What I Do

(With a hat-tip to the Happy Hospitalist.Nothing new or profound here so my regular readers may, if they desire, ignores this article completely or read on and forgive the basic level of information presented. -PB)

A young reader writes, “Dear Dr. Bear, I am a senior in high school and am thinking about being a doctor. What does your job involve?”

I am a resident physician, meaning that I have graduated medical school and am now doing my specialty training, in my case in a specialty known as “Emergency Medicine.” Some people do not know that Emergency Medicine is a specialty but as you will see, its practice does involve some specialized training as well as an approach to medical care that is somewhat unique. I am a little more than halfway through what will turn out to be a four-year period of post-medical school training. Emergency Medicine training is typically three years but I did an intern year in Family Medicine after which, screaming in fright, I made the switch to Emergency Medicine. (I did not get “credit” for that year in my new residency program.)

No matter what specialty you pursue, you will have to do an intern year which will consist of exposure to all of the major medical specialties. You may perceive this to be of little value if you are, for example, going to do dermatology but since Emergency Medicine is a generalist field, every little thing we learn is useful and can be applied somehow. In other words, I have never been delivering a baby on an obstetrics rotation and said, “Man, this is bogus. I’ll never have to deliver a baby in my real job.”

Medical school itself lasts four years and in all but a few cases needs to be preceded by a four year (or however long it takes you) course of study at an accredited college that leads to a Bachelor’s degree. I have a Bachelor’s of Science in Civil Engineering and, unlike most physicians, did not go directly from college to medical school but instead worked as a Structural Engineer (the cool branch of Civil Engineering) for many years. This made me what is called a non-traditional student but if you’re sure you want to be a doctor there is no need to interrupt your journey and you may as well take your lumps when you are young. The process of applying to medical school and positioning yourself for acceptance is well described on the Student Doctor Network and to them I refer you to find all the information you could ever need. Take advantage of it because even ten years ago, when I was applying, this kind of thing either didn’t exist or was a spare sketch of the resource it has become. I think we now have the first generation of people who take the internet completely for granted.

So I am what is known as a Resident, a physician but one who practices under the supervision of other physicians who have finished residency and are fully-trained in their specialty. These doctors are known as “Attendings” or “Attending Physicians.” We are called residents because once, long ago, if you desired additional training past medical school (which was at one time not common or even felt necessary to practice) you lived in the hospital while you trained. While the hours are long in residency, we no longer live in the hospital but the name has stuck. Residents are also called “House Staff” at many hospitals, again with the implication that they belong to the “house.”

Just for your information, you can be a licensed physician and still be a resident. In other words, I occasionally have patients who insist on seeing a “real doctor,” not a resident. Leaving aside the debate as to whether you are a “real doctor” on the day you graduate medical school (you are), licensing in most states only requires that you complete an intern year and have passed all three steps of the United States Medical Licensing Exam. From a legal point of view, there is a basic level of knowledge and skill that every doctor should possess and this is the minimum for legal independent medical practice doing anything which you feel comfortable doing, can get insured to do unless you want to work without liability insurance, can convince hospitals to give you privileges to do, and can convince patients that you know how to do. Practically, however, you need to specialize and get additional training unless your ambition in life is to work at a low-level Urgent Care. I don’t have to tell you that medicine is very complex with a rapidly expanding body of knowledge that one person wouldn’t be able to assimilate in a hundred lifetimes. Specialization is a de facto necessity.

I generally work 14 twelve-hour shifts in every 28-day block. I either work the 9 AM to 9 PM shift or the 9 PM to 9 AM shift, with seven consecutive days on one or the other. Next year I will work seven to seven instead of nine to nine which allows for some overlap between the third year and the second year residents. The most we ever work is three shifts in a row with at least two days off afterwards. Our schedule is set up so we work Friday, Saturday, and Sunday for two weekends in every block but get the other two off. It sounds like a pretty reasonable schedule and it is. We are allowed to trade shifts so if, for example, you need a bigger block of days off you can swap with another resident provided that you don’t violate the work-hour rules for Emergency Medicine.

During our first year we work mostly off-service (not in the Emergency Department) rotating on other specialties such as Trauma Surgery, Internal Medicine, Critical Care, Pediatrics, and Obstetrics to name a few. During second and third year we spend most of our time in the Department with a few months reserved for electives. Some programs mix it up a little more. The advantage of doing all the off-service training early is that by the start of second year, you are done with call forever. “Call” is the practice of spending the night in the hospital, in addition to your regular daytime duties, to take care of your existing patients, admit new patients, and handle emergencies. I did two intern years, approximately 150 nights of call, and got meaningful sleep on so few call nights that I can count them on the fingers of one hand. Considering that you may have call every fourth night for most of intern year and you cannot just go home in the morning afterwards but usually stay until one in the afternoon, you can imagine that intern year can wear you down.

But shift work isn’t too bad. You have to discipline yourself to sleep during the day or else the temptation to carry on as if nothing has happened can lead to a big sleep deficit which manifests as the subjective feeling of always being tired and falling asleep whenever you sit down. But if you can master the art of sleeping during the day you will always be well-rested for your shift, bright-eyed, bushy-tailed, and ready to go.

We also have conferences to attend during the month. Unlike other residencies that may have an hour of didactic training (lectures) every day, because of the nature of our work we throw them all into a once-a-week, five hour block. If you are just getting off of a shift you still have to go. Likewise if you are on a day off. No excuses. On the other hand conference sometimes runs concurrently with a shift and since conference is mandatory, you are excused. It all evens out. We also have a Trauma Conference once a month which is also mandatory as well as an occasional wild-card thing like Animal Lab where we practice procedures (chest tubes, internal pacers, surgical airways, for example) on live, anesthetized pigs or dogs (all of which are euthanize at the end of the lab). I love dogs (I have five of them) so it can be a grim business. On the other hand we rarely get the chance to do a surgical airway on human patients and if one day, the skills you learned on a poor dog help you save somebody’s toddler…well….it will have been worth it. No question about it.

So I mentioned that I am learning the field of Emergency Medicine which, as medical specialties go and despite what you have seen on television, covers a broad range of medical complaints. A “complaint,” by the way, is medical-speak for the problem that brought the patient to the Emergency Department. In Emergency Medicine, we can see patients with complaints that are so idiotic they transcend idiocy and achieve a sort of moronic nirvana (“My ass is sweating”). We also see patients with some of the most serious injuries and medical problems that you can imagine. Like that biker who you saw get hit by a truck when you were twelve who had big chunks of himself smeared across the road. You can bet that if he wasn’t dead at the scene, some Emergency Physician struggled mightily to keep him from dying long enough for the trauma surgeons to save his life.

So it’s a real mixed bag. Some nights you feel like a school nurse treating things that would have kept normal people home and some nights the trauma and serious medical complaints just keep rolling in and the minor complaints stew for hours complaining about the crappy sandwiches and the limited television stations.

The purpose of Emergency Medicine is two-fold. First, our job is to assess and stabilize injured or severely sick patients until they can receive definitive treatment. “Stabilize” means to keep them from dying by reversing or halting the processes that lead to death. Shock, for example, is a common presentation and as it is just brief rest stop on the road to death, a chance for the Grim Reaper to sip his latte and finish his bagel before he gets to you, we treat it aggressively. Now, as hospitals are somewhat crowded and we can not always get even extremely sick patients admitted quickly (and even if we can the admitted patient can wait in the Emergency Department a long time until a bed is available) we often not only stabilize but make the diagnosis and initiate the definitive treatment. Critical care (also known as intensive care) is a big part of our job and while most of us enjoy it, it sucks up huge amounts of time and detracts from our second job which is to see as many patients as possible in the shortest amount of time.

For a practicing Emergency Physician, this means seeing at least four patients an hour to be considered a guy who pulls his weight. It may not sound difficult but while many complaints are minor, some are not and almost every patient we see is completely new, a Rossetta stone who needs to be deciphered. In fact, it is not unusual to get a “drop off,” a severely demented (senile) patient from a nursing home who hasn’t spoken a word since the Clinton Adminstration and for whom you have only a sketchy medical history (if that) and a chief complaint of “altered mental status.” If you’re lucky you can elucidate a reasonable list of her many, many medical problems from the medication list (if it was sent with the patient) but sometimes you have nothing to go on at all. Sorting it out takes time.

On arriving at the beginning of my shift, I pick up a computer tablet, scan the list of patients waiting to be seen, and select the next one on the list. I do this for the next twelve hours, consulting with my attending to some level depending on the seriousness of the complaint. I am now carrying the trauma pager so when a trauma comes in I drop what I am doing (if it is not an emergency) and run the trauma with trauma surgery and the attending who usually just stands back until his resident scews something up (which happens a lot, it’s training you understand). Occasionally critical patients, those with potentially life-threatening problems, come in and I again drop everything to take care of them. All of this is done in cooperation with the nurses who do most of the actual patient care, the Unit Coordinators who keep the administrative life-blood flowing, and a team of allied health professionals which includes Physician Assistants, Respiratory Therapists, Phlebotomists, Radiology techs, and the like.

One of the biggest parts of our job is coordinating care which involves, among other things, arranging consults, calling on-call physicians to admit patients, talking to the medical examiner after a death, calling patient’s primary care physicians, and a myriad other tasks that keep us on the phone longer than any other specialty.

If you like multi-tasking you will like Emergency Medicine.

What I Do

Two Minute Drill VI Special Edition: Hell Freezes Over

Physical Medicine and Rehabilitation

“It’s the end of the world! The end is here!” shouted the unit clerk as she pulled out clumps of her hair and rocked in her chair. This sort of thing is normal for a unit clerk so I wasn’t too alarmed until I saw the nurses tearing their scrubs and smearing ashes on their faces. The respiratory therapist pushed a vat of Koolaid towards the back and everywhere I looked there was wailing and gnashing of teeth. When I asked what was wrong the charge nurse, who had changed into sackcloth scrubs, pointed in horror to the “cubby.”

“He’s in there, Panda. Oh the humanity! It’s past 5PM! Surely the horsemen are abroad!”

Cautiously I made my way to the cubby (a little alcove where admitting physicians sit to do their paperwork) and was surprised to see a pleasant-looking fellow sitting at the computer studying lab values. But there was something odd about him. His white coat was not just white but pristine. It glowed under the fluorescent lights and the starched creases on the sleeves crackled as he moved his arm. His scrubs, too, were of a strange color the likes of which I had never seen and they appeared new or so clean that he must have been an ethereal phantom passing unsoiled among his ghostly patients. A shiny, electronic stethoscope with the price tag still on as if it had never been used glinted like burnished bronze from his pocket.

“Hi,” he said, turning from the screen, “I’m Dr. Jones, one of the PM&R residents. I’m almost done admitting one of my patients if you need the computer.”

And I was afraid.

But as I am a good (if sometimes wayward) son of my church and made of sterner stuff than the medical students outside in the hall cowering in the corners in the fetal position, I confronted this impossible creature.

“Spirit,” I said, “whether you come as a dark portent of the end times or whether you are merely a phantasm is it not true that Physical Medicine and Rehabilitation is a specialty which treats a wide range of problems from sore shoulders to spinal cord injuries as part of a multidisciplinary team and whose particular focus is planning and implementing physical and occupational therapy to alleviate these conditions?”

“This is so,” intoned the so-called Dr. Jones.

“And is it not true,” I continued, “that you are sometimes called Physiatrists and part of your dark art is to predict the long term consequences of muskuloskeletal injuries and to develop treatment strategies to alleviate these?”

“In this also you are correct,” said Dr. Jones quietly but with obvious menace.

“Is this not the specialty that deals with prosthetics? With orthotics?” I asked, “Is this also not true? Confess, spirit!”

“All of those things of which you speak are correct,” said the corporeal representation of the entity known as Dr. Jones, “But know you that my dominion extends also to movement disorders, muscle pain syndromes, and even unto manipulative medicine in whose service I have made a dark covenant with osteopathic physicians among whom my name is Legion.”

“But spirit, how can this be?” I was perplexed. “The hour is late. The sun sets behind the hills and you, a PM&R resident yet labor in our department, a department whose walls have never seen the likes of you in the morning much less after normal working hours. Is it not written that a PM&R resident knows not the lethargy of the early morning hour nor does he keep the watches of the night (or the late afternoon for that matter)? Does not your kind slumber on the weekends and know not the sting of call or long hours? How can these strange signs be ascribed to anything else but the apocalypse?”

“Oh, don’t worry,” laughed Dr. Jones, “This is the first patient I’ve admitted in two years. But I’m done so if you’ll excuse me…”

And then he was gone.

We still talk about that day when hell froze over.


Two Minute Drill VI Special Edition: Hell Freezes Over

Barking Mad

Psychiatric Ward

Inpatient psychiatry wasn’t as fun as I thought it would be. The people locked up on the tenth floor of our hospital were just a little too crazy to really be interesting. A little insanity, like a little spice, adds flavor to a patient’s personality. Too much of it and it overpowers everything. After all, a patient can only cut his scrotum open with a razor blade a couple of times before everybody just yawns and moves on to the next sensation.

It’s not that I don’t appreciate odd behavior. I am as mean-spirited as anybody and take the usual guilty pleasure in other people’s misfortunes, particularly when they are the result of some absolutely inexplicable but voluntary lapse of common sense.

It’s like slapstick comedy. We shouldn’t laugh but we do.

The truly insane, however, are directed by impulses so remote from the normal as to be both chilling and profoundly boring at the same time. If you’ve heard one patient explain how the television has commanded him to kill you’ve heard them all. If it’s not the television it’s the lawnmower, the dog, or the dead people next door. Just some variation of minds so out of whack that there isn’t even any guilty fun to be had. We don’t laugh and point at a diabetic. It’s the same with insanity.

Now if someone claimed that his cat was hissing dark commands in his head, instructing him to take night courses at the local community college towards a degree in medical coding, well, that would be unusual. I’d settle for his dead mother screaming at him about the benefits of good dental hygiene, something you almost never see in the insane.

What is your job as a medical student working on the psych ward? In essence, nothing. Oh sure, you will follow patients but except that you may have extraordinary conversational skills, you might as well just sit and stare at each other for all the good it will do. They’re schizophrenic. Their brains hear and see things that are internally generated but perceived as absolute external reality. Maybe they can be talked out of it but it will require someone skilled in the black arts of psychotherapy, not little old you casually rotating through. All the talk in the world probably isn’t going to make a difference anyways. The voices will not listen to reason and have to be silenced with psychiatry’s ever-expanding arsenal of medications.

So you will round on your patients and write your notes. Unlike, say, a surgery rotation where you can state proudly on your progress note that the patient “has had a bowel movement and is tolerating a soft diet on post-op day three of his bowel resection,” in psychiatry progress is hard to measure and most of your notes might as well conclude that “The patient is still as crazy as a shithouse rat…but we’re going to discharge him today because he is not a threat to himself or others…for now.”

About all you can do is be a little familiar with the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, the fourth and current edition) which is the Bible, Koran, and Vedic Texts of psychiatry rolled into one hard to digest bolus. When I say to become familiar with the DSM-IV I mean to get a review book, preferably one that will fit in your pocket. The DSM-IV is a large reference text and therefore highly unreadable except on the idiot savant level.

The DSM was developed to standardize the language of psychiatry between different mental health professionals in different countries and psychiatric traditions. This was necessary because as you can imagine, psychiatry is one of the most subjective medical specialties and has previously been very flexible even in the objective description of psychiatric pathology. The DSM also sets forth criteria for the diagnosis of discrete disorders as well as providing a framework for completely describing a patient for the purposes of psychiatric diagnosis and treatment by the use of five categories or “Axis.”

Axis I, for example, describes major disorders like schizophrenia or bipolar.

Axis II is for underlying or pervasive personality disorders or things like mental retardation.

Axis III is a “gimme” or a “freebie” for most medical students and residents who are not interested in psychiatry because while it is technically a description of other medical conditions that may contribute to the disorder, in practice it is the non-psychiatric past medical history. It gives you something to grab a hold of on an otherwise mystifying patient. Here, at last, are conditions that we can treat definitively, or at least definitively know we can’t treat.

Axis IV describes psychosocial factors, things like homelessness, unemployment, or poor family support. Axis V is the Global Assessment of Function (GAF) and is a numeric score from 0 to 100. Most of us function at around 90 to 100 which is considered normal. Someone lower than 60 probably needs to be committed except our society has unfortunately moved away from institutionalizing the mentally ill. That’s a subject for a different day but it would freeze your blood if you knew some of the truly unhinged characters standing in line with you at Wal Mart.

If you know a handful of common psychiatric presentations and can fit them into the five axis you will do all right.

Your psych ward patients will be a mixed bag (of nuts), ranging from the homeless guy claiming suicidal intentions for “three hots and a cot” to the raving but mostly non-violent schizophrenic. It is unlikely that you will rotate, as a medical student, on a ward for the criminally insane which would definitely kick things up a notch in the fear department. Students are occasionally attacked but this is not as common as you imagine. Just make sure to never let the patient get between you and the door, never wear a tie, and don’t get into a pissing contest with a lunatic. With a little common sense you will be fine.

My favorite patients are the bums who have the system figured out. They typically draw a disability check every month and use most of it for booze and drugs. By good economy and thrift they may manage to get almost to the end of the month at which point, malnourished, hung over, withdrawing, and cold they present to the Emergency Department, the 24-hour representative of “The Man” and claim they want to kill themselves. This buys them a stay in the psych ward where they can get a shower, hot food, and some rest in the bosom of the system. The only price to pay is being interviewed every day by an earnest medical student trying to cure them. Most of them actually have underlying psychiatric disorders that contribute to their situation but this disorder by itself is usually not serious enough to warrant inpatient care.

The bipolar patients are probably the most interesting. They will talk for hours in response to one question when they are manic. Even their medications can’t completely suppress this. I’d hate to be friends with a person like that but if you’ve got nothing better to do (and you won’t) you might as well listen to somebody who has everything figured out all the time. Beginners try to faithfully record everything the patient says in their progress note, often scribbling away furiously as the patient talks. Eventually you realize that it doesn’t really matter what the patient says and you condense your description of thirty minutes of frenzied speech to “Expansive mood, inflated self-esteem, and grandiosity.”

When they’re depressed, and you can sometimes follow the same patient long enough to see both sides of the disease, they can be almost catatonic and you will miss your chatty buddy from the previous week.

Will you like inpatient psychiatry? It is an easy rotation. You don’t really do anything but talk and there are no procedural or physical exam skills to learn. The hours are generally pretty good. You see your patients, present them, and maybe sit in a group therapy session and listen to the patients try to one-up each other. It can be frustrating, on the other hand, to write notes that nobody even reads, see patients for whom you don’t even have the usual medical student pretend-responsibility, and get the same tired story from the same patient day after day after day until somebody decides that, mirabile dictu, they are well enough to be discharged.

Barking Mad

Two Minute Drill V

“Opthomology”

The first rule of ophthalmology is to spell it right. Nobody does. I’m not even sure if I just did. The second rule is that nobody should ever mess with the eye unless he is an ophthalmologist. It’s the eye for crying out loud. We see out of them. The margin of error is small. I’m not exactly a crack addict but compared to an ophthalmologist, my hands shake as if I’m doing a couple of rocks a day.

As those of you who don’t confuse ophthalmologists with optometrists know, an ophthalmologist is a surgeon who specializes in the eye. Optometrists make glasses and there is an intense but one-sided rivalry between the two professions. One-sided because the ophthalmologists don’t care and if they did have been known (unfairly) to call optometrists “Chiropractors for the eyes.”

(Optometrists are not medical doctors but go four years of optometry school after which they are conferred a OD degree. There is a lot of overlap between optometry and ophthalmology. Ophthalmologists usually include retail glasses and contacts in their practice and optometrists manage some diseases of the eye. A better comparison would be that optometrists are like primary care for the eyes. Still, I have known several optometrists and there is some bitterness towards their MD cousins.)

What do I know about ophthalmology? A good deal less than I know about any other specialty. As you know I was a family medicine resident for a year and am currently an Emergency Medicine resident. I think I know enough about these to specialties to offer some tentative opinions. I have rotated on most of the specialties I have described in this series of articles and know enough to at least give you an outsider’s perspective of them. I am not a surgeon, for example, but I have done a total of six months of surgery rotations so I have at least a vague idea of what goes on.

I spent a week in ophthalmology during third year of medical school. Less than a week, actually, because Friday was a holiday, I made some lame excuse to slime out of going on both Tuesday and Monday, and went to one procedure on Wednesday where I did nothing and said nothing (which is all that is expected of you). On Thursday I went to clinic, shadowed the resident for and hour or two until his annoyance reached a certain threshold and he signed my evaluation sheet and allowed me to leave.

Ophthalmologists tie knots with suture threads so fine that it looked like the guy was using spider-web on the eyeball he had popped out of the patient’s eye-socket. You are not going to do much on a rotation like this, even if you want to. “Hey, Mrs. Smith, how about I let this third year medical student jeopardize your eyesight?”  One week is also not long enough to learn anything really useful, at least anything that will stick. I go to an ophthalmologist for my glasses and am as mystified at what he does as my patients are when they look at the squiggly lines on their EKG.

Ophthalmology is very competitive as specialties go. It will make even the best students in your class feel like losers when they don’t match, a common event. You might hear people say, “I’m trying for Ophtho but I’ve got derm as a backup.” The lifestyle is very good in residency but it is a surgical specialty so you will come in early and stay late occasionally, at least this is my understanding. You do have call. Eye injuries are common and every injury is an emergency until proven otherwise. Half of your brain is devoted to visual processing. The eye is important.

On the other hand you won’t be admitting patients to the hospital so how bad could it be? (I know there are exceptions to this but we’re talking generally)

The definition of “stressed” is an ophthalmology resident trying to manage a medical problem on the floor. I’ve seen it happen and it wasn’t pretty. But when it comes to the eyes they are magnificent bastards and everybody breathes easier when Ophtho shows up to give slightly bored guidance on the management of an ocular injury that curdles everybody else’s blood.

Orthopedic Surgery

How do you know a note was written by an orthopedic surgeon?

It’s written in crayon.

Other specialties make a lot of jokes about orthopedic surgeons. Heck, the orthopedic surgeons make a lot of the same jokes that they “tell on themselves” with great relish. I don’t know how it came to pass that other specialties think the orthopedic surgeons are dumb. Maybe it’s because most of them (and you will see this) are big, muscular, guys who look pretty easy-going. Maybe it’s because of the mechanical nature of the job which involves a lot of power tools that would not be unfamiliar to Joe Six-pack building a deck for his wife.

In reality orthopedic surgeons have higher Step scores and grades than most other surgeons and the specialty is a good deal more competitive than, let’s say, General Surgery.

But they do use a lot of tools. And it may be the only medical specialty where leverage is important. An orthopedic surgeon carefully balances precision and brute force. Just watch what is required to replace a hip for an appreciation of this balance. And when they’re done the patient walks as if she were a teenager (after rehab of course), or at least that is a reasonably expected outcome.

It’s a competitive specialty but I think there is a large element of self-selection. People who want to do ortho really want to do it. There is none of the wishy-washiness of prospective general surgeons, many of whom bail out after intern year because it’s not as cool as they thought.

Two Minute Drill V

Two Minute Drill IV

Anesthesiology

A poorly understood specialty, especially among surgeons who tend to look at the anesthesiologist in the same way airline pilots look at flight attendants. It certainly doesn’t look like much of a specialty. The anesthesiologist starts the lines, sedates the patient, intubates, turns on the gas and then reads his magazine or does crossword puzzles. If you think about it though, it’s the anesthesiologist flying the plane while the surgeons tinker around in the cabin. The anesthesiologist is responsible for keeping the patient alive and neurologically intact during the procedure.

Almost everyone who undergoes a major procedure gets general anesthesia which involves not only rendering the patient unconscious but also paralyzing his muscles. This explains the need to intubate as a patient in this state needs both ventilatory support and airway protection. The patient is placed into a drug-induced coma, the depth and duration or which are controlled by the anesthesiologist. This also explains the need for residency training as well as the high degree of operating room terror if anything goes wrong.

Anesthesia also involves pain management. If you think about it, the presenting complaint for almost all outpatient visits and hospital admissions is pain of one kind of another. A lot of this is chronic pain and a growing part of most anesthesia practices is pain management.

A lot of the pain is bogus and you will deal with drug seekers like my little old 78-year-old Baptist Aunt who has been addicted to Percocet for the last twenty years. Her doctor prescribed it for something she can’t remember and she has been taking it ever since. She’s not hooked, of course. She’s too respectable for that. But that’s a topic for another day.

It is a lifestyle specialty. The residency hours are pretty good once you get through a standard intern year. You will come in pretty early, earlier than most, but the trade-off is that you’ll have your afternoons free. The anesthesiology residents carry a lot of weight when they are on call, especially when there is a code. We almost never attempt an intubation of what looks to be a difficult airway without having them standing by. I’ve seen an Emergency Medicine Chief resident and a Medicine chief resident both fail to get an airway which the anesthesia junior resident put in while still half-asleep.

They also know the ACLS protocols backwards and forwards as they use them on a regular basis.

Dermatology

Somewhere in this unhappy medical world of ours is a happy place. A place where the grapes hang down from the vines and beautiful maidens cavort in the green pastures and cool forests of Elysium. In this place cows with full udders waddle happily to be milked and the cheeses and hams abound, rich provender for the easy taking.

They call this place “Dermatology.”

Or at least that’s the idea you will get talking to your fellow medical students, the majority of whom will be sick of smelly patients, bodily fluids, the indigent, and the kind of frothy green vaginal discharge that can only be experienced, never described. Dermatology provides an escape from all this. A way out. Not only is the residency, by repute, pretty easy but once you get done you become one of the only physicians around (with the possible exception of the plastic surgeons) who laughs, yes laughs, incredulously at the preposterous notion that he should work for free. And not just any laugh but the full-throated jolly guffaw of a guy who has the world by the scrotum…and has a comfortable grip.

No pay, no play. So sorry. Next.

Now, in reality Dermatology involves quite a few things that people don’t think about. Like severe burn injuries, perhaps the most horrific sight, bar none, you will ever see. It is a legitimate specialty. The skin is the largest organ of the body and if a simple organ like the friggin’ kidneys can have specialists then the so should the skin.

Still, it is the good life, especially as a resident. No call to speak of (“Somebody page the Dermatology resident…his rash is out of control and I’m out of ideas”). Decent work hours, too. Sure, you may work a little in the burn unit but the rest is all outpatient clinic. Nine to five, baby.

This explains the extreme competitiveness of the specialty. The smartest and most capable medical students, all other things being equal and unless they have a zeal for some other specialty, will match into dermatology. Kind if ironic when you think about it because I don’t think anybody professes love for the skin in their AMCAS essay.

We must all weep, as we toil through months of Q4 call, that we are not Derm residents.

Two Minute Drill IV

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

Ask Uncle Panda

1. Say, Uncle Panda, what exactly do you like about Emergency Medicine? I thought the hours were crazy and the burn-out rate was high. What about it?

From the perspective of residency training, Emergency Medicine is far superior to any other specialty. First of all, it’s the most like a regular job of any residency. With the exception of off-service rotations which will fill roughly a third of your three year training (most programs are three years long) you will be working set shifts with a pre-determined start and finish time. (Although you shouldn’t expect to get out exactly when your shift is over as there are usually things to either tie up or sign out.)

To my mind, there is nothing more annoying than coming in early to pre-round on patients only to round on them again with the attending. A tremendous waste of effort. I’m also not exactly sure why we need to come in early on rotations like internal medicine. It’s not like the patients are going anywhere. What invariably happens is a short burst of frenzied activity from 6 AM until ten followed by large patches of dead time until around four…at which point there is usually another burst of frenzied activity. I’m sure this pattern is inevitable but that doesn’t mean I have to like it.

As to burn out, I don’t know. I’m new to the profession and I will have to defer to the opinions of my more senior colleagues. It is my understanding that “burn-out” is greatly exaggerated. Emergency Medicine self-selects for people who like variety, working weird hours, and making quick decisions with incomplete information. While this would quickly burn out someone who likes a more deliberative pace, EM physicians look at this as routine and a good trade for working fewer hours and fewer days.

No questions that the pace is a lot more intense than most other specialties. In a busy emergency department the residents are working all the time. Productivity is critical in the “shop” and second and third year residents are expected to see and “dispo” at least 2.5 patients per hour. On a twelve hour shift this works out to 30 patients which is a lot. It is true that some patients have relatively minor complaints which don’t take that much time but as often as not the next three will be very sick with multiple comorbidities. Not to mention the traumas that roll in periodically. The net result of all this is that a good Emergency Medicine resident has to learn how to juggle multiple patients. If you can’t prioritize, organize, and keep track of multiple plans for many different patients you probably won’t like Emergency Medicine.

As to the hours, they are indeed crazy. While most programs make an effort to accommodate your circadian rhythm, when all is said and done you will be working a lot of nights and leading a vampire-like existence. On the other hand you will be driving opposite rush hour traffic, the banks will be open when you get off work, and academic teaching hospitals are a good deal more laid-back after normal working hours.

Does Family Practice suck?

No, of course not. I didn’t like it but that’s just me. As it emphasizes long-term management of chronic diseases it is not for those with ADD, short attention spans, or who get bored easily. I want to dispel the myth, however, that Family Physicians have some sort of leisurely, non-demanding lifestyle. The fact is that like any other job, productivity is important. In family medicine where the reimbursement for the usual visit is low, patient volume is important. A Family Medicine resident may see as many patients in a day as an Emergency Medicine resident. On the other hand he is unlikely to be working on more than two or three at a time, the presenting complaints are usually less acute, and the chances are good that the resident has seen the patient before and can skip some of the usual history taking.

It is also an unwritten but very real expectation of patients that their family doctor spend some time chatting with them. This is a very important part of the art of medicine but it does add to the time for a patient encounter, especially the family medicine patients that want to talk about everything and who will not shut up. A good family physician masters the art of redirecting the conversation without appearing rude and winnowing down a long list of complaints to the most pressing without appearing callous.

In the Emergency Department it is all right to be a little more brisk as the situation demands.

Just a random thought, maybe if they changed the name of the specialty it might attract more guys. Let’s face it, Family medicine has a decidedly feminine, non-threatening ring to it and calls to mind images of gentle, sensitive men nurturing woman and children. This is not how most guys see themselves. What most of us really want to do is get in touch with our inner Cro-Magnon, not our inner child.

Ask Uncle Panda