Ortho to the rescue!

So, I've given Ortho some grief on my blog, and I think it's time to give them their due.  That's largely because of my innate sense of fair play, and also because they recently saved me from serious injury.

I've never been much of a runner, but I decided to take it up in earnest about six weeks ago.  My decision was made partly to trim a little from my waistline, partly for cardiovascular fitness, partly for bragging rights ("my 5k time is better than yours"), and partly because I was on an out-of-town rotation and staying in an apartment complex with an air-conditioned workout center with treadmills.  I started fairly slow -- just 1.5 miles on each of my first few runs, building up over the course of a couple weeks to a bit past 2 miles.  Nothing out of the ordinary -- not even that long of a run.

My mistake was to run too frequently from the beginning.  My previous attempts to become a runner involved a MWF jogging schedule, adjusted as necessary based on my work schedule, but never with more than three runs per week.  While I was out of town, however, I had lots of free time and none of my normal distractions (family, video games, my movie collection, etc.) so I adopted a M-F running schedule with rest on Saturday and Sunday.

About two weeks into this schedule, I began to develop some left knee pain, particularly at the beginning of my run and after it was finished.  I foolishly rationalized that it was simply muscular soreness that would resolve with time in my new routine, so I continued my aggressive running schedule and used Motrin 800 mg tid to control my discomfort.  To an extent, it worked, and I was able to keep pushing myself more than I should have done.

My away rotation was four weeks long, and by the time it was over I realized something more than simple muscular soreness was at work.  I backed off to two runs per week, but those had become very painful, especially for the first half mile.  After each run, my wife was treated to my best Vanilla Ice impression as I collapsed into a chair ("Ice, ice, baby!").  My knee pain had quickly progressed from something associated with my runs to constant discomfort, hurting me even on my run-less days.  I was loathe to stop running, since I had come to enjoy it apart from my knee pain, but something was clearly wrong with my knee and I knew I needed to back off or risk serious injury.

At this point, I had a quandary: should I use my own medical knowledge to manage my injury conservatively, or should I involve an orthopedist?  It's not always easy for doctors to get time away from their clinical responsibilities, especially if they're residents.  Fortunately, one of the perks of medicine is the ability to informally ask for medical advice from colleagues in many specialties, and I approached an orthopedist in the OR two weeks ago to ask his recommendation.  He replied that he'd be happy to examine my knee in between cases, and when he did he became a bit concerned.

"You have a clear medial collateral ligament strain," he told me, "but you've also got pain too anterior to be explained by that.  I'm worried you may have a small medial meniscal tear."

The orthopedist (I'll call him Dr. Thompson) ordered x-rays and an MRI to further evaluate my injury, asking that I call him when the scans were done so he could check them.  I was able to get the x-rays done the same day, but MRIs must be scheduled and it took a week before I was able to have that study completed.

On the appointed day, I went downstairs for my MRI scan.  It was completed in about 30 minutes, and afterward the technician returned me to the waiting room while the radiologist checked the images to confirm their adequacy before I left the MRI clinic.  Five minutes later, the technician came back and informed me that the radiologist was on the phone and wanted to speak to me.

"Hi, this is Dr. Wong," he said.

"Hi, I'm Matt, one of the anesthesia residents," I replied.

"Matt, I'm looking at your MRI right now and you have a grade 4 stress fracture of your medial tibial plateau.  I want to get you on crutches.  This fracture looks pretty impressive."

I had a sinking feeling, knowing how crutches would complicate my job, which includes pushing patients around the OR suite and spending a lot of time on my feet.  But two things the radiologist said caught my attention.  First, he said the fracture was grade 4.  I was unfamiliar with the criteria for grading stress fractures by MRI, but lots of things in medicine are graded on a scale of 0 to 4 with 4 being the worst.  Second, he said the fracture looked "impressive."  That's generally doctor-speak for, "damn, that looks bad!"

Just to be sure, though, I asked him what a grade 4 fracture was.  He said it meant you could actually see a fracture line on the MRI instead of just bone marrow inflammation and edema.

So off to the radiologist I went.  He showed me my MRI (the picture at the top of this post is a screen capture from my MRI, and all the white crap in my tibial plateau is edema and angry inflammatory cells that shouldn't be there) and wrote me a prescription for crutches, which I could pick up from Physical Therapy.

A few minutes after I picked up my crutches, my cell phone rang.  It was Dr. Thompson, who had already looked up my MRI.  He had taken the time to look up my home number from the hospital computer system, then had my wife give him my cell so he could touch base with me.

"Matt, this stress fracture isn't pretty," he said.  "You need crutches."

"Just picked them up, sir.  Dr. Wong from radiology said the fracture looked ugly."

"Yeah, it's impressive.  In addition to crutches, I want you in a full-length knee brace.  It should be unlocked because I want you to be able to move your knee, but you need to wear the brace at all times.  And you can toe-touch, but no weight-bearing at all on that leg."

That gave me another indication of just how much damage I had done to my knee.  Total non-weight-bearing?  For an active resident who has to walk around the OR suite and the hospital all day long?  That's serious business.

I asked about the other MRI findings and Dr. Thompson told me that the MRI confirmed the MCL strain he'd diagnosed, but my meniscus looked good.  He told me where to go for the brace and said he'd follow up with me on his next operating day.

And that's pretty much where we are now.  I'm hobbling around on crutches because I broke my leg by advancing my running schedule too aggressively.  But for now, I seem to have avoided more serious injury (like the fracture extending all the way through my tibial epiphysis).  I know the extent of my injury and I now know exactly why my knee was hurting me so much, which knowledge is empowering since it allows me to undertake the appropriate management to promote healing.  And it's all because a good, attentive orthopedist was willing to increase his own workload by examining me between his cases, then take an active role in my follow-up and intervention.  And a good radiologist was willing to stick his neck out, too, instead of just dictating his findings and closing the MRI.

So here's a big "thank you" to Drs. Thompson and Wong (whose names have been changed, as always) for their excellent work in diagnosing and treating my fracture.  I'm deeply grateful for their willingness to go beyond the call of duty to follow up with me and ensure that I received the information and equipment required to prevent further injury.

And I learned a lesson from all this: when you decide to take up running, it is important, as with so many things in life, to pace yourself.

How to become a doctor

Most laypeople don't understand the medical education process.  When I was a med student, lots of folks asked me what my specialty was; now that I'm a resident, people sometimes ask when I graduate and become a doctor.  I've spent a lot of time clearing up confusion, often with varying degrees of success.

The pathway into medicine starts in high school or earlier.  Anyone who thinks he or she might like to be a doctor needs to perform well enough in high school to secure college admission, preferrably at a reputable school with a good track record for sending graduates to professional (MD/DO, DMD/DDS, PhD, etc.) programs.  Smart high school students will take a tough courseload with multiple AP and math or science classes.  Over my final two years of high school, for example, I took seven AP courses in subjects ranging from US history to calculus and from English literature to physics.

Then comes college.  Some universities have a dedicated premed major, others don't; but prospective doctors may major in any field they desire, so long as they remember that medical schools have specific requirements for applicants.  Med schools typically require several science and math courses, as well as other courses like literature and philosophy to ensure a well-rounded application.  Premed students also need to consider the content of the Medical College Admissions Test (MCAT), the standardized exam required of all med school applicants.  The MCAT tests physics, biology, and organic and inorganic chemistry, as well as verbal reasoning and writing abilities.  So premed students can major in French or journalism if they'd like, but they'll need to fill up their elective slots with coursework that will both prepare them for the MCAT and satisfy med schools' admission requirements.

As strenuous as these requirements may seem, there are still far more outstanding prospective physicians than there are med school spots, so schools also consider non-academic pursuits as a way for applicants to set themselves apart.  Schools are interested in applicants who are involved in the community, who are engaged in service opportunities, and who participate in extracurricular activities like music and sports in addition to maintaining a full courseload with excellent grades.  They also want applicants who have shown some dedication to the medical field, whether it's going on an overseas humanitarian mission or simply shadowing a local physician after school.  Healthcare-related employment is helpful.  And having published research on your CV is a big plus.

The next step to becoming a doctor is to apply to med school.  Some universities (like the one where I did my undergrad work) have a premed committee that helps guide premed students through this process, advising them about application requirements, counseling them about their chances at different schools, and organizing their letters of recommendation and other supporting documents.  A year before the applicant wants to start med school, the student fills out an online application through the American Medical College Application Service (AMCAS), a service operated by the Association of American Medical Colleges (AAMC).  Nearly all med schools in the nation accept the AMCAS application (the University of Texas system has its own application service), and the applicant simply checks boxes for the schools to which he or she is applying.  There's a fee for the first school checked, then a flat fee for every school afterward.  The AAMC notifies the university premed office of the schools to which the application has been submitted, and the committee forwards the applicant's packet to those schools.

Shortly after submitting the primary application, a prospective med student will begin receiving letters from the schools to which he/she applied.  These letters contain instructions for completing each school's secondary application, which contains individualized questions not covered by the primary AMCAS application.  And each secondary application must be submitted together with an additional application fee; when I applied to med school in 2004, the fees were anywhere between $50 and $100 for each school.

And then comes the waiting.  Each med school reviews the primary and secondary application, together with the supporting documents.  They weed out the applicants in whom they have no further interest; these students receive a letter thanking them for applying and wishing them better luck elsewhere.  The remaining students also receive letters inviting them to visit the med school for an interview.  It is up to the applicants to schedule their interview date, get themselves to the school, make it to the appropriate location on their interview day, and effectively sell themselves to the school.  This can get quite expensive, and applicants often apply to several schools in a given area so they can (hopefully) knock out multiple interviews in a single trip.  The interviews themselves vary in terms of their content and focus; but they all share the similarity of being a final chance for each applicant to set him or herself apart from the thousands of hopefuls who will not be accepted.

After the interviews come more waiting.  Starting in October, med schools start sending out letters telling each interviewee their status: in, out, or wait-listed.  Some applicants receive one admission out of all the schools they applied to; some receive multiple admissions; and most receive none.  Applicants are allowed to accept multiple admissions, but there is a date in the spring by which they must relinquish all but one admission so schools can determine the fates of the applicants who were placed on the wait list.

Med school starts a few months later, generally in the mid- or late summer.  A traditional med school curriculum is four years long and is divided between two years of classroom learning and two years of clinical work.  During the classroom years, students spend several hours each day in lectures and small workgroups, then spend a large portion of their out-of-school time studying.  There are frequent exams, which are uniformly rigorous.  Med students also frequently find themselves in the hospital during the evenings, learning the basics of hands-on patient care (how to take a pulse, how to check blood pressure, how to take a medical history, how to perform a physical exam, etc.).

At the end of the second year of their training, med students are required to take Step 1 of the United States Medical Licensing Examination (USMLE, aka "the boards").  It's a day-long standardized exam involving about 350 questions, and it must be passed before the student is permitted to assume clinical duties as a third year med student.  The exam has long-term implications, too: just as universities consider SAT/ACT scores and med schools look at MCAT scores, residency programs use board scores to determine which prospective residents interest them.  Since it is such an important exam, many schools provide their students several weeks without coursework so they can focus solely on studying for Step 1.

The third year of med school is often the hardest.  Med students spend their time in the hospital, passing several weeks at a time on each rotation before moving on.  My med school required third-year rotations in internal medicine, general surgery, pediatrics, family medicine, obstetrics/gynecology, psychiatry, and neurology.  Students receive grades for their performance on rotations; these are generally subjective grades, but some services also have a written or oral examination that factors into the grade.  The grades are important, as residency programs see them and use them to decide between applicants.

After they've finished their required base rotations, med students are allowed more flexibility in their schedule so they can complete elective rotations.  It's during this time that many med students determine which specialty they would like to pursue.  In my case, I didn't even begin considering anesthesiology until more than halfway through my third year of med school, and I didn't firmly decide on it until I was beginning my fourth year.

During the fourth year, med students also have to take USMLE Step 2.  There are two components: Step 2 CK (for Clinical Knowledge), a computer-based multiple-choice exam; and Step 2 CS (for Clinical Skills), an in-person practical exam with "standardized patients" (aka actors being paid to act as patients).  Step 2 CK can be scheduled at a testing center near the med student, but Step 2 CS is only offered in five cities nationwide: Atlanta, Chicago, Houston, Los Angeles, and Philadelphia.  Students must apply, pay the testing fee, get themselves to the city they've chosen, find overnight lodging, and get themselves home.  For the exam, students see 12 standardized patients and must take a history, do a physical exam, discuss "next steps" with the patient (i.e. labs, studies, etc.), and write an encounter note.  And some of the standardized patients are instructed to simulate the "angry patient."  And the whole thing is timed.

Fall and winter of the fourth year of medical school are spent doing clinical rotations and applying to residency programs.  The residency application process is similar to the med school one: applications, application fees, supporting documents, and in-person interviews.  Some specialties and some hospitals are more competitive than others.  Unlike applying to med school, doctors-to-be are actually applying into their desired specialty at this stage.  Also unlike the med school application process, interviewees are not informed of their status on an ongoing basis.  Rather, applicants rank the programs that interviewed them and programs rank the applicants whom they interviewed.  These rank lists are submitted to the National Residency Matching Program (NRMP), where they are entered into a computer that compares all rank lists nationwide and determines a "best fit" for each applicant.  Each med school receives a sealed envelope for each fourth-year student containing their "best fit."

On a specific day in mid-March is Match Day.  Each fourth-year med student in the nation goes to his or her med school, where they receive their individual envelope.  Inside the envelope is their match, telling them the hospital and the specialty in which they will complete their residency training.  There are no multiple acceptances on Match Day.  Students are free to reject their match, of course, but getting picked up by a reputable program in a desirable specialty is nigh impossible if not done through the match system.  And with hundreds of thousands of dollars of debt, very few med students have the luxury of not working right out of school.

In late spring, the med students graduate.  They are doctors at that point, having received their doctorate in medicine (or osteopathy); but they are not licensed to practice medicine and are not considered competent to operate without supervision.  The next few weeks are spent wrapping up any remaining obligations and usually preparing to move again for residency.

Residency is the period during which new doctors are trained in their specialty.  Residency programs range from three (internal medicine and a few others) to seven (neurosurgery) years in duration.  Anesthesiology is a four-year residency consisting of a non-anesthesia first year followed by three years of clinical anesthesiology training.  The first year of residency is called "internship" and is a year-long exercise in pain.  Long hours, plenty of sleep deprivation, and lots of time spent out of your comfort zone make internship an experience that no physician wishes to repeat.  During internship, doctors are required to complete USMLE Step 3, a two-day standardized exam that must be passed in order to secure a medical license.  (During residency, residents without their own medical licenses practice on the licenses of their supervisors.)  Some residents also choose to subspecialize, which involves a fellowship of one or more years after residency.

After residency (and fellowship, if applicable), the physician has finally completed the training necessary to practice medicine independently.  At that point, he or she is free to take the exams necessary for certification in his/her specialty.  The learning process never really ends, though, because new research is always being done and most specialty certification bodies require recertification at specific intervals.  Anesthesiologists are required to take board exams to recertify every ten years.

Where am I in all this?  I'm in my last year of anesthesiology residency, or my twelfth year of training after completing high school.  A pertinent question, given how long it's taken to get where I am, is whether I would do this all over again.  My answer is...probably.  At the outset, I was warned that this was a difficult career path but there's no way I could fully appreciate how difficult without experiencing it firsthand.  The first two years after med school were without question the toughest ones for me, and I was already too far in to back out at that point.  I love my job, though, and I would likely choose it again, even knowing how tough this path really is.  But I'm also very glad to have so much of it behind me, and I can say without reservation that I wouldn't want to go through it again.  At this point, I'm just enjoying the fact that I can finally see light at the end of the tunnel.

Acute Pain Service pain

One of the best things about anesthesia is being a permanent consultant.  Apart from those who choose to subspecialize in chronic pain management or critical care, anesthesiologists generally sign on for the duration of a case, do their job, and sign off.  We typically do day-after-surgery postop checks on inpatients, but otherwise we don't round on patients or follow them past their surgeries.

A notable exception to this rule is the Acute Pain Service.  Lots of hospitals don't have APS, but in those that do the anesthesiologists can be consulted for patients with difficult-to-manage acute or chronic pain.  APS will evaluate those patients, write notes with their recommendations for pain management regimens, and generally also write orders for those patients' pain medications.  It's a nice service to have around, but as with many luxuries, it is sometimes abused.

There is one service in particular that seems to abuse APS more than the others.  This service -- we'll call it "Shmorthopedics" -- often comes up with flimsy excuses for consulting APS.  When I rotated on APS as a CA-1, I had several conversations that went more or less thusly:

Me: "Hi, this is APS returning a page."

Shmortho: "Hi, I'm calling to consult you on patient X.  He/she is having pain after having (insert shmortho procedure here)."

Me: "OK, what have you guys tried so far?"

Shmortho: "We gave him a couple Percocet and 1 milligram of morphine, and he's still having pain."

Me: "..."

Shmortho: "Anyway, we'd like your input."

Me: "..."

Shmortho: "Are you there?"

Me: "You gave him two Percocet and a milligram of morphine, and now you're calling me?"

Shmortho: "We're just not comfortable giving him more narcotics."

Me: "Tell you what, I'm going to give you some over-the-phone recommendations.  Give them a try, then call me again if they don't get his pain under control."

I'd give them some very basic recommendations, then never hear from them again.

Another disturbingly common conversation I had with Shmortho went like this:

Me: "Hi, this is APS returning a page."

Shmortho: "Hi, I've got four patients I'd like you to see."

Me: "You're consulting me on four patients at once?"

Shmortho: "Well, I'd just like you to help us optimize their medications."

Me: "OK, tell me about the first one."

Shmortho: "It's patient X, who had (insert shmorthopedic procedure here)."

Me: "OK, I've pulled him up in the computer.  It looks like you've already put in a discharge order for him."

Shmortho: "Yeah, we're discharging him this morning.  Can you help us streamline his meds?"

Me: "No, I can't.  APS is a service for inpatient consultations, not outpatient ones."

Shmortho: "He's an inpatient!"

Me: "No, this discharge order is timestamped two hours ago.  He's probably in his street clothes, has his IV out, and is on his way out the door.  He's an outpatient."

Shmortho: "You need to see him, we're consulting you for medication optimization!"

Me: "Look, clearly you have him on a medication regimen that's controlling his pain, otherwise you wouldn't be discharging him.  Do you really want me to mess with it right as he goes out the door?"

Shmortho: "So you can't help us?"

Me: "Let me phrase it this way: Do you really want to be paged at 3am when he's in Emergency screaming in pain because we messed up an effective pain management regimen?"

Shmortho: "..."

Me: "I thought not.  Are your other three consults in the same boat?"

Shmortho: "Yes."

Me: "OK, my answer for all of them remains the same.  Call me if you need help with someone who will be in-house at least overnight."

Sadly, I had these two conversations at least twice a week.  It's like banging your head into a wall again...and again...and again...