Intervening

I guess after a few months, it's time to actually talk about residency. I have finally gotten a chance to see the other side of radiology, interventional radiology (IR). Essentially, this is a specialty that is involved in image-guided procedures. More specifically, it involves variations of one technique used ad naseum: the Seldinger technique. Here it goes: stick a needle into something, stick a wire in the needle, take the needle out, stick a sheath over the wire, take the wire out and put in whatever tool you want inside the sheath to do what you need to do.

Thanks Dr. Seldinger, all I need to do is learn this (from wikipedia)

Of course, there's a little more to it than that, but if you could do that, you're halfway there. It has more of a feel of surgery than diagnostic radiology. There is the same thinking on your feet excitement that I gathered from surgery. The difference is that you're using ultrasound, x-rays, CTs and MRIs and that often, the patients go home (almost) immediately after a major procedure (and much less rounding on patients, getting yelled at by scrub nurses and blood).

There is a great satisfaction to seeing a patient with a problem, directly seeing the problem with your imaging technique, then with minimal invasion of the patient, fixing it and seeing the patient drive home with their problem fixed a few hours later. There is also a wide variety of cases, from simple thyroid biopsies, to draining blocked kidneys or infections, to treating tumors with microwaves, to fixing narrowing or rupture of big and small vessels. It is a great deal of fun.

What draws me away from the field, though, are two things. One is that for the more complicated vascular cases, it really sucks to be twisting a wire inside a vessel for hours trying to get into a small artery. But, what really drives me away from it is that it doesn't have the academic feel. Although you need to be able to read images, you really don't need to be great at it to see a fluid collection (who cares what it is, you'll stick a needle in it and find out soon) or a blocked vessel. The patient often already has a diagnosis or the pathologist will figure out the diagnosis, so the satisfaction of figuring something out is not there as much as it is in diagnostic radiology. Researchwise, it's more about making new devices or new techniques to accomplish a task that people are doing than trying to figure out how the body works.

It's not what I wanted to do when I signed up for radiology, but it's great to know that in a short month I've been able to pick up a lot of these techniques. Simpler (nonvascular) procedures are often also done by other types of radiologists and I would love to be able to do some procedures in whatever branch of diagnostic radiology I end up in. I'll just leave the wire twisting to the professionals.

I actually got to angioplasty a vessel a few weeks ago. The scary part is that the balloons have a "burst" pressure rating, but for some reason, no one seems to worry about going over it.

Some updates to the ever-growing lists

Been pretty busy the last few weeks and am a little behind on updating my lists.

As sham journals (and scam journals) are on the rise. There has been a recent push towards recognizing predatory open source "journals" that take your money, but have nothing to do with peer reviewing or sometimes even publishing your work. Scholarly open access has an ever growing list that I couldn't possibly top, so a link will get added to my list.

As for my list of religious companies, seven more get added. Anthem coffee shop in Tacoma, WA for canceling on hosting an event after finding out it's an atheist group. Oklahoma Joe's in - you guessed it - Oklahoma that decided not to given it's promised donation to Camp Quest after they got all the extra business from supporters expecting that their eating at the restaurant will go to a good cause. Eden Foods, Domino's Farms and Weingartz Supply Co in Ann Arbor, MI for fighting the new national healthcare requirement to cover contraceptives (and unfortunately winning). Come on, Ann Arbor, you could do better than that. A bed and breakfast in Cornwall, England for refusing to accommodate gays because of their religious beliefs (sorry, once you have a business that is open to the public, you can't discriminate). Finally, the United States Postal Service for a pattern of not delivering packages that say atheist on them.

A restaurant to avoid

The Stingray Cafe in New Bern, NC is the latest entry to my list of places of business that try to shove religion down their employees' or customers' throats. The owner, after taking a lesbian couple's money, decided to tell them: 

“God said in the last days that man and wom[a]n would be lover of self, more [than] the lover of God.
That man and woman would have unnatural [affection] for one another. Then, the coming of the Son of Man, who is Jesus. So please, look at your life. See how it hurt[s] everyone around you. And ask the Lord to open your eye[s] before it [is] to[o] late.
The Love of Christ
P.S. my daughter also was gay. It destroy[ed] her life and my grandson.”

Hmm... what are the odds that he "helped" God in destroying his daughter and grandson's lives?

(h/t Ed Brayton)

First Year Radiology, or finding les mots justes

After 5 months, I suppose it's time for an update on first year radiology. The shock of the first few weeks have subsided (though every month, with a new modality or a new part of the body, I get hit with it again), but it is still difficult to think that I'll be a fully functioning radiologist in a mere 3 years and 7 months. I still seem to learn about several medical conditions I hadn't even heard of before once a day. It's an amazingly humbling experience. What surprised me the most on starting the radiology residency is something I'm still having trouble with. It's finding the right words to describe what I'm looking at.

Contrary to what a lot of people think. Radiology is not a big "Where's Waldo" game. It's about knowing the pattern of normal and disease, knowing what's clinically significant and what's just a normal variant, knowing what other findings go with the one that you see, knowing what findings go with the lab tests and physical exam findings that clinicians report. It turns out the describing what you see and communicating your idea of what the findings may represent is tougher than it seems.

In radiology, there is the concept of an "Aunt Minnie" (as evidenced by the popular radiology website). It refers to knowing what an abnormality is because you've seen it before. In other words, it's hard to describe what you see, but if you've seen it before, you know it can't be anything else. The trouble is that description is a large part of radiology. I should be able to convey what I see to a clinician to such a degree of accuracy that the clinician should be able to picture what I see without having the images in front of them (because this is, in fact, usually the case). This, I've found out is incredibly hard. I see what I want to describe pretty quickly, but it takes me several tries to be happy with how I've described it (then the attending changes it anyway).

In addition to finding the right words to describe something, there's conveying the clinical significance of what I see. There are hundreds of minor abnormalities or normal variants in an imaging study and we're obliged to describe them (so that someone else doesn't think that they represent a serious abnormality or doesn't spend thousands of dollars to further investigate it), but we must describe them in a manner that tells the clinician not to worry about it. For example, using words like "tiny" or "of questionable clinical significance" or "a normal variant" tells the clinician that we're not worried about it. Sometimes, it isn't that easy. Today, I saw a bone lesion that I thought was a small fragment from a vertebral fracture, but the attending I was working with was not worried about it. My dilemma was how to describe a fragment of bone near the spine of someone who is having neck pain and convey that it's not a big deal and is likely not what is causing the patients pain. It took me about six tries before I settled on something I was happy with.

The nice thing about these wording difficulties is that once I figure out something I'm happy with, I can use it for every other similar case. This is a major part of what my first year is all about.

I knew these were varices, but I got reprimanded by the attending for just saying "esophageal varices are present." It turns out I should have said "paraesophageal serpigenous enhancing tubular structures likely represent varices." (image from LearningRadiology.com)

Hobby Lobby breaks the law

One of the first companies that was on my list of companies that mix religion and business, Hobby Lobby, and its sister company, Mardel, has decided to break the law for Jesus by refusing to cover birth control pills for their employees as required by the new healthcare law. The owner sued to government to be exempt from covering it because it violates the owners religious freedom. To which, luckily, the US district judge said, "Hobby Lobby and Mardel are not religious organizations."

That's right. By their logic, a company ran by a Jehova's witness should be exempt from covering blood transfusions and one run by a Christian Scientist should be exempt from providing any healthcare at all. The government has threatened to fine them $1.3 million a day if they refuse to comply with the law. The owner thinks he's being a hero and plans on not covering contraception. I really hope that the government follows through with their threat, because otherwise, thousands of other companies with religious nuts as owners will follow suit. Given the Obama administration's habit of giving into religious nuts, I'm afraid they'll let Hobby Lobby get away with it.

(Yes, it's been a while since my last post, but radiology is not as light as I expected it to be. More on that soon.)

Quick update: A federal district court allows another company ran by a religious nut to be exempt from covering birth control for their employees. The flood gates have opened. Expect hundreds of more challenges.

Don't trust a doctor who believes in an afterlife

I keep on telling people that just because you have an MD, doesn't mean that your smart. I'm starting to think that any MD who went to Harvard is especially stupid. Here's an idiot neurosurgeon who I wouldn't want getting close to my brain. He was unconscious for a while, then months later made up a silly story about white clouds and magical people (that somehow seemed to exactly fit the fairy tale stories of Heaven you hear as a child). He’s a neurosurgeon, not a neuroscientist. He’s good at memorizing things to pass a test and maybe how to use a scalpel. He knows very little about brain networks, cellular and molecular neuroscience of hypoxic injury, etc. and he doesn't know that the brain does all types of crazy things when it is injured, and it can easily make people think they are in a magical place or "heaven".  I despise doctors who think that an MD automatically makes them a scientist. He says, "I'm still a doctor, and still a man of science every bit as much as I was before I had my experience." No, sir. You are completely abandoning science. You aren't even attempting to approach your experience (if you ever did have it) from a scientific point of view.

Actually, I take it back. This guy is smart. He's making it all up and pimping his neurosurgeon and Harvard Med credentials to sell a book. There's more money in fleecing the idiots than being honest or scientific.

Radioverwhelming

Wow. Already 6 weeks into being a radiology resident and my head is still spinning. I knew I'd have to start over again, but when you suddenly realize how much you don't know, it's incredibly humbling (and frustrating when you are actually suppose to be a productive physician and other physicians ask for your advice). Learning pretty much every medical and surgical condition about every part of the body is suppose to be hard. That's why radiology takes 4 years. I was prepared for that. What didn't hit me until now was how hard it is to know where to begin when you don't know anything. It translates to stumbling through studies with the attending correcting essentially everything you say, then going home and highlighting everything you reading. The first few weeks were actually pretty terrible. But, like everything, you start to pick things up without even knowing it. I've already had one rotation and by the end of it, it seemed much more manageable (I still don't know much, though).

Am I glad I chose it? Yes, but I could see how lots of people would hate being a radiologist. Unlike internal medicine, you really don't have much of a downtime. I thought I'd be taking coffee breaks all the time, but the studies don't stop coming. You sit (or have the option to stand) in one place for a long time looking at the same few computer screens. You rarely actually see or talk to patients. I'm fine with all those (though I would appreciate more breaks). What makes up for it, though, is that it you really become an expert. Even after 6 weeks, I have physicians with years of experience calling me for advice, which, incredibly, I can actually provide for them. Learning to pick up pathology (and normal variants) on imaging is actually fun (even though it is incredibly overwhelming). Once you see something, it sticks (way easier than memorizing books).

I've heard it gets less overwhelming after the first year. That means 10 1/2 more months of feeling lost (but I have a feeling it might be longer).