25 March 2008

Matching and Specialties

This is likely to be a multi-part posting but I thought that I needed to start to address this topic at some point. Speciality choice can be quite difficult for many medical students because some schools never quite spend much time on how to choose a speciality. This choice can be a source of life-long misery or it can become like a marriage with deep and passionate love in the early years only to be replaced with a wonderful familiarity that is both surprising and satisfying at the same time.

The wrong way to choose a speciality is based on what you will believe will be potential income. While it's generally true that surgical specialties are better paying than primary care specialities, this is not always the case especially if you find that you just don't enjoy surgery and surgical procedures after a while. Anesthesia has become very popular in the sense that people feel that this speciality pays well and had less hours than surgery but a description of Anesthesia as "hours of boredom punctuated with seconds of sheer terror" can be pretty accurate at times. Many people find that this aspect of anesthesia far outweighs any monetary rewards.

Another wrong way to choose a specialty is by how wonderful your medical school experience was in that particular rotation. While you may have loved your residents and interns, you may have not loved the patients that you were treating. This can make for a miserable residency experience and an even more miserable practice experience.

As you rotate through your required third-year clerkships, you may want to pay close attention to the types of patient that each speciality treats. Do you enjoy a long-term relationship with your patient and handling of chronic problems? If this is the case, then family medicine and internal medicine may be of interest to you. Do you enjoy treating only female patients? This brings to mind OB-Gyn but you may find yourself drawn to internal medicine with a track in women's health.

Do you enjoy procedures? You may want to investigate the procedure-heavy specialties such as anesthesia, radiology, orthopedic surgery, ophthalmology and invasive cardiology. You might also place any of the surgical specialties in this category. Finally, do you enjoy the outpatient treatment of patients? This might lead you to emergency medicine as EM spend most of their practice time dealing with outpatient issues with a bit of trauma thrown in. Dermatology is also a specialty that has far more outpatient care than inpatient care. Psychiatry can also go into that category.

Pathology tends to appeal to individuals who love to study tissues and medical problems. Pathologists do not treat inpatients and pathologists perform few procedures other than those pathologists who subspecialize in tissue banking and transfusion medicine. If study and evaluation of tissues and medical problems are appealing to you, look into pathology.

Another way NOT to choose a speciality is by what your classmates have to say about a particular specialty. Don't be drawn into the "the smartest people in medical school go into derm so derm is the best specialty". This might not be the case for you if you don't enjoy the scope of practice of the dermatologist. While dermatology is a competitive specialty, you may not enjoy much about this speciality other than the look on your classmates faces when you announce that you want to pursue Derm.

The telly shows such as "House", "ER" and "Scrubs" have also tended to glamorize certain specialties. Do keep in mind that telly watching is for entertainment purposes. There is little reality to any of these shows no matter how compelling the characters and patient situations. These shows are written by people who are generally not in medicine with input for practitioners. These shows are written with entertainment factor built into them. Most of actual medical practice is not entertaining.

As you study through medical school years one and two, you are creating the foundation upon which you will enter your third year. It is during that third year that you will be exposed to different specialties and their patients. It's good to keep an open mind during third year. Do not feel pressured to decide upon anything if you don't have an idea of what type of specialty might be of interest.

I can tell you from experience, that I generally liked every rotation that I encountered during third year. Basically, I enjoy the practice of medicine and patient interaction. I saw plenty of very interesting pathology and patients on OB-Gyn but I didn't particularly find this specialty appealing other than how I could learn to differentiate pelvic problems from abdominal problems in the course of seeing patients.

I loved my Psychiatry rotation and found the expertise of my preceptor far greater than any clinician that I have dealt with to date. I developed a very strong appreciation and high degree of respect for that multitude of psychiatrists out there that just do a good job taking care of their patients. While psychiatry was not for me, it was an awesome rotation that brought a depth of understanding as to how many medical and surgical problems might present with psychiatric symptoms.

As you go through first and second year, take the time to join one of two specialty exploration/interest groups at your medical school. By joining these groups, you ca expose yourself to residents and attendings that can assist with your exploration of their specialty. It is participation in these types of specialty interest groups that can allow you to keep your focus when you feel that you just can't look at another histology slide or review another article for biochemistry.

Also keep in mind that certain specialties do require a high level of academic achievement in medical school. I have often spoken to medical students who have struggled with a course or two in medical school who feel like doors have closed for them because they won't be competitive for a dermatology residency. My first inclination when I speak to theses folks is to find out if they actually understand the scope and practice of dermatology. If they do have this understanding, are there other less-competitive specialties that will satisfy many of their need? In the vast majority of cases, the answer is yes.

Finally, as a close to this little essay which is like a part one of this issue, if you know that you are not particularly competitive for a speciality that you feel you can't live without, spend some quality time with the program director/department chairman of that specialty at your school. Try to figure out if you have some options that can increase your competitiveness for said specialty such as research. There might even be a possibility of finding a program or two in that specialty that might be in a less desirable location and therefor less competitive.

Don't listen to anyone except yourself when it comes to your needs in terms of the practice of medicine. In the end, it doesn't matter what you classmates say about the specialty that interests you. It's how you feel about what you are interested in practicing and your suitability for said specialty. It's also about your attentiveness to your academics/boards too.

If you had a slow first year, try to have a strong second year. If you had a weak second year, then try to have a very strong third year. In short, you can decide at any point, that you are going to upgrade your work ethic and performance.

13 March 2008

Dealing with patients you might not "like" for whatever reason.

I received a call about a consult for placement of a temporary dialysis catheter in the Medical Intensive Care Unit. When I arrived I quickly scanned the chart (coagulation profile, patient’s medical information etc.) and entered the room of the patient who needed the temporary dialysis catheter. Just before I entered the room, one of the resident physicians pulled me aside and said, “This guy weighs 500 pounds and let himself get to this point. On top of that, he smells. I just want to warn you to have your gas mask ready”. He laughed and I “thanked” him for the information and entered the room.

Lying in the bed was a 500+ pound gentleman who was restrained and mechanically ventilated. In one hand was an intravenous line which was leaking intravenous fluid. He had a very large abdominal pannus (apron of adipose tissue), multiple scars on both arms and both legs with both legs having open venous stasis ulcers that had become infected. I walked up to the bed and spoke to this patient to explain to him that his kidneys were failing and that he was going to need to have a dialysis catheter to help them along. He nodded to me but I wasn’t sure he could understand. I explained what I was going to do and that it might be uncomfortable but I would use as much local anesthetic as needed.

The nurse told me that the small intravenous line in his hand was not going to be adequate and that it was the only source of IV access that the patient had. It was tenuous at best. I asked if the patients family was present and the nurse said that they were in the waiting room. I told the nurse to gather the equipment for both a central venous line and a temporary hemodialysis catheter insertion while I went to speak with the patient’s family.

The patient’s wife was sitting in the waiting room with her daughter. She was tearful and spoke lovingly about her husband. She said that as he gained more and more weight, he became immobile. Finally, she said that nothing could get him out of his room and that she had difficulty getting him to comply with medications for diabetes and hypertension. She said that he would become angry and depressed when she attempted to help him with his personal hygiene or care of his venous stasis ulcers. I explained the need for the central venous line and the temporary hemodialysis catheter. I also explained the risks and benefits of the placement of these lines so that she could make an informed decision. She asked me to do what I could to help her husband get back to health.

After washing my hands and washing the areas of the patient where I intended to insert the catheters, I used a portable ultrasound machine to locate both the subclavian vein and the femoral vein. Both were fairly deep because of the large amount of subcutaneous fat that was present in this patient. I was able to mark off some landmarks and get to work. With the aid of a couple of nurses, I used adhesive tape to tape as much of the patient’s fat out of my way so that I could get to my intended target. After 30 minutes, I had inserted a central venous line into this patients left subclavian vein after taking about 20 minutes to carefully prepare the site. The more time I spent in prep, the easier it would be to get the line in under the best and most sterile conditions. I also had asked the nurse to give the patient a small amount of sedation so that the whole experience would be a little less alarming.

I then turned my attention to the femoral vein. Since temporary hemodialysis catheters were very large, I chose a long catheter and moved closer to the inguinal ligament as the vein would be larger there. As with the subclavian vein, I used a large amount of adhesive tape and three nurses to hold this gentleman’s large fat pannus out of the way. I inserted the line and had great blood flow and return. I also carefully secured the line with locking tape and sutures. I wanted to make sure that the patient would not be able to easily “pull” the line if he became disoriented and unrestrained. I also gave the local anesthetic plenty of time to take effect as most patients are pretty still if they are comfortable.

After a chest radiograph to confirm that my lines were in good position (with no pneumothorax), I phoned the nurses to let them know that the lines were safe to use. I also had “blocked” the hemodialysis catheter with an anticoagulant and thus I let the hemodialysis department know that this line was ready for use. I spoke with the patient’s family and let them know that the procedures, while taking a couple of hours, had gone well.

For the next three days, I went into the intensive care unit to check on the those lines and make sure that they were working fine. I spoke with the residents who kept congratulating me on “getting the lines in the whale” and laughing about this patient’s body habitus. On the third day, I didn’t see the joke and I didn’t see where calling this man a “hippo”, “whale”, or anything other than a sick patient was necessary. I asked them why they felt obligated to demean this gentleman that they didn’t really know (because he had been intubated) and they were charged with treating.

One of the residents said that he just doesn’t like “fat” people because they don’t take care of themselves and won’t follow his direction. He said that they could follow a good diet, exercise and not end up using up our precious health care resources for something that they “did to themselves”. Another resident said that he could “stand” the smell of the venous stasis ulcers and that he had to get out of the room as quickly as possible. While I appreciated their honesty, I couldn’t help wondering why they didn’t have a problem with treating an alcoholic or a drug addict who had become ill because of self-inflicted abuse of a substance. I had encountered some “skin popper” IV drug abusers who had multiple cutaneous abscesses that smelled far worse than a couple of venous stasis ulcers.

I find it difficult to blame the patient for their disease. In my mind, just as a diabetic can’t make insulin, a morbid obese patient has a metabolic problem that is not under their control. By the time a patient winds up weighing 500 pounds, all personal control is lost. If you couple the massive weight with psychiatric disorders such as depression, one finds a very difficult and challenging patient with multiple problems that need to be addressed. I can’t just afford to “like” or “dislike” any of my patients because they need my help and not my judgment.
Two weeks later, I received a call from the hemodialysis unit secretary. The nephrologist wanted me to stop by the unit so that I could “speak” to this patient. He was off the ventilator and was not going to need hemodialysis as his renal function had greatly improved. When I saw him, he said that he remembered my speaking to him in the ICU. I was amazed that he would remember me with his condition but he remembered how I explained everything that I was going to do for him and how I spoke to him with respect.

I later heard from his attending physician that he entered a rehab center and was on his way to losing 100 pounds. His hypertension was greatly improved and his diabetes was managed by diet. Though he had a long way to go, he was moving along on his journey. Hearing this made me remember why I went into medicine in the first place. It is simply to help people regain their health.

I can’t make judgments on my patients because “there but for the grace of God, go I”. I have been given the privilege and opportunity to touch the lives of thousands of people. I have also been given the trust of those thousands to also have only the best of intentions when I treat them. This is what makes medicine like no other career on earth.