Monday, November 30, 2009
Wednesday, November 25, 2009
Jesse's MRI confirmed some long-held suspicions...
3 Reasons for going into Neurology:
1. You might actually get to see your kids grow up.
It’s no psych, but damn it’s good to be a neurologist. During my time on this rotation, on most days it seemed possible for the non-call residents to get their patients tucked in and notes written by mid-afternoon. Plenty of time for David to get home and watch the nanny take care of the kids. Definite life-style points.
2. Fascinating pathology
While the neuro hospital floor is primarily dominated by strokes and seizures, consults come from all over the hospital. Although much of this will inevitably end up being delirium (or even nothing), every now and then the illusive and coveted zebra appears. The brain truly is a wonderful and enigmatic organ, and just because everyone keeps cheering that we’ve made so much progress in the past 10-20 years it doesn’t mean you still wont be surprised.
For example, I will truly never forget the consult on a patient with anoxic brain injury where, about 15 minutes into the interview, I realized the patient was confabulating everything! Because of his brain damage, he had gaps in his memory where he would fill in with false information. If the lie is subtle enough, it can be difficult to discern the confabulations from the truths. But then again, sometimes the lies are so outrageous they become readily apparent. No sir, I dont believe I've asked you these same questions 30 years ago...
Anyways, just remember the next time you see a patient who just had a right-sided intraparenchymal hemorrhage (i.e. brain bleed), it probably is worth it to ask them to draw a clock face.
3. Informative physical exams
Depending on which specialty you go into, the physical exam could either be a crucial component of the clinical picture or only a necessary hassle for billing purposes. For example in surgery the physical exam boils down to two things: bowel sounds = good, no bowel sounds = bad. Neurology lets you do a bit more. If you like solving puzzles, this is where it’s at. If you’re savvy enough with your physical exam skills and knowledge, not only can you identify at which level of the nervous system the lesion is located, you could probably tell something about exactly where in the brain or spinal cord you expect it to be. Some party trick, huh? Then you order the appropriate scan plus labs to get a more definitive answer. Neurologists out in the community or away from a major academic center may be the true LOTPEs.
It's (reflex) hammer time
3 Reasons to stay away from Neurology:
1. You can't cure a lot of the things you diagnose
Here’s a quote from a real-life attending: “Hmm… you know, I’ve never really felt the need to cure anything—sometimes it’s enough to just be able to tell them what it is.” While this is true, in some cases just being able to put a name on what ails you is therapeutic enough, it may not be very satisfying to you. Not mention, even if you do locate a resectable lesion, the patient gets bounced to neurosurgery. Sigh, those guys hog all the glory (and reimbursement). So if you’re on your neuro rotation and find yourself feeling a little too excited and relieved by meningitis because you can kills the buggers with antibiotics, then maybe this isn’t the field for you.
2. Medically sanctioned elder abuse
The patient might look like your favorite grandparent or that sweet little old lady down the street, but if they’ve got a decreased level of consciousness you can be sure you’ll be giving them a strong pinch! The idea is that you’re looking at their ability to sense, localize, and/or withdraw from painful stimuli. Keyword: Painful. Abnormal posturing (e.g. decorticate – flexor, decerebrate – extensor) can tell you something about the severity of what’s going on in the ole think-box. However, when my patient’s tearful and terrified wife is standing right there, it can be a pretty uncomfortable to do what would be considered elder abuse in any other situation.
Your heart sounds great ma'am. Just FYI, I may or may not need to jab you with a sharp stick in the near future.
3. Half your patients are delirious
For me, this is the biggest problem in neuro. Inpatient neuro is dominated by strokes, withdrawal, seizures, delirium, coma, and bad ass brain tumors. In short, most of your patients are going to have some sort of altered consciousness, so the normal exchange of the physician-patient relationship is lacking. Oncology is another specialty where there is a relatively low “cure” rate, but in the battle against cancer you the provider can learn so much from your patients. For me, this is probably the most challenging aspect to deal with day in and day out in neurology. It's hard feeling connected to my patients when they're accusing you of stealing their Jello to give to our alien overlords.
Friday, November 20, 2009
The recent revival of this blog and its stream-of-consciousness ranting affords a golden opportunity to similarly revitalize my own journalistic career – since this medicine thing may soon come to a screeching halt. I’m currently on pediatrics. I could simply refer you to Kevin’s elegant artistry to depict my feelings about the rotation, but that would ruin the cathartic nature of this medium. I’ll take a more positive approach than my colleague did with childbirthing – I’ll give one positive before launching into my top pediatric peeves.
The Good: A lot of kids are cute. When they’re in a good mood, they’re friendly and laugh and want to see how your tools work and it gives you that warm fuzzy/good feeling that you can only get from the sound of a child’s laughter – before passing them off to the demonized shot-giving nurse (which, by the way, must be the worst job in the world). I genuinely enjoy kids in general so this works out well. But there’s a lot to hate in general, so let’s not delay:
1. The Vaccine Talk.
Every physician knows this one. For those of you unawares, let me break this down for you. We have, on one side, modern medicine and every doctor you’re likely to ever meet who contend that babies shouldn’t die. We have, on the other side, this guy. Now here’s the kicker: People believe Jim Carrey. To be fair, a “doctor” did originally perpetrate this bogus theory. One Andrew Wakefield proposed that MMR vaccine was related to a small subset of cases of autism via immunologic shenanigans. He then proceeded to present this and cause a panic which led to refusal of immunizations and then an outbreak of measles. Read that again. Of measles. Let’s get one thing clear: no one in the Western world should ever contract measles. The only time anyone should get measles is playing Oregon Trail.
If only YOUR MOM had vaccinated you.
Meanwhile, of course, autism didn’t miss a beat. Andrew Wakefield has now lost his medical license and practices homeopathic medicine in Texas. There are even new allegations that he fudged his data – but by God, that doesn’t matter, because a lack of understanding of basic statistics or physiology is no reason you should listen to your “doctor” about vaccines, because he’s probably just brainwashed and doesn’t think for himself (I swear, people say this). And you’ll hear the same random half-baked logic:
“Too many shots these days,” “given too young,” “those diseases don’t exist anymore (AND WHY MIGHT THAT BE?!?!)”
It wouldn’t be so bad if these people listened to reason. Or at least attempted to listen to reason. The following is an almost word-for-word transcription of my preceptor’s attempt to convince someone to get their kid a meningitis vaccine:
“Here’s all the excellent and well-founded scientific reasons why your kid is way more likely to die from meningitis than from getting this very safe vaccine.”
“Yeah but I don’t give my kids shots until they’re 1 year old.”
“I just don’t. I’m convinced I know better than decades of data and scientific research and besides I can selfishly rely on herd immunity which, by the way, I undermine by not getting vaccinated.”
“…..Kay. But seriously, why?”
“I just don’t.”
You get the picture.
2. Schools waste doctors’ time.
Everyone has had this experience –little Johnny had a cough/cold/stubbed toe but, because he missed time from school, he requires a doctor’s note to allow him back. This means that little Johnny gets to wait in the office for 2 hours with all the bacon-lungers so that he can get a doctor to confirm that yes, in fact, he was coughing, and no this was not some elaborate falsehood perpetrated by the parent. But even if he wasn’t sick, he sure as hell is now. In which case, of course, he’ll have to come back and get a separate doctor’s note just so he can expose everyone to it. At what point did we stop believing parents when they say their child is ill? Congratulations, Principal Jones, you’ve once more saved the integrity of your pedagogical bureaucracy – but at what cost?
At least they're NOT VACCINATED.
3. First-time parents possess no common sense.
This may represent a failing of our public education in some ways, but so many new parents seem to have no other option when their child is ill but to come to the ER in the middle of the night and/or demand to speak to the pediatrician on call. I understand that you can’t tell for sure how sick your 10-month-old child is. He can’t talk. But with a few tidbits of arcane medical knowledge, several ER visits could be avoided:
1) 99 degrees is never, under any circumstances, a fever. I don’t care that your baby usually runs 98.4 so it’s a little hot. Being asked to write a note justifying school or daycare absence for a temperature of 99.1F rings hollow. Pediatricians don’t get too concerned until 100.5F, so don’t bother them.
2) Babies are rashy. Please do not demand to speak to the on-call pediatrician because your child has one new red mark on their skin. It’s not cancer. It will likely be gone within a week without a single symptom. Go to bed.
3) Babies are loud. If your baby is crying, try feeding the baby. Try holding the baby. Try rocking, cuddling, or singing to the baby. (Do not ever shake or throw your baby). If these don’t work, does baby otherwise seem sick? If not, it’s probably not an emergency.
4) For God’s sake, triage nurses exist for a reason. Self-explanatory.
I enjoyed my time on peds, but as you can tell, there are more than a few things which could be more satisfying about the setup. I did almost entirely outpatient pediatrics, so I was mostly in clinic the entire time – which can be numbing on its worst days.
Tuesday, November 17, 2009
1. You get to do stuff and see if it works
Surgery is the pinnacle of immediate feedback; you identify a problem, do something concrete to fix it, and then evaluate whether or not it worked. More than any other specialty, the outcomes are measurable, tangible, and observable. You may sacrifice the continuity of primary care fields, but you also experience the unique satisfactions of knowing what’s wrong and getting your hands dirty trying to make things right. Fields like neurology, psychiatry, and others may involve long battles with nebulously defined disease processes where victories are measured in small, incremental improvements over years. That process yields its own personal and professional rewards and frustrations, but may not provide the same acute results that some students may find particularly appealing and which surgery deals out in spades.
2. Certified badassery
Few things in medicine are cooler than surgery. Though it may not be for everyone, no one can deny the sheer awesomeness of removing tumors, transplanting organs, and augmenting breasts (just kidding…?). Perhaps more commonly than in other fields, decisions are realistically life or death; a miscue here or a careless error there in the OR could have disastrous results. What’s more, the wealth of new technologies and general trend towards minimally-invasive procedures ensure that general surgery and the many surgical subspecialties will only further badassify in the future. Sure, more surgeons spend their lives in the bread and butter world of inguinal hernias and appendectomies than in the rarified air of reconstructive plastics and neurosurgery, but even the more vanilla procedures provide all the benefits listed above and below and may, due to volume, be even more targeted for technological advancement in the coming years.
I can’t believe Da Vinci painted the Mona Lisa and invented this robot…
3. Options like whoa
It is generally believed that medical students should first and foremost decide whether they want to be surgical or medical. If surgery is your cup of tea, there is a seemingly limitless array of opportunities to pursue. A general surgery residency is a common gateway to further subspecialty options such as burns, cardiothoracic, vascular, and pediatric surgery, among others, while other students choose to enter fields such as orthopedics, plastics, and ENT straightaway. Going further, many surgeons identify a specific procedure or set of similar procedures that becomes their uber-specialty within their broader branch of surgery. Basically, if there’s some type of cutting you want to do, you can probably make a career out of it.
3 reasons not to:
1. Training don’t quit
More than any other field, surgery demands an extensive period of training. A typical general surgery residency lasts five years, and further subspecialty fellowships can push that requirement into the two-digit territory. An R3 I worked with recently is pursuing a career in pediatric cardiothoracic surgery, a path that, with a general surgery residency, two years of research, a three-year CT fellowship, and a one-year peds CT fellowship, will ultimately require 11 years of training after medical school. Assuming one entered medical school immediately after undergrad at 21-23 years old, this would push off attending status – and the benefits of a legitimate salary and some semblance of a personal life – until one’s mid-to-late 30s. And though in a badass field like peds CT surgery you’d make it rain early and often thereafter, you’d still be spending the majority of the prime of your youth before ever realizing many of your career goals.
2. The hours never stop
Similar to OBGYN, surgery in nearly all of its forms is notorious for an extremely demanding workload and long hours on call. Though some subspecialties and practice settings may be less demanding, the fact remains that surgeons spend more time in the hospital than almost any other type of physician. When you factor in the extensive training required before even reaching the attending level, the demands of the subsequent career may simply not be something many medical students want in their future. (On a related note, it's worth mentioning that the hours / training demands take their toll on relationships as well; some surgical residencies have been known to have divorce rates exceeding 100%. In other words, residents get divorced, remarry and get divorced again. Just FYI...)
3. High-intensity work environment
By its nature, surgery is a high-stress world. The patient is commonly under general anesthesia and the manipulations of the procedure often entail significant blood loss. Small or careless transgressions can kill a patient either immediately or as a post-operative complication, and the surgeon running the show is ultimately responsible. Many surgeons trumpet the philosophy “trust no one,” something potentially disheartening on its surface but logical in a world where the surgeon is held accountable for any number of errors in the pre-, intra-, and post-operative setting. All these truths foster an environment some find less than hospitable, especially to those lower in the training hierarchy. Surgeons, on average, may be blunter and less forgiving in a professional environment than other physicians, and this, coupled with the long hours, can create a working world some students may choose to avoid.
Sunday, November 15, 2009
If you’ve ever spent any time in a card aisle or Hallmark store, you should know that it’s obviously geared towards women and children. The cards come in three general themes: cartoons, flowers or kittens. Even when I did find an acceptable design, there would be some message scrawled on the inside that was so sentimental it made me uncomfortable just reading it.
That's really nice, do these come in Mens?
This was also something I never understood. Why do people want their cards to have messages preprinted inside? Isn’t that a little impersonal? Most people write in messages anyways so the text just becomes some odd impediment to a continuous paragraph. If someone doesn’t write anything, it’s not like the receiver will attribute the printed text to the giver. They’d just assume the giver was a lazy asshole that didn’t write anything. Either way, the text is worthless at best, a net-negative at other times. Much like Jess. Anyways, I digress.
After much shuffling around and digging, I finally settled on a generic green card with no text inside. I guess that’s the best I can hope for. Now if I only knew what I should write…
Wednesday, November 11, 2009
Friday, November 6, 2009
3 Reasons why I want to be an OB/GYN
1. It’s the black and white cookie of medicine
When choosing a medical specialty, one of the biggest questions people consider is whether they would like to do a lot of procedures or whether they’d prefer something more cerebral. One would naturally lead you down the surgical path and the other likely towards something like internal medicine. But for those who would like a little bit of both, Ob/Gyn offers an intriguing alternative. Before my rotation my only knowledge of Ob/Gyn is that you probably deliver a lot of babies and treat a lot of gonorrhea, neither of which were particularly appealing. But what I didn’t realize was that a lot of things can go wrong south of the border and often times you gotta cut ‘em to fix ‘em. The docs I followed did about 2 procedures each morning on Monday Wednesday and Thursday and a full day of procedures on Tuesday. This ranged from tumor removal to urethral slings, prolapse repairs, ovary removal and every flavor of hysterectomy you can imagine. That’s a lot of surgery considering a general surgeon without specialization likely does less with more training time.
Mmmm... tastes like placenta
On the medical side there are a lot of diseases to that can happen to the entire baby making apparatus and you’re the guy/gal to fix it. Often times symptoms can be vague or the etiology multifactorial so there’s a reasonable amount of brain power that must be expended to properly take care of your patients. Not too shabby
2. Good subspecialty options
I only spent 2 days with a gyn/onc but I found the subspecialty pretty fascinating. It’s the only surgical oncology specialty that also manages chemotherapy. So there’s a good amount of continuity of care that lets you manage a patient’s cancer from presentation to remission. Pretty cool.
The surgeries themselves are pretty interesting as well. They’re not particularly challenging from a technical standpoint but the stories I’ve heard at hilarious. My preceptor told me about an obese patient she had that had a slow growing tumor inside her that weighed over 70lbs at time of presentation. In order to do to the surgery, she had to perform a pannectomy as well. By the time the patient left the OR, she was half the weight she went in.
3. Strong continuity of care
My main preceptor was an older doc who had been in practice for over 30 years and many of his patients have been with him for about as long. He’s delivered entire families and really followed some patients from the beginning of motherhood to menopause. This seems like a rewarding process and something a lot of other specialties don’t get to experience, especially if you’re in surgical field.
3 reasons why that might not be a good idea
1. The hours are terrible
OB probably has one of the worst call schedules ever unless you’re part of a large practice with an elaborate call system. When a mother is ready to deliver, she’s ready to deliver and there’s nothing you can do about it. If you have a large patient base and there’s 3-4 women laboring at any given time, you could be in the hospital constantly, at all hours of the night. It sucks.
I think I’ve said enough on that subject
3. You get sued a lot. A LOT
Hopefully, if you give OB/GYN any consideration, you would know this fact but it bears mentioning again. Ob/Gyn's get sued all the time. Their malpractice insurance is some of the highest in the entire industry and everybody has had at least one case brought against them for something or other. Basically, it sucks ass. All kinds of things can go wrong and 98% of it isnt your fault, but that doesn't stop patients from suing your ass because little Timmy isn't reading up to his grade level.