Anguish. Choosing a medical specialty is difficult, Part II

The following was recently posted by an anonymous woman as a comment on a blog post I wrote about the difficulty one has in choosing a medical specialty. I was so taken with it that I wanted to give it more exposure. [Note: The comment contained a few typos which I have corrected. Otherwise it is unchanged.] My response has been amplified slightly.

Since you are so senior to me, let me ask you for your thoughts. I got into medical school, studied, worked hard, got into residency and learnt, spent hours and hours in hospital, loved critical care and got into fellowship. Along the way met a guy (both were residents at that time), fell in love and we both dreamt and read and learnt and discussed cases. He decided on cardiology and I decided on critical care. Both got into fellowships ....worked hard, spent long hours into fellowship...we were committed. We ARE committed but divided.... We had kids and now every day I feel divided. I have a feeling that all "old timers " like you who worked for longer hours and did frequent night calls, had " spouse" who take care of your kids and you did not have to worry as much. Times were different. Times were not so dangerous and kids’ safety outside of the house was not so concerning.

In my situation, my spouse and I are both physicians in fields that require us to spend lots and lots of hours in hospital. If I were to find a traditional practice and work every 3rd night, who will raise my kids? Who will teach them right from wrong? Everything is on rise–drug abuse, physical abuse, drop-out rates. I WANT to raise my kids and be there to guide them. So yes I want a practice where call frequency is lesser, where I can spend evening with my kids (not because I want to have fun but I want to be there).

We do not think about all this when we get into medical school and I did not think about this when I married my husband and we did not think about this when we chose our subspecialities. Perhaps that was a mistake.

It was easier for us. There were far fewer women in medical school. My class of 180 had only 20 women in it. Our chances of marrying another doctor were much lower, especially since same sex marriage was not in vogue back then. I was fortunate to have married a woman who is both a nurse and a saint. She took 13 years off from work to raise the children.

Have you thought about joining a group and working part-time, maybe with shorter hours and fewer nights on call?

I was touched by your palpable internal turmoil. My heart goes out to you. I hope you can find the balance you seek. Your last paragraph sums it up. Everyone in medical school should read it.

A HIPAA and ethical conundrum

Do you know anything about HIPAA?

Here’s a scenario for you.

Patient A comes in from the parking lot of a doctor’s office and said to the nurse, “I just saw a patient leave here and when she was backing out of her space, she hit another car. Then she just drove away.” Patient A was able to accurately describe the perpetrator and said she would sign a statement saying she witnessed the incident.

The nurse finds out that the car that was struck belonged to Patient B. Patient B then asks the nurse to tell him who was driving the car that struck his.

The nurse, knowing exactly who the hit-and-run driver was, said, “I can’t tell you that. It would be a HIPAA violation.”

Patient A and Patient B appeal to the doctor. What would you tell the doctor to do?

Signs that the apocalypse is near. Part 2

I reviewed a few signs of the impending apocalypse in a previous blog. It looks like it will take many blogs to cover all the signs that keep appearing. Here we go.

Tech company Citrix released the results of a national survey which showed that 51% of Americans think that the weather can affect cloud computing.

A Swissair flight from Zurich to Beijing had to turn back when two passengers began to fight over a reclining seat. The men fought in the aisle, rolled around and cursed at each other. Why can’t we all just get along?

If you’re a man, it’s OK to walk around naked in San Francisco. However, what you cannot do is wear a ring (ahem) … down there, but only if someone complains about it. I haven’t been to San Francisco in quite a while and the photo (SFW) accompanying the article does not make me miss being there at all.

The Chief Diversity Officer at the State Department has issued an advisory which says that the use of phrases like “hold down the fort," “going Dutch” and “rule of thumb” are racially or culturally insensitive and should not be used.

In cooperation with the Discovery Channel, Harvard University, which made my first list because of its cheating scandal, is presenting a “media training boot camp for doctors.” The advertisement says, “This amazing 3-day event is only $1997 to attend.” I’ll pass.

A cheating scandal has rocked the world of competitive Scrabble. A contestant was caught with extra blank tiles. I’m not sure how he planned to use them since the game has only two and it would have been pretty obvious is he played a third one. I suppose the next thing will be doping in chess.

Professional image consultants charge $300 per hour to coach young women on what to wear and how to speak during college sorority rush week. The business is called “Rushbiddies.” The ABC news story has a happy ending as the woman featured in the story was accepted into Alpha Phi, which was her first choice.

A 2011 test of US eighth and twelfth graders reveals that only about 27% had proficient writing skills even if they had access to spell check. The problem is those who didn’t do well had poor organizational and grammar skills. According to the story, “In 2007, 33 percent of eighth grade students scored at the proficient level, which represents solid writing skills, as did 24 percent at grade 12.” The most recent test was done on computers while the 2007 students used things called pencils and paper.

A dance school in British Columbia is offering pole dancing classes to grade school children. If that's not bad enough, note that parents have enrolled children at $70 for an hour session. “The kids just love it,” said [the] president of the Canadian Pole Fitness Association, which is said to be holding championships in what it association president says is becoming a “sport.”

New post on "Ask Skeptical Scalpel"

A new post on "Ask Skeptical Scalpel" is about a question from a college student who is having second thoughts about going to medical school. Here's the link.

Does the timing of appendectomy influence the wound infection rate?

“Yes,” says a large review of a single institution’s experience with appendectomy for acute appendicitis.

The study looked at over 4500 patients who underwent appendectomies over the 8-year period between 2003 and 2011. The main findings of the study were that patients who developed surgical site infection (SSI) had a significantly longer delay in going to the operating room. Time to appendectomy was defined as the time the patients were admitted to the surgery service until they reached the operating room (OR).

Patients who developed infections were taken to the OR after a mean of 14 1/2 hours compared to 11 hours and 45 minutes for those who did not, which was a statistically significant difference, p = 0.013.

The delay in taking patients to the operating room did not lead to more perforations. However, the rate of perforation in this series was rather high at 23%.

The abstract concluded, "prompt surgical intervention is warranted to avoid additional morbidity in this population."

Since this paper supports my bias about performing appendectomies as soon as the diagnosis is made (as I have previously blogged), I was hoping that its findings would be valid. Unfortunately, that is not the case. The paper is not as convincing as the abstract.

The authors state that surgeons and operating room personnel are in the hospital 24 hours a day. It is not clear why patients’ operations were delayed so long. There is no mention of whether the patients received antibiotics while they were waiting. If more patients who did not suffer SSI's had received antibiotics, the paper’s results could be misleading. If you look at the mean difference between times to the operating room for non-infected versus the infected patients, you will note that it is a little less than 3 hours, which really is not that long.

Another issue is that only 41% of the patients underwent laparoscopic appendectomy. In my practice and that of most other surgeons, 90%-95% of patients with appendicitis are operated on via the laparoscopic approach. Laparoscopic appendectomy is known to have a lower wound infection rate than open.

The mean hospital length of stay for the non-perforated patients was 3.4 days, highlighting the outdated nature of the information. Most patients with non-perforated appendicitis are discharged within 24 hours of surgery in 2012.

However the most important problem with the paper has to do with the key factor that the paper emphasized; that is time. Not only was the duration of the patients’ symptoms prior to arrival at the hospital unknown, the authors also did not account for the length of time that the patients spent in the emergency department. If diagnostic CT scans, which are done about 90% of the time for appendicitis, were performed, the patients probably spent at least 6 hours in the ED.

It does not stand to reason that a less than 3-hour average difference in taking patients to the operating room when the preop duration of symptoms is unknown could possibly be significant. And 11 hours and 45 minutes to get a patient to the OR does not define “prompt” for me.

Bottom line: As I have said before (here and here), you have to read the entire paper and not just the abstract.

Some signs of the impending apocalypse

Here are some examples of why I believe the apocalypse is near.

The eighth annual "Pregnant Bikini Contest" was recently held in Houston. Before you click the link, I must warn you that what has been seen cannot be unseen. Notice of the first seven contests somehow escaped my attention.

A dispute at a bar in Calgary, Canada erupted in violence resulting in the death of a man. The disagreement was about the pitching staff of baseball’s Toronto Blue Jays.

Harvard University is investigating 125 students who may have plagiarized their test answers for a course ironically entitled "Introduction to Congress." After looking at some examples of the course material, I wonder why it would be necessary to cheat. An article in Salon magazines states, "The student source said Professor Platt was a fun lecturer who presented with accessible slides. In just one lecture he used ‘Sesame Street,’ ‘The Simpsons’ and the singer Bobby Brown to explain the origins of modern Congressional careers and committees." The same article quotes a student as saying Harvard is “out for blood” for daring to look into the matter. At least the students will be well-prepared for futures as politicians.

Also in Boston, a federal judge ruled that the state of Massachusetts must pay for a sex change operation for a prisoner serving a life sentence for murdering his wife. The Wall Street Journal reports that this prisoner has been receiving female hormones since his diagnosis of gender identity disorder in 2003. The judge noted that the murderer may receive better care for his problem than many law-abiding Americans.

A judge in England has let a burglar off without jail time while praising him. According to the BBC, the judge said, "It takes a huge amount of courage, as far as I can see, for somebody to burgle somebody's house. I wouldn't have the nerve." Prime Minister David Cameron had a dim view of the judge’s remarks.

As a charity fundraiser, donors in Japan were offered the opportunity to squeeze the naked breasts of young women, described as "adult video actresses." For an unspecified amount of money, one was allowed two squeezes per hand.