Monday, February 23, 2009

One Pathologist's View

I have been really busy this past week and sick on top of it. Thankfully, I am on a pretty light rotation where I was able to take a sick day and let my work pile up to deal with on my return. Anyway, I hope to get back in a better blogging groove soon. In the meantime I was interested to find this blog, Patience Lost - Lines from a Hospital Trench, which is one academic pathologist's thoughts on the state of pathology in the current day healthcare system. I must admit I have not had time to read the entire thing, but the bits I have read have been interesting. I hope to read through it all soon. It is always great to find other pathologist bloggers and writers out there.

Monday, February 16, 2009

The Physical Exam

Pauline Chen has an interesting piece in last week's New York Times about the role of the physical exam in modern medicine. I must admit that as a medical student I was often frustrated by the physical exam. Likely, some of the frustration was due to a lack of confidence in my ability to perform some of the maneuvers. With practice this got better. After a month with an FP physician with a passion for sports medicine, for example, I was not afraid of patients with lower back pain anymore. He taught me a nice formula with a few simple tests to do each time that covered the range of motion of the entire back and pinpointed the location of the injury. Repetition does work.

A great deal of my frustration, however, I now realize was brought on by certain aspects of my training itself. During our first year we were taught physical exam skills in our Doctoring course. The course was taught by an NP who was very skilled at the physical exam and emphasized its importance. Smaller, more specialized parts of the exam were reinforced in our 2nd years coursework relating to organ system. By the time we hit the wards, I was pretty comfortable going leisurely through the motions on my classmates and the mostly healthy patients I saw at the student-run free clinics.

On the wards things were different. Everything moved much faster and the patients were often very sick. Residents were overworked and focused on collecting the volumes of data necessary for following the patients imaging, labs, and vitals. It was what Dr. Chen describes--spending a lot time touching the patient became low on the priority list. In rounds the physical exam was not usually emphasized. It was often brushed over to focus on imaging results. If a medical student brought up some exam maneuver to attempt it might be viewed with amusement as a relic of the past or as a teaching point. "Oh, that, well we rarely use that anymore since it is unreliable and we can just look at the CT, but why don't you try it when we go in to see the patient."

There were some exceptions to this seeming cultural norm, of course. On Trauma Surgery the physical exam carried a lot of weight, especially since initial treatment decisions often had to be made immediately and could not wait for imaging. On the wards I had one Internal Medicine attending who is very much like Dr. Abraham Verghese, the physician whose work that inspired Dr. Chen's article. With this attending all of the medical students went weekly on physical exam rounds and listened to the patient's stories in great detail. It was interesting and usually a more rewarding way of seeing patients than the usual rush-in, rush-out. Unfortunately, it was only once a week for a small part of my 3rd year.

So as I look back on my training it does not surprise me that as a medical student I tended to use the extra time I had with patients talking to them and not on performing detailed physical exams. I felt I could contribute more to their care by listening to them, being supportive, answering questions they felt had not been addressed, building rapport, and maybe even by finding some detail in their history that might have been missed. Perhaps the physical exam, as Dr. Verghese suggests, is another avenue for building trust with patients and finding the missing puzzle pieces to make the diagnosis. And with more emphasis on its importance in medical education and more physical exam teaching at the bedside, maybe the medical students who come after me will not find it to be the sometimes puzzling and frustrating experience that I did.

Thursday, February 12, 2009

T-2 Weeks and Counting

It's almost time for all of the folks planning to match in this year's Match to submit their final rank lists. I can hardly believe that just one year ago I was in the same boat. Trying to figure out which residency program will be the best fit for you can, if you are lucky, be quite simple. Or, for many people, making the final decision can be rather difficult.

We had someone come back for a second look at my program today and I was one of the lucky few who got a free lunch at a posh restaurant to answer the applicant's questions. Being on this side of the matching process I can honestly say that I have no investment in what people decide to do. Of course, I would like to have friendly, hard-working people come to our program. But I also know that decisions are highly personal and take into account many factors, which often are about more than just the program itself. For example, last year I visited a program that I knew throughout the interview day would be perfect for me and my career goals. I clicked with the faculty and the residents, loved the hospital and the patient population, and thought the program structure and schedule were among the best I saw. But it was in a city that I knew we would be miserable living in, so it went lower on the rank list than it would have gone bases solely on the program.

Making my final rank list was difficult and caused a lot of stress, especially in the last couple of weeks. Based on my experiences last year interviewing/matching, my residency so far, and the experiences of some who have come before me, here are a few thoughts on trying to figure out how to make the rank list.

1. Relationships. Yes, this is about your career and getting good training so that you can become the best doctor possible. But it is very important to be happy and supported outside of work too. And maintaining relationships, of any type, in residency definitely takes work given the constraints on your time. If you have a spouse/ significant other, take his/her feelings into account about where he/she would like to end up. If you are single and hoping to meet someone in the next several years, you may want to consider how hard/easy it will be in the location of your program. Having friends/family to hang out with, especially, those who are not in medicine, can also provide a nice escape from work.

2. Location matters. You do not want to be in a place that you think you will be miserable living in. Yes, you will not have a lot of free time in residency, but you want to be able to enjoy the time you do have outside of work. Also, think about quality of life issues. How long will your commute be? How pricey is housing? If you have kids or are planning to do so, how is daycare availability?

3. Be realistic. Every program puts their best foot forward on interview days and at second looks. Even rotating at a program may not give you the whole picture. Realize that every programs has its high points and its flaws. If you talk to enough people you will likely find someone who will complain about something. Try to feel out obvious red flags, ie programs on probation, multiple residents who openly express unhappiness about teaching/mistreatment, programs that do not let you talk to residents at all. Often you don't see any obvious things and this can be good--it can mean that you are considering programs that will all train you well.

4. Match your career goals. This may seem obvious and is more applicable in some fields than others. But I think this discussion sometimes gets lost. Many of us are influenced by our advisers, who are academic physicians, to pursue academic medicine or have only been exposed to academic practices. Also, I've seen that programs often sell themselves by touting fellowship placements since fellowship is the next step in many fields. If you want an academic career, are set on doing a fellowship, or want to do research you should consider these things. However, if you honestly see yourself in private practice as a generalist, this might not matter as much. It is okay to match at a "less prestigious" program if it is the best fit for your goals. When evaluating a program think about where you really see yourself in 5 years, 10 years, 20 years down the road. Then see if the program's placement of graduates will help you get there.

5. Think ahead. It's easy to focus on intern year since it looms ahead, just as it is easy to focus on things like the basic science curriculum when trying to pick a medical school. If you can get some input from upper level residents it can be helpful when evaluating programs. See if they feel supported throughout the program, if they get good career advising, and what they feel their strengths and weaknesses are at the end of the program.

The bottom line is that you will probably have several programs at which you feel you will be reasonably happy at and get good training. In the end, it works out for most people, even if it does not feel that way right now. So take a deep breath and make that final list.

Tuesday, February 10, 2009

The Lone Coyote Returns

It has been almost seven months to the day since I wrapped up my blog, Medical Student Musings, which explored my experience in medical school. When we last left our heroine, The Lone Coyote, she was adapting to her first rotation in a busy lab and wondering when the heck she was going to have time to study for boards. Since then a lot has changed for the better:

1. I know my way around the hospital and can log into the computer regularly
2. I passed Step 3, so can become an officially licensed physician someday
3. I am more than halfway through this year and eventually will not be the lowest person on the totem pole anymore
4. I am pretty used to getting called and paged and don't feel that sinking feeling in my stomach that plagued me on my earliest call nights
5. Most importantly, I don't look over my shoulder or freeze up on the phone when someone calls me "doctor"

Clearly, I needed some time to adjust to my new life as a resident. But in the interim I really missed writing. Of course, I wrote on a daily basis at work, but it is usually in the form of little bullet points--names, lab values, tests, things to do. I even tried writing about things outside of medicine. Then I realized that I am a resident, so there really is not that much to talk about other than medicine. Even in a "lifestyle-friendly" field, the reality is that work makes up the biggest portion of your day.

So it is time for The Lone Coyote to return to blogging about medicine. If you enjoyed the old blog, I will warn you that this one is going to be a bit different. It is not going to chronicle my day-to-day life in residency. Instead, it is going to be more general in its exploration of issues relating to medical education and health care. We'll see how it evolves, but I can only hope that it will be as fun to write as the last blog was.