Intro to Med Professions Module 1-7 Notes
Intro to Med Professions Module 1-7 Notes MDU4003
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MDU4003- Intro to the Professions of Medicine Lesson 1: The Future of Physicians The Power of Pooling Medical Data Avicenna wrote a book called The Canon of Medicine o Rules for testing medicine Disease and medicine must be the same strength Medicine needs to be pure We need to test it in people Carlos Finlay o Hypothesized that yellow fever was not transmitted by dirty clothing but rather by mosquitos—tested this in people Proved this hypothesis & used informed consent o Clinical study—combination of narrative hypothesis, experimentation in humans, and informed consent— form the basis of how we investigate medicine Silos are created to store data and statistics for studies o This can’t be networked, integrated, or by people who are not credentialed o Informed consent and privacy rules actually prevent data from being used that could go towards important medical research Nowadays, we have become quantifiable—digital exhaust can help us learn more about our health John Wilbanks (speaker) proposes that we build a commons—a public good that we build out of private goods o A commons of data is built from our own data that voluntarily shared o He proposes a giant pool of freely available health and genomic data The E-Patient Movement “e-Patients are equipped, engaged, empowered, enabled” – Tom Ferguson Dave deBronkart (speaker) was diagnosed with stage IV kidney cancer with satellites all over the body Dave joined an online cancer patient support community in which he found the appropriate treatment for his disease, called high-dosage Interleukin o His tumor sizes plummeted Regina Holliday is a woman whose husband died of kidney cancer She created a medical facts “nutrition label” for her husband’s medical chart, so the nurses would know the basics of her husband’s condition Kelly Young is a rheumatoid arthritis patient found a nuclear bone scan that can reveal inflammation that is typically used for cancer She used it to prove that she was in pain o Patients are the most underused tools in healthcare Healthcare Reform for Dummies Affordable Care Act (ObamaCare) will be enacted in 2014 Half of citizens will get health insurance through employer 1⁄3 will be covered through the government 1/10 will buy insurance themselves 30 million may not have coverage at all Employer Caps/Maximums on how much will be paid out of pocket 2 Free preventative care Companies with 50 or more workers will be required to cover full-time employees Smaller employers won’t face the same penalties for refusing to buy insurance but they’ll be encouraged to do so; small marketplaces Small companies will be given temporary tax breaks Insurers can’t inflate prices if some employees are sick Government Medicare has already started helping with prescription drugs and better preventative care Medicaid is expanding to cover more people (esp poor adults) If income is low, Medicaid will cover you most likely through private insurance plan • State ruled that states decide individually to implement Medicaid—for states on board, the feds will cover all the cost; for those who aren’t, the poor won’t have many options On your own Health insurance marketplaces are private insurers competing for your business o Like a virtual insurance megamall—has several options based on what you want o As wish Medicaid, not all governors are on board to set up these marketplaces, but the feds will set up their own in these states o Fed gov will provide most ppl w a tax credit if income is below a certain level o Marketplaces make sure everything’s operated fairly (can’t charge more for preexisting conditions, prices for older ppl down and young people up) o Hospital visits, doctor visits, maternity care, mental health care, prescription drugs 3 o Stay on parents plan until 26 years old o Only allowed to sign up during enrollment periods o Enrollment in the new marketplace runs from October 1, 2013 to March 31, 2014 o No insurance Individual mandate says that no insurance will result in a fine Patient-centered Medical Homes (PCMH) 19% greater chance of survival when the doctor knows the patient’s name (suggests better care and relationship with the patient) America is #1 in cost of healthcare, but #37 in outcomes of healthcare We have lots of perverse incentives in American healthcare o Often the medical bills are too expensive Primary care physicians handle a wide variety of needs New model: superb access to care, patient engagement in care, clinical information systems, care coordination, team - care, patient feedback Creating medical neighborhoods where all medical professions work together Need to change our educational system and rework how we all work together Need to train more generalists and less specialists Bottom line: working smarter, not harder; team-based care PCMH Example Traditional healthcare is centered around sick care and paying for services rather than paying for better outcomes Integrated Care Deliver means that a variety of healthcare professionals are connected by a powerful network of info and armed w insights driven data o Enables each provider to offer the best solution for each individual and the primary care physician is at 4 the center of it all o It is designed to help people live an overall healthier life o Personal mix of preventive care, emotional support, care programs, education, and online and mobile tools o Health info and history also made available to urgent care staff Changes in Medical Education By 2030, 22% of the world will be aged 65 and older and there won’t be enough doctors to take care of them all Smart technology will supplement care both in hospital and home Doctors will become less central to medicine Stronger focus on skills rather than memorization Traditional curriculum was a 2 + 2 curriculum: 2 years in the classroom learning science and 2 years in a clinical setting learning clinical skills Hofstra University Medical School has a 4 year clinical study curriculum that also requires EMT certification, teaching both medical skills and teamwork o Puts students at center of long term care o Goal is to develop core skills for medicine, both science and personal People are questioning whether medical schools will now be redesigning their teaching methods to focus on skills rather than textbook work Improving Medicine with Technology The proliferation of gadgets, apps, and Web-based 5 information has given clinicians new ways to diagnose symptoms and treat patients, to obtain and share info, to think about what it means to be both a doctor & patient Older doctors worry that the human connections that lie at the core of medical practice are at risk of being lost o The older generations assume that physicians are the unambiguous source of medical knowledge o They don’t go to computers first because they must adjust treatment recommendations based on the patient’s own priorities& take their social and psychological complexities into account Medical students argue that technologies, such as iPads, help increase efficiency in their duties and accuracy in their performance The Need for Research Medical research is dominated by new tests, new treatments, new disorders, new fads—but it’s mainly about new markets We don’t need to find new things to spend money on; we need to figure out what’s being done now that isn’t working We need to start directing more money toward evaluating standard practices—the tests and treatments that doctors are already providing Bc of Medicare, we have a clear view for patients age 65 and older, but it’s a lot cloudier for those under 65 A research culture that promotes a healthy skepticism towards standard medical practice is also needed o Requires physician researcher who know the 6 standard practice, have the imagination to question it, and the skills to study it These doctors need mentoring of senior researchers & assurance that investigating accepted treatments is not career suicide The administrative demands of clinical care and competition for research funding make it increasingly difficult for researchers to see patients o Become isolated from standard practice Welch (author) proposes that we devote 1% of health expenditures to evaluating what the other 99% is biuing & figure out what works and what doesn’t Lesson 2a: Family Medicine - Family Medicine with Dr. Rooks o Second newest board speciality (besides emergency medicine) o Spawned from the old concept for family practitioner (grandfathered into family medicine) o 3 years residency -Most go into general practice - end up w board certification in family practice - residencies dispersed across the country oFamily medicine is the only specialty that defines itself in terms of a context of care (others are mainly focused on organ systems) 7 o Characteristics you need to enjoy being a family physician 1 - A broad knowledge base; very generalist mindset; know a little bit about a lot 2 - The ability to know what you don’t know 3 - Common sense 4 - Things to think about with regards to the patient: electricity, money, religion, IQ, social situation, season of the year, the time of the month, the day of the week, pharmacy status and intelligence of pharmacist on duty, how you’re feeling, ability to enjoy all types of people 5 - Roles that Family Medicine practice: the expert diagnostician, the educator, the learner, the critic, the validator, the shoulder to cry on, the cheerleader, the vendor, the partner (patient wants physician to go thru this w them), the mobilizer (helps patient get resources), the permission giver, the parent, the friend, helping people die, caring for those who won’t care for themselves o What will the future hold? (controversial possibilities in the future of family medicine) -Genetic wizards—create genetic changes in humans - The death option—euthanasia o Sense of humor 8 -Laugh at yourself -Stick bites (people thinking that they have snake bites when they really don’t—they were really just poked by a stick) Military Medicine with Dr. Brandt rewatch! • 3 year residency -Dr. Brandt did med school at University of Kansas and residency at University of Tennessee • Take care of patients from birth to grave • Family medicine fellowships are: obstetric, emergency, addiction medicine, and sports medicine • When she worked part time—made $60,000 for 20 hours a week; full time now—make $90,000 • Dr. Brandt did the military air force scholarship program to pay for her medical school. She now walks out with zero debt Communication (Article: Improving Patient Communication in No Time by: Ellen J. Belzer, MPA) • The average patient visit lasts only 15 minutes Most patients today prefer a partnership w their physicians and want to share responsibility for their care Meeting these new patient needs isn’t time consuming, but it does require adjusting the communication skills you already have An efficient office will enhance your relationships w your patients & save time 9 Your staff represents you—they must receive proper training in effective patient communication Taking shortcuts too often or in the wrong places may weaken the doctor-patient relationship Don’t appear rushed, even when you are Communicate w a dual purpose Listen without interrupting Eye contact 15-minute patient visit—BATHE technique o Background ("Tell me what has been happening."); o Affect ("How do you feel about that?"); o Trouble ("What's upsetting you most about it?"); o Handling ("How are you handling the situation?"); o Empathy ("That must have been difficult."). Make an extra effort to build trust researchers found that physicians who used a participatory model of care (i.e., the doctor serves as educator, shares decision making and encourages patients to participate in their care) had twice the patient retention rate the patient normally speaks for 18 seconds before the doctor interrupts educate your staff make special efforts to meet individual needs follow up with the patient Single most important thing by which patients judge you as a physician is the way you interact w them Diary of a Doctor Dr. Tony Miksanek joined the Good Samaritan Hospital where he is the sole physician in the rural health clinic Monday—man had a subarachnoid hemmorage Wed—Dorothy admitted her fear of being admitted to the hospital and passing away; she was given outpatient care 10 HMOs Different types of managed care o Health maintenance organizations (HMOs) o Preferred provider organizations (PPOs) o Point-of-service (POS) plans HMO o A health care organization created in an effort to lower health costs for you and whoever is helping you pay for your health care (i.e. employer or government) o usually large organizations that can buy services for thousands of people and, at the same time, decide what type of care they will receive allow HMOs to lower the cost of health care and give companies cheaper health care rates for their employees o most obvious advantage to HMO- cost o disadvantages: o HMOs operate on the concept of capitation— they receive a flat fee each month for each person they cover o You only use doctors and hospitals that use HMO Lesson 2b: Pediatrics -Pediatrics with Dr. Novak • Pediatrics takes care of people from birth till about age 21 - Studies how illness affects growth and development -Go from high school to college to 4 years med school to 3 year pediatric residency, after that many become 11 generalist but then could specialize (surgery, pediatric endocrinology, etc.) • Part time and sharing practice options are very popular for pediatricians • Private Practice vs University 1 - University 2 • Allows you to work with students and teach in context of clinical care 3 • Sub-specialist pediatricians are able to work on research in lab ▯ - Private Practice 1 • General pediatric practice in the community 2 • Help set policies in education and school board 3 • Pediatrics is integrally involved in CDC at government level • Competition Primary care specialities are not as competitive as surgical specialities Huge need for pediatric sub- specialities, such as endocrinology and cardiology • Availability of pediatricians vary based on practices General practices have phones staffed by nurses or residents for night calls • Current research Primary prevention 12 -#1 cause of trauma in children is motor vehicle accidents -Gene therapy Et•ics in pediatrics ▯ - Confidentiality is harder in adolescents and are given more responsibility to make their own decisions ▯ - In Florida, if a minor is pregnant, she has complete control over the decisions of the pregnancy • Typical day ▯ - Clinic: full schedule with well visits, newborn visits, prenatal visits, sports physicals, chronically ill children, open schedule for acute problems (ear infections, etc.) ▯ - Teaching residents ▯ - Lots of reading to keep up with current info and attending conferences ▯ • Why did she choose pediatrics ▯ - Love kids and science ▯ - Goal is to prevent illness and injury to reach best level of health approaching adult life ▯ Pediatrics 101 pediatricians diagnose and treat infections, injuries, genetic defects, malignancies, and many types of organic disease and dysfunction Primary care pediatricians- focus on care of children from birth to 21 years of age Their skilled assessments may uncover depression or anxiety in children, particularly those who are technology-dependent, or whose activity is limited by chronic conditions Pediatrics is a collaborative specialty 13 Lesson 3a: Internal Medicine -Internal Medicine with Dr. Pauly • Dr. Pauly is associate professor and director of the division of internal medicine - Emphasize both verbal and nonverbal communication (ex. Empathy) • Hospitalist takes care of in patients who need to be hospitalized • Out patient takes care of people such as hypertension, diabetes, women’s health, etc. • Teaching program Essentials of patient care: 4 semester course taught by Dr. Pauly • Went to medical school at UA Birmingham and residency at UNC Chapel Hill, then 2 year cardiology fellowship • Interested in medicine because of living in a small town with a lack of physicians • Less than 50% of prescriptions are filled after an appointment • Internal medicine “shuts no doors” -Care for adult patients • Internal medicine is 3 year residency program 14 - Many people will go on to sub specialize in cardiology, GI, infections disease (generally 1-4 years long) • Good listening skills needed • Internal medicine stresses inpatient intensive care and outpatient experiences -Takes care of patients with more complicated problems then family medicine -Options are open to subspecialize in internal medicine, which is not applicable in family medicine • Challenges: Managing new technology, balancing risk/benefits of a procedure, HMOs, underinsured and non- insured patients • Husband-Wife patients are exciting -Case Studies by Dr. DuBose • He is currently a third year resident in internal medicine • College at Clemson, Med school at USouth Carolina, Residency at UF • Typical day as an intern 1 - 4-10 patients on their own ▯ - About 20 minutes to assess each patient before rounds to check vitals 15 ▯ - 8:00 Check in with resident (team usually made up of 2 interns and 1 resident) ▯ - Morning meeting that usually discusses a unique case, or a common case but there are a lot of points to learn from (1 hour) ▯ - Attending rounds (check in on patients could last 30 mins, 3 hours, depends on skill) 1 - Hour or so to get work done before lunch (write notes, check labs, follow up on studies) 2 - Noon conference that teaches you about a topic 3 -Rest of afternoon, do more work but also you’re admitting patients • Diagnosing ▯ - Open ended questions is the best way to assess patients 1 • 85% of the time the patient will tell you what’s wrong without you even having to talk much to them ▯ - 1st: Past history ▯ - Family history ▯ - Social history (marriage, career, hobbies, drug use etc.) ▯ - Medical history (what medications the patient is on) 16 ▯ - Physical Exam ▯ • Vital signs ▯ - Labs and scans ▯ • Conclusion: patient has a pulmonary embolism • Intern day ▯ - 80-100 hours per week; interns usually have 12 hour shifts ▯ - generally Monday through Friday ▯ • 9 months of this • Factors for choosing residency: Location, academic institutions vs community programs, - Medical SubSpecialities with Dr. Kloize • Internal medicine -Focuses on adult medicine (18+) -Treatment of complex adult disease processes and the prevention of them -Hospital, office, and nursing homes - How internal medicine differs from family practice: - Family Practice covers: - Pediatrics 17 - Adolescent Medicine - Adult Medicine - Geriatric Medicine - Surgery - Obstetrics and Gynecology -Therefore the name: GP- General Practitioner -Training of internist: 3 years of residency (after 4 years of med school) -1 year of training: intern or PGY1 (post-graduate year 1) -later years: resident; trying to change this by calling 1 years, 1 year residents -Why she chose General internal medicine • Patient population (enjoys working with adults more) • Problem solving • Diversity (deal w all organs, different problems) • Option to sub-specialize • Procedures • Follow patients throughout their life • Varying intensity (sometimes patients are not that sick, others have very complex problems) -Heart failure- when heart becomes very big and doesn’t contract very well; leads to fluid in lungs, shorter breath, could affect kidneys -Hematologists- specialize in blood disorders -Oncologists- specialize in cancer -often trained in both hematology and oncology 18 Lesson 3b: Emergency Medicine ER Medicine with Dr. Ferguson Areas specific to emergency medicine that you won’t get anywhere else: EMS (begin treating patients before they even see them) 2/3 of training in emergency room Have standard lectures on terrorism instances (ex. Gas attacks) University of Michigan College of Medicine o 1 of the oldest med schools o uses a passfail system Dr. Ferguson chose emergency medicine bc he likes the rush it offers ER Medicine with Dr. Lottenberg Part 1 • Trauma and critical care general surgeon o Typical day Wake up at 5, out of the house by 5:30 At hospital by 6:15ish Check patient list and prepare for the day, look at cases Teaching and business conference Most days operate every day; if on call surgeon, will be in operating room most of the day, also making rounds in ICU and emergency room o Best part: driving to work everyday with a good feeling and a smile on face o Worst part: deal with death more than any other surgeon in trauma surgery; delivering bad news 19 o Percentage of patients who die is 5% at UF o What made you go into surgery? Exposed to medicine very early by both parents Watched surgeries at Jackson Memorial Hospital during college breaks One brother is radiologist one brother is hematologist o Misconceptions: we’re not miracle workers o Trauma nothing is cookie cutter, but they have an ABCDE, “easy cookbook” method for taking care o ER Medicine with Dr. Lottenberg Part 2 • Most interesting case: two 16 year old patients were impaled with a wooden fence and they both survived • He believes there’s no comparison between medical school and undergrad o Med school—all studying and work o Undergrad—room for less intense work o bc surgical training was best in Chose University of Miami Florida back in 70s • Trauma is all about getting the people to the right place at the right time • What was medical school like for you? 1 No margin for error 20 2 Extremely intense 3 Opportunity to gain as much knowledge as you can 4 Chose UM because the surgical program was better than anything else in the 70’s ER Medicine with Dr. Lottenberg Part 3 • MEL course at UF is a great opportunity for students to be exposed to medicine and to be mentored by physicians • Dr. Lottenberg surrounded himself with surgeons who could mentor him in college Lesson 4a: Surgery Surgery with Dr. Lam • Chief of general surgery • Why did you choose to become a surgeon? Liked all specialities except for pediatrics and psychiatry Likes to work with hands and 3D views of objects Resultsoriented person She likes being the captain of the ship/control freak Have to be very compulsive, drive for perfection Traits of surgeon: relatively anal, controlling and arrogant 21 Would have chose educator if she didn’t choose surgery Not touchy feely Not emotional • Training ▯ 4 years med school, 5 years residency, 23 years of fellowship or 12 years of research ▯ Very competitive; top 25% of medical school class • Lifestyle ▯ Responsibility will mandate working more than a 40 hour workweek (usually 60 hour) ▯ Speciality should be driven by passion ▯ Quality of life depends on if you pick an elective or emergent subspecialty • Practice options Solo practice, HMO, group practice, academic practice • Challenges ▯ Rapidfire decisions, sometimes without all information at hand ▯ Directly taking responsibility for life of patient while operating ▯ Decisions regarding practice are made by people who aren’t the physician or patient, such as an insurance group 22 • Traits Confidence Compulsive based on outcomes Good decision making, regardless of information ▯ General surgeon 1 alimentary tract, endocrine surgery, breast, lung surgery... neck, chest, and abdomen primarily 2 GI tract surgery (take out colons,etc) is main for Dr. Lam • She works with a lot of malignancies 3 all of surgery is teamwork, direct team approach ▯ Laparoscopic (minimally invasive) surgery Used with minor incisions ▯ In academics, esp in surgery, there’s a lot of research She does biomaterials (plant in body temporarily or permanently—ex. Artificial valves, sutures) We can do a biotic hand ▯ Patients and procedures ▯ surgery itself is fun/easy part of job; harder part is deciding who/what/when for surgery At the VA for hip replacement because of arthritis, then had a cardiac arrest on the floor • Perforated an ulcer• Revived then had an arrest again • 8 months later he is fine Triple Zero (lost vitals)• Multiple gun shot wounds in chest and abdomen • 23 Revived the patient with a cardiac massage• Operated and brought to ICU• Stayed there for 7 months until fully healed• A year later, the patient robbed a bank Biggest reward: you are there, you make a difference Biggest concern with women is lifestyle issues lifestyle is dependent on what your priorities o Surgical Knot Tying Tips• • 11 • The knot must be firm, to prevent slipping • Use the simplest knot for the material • The knot must be as small as possible • Ends should be cut short without creating instability • Avoid friction between the strands (sawing); this can weaken the suture • Avoid crimping the suture with instruments, except when grasping during an instrument tie • Excessive tension may break sutures and cut tissue • Avoiding excessive tension allows use of finer sutures • Do not tie sutures too tight 24 • Approximate, do not strangulate • After the first loop is tied, maintain traction to avoid loosening of the throw • Ideally, the two ends of the suture should be pulled in opposite directions with equal tension • The surgeon should change stance or position in relation to the patient to place a knot securely • Extra throws do not add to the strength of a properly tied knot, only to it’s bulk Kno• tying Lay flat ties and set each knot as it’s tied • andard Square Knot ▯ May be used to tie: gut, collagen, coated VICRYL suture, PDSII suture, silk, stainless steel ▯ Commonly used when wound tension requires a double loop on the first throw for security ▯ When a suture’s coefficient of friction requires a double loop to maintain position ▯ When the first throw cannot be slid down by the second throw ▯ Commonly used with: MERSILENE polyester fiber suture, ETHIBOND EXTRA polyester suture, NUROLON nylon suture, PROLENE polypropylene suture ▯ Surgeon’s Knot ▯ When a suture’s coefficient of friction requires a double loop to 25 maintain position ▯ When the first throw cannot be slid down by the second throw ▯ used w MERSILENE polyester fiber suture, ETHIBOND EXTRA polyester suture, NUROLON nylon suture, PROLENE polypropylene suture ▯ construction of ethicon sutures produces strength and uniformity provides ease of tying and security ▯ dependent on each surgical circumstance and experience of surgeon ▯ Two – Handed Square Knot ▯ loose loop is created over the left second digit, tip of the left second digit which is now through hthe loop is touched by the tip of the left first digit, passed through first loop, tip of short end is grasped between the two fingers and first end is brought thru the loop, pull, and nice, flat, snug throw is created ▯ second throw is created by creating loose loop, this time tip of left first digit is used, left second tip is then approximated to left first digit and both approx.imated digits is brought, short end brought through loop ▯ Surgical Suturing ▯ Depends on surgical circumstances and experience of the surgeon ▯ Simple Interrupted ▯ needle holder is a ringed instrument, held by inserting thumb of st th 1 digit and 4 digit in the rings, some surgeons will allow for more rotatory movement by not putting thumb in ring and instead 26 supporting it with pointer finger; less trauma is use multitoothed forceps ▯ thumb forceps acts as a counterbalance and facilitate passage of needle; in order to pass needle w least bit of trauma to the tissues, you must recreate circle; point of needle inserted at right angle to skin’s surface, circle recreated; goal of 2 pass is to nd recreate a mirror image of 1 pass, be at depth equal to depth of first pass; suture is tied, creates an everted state, promoting cosmetically acceptable healing ▯ presents as a square or rectangle—important bc maintains everted state—essential for proper healing of tissues ▯ Simple Continuous ▯ use 2 individual sutures1 begun at one end and close ½ incision, other opposite; other strand closes remaining half of incision, two tied together ▯ Continuous—only use one strand looped through skin like loop de loops ▯ Vertical Mattress ▯ almost perfect approximations of skin edges and results in cosmetically accepted scar—used for fine skin ▯ farfar in mirror image fashion, then nearnear vertically oriented to farfar component, very close to skin edges taking as little of the skin as is possible ▯ Horizontal Mattress—will provide everted fashion; closer of deeper tissues, composed of 2 interrupted sutures that are in series ▯ Far Near, Near Far 27 ▯ speed Jones version, used for facial closure ▯ insert retractor ▯ Figure Eight Suture used for deeper plains ▯ Subcuticular very cosmetically approved scare bc it doesn’t cross skin’s surface, crosses in meticulous fashion below the skin’s edges and avoids the cross types sections usually seen in sutures Lesson 5a: Obstetrics and Gynecology OBGYN with Dr. Davis o Caring for women of all ages o Provide: Primary care, preventative care (screening), obstetric care, surgical care o Subspecialties Generalist Internal fetal medicine Reproductive endocrinology and fertility Oncology Pelvic reconstructive surgery o Why did I choose OBGYN? Didn’t have the personality of a general surgeon Enjoyed the nature of OBGYN Could still be in the operating room but wasn’t confined to the OR o Characteristics Willingness to work hard Personable and have to keep a smile on your face Actionoriented person o Training 4 year residency • 12/15/18 months of obstetrics • 1 year gyno• 6 months REI• 6 months oncology • Ultrasound, internal medicine, ER On call every 3rd to 4th night 28 o Practice types Private practice • Most go into general OBGYN13 Group practice of 5, 6, 7 people Shares responsibility and obtain good lifestyle • Focus on obstetrics in the beginning then gradually moves towards gyno • Subspecialists do exist, though most stay in academic field Academic practice • Greater call for generalists (focus on preventive care, contraceptives, gynecological care) here in present day majority of people who go in fellowship usually stay as academic specialists • Challenges ▯ Hard work and taking call (work between 12am to 6 am, work all night, etc.) ▯ 80 hr work week rule ▯ Whoever is oncall in labor and deliver is responsible ▯ Malpractice • Crisis where women are not able to get proper care • Fund designed to pay money to parents who have babies who suffer from birth related injury ▯ Patient who went to infertility doctor when she was already pregnant (has troubles getting pregnant), had a large pelvic mass, operating on pregnant woman could cause problems to baby/not operating could harm the woman, decided to operate, she and baby both did fine—reflects 29 complexities in gynecology • Very competitive field • Ratio of men to women 2⁄3 of residents are female, 1⁄3 are male 1015 years ago it was 3:1 male to female • Schedule on day to day basis Academics has more structure than private practice Work with residents and more complicated patients Private patients in the morning Meet with medical students and work in labs to teach them Wednesdays in OR Doesn’t do a lot of research – OBGYN tour with Dr. Davis • Saving a life and bringing a life into the world patient had dysmenorrhea—painful menstruation, cramps; suspected endometriosis—one of most common causes of pelvic pain in women, caused by • Laparoscomy10mm incision, minimally invasive surgery Pap smear put 2 fingers in vagina to check ovaries IVF involved using medications to make ovary produce multiple ovum, semen is produced by male and specially prepared in lab; can inject individual sperm into an individual egg; then matured in lab generalist obgyn—have time for research, oncall, etc.; there are women’s health fellowship for interns too most obstetricians will be sued for a bad outcome at least once in their career 4 year residency, then most go into practice but decide to subspecialize (3 30 years of fellowship)—reproductive endocrinology & infertility, gynecologic oncology, maternal fetal medicine (highrisk obstetrics), urogylecology & pelvic reconstructive surgery Gynecologic oncology o Primarily a surgery subspecialty o Also trained in managing complications of cancer, including sensitive endoflife issues o One of the most challenging Maternal fetal medicine o Take care of patients w sometimes complex health issues like heart disease and diabetes o Called upon to diagnose fetal anomalies o All OBGYN residents trained in basic sonography o Even experienced OBGYNs turn to them Urogynecology o Common prob amongst women getting older relaxation of pelvic floor muscle—can result in urinary incontinence o Specialize in the diagnosis and treatment of different types of incontinence—urodynamics o Detailed knowledge about anatomy of pelvis o specialists in pelvic reconstructive surgery on average, oncall every 4th (??) night or so; divided up so can cover even number of weekend days during the year • 85% of medical students change their mind on what specialty they want Women’s Health with Dr. Guzick • Reproductive endocrinology and infertility Subspecialty ▯ Two types of patients Women who have hormonal disorders 31 o (abnormal/no periods, osteoporosis in menopause, premature ovarian failure, the kinds of things that endocrinologists may look at except at a reproductive slant) Infertile women o In vitro fertilization ▯ Typical day Pr• edures/outpatient (ultrasounds, egg retrievals, etc.) visits for first half • atients in the office in the afternoon (couples w infertility for evaluations, etc.) ▯ Advantages and disadvantages 1 Advantages 2 Combines medicine and surgery 3 Primary care with focus on prevention and long term care 4 Work with couples and patients in a variety of situations 5 Work with otherwise healthy individuals who have a discreet issue that can be solved 6 In vitro fertilization 7 Disadvantage 8 Very specific, expert in small area with subspecialty ▯ Why did you choose OBGYN? Drawn to acut• problems, not chronic • Grew up with in vitro fertilization when starting out with medicine ▯ Octomom should have been a case of medical malpractice ▯ • 1978 first IVF in England ▯ • 1981 first IVF in America 32 ▯ 4 million babies have been born from IVF • ▯ • 1 in 5 couples experience infertility ▯ Lesson 5B: Ear, Nose, and Throat ▯ ENT with Dr. Sedwick Otorhinolarynology—ears, nose, and throat o Oldest medical subspecialty in the US o Medical diagnosis and treatment of diseases of ears, nose, and throat o Referred to as ENT physicians o Special skills involved w treatment of sinuses, voicebox problems, diseases of cavity, and structures of head, neck, and face o Treat ears—hearing loss (affects 1 in 10 Americans), noise in ears, congenital disorders of inner and outer ear o Nose—about 35 million Americans develop chronic sinusitis Treatment of allergies, loss of sense of smell, breathing problems, problems w nasal appearance o Specific is managing diseases of the voicebox o Treatment of throatswallowing and voice disorders o Treating head and neck—cancers of these areas Primary oncologists for cancers in this region o Trained to treat infection, malignant and benign tumors o Treats broad range of ages o Common Problems Ears (otology)—swimmer’s ear, infection in children, hearing loss, ringing in ear, ear pain Pediatric—asthma, airway problems, tonsil infections, allergy & sinus disease Head and neck—cancerous tumors, lump in neck, cancer of voice box, nodules in thyroid Facial/plastic—rhinoplasty (nose jobs), cleft palette repair, aging in face, surgeries to improve grouping in the eyelids (due to age, genetics, or sun exposure) Rhinology—sinus disorders, nose bleeds, stuffy nose, 33 loss of smell Typical case he presents—T1N0 squamous cell carcinoma of the true vocal cord o TNM staging system: T tumor size, N whether or not it’s a normal metastases, M metastases - Typical 5 years of residency, can have additional 12 years of training if don’t go straight into practice Very competitive about 400500 medical students who apply for 205 spots; top quarter of med school class Board certificationmust pass this after 5 year residency, oral & written exam 2 days As residency numbers increase, some decrease in demand, but no significant increase of otorhinolarynologists trained - Medical & surgical subspecialty Lesson 6a: Radiology Radiology with Dr. Abbitt o Training Internship 4 year residency Fellowships to become specialized o Huge career availabilities Demands increasing for private and academic practice o take care of kids, adults, work w surgeons, oncologists, can be a generalist or pick a specific topic to become an expert in o many images on computers, 3D reconstruction—lots of technology o be good students, tremendous community service 34 o Currently specializes in abdomen problems o Right upper quadrant=liver, gall bladder, kidney o CT scanner= beam of xray o Innovative radiology: tips shunt= severe GI blockage, diminishes effect of life threatening hemmorage Radiology Oncology with Dr. Lynch • Study of cancer • Liquid malignancies and tumors Surgeons are for tumors Liquid tumors are oncologists • 4 year residency for radiation oncology • 5 year general surgery, 2 year oncology specialty • His aunt was one of the first people to be treated with chemo; she had Hodgkin’s disease • Biggest issue is struggle between wanting to be a workaholic surgeon and having a personal life • Lesson 6b: Pathology/Infection Disease Pathology with Dr. Crawford • Why he loves medicine: Trying to understand human disease 35 • Pathology: providing information to the health care team and patient on how to treat the disease ▯ Training 1 4 year residency 1 Anatomic microscopic view of human tissue Ex. biopsy for malignancies 2 Laboratory medicine/clinical “what was the lab test result?” 3 Choosing one speciality takes 3 years instead of 4 2 Subspecialties: transfusion medicine, cytopathology, forensic pathology, 2 dozen subspecialty • His specialty is in abdomen/GI disease ▯ Patient: Malignant cells clogging up blood vessels in the bowel, ended up being leukemia ▯ Every patient will need some sort of pathology services ▯ Changes in pathology Anatomic pathology techniques were invented in 1870s Molecular medicine and the human genome Pharmacogenomics Response to medicine due to gene differentiation 36 ▯ Tour ▯ 23,000 specimens per year in the UF lab ▯ Lifestyle More scheduled and predictable You can put in as many hours as you want (typically 50 hours) Training 4070 hours per week Peds Infectious Disease with Dr. Vijayan ▯ Loves pediatrics, couldn’t figure out what speciality, worked as a hospitalist, likes the variety, likes how the children weren’t chronically ill, likes the variety ▯ Medical school in India, residency in the UDMJ, fellowship at Harvard UCLA Residency in pediatrics and fellowship in infectious diseases ▯ Led to success: supportive family, being trained in India ▯ Typical day Very busy Drop off kids at school Start rounds at 8:30am Teaching Come home around 5 • Common treatments Doesn’t have a lot of procedures Heavy on medical management Pros and cons Seeing kids get better is the best thing When • children pass away is the hardest part • Favorite age is 24 years old because they are so magical 37 • Going into medical school: pay attention, read a lot, work hard, live your life, find the balance Lesson 7a: Plastic Surgery o Cosmetic to reconstructive• Majority of his patients are breast cancer, cosmetic, and hand o Rosenberg: graduated as 5th year medical student o Education/training • Medical school, general surgery training (4 years), 3 years of plastic surgery residency, specialize in breast cancer o Job market for plastics 1 Residency spots are still competitive 2 Variable in job market depending on location 3 Salary ranges: 5 years out $350,000400,000; could start at $200,000, average 400,000 o Schedule 1 3 operative days (M, W, F) Monday is hospital day Wednesday surgery center 2 2 clinical days 38 3 On call 56 times a month (1 weekend and a couple days) o Patients• 830% of women choose to get breast reconstruction (18% at UF) o Ethical, moral, legal• Medically necessary cosmetic vs not medically necessary to call insurance • Malpractice insurance is expensive ($4050,000 a year)• 2% complication risk; 1/10,000 die from a procedure o Innovative research/new technology • Some of the most creative people 39
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