Insights for those going into the medical career

I was talking to a colleague today about his path into medicine which I thought was really smart. His parents, aunts and uncles were physicians and had recommended that he travel and enjoy what life had to offer before he started on his medical path. Specifically, they advised him to extend his college years and use the "study abroad" option of college to spend extended time abroad for these reasons:

1. study abroad keeps your status as a student, so you don't go into a loan repayment program
2. when you use the study abroad option in Europe, apparently tuition is very low ($2000-4000) and thus, you are able to live comfortably while discovering / exploring the country
3. since you are registered as a visiting student, you get benefits from a student visa that you would not otherwise get as a visitor
4. you could stay for an extended period.

What he ended up doing was spending 4 years abroad (2 years in France and 2 years in Germany). He also happened to meet his future wife during this time. He returned to US having mastered two languages to complete his bachelor's degree. Then, he went onto get his masters degree and complete his premedical prerequisites for medical school.  What great guidance he got! He was able to enjoy life and relax before embarking on a long medical path. In addition, he is probably a lot more worldly and mature. These traits are critical in the medical field because you work with ancillary staff, patients, etc. In retrospect, I think this is such a great alternative to the direct paths that most of us take. I think we forfeit our opportunities to go on these adventures when we just keep drudging along and looking forward to finishing training. The reality is that the hard part of life probably starts when we complete training.

Image guided Ablation

I listened to a great lecture by Dr David SK Lu on the primers of image guided ablation for tumors and it's so inspirational. Having been a former surgical resident, I know how morbid open surgical resection can be. I think the beauty of image guided ablation are as follows:

1. Allow non-surgical candidates an option for treatment: many patients are not operable because of disease burden, location or prior resection with local tumor progression. Image guided therapies can potentially help these patients.
2. Image guided therapies are less morbid. Most procedures are done on an outpatient basis. Therefore, patients usually have better quality of life and shorter hospital stay.
3. Additional procedures can be done. If patients develop more disease (for example, in the case of liver cancer), image guided therapies can be repeated without added complications. During my surgical residency days, we dreaded operating on patients who had prior surgeries because there was so much adhesion and scars. So, the surgical planes were obscured. This is not an issue with image guided ablations because it is performed subcutaneously. Many patients who have genetic predisposition of multiple cancers (liver cancer in the setting of hepatitis induced cirrhosis, or renal cell carcinoma in the setting of Von Hippel Lindau disease). 
4. Ablations can be adjunct to systematic therapies (chemotherapies). Though the results are preliminary, combination ablation with chemotherapy show better results over chemo therapies alone for metastatic breast, ovarian, neuroendocrine cancers, etc.

Important variables considered for proper patient selection include:

1. Size: the ability to ablate depends on the size and number of the tumors. 
2. Location: most lesions can be treated. Sub-capsular lesions are more challenging but with appropriate technique, the lesion can be adequately treated.
3. Access: most procedures are done subcutaneously, at UCLA. Some institutions use open or laproscopic approach as well. 
4. Visibility: the lesion should be available by ultrasound, CT (or less commonly MRI).
5. Extra maneuvers: hydro-infusion, curved needle, combined with chemo-embolization, concurrent ethanol injection, adjuvant systemic therapies.

Types of ablation therapies:

1. Radiofrequency ablation: this is the mainstay and the original ablation modality. This was first described by Dr John McGahan at UC Davis in the 1990 and in 2000s, became the main ablation approach. Though there are different probes, RFA is limited to tumors that are smaller in size, usually <3 cm. At UCLA, RFA is the preferred method for treatment for renal and most liver lesions. RFA of renal lesions have shown to have effective intermediate to long term outcomes for renal cell carcinoma. RFA is also an option for cystic renal cell carcinoma.
2. Microwave ablation: this is the new kid on the block and was described by Dr Fred Lee at University of Wisconsin.  It allows treatment of tumors are are larger, > 3 cm.  This is becoming the preferred method due to its size coverage and ease of use. 
3. Cryoablation: this uses cold to treat lesions. The border of the ablation can be seen well on image guidance. However, there is an increased risk of bleeding for certain organs such as renal ablations. Some internationalists prefer cryoablation for superficial treatment, like breast lesions or metastatic bone lesions. At UCLA, Dr Scott Genshaft prefers and uses image guided cryoblation for metastatic bone tumors for pain palliation. 
4. Focused Ultrasound Surgery: unlike the other thermoablations, this approach is completely non-invasive. Individual elements of the transducers (up to 2000) are activated and focused on the region of the interest. So, the soundwaves pass through the skin like a normal ultrasound wave. However, at the focal point, the termperature reachs >90 Celcius and burns the tissue. FUS is available for osseous metastasis for pain palliation, symptomatic fibroid treatment and essential tremor. It's under investigation for prostate cancer. 

Image guided ablations do not replace surgery, but can be an adjunct to current therapies and improve quality of life and oncologic outcomes. 

Make It Stick: The Science of Successful Learning

This is such a great audiobook. I was browsing through different resources to help me study for my boards. I've been in the learning business for so long, I thought I knew how to study, but I didn't. 

The take home messages from this audio-book were:

1. Interleave : I use to study by subjects. But Brown argues that we should interleave subjects and it helps with retention better. So, now rather than studying MSK for one week, I study MSK for a few hours and go onto the next subject. Although this process doesn't give us the satisfaction of having mastered a subject, Brown shows evidence that interleaving is more effective at retaining materials, than to study a subject at a time. (I practice interleaving with tennis also; before I would only work on backhand or forehand. But, now I mixed up the shots because Brown shows that each of the individual strokes improves when we practice mastering a dynamic range, rather than a narrow field). 

2. Active Recall: I would read through contents and feel like I've done my duty to review the materials. But, Brown promotes actively recalling materials to improve retention. The most obvious way to do this is flashcards and multiple choice questions. What I've done now is to practice recalling differential diagnoses when I have a few minutes to spare while walking, eating, etc. This is a great way to keep distracting thoughts out of my mind too. :)

3. Mental models: Brown advised using mental models to learn materials matter. This is hard to do because you have to go the extra steps of synthesizing the materials and relating key information to other similar but different topics. I find that doing this helps a lot because you draw from other areas and that is more relevant information to help with recall. 

4. Acronyms and more: I wasn't a big fan of acronyms before but I am now. You have to memorize a lot of materials in radiology and you got to do what it takes. When I started putting everything into acronyms, I recall the materials better. This is how one of my colleagues remembers the deep veins in the arm (cephalic and basilic)...Basilic vein starts with B and it's closer to your boobs. I heard this 10 years ago and I still use it to this day. Apparently, the dirtier and more raunchy your memory trick, the easier it is to remember according to Joshua Foer (his book Moonwalking with Einstein is another must read) for life long learners). 

Overall, I love this book and highly recommend it anyone who has to seriously learn and memorize a whole lot.  I got an audio-book version (Audible from Amazon). 

3 Keys for Mastering an Unbalanced Life -- by Kristy Campbell

I came across this post from Maria Shriver website written by Kristy Campbell about work-life balance, which most (if not all) of us will encounter as some (many) points in our lives and it was very enlightening in terms of how to change our perspective of Work-Life balance. Kristy Campbell's approach is more realistic and attainable compared to the unrealistic expectations we often set for ourselves. The crux of her message is as follow:

There are a few keys learnings, but I start each day with the goal of doing the best I can. I stopped chasing perfection, and I give myself the permission to fall because I know I can get up again. I’ve learned that the answer in seeking work life/balance is not in mastering balance, it is in mastering the unbalance.

Three Keys to Mastering the Unbalanced Life

1. Give Whatever is in Front of You Your All and Move On

Unbalanced doesn’t mean you slack off. It means you look at what is in front of you and you give it your best effort and focus. And then, move on.

2. Forgive Yourself: Balance requires perfection. Unbalance requires forgiveness.

Everyone can fall off the balance beam or out of the yoga pose. It’s easy to do. The success is in the getting up…in the not being afraid to fall because you know you can get up again. Find strength in your ability to adapt and recover and forgive yourself for falling. Remember falling is not failing.

3. Measure Your Balance in Years, Not Weeks or Months

Be patient. You can have it all, just not at the same time in the same moment. Give yourself the gift of time to measure your success.