Career advice in the face of a new diagnosis

[SuperflyMD]

So, yesterday I got diagnosed with IgA Nephropathy. If you can't remember the details from pathology (I didn't), it's the autoimmune disorder also known as Berger's.

The diagnosis was based on a renal biopsy. I chose to go without sedation, so I can tell you that the procedure wasn't that bad. Unfortunately, the next two days felt like someone moved my testicles to just underneath my ribscage, then used a nailgun to make sure they would stay in place while they were kicked repeatedly.

In regards to the disease, I can look forward to hematuria and proteinuria associated with every URI or gastroenteritis I ever get. With each of these episodes I will have to take 6 weeks to 3 months of steroids in an attempt to reduce the scarring and permenant renal damage from IgA deposition that leads to ESRD/dialysis/transplant listing in up to 40% of patients. At the ripe age of 31 I'll be placed on lisinopril to reduce proteinuria and control hypertension that also results from renal scarring/decreased GFR. Lipitor will keep my cholesterol under control, as this may have some protective effect. It also gives me a chance to damage my liver as well, since my other waste elimination system was feeling left out.

Background: I am finishing up my first year of EM residency. EM is what I've wanted to do for the last 10 years--since well before medical school. Recently (before this diagnosis) I have been thinking about a critical care fellowship, cause I really dig that too--all of your patients are really sick, the drunks are already intubated, and I just like the environment.

Concerns:

1. I have never been sick as often or as bad as I have in the last year. If every URI/gastroenteritis is moving me one step closer to dialysis, is the ER really the best place for me to be? Some have told me (again, before this diagnosis) that they essentially stopped getting sick after their intern year, but can I trust this anecdotal info?

2. Even if I stop catching every URI that walks in the door, what about being on steroids while being exposed to every bizzare, virulent bug that walks in the door? What about the serious infections that occur in immunocompromised states? Again, seems like the ED may not be the ideal environment.

3. If I decide to do something else, what specialty do I move to? IM/FP would be no improvement (and I've never been interested). Radiology certainly has the least contact with sick people, but how difficult is it to transfer into? Anesthesia would be another option with the same question. Also PM&R seems like a good lifestyle, probably easy to find a spot (speculation), but would I be bored out of my skull (again, speculation based on ignorance)?

I know this sounds like a big pity-party, and I am kind of overwhelmed, but I'm serious about these questions, so I'd appreciate any advice or suggestions.

SF

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[GrandMasterB]

Hey Superfly, sorry to hear about your dx. i dont think your post sounds like a pity party ar all. rather, i think you seem to be dealing with a difficult situation with bravery and wit.

anyways, if u will have such a severe rxn to every uri etc, which i never knew was the deal with bergers, then perhaps rads/interventional (assuming you have a penchant for procedures since you are in the ed) is the choice for you. since you got into an er program i would suspect you are reasonably competetive for rads- and you have a great story and reason to jump ship. rads has tons of spots, and is quite competetive, but there are lots of community hospitals out there that you might be able to approach.

i dont think you would havea prob switching to GAS. a lot of ppl that switch residencies find their way into GAS (and if i am not mistaken- ER too).

i wouldnt risk staying in the ER *if the URI response is as you say* if your life/health is at risk. however, consider how you are going to deal with illness in general- how comfortable are you with the normal daily risk of getting sick? perhaps once you figure that piece out- you might have an easier decision about er too.

i wish you great luck, and a long relapse free life.

So, yesterday I got diagnosed with IgA Nephropathy. If you can't remember the details from pathology (I didn't), it's the autoimmune disorder also known as Berger's.

The diagnosis was based on a renal biopsy. I chose to go without sedation, so I can tell you that the procedure wasn't that bad. Unfortunately, the next two days felt like someone moved my testicles to just underneath my ribscage, then used a nailgun to make sure they would stay in place while they were kicked repeatedly.

In regards to the disease, I can look forward to hematuria and proteinuria associated with every URI or gastroenteritis I ever get. With each of these episodes I will have to take 6 weeks to 3 months of steroids in an attempt to reduce the scarring and permenant renal damage from IgA deposition that leads to ESRD/dialysis/transplant listing in up to 40% of patients. At the ripe age of 31 I'll be placed on lisinopril to reduce proteinuria and control hypertension that also results from renal scarring/decreased GFR. Lipitor will keep my cholesterol under control, as this may have some protective effect. It also gives me a chance to damage my liver as well, since my other waste elimination system was feeling left out.

Background: I am finishing up my first year of EM residency. EM is what I've wanted to do for the last 10 years--since well before medical school. Recently (before this diagnosis) I have been thinking about a critical care fellowship, cause I really dig that too--all of your patients are really sick, the drunks are already intubated, and I just like the environment.

Concerns:

1. I have never been sick as often or as bad as I have in the last year. If every URI/gastroenteritis is moving me one step closer to dialysis, is the ER really the best place for me to be? Some have told me (again, before this diagnosis) that they essentially stopped getting sick after their intern year, but can I trust this anecdotal info?

2. Even if I stop catching every URI that walks in the door, what about being on steroids while being exposed to every bizzare, virulent bug that walks in the door? What about the serious infections that occur in immunocompromised states? Again, seems like the ED may not be the ideal environment.

3. If I decide to do something else, what specialty do I move to? IM/FP would be no improvement (and I've never been interested). Radiology certainly has the least contact with sick people, but how difficult is it to transfer into? Anesthesia would be another option with the same question. Also PM&R seems like a good lifestyle, probably easy to find a spot (speculation), but would I be bored out of my skull (again, speculation based on ignorance)?

I know this sounds like a big pity-party, and I am kind of overwhelmed, but I'm serious about these questions, so I'd appreciate any advice or suggestions.

SF

 

[Sessamoid]

In your shoes with the situation you've described, I'd choose another specialty. I've been out of residency for a few years now and I still spend a fair number of weeks (months) out of the year with URIs and sinus infections. I'd definitely opt for a specialty with less patient contact and even less contact with other health care workers. It sounds boring, but if it's going to speed you to ESRD then maybe boring isn't all that bad after all.

 

[kungfufishing]

I cant imagine what it must be like to be in your shoes. I dont think any job, no matter how much you love it, is worth extra kidney damage. I wonder if other specialties are really significantly less likely to expose you to bugs or if we just perceive it that way?

 

[NinerNiner999]

Hang in there - when life hands you lemons, throw them in someone's face I say... Pathology is a great lifestyle, no "patient" contact, and pays pretty well... Good luck and sorry to hear about your turn for the worse.

 

[SuperflyMD]

I wonder if other specialties are really significantly less likely to expose you to bugs or if we just percieve it that way?

My question exactly. Am I (potentially) giving up what I've always felt was the specialty for me, for what may only be a slight, or even theoretical exposure reduction.

The other option I've thought about was one that I was tooling around with previously, push through the next two years, then try to get a critical care fellowship. Sure, there are some nasty bugs in the ICU as well, but probably not the constant onslaught of new bugs. Also, if my idiot's understanding of IgA nephropathy is correct, the URIs and gastroenteritides (is that a word?) are the real concern. Mucosal infections trigger the increased IgA immune complexes which are the cause of the damage and scarring. My gut feeling is that there would be less of this type exposure in the unit, but I could be wrong.

The other two front runners, Rads and Gas, still make sense too. Rads because of the decreased patient (and human) contact. Gas because, like the unit, URI and gastroenteritis don't tend to be what you are seeing the patients for, patients are typically breathing on a closed system, the environment is constantly sanitized.

I just don't know.

I am in the ED for most of the next several months, during which I will be on 60mg of prednisone daily. I suppose I can call this my trial by fire. Also, I have an elective coming up in August. I was going to try to do a Rural ED month in Colorado, but maybe radiology or another month of anesthesia would be better in light of recent occurrences.



BTW: Thanks for all of the quick responses. This is a trying time for me, especially with my wife and daughter out of town, and I appreciate your support and ideas.

 

[docB]

I’d say gas or critical care would be good alternatives. Something else to consider is the benefit package offered by your future employer. You should not consider signing on with any group that doesn’t offer a very full GROUP benefits package. You will never again be able to get any insurance on your own. That includes life, health and disability. If you can get into a group plan they may not exclude your pre-existing condition and you could be covered. Good luck.

 

[WilcoWorld]

I don't have any advice to offer that hasn't already been offered. I just wanted to say that I think your situation would seem incredibly reasonable to a potential PD, and that I think you are handling this with admirable maturity.

 

[ERMudPhud]

I don't know that I get anymore URI and GI infections now then I used to. In fact I think I get sick pretty infrequently these days. I had a horrible episode of influenza a few years ago but I think I caught it while on vacation. Other than that I've had very few illnesses the last few years so I'm not sure you will get sick that much more frequently working in the ED.

As for steroid use while working in the ED I'm sure you aren't the only one on frequent steroids who does what we do. Roja mentioned having some sort of rheum condition so you might ask her.

I would ask your nephrologist what they think of various career choices

DocB is right that whatever you do you are going to want to work for a large group or institution where you can get good benefits without regard to pre-existing health. If you were fortunate enough to buy your own disabillity or life policies before your diagnosis you may be able to increase your coverage without any health screening. My own disabillity policy offers that option once a year and the increase is limited only by your current income

 

[margaritaboy]

A close family member of mine has IgA nephropathy and recently received a transplant, so I know it is a bum diagnosis. Sorry to hear about the biopsy results.

To offer an opinion that differs from some of the ones above, I'd say do exactly what you want with your life and career. Although a bum diagnosis, it certainly isn't the worst and any limitations you have on your career/private life will be self-imposed.

You can live a long time before renal function becomes and issue, and I'm not so sure that avoiding the ER will necessarily buy you any more time nor do you kidneys any favors in the long run. You can ask the nephrologist, but I'm far from certain they would offer you a difinitive answer.

I do agree that health & disability insurance are issues to consider with future employment etc.

 

[ThinkFast007]

A close family member of mine has IgA nephropathy and recently received a transplant, so I know it is a bum diagnosis. Sorry to hear about the biopsy results.

To offer an opinion that differs from some of the ones above, I'd say do exactly what you want with your life and career. Although a bum diagnosis, it certainly isn't the worst and any limitations you have on your career/private life will be self-imposed.

You can live a long time before renal function becomes and issue, and I'm not so sure that avoiding the ER will necessarily buy you any more time nor do you kidneys any favors in the long run. You can ask the nephrologist, but I'm far from certain they would offer you a difinitive answer.

I do agree that health & disability insurance are issues to consider with future employment etc.

hey...

sorry to hear about ur situation, i hate it when MDs who try doing their best with others get sick..

but as margaritaboy was saying about his family member, what about at a kidney transplnt.

ya we all know tthat there are waiting lists long as the distance b/w NY to freakin anchorage, alaska....... but, perhaps talking to the transplant surgeon at ur institution, he/she mgiht be able to make something happen. i'm know sure if a kidney transplant would do the trick (i too forgot the pathophys behind IgA neph), but perhaps it will.

good luck

 

[margaritaboy]

hey...

sorry to hear about ur situation, i hate it when MDs who try doing their best with others get sick..

but as margaritaboy was saying about his family member, what about at a kidney transplnt.

ya we all know tthat there are waiting lists long as the distance b/w NY to freakin anchorage, alaska....... but, perhaps talking to the transplant surgeon at ur institution, he/she mgiht be able to make something happen. i'm know sure if a kidney transplant would do the trick (i too forgot the pathophys behind IgA neph), but perhaps it will.

good luck

Whoooa, easy there tiger. I wasn't suggesting outright transplant. That is something reserved for advanced disease states ie. ESRD. People with IgA nephropathy usually live a long time with completly normal lives before hitting that point and having to consider transplantation. There are no overt signs that indicate to friends or coworkers that these people are any different than we are.

I was trying to communicate as much in my previous post, and trying to suggest that alteration of a career may not be warrented, especially if he/she is really happy in that field. Just my opinion though.

 

[SuperflyMD]

Whoooa, easy there tiger. I wasn't suggesting outright transplant. That is something reserved for advanced disease states ie. ESRD. People with IgA nephropathy usually live a long time with completly normal lives before hitting that point and having to consider transplantation. There are no overt signs that indicate to friends or coworkers that these people are any different than we are.

I was trying to communicate as much in my previous post, and trying to suggest that alteration of a career may not be warrented, especially if he/she is really happy in that field. Just my opinion though.

Also, although transplant provides years of relief from ESRD, it is not curative of IgA nephropathy. It is apparently a systemic problem, rather than one intrinsically of the renal system.

Biopsies of transplanted kidneys show continued mesangial deposits of immune complexes. In fact, one source said that kidney's transplanted FROM patients with IgA nephropathy (not sure how or why this would be allowed) actually show improvement once they are in another system.

 

[SuperflyMD]

I want to thank everyone for your support and suggestions. Please keep them coming.

My plan of action for now is to see how I do in the ED on prednisone for the next few months. If things go well I will continue with my EM residency with the possibility doing a fellowship to get into the ICU, or possibly EMS or Admin.

In the meantime, I'll choose radiology for my upcoming elective, on the off chance that I may need an in-road into another specialty. This seems like the best use of my time since we had a required month of Gas in our first year and since, like most of us, I could always use more skill reading films.

Again, thank you and please continue the conversation. This plan is anything but set in stone.

SF

 

[medlaw06]

My question exactly. Am I (potentially) giving up what I've always felt was the specialty for me, for what may only be a slight, or even theoretical exposure reduction.

BTW: Thanks for all of the quick responses. This is a trying time for me, especially with my wife and daughter out of town, and I appreciate your support and ideas.

Hey Superfly...sorry to hear about your Dx. i wish you the best of luck with everything!! I hope things work out well for you. Can't give you any advice, since I am a lowly 4th year med student. Just wanted to write you to wish you well! I hope I can have a sense of humor like yours if something like that happened to me!

You definitely made my problems sound like chicken s**t!!

I wish you the best of luck in everything/anything you do!!

 

[DrQuinn]

Why not try to work for a pharmaceutical company or something along those lines? You'll still be invovled in the medical field, use your degree, and get paid some good $.

Sorry to hear about your Dx... but you are handling it well! Good luck!
Q

 

[SuperflyMD]

Why not try to work for a pharmaceutical company or something along those lines?
Q

1 word: Ties.


Seriously, I guess I could if I had to, but that would be a last resort--well next-to-last resort after prophylactic renal transplant

S.

 

[la gringa]

hey superfly...

sorry to hear about the bad news - it's the sort of stuff that stresses me out just to think about it. i can only imagine how tough it is to have to re-evaluate your specialty for a medical reason... geez. anyway i'd probably give it some time like you've said... and if you stay away from the kiddos as much as possible that might help too! i worked in a peds hospital before med school and i had 3 uri's in 6 months. never had such trouble as i did then!!!

 

[SuperflyMD]

hey superfly...

sorry to hear about the bad news - it's the sort of stuff that stresses me out just to think about it. i can only imagine how tough it is to have to re-evaluate your specialty for a medical reason... geez. anyway i'd probably give it some time like you've said... and if you stay away from the kiddos as much as possible that might help too! i worked in a peds hospital before med school and i had 3 uri's in 6 months. never had such trouble as i did then!!!

That's not a bad idea. I wonder how my 14 month old daughter will feel about it?

This was actually brought up by my Assistant PD, "Nothing you are exposed to here [ED] will compare with the crap your kid brings home every day."

He's probably right. I love her, but kids are just gross.

S.

 

[southerndoc]

If you want to limit patient contact, have you considered toxicology?

I would continue working in the ED if that's what you want to do. In the end, you will probably have the same number of illnesses if you did or did not practice emergency medicine.

Keep your dream alive! Hang in there. You are not alone -- there are many of us who have diseases that affect our quality of life, or in my case, longevity and continue to work.