Ask Uncle Panda

1. Say, Uncle Panda, what exactly do you like about Emergency Medicine? I thought the hours were crazy and the burn-out rate was high. What about it?

From the perspective of residency training, Emergency Medicine is far superior to any other specialty. First of all, it’s the most like a regular job of any residency. With the exception of off-service rotations which will fill roughly a third of your three year training (most programs are three years long) you will be working set shifts with a pre-determined start and finish time. (Although you shouldn’t expect to get out exactly when your shift is over as there are usually things to either tie up or sign out.)

To my mind, there is nothing more annoying than coming in early to pre-round on patients only to round on them again with the attending. A tremendous waste of effort. I’m also not exactly sure why we need to come in early on rotations like internal medicine. It’s not like the patients are going anywhere. What invariably happens is a short burst of frenzied activity from 6 AM until ten followed by large patches of dead time until around four…at which point there is usually another burst of frenzied activity. I’m sure this pattern is inevitable but that doesn’t mean I have to like it.

As to burn out, I don’t know. I’m new to the profession and I will have to defer to the opinions of my more senior colleagues. It is my understanding that “burn-out” is greatly exaggerated. Emergency Medicine self-selects for people who like variety, working weird hours, and making quick decisions with incomplete information. While this would quickly burn out someone who likes a more deliberative pace, EM physicians look at this as routine and a good trade for working fewer hours and fewer days.

No questions that the pace is a lot more intense than most other specialties. In a busy emergency department the residents are working all the time. Productivity is critical in the “shop” and second and third year residents are expected to see and “dispo” at least 2.5 patients per hour. On a twelve hour shift this works out to 30 patients which is a lot. It is true that some patients have relatively minor complaints which don’t take that much time but as often as not the next three will be very sick with multiple comorbidities. Not to mention the traumas that roll in periodically. The net result of all this is that a good Emergency Medicine resident has to learn how to juggle multiple patients. If you can’t prioritize, organize, and keep track of multiple plans for many different patients you probably won’t like Emergency Medicine.

As to the hours, they are indeed crazy. While most programs make an effort to accommodate your circadian rhythm, when all is said and done you will be working a lot of nights and leading a vampire-like existence. On the other hand you will be driving opposite rush hour traffic, the banks will be open when you get off work, and academic teaching hospitals are a good deal more laid-back after normal working hours.

Does Family Practice suck?

No, of course not. I didn’t like it but that’s just me. As it emphasizes long-term management of chronic diseases it is not for those with ADD, short attention spans, or who get bored easily. I want to dispel the myth, however, that Family Physicians have some sort of leisurely, non-demanding lifestyle. The fact is that like any other job, productivity is important. In family medicine where the reimbursement for the usual visit is low, patient volume is important. A Family Medicine resident may see as many patients in a day as an Emergency Medicine resident. On the other hand he is unlikely to be working on more than two or three at a time, the presenting complaints are usually less acute, and the chances are good that the resident has seen the patient before and can skip some of the usual history taking.

It is also an unwritten but very real expectation of patients that their family doctor spend some time chatting with them. This is a very important part of the art of medicine but it does add to the time for a patient encounter, especially the family medicine patients that want to talk about everything and who will not shut up. A good family physician masters the art of redirecting the conversation without appearing rude and winnowing down a long list of complaints to the most pressing without appearing callous.

In the Emergency Department it is all right to be a little more brisk as the situation demands.

Just a random thought, maybe if they changed the name of the specialty it might attract more guys. Let’s face it, Family medicine has a decidedly feminine, non-threatening ring to it and calls to mind images of gentle, sensitive men nurturing woman and children. This is not how most guys see themselves. What most of us really want to do is get in touch with our inner Cro-Magnon, not our inner child.

Ask Uncle Panda

Can a Physician have an Opinion?

You No Like?

Although the comments posted by the readers of this blog have been generally positive, you may as well know that I have recieved quite a few irate private communications about my impression of Duke, Duke’s now defunct family medicine program, and Family Medicine in general. I say “irate” but perhaps dismissive would be a better word, the general tone being that as I was just an intern I don’t know what I’m talking about.

Some have even suggested that I am jeapordizing my professional career by publically criticising such a behemouth as Duke. I can’t get this image out of my head of Don Vito Corleone using all of those good empathy tricks to engage me, communicate his interest in me, and make me feel like I was a person worth his time before he had one of his heavies whack me.

I’m not going to belabor the obvious by chanting the mantra about this blog being just my opinion. Of course it is. And of course I am right about some things which makes it both my opinion and fact at the same time. Family Medicine is unpopular among American medical school graduates and the approach taken by Duke is not going to change this. The first statement is objective fact and the second is educated opinion. You can scream all you want, call me ignorant, insensitive, and a know-nothing but the community medicine experiment didn’t pan out, at least from the point of view of physician involvement, and I would suspect that other programs, particularly at my Alma Mater LSU Shreveport, who are either implementing or considering the Duke model are now having second thoughts. Either that or bureaucratic inertia, being the one unstoppable force in this bad old world of ours, is carrying them to their ruin.

As for not liking Duke, well, that is just personal opinion. This is going to sound trite but when I eat lunch with my collegues I like to talk about interesting things. At Duke, all anybody ever wants to talk about is medicine. Hey, I like medicine. It is interesting but it ain’t that interesting. Or rather, listening to somebody pontificating about it is not that interesting, particularly when they start throwing the results of studies at me.

Eyes glaze over. That’s why I do my own reading every day. It is more efficient, I learn more, and I am not trapped in a lunch conference looking at power-points eating organic chicken wraps. What I really like to do for lunch (if all of my patients are taken care of and nothing needs to be done) is drink a Cherry Diet Coke and listen to Rush Limbaugh.

Is that a crime? Just like I believe that sleep should not be a privelege and therefore call blows, I also believe that a break every now and then is not a sign of weakness but merely a desire to refresh the brain by contemplating other things besides work or even nothing at all. Unless you are a surgeon, the day is not so chock-full of activity that we can’t enjoy a pleasant meal together where we talk about sports, movies, or girls we’ve banged.

So the thing I dislike about Duke was that everybody was so obssesive, to the point that it was nearly impossible to hold a normal conversation. I actually witnessed, on many occasions, interns pimping other interns. This happened to me at lunch once when the conversation inevitably turned to medicine and one of my fellow interns turned to me and said, “Hey, Panda, what’s the differential for painless hematuria.”

“Your mother,” was my prompt reply.

Hey, I’m eating here. I don’t want to talk about or contemplate genitourinary issues. Is that too wierd?

Can a Physician have an Opinion?