M3 PCM Reflection

By Kate Pawloski

Since entering medical school I have been drawn to women’s health. During my summer abroad in India between first and second year, I was moved by the great need for women’s health care in the rural Himalayan population I visited. I saw firsthand how the lack of routine gynecological care, specifically the Pap smear, could devastate an otherwise healthy population. As I reflect upon my third year of medical school, I realize that so many impactful experiences have been related to the care of women, especially in handling sensitive reproductive issues. Recently, I worked in an endocrine clinic during my pediatrics rotation, where I saw many interesting cases such as a young girl with non-classical CAH, an adolescent with newly diagnosed PCOS, and another case that will forever be imprinted on my mind.

B was a beautiful 14-year old girl who had a complex medical issue that required sensitivity and compassion from her physician, whom I admired greatly for the ease and grace with which she handled this case.  B presented to the clinic for short stature and delayed puberty, and upon an extensive work-up was found to be a 46XX female with MRKH anomaly, no ovaries, and idiopathic short stature. B’s mother had not yet explained what this meant to her daughter, so the patient knew only that she was shorter than her friends and that she didn’t have breasts, which was extremely distressing to her. During this visit, B was started on the lowest dose of estrogen, with the goal of developing a breast contour without sacrificing any of her growth potential. The physician spent a great deal of time explaining how the hormone would help her develop but also how it could prematurely stop her linear growth. Armed with an extensive amount of complicated yet impeccably explained information, B understood exactly her predicament and was hopelessly torn between wanting more hormone for what she viewed would be faster breast development and wanting to be taller. All the while, she had yet to discover the gravity of her problem – one day she will require multiple reconstructive surgeries just to have intercourse and she will never be able to conceive or carry a pregnancy.

B’s mother struggled to determine the right time to explain this to her daughter and was not of the opinion that sooner was better. I noted how important it was for the endocrinologist to work closely with B’s mother, in the truest sense of shared decision making, to create a plan centered around the patient’s best interests but that still valued her mother’s concerns. At the end of the visit, B’s mother was ultimately satisfied that she was making an informed decision about her daughter’s care, and she felt confident in the plan that was so thoughtfully explained by her daughter’s physician. There was no discussion of how or when she would tell her daughter about her different anatomy, but I was told later that a multidisciplinary team approach lead by the endocrinologist would be implemented when the time came.

B’s case was an example of how quality of care is so vital in the biopsychosocial art of medicine. The physician was skilled in handling the information and humble enough to recommend a second opinion if the family so desired. When asked by B if she would someday look like her friends, the physician replied that her goal was to bring her into the normal range for height and secondary sexual characteristics, but that she could not say exactly where B would end up. The physician ended by telling B that she was beautiful no matter the outcome. I will never forget how these kind words painted the broadest of smiles on B’s face, and how, on a personal note, they deeply inspired my vision of how I want to someday practice medicine.

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