Indifferential Diagnosis

David finishes learning for the rest of his life

2011-05-02T09:37:00.000-07:00

As of last Friday, when I completed my last medical school clerkship, my brain has officially closed for business as far as all further medical edification is concerned. Now that I – and Kevin soon after – have fully internalized everything ever known about medicine, I have finally reached that ultimate goal set so many years ago in college: have another Senior Spring.

Goodbye, short coats. Hello, mid-week golf.

Ideal vs. Reality - Orthopedic Surgery

2011-04-02T21:59:00.000-07:00

David and Kevin match

2011-03-20T20:45:00.000-07:00

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)

2011-03-09T19:03:00.000-08:00

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

2010-07-02T02:03:00.000-07:00

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

2010-03-16T18:35:00.000-07:00

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

2010-03-07T11:29:00.000-08:00

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

2010-02-23T08:48:00.000-08:00

David doesn't believe in magic

2010-02-21T19:39:00.001-08:00

As scientific, evidence-based fields go, medicine has to rank at or near the top. The best doctors make clinical decisions based on both years of experience and what the newest research has identified as the appropriate standard of care. Yet anyone who’s seen a medical TV show or spent any time on an inpatient ward has probably noticed the prominent role of superstition in what is otherwise a primarily logic-based endeavor.

One of the more benign examples is the concept of “clouds.” For those unfamiliar, a white cloud is someone who brings good luck and light call nights along wherever he or she goes, while a black cloud puts Murphy’s Law to the test with regularity. These terms are often applied jokingly or even affectionately on the wards, yet it’s not uncommon hear them said with a completely straight face. I’ve also heard students and interns scolded for predicting easy call nights or forecasting uncomplicated patient stays based on all of the relevant admitting information.

I hope this isn't the MI cloud...

Admittedly, a fair amount of this superstition is tongue-in-cheek inside joking. Yet I’ve been repeatedly surprised at how superstitious nurses, residents, and even attendings can be, particularly with regard to call nights and new patient admissions. As another example, during sign-out, when the daytime team gives a quick heads-up to the call team or night float about any pressing patient issues to be aware of overnight, I’ve had multiple permutations of the following exchange:

David: Ok, for Mr. X, I don’t anticipate any issues…

On-call Intern: Gah! Don’t say that! [Scrambles to knock on table]

David: …with him…wait, what?

On-call Intern: Never. Say. That. It’s bad luck. [Knocks on wood again and prepares to sacrifice small bunny on a tiny altar made of old reflex hammers and adorned with four-leaf clovers]

David: Uh…Ok, sorry. I, uh, hope everything goes to pot and you get called all night about him…?

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After a few of these encounters on multiple rotations, I’ve come to take a slightly different tact, at least with those superstitious housestaff members with whom I’ve developed a friendly rapport:

David: Light call so far? No admissions?

On-call Intern: Shhhhh! Don’t jinx it!

David: Jinx what? The fact that tonight guarantees to be a complete admissions shut-out?

On-call Intern: Dude…

David: That this call will henceforth be the standard against which all other easy calls will forever be judged?

On-call Intern: I’m going to slap you…

David: The fact that the Deities of Patient Admissions – may they smite you if they exist – are clearly too impotent to put forward a worthy challenge on your call night?

On-call Intern: Forget the bunny, I’m going to sacrifice you instead.

David: That…

On-call Intern: You do realize I evaluate you, right?

David: Ruh-roh.

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Maybe this is why I’m a black cloud…

Kevin and David think you might be interested in some merchandise

2010-02-19T22:13:00.000-08:00

Now that David and I have reached our goal of becoming internet hundredaires, the next goal is to be come gajillionaires. After some brainstorming, we decided selling various merchandise at a 10% commission rate is the obvious way to go. So I've gone ahead and started a Zazzle store using the comics on iddx. Feel free to buy one or ninety. This is a pretty preliminary start but theres some mousepads available and a calendar of the comics. If you guys have any specific requests, let me know and I'll make it available (iddx underwear perhaps?). All proceeds do not go to charity. Unless you consider sleep-deprived med students to be charity cases, in which case 100% of the proceeds will be going to charity.

Store link: http://www.zazzle.com/iddxblog

make custom gifts at Zazzle

David and Kevin become internet hundredaires

2010-02-15T22:20:00.000-08:00

When Kevin and I first started this blog, we wanted to provoke meaningful thought and discussion about medical education and chronicle the early steps towards physician-hood from the basic sciences to graduation and everything along the baby-saving, Jess-antagonizing, sleep-not-having way. All this, of course, only if the blog failed in its primary purpose of making us wealthy internet blogopreneurs who could quit med school and live a life of leisure for rest of our days.

Well, friends, that day has finally arrived. Buoyed by a 100% legitimate string of ad-clicks, Kevin and I have reached the rarified status of making $100 in advertising revenue over the course of only two years. Averaged over all of the time spent writing and brainstorming, we’re in the oft-discussed yet rarely realized realm of multiple cents per-hour earnings.

While we contemplate which Cayman isle to retire to now that this gravy train is going full-bore, we're planning a celebration in the interim, funded entirely by this massive windfall. Expect a spread truly befitting our recent successes; every attendee will get at least 1-2 pretzels, maybe more.

See you there!

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What?: IDDx Earnings Extravaganza

When?: Saturday, March 27^th, 8PM - ???!?!?

Where?: TBD

Who?: Kevin, David, Julia, you, maybe Jess

Kevin is Fat Joe...

Kevin might want to know watcha thinkin' about.

2010-01-30T12:26:00.000-08:00

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.

Comic: Ideal vs. Reality - Psychiatry

2010-01-04T20:04:00.001-08:00

David and Kevin present some old favorites

2009-12-09T20:36:00.000-08:00

Almost 2 years ago, David and I started IDDx with the humble hope of turning this site into a blogging powerhouse that could be our one-way ticket out of the obvious career dead-end that is medicine. Clearly that has not happened. But we have still managed to build (and re-build) a loyal following of readers that have somehow found our inane drivel to be entertaining (or at least interesting in a car crash-y kind of way). We thought this would be an appropriate time to revisit some of our old posts as a kind of year-end-review and maybe serve as a best-of (or worst-of, as the case may be with Jess) list for the newer readers. (Re)Enjoy.

-Kevin and David

Medical student life: A few insights into the fast-paced world of call-taking, baby-saving, and retractor-holding.

David, Robby, Dan, Beth, and the Johns save lives while on vacation.

Kevin wishes these classes were real.

Kevin falls, David watches.

Pre-medical advice: Words from the arguably wise about facing the application gauntlet.

David tells you what to do (in an admissions interview).

Kevin debunks 2 myths about med school.

David presents the 15-15-1 theory.

Comics: Only stick figures can provide a true window into the inner med student soul.

MCAT - Then and Now

OB exams are tricky

Ideal vs. Reality - Emergency Medicine

Guest authors: Who's better - Julia, Jess, Julia, or Julia? You decide.

Julia knows exactly the kind of doctor she will become.

Jess tries to reach the keeds.

Julia presents a landmark case of PMS.

Random thoughts, pet peeves, and theories about life: A potpourri of IDDx musings.

David Presents His #2 Pet Peeve: Considers It Tomorrow At Midnight Guy

David has difficulty with doors.

Kevin contemplates the diet of the Little Mermaid

David treats a wise child

2009-12-04T20:22:00.000-08:00

During a recent shift at a pediatric urgent care center, a young boy came in with a scald burn to his arm. As I debrided his wound, we discussed some of the pressing issues of youth, including how awesome dinosaurs are and whether or not mall Santas are real (consensus: of course they are). All of 5 years old, he was a total fighter and didn't complain one bit throughout the procedure.

After a heated debate about how fast Spot runs - we both said some things we didn't mean - the following exchange occurred:

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David: This must've been pretty scary, but you've been doing great.

Kid: Hey, I'm not scared of anything.

David: Nothing? Really (unsure whether or not to entrust him with my fear of clowns)? That's pretty impressive.

Kid: Nope, nothing...

...except bush babies.

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Mildly confused about what he was taking about, I allowed the conversation to shift, and soon he was all fixed up and on his way home. Later, a quick Google search provided the images that will give me night terrors for the rest of my natural life.

Wise choice, kid...

Kevin might save babies like it's his job

2009-12-01T11:53:00.000-08:00

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 ~~patients~~parents.
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.

Comic: Ideal vs. Reality - Plastic Surgery

2009-11-30T12:17:00.000-08:00

Julia ponders a career in Neurology

2009-11-25T13:19:00.000-08:00

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.

Comic: G16P10

2009-11-23T12:46:00.000-08:00

Jess tries to reach the keeds

2009-11-20T12:05:00.000-08:00

Back and angy as ever, Jess attempts to unseat Julia as the premiere guest author with this, his latest rant. Enjoy.

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The recent revival of this blog and its stream-of-consciousness ranting affords a golden opportunity to similarly revitalize my own journalistic career – since this medicine thing may soon come to a screeching halt. I’m currently on pediatrics. I could simply refer you to Kevin’s elegant artistry to depict my feelings about the rotation, but that would ruin the cathartic nature of this medium. I’ll take a more positive approach than my colleague did with childbirthing – I’ll give one positive before launching into my top pediatric peeves.

The Good: A lot of kids are cute. When they’re in a good mood, they’re friendly and laugh and want to see how your tools work and it gives you that warm fuzzy/good feeling that you can only get from the sound of a child’s laughter – before passing them off to the demonized shot-giving nurse (which, by the way, must be the worst job in the world). I genuinely enjoy kids in general so this works out well. But there’s a lot to hate in general, so let’s not delay:

1. The Vaccine Talk.

Every physician knows this one. For those of you unawares, let me break this down for you. We have, on one side, modern medicine and every doctor you’re likely to ever meet who contend that babies shouldn’t die. We have, on the other side, this guy. Now here’s the kicker: People believe Jim Carrey. To be fair, a “doctor” did originally perpetrate this bogus theory. One Andrew Wakefield proposed that MMR vaccine was related to a small subset of cases of autism via immunologic shenanigans. He then proceeded to present this and cause a panic which led to refusal of immunizations and then an outbreak of measles. Read that again. Of measles. Let’s get one thing clear: no one in the Western world should ever contract measles. The only time anyone should get measles is playing Oregon Trail.

If only YOUR MOM had vaccinated you.

Meanwhile, of course, autism didn’t miss a beat. Andrew Wakefield has now lost his medical license and practices homeopathic medicine in Texas. There are even new allegations that he fudged his data – but by God, that doesn’t matter, because a lack of understanding of basic statistics or physiology is no reason you should listen to your “doctor” about vaccines, because he’s probably just brainwashed and doesn’t think for himself (I swear, people say this). And you’ll hear the same random half-baked logic:

“Too many shots these days,” “given too young,” “those diseases don’t exist anymore (AND WHY MIGHT THAT BE?!?!)”

It wouldn’t be so bad if these people listened to reason. Or at least attempted to listen to reason. The following is an almost word-for-word transcription of my preceptor’s attempt to convince someone to get their kid a meningitis vaccine:

“Here’s all the excellent and well-founded scientific reasons why your kid is way more likely to die from meningitis than from getting this very safe vaccine.”

“Yeah but I don’t give my kids shots until they’re 1 year old.”

“Why?”

“I just don’t. I’m convinced I know better than decades of data and scientific research and besides I can selfishly rely on herd immunity which, by the way, I undermine by not getting vaccinated.”

“…..Kay. But seriously, why?”

“I just don’t.”

You get the picture.

2. Schools waste doctors’ time.

Everyone has had this experience –little Johnny had a cough/cold/stubbed toe but, because he missed time from school, he requires a doctor’s note to allow him back. This means that little Johnny gets to wait in the office for 2 hours with all the bacon-lungers so that he can get a doctor to confirm that yes, in fact, he was coughing, and no this was not some elaborate falsehood perpetrated by the parent. But even if he wasn’t sick, he sure as hell is now. In which case, of course, he’ll have to come back and get a separate doctor’s note just so he can expose everyone to it. At what point did we stop believing parents when they say their child is ill? Congratulations, Principal Jones, you’ve once more saved the integrity of your pedagogical bureaucracy – but at what cost?

At least they're NOT VACCINATED.

3. First-time parents possess no common sense.

This may represent a failing of our public education in some ways, but so many new parents seem to have no other option when their child is ill but to come to the ER in the middle of the night and/or demand to speak to the pediatrician on call. I understand that you can’t tell for sure how sick your 10-month-old child is. He can’t talk. But with a few tidbits of arcane medical knowledge, several ER visits could be avoided:

1) 99 degrees is never, under any circumstances, a fever. I don’t care that your baby usually runs 98.4 so it’s a little hot. Being asked to write a note justifying school or daycare absence for a temperature of 99.1F rings hollow. Pediatricians don’t get too concerned until 100.5F, so don’t bother them.

2) Babies are rashy. Please do not demand to speak to the on-call pediatrician because your child has one new red mark on their skin. It’s not cancer. It will likely be gone within a week without a single symptom. Go to bed.

3) Babies are loud. If your baby is crying, try feeding the baby. Try holding the baby. Try rocking, cuddling, or singing to the baby. (Do not ever shake or throw your baby). If these don’t work, does baby otherwise seem sick? If not, it’s probably not an emergency.

4) For God’s sake, triage nurses exist for a reason. Self-explanatory.

I enjoyed my time on peds, but as you can tell, there are more than a few things which could be more satisfying about the setup. I did almost entirely outpatient pediatrics, so I was mostly in clinic the entire time – which can be numbing on its worst days.

David breaks down Surgery

2009-11-17T19:10:00.000-08:00

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 struggles to find a Thank You card

2009-11-15T08:50:00.000-08:00

After returning home from my most recent rotation I stopped by the stationary aisle in my local grocery store to look for a Thank You card for my preceptor, just a simple gesture of my gratitude. Little did I know, it would be the most frustrating 15 5 minutes of my life. Finding a card, whether it’s a thank you card or a birthday card, is tricky business. Not in the sense that I’m afraid the opposite party wont like the card, but more that the card is an extension of me and I don’t want to be represented by a glittered up pink butterfly with a bad sense of humor. The fact that I have to give a note in a professional capacity adds a further wrinkle into this dilemma. Sorry Mr. Butterfly, not today.

If you’ve ever spent any time in a card aisle or Hallmark store, you should know that it’s obviously geared towards women and children. The cards come in three general themes: cartoons, flowers or kittens. Even when I did find an acceptable design, there would be some message scrawled on the inside that was so sentimental it made me uncomfortable just reading it.

That's really nice, do these come in Mens?

This was also something I never understood. Why do people want their cards to have messages preprinted inside? Isn’t that a little impersonal? Most people write in messages anyways so the text just becomes some odd impediment to a continuous paragraph. If someone doesn’t write anything, it’s not like the receiver will attribute the printed text to the giver. They’d just assume the giver was a lazy asshole that didn’t write anything. Either way, the text is worthless at best, a net-negative at other times. Much like Jess. Anyways, I digress.
After much shuffling around and digging, I finally settled on a generic green card with no text inside. I guess that’s the best I can hope for. Now if I only knew what I should write…

Comics: Ideal vs. Reality - Pediatrics (2009 edition)

2009-11-11T00:27:00.001-08:00

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

2009-11-06T08:59:00.000-08:00

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

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.

Kevin learns some important facts about childbirth

2009-10-31T20:23:00.000-07:00

Ah, 3rd year. The promised land every 2nd year is dreaming of and the 9th level of hell that every 4th year wishes they could forget. So far David has given you a glimpse into the life of a 3rd year surgery rotation student. Now that I’m done with my OB/GYN rotation, I feel obliged to share some intriguing insights into the entire miracle of childbirth that people might not know.

1. It takes a long time
I know what you’ve seen in the movies: Katherine Heigl is out eating some dinner, talking about nothing, when suddenly her water breaks. She goes to the hospital and 15 minutes you have a baby. Not so much in real life. Life on the labor and delivery floor for a medical student is long and tedious. Your duties include watching the mom groan for a really long time, checking the fetal heart rate and then going back to watching the mom groan. Luckily most women are reasonable enough to ask for an epidural (or they’re so beaten down by the constant sensation of having a human being pass through their vagina that they’re willing to compromise on their previous beliefs) so that it’s mostly just waiting without having to hear the groaning. But really, the entire process from onset of labor to actual delivery can take hours, hours where you’re not allowed to sneak away and go watch ESPN in the doctor’s lounge. Or so I’ve been told…

Sigh... if only

2. It smells really really bad
Despite all the lectures about fetal positioning, physiology of pregnancy and the birthing process, no one bothered to tell me child birth is by far the smelliest processes a human being can experience. I mean seriously, it’s awful. First of all, everybody poops, especially in childbirth. When the pushing process takes an hour or two, it’s just a constant dribble of little poop balls. Luckily the nurses are really good about whisking them away but unfortunately the smell is always just hanging in the air. Then once the baby is delivered, there is a huge gush of amniotic fluid, blood, vernix and sometimes meconium. In case you don’t know what vernix is, here’s what up:

“Vernix has a highly variable makeup but is primarily composed of sebum, cells that have sloughed off the fetus's skin and shed lanugo hair.”

So in other words, if you were able to collect BO from 100 fat hairy dudes and somehow condense it into a paste, you’d have some vernix on your hands. I’m absolutely sure vernix was invented just to be the bane of my existence. Well… at least 80% sure.

This reminds me of one delivery I was on where I caught a vernix covered baby onto my chest, right between the numbers. Even though we clamped and cut the cord in a reasonable amount of time, it was too late. I was pasted in baby goo. No matter where I turned, the waft of vernix followed me. Unfortunately I still had to deliver the placenta (another thing people never tell you) and check vaginal lacerations. But, after being hit with the fetus grenade all I could focus on was not vomiting. Every time I moved, it would stir the air and I’d get a little more of that cheesy goodness. By the end I think I was taking about 1 breath a minute. If I was on a pulse ox someone probably would have called a codeAfter that delivery I had to excuse myself to dry heave in the bathroom.

3. You have to be happy for the parents
Maybe this is just a personal struggle of mine but I have a lot of trouble mustering up the happy feelings at 3am in the morning to congratulate the mom and dad on their new baby. Clearly the birth of a child, especially the first, is one of the greatest moments a person can experience… unless it’s not your baby, and especially if you’ve already seen 5 that day. At the end of the day, I really have trouble feigning the fake joy necessary to congratulate some new parents on their new baby, who happens to look exactly like the baby I saw 15 minutes ago. I can say he looks cute but really, that’s not true at all. New babies look like pink little aliens that cry a lot. That’s about all they do. It takes awhile before they develop the chubby cheeks necessary to look hilarious in lobster costumes, which you can then spread across the internet and hopefully haunt them in their adulthood. Until then, they really bring nothing to the table.

This is payback for being so smelly