Abstract
Introduction
The obstetrics and gynecology (OB/GYN) clerkship is one of the most engaging and unique experiences of the clinical year of medical school. During this rotation, students are exposed to subspecialties across multiple clinical settings with patients across the lifespan. Students experience deliveries, learn teamwork and situational awareness, and practice efficiency, multitasking, and trauma-informed care in their first and sometimes only experience on an OB/GYN service. Furthermore, OB/GYN topics related to reproductive justice, health disparities, women's health, and sexual and gender minority health are pertinent to our evolving geopolitical and sociocultural landscapes and affect all patients. Therefore, all medical students should be trained to provide competent, well-informed, and thoughtful care for obstetric and gynecological presentations in any specialty. Much of the available literature to prepare students for the clerkship borrows from medicine and surgery clerkships, with students feeling less prepared for OB/GYN than other core clerkships like internal or family medicine.1–3 This article summarizes what makes OB/GYN unique and how these characteristics impact the student experience to help learners and educators optimize student preparedness and learning during the OB/GYN clerkship.
Labor and delivery
On labor and delivery (L&D), students help with deliveries, evaluate patients in OB triage, manage patient care on the postpartum floor, write notes, and interpret tocometry strips. Flexibility and adaptability are key for student learning. Many deliveries happen at night and teams are generally smaller, creating more opportunities for students to demonstrate skills and knowledge. While the time on the labor floor can be educational and meaningful, it can also be a uniquely challenging rotation to adjust to as a learner. The clinical environment can acutely rise in intensity and shift from teaching to optimizing patient care during emergencies. Students may encounter a rollercoaster of emotions, with the highs of childbirth and the lows of obstetric tragedies. Learners in these emergencies should practice situational awareness and debrief their experiences with a team member when appropriate.
L&D is unlike other medical floors because it has mostly healthy birthing people. Understandably, expectant parents will want to practice control over their birthing experience, which may or may not include students. Bedside manner and previous experiences with students are the most common factors that cause patients to reject or accept medical student participation. Medical student gender has minimal impact on patient decisions on L&D. 4 The 1:1 care provided by labor floor nurses allows them to form strong bonds with patients and nurses can be protective of their care. Students should introduce themselves to nursing staff, patients, and their families. It is important to note that many nurses advocate for student involvement in cases and feel that supporting students and their education is part of their role. 4
OB triage is where common conditions like preterm labor, vaginal bleeding, and high blood pressure are encountered. Medical students can be the first touchpoint for patients upon arriving to triage, independently taking a detailed history and performing a limited physical exam. This can be a great opportunity for students to build trust with the team and demonstrate independence. Students should familiarize themselves with asking the 4 cardinal symptoms of pregnancy: (1) vaginal bleeding, (2) loss of fluid, (3) change in fetal movement, and (4) contractions.
There are also opportunities for procedural independence in OB triage and the delivery room. Ultrasonography is commonly performed in OB triage to evaluate fetal wellbeing, fetal positioning, and placentation. Students can observe a resident and then advocate to try a bedside ultrasound with guidance. In both delivery rooms and operating rooms (ORs), medical students can deliver the placenta. During cesarean sections, medical students can suture skin and subcutaneous tissue with supervision.
Surgery
Gynecological surgery encompasses procedures across gynecological oncology and benign gynecology. Students will perform a surgical scrub, use sterile technique, and must be familiar with indications for surgery, operative steps, and relevant anatomy for the case. Before the procedure, students should introduce themselves to the patient and surgical team, clarify their role (observer, scrubbing in, etc), obtain patient consent for participation, and retrieve their gown and gloves. Downtime between OR cases can be opportune to read about the next cases, review anatomy, and follow up on postsurgical patients on the inpatient floors.
During surgery, students can actively learn anatomy by “driving” the laparoscopic camera. Most patients are in the dorsal lithotomy position during gynecological surgeries and students can set up footrests, position the patient's legs, and place sequential compression devices. A uterine manipulator is often placed to help with optimal positioning of the uterus during surgery, which students are commonly tasked with holding. Additionally, performing a pelvic exam under anesthesia (EUA) and placing a foley catheter are important student learning opportunities that must be performed with advanced written consent from the patient for student participation. 5
Students should also know what to expect from the unique surgical culture of OB/GYN. Like many surgical specialties, the workflow may involve frequently changing teams, longer hours, night shifts, and hands-on learning emphasizing quick, on-the-spot thinking. OB/GYN surgery has a wide range of acuity, duration, and risk of procedures, which can be planned or unplanned. Unplanned surgeries carry a sense of urgency for the patients and their providers that often hasten surgical preparation and performance, intensifying the learning environment. Students in these cases should be aware that the intensity of the OR can lead to student mistreatment involving obstruction of learning and exclusion from the medical team. 6 Students should be informed of their institution's resources for reporting these situations if they arise.
Outpatient care
Students should look for opportunities to practice bimanual pelvic and speculum exams in outpatient clinics, where they will have more time to build relationships with patients. For example, if patients are due for Pap tests, medical students can practice the procedure, help out the provider, and support patients’ health maintenance. 7 Students should communicate with the supervising resident or attending about their comfort level with pelvic exams and Pap tests, and advocate to do at least one each day in clinic while observed by a chaperone. In OB and dedicated ultrasound clinics, students can become more comfortable with ultrasound techniques, a fundamental component of OB/GYN care. 8 Colposcopies have multiple steps appropriate for student involvement, including speculum placement, colposcope adjustment, and application of acetic acid solution to the cervix. Finally, family planning is a procedural outpatient experience unique to OB/GYN and central to the mission of reproductive justice. In addition to assisting in a dilation and curettage, students can practice empathic and supportive communication and counseling with patients.
Life-course approach
OB/GYN providers care for patients of all ages with distinct clinical concerns. OB/GYNs see many younger patients in what might be their first independent experience with the healthcare system, sometimes with highly sensitive chief concerns. There are opportunities to provide fundamental sexual and reproductive education and contraceptive counseling, in addition to empowering patient autonomy in the clinical setting, establishing trust, and building a therapeutic alliance that can persist for years.
OB/GYNs also care for patients during their reproductive decades, which range from adolescence to age 50+. They might care for a patient through multiple successful deliveries, support them during pregnancy losses or terminations, or guide them through fertility treatments. During these years, OB/GYNs also manage hormonal concerns such as polycystic ovarian syndrome, structural concerns (eg, fibroids and endometriosis), and more. As rates of breast cancer have increased in recent years, 9 early detection and treatment (alongside questions of fertility preservation) have become increasingly important roles for OB/GYN physicians. With menopause, new structural and oncological concerns emerge that can also be highly sensitive and vulnerable for patients. Stress incontinence, uterine prolapse, GYN and breast cancers, and more can all be impacted by prior pregnancies, deliveries, and menarche.10,11 Following patients over many years uniquely positions OB/GYN physicians to establish trusting relationships, educate, and engage in primary prevention.
Trauma-informed care
OB/GYN providers must be aware of the impact of social and experiential triggers on patient care and practice trauma-informed care with every patient. The persistent social stigma around sex, sexual health, and contraception means that from a very early age, interactions with OB/GYNs are likely to cover topics that are particularly sensitive and possibly traumatic. Some patients will have experienced sexual or other forms of physical or emotional trauma before they see an OB/GYN. 12 This necessitates understanding the role of trauma-informed care in OB/GYN and vigilance about preventing healthcare-associated trauma. Students should ask residents and clerkship leadership about their institution's trauma-informed care resources. 13
Pelvic exams, which are fundamental to many aspects of OB/GYN care, can be extremely distressing for patients. 14 A trauma-informed approach to a pelvic exam is centered around empowering patient autonomy by asking for consent, explaining the steps before and as they are performed, and asking about pain or discomfort. Additionally, most institutions have a universal chaperone policy, which can ensure autonomy, safety, and prevent healthcare-associated trauma in the exam room. Pregnancy and birth are other OB/GYN settings where patients may have experienced trauma and tragedy. On L&D, it is critical to elicit, discuss, and respect patients’ birthing plans. 15 Similar principles apply to abortion care, as patients may have experienced pressure or discrimination around abortion in the past. Students can take advantage of their role as learners to educate themselves, listen to their patients, and advocate for them when necessary.
Social justice
OB/GYN care is inextricably linked to social justice and public health. Rates of unintended pregnancy, sexually transmitted infection and cervical cancer among women in the United States are much higher than counterparts in similarly developed countries. 16 These poor reproductive health outcomes are also driven by social disparities related to race, socioeconomic status, employment, education, and insurance access. 16 Similarly, the rate of maternal mortality in the United States surpasses many similar high-income countries, with studies showing frightening disparities among Black and Native American patients. 17
Learning about abortion care and family planning (FP) services (the contraception and counseling provided to support patients’ childbearing decisions) is particularly affected by students’ geopolitical context. Access to FP and abortion care is severely restricted in many states, so the OB/GYN clerkship may be a student's only exposure to abortion care. 18 For many medical students, the OB/GYN clerkship is the only time they will be exposed to abortion care throughout their career. However, around 1 in 4 pregnancy-capable patients will receive an abortion at some point during their lifetime. 19 Exposure to abortion care and the socio-emotional factors that can influence patients’ experiences can help prepare students to better care for patients seeking and experiencing abortion in the future. 20
Student feedback
It can be challenging to build trust in a way that garners genuine and constructive feedback when teams change frequently during the clerkship. Priorities change quickly, and the acute pressure of the surgical environment can limit convenient moments for feedback. Some appropriate times to ask for feedback include when closing incisions, giving a presentation, after a delivery, and after rounds. Students looking to improve in certain areas should ask a resident or an attending early in the rotation so that they can give specific feedback. Creating an individualized learning plan (ILP), where students self-reflect and document goals they would like to achieve during a rotation, can be effective for organizing learning goals.21–23 Students can share their ILP with faculty or residents to garner specific feedback and tailor their clinical experiences. Feedback in surgical rotations may look different than in medicine. For example, direction or a correction during suturing or the physical exam is a form of feedback and may not always come in a formal meeting. Nurses can also be a rich resource for feedback on bedside manner and placing orders.
Conclusion
The skills students learn during the OB/GYN clerkship are essential for all medical specialties. The ability to care for the needs of pregnancy-capable patients, consider gynecological care across the life course, and practice in a trauma-informed way are essential components of medical student learning and overall comprehensive clinical care. This article is intended to highlight the unique aspects of OB/GYN care from a student-informed perspective to help educators and students ensure they are set up for success during the clerkship. We hope this article will serve as a resource for students and educators to maximize medical student learning.
Footnotes
Author contributions
Declaration of conflicting interests
Funding
ORCID iDs
