Impressions of Dermatology

Shadowed Dr. S today. Dr. S is the chief resident of Derm in a tertiary care center who ultimately wants to enter academic medicine. Over four hours I watched him examine a patient for premature male-pattern baldness, do a couple of new patients intakes, do a few procedures like removal of moles and possible melanomas, and got at taste of what it was like to dictate, write up notes and interact with attending physicians. In contrast with cardiology consults the day before where we were standing up most of the time, here we were sitting down with patients in rooms. Unlike in the wards or the ICU, the patients were ambulatory, most did not have dire conditions and no one was in any real distress. Throughout our session, the dermatologists role was one of counselor and diagnostician. Although I did see several procedures, none were very involved nor complex. Most diagnoses in derm did not involve complex pathophysiology although several were not straightforward. As in my previous experience shadowing in the pain clinic in SF, I heard the word “crazy” used to refer to several patients which I did not like.

Overall, dermatology as a specialty seems to be characterized very much by choice rather than necessity from both the patient’s and the practitioner’s standpoint. Most patients that come into dermatology seem to have a choice of whether or not to go to a dermatologist. Hair loss, while traumatic, is not life threatening. The top three most common cases with the notable exception of skin cancer are acne, skin infections, mole removals, all non-life threatening. The physcian though is allowed a choice to some extent. Most dermatologists are in private practice (I was informed that DHMC actually does not keep any dermatologists on staff – too expensive) and have the choice to work more or less (make a lot of money or a lot more).

Yet the hours are great, the environment is generally upbeat, people are attractive and nice. I have yet to learn whether this difference between cardiology and derm is more due to the difference between outpatient and inpatient medicine or if the symptoms I saw were just specific to derm. What I take away from these two days of derm and cardiology is the lesson that shadowing experiences can be highly variable and that I should hold off judgement until I have seen a good sampling of interactions and get more direct experience in a field. Yet if I had to choose after today what I would be just based on what I have seen thus far, I’d choose to be a cardiologist.

Impressions of Cardiology

Shadowed Dr. A in Cardiology consultation today. Rounded with two residents and the attending cardiologist for about 3.5 hours, saw several patients in both the wards and the ICU. The cases were exciting and the pathophysiology was complex. For instance, saw one patient who had non-small cell lung carcinoma that had caused fluid to accumulate in his pericardium (called tampinade) which was restricting his cardiac output. The treatment

I saw several really positive things about cardiology which I liked:
First, the attending was an EXCELLENT doctor, perhaps one of the best that I have seen in action. He genuinely cared about his patients and his students, even noticing and changing minute details that would help the patient feel more comfortable while receiving care (such as allowing a patient to use an innocuous nebulizer because she thought it helped her breathe better). Second, I liked the intellectualism and problem-solving. I liked the applicability of it all, that the concepts in physiology we learn in class were really used to diagnose and model what was going on in someone else’s chest and body! I also liked the importance and meaningfulness of it all. The cardiologist or internist is like the brain and the mouth of medicine. Without their diagnosis, achieved through careful observation, reasoning and testing, there is no telling what kind of heart treatment or surgery to give. There is the opportunity and risk of making decisions that have a high impact on a patient’s well being. Innovation in technology have made “seeing” the heart much more easy although diagnosis remains a real challeng. There is the opportunity to deliver very important news in a very simple way to a patient or a patient’s family which itself is an interesting and fascinating prospect.

Overall, I was very intrigued by this experience and it makes me want to seek more in the way of examining speciallties closer to internal medicine.

Passed first term Med school!

P=MD and I am 1/12 a doctor! Hoo-ray!

Buuuuuuu

Just failed my first quiz. Its a crappy feeling and pretty scary because I really felt like I knew the material fairly well although its obvious I did not. I really need to spend more time on this quiz next round.

Man, I really gotta get back my groove like I did on the first two quizzes, more independent studying with Deo, less socializing and screwing around.

That said, I will probably go to NYC this weekend. We get Friday off and I will be done with my bschool applications.

Need to really clear my head, be in a big city, watch a movie in a real theater, eat ethnic foods, maybe go to a club. Based on my quiz scores, looks like I will be bringing some books too though. hahaha

Man, this life balance in med school stuff is really no joke.

Look mom, I’m gonna be a doctor!

Pictures from my white coat ceremony this past weekend where my classmates got to sit through talks about what great doctors we are going to be, hear about the huge need for more compassionate doctors, yada yada, it was nice to take lots of pictures with family and friends

Trying the white coat on for the first time, the sleeves were a little big . . . :)

Me with the Dean, nice smile eh?

Me and my classmates! Whoo hoo, we’re gonna be doctors!

Taking another deep breath . . .

This labor day will mark three weeks since classes began. Time has passed quickly though, as I take account of what I have learned, much has happened in a very short time.

These past weeks, I have made the transition from a pre-med, looking forward to med school with nervous anticipation and hopeful idealism, to a first year medical student living wholly in the present. Becoming a physician is both the most intense experience of my life yet full of everyday moments that are routine and uninteresting. To wit, I have never studied so seriously in my life yet there is still time to stare into space, look up the latest NBA freeagent news, talk on the phone . . .

Life in Hanover is very simple. There are trees, trees and more trees as far as the eye can see. No view of the ocean, no big buildings, no crowds, no hustle and bustle. The air is clean, very clean and there are rivers and hiking trails all over the place. There is no smog, no dirty rivers or harbours, and not a lot of noise. There is a college town here that seems to be an extension of the college campus. It contains the Dartmouth bookstore, Gap, North Face, Molly’s diner, Mai Thai restaurant, a couple of banks and a small movie theatre. There is no mall here, no Blockbuster Video, no CostCo, no In N Out. There is a very efficient 2hr bus service to Boston, comfy seats, smooth driving, free gourmet pretzels and an in-drive movie. My routine: studying every day, sleeping-in on the weekends, partying every two weeks after the quiz and taking a trip to Boston every month to recover my sanity.

I think I can live with that.

My first cadaver

We had a “sneak peek” in the Anatomy lab today hosted by the 2nd year students. I had pretty high expectations of myself going into lab. I had seen and touched several dead bodies in South Africa and seen the Body Worlds exhibit in LA so what could be so bad about a few embalmed cadavers?

And yet, as the 2nd year students calmly unzipped the blue plastic bags holding them, I felt my stomach turn a little. The formalin stung in my nose and I felt a mild tingling sensation in my hands and feet as they peeled back the shroud to reveal the grey, rubbery skin. One of the cadavers, an old man still had all of his chest and back hair which stuck out all over the place. He was barrel chested and had a protruded belly which looked like it may have once been soft and plump but was now hard, rubbery and unyielding. Luckily for me, the hands, feet and head were bound up in gauze (we won’t unwrap those until we study the head and neck).

A few presses, pulls, rubs later, I felt more comfortable around the bodies and ready for labs to start next week.

All in all, it wasn’t mind-blowing but it was a significant experience in my second week of med school nonetheless.

I guess, in a way, this is a microcosm of the whole process of starting med school. No major epiphanies, just a few tiny revelations here and there. Maybe in another couple of weeks, I will finally feel like I’m a med student?

Pictures from Orientation

The traffic circle, I wonder if you can use it when it snows?

The entrance to DMS, nice eh?

We went on an overnight retreat as part of orientation. Took a nice hike with some of my new classmates, then climbed this aluminum weather tower thing to get to the view . . . stay tuned to see if we made it.

Made it! Now where the heck is the ocean?

New classmates Jared, Ako and Michelle hanging on for dear life!

Gonna try to make it back to civilization now . . .

Sword, Khue and Vasi in front of the Moosilauke Lodge(MORE NEW CLASSMATES!!!!)

“THIS IS HOW YOU EAT WATERMELON . . . ”

My On Doctoring group doing some team building . . .

From left to right (Rachel, Katie, Mike, Brittany, Narath, Jane)

My new room and my most important piece of equipment, my bed

‘Twas the night before med school . . .

After an action packed week of moving to the other corner of the country, meeting my 80 classmates, and trying to psyche myself up for med school, its finally going to happen . . . med school and the much anticipated new chapter in my life starts in T-minus . . . 10 hours!

I can’t say I am excited so much as anxious . . . kind of like walking up the platform at the Dartmouth Rope Swing and looking down (the DRS is a 40 foot long rope which hangs over the river that you can use to swing you over the river at which point you are supposed to let go and do a swan dive into the river). I feel like I am getting ready to take that first step off the platform, feel the drop, the exhiliration and excitement. The important thing here, just like in the rope swing is conquering that first step and getting into the water, not to be pretty but to JUST DO IT.

Its weird, so much is different yet a few things remain the same. As with any cultural adaptation process, I have felt several emotional states during orientation. I went from excited and energized the first few days (to the extent that I was able to survive 4 hrs of sleep over two days, jet lag, coming to the first day of orientation without a car, place to live, furniture or any clue about living in the Upper Valley and still have the energy to meet and laugh with my classmates and spend a little QT with my family) to somber, thoughtful and a bit aloof in the final days of orientation as if taking a deep breathe before the plunge. Its funny but although I try to be the former personality (laughing, smiling, friendly), I find I am almost more comfortable these days as the latter, more thoughtful and withdrawn, independent and doing my own thing. So far, my classmates have been extremely supportive and adaptive to both Eugenes . . . Well, we shall see, classes start tomorrow.

My Goal (for now)

Dartmouth asked me to describe my goals and dreams for the future for advising purposes so I suppose I will take an excerpt out from my response:

I saw a woman today who was suffering: eyes bulging out of their sockets, body emaciated, legs so weak she could not stand. Although we went through the motions of an HIV test, we did not have to look at her chart to know the result: she was HIV positive.

I decided to become a physician in order to equip myself with the tools to help patients like this. However, the experience of watching patients die in South Africa this summer has taught me that even as a physician, I will lack the tools to treat the underlying causes of disease: unemployment, poverty, malnutrition, drugs, violence, conflict.

My ambition is to find ways to treat both socioeconomic ills as well as the diseases afflicting the poor and sick. Currently, I would like to start my own organization providing health care and micro-loans to the poor and sick. This organization would have both a clinical and social objective. Clinically, it would aim to improve the health outcome of HIV positive patients by increasing access to ARV drugs and health counseling in under-resourced communities. Socially, it would help the poorest of these patients generate income through micro-loans. These two objectives would reinforce one another, for instance the loans would make provision of drugs sustainable as the patients would make contributions from their interest payments to the cost of drugs. It would also create economic incentive for the patients to remain healthy and productive. Ultimately, the goal of this clinic would be to show poor people that they can take charge of their own health and lives and that they do not need to depend on government handouts.

The point of this exercise is to be idealistic of course and I am sure this will change as time goes on but for now, I think its a pretty good target to shoot for. Now if I could just make money doing it . . . :)