Tuesday, August 05, 2008

Outpatient Medicine and Pulmonology

For the next three weeks, I will be doing general outpatient medicine in the mornings, and then specialty clinics in the afternoons. The general medicine clinics are exactly like the longitudinal clinics that I was doing for the past two years on Tuesday afternoons. In fact, I even spent yesterday morning in the exact same clinic that I worked in first and second years (though not with the same preceptor, because my old preceptor is now out at one of the suburban satellite centers). The general medicine clinics seem downright slow after the hectic bustle of the family medicine clinics. I am only seeing two, maybe three patients each half day, and I never have trouble finishing my notes or logs before lunch. To be fair though, the IM department cuts back the schedule so that the preceptors have more time to teach us, and the patients tend to be older and have more complex problems compared to the typical family medicine patients.

My specialty clinics for this week are all with pulmonologists. These are lung specialists. It's a really cool and interesting specialty. I spent the past two afternoons working with people who evaluate patients for lung transplants. Most of the patients have chronic obstructive pulmonary disease (emphysema) due to having smoked for a few dozen pack-years. (A pack-year is equivalent to 365 packs of cigarettes, or one pack of cigarettes per day for a year. So someone who smokes two packs per day is actually accruing TWO pack-years in a year.) There are a lot of factors that go into deciding whether to list someone for a lung transplant. First of all, the patient has to be sick enough to need a new lung (or pair of lungs), but not too sick to perform the surgery. Second, there are many psychosocial factors that come into play. If the patient is still smoking or doesn't have enough psychiatric or social stability to comply with the demanding anti-rejection regimen that they will need to take for the rest of their life, they won't be eligible for the transplant.

I learned several interesting things from the past two days. One is that the Cleveland Clinic performs the second largest number of lung transplants in the country. (Interestingly, the preceptor wasn't sure who performs the most!) Another is that Cleveland Clinic operates on much sicker patients than most other centers do. For example, one of the restrictions for lung transplants is age, but some of the patients who have received lungs here are older than the upper limit. The last thing I took away from these past two days is a strong reminder of the importance of talking to patients who smoke about quitting in the general medicine clinics. The COPD patients have to have a really awful quality of life by the time they are sick enough to merit being listed for a transplant. They're in wheelchairs and have to be on oxygen all the time. They can barely speak one sentence without getting short of breath. And all of this suffering is for what, exactly? It is sickening to see teenagers or young adults smoking and know that in a few decades, they could end up in this exact same pulmonology office with a life-threatening illness that is entirely preventable.

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