Take a Trip To The Dark Side

Dead to Rights

I invite all of you to visit a very interesting blog called “Med School Hell,” the link for which you will find on the right. It is the diary of a disgruntled medical student who decided not pursue further training after medical school. I must warn you that his blog is not for the faint of heart or the easily offended. Those of you who are not yet in medical school will find most of your cherished beliefs about medical education not just challenged but assaulted, bayoneted, and left to die a lingering death with their entrails cooking on the hot sand.

It is, in short, very well written, extremely entertaining, and as thoroughly subversive a manifesto as you will find anywhere. And it’s all true. Every line of it. There is nothing he mentions that I have not either experienced myself or witnessed on many occasions as it was inflicted on others.

I recommend his blog to all of you contemplating a medical career, not to discourage you but only so you know what to expect.

Take a Trip To The Dark Side

Random Madness I

Free Chow

Free food. Just another thing to consider when selecting a residency program. I’m not saying this should be one of the top three factors guiding your ranking decisions but if you have no other way to differentiate programs, I’d go with the place where you can eat for free. If you think about it, you have the potential to drop some serious money on food during almost any residency. Not to mention that it is more convenient to grab a bite at the cafeteria than to brown bag two or three meals a day.

I eat most meals at the hospital. I didn’t last year because the administration at Duke are cheap bastards and the most they could cough up was a paltry six buck on-call meal allowance at their over-priced cafeteria.

I also drink a lot of Cherry Diet Coke (the official soft drink of Panda Bear, MD), probably six or seven a day, which could otherwise be a very expensive habit if I wasn’t getting them for free.

So don’t be embarrassed to ask about this when you interview. If the cafeteria has Starbucks or equivalent coffee then you have hit the jackpot.

Call Schedules

Should you ask about call schedules when you interview or is this a sign of weakness?

Definitely ask, but ask the right people, preferably the residents and preferably at the pre-interview social event. Maybe you don’t want to seem pre-occupied with your free time when talking to the program director but, and trust me on this, by the first week of intern year almost every resident has lost whatever idealism they may have salvaged from medical school and they will perfectly understand your aversion to call and long hours.

Your call schedule will vary over the year. A standard call schedule is what is called “Q4″ or every fourth night overnight call. “Q3″ is not unheard of but it is difficult to stay in compliance on your hours with this kind of schedule. The surgery interns I worked with at duke were on “Q2″ which meant that they did 24 hours on, 24 hours hours off. This doesn’t seem too bad but it will wear you out pretty quickly. Some more enlightened programs have Q5 or even Q6 call.

Intern year in most specialties is pretty standard as far as call is concerned. You will have a lot of call. Be sure to ask how many call months you have in the year. When I was at Duke last year I had eight months where I took call, mostly Q4. How much call you do as a PGY-2 and beyond is highly specialty dependent. Pathology, derm, and urology to name a few hardly do any in-house call after intern year and if they do, it is usually pretty benign. Medicine and Surgery, on the other hand, are call heavy for most of residency. Medicine call especially blows no matter what level resident you are.

So a good question to ask is how many call months you will take as an upper level resident. Personally, I would rank the programs highest that had the least call but that’s just me.

Also ask about night float. You want to go to a program that has night float as this usually means that the program has decided to make residency more pleasant by curtailing call, or at least making it less onerous. Generally, the night float is a resident who comes in after normal quitting time and leaves in the morning. It is a quasi-shift system as there may still be somebody on call. The night float, however, is supposed to do most of the admissions and handle most of the floor calls only waking up the on-call resident if things get really busy.

While doing cardiology at Duke, we had one week of the month on night float where we came in at seven PM and left at seven AM. Generally the on-call person got to sleep after midnight and the night float took care of business. The advantages of being on night float are legion and I would volunteer for it for all of intern year if I could. Some people don’t like it but I’ll trade vampire hours for not having to round, not having to present patients like a trained monkey, and not hanging around the hospital unsure of whether you can go home. The night float comes in, is relaxed and rested, does his job, and goes home in the morning. It is usually high quality training as you spend the night admitting patients, the key difference between this and being on call is that you are not too tired to give a rat’s ass.

A special warning about family practice residency training and something about which you should ask. Is family medicine more benign from a call point of view than, for example, medicine? Probably. But keep in mind two things. First of all, your program will likely have an inpatient service and you will pull call to admit and cover the Family Medicine patients who come to the hospital. The Family Medicine service is usually not as busy as the medicine service (unless you are at an unopposed program in which case you are the de facto medicine service) as they usually only takes bona fide family medicine patients who belong to your outpatient clinic.

I had a census of about 25 at any given time while doing pulmonary last month. The family medicine service has four or five.

A medicine service generally admits anybody from anywhere with various services taking their turn as “no doc” for the uninsured or unassigned patients.

Small or dying Family Medicine programs either have no inpatient service in which case you will spend a lot more time rotating on medicine services than you probably want to or they have home call where you can sleep at home, only coming in to admit patients. The medicine interns are usually called for overnight problems with these patients, either by formal arrangement or because the nurses know that it sometimes takes a Papal Bull to get a family medicine resident to come in. Some hospitals also don’t let Family Medicine admit or manage ICU patients which is probably another thing you need to ask about.

You will also have obstetric patients as family medicine resident and the custom is to call you in when your patient is in labor. This throws a whole new level of unpredictability into your life as you can be called in at any time to deliver one of your mothers. You will either be excited about this or you won’t but you’ve got to do it. You will also have to come in to admit your obstetric patients for other reasons besides labor. I like to think of it as having forty or fifty ticking time-bombs hidden around town any one of which can go off and ruin your weekend.

You know, sometimes when you’re managing real problems on the floor or admitting interesting and complex patients, call can almost be fun. Usually, however, it is just a grind. After you admit your fifteenth COPD exacerbation the thrill will be gone. So think about it before you rank programs.

Random Madness I

Pulmonary Consult

Breathe

“I’m a difficult patient,” declaims Mrs. Olafsen proudly around a mouthful of Whopper with cheese. “Nobody knows what’s wrong with me.”

“Really? It certainly looks like that from your chart.” Mrs. Olafsen is gigantic. It took four nurses to get her from the stretcher to her bed. Her legs, like two scaly tree-trunks, encircle a greasy fast food sack which was supplied by one of her skinny daughters.

“I’m Dr. Bear, one of the Emergency Medicine residents working with the pulmonary service. Your doctor asked us to come take a look at you.”

There is a lot of Mrs. Olafsen to look at.

“They tell me you had some trouble breathing.”

“Oh yeah.” She carefully shifts her enormous body and gestures for her daughter to hand her the vat of soda resting on the night stand. “I couldn’t hardly breath when I came in. Isn’t that right?”

Her daughters nods furiously.

The chart does not do Mrs. Olafsen justice. Asthma, COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure), NIDDM (Non-Inuslin Dependent Diabetes mellitus), PVD (Peripheral Vascular Disease)…all the usual abbreviations. Everything about her is larger than life. She actually looks and sounds pretty good, all things considered.

“I’ve had the flu or something for the last two weeks. I just couldn’t breath at all this morning and my daughter called the ambulance.” She roots in the bag for the greasy debris and finishes her drink with an exuberant slurp.

No kidding. She presented a few hours earlier in Status Asthmaticus, a sometimes fatal exacerbation of asthma which is refractory to the usual treatments. Imagine every small airway in your lungs clamping down tight. I read with interest on her chart that the use of heliox (a low-density mixture of oxygen and helium that results in less airway resistance) was contemplated but not used because she got better.

The oxygen going to her small tracheostomy hisses and bubbles in the humidifier. I see that she is at her baseline oxygen requirement and is “satting” in the upper nineties. Vitals suprisingly good. Her blood pressure is better than mine and she is the most alert and engaged patient I have seen all day.

Mrs. Olafson. Viking fertility godess surrounded by her pretty, reverential daughters. Nothing much to do, really, except write the usual admission orders and the standard prose on the admission HPI. (“46-year-old woman with a history of asthma presented to the Emergency Department in staus asthmaticus…etc. etc.”) However, If there’s one thing I’ve learned this month it’s that everybody can have a pulmonary embolus and Mrs. Olafson is a set-up for one. The D-dimer was equivocal so I order a doppler ultrasound of her massive lower extremities.

The ultrasound lab pages me an hour later.

“You’ve got to be kidding.”, says the tech, “It’ll take three of us just to lift her pannus out of the way.”

“Just do the best you can. I don’t think she’ll fit in the CT scanner.” I know it’s asthma but we’ve had a bad experience recently with a pulmonary embolus (PE) so the service is a little spooked. I examine my logic for ordering the ultrasound. A negative scan, by itself, does not rule out a pulmonary embolus which can only be confirmed or excluded by a CT 0f the pulmonary artery and it’s branches. A low D-dimer would have done it but it is high…but not that high. Why not just skip the ultrasound? We’re going to start DVT prophylaxis anyways.

“When will I get a bed,” asks Mrs. Olafson clearly tired of repeating her story to another guy in a white coat.”

“I don’t know. But we’ll get you upstairs eventually.” The moon will not set before I see Mrs. Olafson safely transferred and slumbering in semi-upright splendor. She seems melted in the flickering light of the television.

The Fresh Prince of Bel Air. I swear, it’s the only thing on at 3 AM.

Mr. Bomagard has died. An hour ago, the ICU informs me.

“Who?” I’ve never heard of him. I’m cross-covering.

“You know, the guy we coded for half an hour yesterday.”

Oh. That guy. I was at the code but it was very well-attended so I didn’t do much. An elderly and demented gentleman who checked out several months ago but whose body had been preserved as a museum to our arrogance and folly.

Mr. Bomagard actually died yesterday. He was in asystole for close to ten minutes before his heart was coaxed back into sputtering life. That was the best CPR I have ever seen. His arterial line measured optimistically normal blood pressure during compressions but trickled away to nothing when they were stopped. And he had the oxygen saturation of a teenager. He came back in stages. From asystole to ventricular-fibrillation at which point he was shocked, the response becoming more dramatic as the current was dialed up. He was finally stabilized in a tenuous sinus rythm on a continuous infusion of amiodarone. And three different pressors to keep his blood pressure up.

What were we doing to you, Mr. Bomagard? You have been in a nursing home for the last three years and haven’t spoken or moved in nine months. This was your fourth ICU visit in the last year. Maybe when you’re being fed through a tube, breathe through a tube, defecate and urinate through a tube…maybe it’s time to let you go. It’s not even a question of your dignity because we’ve taken that away from you. Your shrivelled naked body bounced to the rythms of chest compressions under the bright flourescent lights for ten minutes while your children looked on from just outside the door. Another minute and we would have called it off.

We should have let him go a year ago but families lie. The patient always perks up for them. He knows they’re in the room. It’s not much of a quality of life but we’ll take it. Please don’t let him die. We still see the man we knew in the contracted husk with the tubes and wires sticking out of him. You didn’t see him when he held his first grandchild or on our honeymoon before he shipped out for the Pacific. He’s still in there, somewhere.

He has to be.

“It’s not like they held a gun to my head and made me smoke,” says Mrs. Needlebacker between coughs. “I knew it was bad but I still did it.”

“Don’t beat yourself up, Mary,” I say, “We all have bad habits.”

“Do you, young man?”

“Well, I used to drink but my wife made me quit.”

Mrs. Needlbacker laughs then coughs. I didn’t really drink that much but what can I say? She is 65-years-old and lung cancer has got her in its death grip. When, in her 150 pack-year history of smoking did she realize it was kiling her? When she became short of breath working at her job as a cashier? When her need for supplemental oxygen finally overlapped into her entire day?

She has been coughing up blood. I write “hemoptysis” on my daily note.

“Can I do anything for you, Mary?”

“Yeah, let me out to smoke.” She laughs but she’s serious.

“You’re on oxygen. Your hair might explode.” If it was in my power I’d wheel her downstairs myself and let her smoke as much as she could stand. “Besides, those things will kill you.”

More laughter, more coughing. “No, you’re killing me.” We make the same jokes every day.

I will be off the service on Monday. We are transferring her to hospice in the morning.

Pulmonary Consult

An Exercise in Frivolity

Why Suffer?

There are two broad categories to keep in mind when selecting and ranking residency programs. One type is at a large academic teaching hospital. The other is at a smaller “community” hospital that may have only a polite affiliation with a university or even none at all.

You can get good training at either type of program but all other things being equal, life will be a lot more pleasant if you opt for a community program.

Take a big institution like Duke where I did my intern year. A good place to train. World class faculty. Impressive facilities. All of that crap that looks good on a brochure. On the other hand it is a relatively miserable place to do an intern year unless you are a robot with no interests outside of medicine. I am repeating intern year in a community program at a small regional hospital. I like it a lot better, mostly for reasons that some of you might find frivolous.

It is hard to believe that although I have no outpatient rotations whatsoever this year and have done three critical care months almost back to back, I have had more weekends off in the last four months than in my entire intern year at Duke.

At Duke, which you may take to represent big academia anywhere, they have the old-school attitude towards the house staff, namely that residents don’t deserve time off and have to earn it by becoming attendings. Thus, they make a big deal about the rare times in your schedule when you have Saturday and Sunday off. In fact, they call this a “Golden Weekend” under the insulting premise that you should be happy and grateful to have been awarded such a special treat.

At my new program, on the other hand, we have weekend call but the residents on most services decide among themselves if everybody needs to come in. We usually don’t need to. This works out to two or three full weekends off per rotation. The difference is that our attendings are usually in private practice, don’t want to come in on the weekend either, and are generally a lot more easy-going than their academic counterparts.

It’s not as if you’re going to be following the ideal model of intern education where you admit, follow, and lovingly discharge a small group of patients with whom you become intimately familiar. If that were the case, maybe it would make sense to come in every day and see how they were getting on.

In a real hospital, however, you will work on service with a steady stream of admits and discharges and it will be impossible to follow all of the patients you admit. You will dive in and out of the torrent following patients somewhat randomly. If this is the case, you may as well round on patients you don’t know over the weekend because you hardly know your own from day to day. (At most residency programs, big or small, residents are just cheap labor. Learn and understand this.)

At a small community hospital, nothing much gets done on the weekends anyways unless it is an emergency.

How about rounding? Academic physicians have the tyrant’s love for an audience. The more academic the institution, the more you will round and the longer the rounds will take, even if this is not the most efficient way to either learn or conduct business. You can learn valuable pearls of wisdom from rounding but a good deal of the time the discussion devolves to merits of competing studies which address the patient’s treatment. Fascinating stuff, no doubt, but I have no dog in the fight. I’ll follow whatever practice guidleline is eventually developed after the adults hammer things out as I am uninterested in the nuances of research.

I’m not saying that you will not round at a community program, just that the odds are your attendings will not have such a zeal for it. Remember, it is a deliberate decision to go into academic medicine. Most people do not. Odds are that if you want to work in academia you like how they do things and will trade a little bit of salary for an entourage and a team of residents to do your scutwork.

Big institutions are also a good deal more bureaucratic. Duke was almost insufferable. They have a form for everything and you can hardly wipe your ass without some kind of certification that you have completed the mandatory yearly ass-wiping seminar. This is all driven by the legal department and is part of risk management. The idea is that if you ever yell racial epithets at a patient the institution is protected from liability because they can demonstrate that you had a certain number of hours of diversity training.

They are out of control. I received almost daily notifications that some compliance requirement or another would expire in a certain number of months. The emails always ended with a sinister threat of being fired or otherwise disciplined for failure to comply.

Intern orientation at Duke took two days and I must have filled out fifty forms acknowledging that I wouldn’t sleep with patients, call them bad names, and had read and understood that surfing for porn on a Duke computer is verboten. It’s all horseshit, of course. They preach at you for an hour, you sign a piece of paper, and then you forget about it. If you’re the kind of guy who hits on patients you’re not going to be deterred by a signed disclaimer.

That’s mostly my point. They make a big deal about things that should be common sense. Everybody knows not to date patients. It happens, of course, but do I need two hours of instruction on it?

They were also mad, absolutely barking-mad, for evaluations. Quality control is great but is it necessary for any instititution to be so self-centered that they’re always asking, “How’m I doing?”

You’re doing fine. Now fuck off.

Asking for evaluations is a way to dilute responsibilty. Bureaucrats hate making decisions, especially decisions for which they will be held accountable. Evaluations and other forms of “decision support” are tools to deflect criticism if something goes wrong. Consensus is a totally gutless form of management employed by the spineless.

I suppose that ever since Press Ganey, the Fifth Horseman of the Apocalypse, issued forth from management hell it is inevitable that we will have to fill out evaluations. Smaller programs seem to have less of this and take them less seriously. Nobody at my current program has ever threatened to fire me if I didn’t turn in evaluations which did happened at Duke.

Pick your program carefully.

The Devil, for those of you wondering how he will come:

http://www.pressganey.com/

An Exercise in Frivolity

Two Minute Drill III

Pathology

Instant credibility at a parties. Hushed respect from the public. Pathology is the coolest specialty. Sure, shows like Nip/Tuck and ER have made plastic surgery and Emergency Medicine seem glamorous but pathologists cut up dead bodies, man!

They certainly do, but not every pathologist does this regularly. Pathology is the study of disease. In this respect Pathologists are “Doctor’s doctors” as they are consulted by physicians. Much of a pathologist’s day is spent looking through a microscope, nailing down an exact diagnosis. But the public doesn’t know this…all they know is that they cut up dead bodies, man!

Let’s say a patient is having a tumor surgically removed. The surgeon takes tissues samples at the margins of his his resection and sends them to pathology. There a technician makes a frozen section of the samples and puts them on slides with the appropriate stain. As the surgeons stand around the patient talking about their golf-game, the pathologists looks at samples to see if there are “clear margins,” that is, no abnormal cells indicating that the surgeons have removed the entire tumor. If the pathologist detects abnormal cells, the surgeons take wider margins. The examination of tissue samples like these is a big part of a pathologists job.

Another function of pathologists is to make the rest of us slap our foreheads like country rubes and say, “Dammit, it’s so obvious given the symptoms and blood smear. Why didn’t I think of that?”

Pathology has two main divisions, anatomic and clinical. Anatomic pathology involves autopsies and examination of tissue. Clinical pathology focuses on diseases, particularly those that leave their imprint on a cellular level. A pathology residency covers anatomic and clinical pathology.

It is a lifestyle specialty. The hours are good in residency and there is almost no call. There are no, repeat no, pathological emergencies. The dead will keep and while some malignant cancers spread fast, they don’t spread that fast. I have never heard anybody say, “We need the pathologist and we need him right now!” It pays fairly well too once you get into practice. It is also one of the few non-surgical specialties which doesn’t worry about competition from mid-level providers. A Nurse practitioner may be very comfortable managing someone’s blood pressure but pathology is way, way out of her league. Heck, it’s out of my league if we get down to it.

The competitiveness of pathology varies, it seems from year to year. If you like pathology and want to do it (and are not a moron) you can probably match into it.

Neurology

You need a lot of tools. That’s why neurologists are the last doctors to carry the old-fashioned “doctor’s bag” which your mother may have bought for you as a present when you were accepted to medical school. For a good neuro exam you apparently need more tools than an auto mechanic even if most of get by with a reflex hammer, a pen-light and sharp stick. A tuning fork is necessary to assess the posterior column senses (or is it another column?) but I have rarely seen it deployed by anybody other than a neurologist.

One of the first real skills you will learn is to do a good neurological exam, everything from the cranial nerves (On Old Olympus Towering Top A Fat Veiled Girl Vends Ancient Hops) to motor and sensory. At first you will feel silly going through the motions but one day you will find a real, honest to God focal neurological deficit and you will be hooked. Then the CT or the MRI will confirm your finding and you can harumph and insist that those studies were unnecessary as you localized the lesion with nothing but your physical exam prowess.

Neurologists are kind of like that but on speed. As most of you know, the brain (and spinal chord) is an organ of bewildering complexity. Everybody should know the basics but the neurologist easily localizes a small lesion to an obscure section of the brain that you only dimly recall reading about. In a conscious patient, I don’t believe neurologists really need CTs or MRIs.

Neurology is a typically a four year residency. It is more competitive than internal medicine but somewhat less competitive than surgery. If you show an interest and do a lot of neuro rotations in fourth year you are probably in. There is some overlap with neurosurgery (and orthopaedics) but neurologists are not brain surgeons. It’s like the difference between a cardiac surgeon and a cardiologist. They usually work in concert, each consulting the other as required.

Bread and butter for the Neurologist? Alzheimers. Multiple Sclerosis. Strokes. 98 percent of the patients I saw on my neurology rotation fit into these categories. An occasional glioblastoma but most of these were referred to neurosurgery.

Neurologist are all a little “off,” at least I have never met a totally normal one. Every neurologist I have met had at least one annoying mannerism or a certain way of interacting with his patients that made me cringe. But I must confess my ignorance. I don’t know anybody who even considered matching into neurology. Nobody from my class did. I just don’t know what kind of person goes for this kind of thing.

Neurosurgery

Top of the heap and the most competitive of all specialties. The only job where you can say, “Well, actually, it is brain surgery.” The board scores, letters, grades, and general knowledge required to match into neurosurgery are so far above my capabilities that I blush to even comment.

For all that, I have never met a malignant neurosurgeon attending or resident. I think they are above all of that petty bickering and emotional masturbation which is typical of many other competitive specialties. I guess if you are spooning a lesion out of somebody’s brain, trying to isolate a ball of slightly dense yogurt from the background of less dense yogurt, you just can’t be bitchy and high strung.

The first rule when rotating on neurosurgery is to pretend you have been pulled over by a cop and keep your hands where he can see them. Don’t touch anything. One slip and there goes your patient’s ability to form coherent words. There is nothing in there you want to mess with. Put your eyes to the other eyepieces of the surgical microscope, keep your mouth shut, and laugh at all the attendings jokes.

A specialty of incremental success. Very few people escape serious head injury with no deficits. A bad outcome is a question of degrees. Grandma can’t talk but at least she’s alive.

Some overlap with orthopaedic surgery as both specialties work on the spine and the spinal chord.

Two Minute Drill III

Two Minute Drill II

Psychiatry

A specialty at a crossroads. Once dominated by Freud and Jung but now becoming evidence-based like the rest of medicine. The psychoanalyst’s couch being replaced by the SSRI. Now as much pharmacotherapy as behavioral therapy.

No specialty is more polarizing for medical students. I don’t think anybody hates psychiatry (because how could working with the insane not be interesting) but people are very clear early in their psychiatry rotation whether they will consider matching into it. The specialty seems daunting at first. How is it possible to classify something as complex as human behavior and then develop a rational strategy for treating its dysfunctions? Can progress or a cure ever be objectively demonstrated? If these questions bother you then you will find psychiatry frustrating.

The only specialty besides radiology in which you can probably get through the day without touching a patient. It’s not that psychiatrists don’t know how to do physical exams, just that their area of interest does not lend itself to traditional physical exam skills. We all need to learn to listen to our patients but this is probably all a good psychiatrist really needs to do to nail a diagnosis, apart from asking the occasional leading question.

Not very competitive which leads to the same sort of thing you see in other non-competitive specialties, that is, a wide range of abilities in people who apply for it. Some of the worst residents I have ever seen were in psychiatry-but also some of the best. Some people match into it out of a real love for the specialty. Others, particularly foreign medical graduates, use it to establish a toehold in the United States.

About the worst intern I have ever seen was a guy from some South American diploma mill whose only redeeming characteristic was that he made the third year medical students look good. I was a third year medical student at the time and helped him out as much as I could by identifying the location of major organs for him and keeping him up to date on the latest guidelines for normal blood pressures. You know, complicated things like that. He didn’t actually ask me what all of those squiggly lines meant on the EKG but I know he was thinking it.

A good psychiatrist, on the other hand, can work what seem like miracles. So pick your program carefully.

Also a “lifestyle” specialty. Very much a nine-to-five job. There are psychiatric emergencies but Vitamin H will keep the patient fresh until morning. Many, many different ways to practice with a wide range of income potential depending on what you do and how well you do it.

Radiology

What’s there not to like about Radiology? Good pay, relatively easy residency, no rounding, no physical exams, no urine spattered drunks, no drug seekers, and empathy is optional. If you play your cards right you can spend your career sitting in a darkened room like some ancient Greek oracle looking at interesting pictures and making profound but strangely non-committal comments. Is it any wonder that radiology is one of the more competitive specialties?

You can do interventional radiology as well and get the best of both worlds. That is, patient contact with the ability to retreat into your mysterious lair when you get tired of it.

I am jealous of radiologists. As an Emergency Medicine resident I spend my day thinking to myself, “Thank God I am not that poor slob. His residency is brutal.” But not when it comes to the radiology residents. That, my friends, is the life.

The big worry of radiologists is that they will be replaced, either by off-shore sweatshop radiologists working for Indian minimum wage or by advances in imaging technology which will make studies so easy to read that the radiologist will be like the guy bringing punch to your prom date. Helpful, but not a real factor in your chances to score later on.

These fears are unfounded. As long as medicine continues to operate in a predatory legal environment, the carnivorous lawyers are not about to let their prey scamper away to the green pastures of safety beyond the big water. In this respect the lawyer is the radiologist’s friend. Sure, you may get a “wet read” on a CT at 3AM from Bangalore but liability being what it is an American (and thus litigatable) radiologist is going to have to sprinkle holy water on it.

With this being the case, why bother having somebody on the other side of the world look at it if he can’t cover your ass? Most of us can (or will learn how to) distinguish the big killers and the common things on x-rays, CTs and MRIs anyways so there is no real service being offered here.

Will imaging technology ever get so good that he radiologist will be redundant? Don’t bet on it. Better images will paradoxically lead to the need for a more precise and expedient diagnosis. One day, when every patient who enters the hospital walks through a whole body scanner a la Star Trek, we will still need radiologists to make sense of it all.

Nuclear Medicine

Radiology’s slightly slow cousin Wilbur. A two-year residency after a preliminary year in anything. The use of radioactive isotopes which are ingested, injected, or inhaled to make images of the body using gamma ray cameras (Scintilography). Different from radiology where external radiation (well, except for MRI) is used to produce an image of anatomy, nuclear medicine uses internal radiation to produce an image of physiological function.

Thnk things like PET, SPECT, radionuclide angiocariography (RNA), multiple gated acquisition (MUGA), and the like. Not to mention V/Q scans, bone scans, and all kind of whiz-bang, golly gee image modalities.

Can you get a job just specializing in Nuclear Medicine outside of academia? Probably not. I was thinking about it as I looked for a way to escape the empathetic talons of Duke and did a little research. Generally speaking, most places want their nuclear medicine guys to be double-boarded in radiology and nuclear medicine. As a result nuclear medicine is functionally a radiology fellowship. Either that or it is used as an “in” to radiology.

There are very few nuclear medicine residency programs because of this.

If I am wrong about his than I am willing to be corrected.

Two Minute Drill II

Two Minute Drill

Your Opinions Will Vary

Haterade is welcome but please have a point.

Internal Medicine

The backbone of medicine. You will know a lot about everything upon completion of residency, so much that you will frighten those around you, especially when you generate a three page differential diagnosis from obscure symptoms, every item of which is reasonable and makes sense. I genuflect to IM residents for whom I have the deepest respect.

Rounding. Rounding. Round some more. If you don’t like it, don’t even think about it.

Unpopular specialty with American medical students except those hoping to subspecialize because, well, primary care is unpopular at this time. Many, many fellowships in anything from Infectious Diseases to Hematology-Oncology. Nephrologists are so smart they make other doctors submissively urinate. Very easy to get a residency position somewhere although there are many programs which are individually extremely competitive. Somewhat more difficult to land a good fellowship so you are not done with writing personal statements and begging for a job just yet.

Urology

I am not mature enough to be a urologist because most of the jokes I know involve testicles and penes. (The plural of “penis”) One week in medical school was enough. I am just not interested in men’s sexual dysfunction and I don’t want to pry into their sex lives which is what a good urologist needs to do. I suppose you can get used to anything but I just don’t know.

Very competitive specialty, by the way. Well paying and the residency hours are not bad for a surgical specialty. Heck, the hours are pretty good compared to any residency. I can’t imagine call is too intense. Are there really that many urologic emergencies?

Of course, the ideal urologist would be named Richard Johnson, Dick Wiener, or Dong Hung Lo. I understand they give you extra points for the match if you have a descriptive name.

Seriously, though, a very cool surgical specialty which is broad enough to encompass clinic work and a variety of surgical procedures but focused enough where you are not worrying about every little thing. From talking to residents, I understand that they have tremendous job satisfaction primarily because of patient gratitude. You hate the guy who gives you blood pressure medications. You love the guy who gives you Viagra.

Family Medicine

See my many post on this subject. “Family” Medicine. Not manly. Not manly at all. “Family” anything is just not sexy. Too non-threatening. Trauma Surgery is the dangerous-looking thug dating and impregnating your daughter before dumping her for a Bolivian hooker with a wooden leg. Family Medicine is the decent, slightly pudgy guy named “Walter” who really loves your daughter for her personality and will live with the shame of being the step-father to the dangerous guy’s kid. And even though he beat her, your daughter still prefers the thug to her husband.

But that’s just me. It is a decent specialty but hugely unpopular like most of primary care. Despite pages of AMCAS personal statements now in the dustbin of application history, most people grow to find chronic management of patients somewhat unappealing. Sure, I liked some of my patients and was very happy to see them but you’re pretty much stuck with them all.

Family Medicine’s scope is too broad as it encompasses pediatrics, internal medicine, and Obstetrics and Gynecology (OB/Gyn). Let’s give it the benefit of the doubt and say intern year is interchangeble between these specialties. (it isn’t, you understand but let’s be charitable) You are still left with 2 years of FM to learn 2 year worth of peds, two years worth of internal medicine, and four years of OB/Gyn. That’s eight years of knowledge to cram into two years of FM after intern year.

Now, Family Physicians don’t claim to be pediatricians or internists but why take your kid to the FP whent there is a pediatrician in town? Also, most FPs don’t do a lick of OB secondary to the inabilty to get priveleges and liabilty so why bother getting the training other than the basic intern training that I believe every intern in every specialty should have?

Tremendous fear among family physicians and residents that they will be replaced eventually by Physician Assistants and Nurse Practioners who operate as primary care providors in many states almost free from physician supervision. Maybe not replaced but salary parity would make going to medical school and residency, seven years total, seem like a bad investment when a two or three years master’s degree gets the same pay.

If that weren’t bad enough, the fellowship offerings for those who wish to subspecialize are mighty slim pickings and few lead to accredidation in the new specialty. Sports Medicine is one good fellowship and much sought after. You can do an OB fellowship and (I believe) an Emergency Medicicne fellowship but neither lead to board certification and may or may not be career enhancing. Plenty of government jobs if you have the hankering to get a Masters of Public Health or work as the liason to some quasi-governmental group pushing hard for socialized medicine so the nanny-state can get us to eat our vegetables and lose weight.

General Surgery

Some surgery residency programs brag (well, sort of) that they have a 100 percent divorce rate among their residents. Work hour limitations or not, surgery is a very demanding residency. You have to be very dedicated to surgery to survive. Emergency Medicine, family medicine, anesthesia, and many other specialties are littered with ex-surgery residents who looked around and said, “It’s not worth it.” And not just interns, either.

Very demanding schedule. Not only will you operate but you will also have clinic duties which most surgeons dislike as it keeps them from the OR. Expect early mornings and late evenings with plenty of call.

The tradeoff is that surgery is very cool. It requires skill and precision and ideally will yield concrete results. Patients love their surgeons. Again, the internist can have worked with the patient for ten years managing a plethora of potentially deadly and complex medical conditions but take out his gall bladder and you are his hero for life.

General surgery is mostly abdominal and digestive tract surgery. Colectomies, gall bladders, and the like. Hernia repairs. A lot of wound management. Many opportunities to sub-specialize. Cardiothoracic surgery is a separate specialty and residency as is neurosurgery.

I liked trauma surgery but it and another month of general surgery during medical school was enough for me. I endured rather than enjoyed my two surgery rotations as an intern at Duke.

Pretty competitive, too.

Obsterics and Gynecolgy

After you get over your natural revulsion at looking at vagina as a career, it is a very intersting specialty which is, like urology, broad enough for plenty of variety but not so broad that you spend your career chasing every little thing. For those who don’t know, it is both a surgical and a clinic-based specialty. Mostly pelvic surgeries of course. Hysterectomies, obviously. But all kinds of other things including “slings” to repair prolapsed bladders and cancer surgery. Also primary care for women, annual exams, pap smears, and other bread-and-butter stuff.

Babies too. Managing pregnancy and delivery. A lot better than pediatrics because once the umbilical chord is cut you never have to deal with the child again…ever….a big plus in my book.

Scroll down for description of a typical day for an intern on an OB servive.

Do I like delivering babies? I don’t dislike it but it is not on my top twenty list of things I enjoy. Can men do OB? Of course, but the specialty is female dominated and getting more so under the general and absolutely wrong-headed assumption that patients should be treated by Doctors who “look like them.” My internist is a chick. I don’t begrudge her the yearly prostate exam.

Probably the most clique-ish of any residency. Relatively cool towards outsiders and rotators. I also think that OB residents are the most malignant towards medical students and interns, not surgeons as is commonly believed. You can get along with a surgeon. I cannot, easily, grow a vagina so it is an uphill struggle.

I have tremendous respect for the specialty, however.

Pediatrics

Perhaps the most boring clinic known to man. Most kids are healthy, thank God, but they are still brought to the doctor with distressing regularity for “well child checks,” colds, eczema, diarrhea, and other usually minor complaints.

“Well Child Checks.” Pointless but you have to concentrate because every now and then you will pick up something that will have lifetime consequences if not treated. Can someone please computerize the growth charts? I get eye strain looking at them.

Pediatric wards, however, are very cool. Sick kids usually get well when skillfully managed (and even unskillfully managed) which is very gratifying. Pediatric residents are the equal of internal medicine residents when it comes to medical knowlede. Pedatrics is internal medicine for children when you think about it. Every adult sub-specialty has it’s pediatric equivalent. Pediatric Nephrology, Pediatric Gastroenterology etc. so there are many opportunities for fellowships.

A very challenging but at the same time non-malignant residency, I have been told. Come on. These people talk to kids all day. It takes a true psycopath to talk sweetly to a four-year-old and then turn to his confused intern and call him a “waste of sperm.” It’s just not like that.

General pediatrics suffers from low salaries in practice but the specialty is still popular and is probably the one field which is a “calling” to most of it’s participants. I am a cynical dog and something of a misanthropist but I love our children’s pediatrician.

Emergency Medicine

What’s there not to like, especially in residency? Regular and predictable hours as it is shift-work. Incredible variety of patients, everything from chronic stable back pain that all of a sudden became an emergency at three in the morning to major, extremely sloppy trauma. Gynecological exam for an STD and five minutes later pushing thrombolytics for a massive pulmonary embolus. Plus you are safe from those “two dudes” are causing all of that mayhem out there.

It’s the only specialty where SOCMOB (Standing on Corner, Minding Own Business) is a legitmate abbreviation, as in “Patient was SOCMOB when he was attacked by two dudes. Also a good specialty to meet fellow christians as everybody was either sitting on their porch at 2 AM reading their bible or coming home from bible study when they were attacked.

The residency hours are pretty decent too, although you will be on a vampire schedule much of the time. It is a stealth “lifestyle” specialty as most people don’t realize the advantage of working four days in a row and then getting three days off. It pays very well, too, as there is currently a shortage of board certified Emergency Physicians. It is definitely the best paying three-year specialty.

Best jokes and most laid-back colleagues of any residency. EM residents need to cultivate affability and calmness. Other specialties might throw a hissy fit but we feel your pain even if we are killing you with admits. You need to like multi-tasking and managing many patients simultaneously. Prioritizing is important. The triage nurse stacks them in the order of severity and you also have to decide who needs the attention like right now and who can simmer a bit.

You also need to develop the ability to make decisions with limited information. If a patient has no chart and can’t communicate there’s not too much history to ellicit except what the paramedics tell you.

Two Minute Drill