principleintopractice

No- this isn’t an addendum to the “spring mating games” I mentioned in my last post.  (I feel like I might have just lost half my readers…)

The third year of medical school is a hectic one.  For those that aren’t familiar with the system, the first 2 years of medical school (in the US at least) are “pre-clinical” years, where future physicians learn the ‘basic science’ behind medicine. The foundations of our clinical knowledge are fields such as anatomy, embryology, biochemistry, pharmacology, physiology, pathology, microbiology, immunology, and, at least in my school, some basic biostatistics.  The end of second year culminates with the first step of the USMLE Boards.  Those that aren’t daft enough to take a hiatus to do a PhD (and when those of us that were daft enough finally come back) then start clinical clerkships in the third year.

For lack of a better description- 3^rd year medical school is like speed dating for future physicians, but we’re looking for a career not a partner.  There’s a lot to be learned in third year (there is a very steep learning curve when you finally step foot on the floors), and each clerkship (Psychiatry, Neurology, General Medicine, Surgery, Obstetrics and Gynecology, Family Medicine, and Pediatrics) requires the acquisition of new clinical skills and knowledge.  The idea, obviously, isn’t to make you a surgeon in 2 months, but to give you some basic knowledge in these fields and to give you an idea of what it is like to be a physician in each of these specialties.

Some students come into medical school knowing what they want to be (though even the most determined often change paths), but many (myself included- more so at the beginning of medical school than now) really have no idea.  Over the course of a clerkship you not only get the basic clinical knowledge of a specialty, but you also get a feel for the specialty itself. These clerkships are short- I had a month on both Psychiatry and Neurology, and two months on Surgery.  This is barely enough time to figure out what a specialty is all about, and of course your experience is very much determined by the hospital you work at and the people you work with, yet this is the system in which we work (and in this instance I’m not sure there’s a better option).  By the end of third year, medical students need to know what they want to be “when they grow up”.  That’s when you have to start getting ready for “The Match”, the process in which medical students and residency programs rank their respective top picks and a computer determines their destiny (think of it as speed dating meets arranged marriage).

As I come off my surgery rotation, now a third of the way through my third year of medical school, it seems like an appropriate time to take a look at the clerkships past, and to glance forward to those awaiting me.

I started with Neurology- a very cerebral specialty (pun intended), where, at least when I spent my time with the stoke team, we spent a lot of time doing very thorough histories and physicals, teasing out the specific deficits and abnormalities of a patient’s presentation to determine (“localize” is the medical term) where in the brain there was an issue.  This is a wonderful exercise, and a skilled neurologist can take a thorough physical and, based on presentation, precisely localize where in the brain the problem has occurred… Now a day, this is frequently done as somewhat of an academic exercise after the determination has already been made by a CT scan and/or MRI. While there definitely is space for aspects of neurology to be explored with an ancestral/evolutionary health gaze (more hemorrhagic strokes during the winter? Maybe there’s a role for Vitamin D?), for me I found the specialty one of “a lot of thought, not much action”. Engaging as the thought process is, and as cool as some of the physical-exam detective work can be, I’m fairly sure that on my speed-dating card, Neurology is a “No”.

I was surprised by my Psychiatry clerkship. I wrote about my experience previously and, from the assessment of the clinicians I worked with and my own thoughts, I’d say Psychiatry is a mutual “Maybe”.

As I reach the end of my two-month trial on surgery, I will mark, without hesitation but with definite heartache, “No”.  Had my surgical rotation ended after my first month, when I had experienced only general surgery, there would have been no hesitation nor heartache.  General surgery is, without a doubt, not for me.  Over that month I saw many surgical revisions of the human body that were necessary, almost exclusively, because humans are living outside of an evolutionary appropriate lifestyle.  The removal of large portions of bowel because of diverticulitis, appendices and gallbladders removed around the clock, amputations because of uncontrolled diabetes… It all seems so unnecessary (for the most part) if we figured out how to live within the confines of how our body evolved to thrive.  In many of these cases, surgery is a (hopefully) definitive treatment for a preventable disease that I would rather just see prevented.  Other specialties within surgery- such as vascular, transplant, and cardiothoracic, or totally different training programs such as neurosurgery or orthopedics- all have their place, but none of them enthralled me. The other major issue with surgery is the toll it takes on your body and your life.  Surgery is physically demanding, not just for the hours of standing in one place, sometimes hunched precariously or stooped over a microscope, but also for the hours it requires.  Surgical training requires residents spend very long hours in the hospital, and to be honest, it’s not a price I am willing to pay.

The reason my rejection of surgery turned from an adamant “No” to a sorrowful one is because of Trauma.  My second month of surgery was spent with the Trauma team at my university’s hospital, a level 1 trauma center in a very rough inner city.  In many ways, Trauma surgery is the antithesis of neurology.  No- the people I was working with are not “just dumb trauma surgeons” as one of our attending physicians liked to self-deprecatingly refer to he and his collegues, but they are men (and women) of action.  There is a standard protocol that you run through when a trauma comes in, the “ABCs” (Airway, Breathing, Circulation, Disability, Exposure (yes, if you come into the trauma bay, you will lose your clothes)), but when something needs to be done, a trauma surgeon does not stand on protocol and wait for the final assessment. Many of the cases we saw in the trauma bay were definitely not “traumas” (simple falls, bar fights and assaults are generally things that should be taken care of in the Emergency Department), but many were full of the excitement and noise that years of watching ‘ER’ might have you come to believe is the norm.  One night on call I was part of the team that picked up a Motor Vehicle Crash (MVC) patient from the helipad on the hospital roof.  I’ve now seen gunshot wounds to all different parts of the body.  Trauma surgeons (or the good ones, as I witnessed in our hospital) know when to let assessment carry on, and when they’ve seen enough and something needs to be done NOW.

There is an urgency to trauma surgery, an element of intuitive action, that is lacking in other fields of medicine.  When you go to the operating room with a trauma patient you will see things you’ll never see in a hospital surgery patient, like the milky lymphatic ducts of the intestines (in all other surgery cases, patients are kept without food for many hours before surgery so their bowels (and the lymphatics which carry the emulsified fats we eat) are empty.). In trauma surgery, you’re working on a running engine.  Also, there’s often a significant element of “unknown” when you go to the OR with a trauma patient. These cases are time critical, and often the only imaging study you’ll have is a simple X-ray (no CT scan or MRI to tell you exactly what’s going on- there’s just no time).  A quick ultrasound may tell you there’s fluid in the belly, but you don’t know what that fluid is until you see it, and you don’t know where it’s coming from until you poke around for the source.  Trauma surgeons live in the moment- identifying, controlling, and treating acute injuries at times when minutes can make all the difference.

Another thing I like about trauma surgery, which is so different from general surgery, is that you are treating an acute incident that brings your patient to the table, not a chronic lifestyle (though one can argue that the lifestyle that many of our patients live is what is responsible for their trauma.  This is undoubtedly true for many or our MVC patients (please people- DO NOT DRINK AND DRIVE!) and some of our gun shot wounds and stabbings (we have quite a few repeat customers coming into our hospital for these injuries…).  There’s something about taking an acutely injured patient and ‘fixing them’ (or I prefer ‘putting them back together so they can heal’) that I enjoy that is missing in general surgery.

This feeling, however, comes at a cost.  The hours for any surgeon are long and arduous, but those of a trauma surgeon are longer and harder.  Yes, general surgeons get 3am consults, but a gunshot would to the chest is a lot more time-sensitive than an acute appendix or an obstructed bowel.  The lifestyle of a trauma surgeon is hard and it is wearing, and it obviously takes its toll.

Not surprisingly, trauma calls to a certain type of person… I loved the trauma surgeons- they were all so different: unique in their own ways and so obviously Trauma surgeons. During the last week (prior to my surgery exam) all the students (from all the different teams, about 30 of us in all- 5 had been on Trauma) were lectured by a number of surgical faculty.  You could always tell the trauma surgeons (even if they didn’t introduce themselves as such).  They lectured off the cuff- dynamic and fast.  None of them sat or stood by the computer flipping slides (if they used them)- they paced, gesticulated, called people out and made bold statements… They’re a little wild, often quick to act, and if I ever need a trauma surgeon, I’m really glad they are the way they are.

It was my experience on trauma, and with the trauma surgeons, that makes my heart ache a little bit as I check “No” for surgery. I know I could not mentally or emotionally hack the surgical residency (the hours and the years of all the other surgical specialties that you have to endure in order to do a fellowship in trauma). I also know that I will not put my body and my mind through the rollercoaster ride that is the call schedule of a trauma surgeon.  I know I need sleep. I know I need good food. I know I need sun and socialization.  But I will miss Trauma…

With 4 months and three specialties down, I look forward to my remaining 8 months and 4 specialties of third year.  As far as my speed-dating card goes, I think the best is yet to come. I don’t think Pediatrics, my next clerkship, will be the right fit, but I’m optimistic for the Family Medicine clerkship that follows and then the tour-de-force that is the Internal Medicine 4-month marathon.

When it comes down to it, I don’t think I’m going to find my perfect match in the speed-dating clerkships of medical school. Evolutionary medicine is a yet-to-be-defined specialty, and no residency program offers training in this field (though I have hopes for a fourth year elective in this area!). Indeed- just yesterday NPR mentioned evolutionary medicine and somewhat scathingly pointed out that it was not a practical discipline and at this point “only a theory”.

Actually, when it comes down to it, I don’t really think evolutionary medicine should be its own specialty… Much as it has been said that “nothing in biology makes sense except in the light of evolution”, I think “most (dare I say all?) issues of human health are best understood in the light of evolution”. You can find aspects of each specialty that would benefit from the keen focus of evolutionary minded individuals who, with careful thought, research, and synthesis of new ideas, could push the standards of medicine to new heights.