Surgery

I am starting surgery at Cook County on Tuesday. Cook County is a huge hospital that mostly serves the inner city of Chicago. The TV show ER is based (very far from reality) on the Cook County Emergency department. 

In medical school the surgery rotation is often considered to be one of the hardest if no the hardest rotation of all. The hours are long and often the people you work with are not the most pleasant. There are all kinds of horror stories going around about different experiences that students have had while on surgery. Much of these experiences are location and person specific. If you work with a surgeon who is a jerk you are going to have more horrific stories than if you work with a surgeon who is human. 

You can bet that you will be yelled at and told that you are an idiot at some point during your rotation. The hours will be long and tiring and most people either love it or hate it. I am approaching this rotation with an open mind and I am very excited to see if this is a field I could see myself doing for the rest of my life. As I entered medical school I always thought that surgery may be one of my options and I still think that it may but I have never wanted to fully commit or reject the notion of being a surgeon until I had experienced a surgical rotation. This is why I have chosen to do my surgery rotation early in the year. If I love it then I can further pursue it as a career or choice and if I hate it I can erase it from my options. 

I am excited to learn and see all the different procedures. 

Study tomorrow is the Family Medicine Shelf Exam

Ok so today is supposed to be my day to get all caught up on my studies for the shelf exam I have tomorrow. The shelf exam is a national exam given to medical students after they complete a rotation. Tomorrow I take the family medicine shelf exam which is touted as being a very difficult exam especially if you face it early in your 3rd year prior to having completed many of your rotations. Why is it so difficult? Family medicine is a very broad specialty. You see internal medicine, pediatrics, and OB/GYN etc. This means that the exam can cover any of these areas. You have to be prepared to answer a wide variety of questions. 

I have been studying everyday for the past month by reading a couple of different clinical books about family medicine. I also have been doing practice questions from a variety of sources. The main problem is that after you finish a long 11 hour day of seeing patients the last thing you want to do is study. I probably have not put in the amount of hours studying that I should have, so I am hoping that is the case for everyone and that the national curve will reflect accordingly. 

Here is an easier example question:

A 50-year-old man has had progressive weakness and shortness of breath with exertion for 3 months. He appears malnourished; conjunctivae are pale and there are scattered petechiae. Labs:

Hemoglobin 6g/dl

Mean corpuscular Volume: 114 mm3

Leukocyte count 2500/mm3 with hypersegmented neutrophils

Reticulocyte count 0.5%

Platelet count 60,000/mm3

The most likely cause of his condition is a deficiency of which of the following?

a.) Folic Acid

b.) Iron

c.) Thiamine (Vit. B1)

d.) Vitamin B6

e.) Vitamin C

f.) Calcium

g.) Potassiun

h.) Copper

i.) All of the above

j.) none of the above

There are a couple of things that they a testing here. You need to understand that this patient has anemia by understanding his lab values. Just knowing that the patient has anemia will not get you the answer though. You also need to know that the patient has megaloblastic anemia. Then you need to understand that the 2 major causes of megaloblastic anemia are folic acid deficiency and vitamin B12 deficiency. In the answer choices they do not have Vitamin B12 listed, nor do they explain any neurological symptoms that are often caused by vitamin b12 deficiencies. So this leaves you with one answer that fits the scenario and that is choice a = folic acid deficiency. The questions are usually 2 - 3 step logic and it is easy to get turned around even if you understand the tested concepts fairly well. 

Family Medicine = Done

So yesterday was my last day of family medicine. There is some excitement as well as some sadness in this statement. Going into the family medicine rotation I did not expect to like it it too much. After completing a month of it, I can say that there were many aspects of it that I enjoyed. I do not think that I would choose family medicine as a career. Last night I was speaking with a someone on the phone and they asked me; "What did you like about family medicine and what did you dislike?" Although that is a difficult question I will attempt to break it down in today's post.

Here are the things I like about family medicine:

There was a lot of variety day to day. Essentially you could see a sports physical followed by congestive heart failure followed by HIV. Hopefully you did not see all of these in the same patients. Also family doctors have a wide range of things they can do in their practice. They can do cosmetic type procedures, Gi / colonoscopy, OB / deliver babies, wound management, urgent care, etc. Basically a family doctor could choose to focus on almost any area of medicine and make a practice around that area. Another thing I noticed about general family medicine is that it was fairly simple and not very stressful from a medical management aspect. There is a running joke with some doctors that says, family medicine doctors so not see sick patients. There is some truth to this which makes their day to day medical management stress not as intense as some other specialties. These are a few of the things I enjoyed about family medicine.

Now for the things I did not like. It seems that reimbursement has been lowered so much that it is difficult for family medicine doctors to make decent money. Especially in their own private practice. This financial stress, takes the joy out of the work. The average family physician needs to see between 30 - 40 patients / day to make a decent living. With this volume it is hard to practice quality medicine and everyone suffers. Then at the end of the day the doctor spends most of the evening charting and returning calls. This makes for long hours and a stressful life. Although family docs can pursue a wide variety of different practices within medicine they are often politically blocked from doing such things. For example, a properly trained family medicine doctor has no problem delivering babies, however in today's world most babies are delivered at hospitals. In order to deliver a baby at a hospital the doctor must have delivery privileges at the hospital. Often the OB/GYN doctors at the hospital will block family medicine doctors from getting privileges to deliver babies and without the privileges they obviously can't deliver any babies. 

These turf wars are common and the family practice doctor always loses as they are not considered the foremost specialty in OB, GI or other areas that they may want to focus on. Even if a hospital does give the family doctor privileges to do the different procedures they will always require that they have a back up doctor in the given specialty on staff at the hospital. It is difficult to find a doctor that you are competing with to want to take back up and liability for you as a family practice doctor. This prevents many family doctors from being able to practice in the many diverse areas of their training. 

In the increasing world of specialization the family doctors seem to be stuck in an overworked, underpaid and under appreciated capacity in our complicated medical world. I think the only way I would consider going into family medicine would be to work in a rural area or as a 2nd / combined specialty. There are some combined residencies that someone can pursue like emergency medicine / family practice or psychiatry / family medicine. The advantage of a combine residency is that you get trained in both specialties and end up being board certified in both specialties and overall you cut down on the training by 1 year. A psychiatry residency is 3 years and a family medicine residency is 3 years but if you do a combined psychiatry / family medicine it is only 5 years so you save a year.

Career in medicine = a privilege

Saturday we had a fairly busy day. Each morning as I drive into the office to see patients I have a great feeling of satisfaction. I have never had a job in my life before where I actual was excited to go in. This feeling of excitement was always experienced as I finished the day and was driving home. Even though family medicine is not my favorite kind of medicine I still get excited to go in and see patients. Each day there are a handful of difficult and frustrating situations the interaction with the patients makes it worth it. I am not naive enough to think that it will always be this way. I am sure as I move along in my career in medicine the newness and excitement may fade and the frustrations may become more common. Hopefully the satisfaction also continues. I just feel very lucky to be able practice medicine. It is a privilege.

During my previous careers my main goal was trying to figure out how to get out of work, trying to get more time off, waiting for the day to end. I longed for the weekend and could not wait to be away from work. It was more like work was a necessary evil to afford the things for my free / family time. My feelings for my free time have also changed. For example, in the past with previous jobs when things became busy it was often necessary to work nights or come in on the weekends and this caused feelings of  extreme dissatisfaction and ultimately job resentment. However so far in medicine, when a patient exam runs late or I am scheduled for Saturday I do not have the resentment (yet). It feels natural to me that if a patient needs to be seen in the evening or on the weekend, you just do it and I actually gain satisfaction from the process and the patients gratitude. Again I realize this may be a temporary utopia that fades over time as I become more and more jaded with the system. Right now I am going to enjoy it. One of my theories is  that because my day is spent helping / worrying about others I find it difficult to focus on my problems and this prevents me from feeling sorry for myself. The reduction in self pity makes everything seem better.

I still love my free time and family time. In fact on this rotation my only day off has been Sundays and I love these days. I feel like this is my time to recharge and spend time with the kids. It is needed time but as monday approaches instead of feelings of resentment or despair of having to go back to work I feel this excitement and look forward to the upcoming adventures. Hopefully this lasts for a little while. We shall see. A lot of the doctors that are my mentors and that I look up to still have this excitement. They obviously get bogged down by the frustrations of their career and they enjoy their time off but surprisingly they lack  much of the resentment that is typically seen in "work". I asked a surgeon mentor of mine how he can work some of the 24 hour shifts he occasionally has to do and his response was, "I do not even realize its 24 hours, in the middle of surgeries I am so caught up in the patient that the time flies by and before I know it I have finished my last surgery and I leave tired and ready for bed but extremely satisfied". I have worked with this surgeon several times and he is definitely sincere in his feelings. This is why I think that the ability to have a career in medicine can be a privilege rather than a burden. 

Another way of explaining it, is to compare it to video games. As a young boy I loved to play video games and I could play for hours on end. The limiting factor was usually my mom or dad forcing us to stop playing or having to go to school, church or other activities. I could play for hours because I loved the games and my brothers and friends who played with me. If someone said; you are going to have to play video games until midnight tonight I would have been thrilled and happily accepted the assignment. To a certain degree I feel like this way about medicine. On the other hand I would say my previous jobs / careers were more comparable to weeding. As a boy if I was told that I had to weed the rock pile, resentment would undoubtedly creep in, especially if it was on my brother's birthday. 

This is why I think that the opportunity to have a career in medicine can be a privilege rather than a burden.

Doctors and Money problems

One of the things I have noticed while working in family medicine is that many patients and the public in general have this idea that all physicians are rich / wealthy. Certainly many physicians make decent money. However the days where being a physician automatically meant being wealthy are over. I think that the specialties hit the hardest with decrease in reimbursement and pay are the primary care fields, particularly family medicine and pediatrics. 

As I have gotten to know and understand the 2 doctors I am working with right now in family medicine it has become very clear that they are struggling to make ends meet with their clinic / business. It is a common story that can be seen throughout the united states. A new physician just finishing their 7 years of training (not counting college) and they have an average of $150,000 + in student loans. As they interview and look for jobs they feel that the offers are too low so they decide to open their own practice. The usually lack the business skills and abilities to run a business and they struggle to get things going. Often they are required to borrow more money to get the capital to start their practice.

It will take them 2 - 4 years to get their practice up and running if they are fortunate enough to not go out of business. Finally when they have enough patients to make a living they realize that reimbursement has continued to drop and when all is said and done they never make the kind of money they thought that they were going to make. I tell people when asked about medicine as a business to not go into medicine if they are doing it for the money, because simply put the money is not there anymore especially if you are considering primary care.

Most of the rich doctors you hear about, make their money by running a good business and not from the practice of medicine alone or they are highly trained specialists. A doctor with superb business acumen can still carve out a niche business and do well but the days of "rich" doctors from what I am seeing are but a fading memory. The reasons for this decline in reimbursement are vast and could fill up an entire book on the subject. I still think that medicine is a great career but I knew going into it that I could make a lot more money doing business than I could practicing medicine and I still decided to leave business for the time being and pursue medicine. I am sure when I am done I will reunite with business and combine medicine with it. 

Subungual Hematoma

What is a subungual hematoma? This is an injury that causes bleeding to occur under a toenail or fingernail bed. It usually occurs from blunt force trauma. The current medical standard is that if the blood takes up more that 25% of the nail bed then it should be released. In order to perform the procedure the injury should be less that 48 hours. Once the blood coagulates treatment no longer provides a beneficial outcome. Basically a hole is made in the affected toe and the blood comes flowing out relieving the pressure.

For the most part subungual hematomas are benign, however the larger they are the more likely a complication can occur. What are the complications, you ask? Well, due to the tremendous pressure as the new nail forms it will be deformed and its growth may be stunted or not occur at all. Also there is a greater chance or infection with the larger hematomas. 

I have had a few opportunities to treat patients with this type of injury. A couple of times in the ER and today in the office. an 8 y/o female, african american patient presented complaining of a subungual hematoma in her right had in the thumb. The hematoma was the result of getting her thumb shut in a car door the evening before. It was determined to involve approximately 60% of the nail bed. The pain was stated to be 8/10 and the patient had not slept at all the previous night due to the pulsatile pain. The patient failed over the counter analgesics administered by her mother. After close examination it was determined that the best course of treatment would be to make a hole in the nail bed to release the blood and relieve the pressure. I used an electric cautery device to burn a hole in the nail bed. The initial sting from this procedure is very painful but once the blood is released the patients pain from the pressure is relieved and they usually say that the pain from the procedure was well worth it as the pain relief from the release of the blood is amazing. 

1 thing that I like about this procedure is that as soon as you burn through the nail the blood bursts out like lava from a volcano. There is so much pressure that the blood explodes out. In fact blood splattered all over my white coat today as I performed the procedure. The patient was very brave but let out a horrendous cry as I made the hole in her nail. About 10 minutes post procedure all of her pain was relieved and I have a good feeling that she is going to sleep just fine tonight. Her mom was very happy especially when we told her that her daughter has a much better chance now of a normal nail re-growing. 

Lottery Results

It was great to go to the lottery last night. The entire class was there, I got to see friends that I have not seen in a while. Everyone was exchanging stories from there rotations. It sounds like everyone is happy and satisfied to finally be acting like doctors. 

At the lottery I was able to talk to a few classmates who are currently in the internal medicine and I found out that the North Chicago VA hospital is great for internal medicine. I decided to go for that rotation, but there was only 1 spot available and another student from my track really wanted it. So I went with Lutheran General as I had originally planned, but I have emailed the director asking if it is possible to add another spot at the VA. I will have to wait and see what she says. 

I did not have to use any points, which was nice. I still have all 20 of my points. I only have 1 week left of family medicine and then I start surgery at Cook County.