On Traveling, Surgery Residency, and the Intensity of Experience

In his recent book "Thinking, Fast and Slow", Daniel Kahneman expands upon an interesting concept. He describes two ways that human beings perceive reality: the experience of the present and the remembrance of the past. He calls them our "experiencing selves" and "remembering selves" and shows that they often fail to come to a consensus, as illustrated by a beautiful experiment with absurd results:

Participants are subjected to two forms of torture. In one form, the participant's hand is immersed in painfully cold water for 60 seconds. In the other, the hand is immersed in the same painfully cold water also for 60 seconds, at which point the water is warmed 1 degree Celsius and the participant must now endure 30 more seconds of slightly less painfully cold water, for a total of 90 seconds.

If I was going through this torture, at the end of 60 seconds I would obviously prefer to just take my hand out of the water instead of endure another 30 seconds of still very cold water! And most people, if given that option at the time, would do the same. Remarkably, if the participants are later asked which form of torture they prefer, they actually choose the 60 + 30 instead of just the 60. They are voluntarily willing to subject themselves needlessly to an additional 30 seconds of pain!

Why does this happen? Kahneman explains that while the duration and aggregate of an experience might matter to our experiencing selves, those details are easily glossed over by our remembering selves. In fact, our remembering selves focus disproportionately on the beginning, end, lows, and highs of an experience. Another question is posed by Kahneman: would you bother to go somewhere on a vacation if you would have complete amnesia of the entire trip? I'm not sure I would. At that point, relaxation is the only thing that matters (and maybe sun exposure). I might opt for Florida instead of the Bahamas or somewhere more exotic, if I was going to go anywhere at all.

The conflict between our experiencing and remembering selves was an interesting subject for me to read, because it neatly explains a paradoxical trend I had noticed: I remember some situations as being better than I know they actually were at the time (if I am thinking of the sum of the entire experience in aggregate). For example, one of my favorite semesters as an undergraduate was the spring of my junior year, but I also know with certainty that I was insanely busy, studied harder than I ever had, and went out very infrequently. I remember my social life being significantly better than average that semester, which I know empirically is not actually true (I even went to bed early on my 21st birthday because I had a physics test the next week, to the chagrin of my roommates at the time).

In light of Kahneman's book, it makes perfect sense. I didn't go out as frequently, but when I did, it was a much more intense experience. Going out after two weeks studying is just a different feeling than going out for the fourth night in a row. In fact, I remember having significantly MORE fun in medical school than I did in undergrad. Frequency matters less than intensity of experience.

I've noticed this paradox about traveling as well. Traveling is by definition not a relaxing experience (that would be vacationing). Right before medical school I went on a 6 week trip through Europe with some friends. It was a mad rush, to fit in as much as possible, stopping at places sometimes for only 1-2 days before moving on. The trip was exhausting, I remember thinking on more than one occasion. Yet, my remembering self recalls more easily the positive experiences - which were many, and noteworthy, and easily forgets the baseline exhaustion of the grind of intense traveling. This phenomenon can be explained graphically, with the spikes representing the intensity of experiences while the baseline is the quality of life day-to-day. When traveling, there is an obvious sacrifice of short term conveniences, habits, and luxuries for the opportunity to have heightened experiences:

I chose to go into surgery, which as a career has a reputation of being brutal. The long hours and the daily grind mean that I know my experiencing (present) self is, while maybe not completely miserable, certainly wishing I had chosen a more relaxing life. There is a conflict, because when my remembering self recalls the last six months, it think it has been one of the best times of my life. My experiencing self thinks surgery residency is tough and often painful, but my remembering self thinks its great and not so bad. I remember the interesting surgical cases, complex patients, and funny stories - not the long hours.

Like is the case when traveling, I've sacrificed my experiencing self for the sake of the remembering self, in this instance the sacrifice being ample sleep, free time, etc. I am compensated by doing really neat things on occasion. Finally, recall the anecdote from my junior year in undergrad: in residency, when I do get time off, its much more high impact. The fact that I only get every other weekend off on average is more than compensated by the fact that each weekend has 2-3 times the impact that they used to.

I suppose this is something to think about, whether traveling or choosing a career path. Perhaps the difference maker for me is that I am too willing to make decisions based on the preferences of my remembering self. Still, for a person choosing whether or not go to into medical school, or whether or not to go into surgery, "long hours" is something I am glad I never put too much weight on (because hours are essentially forgotten by the remembering self). Like a person who subject themselves to 30 seconds of needless pain in Kahneman's torture experiment, I would choose surgery residency all over again, even if my experiencing self would prefer a more laid back profession. Absurd results, indeed.

on PSA screening

The US Preventive Service Task Force (USPSTF) recently recommended that primary care physicians not screen men for prostate cancer. The question I have is, why were primary care physicians ever screening for prostate cancer with PSA levels in the first place if it hasn't been proven to be effective at reducing mortality?

And what of the contentious debate? I don't think anybody is saying don't screen for prostate cancer. There is an appropriate context in which to do it: a randomized, controlled clinical trial. Outside of research, it is ethically and economically* inappropriate to advocate for treatments that have no proven benefit. Am I missing something?

*I suspect that economics will increasingly play a major role in our clinical decision making. We might as well embrace it now and do the leg work early. We need to stop doing things that don't help so there is money to keep doing the things that do help. Physicians have the ability to trim the excess fat from our health care system with a scalpel. If we wait for the government to do it for us, its going to be with a guillotine.

What's wrong with this picture?

This patient has situs inversus. It is a mistake in embryogenesis where the major organs in the body end up in a mirror-image position from where they should be.

On medical images, the right is on the left and the left is on the right. So what you see in this chest x-ray is a heart that extends to the patient's right side. It is normally the opposite, of course.

Why I love oncology

This applies to medicine as a whole, but in particular to oncology.  A lot of people "question my sanity" when I tell them that I want to be in a field like oncology.  "Wouldn't it be depressing to be treating cancer patients all of the time, especially when ones that you become close with ultimately have unsuccessful treatments?"

It is all about how one looks at things.  For starters, maybe cancer as a disease is a depressing thing but oncology as a specialty is amazing.  Before 1950 or so, all cancers had the same prognosis:  zero, give or take a few hundredths of a percent.  Now, we save people all of the time.  Colon cancer can be resected and cured with surgery and chemo.  Testicular cancer has a 95% survival rate when only a few decades ago it was 5%.  Many pediatric leukemias we can treat with some efficacy.  For cancers we can't cure, we can certainly make the remaining life better.  In oncology, is it isn't about who you lose - its about who you don't.  Those are the cases where, after, you can look Mother Nature in the eyes and say "we beat you."

The other thing about oncology, although this applies to other fields as well (for example, transplant surgery, which I am on right now), is the effect it has on me as a person.  Its so easy to go home at night and be tired and think, "I want to do nothing", or "I am too tired to go on a run."  Then you remember the stage IV cancer patient who is bed-ridden and beyond cure, without long to live.  Or you might remember the young guy who is stuck in the ICU.  He already had a liver transplant once to save his life, but his immune system has systematically destroyed it despite our best efforts.  Each day we see the new numbers, each day more abnormal, as the liver functions less and less. 

Remember those things and all of the sudden, you have the energy to go for a run or to go out and socialize - because you can.  Because you are so aware that someday, you won't be able to.  Think forward - many of us will be in that very position some day.  What would we give for the chance to come back and be 28 and be healthy enough to do those things?  If that time comes for me, I will smile when it does, because I will know I did.  With the right perspective, oncology is an incredibly uplifting discipline.

First Teachers, then Physicians?

If you view our governmental system as nothing more than a long protracted partisan war, I think the actions of Republicans make a lot of sense. Budgets need to be balanced, so why not make your political enemies foot the bill while letting allies off the hook? Teachers traditionally vote Democratic and their unions are a huge boon to Dem politics, so the GOP has come after them. I worry about this sort of 'trade warfare' as an American and as a future physician. I could be wrong, but my suspicion is that physicians as a group generally vote Republican. What if some hypothetical future extreme Democratic Party comes to power, looks at explosive health costs and deficits, notices that physicians support Republicans, and decide to punish us for it? They could simply block the medicare doc fix, or worse.

I resent the idea that one group should be faced with a disproportionate share of a social burden because they are on the losing side of politics. It is not unreasonable to expect sacrifice from public employees - and it looks like they were prepared to sacrifice in Wisconsin. At the same time, is gutting education spending the best way to secure our nation's long term prosperity? (If it was up to me, we'd cut teacher unions and tenure, but expand benefits and pay such as to make teaching jobs more competitive). There are more millionaires in New Jersey than teachers. There are other forms of public spending, including inefficient subsidies to various industries. There are of course costly entitlements, and the military. These dwarf our education spending in scale.

If Republicans are serious about improving our deficit situation, they need to do more than pay lip service to the notion of shared sacrifice. Focused partisan assaults on a few groups will never be accepted as fair. Any gains will be only temporary, and will simply be undone in the next electoral cycle. To make sustainable changes, changes that are accepted as fair by both political parties and thus not likely to be reversed, Republicans will need to cut government spending in all areas. They may have to injure some political allies in the process. That is the nature of compromise. Without mature leaders who were willing to compromise, our nation wouldn't exist; without them going forward, our nation won't exist.

The importance of evidence based medicine

From my inexperienced vantage point, the greatest internal battle going on in the medical profession is the contest between medical dogma and evidence based medicine. Believe it or not, there are quite a few interventions that physicians utilize on a regular basis that have never been proven to actually benefit patients.

If some treatments aren't proven, why are physicians still doing them? Well, lets hypothetically say that obstetricians have been doing "x, y, and z" for premature babies for the last two decades, but there is actually no evidence to support z. Are you going to let your premature child be the first in an experimental group that forgoes treatment z? And what kind of malpractice insurance would a physician have to have in order to conduct that sort of experiment?

A New York Times article about a new breast cancer study touches on this challenge. Its pretty easy to convince someone to try something new that is not proven, but getting them to pass on established treatment options in the name of science is another matter. And yet, the physicians who carried out this study on breast cancer did just that. A quote from the article:

The complications — and the fact that there was no proof that removing the nodes prolonged survival — inspired Dr. Giuliano to compare women with and without axillary dissection. Some doctors objected. They were so sure cancerous nodes had to come out that they said the study was unethical and would endanger women.

As it turns out, the study proved that axillary dissection in some women provide no benefit. This is a win-win-win. The surgeons can be confident they are providing the best care, the patients are not getting unnecessary treatment with lots of complications, and the health care system is not losing thousands of dollars on a procedure that isn't helpful. A very courageous study, and we need more like it. I don't presume to know all of the barriers that prevent more research studies like this from being executed, but we should all be working to break them down.

Intern work hours

Maybe some people wonder why I don't spill my beans about the medical profession the way that I do about politics. Ultimately it comes down to what is a career and what is a hobby. Politics / economics / et cetera is a hobby for me, and I'm not making a career in it. Thus I feel no inhibitions whatsoever (as is probably painfully obvious) and say pretty much whatever I feel like. If I was currently pursuing a political career, you can bet that this blog wouldn't exist. When it comes to medicine, since I am such an amateur and anyway am attempting to build a career, input (I need to learn a LOT) is far more important than output (nobody in the medical profession cares about my opinion).

I will comment about the new law regarding intern work hours, however. Previous restrictions implemented in 2003 or so limited residents to an 80 hour work week. In the last few weeks, a new law was passed that limits interns to a 16 hour shift only.

My perception on the issue is this: certainly, there should be reasonable limits to how much residents work. I don't care what anyone tells me, I don't think it is sane or reasonable to expect a resident to regularly work over 120 hours per week. Although I do know those crazy times come and go periodically; even as a medical student I clocked approximately 110 hours one week (it was a big funny joke at the time, but would get old if continued for 5 years). On the other hand, residents should not be limited too much; in Europe they can't even work over 40 hours. Training will certainly be inhibited.

I do think the 80 hour week is a reasonable goal. I don't like the new law, limiting us to 16 hour shifts though. This will compromise continuity of care, which is important for learning. Also, working 16 hours straight is easy. I'm just hitting my stride at 16 hours. Working 24-30 hours straight isn't really hard either, even when not used to it. So I think the 16 hour limit was misguided. That really doesn't make anyone's life better.

Chinese docs and patients

I did a month long surgery rotation in China in April.  When I came back, I told people (friends, family, docs) that American surgeons have it lucky:  if the patient does not do well, the worst that could happen is we get sued.  In China, you get sued and you get beat up by the patient's family.

 

I don't think people believed me when I told them this, or maybe thought I was exaggerating.  I'd tell them that if a patient had a bad outcome, the docs in some places would wear a helmet to work the next day.  And I'd get this look like "Nick, you're full of it."

 

Quote from a recent NYT article.  "In 2006, patients or their relatives attacked more than 5,500 medical workers, reflecting wide discontent with China's public health care system."

 

http://www.nytimes.com/pages/world/index.html

 

See?  I wasn't exaggerating.  American doctors have it great.  Our patients generally respect us.  They only sue us 5% of the times when they could.  And, they don't beat us up when things don't go well.