Sunday, September 28, 2014

Which Medical Specialty Should Medical Students Choose?

A medical student recently asked my advice on her decision to pursue a career in dermatology.  It was about 25 years ago when my own parents encouraged me to pursue this specialty.   What was their deal?  Perhaps, they anticipated future developments in the field and were hoping for free Botox treatments?   As readers know, I rejected the rarefied world of pustules and itchy skin rashes for the glamor of hemorrhoids, diarrhea and vomit. 

My parents were making a lifestyle recommendation.     Dermatologists are doctors who sleep through the night.  Spying one in a hospital is a rarer sighting than spotting a liberal Democrat at a Michelle Bachmann rally (unless a planted heckler).  Nocturnal acne medical emergencies are uncommon.   And anyone who has had cosmetic work done understands painfully that this is a cash business.

Diagram of Skin
Luckily, the Whistleblower is thick-skinned

Here’s where some readers or Dermophiles will accuse me of skin envy.  Not true.  Some dermatologists may be a tad thin-skinned over this assertion, but facts are facts.  These docs have a soft lifestyle and earn much more money than most physicians do.   Sure, these guys and gals see some serious stuff, but the nature of their specialty is less intense and frenetic than that of other colleagues.  

Many professions push back when it is suggested that they are afforded unique and soft perks that most of us don’t have.  Teachers, for example, never state out loud that having every Federal holiday off, enjoying school vacations every few months and having 10 weeks off in the summer are unbelievable soft padding that no one else has.  We know you work hard under difficult circumstances and we respect you and your profession.  But just admit that you have some unbelievable professional cushions.  This won’t diminish your self-worth or contributions to society. 

Many medical interns and residents don’t consider lifestyle when they are making their career choice, and they should.  Obstetrics is thrilling when you are 30 years old.  Fifteen years later when you are overworked, tired and have your own kids, it may be slightly less thrilling to bring new life into this peaceful world in the middle of the night on a regular basis. 

For me, leaving my own bed at an ungodly hour to haul out to the hospital is an unwelcome activity.  I do not relish being awakened with phone calls or having to attend to an individual in the emergency room when the rest of Cleveland is soundly snoring.   While gastroenterology is a more taxing specialty than the skin gig, it is still uncommon for me to have leave for the hospital during the black of night.   Since we are in the era of medical hospitalists who are on staff around the clock, there is only a rare need for me to make a personal appearance.   On most nights, my scope rests securely in its holster. 

Do I think that medical students should consider lifestyle as they are contemplating their future?   Absolutely.   Indeed, the emerging culture of the medical profession has morphed from the prior culture when doctors worked 24/7 and interns were proudly on-call every other night.   Medical doctors today are increasingly employed by institutions, work shifts and delegate the hassles of hospital life to hospitalists. Doctors are self-prescribing R & R.  

Leisure, relaxation, avocations and personal time for reflection are not evil pursuits.  They are the fuel that cultivates and sustains our humanity.   Who wouldn’t welcome a little more humanity in the medical profession?



Sunday, September 21, 2014

Medical Complications Torture Doctors Too

If you are a physician like me who performs procedures, then rarely you will cause a medical complication.  This is a reality of medical life.  If perforation of the colon with colonoscopy occurs at a rate of 1 in 1500, and you do 3000 colonoscopies each year, then you can do the math.

Remember that a complication is a blameless event, in contrast to a negligent act when the physician is culpable.  These days, for many reasons, an actual complication is confused or misconstrued as an error.
Some complications are more difficult on physicians than others.  For example, if I prescribe a medication and the patient develops a severe rash, I do not feel personally responsible.  It’s the drug’s fault.  However, when I perforate someone’s colon as a medical complication, I feel responsible even if this act was a blameless event which will occur at a very low but finite rate.  (Of course, there are perforations of the colon which result from medical negligence, but I am leaving these aside to make my point here.)  

I Didn't Cause This Rash.  The Drug Did It!

I feel responsible because my hand was on the instrument that caused harm.   I can’t as easily blame the scope, as I blamed the rash-causing drug.   I’m sure that surgeons feel the same painful emotions when they perform a routine operation and serious bleeding results that requires additional surgery and complicates what should have been an uneventful recovery.

When your hand is on the colonoscope or the scalpel, and the unexpected happens, it’s an awful experience for the doctor even if we have performed according to proper medical standards.
Of course, serious medical complications are much more difficult for the patients and families involved than they are for us.  But, we physicians suffer greatly when a patient is harmed from a procedure that we recommend and perform.    You can imagine how we torture ourselves with second-guessing when these events occur.

Complications are inevitable.  The only gastroenterologist who hasn’t had a perforation of the colon is one who is brand new.   So, if you are drawn to a gastroenterologist because he has a 0% perforation rate, caveat emptor!   Paradoxically, the most experienced colonoscopists have accumulated many more complications over their career because of a much higher volume of cases or that they are referred very challenging cases by virtue of their skill and experience. 

A medical complication is an especially difficult event when it occurs in what was expected to be a routine outpatient examination.   Patients who come to our office for a screening colonoscopy understandably expect to be home 2 hours later.  So do we.  On those rare occasions, when this recovery path is altered, we must have a very serious, sober and unexpected conversation with the patient and the family.  Our plan is always to tell the truth and reassure all involved that we will do all that we can to make it right. 

Medicine is not a simple or predictable endeavor.  Sometimes, it can be rather complicated.

Sunday, September 14, 2014

Should You Trust Your Doctor's Advice?

Is your doctor a hammer and you're a nail?  Here's some insider's advice coaxing patients to be more wary and skeptical of medical advice.  Should you trust your doctor?  Absolutely.  But you need to serve as a spirited advocate for your own health or bring one with you.  Ask your physician for the evidence.  Sometimes, his medical advice may result more from judgement and experience as there may not be available medical evidence to guide him.  Make sure you have realistic expectations of the medical out me.  And most importantly, try as best you can to verify that the proposed solution is targeted to your problem.

Is Your Doctor a Hammer?

Consider a few hypothetical scenarios.

A 66-year-old patient has chronic right lower back pain.  Physical therapy has not been helpful.  Radiological studies show a moderate amount of hip arthritis.  A hip replacement is flawlessly performed.  The orthopedist discharges the patient from his practice.  The pain is unchanged.

A 60-year-old patient has chest pains that are not typical for angina.  Her internist arranges a stress test and the results are equivocal.  A cardiologist performs a cardiac catheterization and a moderate narrowing is found in an artery.  A stent is successfully placed in the proper location.  The patient is reassured that her cardiac pipes are all wide open.  She returns to see him a month later wondering why the pains have continued.

A 50-year-old patient sees his gastroenterologist for stomach pain.  An ultrasound confirms the presence of gallstones.  The patient accepts the specialists advice to have his gallbladder removed.  The operation proceeds smoothly.  You can guess the rest.

This is not meant to serve as an indictment of the medical profession.  The examples above have been highly simplified to make a point.  First, making accurate diagnoses are complex undertakings that can frustrate even seasoned diagnosticians.  Patients' medical histories are often vague and evolving.  Many diseases and conditions have clever mimics that can lead doctors astray.  Every doctor can regale you with anecdotes detailing episodes when they have been fooled.  There isn't a medical doctor alive who hasn't fumbled over a case of chest pain. 

Just because medical advice doesn't lead to the desired outcome, doesn't mean that the advice was wrong.   I concede, of course, that bad medical advice can cause adverse outcomes, a self-evident statement. 

Despite the vagaries and uncertainties in the medical arena, physicians try as best we can to propose a remedy that is directed to your symptom, rather than serve as a fix for something that is not ailing you.  My advice to patients is that when your doctor is raising the healing hammer, is to try not to get nailed. 

Make sure this inquiry is in your tool box.  "Doctor, can you please explain why the treatment will cure the symptom that brought me to you in the first place?

Maybe a hammer is the right tool for you.  Without doubt, the time to have this conversation is in advance of pulling the treatment trigger. Having realistic expectations can prevent future frustration when a treatment doesn't bring you to the end zone. 

So, next time your physician proposes a plan of action, hammer away.




  

Sunday, September 7, 2014

Bariatric Surgery: Pulling the Gastric Bypass Trigger Too Soon

If losing weight were easy, we'd all be skinny.  If exercise were fun, we'd all be doing it.  If quitting cigarettes were effortless...

What should our response be toward rising societal tonnage?

A Weighty Issue
  • Pass laws restricting access to the wrong type of food.  Former Mayor Bloomberg got stiff-armed on this approach by the courts.  It's also always fun to watch folks argue over the definition of a 'wrong food'.  The debate on which foods warrant prohibition at least brings some entertainment into the public square.  Imagine trying to achieve consensus over 20 or so food items that should be banned.  If this task were actually accomplished, cigarettes and alcohol would still be legal.  Make sense?
  • Initiate a massive public education campaign to scare us skinny. Show ads of scary pictures with scary music reminiscent of an iconic anti-drug ad (This is your brain on drugs...) from a few decades ago.
         "This is your heart."  Screen shows cartoon of a happy and vigorously beating heart.
         "This is heart on ice cream."  Screen shows depiction of gasping and quivering organ, coughing up fat              globules.
          How would we fund this effort? Simple.  Tax the manufacturers of 'wrong food''.
  • Allow individuals to choose their food and beverages freely and to accept any health consequences of their decisions.  (LOL on steroids here.)
  • Give tax breaks for every 5% loss of excess body weight.  Interesting concept.  Might thin folks file a discrimination lawsuit here?
Most folks who are overweight want to be thinner.  The reasons why folks carry extra weight are complex and are not simply because they eat too much.  There is a powerful mental component that for many people is part of the problem and must be part of the solution.   Sure, caloric control is fundamental, but many overweight people do not eat just to satisfy hunger.  They do so for other reasons which must be attacked directly if a successful outcome is to be achieved and sustained. 

The quick fix has been luring folks with false promises for generations.  Infomercials on the air every day hawk agents that will melt fat away, although there always appears a disclaimer in a font size too small for the human retina to discern that states that 'results not typical'.  The threshold for recommending bariatric surgery is getting progressively lower, and it has not hit bottom yet.  My sense is that this treatment is becoming regarded as a routine remedy, rather than a last resort measure after multiple other attempts have failed.  I suggest that many dieters may not be as disciplined and determined with conventional weight loss programs knowing that a bariatric rescue is available. 

Obesity is a serious health issue without an easy external cure.  Weight  loss medicines are either ineffective or dangerous.  Fad diets don't work.  Gastric bypass surgery is a serious operation that profoundly changes every day of your life by design when it is working properly. 

Weight loss can be viewed as two distinct tasks.  Losing weight and maintaining the loss.
Success, in my view, will come from within. 

Weight loss is not a sprint, but is a long distance run.  Consider this point.  Very modest lifestyle changes over time can deliver big results.  Lose a pound per month, for example.  Do the math and calculate your new weight 2 years later.  This cold math works the same way if we gain a pound each month.

Write down your reasons why you are overweight.  Are these reasons stronger than you're desire and commitment to change?  If not, then get yourself to the starting gate.  Your marathon run is about to commence.




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