Winding Down

This post has been simmering for a long time, mostly because not much has been going on in the med school world. Except for today. Two code blues, at the same time. And by my count, this would be my first code - at least where I did something. I ended up at the one that was actually kinda cool (except for the patient). Postop patient refusing DVT prophylaxis is begging for a pulmonary embolism. My money is that's what threw the poor guy into vfib. As an aspiring EM doc, I actually knew a lot of what was going on and why. I got to do chest compressions, which was kinda cool since I've never done them. It's actually a decent amount of work and ended up getting reasonably sweaty and tired - 100 compresssions/minute with each one trying to slam 1.5 inches into the guy's chest adds up. Long story short, the guy's heart freaked out since it didn't get oxygen and was functionally stopped, after about 12 minutes it actually stopped. And no exaggeration, with literally the last round of pressors, antiarrhythmics, and shocks before they were gonna call it, the guy flips back into sinus rhythm. Sixty seconds later, the guys writhing around and trying to verbalize. Pretty cool.

Anyway, I'm at the halfway point of my last rotation (internal medicine) and six weeks away from the end of third year. I don't feel as if I've studied all that much. Compared to a year ago, my former self wouldn't recognize my current self. I actually know some stuff, both book-wise and clinically. I'm somewhat comfortable on the wards, and can handle a brand new patient and managing a basic workup on an uncomplicated patient. As for the details and logistics of patient care, I'm lacking for sure. Same story if the patient is remotely complicated or requires deep differential diagnostic skill. But IMHO, I've progressed nicely over the past year and for sure over the past three years. I can actually see myself as a resident and not as a bumbling, awkward med student.

All that said, it's scary how much I don't know. Knowing limits and what one doesn't know is by far the best thing to have learned over the past year. I like the idea of being able to handle anything that's thrown at me, and don't really wanna give up anything. Fields that are typically polarizing I've enjoyed, including OB/gyne and pediatrics. As someone considering EM, I should traditionally despise the slower pace and more in-depth management of patients. Shockingly, I actually enjoy both aspects.

And it's for those reasons that my ever-evolving list of specialties includes the following: EM, EM/IM, med/peds. Part of me likes the idea of being able to handle pretty much anything. For the combined residencies, part of me likes being able to put off a true specialty decision for a little bit longer.

When I Grow Up

Nine months into my M3 year, I still don't know what I wanna be when I grow up. Put into context, I'm fourteen months away from graduating and actually getting an MD. I'm twelve months away from "the match," where I find out what specialty/residency I matched into and where I'm going for the next few years.

In making my M4 schedule, I've been forced to think about what I've truly liked. This has proven to be pretty difficult, since I've liked everything. Having done seven rotations to this point, we basically decide our careers based on these experiences and impressions of ones we've yet to do. I'm not one of those who knew exactly what I wanted to do when I came to med school. I'm jealous of them at this point. I always figured it would kinda come to me along the way. Not so much.

At this point, I can safely say that I probably won't be going into OB/gyne, neurology, psychiatry, pathology, radiology, or dermatology. I'd be pretty competitive in most of those fields, but I just don't see myself doing them. Of the six, I'd be most likely to go into OB/gyne. I'm ambivalent towards neurology and psychiatry. I have zero interest in pathology, radiology, or dermatology. A word about derm. It truly appeals to some people: that'll happen and good for them. It appeals to others because its among the most competitive specialties to match into, it's a decent lifestyle, pays well, and there's an according "prestige factor." Zero appeal on those fronts for me.

Traditionally, the first decision to make is surgical vs. medical. I really liked surgery and could see myself enjoying it. As an attending. Five years of a general surgery residency are not really to my liking though. The thought of five years of 80+ hour weeks and getting zero sleep every third or fourth night isn't all that appealing. Problem is, gen surg is pretty much the gateway to most of the subspecialties: peds surg, cardiothoracic, vascular, trauma, colorectal, transplant, surgical oncology. And for these subspecialties it's another 1-3 years in fellowship. I think not.

There are more lifestyle friendly surgical specialties: otolaryngology, urology, plastics, and ophthalmology. These have a reasonable mix of surgery and medicine and are less intense than gen surg residencies. For these very reasons, they're ridiculously competitive, on the same level as derm. My refusal to be extracurricular (research, volunteering, networking in those fields, etc) is a pretty limiting factor. More importantly, my board scores are slightly to decently below average for these fields. Ortho is another pretty competitive specialty, but it doesn't really interest me all that much, and its residency can be pretty intense.

Sadly, the above thought process puts a lot of things ahead of surgery. And my body of work realistically limits me to general surgery and it's associated fellowships. It was a realization that I had been hoping to avoid.

That leaves the medical half of the equation: internal medicine, pediatrics, family medicine, and their associated subspecialties. I haven't done IM yet, but I could see myself doing any and all of the above fields. Family medicine has turned out to be surprisingly appealing, as it's generalist medicine in the truest sense. Anything can walk through the door, and you've gotta be able to at least recognize what's happening so as to either manage it or refer it out. There's a decent number of minor procedures, a chance to work in urgent care centers, and opportunities to practice obstetrics (becoming rarer with malpractice).

All that love for the medical specialties, but I'm actually in a gray zone with the surgical/medical debate. Top two specialties right now are emergency medicine and, wait for it: anesthesia.

Emergency medicine is something that's always been on my radar. A nice breadth of pathology and patients, potential for lots of procedures, shift work, and all sorts of acuity. The major downers are no continuity of care and (strangely enough) shift work. The shift work is nice as a younger attending, since it's pretty easy to work 36 hour weeks and consider that your work week. The downer is still working 7PM-7AM shifts on a regular basis as a middle aged attending. Most attendings at that age transition over to administrative work, which is something I'm not remotely interested in.

Anesthesia is probably the shocker for those who've kept tabs on me over the years. It gets me involved in the care of different types of surgical patients, it's a medical field where I getto use my brain (vs. surgery). For being in the OR and involved with surgical patients, there's a decent amount of physiology and pathophysiology that has to be applied. There's also a reasonable number of procedures and yes, it pays pretty well.

To add more confusion to the picture, I just finished my family medicine rotation. And I actually thoroughly enjoyed it. I could see myself being a family doc - good breadth of pathology, some minor procedures, continuity of care - just no acuity and the hours aren't set in stone. The other downer is that the training isn't as in-depth as I might like. Not to say that FPs aren't qualified, because they are. I just wouldn't mind having a little more in-depth training, maybe to the tune of a combined med/peds residency. I wouldn't want to lose treating kiddos by doing an internal medicine residency, so I'd be amenable to combining my training with a peds residency. The med/peds idea and whether it moves forward hinges pretty heavily on whether or not I like my internal medicine rotation - which starts tomorrow.

Basically, I there's no field that I *have* to be in. But I know what I don't want to do. And there are a few fields that have either piqued my interest or that I could see myself doing. Which brings me to the current list: emergency medicine, anesthesia, family, med/peds. And as a sign of how unsure and fluid my thoughts are, those last three fields weren't on my radar a month ago.

Tapas!

I don't actually dabble too much in Spanish cuisine. That said, my main interaction with it has been through tapas, having been a few times over the past several years. From this limited sample size, I'd have to say I had my best experience so far last weekend at a South Loop place called Tapas Valencia. I left the place stuffed, which has never happened, from either a tapas or dim sum place. And for the price of $35/head, the eight of us got stuffed with roughly twenty dishes of tapas, six plates of dessert, and two pitchers of sangria. Even the server got stuffed with a pretty reasonable tip.

The things that stuck out to me were the tuna canneloni, baked goat cheese, spanish omelette, lamb medallions, and calamari. If I had to pick one dish from each of the "entrees" and dessert, it'd have to be the bacon wrapped dates and the profiteroles.

For the price point, it was a really satisfying and delicious meal. There wasn't a dish I didn't like. The only downer is that it probably takes a bigger group to get your money's worth and while still being able to try out a lot of the different offerings.

The Beat Goes On

I closed out my peds rotation a few weeks ago and am two weeks into my family medicine rotation. Long story short, although nothing's been too mind blowing over the past four weeks, I've still enjoyed my time on the rotations.

Peds was a good rotation: good children's hospital, diverse pathology, fun med students, enthused residents, good faculty. I was/am in shock at how much I actually enjoyed everything. The best parts were well-child visits in clinic. Brief enough encounters that I don't get sick of the kid, but long enough that I get to play with them when they're healthy. Ironically enough, the worst part of the rotation was clinic. Outpatient just isn't as fun as inpatient stuff, especially when I'm seeing my fifth cold/flu/gastro of the morning. Up on the floors, my patients had things including: DiGeorge syndrome, osteosarcoma, CVID, and complex congenital heart disease.

By far the saddest patient on during my rotation was a two month old kid who came in with shaken baby syndrome. Yes, it's exactly what it sounds like. DCFS and the cops were close to making an arrest but couldn't tell us who, though we all suspected the dad. The kid had broken ribs, retinal hemorrhages, hypoxic ischemic encephalopathy, and ended up with both a tracheostomy and gastric feeding tube. At two months old. I hope the sick fucker rots in a cell.

Peds is actually a surprisingly diverse field, once you get outside of clinic and all its colds and stomach bugs. There's a pretty extensive set of pathologies that are peds specific and even common pathologies which present atypically in the peds population. Long story short: I liked the rotation and it's still on my radar.

Transitioning from one primary care field to another, I'm now two weeks into my family medicine rotation. As is becoming a common theme for my M3 year, I'm surprisngly into the rotation so far. As a student, I'm given a lot of autonomy: see the patient, workup an assessment/plan and present to the resident/attending I'm working with that day. Kinda makes me feel like a doctor :)

As a career, it's a diverse enough field for my liking, as pretty much anything of any age can walk through the door. Pathology-wise, I see whatever most people go to the doctor for, as family docs are most people's interaction with the health care system. Lots of colds, back pain, headaches, dizziness, belly pain, asthma, COPD, GERD, etc. Since a lot of this stuff is less acute and complicated, it's a lot more amenable to student level assessment and management. That right there might be why I like the rotation so much. This lower pathology complexity affords me more opportunities for patient education and counseling, which I actually enjoy. Since a lot of these conditions are also chronic, there's lots of continuity of care (which ER is lacking by nature). It's somewhat nice to see the same patients again, but also educational as a student to see how things progress, both for better and worse.

Some things I'm not a fan of are the lack of acute, diversified pathology (e.g. heart attacks, collapsed lungs, etc.), lack of inpatient experience (family med's by nature an outpatient practice), and patient noncompliance. All of the above things can be brought back to family being an outpatient specialty. If you're being seen in clinic, you aren't that terribly sick, which can secondarily lead to noncompliance. In the hospital, odds are you're reasonably sick and as such more amenable to treatment compliance. Compounding noncompliance is lying about it. I'm open to noncompliance if I'm told about it. Bonus points if it's reasonable: insurance, treatment timing, etc. But as long as I'm not lied to, then it's something we can work on.

The biggest thing I'm not a fan of is the compressed timeframe of family med visits. Sure, some things are bread and butter, like a slam dunk otitis. Grabbing the HPI (history of presenting illness), doing a quick exam, getting the azithro written, and giving followup instructions should take under ten minutes. Fifteen at a residency program where we present to attendings. But that's for a simple case of otitis.

If anyone ends up being a psychosocial visit (e.g. depression, bipolar, anxiety disorder), it's probably at least fifteen minutes just for the HPI. As a student, I haven't figured out how to diplomatically and also feel bad about cutting patients off. Especially if they're in for or bring up the aformentioned. And probably at least a third of my patients so far have had some flavor of psychosocial problem in their visit. As someone who wants to address everything that's brought up, I have a hard time condensing the visit into an appropriate timeframe. It's a bit frustrating and unfulfilling, since I don't want to diminish what's been brought up. Maybe it gets easier as I get more experience. But even as a resident, I then get slowed down by all the paperwork, presenting/discussing, and more paperwork.

Overall, family's been pretty good: great residents/attendings, decent autonomy, reasonable hours (including no call or weekends), and that "being a doctor" feeling. Downers include lack of time crunches, lack of acuity, and noncompliance. Thus far in my mind, the pros outweigh the cons though.

Pediatrics

I'm four weeks into my six week peds rotation. At my site (Hope Children's Hospital), I spend three weeks on a general floor, one week in the nursery, one week in outpatient clinic, and one week in a subspecialty (just finished up my peds GI week).

Taking a further step back, this half of my M3 year is more medically oriented (vs. surgical - e.g. ob/gyn, surgery). As such, I have had dust off my thinking cap and throw it on in the morning. And there was quite a bit of dust on my hat.

At this stage in our careers, I'm realizing it's not all about nailing the correct diagnosis. Yes, it's nice when your residents and attendings agree with your assessment But it's all about thinking about what something could be and what else it could be.

Take appendicitis for example. Classically, it will present in 10-15 year olds beginning with diffuse abdominal pain and cramping that localizes a few hours later to the right lower quadrant, 2/3 the distance from the navel to a hip landmark. Pain should precede any vomiting or anorexia (vice versa in gastroenteritis). On exam, the patient'll probably be febrile, hopefully without any peritoneal signs, and hopefully positive one of a few classic signs: psoas, obturator, Rovsing. It's said that 80%+ of diagnosis is based on history and physical and they guide appropriate workup. A story convincing for an appy will buy you a CBC to confirm infection and probably imaging to confirm that you've actually got an appy.

The story I just gave is pretty straightforward for an appendicitis. In thinking of right lower quadrant pain, one's also gotta consider adnexal cysts/torsion, ectopic pregnancy, PID, mittelschmerz, mesenteric lymphadenitis, Crohn's, volvulus, intussusception, pyelonephritis, urolithiasis, Yersinia enterocolitica. In entertaining thoughts of appendicitis-mimics, the vice versa also has to be considered - appendicitis mimicking other conditions. That is, appendicitis presenting in an atypical fashion.

Long story short, it's interesting having to actually think through a patient's story. And I'm pretty sure I like the process. Even though I'm realizing how much I don't know at this point. At the same time, I still have an itch to do procedures. Sooo, I still haven't made any progress in the surgical vs. medical debate.

That said, I'm actually enjoying my peds rotation a lot more than I thought I would. The floor patients are pretty interesting - if a kiddo's in the hospital, there's got more going on than the stereotypical sore throat or ear infection. Patients I've had include: congenital heart defects (mostly tetralogy of Fallot), foreign bodies, ovarian cysts, nephrolithiasis, pill ingestions, hydrocephalus, diabetic ketoacidosis, Crohn's, supraventricular tachycardia, common variable immunodeficiency, and seizures. More typical peds admissions include RSV bronchiolitis (shittons) and appendicitis.

On a sadder note, some kids ended up having with serious shit. I.e. hepatocellular carcinoma, leukemia (ALL), and osteosarcoma. The osteosarcoma was particularly sad - a 17 y/o girl whose presentation was a lumbar vertebral fracture leading to paraplegia. It was on her workup that a femoral osteosarcoma was found with metastases to her abdomen and spine.

Those sad stories aside, probably the only interesting case to nonmedical folk would be an incidental finding of pinworm in a girl getting scoped for Crohn's. Note: the upcoming in parentheses might be a bit disgusting.

(Classically, its presenting symptom is perianal itching. If having worms in your colon isn't offensive enough, the reason for the itching is because they come out of your GI tract at night and lay eggs perianally - it's these guys that cause the itching. The traditional diagnostic test is the scotch tape test. Double side some tape around that area before bed, let them do their thing, have a look at the tape in the morning.)

Now that I've gotten sad and disgusting stories aside, there's not much to write home about. I'm shocked at how much I'm enjoying the rotation. I can appreciate the diversity in pathology, patient age, and the fact that kids' problems aren't self induced (alcoholic cirrhosis, noncompliance, etc). In all honesty, it's playing with the little ones that's the best part of my day. Especially the 3-15 month olds in clinic - good age group and if they're in clinic they're reasonably healthy and amenable to playing. This week I'm in the nursery and the NICU. Not gonna lie, the kiddos are pretty cute.