Ideal vs. Reality - Orthopedic Surgery

David and Kevin match

In what will clearly go down in history as an against-all-odds triumph of previously unfathomable proportions, Kevin and I have managed to successfully match into (what we’ve been told are) accredited residency programs, keeping our medical hoop dreams alive for at least a few more years.

Since extreme levels of sarcasm and immaturity aren’t good for patient care, the NRMP supercomputers have deemed it necessary to place us on different coasts, leaving a chasm of barren, uninhabitable flyover country (like Iowa) between our respective programs.

Where we go from here, no one knows. Still, one thing is certain – it would probably be a bad idea to get really sick this June…

The David and Kevin Story

David stares at your body (CT)

After an extended hiatus to complete the residency application process - which is now out of our hands pending the upcoming NRMP Match - Kevin and I are making our triumphant return to the international zeitgeist. That special, tingly place in your hearts will once again be filled by our inter-musings, at least until the next point at which laziness, work, or lucrative alternatives occupy our lives.

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One of the greatest perks of the 4^th year of med school is the opportunity to relax once the rigors of application submissions and expensive interview trips are appropriately in the rearview mirror. Since med school isn’t over after rank lists go in or the Match occurs, most of us fill the remaining time with a combination of really relaxed rotations, useful electives we didn’t have time for earlier, and really, really relaxed rotations. Enter Radiology and a few thoughts about the pros and cons of a potential career in the reading room catacombs.

Pros:

1) You get to squeeze your mind grapes: Radiology requires a relatively unique combination of both general and specialized knowledge. Obviously, the field demands mastery of the intimate details of all of the numerous imaging modalities in the clinical repertoire. Yet it also requires a nuanced understanding of the clinical, anatomical, and surgical correlates of essentially all major radiological findings. Since clinicians order scans to assist in the diagnosis, treatment planning, or monitoring of disease, radiologists must have a working understanding of each of these processes in order to provide the most beneficial interpretation of whatever image comes their way. This keeps even a specialized radiologist fluent and up to date in many more facets of clinical and surgical medicine than many clinicians in any of those individual fields. For the learn-y types, this is a huge plus; you maintain a large database of clinical knowledge that’s not limited to any one particular patient population. For Jess, it’s probably a deal-breaker.

If Jess was a radiologist...

2) Calling out squiggles saves (many) lives: Though my role during the rotation was mainly perfecting formal terminology such as “badness,” “thatthingrightthere,” and “oooohhh noooo,” radiologists get the opportunity to employ the knowledge listed above to make a meaningful positive impact on a lot more patients than basically any clinician. An experienced radiologist can motor through figurative stacks of scans, each of which could provide the key finding that clinches an otherwise tentative diagnosis or redirects a lost primary team in an entirely new direction. Though the radiologist isn’t removing tumors or prescribing meds, she’s still saving babies as fast as anyone else in medicine.

3) You can make it rain then leave early and go play golf: It’s no secret that Rads offers a pretty cushy lifestyle relatively short on hours and long on compensation. In most practice settings, the time and energy sinks that plague other fields – things like overnight call and late-night emergencies – tend to be non-issues for radiologists. Come in at 8? Leave at 4? Don’t mind if I do!

Standard radiologist trophy wife

Cons:

1) No more patients (or people) for you: The stereotype of the isolated radiologist sitting alone in a dark room without that much human interaction really isn’t that far from the truth. Aside from the occasional image-guided biopsy or fluoro study, most radiologists spend the day…alone in a dark room without that much human interaction. Sure, they’ll chat with a few fellow radiologists, relay any pressing results to ordering clinicians, and talk with a variety of techs and administrators, but that’s essentially it. That may be a plus to some, but for the majority of those entering medicine, at least some meaningful patient interaction was probably a big part of their interest in becoming a doctor. In Radiology, you get vitamin D deficiency instead.

2) Med-malnanigans: The realities of Radiology make it an easy target for malpractice suits of all flavors. Any X-Ray, CT, MRI, etc., is saved and available in all its glory to anyone with 20/20 hindsight and a bone to pick after a less than favorable outcome. Though mistakes are made in rads as in any other field, the opportunity for second-guessing is greater when essentially the entirety of the clinical presentation is forever available for review. The byproduct is both frustrating and inevitable; many radiology reports devolve into nothing more than a list of sweet CYA nothings such as “cannot exclude,” “could represent,” “may suggest,” and a laundry list of kitchen-sink differentials. I’m sure the radiologists hate dictating those as much as everyone else hates reading them, but it’s hard to expect anything different in this particular medico-legal climate.

3) They could taakk yeerrrrrr jerrbs: A relatively hot-button topic, at least among many radiologists I’ve talked to, is the concept of outsourcing certain diagnostic radiological services to cheaper domestic areas or even abroad. After all, the radiologist doesn’t really need to be right downstairs all the time, and probably costs more sitting there in the dark than an equally competent physician working remotely (and sitting in the dark). If the notion of who is acceptably “remote” includes foreign docs or others willing to work more cheaply, then the current set-up for radiologists would clearly erode. Somewhat relatedly, Interventional Radiology, which can currently be pursued via post-Rads fellowship – and which offers patient contact, cutting-edge procedural awesomeness, and compensation up the wazoo – is also expected to diverge into its own completely independent residency and field in the not-too-distant future. Separating IR from diagnostic rads would remove one pretty appealing career path for the field, and only contributes to the uncertainty facing the profession in the next few years. (That said, given the scarcity of training positions and subsequent competitiveness of IR, going into diagnostic rads with an IR-or-bust mentality is sort of like getting a job at McDonald’s on the off-chance they’ll let you be the next Grimace. It’s risky to dream that big…)

Diagnostic or Interventional?

David and Kevin approach doctordom

After a year of 6-week journeys into the depths of numerous medical specialties, acquiring enough experience along the way to become indubitable experts capable of writing a series of specialty summaries, Kevin and I are now newly minted MS-IVs.

Farewell, penultimance. Greetings, ultimiosity.

Kevin learns amusing words

Rock
-noun
1. A currently admitted patient who no longer requires >$3000/day medical services but can not be discharged because of social/legal/financial reasons. He/she stays on service getting 3 hot meals a day and unnecessary daily CBC and chem7s.



Rock garden
-noun
1. A collection of rocks (see above) that demand increase your daily paperwork time for no educational gain.

"Hey, are you done with your daily notes yet?" "I've taken care of all the acute patients, just need to tend to my rock garden and I'll be done."

Kevin deals with the Cross-Eyed Gunner

Medicine, much like golf, is often filled with oddball behavior that, while not being detrimental to patient care, can often raise the eyebrows of colleagues and patients alike. Medical students stumbling around in their 3rd year clerkships certainly aren't immune to this. So as a small case series, David and I would like to present a few of these "that-guy/girl" stereotypes

I'm sure most of you have all heard of "the gunner." The guy/girl that prerounds on your patients, asks questions during rounds to make you look bad and generally being an annoying dbag. I havent met one myself, but I'm sure they're out there... waiting to make me look bad. However, fewer people know of, or at least speak of, the cross-eyed gunner. This person has all the eagerness and moxie of a regular gunner but none of the competence and medical knowledge to match. This leads to a sad-parade of self-destruction that is pretty intriguing for an innocent bystander like myself.




The CEG is eager, very eager, to answer questions. Whenever the attending proposes a question, even if it's rhetorical, he/she will shout an answer as fast as possible. Unfortunately, the answers are usually wrong and only met by uncomfortable stares from the rest of the team. Often times CEGs have some self-awareness and realizes they've just given the wrong answer(once again) so they might backpedal and try to justify their answers in a really convoluted fashion that clearly has nothing to do with the actual patient. But luckily, this helps make me look good since I can step in and give the correct answer (although ultimately adding nothing to the overall care of the patient). Ah, the simple joys of medicine.

Comic: Ideal vs. Reality - Dermatology