Radiation-Oncology: Day 6

Just another day in the wonderful world of Oncology!

I seriously love this job. Today, my attending asked me if, after 4 years of undergraduate education and 3 years of medical school, I was still excited about becoming a doctor...Without hesitation, I replied with childlike enthusiasm: "Yes! Of course! I could never imagine doing anything else for the rest of my life!" The reason he asked me this was because of a recent poll (which was released on Friday) regarding physicians' salaries and quality of life. One question which was asked in the survey was: "If you could do it all over again, would you still go in to medicine?" and the overall result was that only 54% said yes... Kind of a scary thought, knowing that about half of physicians wouldn't go into medicine if they could do it over again...

It is an interesting survey. To see some other results (including salaries for various specialties, compensation, quality of life, hours per week of patient contact, hours per week of paperwork, etc), click here.

I'm not ashamed to admit that I was excited to find that the books I purchased online last week arrived...I finally have the USMLE Step 2 Prep Book that corresponds with my Doctors-In-Training Review Course. This Mass Gen Pocket Medicine reference book (that fits perfectly into the pocket of a white coat) will undoubtedly come in handy when I am an Acting Intern on the medical wards this fall; I'm sure it will be useful when I am an actual intern as well.

I mean, who needs to buy new clothes when you can spend $80 on a few more medical reference materials?!

Radiation-Oncology: Day 2-5

So the rest of my first week on Radiation Oncology involved doing the things that the physician does. As such, I met several patients in the clinic, either as a primary consult or as a six month follow-up.

One man I had the pleasure of meeting has a very large tumor in his neck. So large, in fact, that it has started to consume his mandible, and he is having significant difficulty with swallowing (and has lost around 20 pounds in the past 3 months). He also had what we not-so-technically label "hot-potato speech", where he talks like he has a hot potato in his mouth (muffled voice). What was particularly frustrating is that although he had taken the initiative to be seen by a physician in a timely manner (several months before our encounter), the physician he spoke to suggested that the mass was caused by a dental abscess and simply prescribed antibiotics without further investigation. This doctor was not an American-licensed physician, just to make that clear! So he came to us with a very advanced, and aggressive, tumor instead of a smaller, more curable tumor. We will radiate the tumor area after he undergoes teeth extraction. He will likely need plastic surgery to reform the mandible after radiation. But his prognosis is not very good, maybe at around 15-30% 5-year cure. It is horrifyingly sad, knowing that the patient had the initiative to be seen to at the onset of this illness, but it was brushed off inappropriately and has significantly impacted his chance of survival.

I have also seen many patients with prostate cancer, breast cancer, rectal cancer, lung cancer, vaginal cancer, and lymphoma. And I am learning a LOT! While I don't feel like this is where I perfectly belong, I DO love the patients and learning more about radiation. It is pretty fascinating!

Style Saturday

I've been on the look-out for more professional clothes, as I will be starting my final year of medical school soon and I really want my wardrobe to reflect who I am and how seriously I take my career. I do have a good start on a nice work wardrobe, but I do have a lot of purchases to go before I feel complete.

So this week I wanted to have a look at some dresses (which are my favorite things to wear at work), but I have also included a few things I would wear outside of work. I'll let you decide which outfit belongs in which category!

Seriously considering #2, #4, #6 (although a little over-priced), #9, #10, and I would LOVE to play around with #11!

1. Zara Dress with Lace V Back: $89.90 

2. Next Slub Dress: £45

3. Zara Printed Dress with Contrasting Collar: $59.90

4. Next Ribbed Pointe Dress: £35

5. Zara Blouse with Contrasting Collar and Irregular Fine Pleated Skirt: $49.90 each

6. Dorothy Perkins Stone Wrap Pencil Dress: $69

7. Dorothy Perkins Black White 2-in-1 Dress: $59

8. Dorothy Perkins Petite Blush Bird Print Top: $45

9. Zara Twill Capri Pants: $35.90

10. Dorothy Perkins Petite Navy Lace Bubble Top: $21

11. River Island Pink Raised Front Maxi Skirt: £40

A Week Off!

Oh I know I've been neglecting my blog, but this is my one week off during third year! And I've been BUSY working on all of the areas of my life that I have neglected for the past 10 months. Sorting through the huge amounts of information out there regarding finding a position as a foundation doctor (so that I have a job after I graduate next year), beginning to compile immigration documents, working on my Rad-Onc presentation, reading the 500+ novel, "The Emperor of All Maladies", watching every episode of New Girl, going on long runs (well, long for me anyway!), taking a bunch of little walks each day with Mike and Marley, spending time with my family, fixing the second vehicle which has been acting up lately, giving the house a good clean, cooking dinner each night, baking cookies, trying out a few different types of wine, and even a little bit of wedding planning has been going on. So I guess it isn't really a "week off", but I really am enjoying the time away from medicine.

...saying that, I haven't actually been staying away from medicine. I've been in to work 3 out of the 5 days that I was meant to have off this week. There was a good lecture going on that I didn't want to miss, and today I saw a bronchoscopy and placement of a brachytherapy device into the metastatic lesion in a patient's lung (which was actually quite exciting!). Tomorrow I will be going in for a final lecture regarding Radiation Oncology treatment options and outcomes. Let's face it - I would be bored out of my mind if I didn't have any work for a full week. So this week off has been pretty much perfect for me. Except for the chilly weather...but even that hasn't been too bad. I had a nice run in the light rain last night that reminded me of the time I spent running while I was in England last year. So I really can't complain! It is so nice to have the time to do some of the things I love to do outside of medicine.

Oh and I also signed up for my first 5K! My goal is to raise some money for its sponsoring philanthropy and to complete the race in under 25 minutes!

Radiation-Oncology: Day 1

I began my elective clerkship in Radiation-Oncology last week. This is definitely an area of medicine which we aren't taught much about while in medical school. I'll admit that I felt quite overwhelmed the first day; there are so many aspects of this branch of medicine which are simply overlooked during medical school. Honestly, I haven't had any sort of physics class since my Junior Year of Undergrad; at least we were required to have taken physics during our undergraduate years, before going to medical school, so that I do have some background in physics! I also have taken a lot of math courses through the years (and I'm actually fairly good at math considering I went into biology/chemistry/physiology and medicine!), which definitely helps to better understand physics...

Day 1: The morning was spent learning what the Radiation Technologists do, which includes friendly conversation with patients while they are properly positioned prior to the radiation treatment. On the patient's first day in the clinic, the techs and the physician select a position in which the patient will be during each following radiation treatment. They create a mold of the patient's legs so that the position of the legs is the same during each treatment. They place a small dot tattoo where the cross-hairs of different stationary lasers in the room meet, which allows them to ensure that the patient is in the proper position during each treatment (so that the radiation goes precisely where it is intended to go). For prostate cancer patients (and for a vaginal cancer patient), we also monitor the bowel and bladder positions prior to treatment. This is done by using an ultrasound machine to examine the expansion of the bladder and bowel. It's an important consideration because the prostate and vagina are quite mobile relative to the size of the bowel and bladder. Also, since the bowel and bladder cannot really tolerate the doses of radiation that we prescribe for the prostate, we need to ensure that the radiation beams are reaching their target (prostate) and not instead hitting another structure (such as the bowel or bladder). The techs are quite fast when it comes to placing the patients in the proper positions, and they are so good with the patients; they really bond with each patient, which makes the job so much more enjoyable. 

The afternoon was spent learning the basics about the medical physics behind radiation. I learned a bit about how using different sources as energy for radiation affects the penetration and preciseness of the beams (examples include photons versus protons versus electrons as a source). One of the PhD students went through the computer analyzing software that is used to determine the radiation fields and movement of the leaflets to obscure or enhance radiation to different areas, and how the Medical Physicists double-check to ensure that the algorithms produce the best treatment plan possible for each patient. 

There are different ways to go about administrating radiation, and there is a highly effective way to ensure that a vital structure which cannot tolerate much radiation (such as the spinal cord) does not get much of a dose while a near-by structure can still be treated with an optimal dose of radiation. This is accomplished by using what is called IMRT (Intensity Modulated Radiation Therapy). IMRT is really, really cool. It's nothing short of amazing to me, to be able to be so precise in administration of radiation so that the morbidity associated with radiation can be lessened. Other forms of external beam radiotherapy include: Conventional External Beam Radiation Therapy, and Stereotactic Radiation. Another form of radiation therapy, which is a targeted therapy, is called Brachytherapy. This involves the placement of a source of radiation inside of the body so that radiation can be administered to the desired area through the brachytherapy device. I have seen this technique used often in breast cancer and prostate cancer, but I have also seen it used to treat vaginal cancer. Another form of targeted radiation therapy is Radio-isotope therapy. This therapy involves administration of a radio-isotope through either infusion or ingestion, and the chemical properties allow the material to be taken up by selected cells. This therapy is most often used in the treatment of thyroid cancer and bone metastases. 

The guys (and one girl!) in the medical physics program are incredibly smart. They greatly enhance patient-care by acting as another safety guard against morbidity and mortality associated with high-dose radiation. I'm also quite impressed by their knowledge of anatomy. They are yet another example of the importance of integrated teamwork to ensure the best outcomes for our patients.

I went home after my first day on Radiation-Oncology and read for hours about different radiation techniques and the physics behind radiation, feeling quite overwhelmed by the physics and mechanisms of treatment which correspond with radiation therapy. This clerkship will be quite useful for me as a future oncologist, so that I will better understand what my patients will be going through while in the care of a referred Radiation-Oncologist.

Easter & Birthdays!

Now that I have a bit of time to catch up on my life outside of medical school, here's a little bit of what I've been up to:

Mike's Birthday:

Our friends enjoyed a meal at a Japanese Hibachi Restaurant to celebrate Mike's birthday. The food was, as always, delicious. Mike loves to try different types of food that he has never had before, so his birthday was certainly no exception. For the starter, Mike ordered sushi made of Salmon Roe and Sea Urchin. The picture isn't exactly appetizing, is it? The salmon roe tasted like "licking a stone at the bottom of the sea" - salty, fishy, and fresh. The texture is fun - it just pops in your mouth!

Mike and Me on his 25th Birthday:

Work outfit from his mum and dad! ;)

Sea Urchin (left) and Salmon Roe (right)

We also got some amazing sushi of tuna, salmon, and swordfish with avocado and salmon roe sprinkled on top. It was phenomenal. Uh-oh, now I'm craving sushi again...! ;)

Cooking Dinner:

Some Friends at Dinner:

My sister, Andrea, and Me: 

The following weekend, we went home to celebrate Easter with my family. As a surprise, on Saturday night, my family put together a little birthday dinner with cake and ice cream and a few gifts for Mike! I know it's hard on him to be so far away from his family for his birthday (he's not been home for his birthday for the past 4 years), and I know he appreciates a little birthday party with my side of the family.

Mike & Alex:

Easter:

This Easter was a little different from our traditional celebrations, and things certainly felt different without my grandpaw there. We had a nice dinner and spent time with the family, which was nice. And of course it wouldn't be Easter without "Grandpaw's Beans" - which were almost as good as when he made them! The kids  (and Grandpaw's dog, Zim) enjoyed a little joy-ride on Grandpaw's Golf Cart.

 Grandma and Alex, Coloring Eggs:

Godmother Andrea and Katelyn:

Collecting Easter Eggs!

Princess Kate getting her hair done:

Andrea & Joe

Alex's Fifth Birthday:

After my shelf exam on Friday, we went to Alex's birthday party. He and Katelyn got a new swingset and slide and a tee-ball set that they played on while the rest of us sat around and chatted. We had some snacks and birthday cake after Alex opened his gifts. I can't believe that he's 5 already. Seems like just a few weeks ago that I would babysit him and nap with him in my arms and carry him around the house! He's growing up so fast, he's such a little man now! The conversations you can have with him now are so well developed, and he always makes me laugh. We just love our little nephews (Alex and Luke) and niece (Katelyn)!

Katelyn on her new slide:

Andrea and Luke:

Luke is always smiling!

Such a cutie!

Katelyn & Godfather Joe

Alex on his new slide:

Alex and his birthday gifts:

Candles & Wishes:

Final Thoughts: Neurology

My sixth clerkship of third year (Neurology) has come to an end...

• 5 weeks, 27 days, 170 hours of work in areas ranging from Outpatient Neurology (Specialties including Headaches, Seizures, Neuro-muscular Disorders, Movement Disorders, and Vestibular Disorders) to Inpatient Primary and Consult Services.
• Working on Outpatient, I worked 11 days for 71.5hours (average of 6.5hours/day; about 28.6 hours/week)
• Working on Inpatient, I worked 16 days for 98.5 hours (average of 6.2hours/day; about 39.4 hours/week).
• I enjoyed 5 days off in the last 33 (that's ~1 day/week).
• I completed 0 nights on call.
• I studied neurology outside of work a total of 70 hours.
• My total work in Neurology over the past 5 weeks is: 240 hours in 5weeks (48 hrs/week...about 7 hrs/day).

What I LOVED about Neurology:

• The neurologists seem to love their lifestyle.
• There is adequate time to teach (or study).
• The diseases are interesting; Diagnosing neurologic problems is kind of like solving a good mystery...you find the clues, trace it back to the places in the body where the lesion(s) is/are located, and placing a name to the process. 
• You get to read a lot of CT and MRI images, which is something I'm finding that I quite enjoy doing.
• I love Parkinson's patients. I just do.
• I'm fascinated by seizures. They are interesting, and (for the most part) treatable.

What I DIDN'T love about Neurology:

• While the daily hours worked weren't too bad, you still need to be in the hospital every day. In the perfect world, I'd rather work a few long shifts and have proper days off.
• There are a lot of diseases which aren't very treatable. Especially ALS, strokes, MS, and all of those neurodegenerative diseases. They make me incredibly sad, and its frustrating not to be able to offer much help to the patient (aside from your kindness, care, and commitment).
• You see a fair amount of psychiatric patients, which can lead to multi-million dollar workups that don't yield any significant neurologic diagnosis.
• The tests can be so expensive! With the cost of healthcare continually rising, I fear that some of these expensive tests might not be as easily ordered after the healthcare reform takes place.
• I've seen more pain med seekers on this service than I have on any other service.
• There are a lot of frequent readmissions, especially for migraineurs. I wish we had more to offer them to help relieve their pain without expensive hospitalizations.
• There aren't many patients that you can "cure", but there are many patients whose diseases are manageable.

Neurology: Day 17-25

During my days on the Primary Neurology Inpatient service, I had the opportunity to care for this patient (information has been modified to protect patient privacy/confidentiality). She is a 64 year old right-handed female who presented to our emergency department with a complaint of a seizure-like episode. The episode began while she was reading a newspaper; her left hand began to shake, then her left arm, then her left leg, and then spread to all four extremities. During this episode, she was unaware of her surroundings and was unable to respond. This episode lasted for 4-5 minutes, followed by a period of confusion. She then came to our ED. *A seizure of this description can be classified as Complex Partial with Secondary Generalization (if interested in more information regarding seizures, see this blog post.) While at the ED, she noticed weakness of her entire left side, which quickly improved (possibly Todd's Paralysis - a weakness of one side of the body following a seizure).

New onset seizure in a patient can have many different causes. The 4 M's/4 I's: Metabolic, Mass, Missing drugs (alcohol withdrawal), Miscellaneous (Eclampsia, Hypertensive Emergency, Non-epileptic), Infection, Intoxication, Ischemia, or Increased ICP. In her age group, we were initially concerned of a stroke (Ischemia caused). So we ordered a CT and a complete stroke workup, which did not elicit any findings consistent with ischemia as a cause for her seizure. On CT, an area of suspicion was noticed in the right parietal region - what appeared to be edema in an area non-consistent with an arterial distribution. Thus, an MRI was ordered, which revealed a mass in that region. This mass was fairly well demarcated, and a dural tail could be appreciated. This led us to believe that the lesion could be one of two likely etiologies: a metastasis to the dura matter or a meningioma.

The CT-Scan: note the edema (hyperdensity) in the patient's right fronto-parietal region (not localized to an area of arterial distribution):

MRI-DWI (Diffusion-weighted image) - this image is used to investigate the possibility of a recent infarct. It is often used to diagnose a stroke. If a stroke had been present, there would be an area of hyper-intensity that would look bright white, and it would be in the area of an arterial distribution (like the ACA, MCA, or PCA). This MRI-DWI does not show evidence of a stroke:

(If a stroke is present, the MRI-DWI would look something like this:)

The MRI-T1 is used to look for any structural abnormalities.

This patient has hypertensity (on the left image) due to the edema.

On a sagittal section (right image), there is an area of suspician (can you spot it?!)

The MRI-T2 is used to look for areas of hyperintensity.

You can see the edema (left image) and the mass (right image):

The MRI-T2 FLAIR is used to look for regions of hyperintensity which are likely to be pathological.

The MRI-T1 Post-contrast helps to better visualize the pathological lesion. The lesion takes up the gadolinium contrast and enhances the visualization of the lesion.

Note the dural tail (circled in red in the middle image).

This patient subsequently underwent surgical excision of the mass, and pathology has revealed that it is, in fact, a meningioma.If all of the tumor was excised, the likelihood of recurrence is exceedingly low. Good news for this patient! She has done very well post-operatively and is likely to make a full recovery.



Most common primary malignant brain tumor in adults: astrocytoma. Most common primary brain tumor in adults: meningioma.