The Mystery of Otolaryngology

The unbelievable has happened this week. I have been home before about 9 or 10 pm in the evening! With all of this free time I hardly know what to do with myself. Perhaps that is why I began to ponder otolaryngology.

Ah, ENT, a specialty that medical students strive to match in. But after being exposed time and again to the specialty in the OR and the gross room, I really have to wonder why is this field so popular? The high income aside, of course. Maybe someone out there in the blogosphere can enlighten me on this?

Here is the way I see it. The surgeries that we get specimens on are long, brutally long, lasting the whole day or even into the night. They seem to involve digging around in very small spaces in the face with random names that I tried to block out of my brain soon after that unit in first-year anatomy. Even worse, these spaces are often filled with puss, fungus, tumor, necrotic debris, or other goodies.

They dig and dig to pull out a tiny little piece of tissue and then call us for a frozen section. Um, okay, we'll see what we can do with this limited sample. Granted it is being pulled out of someone's maxillary sinus so it's not like any more tissue can be obtained. Sigh... but it can make things difficult.

Then the next day the specimen arrive on my bench in 19 tiny parts which all have to be measured, inked, and dictated. If they need decalcification it slows everything down for another day.

Wait, this was supposed to be about ENT, not my work, so I digress. But let's talk about enucleation for a minute. I hate these specimens. Not a lot grosses me out at this point, but seeing an eye staring up at me out of a container really freaks me out. The eye had a long suture attached to one end. When I called the ENT surgeon (very nice guy) to ask about orientation, he told me, "oh that was just for us to pull on."

Whoa... pulling eyes out of the socket. Another reason, or not, to do ENT.

Garbage In, Garbage Out

Sometimes when I go down to get specimens from the ORs for frozen sections, I feel like there is a huge disconnect between us and the surgeons regarding how we do our job. I guess it must seem that we appear, pick up the piece of tissue, disappear for awhile, and come back later with the results. It's magic: tissue in, diagnosis out.

Let me tell you, it is not quite that easy. And to make the magic work there are a few things that can help the spell along. Unfortunately, we sometimes do not have much help in this regard. Here are just a few examples.

1. Adequate specimens. Okay, you gave me a huge container with a piece of Telfa in it that I race back up to the gross toom. Is there anything here? Maybe if I hold the Telfa up to the light... oh, wait, there is a tiny fragment of soft tissue that is maybe 0.2 cm? On a good day? Hmmm... now you are angry because because we need to "defer to permanent" to really call what it is? Let's think about this for a minute...

2. Bovie-licious. In the same vein... I return to the gross room with another container and open it. What is that smell? Is that a new BBQ dish in the cafeteria? Or the smell of the fast food from across the street? Wait... that is wafting off of the specimen. Singed flesh smell. The specimen is charred, black ball. Guess what we see under the scope? Bovie artifact! And maybe not much else.

3. Clinical history. Believe it or not, we do play a role in the patient's care. Yes, the patient's care. We're not just looking at tissue in a vacuum. It helps to have some clue of why we are even looking. That box on the specimen requisition sheet about clinical history? Just one legible sentence with the patient's presumed diagnosis or presentation and the surgery they are undergoing can be a big help. Oh, and when I ask for history in the OR, speaking clearly and not being rude is really helpful too.

4. Orientation. I am not a mind reader. And, unfortunately, I was not there when you pulled that tissue margin out of Mrs. Jones' pelvis. So there is really no way for me to know which side of the specimen is anterior. Putting in a suture to orient the specimen and telling us what it is can go a long way. Oh, and about those sutures, please just keep it simple. If I see a rainbow of different lengths of various suture material sticking out of the tissue from every possible angle, it's just a hot mess.

You Know You Are A Pathology Resident...

... when you are cooking chicken stir-fry and realize that the pieces of chicken you just cut and are stirring about are all frightfully symmetrical.

The Thing?

The Thing? Exit 322.

What the hell is it? That was the question we pondered as we saw billboard after billboard along I-10 in the southern Arizona desert advertising "The Thing." In case you could not guess, this type of gimmick that promises total randomness in the middle of the desert is what The Lone Coyote lives for. There was no question about it. Once we hit Exit 322, we were stopping.

We hit Texas Canyon, home to some very wild and other worldly rock formations. The rest area was closed, unfortunately, so I did not get to take any cool pictures there. Shortly after exiting the canyon, we saw it the magical exit. The Thing?! What is it??



Uh, it looks like a gas station in the middle of the desert with a big gift shop and an attached Dairy Queen. Inside we found the typical tacky desert souvenirs--animal carvings, jewelery, "rattlesnake eggs," cheesy T-shirts, and Mexican jumping beans. At the back was a huge metal door to nowhere with a $1 admission fee. It took some convincing to get the Mrs. to agree to enter, but I prevailed.

The lady took our money and told us to follow the yellow footprints through the other buildings. Other buildings? These yellow tracks were supposed to be made by Bigfoot, I guess. There was no turning back. We went through the heavy door and entered the first of several open-doored bunkers. That was about the time we realized we had forgotten the camera. It was in the car. After some consideration we concluded there was no way to exit, get the camera, and re-enter. So, sorry, no pictures from here either.

The buildings were full of completely random, and kind of creepy, stuff. There were the "one of a kind" wooden sculptures of people being tortured, a collection of ancient guns including one from the Ottoman Empire (supposedly), and some strange creatures that appeared to be made from tree roots. Then there were the collections of "artifacts," which included old cars, including one that was supposedly Hitler's, a buggy that Abe Lincoln once rode in, and random old household items. Then there was the more "ethnic" stuff--an ancient Chinese stool, Native American baskets, and random pottery.

In the last building one can find out what The Thing? actually is. I will not spoil it, in case you are ever driving along I-10 and want to find out. You can Google it if you are really curious. Let me say you'd likely never guess what The Thing? really is. The whole experience was totally awesome in its randomness, even if it was a bit creepy. I love America.

Well Blog

There's some good discussion/cathartic rambling going on at the NYT Well Blog. If you are a frequent reader of the Well Blog, you may be familiar with the links to Dr. Pauline Chen's columns and the responses. In a nutshell, she is an academic surgeon and will often write something about a current issue in medicine, particularly regarding medical education/training. She usually starts with an anecdote from her own training/teaching experiences, then finds a recent study that addresses the main point of said anecdote, and ends by interviewing the author of the study who offers his/her ideas about how we might change the system. Often, she addresses topics that are "taboo" to discuss in the hospital, like this week's topic: when physicians, especially stressed out residents, have "distress" in their lives, it impacts the care they provide to patients.

Now my first response, as it often is to these columns, is, "did we really need to conduct a study to reach this conclusion that seems so obvious?" But since the culture of medicine is not to address issues related to stress/being overworked/ balance in life/etc, I guess unfortunately the answer is yes. What I enjoy most about the Well Blog referencing her columns are the comments that soon appear. Several players dominate the discussion:
1. MDs - usually we hear from current residents/young physicians about the hell of residency currently, older generation MDs whining about how easy our generation has it or about how much medicine now sucks, a few voices from somewhere in between acknowledging the horror of training and the need for change, but reminding the young ones to remember why we entered this profession in the first place.
2. MD Haters - a few people will then start posting that MDs need to stop whining because our salaries are too high, we all have god complexes, we knew what we were getting into, we drive up health care costs, etc.
3. MD defenders - some people, often nurses, jump the aid of MDs and talk about the high debts we have when finishing, the awful hours in residency, the declining reimbursements, and the difficulty of seeing so many patients in limited time.
4. Lawyers/PhDs - then some other professionals, usually JDs/PhDs start posting about what they go through, how they work 80+ hour weeks/slave in labs and have debts/low wages, are underappreciated professionals too.
5. Some MDs then start to post again whining how the attorneys need to get off this blog because "we save lives" and being a lawyer is never that stressful. They then say the PhDs should go because they do not have the debts we do.
6. Repeat, around and around.

Will the problems ever get solved on the Well Blog? Probably not. But I do think the discussions are good because they give the public some idea of what goes on behind the scenes in health care. And they provide MDs/other health professionals with a virtually anonymous way to voice their feelings, which they often cannot do elsewhere. It can be a lot of negativity, but there has to be a place to let that out if it is not safe to do elsewhere. I think that is one reason why sites like SDN and medical school/resident blogs get traffic. Communal sharing of the pain is one way to deal with it.

Here were a few choice comments from anonymous MDs (not me, thankfully) on the current Well Blog discussion on the residency experience:

I’m currently in my internship and I would love for the next generation to be able to survive their training more healthily than I am.

1. Doctors from before the 80 hour work-week LOVE to hassle this generation for being weak because we don’t have to work more than 80 hours a week or 24 hours in a row. BUT:

It is just not HUMAN to work 24 hours in a row.

For anybody.
I don’t care if you are scooping ice-cream or folding socks, 24 hours is not do-able, the human mind can’t stay sharp, being awake for 24 hours does bad things to your muscles, your digestive tract, your mind, your circulation. As doctors shouldn’t We know this? For gods sake people, I come off a 12 hour shift with leg edema! After 24 hours I want to scream at people even when they are just being people and I’m pretty mild-mannered!

One of the arguments against changing shifts completely every 12 hours, for example, is that there are many details lost in translation between shifts. The ability to communicate succinctly, easily, comfortably are not skills that are valued in the application process to medical school. These skills are in fact underdeveloped in most applicants because we are still pushing those who are ‘good at science’ into this role of physician and unfortunately studying science can be a solitary and unsocial effort. Medical schools and residencies market themselves as looking for well-rounded individuals but they rarely consider anyone with poor scores or grades.

2. Psychology and therapy are not bad words. Why shouldn’t it be mandatory for anyone taking on the job of caring for others to spend time examining themselves, their motives, their influences. Cognitive Behavioral Therapy for example can help with depression, anxiety, perfectionism. If there is ever a group of people I have seen who ALL suffer from these and need some therapy it is medical students.

3. Hospitals are unfortunately extremely unhealthy places. The food for both the staff and the patients is generally low-quality. There is no respect for the act of eating and taking breaks. The only breaks universally accepted are smoking breaks. Wearing scrubs while it is comfortable, I believe, contributes to the normalization of obesity among the staff.
It smells bad. The lighting is depressing. The facilities in community hospitals where much of my training has taken place are deplorable. Why not have intelligent and sensitive and HUMANE architects design the next generations hospitals? With a little aromatherapy, more break areas and areas designed for quiet reflection (who hasn’t hid in the clean utility room to cry when things get overwhelming) hospitals can be less hostile toward those working there and therefore also the patients.

4. The bullying. The elephant in the room in the hospital is the overwhelmingly negative behavior between staff members. It is considered wimpish (and maybe un-American?) to complain about bullying as an adult, but there is an attitude of pouring the negativity that is poured on you onto those below you in the hierarchy. This happens within residency programs, between nurses and doctors, toward the medical students, the aids, the social workers, it is everywhere. How can people who supposedly want to help people treat each other with so much hostility? I think this daily. The culture of negativity and complaining and talking behind people’s backs and criticism without encouragement, etc, etc, creates such a malignant environment that any doctors with a shred of sanity and humanity left opt out leaving behind those who create and harbor the caustic attitudes.

5. I could go on and on but I have another 24 hour shift tomorrow…

---------------------------

Residency turned me from an upbeat, happy, optimistic person into a crabby, ultrasensitive, irritable, depressed and angry person. There are the “80″ hour (my record was 107 hours) work weeks, the “24″ hour shifts (my record was 37 hours straight - without sleep) up to 3 days a week, the condescending and power-hungry attendings who belittle residents and tell them “how easy they have it nowadays”, the average 12-14 hour work-days full of nonstop beeping beepers/paperwork/inability to scarf down a snack or even go to the bathroom without 23 interruptions/and legitimately sick patients, the four days off a month (to pay bills, buy groceries, change the oil, call your parents, and “do all that reading” so you don’t feel like a complete idiot when you’re being pimped at 6 AM the next day in front of 10 other people), the friends who leave you because they “don’t understand why you never call them”, the sheer constant exhaustion that never goes away…

…and you do that for 3-6 years of residency! Of course you get depressed and distressed and hate yourself and the world and that damn patient who comes in in the middle of the night requiring emergency surgery. Of course you very seriously consider dropping out of residency… or life altogether, as a woman in my class attempted to do.

This is NOT a pity party. This is the reality on how doctors are trained.

Until serious and considerable changes are implemented, the smart people will be doing their homework and will take a different career path.

I wish I had.

White Sands, NM

This place is so incredible. If you have never been, definitely put it on your list of must-see in your lifetime places.