Saturday, July 22, 2017

When Breath Becomes Air by Paul Kalanithi - A Scrub Notes Book Review

"When Breath Becomes Air" is a memoir written by neurosurgeon Paul Kalanithi. The book is a poignant look at the human spirit in both the pursuit of excellence as well as in coming to terms with its own impermanence.

Kalanithi was a Stanford neurosurgery resident when he found himself becoming fatigued, with worsening pain and decreasing weight. A routine chest x-ray discovered multiple lung masses, which were soon proven to be metastatic lung cancer. The book was borne of Kalanithi's other passion, literature, as well as his unfortunately unique perspective as both a healer and now a patient at a time when he was poised to be at the peak of his talents.

The first half of the book details Kalanithi's upbringing and path into medicine. His first love was literature, which he pursued all the way to a master's degree. However, upon further reflection, he felt a desire to pursue medicine after grappling with the question of the intersection of "biology, morality, literature, and philosophy." Since he had initially pursued literature, Kalanithi took two more years to complete the pre-med requirements and then apply to medical school. Accepted at Stanford, he was a fast rising star in the neurosurgery world, despite grueling 100 hour weeks year after year.

The diagnosis, coming near the end of his training, shatters Paul's identity. After striving for close to a decade to become an attending neurosurgeon, his diagnosis is his undoing. He rapidly transitions from physician to patient, and has to learn to let go, to trust in others to have his best interests at heart. The book shows how he meditates that cancer in particular is pernicious in that it makes one mortality both immediate and yet still remote: no longer a hypothetical, but not an immediate reality. Everyone has an answer to what one would do with their last day, but what about one's last decade?

Kalanithi then details the long road back to completing his training, the successes and failures of his treatment, and how he learned to live and ultimately succumb to his fate on his own terms. He died in 2015, leaving behind his wife Lucy and their newborn daughter.

For me, the last part of the book was the most moving, an epilogue written by Lucy about Paul's last days. She charts the uncertainty of his final hours and how he was resilient even while facing the unknown. His final wish was that they see the book to fruition, in which they clearly succeeded.

The book reads like what one would expect of a memoir of a first-time author, but Kalanithi's first rate intellect shines throughout. Even though he never uses the label, it is clear that Kalanithi was a humanist at heart. He does touch upon his wavering relationship with religion. For a reader who questions both their path in healthcare or wants a glimpse of how even the best laid paths can abound with uncertainty, "When Breath Becomes Air" will not disappoint.


Monday, March 27, 2017

Do Medical School Rankings Matter?

This is a guest post / repost from Smart Money, MD on the topic of whether going to a highly-ranked medical school matters:

Some of us are overachievers. Some of us are overachieving doctors. What if you’re in-between? Let’s say that you’re an overachiever, and you want to become a doctor.

Should you go all the way up top and get that medical degree from a top private institution? Does it even matter? With tuition costs skyrocketing, you can easily spend $60,000 annually on tuition alone for each year in medical school. Add another $10-$15k in room and board, and you will be about a quarter million in the hole by the time you get out. In contrast, medical school tuition in 2016 for UT Houston for in-state resident is only about $20,000 annually. That’s a big difference.

These are considerations that are rarely taught or even discussed. If you are planning to go to medical school, it does pay to consider the consequences thoroughly before you proceed.

Does a prestigious degree help get you a better job?

It depends. It depends on where you plan to work. In clinical medicine, you can either work at an academic institution or in the private sector. Many job situations in the academic world require teaching, research, or involvement in administration. If I were a departmental chair looking to bring on a clinician-researcher, I’d want someone who not only can practice medicine well, but also has strong writing skills, coherent presentation abilities, and innovative characteristics. If two candidates had similar track records with similar recommendations and charisma, I might lean towards going for the gal with the Ivy-league degree, especially if I am running an Ivy-League department.

If I needed a doctor in the private sector, the institution that granted the degree is unlikely going to matter much at all. Yale? Great. Wayne State? That’s okay with me. You just need to be ethical, hard-working, and reasonable to deal with. For all other qualities, the verification process in each state and governing medical board can do the rest.

DO DOCTORS FROM PRESTIGIOUS INSTITUTIONS MAKE MORE MONEY?

It depends again. To understand this question, you should understand how doctors make money to see whether an Ivy-League degree will translate to higher dollars. This is also contingent upon how you are using your medical degree, whether you are practicing medicine, performing administrative work, or consulting. Remember, you don’t have to be a doctor to get rich. Or you shouldn’t become a doctor if your main goal is to become rich.

If we are considering doctor worth from revenue alone obtained through clinical practice, insurance companies make no distinction between where you obtained your degree. U.S. grad, international grad, it doesn’t matter. As long as you pass your boards (sometimes you don’t even have to do that!), you’re golden. From clinical practice alone, you’re not going to make more money having gone to a top college or medical school. Period.

Now having that special degree CAN get you more business, depending on which part of the country you practice medicine. This is particularly true (and sometimes annoyingly so) in the New England area. Patients in New Caanan Connecticut do (in general) care where you obtained your degree. They may or may not even be highly educated, but the high concentration of Ivies in that region predisposes this behavior. Unless you have significant street cred and have been working in the area for a long time, your patient may doctor shop your degree.

OKAY, I SANK $200,000+ INTO AN IVY-LEAGUE MEDICAL DEGREE, WHAT AM I GOING TO GET IN RETURN? 

Many of us, under the guidance of family, friends, or schooling, end up enrolling in well-known [read: expensive] private universities and medical schools.

DESPITE the equivocal conclusion by Smart Money MD.

Don’t fret. You’re not totally screwed. If you have a good inheritance coming your way or an alternative means to fund the process, you’re actually in great shape.

If the above doesn’t apply to you, don’t fret either!

STEP 1. PAT YOURSELF ON THE BACK.

Congratulations. It is not easy getting in. It is SIGNIFICANTLY more difficult to get in medical
school than law school, business school, or college. Kudos to you.

This is a fact. By numbers alone. There are simply fewer number of available positions in medical school. The Class of 2018 Stanford Graduate School of Business has 417 new students. Last I checked, the Stanford medical school had fewer than 90 students per class. I think the acceptance rate in the medical school was about 2-3%, while the business school acceptance rate was 6%. If you compare these numbers to that of an average public medical school and public business school, you’ll see that the class sizes will be larger and the acceptance rate will also be higher.

STEP 2. YOU’VE GOT A LIFETIME OF PRESTIGE ATTRIBUTED TO YOUR NAME.

Yup, your mother can brag about her daughter at every holiday party. Your distant relatives will direct their children to you for advice. Your alma mater will also hit you up for donations every single year. You can volunteer with your local alumni group and have “exclusive parties”.
You have a lifetime of memories and connections to potentially successful friends and colleagues.
This is not a bad situation to be in.

STEP 3. CLEAR YOUR MIND AND GET TO WORK.

Get yourself back into the real world. Don’t let anything else cloud your judgment. You’re probably not even that smart. Your coworker at the hospital who came from Portugal probably is one the smartest gals in her country. She memorized Harrison’s twice to pass her country’s exams. Oh yea, she also repeated residency in the U.S. and passed all of her U.S. board exams…in English.
That’s right, her native tongue is Portuguese, and she learned Spanish as her secondary language. English was her third language.

Get yourself out of debt if you funded your education through loan sharks. If I dug myself out of debt, so can you. Save up your money. Figure out how much you are worth.

Figure out what makes you happy. Then work to get there. Easy peasy.


Smart Money MD, an ophthalmologist run financial website, focuses on proper management of medical trainee debt, lifestyle, time, and getting the most out of your hard-earned degree.


I can only second what Smart Money said above. In the grand scheme of things, getting into medical school is a much bigger deal than which medical school you get into. For most residency programs, what you get on USMLE Step 1 will carry much greater weight than your medical school. However, all else being equal, more prestigious medical schools will have more famous faculty, who will be better able to plug you into opportunities to advance your career as well as make phone calls on your behalf when it comes time for Match Day or even beyond with jobs. For more competitive training programs, specialties, or jobs, this may make a huge difference. To decide, ask yourself what type of training and career you want, then find a medical school training program that will you make you happy. Good luck!

Thursday, March 23, 2017

Age-Appropriate Screening Guidelines

As you encounter patients in a primary care setting, you play an important role in preventative medicine. Specifically, you must ensure that your patients are receiving appropriate screening given their age, gender, and risk factors. Especially after the implementation of the Affordable Care Act, preventive services have taken on an even greater importance.

 The main body that puts together guidelines in the United States is the U.S. Preventive Services Task Force, or USPSTF:
The U.S. Preventive Services Task Force is an independent panel of experts in primary care and prevention who systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. These reviews are published as U.S. Preventive Services Task Force recommendations on the Task Force Web site and/or in a peer-reviewed journal.
Often, the USPSTF guidelines are complemented by recommendations by specialty societies, such as the American Cancer Society or the American College Radiology. Be careful though: sometimes the guidelines may be contradictory, such as what age to start breast cancer screening with mammography. For a comprehensive list, visit the USPSTF website or download their app.

The selected guidelines below cover some of the most common recommendations:

Women
Age Recommendation Grade
Puberty - 24 Chlamydia/Gonorrhea if sexually active  B
21 - 65 Pap smear every 3 years (if combined with HPV testing, can be every 5 years after age 30) A
40 - 49 Individual decision for screening mammogram based on relative benefits vs risks C
50 - 74 Biennial screening mammography B
50 - 75
1) Annual screening with fecal immunochemical test (FIT)
2) screening every 10 years with flexible sigmoidoscopy and annual screening with FIT
3) screening every 10 years with colonoscopy
4) screening every 5 years with CT colonography.
A
55 - 80
Low dose lung CT if one has a 30 pack-year smoking history, currently smokes or quit within the last 15 years. 
B


Men
AgeRecommendationGrade
50 - 751) Annual screening with fecal immunochemical test (FIT)
2) screening every 10 years with flexible sigmoidoscopy and annual screening with FIT
3) screening every 10 years with colonoscopy
4) screening every 5 years with CT colonography.
A
55 - 80Low dose lung CT if one has a 30 pack-year smoking history, currently smokes or quit within the last 15 years. B

Several interesting or unexpected exceptions to screening guidelines exist. For all, there is no specific recommended screening for skin cancer for the general population. That being said, one should still protect themselves from excessive skin exposure and follow up on any unusual skin findings. For men, the USPSTF recommends against screening for testicular and prostate cancer with PSA. For women, no screening for ovarian cancer exists presently. Women who have a strong family history of breast or gynecologic cancers should be screened for BRCA-1/2 and referred for genetic counseling if the tests are positive.

If there are other screening guidelines you feel should be included on here, please comment below or contact me. For more detailed information, check out Current Practice Guidelines in Primary Care for 2017:

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