Why I like Pain (management that is)

For the past two weeks, I've had the opportunity to do a pain management elective. I picked this elective rotation because pain management is a field of medicine that has interested since before arriving at medical school. 

I'm going to talk about that experience in the next post, but for now, let me explain why I find pain management interesting. 

• Pain is a universal problem that touches all people of every age. There will always be people in pain who need relief. 
• Watching someone else in pain is just viscerally disturbing. When I see someone in pain, I feel it too. Like watching another guy get kicked in the nuts. You can feel it! Therefore, it would be supremely rewarding to alleviate someone else's pain.
• Pain is a problem that current medical practice handles sub-optimally. There are drugs that reduce pain effectively, but not without significant side effects and addiction. I'm thinking mostly of the opioids. To be sure, there are people who do get relief from what we have to offer, but many, particularly those with neuropathic pain, or with intractable pain syndromes like fibromyalgia, don't get much relief from the current therapies.
• Chronic pain is huge issue that doesn't get enough attention. There are over 100 million chronic pain sufferers in the US alone, according to some estimates. 
• From both a clinical and basic science perspective, there are huge gaps in knowledge in pain. There have been great advances made in the past few years about the neurobiology of pain, but there is still a lot we don't know. And for what we do know, translation of that knowledge into new therapies for patients has been very slow. So for someone wanting to be a physician-scientist, pain is an ideal arena. The entrepreneur in me goes to where the unmet needs are and where there are opportunities. More mature areas of study where there are a lot of smart people already working, such as heart disease and cancer, don't really attract me. 
• Because pain is such a pervasive and underserved problem, it is now starting to get a lot of attention from the people who control the funding (NIH). The institute of medicine (IOM) just put out a position paper called Relieving Pain in America, in which it calls for more research and more physicians to treat pain. It seems like pain is starting to get hot, so now would be a good time to enter the field. Hopefully during my PhD, I can make my entry by doing some basic research into the mechanisms of pain.
• Since pain is a such a multidimensional problem, so too is the clinical practice of pain management. People come to pain management from anesthesia, neurology, psychiatry, PM&R and even internal medicine. That works because pain requires knowledge in all of these areas. The majority of pain management practitioners are from anesthesia, and thus current pain practice is heavy on interventional techniques, but most everyone acknowledges that excellent pain care requires a multidisciplinary approach. The versatility of pain management is very appealing to me. Depending on my preferences, I can do interventional procedures (epidurals, joint injections, stimulator implants, etc), and non-interventional, medical management of pain. I think such variety in a practice would be intellectually satisfying for sure.
• Pain management is usually not high acuity, unless one is working on an acute pain service. Therefore, I can manage my time more easily and make time for research and see patients when time permits. 
• I'd be remiss not to mention the lifestyle is appealing. Pain management is practiced in an outpatient setting. Hours are regular work hours (8-5, usually). Compensation is commensurate with the time it takes to train to be a good pain physician. No call. Practicing pain would allow me to have a lab, be a clinician and have time to be with my family and live a semblance of a life. I like that :)
• Lastly, a personal reason. I was keen on pain management even before medical school because for years, I watched my mother and brother suffer with chronic pain issues. I don't suffer like they do, but watching them be in pain everyday is nearly as bad as having the pain myself. Through their struggles, I became aware of how big a problem chronic pain is and I felt like pain would be as good an area as any to dedicate my efforts to. So I feel an emotional pull toward pain. In working toward becoming a better pain physician, I'd be doing a service for my family too. Perhaps I can bring them relief someday.

I think that's it for now. As time goes on, I'll probably find even more reasons to like pain. And who knows, perhaps something will happen in the next few years that will make me do a complete about-face, but for now, pain is top of the list for the reasons above. 

Translating Docspeak

My car was running a little funny the other day, so I took it to a local mechanic.

I know next to nothing about cars. This is not something I'm proud of, but it's the truth. So I'm completely at the mercy of the mechanic to fix my car, and because I know so little, my ability to assess the honesty and validity of the mechanic's diagnosis is severely limited. It's not a good spot to be in.

I took my car into the shop and left it for an evaluation. I got a call later in the evening from the mechanic.
This was our conversation (or my recollection of it at least)

Me: Hello
Mechanic: Hello. So I've taken a look at your car and I think I know what the problem is.
Me: Oh good! That was quick. I'm glad you got to the bottom of it. So what's the problem?
Mechanic: Well your computer said it's a P0300 problem which means that you're having a random misfire.
Me: Um. OK. I'm not sure what that means, but I trust you. So can you fix it?
Mechanic: Well, yes I can, but ya see, the spot I need to get to is behind the fuel injection block and it's buried deep behind the cylinders and I'd have to take off the whatcha-ma-call-it cap to get to the flux capacitor to remove the belt and then replace the spark plug with a widget.
Me: Oh I see. (I have no freakin' clue what that means) But can you fix it?
Mechanic: Yeah, but I gotta get behind that fuel injector...car part... widget...new flux capacitor.
Me: Fine. How much will it cost?
Mechanic: Hmm.. I think about $500. So do you want me to fix it?
Me: Go for it. I'll pick it up tomorrow.

So that was our conversation, as I remember it. I consider myself a pretty well versed guy, but at that moment I felt completely stupid. The mechanic was speaking English, but whatever he said to me sure sounded like some Greek mixed with some Chinese and some Back to the Future. How could I make an informed decision if I didn't understand the problem and my options? I had no choice but to trust the mechanic and to let him handle the problem as he saw fit.

When I got off the phone, I thought to myself, "Wow. That must be what patients feel like every day."

I've seen this scenario play out too often on the wards in dealing with a matter far more important than a car - peoples' health.

What does one say when a doctor says to you "you've had a myocardial infarction caused by years of atherosclerotic plaque deposition in your coronary arteries. We'll need to perform a CABG (cabbage) to bypass the stenotic vessels so that your myocardium can be perfused again"?

Or, "we're going to do an SI-joint nerve ablation first and then place a stimulator device rather than a PCA... does that sound good?"


Even simple words that medical folks use every day, like "biopsy" is not part of the lexicon of a great number of people. I remember on pediatrics we rounded on young teenage boy who had a large mass in his brain that had no diagnosis. We wanted to biopsy the mass but the surgeons were hesitant. The patient waited in the hospital for a week while we deliberated, and every morning during rounds we'd report to the mother of the boy that we wanted to do a biopsy on their son. She nodded but looked confused every time. Then I realized, she didn't know what biopsy meant. Finally, my attending realized this after a week and said, "We're going to go into your son's head surgically and take out a small piece of his brain to look at under the microscope."

This kind of translation from doctor-speak to everyday English is what is sorely lacking in so many medical interactions. In medicine, we get so used to using our own parlance that we forget that the rest of the world does not speak in our tongue.

Patients come to doctors to find out what the problem is and then to fix it. There is therapeutic value in getting a diagnosis. When doctors don't simplify their language so that the average patient can understand what the problem is, they do them a great disservice. 

My hospital goes through great pains to make sure that Spanish speaking patients have translators in every interaction so that they can be adequately informed of their medical status and care. This is the right thing to do. But perhaps we need English-to-Doctor-speak translators as well to ensure that the majority of patients actually know what their problems are too. That's actually a role I think medical students can play. Only a year ago, we were non-speakers of Docspeak, so we have all these new words in our lexicon but we still remember what it was like to speak without medical jargon. We can play the role of translator if we want.

But that doesn't solve the problem. Doctors need to make a greater effort to ensure that their patients have a basic comprehension of their problem. That might mean slowing down, or taking an extra second to rephrase what one wants to say.  Or even spending a few minutes doing a little teaching and patient education. I don't think that's asking too much. 

Beginning Ob/gyn rotation today

Today I start on a new rotation - Obstetrics and Gynecology.

I've been somewhat looking forward to this rotation for a while now. I actually find the subject material interesting, mostly Ob. I really like babies, which is why I liked pediatrics quite a bit when I did it. It'd be the highlight of my year if I could help deliver a baby. I hear this is a possibility if I'm assertive enough and if I have the good fortune of being in the right place at the right time. This rotation will be a flop if I don't get to do that.



I don't see myself going into Ob/gyn in the future, but I'm going to make the best of this rotation and take
away from it what I can.

Women have unique and interesting problems, and I'd like to learn more about them. Some med students are squeamish about the idea of being up close with female anatomy. I'm impartial. As a physician, you have to be comfortable with everything and once you do something enough the 'shock factor' goes away and it just becomes a job.

Amongst medical students, there is perception that Ob/gyn has a certain culture associated with it that is estrogen-heavy and hostile to men. I don't know if that's true or not, but that notion is out there. Also, for whatever reason, people talk about Ob/gyn people being unhappy. Those are broad generalizations and most likely they're not true. And if there is any bit of truth to them, I imagine there are differences from institution to institution, service to service, and person to person. So I'm not going in with the expectation of being attacked by a wave of cattiness. I'm just going to take it as it comes and do my best to enjoy.

I think it's always good to lay out goals before you engage in anything so that you have some criteria with which to measure your experience when it's over. Here are mine:

1. Deliver a baby!
2. Learn to do a competent pelvic exam.
3. Understand basic topics in Ob/gyn
4. Learn what I need to learn about Ob/gyn for Step 2 CK
5. Ace the Ob/gyn shelf

All those goals with the exception of the first requires some studying. So with that, I'm off to study. I'll report back later in the week.

New Year, New Blog

Happy New Year Everyone!

I know I'm late by about half a month, but that's OK.

As is customary for many, I like to reflect on my life at the turn of the new year and take stock of what I've done and what I'd like to do going forward.

One of the things I really thought about was this blog. I asked myself, What is the purpose of this blog? Why am I writing this? What do I hope to get out of it? And importantly, what's in it for you dear readers? Why do you come here?

Let's tackle these questions one at a time.

Why am I writing this blog?


First, I created this blog and continue to write in it because I've got a lot of ideas, thoughts, and observations that I'd like to record somewhere. There is something enjoyable and cathartic about having a space where you can unload all that mental baggage.  I like the idea of having a record of my life so that years from now I can look back and see what I was thinking and how I've grown and changed.

Second, I keep this blog because I want to hone my writing skills. In a private journal, there is no audience and therefore, there is no one to try to impress and no source of feedback. Knowing that my words will be visible to many others makes me want to be more polished and precise. The urge to just be sloppy and unload in a stream of consciousness is held at bay by the knowledge that other people are actually going to read my writing.

Third, I want to use this blog as a means to improve the practices in my life. When I get down to it, this is the most important objective of this blog. I want to use DrWillBe as a means of learning new ways to live a better, more happy, more productive, more organized life. The internet is replete with information about people's life practices - eating, sleeping, studying, organizing, working, playing, etc. It's overwhelming how much information there is and how many different ways there are to do basic things.

So, instead of trying to curate all that information by myself, I'm hope to bring the information here to one place. In the coming months, I plan to write a series of blog entries called "How I...." in which I describe basic practices in my life and my reasons for them. I'm just going to lay it all out there. I hope then that you, readers, will participate in a robust discussion and give your feedback. In this way, we'll all benefit. I'll tell you how I do things and if my methods are appealing or make sense, then you can benefit from adopting or adapting them. If you think how I do things is not optimal or just plain stupid, that's fine too. Tell me straight out, "Alex, you're doing it all wrong." I want to learn. I want to learn how other people think, confront obstacles, and live their lives. In this way, DrWillBe has a the potential to be a useful resource for everybody.

Finally, I plan to use this blog as a sounding board for issues dealing with medical school and medicine in general. After all, that is what I am most familiar with and it is how I spend the majority of my time. Hopefully my rants and commentaries don't turn people away but lead to good discussions and maybe, just maybe, some changes in the areas that are lacking.

So, to get the process going, chime in. Let me know what you think. If you keep a blog yourself, what are your reasons? I'd love to hear them.