Incoming intern with (too many) subspecialty choices

[zatennis]

Hello everyone,

I suppose everyone deserves a congratulations on the match (mauvespice)

I present to my fellow interns, current residents, and GI/oncology fellows this situation -

For the first 6 months of my 4th year of medical school, I was sure that I would do medical oncology/hematology following IM. I greatly enjoyed my outpatient medonc rotation because of the close physician-patient relationship. I felt that in no other field of medicine was the physician as "present" as was the *good* medical oncologist. (Perhaps, palliative care may compete...) Furthermore, many of the patients that oncologists encounter are people that have a great perspective on life; one patient receiving palliative chemotherapy for pancreatic cancer sticks out in my mind as being more at peace than 99% of patients that I have encountered. It is truly a pleasure to care for such patients who are truly "in the moment". This NY times article touches on how cancer changes people: http://well.blogs.nytimes.com/2009/04/07/in-cancer-a-deeper-faith/
I continued 4th year and took on 2 research projects on cancers of the GI tract. My interest in the etiology/pathogenesis and prevention of GI cancers has grown since then.
However, I saw chemotherapy in a different light than previously when I read this Australian article: Morgan G, Ward R, Barton M. The contribution of cytotoxic chemotherapy to 5-year survival in adult malignancies. Clin Oncol 2004;16:549-60.
Despite the author's bias (radiation oncologist) and his questionable research methods (grouping some 20 solid malignancies together), the results are not encouraging - "The overall contribution of curative and adjuvant cytotoxic chemotherapy to 5-year survival in adults was estimated to be 2.3% in Australia and 2.1% in the USA."
In this radio show ( http://www.abc.net.au/rn/talks/8.30/helthrpt/stories/s1348333.htm), a medical oncologist provides his take on the study:
Norman Swan: But I mean a 2% additional survival does not sound impressive.

Michael Boyer: Well it doesn't sound impressive and it's also not correct. It's not correct for a number of reasons. That 2% figure is achieved by including a whole series of diseases in which chemotherapy would never be used. The paper itself actually states that yet they are included as part of the denominator if you like. So if you start taking those things out and saying well OK, how much does chemotherapy add in the people that you might actually use it, the numbers start creeping up. If you pull it altogether that number probably comes up to 5% or 6%, I guess what's important is that it doesn't go up to 50% or 60% but we know that and we know that these treatments are at the margin. I mean we are adding a little bit to survival and that has been the nature of all advances in cancer treatment that you actually add to marginal survival rather than these huge leaps with a couple of exceptions.

That wasn't too encouraging either. Although the rapid pace of chemotherapy development and the applications of genomics into drug development (k-ras mutation in CRC, etc.) should make me excited... actually, oncology's whole focus on treatment after the fact seems like tunnel vision to me. Aren't preventative strategies more cost-effective and don't they deserve a bigger piece of the research pie? And perhaps I deceived myself, believing the new generation of chemotherapy agents ("biologicals") would have less side effects. See the cardiotoxicity associated with tyrosine kinase inhibitors for more discouragement.

With these (perhaps skewed) perceptions, I have been thinking about GI. Encouraged by the preventative approach to GI cancers, BUT!
Several doubts about this field --
1) My perception that there is much less patient time and it is much more procedure-heavy. I have never been much of a surgery/procedure person.

2) Diagnose your cancer and adios.
That sucks
3) Dealing with patients who can hardly communicate with you (cirrhosis and hepatic encephalopathy patients) (and can smell really bad)

To make things more confusing, I did a dermatology rotation abroad in February and thought it was splendid. Of course, this seems like a dream because I have no prior clinical or research experience in dermatology. Even after a 3-year IM residency, I think there would be a slight risk of not securing a derm residency.

Any thoughts about heme/onc vs. GI are very welcome.

addendum:
I spoke with my research mentor in med onc today regarding some of these issues. She said that even with regards to preventative oncology, medonc is a better field in which to do this sort of research and that GI docs are too consumed by procedures to do research.
I think my GI rotation next week will serve me well in figuring this out.

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[Gastrapathy]

She said that even with regards to preventative oncology, medonc is a better field in which to do this sort of research and that GI docs are too consumed by procedures to do research.
I think my GI rotation next week will serve me well in figuring this out.

There is lots of research going on in GI. Thats a purely self-serving statement from a H/O physician. In fact, if you are looking to do prevention research, you're probably better off in GI (recent major trials in adenoma/CRC prevention were GI driven, for example). Screening and surveillance for GI cancers is a GI field (see the work out of Hopkins and UW on pancreas cancer). Google GI research fellowships (vice clinical fellowships). Both groups do enough endoscopy to get credentialed but the research fellows do a lot less elective clinical time.

But...I'm "consumed" by procedures, so take what I said with a grain of salt.

 

[gutonc]

With these (perhaps skewed) perceptions, I have been thinking about GI. Encouraged by the preventative approach to GI cancers, BUT!
Several doubts about this field --
1) My perception that there is much less patient time and it is much more procedure-heavy. I have never been much of a surgery/procedure person.

If you don't like procedures, you probably shouldn't go into a procedural field.

2) Diagnose your cancer and adios.
That sucks

Let me tell you though...as an oncologist with a research/clinical focus on GI oncology, sometimes that would be nice. The nice ones seem to die right away...the bastards live forever.

3) Dealing with patients who can hardly communicate with you (cirrhosis and hepatic encephalopathy patients) (and can smell really bad)

Just work in an academic setting and make all the house staff deal with it. I did my residency at a program that included one of 3 VA liver transplant centers in the US. I have taken care of more than my share of ESLD patients (pre, post and non-transplant) and the GI notes on these guys are all the same..."continue lactulose, titrate for 3-4BM/day. Await donor organ."

In all seriousness, if I was more procedurally oriented, I probably would have done GI. But I can hardly be bothered to do a bone marrow biopsy (done in 15 minutes) so that didn't seem like the right plan for me.

Do a GI rotation now, and again as an intern and see what you think. It will be a harder fellowship to get than H/O but not impossible.

 

[tacrum43]

I have taken care of more than my share of ESLD patients (pre, post and non-transplant) and the GI notes on these guys are all the same..."continue lactulose, titrate for 3-4BM/day. Await donor organ."

Not related to the original topic, but why is lactulose the first line choice for hepatic encephalopathy? Why is rifaximin not used more? Same effect on ammonia levels, and no diarrhea. The diarrhea is really not pleasant for patient or nursing to deal with (even with a rectal tube). I suppose it does cost more though.

 

[zatennis]

Not related to the original topic, but why is lactulose the first line choice for hepatic encephalopathy? Why is rifaximin not used more? Same effect on ammonia levels, and no diarrhea. The diarrhea is really not pleasant for patient or nursing to deal with (even with a rectal tube). I suppose it does cost more though.

I saw this NEJM article just yesterday (N Engl J Med. 2010 Mar 25;362(12):1071-81.). It could influence guidelines in the future:

[FONT=arial, helvetica]A breakthrough episode of hepatic encephalopathy occurred in 22.1% of patients in the rifaximin group, as compared with 45.9% of patients in the placebo group.. (90% of patients in both groups received lactulose)

Compare this with a prior study of lactulose vs. placebo:
During a median study period of 14 months, the proportion of patients with episodes was smaller in the lactulose group than in the placebo group (19.6% vs. 46.8%, P=0.001)

As to why rifaximin isn't more routinely used, I defer to the review article in the same NEJM issue :
"Despite the widespread, long-standing clinical
impression that such therapy is effective, a critical
appraisal of relevant trials published from
1969 to March 2003 concluded that the results
of those studies did not meet current standards
of evidence-based medicine."

 

[Gastrapathy]

Not related to the original topic, but why is lactulose the first line choice for hepatic encephalopathy? Why is rifaximin not used more? Same effect on ammonia levels, and no diarrhea. The diarrhea is really not pleasant for patient or nursing to deal with (even with a rectal tube). I suppose it does cost more though.

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