On the Shoulders of Giants

Shaman Healer of the Lame Caribou Clan

(After years of research, French anthropologists have managed to translate the famous cave paintings of Lascaux. The full translation will appear in next month’s “Journal of Linguistic Anthropology” but I thought I’d publish a sneak preview. -PB)

Me. Tharg. Shaman Healer of the Lame Caribou clan. Master of the Elk. Spirit-Hunter of the Sky Bison who is called Tharg-Who-Outran-Cave-Bear. I paint this in the Cold Time after the rains when the moon shines like new flint by glow of Brother Flame deep in the caves of our ancestors.

Troubled times. Like mastadon balancing on ice floe is to be Shaman of clan. Precarious, like squirrel caught between tree and wolverine. Like seal pup in path of charging walrus. You get picture.

“New magic salve,” say Olerg, wandering master of lore,”much better old salve. From dung snow fox.”

“Ward off tiger?” Olerg smile too much. Like crazed hyena.

“Tiger? New salve ward off even charging musk oxen. Know Tholar and Gronak?”

“My two brother shaman whose eyes dark from spell at birth?”

“Yes. Salve save them from musk ox. I Swear by Otter spirit. Study was double-blinded.”

Roll eyes. Old salve plenty good.

“Here, have spear with fox totem,” say Olerg offering crappy Neandrathal spear.

“I thank you, oh Olerg, my brother. Have plenty from last visit. But great joy have I for haunch of elk.”

“Oh wonderous spear!” say Otter-spawn, Shaman-to-be, resides-in-cave lo these past winters, “I take?”

Otter-spawn Chief of those-who-reside-in-cave and from me learn dark arts of shaman. Good boy but lazy.

“I go my fire, Otter-spawn. Keep the long watches of the night. Othar has demon of pestilent bowel and need sacred smoke when Sister Moon dips to embrace of far hills. Trulak need horn of great elk when Sister Owl return to tree. Sound ram horn if not work.”

“I abase myself oh Tharg-Who-Outran-Cave-Bear but I, too, go to my fire now,” Say Otter-spawn.

“Who will keep watches of night?”

“Is wonderous puzzlement,” say Otter-spawn, “But great hearth-fire in sky has passed in number like petals of tundra blossom and great spirit commands that He-Who-resides-in-Cave also lie by fire, gnawing rib of great sloth.”

“Does not Cougar-paw reside-in-cave?”

“He reside-in-cave of Bone Diviner in valley of snow hare. Not return for many moons.”

“Twisted-crow?”

“In service of Painted Eagle clan.”

“Go then,” I irritated, “But when Tharg reside-in-cave, took night watches in number like bison on plain.”

“Fetid Badger,” I call. Him best Shaman-pupil.

“I grovel oh Tharg-Who-Outran-Cave bear,” say Fetid Badger. Other pupils cower behind.

“If sky-wolf eat sister moon and woman yet bleed, what cause?” Simple question. They third winter pupils.

“Curse of Otah, the Cave Demon?” Ask Fetid Badger, like tremulous new-born caribou.

“Bah. Laughing Brook?”

Laughing Brook knit sloping brow. “Spell of Wola, the Womb Blighter?”

“Not see picture-on-rock? Not listen song of ancestors?” I irritated again, “Come pupils, hear thunder of hoofs, think bison, not cave yak. Go prepare magic wall picture of many cause womb bleeding.”

Ragrak, Chief of Lame Caribou clan stride into cave. Pupils cower, urinate submissively.

“Tharg Who-Outran-Cave-Bear!” growl Chief, “Ill tidings I bring.”

“What is problem?”

“Know you new female stolen before rains from Clan of Painted Eagle?” Ask Chief.

“Female with hair like mane of horse?”

“That her. And haunches like snow leopard, hips like fertile hills, heavy with promise of many fine sons.” Chief kick last of pupils out cave. Chief old, hair like snow of many winters. See where this going.

“Sometimes brother ferret not want come out of den.” say chief.

“Not understand.”

“No longer rampant stallion but seal pup, soft and helpless.” Chief annoyed.

“Have new salve. Dung of snow fox. You try.”

On the Shoulders of Giants

Clinical Evaluations

Actual Evaluation by My Residents and Attendings

(Just for old time’s sake I reviewed my Dean’s letter. Man, those were the days! -PB)

OB/Gyn: Student is on time and does everything asked of him willingly and with good humor but seemed uninterested in assisting in any more vaginal deliveries than were required to pass the rotation. Actually winced, yes winced, when he was sprayed with urine and feces during one particularly rapid delivery. Commented to me that it was “Nothing like the Discovery Channel.”

OB/Gyn: Student Doctor Bear is on time and cheerful but does not fight hard enough to be the first to see patients complaining of vaginal discharge. I don’t think he should fail the rotation but I am giving him low marks for referring to our weekly STD clinic as “Kooter Patrol.” I also caught him rolling his eyes as I lectured a young, single, G5P4004 on the need for greater personal responsibility. I didn’t quite understand what he meant when he invited me to “repeat my advice to the wall and see if there was any difference” but I think he was making fun of me. Student Doctor Bear also showed no interest in standing around doing nothing while I performed a particularly difficult colposcopy.

General Surgery: Student Doctor Bear did everything asked of him but was singularly unenthusiastic about holding a retractor for six hours. He does not seem to enjoy call and never seems to either know or care about the answers to the random trivia question I ask him just to keep him on his toes.

Medicine: Does not seem enthusiastic. Once actually sat down (!) during rounds…and the attending and all of the residents were still standing! Had an insolent, “you people keep talking while I rest my feet,” expression on his face and ignored every frantic hand gesture to stand up before he made the attending mad. When the attending asked, with admirable sarcasm, “Are you tired, Student Doctor Bear?” he said, “Yes,” and persisted in his sitting position until we had moved to the next patient. And then, oh weep thou heavens and hide thine eyes in shame, when the attending suggested that maybe he wasn’t cut out for internal medicine he replied, “You’re probably right about that.”

Medicine: For reasons unknown to me, Student Doctor Bear is uninterested in electrolytes. Even after spending a brief forty-five minutes discussing a patient’s Potassium (Peace Be Upon Its Holy Name) level his only comment was, “So, do you think we need to supplement it?” Supplement it? Is the wind’s name Mariah? Can we began to explore the intricacies of Potassium (PBUIHN) in the brief time we had between five PM and eight PM when the silly rules require us to let our medical students go home to study?

Pediatrics: A good medical student but he has kids of his own so I don’t think he believes us when we say how great working with kids is. Changes diapers like a pro and is not awkward at all when handling the babies.

Heme-Onc: Did not directly observe the medical student. If you tell me he was on the rotation I’ll believe you and I do seem to remember catching a brief glimpse of him hanging way, way back in the team but when I blinked he was gone. I could probably review the hospital surveillance tapes if you really need an evaluation but I suspect finding more than a few seconds of footage will be more difficult than locating Big Foot.

Surgery: Not a good medical student at all. Despite never having been in an operating room, rotated on a surgery team, observed any operations, or completed a surgery residency, Student Doctor Bear displays absolutely no knowledge of how we do things in the OR, where to stand, and what my favorite music is. And this was his his second day of third year, for crying out loud. And he is woefully ignorant of the collateral circulation supplying the anterior two-thirds of the left adrenal gland even though he should have learned this in first year anatomy.

Family Medicine: I detected a lot of resistance from Student Doctor Bear. He seems reluctant to hug the patients and his sympathetic nodding skills are woefully inadequate. His empathy skills also need work. For example, when a patient complains about knee pain Student Doctor Bear needs to refer her to physical therapy, not comment that it is “No wonder because every time you stand up you squat-press a small German car.”

Family Medicine: He’s not buying it. Student Doctor Bear is not ready to board the Primary Care Mother Ship. Maybe we could have tried sleep deprivation and a low protein diet but he we didn’t have the time.

Clinical Evaluations

The End of the World As We Know It

Back to the Future

“So you want to hear how your old Grandpa lost his leg do you? I know what you’re thinking and no, I didn’t lose it in the Burger Wars. You’ve seen my old uniform hanging in the closet but by the time I enlisted…oh..had to have been the Summer of 2057… the war was almost over and what was left of the McDonald’s forces were either surrendering in droves or holding out at isolated food courts in places like Duluth.”

“I’m sure you’ve seen the videos and learned all about it in school. I’m sometimes sorry I missed the action but I guess it was for the best. I’m not sure I had what it takes to kill a man, even if he was one of those bloodthirsty pan-frying monsters. (‘Happy Meal’ my ass.) I remember watching thousands of them being marched to the prisoner of war camps. But you know, other than their yellow and orange uniforms and their Iron Clown insignia they looked pretty much like our boys so maybe they really didn’t commit all of those atrocities.”

“Anyways, I spent my enlistment in the Burger King Reserves guarding a couple of Arby’s and a Wendy’s off of Exit 54. In fact, I never even fired my weapon except for a couple of potshots at a burning Golden Arches in front of a McDonald’s down the road that had taken a direct hit from a lard-seeking cluster bomb.”

“My leg? Oh. Well, one day…must have been twenty years ago…I started having chest pain and figured I needed a doctor…”

“What’s a doctor, you ask? Well, I guess you kids have never heard of doctors. I suppose they don’t mention them much in the history holograms either. Let’s see…Well…Once upon a time if you got sick or injured you went to see a person called a ‘doctor’ who supposedly knew a lot about diseases and how to cure them. These guys went to school for years and years learning a bunch of essentially useless knowledge and then spent the rest of their lives rubbing it in our faces. Not to mention raking in obscene amounts of money. They were replaced by something called a Physician Assistant around thirty years ago.”

“I see some of you remember Physician Assistants or have at least heard your parents talking about them. They’re pretty much gone now, too. Same with Nurse Practitioners. If we weren’t going to let somebody with ten years of medical education strut around there was no way we were going to allow some wanker with only two years to get all big-headed either.”

“My leg? I’m getting to it. Patience.”

“So anyways I started having chest pain and since I wasn’t sure if it was my heart or reflux I thought I’d get it checked out at Cath-in-the-Box.”

“Never go through the hover-through. They fuck you in the the hover-through. If I could do it over again I would have gone in but I was in a hurry. I’m pretty sure they got my order right. It’s pretty hard to yell symptoms into that stupid clown microphone and the questions they asked me were kind of garbled but I figured, hey, it’s a just a heart cath. Their sign says ‘One Billion Stented.’ They do them all the time. It’s not rocket science after all. Just squirting some dye into an artery and inflating a balloon. A monkey could do it.”

“So I get to the window and pay (I think it was 50 bucks which was a lot back then), turn on the radio, stick my leg into the slot and figure I’ll be out of there in five minutes. The pimply-faced kid who took my symptoms is running around putting in arterial sheaths which is not very difficult to do and why they have minimum wage high-school kids doing it. I could tell he was having a little trouble and his “trainee” badge should have tipped me off because by the time he got to me…well…let’s just say his sterile technique left a little to be desired. At least the assistant manager did the actual procedure. He was probably pretty good at it because, as you know, Cath-in-the-Box sends all of their managers to PCI-U for an extensive six-week training course. He maneuvered the C-arm into my car and six minutes later I had a stent in the ‘big artery thing that, like, runs down the front of the heart.’ I felt pretty good and my chest pain was gone so I figured that the a little bit of melted plastic on the dash was a small price to pay. The little “dosimeter” toy that came with the PCI-combo said that my radiation dose was within normal limits and the complementary EKG thingy showed the usual incomprehensible squiggly lines which the assistant manager believed were normal but wasn’t really sure.”

“A couple of days later I notice that my groin was all red and puffy and, to be perfectly honest, I felt like crap. They always stiff you on on the antibiotics at Cath-in-the-Box so I figured I’d get some from the corner Jiffy-mart. A pharmacy, you say? I see we’ve got a budding historian here. Of course I didn’t go to a pharmacy. Even back then they were all gone. As if I needed some over-educated pharmacist with his pricey doctorate-level education and thousands of useless and expensive facts giving me high priced pills with fancy Latin names. No thank you! The last Pharmacist died of old age at Suburbia Village a couple of years ago. (You know, it’s that replica of a small town from the early 2000’s where people dress in period costumes and work at authentic jobs from the turn of the century. Remember how we took you kids there a few Ramadans ago and Jimmy got sick on Slurpees?)”

“So they have a couple of good antibiotics there. I picked Panabx because it has a good blend of antibiotics and I don’t think I’m allergic to any any of them. I like their jingle, too:”

“Panabx, Panabx,
Drip, fever, sepsis got you in a fix?
Need somethin’ that’ll do the trix?
Then you need Panabx!”

“And then they had all of the good-looking topless girls running through the woods. Come on, I’m sure you’ve seen the commercial on the holoscreen. It’s the one set to the tune of that really cool, old Kevin Federline song.”

“Anyways, my leg kept getting redder and redder and I started having alternating chills and fevers. ‘Oh great,’ I said to myself, ‘you’re septic again, just like after your self-service splenectomy over at Organs n’ Things.’ I tried a few more brands of antibiotics but I’m pretty loyal to Panabx so I thought if one dose wouldn’t do the trick, I’d try eight. Your Uncle Scott who’s a professor over at Marshal Mathers University (or M and M) suggested that I might need to get it amputated but he’s a rich frickin’ psychologist. What did he know?”

“Turns out he was right. I staggered over to Home Depot and I’m afraid I might have been a little incoherent from the fever because their little orange aprons looked like the MacDonald’s uniforms and I might have tried to eviscerate a couple of the associates with a cordless laser saw. After they tackled me to the ground and duct-taped my arms to my sides, I sat through a health-improvement seminar taught by a really nice guy named Chip. I bought the Black and Decker Limbzall and your grandma and Uncle Scott held me down while the take-out anesthesia took effect. When I recovered my leg was gone and everybody looked at me like, ‘Dude, you were so acting like a retard.'”

“I wrote a nice letter to Cath-in-the-Box and they refunded my money which was nice of them.”

“Would a doctor have done a better job? Maybe a little better but it’s not worth all of the questions, testing and general screwing around that they used to do to get your money. What my past medical history or whether I smoke has to do with anything is beyond me. They never waste your time with that kind of thing at Cath-in-the-Box or Bile, Bowel, and Beyond which is why medical care is so cheap, quick, and affordable nowadays. If I have another heart attack I’ll probably just get a quick thrombolytic out of the vending machine. They have a whole bunch of them down at the Stroke-o-mat. It’s pretty safe if you just read the friggin’ instructions on the front of the machine.”

The End of the World As We Know It

Guest Blogger: Mrs. Panda Bear

My Better Half

(Every guy has one great love. A woman who sets his heart beating by her beauty, her wit, and her charm. She doesn’t have to be Rebecca of Sunnybrook Farm but some combination of her looks and personality strikes you like a thunderbolt the first time you meet her. Unfortunately, not every guy marries this girl and many end up settling. I was lucky enough to trick the perfect girl into marrying me and I have never regretted or been unhappy for a single day in our marriage, probably because our relationship is built on a long friendship before we started dating. Not that I didn’t want to date her the first time I saw her, you understand, but I guess I had to grow on her.

Of love, that over-rated and poorly understood emotion, respect is the better part and without it love would be little more than thinly disguised contempt. Such a relationship would be an unhappy one if it even lasted. I am lucky, on the other hand, to have the respect of my wife and I work hard to justify it. I owe her a lot. Simply because I wanted to, she allowed us to trade a good career, financial security, and stability for the instability and poverty of medical school and residency. She has given up a lot. The last move was particularly hard as we had just unpacked, it seemed, when we began the long and arduous process of selling the house and moving again.

So I don’t ask for a lot of sympathy from my wife and she is confident enough in our love and our friendship to give it to me straight, especially when I am tempted, like most interns, to feel a little sorry for myself. Residency is hard but there are harder things, particularly the sacrifices of a stay-at-home mom taking care of four young children. Those of you who are married with kids need to keep this in mind as you slog through medical school and residency. It is a grind for your wife, too. My wife periodically had to set me back on track last year when, as you my faithful and tolerant readers know, we had suffered the setback of scrambling into a specialty and a hospital which I disliked intensely.

In this article, Mrs. Bear identifies one of the worst aspects of intern year as well. -PB)

It was that time of the month. Those first five days when he felt awkward, inadequate, and really, really dumb. Every month of intern year he suffered from the anxiety and low self-esteem of being the new kid on the block. As for myself, being a stay at home mother of four children, I have many many things on which to concentrate my efforts. I depended on my husband to fulfill his commitment to his residency program so that I could take care of the home front. So why did he exhibit anxiety and depression?

Children often have temper tantrums when their routine is changed. I suppose these children grow up to be adults who flourish in a stable consistent environment. I knew our son had difficulties with changes in his routine. I wasn’t expecting my husband to have these difficulties as well. In fact, he was the last person on Earth I would have expected to have difficulties with switching from one rotation to another during intern year. When I knew him as a Marine, he was always on the go. He never owned more than what would fit into one sea bag. I cringe at the things he tells me he and his Marine Corps buddies threw overboard as they approached shore.

My job as his wife metamorphosed to include therapist. I sat on the couch and listened to his stories about his day. They were a lot more interesting than what I had to say about our children’s bowel habits (which are very important to a mother). It was several months into intern year that I recognized a pattern. During the first week of a new rotation he was almost miserable. As the days went by he became more and more confident. About the time when he felt he had become a useful team member it was time to begin a new rotation.

When one member of the family is suffering, the whole family suffers. It became my purpose to remind my husband that everything is new and “they” didn’t expect him to know anything when he started a new rotation. With this realization he became more at ease with his ever changing schedule thus becoming a better human being to live with.
Guest Blogger: Mrs. Panda Bear

Ask the Panda: More on Physician Assistants

Hey Panda. I’m a PA and I don’t like you much even though I inflict your blog on myself religiously. What do you think about Physician Assistants and Nurse Practitioners taking over from doctors? They might even replace you, Mister Emergency-Medicine-Smarty-Panda-Pants.

Another excellent question and a source of great angst among those who are contemplating primary care. As some of you know, Physician Assistants and their sinister cousins, Nurse Practitioners, practice pretty much independently as primary care clinicians in much of the United States, especially the rural and so-called medically underserved areas. Ostensibly they practice under the supervision of a physicians but this supervision is often pro forma and might involve an infrequent cursory review of a handful of charts by a retired physician not concerned about liability and just looking for an easy gig to make a little extra income.

Let’s get a few thing straight at the outset. First, we live in an egalitarian society that delights in thumbing its nose at authority. With this in mind, you are never going to convince the public that physicians should monopolize health care through anything equivalent to the divine right of kings. The public will turn against any group of uppity physicians oppressing the little guy to protect their ill-gotten six-figure salary. You know what is involved in medical training but I guarantee that the bulk of the sturdy and not-so-sturdy yeomanry don’t have a clue and don’t care about your sacrifices. I may think you deserve the six-figures but it’s going to be a hard-sell to the voter working down at the plywood plant for a small fraction of your salary.

Second, we should be against monopolies. A good or service of reasonable quality should be provided to the public at the lowest possible price which is determined by competition in the free market. I’ve been anti-union and for free trade for my whole life and I’d be a hypocrite to change my position simply because it’s my ox being gored.

The question then becomes, as was implied in the previous post, are the services of a residency-trained physician of greater value than those of a less well-trained physician assistant? I believe they are but let’s not get silly about it. Physician Assistants and Nurse Practitioners are not stupid and are more than qualified to handle the majority of primary care. I think it would be criminally insane to send your aging mother with twenty competing comorbidities to a PA but does it take a doctorate level degree to treat a kid with an ear infection?

Of course not, and this is the hook that mid-level providers have with the legislature. They are cheaper than physicians, they can reasonably demonstrate that they can do some of the same work, and since giving away other people’s services is the epitome of compassion, the mid-levels provide the trapping of political compassion at fire sale prices. Whether the public is being well-served is immaterial. It’s just primary care, after all, and the mistakes are slow to evolve and can be ascribed to half a dozen causes other than clinician error.

So what’s the drawback? As you know I’m an Emergency Medicine resident. Forget what you’ve heard about Family Practice or Internal Medicine, the Emergency Physician is the true generalist. From Pediatrics to Obstetrics to Internal Medicine, the Emergency physician has to be able to make intelligent decisions involving almost every specialty and the amount of medical knowledge and skill required to do this is immense and humbling. Not a day goes by where I don’t come against the limits of my knowledge and I have been hard at it for almost six years. And I still have two more years of training before I can practice independently of skilled supervision. If you think that some guy straight out of a two-year masters program is equal to the task then God love you, you’re a true man of the people, but you are crazier than a shithouse rat.

Also consider the training required for by an internist, the basic foot-soldier of the medical profession, not to mention that required for surgical or subspecialty training. To say that a mid-level is equivalent to a trained physician is the same as saying that we are all wasting our time in residency. And that, my friends, is the question which leads us too…

Will Physician Assistants and Nurse Practitioner take over primary care?

Yes. No. It doesn’t matter.

Yes, because American medical school graduates are not exactly flooding the zone protecting their territory from the rapacious inroads of the mid-level providers. Family Medicine, the paragon of primary care is, for several reasons, the least popular career path. It takes a special person to want to do family medicine as you must not only run between the Scylla and Charybdis of your peer’s ridicule but you must also lash yourself to the mast of primary care against the siren call of more lucrative specialties.

It is no wonder then that mid-level providers can move effortlessly into the vast, unpopulated territory of primary care. They may not be residency trained and a typical graduating family practice resident may have three times the skill and knowledge but (to paraphrase the popular World War II joke) they may not have have more than the doctor but what they have they have over here.

For its part, the family medicine establishment has done everything in it’s power to ease the transition towards primary care by mid-levels. First it was the “gatekeeper” paradigm where the primary care doctor was the traffic cop directing most of his patients to the appropriate specialist for definitive treatment. Many things need to be referred, of course, but it doesn’t take an expensive degree to decide which specialist should see a patient. When you surrender your ability to diagnose and treat complicated patients, or lose your nerve, all that you have left is low-level primary care which really could be done by a motivated high-school student much less a Physician Assistant.

The current paradigm is “community medicine” where the traditional diagnostic and treatment function of the physician, the medical skill for which he is sought, is subordinated to the needs of society, “well-being,” and half a dozen other cockamamie functions which dilute the only advantage a residency trained Family Practitioner has over a social worker, much less a lean and hungry PA stalking wolf-like along the periphery of the sickly primary care herd.

Not to mention that those in the avant garde of Family Practice have fallen so deeply in love with team-based medicine where the physician is just an equal player in one of those goofy, non-competitive games where nobody loses and everybody wins that change will never come from that direction.

On the other hand, even many PAs don’t want to go into primary care preferring to subspecialize as physicians extenders. It seems every specialty group has it’s cadre of PAs and NPs rounding on stable patients, assisting in the operating room, or clearing out the backlog of routine clinic patients. In fact, as one of my readers once pointed out, Physician Assistants perform many of the same functions in private practice as residents do in academic medicine.

So no, despite the snowballing numbers of midlevel providers, physicians will not vanish from primary care. They may just have to practice at a higher level, eschewing the current trend to water down their medical knowledge with all of that creepy social work stuff but there are plenty of sick people out there. Not to mention that there is huge bolus of baby-boomers about to start getting really, really sick and they are going to want to see a doctor, not a school nurse.

But you can probably kiss the typical low-acuity practice goodbye.

Ask the Panda: More on Physician Assistants

Ask the Panda: Physician Assistants

Hey, Panda, what’s up with Physician Assistants? There are a bunch of them rotating with me and they say that they are just as well trained as doctors and can make more money. To tell you the truth, they are kind of a pain in the ass.

Excellent question. For those of you who don’t know, Physician Assistants are non-physician clinicians who are licensed to practice medicine under the supervision of a physician. Ideally, they are used in the role of “extenders” and might, for example, round on a surgeon’s patients in the hospital leaving him free to spend more time doing cases. Almost all specialties have a definite need for PAs. In Emergency Medicine, for example, PAs often handle the urgent care or less acute cases. Some rural Emergency Departments, however, are staffed by PAs who have received extra training in Emergency Medicine. This is a direct result of both a shortage of physicians in underserved areas and financial pressures on hospitals, private practices, and municipalities as PAs are generally cheaper to hire than a residency-trained physicians.

Many PAs working in lucrative specialties can, in fact, make more money than physicians working in primary care. I know a PA who has been working for a local neurosurgeon for the last twenty years and without going into the specifics, most Family Practice physicians would be envious of his compensation. But generally, a PA will make considerably less than the residency-trained physician in that specailty. I mention this because you will hear many PAs bragging that they can make more than doctors. This is true, but in any given specialty PAs are hired because they are more economical than physicians for the level of work they do. If the cost is the same or more there is no advantage.

Are they as well-trained as you will be after you finish medical school and residency? Of course not. No doubt a PA who has been in practice for ten years probably knows more practical medicine than a freshly minted intern. But we’re not comparing apples on apples. If you compare, let’s say, the training of a brand new PA who has just finished his two-and-a-half year program with the training of a brand new internal medicine attending who has just finished his seven year training program there is no contest. I am going to get a lot of hate mail for pointing out this simple and obvious fact but a PA, by and large, can practice after he completes PA school. A physician can only practice after both medical school and an extensive period of residency training.

Do the math.

The question then becomes, do you need seven years or more of training to function as a physician? This is the 64-dollar question. As many of you will find out, apart from the legal requirements, a lot of medicine is fairly bread-and-butter and could be handled by a school nurse much less a PA. I have done several out-patient pediatric rotations and with the exception of a few interesting cases, it was nothing but viral gastroenteritis (the craps), viral upper respiratory infections (the coughs), or eczema (the itches). Not to mention “Well Child Checks” that could be done by a trained monkey which is why they have interns do them. Likewise, an otherwise healthy man with hypertension probably does not need your medical degree from Johns Hopkin and your residency training from Duke to have a couple of prescription written every six months.

On the other hand a lot of medicine is not bread and butter. Part of your training is learning to know your limitations and the scary thing about PAs and other mid-levels is that, having only sipped sparingly from the well of knowledge, their little knowledge can be a dangerous thing. Things can get out of hand easily in medicine, either quickly because of mistakes made in acute interventions, or slowly as the result of bad judgement or mismanagement of chronic conditions. Physicians, for their part, are not immune from errors and bad decisions but imagine the danger from someone with a third of the formal training who gets in over his head and doesn’t know enough to realize it except when it is too late.

I had a patient with a Pulmonary Embolus, for example, who despite a history of obesity, oral contraceptives, and smoking was diagnosed with “Viral Upper Respiratory Infection” by a PA in an urgent care clinic only hours before she was brought in by ambulance for severe shortness of breath. This is a pretty simple example and most PAs would pick up the not-so-subtle clues in the patient’s history but there are thousands of permutations and combinations of symptoms and long formal training which includes didactics is definitely a major advantage. Whether this is recognized politically is another story. To a politician or anybody making public policy, “health care providors” are interchangeable components and one is as good as another to demonstrate a compassionate concern for univeral access to health care. It is also easy to make scapegoats out of “rich doctors,” most of who are not actually rich, especially as the public by-and-large has no idea how much low-paid and no-paid training is required to make a doctor. My neighbors sneer at the state of my lawn and opine that a guy like me pulling in the proverbial six-figures could pay to have it mowed more often.

The other thing you’re going to hear a lot from PAs is that they get better clinical training in PA school than you get in medical school. As evidence of this they will point to their greater facility with physical exams, blood draws, and other basic medical skills than you have as a third year medical student. Again, this is not comparing apples with apples. PA students learn practical clinical skills almost from the start of their training so they show up on the wards with a slight advantage. Medical students, on the other hand, learn practically no clinical skills during first and second year as these years are dedicated to basic science and general medical knowledge. By the end of fourth year your practical skills will be far beyond those of a PA student who only acutally does one year of clincal work compared to your two and, at least at the three medical centers where I have rotated with PAs, don’t do call and work substantuially fewer hours than the medical students.

“Oh yeah,” some PAs say, “But most of what you learn in first and second year of medical school is of no practical value and besides, you forget most of it.”

As you know, I am not the biggest fan of medical training. And it is true that a knowledge of some esoteric topics like embryology is rarely, if ever, needed by the majority of physicians. But I have never regreted the many hours I spent learning these topics and I think it is the height of arrogance for both medical students and PAs to decide, based on their limited experience, what is necessary knowledge and what is not. Medical knowlege forms part of your deep medical personality and besides serving as a platform on which to build the knowledge that you should be acquiring for your whole medical career, also allows you to speak intelligently and authoritatively to an increasingly medically sophisticated public.

Besides, this particular sword cuts deeply both ways. Why stop at medical school if we want to eradicate useless knowledge? I’m sure I can ride aggresvely through the curriculum of PA school, nursing school, paramedic school, and any school you care to mention, slashing, burning, raping, and pillaging innocent knowledge from the curriculum with the abandon of a deranged mongol and the bread-and-butter patient would still get his prescription for Glucophage. Let’s just do away with the whole deceptive edifice and recruit motivated and reasonably intelligent high school students to staff highly specialized low-level clinics in much the same way we fill positions in the fast food industry.

In short, while it is reasonable to worry about the encroachment of mid-levels into the practice of medicine, this is a political thing and not a reflection on the intensive and necessary training you are recieving.

Ask the Panda: Physician Assistants

Again Apropos of Nothing Part C

Half-Measures

( Disclaimer: Those of you with weak stomachs or who are excessively idealistic may skip this article in which I describe how one may subvert the conventional wisdom and get accepted to medical school. As you know, I believe the medical school admission process is idiotic. It encourages self-aggrandizement and has more hoops to it than a traveling poodle circus. It is also weighted heavily against the older, more stable applicant who may have a job, a family, and no time for the usual mock compassion of the typical pre-med student.

My favorite character from literature is Odysseus. He was neither the strongest, the bravest, nor even the smartest of the Achaeans but he was certainly the most cunning. Wiley Odysseus could keep his head and accomplish through cunning and a little chicanery what others with more overt prowess couldn’t. Somewhat like Odysseus, I’m not stupid but on the other hand I am not nearly as intelligent, talented, motivated, or even as passionate as the medical heros with whom I had to compete. -PB)

I wouldn’t say I had it harder than a typical pre-med student but I did have some unique problems. First, I had a full-time engineering job at a firm that expected some real work out of me. This would complicate the task of taking the pre-requisites I lacked, about 18 month’s worth at the rate of one course a quarter. But I did have contacts and a solid reputation so by virtue of being a licensed Professional Engineer I was able to start my own engineering firm and get a little more schedule flexibility.

Next, my GPA “blew hind titty” as my advisor was so kind to point out. This only confirmed what my mother warned me about: You do have permanent record and it will bite you in the ass some day. There wasn’t much I could do about it but I did have a couple of advantages. First, from the point of view of an engineer, classes in the biological sciences, at least at the level required for medical school admissions, are ridiculously easy. There are no formulas to memorize, no design problems to solve, and no math is required. It’s all just reading and a little binge-and-purge memorization. Organic chemistry was challenging but I latched onto a professor who didn’t believe in grades and rode out those classes with no worse damage then having to listen to his philosophical ramblings.

Second, I have always been good at math and had gotten good grades in just about every math course from Algebra to Differential Equations. This is important because a big component of your AMCAS application is the BPCM (Biology, Physics, Chemistry, and Math) GPA. The upshot of this was that my BPCM GPA was almost perfect, considering the easy A in organic chemistry, the easy physics A when I was just out of the Marines and studying like a real student, and the child-like simplicity of “Biology 101″ and “Anatomy and Physiology (for Sociology Majors).”

Not to mention that Engineering classes, as they are neither math nor physics don’t count in the BPCM GPA, or at least that was my assumption and I guess I was right because the AMCAS bought it. The only ones I counted as either Math or Physics were the ones were I got an A (very few actually) and that I could stretch a bit. I listed Statics as physics and Finite Element Design as math but left Structural Concrete and Fluid Mechanics alone. Hey, at that time I was angling for every advantage I could get. I really enjoyed college in the early eighties and my cumulative GPA was really, really low. (2.8).

Then there was the question of volunteering. As there was no online pre-med community at that time I never felt it necessary to go to Africa to hold dying babies. I figured EMT training might be interesting and, as I had no disdainful premed friends to talk me out of it, I took a course at the famous Delta Ouachita Community College (or the “Harvard of Ouachita Parish” as it is commonly known).

I did the minimum possible volunteering as an EMT, and I mean minimum, to let me put it on my AMCAS application with a clean conscience. What’s the point, really? At that time my wife and I had a new baby in the house who refused to sleep, I was taking classes, working full-time, my father had just died, and I was gearing up for the MCAT. Medical school admissions, as I realized even then, was a game and if I needed to show some volunteering, well, I’d check the box but there was no need to get stupid about it. There are just not enough hours in the day, especially as I now know for sure that none of it really matters. The top students in your medical school class, the ones who shadowed doctors so much that they could get board certified, are all gunning for radiology just so they don’t have to touch patients ever again.

Or, to put it another way, medical school admissions is a big fat guy standing between you and the basket. You’re going to have to get by him. He’s fat but suprisingly agile. You can charge him and hope he backs down or you can try to sneak around him. Sometimes he’ll fall for a feint and you can get around clean but the odds are you will make contact and he will get some sweat on you. Getting past him is the challenge and it doesn’t matter how you do it. I’m not advocating kicking him in the nuts or anything like that but fortune favors the crafty and the bold. Later, as you eat the cheeses and hams of victory, you’re not going to look back and regret outwitting the fat guy.

The MCAT was a big hurdle but more of a psychological one. I geared up to study, as I said, but I never actually did except for a few desultory attempts to read the MCAT “Gold Standard.” I figured I would do well enough on the Physical Sciences section, would eat the Verbal Reasoning Section for lunch, and could fake my way through the Biological Sciences section which is pretty much how things went down. I got a 29. Not spectacular but good enough for Louisiana. When I got my scores, my wife read me the sample scores from the front page over the phone which added up to 24. “That’s it,” I thought. All that effort for nothing. She called me back a few minutes later, apologized, and read the actual scores.

The MCAT is a standardized test. It is all multiple choice and designed to test your knowledge in a broad but still limited number of subjects. None of the MCAT questions will come from left-field or require any creative thinking on your part. The concepts are fairly simple, the questions don’t go into great detail, and in the rare case that a question might absolutely turn your guts, you can skip it and write it off to bad luck. You have to know a lot, no question about it, but the most efficient way to study for any multiple choice, standardized (emphasis on the “standardized”) test is to do practice questions. You can take an MCAT review course, you can buy review books and read them religiously. I’m not saying this is useless. But, like the USMLE, to truly focus on testable subjects you need to pay for any or many online question banks and go to it. And make sure the question bank includes explanations for the right and wrong answers.

The authors of standardized tests have a limited repertoire. There are only so many ways, for example, to ask you a multiple choice question on the basics of circuit analysis. If you do enough practice questions you will recognize the pattern. If you just read about it you will rapidly forget the specifics. The same with sitting in Kaplan and listening to some graduate student drone on about it. It is easier to remember a pattern than facts and the facts will come if you remember the pattern. If you don’t agree with me you may do as you please or go to the devil for all I care. The object here is not learn the subjects, you should already have a grasp on them.

The object is to get by the fat guy.

I only completed applications for my two state medical schools. I figured, probably correctly, that if I couldn’t get in at either of these I probably didn’t have a chance anywhere else. I did apply to a few more schools but got bogged down in the secondaries, most of which asked for essays on truly ridiculous topics like “Qualities that Will Make You a Good Physician” or “Describe your Greatest Weakness.” Not to mention, “Why Did You Select Tulane?”

Hey, I’ll do what it takes but I do have some self-respect. The secondary application questions for LSU were along the lines of, “Have You Ever Been Convicted of a Felony?” which I believe is the only legitimate question that should be asked of anybody applying to medical school. It has a simple, easily verifiable yes or no answer and allows no room for the usual cringe-inducing tripe.

After the usual nail-biting, I was accepted to LSU Shreveport and, after a late interview invitation, was also accepted at LSU New Orleans. I liked New Orleans better but Shreveport was closer and the real estate was cheaper. Hey, I’m not fussy. Harvard, LSU, Duke, the Carribean…it’s all the same. Or at least the differences are not worth getting worked up about.

We moved to Shreveport and the rest of the story can be found on my blog.

Again Apropos of Nothing Part C

Again Apropos of Nothing Part B

Was it That Long Ago?

It was one of those cool, clean April mornings in North Carolina when I was discharged from the Marines. The sun shone brightly in the clear sky as the last of the mist lingering in the shadows evaporated. A gentle wind ruffled the surface of the New River and tugged at the tops of the pine trees.

I saluted the Officer of the day who had come out of his office to admire the weather.

“Good luck, Sergeant Bear,” Said the Lieutenant (who had been my platoon commander) as he shook my hand.

“Thanks, Mister Roland,” I said, “It was a real pleasure working for you.”

“You know you’re going to miss it.”

“Not a fucking chance, sir.”

And that was that. With considerably less trouble than it had taken to enlist, I was honorably discharged. It was anti-climactic, really. Almost eight years, an eternity to a young man, at an end with a respectful salute and a friendly handshake.

Have you ever been free, my friends? I’m not talking about some unobtainable existential freedom. I had money, I had a car, I had a beautiful girlfriend, and I had nothing but time until I started classes. If that’s not freedom, then nothing is. I drove out of the main gate of Camp Lejeune and have never been back.

I started at the University of Vermont that June as a Civil Engineering major. I went to class religiously, studied, and did pretty well. A little self-discipline makes all the difference. Besides, the lifestyle of a college student is an easy one. Other than going to a few classes, your day is pretty much your own. There is plenty of time to study without turning into a jittery freak, especially if you finally see the college lifestyle for the bullshit it really is.

It’s just a job. They can dress it up, put you in a picturesque campus and you can strut around getting educated but strip away the pretensions, the inexplicable loyalty to an organization that takes your money and can cheat you out of your education if you let it, and it’s a wonder the bookstore does such a brisk business in university branded paraphernalia.

Campus politics were ridiculous. The year I returned was the year of “Diversity University,” a little shanty built on the green to protest just about everything. It was a focal point for the usual left-wing crazies making a career out of protesting. It was also the year that the usual band of idiots, in an homage to their equally idiotic parents from the sixties, stormed and, for a number of weeks, occupied the administrative offices of the President of the University…and got course credit for it. The whole scruffy, useless pack of them were eventually driven out but not before they held numerous rallies with politburo style banners of Mao and Lenin.

Nothing but the spoiled children of the elite pretending to stand for something, just like their equally spoiled baby-boomer parents. Naturally I had a lot of fun with them. I was something of a conservative political activist and even started tearing down the shanty on TV before some little tofu-eater threw himself between the shack and my sledge-hammer. I attended all the diversity meetings and agitated for conservatism, politely and in my turn, of course, until they told me that I wasn’t welcome because it’s only diversity if it is left-wing and anti-American. I got in a little trouble and had a few conservative Vermont lawyers offer to run interference for me but it never came to that. The funny thing is that many college students spend their entire four, five or six year college career doing little but political activism. They take the usual Mickey Mouse courses where one bemoans “the Man” but, other than that it’s all posturing and pontificating in the fantasy world that is Academia.

Then they spend their lives wondering why nobody takes them seriously, lamenting their glory days in college with the same intensity as the former high school jock drinking his beers of despair in some fly-blown trailer park. Or they work at Starbucks, the graveyard of liberal arrogance.

Our original plan was to wait until I graduated to get married but we decided that this made no sense and my lovely and highly intelligent wife and I were married in May of 1992. Since she was going to quit her job (in television), we looked around and realized that it made no sense to spend the kind of money demanded by UVM when Louisiana Tech could supply the same education for a fraction of the cost. I transferred and finished my degree in 1994 with decent but not spectacular grades. I did a year of graduate school because we were young and didn’t need that much money to live.

Graduate school is useless in most engineering professions if your object is to work as an engineer. It doesn’t increase your starting salary, either. I had a friend who wrote his thesis on the percolation of water through a sand bed, an important topic to be sure, but very specialized and more likely to make your prospective boss scratch his head and wonder how it’s going to help him make money off of you.

So one day I got an engineering job, started working for real money, and just lost interest in academics. I came home one day and asked my wife for permission to quit graduate school. Working and studying, not to mention grading papers and the other lame things you must do to earn your stipend was wearing me out. Graduate students, like residents, are little more than slaves. Maybe graduate students are house slaves compared to residents cutting the cane but they are slaves none the less.

Besides, I was tired of being the only guy who didn’t speak Chinese in my advanced Finite Element Design class.

I worked as an engineer for a few years. No real complaints. It’s a good career and I highly recommend it.

Why medical school? I don’t remember. That is, I remember getting the idea of being a doctor in my teeth and not being able to let it go but I don’t remember from where the idea came. I had never been to a hospital except for the birth of our first child and in no way did this spark an interest in medicine, even if I did say it did in my AMCAS personal statement.

Hey, I lied. Doesn’t everyone?

The nearest I can tell, one day I was mowing the lawn under the merciless Louisiana sun and just got sick of it. I asked my wife what it would take to hire a lawn service and she said, “Maybe if you were a rich doctor we could afford it.” This was kind of silly, of course, because I was doing pretty well as an engineer and we hired a lawn service the next week. But, like I said, I got the idea in my head and a little research revealed that it was not impossible. I don’t believe the numerous medical school discussion forums existed back then so I had very few places to turn for advice. There were a few books at Barnes and Nobles, and the head of the pre-med advisory committee at Louisiana Tech, after the obligatory “crap shoot” remarks conceded that it was possible.

More importantly, there was, as I discovered, a medical school just down the road (well, fifty miles away).

After a lot of discussion, we decided to give it a try.

Next: The Plan. MCAT Secrets.

Again Apropos of Nothing Part B

Again Apropos of Nothing Part A

Random Musings on the New Year

The years roll by. I have vague memories of time passing with glacial slowness. Waiting for summer vacation. The eternity of high school. The time when it seemed that I had alway been in boot camp and always would be. The months I counted during the first Gulf War waiting to be reunited with my beautiful girlfriend who I later married.

And yet, it has all come and gone in what seems like an instant. Was it really nine years ago when my oldest was born? It doesn’t seem like it. The memory is too vivid. With easy reflection I recall the eternity of of sleepless nights spent walking the baby back and forth in the nursery, the fatigue from the second child who refused to sleep and spent what seemed like her first six months of life perpetually crying, and the death of my father from what I now know was brain mets from a malignant melanoma.

So I remember this time six years ago when, like many of you, I was checking the mailbox every couple of hours for the fat envelope announcing that I had been accepted to medical school. I had to wait a little longer, unfortunately, as I wasn’t accepted until early March.

You almost wish that you could get an answer-yes, no, something, anything-right after your interview. Of course this is not the way admissions work. Medical schools angle for the big fish, patiently working the lure hoping for a strike. After the pool is played-out they may throw a common worm on the hook and go after some trash fish. I guess that was me but I don’t care. One of the top students in our fist year class who was probably offered admission on her interview couldn’t handle the stress and quit halfway through first semester. I am sorry to say I felt vindicated. I may have been on the third-string roster but obviously there are other traits besides a 4.0 GPA and a 39 on the MCAT that maybe aren’t selected for as aggresively as many of you, oh my patient readers, would hope.

I don’t know why I decided to apply to medical school. There was certainly nothing in my background that would point anybody in that direction. As many of you know, I began my career as a United State Marine back in the early 1980s. I had just been kicked out of the University of Vermont for bad grades. Well, I actually had almost no grades as I seldom went to class and a couple of times didn’t even know where or when to sit for the final.

Have you ever had that dream where you are late for a big exam for which you forgot to study? That was pretty much my reality. I partied a lot too, although that’s not much of an excuse because a lot of people party and study (the college ideal). So with no prospects, no interest in academics, but also no desire to flip burgers for a year before I re-applied I thought I’d give the military a try. I directed my pasty, lackadaisical body to the local recruiting station and presented myself to the representatives of our country’s military might, slowely recovering at that time from the ravages of the both the Carter years and Viet Nam.

The Army, Navy, and Air Force were like car salesmen and tried to sell me on the options. “College!” said one. “Travel!” another. “Great lifestyle!” said the third. Sign with us and reap the tangible benefits of job-training, medical care, good pay, good chow, and easy promotion.

The Marine recruiter on the other hand, the most ferocious-looking individual I had ever seen, looked me up and down contemptuously and said, “Son, I’d like to take you but I just don’t think you have what it takes to be a Marine.”

Bait taken, hook set, nothing to do but reel me in.

Three weeks later I was sworn in at the Manchester, New Hampshire MEPS station and eventually found myself on the famous yellow foot-prints aboard Marine Corps Recruit Depot, Parris Island. After boot camp I went to the Basic Armor Crewman Course at Fort Knox, Kentucky and spent my first four years as a Tanker, eventually becoming a Tank Commander of a 62-ton M60A1 RISE Passive Main Battle Tank. A pretty good job, all things considered. Plenty of firepower, big engines. And limited walking. All the more reason my Battalion commander thought I was crazy when he re-enlisted me for another four years and a transfer (or lateral move) to the infantry.

I did my second enlistment as a machinegunner and then a mortarman in the heavy weapons platoon of an infantry rifle company, Company K (or “Kilo”) of the Third Battalion of the Eighth Marine Regiment…or “K 3/8″ for the cognoscenti. I know I complain a little on this blog about the difficulties of medical school and residency. I have apparently grown an ovary or two since my Marine days. But the life of an infantryman is a hard one and I laugh whenever some idiot surgery attendings justifies his abuse of me by how tough he had it.

Mother-fucker, I have operated for weeks at a time above the arctic circle humping a 120 pound pack as well as a machine gun, a mortar tube, or some other heavy ordinance. I have slept in the snow and longed for nothing more than a pair of warm socks to make my life perfect. I have baked in the desert, thankful for the shade of a low bush and a couple of warm gulps of plastic-flavored water from my canteen. You were on call in a nice, air-conditioned hospital while I swam in the dark, through the close, humid underbrush of a nightime jungle and while you were mistreating your medical students and junior residents I was leading some of the finest men you are ever likely to meet, without belittling them or treating them like they were somehow inferior by virtue of enlisting a few years later than me.

So this explains my low tolerance for abuse. Put on your body armor. Shoulder your pack. Grab your 19 pound machinegun and thirty pounds of ammo and lets go humping, you and I, up and down the mountains. Then we’ll talk about your so-called difficult life and your right to talk down to me. You’d have your ass kicked in the Marines by the first Private First Class to whom you opened your stinking cake hole.

But I digress. I was honorably discharged as a Sergeant and decided to go to back to college for the right reason, that is, to get a well-paying job.

Next: College. A job. You want to do what? The Plan. MCAT secrets.

Again Apropos of Nothing Part A