Many times, third-year medical students will have to spend a portion of their required surgical clinical clerkship on Cardiothoracic Surgery. This portion of your surgery clerkship can provide a good informational background for anyone going into medicine, pediatrics or surgery. For the medicine, emergency medicine and anesthesia folks, you get first hand experience with the actions of pressors such as dopamine and dobutamine and other cardio pharmaceuticals in the postop management of these patients. You see the real-time effects of agents like nipride and nitroglycerine because most cardiac surgery patient will have pulmonary artery catheters in place in the immediate post-operative period. For those anticipating entering pediatrics, you will get a chance to see some of the effects of the congenital heart disease entities and how repairs are undertaken. For those entering the surgical specialties, you can develop an understanding of some specialized surgical techniques in addition to becoming familiar with the surgical intensive care unit.
Approaching the Rotation
The first step in any clinical rotation is to have good reference materials so that you understand the language that these surgeons will be using. For cardiothoracic surgery, I strongly recommend the following: Essentials of the Surgical Subspecialties by Lawrence, Cardiac Surgery Secrets by Solotoski or Handbook of Patient Care in Cardiac Surgery by Vlahakes. Any of these books will provide a solid background into the types of pathology that you will encounter in your rotation. The Lawrence book includes good sections on the thoracic elements of this rotation which are not included in the other books. In addition, you need the usual pocket books such as the Pocket Pharmacopeia or Epocrates which may be used to look up dosages of medications and the Maxwell Book which outlines SOAP charting, brief operative notes and discharge summary writing.
The players on any cardiothoracic service are the Cardiothoracic attending surgeon, the resident or fellow surgeon, the intern and you the medical student. You need to understand your role as both a member of the team and as a student of medicine/surgery. This means that in many cases, this busy service will require that you become very proactive in terms of getting the information that you need. You should thoroughly understand the following for every case that you encounter on this service (or any service for that matter):
• The relevant pathology of the underlying disease entity
• The relevant anatomy of the underlying disease entity
• The “gold-standard” of diagnosing the disease entity
• The accepted treatment of the disease entity
• For surgery- the surgical approach and performance of the operative procedure
• For surgery – the postoperative disposition and management of the patient
In the case of a patient that is undergoing a coronary artery bypass graft procedure, you need to understand the indications for the procedure, how the diagnosis of coronary artery disease was obtained (how to read the cath report), where is the disease (in which arteries), the relevant surgical anatomy, how the case is done including the operative approach, how cardiopulmonary bypass works, the effects of the cardiopulmonary bypass pump on the patient and how these effects are managed in the postoperative period, how to read and interpret data from the pulmonary artery catheter, where the grafts for bypass were obtained and how they were utilized and the care of the patient both in the intensive care unit and on the postop ward before discharge home. You should also know why the patient is discharged on certain medications and what you may expect to see and evaluate in the clinic when the patient returns for postoperative care.
Armed with that knowledge, you should make sure that you observe (you probably won’t be actually scrubbing in these cases)the preparation for anesthesia, how the chest is opened and closed, that you see how the grafts are harvested (done by a surgical resident) and how that wound is closed, how the grafts are sewn I place (best to use the camera overhead for this observation rather than try to look over the shoulder of the surgeons, how the pacemaker wires are placed, how the patient is placed on and taken off the cardiopulmonary bypass pump, how the chest tubes are placed in the chest cavity and how blood is evacuated from the chest cavity when the sternal wires are placed. Placement of the sternal wires is also a good opportunity for you to observe an interesting procedure.
After the case, you should accompany the patient to the intensive care unit and you should carefully note and observe the data that is obtained from the pulmonary artery catheter, the arterial line and the 12-lead ECG. You should look at the pre-operative ECG and compare the two. Another good exercise is to note where the grafts were placed and the number of minutes of pump time and any circulatory arrest time. You thoroughly familiarize yourself with the preoperative workup and the postoperative course of every patient that is on your service. Look at things like electrolyte replacement, ventilator weaning, urine output and transfer from the intensive care unit. This is also a good time to learn how to remove chest tubes and arterial lines. You should observe the conversion of the pulmonary artery catheter to a central venous line but leave the rewiring duties to a resident. If you anticipate entering a surgical subspecialty, you might observe these procedures but you should never perform these procedures as a medical student.
In addition to the routine patients, you may get an opportunity to observe some trauma that involved the cardiothoracic service. You may see the repairs of lung lacerations, penetrating cardiac injuries and the relief of cardiac tamponade from a traumatic injury to the chest. It is always interesting to see a patient who is admitted to the emergency department with a stab wound to the chest, knife in placed, rushed off to the operating room where the object is removed and the repair completed with survival of the patient. These are some of the most interesting cases. You may also see how damaged cardiac valves are replaced and how congenital heart defects are repaired. All of these cases are under the practice of a cardiothoracic surgeon.
The thoracic cases may afford you an opportunity to scrub in on the procedures. In the case of the video-assisted thoracic (thorascopic) lung procedures, you will have a good view of lung pathology. You can follow the patient from biopsy (in the case of a tumor) or chest wall abnormalities/problems through the repair. These cases will have interesting anatomy and will have excellent postoperative observations and challenges that will teach you many good skills. You can learn about chest tube management and the physiology of the chest cavity. You will also learn about pain management and the prevention of major postoperative complications as these patients may often be a challenge in terms of pain relief. You may get a chance to observe a thoracentesis or placement of a chest tube.
This rotation can teach you many important skills and hone your ability to understand the critical care of patients. It is an excellent learning opportunity for you. You may not get much hands-op operative experience but you can be invaluable in the post-operative care of these patients.
Showing posts with label choosing a medical specialty. Show all posts
Showing posts with label choosing a medical specialty. Show all posts
18 July 2008
Why I chose Surgery (Part 1 and Part 2)
Part I (an earlier post)
I can vividly remember starting my third year of medical school. My school chose our third-year schedules for us and I remember some of the angst of my fellow classmates when our schedules were posted during the summer between our second and third years. I was in the midst of a wonderful Pathology fellowship that I had received for scoring very high in my Pathology course. I was assigned to various Medical Examiners offices and to the Pathology Departments of a couple of very large teaching hospitals. I had been spending the summer doing everything from crime scene investigation to transfusion medicine to bone marrow transplant. It had been a great summer. I was very strongly considering Pathology and Transfusion Medicine as my specialty.
I stopped by my Dean of Academic Affairs office and was told to wait for my USMLE Step I scores. The school had received them before I had received them. I took a deep breath because I really hadn't prepared myself for facing the prospect that I might have failed that test. I sat in a chair outside the Dean's inner office and ran a couple of scenarios as to what I would do if I had failed. I would quickly sign up for a retest and I would only miss one rotation at the start of third year. Since I was doing Pathology, I could study in between cases and get my preceptors to help me with covering the material.
The Dean came out and handed me a sheet of paper. I had to just sit there in disbelief. Not only had I passed, I had done extremely well. I was on my way. It was hard to hold back the tears of joy because I had studied about two and a half weeks for Step I. My fellowship had the requirement that I take Step I by the second week in May and my last exam from second year was on April 28th. I would be starting third year and I would be starting third year on Pediatrics with one of my best friends as my rotation partner. Life was good... I found out later that two people from my class did not pass USMLE Step I. It was very sad because one girl ran down the hall screaming and sobbing when she received her score. That put loads of people on edge.
I started third year on Pediatrics. It was a good rotation and I received Honors. I really enjoyed taking care of patients and I was very popular with the residents because I could place IVs and draw blood. I had also spent loads of time with an excellent pediatric pathologist so I knew my congenital defects inside and out. I could interpret cath reports and I was quite comfortable in the Pediatric Intensive Care Unit. I had been a Pediatric-Perinatal Respiratory Therapist before starting medical school so the interns found me quite useful.
My second rotation was Psychiatry. This was one of my best required clerkships. I knew that I wasn't going into Psychiatry (you know these things early) so I was free to enjoy the rotation and pick up anything that I could. My preceptor was an excellent Consultation-Liaison Psychiatrist who exposed us to everything from the wards for the criminally insane to hard-core substance abusers to schizophrenics and other stuff. I earned another Honors grade and got some excellent experience. I learned above all that I was not crazy, my friends are not crazy because I spent loads of "quality time" around people who were genuine crazy.
My third rotation was Family Medicine. I had a great preceptor who even delivered babies. This rotatations was entirely office based but I learned to do prenatal exams and care for entire families. I also learned how and when to refer which is great stuff to know. My preceptor was extremely brainy and "pimped" me on just about everything. Turns out this was a good test for USMLE Step II because we either discussed or I had to report on most everything in Family Medicine that was on the shelf exam or on USMLE Step II. I received Honors for this rotation but decided that I really did not enjoy being out of the hospital too often. I also did not enjoy the slow pace of the office.
Holiday break came and I was happy to be done with shelf exams and rotations for five weeks. I knew that Surgery was coming up and my friends had warned me to be ready for two months of pure hell. The rotation is designed so that you spend your first month on General Surgery on one of two services: Trauma or General Surgery. I drew Trauma out of the hat and I received the condolences of my classmates. I figured, "you can do anything that you want with me but you can't stop that clock." No matter how bad, in four weeks, it would be over.
I was hooked on Surgery from my first case. It was a total colectomy with four females operating. My chief resident was female, the junior resident was female, the attending was female and I was female. We talked about shoes and Chanel suits during the case. I tied tons of knots and helped the junior resident close the incision. It was heaven. I found out that I loved Trauma and I couldn't wait to be on call every third day. I had the time of my life and I loved everything about surgery.
My next month was spent on ENT and then on Cardio-thoracic and Vascular Surgery. I scrubbed every case that was assigned to me and many cases that were assigned to some of my colleagues. I became hooked on Vascular Surgery during that rotation. I loved the detective atmosphere on Vascular and loved taking care of the patients. My chief resident on Vascular taught me some great pearls about making sure that even with an amputation, fashioning a well-constructed stump can make the difference between ambulating and not ambulating for the patient. It was great stuff.
After Surgery, I rotated through OB-Gyn. I hated everything about this specialty. This rotation became my only High Pass during third year. I just couldn't get into delivering babies and I wasn't thrilled with tubal ligations. I wasn't thrilled with spending too much time in the clinics and offices. The one bright spot was the Gyn surgeries which I excelled at. I learned the surgical anatomy like a sponge but I knew that this was not going to be the specialty for me.
I finished up on Medicine and Neurology. This would be my final sixteen weeks of third year. I was fortunate to have medicine last because this made study for USMLE Step II a snap. I totally enjoyed Medicine and Neurology but my heart was back in surgery. All of my Pathology experience really paid off because I aced these rotations and moved onto fourth year.
My faculty adviser was chairman of surgery and helped pave the way for my entry into this specialty. I was also co-president of the Surgical Society during my fourth year which also helped. My USMLE scores were good so this helped too. I had some awesome interviews and I landed at a great residency program. My experiences began there and they keep on.
As I continue to write, I will be posting more of my experiences.
Part 2 Why I chose Surgery.
As I moved through medical school, I knew that any specialty that I would enter had to have the following aspects:
Ability to have long-term relationships with patients
Ability to see every type of patient under a variety of circumstances
Practice in office, clinic, hospital, intensive care, operating room and emergency department.
Ability to handle a wide variety of clinical conditions
Ability to deal with both acute and chronic conditions
Ability to perform many procedures
The only specialty that met all of those requirements for me was Surgery. I also loved the aspect that I had to utilize my knowledge of both medicine and physiology to the surgical patient both preoperative and postoperatively. This was very appealing for me. I also utilize pathology and biochemistry to a great degree especially in my teaching of surgery and surgery practice. Again, this made surgery a very attractive specialty.
I definitely started out in residency with a strong interest in vascular surgery. Not only were the vascular surgical patients among the sickest in the hospital on any given day, I also loved seeing the immediate aspects of my work. Once you increase blood flow to an extremity that had previously been lacking blood flow, you see the immediate effects both good and bad. I also liked becoming very familiar with wound care and the healing of chronic wounds.
I had heard about the "surgical personality" and that some surgeons were very difficult to deal with but that never became a factor in my choice of specialty. I don't care if the devil himself is teaching me if the teaching is good. Fortunately for me, that was rarely the case and my knowledge base expanded exponentially with every year of training. Good teaching is good teaching and good faculty allow you to grow and learn from both them and your mistakes in a constructive manner. I also found that I could profit from the mistakes of others at time too.
The other factor that did not deter me from surgery was the horror stories that I had heard about the residency experience. Yes, sometimes I had to work long hours but those long hours yielded some of the best teaching of my life. Yes, I did miss parties and social events but that happens with any aspect of medicine and comes with the territory. Physicians often work long hours taking care of patients who are sick. If you don't like to take care of sick patients, medicine/surgery is not the career for you.
Finally, I have a very good life. I do something that is very interesting and I give my patients 100% at all times. I have encountered some physicians who were psychotic, neurotic, dishonest, unprofessional, racist, sexist, anti-Semitic and just down right stupid. The interesting thing is that I am none of those things and my life is good. Good will goes out from me to my patients and it come back to me in droves. Yes, I work very hard and under extreme conditions at times but I have been blessed with an even temper and a love of my fellow humans.
If you choose a specialty, choose for what you know that you will enjoy doing in most aspects for the rest of your life. If not, you have many years of misery ahead of you. Conditions of practice will change and your income is largely based, not in how hard you work, but on what third-party payers are willing to pay for your services. If you can't deal with this aspect of your chosen profession, get out as soon as you can.
If you choose a specialty because the rest of your classmates were in awe of you, you are likely going to be very unhappy in that specialty. Specialty choice is personal and your classmates will not be entering residency or practice with you. You, and not your classmates, will be the person at 0400h who is admitting that patient with the chronic condition, thousands of medications and multiple needs. You have to love that aspect of medicine/surgery as much as you love the other aspects of medicine/surgery.
Finally, you have to be a ethical and honest person. Showing up at the church door every Sunday does not make you a moral person if you know that deep inside yourself, you couldn't be honest with yourself, your patients or your colleagues. You may not "like" everyone that you work with or work on but you have to have respect for them and give them your best. In short, you can't be having a "bad day" unless you are on vacation. If you are prone to allowing external influences to influence you internally, you are going to have a difficult time medicine/surgery.
Especially with surgery, you will find yourself multi-tasking, juggling six or seven balls at once, shifting up and shifting back on a daily basis. That's the nature of the work and the challenge of the work. If you can't do this, surgery is going to be tough for you on a regular basis. In short, I have never had a day that was strictly "routine" unless I was just teaching for the entire day.
Finally, take some time and get to know yourself and your career needs because after all, this is YOUR career. Your parents, your significant other, your classmates or anyone outside of yourself, can't make this decision for you. You have to know your competitiveness for certain specialties (forget derm if you struggled with every aspect of medical school including boards) and you have to have a good idea of how competitive you are for programs within that specialty.
Also, remember that while residency is when you will hone your skills, it is a short period out of the length of time that you will actually practice those skills. Again, I heard that surgical internship was the worst time on earth but I actually enjoyed my experiences during internship. I heard that surgical residency was the worse time on earth but it wasn't. No residency program is going to be perfect but unless you encounter dishonest or illegal activity, you can live with residency. The clock is always ticking and time passes (quickly in most cases).
Residency requires hard work and hard study. In my case, during my first two years of residency, I studied far more than at any point in medical school in addition to getting my work done. At times, I was "bone tired" but I made myself read and study (minimally for 30 minutes daily). No, I didn't get to the gym as often as I would have liked and I didn't hang out late at night (outside the hospital) but I did live pretty well and my significant other saw as much of me as he could stand anyway.
I can vividly remember starting my third year of medical school. My school chose our third-year schedules for us and I remember some of the angst of my fellow classmates when our schedules were posted during the summer between our second and third years. I was in the midst of a wonderful Pathology fellowship that I had received for scoring very high in my Pathology course. I was assigned to various Medical Examiners offices and to the Pathology Departments of a couple of very large teaching hospitals. I had been spending the summer doing everything from crime scene investigation to transfusion medicine to bone marrow transplant. It had been a great summer. I was very strongly considering Pathology and Transfusion Medicine as my specialty.
I stopped by my Dean of Academic Affairs office and was told to wait for my USMLE Step I scores. The school had received them before I had received them. I took a deep breath because I really hadn't prepared myself for facing the prospect that I might have failed that test. I sat in a chair outside the Dean's inner office and ran a couple of scenarios as to what I would do if I had failed. I would quickly sign up for a retest and I would only miss one rotation at the start of third year. Since I was doing Pathology, I could study in between cases and get my preceptors to help me with covering the material.
The Dean came out and handed me a sheet of paper. I had to just sit there in disbelief. Not only had I passed, I had done extremely well. I was on my way. It was hard to hold back the tears of joy because I had studied about two and a half weeks for Step I. My fellowship had the requirement that I take Step I by the second week in May and my last exam from second year was on April 28th. I would be starting third year and I would be starting third year on Pediatrics with one of my best friends as my rotation partner. Life was good... I found out later that two people from my class did not pass USMLE Step I. It was very sad because one girl ran down the hall screaming and sobbing when she received her score. That put loads of people on edge.
I started third year on Pediatrics. It was a good rotation and I received Honors. I really enjoyed taking care of patients and I was very popular with the residents because I could place IVs and draw blood. I had also spent loads of time with an excellent pediatric pathologist so I knew my congenital defects inside and out. I could interpret cath reports and I was quite comfortable in the Pediatric Intensive Care Unit. I had been a Pediatric-Perinatal Respiratory Therapist before starting medical school so the interns found me quite useful.
My second rotation was Psychiatry. This was one of my best required clerkships. I knew that I wasn't going into Psychiatry (you know these things early) so I was free to enjoy the rotation and pick up anything that I could. My preceptor was an excellent Consultation-Liaison Psychiatrist who exposed us to everything from the wards for the criminally insane to hard-core substance abusers to schizophrenics and other stuff. I earned another Honors grade and got some excellent experience. I learned above all that I was not crazy, my friends are not crazy because I spent loads of "quality time" around people who were genuine crazy.
My third rotation was Family Medicine. I had a great preceptor who even delivered babies. This rotatations was entirely office based but I learned to do prenatal exams and care for entire families. I also learned how and when to refer which is great stuff to know. My preceptor was extremely brainy and "pimped" me on just about everything. Turns out this was a good test for USMLE Step II because we either discussed or I had to report on most everything in Family Medicine that was on the shelf exam or on USMLE Step II. I received Honors for this rotation but decided that I really did not enjoy being out of the hospital too often. I also did not enjoy the slow pace of the office.
Holiday break came and I was happy to be done with shelf exams and rotations for five weeks. I knew that Surgery was coming up and my friends had warned me to be ready for two months of pure hell. The rotation is designed so that you spend your first month on General Surgery on one of two services: Trauma or General Surgery. I drew Trauma out of the hat and I received the condolences of my classmates. I figured, "you can do anything that you want with me but you can't stop that clock." No matter how bad, in four weeks, it would be over.
I was hooked on Surgery from my first case. It was a total colectomy with four females operating. My chief resident was female, the junior resident was female, the attending was female and I was female. We talked about shoes and Chanel suits during the case. I tied tons of knots and helped the junior resident close the incision. It was heaven. I found out that I loved Trauma and I couldn't wait to be on call every third day. I had the time of my life and I loved everything about surgery.
My next month was spent on ENT and then on Cardio-thoracic and Vascular Surgery. I scrubbed every case that was assigned to me and many cases that were assigned to some of my colleagues. I became hooked on Vascular Surgery during that rotation. I loved the detective atmosphere on Vascular and loved taking care of the patients. My chief resident on Vascular taught me some great pearls about making sure that even with an amputation, fashioning a well-constructed stump can make the difference between ambulating and not ambulating for the patient. It was great stuff.
After Surgery, I rotated through OB-Gyn. I hated everything about this specialty. This rotation became my only High Pass during third year. I just couldn't get into delivering babies and I wasn't thrilled with tubal ligations. I wasn't thrilled with spending too much time in the clinics and offices. The one bright spot was the Gyn surgeries which I excelled at. I learned the surgical anatomy like a sponge but I knew that this was not going to be the specialty for me.
I finished up on Medicine and Neurology. This would be my final sixteen weeks of third year. I was fortunate to have medicine last because this made study for USMLE Step II a snap. I totally enjoyed Medicine and Neurology but my heart was back in surgery. All of my Pathology experience really paid off because I aced these rotations and moved onto fourth year.
My faculty adviser was chairman of surgery and helped pave the way for my entry into this specialty. I was also co-president of the Surgical Society during my fourth year which also helped. My USMLE scores were good so this helped too. I had some awesome interviews and I landed at a great residency program. My experiences began there and they keep on.
As I continue to write, I will be posting more of my experiences.
Part 2 Why I chose Surgery.
As I moved through medical school, I knew that any specialty that I would enter had to have the following aspects:
Ability to have long-term relationships with patients
Ability to see every type of patient under a variety of circumstances
Practice in office, clinic, hospital, intensive care, operating room and emergency department.
Ability to handle a wide variety of clinical conditions
Ability to deal with both acute and chronic conditions
Ability to perform many procedures
The only specialty that met all of those requirements for me was Surgery. I also loved the aspect that I had to utilize my knowledge of both medicine and physiology to the surgical patient both preoperative and postoperatively. This was very appealing for me. I also utilize pathology and biochemistry to a great degree especially in my teaching of surgery and surgery practice. Again, this made surgery a very attractive specialty.
I definitely started out in residency with a strong interest in vascular surgery. Not only were the vascular surgical patients among the sickest in the hospital on any given day, I also loved seeing the immediate aspects of my work. Once you increase blood flow to an extremity that had previously been lacking blood flow, you see the immediate effects both good and bad. I also liked becoming very familiar with wound care and the healing of chronic wounds.
I had heard about the "surgical personality" and that some surgeons were very difficult to deal with but that never became a factor in my choice of specialty. I don't care if the devil himself is teaching me if the teaching is good. Fortunately for me, that was rarely the case and my knowledge base expanded exponentially with every year of training. Good teaching is good teaching and good faculty allow you to grow and learn from both them and your mistakes in a constructive manner. I also found that I could profit from the mistakes of others at time too.
The other factor that did not deter me from surgery was the horror stories that I had heard about the residency experience. Yes, sometimes I had to work long hours but those long hours yielded some of the best teaching of my life. Yes, I did miss parties and social events but that happens with any aspect of medicine and comes with the territory. Physicians often work long hours taking care of patients who are sick. If you don't like to take care of sick patients, medicine/surgery is not the career for you.
Finally, I have a very good life. I do something that is very interesting and I give my patients 100% at all times. I have encountered some physicians who were psychotic, neurotic, dishonest, unprofessional, racist, sexist, anti-Semitic and just down right stupid. The interesting thing is that I am none of those things and my life is good. Good will goes out from me to my patients and it come back to me in droves. Yes, I work very hard and under extreme conditions at times but I have been blessed with an even temper and a love of my fellow humans.
If you choose a specialty, choose for what you know that you will enjoy doing in most aspects for the rest of your life. If not, you have many years of misery ahead of you. Conditions of practice will change and your income is largely based, not in how hard you work, but on what third-party payers are willing to pay for your services. If you can't deal with this aspect of your chosen profession, get out as soon as you can.
If you choose a specialty because the rest of your classmates were in awe of you, you are likely going to be very unhappy in that specialty. Specialty choice is personal and your classmates will not be entering residency or practice with you. You, and not your classmates, will be the person at 0400h who is admitting that patient with the chronic condition, thousands of medications and multiple needs. You have to love that aspect of medicine/surgery as much as you love the other aspects of medicine/surgery.
Finally, you have to be a ethical and honest person. Showing up at the church door every Sunday does not make you a moral person if you know that deep inside yourself, you couldn't be honest with yourself, your patients or your colleagues. You may not "like" everyone that you work with or work on but you have to have respect for them and give them your best. In short, you can't be having a "bad day" unless you are on vacation. If you are prone to allowing external influences to influence you internally, you are going to have a difficult time medicine/surgery.
Especially with surgery, you will find yourself multi-tasking, juggling six or seven balls at once, shifting up and shifting back on a daily basis. That's the nature of the work and the challenge of the work. If you can't do this, surgery is going to be tough for you on a regular basis. In short, I have never had a day that was strictly "routine" unless I was just teaching for the entire day.
Finally, take some time and get to know yourself and your career needs because after all, this is YOUR career. Your parents, your significant other, your classmates or anyone outside of yourself, can't make this decision for you. You have to know your competitiveness for certain specialties (forget derm if you struggled with every aspect of medical school including boards) and you have to have a good idea of how competitive you are for programs within that specialty.
Also, remember that while residency is when you will hone your skills, it is a short period out of the length of time that you will actually practice those skills. Again, I heard that surgical internship was the worst time on earth but I actually enjoyed my experiences during internship. I heard that surgical residency was the worse time on earth but it wasn't. No residency program is going to be perfect but unless you encounter dishonest or illegal activity, you can live with residency. The clock is always ticking and time passes (quickly in most cases).
Residency requires hard work and hard study. In my case, during my first two years of residency, I studied far more than at any point in medical school in addition to getting my work done. At times, I was "bone tired" but I made myself read and study (minimally for 30 minutes daily). No, I didn't get to the gym as often as I would have liked and I didn't hang out late at night (outside the hospital) but I did live pretty well and my significant other saw as much of me as he could stand anyway.
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.
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.
03 February 2008
What do you want from a career in medicine?
I am often asked why I decided to pursue a career in medicine; starting at a later age and with many demands both mentally and physically. Quite simply, I knew that I would enjoy those mental and physical demands because I love working with my patients to identify and help solve their health problems. When a patient walks into your clinic, office or you encounter them in the hospital, the most amazing relationship develops that you will ever experience. A person walks into your life and puts their health and trust into your hands. This trust means that you give your best knowledge in terms of figuring out their needs and meeting them.
Too many people will confuse what they see on the telly (House, Dr. Kildare, Gray’s Anatomy,Ben Casey, Scrubs, ER) with what is the actual reality of being a physician. There is little “glamor” in this job but there is loads of personal satisfaction in winning those hundreds of little “victories” that you will win over the course of a day. There is also the knowledge that if the health care system continues along the road that it has taken, you are going to make less money for every day that you work in the practice of medicine. The question that you need to ask is “am I willing to work this hard for this career?” If you can answer this in the affirmative no matter what the future holds, then likely you will have a satisfying career in medicine.
In no other career are you asked to be out of the work force for essentially 8 years just to be able to enter a job where you will be making less than minimum wage with an average educational debt of more than $150K. In no other career is your income totally dependent on the policies and regulations of private industry, government regulatory agencies, Congress and state governments. You have no control over what reimbursement will be for your services (those reimbursements have been cut every year in the name of holding down costs) while your costs of maintaining your practice have continued to increase dramatically.
Primary care (Internal Medicine, Family Medicine, Pediatrics and OB-GYN) have seen their ranks shrink in popularity among graduates of American medical schools for a number of reasons not the least of which is the extremely high costs of medical education, rising interest rates on loans and decreased pay. Those people who are yet to enter medical school and those who are yet to graduate face even more challenges in terms of just being able to make a living (purchase a house, pay off educational loans, open a practice). If you are not yet in medicine/medical school, you are likely (unless you enter the armed forces) not going to be able to afford to enter primary care because of past educational expenses. Along with that, add the fact that if you are not a very strong performer in medical school, you won’t be eligible for residency in one of the “money” specialties and thus, you will be scrambling to make a living even if you are able to get into medical school.
The American Medical Association has been extremely slow to organize and speak for the needs of the young physician. Most of the people (and I am thankful for their efforts) that are able to lobby, have been established physicians in specialties such as opthalmology who can afford to take a day away from practice because their loans are paid off and their homes are purchased and their children have their college education paid for. They have little in common with the newly minted physician who has a young family, a 10-year-old car from residency and a $2,000 a month loan payment in addition to rent (mortgage if they are lucky)and office overhead expenses. I remember my cousin, who is a neurosurgeon state back in the early 1990s that she had to make a minimum of $10,000 per week in order to keep her office door open. I am sure that number has increased (increased malpractice costs and office costs) while her payments have been decreasing. In the face of this, why would anyone want to enter this career? How would anyone afford to enter this career?
The answer to these questions are not easy but they are expensive both in time and energy. The truth of the matter is that you had better know as much about the day-to-day practice of medicine before you enter your pre-med curriculum because by the time you have finished your first two years of medical school, you have racked up too much debt to be able to do anything else. Little is taught about practice management/investment/finance either in medical school or residency. Medical school prepares you for residency and residency prepares you for practice.
Some people want residency programs to include more about practice management, marketing and finance but along came the 80-hour work week restrictions and thus, most residency programs are still scrambling to make sure that they can include all of the experiences that residents need to learn just to practice let alone add to what they need. The business of medicine is very complicated and growing more complicated daily with policy changes at both the federal and state level. It takes many hours to keep up and keep yourself informed.
This gets back to what do you want from a career in medicine? Financial/job security isn’t out there anymore. Definitely respect and admiration are not out there anymore. Hard work, long hours of study and personal and financial sacrifice are definitely out there and ahead. i caution anyone to look long and hard at this career because it’s not easy and there is no relief on the horizon. Be very, very sure that you have a realistic idea of what day-to-day life is like for physicians who are coming out today and not what you see on the telly. None of those shows are remotely close.
Too many people will confuse what they see on the telly (House, Dr. Kildare, Gray’s Anatomy,Ben Casey, Scrubs, ER) with what is the actual reality of being a physician. There is little “glamor” in this job but there is loads of personal satisfaction in winning those hundreds of little “victories” that you will win over the course of a day. There is also the knowledge that if the health care system continues along the road that it has taken, you are going to make less money for every day that you work in the practice of medicine. The question that you need to ask is “am I willing to work this hard for this career?” If you can answer this in the affirmative no matter what the future holds, then likely you will have a satisfying career in medicine.
In no other career are you asked to be out of the work force for essentially 8 years just to be able to enter a job where you will be making less than minimum wage with an average educational debt of more than $150K. In no other career is your income totally dependent on the policies and regulations of private industry, government regulatory agencies, Congress and state governments. You have no control over what reimbursement will be for your services (those reimbursements have been cut every year in the name of holding down costs) while your costs of maintaining your practice have continued to increase dramatically.
Primary care (Internal Medicine, Family Medicine, Pediatrics and OB-GYN) have seen their ranks shrink in popularity among graduates of American medical schools for a number of reasons not the least of which is the extremely high costs of medical education, rising interest rates on loans and decreased pay. Those people who are yet to enter medical school and those who are yet to graduate face even more challenges in terms of just being able to make a living (purchase a house, pay off educational loans, open a practice). If you are not yet in medicine/medical school, you are likely (unless you enter the armed forces) not going to be able to afford to enter primary care because of past educational expenses. Along with that, add the fact that if you are not a very strong performer in medical school, you won’t be eligible for residency in one of the “money” specialties and thus, you will be scrambling to make a living even if you are able to get into medical school.
The American Medical Association has been extremely slow to organize and speak for the needs of the young physician. Most of the people (and I am thankful for their efforts) that are able to lobby, have been established physicians in specialties such as opthalmology who can afford to take a day away from practice because their loans are paid off and their homes are purchased and their children have their college education paid for. They have little in common with the newly minted physician who has a young family, a 10-year-old car from residency and a $2,000 a month loan payment in addition to rent (mortgage if they are lucky)and office overhead expenses. I remember my cousin, who is a neurosurgeon state back in the early 1990s that she had to make a minimum of $10,000 per week in order to keep her office door open. I am sure that number has increased (increased malpractice costs and office costs) while her payments have been decreasing. In the face of this, why would anyone want to enter this career? How would anyone afford to enter this career?
The answer to these questions are not easy but they are expensive both in time and energy. The truth of the matter is that you had better know as much about the day-to-day practice of medicine before you enter your pre-med curriculum because by the time you have finished your first two years of medical school, you have racked up too much debt to be able to do anything else. Little is taught about practice management/investment/finance either in medical school or residency. Medical school prepares you for residency and residency prepares you for practice.
Some people want residency programs to include more about practice management, marketing and finance but along came the 80-hour work week restrictions and thus, most residency programs are still scrambling to make sure that they can include all of the experiences that residents need to learn just to practice let alone add to what they need. The business of medicine is very complicated and growing more complicated daily with policy changes at both the federal and state level. It takes many hours to keep up and keep yourself informed.
This gets back to what do you want from a career in medicine? Financial/job security isn’t out there anymore. Definitely respect and admiration are not out there anymore. Hard work, long hours of study and personal and financial sacrifice are definitely out there and ahead. i caution anyone to look long and hard at this career because it’s not easy and there is no relief on the horizon. Be very, very sure that you have a realistic idea of what day-to-day life is like for physicians who are coming out today and not what you see on the telly. None of those shows are remotely close.
Subscribe to:
Posts (Atom)
