Last week

Requisite Mona Lisa
sighting at the Louvre

I spent this past weekend in Paris with the same friends from the weekend before in Amsterdam. What a beautiful city! It was great to see the Eiffel tower during the night. Because it is so tall, you can see it from so many parts of the city; it serves as a great backdrop. While a couple days in Paris is not enough, I'm glad we were able to see the main tourist attractions as well as a few others. I think you could spend a weekend just seeing the Louvre.

Bridge over the Seine river with the Louvre backdrop

A beautiful sight anywhere in the city

This last week went by faster than I thought partly because I knew it was the last week and because I was busy both inside and outside of the hospital. Dr. Basto kindly invited me to his house for dinner. I had a wonderful time meeting his wife and children. His wife cooked an amazing dinner along with several desserts!

Observations from this final week:

Serghei, a medicine intern, and his wife, Olga, hosting me for dinner

-One of our patients has gradually become less tolerant of dialysis and had hypotension with systolics in the 70s. After discussing with nephrology regarding management, it was decided to reduce the frequency of dialysis. We started morphine as well for comfort due to some respiratory difficulty. One of the topics of discussion was what to do if the patient stops breathing. Do we resuscitate? For me, I wanted to know if there was a DNR/DNI order in place. However, it was not so simple with these patients. Discussing the issue was slightly unnerving giving that, as physicians and medical students, we are trained to focus on disease treatment, but now were looking at end-of-life issues. Interestingly, this topic is one that we've had for several of the patients on our floor, some more pressing than others. While we as physicians do need to make tough decisions, these ethical dilemmas can often convey a greater sense of power and responsibility to deal. The one challenge that comes with this is that physicians, as all humans, are unique and influenced by past and current experiences. Thus, each physician, if given such responsibility, might act differently according to his/her belief/experience structure. This coupled with the fact that end-of-life issues are fraught with uncertainty makes this an even more difficult issue. In other words, physicians left alone to decide the fate of patients might do drastically different things for the same patient. If I had an elderly relative I was caring for, would I want a physician who was risk-averse or risk-seeking? One that focuses on palliative care or one that pushes for resuscitation? Here I think it is important to have a structure or governing body help physicians with these difficult choices and one where lawyers can come in handy to navigate power of attorney and legal ramifications of decisions by patients, patients' families, and physicians. Last week I discussed the cost of health care. Here, again, cost is an important player in end-of-life issues. Resource allocation, I've noticed, is constantly on the back of people's minds. Should be push more for this in the US? Educating patients and their families about realistic expectations of resuscitation and care can be very important and seems to me should be an increasing focus back home. Even though it might introduce more policy, guidelines are necessary to help all parties navigate the issue.

Serghei and I on the famous Dom Luiz bridge overlooking Porto below

Dr. Basto and his family hosting me for dinner

Port wine, nata, and other desserts
made by Mrs. Basto!

-The night I went to Dr. Basto's house for dinner, I met him at his private outpatient office. It was a beautiful, modern building with all the latest equipment and subspecialty outpatient care for patients. Dr. Basto also gave me a quick tour of the private hospital. Comparing the two, it is clear that the money is in private enterprise. As we discussed, some private hospitals, such as the one we visited, are now able to do just about anything that public, teaching hospitals can do. For me, this raised the question: what can be done to keep residents at the teaching hospitals after they finish their residency? Currently, many physicians have dual roles: one in private practice and other in a public, teaching hospital. However, there are some shifting to just private practice. In the US, NIH funding, endowments, and established, wide-reaching infrastructure has kept the research and innovation aspect at teaching hospitals. There is some research being done at big private hospitals, but still the guidelines come out of academic institutions. It is interesting to see how much this public-private balance and money influences the work being done. For now, the public teaching hospitals still manage the teaching and research and see complex cases. However, only time will tell about the shift. I wonder what impact this will have on health care costs for the country as well.







-I had the chance to see the stroke unit this week as a friend and colleague of Dr. Basto's helps run it. We got to talking about the "fast-track" system set up at Sao Joao along with other hospitals in the area. Basically, once a stroke comes it, the team is immediately called allowing them to see the patient, review imaging, and come up with a diagnostic plan within the allotted time for thrombolytic administration if needed. The stroke unit at Sao Joao consists of internists and a neurologist. Given the structure of the "fast-track" system, it is clear how it can be replicated at other hospitals and objectively assessed for compliance. This brings up the issue of regulation vs autonomy. As physicians, we train in order to have the knowledge to assess each situation and make a thoughtful decision. However, a "fast-track" system is, in essence, evidence-based regulation regarding stroke management. Physicians do have some autonomy, but it is within the framework and guidelines written. If I had to choose, I would argue for more structure with some sacrifice on autonomy if this can yield better patient care in the long-run. Per Atul Gawande, a checklist might force a surgeon to review items he believes he covered, but it allows for a systematic approach reducing medical error. I think the worry is that physicians will no longer have the freedom to think through patient management and instead simply be following one guideline after another. However, I think there will always be further research and innovation on these guidelines and patients will still need personalized care. The area where a "fast-track" system for stroke or other overarching guidelines can help is in rural parts of a country that might not have as many physicians nor the resources in place. These guidelines allow for systematic improvement in whatever the disease focus.

Porto at night

As I wrap up my blog, I wanted to say I had a wonderful time in Porto and at the hospital learning about the health care system and issues that arise as it undergoes changes. Also, thanks to Dr. Basto for being such a welcoming host!

Gasometria

I had a great weekend in Amsterdam! I met up with a couple Northwestern med students who are doing a radiology rotation in Berlin. Airbnb was clutch once again. The canal boat tour was nice, but I am glad I took the time to see the house where Anne Frank and her family lived in hiding. Powerful stuff. Europeans are quite lucky they can travel to so many countries with different cultures and rich histories in a 2-3 hour plane ride.

Standing on the "Amsterdam" sign

This week I went back to medicine and picked up from where I left off. 4 new medical students started mid-week so it has been nice getting to know them.

Amsterdam waffles with chocolate

Some observations:
-While helping Serghei, the intern, with orders, I noticed that next to each item is a price for the test. Given that the cost of healthcare is an issue in all countries, not just the US, it was interesting to see this approach as a possible way to make residents and faculty aware. I know it is something I've read about as a method to try in the US, but have not seen it implemented. Does it work? When we were putting in orders, the focus, understandably, was on the patient and the right tests to order given her problems. However, on rounds, cost is something that has come up several times. Specifically, does the cost of a certain intervention/procedure/test lead to better outcomes for the patient. While I value the discussion, I wonder if there is a broader set of guidelines given by the hospital or a certain committee. I think listing prices can change a person from ordering a specific lab test if the price differences are egregious. It, more importantly, brings the issue to the limelight. End-of-life care is very expensive no matter the country. An attempt to target this issue via the Affordable Care Act was touted in some media outlets as "death panels." Politics aside, the issue of cost is tied to our views on mortality. Some studies have shown that among doctors, less intervention is preferred regarding end-of-life care while the lay population advocates more for an aggressive approach. Is this difference because we see the futility of certain interventions or procedures while a lay person does not have that perspective? Or does our American cultural views on death and dying see dying as yet another disease with a variety of interventions that require aggressive management? I think it is a mix of both among other things. Interestingly, can cost be so prohibitive a factor as to change a culture psyche regarding an issue as personal as death? In other words, if costs continue to rise and more pressure is placed on less intervention, can we, as an American society, shift our views on death and dying in order to cope with the fact that less intervention is the only approach? Many questions on this topic with no clear right answer. However, I feel it is important to start now given that elderly populations around the world continue to grow.

Amsterdam canals at night

-Many patients on our service are above 80 years old. While I noticed it the first week, it became more apparent to me now. For many, given the underlying conditions and current mental status, there is not much we can do for them long-term. I've seen CHF, stroke, and pneumonia among a few other things, but I wonder are younger patients with acute disease processes are handled by specialist services? I say this because, while on cardiac MR, the cardiologist mentioned a few cases of viral myocarditis recently admitted from the ED. Did the patient go straight to them or did a medicine service create a note and then consult cards? The other possibility is that the time of year is such that the elderly population is disproportionately more affected right now. On one hand, specialist services could have more control over the full course of the patient rather than just as a consult. However, the flipside is that teaching cases are taken away from the medicine service and thus they see a narrow set of pathologies. Some investigation to do on my part.

-On another note, I've gotten much better at ABGs (gasometria) while on service. ABGs and EKGs are done by the residents and many patients need these tests. As with other topics above, there are two sides to the issue. On one hand, residents gain experience and comfort doing procedures that are vital in critical care situations. On the other, the time spent doing these procedures can take away from time spent learning more about a patient or reading about disease management. I know there is a phlebotomy nurse and there might be an EKG tech, both who could do their respective tests.

View along the Duoro river

-Lastly, I wanted to touch on the issue of global health again. Dr. Basto and I had a great talk last Friday about it especially the work done by Hospital Sao Joao in Africa in ex-Portuguese colonies. Clearly, there are many challenges and the work can be deflating if years spent building partnerships and providing clinical teaching go nowhere. Also, if doctors from these countries are brought to Portugal to train, there is a risk of them staying forever since the situation they are coming from is worse. Interesting, Dr. Basto mentioned how charitable donations to governments can easily go into the wrong hands and can sometimes be a crutch that countries have come to anticipate. This got me thinking, can we do more harm through intervention and charitable donation? The earthquake in Haiti  is a great example where people feel this is true. Excessive intervention by NGOs and various donations have not gotten the country far since 2010. In addition, many within the country have gotten accustomed to the financial support of the donations. NGOs can sometimes fail to involve a country's own citizens in creating change leaving a country crippled by various, unaligned changes from differing NGOs. Obviously, global health outreach is a difficult process. From my various experiences, it seems that it really comes down to the context, which defines the intervention and method through which it is hopefully accomplished.




That's a wrap. Only one week left! Time flies. 

Radiologia

Serghei and I along the Duoro riverfront

I spent this past weekend exploring Porto, Lisbon, and Braga. So much fun. Finally made my way down to the riverfront along the Duoro river, a must for anyone traveling to Porto. It was great to have Serghei, a medicine intern who moved to Porto 6 months ago from Moldova, and his wife as company. I went to Lisbon for a day just to get a taste of the city and ended up going to Sintra from Lisbon to see the Pena palace, a beautiful, multi-colored palace that used to serve as a summer home for royalty. Serghei, his wife, another Moldovan friend of his, and I went to Braga on Sunday to see a town recommended to me by some of the medical students. With the weather being sunny all weekend, it was a great way to spend a few days off.

Since I am applying into radiology, Dr. Basto set up this week for me within the department. I had an amazing time not only meeting faculty and seeing the department, but also getting to know the residents. They are so welcoming and took time to teach me each day. I've gotten to see the x-ray, MR, CT, IR, Cardiac MR, and Pediatric units.



Some observations:
-One of the first things I noticed this week was the size of the residency class. Each class has 2 residents, which is much smaller than the average of 10 or so residents for each radiology program in the US. Because of this, ED x-rays are reviewed and reported by ED physicians and inpatient x-rays by internists, pulmonologists, and others. It seems there is more work than can be done by the department so the focus is toward advanced imaging, such as CT and MR. In the US, as we continue to advance imaging modalities, I wonder if we, too, will shift x-ray reporting away from radiology to other branches of medicine. Clearly, with the radiology market being tough, we do not need to increase the number of residency seats. Yet the number of imaging studies continues to increase. A big gripe among radiologists is the increased pressure to read faster. We'll see when the tipping point will be.

Central square in Lisbon. The gate on the left was the entrance
to the city from the port.

-Here, radiologists, and I'm sure other physicians as well, work in both public and private hospitals. The public hospitals are academic and see more complex cases and have all subspecialties to manage these patients. However, per the radiologists, salary is an issue. Thus, they spend some time during the week at private hospitals. Interestingly, the market for private hospitals and private insurance is increasing to meet the needs of citizens who can pay for such services. One of the problems, I believe, is that it can take teaching opportunities away from residents who need attendings to review cases and edit radiology reports. On the other hand, it gives attendings the flexibility to see cases in both environments and tailor their work week. In the US, salary differences between academic and private practice physicians exist, but not enough to force academic physicians to have a private practice job. What is interesting, though, is the increase in research opportunities in the private practice setting. For example, CMC in Charlotte has a new Levine Cancer Institute that runs several clinical trials and is run by an oncologist with an academic background. With the private hospital system growing in Portugal, I wonder if research, primarily translational, will follow suit.

Pena Palace in Sintra

-One thing that radiologists at Sao Joao pride themselves in is their ability to both read and scan ultrasounds. Being able to scan has allowed them to hold onto the modality from other specialties. This is important to point out given the current debate over ED ultrasound and whether ED physicians or radiologists should read the imaging. It is great to see ultrasound being maximized as a modality because it is cost-effective and there is no radiation exposure. During my time in pediatrics, it was exclusively used on a wide variety of complaints. In the US, given the ongoing advances in imaging technologies, we sometimes forget the utility of the most basic modalities. Also, while ultrasonographers are an asset, it is important for radiologists to learn scanning skills since it is a skill that allows for great flexibility.

-Many of the attendings here mentioned how they spent time during their last year of residency to do externships at US institutions, such as UCSD, UCSF, Vancouver, and NYU. They were able to translate skills gained during this time into new procedures within the radiology department at Sao Joao. For example, one attending who gained experience in lung and abdominal biopsies grew that aspect of the department here. And he's only 33 so clearly many years left to teach residents. Another first saw cardiac MR 15 years ago and was trained by a US radiologist. He brought those skills back to Sao Joao and now runs the cardiac MR program in collaboration with the cardiology department. I have an interest in global health outreach. My mindset so far has been to target less developed countries and find ways to provide outreach. While this is important, my experience here has shown me another avenue through which to foster outreach and, more important, global collaboration. In the same way communities have sister cities, is there a way for academic departments to have sister cities in other countries? Through this, a constant radiology residency exchange program can allow for shared growth of knowledge. One of the problems in global health is that you want sites to become self-sufficient. Here is a case of a developed country advancing their own department by their own radiologists with the experiences gained from externships. These radiologists can further radiology practices within their own country in lesser-equipped parts of the country, if possible. Self-sufficiency from the top-down.

Lunch in Braga with new friends. Tried the francesinha; the sauce is so good.

What a great week in radiology. I'm so glad to have met many in the department here.

Ola! Bom Dia!

I arrived in Lisbon Sunday morning, February 1st, via TAP Portugal. The Portuguese seem to take pride in their country colors as the pillows and blankets were a vibrant green and red, respectively. Dr. Basto, being as nice as he is, gave me clear and complete directions for getting to Porto from Lisbon. The train was a very smooth ride and got me to Porto in about 3 hours. Lucky for me, the stop for this inter-city train is Campanha, which is only a couple minutes walk from the hostel, WorldSPRU. I had grand plans for spending the day exploring Porto, but the jet lag got to me and I quickly fell into a long nap. On the positive side, I was wide awake for an amazing Superbowl between the Patriots and Seahawks!

My room at WorldSPRU. As you can see, there's a kitchenette
with a small fridge under the stove.

I was to meet with Dr. Basto on the first day at 8:15. Conveniently, the stop for the Porto metro is literally below the hostel. While the ride is about 25-30 minutes, it is pretty straightforward. Also, Trindade, the stop where I have to switch metro lines, is one that every metro line stops at so I don't have to wait more than 1-2 minutes to catch the metro at Campanha. Hospital Sao Joao is the last stop on the yellow line so its nice to just sit back and watch as the train bobs above and below ground as it makes its way there.

Hospital Sao Joao

Dr. Felix was right. Dr. Basto is a very nice guy who has our best interest at heart. He is clearly passionate about his work and his enthusiasm showed as he gave me a tour of the old wing and new wing of the hospital. I then met Dr. Pestana,, the attending on the team I will be spending my time with at the hospital. Previous UNC students have worked with him as well. As previous student blogs have mentioned, each team consists of an attending, residents, interns, and medical students. Besides Dr. Pestana, ours had 2 residents, an intern, and 2 medical students. Also, as others have mentioned the days usually start at 8 and go until 2 pm. The residents sometimes stay longer to finish notes, orders.




Some observations from the first week:

- Growing up, I wanted have something about me that set me apart from other people. Yes, mostly fit in, but still something unique, you could say. As I get older, it's funny how people are more similar than different. The subtle neurotic nature of doctors, the sass of the nursing staff, the doctor-nurse interactions, the frustration we feel sometimes when we don't think our interventions are doing anything for the patient. The same things I saw and experiences I had as a new 3rd year student on the wards I see here in Portugal, thousands of miles away. I saw the same when I was in India last year. Is it that we emulate this personality be being around others like that? Or is there some invisible thread that binds those with similar personalities to similar professions?

-One thing, though, that is different is the hours. We cap hours at 80/week for residents and put clear instructions for faculty to exercise that for their residents. Talking to the residents here, the numbers are 40-50 hours a week. This got me thinking: are we really improving care in those additional 30 hours? Sometimes I feel it's made up of idle time, that afternoon lull where notes are done, discharges done, no new admissions, and you are waiting for sign out. On the other hand, there is something to be said about continuity; the 10-12 hours you spend monitoring patients, following up on orders makes you more aware of disease processes. That being said, as I write this, I realize I need to learn more about what happens during the evenings, which residents are on service then, and if/whern there is sign out here.

-We pride ourselves in individualism, but there is something to be said about teamwork. Here, the team stays together for most of the day. The discharges are done together by the residents with Dr. Pestana providing edits and medical students listening in. We go to coffee break together in the morning and no one ever grabs lunch on their own. Part of the reason is the limited resources. There is one physicians' work room where there are 4 computers, one for each team, not one for each resident like it is in the US. On rounds, we are judicious in our use of supplemental oxygen. We are cautious about invasive therapy if quality of life cannot be improved. That is why we are hesitant to rush to coronary cath a lady with multiple strokes and limited mental status. Resource allocation is an issue in the US, but to another degree here in Portugal. We could learn something in the US, but I doubt it'll sink in when we know resources are still available around us. I think we often rush to question ourselves if we are doing enough when we should focus on doing what has the highest yield. Obviously, this is something I've talked about before with colleagues at UNC, but it is interesting how it hits you in the face when you see it in action somewhere else.

The view from my room window. That train is the metro I take to get to the hospital.

-I ran into a couple Erasmus students during this first week from Italy doing the equivalent of their 3rd year clerkships in Porto. To clarify, the Erasmus Programme is a European Union student exchange program. To the more important point: Medical students from Italy doing medical clerkships in a different country, let alone different hospital?? For me, doing my entire 3rd year at CMC in Charlotte was a big deal because I wasn't at my home base, UNC. I know students who have done college, medical school, and then residency all in one state. I will point out, though, that for much of the world medical school starts at 18 and goes for 5-6 years. In essence, college and medical school are combined. Maybe this allows more flexibility for the European students. Whereas we study abroad in college, they do it during their joint college/medical school. That being said, these students are doing core medical school clerkships, not electives for a major in college. A big deal with serious logistical issues since it is medical education across countries. That being said, if the EU can do it, why can't we? Should we create a student exchange program for US medical students to do a few core rotations in other states? You know, as a way to explore this large country we live in? And I'm not saying 4th year 'audition' electives, but core 3rd year clerkships. Language, laws, and government would not be an issue. But still, logistically, can we? Looking back, I remember it being sexy to study abroad in a different country. I am guilty of it now. Maybe we can encourage studying abroad in our own country, one that is larger than all of Europe.

-Man, have I done some digressing on these observations or what? I want to end on the influence of the United States. Here, we follow a lot of the guidelines created in the US; CHF, stroke, diabetes, HTN. We use Up-to-Date. All the research I hear being done at UNC or big journal papers coming out in the US have a world impact. Powerful, huh. Of course, there is research being done at European institutions and we reference it as well back in the states, but it seems that a lot of the paths are paved by US medical guidelines. It's interesting that this goes beyond medicine into pop culture. A kid on the metro was blasting Jay-Z on his headphones. The residents and med students one day started talking about their favorite TV shows: Modern Family, Walking Dead, Breaking Bad, How I Met your Mother. There are posters for "50 Shades of Grey" in Portuguese. I saw and heard the same when I was in India and that is country with a strong culture outlet with Bollywood. I heard the same from Mexican students I met during my year in DC who had come to the US for a 6 month internship. I'm not sure what my point is here. Maybe its just that I'm proud. Proud to call America home.

A week of radiology next! More observations await.