May 2008 Archives

As a medical student in my second year one of my favourite past times is pretending like career development and specialty choice are important decisions for me in the here and now. In truth they're not, not really, not now at least. Still, when I graduate, become an intern and start my career as a medical doctor it will be at turbulent and dynamic time in postgraduate medical education.

2012 is the year I start work as an intern, a year where the number of medical graduates will have increased by more than 80% since 2005. Questions are already being asked about how this will effect the quality of internships in Australia and what level of supervision will be allowed by stressed hospital systems. The availability of specialty places will be even more of an issue. Gaining admission to specialty training programs is already a competitive business and as the wave of medical graduates progresses through their postgraduate years competition will increase exponentially. A difficult endeavour in specialty training is set to become all the more frustrating and stressful.

 So, I wonder if maybe my medical career is, perhaps, a more pressing issue to me right now than I thought. Perhaps it's worth considering the difficult times that are sure to lie ahead of me and mentally prepare myself as best I can. As long as I don't lose sight of more immediate concerns as a junior medical student maybe it wouldn't hurt to look forward a little, to start thinking about where my real interests lie and where I might see myself in 10 or so years time.

The way I see it, and you have to understand that this is purely how I see it, there are 4 kinds of specialties.

 Systems based specialties: are just what they sound like, specialties based around one system of the body, cardiology, neurosurgery, gastroenterology, endocrinology etc etc. These specialties seem to deal with all kinds of patients in all kinds of settings but with a very narrow range of diseases. I decided fairly quickly in my first year I didn't want to do one of these systems based specialties. Why? To be honest I found the idea boring and frustrating. Restricting yourself to one system of the body didn't seem right for me. The first reason was that I found all body systems interesting, to exclude heart conditions just because I was a neurologist seemed like it would be frustrating and limiting. The other was that these specialists unlike the other two categories seem to have almost comprehensive knowledge in their chosen field, and it seems to me that once you know everything about something it gets boring, after all there are only so many different kinds of glomerulonephritis and once you know them well... then what? I want a specialty where you never know completly what's going on where knew stuff comes out every day.

 Patient Based Specialties: These are the kinds of specialties based around who your patients are, paediatrics, geriatrics, paediatric surgery, refugee medicine etc. These specialties seem to deal with all kinds of diseases in all kinds of settings but with a very narrow range of patients. These always seemed slightly less restrictive than the systems based specialties. these always held an interest for me as they seemed to define a field of practice for a practitioner rather than restricting them to one. I like kids and old people too so these both seem like legitimate choices. To be honest paediatrics was what I first thought about doing when I applied for medicine

  Setting Based Specialties: This is probably the smallest group of specialties, those based around the setting in which the patient presents, including Rural and remote medicine, General practice and emergency medicine. These allow for a broad range of diseases and presentations, as well as demanding a pretty good knowledge base with a pretty good capacity for independent learning. Sounds good right? Right. I could see myself doing all these specialties. Each has a downside though, emergency medicine is not a lifestyle friendly specialty and is possibly one of the most high stress environments available, GPs are essentially running a buisness something I don't look forward to and Rural and Remote medicine tends to be, well, remote and I'm a city boy.

  Technique Based Specialties These include all specialties defined by a particular approach rather than a particular type of patient or body system or setting, things like radiation oncology, public health, medical geneticists and medical oncology. These are a pretty heterogenous group of specialties some deal with many diseases, some deal with only cancer, some operate on a population level, some on individual cells. The defining feature of these specialties is a mastery of technology or technique, either using whatever it is radiation oncologists use, or drafting a good whatever it is population health people draft, these specialties display a level of technical mastery related to an interventional technique rather than an individual body system or patient type.

 The reason I say this is that I thought up until this rotation that I wouldn't find a systems based specialty that would be interesting enough to do my whole career. I was quite certain I'd end up in the second or third category, paediatrics, geriatrics, GP, emergency medicine, the broadness of these specialties appealed to me and I thought that's where my future lay. That is until we stared neurology. After I'd mentioned that I wanted to do neurology to a tutor of mine from last year he said "I could really see you doing that Kyle". Maybe I will be a system specialist after all.

Good things about medicine:

It's pretty interesting; I'm not sure if practicing medicine would be as interesting as learning it, I'm told that a lot of people once they become specialists became frustrated by the monotony of seeing the same cases day in day out. I'm not sure this is that much of a problem, after all if it ever becomes absolutely mind numbingly painful there's always a chance to change specialty, or go into academia, or become political and join the AMA or something. Besides most colleges encourage Life Long Learning now anyway, so I'm pretty sure I'm set in this regard.

You get to talk to people; depending on the specialty you keep some patients for life, I think this really just comes down to me liking to be able to see the results of my individual work. I'd hate to do a job where I worked in aggregate, bumping sales of a retail giant by an inexorably small percentage, or being a police officer an keeping crime down in an abstract manner day by day. That's not for me I like to see the results of my work in front of me, concrete.

Safe employment; people are always going to get sick, so there'll always be a demand for doctors. From what I can see of history the more simple diseases we cure the more complex ones people die of, medicine is getting more complex and people are living longer, being a doctor means having an (admittedly very good) source of income for life.

Altruism and ego stroking; anyone ever seen the episode of scrubs where JD takes a 60yo man (patient) to his high school reunion when everyone  has trophy wives and says "yeah, he's alive because of me". That guy is my hero. 

Crises are common: I love it when the proverbial hits the fan and love being stressed, at least for now, we'll see how I feel in 20 years. 

Bad things about Medicine: 

It's a time sink: It already costs me so many social engagements because I have to study etc etc. And it's not as though most doctors work a 40 hour week now is it.

Stuff up and people could die: This one's pretty self explanatory 

So what kind of specialty do I want?

 I want a specialty that:

• Is interesting and has a massive amount of content to know, preferably where new knowledge is still coming out 
• Lets me see the results of my work
• Has good job security
• Makes me feel like I'm doing something good
• Is prone to crisis
• Doesn't lead to someone dying if I make 1 mistake

Med school isn't really as expensive a business as people say and I found that with a decent part time job it wasn't even much of  a stress to buy any piece of equipment or textbook I've wanted. That being said there's a lot of choice out there as to what equipment to get, and paying a bit more can get you some nicer toys. Here's what I have (bought, was given, otherwise acquired etc):

Stethoscopes

Littman Cardio III: The workhorse of my stethoscope range it's comfortable to use, hardy, has never failed me and sounds as clear as any steth I've tried.

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Littman Classic II SE: Nice enough, but I find the flatter chest piece far more uncomfortable to grasp than the cardio, so this end to be my backup.

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Doctor's Brand Stethoscope: It as $15, I bought it for a lab coat + steth pubcrawl so I wouldn't have to take my expensive one. It's painful to use the earpieces are so hard and there is so much tension on the headpiece, acoustics are near non existent and the tube actually kinks. But hey at $15, I can certainly afford to lose or break it. This is my only steth I'll wear in a state of non-sobriety.

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Sphygmomanometer

Not sure of the brand, I bought it from the co-op, $35, great investment, I practiced with this non stop for a couple of months and now it's second nature

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Tuning Fork

Prestige Medical Tuning fork, with weights I got 2 of these, 128 Hz for sensory exam testing vibration perception, and 256hz for air bone conduction testing. They have the funny discs of metal at the end so they hold vibration longer, and they work wonderfully, the difference with weights is so noticeable, the vibration is so much stronger stronger and lasts much longer (this sounds like an ad for viagra). I would never go back to one without weights after this.

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Tendon Hammer 

Prestige Medical Queen Square Hammer. I got a queen square style because I found the longer handle useful, but they all work, and they're all very cheap.

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Penlight

It's a torch the size of a pen.

Ophthalmoscope

Welch-Allyn 2.5v Pocket Ophthalmoscope (Purchased as part of a diagnostic kit). Absolutely wonderful, ophthalmoscopes are expensive so I tried a few before settling on this one, most of the other brands I tried were cheaper but I found this one much easier to use, the controls are at the level I grip the ophthalmoscope naturally anyway so it's less clumsy to focus, it's large enough to use but small enough to throw in my bag where space is at a premium, it runs on AA's which is convenient and I find that locating vessels is so much easier with this than with the other brands I tried. I cannot recommend this particularly goodie highly enough.

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Otoscope 

Welch-Allyn 2.5v Pocket Otoscope Haven't used it yet just bought it with my ophthalmoscope because that's the only way the latter was available.

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Right now no matter what I do in life it better involve an ophthalmoscope, fortunately there's a pretty big range of specialties there, ophthalmology, nephrology, neurology, general practice, emergency, paediatrics, general medicine... Did I miss any anyone? 

As a second year med student I've done about 45 academic weeks so far, in that time I've had about 40 P.B.L.s, seen about 60 patients in person and had 15 sessions in the skills lab. 

Some things I've done to (willing) patients

• History taking
• GI exams
• Cardiology Exams
• Respiratory Exams
• Neuro Exams
• Fundoscopy
• Taken blood pressure

The Royal Australian and New Zealand College of Psychiatrists has launched a DVD which provides medical students and junior doctors with information about the benefits of a career in psychiatry.

"The DVD consists of four chapters which cover information relating to: why medical graduates should consider psychiatry as a career – including evidence for the specialty’s benefits such as work conditions, a rewarding and flexible career, the quality of training, career prospects, the range of settings to work within, the diversity of sub-specialties and emphasis on team work; detailed information about training and exams; testimonials from other psychiatrists; and opportunities in rural and regional psychiatry..."

View a sample or order a copy here, or head to our psychiatry specialty profile.

I'm a second year student studying for an MBBS at UWS. I'm a school leaver who decided to do medicine sometime in year 11, and I've kind of stuck with it ever since. Since this blog isn't anonymous I wont be mentioning any patients but I will be documenting the new skills and any interesting facts I learn along the way.

I'm a member of:

• The NSW Branch Executive of the Public Health Association of Australia
• The UWS Medicine curriculum committee
• Medstudentsonline.com.au (As a moderator)

I intend to use this blog to see just how quickly I change between preferred specialty and wether my reasons for liking and disliking specialties change in clinical years.

 Going into medicine I thought definitely paediatrics. Why? I like kids. That was pretty much it. Hospital can be pretty traumatic for kids and being a good paediatrician can really help. It's a job where not being a dickhead/asshole/general-pig-headed-aggressor actually helps you do your job properly. I just hate the whole nice guys finish last thing, because I'm not willing to become an asshole. The thing about the rat race is even if you finish first, you're still a rat. Paediatrics is one of those things where being nice makes you better at your job not worse. Maybe all medicine's like that because all patients are vulnerable to some extent, but there's somethign about kids that makes them especially vulnerable, and if I can help them avoid major trauma (psychological) by being nice then I'm doing something right aren't I.

 I've moved on from that position a bit, though paediatrics still occupies on of the top spots on my list, but I'll elaborate on what I currently think would be good specialties and why at a later date. I just thought in keeping with this being the first post and all i should tell you where it started, so to speak.

For a fantastic round-up of new technology on the horizon in a range of medical specialties head to Medgadget.com. It's an independent journal edited and published by doctors and biomedical engineers, which is frequently updated with the newest medical gadgetry, discoveries and technology.

Featured innovations have included a bikini which develops "moles" with excessive UV exposure, and radioactive microspheres delivered into liver tumours via the hepatic arteries.