medical school

I don't know the US units, I guess that's not too high?

There's evidence that statins are effective for primary prevention of cardiovascular disease, but the number needed to treat is high (less than 2% would benefit after 5 years of treatment). http://summaries.cochrane.org/CD004816/statins-for-the-primary-prevention-of-cardiovascular-disease

Given that you're otherwise quite healthy, presumably the indication to treat would be even less in your case than in the evidence reviewed by Cochrane.

You should ask your doctor but I'd imagine it'd be reasonable to hold off on medications for now, try to change your diet and watch the numbers for a year.

plasmon, i always thought you were based in the US? where do you practice?

those labs are a little on the high side (assuming they're fasting numbers) but, assuming he's normotensive and non-diabetic, this guy's 10-year risk is something like 5%. if you look at the ATP III guidelines, iirc they say for a guy like this statin therapy should be considered if the LDL is above 190 (though word on the street is that ATP 4, if they ever are published, are gonna bump everyone's goals down by 30 mg/dl). IANAD but as plasmon says this might be a "refer to dietitian and see me in a few months" situation. with the caveat that i know only what you've posted, it's not a "holy shit start intensive therapy now" deal

Yeah I checked the ATP III guidelines and it looked like a statin wasn't a must at this point, but I'm going to be nag for him to get his numbers done again next year (he tends not to go to the doc for years at a time; only went this time due to spousal nagging). He had tried changing up his diet a few years ago, but it didn't really make an impact on either LDL or HDL. His blood pressure is consistently excellent and he is not overweight.

What about the high TG? I should have paid more attention to the prevention stuff when I was the managing editor for a cardiovascular medicine web site, but the docs I worked with there mostly interventionalists, so I know more about PCI than anything else!

what does the PCP say? he or she deals with patients like your dude daily and will have more experience dealing with his situation than a couple of neurologists, a med student, and a pharmacy student. i can say that my understanding of the data in this area is that the link between mildly elevated TG (in the absence of a high LDL) and CV disease is pretty tenous and i'm not aware of any any data that proves that lowering TG lowers your risk of CV disease, particularly in someone as healthy as him (others can correct me if i'm wrong)

We would definitely ask the PCP if he had one! I made him go to a doc-in-the box for a basic physical and labwork (which was e-mailed to us. For follow up he'd have to go back in, and we've already left town).

We have joined the millions of Americans who have basically no preventive medical coverage--when we quit our jobs, we said bye-bye to our affordable-ish coverage. We are now covered under a high-deductible plan that will, like, airlift us out of Mexico if needed, but on a tight budget we are doing what folks in our situation do--rationing our own health care and self-diagnosing/treating via the internets. Meanwhile, my Medicare mother's doctors order every available imaging test for her stiff knee. Unbelievable.

(sorry for rant)(and thanks for the info, confirms what we figured!)

i'm sorry if i sounded rude! i'm sorry you find yourselves in that situation, obviously everyone should have access to basic preventative care. will the ACA help next year?

you're a couple of the lucky ones, of course - i've seen plenty of people in their 30s who haven't seen a doctor since they were kids - and have no idea they have diabetes - come into the hospital with full-blown HHS and an A1C in the teens.

Oh you were not rude at all! We have been ridiculously lucky to have had pretty damn good insurance for many, many years, and also lucky to be in good health (I take a couple of Rx meds, but was able to get them all filled for a 6-mo time period while I was still covered under my employment insurance). Having that sort of insurance was something I took for granted, so it is really good for me to now see how lucky I/he was.

I will likely be doing social work in a medical setting when I finish my MSW, so I'll be learning more about the many downsides of our system in intimate detail, I'm afraid :(

120 pack-year history = 876,000 cigarettes

so drs and drs in training... what can you tell me about graves disease and more specifically graves ophthalopathy??

(raises hand)

Graves ophthalmopathy is also called thyroid eye disease, which is easier to spell.

Graves disease is an autoimmune thyroiditis in which antibodies bind to the TSH receptor in the thyroid and activate the production of thyroid hormone. Elevated thyroid hormone levels shut down TSH (thyroid stimulating hormone) production in the pituitary gland, which normally leads to thyroid activity being decreased until thyroid hormone levels (T4) drop far enough that the pituitary (really, the hypothalamus) notices and starts making TSH again. With the antibodies bound to the TSH receptor, this feedback loop is broken. High thyroid hormone levels suppresses TSH as usual but the antibodies alone are enough to continue to drive thyroid hormone production, leading to hyperthyroidism, which can be severe. Typical symptoms of hyperthyroidism are a little like an adrenaline rush: rapid heartbeat, weight loss, sweating, tremors, agitation, poor sleep, heat intolerance, etc. We can control the symptoms in the short term with beta-blockers and antithyroid medications until we get the underlying problem under control by knocking out the thyroid with radioiodine or surgery.

Thyroid eye disease often appears as part of Graves disease but can appear without symptoms of hyperthyroidism (euthyroid) or any abnormal thyroid function studies on lab results. The same auto-antibodies that bind the TSH receptor (TSH-R antibodies) also bind preferentially to a similar epitope (immunological target) found specifically on the extraocular muscles in the orbit. For some reason, the medial rectus and inferior rectus muscles are most often targeted, but any of the 6 eye muscles around each eye can be involved, usually bilaterally, and sometimes symmetrically.

Antibodies binding to tissues in the orbits triggers an inflammatory reaction, producing thickening of the muscles and swelling. The eyeball can bulge forward (proptosis) and often gets red and inflamed looking (conjuctival injection). If the proptosis is bad enough the eyelids won't close fully (lid retraction). Thickened eye muscles don't move normally; in particular, they don't relax and extend when the eye is being pulled in the opposite direction by the antagonist muscle. So the medial rectus (which pulls the eye to the nose) being thick and inflamed won't let the lateral rectus (which pulls the eye out to the side) do its job, so the eye's movement in that direction is restricted, which can cause double vision b/c the eyes are pointing in 2 different directions.

There aren't many mimics of thyroid eye disease, especially if the patient also has hyperthyroidism. Other inflammatory conditions can cause pain and swelling in the orbits. Rarely, an aneurysm or other abnormal blood vessel can cause painful swelling and bulging of one eye. Myasthenia gravis, a neuromuscular condition, can cause variable weakness of the eye muscles and eyelids, but doesn't cause proptosis.

The diagnosis of thyroid eye disease is made clinically and supported by testing for TSH-R antibodies, thyroid function studies and scans (CT or MRI) showing the typical pattern of inflamed eye muscles. Thyroid eye disease usually requires treatment with steroids to control.

...that was from memory, in honor of my friends writing Royal College and board exams in the next few weeks.

thanks! are there treatments besides steroids? i've heard that the usual length of the disease is 1-3 years, is that usually the case? (asking on behalf of my mom, unfortunately)

i guess, we are hoping that there's a good chance that the disease will go away by itself, without having to resort to 131 or surgery.

this is for my hypothetical mom, of course

Many immune conditions do settle down considerably after a couple of years. Not sure how confident I'd be in the 1-3 year prediction.

It's reasonable not to treat if the problem is mild enough. Knocking out the thyroid won't help the eyes -- the problem in the orbits doesn't come from hyperthyroidism but from the direct action of the autoantibodies. AFAIK nothing controls the autoimmune aspect of it except steroids. I don't know if any of the "steroid-sparing" drugs used in other immune conditions would work (Imuran, methotrexate, Cellcept, etc). If the eyes are bulging right out despite high dose steroids, there can be a risk of loss of vision from compression of the optic nerve, in which case an ophthalmologist can do surgery to decompress the orbits.

Ophthalmologists and endocrinologists would have more experience treating thyroid eye disease than neurologists like me. Hope it goes well for her.

thanks for the info!

plasmon is such a cool attending

plus I'll take the whole team to Starbucks twice a week and bring in panini for lunch the last Friday.

Bagels (or donuts/munchkins) on the weekends are also much appreciated

$STAFF brought mcdonalds for breakfast one weekend for rounds and i nearly wept (not even sarcastic, it was like lembas, i could've done all the surgeries)

The overnight nurses on the surgical wards of the hospital where I used to work as a house officer would make hot breakfast weekends at 3am in the back room behind their nursing station -- hot plates sizzling with bacon and sausage and eggs and pancakes, and I'd walk past to check up on a hypotensive fast AFib at the end of the ward and my knees would buckle. They were always good about sharing.

We're lucky enough to have a Starbucks in the main atrium of the hospital with the neuro ward, I got good at begging the baristas for leftover muffins when I was a resident.

http://i43.tinypic.com/1ot0uw.png

i know this is poor form, but the patient from last month's NEJM interactive case was pretty hot

way to make me feel weird guys

Well, tbh it IS weird!

And gross.

yeah ok my bad

Yeah, nagl.

The NEJM thing is weird, wonder if they've had any feedback on that. The number of times a doctor will examine a patient who's stripped completely is zero. Most physical exam stuff is done on top of, around or under clothes/gowns. Proper draping to protect privacy is crucial and is something you get examined on in clinical skills training. The more intimate parts of the exam (breast exam, rectal exam, genital exam of either sex) should only be done when indicated. On the few occasions when I need to do that kind of exam on a female patient, I always offer to have someone else in the room as an observer (out of the line of sight), the patient's family/friend or else a nurse or other female. I guess they're trying in this online case to give you the big picture of the exam, to make you decide which parts will give you relevant clinical information, but there's no good reason I can see why the patient wouldn't be gowned.

Before the hosp would discharge me last Dec, they said someone had to do a full-body check to make sure they hadn't missed any injuries. Keep in mind I could barely raise my head/sit up, much less walk around the room. The young dude doctor who was going to do the exam told me to stand in the middle of the room and strip. I told him to get out and send back a doctor who was also a woman.

The woman just looked down the back of my gown and at my arms and legs and signed off. I swear.

yeah that's weird---the only time i've seen fully nude patients is in anatomical illustrations (as above), in the ED (when looking for injuries on an obtunded/unconscious/etc patient), or when they're getting prepped for surgery. and even in the case of the latter two, it's usually very brief---they get covered and draped (or put into a gown) pretty quickly ime. the nudity is a necessary part of the clinical transition, but it's incidental.

as plasmon said, the whole point of a hospital gown is that it makes selective examination fairly easy.

this is old but is doing the rounds (ha) again

http://jseliger.wordpress.com/2012/10/20/why-you-should-become-a-nurse-or-physicians-assistant-instead-of-a-doctor-the-underrated-perils-of-medical-school/

had to stop reading after like the 5000th word but that was mostly nonsense

9 bloggers like this.

(so this was the wrong thread to check while woken up for a page in the middle of a night on call...)

This seems very much to have been written by someone in his 20s, single and without kids, who's never had a real job. Notable to me that he talks to no one actually practicing medicine independently (not as a resident) who calls their career choice "a huge mistake".

Point by point:

1. Money

Doctors make more than he says, because more than half of them are specialists. Lots of them make lots more than $160K per year. Residents don't work for free, they make about as much as a starting level RN, most starting at age 25-26.

"Most doctors earnings probably fail to outstrip nurses’ earnings until well after the age of 40." Well, maybe in primary care and/or for late starters, but otherwise no. And even if true, if you don't think that making double to quintuple the money you would've made otherwise in your 40s (and every decade of your career thereafter) isn't going to matter to you, you're probably still young, don't have kids and can't imagine what it would be like to be that old. "To some extent, you’re trading happiness, security, dignity, and your sex life in your 20s, and possibly early 30s, for a financial opportunity that might not pay off until your 50s." Or maybe your mid 30s to early 40s, and then constantly thereafter. But if your sex life in your 20s is your main life goal, you're right, better stay out of medicine.

2. Lifestyle, respect

LOL at blaming relationship failures on the "bullying culture" of medical school. It's obvious he's only talked to medical students, poor dears. Most doctors aren't any nicer than anyone else -- they can and will get themselves into more than enough misery in life without blaming medical school for it.

For lifestyle, residents do suffer, especially in the early years. Med students have lots of free time until they get to the clinical years. Doctors in independent practice have control over their schedules, can give themselves holidays (though the overhead doesn't change when you close up clinic for a couple of weeks). That flexibility is limited for the docs who work on salary for a hospital or university, but those jobs usually have quite limited hours for call exposure etc. The best comparison for a doctor in independent practice is a small business owner -- if you're running a restaurant or a contracting business you're not going to want to take much time off by choice, because that's how you build your business and your income. It's not entirely a bad thing, you're working for yourself.

He misplaces the difference in roles between doctors and nurses as something to do with social status. What's that supposed to be -- how impressed someone will be a party when they hear what your job is? The point where the roles become important is at work, not in social situations (since his sources have never worked and spend lots of time in social situations, they miss this point too). Obviously nurses are professionals in their own right and have their own autonomy (and PA's practice semi-independently). But in many or most medical settings, the doctors give instructions that the nurses carry out, and the nurses report information that the doctors are responsible for interpreting and acting upon. It's not just about social status, it's about being able to say "go and do this and this and this, then call me back and let me know what happened" vs having someone tell you that instead. Doctors probably have too much authority, and are fairly criticized as being arrogant, but it's still the case that the job carries with it much more managerial responsibility. If you like that kind of thing, you won't find nearly as much of it in most RN jobs.

"Medicine is, in effect, at least a ten-year commitment: four of medical school, at least three of residency, and at least another three to pay off med school loans. At which point a smiling twenty-two-year-old graduate will be a glum thirty-two-year-old doctor who doesn’t entirely get how she got to be a doctor anyway, and might tell her earlier self the things that earlier self didn’t know." Oh no, a glum 32 year old who's paid off student debts already, looking forward to making $150K a year in a well respected career with job security that offers a fair amount of flexibility and control, at the cost of feeling older and wiser than 10 years ago! What a disaster for that 32 year old.

3. Residency programs as a cartel

Total bullshit. The match is mutual: no resident is matched to a program they don't list as one they're willing to work in, and no program is matched a resident they didn't list as someone they're willing to hire. On the face of it, that's fair.

Lots of residency programs are poor. They sometimes go unmatched, that's the market feedback. Many residents are unhappy in their residency programs; in my experience, a solid half of that is a problem with their expectations. Every residency is a job, and every job has its problems. Many residents have never had a real job before and have no baseline to compare with. Again, it seems the writer has never talked to anyone who's finished residency or who deals with resident education from the other side.

This paragraph would be scary if it wasn't so silly: "The education at many residency programs is tenuous at best. One friend, for example, is in a program that requires residents to attend “conference,” where they are supposed to learn. But “conference” usually degenerates into someone nattering and most of the residents reading or checking their phones. Conference is mandatory, regardless of its utility. Residents aren’t 10 year olds, yet they’re treated as such." The person "nattering" is probably trying to teach these young doctors something useful. The residents checking their phones instead of paying attention are being paid to be there, that's why it's mandatory, and yet are failing to be professional and to take seriously the opportunity to learn. Continuing professional development is a part of every single profession these days (nurses too) -- to think that that's "being treated like a 10 year old" shows a lack of understanding of how the world actually works.

4. Helping people, doing what you want to do, and being happy

Nowhere does he recognize that spending half a lifetime doing a challenging job as a doctor might be in itself interesting or worthwhile. He seems to think the main goal of most doctors is "helping people", but that's a running joke in medicine, it's what you say in your med school interview. "Helping people" is part of being a doctor, but there's also lots of "figuring things out" and "being in charge" and "doing cool tricks" and "knowing what's what". Medicine is hardly the best way to help people (and neither is nursing). If your main goal is being nice to people and helping them do what they want, I'd suggest social work.

Everything he says about happiness research is bullshit, because happiness research is bullshit. People will say all sorts of self-serving things. For instance, as he points out, most medical students are resistant to thinking that they've made a huge mistake, even when it's pointed out to them by this guy who clearly doesn't know what he's talking about. Meanwhile, many people who thought about going to med school but then opted not to for whatever reason like to tell themselves that those grapes on the top branches are probably sour anyway.

i think i am interested in neuropsychiatry?

Yay. I'm reviewing a book on the neuropsychiatry of headache, that's a huge part of what I do all day.

have headaches?

so what can you tell me about neuropsych fellowships, Plasmon?

tell us about the first couple months of residency, gbx

and by couple i mean one

it's busy but not too bad (yet)

I've got the weekend off, so that's nice

Don't know much about fellowships, sorry. Decided fairly early on I wasn't going to move the family and delay going into practice.

took a kaplan practice MCAT this morning, no studying yet = 30. very pleased. signed up for a kaplan course, actual MCAT will be next spring

Nice! Must be a relief.

well it's just the practice one! it was definitely reassuring though to have it affirmed that my foundation is pretty strong, studying for the next 6 months or so can only help. and the kaplan lady said not many people break 30 on their first legit in-person practice one. supposedly they're pretty valid predictors of the actual test, but who knows, of course kaplan would say that. most people i've talked to seem to agree though

felt like i did awful on physical sciences (i...haven't taken basic chemistry since i was 17), but my scores were even, 10/10/10

Strong work, good prognostic indicator.

I taught physics, verbal reasoning and writing for Kaplan. Main thing is to be able to get double digits on verbal reasoning on your own accord. The rest of it is teachable but I had no luck bringing my students' VR scores up more than a point or two.

thanks!

the verbal was by far the easiest, yeah, i actually "didn't answer" two of the questions by mistake (by some brain fart i clicked on the answers themselves instead of the bubble next to them, which placed a strikethrough line through the answer instead of actually selecting the answer. both of them would have been right). no reason verbal should be less than a 12.

physical chem is going to be the place i need to improve the most -- i was able to deduce my way through some things but all of this anode/cathode half-cell whatever stuff is buried somewhere in the back of my brain along with whatever dumb stuff was thinking about in high school

yeah that's a great baseline, kev

my verbal reasoning score did most of the heavy lifting on my MCAT, bigtime. when i took practice tests i'd finish that section super early, and get like 11 on it. once i actually slowed down, and didn't make silly mistakes, i was able to get 13-14s

This discussion made me thing "oh thank god I never have to do standardized tests anymore" and then "oh wait I have two levels of borads to pass for LICSW and more for geriatric cert oh fuck"

however I do not believe I will have to remember any pchem for them

I totally thought I was going to lean heavily on my VR score but noticed that the more practicing I did, the lower my score on the practice tests would run (from like 12-13 down to 10 at one point), which I interpreted as a sign of overthinking (when I start obsessing about the test I tend to think it is all an elaborate trap, whereas sticking to my gut would normally be OK). I backed off a little but ended up doing a little worse than I had hoped. However, I got pretty lucky on the Biology part (which had been my highest-variance section, ranging anywhere from 10 to 13) on the actual MCAT, and that balanced me out.