Not On My Body! The Dirty Secret of Surgical Training

It's the resident's responsibility the morning of surgery to check on the patient in the pre-operative area, make sure there's a current history & physical, make sure surgical consent has been signed, ensure the surgical site is marked, etc. It's often one of my favorite parts of the day. It puts a face to the person in front of you in the OR, humanizes them after the yellow iodine has been slapped on and the surgical drapes have been placed. Most of the time, it's the first time I'm meeting the patient and it reminds me of how important it is to be meticulous and thoughtful in the operating room. There's often some good-natured banter to soften the patient's nerves. I have a fairly consistent spiel I give when I first walk up.

"Good morning, I'm Dr. MedZag, one of the surgery residents. I'll be helping out with your surgery today."

Some small talk typically follows. I may explain to them what's going to happen during their surgery, or what to expect following it, or let the family know how long the operation is going to last. Many patients are curious about residency and what that actually means I am. I explain that it means I have completed medical school but this is part of my post-graduate training. A mentorship or discipleship, of sorts. I have a medical license but am not board certified. Many people ask how long it lasts. I explain that for the surgical fields, it's between 5 and 7 years, and many of us go on to do fellowships afterwards. "Oh wow, that's a long time!" is the common response. "Well, they don't let us go out and start operating on people without earning it first!" is my usual one liner. But occasionally, I get a bit of a skeptical eye from the patient, and I know what is coming next:

"But Dr. Very-Important-Attending is doing my surgery right?"

I still don't have a good way of answering this question. But I have a few canned responses I cycle through:
1. "Don't worry, Dr. Very-Important-Attending is the boss in the operating room."
2. "I will be assisting Dr. Very-Important-Attending in any way he/she feels necessary."
3. "My role is to help Dr. Very-Important-Attending as appropriate."
4. "Dr. Very-Important-Attending runs the show, simple as that."
5. "Yes, Dr. Very-Important-Attending will be calling all the shots."
6. Variations of above.

I admit that some of my responses are farther from the truth than others and I also acknowledge that I'm always intentionally vague. The fact is that as an intern, yes, for many operations I'm simply there to "assist where appropriate." But for some operations, I'm performing parts if not all of the surgery. This is how we move from "intern" to "junior resident" to "senior resident". You can't become skilled at operating without, well, operating.

But I often wondered what the patient would think if we were brutally honest and told them who would exactly being doing what in the operating room. And the general surgery department at Madigan Medical Center in Washington looked at just that:

It's a very though-provoking study, but there are a few particularly salient and dramatic points they found, with the last two being most interesting:
1. 91% of patients believed their care would be equivalent or better at a teaching institution.
2. 68% of patients perceived a personal benefit from participating in resident training, and 87% believed that their participation would benefit other patients.
3. Patients "overwhelmingly" preferred to be informed if a resident would be performing parts of their operation.
4. 94% of patients stated that they would consent to the involvement of a resident in their operation.
5. However, after being given specifics of the role of resident involvement, patient consent dropped to 32% if the resident was performing the operation with the attending assisting, and 20% if the resident was performing the operation with the attending observing.

The overall message: Patients recognize the importance of training the next generation of surgeons. They just don't want to be the ones being learned on.

There was a great study published in the Journal of the American College of Surgeons earlier this year:

They looked at over 600,000 surgeries at private and training hospitals, and what they found was both expected and surprising. There was a slightly higher rate of complications, but a slightly lower rate of death, when residents were involved in an operation. I find that a very interesting and telling statement. It acknowledges that yes, we are learning, and as such, we make more mistakes. But it also acknowledges that we care about our patients and their care, and I think the mortality benefit reflects the reality that at a teaching institution there are more doctors who care about you keeping their eye on you.

I struggle with this underbelly of my training. The reality is I am learning. But at some point in technical fields such as surgery, you must learn by doing. Even in my short time in residency, I have had complications as a result of things I have done in the operating room. Nothing life-threatening or dangerous, but complications nonetheless. Mistakes that a more experienced surgeon likely would not have made. The reality is that these mistakes follow me. I think about them daily. And I regret that a patient has suffered harm, however great or little, as a result of my actions. But I also recognize that they have imparted to me great lessons, and have made me a better surgeon as a result.

Like I said, I find answering the "but Dr. So-and-So will be doing my surgery, right?" question difficult. Do we accept the half truths that permeate such a conversation as a necessary evil for the greater good so that myself and other surgical trainees will be ready to serve society for the next 30-40 years? Or do we instead veer towards blunt honesty, acknowledging that at an 80% consent attrition rate it would take me 20 years instead of 5 to gain that necessary operations and experience to be a competent surgeon? Do we be completely honest with patients but focus on educating them on what "resident participation" means from a value standpoint? That seems to be the ideal scenario, but my inner pessimist tells me that no amount of patient education would make most people willing to be learned on.

These issues are important ones to think about, but ones I can't afford to think about too much right now. Because I'm an intern, and I have too much to learn and too much to practice. So tomorrow, I will be in the operating room. I'll cut skin with the knife, buzz blood vessels with the cautery, tie sutures. And I'll keep learning.

Warrior

He was young for his type of cancer - squamous cell carcinoma of the larynx. I can't remember if he was a smoker or not, I don't think it matters, because those little details tend to deceive us into judging whether a patient "deserves" their cancer or not, and no one deserves a diagnosis of cancer. His tumor fell into the "organ preservation" limb of treatment, and he underwent weeks of grueling radiation and chemotherapy with his wife steadfastly by his side. The first few scans came back clean, then a year or so after treatment - recurrence. The cancer would prove to be a formidable enemy.

"Salvage laryngectomy" is the term we use when our first treatment has failed for voice box cancer and the ultimate decision is to be more aggressive and wield cold steel and hot cautery against our opponent. I think in some ways the term is quite poignant. It implies a battle of sorts raging within the body - treatments and human will versus the scourge of the malignancy infiltrating the tissues. Poetic interruptions aside, it meant the patient lost his ability to speak when we removed his larynx in an attempt to also in turn remove the cancer. Once again, a period of reprieve and healing. He became artful in speaking with the electrolarynx, attacking this new challenge the way he had all other challenges before then. But once again, the cancer returned with a ferocity, infiltrating the skin around where his airway now exited from his neck.

"Peristomal recurrence" is the term we use when the cancer returns in such a location. In general, it is considered a very poor prognostic sign. The type of sign where all you have to do is utter the term and those knowledgable to the lingo simply nod their head sadly, understanding that you're implying the chance cure is essentially zero.

And so it went on, another round of chemotherapy. More radiation. More chemotherapy. Experimental regimens that were so new or different they weren't even clinical trials yet. He lost a lot of weight. Nausea. A tube was placed through his skin into his stomach. His tumor grew larger. He was hospitalized. His tumor grew larger. He had bleeding. He spent time in the ICU. His tumor grew larger. He had abdominal pain. That earned him a surgery, and more pain, only to find that the cancer had further metastasized. His tumor grew larger. He would spend the last few months of his life in the hospital, until one night he quietly passed.

The unfortunate fact is that half of head & neck cancer patients in an academic institution will succumb to their cancer. His story, however, struck a chord with me.

Our team was frustrated with his care. We had tried many times to lay out prognosis to him, to arrange end of life care, to make him comfortable. But he would always talk about the next round of treatment. He would always talk about the day when his cancer would be gone for good. In fact, up until the end, he talked quite a bit. About his favorite football team and the upcoming season. About his rec sports league and the joy he got from the competition. He struck he as the scrappy small guy you hated to compete against but always wanted on your team. Ultimately, he always equated palliative care with quitting no matter how how we tried to frame the conversation. We, the team of residents caring for him, had trouble with transferring our own opinions onto his life. We saw the last few months spent in the hospital as time wasted, unnecessary pain and suffering. (And wasted healthcare dollars if you work in Washington). Some would paint his case as a failure of our medical system to navigate end of life care. Every day as we passed through his room we were left with a dampening of our spirits, a daily reminder of our own mortality, and the futility of our care at times. He was the other, more real, 50% of head & neck cancer patients.

I think when it comes down to it, he derived value and meaning from the fight. And I think he measured the worth of his life in the end by how hard he fought. He was a warrior. He outlived prediction after prediction. 6 months to live. 3 months to live. 1 month to live. He tolerated an inhumane amount of painful and debilitating treatments. He demonstrated the tenacity of human will.

And ultimately, I can't help but admire his story. In the end, I think, it was a good death. A death befitting a warrior.

Worrywort

There was this one moment I remember vividly from when I was a third year medical student. I had been working with one specific doctor all week in clinic, and we were talking about an interesting patient we had seen the day before.

"I worried about her all night," the attending said.

I remember reflecting on that line later that night. I remember it so vividly because I didn't worry about her at all. I went home that night, did some reading, mucked around on the internet, and had a blissful night's sleep. And I wondered why. Was it because I didn't understand the complexity of her case? Or was it, I really worried, because I didn't care about my patients enough?

That continued throughout the rest of medical school. I felt like I connected well with patients during the day. Empathized with them. Felt concern for them. But when I went home, I could unplug from that. And always in the background was this vague gnawing feeling tha maybe I didn't care enough.

From the other side, I can see it was because you are so well protected as a student. Sure, you dabble in independence. One night as a fourth year student we were being hammered on call. The resident was busy with our 8th trauma ICU admission of the night and a big case just got out of the operating room. The resident sent me to evaluate the patient and come back and tell me "stable or spiraling" (i.e. is this a patient I need to see now, or in an hour when the traumas are done). I remember the anxiety of that moment standing in the ICU room alone with the patient - looking at monitors, drains, and drips and trying to get the overall gestalt of the situation. But by the end of the night, the resident had come and seen the patient, and had agreed with my assessment. I went home and had a worry-free nights sleep.

In some ways, moving from student to resident is like being a sheltered teenager that suddenly graduates high school and moves away to college, thrown into a crazy world where dangerous things lurk around the corner.

I worry about my patients now.

The patient I just operated on with post-op tachycardia and EKG changes. I do an assessment, order labs, look at her old EKG, and make the determination that her heart rate is secondary to pain and she ends up going home. I worry that she is doing OK, and I didn't miss her heart attack.

The patient whose feeding tube comes out prior to discharge. I place a new one, order the xray, and see it isn't comfortably into the stomach. Go, advance the tube, and re-order the scan. Somehow the patient gets discharged before he follow-up x-ray is taken, and I worry all night that the tube is in the right place.

The patient with shortness of breath after an operation where you SHOULD feel some shortness of breath, and I worry that her symptoms are covering up something more insidious.

There's a few things that I mull over about this newfound worrywort quality of mine:
1. I wonder if it is because I don't want to "get caught" doing something "wrong." I think that may be part of it, because all of us in medicine tend to have a perfectionistic quality. And I recognize that, as a person who didn't really get "into trouble" as a child growing up, I retain some of that quality in adulthood even now as a resident where I don't want to be in "trouble."
2. That being said, most of my focus is on my patients. The worst thoughts I have are of my patient at home, suffering, because of something I did or something I missed. So I think my worry comes from a good place, because my focus is on keeping my patients well.
3. I'm learning that its good to have worry. It keeps you vigilant. But you have to be able to turn it off. You have to be able to trust your colleagues to handle issues for you. You have to be comfortable with uncertainty and trust that if things begin to go downhill, the patient will let you know.
4. I'm also learning that perfection is a noble and good goal but not an attainable reality. You will make mistakes. There are mechanisms in place to pick up on mistakes. And, to use a cheap sports analogy, you have to forget about the botched play and get ready for the next one.

I think back to those days of medical school when I worried that I didn't worry enough and I smile. It's always fun to reflect on your own naïveté.

Big Boy Pants

Intern year is a weird limbo of sorts. In some ways, you're still like a medical student(+). Your activities consist some days mostly of carrying out other peoples orders throughout the day. The things you do handle independently are mostly algorithmic. Manage this patient's pain regimen. Work up this patient's chest pain. Evaluate this patient's shortness of breath. Put in this patient's admission orders. Anything beyond that, you are generally encouraged to page up the food chain to residents above you (or discouraged from handling these things on your own, depending on how you look at it).

But the other day I had to put on my big boy pants.

Due to a combination of the chief resident being out of town, one of our residents being post call, and the last one being in the OR all day, I was gifted with the responsibility of handling the otolaryngology consult pager for the day. The ENT consult pager is an interesting beast. Most of the time, our consults are something very benign and not particularly time-sensitive. The little old lady with an incidental mass found on imaging when she presented with stroke symptoms. The level 3 trauma with the mandible fracture. The cheek laceration in the motor vehicle accident. But the consult pager is also a terrifying thing, because it is also the emergent airway pager. These are very rare, but present. So every time the pager goes off your heart rate jumps a couple clicks.

Luckily, I escaped without an airway emergencies. However, I did pick up an emergency department consult later in the afternoon. It was supposed to be a curbside consult. "We have a patient with sinusitis and I was wondering whats the best imaging test to order." I ask to hear more about the patient, and there was enough concerning bits about the story I say "you know, we should probably formally consult and lay eyes on this patient." Go to evaluate the patient. Run the story by the chief on call, who is already home for the day. Get the imaging ordered. Read through the images with the chief, and decide the patient has to go to the OR. Immediately. Staff with the attending on call. Get the case booked, talk to the ED resident, explain the findings to the patient, answer questions, get the consent.

As the patient is being wheeled into the OR, the chief and attending still have not shown up, and I realize... I'm the only person who has physically seen this patient.

The necessary powers show up. The attending sits at the computer checking email and the chief ends up taking me through the case in its entirety. Whether it was luck or whatever may be, I end up being right, the operation was appropriate, and everything goes smoothly. With the case complete, I put in the admission orders and go and talk to the family.

When I finally get home later that evening, I think back on the whole sequence of events. It was a fairly straightforward consult. But I was the one who decided we needed to formally consult. I was the one who saw the patient, took the history, performed the physical exam, performed the endoscopy, and ordered the imaging. I was the one who talked to the patient about the findings, talked about the implications, obtained consent, booked the operation, performed the surgery, and talked to the family afterwards. From the patient's perspective, and from the family's, I was the only person they had seen and talked to. I was their doctor.

That was a profound feeling.

I know that is the endpoint for residency, to be able to independently evaluate and treat patients who come under you care. And I know that my chief and attending had my back, and if it wasn't something straightforward, they would have been there to see things over in person. But for someone still so green at all of this, it was a refreshing (and, in some ways, terrifying) experience to be the point person for everything.

The patient did great and went home the next day. I saw him on morning rounds, staffed with the attending by phone, and put in his discharge orders. He is scheduled to follow-up with the attending surgeon in two weeks for post-operative care. And part of me wonders what he will think when he shows up for his appointment and my attending, a person he never met, opens the door to the exam room.

I think I'll try to be there.

So are you going to be doing my surgery?

Residency is very different from medical school.

(Thanks, Captain Obvious.)

I had a flashback this week to our "orientation to the clinical years" just before beginning my third year of medical school. I remember the out-going third year trying to coach us on various things - like writing a good note, making a good presentation, etc. I remember asking "So, what does do you do as a third year?" He gave some answer involving "helping with floor work, updating the list, faxing for records, following up on labs, ad infinum", and I remember thinking by the end of is "Yeah... but what do you DO?". I ahd not tangible mental image of what my days would be like. As I discovered over the next few weeks, you can't really understand it until you have to do it.

I think the same goes for residency. Sure, you have a lot of interaction with residents as a student and you get a sense of their responsibilities and how a resident's day is structured. But you don't really understand until you have to do it. A few of the key differences I've found include:
1) There's way more things competing for your time than you have as a student. At any given time, this includes: managing patients on the floor, discharges, seeing patients in clinic, logging procedures, prepping for conferences or tumor board, teaching time, self-guided reading time, prepping for OR cases, didactics, preparing a presentation, practicing basic surgical skills, graded laparoscopic assignments, and maybe a research project or two. As a student, you also had some of these requirements, but if you skimped a bit someone may or may not notice, and no harm no foul. As a resident, if you don't do them, they don't get done, and someone always notices.

2) As a student, you try to know everything about your patients. As a resident, you need to know everything about your patients. There's redundancy in teams to help mitigate this, but there's always the possibility that you may be the only person to follow-up on a lab or check a vital during the day. And that may end up being critical to the patient. It requires a great deal of focus throughout the day to remember to follow-up on things when there's a myriad of other issues continually competing for your focus and attempting to distract you.

3) As a student, you study a lot, but your primary motivation is often your grade. Sure, you convince yourself to read sometimes because "you need to know this for the future" but that often becomes much less of a motivator than impressing those that will evaluate you or an upcoming shelf exam. You also jump around every month, so you reading often will be a sample platter rather than a 4 course meal. As a resident, you read because you need to know the information. Not just because its expected of you, but for the good of your patients. Reading is more intensive on given topics and can feel more exhausting - I feel like I need to hang on to everything that passes in front of me because it is all important, and I feel like there's so much to learn and retain and I want to tackle it all at once.

4) Your skills explode by sheer repetition. As a student, you develop certain skillsets, but the next month you're on to a new discipline and most things you learned pertinent to a specific field fade away. As a resident, the skills you need to learn how to do are the things you are doing every day, and you do them over and over again.

5) The attendings really do rely on you. There was talk at my medical school that a good student is always "value added" on a service. As a resident, you are "value needed."

I think it all comes down to a switch in the manner of your responsibility. As a student, you try to take on as much responsibility as possible. But a lot of it is faux-responsibility (both for medicolegal and practical reasons). As a resident, you continually accrue more and more responsibility over the care of your patient.

I was in clinic the other day with a pleasant patient. I went through a lot of the things I had practiced in medical school - took a history, did a physical exam, developed a plan, went and presented the patient to the attending. The attending came and whirled through the room, checked a few things, talked to the patient about surgery, then left me with the patient to consent them for the procedure.

As I shook his hand as he walked out the door he asked, genuinely: "So are you going to be doing my surgery?"

I think that encapsulates the big switch that occurs in residency. You turn from purely a student into a provider of care. Over the coming years, I will read about the patient's condition, I will learn how to do his surgery, I will learn how to manage patients like him post-operatively. And I will do it not just to provide care, but the best care possible for that patient. Residency is about living that mantra.

Residency, huh?

First of all, apologies for leaving the blog hanging in the wind like a bad M. Night Shyamalan cliffhanger for the past 3 months. You may (or may not) have noticed I dusted off some of the things around here and updated the header to note than I am no longer a short-coat-wearing, deer-in-headlights, hopelessly-clueless medical student. Since our last interaction, dear reader, I have shed the shackles of medical school, packed up all of my "stuff", drove 2,353 miles across the country, and settled down in a small city with a very big medical center where I have spent the last week preparing to be a long-coat-wearing, deer-in-headlights, hopelessly-clueless... intern.

Progress.

I debated for a long time what the fate of this little corner of the interweb would be when I would be forced to stop writing about medical school. For a long time, I was content to let it ride on out into obscurity like many medical student blogs before me. Less time during residency (especially a surgical residency), the changing face of medical social media, and increasingly stringent institutional policies would all stack up and make it easier to just stop writing altogether.

But a few things changed my mind. First, I remembered a conversation I had with a good friend of mine who is in a *wink* elite *nudge* branch of the military. During our conversation, we talked about unique and stressful experiences and how it is important to take time to reflect on those experiences to learn and grow from them. I know myself well enough to know that unless I'm writing it on this blog, I won't take the time to write it at all (I don't know what that says about me as a person... but moving on). Secondly, as I nostalgically romped through the end of medical school, I decided to go back and read this whole damn blog in its entirety. Reading posts was like reliving experiences all over again, and I was surprised by how much of those memories had already began to seep away into the dark recesses of my brain. Finally, during a conversation with one of my new co-interns, I discovered that he both read my blog and liked it, despite the fact that we never interacted on the interview trail and hailed from states on different ends of the continental time zone. I was reminded about the common thread of the medical student experience and how many comments in the past have remarked "I'm glad you're writing about this." These things have led me to the conclusion that:

Remembering the process is important.

Over the 4 rapid years of medical school, this blog has evolved from something analogous to a teenage chick flick, to a place for me wax sophomoric about my "difficult" life, to a place to reflect on the incredibly powerful moments laced into and around my chosen profession. But what this blog is is far less important than the purpose is serves... to remember the process.

So I plan to keep on writing. I have no idea how this space will change, only that it will change along with me. Hard to believe over 60,000 of you have been here to this point, but hopefully a few of you stick around for the next chapter. Because tomorrow I'll put on a long white coat for the first time, walk into the hospital, and get to be Dr. MedZag. And I'm sure it'll be a process.

These Healing Hands

It's a reality in medicine that sometimes your patients die, and patients generally do not take exception to this fact if they happen to be cared for by a medical student. Some deaths can be more difficult than others as a student, depending on how well you got to know the patient beforehand or the circumstances of their death. Throughout my third year of medical school, I had several patients who I was caring for pass away while I was on service. Generally, these deaths were of one of two varieties:
(1) A healthy individual crashes and burns, a code is called, and we try our damndest for hours to fight the inevitable tide of death. Eventually the code is called, the team collapses in exhaustion, but there is a certain amount of solace to be taken in knowing that we tried everything.

(2) An individual with end stage x disease, who has been playing ding-dong-ditch at Death's front door for far to long, finally catches Death as he/she is walking by the front door in a bath robe and passes quietly in the night. News of these deaths comes during the AM handoffs and is generally met with a general sense of "Damn." but part of your psyche had already begun stacking the sandbags, knowing full well that your dying patient was, well, dying.

I had another, unique experience with death while on my neurology rotation. We had been consulted on an elderly woman admitted with altered mental status, in the classic CYA consult "rule/out stroke" that elderly patients with AMS tend to collect as they pass through the ED. I originally went to examine her with my attending in the AM, to find a frail looking woman, eyes open staring directly at the ceiling, unresponsive to anything in the room around her. She was altered (frankly, encephalopathic), but we did a full exam anyways and determined that she most likely did not have a stroke. Her breathing was shallow, raspy, and moist, a death gurgle of sorts as she was having difficulty handling her secretions. Labs would show a CO2 of >150... the likely culprit of her current stuporous state.

We weighed in our opinion and were off to clinic for the day. When the late afternoon rolled around, I decided to check back up on her, anticipating that after the requisite therapy for her COPD exacerbation, she would be doing much better. Luckily, I decided to glance at the chart before entering the room, and found a note from the medicine team "Discussed situation and prognosis with family. Family wishes DNR/DNI, palliative care consult."

I enter to find her much as she was that morning. Eyes open, staring blankly at the ceiling, still unresponsive. The late afternoon tends to be quiet in this wing of the hospital, and it was just her and I and the setting sun through the hospital window. Her raspy breathing penetrated harshly through the serenity of the moment. Like a good medical student, I set to task repeating the neurological exam, looking for any differences from the morning. Dolls eye test. Corneal reflex. Tap on the tendons. Check tone. It is just as I remove her sock to perform a babinski exam that I notice a subtle change in the room. It takes me a moment to realize that the throaty death rattle, my patient's weakened attempts at oxygen exchange... had stopped.

The first thought to race across my mind was "Oh shit!" I don't know how, but I remembered at that moment her do-not-resuscitate status, which fortunately prevented me from running into the hallways like an idiot yelling "Call a code!!!!" I watched as the color rapidly drained from her face, and stepped out of the room to talk to the nurse. "Ms. R just passed away. I don't know the protocol for the hospital, do you need to page the attending? I'm just a medical student." She replies that it is ok, as the patient was on comfort care. "Just go listen to the heart and lungs to confirm."

As a medical student, you are not trusted to do a whole lot. In today's chaotic environment of CYA-medicine and medical malpractice, we mainly pretend we can do things while someone holds our hand, until intern year rolls around. And a task as simple as listening to a patient's heart & lungs and feeling for a pulse should be elementary for a fourth year medical student, who has felt hundreds of pulses and listened to hundreds if not thousands of hearts. Regardless, there was a certain amount of anxiety involved in confirming a patient's death. Placing a finality on a life, even a life known to be near it's end, felt like a heavy responsibility. "I'm just a medical student."

"Time of death 18:21."

There would be no code, no crowd of people in the room, no blood staining the gown from STAT blood draws. Just myself, and my patient - a patient I had never even talked to. This was a different death than what I was used to. Some would say a good death. But the intimacy of the moment, especially considering it happened while I was performing the physical exam, struck me.

I page my neuro attending to tell him the news. He breaks the mood with some levity: "Well don't go see of the other patients now... I thought they were supposed to be healing hands!"

I looked down at those healing hands.

Empathy, Tragedy, and Progress

She was 28 years old when she first noticed the spot on her tongue.

Red and bleeding, it resembled a pinpoint ulcer along the left lateral border. She went to her doctor, with understandable concern. And he reassured her it looked like a small aphthous ulcer. He told her if it did not get better, or got larger, to come back and see him.

Shortly after that, she became pregnant with her third child. And as anyone would in that situation would likely do, concerns of small aphthous ulcers were placed into the back of her mind as her and her husband went about planning the new addition to their family. Months went by, until one day in her third trimester, she was brushing her teeth and noticed blood on the toothbrush. She took a look at her tongue again, only this time to find a large hard mass in place of the small red spot from before.

What followed was more doctors visits, biopsies, referrals, and a diagnosis... squamous cell carcinoma of the left lateral tongue. She was told there would need to be surgery, but not for another few weeks until her baby was safely delivered.

The baby was safely delivered.

It was the morning of her operation when our paths first crossed. I introduced myself to her, and the entirety of her large, supportive family in the pre-op room. I made small talk, and she spoke in articulate words with a slight British accent. I asked if she had any questions, and she shook her head no.

Back in the operating room, it was business as usual. Help transfer the patient to the OR table. SCDs on. Bovie pad on. Extra blanket on. Warm air circulating. She succumbs to the general anesthetic. Intubation successful. Rotate table 180 degrees. I go out to scrub with the attending and resident, yellow iodine dripping down my forearms into the sink. Sterile towel. Sterile gown. Gloves. Spin. Prep the operative field.

We are finally ready to begin, and we finally get a good look at the tumor. It it large, extending from the lateral edge nearly to the tip. Fingers of white parasite extending deeper into the tissue.

Calmly, the operation commences. According to the pre-operative MRI, it looked like the tumor did not creep too deep. The hope was to get in, get clean margins, and close primarily, leaving her enough residual tissue that her speech and swallowing would be largely unaffected. The dissection proceeds around the mass, and finally the bovie tip penetrates out the opposite side. Frozen sections are sent off to pathology, and we breathe a sigh of relief for the moment. We sit and absorb ourselves in the BB King playing from the iPod. We have a discussion about how much we enjoy the blues.

The phone rings, pathology on the other end. "Frozen sections show margin passing through tumor." In the passing 3 hours, more tissue was taken, more sections were sent, more phones ring, and more swear words penetrate the soft, solemn blues of BB King wafting through the air. The partial glossectomy transforms itself into a hemoglossectomy, which creeps towards a near total glossectomy with each positive margin. Finally, margins are clear and we close, folding the thin strip of remaining tongue over onto itself and securing it with the appropriate number of half hitches.

I am reminded on my last question to her before the operation, when she simply shook her head and smiled. What brings me back to that moment is that for the next few days, her sole mode of communication involves those same left-right, upwards-downwards motions. Any pain? Shake no. Comfortable? Shake yes. Ok, more of the same today. Try to get out of the bed. She turns out to be quite lucky in some ways. Her swallowing was intact. And she will eventually speak again, though not without a heavy lisp and not until the burns of the radiation therapy subside and many months of speech therapy are completed.

There were two things that stuck out to me as particularly profound about this case, about this mother of three.

First occurred during those nauseating hours in the OR as frozen section after frozen section returned with tumor as we burrowed deeper into tongue tissue. With each subsequent resection, I could not shake the feeling of how horribly I felt for the patient, that we were slowly robbing her of her chance at a normal life. Part of that is good, I think. It means these past four years of medical school have not robbed me of those intimate emotions, of the ability to feel empathy for the person prepped and draped in front of me. But I was also struck by how calmly and confidently the attending surgeon, a man I greatly respect and admire, went back to work with each setback... steadfastly marching with tenacity towards negative margins. He knew the data, but more importantly he had lived the data in his many years of practice. He knew that if we did not get clear margins, this woman in front of us would be robbed of her chance to see her children grow old. So he could bury those emotions in order to do what is necessary. Me, I could not yet detach myself from those feelings of horror, because I was not yet convinced it was necessary. Quite bluntly, I have not seen enough people die to be convinced.

It reminded me how much time and space still yet separate myself, inquisitive pitiful fourth year medical student, from the title of surgeon. Because in that situation, I'm not sure I could have done what was necessary. That was humbling to realize.

The second profound moment came the next week in clinic when the attending, chief resident, and myself saw the name of a 32 year of woman on the schedule for follow-up. She too had developed a tongue cancer noticed after becoming pregnant. She too required an operation and radiation. We got to talking, and the chief resident remembered another young woman from her second year of residency who had a tongue squamous cell. We look at her chart and notice she was pregnant. "Interesting," the attending states, and we go to see our follow-up patient. Somehow the conversation turned to what we were discussing earlier, and the patient states she also knew another young woman in the south part of the state who had tongue squamous cell. The momentum of the conversation between the three of us accelerated throughout the day. By the end of clinic, we had assembled a list of 9 young pregnant women with tongue cancer who had been operated on in the past several years. Questions floated about to the tune of the scientific method. Why pregnancy? Why are we seeing more of these tumors? What's different about these tumors? Are there unique ways of approaching treating them?

And so a hypothesis was born. And a plan. There would be a study. IRB protocols and special stains and information databases and eventually a publication. And hopefully... progress. And I thought that all is not so horrible after all.

Sub-I... Check.

Man, time flies when you're having fun, I guess. My four weeks on my otolaryngology sub-i were over in a flash. I have to admit, I was a bit nervous coming into the rotation. I felt like I had a fair amount of exposure to the field of otolaryngology, but any time you're making a decision to enter a field when you haven't spent dedicated time rotating through the specialty, you have to wonder if you'll end up enjoying it as much as you think you will. Luckily, I found a great experience during my rotation that reaffirmed rather than undermined my decision.

That being said, talk about a crash course of an experience. Doing a sub-i in a field that is only peripherally covered by the third year rotations, I found myself having to read quite a bit every night just to stay on top of the topics I may see in the clinic or OR the next day. Luckily, I got to rotate through a different service each week, so I could focus each week on learning one specific aspect of the field, be it head & neck, rhinology, peds, or facial plastics. That being said, I felt like the rotation was much less about showing what I knew and much more about showing my willingness to learn. Definitely a different experience than some of my friends who were doing sub-i's in general surgery, internal medicine, etc where you're expected to have mastered basic principles as a third year and graduated on to more patient management.

That being said, being a sub-i kicks butt compared to being a third year. The attendings know you are entering their field, and are much more willing to tolerate your presence and teach. You're given more hands-on opportunities. You're seen more as part of the team and less as a stranger passing through for a few weeks. Good times abound.

Some highlights from the four weeks:
- First assisting an entire anterior lateral thigh free flap
- Getting to perform a trachesotomy on my own
- Pulling a popcorn kernel out of a 3 year old kiddo's ear
- Draining 350cc's of pus out of a patient's neck who has a post-op infection (I'm afraid to admit... I love I&D's)
- Becoming known as "the PEG man" on service, and being paged specifically to come put one in
- First assisting an entire rhinoplasty with rib cartilage harvest
- First time getting to use the microdebrider
- First time getting to play with the DaVinci robot
- First time getting to shoot the laser

But, all good things must come to an end. My sub-i wrapped up and now I'm off on an away rotation. Living in a different, large city with only a small furniture-less room and a twin sized bed to call home. But still otolaryngology, so I can't complain. Grin.

Reflections on Third Year

So third year ended 2 weeks ago for me, and I've yet to write about it. You think after an "accomplishment" such a surviving third year I'd be bursting with feeeeeelings about the matter. After all, I briefly delved into the realm of the introspective when I finished first year, and I got damn near teary-eyed after taking down Step 1. After third year, I don't know. I don't have that same sense of accomplishment, and the same sense of transitioning onto something new. Am I glad I no longer have to rotate through specialties I have no interest in showing faux-interest along the way? You betcha. But I didn't wake up the day after my OB/Gyn shelf feeling any older or wiser. I think part of that is because the transition to the next level of competency tends to come throughout third year rather than after it. Before my last shelf exam, I was thinking a lot about my first rotation on peds and the student I was then was very different from the student I am now. But that change was a slow process that had little to do with the MS label after my name. Basically, I can see the progress I made this year, but don't really feel like I "survived" anything. Maybe it's because I really enjoyed third year and the things that are historically dreaded about it weren't that big of a deal to me. Maybe it's because I'm going into a surgical field and I know my days of sleep deprivation, early mornings, and busy days are far from over. And you know what, I'm cool with that.

That being said, good riddance to the third year label. It'll be nice to not have people automatically assume you know nothing and can do nothing just because you're a third year medical student.

Anyways, it was a good week off, and now I'm on to the greener pastures of fourth year, the "best year of medical school."

Normalizing.

I had an interesting conversation with a friend in the military the other day about the things we do for work and how they become so mundane to us, that we lose sense of what's normal. As third year draws to a close and I look back at the experiences of the past 12 months, I realize how much I have seen and experienced that to many (or most) people would be vasovagal-inducing, nauseating, disturbing, masochistic, macabre, or just plain strange which has simply become... normal, to me. It is normal to be covered in blood or various other bodily fluids. It is normal for the workplace to smell of feces and urine. It is normal to work 15 hours a day. It is normal to stick your hand into various bodily orifices, natural or artificial. It is normal to disassemble the human body, intervene in a problem, then reassemble using silk, nylon, and stainless steel. It is normal to discuss bowel habits, suicidal thoughts, and sexual activity the first time you meet a person.

Back when I was in undergrad, I remember some of the jokes about certain medical specialties. Proctology. Who would want to deal with butts all day? Urology. Who would want to touch penises all day? Gynecology. Who would want to stare down vaginas all day? C'mon man, that's gross. Seriously, who would want to do that for a living? Especially a guy.

Well, after two weeks on OB/Gyn and numerous sterile speculum exams, the field has become... normalized. And really, once the pelvic exam stops being weird and starts being just one more physical exam you "do" to get information, you begin to see what's cool about the field. It's fast paced and busy, where things can go from reassuring to tenuous quickly. A good balance of medicine and surgery. Good outcomes for the patient in most circumstances, and a chance to significantly improve outcomes in cases where things are more dire. A sense of participating in an important moment in the patient's life.

But yes, all "that" stuff about OB/Gyn is now nothing unusual. So much so that when I do a pelvic exam now, all the anxieties I felt before about an exam that seemed so "gross" and inappropriate before just seems like another part of my job. My main concerns are more for the patient and how she may feel about a baby-faced male doctor-to-be performing an exam that is uncomfortable and in principle socially taboo. I am still very much in tune with that, and still struggle with balancing patient discomfort with my own education. But as far as it seeming gross, or unusual, those feelings are gone. I already find myself forgetting what it was like to know nothing about obstetrics. The 17 year old nulliparous patient who has no idea it is normal to defecate the bed during delivery. The couple who just welcomed their first child into the world who have a brief look of horror when the resident says she is now "using suture to reapproximate the vaginal wall." The 28 year old new mother who glances down in horror after we "remove" 300cc's of clot from her uterus post-partum. I forget how strange these things must seem.

During a c-section earlier in the week, the anesthesiology resident was comforting the patient during the procedure, talking her through the steps of the procedure. We had just finished closing the hysterotomy, and the resident says flatly "they just finished closing the uterus, you may feel some discomfort as they return the uterus to inside the body." I can imagine the patient's eyes growing wide, but all I hear over the drape is "WHAT!?!???" A large part of me cannot find fault in his faux pas, as these things seem routine to us. There is nothing strange about removing the uterus and placing it on the stomach to better sew the incision.

Just a few things that are now normal to me.

Ironically, 3 of the first 8 image results for the keyword "normal" in google images are of genitalia.

"The Look."

As part of our internal medicine rotation, we were required to spend 5 weeks at a hospital out in the community. The hospital I was sent to was a fairly large medical center with close to 500 licensed beds, and part of my hospital was a large tower of a structure dedicated as the "cancer center". The problem with the cancer center is that it was built as an addition to the hospital, which meant to get access to the beds within the tower, you had to go up to the 3rd floor of the regular hospital, through this back hallway attached to the corner stairwell, go through a tiny side door, which brought you to a back elevator shaft. You then went up the curiously slow elevator, through a set of double doors, then up another set of stairs, just to get to the beds in the tower. As a result, the tower had been nicknamed the "Death Star", because every time a code or rapid response was called in the tower it took several minutes to respond simply by virtue of its reclusive location. While rotating at the site, I worked with a senior resident who took the code pager very, very seriously. Whether it was a code blue or a rapid response, we. were. running.

One day on short call, we had an afternoon where the code pager would not shut up. As a result, we were running all over the hospital to various locations within the hospital, always at an aggressive jog with my 30 pound white coat flapping around me and sweat beading on my forehead. All the codes that morning ended up being fairly well controlled situations... a patient in the post-op area of the day surgery who got too much narcotic, a code blue called on a patient already in the cath lab, a patient who had an an RRT called simply because the attending wanted a stat ECG. We had just finished up our 5th code of the morning when the code pager started blaring again, this time for a patient in the Death Star. "Crap." my senior muttered, and off we took, up to corner stairwell, down the back hallway, through the tiny side door, to the elevator. Wait for it. Wait for it. Wait for it. Up the elevator. Through the double doors. Up the stairwell. Down another hallway.

When we arrived the scene was fairly chaotic. An elderly woman was sitting tensely up in bed. Nursing staff was trying, quite unsuccessfully, to get an ABG, and blood was spotted all over her arm and hospital gown. The ECG showed new-onset a-fib and the patient was satting 70% on 12 liters of oxygen through a rebreather mask. But what struck me most profoundly was the look on the poor woman's face. She had what we called "the look": sitting rigidly upright, arms locked with hands grasping onto her sheets, desperately trying to breath with eyes wide and an expression of impending doom on her face.

There's only a few things that give someone "the look," and in an elderly bed-ridden hospital patient, we knew even before the labs came back that she had thrown a clot to her lungs. She was wheeled down the hallway, down the elevator, through the lobby, up another set of elevators, and into the ICU. Luckily, she did quite well and survived her PE with only a scare. The Death Star had been defeated that day. But I'll forever be imprinted with that look she had the moment we walked through the door. It's one of those indelible moments that are sprinkled throughout the third year of medical school - when what you learn in textbooks manifests itself in a living, breathing human being tenuously placed in front of you.

Happily exhausted.

There's a lot of mystique surrounding the internal medicine rotation in the third year of medical school. Besides the fact that your IM core clerkship grade is considered one of those "important things" for residency, its also the rotation that best integrates the various informations you crammed into your head during the pre-clinical years. Some say its where you learn to "think like a doctor" or "be a doctor." While my IM clerkship has not turned out to be nearly as dramatic as some would make it out to be, I have seen myself making small but significant strides on being able to capably diagnose and manage patients in the acute setting. I'm on week 6 of 10, and so far it's been exhausting, but incredibly rewarding.

It's amazing how many different experiences you can pick up in a short period of time, and how patient's stories are intertwined within all of it. Some are humorous, some are sad, some are powerful.
The little old lady found wandering the streets at 3am looking for her favorite starbucks, pleasantly delirious due to a UTI.
The woman admitted with herpes zoster ophthalmicus, who always wants you to linger just a little longer when pre-rounding, and you can tell she is lonely.
The patient who has a syncopal episode while masturbating.
The woman who has never smoked a single cigarette in her life, who dies from lung cancer.
The woman with sickle cell who is allergic to opiates, forced to endure the pain of her acute crises with only tylenol, who handles herself with awe-inspiring stoicism.
The 22 year old asthmatic, who can't afford an inhaler because he spends all his money on heroin.
The man with end-stage liver disease who can't get a transplant because he can't kick the bottle.
The 600 lb man, bed-ridden for over a year, who stands for the first time, and the attending shakes your hand and says "strong work, without your help, I don't think he would have ever left the hospital."
The patient with a-fib who passes suddenly in the middle of the night.
The woman who comes in with difficulty swallowing and leaves with a terminal cancer diagnosis.

It's humbling that these experiences are considered my "education." But I don't think I've ever appreciated or enjoyed medical school more than now. Its funny that it happened on this rotation, because internal medicine can sometimes (often) be much too rhetorical and slow paced for me. But there's something to be said about the principles of internal medicine being the foundation of how medicine is practiced, regardless of specialty. And I think my experiences on this rotation have allowed me to cross another one of those thresholds of clinical competency. I found as I was getting my feet wet in third year, I was often so concerned with not screwing up that the nuances of clinical medicine whisked right by me. I was so concerned with not missing anything in my history, I missed connecting with my patient. I was so concerned with my notes being perfect, I didn't stop and think about what I was looking for in my physical exam, or why certain things were in the plan. But as you gain competency in those skills, you learn to enjoy the process as much as the result. Medicine becomes less of a checklist and more of a visceral experience. And it becomes much more fun in the process.

So tomorrow, my alarm will go off at 4:30am. And I'll groan, because I'm exhausted. But then, I'll get up, and I'll smile. Because I get to do this for a living. How awesome is that?

Onward and Upwards

2010. Has a nice ring to it - I'm a big fan on even numbers. It will be interesting to see how people abbreviate it. "Oh-Ten" is inaccurate but it sounds silly to just call it "Ten". But I digress.

I'm not normally a big fan on new years resolutions, but I've been trying to integrate more mindfulness into my life and resolutions seem like a good assess-and-change exercise, so here's my top 4 for the new year:
1. Take Better Advantage of Learning Opportunities
I've found myself too often getting caught up in the drudgery of third year. When you're tired, it's easy to check out mentally at the end of a long day, post up on the couch, and drown your sorrows in a big glass of reality television. And with medical school costing me $115 a day (and that's in-state tuition!) it'd be really stupid to waste the opportunity to maximize my education. So, in a small-changes-leading-to-sustainable-change sort of way, my goal is to read at least one article/subject/etc related to a learning issue from the day each day. I can polish off a good review article in 15-30 minutes, so there's really no excuse to not be able to go this... except laziness.

2. Get More Procedures!
The first part of third year, I've been pretty timid about standing up for myself and taking advantage of opportunities to get my hands dirty. Part of it was probably the shock of jumping into the deep end of clinical medicine - I think a certain part of me didn't believe I deserved to do s**t to real live people yet. And with residents abound in the hospital, its been easy to defer to them when chances do come up because they "need" it more than me, for accreditation issues, etc. But with fourth year and graduation barreling towards me, I'm starting to realize I'm going to NEED those skills faster than I realized, and I better get to work gaining competence in those skills I'll need as an intern sooner rather than later.

3. More Self Care
I got an hour long massage the other day (my first in 6 years) and quite plainly, it was probably the one thing I've needed most for quite a while. I tend to hold my stress in my neck and back, and both were starting to resemble cargo netting with the number of knots I was accruing on a daily basis. Along the same lines, I've gotten lazy when it comes to eating, and have found it easier to whip up some ready-made meal rather than deal with cooking/cleaning the various dishes and pans required to cook a real meal of food. So, goals for the new year are to: a. Get one massage a month - all that loan money has to be good for something, right! b. Cook at least one real meal of food per week.

4. Socialize
I've found myself falling into a trap the first half of third year. If there's one word to describe the clinical years of med school, it's: tired. Always tired. So when those few daybreaks of free time do pop up, I found myself staying in to sleep, waking up afterwards to find myself... still tired. So I waste all my free time trying unsuccessfully to become untired, and miss out on opportunities to, you know, be a normal human being for a couple hours. So the goal for the new year: at least 3 social events a month, where I engage in activities such as imbibing delicious deverages and debate the psychological intricacies of Jersey Shore. You know, stuff a normal 24 year old should be doing. Who cares if it means I'll be tired? I'd be that way anyways.

Onwards to 10 weeks of internal medicine starting tomorrow. On call this week, and I haven't taken call since October, so it'll be another "0-to-60" adjustment. But I'm looking forward to rejoining the clinical world. I feel like my medical brain has atrophied over the past month, so it's time to start practicing the mental gymnastics again. Hooah!

Flying Solo

Few things represent the hierarchical and tradition-seeped natures of medicine better than the operating room. As many med students will attest, half of the battle of the general surgery rotation isn't learning the post-operative management of surgical patients or how to properly manage a wound infection - it's learning the ebb and flow of the operating room. Tales abound which serve to strike fear and trepidation into subsequent generations of medical students of students being yelled at for touching something, looking at something, breathing improperly, blinking improperly, etc, etc. There's a procedure and tradition for every minute detail of the choreography of the OR, and you are expected to know it all before you learn it all, which contributes to awkward or embarrassing moments aplenty for medical students as they rotate through. I remember when I got yelled at while participating in a patient transfer off the operating table. I was the one pulling the majority of the weight on the rollerboard, and assumed it was my responsibility to do the countdown. 3... 2... 1... I get glares. I'm told to step away from the patient and not touch anything anymore. Turns out it's always Anesthesia which does the countdown, which is logical as they are overseeing/moving the airway, everything that happens in the OR is logical, but how in the hell was I supposed to know that beforehand? Such is life sometimes for a medical student in the OR - expected to know these things, before anyone tells them. In my own limited time in the OR, I have collected a small bundle of mortifying anecdotes. The time I almost desterilized the entire instrument table with a sneeze, the time I put the SCDs on upside down, the time I almost face-planted into the operative field when I slipped on some sigmoidoscope-associated KY jelly which had dribbled onto the floor... the list goes on.

But this post isn't about embarrassment; it's about hierarchy. When standing around the surgical field, there's also a rigid structure to where one must place one's feet. Traditionally, to the upper right of the patient, by the patient's right armpit, stands the lead surgeon. The lead surgeon is, by virtue of the position, the individual in charge of directing and performing the majority of the operation. To the left of the lead surgeon stands the scrub nurse or scrub tech, whose job is to, among other things, maintain sterile technique during the operation, pass instruments to surgeon during procedure, and help perform counts of surgical instruments throughout the procedure. To the upper left of the patient resides the individual providing first assist to the operation - who, among other things, uses the bovie to cut vessels and tissues at the lead surgeon's discretion, helps provide traction to tissue planes to aid in dissection, etc. And to the right of the first assist lies the domain of the medical student: the position of second assist. Here one typically aids in the operation by holding retractors to open the operative view, use suction to remove smoke, fluid, and blood from the operative plane, and tightly covet the Mayo scissors that one uses to cut suture ties. But with the myriad of surgeries and surgical approaches out there, there's also a wide variety of places where the surgeon and assistants stand to get the best exposure into the surgical field. And just likes plays on a football field, its up to the medical student to learn where to proverbially 'line up' for the snap. In an academic institution like my own base of operations, typically a resident provides first assist during the operation and the medical student stands beside as second assist for the operation. But during chance opportunities, such as when the resident is taking the lead on a case, med students are given the opportunity to run first assist, which is infinitely more fun for obvious reasons - namely, being able to more actively participate in the case. Rarely, a med student is offered to take the lead on simple cases (appendectomies, cholecystectomies, etc), which is always something worthy of writing home about, no matter how mundane the case may be for everyone else in the OR.

So a couple weeks ago I was spending a day in the OR with the ENT surgeon who I'm doing research with and a third year resident. We were powering through several of the half dozen cases on the docket for the day and next up on the case list was a simple tonsillectomy. The resident gets called down to the ED for a consult, and suddenly the attending turns to me and says:

"Want to take a whack at it?"

The third year of med school is a lot like the game of golf. All too often, you find yourself feeling incompetent, frustrated, disheartened, or some combination of the three. As your shot out of the shrub grass careens off the tree and lands in the water hazard you didn't take into account, you begin to ask yourself why you even play this stupid game to begin with. But a handful of times during a round, the balls rises gracefully into the air and plops, like it should, down onto the green within spitting distance of that birdie. And before you know it, you're paying another set of green fees and are back for more. Likewise, third year is full of foibles and f*ckups, sometimes asking yourself why you're doing this for the rest of your life. But every once and a while, you get to see or do something incredibly cool that reminds you why you're in it in the first place. And you come back for more.

Well this moment was my proverbial 240 yard approach shot plopped down 6 inches from the pin. The first time I get to take the lead during an operation. I step into position above the patient's head and gaze down at the base of the mouth. Just as I get bovie in hand, the attending laughs and says: "Don't worry... the first tonsillectomy I ever scrubbed on, the patient lost 1800ml of blood. The bar's set pretty low." Great. My resting tremor kicks up a couple notches.

But before I know it, we're off. I go in alongside the anterior tonsillar pillar, find the capsule, and before I know it, the procedure is over. Less nervous than I thought I'd be, but still trying to contain the 8 year old inside of me jumping off the walls going "WOW! That was COOL! Let's do it AGAIN! WHEEEE!"

Yup, back for more.

Marty and Me

One of the most overused cliches in medicine is the oft referenced: "When you hear hoofbeats, think horses, not zebras."

It's a valid reasoning in which to guide one's thought processes. After all, common things are common, uncommon things... aren't. But part of the responsibility of a physician also is to provide comfort and reassurance. It's our job to think "worst case scenario," to work up patients for those conditions, and provide reassurance when evidence is sufficient to quell our suspicions. Another common phrase in medicine is "until proven otherwise." Vaginal bleeding in a postmenopausal woman is cancer until proven otherwise. Acute onset of dyspnea or hypoxemia is a pulmonary embolism until proven otherwise. Severe epistaxis in an adolescent is a nasopharyngeal angiofibroma until proven otherwise. I recently had two patient who elucidated just how true this axiom can be.

A 62 year old woman presented with lateral chest pain of two weeks duration. On physical exam, her pain seemed very musculoskeletal in nature. Pain to palpation, pain on deep inspiration and with sneezing/cough, etc. The horse in this situation is a simple intercostal muscle strain. Regardless, we ordered a chest xray which showed ambiguous opacification of her right lower lung. It just didn't quite add up with the lack of any pulmonary symptoms. So, congresspersons and escalating health costs be damned, we decided we couldn't quite be comfortable with just writing things off, and sent the patient off with a referral for a CT scan and instructions for prn ibuprofen and heat. We saw her back today. The CT scan showed findings pathognomonic for lung cancer. Turns out, her pain was musculoskeletal in nature, as the cancer had begun to invade into her 8th rib. It had also spread to her spine. Zebra. Ironically, the patient returned to say that the heat and ibuprofen had really helped with the pain. If it wasn't for the CT, she would have been sent on her way with the belief that it was all just an intercostal muscle strain, while the cancer continued to grow in her chest.

A 22 year old woman presents with a painful unilateral cervical lymphadenopathy which had been present for 1 month. The horse in this situation is some form of infectious etiology: mononucleosis, cat-scratch fever, occasionally HIV (though this didn't jive with her history). She had been to several urgent care centers, and, going with horses instead of zebras, prescribed two antibiotic regimens, with no improvement of her symptoms. There was still a high likelihood her neck mass was viral in etiology, but we ordered a chest xray "just in case." It ended up showing an extensive mediastinal mass. One biopsy later, the diagnosis returned nodular sclerosing Hodgkin's. Zebra. Luckily, her prognosis is excellent and the delay in diagnosis likely will have no significant effect on her therapy. But it is never easy telling a previously healthy 22 year old that they have cancer, and there is a certain level of embarrassment that it took 5 visits to a physician to reach a diagnosis.

I think the most telling thing I've taken away from these experiences is how important the differential diagnosis remains in clinical practice. Most common symptoms can be attributed to the relatively benign conditions that afflict the gross majority of the general population. But it is important to always consider what else can be consistent with a clinical picture that is truly dangerous, as just because a condition is rare does not mean it cannot be affecting the patient sitting in front of you. Bacterial pharyngitis is common and fairly benign. A retropharyngeal abscess is not, and can often present identically. It is the responsibility of the clinician to use their clinical judgment and work up a patient to the point that they can confidently feel the patient is safe in the context of their illness.

After all, just one day, you may come across a zebra in downtown New York.

Choosing a Medical Specialty (Part Dos/Deux/II/0b10)

As a continuation on my previous thoughts on picking a medical specialty, I've once again channeled my Dear Abby and have a new column up over at Headmirror.com.

Check it out here: Why ENT? Choosing a specialty and what drew me to ENT (navigate to Medical Students -> Blizzog)

MedZag Picks A Specialty.

There are few decisions more consternating to a medical student that choosing their eventual field. Sure, there's a few students born to be pediatricians or neurosurgeons or ED docs out there who know it, but the gross majority of us go through a great deal of waffling and procrastinating when it comes to deciding what more we want to be when we grow up besides the esoteric "I wanna be a doctor! Cause its cool!" Even those who were convinced they were going to go into x when they entered med school often do a complete 180 once they rotate through the clinical aspects and their face is to the table saw as they hover over the "submit" button on their ERAS residency application.

There's a certain progression to the process:
(1) Panic: The Lifestyle Specialties
When you first come into medical school, you have these idealistic views of what being a physician entails. Then you actually get into medical school, and a disenfranchised attending comes along, convinced the entire field of medicine now sucks, and blows that idealism into tiny, sparkly little pieces. You begin to become convinced that the only way you could possibly be happy is if you find your way into one of the highly-touted ROAD specialties: Radiology, Ophthalmology, Anesthesiology, or Dermatology. You begin to become convinced you could be happy staring at a computer screen all day, or rashes for that matter. After a while, you realize that all rashes look the same to you anyways, and you move on to...

(2) Resolve: Screw What Everyone Thinks
You encounter a doc who absolutely flippin' loves what they do. They tell you that it doesn't matter what area of medicine you go into, as long as you love what you do. You begin to convince yourself the same. You tell yourself that the disenfranchised attending from step 1 can go to hell, and you're going to go work for Doctors Without Borders as a surgically trained general practitioner. As medical school and the ongoing debate about healthcare reform progresses, you begin to notice that little "Total:" line on your student loans climbing at a otherworldly pace. You then move on to...

(3) Hopelessness: It All Sucks Anyways
Why does it matter anyways? In a few years, you're either going to be a government employee, and make peanuts, or privately employed, and make peanuts. Either way, you'll be working your glueteals off the rest of your life. You'll never pay off your loans. You're going to be driving that 1995 sentra for another 20 years. Your daughter is going to grow up with daddy issues because you'll never be home. You procrastinate thinking about what you want to do, because its no longer fun to think about it. Some stay in this stage perpetually, and become the attending referenced in Stage 1. If you're lucky you get to move on to...

(4) Chance: Your Specialty Picks You
The residents and attendings I've talked to who really enjoy what they do, and are pleasant people in turn, almost universally give the same advice about picking a specialty: get rid of your preconceptions, analyze your strengths and weaknesses, the things about practice which are important and unimportant to you, prune your list, then go out there and experience as many areas as you can. When you come across your specialty... you'll know. It'll be the one where you don't want to go home at the end of the day. Where you'll look and read about things not because you have to, but because you want to.

I came into medical school convinced I was going to be a surgeon. My friends told me as much, I told everyone as much, my ESTJ Meyers-Briggs personality evaluation told me as much. Now granted, my concept of "being a surgeon" wasn't all candycanes and lollipops - I had shadowed enough in undergrad to have a general idea - but I will be first to admit I had a very naive and limited view on the scope of medical practice and the proverbial "potpourri" of options afforded to me early in medical school. I found out in a hurry that telling people in the Real World™ that you want to go into surgery evokes an entirely different response to telling people in the medical field that you want to go into surgery. Namely, that instead of eliciting the token "Ooooo! Like Gray's Anatomy!" response, they instead try to scare you the hell out of considering the field. And granted, much of that behavior is grounded in either reality or stereotype of the field. And so began my progression of through the steps.

First was "what have I gotten myself into? I don't want to work 120 hour weeks for the rest of my life!" Followed "I'm going to do it anyways! It'll be fine!" I eventually just resigned to telling myself "you'll know when you rotate through surgery if its for you." But alas, my surgery rotation came and went, and by the end I was still just as on the fence about the whole surgery conundrum as before. So I began to break it down. I knew that there was nothing like being in the OR for me. That time flew when I was in it, and I missed it when I was out of it. But surgical clinic also left a bad taste in my mouth. I found myself enjoying the clinical aspect of medicine more than I anticipated, and I found clinic in general surgery too fixated on "to operate or not to operate?" Yet after leaving surgery and venturing into the realm of psychiatry, I found myself missing the faster paced lifestyle of the specialty.

ENT was a specialty that first caught my eye during second year. I had a small group doc who specialized in laryngeal surgery and speech therapy, and he really tried pushing us to take a look at the field. But at the time, I was too hung up on the "to surgery or to medicine?" that I never stopped and said to myself "self? how about both?" It was a field I kept on my list but never really investigated... namely, because I had no idea what in the hell an "otolaryngologist" was or did. With no frame of reference, I wasn't in a position to realistically examine the field. But the seed was there, and as third year started and I began to have more interaction with various specialties, I began to notice that I was really digging this ENT stuff. The more I read about the field, the more it seemed to jive with my expectations and desires for how I wanted to practice medicine. There was a monday morning report I went to that was presented by the ENT department... and instead of sleeping through it I found myself taking notes. I scrubbed on a pharyngolaryngectomy with a free jejunal transplant and even though I was on the colorectal service and was parked by the abdomen, supposed to be focused on the jejunal resection, I found myself fixated instead on the bilateral neck dissection. It was the small things that slowly roped me in, and after extensive email conversations and a few tall coffees with a couple members of the faculty, I've finally come to a decision. I said to myself: "Self, you're going to match into otolaryngology."

Along those lines, I'm going to be guest-posting about my experiences in discovering ENT, rotating through ENT, applying, and such over at headmirror.com (see the new side banner). If you're considering ENT, I suggest you check it out - there's a lot of great info on the site. All I can say is that its incredibly exciting to find that niche of medicine which really vibes with your persona. When I decided to commit myself to the field and really get after it, all I felt was this overwhelming sense of relief. I think that was really telling.

Till next time.

Friday Night Lights

So I happen to be attending med school in the same city I grew up in. There's a lot of advantages to the situation: I know the area really well, the city "feels" like home, I'm close to friends and family, in-state tuition, etc. There's also the annoyances that come from returning to your hometown. Namely, running into old acquaintances, especially high school classmates, everywhere from the deodorant aisle at Safeway to the self-help section at Borders (you to!?!). Now, these aren't the good friends from the old days - those I've actually kept in touch with over the years and still make plans with from time to time. These are the people you see in a crowd, recognize the face and try to place their name, and before you can think of it they jump you with with the "Heeeeyyyy how are yoooouuuuu? What are you uppppp to? *awkward pause*" before you can make a quick getaway. At first these spontaneous encounters were kind of fun, namely because my younger self got to pull the "I'm in medical school card" (Yeah. I know. You don't have to tell me.) But after a while it becomes an annoyance more than anything. That being said, there's one place I never expected to bump into an old high school friend.

I was on trauma call on Friday night and going through my usual routine. Which means I was in the cafeteria at 10 at night, justifying to myself that I should get the ham and cheese sandwich and fries instead of the halibut and grilled veggies because "You deserve it. You're on call." Before I could contribute to my future coronary artery disease, the trauma pager goes off and I hand the delicious ham and cheese sandwich back to the cook and shrug, mumbling "Sorry. Trauma." I do my best doctor walk (you know, the walk where you don't look like you're running but you're tearing down the hallway on pace for a 4.0 40) down to the ER and work my way over to Trauma Bay 3. Ten minutes later the action starts as the paramedics wheel in the patient in a c-collar. My role is the lower extremity exam so I work on peeling away the patient's trauma-sheered pant legs, feeling for pulses, checking capillary refill, etc. The presentation of the patient begins.

"25 year old male was swimming with friends in the river. Dove off a rock and misjudged the depth of the water. Landed head first into shallow depth and immediately lost use of all extremities."

I examine the legs in front of me for lacerations, abrasions and such. The ED resident begins to talk to the patient.

"Sir, can you hear me?"

"Yeah," the patient replies.

"Can you tell me your name?"

"Mike." The appointed scribe sets out her form and begins to write in the elucidated info. "What's your last name, Mike?"

"Jergens."

Mike Jergens*. The two names snap together in my mind and I immediately glance up to the patient's face poking out above the c-collar. He had a beard now, but there was no mistaking his face. This was the same Mike I sweat and bled with during countless hours of football practice back in high school. He was a linebacker, I was a cornerback, and we spent more than a few hours shooting the sh*t in the huddle back in the day. I think back to my last vivid memory of him - also a Friday night, 7 years ago. We were walking off the football field my senior year, knocked out of the state playoffs in the quarterfinals in a royal butt-kicking from our local rival. He had cried that night in the locker room. I suddenly had the urge to cry myself.

I somehow pull myself together enough to help finish the triage and he is sent off to imaging. It would find that he had a C6-7 fracture dislocation. His cord was compromised. He was taken to the OR the next day.

Mike would eventually regain some motor use of his upper extremities. He had a long hospital stay with a rocky course including a ventilator-associated pneumonia. He was eventually discharged home 4 weeks later with a trach, facing a long road ahead I cannot even begin to fathom.

I never let him know I was there in that trauma bay. I tried to muster the courage several times to go visit him in his ICU bed, but the best I could do was to post a message on the website that had been erected for friends to send well-wishes and prayers. I still don't know what kept me from stepping into that room, but I carry a certain amount of guilt knowing that we now face such divergent paths in life. If anything, it has certainly helped me to gain perspective on how precipitous our lives can be and how quickly they can change. The minor annoyances in life, such as being "forced" to make small talk with an old acquaintance, are suddenly seen as blessings instead. An opportunity to see and know that that person is well. It's a strange world we live in.

As if to emphasize this point, the next night on trauma a patient in his early twenties was life-flighted in with nearly the exact same injury. He had dove into the river off a large boulder. Misjudged the depth. Landed head first in shallow water. But he escaped with only a hairline skull fracture.

It's a strange, strange world we live in.

* = Name obviously changed to protect his identity.