:

• She wasn’t getting her period

• She had hypothyroidism (elevated level of thyroid-produced hormones)

• She was slightly diabetic

Dr. Trevidi showed me the patient file with information from her tests that depicted:

• The serum iron was low

• She was low on haemoglobin

• The patient had an iron deficiency (low ferritin)

• She had low vitamin D → Dr. Trivedi mentioned how most people would have vitamin D deficiencies because of the UV rays present.

To end our session today, we spoke briefly about lifestyle disorders, including topics like the benefits of exercise and effects of smoking. She discussed that the endorphins released from exercise help regulate the other hormones in the body. Furthermore, smoking affects clotting factors in the blood and works on the platelets. Overall, it was an informative session; I especially liked looking at the patient’s file with Dr. Trivedi and understanding how she comes to a diagnosis.

08.05.22

Today’s session started off with a presentation on lifestyle disorders from which I learned about how certain factors in our daily lives profoundly impacts our health. Firstly, Dr. Trivedi shed light on the risks of smoking which include chronic diseases and cancers. She mentioned that from her experience in the field of gynaecology and obstetrics, she has seen cases where stopping the habit of smoking increases fertility. The main issues behind smoking are the effects of carcinogenic chemicals which cause the hardening of the arteries. These chemicals cause difficulties for cells to repair damage.

Furthermore, we briefly discussed alcohol consumption and sleep; the main idea is that there isn’t a safe alcohol threshold and sleep is essential for regeneration. Then, we moved on to a rising issue, anxiety. Chronic stress, anxiety and depression all make the body susceptible to disease and as mentioned by Dr. Trivedi can decrease fertility. She noted that most of her patients suffer from chronic stress. In addition, these factors can decrease libido, increase blood pressure and lead to an increase in weight, which may need PCOS in women. Overall, I feel that this presentation provided a good base from which we could discuss comparatively more specific topics.

The second presentation in today’s session was, ‘Diet and Nutrition; Women’s Health which was incredibly insightful. Though it may seem like a straight-forward subject on the benefits of balance, this presentation went through the impact of age on women’s health and the various food products that could aid in treating the draw-backs of menopause. We first addressed obesity and I learned:

• Genetics have an impact on metabolism and therefore obesity

• There isn’t a universal set of hormones right for every individual

• Hormonal imbalance is usually the cause for obesity issues in women

• Women store fat in the middle of the body (the hips) as they age

Dr. Trivedi stressed how menopause can cause complications, like hot flashes, for females as there is a decrease in estrogen production. Ergo, women can opt to take phytoestrogens which aid in the balancing of hormones and allow women to opt against taking estrogen supplements which disturbs the normal process of menopause. For females aged 45+, medical professionals should not supply estrogen externally as they can be cancer causing. Hormones that can be supplied as a substitute are bioidentical hormones. Further in the presentation, Dr. Trivedi noted the advantages of soya isoflavones, which are considered phytoestrogens, found in legumes and soy. Women after 40 are advised to increase their intake of soya isoflavones as they:

• Supplement estrogen in a healthy manner

• Lowers cholesterol

• Can prevent cancer

• Reduce hot flashes

We summarised the influence of estrogen, discussing that estrogen has roles in:

• Cellular division

• Bone health

• Heart disease

• Storage and distribution of body fat

• Skin health

Examples of complications caused by a lack of estrogen include:

• BMR decrease, affecting the metabolic rate

• Decrease in ability to memorise, effect on memory

• Osteoporosis, bone complications

• A fat shift to the abdomen which increases chances of heart disease, affects blood pressure and makes the patient susceptible to diabetes

Moving to general diet and nutrition, Dr. Trivedi listed that the main causes of lifestyle disorders are:

• Obesity

• Non-organic animal products (leading to hormonal imbalance)

• Pills

• Antibiotics

• Refined oil

• Caffeine

• Alcohol

• Smoking

We then went on to discuss food products and portions, discussing the implications of ‘bad fats’ which deposit in our tissues over time, impacting the arteries, kidneys and liver. The presence of these bad fats increases LDL cholesterol and decreases HDL. LDL cholesterol is the bad cholesterol that collects in the walls of the blood vessels, making health problems like heart attacks and strokes more probable. HDL is ‘good’ cholesterol that absorbs cholesterol and carries it to the liver.

Next, Dr. Trivedi went on to talk about the major metabolic types, saying that there isn’t a correct balance of hormones for every person.

^This table is similar to a table shown in her presentation, depicting the combinations possible. Insulin resistance and burned-out adrenals are considered bad for the body.

Overall, I liked the way she presented womens’ issues and connected it to hormones and age. This aids me in completing a project where I explore the connection of fibroids to anaemia in females of reproductive age; this information is especially useful in understanding the the life-cycle of cis females.

09.05.22

Today’s session focused on fibroids; its development, complications and treatment options. She began explaining that it is likely to cause difficulties for the patient as it is taking up the blood supply to form. With larger fibroids, this would be a significant issue. The location of fibroids is essential to understand because it reveals the types of symptoms the patient may experience. With fibroids in the uterus, there would be excessive bleeding during the menstrual period.

Additionally, there could be multiple fibroids formed which would be hard to operate and take out since small fibroids cannot be removed surgically. When removed, there is a chance fibroids may grow again and there is a certain extent to where medical professionals would operate and remove the fibroids, considering that its removal would also cause bleeding.

When fibroids grow during pregnancy, they could cause pregnancy complications like changing the position of the growing baby. It is likely for fibroids to develop in the first trimester as these tutors need estrogen to develop. The body produces more estrogen during pregnancy. Primary issues include bleeding, pain and miscarriage. According to WebMD, fibroids tend to shrink after pregnancy; “In one study, researchers found that, 3 to 6 months after delivery, 70% of women who had live births saw their fibroids shrink more than 50%.” (2020)

Dr. Trivedi mentioned that the types that can be serious include:

• Broad ligament fibroids: These cause stress in the ligaments and can be serious if its vascularity is large. With a large vascularity, it can be very hard to operate on considering it is coated in a layer, called the peritoneum. The peritoneum is a sheet-like transparent layer that contains many blood vessels, and cannot be stitched together. This makes it harder for the medical professionals to remove the fibroid as tearing the peritoneum would cause excessive bleeding.

• Coronal fibroids

• Cervical fibroids

We then moved on to treatment options; she first discussed the non-surgical options of treatment which included:

• Medicines: These medicines create a non-estrogen environment and usually results in temporary shrinking. When the patient stops taking these, their fibroids would grow back so it isn’t a good option, long term, especially since these medicines can be expensive.

• Radiology treatments: These involve blocking the blood supply to the uterine artery, which would block the supply to the fibroids.

• HIFU: This is like a sonography where high intensity beams are focused on the fibroid. This can only manage a small number of fibroids and multiple sessions are required (6-8 sittings) which could take up to 8 months. Additionally, only fibroids with a size of 2-3 cm in size would be acceptable for this sort of treatment. HIFU would often result in a size decrease but not complete removal.

Dr. Trivedi then moved on to discuss the surgical treatments, which seemed to be the most effective in removal.

• Myomectomy: Where an incision is made and fibroids are removed.

• Hysterectomy: The surgery is conducted through the natural birth passage.

^These treatment options however cannot remove very small fibroids and new fibroids can still grow post-op.

• Uterus removal: As the only function of the uterus is to carry a baby, this may be a good option for females with many fibroids and/or those past reproductive age. The hormone function from the ovaries would continue to function.

• Mifepristone: This is used in abortions and can be applied in reducing the size of fibroids. This would allow the bleeding to stop though the fibroid(s) would still be present. Additionally, this must be continues till menopause.

I think this session was particularly interesting because I got to see surgeries and images of the female reproductive system and how fibroids actually look like. To my surprise they were different from the anatomical figures I’ve seen so it really built a foundational knowledge framework for me; I now understand that surgeons must comprehend the human body extensively to even locate the issue.

To aid me in my understanding of women’s issues, Dr. Trivedi sent me a data set with her previous patients’ symptoms and test results. I found it complicated to go through, however I plan on organising this data by a subject-based approach so I comprehend it better.

11.05.22

Today’s session holistically focused on treatment and the surgical removal of fibroids. Today, I had the opportunity to sit in on a patient consultation related to fibroids and excessive bleeding, which was leading to issues such as anaemia.

We first started off with a presentation on treatment options, beginning with laparoscopic ovarian drilling, which is a surgical treatment for PCOS. The medical profession starts by making an incision to inflate the abdominal region so that they can insert the laparoscope (viewing tool) without damaging the internal organs. “Electrocautery or a laser is used to destroy parts of the ovaries.” (PeaceHealth)

We then progressed into a discussion about cysts, fluid filled sacs that commonly form during ovulation. Dr. Trivedi discussed three types of cysts:

• Simple: “Cystadenomas are filled with watery fluid and can sometimes grow large.” (OASH, 2021)

• Chocolate: These are endometriomas, caused by endometriosis, where the lining of the uterus grows outside of the uterus. This tissue conducts the role of outer tissue which would break, thicken and bleed during menstruation. However, this tissue does not permit a pathway for the blood to exit the body, which traps the blood, making it appear brown with time.

• Dermoid: these cysts contain solid and liquid material from any organ in the body. Dr. Trivedi noted that this could be blood, tissue, teeth or others.

I was fascinated by how the chocolate cysts were removed and how the surgeons would deal with the amount of blood being released from these cysts. Ergo, Dr Trivedi began to discuss endometriosis, caused by endometrial deposits. The collection of blood that occurs causes neighbouring organs to stick together, causing pain during and after periods. This also leads to irritation in the lining, causing excessive bleeding (which would increase the probability of low haemoglobin). Adenomyosis specifically is where endometriums are present in the muscle wall of the uterus. It causes severe pain and heavy bleeding. She mentioned how this is more common in middle aged women. The symptoms she looks out for include:

• Longer periods

• Shorter intervals during periods

• The patient begins passing clots during menstruation, which is abnormal. Clotting occurs when bleeding is in excess.

• Pain during periods

The surgery videos I saw for these cysts were incredible and so distant to what I could have imagined. Laparoscopy especially was difficult to even comprehend because the process sounded complex. It seems impossible to think that surgeons are able to operate on the female reproductive system through such small incisions. Moreover, the stitching process and clean-up looked very interesting because the process was done with conscious care; the surgeon made clear stitches but still took ample time threading each part of the uterus/cyst. Additionally, Dr. Trivedi explained that there is a dead space left after a cyst or fibroid removal, especially when they are large, so the surgeons account for that by stitching the area up (or sealing it from further bleeding).

Dr. Trivedi directed the conversation towards fibroids and reiterated the severity of submucosal fibroids which cause pain and excessive bleeding. The surgery would depend on the vascularity of the fibroids; surgeons would want to ensure the patient doesn’t lose too much blood during the operation.

We briefly discussed prolapse again, where the uterus starts coming out of the birth passage as the ligaments holding the uterus begin to weaken. It is important to note that this occurs in elderly patients. A course of action includes complete removal of the uterus, however the patient can opt for support where medical professionals mechanically pull the uterus up.

Towards the end of the session, I sat through a patient consultation. The female patient described her symptoms as long periods, lasting 10 days and a low haemoglobin level. She is aware that she is anaemic and has recently had IV drips (4 sessions) to restore her levels. However, the level soon dipped back down. After looking at the patient’s results from her CT scan, Dr. Trivedi identified a fibroid in the patient's uterus (approximately 1cm). She explained that this fibroid is the cause of the bleeding and that she should look at getting it removed before her next period, to avoid excessive bleeding. More bleeding could cause complications as her haemoglobin levels would be too low to operate on. Dr. Trivedi recommended a hysterectomy for the patient, and explained that this would be the most effective procedure. I respected the manner in which Dr. Trivedi explained the issue using a diagram and communicated the treatment options clearly, putting the patient at ease.

Overall, I found this day to be the most productive since I was able to connect by learning from previous sessions, I got to see the surgeries (through videos) and I was able to observe how a medical professional addresses a patient’s concerns and identifies viable treatment options.

Works Cited

1. WebMD. “Uterine Fibroids and Pregnancy.” WebMD, 8 Nov. 2020, www.webmd.com/women/uterine-fibroids/what-if-i-have-uterine-fibroids-while-pregnant. Accessed 14 June 2022.

2. Peace Health. “Laparoscopic Ovarian Drilling (Ovarian Diathermy) for PCOS – Health Information Library | PeaceHealth.” Www.peacehealth.org, 22 Nov. 2021, www.peacehealth.org/medical-topics/id/tw9171. Accessed 15 June 2022.

3. OASH. “Ovarian Cysts | Womenshealth.gov.” Womenshealth.gov, 22 May 2018, www.womenshealth.gov/a-z-topics/ovarian-cysts. Accessed 15 June 2022.

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Cleveland Clinic. “Polycystic Ovary Syndrome (PCOS) & Treatment.” Cleveland Clinic, 21 Sept. 2021, my.clevelandclinic.org/health/diseases/8316-polycystic-ovary-syndrome-pcos. Accessed 7 June 2022.

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Nichols, Hannah. “Estrogen: Functions, Uses, and Imbalances.” Medical News Today, 12 Mar. 2020, www.medicalnewstoday.com/articles/277177. Accessed 12 June 2022.

OASH. “Ovarian Cysts | Womenshealth.gov.” Womenshealth.gov, 22 May 2018, www.womenshealth.gov/a-z-topics/ovarian-cysts. Accessed 15 June 2022.

Peace Health. “Laparoscopic Ovarian Drilling (Ovarian Diathermy) for PCOS – Health Information Library | PeaceHealth.” Www.peacehealth.org, 22 Nov. 2021, www.peacehealth.org/medical-topics/id/tw9171. Accessed 15 June 2022.

WebMD. “Uterine Fibroids and Pregnancy.” WebMD, 8 Nov. 2020, www.webmd.com/women/uterine-fibroids/what-if-i-have-uterine-fibroids-while-pregnant. Accessed 14 June 2022.