Friday, July 25, 2008

"only at Moffitt"

Since my first two blocks have been at Moffitt -- UCSF's fancy shmancy ivory tower tertiary medical center -- I'm starting to realize that my view of medicine can be a bit skewed. Someone observed that yes, we can get regular bread-and-butter medical cases like pneumonia or heart disease, but there's usually some exotic past medical history (a transplant, a rare genetic disorder) or some unusual aspect of the case (patient has PCP pneumonia). We see patients that can be very sick, and an attending warned us that it is not uncommon for a fair number of patients to pass away at Moffitt.

Some people have jokingly dubbed Moffitt "the Death Star," partly because of the complexity/severity of the cases, but also because there appears to be this consensus that the medical culture at Moffitt is highly intense, demanding, and academic.

From my perspective, there appears to be some truth to the rumors, but I wouldn't have ranked Moffitt so highly on my list if I wasn't interested in seeing rare medical cases (nicknamed "zebras" in medical slang, as opposed to the more common afflictions called "horses" ). I have always had a soft spot for academic medicine, and it's interesting seeing how different specialists work together to unravel or treat challenging medical conditions. Later this year, I will be doing family medicine in the Bay area, ob-gyn in "rural" Fresno, and neuro-psych at the General (SFGH), so there will be an interesting mixture of sites and practices to experience.

However, I am enjoying my time at the medical Ivory Tower with the aforementioned zebra folks. In pediatrics, I saw a patient with a disorder so rare that it affects 1 in 2 million people and there are only 230 cases in the U.S. It was also fairly common to see kids with fetal or neonatal abdominal surgeries, 2 babies with short gut syndrome who are on Hospital Day #301, kids with rare genetic mitochondrial disorders, a 14-year-old with a stroke who left AMA, a teenage boy with lupus (SLE), and a 12-year-old boy with anorexia. Kawasaki syndrome was not an outrageous differential when a child had a fever for over 3 days.

Adult medicine at Moffitt has been similarly intense and interesting. During our last intersession, Dr. Don Ganem told us anecdotes from his days as an infectious disease fellow at UCSF in the 1980s during the HIV/AIDS era, and how bizarre infections like PCP pneumonia, cryptococcal meningitis, and Kaposi's sarcoma became "bread and butter" cases at SF General Hospital and Moffitt. When he asked a third-year med student what the most common cause of community-acquired pneumonia was, the MS3 answered, "PCP." Dr. Ganem continued by saying, "I was going to whale on the student, until I realized that that was really all that he ever actually saw in the hospital." Sometimes, I can sympathize with the situation of Dr. Ganem's hapless student -- all zebras and no horses.

Our medicine service had 11 patients, three of which were double-lung transplants. We usually have at least 1 lung transplant patient, sometimes a kidney transplant or a patient with a rare cancer (adult rhabdomyosarcoma of the cervix, primary CNS lymphoma and HIV negative, a metastatic paraganglioma presenting like pheochromocytoma). Many of our patients have serious bacterial infections, and some have end-stage liver or renal disease.

Whenever a resident or attending hears a fantastically unusual medical case -- say, a 22-year-old with a STEMI, intermittent fevers, acute renal failure, bilateral PE's, and a violaceous vesicular rash on the left side of the body -- there is a classic reaction: the doctor's eyes widen slightly, the eyes roll up to the ceiling, there is a deep sigh, and finally exhalation of the ritualistic phrase, "Only at Moffitt."

Lunchtime conversation with a fellow med student at Moffitt:
A: "My vision has been blurry and my head hurts lately...I think I have a brain tumor."
B: "Are you sure it's not a vasculitis...or a demyelinating disorder?"

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