'분류 전체보기'에 해당되는 글 131건

  1. 2021.08.23 :: Hormone Therapy and Other Treatments for Symptoms of Menopause
  2. 2021.08.20 :: Nongenital Herpes Simplex Virus
  3. 2021.08.19 :: Corticosteroid injection for adhesive capsulitis in primary care: a systematic review of randomised clinical trials
  4. 2021.08.19 :: Acute diarrhea
  5. 2021.08.17 :: ISOLATED HYPERBILIRUBINEMIA
  6. 2021.08.17 :: ELEVATED ALKALINE PHOSPHATASE
  7. 2018.06.17 :: 6.17
  8. 2017.07.13 :: 7.13
  9. 2017.06.20 :: 6.20
  10. 2017.06.18 :: 6.18
Diary/2021년 2021. 8. 23. 15:54

https://www.aafp.org/afp/2016/1201/p884.html

 

Hormone Therapy and Other Treatments for Symptoms of Menopause

The results of large clinical trials have led physicians and patients to question the safety of hormone therapy for menopause. In the past, physicians prescribed hormone therapy to improve overall health and prevent cardiac disease, as well as for symptoms

www.aafp.org

 

Combined estrogen/progestogen therapy, but not estrogen alone, increases the risk of breast cancer when used for more than three to five years.

 

Therefore, in women with a uterus, it is recommended that physicians prescribe combination therapy only to treat menopausal symptoms such as vasomotor symptoms (hot flashes) and vaginal atrophy, using the smallest effective dosage for the shortest possible duration.

 

Although estrogen is the most effective treatment for hot flashes, nonhormonal alternatives such as low-dose paroxetine, venlafaxine, and gabapentin are effective alternatives. 

 

Women with a uterus who are using estrogen should also take a progestogen to reduce the risk of endometrial cancer. 

 

Women who cannot tolerate adverse effects of progestogens may benefit from a combined formulation of estrogen and the selective estrogen receptor modulator bazedoxifene.

 

black cohosh, botanical products, omega-3 fatty acid supplements - not helping

 

One systematic review suggests modest improvement in hot flashes and vaginal dryness with soy products, and small studies suggest that clinical hypnosis significantly reduces hot flashes.

 

Patients with genitourinary syndrome of menopause may benefit from vaginal estrogen, nonhormonal vaginal moisturizers, or ospemifene (the only nonhormonal treatment approved by the U.S. Food and Drug Administration for dyspareunia due to menopausal atrophy). 

 

There is no evidence that using low-dose vaginal estrogen increases the risk of breast cancer recurrence.

 

Risks and Benefits of Hormone Therapy

combined oral regimen consisting of conjugated equine estrogen and medroxyprogesterone with placebo, and found that the combined regimen increased the risk of coronary artery disease, breast cancer, stroke, and venous thromboembolism (VTE). The study also found a decreased risk of colorectal cancer, hip fractures, and total fractures with combined hormone therapy.

 

women without a uterus  = those taking estrogen alone -> had no significant change in risk of coronary heart disease or breast cancer.

but increase in strokes and VTE (similar to the trial of combined estrogen and progestogen)

 

Estrogen - Stroke, VTE

 

combined hormone therapy had a significantly increased risk of breast cancer and VTE, and a reduction in hip fractures. In contrast, women taking estrogen alone had a significantly reduced risk of breast cancer.

 

timing hypothesis : starting hormone therapy early in menopause (compared with starting it 10 years or more after the onset of menopause) may be cardioprotective because of estrogen's apparent ability to slow the progression of atherosclerosis in younger women.

 

Vasomotor Symptoms : common in women with a higher body mass index, with lower income and education, who smoke cigarettes, or who are black

 

Estrogen is the most effective therapy for hot flashes

there is no evidence that lowering the ambient temperature; using fans; exercising; or avoiding triggers, such as alcohol and spicy foods, improves hot flashes

 transdermal estrogen, which avoids the first-pass liver effect, may have a lower risk of VTE compared with oral estrogen

 

 the dosage may be increased after evaluating for effectiveness during the first eight weeks of therapy, with reassessment annually or as needed.

 

Progestogens can cause fatigue, dysphoria, and fluid retention. 

 

Patients with a uterus who cannot tolerate these adverse effects may benefit from Duavee, a combination of 0.45-mg conjugated equine estrogen and the selective estrogen receptor modulator bazedoxifene, which is approved by the FDA for treating hot flashes and preventing osteoporosis. Bazedoxifene does not stimulate the endometrium.  Duavee is contraindicated in women who have a history of breast cancer or VTE. 

 

The levonorgestrel-releasing intrauterine system (Mirena) is an off-label option for providing local progestogen to the endometrium for patients who cannot tolerate systemic therapy.

 

Low-dose paroxetine (Brisdelle) is the only nonhormonal medication approved by the FDA to treat hot flashes,  Patients taking tamoxifen should not use paroxetine because of inhibition of the hepatic enzyme cytochrome P450 2D6, which decreases the effectiveness of tamoxifen.  Desvenlafaxine (Khedezla) and venlafaxine do not inhibit CYP2D6 and are appropriate alternatives.

 

Other nonhormonal options include gabapentin (Neurontin) and pregabalin (Lyrica). These medications can cause dizziness and other adverse effects, and should be titrated from a lower dosage.

 

 

Deciding When to Discontinue Hormone Therapy

after three to five years. Clinicians should inform patients that some women will have a difficult time stopping hormone therapy. 

 

Transitioning from Contraception to Hormone Therapy

 

Genitourinary Syndrome of Menopause

 

This condition affects up to one-half of women during menopause. In 2014, a consensus conference endorsed the new term genitourinary syndrome of menopause to replace the terms vulvovaginal atrophy and atrophic vaginitis, partly because the older terminology does not encompass the extent of genital tract symptoms many women experience.

 

Thinning of the vulvar mucosa may cause vulvar burning, irritation, or constriction of the introitus, resulting in entry dyspareunia.

 

vaginal estrogen, nonhormonal vaginal moisturizers, and the newer oral systemic estrogen agonist-antagonist ospemifene (Osphena). It is reasonable to try nonhormonal therapy as a first-line option to alleviate vulvovaginal symptoms caused by genitourinary syndrome of menopause.

'Diary > 2021년' 카테고리의 다른 글

Hormone Therapy and Other Treatments for Symptoms of Menopause  (0) 2021.08.23
posted by 차도닥

댓글을 달아 주세요

Learning/Medicine 2021. 8. 20. 15:36

https://www.aafp.org/afp/2010/1101/p1075.html

 

Nongenital Herpes Simplex Virus

Nongenital herpes simplex virus type 1 is a common infection usually transmitted during childhood via nonsexual contact. Most of these infections involve the oral mucosa or lips (herpes labialis). The diagnosis of an infection with herpes simplex virus typ

www.aafp.org

 

 

Nongenital herpes simplex virus type 1 is a common infection usually transmitted during childhood via nonsexual contact. 

 

 Most of these infections involve the oral mucosa or lips (herpes labialis). The diagnosis of an infection with herpes simplex virus type 1 is usually made by the appearance of the lesions (grouped vesicles or ulcers on an erythematous base) and patient history. However, if uncertain, the diagnosis of herpes labialis can be made by viral culture, polymerase chain reaction, serology, direct fluorescent antibody testing, or Tzanck test. The differential diagnosis of nongenital herpes simplex virus infection includes aphthous ulcers, acute paronychia, varicellazoster virus infection, herpangina, herpes gestationis (pemphigoid gestationis), pemphigus vulgaris, and Behçet syndrome. Oral acyclovir suspension is an effective treatment for children with primary herpetic gingivostomatitis. Oral acyclovir, valacyclovir, and famciclovir are effective in treating acute recurrence of herpes labialis (cold sores). Recurrences of herpes labialis may be diminished with daily oral acyclovir or valacyclovir. Topical acyclovir, penciclovir, and docosanol are optional treatments for recurrent herpes labialis, but they are less effective than oral treatment.

 

Pathophysiology

HSV invades and replicates in neurons, as well as in epidermal and dermal cells. The virus travels from the skin during contact to the sensory dorsal root ganglion, where latency is established. Oral HSV-1 infections reactivate from the trigeminal sensory ganglia, affecting the facial, oral, labial, oropharyngeal, and ocular mucosa.

 

Recurrent infections may be precipitated by various stimuli, such as stress, fever, sun exposure, extremes in temperature, ultraviolet radiation, immunosuppression, or trauma. The virus remains dormant for a variable amount of time.

 

Oral HSV-1 usually recurs one to six times per year. The duration of symptoms is shorter and the symptoms are less severe during a recurrence.

 

Clinical Presentation
In primary oral HSV1, symptoms may include a prodrome of fever, followed by mouth lesions with submandibular and cervical lymphadenopathy. The lesions usually heal within 10 to 14 days. 

 

In recurrent herpes labialis, symptoms of tingling, pain, paresthesias, itching, and burning precede the lesions in 60 percent of persons. The lesions then appear as clusters of vesicles on the lip or vermilion border. The vesicles may have an erythematous base. The lesions subsequently ulcerate and form a crust. Healing begins within three to four days, and reepithelization may take seven to eight days.

 

Herpetic keratitis is an HSV infection of the eye. Common symptoms are eye pain, light sensitivity, and discharge with gritty sensation in the eye. Slit lamp need. 

 

Herpetic whitlow is a vesicular lesion found on the hands or digits.  It occurs in children who suck their thumbs or medical and dental workers exposed to HSV-1 while not wearing gloves. Herpes gladiatorum is often seen in athletes who wrestle. Herpetic sycosis is a follicular infection with HSV that causes vesiculopapular lesions in the beard area. It is often caused by autoinoculation from shaving. 

 

HSV infection is one of the most common causes of erythema multiforme.

 

 

Diagnosis

by the appearance of the lesions and the patient's history. if the pattern of the lesions is not specific to HSV, its diagnosis can be made by viral culture, PCR, serology, direct fluorescent antibody testing, or Tzanck test. Viral culture should be obtained from vesicles when possible. The swab should be sent in special viral transport media directly to the laboratory (or placed on ice if transport will be delayed).

 

Management

EPISODIC ORAL TREATMENT FOR PRIMARY HERPETIC GINGIVOSTOMATITIS

Oral acyclovir suspension (Zovirax; 15 mg per kg five times per day for seven days) can be used to treat herpetic gingivostomatitis in young children. Children should be treated symptomatically with oral analgesics and cold, soothing foods such as ice pops and ice cream.

 

EPISODIC ORAL TREATMENT FOR RECURRENT HERPES LABIALIS

table

The patients took oral valacyclovir (2 g twice for one day) and applied clobetasol 0.05% gel (twice per day for three days) at onset of symptoms. - good result 

 

EPISODIC TOPICAL TREATMENT FOR RECURRENT HERPES LABIALIS

Topical treatment for herpes labialis is less effective than oral treatment. 

Treatment with docosanol cream, when applied five times per day and within 12 hours of episode onset, is safe and somewhat effective. OTC

 

ORAL TREATMENT TO PREVENT HERPES LABIALIS RECURRENCES

Oral acyclovir is effective in suppressing herpes labialis in immunocompetent adults with frequent recurrences. 

oral acyclovir (400 mg twice per day)

oral valacyclovir (500 mg per day)

patients receiving treatment for cancer, acyclovir was found to be effective in the prevention of HSV infections.  In another study, daily valacyclovir (500 mg per day) and acyclovir (400 mg twice per day) were equally effective in the prevention of recurrent HSV eye disease.

 

posted by 차도닥

댓글을 달아 주세요

Learning/Medicine 2021. 8. 19. 21:57

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5165171/

 

Adhesive capsulitis is a common cause of shoulder pain and limited movement. The objectives of this review were to assess the efficacy and safety of corticosteroid injections for adhesive capsulitis and to evaluate the optimum dose and anatomical site of injections. PubMed and CENTRAL databases were searched for randomised trials and a total of ten trials were included. Results revealed that corticosteroid injection is superior to placebo and physiotherapy in the short-term (up to 12 weeks). There was no difference in outcomes between corticosteroid injection and oral nonsteroidal anti-inflammatory drugs at 24 weeks. Dosages of intra-articular triamcinolone 20 mg and 40 mg showed identical outcomes, while subacromial and glenohumeral corticosteroid injections had similar efficacy. The use of corticosteroid injections is also generally safe, with infrequent and minor side effects. Physicians may consider corticosteroid injection to treat adhesive capsulitis, especially in the early stages when pain is the predominant presentation.

 

 

posted by 차도닥

댓글을 달아 주세요

Learning/Medicine 2021. 8. 19. 18:26

https://www.aafp.org/afp/2014/0201/p180.html

 

The most common etiology is viral gastroenteritis, a self-limited disease.

 

Risk factors and signs of inflammatory diarrhea and/or severe dehydration can direct any needed testing and treatment.

 

Most patients do not require laboratory workup, and routine stool cultures are not recommended. 

 

 Treatment focuses on preventing and treating dehydration.

 

Diagnostic investigation should be reserved for patients with severe dehydration or illness, persistent fever, bloody stool, or immunosuppression, and for cases of suspected nosocomial infection or outbreak.

 

Oral rehydration therapy with early refeeding is the preferred treatment for dehydration. Antimotility agents should be avoided in patients with bloody diarrhea, but loperamide/simethicone may improve symptoms in patients with watery diarrhea.

 

Probiotic use may shorten the duration of illness.

 

When used appropriately, antibiotics are effective in the treatment of shigellosis, campylobacteriosis, Clostridium difficile, traveler's diarrhea, and protozoal infections.

 

Prevention of acute diarrhea is promoted through adequate hand washing, safe food preparation, access to clean water, and vaccinations.

 

Acute diarrhea is defined as stool with increased water content, volume, or frequency that lasts less than 14 days.

 

In patients with acute diarrhea, stool cultures should be reserved for grossly bloody stool, severe dehydration, signs of inflammatory disease, symptoms lasting more than three to seven days, immunosuppression, and suspected nosocomial infections.

 

Routine testing for ova and parasites in acute diarrhea is not necessary in developed countries, unless the patient is in a high-risk group (i.e., diarrhea lasting more than seven days, especially if associated with infants in day care or travel to mountainous regions; diarrhea in patients with AIDS or men who have sex with men; community waterborne outbreaks; or bloody diarrhea with few fecal leukocytes).

 

The first step to treating acute diarrhea is rehydration, preferably oral rehydration.

 

Combination loperamide/simethicone may provide faster and more complete relief of acute nonspecific diarrhea and gas-related discomfort than either medication alone.

 

Antibiotics (usually a quinolone) reduce the duration and severity of traveler's diarrhea.

 

Clinically, acute infectious diarrhea is classified into two pathophysiologic syndromes, commonly referred to as noninflammatory (mostly viral, milder disease) and inflammatory (mostly invasive or with toxin-producing bacteria, more severe disease)

Bacterial infections are more often associated with travel, comorbidities, and foodborne illness

 

Salmonella, Campylobacter, Shigella, and Shiga toxin–producing Escherichia coli (enterohemorrhagic E. coli).

 

HISTORY

The onset, duration, severity, and frequency of diarrhea should be noted, with particular attention to stool character (e.g., watery, bloody, mucus-filled, purulent, bilious).

 

evaluated for signs of dehydration, including decreased urine output, thirst, dizziness, and change in mental status

 

Vomiting is more suggestive of viral illness or illness caused by ingestion of a preformed bacterial toxin.

 

Symptoms more suggestive of invasive bacterial (inflammatory) diarrhea include fever, tenesmus, and grossly bloody stool.

 

A food and travel history is helpful to evaluate potential exposures.

 

Children in day care, nursing home residents, food handlers, and recently hospitalized patients are at high risk of infectious diarrheal illness. Pregnant women have a 12-fold increased risk of listeriosis, which is primarily contracted by consuming cold meats, soft cheeses, and raw milk. 

 

Recent sick contacts and use of antibiotics and other medications should be noted in patients with acute diarrhea. Sexual practices that include receptive anal and oral-anal contact increase the possibility of direct rectal inoculation and fecal-oral transmission.

 

The history should also include gastroenterologic disease or surgery; endocrine disease; radiation to the pelvis; and factors that increase the risk of immunosuppression, including human immunodeficiency virus infection, long-term steroid use, chemotherapy, and immunoglobulin A deficiency.

 

 

 

 

The primary goal of the physical examination is to assess the patient's degree of dehydration. Generally ill appearance, dry mucous membranes, delayed capillary refill time, increased heart rate, and abnormal orthostatic vital signs can be helpful in identifying more severe dehydration. Fever is more suggestive of inflammatory diarrhea.

 

Diagnostic Testing

OCCULT BLOOD

LEUKOCYTES AND LACTOFERRIN
STOOL CULTURES : grossly bloody stool, severe dehydration, signs of inflammatory disease, symptoms lasting more than three to seven days, or immunosuppression. 

CLOSTRIDIUM DIFFICILE TESTING patients who develop unexplained diarrhea while using antibiotics or within three months of discontinuing antibiotics. 

OVA AND PARASITES Indications for ova and parasite testing include persistent diarrhea lasting more than seven days, especially if associated with infants in day care or travel to mountainous regions; diarrhea in persons with AIDS or men who have sex with men; community waterborne outbreaks; or bloody diarrhea with few fecal leukocytes

ENDOSCOPY 

 

Treatment

 

 

REHYDRATION THERAPY

FEEDING BRAT diet (bananas, rice, applesauce, and toast) and the avoidance of dairy are commonly recommended, supporting data for these interventions are limited

ANTIDIARRHEAL MEDICATIONS  loperamide (Imodium) may reduce the duration of diarrhea. loperamide/simethicone combination has demonstrated faster and more complete relief of acute nonspecific diarrhea and gas-related discomfort compared with either medication alone. Loperamide may cause dangerous prolongation of illness in patients with some forms of bloody or inflammatory diarrhea and, therefore, should be restricted to patients with nonbloody stool.

antisecretory drug bismuth subsalicylate (Pepto-Bismol) is a safe alternative in patients with fever and inflammatory diarrhea.

ANTIBIOTIC THERAPY

overuse of antibiotics can lead to resistance (e.g., Campylobacter), harmful eradication of normal flora, prolongation of illness (e.g., superinfection with C. difficile), prolongation of carrier state (e.g., delayed excretion of Salmonella), induction of Shiga toxins (e.g., from Shiga toxin–producing E. coli), and increased cost.

when used appropriately, antibiotics are effective for shigellosis, campylobacteriosis, C. difficile, traveler's diarrhea, and protozoal infections.

Antibiotic treatment of traveler's diarrhea (usually a quinolone) is associated with decreased severity of illness and a two-or three-day reduction in duration of illness. If the patient's clinical presentation suggests the possibility of Shiga toxin–producing E. coli (e.g., bloody diarrhea, history of eating seed sprouts or rare ground beef, proximity to an outbreak), antibiotic use should be avoided because it may increase the risk of hemolytic uremic syndrome. Conservative management without antibiotic treatment is less successful for diarrhea lasting more than 10 to 14 days, and testing and treatment for protozoal infections should be considered.  Antibiotics may be considered in patients who are older than 65 years, immunocompromised, severely ill, or septic. 

 

PROBIOTICS

ZINC SUPPLEMENTATION

posted by 차도닥

댓글을 달아 주세요

Learning/Medicine 2021. 8. 17. 13:37

 conjugated (direct hyperbilirubinemia) or unconjugated (indirect hyperbilirubinemia)?

 

An increase in unconjugated bilirubin in serum results from overproduction, impairment of uptake, or impaired conjugation of bilirubin. An increase in conjugated bilirubin is due to decreased excretion into the bile ductules or leakage of the pigment from hepatocytes into serum.

 

 

 

 

posted by 차도닥

댓글을 달아 주세요

Learning/Medicine 2021. 8. 17. 13:32

In patients with cholestasis, the alkaline phosphatase is typically elevated to at least four times the upper limit of normal.

 

The gamma-glutamyl transpeptidase (GGT) may also be elevated in the setting of cholestasis.

 

 Patients with a predominantly cholestatic pattern typically undergo a right upper quadrant ultrasound to further characterize the cholestasis as intrahepatic or extrahepatic; the latter is suggested by biliary tract dilatation.

 

To confirm that an isolated elevation in the alkaline phosphatase is coming from the liver, a GGT level or serum 5'-nucleotidase level should be obtained. These tests are usually elevated in parallel with the alkaline phosphatase in liver disorders but are not increased in bone disorders. An elevated serum alkaline phosphatase with a normal GGT or 5'-nucleotidase should prompt an evaluation for bone diseases.

 

An elevated bone alkaline phosphatase is indicative of high bone turnover, which may be caused by several disorders including healing fractures, osteomalacia, hyperparathyroidism, hyperthyroidism, Paget disease of bone, osteogenic sarcoma, and bone metastases. We generally refer such patients to an endocrinologist for evaluation. Initial testing may include measurement of serum calcium, parathyroid hormone, 25-hydroxy vitamin D, and imaging with bone scintigraphy.

 

Differential diagnosis — If the alkaline phosphatase elevation is isolated (ie, the other routine liver biochemical test levels are normal), is confirmed to be of hepatic origin, and persists over time, chronic cholestatic or infiltrative liver diseases should be considered. The most common causes include partial bile duct obstruction, primary biliary cholangitis (PBC), primary sclerosing cholangitis, and certain drugs, such as androgenic steroids and phenytoin. Infiltrative diseases include sarcoidosis, other granulomatous diseases, amyloidosis, and, less often, unsuspected cancer that is metastatic to the liver.

posted by 차도닥

댓글을 달아 주세요

Diary/2018년 2018. 6. 17. 20:55



오늘부터 일주일에 한개씩 WCI블로그 읽고 요약해보기로 한다. 

첫번째는 12 Things To Know About Student Loan Refinancing. 근데 론 없으므로 바로 다음으로 넘어가기로 한다. 


Top 7 Financial Mistakes Doctors Make and How to Avoid Them


1. Poor Debt Management

빚없으므로 생략. 있으면 최대한 빨리 갚기. 


2. Inadequate Savings Rate

20-25%는 정도는 해야한다. 


3. Inappropriate Tax Management

401Ks and IRAs Max out 할것


Roth IRA (title: Why I Love the Roth IRA (Back to Basics)- Roth IRAs have a lot of advantages with regards to investing, tax reduction, asset protection, and estate planning.  


Anyone with earned income can open a Roth IRA and contribute up to $5000 per year. 


you’re over 50, those limits are raised to $6000 per year.


Roth IRAs are tax-protected.


you get to save a lot of taxes with a Roth IRA since, after the initial contributions, it is never taxed again.  



Backdoor Roth IRA -

The Stealth IRA


Doctors are well-known to make all kinds of stupid investments just to lower their tax bill.  Yet far too many don’t take advantage of the simple tax shelters available to them.  Why some doctors have investments outside their 401Ks and IRAs when they’re not maxing those out is beyond me.  I’m always surprised how few doctors have heard about Backdoor Roth IRAs or Stealth IRAs.  For most doctors, every dollar they put into a retirement plan saves them ~40 cents in taxes.  Some self-employed physicians don’t even open the right kind of retirement plan, severely limiting their contribution amounts.  Those doctors investing outside retirement accounts don’t realize the impact of using tax-efficient investments, minimizing churn (and the capital gains taxes it produces), tax-loss harvesting, and using investments with low tax basis for charitable gifts and inheritances.  Most doctors are smart enough to either learn about the tax code and do their taxes themselves or hire a good accountant to do the job.  But finding a few bucks here and there at tax time is missing the forest for the trees.  The big gains are found in changing your tax behavior throughout the year.


4. Personal and Professional Divorce

의사랑 결혼해라. 의사랑 결혼하면 이혼할 확률도 낮다. 11%. 

결혼하는거 비싸지만 이혼은 몇배 더 비싸다.



5. The Wrong Insurance



Insurance you probably need (circumstances do vary):


$1-$3 Million of 20-30 year level term life insurance

$7500-15000/month of good quality, personal, own-occupation disability insurance

$1-3 Million of umbrella insurance (with accompanying high liability limits on your property insurance)

$1-3 Million of Malpractice Insurance

 


6. Expensive Investments

투자할때 수수료를 낮춰라



7. Loaning Money

돈 빌려주지 마라. 가족이건 친구건. 

'Diary > 2018년' 카테고리의 다른 글

6.17  (0) 2018.06.17
posted by 차도닥

댓글을 달아 주세요

Diary/2017년 2017. 7. 13. 22:28

스포츠메디신이 뭐라고. 이 짓을 하고 있는지 모르겠다. 


2년차에 두번 있는 일렉티브를 다 스포츠메디신을 돌았다. 퀸시와 카본데일. 꽤 먼거리였지만 숙소도 주고, 서류작업이 그나마 적어서(그때당시엔 복잡하다고 생각했지만 지금 하는짓들이랑 비교하니 완전 적음) 그나마 편했다. 


샌디에고에서 하는 전국컨퍼런스에 호텔/비행기/AMSSM등록비/컨퍼런스등록비.. 한 일주일 다녀왔더니 돈도 장난아니게 깨지고. 순전히 이 노력은 오로지 스포츠메디신만을 위해서 투자한것이다. 


어웨이 로테이션을 가기 위해서 J1 visa 받는 프로그램을 찾기위해 150개에 달하는 모든 프로그램에 이메일을 보내서 물어봤다. 그리고 제이원을 받으면 그 다음엔 10월에 로테이션을 이날부터 이날까지 하고싶은데 가능한지 물어봤다. 어느 프로그램에서는 거의 오라고까지 하다가 갑자기 마지막에 캔슬해서.. 완전 멘붕..


우리 GME오피스에서 안될꺼같으니 포기하라고 종용하고.. 그냥 내년에 하라고까지 하기도 하고.. 암튼 우여곡절끝네 오클라호마 겨우겨우 만들어서 지원해서 온갖 서류작업을 다했다. 


일단 기본적으로 어플리케이션 폼은 기본이거니와 학교에서 요구하는 백그라운체크, 그리고 면허국에서 요구하는 백그라운드체크 각각따로 돈내고 그 프로그램에 등록해야 한다. 


뉴멕시코처럼 핑거프린트 요구하는곳도 있다. 스프링필드경찰서 갔는데 애들이 워낙 게을러서 세번에 가서야 겨우겨우 지문을 카드에 찍을수 있었다. 이것도 당연히 페이. 


뉴멕시코에 2주, 오클라호마주에 2주씩 가기로 어찌어찌해서 결국 반쯤 성사. 골치가 아픈게, 온갖 서류(심지어 각 학교 변호사가 사인해야하는 폼이 있음.우리프로그램포함 각 프로그램 디렉터뿐만 아니라 관련된 모든사람들 Director of GME, Dean까지 사인해야 하는경우도 있고 ) 이래서 GME오피스에서 포기하라고 종용한듯 싶었다. 


메일이 정말 수십번 왔다갔다해야한다. Goal and Objectives .. Director's CV각종 PLA서류.. 각 학교에서 수정해야할부분있다면서 변호사 통해서 계속 수정에 수정을 반복... 


여기까지는 그래도 양반. 


내가 3년차라서 각 주에 Full license를 받아야 한다. 이 부분이 압권. 보통 500불-1000불에 달하는 어플리케이션비용을 내야함을 물론이고 우리 의대에서 보내야할 서류, 내가 보내야할 서류, 지금 내가 트레이닝 받는 곳에서 다시 또 그 면허국에 보내야 할 서류.. 우리 GME오피스 그냥 포기하라고 한말이 그냥 한말이 아닌듯 싶었다. 오늘은 오클라호마주 면허 신청하는데 무슨 피디에프파일을 읽고 50문제 풀어서 통과해야 신청할수 있었다. 허허... 


그리고 오클라호마주 GME 오피스는 내가 일렉티브 돈다고 지원만해도 지원비를 따로 받았다. 


또 각 면허국마다 ECFMG, FSMB에 내 성적표와 Certification 을 각 면허국으로 보내달라고 요구해야함. 이것도 공짜가 아니고 한번보내는데 75불..이정도. 


결론은 내가 왜 무한한 시간과 노력을 이 짓을 하는거냐. 


가장 효과적이고 고효울적인 투자는 나를 위한 투자라는것을 깨달았기때문이다. 한국에서도 잘먹고 잘 살수 있는데,,


온갖 역경을 거치고, USMLE 을 보고, 다시 매치에 도전하기 위한 각종 서류작업을 하고, 클럭쉽을 하고, 실습할 자리를 찾아보기위해 수없는 메일을 보내가며 옵저버쉽을 하고, 익스턴쉽을 하고, 한국과 미국을 여러번 왔다갔다 하면서... 때로는 좌절하고 때로는 그만둘까 싶기도 했지만. 어느새 여기까지 왔다. 


나같은 외국의대생에 작년에 스포츠메디신에 매치된 퍼센티지가 겨우 2.9%다. 단언컨데, 이 %는 한국의대졸업생이 미국레지던시에 들어오는 퍼센티지보다 높다. 


아무리 경쟁이 높아도 길은 있기 마련이라는 생각에 이 험난한 작업을 하는것이다. 그래서 일끝나고 책상에 앉아서 머리 쥐어싸매고 이 작업을 하는것이다. 


비록 잘 안되더라도. 이 온갖 노력과 비용이 아깝지 않을것이다. 


펠로우쉽이 실패해도 난 당당하게 말할수 있다. 진짜 내 바닥에 있는 모든 노력다 박박 긇어서 여기에 바쳤다. 그렇게 해서도 실패한거라면 두번해도 안된다.  이렇게 해서 안되면 난 안되는거라고. 


후회는 없을것이다. 





'Diary > 2017년' 카테고리의 다른 글

7.13  (0) 2017.07.13
6.20  (0) 2017.06.20
6.18  (0) 2017.06.18
6.11  (0) 2017.06.11
posted by 차도닥

댓글을 달아 주세요

Diary/2017년 2017. 6. 20. 14:01

3-4일정도 있으면 이제 삼년차. 


메일용량이 다 찼다고해서 작년꺼 메일을 지우고있는데 NICU돌았던 일정이 7월에 있다. 기억이 가물가물할정도로 오래된 느낌. 


오늘도 스벅에 와서 지원서를 정리하고 아직도 결정이 안된 10월 일렉티브와 insurance coverage 와 씨름하는중. 왠지 UIC가 질질 끄는 것을 보니, 다른데를 슬슬 컨택해봐야 할것 같다. 


레지던트 지원을 시작할때부터, 아니 2009년도 여름에 Mount Sinai로 클럭쉽을 지원할때부터 언제나 뭔가를 요청하고 메일을 보내고 그러는것의 일상. 2015년에 레지던트를 시작하고나서는 소속감이 생기면서 좀 덜해졌지만, 졸업을 일년앞두고 또다시 자리를 찾아 나서려니 남들에게 아쉬운 소리를 하려니.. 이런것들이 적성에 맞지 않는 느낌. 


내가 남들을 찾아다니는게 아닌, 남들이 나를 찾아오게 실력을 키워야 하는데 그런것들은 언제쯤 가능할련지. 


레지던트 끝나고 그냥 평범하게 취직할 수도 있지만, 그러면 더 편하겠지 몸과 마음은. 그래도 아쉬움이 남을것이다. 최선을 다해서 배우지 못했다는 생각에. 



'Diary > 2017년' 카테고리의 다른 글

7.13  (0) 2017.07.13
6.20  (0) 2017.06.20
6.18  (0) 2017.06.18
6.11  (0) 2017.06.11
posted by 차도닥

댓글을 달아 주세요

Diary/2017년 2017. 6. 18. 21:10

6월도 벌써 반절이 넘게 지나갔다. 레지던트 동안 밤당직 할 날짜가 이제 오늘 포함 8일정도 남았다. 


문득 창원에서 요양병원에서 근무하던 날들이 생각난다. USMLE공부한다고 짱박혀서 고생했던것들이 생각난다. 


그때당시엔 이게 그냥 이루지못하는 욕심인가 싶기도 했는데 어찌어찌하다보니 여기까지 왔다. 


이미 한국의사면허가 있는 상태에서 미국의사면허를 공부하는것은 꼭 해야하는 일이 아닌 옵션이었는데 그래서인지 동기부여가 좀 부족했던듯 싶다. 


어텐딩이 되면 

난 좀 더 레지던트들을 이해해주겠다. 내가 아무리 잘 알아도 조금더 자유를 부여하고 실수하고 뭔가를 놓치더라도 잘생각해보면 알수 있다. 그러면서 배우느것도 있으리라.


남들이 다 요약해놓은것 보고 빠진것 찾아내기, 실수한것 찾아내기는 쉽다. 자기가 직접 그 자리에 들어가서 처음부터 끝까지 하나하나 해내고 돌아서서 다시 바라봐 뭔가 놓치기 쉽다. 그러나 남들이 요약해놓은 환자 정보를 보고 뭔가 이상하다 싶은것을 찾아내는것은 쉽다. 





'Diary > 2017년' 카테고리의 다른 글

7.13  (0) 2017.07.13
6.20  (0) 2017.06.20
6.18  (0) 2017.06.18
6.11  (0) 2017.06.11
posted by 차도닥

댓글을 달아 주세요