During my recent OB/GYN rotation at Woodhull Hospital, I had the privilege of immersing myself in the world of women’s health, a field that was previously unfamiliar to me. This rotation exposed me to a wide array of clinical experiences, from prenatal care in the clinic to witnessing childbirth in labor and delivery. It was an enriching experience that not only expanded my medical knowledge but also deepened my appreciation for the humanistic aspects of patient care.

The structure of this rotation allowed me to explore different facets of the OB/GYN specialty. Each week, I was assigned to a different area, providing me with diverse perspectives and learning opportunities. In the clinic, I encountered a variety of cases, including routine prenatal visits, contraceptive counseling, and procedures such as implant insertions. I also gained a deeper understanding of diagnosing and managing common gynecological infections, such as bacterial vaginosis, yeast infections, and sexually transmitted infections like chlamydia and gonorrhea. These cases underscored the importance of patient education, as many women were unfamiliar with the causes and prevention of these conditions. Through these experiences, I came to appreciate the vital role of preventive care and education in women’s health.

The labor and delivery department offered some of the most profound experiences of the rotation. Although there were no PAs present, I had the opportunity to witness cesarean sections and vaginal deliveries for the first time. Being in the operating room during a C-section and witnessing the birth of a child were unforgettable moments. They revealed the intricate technical and emotional depth of this field and reinforced my respect for the profession.

What stood out to me during this rotation was observing the lifestyle and responsibilities of the physician assistants. At Woodhull, the PAs rotated between the clinic and being on call. This variety of tasks, ranging from outpatient consultations to managing inpatient cases, made the work dynamic and engaging. It also highlighted the versatility of the specialty, which I found particularly appealing.

Beyond the clinical and surgical aspects, this rotation emphasized the importance of empathy and respect in OB/GYN care. Pelvic exams and discussions about sensitive topics are deeply personal and require patients to be incredibly vulnerable. I witnessed how essential it is to establish trust and create a supportive environment in these situations. I made it a point to ask for permission before entering the room or being present during exams and offered tissues when sensitive topics arose. These small gestures went a long way in building rapport with patients and demonstrated the humanistic side of medicine.

Initially, I approached this rotation with low expectations, uncertain about whether OB/GYN would align with my interests. However, by the end of the rotation, I found myself drawn to the field. The work is multifaceted, intellectually stimulating, and emotionally rewarding. It has become a specialty I deeply respect and genuinely enjoyed learning about and studying.

Overall, my OB/GYN rotation at Woodhull Hospital was an invaluable experience. It not only enhanced my clinical skills and broadened my understanding of women’s health but also reminded me of the profound impact compassionate care can have on patients. This rotation has opened my eyes to the possibility of pursuing OB/GYN in the future and has left me with a lasting appreciation for this vital field.

The Effect of Maternal Antihypertensive Drugs on the Cerebral, Renal and Splanchnic Tissue Oxygen Extraction of Preterm Neonates

Anne E Richter¹, Trijntje E Schat, Koenraad N J A Van Braeckel, Sicco A Scherjon, Arend F Bos, Elisabeth M W Kooi

Drugs with antihypertensive action, such as labetalol and nifedipine, are commonly used in obstetrics to treat preeclampsia. However, they may impact the hemodynamics of preterm neonates. This study examines how maternal antihypertensive drugs influence oxygen extraction in the brain (cerebral), kidneys (renal), and intestines (splanchnic) of preterm neonates (born ≤32 weeks gestation) using near-infrared spectroscopy, where researchers monitored oxygen levels during the first five days of life.

This study is the first to evaluate the effects of maternal antihypertensive drugs on multisite tissue oxygen extraction. It found that exposure to these drugs, particularly labetalol, was associated with significantly lower cerebral oxygen extraction (cFTOE) and higher splanchnic oxygen extraction (sFTOE) compared to nonexposed neonates. These findings suggest that labetalol may increase brain blood flow through vasodilation or reduce oxygen use in the brain. The elevated splanchnic oxygen extraction (sFTOE) likely reflects reduced intestinal blood flow, as the intestines are less protected by autoregulatory mechanisms.

These results underline the importance of monitoring cerebral and abdominal oxygenation in preterm neonates during their early days of life to mitigate potential risks. They also point to the effects of maternal medications from underlying maternal conditions, such as preeclampsia, which may independently influence neonatal oxygenation patterns. Understanding these mechanisms can guide more precise monitoring and management strategies for hypertension during pregnancy and improving neonatal outcomes.

References:

Richter, A. E., Schat, T. E., Van Braeckel, K. N., Scherjon, S. A., Bos, A. F., & Kooi, E. M. (2016). The Effect of Maternal Antihypertensive Drugs on the Cerebral, Renal and Splanchnic Tissue Oxygen Extraction of Preterm Neonates. Neonatology, 110(3), 163–171. https://doi.org/10.1159/000445283

The-Effect-of-Maternal-Antihypertensive-Drugs-on-Tissue-Oxygen-in-Preterm-Neonates

During my OB/GYN rotation, I had the privilege of completing my evaluation with Carlos Melendez, who not only served as my evaluator but was also our OB/GYN professor during the didactic year. This evaluation provided an opportunity to demonstrate my clinical knowledge, critical thinking, and ability to synthesize information from my experiences throughout the rotation.

As part of the evaluation, I presented two cases. The first involved a patient with chronic pelvic pain exacerbated by sexual intercourse. Her symptoms coincided with the placement of a copper IUD a year prior, and her history included recurrent urinary tract infections and a urethral diverticulum. The differential diagnosis included urethral diverticulum, vulvovaginal candidiasis, bacterial vaginosis, and endometriosis. The treatment plan focused on removing the copper IUD, treating potential vaginal infections, scheduling an endometrial biopsy to evaluate atypical glandular cells noted on a Pap smear, and referring her to urology for further evaluation.

The second case involved a patient at 34 weeks of gestation who presented with elevated blood pressure and a mild headache. Her differential diagnosis included gestational hypertension, preeclampsia without severe features, and chronic hypertension with superimposed preeclampsia. The patient was admitted for blood pressure monitoring, laboratory evaluations, and fetal well-being assessments, with plans to monitor for severe preeclampsia features and consider magnesium sulfate for seizure prophylaxis if necessary.

To supplement the discussion, I presented an article related to the second case. The study examined the effects of maternal antihypertensive drugs, such as labetalol, on oxygen extraction in preterm neonates. It highlighted the potential impacts of these medications on neonatal hemodynamics and emphasized the importance of precise monitoring in neonates exposed to maternal antihypertensive drugs for conditions like preeclampsia.

Overall, the evaluation was an excellent learning experience. It challenged me to apply clinical reasoning, integrate current research into patient care discussions, and articulate my findings effectively. Professor Melendez’s guidance and feedback were invaluable, reinforcing key clinical concepts and encouraging me to think critically about complex OB/GYN cases. This experience not only deepened my understanding of the specialty but also enhanced my confidence in presenting and managing diverse clinical scenarios.

Clinical scenario:

 91-year-old Hispanic male, Spanish- speaking, originally from Ecuador with a PMHx of type 2 diabetes, hypertension, osteoporosis presents to Geriatric Outpatient Clinic for a follow-up consultation accompanied by his two daughters. The family reports that the patient receives medical attention during his visits to New York, otherwise has a doctor in Ecuador that prescribes medication as needed. Patient is alert but after sitting on the exam chair appears somnolent but responds when loudly spoken to. Patient has reduced vision and hearing but doesn’t use glasses or a hearing aid despite these limitations. Recent labs show an A1c of 8.0 and his blood pressure is 144/80 mmHg. The daughters confirm that he regularly takes his metformin for diabetes management but does not take his prescribed antihypertensive medications, claiming his blood pressure readings are “normal” at home. However, the patient does not own a blood pressure monitor or keep a log of his readings. The patient has been prescribed both a cane and a walker due to a history of osteoporosis and a prior fall within the last year. However, his daughters admit that he refuses to use either mobility aid. They also report that he has difficulty sleeping, getting only about 4 hours of sleep each night, and frequently appears tired during the day, often taking brief naps. Otherwise, the patient admits to being in good health and has no complaints. Denies any current pain, shortness of breath, dizziness, nausea, vomiting, diarrhea, constipation, urinary incontinence, loss of sensation to the extremities, or unintentional weight loss.

Why does the case require cultural awareness/humility:

Culture plays a significant role in how the Latin population approaches healthcare, with both the individual and the family contributing to decision-making. Understanding and integrating Latino cultural beliefs into medical practice is essential for providing effective, patient-centered care. By applying cultural humility and recognizing the patient’s unique cultural values, healthcare providers can build trust and deliver care that aligns more closely with the patient’s and family’s expectations. This is particularly important in the Latin population, where family involvement in healthcare decisions is emphasized, as seen in this case, with the patient’s reliance on his daughters for support and communication.

Respecting the patient’s cultural health perceptions, such as his views on chronic disease management and his hesitancy to accept recommended treatments like mobility aids, enables the healthcare provider to address these issues in a way that resonates with the patient’s values. Exploring why the patient chooses not to use his cane or walker, or why his family believes his blood pressure is normal at home even when it’s not measured, provides an opportunity to engage in culturally sensitive education that is more likely to encourage future behavior change.

Addressing potential barriers to care, such as language, is crucial, particularly because the patient is a native Spanish speaker. Offering access to professional interpreters or a Spanish-speaking provider can prevent miscommunication and ensure that the patient fully understands his treatment plan.

This culturally competent approach not only improves health outcomes but also fosters trust, satisfaction, and respect between the patient, family, and provider. Failing to integrate cultural beliefs into practice limits the ability to deliver effective healthcare to this patient population and can contribute to health disparities within the Latino community. For example, misunderstandings about medication adherence or the importance of regular monitoring could lead to poorly managed chronic conditions like diabetes or hypertension,. Therefore, integrating cultural beliefs into care is critical for reducing disparities, improving patient engagement, and achieving equitable healthcare outcomes.

The cultural factors that need to be considered:

1. Language Barriers and Communication: The patient is a native Spanish speaker and currently relies entirely on his daughters for translation. However, this can lead to communication inaccuracies and omissions, not only during the visit but also regarding medication instructions, which are in English. To prevent confusion, it is better to have a provider who speaks the patient’s native language or, at the very least, offer access to a medical interpreter or interpretation service.

2. Health Beliefs: The patient comes from a different generation and culture, which influences his perceptions of illness and treatments. In Latin culture, men often struggle to admit they are ill, as doing so might make them appear weak. Many times, patients may decline treatment if they feel fine and only agree when the illness is perceived as severe or shows symptoms. Understanding these perceptions and respectfully navigating them can lead to a more effective care plan that aligns with the patient’s preferences.

3. The Family’s Role in Care: In Latin culture, family plays a significant role in healthcare decisions, particularly for older patients, as seen in this case. Some patients may rely heavily on family members to make medical decisions. Providers must recognize the importance of family involvement, as this helps ensure that both the patient’s and the family’s preferences are heard and respected, leading to more satisfactory outcomes for all parties involved.

4. Relationship between Patient and Provider: Latin patients often prefer a warm, personal relationship with their healthcare providers. More formal, business-like interactions that feel cold may be off-putting to patients. If the relationship is purely business-like, the patient may be less inclined to ask questions or fully understand the disease and treatment plan, which can hinder a collaborative approach to care.

Any beliefs that might be different from western medicine beliefs and Areas Where Conflict Might Develop:  

1. Cultural Perceptions of Health: The patient in this case comes from an older generation where men place significant emphasis on appearing strong, especially to others. As a result, Latino patients may have a different understanding of chronic disease and preventive care. They might believe that if they feel fine, there is no need to take medication or follow medical advice, as taking medications or treatments may be seen as a sign of weakness. In Western medicine, there is a belief that taking proactive measures is essential to prevent health from worsening into something more serious. Therefore, careful consideration should be given to offering alternatives that allow the patient to maintain his self-image while also ensuring his safety.

2. Patient-Provider Dynamics: In Latin American cultures, patients often view healthcare providers as authoritative figures who possess the knowledge and power to heal. Out of respect for authority, or fear of questioning the provider, they may hesitate to challenge the treatment plan. Additionally, many Latino patients, particularly immigrants, may feel vulnerable, which can cause them to appear passive or non-communicative during visits. This behavior may be misinterpreted as noncompliance or disinterest, when in fact, they may simply be afraid to speak up. This can be problematic, as our goal is to provide patient-centered care where the provider and patient work collaboratively to determine the best course of action. Encouraging the patient to ask questions and reassuring them that they are not obligated to follow any plan they don’t agree with can help open communication. If they don’t agree with a recommendation, exploring alternative options should be encouraged.

3. Religious Beliefs in Healing: Many Latino patients have strong Catholic or Christian beliefs and may turn to their faith for solutions to medical problems. Depending on the importance of religion in their lives, they may believe that illness and healing are in the hands of God, and that prayer, faith, and religious rituals are essential components of the healing process. This belief may coexist with or even take precedence over the use of medical treatments.

4. Use of Alternative Medicine: The use of alternative medicine is also common among Latino patients, who may integrate traditional remedies with Western medical practices. They may view herbs or home remedies as safer than pharmaceuticals. This can create conflicts, as these remedies may cause interactions with prescribed medications, potentially worsening the situation. Providers must remain open-minded and non-judgmental, understanding the patient’s use of alternative treatments. If alternative remedies are being used, it’s important to assess whether they are safe to combine with the current treatment plan.

What would be expected of the student in demonstrating Cultural Competence/Humility:  

1. Language Barriers and Communication: The student must ensure that a qualified medical interpreter is present to facilitate clear communication. It is crucial to speak directly to the patient rather than only addressing the daughters, even if they assist with translation. Additionally, the student should build rapport and set aside enough time to develop trust with the patient. Latino patients typically prefer a warm and personal relationship with their providers, and they appreciate feeling unhurried during consultations.

2. Understanding the Patient’s Health Beliefs: The student recognizes that the patient, coming from a different generation and cultural background, may have differing views on health. The student should be mindful that the patient may resist treatment if he feels fine. By understanding and respecting these beliefs, the student can collaborate to create a treatment plan that aligns with the patient’s preferences.

3. Understanding Familial Roles: In Latin culture, families often play a significant role in healthcare decisions. The student should actively involve the patient’s daughters, ensuring they feel heard while also ensuring that the patient remains the central decision-maker if he has the capacity. The student should recognize that the family can play a strong role in supporting the patient’s decisions.

4. Alternative Medicine: The student should inquire about the patient’s use of any alternative medicine, such as herbal remedies, without dismissing or disrespecting the value these remedies may hold for the patient.

5. Religious and Spiritual Beliefs: Latino patients often have strong religious beliefs that may influence how they perceive health, illness, and healing. The student should inquire about any religious practices or spiritual needs and be willing to accommodate those in the treatment plan.

6. Encouraging Patient-Centered Care: The student should recognize that the patient may feel vulnerable, especially as an immigrant navigating the U.S. medical system. Demonstrating compassion, empathy, and understanding of the patient’s cultural background is essential for building trust. The student should emphasize shared decision-making, encourage the patient to ask questions and express concerns, and help him make informed decisions about his treatment plan.

Any patient counseling or education that would be required in the situation:

1. Diabetes Management: Educate the patient on the importance of A1c monitoring. Discuss maintaining blood sugar levels within target ranges to prevent long-term complications such as kidney disease, nerve damage, and vision problems. Ask the patient about his dietary habits and consider a referral to a nutritionist. Reinforce the importance of taking metformin regularly, even if the patient feels well, to control blood sugar levels and prevent complications. Listen to and consider any objections.

2. Hypertension Management: Educate the patient and his family about the risks associated with untreated high blood pressure, including heart disease, stroke, and kidney damage, even if the patient feels fine. Emphasize that feeling well does not necessarily mean blood pressure is under control. Since the patient does not own a blood pressure monitor or diary, prescribe one and encourage the family to monitor and record the patient’s blood pressure at home. Inquire about any resistance the patient may have to taking his blood pressure medication to help him feel understood.

3. Fall Prevention: Address the patient’s reluctance to use a cane or walker by explaining how these devices can prevent future falls and injuries. Falls are particularly dangerous for this patient population, as they can lead to fractures and even fatalities. Using walking aids can help maintain current independence and avoid hospitalizations.

4. Sleep Hygiene: Offer advice on maintaining a regular sleep schedule, reducing naps, and creating a relaxing bedtime routine to improve sleep quality. Ask if the patient considers medication like melatonin to aid with sleep. In Latin culture, many people consume coffee in the afternoons, which should be explored, as it can affect sleep.

5. Individuality: Although the patient comes from a Latin background, it is important not to assume that all Latin patients are the same or hold the same beliefs. Each patient is an individual, regardless of ethnic categorization. Take the time to learn about their preferences and emphasize the importance of adhering to medications and following a treatment plan. If the patient has any issues, they must be addressed, and alternatives should be explored to accommodate the patient and effectively implement a patient-centered approach.

During my recent long-term care geriatrics rotation at Metropolitan Hospital, I had the privilege of experiencing firsthand the unique challenges and complexities of caring for older adults. This rotation was a rich learning experience, exposing me to learn about the many geriatric syndromes and providing insight into the numerous physical, cognitive, and social issues that patients face as they age. Working with Dr. Kotchev, an internal medicine and geriatrics specialist, was an invaluable part of this experience. Not only is he highly knowledgeable, but his dedication to teaching and patience in explaining complex concepts was truly inspiring. His thorough approach to the geriatric assessment and the physical exam impressed upon me the importance of a detailed examination, a skill that, in my view, has become something of a “lost art” in medicine.

Under Dr. Kotchev’s guidance, I performed a cardiovascular exam,  neuro exam, and musculoskeletal assessment each day. Observing his methodical approach helped me appreciate the significance of these exams in identifying subtle yet impactful health changes in geriatric patients. I particularly valued the opportunity to strengthen my own physical exam skills and gain deeper insights into common geriatric challenges, such as polypharmacy and the management of chronic conditions like diabetes, hypertension, and hyperlipidemia. Dr. Kotchev emphasized the importance of ambulation and gait assessment, which are crucial for helping patients maintain independence in their daily lives.

This rotation also highlighted areas I need to develop further. For example, creating a treatment plan on the spot remains a challenge for me, though I am confident this skill will improve with time and experience. Throughout the rotation, I practiced history-taking, comprehensive reviews of systems, and performing head-to-toe exams, all of which reinforced my understanding of differential diagnoses. As I reflect on my time in geriatrics, I feel I am becoming a more well-rounded student, with a stronger foundation in the fundamentals of patient care. The rotation was very inspirational and deepened my appreciation for the complexity of geriatric medicine.

Overall, I am incredibly grateful for the opportunity to complete this rotation. It was an experience that not only strengthened my clinical abilities but also deepened my commitment to providing thoughtful and thorough care to patients, especially those facing the unique challenges of aging.