What do you want from a career in medicine?

I am often asked why I decided to pursue a career in medicine; starting at a later age and with many demands both mentally and physically. Quite simply, I knew that I would enjoy those mental and physical demands because I love working with my patients to identify and help solve their health problems. When a patient walks into your clinic, office or you encounter them in the hospital, the most amazing relationship develops that you will ever experience. A person walks into your life and puts their health and trust into your hands. This trust means that you give your best knowledge in terms of figuring out their needs and meeting them.Too many people will confuse what they see on the telly (House, Dr. Kildare, Gray’s Anatomy,Ben Casey, Scrubs, ER) with what is the actual reality of being a physician. There is little “glamor” in this job but there is loads of personal satisfaction in winning those hundreds of little “victories” that you will win over the course of a day. There is also the knowledge that if the health care system continues along the road that it has taken, you are going to make less money for every day that you work in the practice of medicine. The question that you need to ask is “am I willing to work this hard for this career?” If you can answer this in the affirmative no matter what the future holds, then likely you will have a satisfying career in medicine.

In no other career are you asked to be out of the work force for essentially 8 years just to be able to enter a job where you will be making less than minimum wage with an average educational debt of more than $150K. In no other career is your income totally dependent on the policies and regulations of private industry, government regulatory agencies, Congress and state governments. You have no control over what reimbursement will be for your services (those reimbursements have been cut every year in the name of holding down costs) while your costs of maintaining your practice have continued to increase dramatically. 

Primary care (Internal Medicine, Family Medicine, Pediatrics and OB-GYN) have seen their ranks shrink in popularity among graduates of American medical schools for a number of reasons not the least of which is the extremely high costs of medical education, rising interest rates on loans and decreased pay. Those people who are yet to enter medical school and those who are yet to graduate face even more challenges in terms of just being able to make a living (purchase a house, pay off educational loans, open a practice). If you are not yet in medicine/medical school, you are likely (unless you enter the armed forces) not going to be able to afford to enter primary care because of past educational expenses. Along with that, add the fact that if you are not a very strong performer in medical school, you won’t be eligible for residency in one of the “money” specialties and thus, you will be scrambling to make a living even if you are able to get into medical school.

The American Medical Association has been extremely slow to organize and speak for the needs of the young physician. Most of the people (and I am thankful for their efforts) that are able to lobby, have been established physicians in specialties such as opthalmology who can afford to take a day away from practice because their loans are paid off and their homes are purchased and their children have their college education paid for. They have little in common with the newly minted physician who has a young family, a 10-year-old car from residency and a $2,000 a month loan payment in addition to rent (mortgage if they are lucky)and office overhead expenses.  I remember my cousin, who is a neurosurgeon state back in the early 1990s that she had to make a minimum of $10,000 per week in order to keep her office door open.  I am sure that number has increased (increased malpractice costs and office costs) while her payments have been decreasing. In the face of this, why would anyone want to enter this career? How would anyone afford to enter this career?

The answer to these questions are not easy but they are expensive both in time and energy. The truth of the matter is that you had better know as much about the day-to-day practice of medicine before you enter your pre-med curriculum because by the time you have finished your first two years of medical school, you have racked up too much debt to be able to do anything else. Little is taught about practice management/investment/finance either in medical school or residency. Medical school  prepares you for residency and residency prepares you for practice.

Some people want residency programs to include more about practice management, marketing and finance but along came the 80-hour work week restrictions and thus, most residency programs are still scrambling to make sure that they can include all of the experiences that residents need to learn just to practice let alone add to what they need. The business of medicine is very complicated and growing more complicated daily with policy changes at both the federal and state level. It takes many hours to keep up and keep yourself informed.

This gets back to what do you want from a career in medicine? Financial/job security isn’t out there anymore. Definitely respect and admiration are not out there anymore. Hard work, long hours of study and personal and financial sacrifice are definitely out there and ahead. i caution anyone to look long and hard at this career because it’s not easy and there is no relief on the horizon.  Be very, very sure that you have a realistic idea of what day-to-day life is like for physicians who are coming out today and not what you see on the telly. None of those shows are remotely close.

Physical Diagnosis (You get to play with your toys!)

Most medical students take a Physical Diagnosis class during their second year. This course teaches history taking and the skills necessary for performing a complete physical examination. Back in my second year of medical school, I found this course a bit intimidating in terms of what the syllabus outlined for us to accomplish in a few short weeks. Little did I realize that I had most of the tools that I needed to do well in this class, namely, an insatiable curiosity, a good ear, two good hands and total interest in my patients.

 The first lecturer emphasized that we would get 90% of what we needed to make a diagnosis from a good patient history. “Good” was the operative word here because as one sits and reads the “how-to” of taking a medical history, it seems that there is an abundance of information that we must obtain in the patient interview while writing a couple of notes here and there. How would I remember every detail? What happens if I forget something important? What if the patient lies to me? How am I going to figure out what a comatose patient needs? Those were just a few of my concerns in addition to looking at my opthalmoscope and trying to figure out how I would ever get the “hang” of making this forbidding tool useful in my practice.

One day of the week, we would spend the afternoon in the hospital with our preceptors. My upperclassmen friends looked at the name on my paper and said that I had “hit the jackpot” with my preceptor assignment. My preceptor was a master diagnostician and an excellent teacher too. He was an endocrinologist who specialized in metabolic syndrome, a disorder that runs largely unchecked in most medically under-served populations because of poor diet and lack of physical activity. I was excited to get my practical knowledge underway with  my new preceptor. My preceptor had two medical students assigned to his service at the same time. It turned out later that the other student rotating with me was my rotation partner for all of third year so we were great friends and become even closer.

We met our preceptor in his office and he led us to one of the medicine floors in the hospital. He had made a short list of his patients who were willing to have us use them for our history-taking practice. I entered the room of a middle-aged gentleman who was hospitalized for jaundice. I quickly went thorough my script of questioning this very soft spoken man who lay quietly in bed. I came to find out that he was a physician who had been diagnosed with a biliary disorder that would kill him without a liver transplant in the next two weeks. He was kind and patient as I asked all of those questions about family history, social history, medications and the like. He asked me to stop by later that evening and read my historical write-up back to him. When I stopped by, he helped me organize the information and provided invaluable assistance in thinking about how to question patients. We chatted off and on for a week, until he received the word that he was being transferred for his liver transplant. I saw him three weeks later when he was ready to leave the hospital with a new liver, a new life and such joy!

I practiced with  my stethoscope on my own chest. It became very satisfying to lie in bed at night and listen to my own heart sounds. I listened to each sound appreciating the tones and timing. I also listened to my breath sounds, over the trachea, over the bronchi and over the lung parenchyma. I practiced listening to each heart valve and learned to appreciate the subtle differences between the sounds a the pulmonic site versus the sounds at the mitral site. I appreciated the split in my second heart sound with my respiratory cycle. If I could appreciate the subtleties of my own chest, I would be able to pick out abnormalities on my patients.

That pesky opthalmoscope was the biggest hurdle that I had to cross. The first thing that I did was learn to operate the light and aperture. Since I have no visual defects, I always start with the diopter setting on 0. I also quickly learned the utility of performing this examination in a dim room as bright light makes the patient’s pupils quite constricted. A dilated pupil is easier to examine. The other useful piece of information is to start with the opthalmoscope light dim so that you don’t blind the patient while you are attempting to examine the retina. At first, I could just pick out the “red reflex”. Soon, I found a vessel and later, I learned to focus sharply on those vessels and follow them to the optic disks. In short, there is a learning curve that is most quickly overcome if you force yourself to examine the retinas of every patient that comes into your office. If you don’t practice, you won’t learn to do an adequate examination. I would wager that most physicians out in practice today, other than the ophthalmologists and neurologists, do not perform an adequate retinal exam.

When it came to learning the rectal, pelvic and breast exams, we were taught by professional “patients”. These people knew the exams and used their own bodies to teach medical students. On the pelvic exam demonstrations, one of the demonstrators indicated that she was in the middle of her menstrual cycle. One of the male students in my group, left the room and never returned. I never found out how or if he learned to perform a pelvic examination but those demonstrators were excellent. They allowed us to practice and pointed out landmarks and hints that were invaluable. I found myself thinking about the type of person who is willing to become a professional demonstrator of breast, pelvic and rectal exams. While the job pays well, I would have to cross it off of my list of things to do if I needed loads of money quickly.

The neurological examination is the most fun to perform and write up. I found myself collecting an odd assortment of instruments to test sensations of hot and cold (I used capped test tubes filled with tap water); vibration (tuning fork), smell (alcohol pads, nail polish remover pads); color sensation (photos); light touch (feathers of various colors) and sharp versus dull (paper clip). I had a small bell and a small stuffed kitten as objects for my patients to name. I also collected a tape measure for lesions and an assortment of cotton swabs and tongue blades for cranial nerve testing.

I learned to perform my history while I was performing my physical examination. I would start with the head and ask about problems with headache, earache and vision. I would examine the eyes and nose while asking about sinus problems. I went from head to toe asking questions as I moved along. I always save invasive exams like pelvic and rectal for the end of the exam. While the patient is getting dressed, I would jot down my pertinent positive findings and spend the rest of the time chatting with the patient and explaining my findings. At this point, my preceptor would usually join me and we would discuss the treatment plans for the patient together.

The most important thing that I learned in this class was the value of communicating with your patient. I probably learned more from my patients than they learned from me. I learned to listen to their words and put their words and my physical findings into a cogent clinical plan for treatment. I also learned the importance of just getting to my patient’s fears, concerns, likes and dislikes. When a physician touches a patient, there is a relationship of trust that is begun. Your patient trusts that you will use everything that you have learned in biochemistry, anatomy, pathology, pharmacology and physiology to figure out what you can do to get them healthy and keep them healthy. There is a puzzle and the pieces must be fit together for the good of the patient.

I also came to appreciate the sanctity of the apprentice-mentor relationship that I had developed with my preceptor. In no other profession is that relationship so important than the attending physician/medical student. My preceptor was indeed a master and I was a very willing student. He led me through the maze of various patient encounters and kept me coming back for more. It was truly magical in many ways.

Finally, I mastered that opthalmoscope during the last week of my Physical Diagnosis class. I was quite comfortable with my exam and I appreciate the art of being able to make a diagnosis. While this class seemed to be quite intimidating at first, it became one the the sentinel courses in my medical school experience. After five plus years of practice and thousands of patients later, I wonder if my preceptor knows how many thousands of patients he has touched through all of his students.

What is it that we do in medicine?

There are mornings after a night of weekend call, that I find myself thinking about what I actually “do” when it comes to the practice of medicine. My first encounter with a patient on a call night is usually in the Emergency Department after one of the interns or Emergency Room physicians has asked for a surgical evaluation. Many times, especially if the patient presents in a complicated manner, the Emergency Room resident or attending will call me directly and bypass the junior resident. This is not because the junior resident is incapable of making an evaluation, but largely to save time.

When I get one of these calls, I usually beep the junior resident and we see the patient together with the junior resident taking the lead. It the junior is in the middle of something else, I will start the evaluation and fill them in when they break free of what is demanding their attention at the time. In general, I have no problem “picking up the slack” when a patient needs to be seen earlier rather than later. I also try to pull a medical student or two if there is something of an educational note (definitely in these cases) that I believe will contribute to their learning.

I generally will introduce myself to the patient and begin to ask questions. Last night, I found myself face to face with a gentleman who had a cold right leg. “Mr J, how long has your leg been like this?”. “I don’t know doc, I think since this morning. It started turning color about four hours ago”. “Doc, I don’t want to lose my leg.” He began to plead with me not to “cut off” his leg. At this point, I begin to set in motion a series of orders to get anticoagulation underway for this gentleman. I also phone my vascular surgery attending who is heading in to the hospital. The interventional radiology fellow has the angio suite ready to go in case we need his services but a thorough examination of this gentleman spoke OR to me rather than angio. I quickly thought about my surgical approach and how I would do the embolectomy (removal of a blood clot) from a branch of the femoral artery by common femoral artery approach.

I reassure Mr J, that we are going to do everything possible to attempt to get some blood flow to his leg. I also explain the procedures and strategy which he accepts and understands. I am careful to explain that we have a very short window of time which may have already passed since he does not know how long his leg has been without blood flow. In cases like these, we treat aggressively unless we are sure that the time span is too long to be successful in the prevention of irreversible injury. Since nerves are the most susceptible to ischemic injury, level of pain is a fairly good indicator of injury. This gentleman had a fair amount of pain but not an overwhelming amount of pain.

As the patient was being prepped and anesthetized, I spoke with his wife who had now arrived and was in the surgical waiting room with the couple’s son. She was certain that this problem had occurred no more than three hours ago (more encouraging for me) and that they had taken the time to speak with their primary care physician who encouraged them to call EMS and get to the hospital as soon as possible. I made a mental note to notify the primary care physician as soon as we were done with this case.

Back in the OR, my attending and I scrubbed and examined our operating field. I had asked the surgical technicians to “prep” the entire extremity as minimally, we would remove the clot but we might need to do more. The angio fellow stood by as we would assess our blood flow by intra-operative angiography. I made my incision and carefully threaded a Fogarty catheter into the vessel. I inflated the balloon and withdrew removing several large clumps of clot at the same time. Upon removal of the clot, there was a rush of fresh arterial blood which we promptly controlled. I continued to pass the catheter down both the superficial and profunda femoral arteries until we obtained a strong pulse at both the dorsalis pedis and posterior tibial areas. I also had good backbleeding too.

We shot a quick angiogram which showed both vessels to be open and I closed the arterotomy in the common femoral artery and closed the small incision that I had made to gain access to the artery. The patient would continue to receive heparin anticoagulant therapy and we would watch for signs of re-ischemia and reperfusion injury. The patient was transferred to the vascular intensive care unit.

I spoke with his wife and spoke with the patient’s primary care physician. We would closely monitor this gentleman for signs of reperfusion injury. He might need additional angiographic studies once this immediate threat to limb had passed. I left him early this morning in the hands of the vascular service as I rounded on my patients and headed home. I have called the unit a couple of times and the patient’s pulses are strong. It looks like this gentleman will go home with two legs.

What do we do? I performed an intervention that restored blood flow to a gentleman’s leg. In the back of my mind, I remembered this man pleading with me to save his leg. I was also very careful to explain that even with the surgery, he might lose this leg at a later date. The fact that we were able to restore blood flow is a great sign that all will go well. In this gentleman’s case, the loss of blood flow to his leg was sudden but because of his age (early 70s) he is likely to have some degree of atherosclerotic vessel disease that may need further intervention.

You see a patient in the emergency room and in many cases, you become a significant part of their lives. Your evaluation skills, your procedural skills and your experience immediately kick in and you do what you have been trained to do. The process is almost gradual and you do not realize that it is even happening. That process comes with seeing hundreds of patients and learning the best course of therapy for their problems. The process comes from hours of reading about the pathology of your patient and why you would choose a particular intervention.

I have a very strong interest in vascular surgery. To me, it is a wonderful branch of surgery with many elegant procedures and cases. I also love the patient population that is likely to come in contact with a vascular surgery (middle-aged to elderly gentleman with atherosclerotic vessel disease). These patient generally have multiple medical problems including hypertension, diabetes and some degree of lung disease (former smokers).

When a patient squeezes your hand, looks you in the eye and asks you to save a foot or leg, you know that you are going to do everything possible to do just that. Most of my best vascular cases have taken place in the Veteran’s Hospital where vascular disease abounds. There just isn’t a better population of patients that need the best care than veterans. This is what I “do” in medicine.