Which is the Most Challenging Field in Medicine and Health Care?

 

  

  I received a question from the mother of a doctor in Singapore. She posted her question under this article:

“The Management of Chronic Diseases via Different Therapeutic Modalities with Peptic Ulcer Disease as an Example”

https://scientificlogic.blogspot.com/search?q=the+management+of+peptic+ulcers

Greetings Dr. Lim,

My name is Shanzey, a Malaysian working in Singapore. My daughter and myself have been reading all your articles with great interest especially on health and medicine. My daughter is a doctor here in Singapore who intends to specialize but she is unsure which area would be easiest, and which would be hardest, and which area in medicine can earn her better money. The area should not take too long to study, but more importantly not too tough especially with diagnosis. We solicit your expert advice and thank you in anticipation.

 

My question is:

Which field of medicine is most challenging, time consuming but with better income?

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Thank you for your question, Shanzey.

You have asked me a very tough question. If your daughter cannot decide, how am I to know? I can’t decide for her. The study or the practice of medicine, like everything else in life, is very personal. All depends on individual taste.

Some like to study a certain field to be an expert on it in their working life, others not.  It all depends on individual taste, interest and aims in life.  affordability, economic and social circumstances and other environmental and influencing issues, outcome and dynamics. There is no one sure answer that suit all.

If your daughter is thinking about earning capacity, I think an area such as cardiac and liver surgery can be very specialized and technically very challenging, besides good income as there are not many doctors around who are good in this area. She may not need any other specialist doctors to help out, except in surgery with teamwork effort from supporting staff such as the anaesthesiologist, perfusionist, haematologist, immunologists and theatre nurses.

But this does not mean other areas in medicine or surgery are less important, less difficult, less in demand with less earning outcome. I should say, all health-care professions are equally important, and all are in demand.

However, if your daughter intends to go into private practice, there are only two areas I strongly would not advise her, or any doctor for that matter.  Never go for emergency medicine and forensic medicine. The reason is obvious. If you are in private practice, who would send an emergency case, say a serious trauma case in the streets or in a shopping mall, or someone who is already dead as in forensic medicine to your private clinic?

A Good Samaritan, say who saw a street accident, or someone with a heart attack in the office, or anywhere, even at home, would straight away call an ambulance to dispatch a casualty to the emergency department of a government or public hospital.

He is not going to send him or her to your private clinic or to a private hospital and pay for it. Neither would any sensible person send a person who is already dead to your private practice. He will send him straight away to a mortuary and call the police. He or she will never send a dead person to your private clinic or to a private hospital and pay the private doctor to “treat” a dead person. He will of course straight away send the body to a government hospital and ask them to deal with it. It is a police case. So don’t touch these two extreme areas in medicine unless your daughter intends to stay in government service where she will be paid whether the patient is dead or alive.  

Emergency medicine, which I am more familiar with, is very dramatic and lifesaving, but in terms of income and earning capacity it is almost zero. A doctor specializing in this area in private practice can wait for all eternity, and not get even one patient sent to him or her. It is the same with forensic medicine. It is a dead medicine. Both are at the extreme ends, one highly dramatic sent to the triage red zone in a public or government hospital, the other on the extreme end, into the black or white zone (mortuary). Never, never go into these two extreme areas of specialization if your daughter is thinking of going into specialized private practice later.

I should say, choose something in between where there is a demand such as general medicine meant for all, or O & G for female doctors, paediatrics for families with young children. General medicine probably is the best because all patients generally go to an ordinary GP or a physician first because patients normally would not know what ailments are troubling them, except some symptoms they suffer. So, they will see their doctor or a GP first as front-line healthcare professionals to have it sorted out. I should say, most cases are medical in nature rather than surgical. Once a general doctor or a GP sort this out, he or she will refer the case to an appropriate specialist who may be anyone from a cardiologist, oncologist, rheumatologist, haematologist, psychiatrist, ENT, cardiac, neuro, orthopedic, eye surgeon all the way down from A to Z in specialty. All are relevant with good income in private practice.

As far as length of study and technical difficulty to your question is concerned, I think all are lengthy and challenging to study and to specialize. It takes at least another 4 years from a basic MBBS or an ordinary MD degree to get a master’s degree in a field of specialization. A general medical doctor will have to study all the basic medical sciences such as anatomy, physiology, biochemistry, pharmacology, bacteriology or microbiology, histology, pathology, cellular biology, genetics and basic molecular biology all over again especially if it was for the UK MRCP or MRCS Part 1 before going into the area of specialization where they need to pass the examinations on these subjects before going to Part II examination of the Royal College of Physicians or Surgeons or in other disciplines. It is a long ladder to climb.

Furthermore, in order for a doctor to specialize he or she has to be in permanent post for at least 3 years in a specialized department of a government hospital (not private hospital which is not recognized) for teaching and training purposes, experience and exposure in that area the doctor is interested in. He or she will have to work under the supervision of a specialist or a consultant. So that is another ladder to climb.

 The doctor cannot afford to be a contract doctor with no permanent position and is posted here and there especially to a small hospital or in a rural area where he or she is a stand-alone doctor where every little complication needs to be referred or sent by ambulance elsewhere. He or she can never specialize in any field of medicine or surgery. He / she has to be in a big, tertiary or in a teaching hospital for teaching, experience and exposure purposes first.  

As far as your question on technicality and difficulty on diagnosis is concerned, straight away I should emphasize the diagnosis of malnutrition and nutritional disorders. This is the most difficult and most technically challenging branch of medicine for any doctor or even for an expert nutritionist.

First of all, the word “malnutrition” actually means “bad nutrition” to mean “mal” “bad,” “wrongful,” “ill,” from French word “malapert” such as we say “malpractice, malodorous, malformation, malformed, maladjustment, and so on.

Malnutrition does NOT mean only undernutrition as most people, including even specialist physicians think. It technically includes those who are also over-nourished with excessive nutrition from overeating. Overnutrition too is bad or malnutrition. Does that surprise you? I am more than sure you do, including all medical doctors who thinks that malnutrition means only those suffering from nutritional deficiency diseases such as marasmus, kwashiorkor, beriberi, pellagra, rickets and hypocalcaemia, osteomalacia, vitamin K deficiency, xerophthalmia, anaemia and iron deficiency...all the way down to over 350 different types of nutrition deficiency diseases.

 Unfortunately, most doctors are not familiar with them. They tend to misdiagnose them as something else and prescribe them chemical drugs instead.

For instance, a person who is underweight and always feels tired and lethargic should be a suspect of caloric undernutrition. This is because of the body’s innate response to converse energy rather than to lose body mass. So, he or she feels tired and lethargic most of the time to need rest. This has nothing to do with an under thyroid function and needs to do a thyroid function test with all those T3 T4 and all those unnecessary stuffs.

 On the extreme end, over nutrition is the root cause of most of the chronic and degenerative diseases such as cardiovascular, diabetes, endocrine and metabolic syndromes, gout, arthritis, renal, liver, cancers and neoplastic diseases. All these are mainly caused by malnutrition, either under or over nutrition afflicting mankind today due to affluence and overeating and lifestyles. None of these can be “cured” by any chemical drugs that only mask them into other emerging linked diseases. The only way is dietary and lifestyle modifications which is best treated by a dietician. As clinicians and nutritionists, we are very clear on this.

One of the most difficult challenges in diagnosing malnutrition for a doctor or for a nutritionist whether under or over nutrition is, that their presentations (clinical signs and symptoms and even blood tests) do not show up. Most of them are subclinical without signs and symptoms which would be riskier unlike a heart attack, a fever, pain, nausea, vomiting where tell-tales signs are very clear which we can differential diagnose by asking questions, looking for signs and symptoms, taking medical history, clinical examination, blood tests, radiology and imaging and so on. These are not the slightest problems to do or observe. But not with malnutrition which is a disease that can be fatal leading chronic and degeneration of all body systems if not corrected with dietary and lifestyle modification. None of these nutritional diseases, whether under or over nutritional, can be “cured” by prescribing all sorts of drugs, or rather chemicals. That is more than sure. That makes diagnosis, management and compliance extremely difficult for both the doctor and the patient.  

For instance, if you were to ask me if you are malnourished, meaning either undernourished or over nourished, I would not know. You may appear well-fed and healthy physically in appearance and none of any blood tests would show anything. They would all appear as negative with no abnormality shown unless I perform what we call a saturation  test (British) or loading test (American) on you to look at your water-soluble vitamin such as thiamine, riboflavin or ascorbic acid or Vitamin B₆, (nicotinamide) status where we dose you a certain amount of the water soluble vitamins and see how much is been retained by the body, and how much excreted into the urine.

A person may look perfectly well and healthy but in truth his / her health is below optimal, and optimal health depends so much on optimal nutrition. But what then is optimal health and optimal nutrition? The answer is, we do not know as it varies from individual to individual depending on his / her daily nutritional needs which again depends on gender, age, physical activities, physiological requirements, perhaps race, environmental temperatures, body weights among other internal and external influences such as lifestyles. These problems are very complicated to sort out, and we can only take an average from large population studies of apparently healthy people. That is the reason why every country has their recommended daily allowance for various nutrients according to age, sex, pregnant and nursing mothers, heights, weights, physical activities among other factors to be considered. There is no standard dose for any nutrients so unlike drugs which are standardized. This is the reason why the practice of nutrition is so much more complicated than the practice of medicine where the dose is almost fixed and easy to titrate.

In nutrition variations in physiological and biochemical needs are so wide that no one can give a definitive answer. That is why if you were to ask me if you are eating the optimal requirements for your needs, or for the prevention of any disease I would not be able to tell you with certainty even though I am a nutritionist and clinician. You may only look every fit, healthy and well-fed, but within you, lies latent dietary and lifestyle diseases like metabolic syndrome like diabetes, cardiovascular, stroke and even cancers awaiting you in the years ahead. On the other end of malnutrition (undernutrition) you may suffer subclinical kwashiorkor (protein malnutrition), marasmus (caloric deficiency), beriberi (thiamine deficiency), scurvy (vitamin C / ascorbic deficiency), signs such as sore throat, lesions of the lips and mucosa of the mouth, glossitis, conjunctivitis, seborrheic dermatitis, and normochromic-normocytic anaemia (riboflavin or B2 deficiency), iron deficiency  anaemia, together with vitamin B12 deficiency resulting in Addisonian and pernicious anaemias.

Other nutritional deficiency diseases to name a few are, pellagra (niacin or vitamin B3 deficiency causing delusions or mental confusion, diarrhoea, photo-sensitive dermatitis, angular stomatitis, cheilosis, lacrimation, photophobia, Casal collar…etc, etc without you realizing them.

Most of them may be sub-clinical and do not show up. You may feel well, fit and healthy, but in fact you are not. That makes diagnosis exceedingly difficult. They don't even show up on any blood and biochemical examination unless very serve where certain metabolites appear in the blood due to incomplete metabolisms where these vitamins are needed. One example is erythrocyte transketolase activity coefficient (ETKAC) assay for thiamine (vitamin B1) status.  

Else the assessment of nutritional status is exceedingly difficult even for large populations, let alone for individuals based only on clinical examination alone or some blood tests.

 Please see link below how the assessment of nutrition status is done by the coordinated efforts from a team of nutritional, medical and other health professionals.

In fact, the diagnosis of malnutrition is more difficult even for an expert well-qualified nutritionist let alone for a doctor who knows very little on nutrition unless the clinician specialises in nutrition at post graduate level with a master’s degree in this area.

When I was doing my postgraduate in nutrition at Queen Elizabeth College, University of London we were all retrained by the University on the procedures in assessing nutritional status and how to diagnose clinically cases of acute or sub nutritional diseases. There were a number of us in our postgraduate course. They came from various countries. We were all there at London as students, all medical doctors, plus one biochemist from the University of Manchester and a Master degree holder in pharmacology from St Andrews University, one doctor from the University of Singapore, and one Dr Jason ST Teoh from the Faculty of Medicine, University of Malaya, who later began the Head of the Department of Social and Preventive Medicine, and later became a  Professor and Dean of the  Faculty of Medicine at the  University of Malaya. Unfortunately, Professor ST Teoh has since passed away.

One was a gynaecologist from Oslo, Norway, one doctor from Canada, another from Nigeria, one from Hong Kong, the rest of the doctors from the UK itself.  We were very, very well trained, over and over again by London University on how to recognize, diagnose and also how to assess the nutritional status of a community using all means available to us, not just clinically, using blood or urine tests.

Just to give readers a glimpse how this is done, we need teamwork effort from other experts and specialists such as physicians, nutritionists, anthropologists, sociologists, behavioural scientists, statisticians, medical lab technologists, nurses, and general workers to work together, and not just the doctor or the nutritionist alone.

A nutritionist is a very well-qualified professional who underwent a 4-year degree broad-based training course in a good university. A medical course is just one year extra at 5 years. A student in nutrition too has to study all the basic medical sciences such as anatomy, biochemistry, physiology, pathology, microbiology, etc, plus basic medicine just like any medical student. He carries these subjects in great technical detail in the first 2 years before studying applied nutrition and their practices. 

Nutritionists like dieticians are licensed professionals with protected titles by law in Malaysia as in most countries. Not everyone in recent years can call themselves a nutritionist or a dietician. Both are protected professions, and they must be qualified and licensed for practice. A nutritionist can diagnose malnutrition whether under or over or assess nutritional status far more qualified and much more expertly than a medical doctor or a clinician or a physician who has to deal also with other diseases. Normally a medical doctor will refer cases of nutritional deficiency diseases or nutritional-related disorders to a nutritionist for assessment and diagnosis. 

A dietician prescribes the proper diet for a patient especially for all those with dietary and lifestyle diseases, but a doctor prescribes drugs instead that unfortunately do not cure any nutritional or lifestyle disease. That’s the difference between these two healthcare professionals. But drugs too are very lifesaving in a medical emergency, not to say they are not good.

In most cases especially for modern lifestyle and dietary diseases a very difficult change for proper nutrition is the only medicine but are we willing and compliant. 

"Let Food be thy Medicine" (Hippocrates), and NOT let medicine be thy food as pharmaceutical companies would promote. 

However, drugs too are useful, especially fast-acting ones in a medical emergency.

See my explanation on fast-acting emergency drugs that can be lifesaving here: 

 

https://scientificlogic.blogspot.com/search?q=emergency+drugs

 

Having briefly explained all that, should you insist in asking me again since both, sub-nutrition and overnutrition are mal or bad nutrition, and you insist of which between the devil and the deep blue sea would be the worse, I would say overeating and over nutrition is the greater devil since as far back as in1935 Clive McCay at Cornell University has clearly shown that food restriction especially caloric restriction prolongs life span. Subsequently, over 100 studies done on literally all animals showed the same, not just longevity, but disease-free longevity. I think there is a lot of gospel truth in all these findings since McCay’s time since overeating and over nourishment generates a lot of harmful metabolites, especially damaging free radicals the body, especially the liver and kidneys have to deal with, besides not giving a chance for any bowel and body system rest. It is like churching our food waste and garbage 24 hours a day for clearance with excessive food being thrown out into the streets as garbage.

Which would we choose, under or over nutrition since both are classified as bad or malnutrition  

"Mal" means "bad". 

Explaining further, let us give ourselves an example of normal distribution curve.

In a normal distribution curve there is a minmium on both sides, with a peak somewhere in the middle. The peak is the average or the medial where the cluster of the data is highest. Clustering around the medial are the rest of the data with its Standard Deviation at the tail ends of the the distribution curve. 

Assuming this peak represents the optimal nutrition which we may also represent as optimal health.

Anything on the left of the left of the curse is sub-optimal. Let this be undernutrition. 

Anything on the right of this peak is also sub-optimal, representing excessive and overnutrition. 

Anything on either side of this optimal (maximum) peak is either under or over optimal. Since we are unable to define or determine which would be under or over nutrition for an individual, which side of the curve would we choose to advise an individual how much he or she to take at least to get as close as possible to reach the peak of optimal health? Bear in mind all recommended nutrient intake is based on very large population studies who are in apparent good health through food consumption studies, clinical, anthropometric measurements, age, heights and weight, gender, occupation, physical activities, biochemical, social, economic studies, food supply and food balance sheets among other parameters.  Now we are in hot soup between the deep blue sea and the devil. We cannot answer this with certainty since our nutritional needs are so personal and individualized. We can only  rely on Recommended Daily Allowance based on food consumption studies in large population studies.

As a research nutritionist and food scientist I would not be able to give any specific advice to any individual on his specific nutritional requirements because of vast individual variations. 

This is so unlike the practice of medicine where we can prescribe  the exact dosage of a medicine to a patient. This make the practice of medicine far, far easier than the practice of nutrition for sure. The practice of medicine is quite standard plus or minus a little bit, but not in nutrition because of vast biological needs. 

But if you were to force me for an answer, I would choose the deep blue sea of undernutrition for the simple reason I have explained that there are now over 100 studies both in humans and all animals without exception that under nutrition, specifically caloric restriction greatly prolongs life, not just longevity but disease-free long life. 

I have already proposed a few logical theories to explain this. It is up to nutritionists, nutrition scientists,  and other biomedical scientists to accept these hypothesis and use them as a springboard to work on them further. 

Under nutrition in very severe cases only such as marasmus, kwashiorkor, scurvy, night blindness, beriberi, riboflavin deficiency, pellagra, iron deficiencies...etc, etc can easily be corrected within days, but not chronic degenerative diseases such as diabetes, metabolic syndrome, cardiovascular and stroke, renal, liver diseases due to overnutrition. 

So make your choice between the deep blue sea which can be rescued and the devil that is permanently taken away 

This is just one of the reasons. But I think if we look at this from the evolutionary perspective it is just the way Nature wants any living animal, us included, to adapt to drastic changes in food supply and in harsh environments so that we can become hardier and able to survive with minimum nutritional needs. In a nutshell, the body conserves energy without sacrificing its body mass loss due to caloric restriction to thrive better and longer disease-free. It just merely obeys the biological laws of “survival of the fittest” by being more adaptable to changes in nutritional needs with lesser calories available by being less physically active in order not to lose body mass (body weight) so that it can survive longer.

This theory of mine why we may live not just longer, but with disease-free longevity is just an extension of Herbert Spencer concept he proposed in 1852 after reading Charles Darwin's On the Origin of Species – in his Principles of Biology published in 1864. Evolutionary biology, an area of study coincidentally I happened to be familiar with at Cambridge. 

I think the best analogy to explain this is like a lamp with very little fuel. The lamp will adjust itself conservatively by demanding very little fuel. It will then burn with a very low flame, a slow dim glow for a very long time till the fuel runs out naturally.  But if we start to pour a lot of oil over the lamp, it will suddenly burst into a big fire that will not last very long as the fuel burns itself out fiercely.  In fact, the big fire will destroy the entire lamp and burn it down instead. Likewise, with caloric (energy) restriction, the metabolic rate slows down with less metabolic wastes generated, the body becomes physically less active, and its lifespan is prolonged. 

Vegans and Life Expectancy:

Similarly, I believe if vegans too restrict their plant-based consumption with lower caloric content they too would have longer spans together with the protective effects of antioxidants and thousands of phytochemicals in them. Although the studies on the longevity of vegans are mixed and limited, we cannot refute the belief they would live a longer disease-free life if they do not compensate for their low-caloric diet with greater amount of food intake. But I think vegans do overeat in their belief that: 

"If a little does me good, a lot will do me even better"?

 I am not sure. Perhaps vegans can tell me better! 

  

The lengthy and laborious job of conducting an assessment of nutritional status is summarized in this link below.

https://scientificlogic.blogspot.com/2023/05/the-assessment-of-nutritional-status-in.html

We can see in the study above, how elaborate it is, as it involves so many medical and scientific experts with their expertise working together, not just the doctor or the nutritionist alone.  It is not just the case of just taking medical history, doing some clinical examination, conducting some blood, urine, serological tests, microbiological assays, radiological examination, HPE (biopsies) only, and just prescribing some medicine. It is far, far more and complicated than that.   

 

I hope I have answered your questions and have explained. Nutritionists too are very highly paid. I personally know many of them work as Senior Consultants and in managerial positions in drug, health companies, clinical or analytical laboratories with over RM 18,000 per month salary, or in private practice or teaching in universities as professors or as Dean of a medical faculty like my course mate, the late Professor ST Teoh or Professor Sim my former course mate one year ahead of me in London, who then became a professor at the University of Singapore.

 I myself was offered a WHO job in cancer research at Lyon, France which I declined, and was offered to work at the Massachusetts Institute of Technology (MIT) as a medical and food toxicologist, and later was offered a permanent senior position with the Ministry of Health at the Institute for Medical Research in Kuala Lumpur as a Senior Medical Research Officer and Deputy Head of Rural Health and Community Medicine. Of course, I am now happily retired.

 

So, Mrs Shanzey, the scope in all fields of medicine and health care is very wide, all with good income. Ask your doctor daughter to make her own choice, except in emergency and forensic medicine if she intends private practice later. Emergency medicine, pathology and forensic medicine are only for those who were offered permanent and pensionable jobs with the government. They are a failure and wash out if in private practice.

Regards

Lim ju boo.