Maternal-Fetal Elective in New York
In May 2009, I travelled to New York City for my elective placement in maternal-fetal medicine. I chose this subject as in my obstetrics rotation at medical school I found it to be a speciality that was really hands on and extremely diverse. This elective was a chance to experience care in a first world country, where new techniques and procedures that are not yet in current practice in the UK are tested and to see how healthcare systems differ in their patient care. I would also be exposed to issues such as abortion, domestic violence and STI’s, which are all commonly encountered areas of practice in the UK.
My elective was organised as part of an exchange programme with Columbia University, College of Physicians and Surgeons. Columbia is the oldest institution of higher education in the state of New York and is a member of the Ivy League. Its main campus lies in the Morningside Heights neighbourhood of Manhattan.
View from the Top of The Empire State Building
New York
New York is a city that never sleeps! It is the most populous city in the US with a population of around 8.5 million. It is a global and culturally diverse city, similar to London, and is composed of 5 boroughs: The Bronx, Manhattan, Brooklyn, Queens and Staten Island. New York exerts a powerful influence over worldwide finance, culture, fashion and entertainment. Major tourist attractions include the Empire State Building, Statue of liberty, Ellis Island, museums such as the Metropolitan Museum of Art, Central Park, The Yankee Stadium, Rockefeller Center, Brooklyn Bridge, Times Square and not to mention it is a shopper’s paradise!
Standing on The Brooklyn Bridge
Introduction to the Placements
The main elective location was at Columbia University Medical Center, Presbyterian Hospital. Presbyterian Hospital is affiliated with medical schools of both Columbia and Cornell University. It is ranked 6th overall in America’s best hospitals 2009, according to the US News and world reports. My rotations took place at sites within Presbyterian hospital, including a) The Sloane Hospital for Women and b) Carmen and John Thain Labor and Delivery Unit (10th Floor of Morgan Stanley Children’s Hospital) and c) The Audubon Clinic where I attended Gestational Diabetes and low and high risk obstetrics clinics. These hospitals serve a large Latin community where Spanish is the 1st language for a lot of patients.
The Sloane Hospital provides obstetrics and gynaecology services and has a role as both a research and clinical facility. In 2003, over 3,800 babies were delivered here. It has pioneered many advances, including amniocentesis, the Apgar score and the use of Rhogam (anti D +ve). The hospital has several centers that offer specialised care, such as the Center for Endometriosis Treatment and Research which provides state-of-the-art care and research to identify the causes of endometriosis, and to diagnose, treat, and prevent this chronic condition.
The Carmen and John Thain Labor and Delivery Unit (opened in 2004) has 10 labour/delivery rooms (birthing rooms); 6 assessment/triage rooms; 4 high-risk beds; 3 operating rooms and a transitional nursery. The unit offers advanced technology for high-risk patients such as high-tech ultrasound machines, maternal-fetal intensive care and a neonatal Care Unit which has been recognised as one of the finest in the country.
Dr Smok and Dilan Varsani at The Labor and Delivery Unit
The U.S. Healthcare System
During the month, I became more familiar with the healthcare system in the US. Patients are not refused healthcare if they present to the Emergency Department; this applies similarly to the maternal-fetal medicine department. Patients on lower incomes have their basic care funded by the state (e.g. Medicare). However, the standard of care received depends on the amount of income you have.
In the US medications are prescribed in their trade names and for a lot of medical conditions, they are similar to the ones used in the UK. Also, daily notes are recorded on the computer and there are very little paper based records. In comparison to the UK, more emphasis is put on research to improve investigations and develop new treatments.
The system of entry into medical school is also different. Students finish school at 18 years old and then progress to high school. After four years they can go onto university to study medicine, which is a four year course. Most medical students take time out to pursuit research as some stage in their course.
Diary of My Rotation
My day would start with a ward round at 6am and normally end at around 7pm. On my team I had an intern, a senior resident, a senior fellow, an attending and three medical students. I was responsible for the care of two patients each day. This involved reviewing patient’s progress, following up on investigations, suggest suitable management plans and to report back to the attending or fellow about patients’ progress and any complications. I was surprised by how friendly and accommodating the whole team was and the responsibility I had for my patients quickly made me feel part of the team.
On the Labour and Delivery Unit, I assisted in vaginal deliveries, observed Caesarean sections and clerked patients from triage. Assisting in delivering a baby was incredibly exciting; I found it even more amazing to see how the delivery of a newborn was conducted through a Caesarean Section, which seemed to be a rather traumatic operation but one with a happy outcome for both mother and baby. I was fortunate enough to shadow my attending and her team during a 24-hour on call and saw how the labour and delivery unit coped at night.
Presbyterian’s departments of Obstetrics and Gynaecology have high-risk obstetricians who provide specialty care for pregnant women with a history of difficult or failed pregnancies, as well as those with diabetes, hypertension, and other medical disorders. During my time there, I realised that conditions such as diabetes, pregnancy induced hypertension, postnatal depression, and miscarriage are just as common in the US as they are in the UK.
Twice a week I attended gestational diabetes clinics and other high risk obstetric clinics seeing mothers with conditions such as epilepsy, hypertension, heart defects, asthma, intrauterine growth restriction (IUGR) fetus as well as Jehovah witness mothers. During clinics, I would clerk and examine patients (including measuring fundal height and fetal heart rate) and present my findings to the attending. Some of the females required GBS swabs, STI testing, speculum and vaginal examinations which I also carried out.
Many of the patients I met in clinics could not speak English and their 1st language was Spanish. Most of the doctors and nurses knew Spanish, but for those that did not, there was an interpreter available over the phone. This is similar practice in London and highlights the importance of having an interpreter, especially in a multicultural city.
Interesting cases would be discussed in meetings which were held once a week. One particular case was of a 30 year old patient with a gestational age of 24 weeks with autosomal dominant polycystic kidney disease, chronic hypertension and oligohydramnios.
Every Thursday there was a teaching session with a small group of Columbia students. Topics covered were contraception, abortion, infertility and case based discussions. Every two weeks, a feedback seminar took place, which reviewed how students felt they were performing during the module, interesting cases they had been involved with and their general feelings towards things they had witnessed e.g. at abortion clinics. One morning I was able to shadow doctors at an abortion clinic held at the local clinic. I witnessed all the management options available to mothers, which were in fact very similar to options provided in UK. Something which surprised me was the abortion rates in the US. In 2005, 1.21 million abortions were performed. The figure in the UK, for women resident in England and Wales was 193,700 (2006 census).
During my rotation I spent a few days in the ultrasound unit where I observed and had a chance to attempt scans. I learnt that ultrasonography procedures are invaluable for monitoring pregnancy in a variety of ways, including identification of fetal anomalies, detection of the baby’s position and determination of the baby’s sex. All patients are offered an ultrasonography assessment which includes first, second and third trimester evaluation and screening for Down’s syndrome, ectopics and multiple pregnancies. The ultrasound unit carries out diagnostic procedures such as amniocentesis, chorionic villi sampling (CVS) and fetal blood sampling; as well as therapeutic procedures including fetal shunt procedures and getal transfusion. Fetal anomalies are diagnosed and, in some cases treated, in the fetal ultrasound unit using state-of-the-art sonography, fetal echocardiograms, and percutaneous umbilical blood sampling (PUBS). Other procedures carried out include multi-fetal pregnancy reduction and selective fetal termination.
On one occasion I encountered a patient who had come for her scan and was told that her fetus was not viable. The doctor came in to explain this to the patient whilst the sonographer offered emotional support. The couple were offered counselling sessions and support to help cope with this tragic ordeal. In another case I witnessed a mother who had presented with severe abdominal pain and ended up having a miscarriage in the hospital. This was the first time I had witnessed a miscarriage and found the experience quite emotional and overwhelming. There was no obvious cause for her miscarriage, which is commonly the case. However, trying to explain this to mother was difficult, especially as she blamed herself for the miscarriage.
Conclusion
I was very fortunate to be able to work in an internationally renowned hospital, where I received extensive training in obstetrics, saw interesting cases and improved my skills in clerking and examining female patients. As an obstetrician, the primary duty is caring for two people (i.e. the mother and baby) however I learnt that there also remains a secondary duty to family members and society. Throughout the rotation I had the opportunity to spend time with and work in close collaboration with other medical professionals including midwives, paediatricians, anaesthetists, surgeons, social workers and other healthcare workers, to learn and experience what this diverse speciality has to offer. Maternal-fetal medicine is an extremely rewarding speciality that has massive potential to continue expanding in the future. This speciality includes a mixture of medicine and surgery, which is one of the reasons I am attracted towards it.
By the end of the month, I was feeling somewhat physically drained, but thoroughly enjoyed my time and felt it was a great learning experience, one which I would strongly recommend to any student. An important thing to remember is that the hours can be very long, but you need to find a balance between work and fun, especially as NY is a fascinating city with plenty to see and do.
Acknowledgements: I would like to thank Barts and The London for allowing me to have an amazing experience through awarding me a place in the ‘Elective Exchange Programme’ and to Dr Dorothy Smok (MD), Columbia University Course Director.
Dilan Varsani is a final year medical student at Barts and The London Medical School
dilanvar(at)hotmail.com