A high school student has questions about a medical career and pathology vs surgery

A female high school student asks about pathology, surgery, and medicine in general. [Email edited for length.] See if you agree with my answers.

The field I am most interested in is pathology. I have a very logical mind and would enjoy being able to solve the complex puzzle of disease. I would also like the somewhat flexible hours compared to other more intensive specialties. However, I do have some qualms.

Im also interested in general surgery. I would love to learn how to perform all the different types of surgeries that surgeons perform. If I were to be a pathologist, would it be "knife-free"? Pathology really intrigues me, but participating in the occasional surgery sounds like it would be extremely interesting and full of learning opportunities.

There is some knife wielding in pathology. Specimens must be properly cut, and there is the occasional autopsy. However, its definitely not surgery.

What does a pathologist really do? Ive looked at various descriptions online, and none of them seem to be very specific. What would a typical day look like for a pathology resident? I was also wondering what types of skills pathologists are taught?

Pathologists spend most of their days looking at specimens, mostly microscopic slides. Here is what pathology residents at Johns Hopkins learn.

I know that medicine is constantly evolving. With new medical technology, certain fields will soon become obsolete. Do you think this will happen to pathology?

I suppose there will be some technical advances that might involve automated digital reading of pathology slides, but I believe there always will be a need for pathologists. A residency position in pathology is much easier to obtain than one in general surgery.

Since Im interested in both pathology and general surgery, I was wondering if there was a way I could do them both (in a combined program or something like that). I know this is highly unlikely.

It cant be done.

I am a very anxious person. Specifically, I have health anxiety. (Im all too aware of the irony). Do you think that the amount and intensity of the material covered during med school and residency could take a severe toll on a persons mental health?

I think every medical student at some point worries she might have a disease she just read about. Im not sure what to tell you because I am not a psychiatrist, but studying diseases for four years and having a health anxiety might be a problem.

I would also like to know whether being involved in medicine could dramatically alter a persons personality by magnifying their negative characteristics. I am very driven, hard-working, ambitious, logical, easily annoyed/frustrated, and sometimes easily distracted. Im quite anal-retentive and OCD. Some of my friends and family have described me as an emotional robot. How do you think these characteristics would be affected by a journey through medicine?

Many medical students and residents become less empathetic and more jaded as they go through medical school and residency. Except for being easily distracted, many of your traits are common in med students. Heres more about empathy and medical students.

Do you know how difficult it is for Canadian students to get into American med schools? Or do you know any medical schools abroad in English speaking countries (e.g. Scotland, England) that would be willing to admit international students? Also, would it be more difficult for a woman?

Its not easy. Here is a link to a website that has some data on Canadian applicants to US schools. I dont know much about UK schools. Ive written about Caribbean schools. Type "Caribbean" in the search field of my blog. Being a woman wont matter.

How would medicine affect interpersonal relationships? Im really close with my immediate family, and it would be difficult not being able to see them all the time, let alone during holidays or breaks. How can a person manage a serious relationship and medicine at the same time?

It can be done, but it takes some effort. I have written a few posts about so-called work-life balance.

Choosing a specialty is difficult
More about choosing a specialty
Anguish about choosing a specialty
Surgery and work/home conflict

I hope this helps. Good luck.

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Are surgeons the cause of high postoperative readmission rates

No, according to a recent paper published online in JAMA Surgery.

The authors concluded, "The majority of the variation in readmission was attributable to patient-related factors (82.8%) while surgical subspecialty accounted for 14.5% of the variability, and individual surgeon-level factors accounted for 2.8%."

The investigators looked at data for over 22,000 surgical patients treated at Johns Hopkins and found the overall rate of readmission within 30 days was 13.2%. After the exclusion of those who performed fewer than 21 operations per year, 56 surgeons made up the study cohort.

Multivariable analysis showed significant non-modifiable patient-related factors associated with readmission were African-American race/ethnicity, more comorbidities, occurrence of postoperative complications, and an extended length of stay.

Variation in readmission by subspecialty ranged from 2.1% after breast, melanoma, or endocrine surgery to 37% following cardiac surgery.

The authors pointed out that this study "echoes growing concerns regarding the use of readmission as a quality metric based on its current methods."

Lets compare it to the controversial ProPublica Surgeon Scorecard.

Both the Surgeon Scorecard and the JAMA Surgery paper used data from the years 2009 through 2013. The scorecard involved only eight high-volume low-risk in-patient procedures while the paper looked at in-patient surgery of all types.

From an article written by the authors of the Surgeon Scorecard: "If a patient was readmitted to any hospital (not just the hospital where the surgery was performed) within 30 days of a surgery for one of the conditions we identified, we counted the case as a complication for the surgeon who performed the initial procedure."

What we learned from the JAMA Surgery paper raises some questions about the the Surgeon Scorecard. On Twitter, I asked for comment from Marshall Allen, the lead author of a white paper [not peer-reviewed] describing the methodology of the Surgeon Scorecard.

Between attacks on my credibility because I choose to use a pseudonym, he said that they did not count most readmissions as complications. It is unclear from the article, the white paper, or its appendices exactly which complications were included. For clarification, we could ask the "surgeon experts" who advised ProPublica, but their names have not been disclosed. They are anonymous, just like me.

According to the white paper, surgeons were blamed for 64,367 (46%) of all complications incorporated into the Surgeon Scorecard. Table 3 of the white paper lists the 20 most frequent complications. The top three, comprising 26,795 complications, were postoperative infection, iatrogenic pulmonary embolism, and infection/inflammatory reaction due to internal joint prosthesis.

Other studies have shown that not all occurrences of those three complications are attributable to a surgeons misdeed. Among the rest of the top 20 causes of readmission were postoperative pain, fever, and dysphagia (difficulty swallowing)—again possibly not the fault of a surgeon.

So the JAMA Surgery paper says surgeons are responsible for 2.8% of readmissions within 30 days, but ProPublicas self-published white paper says 46% of all readmissions are due to something a surgeon did or did not do.

Who to believe?

Note added at 7:27 a.m. on 9/2/15: See my next post for a clarification about causation and variation. 

The full text of the peer-reviewed JAMA Surgery paper is available here.

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Code Black Part II It gets worse

Last week, I reviewed the premier of the new medical television series "Code Black" and pointed out several flawed or impossible scenarios. I didnt think Id watch another episode.

But I was alerted to a rather shocking error on last weeks installment. I had to see it for myself.

On this typically chaotic day in the emergency department, a young woman was brought in after a car crash which occurred while she was in her way to the ED because of abdominal pain. A CT scan of her abdomen and pelvis was negative, but her serum lactate level was elevated. They then decided to examine her abdomen and noted tenderness. A bedside ultrasound done in the ED revealed a left ovarian torsion (twisting of the blood supply to the ovary which if not rapidly corrected, could cause irreversible damage). The patient had already had her right ovary removed. Further heightening the drama was that her husband died of lymphoma but had banked his sperm, and the patient wanted to have his baby.

She needed immediate surgery, but all of the hospitals operating rooms were busy. As the window of opportunity to correct the problem was closing, an operating room opened up. But alas, there was not a single gynecologist or surgeon available to do the case. According to the back story about Dr. Neil Hudson, hes a fully trained surgeon who decided to work in emergency medicine. One of the new ED residents begged Dr. Hudson to do the case, and he resisted for a while until it was almost too late.

Despite admitting to having no operating room privileges and surely no malpractice insurance coverage for surgery, Dr. Hudson finally acquiesced. Just before beginning the case, he explained to the OR staff what he was going to do.

Then the egregious error occurred. While scrubbed in the OR and wearing a sterile gloves and gown, he calmly reached up to pull his unsterile mask over his nose and mouth. Thats a no-no.

PS: I could find no reference mentioning an elevated lactate associated with ovarian torsion. The organ is likely too small for ischemia to have any effect on the that lab value.

Some other highlights. For a patient with multiple facial lacerations, Dr. Hudson ligated the maxillary artery—quite a feat in an emergency room without an OR light or any retraction. As you can see from the figure below, the maxillary artery is deep to the jawbone. Not shown are branches of the facial nerve which lie above the artery.

Dr. Leanne Rorich, the all-knowing equivalent of Dr. House, stopped a nosebleed by inserting Foley catheters in each nostril, a well-known trick. However she inflated the balloons with the closest liquid she had on hand—coffee, and the patients blood pressure normalized within seconds.

If the convoluted story of the woman with the ovarian torsion wasnt enough, the patient with the nosebleed happened to be a 14-year-old blind boy on Coumadin who fell while rock climbing with his father.

Stay tuned for the next episode featuring a bus that tumbles off a narrow mountain road while carrying non-compliant hemophiliacs.

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