25 April 2014

Fast asleep

An attending physician who I had just met was going to evaluate me in a "observed patient encounter." For about an hour, he would watch me perform a history and physical examination on a hospital patient that I had never met. Then, I would have to present my findings to him, arrive at a diagnosis and treatment plan, and write a detailed note. I explained that my performance on the activity would constitute a substantial portion of my clerkship grade.

The attending had never done this activity before. He was willing to participate, but felt that he was not the right man for the job. "I've just met you," he explained. "This would be better done by a doctor who has worked with you for a week or two, and knows your abilities and your personality." Then, the attending waxed philosophical. "This stage of your medical training can't be very enjoyable," he said, "what with complete strangers evaluating you all the time."

"That part isn't very fun," I replied. "You probably don't miss being a third-year medical student."

He stiffened. "Not to diminish what you're going through," he said, "but when I was a third-year medical student, it was much, much worse."

I am sure that he is right.

I think the best example is overnight call. Historically, a rite of passage in medical school has been pulling long shifts, many of them overnight. Some of my residents talk about having taken overnight call every third night as medical students, meaning they worked all day, through the night, and into the following day.

My experience has been different. Some nights, I voluntarily stayed late or through the night. During all of third year, though, I was only scheduled for one overnight shift. And even that time, I didn't have to stay overnight. When I showed up at 7 PM, my very nice resident told me that I could go home. (I stayed anyway, for kicks.) Part of the reason is my medical school, which has (humane) policies that discourage overnight call. It is quite possible that I will pull zero overnight shifts as a fourth-year medical student. All bets are off for residency, though.

Am I losing out on some educational opportunities by only being on the wards during the day? Probably. But not much teaching happens at night. And I am glad that I was able to spend nearly all of my nights as a third-year medical student comfortably in bed, asleep.

16 April 2014

Pressure group

Take a guess: what is the leading killer of US women?

The answer is heart disease.

Take another guess: which cancer kills the most US women?

The answer is lung cancer.

Many people, when asked either question, would give "breast cancer" as the answer. And a large reason why is the high visibility of breast cancer. There are prominent fundraisers and charitable foundations. NFL players wear pink uniforms each year to raise breast cancer awareness. Lung cancer, which almost exclusively kills smokers, has much less awareness.

Part of the reason, too, is that there are many more breast cancer survivors than there are lung cancer survivors, because breast cancer is much more survivable. It is the survivors and their family members who raise visibility for their respective disease and raise money for it.

These advocacy groups, in raising awareness, have ended up distorting the public's view of what actually kills people. In an attempt to inform, they misinform.

A group of ovarian cancer survivors came to our school, as part of an event sponsored by an advocacy organization. Students were required to attend. Although I was expecting it to be simply an opportunity for cancer survivors to share their stories, the event instead was intended to show medical students how little we know about ovarian cancer, and to teach us how to diagnose it and treat it. This deviated from how we are usually taught in medical school: usually faculty members lecture us on an organ system or on a set of diseases. In this case, the cancer survivors, who were not doctors, were going to devote the full hour to their one particular disease.

The survivors were highly critical of the medical care they had received from their doctors. They argued that their doctors should have screened them more aggressively, treated them more aggressively, and operated more aggressively. They instructed us what we should do instead, with advice that I found to be ill-informed. They also instructed us to order more CT scans on our patients, and to rely heavily on a blood test (CA125) that is largely useless. They urged us to suspect ovarian cancer in any patient complaining of (vague and common) symptoms like bloating or weight gain, and to suspect patients of any age of having ovarian cancer. One survivor said that antibiotics had helped with her cancer symptoms, and another claimed that the reason she got cancer was because her husband had died a few months before. Another thought she might have caught cancer from her friend.

I was upset that our school arranged for this session. Although the speakers were definitely well-intentioned, they were only able to view clinical practice through the lens of their cancer. The result was that they gave bad clinical advice that probably distorted the clinical judgment of myself and my classmates, who are still early in our careers. Misinformation is a difficult thing to unlearn.

I feel like I have to be wary of advocacy groups, because they only lobby on behalf of a particular constituency. An advocacy group's aim might not align with mine, which is to provide the best care to not just a subset of my patients, but to all of my patients.

01 April 2014


I was asked to assist with a bilateral standard mastectomy (surgical removal of both breasts) for a patient with cancer in one breast. There were two surgeons: the senior attending surgeon, who was to remove the cancerous breast, and the senior resident, who was to remove the healthy breast.

What made the procedure particularly interesting was that the mastectomies were done simultaneously. I had the opportunity to compare the surgeons' techniques as they performed the identical procedure, side-by-side, at the same time.

Unsurprisingly, the more-experienced surgeon did a better job. He made better use of the tissue planes that separate the different layers of the body, making for a cleaner and safer surgery. He worked faster, his dissections were more elegant, and he nicked fewer arteries and vessels, meaning he let less blood. The end result looked nicer.

The experience raised a question that author Atul Gawande discussed at length in his excellent books Complications and Better: how much of a role should trainees should have in performing surgeries? Attendings tend to do a better job than residents at operating. But if residents weren't allowed to operate, how would they ever hone their skills and become attendings?