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C. Snorre, M.B.A., M.D.

Deputy Director, Wake Forest School of Medicine

From a surgical perspective, the approach to brain tumors can be quite challenging. Tumors can arise from any location in the brain, and elaborate surgical planning is required. Anyone who has studied the anatomy of the head, neck, and brain understands the difficulty in gaining access to places such as the skull base, the sella turcica, and the posterior fossa. Complex dissections have been developed over the years such as transphenoidal approaches for tumors of the pituitary axis and translabrynthine approaches for tumors of the eighth cranial nerve (the vestibulo-auditory nerve). Unfortunately, limited success has been the rule in the surgical treatment of highly aggressive brain tumors. Sadly, systemic chemotherapy has been minimally effective in prolonging the lives of these patients. It is likely that these kinds of "minimally invasive" therapies will become commonplace in the treatment of brain tumors in the future. Given the active role that academic neurosurgeons play in developing this technology, many therapies will likely become part of the neurosurgical therapeutic repertoire rather then the realm of neurologists or radiologists. Because of the hot research going on in this area and its direct application to clinical neurosurgery, neurosurgical oncology is a particularly appropriate field for individuals with a bent for academics. Surgery of the Spine: the Other Half of the Central Nervous System An interesting statistic-and one to take to heart if your intent is to be a brain surgeon-is that 60% of the procedures neurosurgeons perform are spine related. This is an interesting statistic considering that, according to many older neurosurgeons, spine as a surgical field was almost lost to the orthopedic surgeons in the not-so-distant past. As the aforementioned numbers suggest, the spine is now a major component of neurosurgery. Medical students interested in this specialty should be aware that a number of older surgeons make a distinction between ortho spine and neuro spine. The latter refers to patients with decompressions and other simple, more delicate spine procedures that are often done under the operating microscope. Ortho spine denotes spine surgery involving instrumentation, such as fusions and spinal deformity operations. As it turns out, these distinctions were made by physicians who were neither orthopedic nor neurologic surgeons. There are neurosurgeons who do the larger spine whacks, including some who do multilevel fusions with complex instrumentation for scoliosis. On the other hand, there are orthopedic surgeons who quite adeptly perform decompressions under the operating microscope. No statistic exists that suggests whether orthopedic surgeons or neurosurgeons are more suited or better prepared to operate on the spine. There are, nonetheless, several issues to consider if you want to be a spine surgeon and are trying to choose between orthopedics and neurosurgery. In general, neurosurgery residents tend to operate on the spine with greater frequency and earlier in their training then their orthopedic colleagues. Lumbar discectomies tend to be beginner cases for neurosurgery residents because these procedures are considered less risky then craniotomies. At many teaching hospitals, a simple spine case involving the lumbar region is usually the turf of the first and second year neurosurgical resident. In contrast, orthopedic spine cases at the same institution are reserved for more senior residents. Furthermore, there are few orthopedic programs in the country where 60% of the cases done are spine related. The chairman of a neurosurgery program in Texas commented that "if I wanted to be purely a spine surgeon, I would have done orthopedics. It would have saved me a lot of sleep and years off of my life lost from the stress of neurosurgical training. Even if neurosurgery residents have an initial advantage in spine surgery because of their exposure and experience, it seems clear that orthopedic surgeons never fall that far behind.

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Because emergency medicine physicians really get to do it all, students who enter this specialty like the fact that they will be real doctors. You will know what to do if someone has a heart attack on an airplane or when a child gets hurt at the playground. In fact, about half of your patients will present with problems that are more appropriate for a primary care doctor-the common cold, musculoskeletal pains, rashes, and other nonurgent complaints. It is kind of like being a family doctor but without the long-term continuity, practice of preventive medicine, and clinic setting. Your goal, instead, is to treat the acute problem at hand and then direct patients to the next appropriate step for their medical follow up. Patients do not arrive in the emergency room with their medical chart or old records. Being the first person to ask the appropriate questions in a limited amount of time can be frustrating. You must have the confidence to make fast medical decisions based on limited, incomplete information. For an emergency medicine doctor, nothing is more satisfying than taking a few bits and pieces of history (and abnormal physical findings), ordering some lab tests, and coming up with a working diagnosis and treatment plan. While one case is being stabilized, many more are waiting patiently (and often impatiently) for evaluation, treatment, discharge, or admission. The emergency physician constantly juggles many tasks at once, whether acquiring data, making decisions, or performing procedures. Patients, lab results, nurses, chest x-rays, family members, and other physicians all vie simultaneously for your immediate attention. Because you are doing so many things at once, emergency care sometimes requires knee-jerk action, after which additional thinking is necessary. With recent advances in medicine, more and more patients are coming to the emergency room with complex problems, such as unusual drug interactions, or complications from procedures that did not exist before, like organ transplants. Now, emergency medicine specialists find themselves with even more responsibilities to manage at once. With many stressful events occurring at the same time, the ability of an emergency physician to triage patients becomes even more important. Based on the French word trier, meaning "to sort," triage involves allocating treatment to patients based on a priority system that assigns resources to where they are most needed. As patient advocates, these doctors must recognize the difference between the truly sick and those with less urgent problems. After all, "some patients are not as sick as they think, and others are not as well as they wish. After sorting patients correctly when many arrive at once, emergency doctors take care of them all the way through discharge or admission. Yes, these doctors really do get to perform much of that wild and crazy stuff seen on television. You will insert nasogastric tubes, reduce joints, defibrillate hearts, suture lacerations, incise and drain abscesses, intubate with endotracheal tubes, and deliver babies. Every day, there are always opportunities to place intravenous, central, and occasionally intraosseous lines. Even more complicated procedures like cricothyrotomies (inserting a needle through cartilage of the neck to create an airway) and thoracotomies (cracking the chest) are also possible. For medical students who like to work with their hands and think surgery is the only answer, take a closer look at this specialty. Emergency medicine is a quicker route to being a broad-based doctor who also gets to play with scalpels, needles, and thread. They are quickly transported to trauma centers and met by eager, capable emergency medicine physicians waiting to perform miracles. The idea of saving lives every day excites many medical students and is the strong appeal of this specialty. A multidisciplinary problem, trauma always involves an entire team of doctors, namely emergency physicians, trauma surgeons, and anesthesiologists. After all, the appropriate management of internal injuries due to trauma falls within the realm of surgery.

These follow-up visits are extremely rewarding-particularly when a patient is cured. You are important to your patients, who are keen to recount the many happy events that have occurred in their lives since their last appointment. Radiation oncology has an important role in the palliation of patients with incurable disease. Although radiation treatment is used with the intent to cure, many malignant diseases have an extremely poor prognosis. If you enter this specialty, be prepared to cope with the emotional toll of caring for patients with cancer. As an outpatient-based service, the practice of radiation oncology is calmer and less dramatic day to day than, for example, treating acutely ill patients on the general medicine wards. Nevertheless, a sizable percentage of your patients succumb to disease within a few years. Although emotionally draining at times, caring for these patients and their families is very rewarding. As you guide them through the rough seas of radiation therapy (not a pleasant treatment for anyone), patients want reassurance that they will not be abandoned. Remarkably, it is often this reassurance-more so than any promise of a miracle to cure-that provides patients and their families with solace, comfort, and peace of mind. This is particularly important as these late effects can become manifest weeks to years down the line, and may even include iatrogenic (radiationinduced! In light of the potential side effects from radiation treatment, if some patients cannot be cured, what role does this therapy have for them You will find that radiation oncologists have an important role maintaining comfort for cancer patients by palliating local symptoms. If surgery is no longer an option to resect the cancer, radiation becomes the preferred (or adjunctive) modality to shrink the tumor mass. In particular, radiation oncologists have much success in eliminating the severe pain caused by cancer (particularly lung, breast, or prostate) that has metastasized to bone. With just a couple of weeks of therapy, most patients report a partial or complete resolution of tumor-related bone pain. The need for radiation therapy as a palliative measure to make patients feel better is often urgent. In this case, radiation oncologists are called in for rapid treatment of spinal cord compression. They are the only specialists who can attempt to reverse quickly the neurologic deficit and prevent paralysis. They also help relieve the symptoms of superior vena cava syndrome, when tumors (usually lung cancer) grow and obstruct the main vessel draining blood from the head and neck into the heart. Although this is certainly not true, it is important to realize that radiation is just one of three major arms in the fight against cancer. Along came radiation therapy, a new modality that also helped to destroy cancerous tissue. Today, chemotherapy is often seen as the most promising therapy, especially because the general public has particularly high hopes that scientists and doctors will discover a magic pill to cure cancer completely. Unfortunately, despite the technologic developments and other promises of twenty-first century medicine, a miracle cure is unlikely in the near future. Given our greater understanding of the mechanisms of cancer, no single modality- whether surgical, radiation, or chemical-will wipe out malignant disease. All future oncologists must accept the mantra that "different cancers in different stages respond to different schemes of therapy. Through conferences known as Tumor Board, the three major types of oncologists come together-along with pathologists and radiologists-to decide on the best course of treatment. Chemotherapy is particularly helpful for its systemic properties, dealing with small numbers of tumor cells that may spread throughout the body. Radiation, on the other hand, is especially valuable in treating the primary disease site, whether a gross tumor or microscopic disease. Interestingly, chemotherapy can also act concomitantly with radiation as a sensitizer, thus enhancing the effects of radiation. For the radiation oncologist then, an awareness of the multidisciplinary approach to cancer is essential.

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Although urologists do in fact operate on the male genitalia (penis, testicles, and scrotum), there is much more to the practice of urology than the penis. They are experts on the diagnosis and management of diseases involving the kidney, ureters, prostate, bladder, urethra, and male genitalia. Urologists are masters of everything that has to do with the passage of urine, from its production in the kidney to its release through the urethra. They surgically correct problems such as obstructing posterior urethral valves in newborn boys or bladder outlet obstruction caused by benign prostatic hypertrophy in elderly men. Urinary tract infections, which affect every age group and can be quite destructive, make up a large proportion of cases seen by urologists, especially if it progresses to a worrisome infection of the kidney itself (pyelonephritis). In the pediatric population, the focus is on male and female congenital abnormalities. The urinary tract is affected by congenital anomalies more than any other organ system. This means undescended testicles (cryptorchidism), ureters poorly implanted into a bladder such that urine refluxes back to the kidneys (vesicoureteral reflux), bladder exstrophy, and the technically difficult arenas of cloacal malformation and intersexuality. Certainly, a general practice urologist will feel comfortable treating some of the more minor conditions, but will likely refer the more complex cases to specialists in pediatric urology. Kidney stones (nephrolithiasis), which form in both women and men, fall under the expertise of the urologist. Some nephrologists also have an interest in treating patients who form stones, but once a stone is obstructing the urinary system, it is up to the urologist to take it out. Certainly a lot has changed since then; with the recent advent of endoscopic technology, minimally invasive techniques can be used to fragment stones and allow passage of the bits without making an incision. Now urologists use high-tech tools like rigid and flexible ureteroscopy, percutaneous stone extraction, and extracorporeal shockwave lithotripsy to treat kidney stones (especially if obstructed and causing infection). For those who like video games, that hand-eye coordination will now come in handy. Imagine being afraid to leave the house because you are worried about wetting yourself. Armed with advanced diagnostic techniques such as urodynamic studies, the urologist can assess the underlying cause of the incontinence and offer either medicines or surgery to keep the person dry. Historically, the focus has been on male dysfunction but more recently, urologists have also thrown their hat into the complicated world of female sexual dysfunction, as popularized by the now famous urologist Jennifer Berman. In the male world, there are medical treatments for impotence such as Viagra and, if those fail, surgical options such as implantable penile prosthesis. In the female world, medical and surgical interventions are still being investigated. Some urologists take on a role in the world of kidney transplant, either as the primary transplant surgeon or as a member of the transplant team, for example, performing the donor nephrectomy. Trauma is another area that is not uniformly experienced in the various training programs. Urologists are key members of the trauma team in the operating room (for patients who have urethral ruptures or renal damage). They draw on advances in renal tract imaging to evaluate quickly for any trauma to the urinary tract. Urethral reconstructive surgery combines interesting aspects of urologic anatomy and plastic surgery. Urologists also deal with a significant number of cases of malignant disease in their practices. The search for bladder cancer or kidney cancer brings in many male and female patients when they have blood in their urine. Although urologists perform the anatomic surgical resection of the tumor (or implant radiation seeds), they work closely with medical oncologists in developing chemotherapy treatment plans. As already mentioned, because of the stress this sometimes causes, some patients are referred to the local teaching hospital where a specialist in urologic oncology can perform the surgery and take care of these patients afterward. Many end up having problems with voiding because of their big prostate, which can be very uncomfortable and can even lead to acute urinary retention.