Specializing

A few decades ago the medical school curriculum committee was meeting to discuss updates to the standard curriculum. As they debated on what courses needed to be added/dropped they decided to ask Dr. James Kirklin (CT surgeon) what information was important for medical students to learn prior to graduating. Without hesitating he replied, "They should know it all."

I want to be a cardiologist. Specifically, I want to focus on heart failure. But not just heart failure; I want to be an expert on acute heart failure. And if I really get to do exactly what I want, I'd like to work on peripherally inserted mechanical support devices for acute heart failure.

My own career goals make what I am about to say that much harder to believe. I hate the current medical model that emphasizes super-specialization at the expense of a broad based knowledge base.

It used to be that the same doctor that diagnosed your heart attack could take out your gallbladder and deliver your baby. Understandably, as knowledge about the various medical fields (Surgery and Medicine) grew, practitioners started focusing in on either surgery or general medicine. As we learned more about the body, these fields further subdivided and now you had speciality training in various subdivisions of either medicine or surgery (cardiology, pulmonary, renal, etc... or GI surgery, cardio-thoracic surgery, etc...). However, as recently as the 1950s, physicians were still trained in both surgery and medicine. In fact, it wasn't until the 1960s-1970s that you had many specialities grow and develop their own specific training pathways. Up to this point, the growth towards specialization dovetailed nicely with and likely contributed towards the explosion in knowledge about the various specialities.

However, sometime between the 1970s and now, we started fracturing the medical landscape into smaller and smaller pieces. Some of this was a direct result of the exponential increase in knowledge. You had cardiologists becoming sub-specialists in heart failure, catherization, or electophysiology. We also started to self-segregate based on other, less clear factors. You had the start of ER and hospitalist medicine. If you just want to focus in on the acute management of all medical problems but did not want deal with any of the long term management or consequences, you could train to be an ER physician. Likewise, if you just wanted to manage inpatient medical issues, you could train to be a hospitalist. These new subdivisions were not directly linked to organ systems or disease processes, but rather to certain situations in health care delivery.

Let me offer an analogy comparing our health care system to flying an airplane. Initially all pilots could fly all airplanes as there weren't that many different kinds. As varying models were designed, pilots started to specialize in certain types of aircraft. The Cessna pilot and the 747 pilot became specialists in their own type of machinery. However, what you didn't see happen is the development of a pilot who specialized in takeoffs, and one that specialized in landings, and one that specialized in flying through hurricanes. What you didn't see is one pilot managing the airplane during takeoff and then openly admitting that he didn't know (or care to know) about how to continue to fly the plane and/or land it, and that that was someone else's responsibility. Add a healthy dose of poor communications between all involved parties to this super fragmented model and you have a great recipe for chaos. If you think such a system of flying airplanes would surely lead to mistakes and deaths, then welcome to our current health care system.

As we have developed this amazing, detailed knowledge base about the human body, physicians have gravitated towards the fields and opportunities that most interest them while at the same time paying lip service towards retaining the basic knowledge base about the field as a whole. Despite my desire to focus in on a very specific patient population, I ardently believe that my ability to offer good care will involve more than a detailed knowledge about a focused problem.

Living or Dying?

Randy Pausch is a computer science professor at Carnegie Mellon. Carnegie Mellon's computer science department has a lecture series titled "The Last Lecture." The premise being that if this were your very last lecture, what would you talk about? They asked Dr. Pausch to give this years last lecture. While meant to be a fun and interesting interlude, this lecture took on much more significance when Randy learned that he had metastatic pancreatic cancer and this really would be his last lecture.

His talk was taped and posted on YouTube. You can watch it here. Over 2 million people have watched the video since it was posted.

Randy Pausch has a website where he posts frequent updates about his medical course. You can visit his website and find out how he is doing.

He even wrote a book titled The Last Lecture -- which you preview here. He did all this within the last year after finding out he had pancreatic cancer. Not bad.

Hope Renewed...


Ms. F lived. She beat the odds. She was found unresponsive at home covered in her own feces, surrounded by flies and maggots. No one knew how long she had been in this state. She was having trouble breathing and was put on a breathing machine as she was transported to our emergency department. Her temperature on presentation was 94.0, her respiratory rate was 40, her heart rate was 130, and her blood pressure was 80/40. She was completely unresponsive, even to painful stimuli. She was bleeding from every orifice except her eyes and ears. Her labs on admission showed a white count of 2.0, a hemoglobin of 5.0, and a platelet count of 10. Her BUN was 255 and her Creatinine was 10! All of here electrolytes were abnormal.

She was infected, her mental status was horrible, she was having trouble maintaining an adequate blood pressure, she required the support of a breathing machine, her kidneys were shutting down, and she was bleeding profusely.

Ms. F has a history of multiple sclerosis and her only other hospitalization had been for renal failure secondary to a neurogenic bladder. It turns out that this time she had also been experiencing decreasing urine output over the prior week or two. She had difficulty urinating and toxins built up that resulted in altered mental status. A CT scan done the night she came in to the hospital showed that she had retained so much urine that she had perforated her bladder.

Ms. F was on a ventilator for ~ 15 days. She received 15 units of blood and platelets over the first 2-3 days she was in the MICU. She was treated with very broad spectrum antibiotics. She underwent bladder repair.


She lived. She left the hospital a few days ago. She has two little kids at home. I met one of them -- a wide-eyed seven year old who will probably never know how close he came to losing his mom.


When she first came into the hospital, I had no idea if she would live. I thought for sure that she would pass away. Her recovery speaks to the strength of youth and the remarkable ability of the MICU nurses to deliver fantastic care.

Cases like hers remind me of advice that one of my surgery attendings once gave me. We had just left a patient's room where he had discussed the pros and cons of getting lung surgery to remove a tumor. The patient had asked my attending how long he had to live. As we left the room, my attending turned to me and said "Never be arrogant enough to think you know how long a patient has. You will always be wrong! Anything you say is a guess... an educated guess but a guess nonetheless."

So much of what we do involves predicting mortality. When a patient asks if he should undergo surgery or when the family asks how likely it is that their loved one will get off of the ventilator, they are really asking what their chances of dying are... And I don't know.

Ms. F was the exception. The next 99 people who come in with her problems will probably die in the hospital within a few days. The question is, do we treat those other 99 people just as aggressively in the hope that they turn around like Ms. F did? Or, do we tell the family that the chances of recovery are so small that they should make the patient comfortable and not pursue aggressive treatment?

The Last Day

I finished my MICU rotation yesterday. As I walked out I couldn't help but think of the failures I had, the people I wasn't able to help.

The 60 year old Boeing factory worker and father of four. He came in with profound hypoxia (unable to oxygenate his blood) and despite everything we did, we weren't able to improve his breathing. He was diagnosed with acute interstitial pneumonitis, a catch-all term that hides the fact that we don't know the cause or the cure. He was completely healthy prior to this hospitalization. He and his wife had been vacationing in San Diego just a few months prior. He died.

The 28 year old deaf/mute mother who had never been in the hospital other than to deliver her baby a few years prior. She also presented with shortness of breath and was soon put on a ventilator. It turns out that she had the flu and her lungs also had been infected with bacteria (staph aureus). We weren't able to help her breathing. She ended up going on the heart/lung bypass machine (ECMO) to give her one last shot. She died.

The 50 year old husband who presented with liver failure due to a disease known as primary sclerosing cholangitis (PSC). He had been on the liver transplant list until he developed an infection and was sent to the MICU. Based on verbal reports, they had actually found him a liver but just a few minutes/hours later, he became sicker, and they realized he had developed an infection. He was taken off the transplant list temporarily, started on antibiotics, and sent to the MICU. He never got a new liver. He was surrounded by family and friends. When I pronounced him dead, his mother looked at me and asked, "Thats it? Is he gone?" to which I could only nod yes. He died.

During my time in the MICU, I took a day off to go interview for cardiology fellowships. As I sat there through the interviews, with my interviewers telling me how impressed they were with everything I had done, I couldn't stop thinking about all the people that I had taken care of the last few weeks that hadn't made it. Its easy to tell myself I did my best and that these people probably wouldn't have made it anyway, but that excuse rings false. I don't like failure -- its a selfish feeling. I want to be better. I don't want my patients to die.

"Give me your tired, your poor, Your huddled masses yearning to breathe free, The wretched refuse of your teeming shore. Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door"
-- from "The New Colossus" by Emma Lazarus (on pedestal of The Statue of Liberty)

I love the intensive care unit. I like taking care of the sickest of the sick. I like working through the pathology, trying to understand the physiology, and utilizing everything science has to offer to give these incredibly sick patients one more shot.

By the time a patient gets into the MICU, they are on death's door. They might be infected, be bleeding, unable to breath, and have trouble maintaining a normal blood pressure -- the sickest might have all of these. We hoist them onto their ICU beds, we remove their clothes, we attach numerous monitors. If they are agitated, we sedate them. We stick them in theirs arms, their legs, their necks, and their chest. We place tubes down their throats, up their rectum, and in their urethra. We give them drugs that have horrible side effects. If their hearts stop beating, we pound on their chest, shock their heart, and give them more drugs. And yet, I love the intensive care unit.

Most of these patients don't live very long. Despite everything we do to try to help, they frequently end up passing away. The mortality rate in our intensive care unit can approach 50%. And yet, despite the torture we put these patients through and despite the sobering final results, I love the intensive care unit.

Why? Why would I love working a place where I fail so much. Why would I want to put anyone through the things I have described above?

I can sum it up best with a quote from the Shawshank Redemption:

"Remember Red, hope is a good thing, maybe the best of things, and no good thing ever dies." -- Andy Dufresne

When patients come to the ICU, they and their family often don't know what they are in for. They might know they are sick but they might not realize just how remote the chance of recovery is. However, they hope. They hope they can overcome whatever it is that afflicts them. Some might call this false hope or even denial. They say that when patients get this sick, physicians should push for advancement of code status -- basically, try to get the family and the patient to withdraw aggressive treatment and accept that they will not overcome the illness. These people argue that treating patients this sick is futile and a waste of medical resources. They maintain that physicians are the experts in all things medical and thus are qualified to tell a patient and a family when further treatment is futile.

While families might not be medical experts, they are the experts when it comes to what the patient would want, what the patient values, and what the patient is fighting for. Maybe, the patient would be willing to go through anything in order to have that extra day at home with his family. Maybe he just wants one more chance and is willing to endure the torture. People have various motives and values and there is nothing I learned in medical school that would make me an expert on what people want. Instead, I tell the patient and the family in explicit detail what doing everything entails. If they want everything done then I do so.

I try not to think about the torture I am putting these patients through. I remember each of my failures. However, I try to focus on those few that do make it -- despite the long odds. The 70 year old with multiple medical problems that had to stay on the ventilator for over 30 days before we managed to get him off. The 40 year old whose heart stopped beating (PEA code) but who was resuscitated and went home with his family 6 days later.

If we succeed and the patient beats whatever illness is afflicting him, so much the better. If we fail, at least we gave him one last chance -- at a terrible cost, but a cost he and his family were knowledgeable of and willing to accept.

I hope my patients get better. I hope I am doing what they would want me to do.

MICU

I am currently rotating through the medical intensive care unit (MICU). My day starts off at 7 am with a morning conference on a topic related to patient care in the intensive care unit. Usually we talk about ventilator management, various treatment strategies in sepsis, or the finer points about hemodynamic management. Yesterday, instead of our usual morning lecture, we had a physician interested in narrative medicine come talk to us about the importance of writing down our thoughts about what we see everyday. Near the end, we were asked to take a few minutes to write about our worst clinical experience. Here is what I wrote:

My worst clinical experience was during my first month of internship and it was in the MICU. There was a patient with lung cancer who had undergone radiation therapy and presented to the hospital coughing up blood (hemoptysis). He underwent a bronchoscopy which did not show any active bleeding. Later that same night -- around 7pm -- one of the nurses came running out of the patient's room yelling "I need a doctor!"

When we ran into the room we saw the patient sitting up on the side of his bed -- leaning on one of the side tables -- with a massive amount of blood pouring out of his mouth. I always think of hemoptysis as coughing up blood, but this was more like a fire hose pouring blood out of his mouth. There was blood all over the floor. While some of us were trying to move the patient so that his left side was down, others were throwing isolation gowns onto the people in the room to protect us from the blood that was spewing everywhere. We could see pallor move down the patient's face. The patient was dead within two to three minutes.

The patient's wife was eating dinner with him when this started. We barely had time to move her outside the room before everything was over. Watching her try to comprehend what had just happened to her loved one was heartbreaking. As I watched his wife cry inconsolably, I felt a tremendous amount of guilt. He had come to the hospital over 24 hours ago. We had done tests and yet the problem had eluded us. Finally, he was in an ICU in one of the biggest medical centers in the country with several nurses and doctors literally sitting outside his room, and we were still too slow to save him.

This is the worst thing I have ever seen and this was the only time I have ever questioned my desire to enter the field of medicine. The feeling of helplessness and the quickness with which it all happened made this a horrible experience.

I would like to think that by working hard in medical school and during training, I would have the knowledge and the ability to at least try to save a patient's life. Even if I was not successful, I could offer the patient a chance. However, all I could do was watch him die.

What Makes A Good Doctor?


Before you can achieve something, you have to know what it is that you are trying to achieve. Thats pretty easy when it comes to some things. For example, a good running back runs for a lot of yards and scores a lot of touchdowns. A good cook creates food that people like to eat. A good salesman produces the most profits for his company. But what is it that a good doctor does to be considered good?

My goal is to be a good doctor but I am not sure what this entails. I was once told that patients judge doctors on the 3 A's (in order of importance): Availability, Affability, and Ability. The emphasis here is that no matter how good you are, being nice and being there are what matter most. The alternative viewpoint is that results are what matter. A good doctor is a doctor that can cure you of whatever ails you. If he or she is nice, so much the better, but this certainly doesn't come into the equation of defining a doctor's quality. Both of these measures of a doctor's quality are from the patient standpoint. If you ask doctors who they consider to be good doctors, they will envariably point to a physician with impeccable credentials, the most publications, the best diagnostic skills, or someone who generates the most profit for the hospital. In short, physicians judge other physicians not on character or medical results but on criteria that are often not even available to the public. Do you know where your doctor went for medical school, residency, or fellowship? Do you know which journals he or she has published in? In a cynical moment, one of my attendings once quipped that "You go into academic medicine if you want to be thought highly of by your fellow physicians and you go into private practice if you want to be thought highly of by your patients. " Maybe there is some truth to that.

In Doctor, Edward Rosenbaum, himself a physican, writes about his experience as a patient. He ends the book by commenting on what he thinks makes a good doctor: Ability and Integrity. In Dr. Rosenbaum's mind, those are the only two things that matter when deciding if a doctor is good. It sounds simple enough but an entire book can be, and was, written on what those two terms entail.


While I try to figure out what being a good doctor entails, I try to follow the following rules that were passed down to me from one of my attendings. Maybe this isn't the key to being a good doctor, but I hope these rules will at least keep me from being a bad doctor:

1) Be honest. At first glance this just means don't lie to others. But, it also means be honest to yourself -- know your limitations and when to ask for help. And finally, being honest means being reliable. If you say you're going to get something done, make sure it gets done.

2) Treat every patient as if they were family. This doesn't mean get emotionally tied to their case so that you can't make clear decisions. What this means is, pay as much attention to detail on each of your patients as you would if they were your family member, and advocate for each of your patients as if they were your loved ones.

3) Have fun. You can't do a good job unless you enjoy what you are doing.

Sounds pretty simple. Be honest, be considerate, and have fun. If it is really that easy why don't we have more good doctors?