The Great Debate

Can’t We All Just Get Along?

Moslem and Jew. Windows and Mac. Republican and Democrat. Partisanship and sectarian strife abound but these are nothing, as tame as church picnics, compared to the seething clandestine war being waged in teaching hospitals across the country over whether the house staff should or should not be allowed to wear scrubs as normal attire. At one extreme in this battle are the dark forces of oppression who would make their residents wear a shirt and a tie under their surgical gowns if the those pesky rules about infection control didn’t make it impossibe. At the other are are the noble advocates of personal liberty who believe that attire is a personal decision that each must make according to his conscience.

I try to stay neutral but the case for scrubs is pretty convincing.

First of all, residency training is not totally hygenical and, unless you are one of those no-good lazy bastards in PM&R, you have a pretty good chance of getting something unwholesome on you. I’m not saying that the wards are obstacle courses of flying bodily fluids because they’re not. Even in the Emergency Department, with a little foresight, you can go days without getting slimed. In fact, the nefarious opponents of scrubs will often point out that your low risk for getting sprayed doesn’t justify not dressing up and they scoff at the house staff’s fear of a little accidental goopage. “What, are you a nurse?” they ask with a contemptuous snicker.

But with how much bodily fluid are you comfortable? I’m zero-tolerance myself. Call me squeamish but one drop of vaginal discharge or vomit on my shirt is enough to make me want to change it. I have no desire to either keep a stock of pants, shirts and ties at the hospital or spend the day enjoying the memories. Scrubs, as they are usually supplied by the hospital, are disposable. I once got sprayed with urine and I didn’t think twice about cutting off my scrub top (because I wasn’t going to pull that thing off over my head). I’m not exactly a metrosexual but I’ve been known to pay as much as 30 bucks for a dress shirt. Ruin one shirt a week, and by definition a shirt with any total stranger’s discharge on it can not be washed enough so I will wear it again, and we’re talking some serious money.  I don’t care if it’s a drop of blood on the cuff.  I’m not wearing it one minute longer that I have to.

Advantage: Scrubs.

Hospitals are not offices.  We don’t work in cubicles, sitting in our ergonomic chairs all day except when we make a trip to the candy machine or to the boss’ office to swap some management jargon.  Most of us spend the day walking and most academic hospitals are huge.  Duke is so big, for example, that they have a train running between the main hospital and the clinics.  I once tried to estimate how far I walked every day and it came out to miles. 

Think about it.  If you’re on the second floor on a remote wing and you get paged to the eighth floor on the other side of the hospital, you might have to walk a quarter of a mile, not to mention taking some stairs. I like elevators, don’t get me wrong, but they are usually full of patient’s families and you have to wait for them (patient’s families never take the stairs).  Do this for a thirty-hour call day and you will cover a lot of ground.

Office attire, as it is designed for people who spend their day working on spreadsheets (or whatever they do in offices) is completely unsuited to our nomadic lifestyle.  Scrubs, on the other hand, are light, airy, and they don’t chaff.  And there is no way to wear a tie while wearing scrubs.  I hate ties.  I know the trend is to disparage them as fomites, carriers of pestilence from one patient to another, and I suppose this sounds reasonable.   But I hate ties simply because they are ridiculous and uncomfortable.  Ridiculous because they serve no purpose and uncomfortable for obvious reasons.  I wear a tie to church but that’s because it is uncomfortable and focuses the mind on the evil of earthly things. 

Besides, office attire is typically worn from nine to five.  Most residents work far beyond the typical work day and you start feeling clammy after wearing your church clothes for more than ten hours.  It’s bad enough we have to stay up every fourth night running around the hospital without having to do it clothing we’ve been wearing since the previous morning.

Advantage:  Again, scrubs.

Do scrubs look unprofessional?  It depends who you ask. Your old-school attending regards them with the same loathing he holds for the greasy pants of a urine soaked wino.  He thinks that physicians should dress to impress.  But isn’t that the point?  If I’m to understand him, I need to wear a tie to impress a guy who they found under a bridge, hasn’t had a bath in six months, and drinks Lysol when he can’t afford “Mad Dog.”

Seriously, a clean pair of scrubs under a clean white coat looks professional enough for everybody short of the Pope.  People have been conditioned to expect their doctors to wear scrubs, even without the white coat.  Just tuck in the shirt, avoid the 101 Dalmations print top and you’ll do fine.

Advantage: Still scrubs.

 

The Great Debate

Other Medical Careers Part One: The Most Controversial Article Ever Which Will Cause A Flood of Irate Comments and In Which I Tread Carefully But Obviously Not Carefully Enough

Osteopathic Medicine

My mother, who is from Greece, is visiting us and was amazed to hear that our program is a combined osteopathic and allopathic program.  She had no idea that chiropractors were used in the Emergency Department. In Europe, you see, osteopaths are not trained medical doctors but confine their practice to manipulation and other alternative therapies.  In the United States, however, osteopaths, who are conferred the DO degree (Doctor of Osteopathic Medicine) are fully trained medical doctors and are without exception completely interchangeble with allopathic physicians, those with the traditional “MD” after their names.  The confusion arises because osteopaths are far fewer in number than allopathic physicians and in some states, particularly my native Louisiana, are as scarce as hen’s teeth.  I had never heard of osteopathic medicine before I started applying to medical school.

Osteopathy was founded shortly after the Civil War by Andrew Still, a former Army surgeon, in a reaction to the general quackish and barbaric nature of most medicine at that time.  He developed a theory of medicine that, as it was based on the manipulation of bones, did not require drugs or surgery.  His idea was that manipulation could restore the flow of blood and nervous impulses, the interruption of which he regarded as the cause of most diseases.  Osteopathic Manipulative Treatment (OMT) has grown out of his theories into a treatment modality which is still taught at Osteopathic medical schools. 

I say “still taught” because there is little or no good evidence that manipulation does anything other than make the patient feel subjectively better.  Hell, you can get a topless massage in most cities and even a “happy ending” that probably would make you feel as subjectively better without all of the fanfare and the embarrassing questions about your diet and bad habits.   In light of this there is a considerable sentiment among practicing osteopaths and osteopathic medical students that just as modern medicine has moved away from now discredited but once accepted treaments, it may be time to move away from OMT.  I have asked many osteopaths if they use OMT and a typical answer is, “I’m not a believer.”

Whatever the case, except for several hundred hours of training in OMT  the science and clinical curricula are similar enough between ostepathic and allopathic medical schools that graduation from an osteopathic medical school will lead to full licensure as a physician with no restrictions on your practice or the ability to receive additional fully accredited training.  Not only are there osteopathic residency programs in every recognized medical specialty but osteopaths can apply for allopathic residency positions as well (but not vice versa).

Many pre-meds apply to both types of schools to increase their chances of being accepted.  I didn’t because I’m shallow and didn’t want to explain the initials after my name.  This is actually not a problem in some parts of the country, particularly the upper midwest where osteopathic physicians are well known and respected. 

Some people believe that it is easier to get into osteopathic medical schools and decide to use them as “back up” schools.  This is the conventional wisdom but it’s silly if you think about it.

While the objective qualifications of allopathic matriculants (MCAT scores, GPA) are indeed slightly higher on average than their osteopathich counterparts, generally, if you’re not qualified for admission to an allopathic medical school you will not get into an osteopathic one either.  Sure, the fierce partisans are quick to point out the higher average scores but these are the result of outliers.  Like most things, the subjective qualificatons distribute themselves normally and it is only at the extremes where the curves don’t overlap.  For my part, since I was an average applicant (at least by MCAT scores and BPCM GPA), almost half of osteopathic matriculants had better qualifications.

So think about this before you get too cocky.  If you want to be an osteopath go to an osteopathic school.   If you want to have the MD after your name you’d be better served just applying to more allopathic medical schools and taking your chances.  The best osteopathic schools are also better than the worst allopathic schools and they can afford to be more selective.

Osteopathy, aside from OMT, distinguishes itself from allopathy by purporting to be more patient-centered, viewing as they do the patient holisitically and not in the disjointed manner that allopaths are accused of doing.  There is something to this but not enough to get excited about.  Osteopathic schools push primary care hard and they’re serious about it, not just paying the usual lip service offered by people who wouldn’t be caught dead in primary care.  Despite this (or because of it) many osteopaths specialize and have the same reasons to run screaming from primary care as anybody else.  At our local College of Osteopathic Medicine, the students have related to me that they spend close to eight months of their clinical years on mandatory outpatient and ambulatory clinic rotations which will tend to make pathology look mighty good.

Keep this in mind if you think primary care ain’t your bag.

Osteopathy Disadvantages: Metaphysically, none.  Full-fledged physicians in every specialty from neurosurgery to pediatrics.  However, lingering prejudice in some states might make licensure more complicated (the requirement for an extra intern year for example).  Also the COMLEX is reputed to be more difficult thant the USMLE, not to mention that the regulatory body for osteopathic residency programs is a lot more stringent about absolutely everything. (Paperwork, etc.)

Osteopathy Advantages: The ability to match into both allopathic and osteopathic residency programs.  It’s true that you will have a disadvantage, all other things being equal, in the allopathic match but you won’t in your own and the rest is gravy.  Not to mention that osteopathy has a certain retro coolness factor to it.

Other Medical Careers Part One: The Most Controversial Article Ever Which Will Cause A Flood of Irate Comments and In Which I Tread Carefully But Obviously Not Carefully Enough

Pie Will Out

I’m a Doctor, Not a Magician

I get accused of being a cynic and a realist, especially by people who are themselves self-proclaimed idealists. Why it is wrong to be a realist or cynical is the topic for another day. But I do actually have an idealistic heart and one that would shame the pretensions of even those whose bumpers are festooned with a kaleidoscope of stickers announcing their support for the typical things that pass for idealism nowadays. I just have a different sort of idealism, especially when it comes to the practice of medicine. It’s an old-fashioned idealism to be sure, and one that many may view as being slightly stodgy at best or a throwback to the stone age at worst.

I’m talking, of course, about the difference between reactive and proactive medicine.

In reactive medicine, the traditional model of medical practice, the physician is trained to diagnose and treat the diseases of people who seek him out when needed. This is my idealism and probably why I chose Emergency Medicine as a specialty. Our entire job is to react to medical problems. In this manner I live my ideals in a way that, unless it involves parachuting into the Himalayas, those whose ideals involve freeing Tibet can never hope to do.

Some believe in “proactive” medicine and to a certain extent I can understand and applaud their ideals. Family Medicine, for example, is full of motivated physicians keeping a careful watch on their patients in the expectation of catching and preventing health problems early enough so the treament is a pill instead of a heart transplant. Some work in preventative medicine and struggle to eradicate the common diseases that afflict the human herd.

Idealism is a good thing except when it becomes zealotry at which point (as absolutism brooks no dissent) reason, moderation, and respect for the heretic are abandoned. The hard-core purveyors of proactive medicine long ago passed into zealotry and have never looked back. Many of you have read of my experiences with community medicine at Duke University where the Department of Community and Family Medicine was the beating heart of proactive zealotry and about which I relate the following cautionary tale:

During our orientation as interns, we sat through many conferences extolling the virtues of Community Medicine, the Shining Path of proactivity that involved physicians, mid-level providers, nurses, social workers, dieticians, and various other minor functionaries of the dependocracy in a coordinated effort to bring good health to the to jibbering inhabitants of North Carolina’s urban and rural hinterlands. One such effort involved a pilot project to combat obesity. A local Baptist church was selected as a test site and the obese parishioners were subjected to all manner of testing, nutritional counseling, cooking classes, motivational speakers and everything and everyone that the initial grant money could bring to bear. To say that this group was targeted would be an understatement. They received the full broadside from the great ship of state which, for good measure, came about and raked them from the other side.

You’d think the pounds would have dropped like French soldiers at the sound of gunfire but, when one of the interns tentatively asked if the target group had lost weight, it turned out that the test subjects had no statistically significant weight loss.

There were no outliers. The most lost was a little more than the weight of a couple of pork chops and some actually gained.

Anybody could have predicted this. Most education, like most preaching, is ineffectual. The parson can talk himself blue in the face but the bars will still be open and the fancy women will have no shortage of customers because unless people have some strong personal motivation for change, a motivation which cannot be accessed by the usual uninspired preacher or government scold, they will continue to indulge their immediate gratification at the expense of of some unknowable future punishment.

Late at night, when the motivational speakers have gone home and the skinny lady from the university has stopped trying to extract impossible promises, the siren call of the pecan pie in the refrigerator is irresitable. Pie will out. This simple yet seductive desert will trump our best efforts. When you’re three hundred pounds hoping to lose the fleshy equivalent of a couple of sixth graders, the smooth seduction of caramelized Karo syrup and the smokey crunch of jumbo pecans offers immediate gratification with which no nebulous promise of low blood pressure can hope to compete.

I am a stocky fellow myself and even though I know better, after approximately twenty years of education and a medical degree I still succumb to the demonic allure of baked goods including that of the very arch-devil of pastry, the apple fritter.

You can lead a horse to water and, if you hold his head underwater, he will eventually drink. But you have to stand there and hold him down. Likewise, we can probably modify people’s bad habits but the level of involvement required is immense. If a small platoon of earnest social workers cajoling and lecturing for a month could only show a couple of pork chops for all their effort and a a couple hundred thousand bucks worth of their time, those are mighty expensive pork chops. So unless you’re willing to swallow the cost of providing everybody in the country who needs one with their own personal trainer to hold their head underwater, well, you need to let it go. People are going to do what they want. They’ll suck down crack, inject heroin, free-base Big Macs, and make love to the pastry cart and nothing short of locking them in a jail cell with Richard Simmons and a crate of lettuce is going to make much of a difference. What little difference it makes is probably not going to be worth the gigantic expense of providing nannies to a third of the population.

It’s probably more cost effective to just say to hell with it and confine ourselves to reactive medicine where at least we can make a difference. Remember, no matter how much you spend, it can all be undone by an 89 cent piece of pie.

Pie Will Out

Don’t Just Do Something, Stand There: Part Three

(In which we mostly belabor the obvious.-PB)

Mostly Over-doctored

How much health insurance do most people need for most of their lives? The answer is none. Most people are fairly healthy and have mostly healthy children who could probably manage to go years between visits to the doctor. When they do go, it is mostly for a minor self-limiting complaint or a long-term health problem that is under good control. Insurance, and forgive me for belaboring the obvious, is supposed to ameliorate the effects of unforseen and and rare events which a visit to the doctor for a cough or an ear infection is most certainly not. We insure our houses against fire, for example, not because fires are common but because the cost of rebuilding a house, the repository of most people’s wealth, is more than most of us can afford to pay. There is no such thing as “lawn mowing insurance” or “garage floor painting” insurance because these tasks are routine and an expected part of home ownership. Putting on a new roof stings a little, I admit, but most normal maintenance of a home won’t bankrupt anybody.

The trouble with health insurance is that it’s not really insurance at all, at least not how most people view their other kinds of insurance. Rather than serving to protect us from the catastrophic financial effects of a major illness, health insurance has become an expensive middleman between the consumers and producers of medical services. If your car needs an oil change, you change it. If you need new tires you buy them. If you need to go to the doctor for your annual physical however, you engage a complicated bureacracy which exists to shift costs from one set of consumers to another. This is why the health insurance for a typical family may cost them or their employer in the neighborhood of twelve to fifteen thousand dollars per year even though their actual expenditures for medical care in any given year are not even close to that amount.

Routine health care is not even completely covered under even the most expensive health plans. There is always a copay and a lot of essential services that the typical family really needs, such as dental and vision, are either not covered or involve an even bigger copay. It has to be this way because health insurance is a ponzi scheme with hordes of investors at the bottom of the pyramid paying the dividends of those at the top who are, in this case, the extremely sick and the uninsured.

It wasn’t always like this. Our current model of health insurance is the result of two historical trends, the first of which was the explosion of medical knowledge and technology in the 1960s. Before this time medical care was relatively cheap because there wasn’t really that much that could be done. Hospitals were more like hotels than the patient processing plants they are today and the amount of doctoring received by a patient was limited by the amount of doctoring that could actually be done. This also limited the number and sophistication of the support staff and equipment required for a typical hospital or clinic. Health insurance before that time was rare and most people payed out of pocket for their doctor visits. It was just expected. Society had not been medicalized and people grew old and died without fanfare because there was nothing else to do.

This is not the case today where our ICUs and nursing homes are filled with the warm dead, people who in many cases are only kept alive at the end of a long and expensive journey through the medical system by increasingly expensive and futile medical heroism.

So there is no question that the real cost of medical care has increased, on the high end anyways.

The other trend was the incredibly high top marginal income tax rates which began to rise in the 1920s, peaked at 94 percent in the forties and, before President Reagan (PBUHN) took an axe to them in the mid-eighties, had stabilized in the high seventy percent range. The result was that increasing the pay of white collar and skilled labor in the post-war boom wasn’t much of an incentive as a raise was often eaten up by increased taxes in the higher income brackets. This was the age when companies started offering fringe benefits to their employees in lieu of increased salaries. One of these was comprehensive health insurance which has now become an expected part of the compensation package for any good job even though the original rationale for offering it has disappeared. Most people would probably be better served if they got the raise and payed for their own medical care as the marginal rates are not nearly as high as they were forty years ago.

The income tax is progressive of course, and the middle-class hardly pay any compared to the upper middle-class and the wealthy. In this case, there would seem to be even more of an incentive for middle-class employees to prefer the money over the insurance. Money is money. Insurance is wasted money unless you need it.

The unfortunate consequence of almost universal health insurance (because 85 percent of Americans are covered under some insurance plan or another) is that the true cost of health care is masked from the consumer. Everybody complains about the cost of medical care but it is a generalized, non-specific complaint. The high cost of medical care is an abstraction to most people most of the time. They have the occasional hospital stay, pay a small fraction of the total bill, let insurance handle the rest, shrug their shoulders and move on. The poor and the government-insured care even less because they are never expected to pay much, if anything, for most of their medical care. If the insured had to pay the complete bill the cries of outrage would send fear and panic through the entire health care industry.

The Big Lie, the scare tactic used by the usual suspects in their craven lust for political power is that people need comprehensive health insurance. They most certainly do not. Most people most of the time need so little medical care that most of the money spent either by them, their employer, or the government is wasted as far as it benefits them. Consequently, In a country where almost everyone can borrow money for automobiles, personal watercraft, and all manners of luxury items, there is no reason why most of us should not be expected to pay for most of our medical care most of the time (even if we have to borrow a little). No reason, that is, except that we have been conditioned to expect it for free. Not to mention that to merely suggest that maybe, perhaps, just possibly, a visit to the doctor is no different from a financial point of view than a visit to the hair salon would be political suicide for anyone with the guts to say it.

It’s easier to give other people’s money away, and more gratifying too because it earns one the reputation for being compassionate even if the long term consequences are harmful to the public.

There is the difference between what people want and what they need. While everybody wants somebody else to pick up the tab, the tab is going to bankrupt the nation. What most people need is an inexpensive high-deductible insurance policy to protect themselves against financial disaster if they should require some big-ticket medical care. Almost nobody, for example, can afford a kidney transplant or even the medical consequences of a serious car accident. Not to mention that people do grow old and eventually, many but not most, will require the expenditure of fairly large sums of money to preserve their quality of life.

The key thing to keep in mind is that the various plans proposed to insure the entire nation will do nothing to lower the cost of medical care because they are just another scheme to shift the costs from one set of consumers to the other. The only difference will be that instead of half, every single health care dollar will take a trip through the federal sausage mill. The money is going to come out of somebody’s pocket and it’s not going to be the government which has no pockets, just hands to grab from one to give to another

It’s just rearranging deck chairs on the Titanic. Twenty years from now when medical spending has doubled as a percentage of GDP the same people will be crying the same tears over the same problem because the entropy of government winds down to expecting less and less of the people while trying to give them more and more. This is why the concept of Health Savings Accounts (not to mention privatizing Social Security) invokes such howls of rage from our ruling elites. Not only do they hold the people in contempt thinking them incapable of planning for their own future but the money tied up in these accounts and owned by citizens is just another chunk of money that cannot be stuffed into the voracious maw of the political influence machine.

As for the poor, well, we live in a society that is both opportunistic and compassionate. It would be demoralizing to our nation to have the disparities of medical access so wide that the poor and ignorant suffer or die from conditions that those who can think and plan ahead easily eacape. We will, unfortunately, always need to give medical care as charity. But the key here is that primary care is no bargain. The connection between good health and acccess to primary care is tenuous. The factors which contribute to poverty and ignorance also contribute to poor health and we have been fighting those since the Johnson Administration with little or no success. Bad health in the poor is mostly a the result of social problems which have shown a surprising resistance to huge doses of federal dollars. Dumping even more money onto the poor is mostly the same as trying to treat a disease with an antibiotic to which it is resistant. Staph Aureus laughs at your ineffectual pennicilin. The poor will laugh and ignore your ineffectual primary care.

What the poor need is the same as everybody else. Major medical insurance for which, if it absolutley must, the goverenment can pay. We certainly pay enough to support the poor now. May as well spend it where it will be effective, that is, on management of the acute health problems that people who don’t think and plan ahead are going to get no matter what we do. To hell with it.

There are many conflicting forces in medical care, each one trying to stiff the other with the bill. The insurance companies want to pay as little in claims as possible which is understandable given the nature of their business. The medical industry, from physicians to the lady mopping the hospital floors, would like to get paid fairly for their services. The government wrings its hands at the cost but at the same time would like as many people dependent on government as possible. The people want all the medical care they can eat but they want somebody else to pay for it.

Nobody else can pay for it unless we become a nation with a government whose sole function is to provide health and other benefits to a universal dependency class in some decaying freeloader heaven.

Don’t Just Do Something, Stand There: Part Three

Random Ramblings

That Doctor

It’s official, I have become “That Doctor.”

You know, the guy who told them that their father only had three months to live and here he is, six months later, being wheeled in by his triumphant family. I mean, he looks almost the same as when I saw him the last time, maybe a little more cadaverish, perhaps a little less animated than I remember but still clinging gamely to life as only the terminally ill can. And I’m not disappointed in the slightest because he is a fine fellow and the family could not be more pleasant or good humored, a real pleasure to have in the department.

But to set the record straight, I did not say their father had three months to live. I said that the oncologist believed that their father had less than three months to live. But it doesn’t matter. I am now “That Doctor,” the guy who their father has outsmarted and outlasted and they are not shy to remind me of this, a remonstration that I take in the same good spirit it is given. Because I don’t mind. I have arrived. The family is profoundly grateful to all of us for our efforts on behalf of their father and I am flattered to be regarded as a wise physician who was never-the-less outwitted by their crafty old dad.

Preliminary Hell

You should see my private email. I have a fan club of sorts who think I am the very Devil and are very defensive about the current state of residency training. They take particular umbrage to my often stated opinion that academic hospitals view residents as nothing more than cheap labor and extract much more value out of them than they end up paying in salary and benefits. My critics insist that even with the large sum of money paid to the hospital by the government for each resident (an average of $100,000 per year), if you take into account the overhead, the increased liability, and the inefficiencies that are unavoidable in teaching residents the hospital actually loses money and is doing us a favor by letting us tag along.

For my part, because I can add, subtract, multiply, and even have some facility with multiplication’s tricky cousin, long division, I have a pretty good idea how much we are actually worth to the hospital. My critics usually have no idea of this themselves and even the fact that the hospital receives federal money for residents is often a revelation.

But I can end the debate with two words:

Preliminary Surgery.

Was there ever a bigger scam than this? Here you have a collection of disposable residents to whom is owed even less, if possible, than to categorical residents. They’ll be gone in a year, some to their real training that required a preliminary year and some to programs into which they match after another go at ERAS. Consequently, their education is viewed with profound indifference by their employer whose only goal is to extract as much medical labor out of them as possible.

I complain about residency but I have it easy compared to those sorry individuals. I once met a preliminary surgery intern who along with another preliminary intern was in the middle of three months of Q2 call. This means, for those who don’t know, that he alternated 24-hour shifts with his fellow serf.

“But Panda, that’s not that bad,” you say, “He gets every other day off.”

Maybe in a perfect world, one where call was actually call and not an extension of the work day, this would be true but the two interns in question essentially missed sleep every other night, went home exhausted, and came in the next morning as if nothing had happened. It is not like working as a fireman, for example, where you may be at the station but if nothing is going on you can eat, sleep, or just hang out. It was a day of the usual rounding, admitting, and scut which only intensified when everyone else went home.

The fact that they also had to stay a few hours extra past the nominal changing of the guard is of no concern to most people who, as they work at normal jobs, are somewhat cavalier about an hour or two. But this little chunk of time is precious to an intern. Be that as it may, this abbreviated day counted as their day off and their hospital could no doubt point proudly to their compliance with the ACGME work hour rules.

Think about it. If you work Q2, you will work approxmately 96 hours on one week and 72 on the next which, with some creative lying about hours which all surgical residents are strongly encouraged to do, can almost be called 80 hours per week averaged over four weeks with at least one full day off every week and at least ten hours between duty periods. It’s diabolical. Their program, smarting from the ACGME’s smackdown devised a way to work the crap out of the help while following the letter, if not the spirit, of the law.

Is it Too Popular?

Emergency Medicine, once a sleepy little-respected specialty which was regarded as something somebody did if they couldn’t do anything else, has enjoyed a tremendous increase in popularity among American medical students to the point that it is now as competitive as some of the surgical specialties. I think it is lifestyle, more than anything else, that is driving this.

Medical students rotate through the specialties and begin to realize that most of medicine, far from being the glamourous career of which they dreamed, is a grind, a slow slog, or a medical Bataan death march. Then they do a month in the Emergency Department where, while also not exactly what they expected, they see a world where the pace is faster, the decisions are quicker and, wonderous to behold, the hours are regular and you can forget about work when you go home as there is nothing to follow up.

It also feels more like real medicine because, unlike most other specialties where the patients all have baggage from half a hundred previous admissions and hundreds of pages of advice from the small squad of doctors who follow them, it is possible to see a patient who is completely terra incognito and upon whose body no physician has yet planted a flag.

So Emergency Medicine has a tremendous appeal, especially for people with a low tolerance for bullshit and wasted time. On the other hand, it’s not for everybody. I mention this because my program has lost several residents recently who decided that Emergency Medicine wasn’t really what they wanted. All fine guys, don’t get me wrong, but after a little exposure it was either the pace, the shifts, or the obvious lack of depth (compared to, let’s say, cardiology) which lured them away.

I happen to like the pace and the lack of depth as I am (true to the cliche about Emergency Medicine) easily bored and have a short attention span. And I don’t mind working shifts because (as I have mentioned a time or two) all I really want is the chance to sleep every day. I also like to be at home when other people are at work.

But like I said, it’s not for everybody. Unlike the traditional lifestyle specialties, Emergency Medicine is only a lifestyle specialty if you like that kind of lifestyle. You trade relatively benign hours and high pay for continuous work while you are at work and a schedule that only a vampire could love. It also has a very reasonable lifestyle in residency once you clear all of the hurdles of intern year which is important but should not be the most important factor in your selection of a specialty. (Unless of course you are one of those lazy bastards in PM&R in which case you probably laugh and point at the rest of us idiots.)

I think we may see a backlash because Emergency Medicine’s popularity is insane and doesn’t make any rational sense. It’s a good specialty but 20 percent of my graduating class went into it. It’s not that good.

Random Ramblings

Don’t Just Do Something, Stand There: Part Two

(Medical care is expensive, no doubt about it, but the remedies proposed by the usual suspects who hope to leverage the problem into political power don’t address the real factors driving up the cost. Maybe I’m just not an excitable fellow but I like to keep a cool head and not get swept up in the hysteria, especially as it is being lead by people who are themselves part of the problem-PB)

Zero Defect

You get what you pay for.

Consider the space shuttle, a technological marvel conceived in the 1970s to revolutionize space transportation by using a reusable space vehicle to drastically decrease the cost-per-pound of lifting payloads into orbit. First flown in 1981, the fleet of incredibly complex and expensive orbiters have yet to achieve their stated purpose of making launches economical and have instead become something of a boondoggle to NASA, sucking vast amounts of money out of less glamorous but probably more important space endeavors. It turns out that disposable rockets are significantly cheaper on a cost-per-pound-to-orbit basis because they are less complex, unmanned, and do not have to be refurbished between flights. The cost of the shuttle program has been almost $150 billion dollars or a little more than one billion dollars per flight for each of the 117 missions. Unmanned rockets, even big ones, aren’t nearly that expensive.

The shuttle is more expensive than was hoped largely due to a rigid zero-defect mentality on the part of NASA. Even a minor malfunction can result in the complete loss of the crew and a two billion dollar vehicle. Consequently, NASA takes an already legendary obsession with perfection to a new level to ensure the absolute reliability of the orbiter before each launch. This obsession is built into the vehicle through redundant systems and meticulous quality control, carries on to the launch where the smallest anamoly can scrub the mission (leading to costly defueling and reinspection), and finishes with an exhaustive post-flight check where the engines and most major sub-systems are disassembled and inspected.

At every stage of the process a small army of engineers and technicians orchestrate a clumsy bureaucratic exercise to document contractually stipulated compliance with procedures and specification. And yet, despite their best efforts, to date there have been two catastrophic losses of crews and vehicles for a failure rate of about two percent.

It wasn’t supposed to be this way but perfection isn’t cheap. If you adopt a zero-defect mentality, you are going to have to pay for it and you will rapidly reach a point where large amounts of money need to be spent for infinitessimal increments of improvement.

Consider modern American medicine which, because it operates in a predatory legal environment, is also expected to be zero defect. It is hard for some people to believe but a physician can be sued by a patient who he treated many years before for a condition that may of may not have been the presenting complaint but which was not discovered at the time even though a reasonable standard of care was used. The patient may even have been told to return if the symptoms did not resolve but for whatever reason was “lost to follow-up” or whichever creepy, politically correct phrase is selected to divorce the patient from his responsibilities, in this case the responsibility to be concerned enough about his health to be more than a passive observer or some kind of oblivious passenger.

The physican’s records will be scrutinized by a rapacious attorney and any mistake or ommission, no matter how slight, will be used to construct a case which, while perhaps not the multi-million dollar jackpot of which all indigent patients dream, may likely be settled out of court to avoid the expense of a trial. It’s a living for many attorneys.

This zero defect mentality costs money and very little of it improves patient care. Mostly it goes to cover the massive cost of defensive medicine which is what, I would dare say from personal experience, most of American medicine comes down to. We know better of course, but it is a lot easier to obtain the CT or order the test than to defend your perfectly reasonable, evidence-based rationale for not obtaining it. We also probably admit many more people than need to be admitted out of the fear of allowing patients to be responsible for their own outpatient follow-up.

A healthy respect for the possibility of error is part of medicine and cannot be discounted. On the other hand, what we have today is an abject terror of making a mistake. Unfortunately, unlike NASA, we are not working with professionals who have contractual obligations that they must honor, at least none that are enforceable. The trendier hospitals make a big deal about their carefully crafted Statements of Patient Rights and Responsibilities but it’s all just fluff to keep Press Ganey, the insatiable God of the Bureaucracy, happy. In our medical system, patients have no responsibilites and therefore the physicians must play a constant game of chess with opponents who moves their pieces at random and out of turn.

The public has to decided what it wants. They can have a reasonable level of relatively inexpensive medical care that relies as much as possible on the clinical judgement of physicians and their own high level of personal accountability with the understanding that occasionally something is going to be missed or they can have a hugely expensive system of medical care where everybody gets the million-dollar workup on the rare chance that something is caught that would otherwise not have been.

But being zero defect costs money and you pay for what you get.

Don’t Just Do Something, Stand There: Part Two

Don’t Tell the Spartans

(Many of you are about to start third year and are looking forward to it with feelings of both anticipation and dread. You know that it’s going to be the real start of your medical career where you finally get to see what all the fuss is about. At the same time, despite the propaganda, you have the uneasy feeling that third year is going to blow, and blow hard, not for the least of which reasons because, after what in years to come will have seemed like a two-year vacation, you now will be working on a rigid schedule with responsibilities that you can’t casually shirk.

There are two schools of thought about clinical education for medical students. One school believes that your clinical years should be a model for residency complete with long hours, pointless abuse, and call. This is under the theory that it will toughen you up for residency where you will be further toughened up so you can be prepared for the real world where medicine is not practiced at all how it is in residency.

The other school, the Panda School, knows that abuse serves no purpose other than self-justification for the past suffering of the abuser, that you cannot condition yourself to do without sleep, and that clinical training as it is currently structured at most medical schools is actually detrimental to education. Not to mention that since you will get plenty of abuse as an intern, there is no point wearing you out now, especially since, despite what The Man says, you have no responsibility for patients.


I was referred to an interesting discussion on the Student Doctor Network about the mistreatment of medical students by residents and since we have been giving short-shrift to this topic (although Brother Hoover has it covered pretty well) I thought I’d try to address some of the common complaints that medical students have about residents and particularly interns.

I am known to be very easy on medical students, by the way, as some of my medical students who read this blog can probably attest.-PB)

1. It’s my first day on the Service, and my first day of the third year, and the intern is mad that I don’t know anything.

I don’t know of another career where the trainees are berated for not knowing their job on the first day but this is a fact of life for medical students. On the first day you won’t even know how to work the phones much less care for patients and it may take you hours to complete a simple task (such as dictating a brief note) that you will complete in thirty seconds as a resident. This is because you have nothing but jumbled facts bouncing around your brain with no experience in marshalling them into a coherent assessment and plan for your patient. You also have no idea about the logistics of the hospital, where they keep things, and who does what.
I don’t know why this is hard for some residents to understand except that medical school admission committees seem to be selecting for assholes and, although medical school is good for personal growth, these people tend to grow as assholes.

The solution? There isn’t one except the general advice that the hospital is not Thermopylae, the patients are not the Persian hordes, and you are not a Spartan who has to sacrifice himself for the greater glory of a large, bureaucratic machine that if possible, thinks less of you than it does of the residents. Pace yourself. Realize that you don’t know anything, and revel in it. Don’t apologize, and be direct in the face of worthless, spiteful criticism, especially from an intern.

I assure you that interns have very little input into your grade for the rotation and generally speaking, as most residents are decent people, we can see as easily as you which interns are socially dysfunctional. You also have to ask yourself if your grade is more important than your self-respect. If it is, then you will have to suck it up. If not then you should establish the ground rules for how you are going to be treated early. As Dr. Phil says, we teach people how to treat us. If you are firm, forceful, and fair, people will either respect you or they will be intimidated, either one of which is fine. If you are a weak, squirrely biach you are going to be treated as such.

It’s like prison. If you pick a fight with the meanest, baddest prisoner on your first day, win or lose you are going to establish some credibility. I’m not advocating beating your intern but it’s not like this guy is that far removed from you. Hell, it’s July. He’s more scared than you because he has real responsibility. So sometimes, as you learn in the joint, a brother has to shiv’ a motherfucker. Establish early on that you are not a biach and you will do fine.

2. My intern is stealing my work and getting credit for it.

One of your duties will be to see patients and write notes, especially the time-consuming Admission History and Physical. No question about it, medical students write exhaustive H & Ps. You usually have the luxury of time while your intern is perptually under the gun so his may be a little more sparse than yours. While you may turn in a copy of your luxurious History and Physical for a grade, to your intern it is nothing but meaningless paperwork, especially since for 95 percent of patients everything pertinent could be written on a small index card in thick black marker. It’s another obstacle in a day filled with obstacles. He also knows that even in the unlikely event that anybody reads the note, the only thing they are interested in is the assessment and plan and not your detailed description of the patient’s travel history since the Carter administration.

Your intern does not get credit for your History and Physical. There is no such thing as “credit” for this sort of thing. It’s done, the box is checked, and it becomes just another scrap of paper mouldering away down in medical records. I have never heard an attending say, “Hey, that was a cracker-jack History and Physical. Take the rest of the day off.”
So don’t sweat it.

3. My intern is stupid.

Have a heart. You are fresh from two years of intensive lectures and the USMLE Step 1. Your intern spent most of the last six months of fourth year playing video games and catching up on sleep. I am a PGY-2 (second year resident). I once asked a medical student a question and when he went into his pimp-defense mode I said, “Relax, I’m really asking you if you have ever heard of this condition because I sure as hell don’t remember it.

Not to mention that your intern is sleep deprived and under a lot of pressure. It is easy to look and sound stupid if you’re supposed to know what’s going on but don’t which is typical of most interns. It’s not that they’re stupid, it’s just that compared to their upper levels and attendings they seem that way. They’re learning too, just like you but the difference is that they count and you don’t (no offense).

On the other hand since “MD” actually stands for “Minimal Doctor,” it is quite possible that your intern is, in fact, a jibbering moron, at least by medical standards. It is inevitable that somebody is going to slip through the cracks and the “questionable admission” may very well have pulled off yet another snow-job and landed a residency position. Not to mention that there are a few specialties that are known for scraping the bottom of the barrel when it comes to the help.

If he’s a jibbering motard but otherwise a nice fellow you might consider trying to cover his ass. You don’t have to, you understand, and nobody is going fault you or even know if you don’t but good residents look out for each other and you may as well start practicing now. I know, I know. You’ll be helping a guy along who will one day be in the position to hurt patients but decent people don’t think like this. Let his State Board sort it out.

4. My intern tries to get me to do his work, especially on call.

I despise call, probably more than most people. Ever since I started publishing this blog it seems like more and more residents are coming out of the closet in this regard. Certainly when I was a medical student to say you disliked anything about medicine, not just call, was viewed with the same horror by your residents as if you had a large, greasy bowel movement in their Lucky Charms. But they’re not fooling anyone. Call blows. Nobody likes it just like nobody really likes residency training for the most part except that some tolerate it better than others.

So it would be natural for an unscruplous intern to try to either shame you or force you into doing his work for him. Just keep two things in mind. First of all, most medical schools have rules about call for medical students. At some, medical students are to be discharged at some reasonable hour of the night because, wonderous to behold, the school realizes that a medical student’s purpose is to learn, not to be a scut ox who is too tired to study. It is up to you to know the rules and grow a set of gonads about sticking to them. Don’t care for the rotation or the intern? Hey, it’s eleven o’clock buddy and I am outta’ here! All you have to lose is the respect of the intern…but…and stop me if this is obvious…he’s just an intern. His respect his worthless anyways if it comes at the price of your sleep and your health. Stay all night if you want and if you feel like you will learn something but scut work is worthless and you’re not being paid to do it.

The second thing to remember is the French Hooker Rule. No matter what they want, you can only give them what you can give them. It is not your responsibility to clear out the backlog of admissions in the Emergency Department. Most interns wouldn’t even think of giving you this task, not for the least of which reasons that you can’t do it. But sometimes a lazy and unscrupulous intern, on being paged for an admission, will send his medical student to knock out the preliminaries which involves most of the paperwork. Learning is one thing and you need to do some admissions to get the feel for it but you are not cheap labor, the intern is…or didn’t he get the memo?

And I am sick of sports metaphors. It’s not a team. If it were a team everybody would get treated better than they do. It’s more like a salt mine (I mean if we’re going to throw metaphors around). Do your assigned work diligently but don’t be patsy either.

5. My intern berates me in front of the other students.

Berate back. He’s not your mother. There is no penalty for shoving back. You are not contractually obligated to take crap from anyone. On the other hand, no need to be on a hair-trigger, either. Certainly don’t buy into the “Welcome to My Service” speech that some interns like to give. I got one of those as an intern from my twenty-something third-year resident who, among other pearls of wisdom, informed me that my family needed to come second after medicine in my order of priorities. This only sounds good to people who don’t have families, of course. The point is that the intern has different priorities and goals for the rotation than you might have. It may be his specialty and he may be really into it. You may hate the specialty and just want to get through it with the low pass.

The irony of medical school is that you are expected to take abuse from people who are only a few years ahead of you in training and whose ass you would otherwise kick if they treated you half as bad anywhere but the hospital.

Don’t Tell the Spartans

Faith, Hope, Charity, and the Jackpot Mentality

Physician Defend Thyself

Imagine you are in a rural Emergency Department on a quiet night. The radio crackles. It’s EMS giving a report to the charge nurse. You overhear “snowmobile,” “Loss of consciousness on scene but patient now alert and combative,” “Open fracture of the left femur,” and “Possible ETOH.”

The patient arrives and the history from the paramedics is typical, that is, typical dirtbag typically drinking, typically lost control of his snowmobile after typically saying to his buddies, “Hey watch this!” Somewhat atypically, however, ran his snowmobile into the side of a barn fracturing his femur on his way through.

You evaluate and stabilze the young daredevil who is otherwise uninjured except for minor cuts and abrasions, put the leg in traction, and start the appropriate antibiotics because the end of his fractured bone was sticking out of his thigh when he arrived.

It is time to call an orthopedic surgeon. You don’t just put a cast something like this.

“Good morning, Dr. Smith. Sorry to wake you up but this is Dr. Bear at the County Hospital Emergency Department. I’ve got a 25-year-old gentleman, snowmobile versus barn, with an open mid-shaft fracture of the left femur but otherwise without significant injuries. We have him in a traction splint and his distal pulses and sensation are intact. On the way through the barn he dragged the end of his broken femur through approximately fifteen feet of cow manure and I’m afraid it was about thirty minutes before his drunken friends decided that he probably wasn’t going to walk it off.”

“How’s he doing now? Fine. He’s fully alert and oriented and threatening to sue everybody in the place. Can you come in and see him?”

If you were an orthopedic surgeon, would you come in, especially as you can come up with quite a few good excuses not to?

Don’t answer yet.

First of all the patient does not have insurance. People riding their snowmobiles drunk on a weekday at 3AM never do. It’s axiomatic. He also has a major injury and he is a setup for all kinds of post-operative complications. Not only is he likely an unrealiable patient and will not comply with his medication or follow-up but the jagged end of his bone was dragged through cow manure, rat turds, hay, and every kind of bacterial goodness that you can imagine. The odds of osteomyelitis (infection of the bone) which even the best antibiotics that the taxpayers can buy might not cure are high. The leg might never heal or it may require mulitple revisions to remove and replace infected hardware and bone.

Now consider that the orthopaedic surgeon is of a new breed, operating primarily out of a privately owned surgical center where he can fill his OR slots with hip and knee replacements on insured, compliant, pleasant elderly people or tendon repairs on insured, healthy young atheletes. Coming in to care for this patient is going to set him behind on his schedule, maybe forcing him to cancel some cases or some clinic appointments for his paying customers. Since he doesn’t need to maintain privileges at the County Hospital they have no hold on him and it is only the tenuous grip the Hippocratic oath has on his heart that could compell him to come in.

I say tenuous because not only is the Hippocratic oath not legally binding but it doesn’t even apply in this situation, a case where before the physician “Can do no harm” he first has to symbolically lay hands on the patient by accepting him, thus establishing the sacrosanct doctor-patient relationship. This is not just a techincality. The entire world is not your patient, only your patient is….which should be obvious. If this were not the case, I would have to hang a big sign in front of my house saying “Here There Be a Doctor” and treat anybody who happened to drop by. It would sort of be like EMTALA gone crazy, at least crazier than it has already become.

EMTALA, or the Emergency Medicine Treatment and Active Labor Act mandates (without providing funds, hence the unfunded mandate par exellence) that every patient who presents to the hospital, regardless of their ability to pay, be provided with a screening exam, appropriate medical care to stabilize them, and transfer to a hospital that can provide the appropriate level of care. It sounds reasonable enough but in practice, the law has become the portal of entry into the hospital for anybody with any medical complaint whatsoever, emergent or not. What was originally intended to stop the practice of “patient dumping” has now become a highly inefficient system of charity care.

The key thing to note here is that EMTALA applies to hospitals, not physicians. Because the “takings clause” of the Fifth Ammendment prohibits the government from seizing an individual’s property (in this case the doctor’s work) without just compensation, no law may compel you to work for free…or even work at all if you don’t want to. Emergency physicians see every patient without regard to ability to pay because it is part of their usual and customary duties to see everybody who come through the doors and are compensated by the hospital. An orthopaedic surgeon who has no contractual obligation to the hospital, on the other hand, has no such obligation.

Which brings us back to the Hippocratic Oath and the sense of duty we all feel as physicians to provide care to everybody and devil take the hindmost. Unfortunately, while the legislature is quick to give rights and privileges to patients, it is a little more deliberative when it comes to ennumerating their responsibilites and limitations. Our patient is going to be very grateful, once he becomes sober, for any help he receives. And yet, when he finally goes home and perhaps walks with a permanent limp or just decides that his job at the local plywood mill is too depressing, he will look up to see the gleaming eyes of the legal predators circling his fire and from then on, the orthopedic surgeon is a marked man.

He may never be sued but the risk is so great of providing free care to a population with poor compliance, poor follow-up, and a jackpot mentality reinforced continuously by lawyer’s television advertisements, that even providing this care will force his skittish malpractice carriers to increase his premiums or even cancel his coverage althogether.

So at the very best, the orthopedic surgeon will lose a little bit of his time and some of his sleep, things that most of us don’t really object to losing if there is a clear need. At the worst, however, he can be dragged through the humiliation of a malpractice suit which, even if he is held harmless, will still tarnish his reputation and while it works its way through the courts can damage his abiity to maintian his credentials. It can cost him directly in increased malpractice insurance premiums which, in some states, are as high as $200,000 per year for surgeons. And it can cost him indirectly in lost revenue from work he could have done, the very real concept of “opportunity cost” which most people who don’t work don’t understand.

All of this for a bad outcome which may not have been possible to avoid.

So would you come in?

Faith, Hope, Charity, and the Jackpot Mentality

Medicine in the Media: More Reviews

Strong Medicine

Every now and then my wife and I like to put on our fleece pyjamas and our fuzzy slippers and sit on the sofa with hot cups of herbal tea watching Strong Medicine, an estrogen-charged medical series offered on Lifetime. The show is about a Group of female gynecologists who have somehow managed to take over a hospital where they can be found, day and night, sticking there noses and considerable medical expertise where gynecologists don’t usually stick their noses. 

The show has a science fiction qualilty to it.  Imagine an alternate universe where women run the hospital and men are their preening, self-centered playthings.  But that’s lifetime for you, a network that only has two flavors of men, Bloodthirsty Rapist or Sensitive Metrosexual.  Even guys who are supposed to be manly, such as the suave Dr. Biancavilla, are just a little too put together, a little too fit, and a little too in touch with their feminine side to really be taken seriously as men.  It’s almost like a reverse kabuki play with specially-trained actresses performing the male roles. 

Like most of Lifetime’s shows, Strong Medicine is an unapologetic feminist screed which is its charm.  You will find no subliminal messages here and the characters seem to continuously clench their jaws and curl their fists at every affront to womyn’s right as if to say, “You will take my curette when you pry it from my cold, dead fingers.”  Conservative and old-fashioned as I am, I can appreciate this no-holds-barred, take-it-or-leave-it, in-your-face world-view especially because unlike other medical shows, while the characters often deal with frustrations and conflicts of which good medical drama is made, there is never any angst or self-doubt.  Dr. Cambell (played by Patricia Richardson of Home Improvement fame) for example, plays a former Army physician and no cabal of good-old-boys are going to stand in her way, no ma’am.

The stereotypes and racial profiling on Strong Medicine are as horrendous as anything else on TV.  There is the sassy black office manager who speaks in the third person (“If Lana wants a bagel, Lana will get a bagel”), bobs her head when she talks, and, as she is a recovered prostitute, flaunts her authentic street cred at the smallest provocation.  They have the obligatory young latina doctor passionately fighting for the reproductive rights of her downtrodden patients who are some of the most articulate, responsible, family-centered crack whores I have ever seen.  And they have Ricky Schroder (well known to sitcom connoisseurs from “Silver Spoons”) representing the stone cold white boys. 

I don’t know if his agent billed this as a good career move but an actor’s gotta eat.

It’s ridiculous. Gynecologists do not typically manage traumas and push the pretty-boy Emergency Physicians out of the way.  It’s contrived.  Every woman with HIV has the perfect story of victimization.  It’s stilted.  They don’t so much speak but give speeches to each other.

But it works.  And my wife and I love to watch it while we talk about that French waiter….what was his name?….Jean Luc!

 

Chicago Hope

LA Law set in a hospital.  That’s all you have to know.  I loved that show and we watched it religiously until the siren call of ER lured us away.  Imagine a show that picked one hot-button social issue per episode and had an ensemble of some of the finest actors on televsion beat the hell out of it. 

And beat they did.  We get it.  Discriminating against HIV patients is bad.  Gay men can make good parents. Guns are bad.  Four legs good, two legs better.

Still, it had marvelous acting lead by my favorite actor-whose-name-I-can’t-remember-but-who-I-confuse-with-the-captain-from-the-Love-Boat.  It also had Mandy Patinkin who is one of the most versitile and under-appreciated actors of our time. 

Just a quick bit of Panda Bear trivia.  I don’t know most of the character’s names on any of the shows I watch.  I have a mental block, kind of how I skip over the Russian names in Tolstoy. I have been watching ER since the late 1960s, for example, and I still can’t tell you the names of anybody but Abby and Dr. Carter.  No sooner had I learned “Dr. Green” and they killed the bastard off from cancer, on the beach, in Hawaii.  So Chicago Hope is full of wonderful characters but I tend to think of them as gestalts rather than real characters, principal among them the lead actress who played the very model of a cynical, bitter, bitchy cardiothoracic surgeon who had sacrificed her personal life to her career.

But angst? You could cut it with a knife.

 

Scrubs

People always ask me, on discovering that I am a resident, if residency is really like Scrubs.  The funny thing is that it is.  Not in the sense that life as a resident is one comic situation after an another and not because the residents are continuously verbally abused by their completely over-the-top-even-for-residency attending but because I believe Scrubs is the first medical program to show that doctors, especially young interns and residents, are not perfect and live with a level of self-doubt that most people can’t imagine.  I saw the first season and the show captured perfectly the sense of inadequacy and dread most of us started to feel about twenty minutes after graduation when we realized that shirking responsibility (“Sorry, I’m just the medical student) was now no longer an option.

And it also portrays residents, even though it is a comedy, more realistically than even the more serious television offerings that purport to be showing a slice of reality.  As opposed to the hip-and-cool, edgy residents on ER or the svelte sexy house staff on Grey’s Anatomy, most real residents are geeks to one degree or another. Dr. Dorian is completely realistic in this respect and even his maturation over the years from complete goof to competent but goofy doctor is completely true-to-life. Or consider Dr. Turk (played by the talented Donald Faison) who tries to live the persona of the angry, street-wise black man when he knows (and we know) that white or black, the discipline and studying required to gain admission to medical school and acceptance to a surgey program does not allow for the bohemian lifestyle and the flaunting of authority required of a gangsta rapper.

It is also a very funny show that breaks out of the usual sitcom formula.  I can hardly watch it now that I am a resident.

Medicine in the Media: More Reviews

A Letter to an Attending

Who do You Think You Are?

Dear Sir or Madame,

I am exceedingly glad to be done with the rotation. I have been a resident for almost two years and that month was perhaps the worst experience of my medical career. You made what should have been a moderately unpleasant experience which is what we expect on rotations in your specialty into an almost unendurable ordeal which no one in any other career except ours would tolerate with as much good humor as I did.

I have most certainly quit jobs for less, and it is only the iron grip on my gonads enjoyed by the hospital that kept me from telling you to “admit your own goddamn patients.”

Now, the fact that you had it harder when you were a resident, something you pointed out on every possible occasion, is completely irrelevant to me. I don’t care. Let’s just assume I am a pussy and leave it at that. I’m not about to change my ways now just to please you. You’re not my mother. You’re not my father. Hell, you’re not even in my chain of command and your bad evaluation is going to sit in my file doing nothing until, one day, some alien archeologist sifting through the sterile rubble of our planet deciphers it and comments to his collegues that you were a real horse’s ass.

You accused me of being unenthusiastic and on this charge I am completely guilty. I am interested in most aspects of medicine including your specialty but if you expected me to clap my hands and squeal for joy at 4AM when confronted with the twelfth admission of the night it is no wonder you were disappointed. As even you grudingly admitted that I did my job and everything asked of me, I don’t know what else you expected except for me to kiss your ass and pretend I live for every-third-night call

I was also less than thrilled to be pimped over the phone in the early morning hours when all I was trying to do was admit an uncomplicated patient. If you want something other than what I ordered for the patient have the goodness to tell me as I am not a mind-reader. And as I am usually physically ill at that time in the morning from fatigue, dehydration, caffeine, and lack of sleep, just tell me which of many formulas you would prefer for me to use to calculate creatinine clearance and I will use it. Don’t make me decide and then ask me to justify my decision.

Did I mention it was 4AM? I don’t care. We weren’t even talking about a renal patient. On every occasion when we spent an hour on the phone picking the nits off of nits I had a board full of admissions from the other services I was covering and a couple of pagers that that would not stop beeping. If I am to sit under a tree in the agora soaking in your wisdom in the socratic manner than call off the dogs from the other services. We don’t have time. I would have also liked to have layed down for an hour or two after I cleared the board and you were seriously slowing me down.

Additionally, if you were reading the lab values off of your computer at home, why did you have me repeat them to you over the phone? This is just sadism on your part and why, after I found out, I refused to do it. Who do you think you are, anyways? You don’t pay my measly salary, I have sworn no oath to be your little scut whore, I’m about ten years older than you, and there is absolutely nothing in it for me to repeat numbers to you over the phone. And your weasel-like excuse that it was good practice make no sense. Practice for what? My eight-year-old can read numbers over the phone. I reviewed the lab values and the fact that you seemed to think I had not belies the trust you purported to have in me as a fellow physician.

I also didn’t appreciate your patronizing attitude and how you called me “Doctor” in an ironic and insulting manner. On one hand you insisted that you expected a lot out of me (“doctor”) and that you expected me to think independently (“doctor). On the other hand you micromanaged every single decision to the point that when I asked you why you didn’t just come in yourself and eliminate the middleman, I was being completely serious. The premise that you were treating me like a fellow physician was ridiculous. If you treated your colleagues like that I’d be surprised. And as I am working for about a tenth of what you make on an hourly basis, well, the reality is that you treated me and every other resident who has worked with you as low-wage sweat shop labor.

Not to mention that If I was a valued colleague you wouldn’t have been so snotty when I gave you my opinion.

That’s another thing, if you don’t want my opinion, don’t ask for it and don’t get all bent out of shape when I give it to you. In my opinion, my job on the rotation was to provide cheap clerical labor for which you otherwise would have had to pay somebody a decent salary. I think I’m on the money with that opinion, at least from my point of view. If you don’t agree, well, you don’t agree and the fact that I didn’t apologize for my opinion should tell you something.

In the end, I think that’s what really pissed you off. When you called me on the phone at the end of the rotation to express your displeasure with me and my attitude you were probably expecting the usual obseqiousness to which you are accustomed and some sort of apology with a promise to do better.

But you don’t own me. I did my job even though I don’t like you and I’ll be damned if I’ll apologize to make you feel better about your personal control issues. You do your thing, I’ll do mine, and I will never have to work for you or with you again.

Sincerely,

P. Bear, MD

A Letter to an Attending