Say Uncle Panda, I notice you haven’t written about chiropractors. What do you think about them and chiropractic in general?
Chiropractors serve a useful role in society, particularly when it comes to taking some of the pressure off of used car salesmen who would otherwise have the market cornered on chicanery. Nobody likes to be the only crook in town you understand, and if chiropractors are good for the self-esteem of used car dealers I’m all for ‘em. Other than that there’s not much use for chiropractors except to keep second-rate strip malls in business as they make that long descent from shopping mecca to consignment stores and karate studios.

On one hand you have the straight chiropractors who preach a strange religion where manipulating the spine can take the place of vaccines and cure all manner of diseases from cancer to your Aunt Dottie’s lumbago. On the other are the so-called “reform” chiropractors who confine their practice to musckuloskeletal complaints. Six of one, a half dozen of the other. Despite the occasional studies showing that it has a slight advantage over placebos in the relief of chronic pain and other fuzzy symptoms, chiropractic is a lot of sound and fury signifying little or nothing. For the money people spend and the effort they put into it (chiropractic school is four years, after all) I guess I’d want a little more than a slight improvement over a placebo. Just for my self-respect, you understand.

The basis of chiropractic is the theory that misalligned vertebrate (called “subluxations”) are responsible for disease. The old school chiropractor will shoot a plain film of your spine and use this as a basis for manipulating it back into position despite the overwhelming evidence that not only do otherwise healthy people have asymptomatic misalignments in their spines but there is no way to change the alignment anyway short of orthopaedic surgery.

But do what you want. I don’t care.

Hey Uncle Panda, I’m considering Emergency Medicine but I’m concerned that it’s just glorified primary care. What say you?

That’s ridiculous, at least from my perspective. As many of you know, I did a year of Family Practice and while I disliked it intensely, it at least gave me a taste of primary care. Emergency Medicine is nothing like primary care.

Here’s what I saw on a recent shift: Two acute MIs (one with significant ST elevations), one acute pancreatitis with nausea and projectile vomiting, a baby with meningitis and CSF that looked milky when I did the lumbar puncture, a motor vehicle accident with bilateral tibia fractures, a tylenol overdose, vaginal bleeding that turned out to be an incomplete abortion, a couple of strokes, a severe COPD exacerbation, a third nerve palsy (which I diagnosed without an MRI, thank you very much) and the usual minor stuff which, although minor, was still more “urgent” than the usual primary care fodder.

People go to their family doctor for diabetes management. They go to the Emergency Department for diabetic ketoacidosis or when their foot is rotting off as a consequence of distal peripheral neuropathy. That’s the difference. I think I see more truly sick patients in one week in the Emergency Department than I did in a year of clinic in family medicine where, on the rare occasion when somebody was really sick they got sent to the Emergency Department.
Now, it’s true that a lot of our patients could be better served at an Urgent Care. On the other hand one of our biggest source of customers are the local Urgent Care clinics, many of which are staffed by midlevels who have the good sense to drop back and punt.

I think a lot of folks don’t really understand primary care which is the long-term management of chronic conditions and not something we do in the Emergency Department, even if we wanted to which we don’t. We refer to primary care almost as much as they refer to us.

The truth is that you get so used to really sick patients that it begins to seem like primary care.

I am not busting down on primary care and Family Practice in particular. Primary care is neither easy nor quick. That’s why residency-trained physicians need to do it. The reason mid-levels do it is because nobody else will and because, cobra-like, they have mesmerized the Family Practice physicians who are their natural prey into accepting them as equals.

How long does it take to write an article for your blog and where did you learn to write so well?

Some articles write themselves and some I have to sweat over for days. I do experience periodic writer’s block and can go a long time without a decent idea (like the past couple of weeks). I suppose I could always write about how much residency blows but I don’t want to be a one trick pony. Besides, that would be like playing a crowd for cheap laughs. It’s too easy.

I also write most of my articles late at night when I should be sleeping. I hope that you, oh my critics, appreciate this when I don’t provide footnotes and an exhaustive bibliography. I just don’t have time. And I blog for fun so while I feel a responsibility to my readers to provide interesting articles, I do have a real job and to be honest, I make more moonlighting for half an hour than I do from the advertisments on my blog for a month.

In other words, this blog is a labor of love and not a money-maker so sometimes responsibility trumps fun.

I am flattered that many of you think I am a good writer. Let’s just say I’m working on it. I have pretty good role models who include Herman Melville, Mark Twain, Anthony Burgess, George Orwell, Charles Dickens, and Joseph Conrad to name a few. People ask me what I think about the Da Vinci Code. I didn’t read it. I don’t read crap. Period. I used to, of course, but after I discovered Robert Graves I have never looked back.

Read the first page of “Bleak House” or “1984″ and compare it to the typical offering at Barnes and Noble and you will see what I mean. Most writing, like most popular culture, is excruciatingly bad. Almost painful to read. I’m probably not too much better but at least I can see where I need to go. One day I will have time to really write something meaningful but not right now.
Paradoxically, the rest of my tastes are completely plebian.

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