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.

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

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.

New horizons in Medicine

Amazing, I’m watching a Natural Orifice Endoscopic surgery, basically laparoscopic surgery where they basically cut a hole in the stomach and stick an endoscope through and perform surgeries like hysterectomies, peritoneal debridement, liver biopsies etc.

Its amazing to watch medicine and surgery undergoing this major shift toward minimally invasive techniques (minimize scarring, infection, procedure time, anesthesia). I saw it in Neurosurgery with the advancement of ultrasound based spatial imaging with DBS placement and now in GI with basically supplanting laparoscopic surgery through the endoscope.

I think we are entering an age where the line between surgeons and non-surgeons is becoming blurred. Surgery is becoming less and less invasive, and medicine becoming more and more invasive.

Rich Rothstein here is even talking about breast implants through endoscopy! Imagine swallowing your breast implants!

Ruling out neurosurgery? Ruling in Hospital Medicine?

So last week I finally shadowed a neurosurgeon. I went into it thinking that I would like to do neurosurg for the following reasons

1) The brain is my fav organ system
2) I like working with sick patients (neurology patients tend to be more chronic outpatient care which I don’t like so much)
3) Neuro is a wide open field with a lot of growth potential and where the potential for technology innovation is HUGE in the coming decades
4) The idea of doing something where you really have a chance to help people in a profound way (I saw a neurosurgery patient with a DBS device who literally demonstrated turning on and turning off a debilitating tremor)

However, my experience was somewhat less satisfying. Although Dr. R, the Chairman of Neurosurg here graciously offered to let me shadow him and is one of the most dynamic docs I’ve met so far here, I found myself being a bit appalled at the culture. For example the chief resident, upon learning that the intern was post-call (which means that he had been up for 30 hours already and was leaving that morning to go home) referred to the intern as part of the “new generation that has to go home”. As for the surgeries themselves (I got to watch a temporal lobectomy and a DBS placement), I found myself not enjoying standing (very) still in one place breathing through my mask and not looking forward to 2-3 years of doing suturing as an “assistant” in the early years of residency before actually performing surgeries. I also didn’t like that the surgeons are so bound in one place and one function by their patients and that the residents all seemed really hard core and uni-dimensional. Overall, I think its a fantastic field but the adrenaline rush of doing these very long and very precise and methodical procedures has to be such a high that you forget what time it is, forget your need to go outside, go home, and have a life outside the hospital for you to really be able to even survive the training for something like neurosurg or any surgery for that matter. Unfortunately, I think for me, its really not enough and I found myself missing the constant excitement and diversity of patients, managing expectations and communicating and leading the hospital team activities of my inpatient rounds with Dr. Perras in Hospital medicine.

One highlight from the day though was our second patient who coded (likely due to some error in anesthesia) during a routine procedure and the ensuing chaos of trying to resuscitate him, thinking at one point that he was gone and feeling an eery tingly feeling go from my head down to my spine through my arms and legs. It was like one part shock, one part excitement, one part helplessness and I think it made me want to go into ER or ICU medicine even more than neurosurg!

A good day in med school

Ever wonder why you have a good day? Today was a good day for me but I think a few simple things turned it from a fairly typical day of dragging my ass outta bed and surfing the web in class to a really good day where I can feel a sense of accomplishment, fulfillment and personal satisfaction as I get ready for bed.

Not surprisingly, most of what I did today was not medicine related although I did at least go to class in the morning and do some very productive studying in the bookstore which made me feel like I was at least doing something productive. I think the main reasons I felt good were that I learned quite a few little insights about myself.

First, I like meeting new people either as well as catching up with old friends. I spent the afternoon interviewing prospective doctors as part of my admissions committee jobs. I also finally caught up with my old high school AP English teacher whom I haven’t seen in 10 years and who amazingly lives in Deerfield MA teaching these days (I can’t wait to head over to visit later this month).

Second, I got to learn a bit about other countries and places by sitting in on a lecture on Ethnic conflict in Sri Lanka. I think when all is said and done it would be great to come back to a place like Dartmouth and be a professor or something . . . or just come back to do a PhD in postcolonial studies.

Third, I feel like I really got a lot done today and enjoyed doing it both personally and professionally while not pushing myself too hard. For instance, just noticing when I was drained studying and taking a break at the right time (small thing but it gave me time to call my English teacher and still rest up so that I could go back and be productive studying afterwards). And I also realized that I study better in a cafe where there are lots of people. This will definitely help when it comes to studying for boards.

Finally, I think just having a day to reflect on my day shadowing a neurosurgeon and realizing how much I value flexibility and being able to do and learn all these different interesting things really makes me feel free from the pressure that you get in med school to “specialize”

Anyway, I guess the best part about days like this is that you get a lot of perspective on where you are and where you’re going. There’s really nothing better than feeling like you are on the right path and feeling like you’ve accomplished something by learning a new and useful lesson about yourself. Good night

AAAAAHHHHHHH

Med school is driving me crazy, seriously, I can’t believe I am paying tuition for this pain

Great Times article by one of my Profs

NY Times

What’s Making Us Sick Is an Epidemic of Diagnoses

By H. GILBERT WELCH, LISA SCHWARTZ and STEVEN WOLOSHIN
Published: January 2, 2007

For most Americans, the biggest health threat is not avian flu, West Nile or mad cow disease. It’s our health-care system.

You might think this is because doctors make mistakes (we do make mistakes). But you can’t be a victim of medical error if you are not in the system. The larger threat posed by American medicine is that more and more of us are being drawn into the system not because of an epidemic of disease, but because of an epidemic of diagnoses.

Americans live longer than ever, yet more of us are told we are sick.

How can this be? One reason is that we devote more resources to medical care than any other country. Some of this investment is productive, curing disease and alleviating suffering. But it also leads to more diagnoses, a trend that has become an epidemic.

This epidemic is a threat to your health. It has two distinct sources. One is the medicalization of everyday life. Most of us experience physical or emotional sensations we don’t like, and in the past, this was considered a part of life. Increasingly, however, such sensations are considered symptoms of disease. Everyday experiences like insomnia, sadness, twitchy legs and impaired sex drive now become diagnoses: sleep disorder, depression, restless leg syndrome and sexual dysfunction.

Perhaps most worrisome is the medicalization of childhood. If children cough after exercising, they have asthma; if they have trouble reading, they are dyslexic; if they are unhappy, they are depressed; and if they alternate between unhappiness and liveliness, they have bipolar disorder. While these diagnoses may benefit the few with severe symptoms, one has to wonder about the effect on the many whose symptoms are mild, intermittent or transient.

The other source is the drive to find disease early. While diagnoses used to be reserved for serious illness, we now diagnose illness in people who have no symptoms at all, those with so-called predisease or those “at risk.”

Two developments accelerate this process. First, advanced technology allows doctors to look really hard for things to be wrong. We can detect trace molecules in the blood. We can direct fiber-optic devices into every orifice. And CT scans, ultrasounds, M.R.I. and PET scans let doctors define subtle structural defects deep inside the body. These technologies make it possible to give a diagnosis to just about everybody: arthritis in people without joint pain, stomach damage in people without heartburn and prostate cancer in over a million people who, but for testing, would have lived as long without being a cancer patient.

Second, the rules are changing. Expert panels constantly expand what constitutes disease: thresholds for diagnosing diabetes, hypertension, osteoporosis and obesity have all fallen in the last few years. The criterion for normal cholesterol has dropped multiple times. With these changes, disease can now be diagnosed in more than half the population.

Most of us assume that all this additional diagnosis can only be beneficial. And some of it is. But at the extreme, the logic of early detection is absurd. If more than half of us are sick, what does it mean to be normal? Many more of us harbor “pre-disease” than will ever get disease, and all of us are “at risk.” The medicalization of everyday life is no less problematic. Exactly what are we doing to our children when 40 percent of summer campers are on one or more chronic prescription medications?

No one should take the process of making people into patients lightly. There are real drawbacks. Simply labeling people as diseased can make them feel anxious and vulnerable — a particular concern in children.

But the real problem with the epidemic of diagnoses is that it leads to an epidemic of treatments. Not all treatments have important benefits, but almost all can have harms. Sometimes the harms are known, but often the harms of new therapies take years to emerge — after many have been exposed. For the severely ill, these harms generally pale relative to the potential benefits. But for those experiencing mild symptoms, the harms become much more relevant. And for the many labeled as having predisease or as being “at risk” but destined to remain healthy, treatment can only cause harm.

The epidemic of diagnoses has many causes. More diagnoses mean more money for drug manufacturers, hospitals, physicians and disease advocacy groups. Researchers, and even the disease-based organization of the National Institutes of Health, secure their stature (and financing) by promoting the detection of “their” disease. Medico-legal concerns also drive the epidemic. While failing to make a diagnosis can result in lawsuits, there are no corresponding penalties for overdiagnosis. Thus, the path of least resistance for clinicians is to diagnose liberally — even when we wonder if doing so really helps our patients.

As more of us are being told we are sick, fewer of us are being told we are well. People need to think hard about the benefits and risks of increased diagnosis: the fundamental question they face is whether or not to become a patient. And doctors need to remember the value of reassuring people that they are not sick. Perhaps someone should start monitoring a new health metric: the proportion of the population not requiring medical care. And the National Institutes of Health could propose a new goal for medical researchers: reduce the need for medical services, not increase it.

Dr. Welch is the author of “Should I Be Tested for Cancer? Maybe Not and Here’s Why” (University of California Press). Dr. Schwartz and Dr. Woloshin are senior research associates at the VA Outcomes Group in White River Junction, Vt.

Smoking is good???

I learned recently that smoking is actually great from a government financial management standpoint. It creates a net financial benefit for social security since people die younger (<65) meaning they pay into SS but don't take out. Pretty amazing huh?