Monday, March 29, 2010

Comfort Zone

One thing I've run across lately are a lot of radiology reports that seem to make statements or recommendations that are a little, well, off. First, let me make clear - my field is radiation oncology, NOT radiology. Another thing that I have to make clear is that in most cases, the radiologist that looks at images from a CT scan, MRI, ultrasound (etc.) never meets the patient, and often doesn't know their clinical history.

So why is it that I often read in radiology reports things like, "fibrosis and scarring consistent with radiation-induced pneumonitis"??? Sometimes the patient hasn't even had radiation! Moreover, pneumonitis is a clinical diagnosis, not just a radiologic one. In a day and age when patients can access their own results, including radiology reports (which I am in favor of), this can be very dangerous to claim. And sometimes downright wrong.

Another thing that happens is that in the report, it reads something like, "5 mm area of enhancement not clearly imaged by CT. Recommend follow-up with CT in 6 months," or "Recommend additional MRI study." I find that it's interesting they can recommend this without even knowing the clinical situation. For example, what if the patient had some clinical condition that easily explained the imaging abnormality, but now because of this report, it's almost necessary to order this additional (and sometimes costly) test. If the reports said something like, "based on clinical scenario and judgment of the ordering physician, a follow-up CT scan may be indicated," I think everyone would be much happier.

Just to give an example - I certainly do not tell a cardiologist how to prescribe or dose anti-hypertensive medications. I expect other specialties to respect the same boundaries.

Tuesday, March 2, 2010

Heavy thoughts

Well, I don't know if I'm back for good, but I've been thinking about things sufficiently to write again... the world of lung cancer is not the most uplifting of worlds.

For example. I was talking to a patient that I like very much - one I empathize with, one I like personally, and one I even identify with. She's a hard worker, in a demanding career, still working through radiation we had given her previously, and chemotherapy, funny, witty, smart, had 3 children relatively late in life. We had a great conversation about how her daughter just went off the pill and was hoping she would get pregnant soon. I shared my story about how I got pregnant only a few months after stopping the pill, and the patient had the same experience. So she was hoping she would have a grandson or granddaughter soon. Her time is limited - she has metastatic lung cancer. In the world of lung cancer, her average survival would probably be about a year. And that's with chemotherapy, which, let's be honest now, will make her feel lousy half the time.

She started coughing up blood lately, and so we are going to give her radiation to her lungs at a low dose to shrink her tumor and hopefully stop her from losing blood. It's not serious. Not yet. I was doing what I do with a million other patients, I was explaining the side effects of radiation:
"You'll feel tired. But fortunately, that will pass."
"You might get a sore throat. But that will eventually go away too."
"You might develop a cough, fever, or shortness of breath, but that's not common."

One of the last things I say is something like "Very rarely, radiation can cause a second cancer in the area we are treating you, but this doesn't happen for 5-10-20-sometimes 30 years."

She snorted and said "if I get another cancer in 10 years, I'll be very happy. Right?" And I nodded my head in understanding and made an mm-hm sound. Then she started crying. I gave her some tissue, she coughed up some blood, and I put my hand on her back. Nothing to say. She pulled herself together, and said, "okay, let's get on with this." And she thanked me for being honest with her.

Here I am, feeling horrible about mentioning a side effect that realistically, she will never ever have the chance to feel, and she thanks me for it. Maybe this is a lesson that I should stop mentioning this particular side effect to certain patients. Or maybe it's not that deep, it's just a manisfestation of a really sad situation, one that I will have to get used to.

Sunday, September 27, 2009


Well, it's been a while since my last post. I have every intention of starting up again, but first let me explain why:

My daughter, Cecilia Jang Lubetsky, was born on May 21st, 2009. Having her and raising her is the hardest thing I've ever done (and am doing), including med school, my PhD, internship, everything. She's also the most rewarding thing I've ever done (and am doing) and I would not change a thing.

Monday, May 18, 2009

Doctors as patients, part 1

It has often been said that the doctor's working in the hospital are the unhealthiest people within the whole hospital. I think I already made a reference to this in a previous post about doctors exercising. I think I can expand this thought and say that in general, doctors are horrible about taking care of their own health and make horrible patients.

I'm reminded of something that happened while I was in med school - one of the most respected surgeons at my hospital suddenly was diagnosed with lung cancer. He never smoked, it was just bad luck. He had been ignoring his symptoms for years and years, and even though he went through surgery and chemotherapy and his colleagues did everything possible to save him, he was dead within something like 4 months, which is very short, even for lung cancer.

I think there are a few reasons why doctors take such bad care of their own health. One is simply a time factor. When you work 80 hours a week, even if you only work 60 hours a week, it's hard to find time to go to a doctor or dentist appointment. Often, even the time you have off from work is spent catching up on the latest medical news or journal articles, which is necessary to stay current. Moreover, since most doctors have daytime working hours, it's nearly impossible to take time off during the day to make it to an appointment - you have to either cancel your own appointments, or arrange for coverage, both of which are costly, time-consuming and extremely inconvenient for you, your patients, and your colleagues.

Secondly, I think it's the medical culture. Even when doctors are deathly ill, they try to come into work unless it's a risk for their patients. This is partly because calling in sick means that you have to inconvenience your colleagues and your patients, and since doctors don't really get sick days, you have to make up the work at some later date, usually on a day off. Additionally, doctors like to be tough, and seem tough, and illness, even for doctors, is a sign of weakness. As a result, many doctors become trained to ignore their own symptoms, even when they are persistent or become serious.

Finally, many doctors feel that they can treat and diagnose themselves, and don't need to go in for an appointment, even though this is often not the case. By treating themselves, doctors again often ignore or miss important symptoms and miss out on getting valuable input or a second opinion from a colleague. Doctors tend to treat themselves very differently from their patients.

In the end, my point is that doctors need to take care of themselves as they tell their patients to do so. They need to go for their yearly checkups, screening tests, etc and not try to manage it all on their own, for their own sakes as well as to be good role models for their patients.

In a very different way, doctors can be bad patients even when they do seek medical advice... I think I'll leave that for another post...

Sunday, May 17, 2009

Doctor Shortage

People have been reporting about this for quite a while, but a friend just recently forwarded me this NY Times article about how there will be a severe shortage in doctors in the future, especially in the primary care field. It seems many people, including the current Obama administration are becoming increasingly worried about this problem. While some steps are being taken to try and delay this crisis, there are many many roadblocks.

Of the ideas that have been proposed or already instituted to try and solve this problem, one includes increasing the sizes and numbers of medical schools. Medical schools may have to admit more students that don't have science backgrounds - while some worry that this may decrease the quality of medical students and eventual doctors, I don't think this is a problem and may even be of benefit. Medical schools already admit plenty of students with non-scientific backgrounds and as long as they can build up a significant fund of knowledge either in medical school or in a year of study before entering, I think it's not a problem. In fact, it may even build diversity and bring new ideas and perspectives to the table, which is definitely a good thing.

Another idea is to increase the use of non-MD sources of health care, including nurses and other health care professionals, which I think is a great idea. However, there is also a nation-wide shortage of nurses, so this avenue may be limited as well. Finally, it has been suggested that we use more minority as well as international doctors as there are many MDs from other countries who would like to practice in the U.S. Obviously this presents many problems as training in other countries can be vastly different than training in the U.S. and currently, depending on the country they come from, international doctors often have to retake licensing exams, as well as complete full residencies (after having already completed residencies or full training programs in another country) in the U.S. This is a huge deterrent for MDs coming from other countries to try and become MDs in the U.S. - I don't know how many international MDs I know who have instead become lab technicians or Ph.D. students or post doctoral students because the requirements for them to practice medicine in the U.S. are so overwhelming. However, I don't have a great solution for this as I do believe the training is different from country to country and that international MDs should practice in the custom of U.S. training, for legal purposes as well as medical.

Despite these efforts, I see a lot of hurdles for which there are no easy answers or solutions. One is that even though medical schools may be increasing their enrollment, there are a limited number of residency training spots available. These are being increased as well, but they cannot be increased as easily or at the same rate as medical school spots. Residencies are much more complex to set up, and must go through a thorough accreditation process every couple of years, which is not only cumbersome, but can be difficult to arrange and maintain.

Moreover, there is heavy competition for competent people by other professions, the major competitors being business and law. Now, with the economy being the way it is, business has been less attractive the last few years, and perhaps the medical pathway is getting a boost from the decrease in business school applicants or business jobs. However, law and business careers can be much more attractive than medical careers - the training is much shorter. School takes half as long, and after school you start earning a relatively good salary right away whereas in medical school, it can take 4-6 years, with 3-5 year of low-paying residency afterwards, sometimes followed by 1-2 years of low-paying fellowship. Once you finally get out of all this training, doctors (especially primary care) often still make lower salaries than lawyers and businessmen, and have to contend with other headaches and costs associated with malpractice insurance, insurance paperwork and red tape, etc. Until there is good health care reform, or salaries become more equalized (either doctors' salaries have to come up or other salaries should be lowered - probably the latter is better for various reasons), there's not much that can be done about this problem.

Finally, even with the increase in medical school admissions and residency spots, many people are still attracted to practicing in medical specialties rather than primary care, in which the doctor shortage is the most severe. Again, this likely is due to a salary differential as primary care doctors make much less than doctors in medical specialties. As with competition with business and law degress, not much can be done about this problem until the salaries equalize - in this case, I think primary care doctors should be valued more highly and their salaries increased.

Wednesday, May 13, 2009

Bruce's Asia Travels Blog

Bruce (my brother) is traveling in southeast Asia for about 2 months, and he'll be keeping a blog about it. I'm so jealous. :)

Monday, May 11, 2009

Sympathy vs. Empathy

I remember in medical school being taught the difference between sympathy and empathy - a lot of people tend to use them as synonyms. In my line of work, when you empathize with someone, it means that you can feel what they are feeling. For example, if they have some type of cancer, and you've had that exact type of cancer, you can feel something similar to what they must be going through and you "empathize." If you feel sympathy for someone, then it's more that you understand, or try to understand as best you can, what the person is going through but you may not feel or have not felt that way yourself. In my opinion, it's very difficult to empathize with someone unless you've gone through a very similar process or situation that they're going through.

Having said all this, I highly empathize right now with all the 9 month pregnant ladies out there who like to deliver soon. :)