A Differentiation Diagnosis — Specialization and the Medical Student

If you walk through my medical school building in the evening and follow the aroma of pizza, you'll probably find your way to a dinner talk organized by a student specialty interest group. Running the gamut from surgery to psychiatry, these groups are made up of first- and second-year medical students, many of whom joined just weeks after they first donned their white coats.


Living Will

And the years fall
And the heart turns,
Releasing what it holds.
And seasons flicker,
And cities fade
As memory looks aside.
Desires, they rise
Like hope, like boats,
And the boats, they
Rock in place,
And no one knows
How the floating
Wears them down.
As darkness grows,
The heart calls out
In search of
What is lost.
Past the turn
Where quiet yawns,
It will sing
For all that comes
To break the fall
Of years.

now@NEJM | selected posts

Understanding the Broken Heart

In 1897, recently released from prison, the author Oscar Wilde wrote to a close friend, “My desire to live is as intense as ever, and though my heart is broken, hearts are made to be broken: that is why God sends sorrow into the world. The hard heart is the evil thing of life and of art.” Heartbreak, Wilde seemed to imply, wasn’t just an inevitability of life; it was an affirmation of it.

The Good Word: Improving Patient Handoffs

Starting at six in the evening, the surgery residents at my hospital gather for sign-out.  This is when residents from the day shift hand over care of their patients to those working overnight.  Sign-out takes place in the residents’ lounge — a room furnished with computers, couches, and a makeshift ping-pong table — and tends to be an informal affair.  Multiple conversations happen at once, and interruptions are not uncommon, whether by phone call or passerby or stray ping-pong ball.

Got Skills? In Surgery, It Matters

In the science fiction film “Prometheus,” set in the year 2093, surgery is depicted as a purely automated process. A woman climbs into a capsule-shaped machine; with the touch of a few buttons, the machine sets to work preparing a sterile field, making an incision, extracting a specimen, and stapling her back up. No surgeon is required.

In today’s world, we still very much rely on surgeons. We expect them to be competent and to deliver the best outcomes possible. But surgeons aren’t machines; no two are exactly alike in experience or skill level. Does this variation matter?


resident 360

A New Way to Desensitize Patients for Kidney Transplant -- Use a Bacterial Enzyme

On a recent season of the fictional television series House of Cards, the President of the United States needs an organ transplant. His chief of staff tampers with the waitlist and moves the President to the top of the list, saving him at the cost of another man’s life.

This sort of scenario plays to what most people understand implicitly to be true: When it comes to organ transplants, the demand is high for a limited supply. In kidney transplants, the supply-demand mismatch continues to grow; today, over 100,000 patients are on the deceased donor waitlist. But availability is just the surface of the problem. Nearly one third of patients on the waitlist carry antibodies against HLA or other antigens, due to pregnancy, blood transfusions, or other prior exposures. Therefore, their immune systems are likely to attack and reject any transplanted organ. Therapies to reduce this antibody count, or “desensitize” patients, have helped to mitigate the problem, but often incompletely remove donor-specific antibodies and can result in rebound antibody production. Such treatments are also expensive and can be cumbersome.


Intravenous Fluid Therapy in Major Abdominal Surgery - Less May Not Be More

Intravenous fluid therapy in major abdominal surgery is a classic Goldilocks dilemma: Too little fluid can result in low blood pressure and consequent organ damage, but too much fluid can cause tissue edema, potentially delaying recovery of bowel function and precipitating cardiopulmonary complications. What is the right balance?