Extra

(I’m going to post brief comments and random thoughts here that might not be worth an entire post-PB)

4/27/07: Cutting Your Losses

Recently, a group of pre-medical students were brought around for a tour of the hospital and a day of shadowing real honest-to-God residents. My group were very nice. Very outgoing and talkative and a real pleasure to have around for half of the day. We all like showing off and they seemed fairly impressed with some of the gritty sorts of things they saw some of my colleagues doing.

I felt sorry for one kid, however, or maybe I didn’t. While being shown an ICU patient he turned very pale, got that deer-in-the-headlight look, and while he didn’t actually run, turned around and left pretty quickly. The patient wasn’t even that gross. Just the typical intubated demented zombie smelling vaguely of stale fishsticks and urine (the stigmata of nursing homes). His friends told me that he went to the cafeteria and waited patiently for his group but that he gave up his medical career after seeing, finally, what all the fuss was about.

Medicine is a good career but it’s not what people expect. The kid looked Indian and, if you will please forgive my stereotyping some of our finest immigrants and citizens, I imagine his parents will be very disappointed. But if you can’t tolerate the sight of the old, the sick, and the deformed no amount of pressure, delusion, or shame should compell you to start the long trek. Better to find out early.
.
4/19/07: A Few Things I’m Concerned About

I don’t really watch the news anymore, probably because I’m sick of the typical media ritual that follows every big story or tragedy. The news may be on 24 hours a day but if you think about it, the major news networks repeat the same facts over and over for hours at a time occasionally adding something new. I also detest most of the commentary and analysis by smarmy politicos and experts spinning the events to reflect their particular point of view.

So I read a few headlines, a few blogs, and a little here and there about health care and that’s about it. I don’t think I miss much because no matter when I turn on the news, it seems that the same subjects are being discussed by the same clones who have the same opinions. I also detest the toxic spew that passes for political debate, particularly from the left who in this regard are absolutely shameless, and since I can’t do much about it I’d rather ignore it.

I hope you folks don’t find my blog as equally monochromatic and predictable. I have a few areas of interest which are, in no particular order:

1. Abuse of medical students and residents
2. Residency work hours and pay.
2. Futile end-of-life care.
4. What I think are the real reasons for the high cost of medical care including defensive medicine, litigation, paperwork, futile end-of-life care, and over-utilization by a public which is insulated from the true cost of it.

I hit these topics pretty hard but I also try to intersperse a little humor, a little useful information for those either in medical school or contemplating it, and some articles that might make you look at things differently than you are used to.Let me know if there is anything you are interested in hearing about. Sometimes I look at the keyboard, look at the clock, and realize that I have nothing to say.

4/16/07: The Usual Suspects

I was a resident at Duke when the story first broke about the rape of an exotic dancer by the Duke lacrosse team, a story that now turns out ot have been competely fabricated by a drug-crazed prostitute looking for some media attention and carried along by a crooked District Attorney looking for the usual votes, the usual race-hustlers looking for money and attention, and the completely spineless President of Duke University looking for the usual accolades from the likes of Al Sharpton as he shamelessly threw students whose interests he purports to protect to the usual wolves.

The conceit and self-congratulation of the usual bureaucrats at Duke was, as usual, almost unbearable as they sought the usual remedies of the spineless which is the usual appeasement to people that most of us would usually tell to fuck off. Oh man. They were so sure those guys were guilty. They revelled in their guilt, experiencing a pleasure that could only be described as sado-masochistic as they extrapolated the lies of a whore to their favorite topic, the evils of White Men and their repressive society. And even as the truth came out, as it usually does, they cleaved to the story with a fanaticism as zealous as it was despicable,which is their usual MO, and to this day probably believe that even though no crime was committed, somebody, somewhere, still needs to pay for the usual sensitivity indoctrination and the usual pointless studies that will show, as they usually do, that rich white men are the Devil.

The point? First, the President of Duke needs to resign and teach elementary school because it seems this is all he can handle. Second, the DA (Mike Nifong) needs to be prosecuted. Third, those three players need to sue the crap out of Duke and screw those weasels out of everything they possibly can.

The fourth point? You can’t trust a bureacracy. Ever. If somebody’s job depends on managing you, he will sacrifice you at the first sign of trouble to keep his job. This applies to corporations, universities, medical schools, residency programs, and every other bureacratic organization.

4/16/07: Do I Look Stupid?

Speaking of abusive residents, I once had a resident who hated my guts. I don’t know why but my wife assures me that when I don’t like somebody, and I most certainly did not like this resident, I can be very grating and annoying despite ostensibly being scrupulously polite. At the end of the rotation the resident sat me down for my evaluation and for about ten minutes berated me for my lack of enthusiasm, my unwillingness to take on additional work, and my generally bad attitude. To be honest, while I was indeed unenthusiastic, I wouldn’t say my attitude was bad per se. I was just uninterested in the rotation and didn’t squeal for joy and wet myself in excitement as you are expected to do by the zealots.

After the ten-minute lecture, the whole time of which the resident was writing furiously on my evaluation sheet, the sparks flying you understand, she put the evaluation sheet in an envelope, sealed it contemptuously and handed it to me in triumph as if to say, “There, you bad man. Now you have got your just desserts!”

I threw it in the trash on the way out of the hospital.

4/14/07: Freeloader Heaven

How on earth we have decided that people “deserve” medical care and how this has managed to become the unassailable conventional wisdom I will never understand. You can’t deserve something that somebody else has to provide, or am I the only one who has not gone insane? The ridiculousness of making everything a right only becomes apparent when you apply it to other things besides medical care. People need cars, for example. Is owning a car a right and do we need to provide everybody with a car whether they can afford one of not? Standard or automatic?

How about clothes? We need those. Are we going to create a single payer system to provide comprehensive clothing insurance? groceries would be nice. Most people spend more on groceries than they do on medical care. Where’s my Groceraid and my Mealicare?

Now, it’s true that we provide food, shelter, and medical care to some of our citizens who are unable to provide them for themselves but this is charity, something we do because we are a decent people and to have the poor starving to death or dying from treatable conditions would be demoralizing to our civilization But it should always be charity, freely given and gratefully accepted, not something demanded by the lazy and stupid in this monstrosity of a nanny-state, this freeloader heaven that we are trying to create.

And the idea that giving people government insurance is somehow going to pay huge dividends in better health and thus lower costs in the long run is ridiculous. Access to primary care isn’t the problem. Plenty who have superb access have crappy health and are indistinguishable in the hospital from their freeloading fellow travellers.

4/11/07: You Know What Drives Me Crazy?

Well, as you may know, I ended up not getting out of Cardiology even though I had the required month last year so technically I don’t need it to graduate. Consequently, I have one more call-heavy month before I am through being an off-service Tortugan sugar plantation slave. It’s a sorry rotation with minimal teaching and maximum sweat-shop labor that puts the lie to The Man’s propaganda about residency being about teaching and not about extracting low-payed work out of the convicts.

In a perfect world, I would have been permitted to add an extra month in the Emergency Department where, paradoxically I would learn a hell of a lot more cardiology because not only would I see more cardiac patients but I would be under the direct tutelage of an attending who, unlike many of the attendings on off-service rotations, would be available to teach. The fact that we are not scut-oxen in the Emergency Department and don’t spend most of our time on repetitive paperwork also contributes to the learning environment.

The fact is, however, that there are 28 call nights in the block that have to be filled by somebody or the cardiology service will have to pay someone around 80 bucks an hour to fill the gap. As I have seven of those things covered, if you subtract my ten-dollar-per-hour salary I represent a cost savings of around $6000 per month to the hospital which, if you know anything about business, is practically the same as a $6000 profit, excluding the tax advantages if they actually had to pay this as a salary. The residents on this service alone, represent a cost-savings to the hospital of around $24,000 per month or a little less than $300,000 per year.

And this is for just one service. Pulmonary, Medicine, and the other concerns also need their labor so it is not hard to see that residents, as they work for peanuts, represent savings in the millions, even for small hospitals like ours. Again, saving money on mandatory expenses is the same as making money. Sorry. I know this causes sputtering and indignation among the represtatives of The Man but that’s the way it is everywhere else and medicine is not a magic place where economics don’t apply (unless you belong to the Cult of Single Payer).

So the key is that paying for call coverage is a mandatory expense and it drives me up the wall when The Minions of The Man say that we don’t really have a purpose as residents and educating us is actually a drag on the hospital. If you believe that you have never seen the panic which ensues when a rotation loses one of their interns. If we’re not important, and serve no useful function, then you’d think the hospital would be deleriously happy is I said, “To hell with it, I’m going home,” instead of slaving away all night for chump change.

4/10/07: French Hookers:

Just so you all know, not all of residency training is bad. I definitely like some rotations. My program does a lot of ICU rotations, for example, and even though I am always glad to go home at the end of the day and we pull a lot of call, we are given a lot of responsibility so I never feel like I am just a paper-work scut whore (even though there is a lot of paper-work).

Same with our trauma surgery rotations that can blow like nothing but surgery rotations can but at least you can see the use of it.

But not every rotation is like that and some have to be endured. How then, can one keep himself motivated for a month of paper-work and scut hell?

By living one day at a time, not looking too far ahead, and pacing yourself.

Let’s take the rotation on which I am currently toiling. I have call tonight. I will be post-call tomorrow and the nature of the rotation is that we can leave at 8AM post-call. That’s two days gone if I can just tough out tonight. The day after tomorrow we have our mandatory didactics until noon so I can hide and slide in conference until at least one which “runs down the clock” until go-home time. I don’t have call over the weekend so Friday is just downhill. That’s a week gone.

The next week I have Monday call but then I have Thursday call which, if I can again tough it out and maybe grab a few hours of sleep will give me almost a three-day weekend. And Thursday morning will find me hiding and sliding at conference. (Memo: All things being equal, Thursday call is the best).

So that’s two weeks down. It’s now all downhill. I have one Friday-Sunday call but after that, hell, I can do a week of any rotation standing on my head and when I’m done with this one, I am done with it forever.

And you have to pace yourself. Just because they call you in a panic with five admissions waiting in the Emergency Department doesn’t make this a crisis for you. You need to work diligently but after the hell of my last medicine rotation, motherfucker, I am taking a break every now and then and if I get too tired to think, I will take a nap. Your stinking PAs who are getting paid three times what I make can admit the ones I don’t get to in the morning. I’m going to invoke the French Hooker rule.

Surely you’ve heard of the French Hooker Rule? It is that no matter how much money you have and no matter how hard she works, she can only give you what she can give you.

Be the hooker.

4/9/07: Filthy Lucre

As you’ve noticed, I’ve added some advertisements to my blog. Nothing big but there they are. One of the services, if somebody bids for the privilege, will open up an ad page after the third page you visit on my blog (something called, with admirable relevance to a medical blog, interstitial advertising). Adbrite assures me that the reader can close it with no ill-effects and it is not a demonic pop-up. If it bothers a lot of you or become too much like a pop-up, I’ll take it down.

Why advertise? Well, I don’t think I’ll make a lot of money but it gives me an excuse to blog when my wife asks me why I can’t just surf for porn like other husbands.

4/6/07: Can a Physician Kick Ass and Take Names?

Every now and then I am asked to reconcile my love for the Marine Corps and my support for those, our Marine brothers and the other magnificent bastards, kicking down doors in Iraq and Afghanistan with the tenants of the Hippocratic Oath which, by conventional wisdom seems to preclude a doctor from calling in an airstrike.

While there are many versions of the Hippocratic Oath and it is continuously edited to suit the demands of political correctness, one thing on which everybody can agree is that the oath enjoins us to “First do no harm,” meaning that nothing we do should intentionally make the patient sicker than he was when we first met him. I agree with this concept completely but, and forgive me if this is obvious, this only applies to one’s patients.

The whole world is not my patient, only the small subset of them who I have symbolically “layed hands on” by accepting into my care. This is why I would give Usama Bin Laden the best treatment I possibly could if he came into the Emergency Department but would, on the other hand, cheerfully blow his head off if I had him in my sights.

Hippocrates himself, as Greek living in the 4th century BC probably owed some military obligation as a Hoplite for his polis and may have been involved in a campaign or two. Even philosophers, playwrights, poets, and others who would eschew miltary service today served in the phalanx when necessary.

4/5/07: Why Bother?

As you know, I am something of a critic of medical training. Not only do I believe that in many cases residency programs are money-making scams for hospitals (not that they started that way but things evolve) but the training itself is often highly inefficient and incredibly wasteful of money and resources. I have also been very clear that I think many of the common practices of residency are nothing but abuse of a kind that would lead to a class-action lawsuit in any other profession.

The drive to limit work hours was a tacit admission of this kind of abuse that, while not as prevalent today as it was even five years ago, is still fairly common. 80 hours per week is better than not having a limit of course, but even 80 hours is a lot. That’s twice what most people consider a normal job. We’re assuming that programs comply with the work hour rules but the truth is that many do not and encourage their residents to demonstrate the high ethical standards for which our profession is known by lying about their hours. Not to mention that even if a program complies with the letter of the law, you can still work a couple of 100-hour weeks in month because the 80 hours is an average over four weeks.

Now, if there’s one thing that makes my blood boil it the various toadies and representatives of The Man who try to justify this sort of thing. There is no justification for making somebody miss one night of sleep out of every three which is what a 100 hour week means. There is also no justification for giving a resident only a couple of real days off a month and sometimes counting post-call days as days off if you go home before noon. This kind of thing is just chicken-shit, along with the truly laughable salary, and you would have to have a spine made out of jello to let The Man convince you it isn’t.

So if it makes some of you uncomfortable to hear it (and you should see some of my private emails), well, that’s too bad.

Will I change anything? Probably not. But one thing I want to do is give you people just starting medical school the vocabulary and the concepts to both debate The Man and understand what a bunch of chumps we’ve all been for the last sixty years. I don’t ever want anybody to tell you that your asking for a day off, for example, or wanting to get a little sleep, is a sign of weakness without you laughing in his face and pulling his punk card.

4/3/07: The 800 Pound Fat Guy

I was going to try to work this into an amusing article but I thought I’d just come out and say it. As you know, the debate about the relative merits of our level of medical care and, for example, a certain European nation which is known for fighting harder to protect the sanctity of its cheeses than its borders…cough…cough…France…seems to boil down to a comparison of the percentage of GDP spent on medical care as it effects life expectancy. France, the francophiles bray, spends 11 percent of their GDP on medical care compared to our 16 percent and enjoys a small (and probably statistically insignificant) increase in life expectancy. This is all very well and good but if France enjoyed the same predatory legal climate that we take for granted here in the United States, who’s to say if their spending would top ours (as a percentage of GDP)?

While it’s true that the cost of awarded damages is insignificant in the big health care picture, this is a red herring anyways and a number quoted by our lawyer friends to justify thier predation on the medical system. The true cost of medical malpractice comes from high malpractice insurance premiums which, like every other business expense, are passed to the consumer (whether private of government), the truly astonishing amount of money spent on defensive medicine to protect against the ever-present threat of frivolous suits, and the huge paperwork burden imposed on nurses, mid-levels, and physicians documenting to the point of absurdity to “cover their asses.

Some estimate this cost as up to 500 billion dollars or more than a third of all costs.

Was there ever a more costly phrase than “If you didn’t document, it wasn’t done?” What does this mean, anyways? That good medical care wasn’t delivered if you didn’t spend an hour writing pointless notes? What it really means is that the legal environment has become so stifling that nobody trusts anybody and huge amounts of money are wasted covering our asses. This is the big fat guy sitting in the room who no other nation has to deal with. To fix this problem is difficult, but certainly easier and less painful than letting the government kidnap the entire health care system.

The ironic thing is that the same people who have no problem forcing physicians to work for free, appropriating to government vast amounts of public money, and even modifying the system to make the private practice of medicine illegal will become extremely sanctimonious about the constitution when it comes reigning in lawyers.

4/2/07: Chumps

I think a lot of my readers think I am making up some of the hardships of residency. I admit, I do use some revolutionary rhetoric here or there such as equating residency training to slavery when it clearly is not. But I figure that in a society where preening actors can claim to be “Fighting for HIV” when they are actually just being driven from fundraiser to fundraiser to have their asses kissed, well, I figure I can be excused if I use some colorful metaphors. I certainly have fought my way through the pack in a crowded trauma bay to a patient who (it is darkly whispered outside the trauma bay) is HIV positive, something that Susan Sarandon has never done.

So maybe residency training is not slavery, or even indentured servitude, but it is sort of like a sweat-shop which is nothing for anybody to either justify or be proud of. Either that or, as one of my good friends puts it, we are just a bunch of chumps to put up with what we do.

That’s it exactly. We’re chumps and punks. Chumps because even many residents buy into the abuse and condone it and punks because we put up with it. If you think I’m just piling on or complaining in isolation, I invite you to visit Irishdoc’s blog and get another view of the problem.

Folks, any employer who requires and expects you to go without sleep every fourth night and makes you so tired that you are a risk to yourself and others on the drive home is asking for trouble. One day some enterprising lawyer is going to make jeapordizing the health of residents a costly mistake for hospitals and that will be that.

Just an aside, when I was at Duke, a part of the orientation delved into the topic of how to effectively use caffeine from beverages to help stay alert and awake on call. I think a lawyer, and surely there are lawyers out there who are good for something, might make some hay out of this kind of de facto admission that keeping residents alert without stimulants might not be possible.

2/30/07: All Pigs are Equal, But Some Are More Equal than Others…

If I am to understand my critics correctly, the dfference between American health care, where we have a two-tiered system with the relatively well-off able to afford better health care than the poor, and the typical European health care system is that they have a two-tiered system with the relatively well-off able to afford better health care than the poor.

So the question is, why does a Greek or a Frenchman need to pay for additional health care if the system works so well? In other words, if health care is a right, it is a pretty sorry one. Imagine if the poor had less freedom of speech than the rich or if the rich could choose their religion but all of the poor had to be Methodists.

If you understand the concepts of scarcity, supply, demand, pricing, and production the answer is obvious. If you don’t, then for goodness sakes call your university and ask for a refund because they cheated you out of some valuable education.

3/28/07: Maybe if We Throw it Another Chunk of Meat it Will Leave Us Alone

All of the support for a Single Payer system of universal coverage seem to run something like this: “Well, since the government, through Medicaid and Medicare, already controls almost half of health care expenditures, we may as well give them control of the rest of it so we can reap the efficiencies of scale.”

This is under the well established theory that drunken sailors have an upper limit on the amount of money they will throw around for hookers and booze and past a certain point they will be as frugal as a parson.

What are you people smoking?