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?

Kevin might want to know watcha thinkin' about.

Time is winding down on my psych rotation and it’s given me plenty of time to reflect on the experience. I think it’s safe to say most students do not go into medical school with a yearning desire to enter psychiatry, quite a shame really. This little odd niche of medicine has quite a lot to offer.

3 Reasons to enter psychiatry

1) The sweet life
It’s no secret that the work hours in psych are awesome. As a medical student I got into the hospital at around 8:30, rounded with the attending and resident (no prerounding) until 11:30, wrote my notes and done by 2pm at the latest. Hey, they don’t call it psychation for nothing. This sweet life style extends to the residents as well. They all come in at around 8 and are done by 4 or 5pm. And EVERYONE is happy. I think in all my other rotations, people are always bitching about something related to their work hours (and I haven’t had surgery yet). It’s really no wonder our friend Jess is seriously considering psych as his future career as a way to maximize the amount of time for his video games.

2) Helping the underserved

Everyone says this during their medical school interview, but if residency match is any indication, most don’t follow through. The patients seen on psych truly are the most in need. These are patients who are so sick that they do not even know they’re sick. Combined with inevitable social and financial losses, these are the neediest group of patients any clinician will see. If you truly believe in the schpiel you gave to the admissions committee, you should take a good hard look at psych.

3) Hilariously bizarre
Mental illness is weird, I mean really weird. When schizophrenics develop bizarre delusions, they can be so bizarre it boggles the mind. I had one patient explain to me that she can see people’s sin by staring into their eyes and that’s how she knows her stepfather was a murderer. Hilarious. Although it became significantly less hilarious when she ran into their house with a knife…

3 reasons not to go into psychiatry

1) You’ll forget everything you learned in medical school

I feel bad for saying this but psychiatrists really don’t know that much about medicine. When you become so specialized in psychological illness, you end up forgetting a lot about physiological illness. At my hospital, we had to consult medicine/derm/neuro/etc for every minor medical issue. Morning blood sugar 180? Stat med consult. Odd looking rash on hand? Holy shit we need to page derm. Maybe this isn’t such a big deal for the future psychiatrists but I would feel like I wasted 4 years of medical school learnin’ by going into psych. Going along those same lines, there are only about 15-20 drugs that are ever used in psychiatry. What’s more interesting is that they all seem to be able to treat everything. I got the feeling that regardless of what your patient has, you can just shout out a random psych drug and there’s a greater than 50% chance you’re right.

2) Holy ambiguity

Mental illness is ambiguous. After all, what separates someone who is truly sick from someone that’s just a bit of an oddball? Psychiatrists tend to refer to the DSM-IV as their holy grail of diagnosis but even then, there are a lot of patients who are right on the edge who end up getting treated anyways. What’s more hilarious is that they are allowed to write things like “Possible Axis II features.” For those who don’t know, Axis II refers to the range of personality disorders people can have that can be maladaptive. But when you just say “possible Axis II features” it’s so ambiguous that you’re essentially saying the person is a bit of a douchebag but you’re not sure why.

3) Nonmedical BS

Treating acute mental illness is only half the battle in most patients. I would say a huge majority of the time and effort spent on patients is in finding appropriate living situations for them after discharge. This involves a herculean effort between social work, PT, OT etc etc to find the right place to live and the necessary financial support. This ties directly into point #3 in the other section. If you love that stuff, psych is perfect for you. If you want to enter tertiary or perhaps quaternary care, worrying this stuff will make you want to end it all, and ironically maybe bring you right back to the psych ward.

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.

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.

David breaks down Surgery

3 reasons to become a surgeon:

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.

Kevin might want to be an Ob/Gyn, yet might not.

Choosing the right career is a difficult task and it certainly doesn’t end with your acceptance to medical school. Finding the right specialty is a challenging thing and the first 2 years of medical school really aren’t that helpful. Sure preceptorships give you a quick glimpse, but it really doesn’t give you the full experience of what a doctor does everyday. In an effort to help future medical students, and perhaps just to put our own thoughts down on paper, David and I are starting a new series of articles that weigh the pros and cons of each particular specialty. Each article will feature 3 reasons why we liked that particular specialty and 3 reasons why we didn’t. Even though each article will likely be personal to our own interests and preferences, hopefully it’ll bring up some interesting points to think about as you make your own career decisions. Enjoy

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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.

2. Childbirth
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.