Wednesday, December 9, 2009

David and Kevin present some old favorites



Almost 2 years ago, David and I started IDDx with the humble hope of turning this site into a blogging powerhouse that could be our one-way ticket out of the obvious career dead-end that is medicine. Clearly that has not happened. But we have still managed to build (and re-build) a loyal following of readers that have somehow found our inane drivel to be entertaining (or at least interesting in a car crash-y kind of way). We thought this would be an appropriate time to revisit some of our old posts as a kind of year-end-review and maybe serve as a best-of (or worst-of, as the case may be with Jess) list for the newer readers. (Re)Enjoy.

-Kevin and David


Medical student life: A few insights into the fast-paced world of call-taking, baby-saving, and retractor-holding.

David, Robby, Dan, Beth, and the Johns save lives while on vacation.

Kevin wishes these classes were real.

Kevin falls, David watches.


Pre-medical advice: Words from the arguably wise about facing the application gauntlet.  

David tells you what to do (in an admissions interview).

Kevin debunks 2 myths about med school.

David presents the 15-15-1 theory.


Comics: Only stick figures can provide a true window into the inner med student soul.

MCAT - Then and Now

OB exams are tricky

Ideal vs. Reality - Emergency Medicine


Guest authorsWho's better - Julia, Jess, Julia, or Julia? You decide.

Julia knows exactly the kind of doctor she will become.

Jess tries to reach the keeds.

Julia presents a landmark case of PMS.


Random thoughts, pet peeves, and theories about life: A potpourri of IDDx musings.

David Presents His #2 Pet Peeve: Considers It Tomorrow At Midnight Guy

David has difficulty with doors.

Kevin contemplates the diet of the Little Mermaid


Friday, December 4, 2009

David treats a wise child

During a recent shift at a pediatric urgent care center, a young boy came in with a scald burn to his arm. As I debrided his wound, we discussed some of the pressing issues of youth, including how awesome dinosaurs are and whether or not mall Santas are real (consensus: of course they are). All of 5 years old, he was a total fighter and didn't complain one bit throughout the procedure. 

After a heated debate about how fast Spot runs - we both said some things we didn't mean - the following exchange occurred:

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David: This must've been pretty scary, but you've been doing great.

Kid: Hey, I'm not scared of anything. 

David: Nothing? Really (unsure whether or not to entrust him with my fear of clowns)? That's pretty impressive.

Kid: Nope, nothing...

        ...except bush babies.

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Mildly confused about what he was taking about, I allowed the conversation to shift, and soon he was all fixed up and on his way home. Later, a quick Google search provided the images that will give me night terrors for the rest of my natural life.


Wise choice, kid...


Tuesday, December 1, 2009

Kevin might save babies like it's his job

The next installment of our career choice series.


3 reasons to do pediatrics
1. Congenital disease is fascinating
The magical journey from fish-like zygote to full blown baby is fraught with wrong turns and side streets to the bad part of town. Sometimes what comes out of the oven isn't what you expect. While most adult medicine follows some kind of logical pathology and things often dont stray too far from the norm, the presentation of congenital disease can be so bizarre it boggles the mind. Situs inversus (your insides are backwards), lissencephaly (your brain is flat), Transposition of the Great Vessels (your aorta and pulmonary artery are plugged into the wrong ends of the heart) are just a taste of some of the things you see as a pediatric specialist. A lot more interesting than COPD or diabeetus.

2. Plenty of subspecialties to suit your fancy
This is likely personal to me but during the first two years of medical school I always pictured pediatrics as a primary care residency with no subspecialty tracks. “Well where do pediatrics cardiologists come from?” you might ask. For some reason I thought you got there through internal medicine, cardiology then a fellowship in pediatric cardiology. Clearly I’m an idiot (but hopefully someone out there on the interweb is with me). In reality pediatrics is just like internal medicine, except you treat little people. This also means there’s a huge range of subspecialties to choose from, and as I mentioned in point #1, you get to focus on a lot of congenital malformations rather than the end result of a lifetime of self-neglect.

3. Saving lives (no seriously)
Adult medicine often revolves around management of chronic disease. Patients undergoing slow, methodical heart failure/COPD/diabetes/lupus(sometimes it is lupus), are never fully cured. The best you can do is manage their symptoms in order to extend/improve their quality of life. On the other hand, pediatrics is full of one-off illnesses that you can definitively treat and they can be on their merry way. Back when medical school was only 1-semester long and involved memorizing the 4-humors, congenital malformations was often a death sentence. Fortunately, we've come a long ways from then and there's a myriad of treatments for what ails children. You have a giant septal heart defect? No problem. Bowels outside the abdomen rather than inside? Just shove that right back in there. As a pediatrician you're really making a huge impact in the "total # of years saved" category. If there was a MD fantasy league, you'd want at least 1 pediatrician to pad those stats.




3 reasons to avoid pediatrics
1. Bad logistics
Unlike what your career counselor might have told you, you should never choose a career just because you like the subject matter. Every field has pros and cons in terms of call structure, location constraints, average salary etc etc that are all vital in making an informed career decision. For example, if you love cardiology but are on the fence on whether to treat big hearts or little hearts, here are some things to consider before you devote yourself to baby saving. Despite all my talk about congenital disease, kids are actually pretty healthy. And being healthy is bad for business. Because of the low demand, you will also make less money than your adult-caring counterparts. So do you really love congenital disease so much that you're willing to take a $100,000/yr pay cut? Furthermore, there are significantly less pediatric specialists than there are adult specialists. Because there simply isnt as many you, your group will be small, which is synonymous with lots and lots of call. What this also means is that there isnt a need for a pediatric neurologist in every town. If you want to subspecialize in pediatrics, you're almost guaranteed to be forced into a large-ish city in order to field the necessary amount of patients to stay afloat. Sorry, no country livin' for you.

2. Noncompliant patientsparents.
When I asked a lot of pediatricians why they decided to do pediatrics and not internal medicine, they often cited that they were frustrated by noncompliant patients such as COPD'ers that kept smoking or CAD'ers that kept eating McDonalds. For some reason, I have no problem with that. As long as the check clears, I dont care what you do. My job is to give you the knowledge, services and tools to allow you to live a healthy productive life. If you refuse, so be it. In pediatrics, the kids barely know what's going on so the work falls on the parents to follow through with the care plan. In this case, noncompliance by the parents means the kid is getting hurt. This I have a problem with. Even though CPS can step in during extreme cases, theres a huge gamut of noncompliance where you really can't do anything even though you really want to punch them in the head.

3. Child abuse
During my peds rotation I had the displeasure of seeing 3 child abuse patients. One of was severely overfed, one was severely underfed and the 3rd was an infant that had a broken femur and two broken clavicles. Obviously by ferreting out child abuse you're saving the child, but it's still a terrible thing to be a part of. Seeing that on a regular basis can be a real drain on the mental psyche.

Monday, November 30, 2009

Wednesday, November 25, 2009

Julia ponders a career in Neurology

As one of our school's rare 3rd years over-eager enough to attempt Neuro before 4th year, the mantle falls to me to talk about the good and negative aspects of this specialty. That… and Jesse is trying to steal away my tiara for himself. For shame.

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.

Monday, November 23, 2009

Friday, November 20, 2009

Jess tries to reach the keeds

Back and angy as ever, Jess attempts to unseat Julia as the premiere guest author with this, his latest rant. Enjoy.

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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.”

“Why?”

“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.