Saturday, August 22, 2009

To: Anonymous (Doctor)

Yesterday I received a series of comments on my post from a doctor as Anonymous. I will refer to Anonymous doctor as AD in this post. AD, I hope you read this post and my response to your comments.

First and foremost, I am surprised and very appreciative that you have taken the time to comment on my blog. I understand that, as a practicing physician, you must be very busy and thus I thank you for taking time to contribute your insights and thoughts. I will re-post your comments below before I respond:
OK, I've refrained from commenting in the past, but I simply have to do so now.

I'm a physician, in practice. I understand your skepticism at the biochemical info, but like it or not, you will use it--more often than you can imagine. Especially once you're out of medical school. I suggest you learn it well now, because you will never again have the kind of time you now have to do so.

As for the inheritance patterns and the like, you won't know enough medicine to be able to understand such material until you're almost through your second year. Some schools start teaching this stuff in first year, but it's most schools' experience that few student can assimilate the information until they have a fair bit of pathology under their belts. For example, there's a lot more to sickle cell than just that the cells sickle in hypoxic conditions. No doubt, you'll argue that statistics isn't worth your time either, and epidemiology is a bore--though it will determine much if not most of how you will practice and be compensated. The pharmacology course won't cover drugs, because you really can not learn them until you're on the wards and in the clinic. I think U of Penn tried to bring drugs into pharmacology several years ago for about 3 classes, and it was little short of a disaster. As for why few med students go into genetics, it isn't a function of the way the material is taught. (Don't believe me if you don't want to, but that's the reality. Choice of speciality is entirely personality driven.)

As for Gross, ancient is good. Those are the folks who really know the material cold. And that's what you need during the dissection. As for the formaldehyde, you will survive. Everyone does. And it beats being exposed to some undiagnosed virus, which is the alternative.

The dissection may seem inhuman (and inhumane), but the reality is that the first step of becoming a physician is learning to detach yourself from your patients. Empathy is good, for sure, but unless one can objectively assess what's going on in a given situation, one is set up for failure as a physician. As you assemble the "pieces" back together when you get to the wards, you'll begin to look at your patients as people, but you'll also be able to take a step and figure out what's going on with them in a dispassionate way. That may sound cruel or like gobbly-gook, but it is what happens, either in medical school or, for some, during their internship. And it DOES happen.

And if you really think I'm full of it and have absolutely no idea what I'm talking about (and I remember thinking exactly the same as you), go volunteer as a med student in the ER for a weekend, or even just a Friday or Saturday night (as in when the Knife and Gun Club has its meetings/activities). Objective observation is often critical for saving someone's life, or at least making certain that nothing has been missed.

Enjoy this year. You'll never have the opportunity to learn this material the way you do now. Though I wouldn't want to go through med school again (three relationships lost in the first year alone), I'd do a lot to have the opportunity to learn that material again.

Oh, and with regard to the wasted info they're making you learn, hey, 50% of what you learn in med school will be out of date if not outrightly wrong within 5 years of your graduation. Which 50%? That's something no one knows.

Oh, one more thing--memorize the brachial plexus. It seems stupid to do so, but that shake one of your classmates' hands and ask them to pretend they lost innervation (through a lesion of the plexus) of one or two specific muscles. Then use what you memorized to figure out where the injury took place. Even with CT scans, knowing how to diagnose a neural injury based on simple things like where an injury took place in the plexus is quite important.
There are several things I would like to address and clarify. My aim is to neither challenge nor dismiss your views, as it is very valuable to me to have someone who's "been there done that" to comment. I would simply like to elaborate where I am coming from.

Our genetics course here is only 3-4 weeks long. Then it switches over to biochem for the remainder of the semester (until December). I fully understand and appreciate the importance of biochem, but in these precious 3-4 weeks I expected to learn genetics and not biochem, as I know biochem will shortly follow anyway. This has not happened. As far as "true genetics" (e.g. the inheritance patterns, genetic diseases, ELSI issues, etc) material goes, I have learned more in high school and undergrad compared to this course. It is my opinion that throughout my medical education there will never again come a point where the opportunity to learn about diseases from a purely genetics point-of-view will occur. To me, this (mini-)course is a missed opportunity to prime and sensitize med students to the emergent importance of genetics in medicine.

I do not believe a complete understanding of pathology is necessarily required in order to highlight the genetic components of diseases. I've taken courses before that have delved quite deeply into the genetics of sickle-cell anemia and Huntington's corea without more than the most basic understanding of their pathology. Pathology comes later to flesh out the details of diagnosis.

With respect to statistics and epidemiology, I was a grad student in Hospital & Molecular Epidemiology for a year before starting med school. Therefore I fully appreciate the importance and relevance of these subjects to clinical medicine. I am actually somewhat disappointed that my med school curriculum does not do much more than mention the most superficial aspects of these subjects. They are critical to evidence-based medicine and understanding the literature, so that each physician may make a critical judgment and opinion about whether the evidence is strong enough to affect his/her practice.

Back to the topic of genetics, in several of my public health courses, we had discussed at length the lack of genetics understanding most physicians possess and/or how they are learning/focusing on the "wrong" material. My genetic counseling friends lament how (many) doctors are not able to recognize what is a genetic disorder and what is not (especially with prenatal and pediatric genetic conditions), or attempt to order a genetic test without being able to understand the results. Many in my courses feel that physicians seem to dismiss the emergent importance of genetics in medicine, especially with the "promise" of personalized medicine on the horizon.

I do not know what to expect in regards to pharmacology. I will not take that course until next year. My friend at Case Western has lamented to me how she had to memorize a list of pain medications, blood pressure medications, and cholesterol medications (at the very least, the major name brands). I understand that each med school has a different way of teaching the same material, and when the time comes, I will likely call my pharmacy friend and ask her for help when studying pharmacology. Because that's what pharmacists are for (and she's pre-agreed to this). :)

While I agree with you that choice of specialty is personality-driven, I also believe it is also in part exposure to the field. Not many med students (that I've spoken to) know that medical genetics is an option. Other more "obscure" specialties (e.g. infectious disease, community health) aren't very well highlighted during rotations. Without exposure, how can a med student know what options there are? Furthermore, I also believe the way a course is taught does impact a med student's decision to pursue a particular specialty. If you're not interested in only looking at the heart, you won't be a cardiologist. If you suck at dissection in anatomy, you should not be a surgeon. Perhaps that's a gross oversimplication.

The curious thing about clinical human anatomy is that, on the first day, we were subjected to a 2-hour long lecture on the ethics of cadavers and respect for them. We were actually warned to not allow anatomy to distance ourselves from our future patients, but rather to bring us closer to them (I'm not exactly sure how this would work). It is interesting, however, that many mainstream media report how patients actually abhor doctors who view them with dispassionate interest - who view patients more as a "bag of symptoms" rather than as a holistic individual. We've been told, time and time again (and just within this last week), how patients don't care how much a doctor knows but rather how much a doctor cares. Call me idealistic (and I suppose I am, for being just a lowly M1), but I would like to believe there is a way to balance the "caring" side with the objective side of clinical medicine.

As for memorizing the brachial plexus, I don't have a choice. It will be on my exam (in quite a bit more detail than I'd like, I imagine) in a few weeks. Besides, I don't think anatomy's stupid. It's good to know where the major things are. I've heard that other med schools do less dissection work, as anatomy is a "dying art." That's rather unfortunate, in my opinion.

Finally, if you read this, thank you again for your comments. It would be interesting to read what you had to say about my previous posts, particularly the ones that relate to health and medicine. As it is, I understand you probably don't have time for that and so I truly do appreciate you taking the time to comment on my last post.

Hi again AD! :) Thanks for commenting further in this post. I won't copy your text, as people should just refer to the comments section of this post below.

I would like to ask you a few questions (if you don't mind answering, hopefully you read this): is it possible to do a fellowship in medical genetics after doing residency in pediatrics? Or is the only "route" to medical genetics through internal medicine? And what kind of physician are you?

I took an embryology course in undergrad and actually really enjoyed it. Even some people in the biology department lament at the "death" of embryology, as developmental biology seems to have overshadowed it. It's a little saddening.

I'm really glad you brought up that point about pharmacists. My friend who's finishing up pharmacy school is actually most interested in hospital pharmacy (I think that's what it's called), where they follow doctors and residents as a part of a team and advise them on which drugs the patient should take. I'm not sure if it's everywhere, but just there seems to be a culture shift in the way medicine is taught and practiced, there seems to be a cultural shift within pharmacy as well. So hopefully by the time I'm done with residency (and fellowship?) I will be able to defer to pharmacists.

I'm also glad you pointed out how it's okay to say "I don't know." I had been wondering/worrying about that aspect of medical culture. I've read (and heard) how mortally dangerous it can be for doctors to either admit fault or that they don't know, for malpractice reasons. Of course, as a fledgling M1 I don't know much in such matters, but I've never had the ego to not say "I don't know" when I truly didn't (in fact, I'm quite uncomfortable giving advice/info that I'm unsure about). My genetic counseling friend refers to that tendency as evidence for my "extensive" scientific background, lol.

Lastly, I have not read The House of God but I fully intend to over winter break. My brother read it in one of his freshman seminars and I've heard many good things about that book. So it's about time that I read it. A book I have read and enjoyed was The Spirit Catches You And You Fall Down.


Dave83201 said...

Fascinating! I'm not sure what percentage I understood, but fascinating!

Oh and I'm writing a post right now about my health issues. I have strong feelings about some aspects of my medical care, and not all of it is positive. While the post will reflect my true feelings, I just don't want you to take any of it personally. It is a mere rant meant to make me feel better more than to change anything

Anonymous said...

I'm not suggesting I'm the last word on medical education, but I think you need to keep in mind there are only four years of medical school, and there's a lot of educating taking place during internship and residency. As for learning medical genetics, this may indeed be the last course you take titled “Medical Genetics”. However, you may rest assured it is not the last time you will take a medical genetics course. Pediatrics increasingly deals with medical genetics, and many clerkships have a solid week on the subject (remember, it’s only a 6 week clerkship, so one week is a lot of time on the topic). Ditto for internal medicine.

Anonymous said...

The biochemistry is quite important, since that’s the means by which therapeutic interventions will likely be administered, and not knowing the biochem, it’s going to be hard to understand the therapies. So I’m not willing to accept your criticism of the course just yet, and not knowing your medical school, I’m not in a position to comment on how the course integrates with the rest of the curriculum. However, I wouldn’t be concerned that you will not get the needed education in medical genetics—just that there’s only 4 years available. Medical school is about learning the terminology. Internship and residency is about how to practice medicine. There’s a lot of terminology to be mastered.

Anonymous said...

The temptation during gross lab is to look at the cadaver as something other than what was once a living person. Either that, or one becomes overly connected to it, as one of the groups in my class did. Two members of that group dropped out of medical school, one repeated the course, and one passed, albeit barely. Master the specifics of the cadaver—there will be time to assemble it together before med school is finished. As for the patients’ desire to be looked at whole—it depends on the circumstance. In the clinic, of course, everyone wants to be considered as a whole human being, and they have every such right. After all, medicine is the only field in which you can go into a room, close the door, tell someone to strip, and not have they screaming for the police. In return, they ask, quite reasonably, to be treated with respect. That’s the pact between physician and patient. They’re there for our assistance, and we ask for honesty from them in order to provide understanding and treatment for them.

Anonymous said...

Woe to the patient treated six times in the last three months for STDs who comes in jaundiced and doesn’t see fit to mention anything about the 6 z-packs they’ve had during those three months. (Or erythromycin, if you want to be dramatic about it.) Or the arthritic in renal failure who doesn’t do anything for their arthritis (except for the gram of naproxen taken each day for the last four years, again not mentioned). People are people. And all they’re asking for is to be treated with respect. Now, when someone comes to the trauma unit with multi-organ damage, the last thing I’m going to start worrying about is what’s going on with their home situation—let’s get them through the acute phase and then we can deal with disposition issues, as well as anything related to why they appeared in the trauma unit in the first place (guns in the home, alcohol abuse, combination alcohol and drugs, etc). It’s a question of immediate priorities.

Anonymous said...

Gross is important, but so is histology and embryology. (If you think gross is a dying art, try finding a competent embryologist sometime!) I liked histo much more than gross, though it didn’t help much in the OR. On the other hand, histo was critical in understanding pathology. I’m sorry if I sounded a bit down on Pharmacology. The course is actually a key one, and you will go through the different classes of drugs etc. Pharmacists are often helpful, though I wish they spent more time on clinical matters during their training. I’d feel much more comfortable in deferring to them if they did. I’ve found my pharmacists train for the drug store rather than the hospital, which is a real waste of their expertise. Pharm was the place where I finally came to understand what the sympathetic and parasympathetic systems were all about, where drug-drug interactions started to make sense, and where dosing schemes began to make sense. Remember, though, that the goal is to learn the terminology, and there’s a lot of that to learn.

Anonymous said...

As for not having that much time, the day I don’t have time for a medical student, with all the kindness shown towards me by physicians when I was a med student, is the day I hang up my shingle. Never, ever be concerned about asking a physician about anything, and never be afraid to say “I don’t know”, because that’s the start of the process of finding out and learning—knowledge likely useful at some time in the future. The most dangerous thing a physician can do is to say “I know” why they don’t. That’s how patients get injured, and that’s unforgivable conduct.

Anonymous said...

As for not having that much time, the day I don’t have time for a medical student, with all the kindness shown towards me by physicians when I was a med student, is the day I hang up my shingle. Never, ever be concerned about asking a physician about anything, and never be afraid to say “I don’t know”, because that’s the start of the process of finding out and learning—knowledge likely useful at some time in the future. The most dangerous thing a physician can do is to say “I know” why they don’t. That’s how patients get injured, and that’s unforgivable conduct.

Anonymous said...

Bottom line: have fun with this year (and read The House of God when you can). It’s really easy to let it overwhelm you. There’s a lot of tension, and classes tend to get really close (and intimate) in dealing with that tension. I recall there were 4 guys in my class who were clearly in the closet; it was only at our end of second year party, which was part orgy and part ode to Bacchus, that they realized everyone else in the class knew they were gay and didn’t care (except for the Catholic fellow who dropped out a week later and went into the priesthood).

Anonymous said...

I'm not sure if you know, but are you going to use Robbins for pathology? Or did your school go with Rubin's?


J said...

Aren't about 90 per cent of psychiatric illnesses genetic in origin, and isn't pharmacology a very important part of their treatment? As late as 50 years ago Freud was everything.

Aek said...

Dave83201: I can't wait to read about it on your blog. :) Hmm, perhaps that sounds a bit too positive. >.>

Anonymous (AD): Glad to see you comment again. ^_^ Your insights are quite interesting to me, and I agree with much of what you said. I will post an edit to the bottom of this post in response (because to do so in a comment here would probably be too long).

Anonymous (b): I'm not sure if we're using Robbin's or Rubin's. I don't have pathology until next year, though I've heard both texts referred to as the "Bible" of pathology.

J: I don't know the answer to your question. Many diseases are at least in part genetic, but to say that 90% of psychiatric illnesses are genetic in origin seems a bit of a stretch to me. Certainly I don't doubt that there is a genetic component, but how large that component is (in comparison to environment) I do not know.

But yes, pharmacology is now quite important to their treatment, at least as far as I'm aware (I'm sure I'll learn more).

Anonymous said...

Actually, current thinking is that most psychiatric diseases are environmental (personal habits as well as physical environment) in origin, with some genetic factors entering into the mix. They are most certainly not all genetic.

Anonymous said...

Or even 90%. If you say 90% are environmental or environmental-genetic, you're probably close to being right.