Medicine – great job, no room for imagination

So finally after two years of painful examinations and sitting in the classroom, my schedule is finally my own . . . sort of . . . Board exams which are coming up in June are around the corner and there is STILL that sense of something hanging over you, something foreboding, another test, another milestone ahead that we must reach, whether its by running, walking or crawling . . .

Its easy to buy into the myth of the “promised land” in medicine. It is easy to admire those urologists, dermatologists, anesthesiologists, radiologists with their tidy little salaries and the “perks” that they have to do what they “love” and ONLY work 60-70hrs a week. After all, if one were to be paying $50k a year in tuition, it BETTER be for something right?

Yet as I sit here procrastinating in the library, I came across an article about Al Gore and the freedom he has now that he is not in politics to be on the board of a private equity company, give presentations about global warming, advising Apple and Google on their business strategy and as usual it reminded me of all the other things in life one misses out on when one enters this profession, or should I say this priesthood that is medicine. In fact, as you look at the average life of a physician, the objective really is to have a stable, well paying, prestigious and interesting job around which the rest of your life is supposed to orbit. When I compare this to the life I would choose to live if I were not in med school, it lacks the spontaneity, the imagination that I think defines who I am. I want to be able to fly to Nice for Cannes and connect what I learn about human nature there to setting up a agricultural project in Burundi, visit my familiy and friends in Taiwan and Japan on the way back to the states for a business meeting while finishing a few interesting books and eating some good meals along the way.

What is the problem with medicine? Its not just the hours in medicine that really prevents physicians from living a life like this, its the culture which replaces the room for imagination and creativity with patriarchy. Ever since the first day of orientation, my life has been planned out, circumbscribed, and micromanaged for me. You are expected to respect a hierarchy. There is an attending physician and below him (sorry ladies, most physicians in positions of authority are still male) a resident and below them an intern then there is the medical student who gets all giddy when they get to do ANYTHING of significance. Within this culture, it is no wonder people are leaving medicine. I heard recently from Dr. B that 3-4% of medical students in the country enter medical school with NO INTENTION of practicing medicine. In fact, I would argue that once training is over, that number is doubled. Take our graduating class of MD/MBA students at DMS this year. 4 out of 6 are going into consulting or banking and to be honest, if some of the other DMSers that did not have exposure to Tuck and the possibility of doing anything OTHER than medicine were properly exposed, I could see 20% or more of the graduating class going into a non medical profession. I think the reason is clear, the cult that exists in medicine really turns away the most imaginative and entrepreneurial individuals that enter medicine. How does this impact patient care? Well it has certainly narrowed the role of physicians to one of being bystanders. I would argue that most of the profound decisions and innovations occur outside of the purview and even peripheral vision of physicians.

Things like new drug or new device discovery, health management and organization building, health care policy, things that really impact the way health care works is done by non full time clinicians (the business execs, consultants, entrepreneurs and inventors may have MD behind their name but generally do not practice medicine). THEY make the real important decisions in medicine, NOT physicians who are mere bystanders in the process

Wow what a rant, I guess procrastinating is really getting to me . . . . anyway better continue this another time before I fail boards.

I DID A SKIN CLOSURE ALL BY MYSELF!!!

Whoo hooo!
After 8 hours of watching surgery, I got to DO some today! Well, just a taste anyway by way of skin closure. I shadowed a urologist and got to watch a cystectomy and histerectomy/oophorectomy today (basically we took out a woman’s bladder, uterus and both ovaries because of bladder cancer).
I figure that if I want to do surgery, urology would be the one. You get to see patients in clinic 4 days out of the week and be in the OR 1-2 a week which is just fine with me. Very few emergencies, you can take home call and whats more is that urologists are in high demand these days. Sort of just like anesthesia but on the surgery side. Similar to anesthesiologists, the people are just much more laid back and happy. Dr. B who I shadowed says that he wants to keep doing it until he is 70. The surgeries are interesting and highly diverse and flexible.

The downside of course is that its a surgical specialty although with a relatively short training period (5-6 years). Also interestingly it is one of the specialties projected to have the greatest shortage in upcoming years yet urologists are very conservative about expanding slots for residencies. Talking to Dr. Birhle there are at least a couple of reasons one of which is the opening up and closing down of some bad programs (UVM, Tufts were mentioned) and hesitancy to open up any new slots unless they are “good” ones and also that there was a little fall out from the late 1990s when some docs thought they were just gonna retire and then ended up going back into practice when the bubble burst.

Anyway, what bothers me about urology is that I don’t know how motivated I would be in the long run in doing some surgical specialty since I am not really the fall in love with surgery at first sight kinda person. For example, I didn’t love anatomy all that much (and was surprised how much surgery is really just like anatomy lab, lots of dissecting, clamping, finding structures) and don’t really get that urge to do things when I am watching. On the other hand, when I finally did get to suture up a patient, I LOVED IT. So I guess I am trying to sort out how much of that excitement was just from getting to do something (which med students don’t really get to do) and how much is actually something I could see myself doing for 20-30yrs!

Its probably all a moot point anyway since I won’t get high enough board scores to qualify anyway.

I PASSED WHOO HOOO!!!

Whoo hoo, just found out I passed all my classes this term which means that . . . I . . . am . . . officially a THIRD YEAR MED STUDENT

(yea lame, I know, but seriously, its finally done with the basic science crap and onto to the really interesting stuff, taking care of patients, clinical medicine and B-school)

Now hopefully my exuberance can translate into work ethic for boards studying

Anesthesia, the best balance

I just shadowed Dr. H in Anesthesia. Saw some pedi anesthesia, got to watch pre-op, post-op prep and even some NORA (Non OR Anesthesia where for example they anesthetized a 2yo girl before her MRI).

Overall I think its a GREAT balanced specialty where you get to DO a lot of stuff (put a patient under, bring them back, control all of their vital functions for them, make them pain free, even palliate or offer them a “good” death a la Dr. Byock, the guy who started our palliative care group), the cases are open and shut, you get to go in, do your stuff, achieve an outcome and get out, GO HOME. Or go on vacation, or travel around the world and give talks. Dr. H does 0.8 which means she takes 1 day completely off per week which is easy to do 1) because its shift work 2) Anesthesia is a MONEY MAKER not money loser in the hospital so you are pretty well protected and supported within the healthcare organization. Its exciting when stuff DOES happen (a la the day I saw a neurosurgery go awry) but when stuff slows down your co-workers are usually nice enough to take over for you so you can take a break for 30 mins (AND you can even rationalize it since as a resident told me, you need to sometimes clear your head instead of stare at the monitors in order to spot red flags). For example, I went in at 8am, left at 4pm and had time for two lunches and some long fun conversations with the attending and residents while I was there. Oh another plus is VERY FEW NOTES and less paperwork than other internal med specialties.

Some downsides: no patient continuity and not much patient contact (although I don’t really care that much about it, just seeing your patients right before you put em down and right after they wake up groggy isn’t super appealing), also not being able to really interact with patients, gather information and make a differential dx kind of takes a lot of fun out of being a doc (although being in scrubs and DOing a lot makes up for quite a bit) and also you are kind of tied to a machine in a hospital without which you are kind of a glorified EMT. Dr H also cited the fact that it is true what they say 30hrs of boredom and 3 minutes of SHEER terror since a patient can crash and crash quickly on you and you can get so used to being in total control over a patient’s life that losing a patient can be really traumatic.

In the end the key will likely be personality fit and culture where I can safely say Dartmouth’s Anesthesia folks rank among the coolest people I have met so far here. They are pleasant without being superficial or ditzy (like Derm), determined and strong willed without being total control freaks. Overall Anesthesia gets an ‘A’ for lifestyle and ‘B-‘ for interesting work (by comparison Hospital medicine would be an ‘A-‘ for interesting work and B for lifestyle and C for pay). Anyway, note to self, schedule a clerkship EARLY (not necessary to do a Sub I and Dr. H recommends against it)

Transition Ceremony Pics!

Finally, done with the first two years of “sit-on-your-ass-all-day-and-listen-to-lectures” part of med school and onto the “never-get-to-sleep-but-at-least-I’m-in-the-hospital-doing-something” part of med school

Here are some pics from our little mini celebration

Dr. Pfefferkorn, one of our favorite profs telling us all about William Pickles who made a contribution to medical science by simply being an astute observant general practitioner in the British countryside

Our teachers those luvable old white guys

Departing Brownies, we’ll miss you guys!

Hangin in Hanover after the ceremony

Ako and Jane getting ready to chow down on sum Indian food (this is before the cheap bastards refused to give us the standard 10% student discount)

Jared and Eugene, skeptical about the service at the Jewel (I mean) the Crap of India

Everyone looking happy and smiley . . . except Abby who is spacing out as usual :)

Rachel loves Florence . . . ewwww

Getting some well deserved ice cream (and Champagne!) at the Hood Museum after the ceremony

Abby, Jared and Jane starting a new modern dance troupe at Dartmouth . . . Pilobi-LUST

Freedom and Belonging

Just got back from a Sonny Rollins concert. Seriously, one of the best parts of being here are the $5 concerts with legends like this man.

Its special. I want to be doing something I love at 77.

Anyway, its amazing how good music can really help you let go of the day to day stresses and worries and remind you of the real good stuff. For me, it really comes down to freedom and belonging. Freedom, like walking along Ocean Beach from the bottom of the alphabet up toward the tip of Golden Gate park and going along PCH to the Sutro baths to watch the sunset. Belonging that feeling of camraderie of being out with the guys driving on the highway with the windows down on a cool summer day. Damn I love the ocean.

Note to self: figure out how to get closer to the ocean! :)

Consultant’s Guide to Dating

For all you single consultants out there

R-O-A-D to success or boredom?

I shadowed an Ophthalmologist today. Fun experience, lots of cool gadgets, get to “see” a lot, patients are a little sicker than in Derm but not sure if its for me. I guess to some extent, I am now thinking of more managerial or business-like functions within medicine like Hospital medicine where I get to do a lot of negotiating with doctors, communicating with patients and get to meet a lot of different people (and walk 6 miles a day!). I DO understand why people go into ophthalmology though, really great hours (we stopped seeing patients at 4), infrequent call schedules, not a lot of patients will die on you, nor do you really have too many emergencies. Plus there are some lucrative procedures with Lasik and Cataract surgery. Btw, I finally figured out why some people do not qualify for Lasik. Apparently, the procedure works by adjusting the CORNEA (not the lens) by making it more concave thus pushing the image focal point which falls in front of the retina in myopic patients to lie on top of the retina. However, some people are just born with thin corneas which are too thin for the procedure which would subject the cornea to perforation (which is REALLY bad). Also, I learned that myopia is actually due to the eyeball flattening out rather than a lens dysfunction and that presbyopia (far sightedness) is more due to the lens. Cool stuff, easy to do, can bill a lot for it, and the patients always live. And apparently there are subspecialties in ophtho like Neuroophthalmology where you get the harder and sicker cases but I guess not nearly as tough as neurology. Anyway, if I change my mind, I can probably do a nice 2 week rotation in ophtho during my Tuck year but for now, I think I’m leaning away from it.

So ruling out Radiology (no patient contact, don’t like anatomy that much), Ophthalmology (patients are that sick, not exciting or managerial enough, not that psyched about the eye itself), Anesthesia (gonna shadow in a couple of weeks but my pain clinic experience wasn’t that fun) and Derm (great for making money but the people aren’t super sick, I think I might get bored). Anyway we shall see, if Jack Wennberg is right and what we need to lower the cost and waste in health care is LESS procedures and acute care NOT more, primary care might just be the place to be in 10 years.