I just came across this Salon interview with Atul Gawande.  I have to say, despite my admiration for this guy, I also have this incredibly childish envy of him.  Because he’s accomplished so freakin’ much!   Rhodes Scholar after graduating from Stanford!  Healthcare lieutenant during Bill Clinton’s campaign, then senior advisor at the Dept of Health and Human Services during med school!  Wrote for Slate and then was hired by the New Yorker as a staff writer while a resident!  Then published books that were nominated for awards and had his essays published in anthologies everywhere!  A MacArthur genius!  Influenced episodes of ER and Grey’s Anatomy!  And he manages to look so laid-back and humble and cool beyond it all!

I admire your work tremendously, Atul Gawande, but I also hate you for being all perfect and superstar-y and making the rest of us aspiring physicians look so darn mediocre by comparison.  Show us a flaw of some kind.  There must be photographic evidence of you doing a keg stand in college floating around the Internet somewhere.  Come on!  Give us something.

When discussing the career path to becoming a doctor, the focus tends to be on medical school admissions as the limiting factor, the point being that if you can make it into medical school, the chances of you getting into residency and becoming a doctor are fairly high.  But the unfortunate reality that is generally glossed over is that you’re not always going to have your pick of specialties once you’re in medical school.  I’m sure there are a good number of premeds who enter medical school with their heart set on a single specialty, whether it’s pediatrics or neurology or general surgery or whatnot.  Nothing wrong with that.  Some of those premeds will change their minds upon entering medical school and some don’t.  The danger, though, of clinging too hard to one specialty is that you might discover that you don’t have what it takes to enter that specialty.  If you enter medical school determined to do dermatology or plastics and nothing else, you better be a superstar or your chances of entering that specialty are slim.  In plastics, only about 50% of applicants actually match.  Kind of frightening.  Feel free to check out the actual numbers here.

Anyway, I’ve been torn for a while about specialties I’m considering.  I find myself liking certain aspects of a lot of specialties, but no one specialty that really stands out so far.  I still have primary care, peds, and OBGYN rotations left, and I want to explore EM, anesthesiology, and pathology before I decide, but it’s been frustrating not to have a definitive answer when so many of my other classmates have begun to make their career decisions and start applying for away rotations and find mentors already.

I really do like psychiatry.  So much of psychiatry involves talking to the patient and trying to get inside their heads, uncover their motives, figure out if they’re psychotic or delusional or suicidal or lying.  It appeals to the part of me that enjoys studying human behavior (one of the reasons I love theater).  It’s fascinating that so much of psychiatry involves protecting people from themselves and their own dangerous impulses.  It’s unbelievable how many blatantly ill or suicidal people, people who try to leap off buildings or stab someone in a manic state, simply believe they don’t need help and refuse treatment.  And I’ve started to become more skeptical of patients and what they say.  It’s not that I accuse patients of lying; it’s just that I think twice about what their underlying motivations might be, rather than taking what they say at face value.

Psych appeals to that part of me that likes an intellectual challenge and the interface between behavior, emotion, and physiology.  But deep down inside, there’s still that part of me that misses surgery, the part that likes instant gratification and getting “down and dirty” (which, now that I think about it, sounds like a skit from the Man Show involving bikini-clad girls and tubs of gelatin).  It’s come down to one fundamental question:  Am I a doer or a thinker?

What if I’m half-and-half?  How in the world do I decide?

It’s a little disappointing, considering I was a clinical psych major in college and all.  But in college, the focus was very much on psychotherapies, like humanistic therapy and cognitive behavioral therapy and so forth.  That’s really not the case with psychiatry, which tends to focus more on diagnostic criteria and pharmacotherapy.  As one of my attendings said, “I know that as med students, you may have a tendency to identify with the patients more, give them the benefit of the doubt.  But it’s better to overpathologize, at least initially, than to underpathologize them.”

That’s where I seem to fail.  Because I’m actually really gullible.  My friends mock me relentlessly about this.  My first boyfriend, a Taiwanese guy, told me that he was Azerbaijani in an attempt to be funny.  It failed, because I totally bought it, even though he looks like your typical Asian guy.  I asked him, “So what’s Azerbaijani culture like?  Do you have your own language?  What’s the GDP of your country?”  And he had to break the truth to me gently, so as not to make me feel like the fool I was (and still am).

So in my psych rotation, I’m encountering patients who will present with symptoms of mania who tell me “I don’t belong here.  My boyfriend had me hospitalized because he’s trying to sabotage my schoolwork, so I won’t succeed in my career and ultimately leave him for a richer guy.”  And I’d think, “My gosh, what a jerk!”  Absolute wrong reaction.  Right reaction?  “Pt is currently exhibiting paranoid delusions consistent with mania and is in need of hospitalization.”

I’m learning to be more skeptical about patients now.  But it still surprises me that patients simply don’t get the benefit of the doubt when it comes to psychiatry.  To a lesser extent, it occurs in medicine and surgery, too, but it’s especially prevalent in psychiatry and for good reason.  Sometimes the patients are in such an acute psychotic or manic state that they can’t be trusted to tell the truth.  But I can’t help but feel for the patients who end up ceding all their control to the mental health professionals once they’re admitted.  And the truth is, the longer I’m in my psychiatry rotation, the more I realize how “abnormal” all of us can become, especially given certain conditions, childhoods, psychosocial stressors, etc.

***Quick, final note:  If you’re considering donating to one of the many relief organizations working in Haiti, consider GHESKIO, a clinic in Port-au-Prince (right where the earthquake hit the hardest) affiliated with Weill Cornell that treats over 100,000 patients and whose staff is now providing emergency services for the victims of the earthquake.  You can find out how to donate here.

…you start to feel a little guilty about being able to sleep in until 7:30am.  Although tomorrow I may attempt to wake up early to exercise.  I might actually be keeping my New Year’s Resolutions after all!  My god.

One quote that my attending made when discussing how psychiatrists are often the ones to make medical diagnoses as well:  “I see psychiatry as similar to veterinary medicine.   A disorganized schizophrenic patient may know when something is wrong with them physically, but they simply can’t express it.  The ER docs and the primary care physicians may not have the time or patience to figure out the medical issue when the patient is so mentally unstable.”

More thoughts on psych to come.

I got caught up in a kdrama episode,  I’m embarrassed to admit.

As I progress through medical school, I have noticed a gradual but perceptible change in the way I relate to patients vs. the doctors.  Before medical school, when working in clinical research, I would see all those med students, residents, and doctors roaming the corridors of the hospital in their white coats, and I would long to be one of them.  I couldn’t wait for the day when I could start my own journey toward that white coat.  It was like a form of lust, my excitement.

Then, when I first began medical school, I felt like such a fraud whenever I wore the short white coat.  Like, I know nothing.  Nil.  Zilch.  I’m more like the patient than the doctor, so why am I wearing an item of clothing that allies me more with the doctor?  The white coat felt like a Halloween costume at times, especially when patients would ask me medically-related questions, and I would be forced to reply sheepishly, “I’m sorry, you’ll have to ask the (gray-haired, more experienced, more knowledgeable, fully-trained and fully-degreed) doctor.”

But now, in the midst of my third-year, I’m starting to associate myself with the doctors more (and by doctors, I’m also referring to the residents).  I don’t feel so awkward in the white coat.  I’m starting to realize that I have valuable insights to contribute, even if I don’t yet know everything about a medical topic.  This doesn’t mean I don’t feel horrendously idiotic and useless at times.  In fact, it happens quite often.  That’s just part of the excruciating pain of being a medical student.  But you do start to recognize that you’ve, by golly, actually learned something over the years!  And that’s actually really gratifying.

Next time, I’ll post thoughts about psychiatry.

I didn’t mean for the title of the post to sound like a WWF showdown.  I just saw Atul Gawande speak at Memorial Sloan-Kettering about his new book “The Checklist Manifesto”, in which he talked about the lifesaving potential of a simple checklist, whether in a major academic center in the U.S. or a rural hospital in Tanzania.  I’m not going to rehash his speech for you here, because most likely, if you’re one of the few people who read this blog, you probably are familiar with Dr. Gawande and his writings and have probably already read the reviews for his new book. If you have no clue who he is, no problem: I’ve added links to reviews of his new book at the bottom of this post.

I was struck by how different his approach was in comparison to Paul Farmer’s.  Both are making amazing strides in improving healthcare but in very different ways.  I’ve seen Dr. Farmer speak at a couple of events, and he has a very opinionated and passionate view of how people should view healthcare (as a right, not a privilege) and the need to improve access to healthcare for the poorest people in the world.  His books are powerful, compassionate, and angry.  He’s a maverick, a guy whose persistence and dedication to his cause has truly paid off for him and for the people he treats.  He really advocates for them in an aggressive way, and that’s why he has accomplished so much and is so widely admired by many people (including myself).

Dr. Gawande is completely different.  His approach to improving healthcare is a more humble one, one that involves checklists and systems and safety checks, rather than advocacy.  He has a thoughtful, carefully considered take on healthcare, one that delves deep into sorting out the inefficiencies and missteps that prevent our healthcare system from delivering the best care it can.  In his books and in his speech, Gawande comes off as a man who can admit even to his own failings.  He discussed how he initially doubted that his own OR would need the same surgical checklist that he was working to implement at other hospitals.  However, after it was implemented in his OR, he was shocked at how many near-misses were caught by that checklist.  He also stated that in this new era of increasing complexity in medicine, our definition of a “hero” may no longer apply to individuals, but teams and systems.  Because of all this, Gawande strikes me as less showy and a little less judgmental than Farmer.  Both are tremendously effective individuals, so this is not in any way meant to say that one person’s style is better than another’s.  In fact, both styles complement each other very well, and each bring about change in their own way.

Anyway, the reason I even bring up checklists is that I will likely take time off from school to get involved in a project that would implement the WHO’s Safe Pregnancy checklist in rural clinics in Africa.  The checklists involve very basic steps, including handwashing, checking vital signs on admission and during labor, and so on and so forth.  Sounds simple, yes, but during a difficult labor, it’s easy to forget one or more of these very simple steps.   The hope is that this checklist will reduce maternal mortality rates by decreasing infection rates and bleeding complications.  It’s a project that I’m very excited about, but more details later, I promise.

Some reviews of Gawande’s new book:

http://www.nytimes.com/2009/12/24/books/24book.html

http://freakonomics.blogs.nytimes.com/2010/01/04/the-checklist-manifesto/

http://gawande.com/malcolm-gladwell-review-of-the-checklist-manifesto