What ED Crisis? (And Other Random Thoughts)

Shake that Money Maker

They say there is a crisis in the Emergency Rooms and while I certainly see a little of its effects at my own program, the crisis is not universal. Some Emergency Departments compete for patients, at least this is my understanding from the numerous billboards I saw the other day as I drove towards Detroit. Surely you’ve seen those billboards? You know, the ones with the pleasant looking ethnically ambiguous doctor, stethoscope carried jauntily around his neck, beaming down at a cherubic youngster whose boo-boo he has just fixed with the caption underneath promising a “New Vision of Health Care” with a guaranteed thirty-minute-or-less wait.

And no, they are not advertising for Urgent Care even though they are clearly angling for urgent care patients. The caption clearly indicates these clean, ultramodern medical establishments are Emergency Rooms. Naturally every Emergency Medicine resident must roll his eyes and curse at the idea of attracting even more ridiculoulsy trivial complaints to make his day even more hectic. On the other hand not every Emergency Department is over-crowded and packed with the indigent and uninsured. A nicely appointed ED in a good part of town can generate real income if it has a favorable payer mix. Even if emergency services themselves are not a money maker they can serve as a loss leader to bring paying customers into the hospital (and out of the specialty centers).

I am not against making money and I certainly realize that competition is ultimately good for the consumer in terms of better services and lower prices. On the other hand one can’t help notice that we are, with the exception of the small fraction of the uninsured who can’t bring themsleves to stiff the system, ridiculously over-doctored in the sense that large amounts of health care firepower, the physician’s time being one of the most important, are brought to bear on complaints that are either so trivial as to be laughable or so serious that they are impervious to our best ordinance.

Take, as one example, my patient of last night who the triage note said was a febrile, nauseous, anorexic, dehydrated infant. The nurse rolled her eyes when I picked up the chart which usually tells you all you need to know. Febrile was an axillary temperature of 99 measured at home and 98.7 in triage. Anorexic was a disinterest in feeding earlier in the day but breast feeding vigorously when I introduced myself. Dehydrated was an extremely wet diaper. Not exactly as billed on the triage note.

I have four kids. Every now and then a viral illness sweeps through all or most of them leading to a solid week of vomiting, diarrhea, and sleepless nights as one child after another succumbs and recovers. I have never taken my kids to the Emergency Department and we rarely take them to the doctor, especially for self-limiting things like that. They’re kids. They get sick. They usually recover. I understand that occasionally a “stomach flu” is meningitis so we are justifiably cautious with ill or toxic-looking children but come on now. EMTALA aside, what we really need is the ability to send people home from triage, as in, “Are you crazy? This is an Emergency Department and you ain’t sick.”

We don’t of course, and the large minority of patients for whom we can and should do nothing contribute to the excessive waiting time for patients who, while not exactly critically ill, never-the-less should be seen sooner than the what can amount to a ten hour or more wait in some departments.

On the other extreme, I see many incredibly old, incredibly sick, fantastically complicated patients who all present for some variation of being as old as dirt and sick as stink. Perhaps complicated is the wrong word. There’s nothing complicated about impending death. When you’re pushing 100 nothing is really standing between you and the Grim Reaper except he’s finishing his bagel and latte and he’ll get to you when he gets to you, dammit. We do what we can but we’re hard up against biology. The interesting thing about these patients is that they swim through the murky depths of American medicine accompanied by a small school of physicians who, like pilot fish, dart ineffectually around their decrepit shark picking off an occasional parasite. Between the cardiologist, the neurologist, the internist, the oncologist, the nephrologist, and the nice young girl in physical therapy who manipulates the fins every now and then these patients devour an incredible amount of medical resources.

My point? Nothing really except we get the health care system for which we pay. The current system can not help but be ridiculously expensive because of the way it is structured. Nothing wili ever change, no matter how or to whom you shift the costs because:

1.Patients are not encouraged or expected to take personal responsibility for their own health.

2. As every insurance scheme insulates the patient from the true cost of health care, there is no incentive for patients to make good economic decisions.

3. The legal environment makes it impossible for anyone in authority to exercise common sense. When I was younger, for example, drunks went to the drunk tank at the police station. Now they all come through the Emergency Department where they are expensive, space-occupying lesions. I understand that in our risk-averse society this is necessary to prevent the possibility of a habitual drunk aspirating his own vomit and dying without immeidate medical care. At the same time this kind of risk management isn’t cheap. If the public knew the cost they might be willing to live with slight chance of a drunk or two dying in police custody.

4. Futile care, which is in no way discouraged, sucks up a vast amount of medical care, everything from the physicians time to the cleaning lady mopping the floor of the ICU. Maybe by the time a patient is being fed through a tube, urinates through a tube, defecates through a tube, and breathes through a tube it’s time to let them go.

5. Doctors don’t know how to say “no” or admit defeat. The temptation, to which we easily succumb, is to shift responsibility by consulting specialists. I understand the need for specialists but by the time a patient accumulates a small platoon of them its time to examine, in terms of mortality versus cost, what all of the hired guns are really buying us.

The true crime is that the zealots believe a single-payer system or some other scheme of “We Swear It’s Not Socialized Medicine” is going to make health care less expensive. Unfortunately, until the structural problems are addressed, health care will just keep getting more expensive. To address them is, ironically, to preclude the need for anything other than consumer driven changes which are the only kind that will work.

What ED Crisis? (And Other Random Thoughts)

Harvard Medical School, The Not Too Distant Future

Commander of the Devout

Like all good medical students, I await the arrival of the Mother Ship as promised and foretold by the Prophets in whose names we have dedicated our lives. But I have begun to doubt. The world goes on beyond the walls of our medical school. I catch brief glimpses of it over the razor wire that our robed masters say is to protect us from The Deceiver. Sometimes it’s an automobile of an unfamiliar type. Occasionally it’s just a snatch of sound, a few notes from what I once remembered as an ice cream truck although the taste of ice cream eludes me. It is haram, or forbidden, to the disciples and I have not tasted it since my parents handed me to the Guardian at the gates of the adminstration building whose threshold I have not crossed for these many long years.

I was not destined for medical training. Some even doubted my dedication during the selection process. My grades and test scores were good, of course, as are everyone’s who is chosen to follow The Way. And it goes without saying that I had a medical degree from a third world country. Everybody does. It’s considered the bare minimum to prove your dedication to the Prophets. But I never really demonstrated my desire to be a physician, at least not where it counts. I amost cured small pox. I almost implemented a Single Payer System (Peace Be Upon Its Holiness) during one whirlwind summer in Tajikistan. I almost did this and I almost did that, never gaining a foothold, something that could convincingly show my dedication to medicine.

Even my admission novel wasn’t as long or as original as it should have been. I only worked on it for five years and the final product, while servicable and the recipient of several literary prizes was not considered Nobel material.

So I sometimes catch the disapproving glances of my fellow medical students. They whisper that I had some help gaining admission. Perhaps a relative on the admission comittee, maybe a few well placed donations to the High Professors.

“Empathy and Caring” Intones my novice, a first year, breaking me from my reveries.

“For the Underserved, now and forever,” I reply automatically, the words of the ritualistic greeting coming easily to my lips though I no longer believe them.

Even during my first encounter with one of the Holy Underserved, though carefully supervised, the brief glimpse I had of her through the Hippa curtain did not inspire the pure thinking in which I had been instructed. She was incredibly fat and reeked of cigarette smoke. Neither had she bathed in a very long time and she smelled like a piece of rancid cheese. I knew on an intellectual level that this wasn’t her fault. After all, are not the secrets of soap kept from the Underserved? And yet I resented her and fought with all of my training to keep from betraying my revulsion to the Guardians.
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My novice looked at me suspiciously. Have I betrayed something on my face? Have I allowed my carefully cutivated external serenity to slip?

“The Commander of the Devout wishes to see you, oh my Fourth Year Brother,” says my novice softly, barely concealing his anger to have been assigned a Fourth Year who is fallen from the favor of The Prophets.

“So it shall be done.” I dismiss my novice who scurries away to his empathy prayers and begin the long climb to the chambers of the Dean of Students.

The Commander of the Devout turns from the window and motions for me to sit down.

“I have had complaints,” he says quietly, looking at a thick file laying open on his desk, “Some even question your faith.” The Commander is known for coming quickly to the point. During rounds he once cut short a resident who had only been discussing a patient’s potassium for thirty minutes.

“I serve the Holy Underserved in the wilderness of health care access,” I blurt out, hoping to buy time to collect my thoughts.

The Commander waves his hand inpatiently. “Let us dispense with the scriptures. You obviously don’t believe them, or at least that’s the impression I get from reading your weekly evaluations. Did you not roll your eyes on several occasions during your primary care appreciation meetings? Have you not said to several of your fellow students that you had considering radiology? Don’t deny it. I can produce witnesses if required.”

“I try to think pure thoughts, Emminence, but of late my mind wanders and I wonder what it would be like to have some time to myself, to think of other things besides medicine.”

“Time for yourself? You blaspheme here in my presence? Is it not written that our fathers fled into the wilderness to escape the uncleanliness of the eighty-hour work week?” demands the Commander, making the the warding sign, “Did not the infidels match into dermatology and consort with opthalmologists jeapordizing their very souls and keeping the Pure from the Rendevous With the Primary Care Mothership in the End Times?”

I have never seen the commander so angry.

“Do not fall for the traps of the Deceiver and his Arch-Devil, the Dark Lord of PM&R whose task it is to lead the Faithful astray and deny the Holy Underserved free access to health care and their just absolution from all earthly responsibilities.”

“I have in my hand the results of the match and I could not help but notice you have matched into Emergency Medicine,” the commander spits out the words as if they taste bad, “But I say unto you that even at this late hour it is not too late to withdraw and fall into the welcoming bosom of Family Medicine, the One True Specialty. To sojourn among the unclean, and certainly their are none as unclean as the Emergency Physicians who as they know not empathy and make cruel jests must surely sit at the right hand of the Deceiver as chief among the damned, to sojourn among them is to fall away from grace precipitously and permanentely.”

I shift nervously in my chair. I have been discovered. My involvement in several primary care interest groups and the oaths I have sworn have been in vain. Have I been so transparent? I say nothing.

“Go then,” intones the Commander of the Faithful, “But know now that you are shunned and for any to speak to you is haram.”

Graduation can not come soon enough.

Harvard Medical School, The Not Too Distant Future

Other Medical Careers Part Three: Physician Assistants

Inspired By Actual Events

(House DO, one of our good blogfriends, has taken a hard look at the requirments of medical training and decided to divert to PA school. To him is this article dedicated-PB)

As an intern, I once rotated on a service that had a lot of Physician Assistants. One night on call I was paged by one of them to come up to the floor and help him with some paperwork. Naturally I refused. It was late, I was tired, I wanted to get a few hours of sleep, and I told him so.

“Well,” came the peevish reply, “I’m here and you don’t see me getting any sleep.”

“Well,” I replied politely, “You’re not on call, you’re working a shift, you got here at six PM and while you will go home at six AM, I will be here into the afternoon. Not to mention that I got here yesterday morning and have been here ever since while you will work your three shifts this week and I will probably never see you again. Call me if I can help you with anything important.”

That’s about all you really need to know, philosophically, about Physician Assistants. They’re kind of like doctors and can and do perform many of the same functions but they have limitations. Hell, we all have limitations. Medical school and residency sometimes seems primarily about teaching us what they are. As a PA, your limitations will just be lot closer than those of a physician, kind of like the difference between a dog with the full run of the backyard and one who is brought up short by his chain while chasing a squirrel.

Physician Assistants were invented at Duke University in the mid 1960s to address the shortage of primary care in rural North Carolina. Their inventor, Dr. Eugene Stead, studied the training methods used to produce doctors quickly during World War II and created a training program based partly on these methods. His first students were former United States Navy hospital corpsmen (what the Army calls “medics”) who then, as now received extensive medical training far beyond that of paramedics, their closest civilian counterparts. An important thing to keep in mind is that medicine was not nearly as complicated in World War II (or even as late as the 1960s) as it is today when there were, for example, only sixty or so medications in common use and most of those were of the crapshoot variety. You could probably train a doctor to mid-twentieth century standards in a couple of years if you got right down to it.

True to the original ethos of Dr. Stead, most PA training programs heavily favor those with prior careers in allied health such as nursing or paramedicine but this requirement is not universal and my sources tell me that not every program necessarily looks for this.

There are now 130 Physician Assistant training programs in the United States. Most are Master’s level programs although a few still offer an undergraduate degree. The curriculum in the Master’s level programs is typically two years with the first spent on didactics and the second on clinical training after which you may become certified and begin to practice. There are opportunities for further training but this training is not required, de facto or otherwise, to start working and earning a living which is the principle appeal of PA training versus medical school. While a typical physician will train for a decade before he even starts his career, a PA can start earning an income after two years.

It’s a pretty good income too. The average PA salary is close to the mythical “six figures” and some, particularly those in the more lucrative specialties, can earn even more. It is not hard to get into a lucrative specialty either as the demand for PAs in all fields currently far outstrips the supply. That’s one of the beauties of PA training. It is versatile and a PA can move relatively easily (compared to a physician) between specialties. A PA, for example, who is interested in surgery can work for a surgeon and by “first assisting” in his cases can get a pretty good practical grasp of it. If, on the other hand, he has a hankering for primary care (although even PAs run screaming away from it…they are highly intelligent profesisonals after all) he can work as an essentially unsupervised primary care clinician in most states especially in the rural areas which have a shortage of doctors.
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The conventional wisdom is that PAs are the equivalent of physicans and this is certainly the mantra you will hear repeated so often during your medical training that it will become a reflex action, kind of like your catechism, to reassure those around you that except for the two extra years of medical school and all of that residency stuff, it’s all the same. But that’s kind of the issue. You either believe that extensive training is required to produce a doctor or you do not. Because our society is highly over-doctored to begin with and most of medicine is fairly routine, those who do not will correctly point out that not every patient is either complicated or critically ill and that it doesn’t take an advanced degree to diagnose an ear infection or treat routine hypertension. Since it it currently takes a minimum of seven years to produce a primary care physician versus two for a primary care PA, the advantages of PAs are obvious. It is also easy to see how in a narrow medical specialty many of the routine tasks can be performed by PAs. If you first assist a general surgeon who concentrates on a narrow repertoire of abdominal procedures, eventually you will have a very good grasp of what is involved and excellent procedural skills without having been through the bottleneck of medical school and a six year surgical residency.
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On the other hand, a lot of medicine isn’t routine, some patients are complicated, and if there’s one thing I’ve noticed about cookbook medicine it’s that most of the patients didn’t read the book and don’t follow the recipes. I’m sort of old school about this. I am perfectly willing to concede that PAs can and should take over many medical duties if they are more cost-effective. At the same time the more I learn about my own specialty the more I appreciate the need for a broad and lengthy period of training before we are released upon a trusting and unsuspecting public. I have been hard at it for six years and I am still humbled on a daily basis by my relative ignorance compared to my attendings. And I don’t think I’m in the minority when it comes to an honest assement of my skills and knowledge as a resident either. There is a lot to know, some of it highly nuanced and much of it requiring pretty good clinical judgement that you cannot learn in a couple of years and especially not without the background in medicine that even those lazy bastards in PM&R can’t help but acquire.

Unfortunately, PAs (and other midlevels) have found themselves at the cutting edge of efforts to dumb down medicine in the name of economic efficiency. If I were a PA I would be deeply offended to be associated with this effort, first because PAs are not dumb in the slightest and increasing their scope of practice will require more, not less, resources. Second, and most importantly, if we buy into the premise that medicine is nothing more than an algorithm that we can read from a card and apply to every patient not only do we not need physicians but PAs themselves are probably over-trained for their jobs and eventually they will be replaced by motivated junior college graduates.
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I mean, there’s nothing to it, right?

Advantages: Practice as a licensed clinician after minimal training. Good salary, can exceed physician salaries in some specialties. Variety. Mobility. You can wear a white coat and many of your patients will think you are a doctor. The training is not as rigorous from either an intellectual point of view during didactics or from a “fuck with your head” point of view during clinicals as physician training. Nobody will ever insist you have a “passion” for physician assisting as a prerequisite for the job. No residency required although you can get further training if you want it. Only two years worth of debt before you start making money.
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Disadvantages: Very few, actually. The training is not as rigorous as physician training and, despite the propaganda, you may keenly feel your lack of skill and knowledge compared to your boss. On a specialty by specialty basis, you will never make as much as a physician for the same amount of work. And your salary will also decrease under any socialized system currently gathering its strength behind the mountains of Mordor before it is loosed upon us all. But other than that it’s not too shabby.

More here and here.

Other Medical Careers Part Three: Physician Assistants

Post-o-rama

Mission Creep

The conventional wisdom is that the American health care system is broken. This is the party line parroted by the various media organs of the dependocracy in their attempt to stampede an excitable public towards socialized medicine. Like a lot of the conventional wisdom, the idea of a broken health care system gets repeated so often that it has become a cliche, something that people spout in a self-righteous reflex. It is certainly a pleasant metaphor and an easy one for the people to get a handle on without having to think about the real complexities of delivering zero-defect medical care to a largely non-compliant public, most of whom care more about their cable television and their personal watercraft than they do about their health.

In other words, while you can poll the public and health care makes it to the top of the list of concerns, most people, at least the ones sucking up a disproportionate number of somebody else’s health care dollars, spend considerably more on cigarettes than they would ever dream of spending on medical care which shows you its true importance to most people.

Putting aside the fact that there is no health care system, just a collection of independent hospitals, clinics, and private practice physicians, the system is not so much broken as it is a tool being used for a job for which it was not intended and for which it is ill-suited, namely being completely responsible for all aspects of the health of a feckless and helpless public for whom the thought that they are responsible for their own health is completely inconceivable. We pay lip service to the idea of patient-centered health care of course, and including the patient as an equal partner in medical decisions is the New Religion. In our society however, where a physician can get sued for not having written on the discharge instructions for a dead crack dealer, “Return to Emergency Department if chest pain returns,” well, there just isn’t as much equal partnering as you’d like to believe.

In fact, there’s none to speak of where it counts. Not an artery hardens or liver fails without a physician somewhere, somehow being blamed. Personal responsibilty having long ago been abandoned in every other part of society has finally been driven from medicine which is the one place above all others where it is critical. The medical schools, for their part, have moved completely away from the notion of expecting patients to care. To even breathe the words “personal responsibility” is to invite criticism from your instructors who despite their professed love for their patients view them as contemptible creatures who are incapable of making rational decisions and little more than slaves to their conditioning. As a result there is a natural tendency to try to become deeply involved in the lives of the patients in the hopes that some combination of cajoling and psychobabble will save them from themselves.

This creeping paternalism is the new medical paradigm and, as it will serve to dissipate finite medical resources instead of concentrating them where they may do the most good, it could not have arrived at a worse time. The level of involvement required to change bad habits is simply more than we will be able to fund. Every patient cannot have a dietician, a therapist, a substance abuse counselor, and a life coach. It’s too expensive. They’ll be lucky to get a physician and he’s not going to have the time to arrange their personal lives, especially when everybody is entitled to all the free health care they can suck down.

Almost every social pathology you can think of has it’s origin in a lack of personal responsibility. As much as we continue to move away from encouraging it we will be continuously chasing the tiger and wondering why he keeps getting bigger and meaner. The solution is a simple one but hard for those deeply invested in paternalism to stomach.

Is it Worth It Redux

Look, if you like medicine and your specialty it is “worth it” (whatever that means to you). I say this after receiving a lot of angry emails from people chastising me for having the unmitigated gall to imply that income potential is a legitimate factor in the decision to pursue medicine. Who am I, yer’ friggin’ mother? Make your own decisions. If medicine is that fantastic a career than I am just a lone crackpot and the desire to smack me down is therefore inexplicable.

What can I say? I assure you that if the potential salary was not substantially more than what I made as an engineer I would never have made the switch. I like Emergency Medicine just fine and am glad to be in it but if all that was waiting for me salary-wise at the end of the dark tunnel of medical training (the light at the end of which I can now see) was the same income or less than I made before I decided to throw it all away, well, I’d be pretty disappointed. And my lovely and long-suffering wife would be devastated. Marriage is a partnership and, while my wife is happy that I am in a rewarding and useful career, the usefulness and intangible rewards of it don’t put vittles on the table and logs on the fire. There’s got to be some bacon to bring home for her to fry up in a pan or it’s just a selfish personal hobby of mine for which she gave up security, stability, family, and financial solvency.

In fact, my wife cried when I didn’t match into Emergency Medicine the first time around and scrambled into Family Practice instead. She knew instinctively that on the balance sheet, the whole adventure had now become a rather bad investment and one in which we might never recover financially. For what Family Medicine physicians make I may as well have stayed in engineering where devoting the time I did to medical training would have paid better sooner. And without the call, the abuse, the humiliation, and the constant feeling that my gonads are not my own.

Why this is hard to understand is beyond me. And if you think I’m unique in my point-of-view then stand by to be surprised and disappointed in your colleagues.

Post-o-rama

Is it Worth It?

(With a hat-tip to Hybrid Vigor for the idea-PB)

Dear Medical School Hopeful,

I wouldn’t presume to imply that you haven’t given your decision to apply to medical school a lot of thought. Of course you have. The application process alone will weed out anybody who is not completely serious. Still, you may have some lingering doubts and if you do, it is better to hash them out now than when it is too late and you are so deeply into it that to withdraw will mean an unacceptable loss of your considerable investment in time and money.

The first thing you need to do is to cool your jets. Medicine is a good career but it’s just a job. I’m sure you will meet some zealots who seemingly breathe, eat, and live medicine but for the most part, by the time you get into residency you will find that most of your colleagues want pretty much what other working people want, namely a useful job with good pay and decent hours. In this regard, maybe the years of working long hours for little of no pay like you’re going to do in medical school and residency beats the idealism out of people but I prefer to think it teaches them the difference between professionalism and fanaticism. Naturally you have to pretend to be driven to get into medical school as showing passion is a de facto requirement. Your real reasons for wanting to be a physician, while perfectly legitmate, would sound trite and self-serving if you even dared breathe them aloud. Just between me and you I didn’t want to save the world either and just applied to medical school because I thought being a doctor would be kind of cool.

And it is kind of cool, at least when you’re not at the hospital making a career out of not knowing things (which is going to be your modus operandi for most of your training). Still, people who don’t know what goes on during medical training are likely to be impressed. Your mother is going to be proud, your friends will be amazed, and your annoying brother-in-law will have a hard time one-upping you on this one.

It’s a decent career but the fanaticism is not warranted. It isn’t that good. Nothing is. That’s why fanatics are so creepy. They see and hear things that normal people do not.

So, as you are about to commit to a huge undertaking in terms of both time and money and one which will set the course for your entire life, you have to ask yourself if it’s worth it.

From an economic perspective, it may or may not be worth it in the end. Doctors do make a pretty decent salary but what seems like a lot of money to a young, single college student might not seem like so much after four years of medical school and a minimum of three years of low-payed residency training. You can, for example, bust your hump for seven years to become a pediatrician (the lowest-paying specialty, on average) and make under the talismanic “six figures” which is the mantra of salary expectations. $90,000 a year seems like a lot now but it’s the medical equivalent of minimum wage.

I understand that the majority of people in the country live on half of this and are not considered poor but most other careers don’t quite involve the same level of sacrifice. It’s a cliche, but never-the-less true, that while your friends in college who decided on engineering, business, or law are building their careers and starting to enjoy the fruits of their labors you will be working brutal hours for very low wages, losing sleep on a regular basis (in fact, sleep deprivation is both expected and built into the training), and suffering the kinds of indignities that you probably can’t imagine at this point in your adventure.

Just keep in mind that all doctors, after residency, start at salaries much higher than is typical for any other profession. Maybe some lawyers can leave law school and go straight into well-paying jobs but most just sort of scrape along. The same with business and engineering. Still, if you put as much effort into your engineering career, let’s say, as you are about to put into a medical career you will probably do better than most. I don’t buy into the theory that people who are smart enough for medical school will automatically do well at other careers but if you have any other other legitimate talents you might want to mull this over.

The bottom line here is that you are going to sacrifice a decade of your life and arrive at the start of your career with almost nothing to show for it but gray hair and a mountain of debt. The debt is inevitable because medical school is an expensive undertaking, the exact cost of which depends on many factors. Some state medical schools, as they are subsidized by the taxpayers, are a relative bargain while others, like super-premium ice cream, are much more expensive. A year’s tution and fees at Harvard Medical School which is a typical pricey confection will set you back close to $40,000 per year. Compare this to my air-injected, vanilla-flavored alma mater, LSU Shreveport, which charges only $13,000 for in-state residents.

These fees do not take into account living expenses which, while minimal for a single, young medical student are not trivial. Fortunately as most pre-meds are used to eating ramen noodles and living in crappy apartments the standard of living in medical school will not be too much of a shock. You’re going to be pretty busy for four years anyways and a futon on the floor of some ratty place with thirty-year-old shag carpets and furniture that makes it look like the set of a pornographic movie will probably be enough and all you’ll really need.

But you do have to live and, as it is almost impossible for most medical students to work while in medical school, things are going to be tight. What do you need to live? Again, it depends where you live. I imagine that housing is a little more expensive in New York City that it is in Bossier City, one of the suburbs of Shreveport. Crossing the Red River to get to Shreveport as it involves a barely noticable interstate bridge is also a good deal easier than crossing the Hudson River to get to New York.

You need to think about these things when you select a medical school. I wouldn’t insult the aspirations and dreams of thousands of pre-meds and their prestige-hungry parents by stating that price is the most important factor but it is top three. However, at the risk of drawing their ire, if you know perfectly well that you despise research and academic medicine and are almost completely sure that your goal is private practice, it probably makes no difference where you go to medical school as you can match into any specialty from any medical school provided you have the grades and the board scores. Not to mention that a Radiologist who went to medical school in Sistercouple, Arkansas and trained in Trailer City, Oklahoma probably makes the same as one who trained at Dartmouth.

There are no bad LCME accredited American medical schools. They are all good and you will get a quality education at any of them which, no matter where you go, also depends on how much effort you put into it. So you have to ask yourself whether the potential for a quarter-million in debt (on top of your undergraduate debt) for nothing but prestige and name recognition among a very small subset of people is is better than $80,000 dollars of debt at your state medical school.

Having a familiy will magnify the difficulties of selecting a medical school (assuming you have the luxury of more than one acceptance) especially if you are giving up a well-paying career. The bills will not go away and the cost of living needs to be considered carefully.

Practically, unless you go to an inexpensive medical school, can live without a salary for four years, and can pay for tuition and fees out-of-pocket, you are going to have to borrow money and lots of it. Fortunately (or unfortunately because the availibility of financial aid is one of the most important factors driving up the cost of education) the financial aid office at your medical school can arrange a combination of federal loans and the occasional scholarship or grant to almost exactly cover your cost of attendance.

Funny how that works out.

In a nutshell, your medical school’s finanacial aid office will calculate you cost of attendence which includes tuition, fees, and estimated living expenses and tailor an aid package, primarily of loans, to cover as much of it as they can. Almost nobody actually writes a check to their medical school and it’s easy to think of these loans as funny money. This would be a mistake because you will have to pay them back. They can, however, be deferred while you are a resident and you can consolidate them at a lower interest rate. There are some drawbacks to consolidation as you may lose your rights to deferment and forebearance but if you run the numbers, it will be a lot less expensive to service and pay your debt if you can consolidate at a low rate.

So that’s the choice you have to make, namely, whether a decade of your life, huge debt, and the opportunity cost of medical training are going to be offset by what you can make as a doctor. People are pretty good at gauging their willingness to incur debt but are unfamilar with the simple concept of opportunity cost. Opportunity cost is the price you pay for not doing something. Suppose you have a $60,000 per year job (or the potential to have one) which you give up to attend medical school. The real cost of your education is four years of lost income plus the money you pay for tuition and fees plus the difference between the salary you gave up and your pay as a resident.

Suppose you need to borrow $40,000 per year. Thats $160,000 in debt added to the $240,000 opportunity cost of medical school plus the $60,000 dollar opportunity cost of a three-year residency where you will make about forty thousand a year. That’s almost half a million bucks, not even considering the time value of money which is not working in your favor. if you match into pediatrics and make $90,000 per year, your net benefit from all of those long years will be $30,000 a year which, again ignoring the time value of money, puts your break-even point sometime in 2031. This explains perfectly why American medical school graduates eschew the lower-paying primary care specialties. They are fairly intelligent and can do the math.

Many pre-meds have degrees that, while rigourous, are not worth much except as a requirement for medical school and some people don’t incur nearly as much debt as others so your mileage is going to vary considerably. But as opportunity cost is a measure of what you could have done, not what you did, I think you can see how you still have to consider it.

Another thing to consider is that you can match into specialties that currently pay very well and, even if they require a few more years training, will obviously pull your break-even point closer. Working against you, however, is the disturbing trend of the electorate to insist on paying nothing for health care. While there is no such thing as a free lunch, the vast amounts of money needed to pay for free health care is not necessarily going to be paid to you. You need to know that in some Western democracies with socialized medicine, physicians make less than a typical American electrician. In Germany, for example, surgeons are pulling in the equivalent of sixty to seventy thousand dollars a year, on top of which they live in a high tax society which pays for cradle to grave socialism by punishing the productive sector of which they are a part. Now, it’s true that they didn’t incur the debt that you will and their opportunity cost was less but suppose you muddle through only to have the rules change on you five or ten years from now when the electorate, driven by the trailer-park and ghetto vote as it sometimes is, finally takes leave of its senses and leaves you holding the bag?

That’s going to smart a little, no doubt.

And then their is the question of malpractice. I’m not one to be an alarmist but in this case, medical malpractice is a very real crisis and is sucking the life out of medicine. Under the onslaught of completely unethical plaintiff’s attorny’s it is possible to be successfully sued even if you did nothing wrong. Remember, the case is not decided by a jury of your peers unless your peers are people who can take two weeks off from their job and look at living at the the local Motel Six and eating off of meal vouchers for that time as a little slice of hog heaven. The days are also coming to a close when your malpractice carrier, win or lose, would protect you. Even they are forced to stipulate caps to their liability and the lawyer is now going to come looking for your assets. Because medicine is a high risk profession that deals primarily with an unhealthy and irresponsible public, the simple act of plying your trade will routinely place your home, your livelihood, and your savings in jeapordy. Think about how you’ll feel having your wages garnished to pay the widow of a crack dealer on whose discharge instructions you forgot to write, “Follow up in the Emergency Department if your chest pain returns.”

Just a few things to consider.

Respectfully,

Panda Bear

Is it Worth It?

Hippocrates Calls for Close Air Support

Standardized Propaganda

I am often asked to reconcile my love for the Marine Corps and my support for our troops in Iraq and Afghanistan with the tenets of the Hippocratic Oath which, by conventional wisdom, seems to preclude a doctor from calling in an air strike.

There are many versions of the Hippocratic Oath and it is continuously edited to suit the demands of political correctness. One thing on which everybody can agree is that the oath enjoins us to “First do no harm,” meaning that nothing we do should intentionally make the patient sicker than he was when we first met him. I agree with this concept completely but, and forgive me if this is obvious, this only applies to one’s patients and not to the whole world.  Only a small subset of the population, those whom we formally accept into our care, are our patients.  The rest are strangers and to them we owe no obligation whatsoever.  Dropping a laser-guided bomb on a nest of islamofascist vipers is as acceptable as providing them with their annual physicals.  It’s the context that’s the thing.

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

I mention this because it is not a requirement that physicians be social activists or professional busy-bodies.  In fact, as much as doctors becomes these they dilute the only real authority they have, the authority to make medical decisions on behalf of the small subset of the population who are their actual patients. This is the fallacy of “community medicine” and every recent effort to turn doctors into organs of the dependocracy.  The community, various ethnic groups, and even families are not your patients, the individual patient is.  Even then his role as your patient is as limited as your responsibility for him.  You can’t follow him home, you can’t pick his friends, you can’t heroically throw yourself between your patient and his pie, and you certainly have no influence on him outside of the quick talking you can do when you attend him in the clinic or the the hospital.

You can’t, in short, profoundly influence your patient’s lives even though that’s the paradigm being taught in medical school where nebulous concepts such as “wellbeing” are stressed to the exclusion of old-fashioned clinical and diagnostic skills.  Not only will you not have the time but in many ways, your patient’s wellbeing isn’t even your business as it depends on many factors, over only one of which you have even a semblance of control.   If the patient himself can’t get his life’s house in order,  it is completely unreasonable to expect his doctor who sees him for twenty minutes every other month to do it.  We have no special powers of persuasion denied to the general population.  You’re just a doctor.  Not a magician

Under various guises however, and in classes of different names at different medical schools, you will be taught to regard patients with an almost insulting paternalism predicated on the belief that they are helpless creatures who, if you only learned the art, can be hypnotized by your magical doctor voice to make good decisions.  This is essentially what is taught in most standardized patient encounters.

For those of you who don’t know, a “standardized patient” is an actor pretending to be a patient against whom medical students are pitted.  Apart from learning the mechanics of the patient interview, most standardized patient exercises are constructed to allow the student time to explore psycho-social issues they would be wise to avoid, both because there is no time in the real world to explore the intricacies of your patient’s convoluted lives and because there is nothing you can really do for him anyways outside of attempting to manage his medical problems (the successful achievement of which would be a small victory all by itself).

Medicine is not social work and you are not training to be a case manager.  To believe you are is to fall for the propaganda being disseminated by the usual primary care culprits who, if they just stuck to the basics, would find justification enough for their jobs without dragging the profession into a sloppy bog from which it will never extricate itself.  Society and your patients already expect too much from their doctors, goods that you cannot possibly deliver in the confines of a doctor-patient relationship.

Hippocrates Calls for Close Air Support

Sink or Swim: Call and The New Intern

(I had call on my first night as an intern almost two years ago and as of last week I am officially and forever done with call. It’s been a long two years and I won’t miss it. I’m working the 11PM to 9AM shift in the Emergency Department this month and I marvel at how good I feel getting seven hours of sleep every day. It’s also pretty nice having a regular job again with a schedule that I can make plans around. Here are some random observations about call with a little advice thrown in for those of you who will be starting intern year in just two short months.-PB)

No Atheists in the Call Room

Despite having scoffed at religion for your whole life, disdained the faith of your parents, and professed to only believe what can be experienced by the senses, on your first night of call you will find yourself praying the universal prayer of the new intern, “Please, God, don’t let anything happen tonight.” Later, as you gain more experience, you will grow to despise call because you like to sleep. As a brand-new intern however, not only will you be too tense to sleep even if you could but your twice-weekly call nights will be anticipated with a profound sense of dread and a yearning for the simpler days when your only responsibility was to pass a measly test every couple of weeks.

Objectively it shouldn’t be that bad. Your program will point out that you are never really alone. A senior residents is always likely to be in-house with you and you can always call your attending at home if you get in over your head. No doubt this is true but as the last of the People Who Know What They are Doing leave for the night, the hospital becomes a lonely, threatening place full of patients who seemed friendly enough during the day but have now become half-dead ghouls, swaying precarioulsy on the knife edge of life, ready at any moment to shuffle selfishly off their mortal coil.

Unfortunately, you have been left you in charge of a certain number of patients and they expect a reasonable number of them to be alive when they return in the morning. If not, you’ll look like an idiot. The patients will be dead and beyond any worries. Kind of makes you regret not paying attention to ACLS in medical school. As if you were ever going to be in charge of a code.

Relax and remember the French Hooker Rule.

No matter what they want, you can only give them what you can give them. Nobody is expecting you to run the hospital. It runs on autopilot most of the time anyways. All you have to do is be attentive to your duties, make decisions that you are comfortable making, get to all the codes and if you don’t know what you’re doing, get out of the way of the people who do.

Listen to the Nurses

As you gain more experience, you will tend to roll your eyes at some of the pages you get at 3AM. You need to be polite but sometimes it’s hard to keep the “You woke me up to tell me that?” tone out of your voice.

“Dr. Bear, this is Cindy on Five South, Mr. Jones in room twelve just had a five-beat run of V-tach.”

“How’s he doing now?”

“Fine, he’s asleep and his vitals are stable.”

“Um, thanks.”

Keep in mind that she has to call you. It’s part of her protocol even though she knows more about Mr. Jones than you do, knows he has a list of life-threatening conditions that reads like the PDR, and knows perfectly well that he’s probably not going to die tonight. If on the other hand she asks you to come up to see him, well, usually it’s her long experience telling her that things are heading south and they are going to need a decision maker at the bedside. So while the tendency for a new intern is to panic and over-react to everything, even agonizing over the choice of simple pain medication renewal order, take a cue from your nurses, they know it’s July, they know you’re new, and they know you need a little guidance.

This does not apply at the VA, of course, where after five o’clock you can see tumbleweeds blowng down the corridors and the nurses vanish to some secret nurse’s lounge and are not seen until morning. I was on call there one night and a patient coded and died without anyone thinking to call me. I only found out in the morning when I walked into his room with a cheerful “Good Morning” only to see his lifeless body, endotracheal tube still in place, equilibrating with room temperature. Some people pre-write skleleton notes before they round and fill in pertinent information as they go. In this case, “Patient was without complaints,” while a completely true statement, would not quite have captured the flavor of the situation.

Stay Hydrated

Pure anecdote on my part but caffeine is over-rated. I used to drink a lot of Diet Cokes on call but it just made my jittery and, for lack of a better word, edgy. I’ve cut back considerably lately and I’ve found that good old-fashioned honest fatigue is better than the lying, cheating alertness you get from caffeine. I seem just as tired after a four or five Diet Cokes as if I just drink water, the only difference being that I yawn a little more with water.

It’s more important to stay hydrated. You can easily get mild dehydration if you’re running around all night which can be all the difference between being just tired and being physically ill. Drink water.

Oh, and avoid eating crappy food on call. Greasy fried food or sweets are going to follow you the whole night. Unfortunately, the hospital gets a good deal more casual at night and there are always cookies of doughnuts laying around somewhere. Better to have a turkey sandwich or something with some protein in it. My experience is that I always felt better on call if I ate light.

Stay Motivated

The definition of eternity is the time between midnight and five AM. If you look hard enough you can almost see the clock hands moving backwards and no matter what you do, it’s always just a little after one. In fact, it will be one AM for hours. Your brain will cry for sleep and you will be totally uninterested in the mundane crap that fills a lot of your night. At the same time your most ferverent wish will be that it’s all mundane crap. No two ways around it, call, like most of intern year blows with the power of a thousand hurricanes.

But you’re there. You’re stuck. There’s nothing to do but suck it up and make the best of things. If you have a few good friends in the same predicament you can even have a lot of madcap fun on call. Just hang out with people with a sense of humor who can appreciate the ridiculousness of the situation.

Laugh it Off

You’re going to make mistakes. Your not going to know what to do in a lot of situations. Everything is going to be difficult at first and being a real doctor is going to be nothing like you expected it to be when you were a pre-med those many long years ago but pretty much what you expected as you counted your last days of irresponsibility in fourth year. Every day and every call night will bring some secret humiliation but you have got to let it go. Don’t internalize the inevitable criticism. Sure, you’re worthless and weak, a real danger to the patients, and a jibbering, ignorant intern monkey but we’ve all been there, man. It will get better.

I promise.

Sink or Swim: Call and The New Intern

A Quick Note

100K

My hit counter tells me that I’ve had 100,000 unique visits to this blog in the last six months. Add that to the 120,000-or-so visits before I started using Sitemeter and that’s not bad for sixteen months of blogging. Readership is growing and I like to think it’s because I have a lot of well-written articles on interesting subjects which offer a unique insight into the world of medical training that you will not find anywhere else.

It’s either that or the doggy-porn but I’m not complaining.

CAM and Academia

Part of what passes for being open-minded in academia these days is the inability call “bullshit.” This is also known as being so open-minded that your brain either falls out or flaps listlessly in the breeze like a ratty pair of underwear on a line. There is, apparently, very little under heaven, no matter how ridiculous, that some earnest academic, frightened of giving offense, will not either embrace or tolerate even though somewhere, deep down in his crocadile brain a little voice must be shouting at him to grow a spine.

This is because the ethos of the ivory tower is anti-Western, anti-Judeo-Christian, and almost anti-intellectual, at least in the sense that reason and disciplined thinking are subordinate to the latest political fads that periodically sweep through our highly impressionable, somewhat provincial academic community. This is why people who will scoff at traditional religion and impune it’s adherents will never-the-less become extremely reverential when discussing Buddism, Hinduism, and any other religious practice which doesn’t carry the baggage of morality against which they have been conditioned to rebel.

(In regards to Islam, the militant variety of which is antiethical to every principle of liberal Western thought, they are silent either out of fear or because the anti-American strain that pervades it is convenient to their political beliefs. In the the screwy world of academia, you can have liberal, pro-choice professors actively supporting groups like the Taliban who treat women like property, execute dissenters, and would merrily burn their universities to the ground if given the chance.)

The point is that while acupuncture, homeopathy, and other faith-based healing practices will be embraced tightly, faith healing, snake handling, and speaking in toungues, also known as Traditional American Medicine (TAM) will be ridiculed as absurd by the same people who will credulously clap their hands and burn joss to nightmarish asian gods. How some sweaty pastor of a secretive congregation in Arkansas casting out demons through his traditional practice of medicine is different than some svelte intellectual with equally shoddy academic credentials pushing homeopathy or acupuncture is not exactly clear from a strictly rational point of view.

A Quick Note

Other Medical Careers Part Two: Complementary and Alternative Medicine

Quacks Like a Duck

Almost everything about Complementary and Alternative Medicine (CAM) is bunk and its purveyors are at best deluded and at worst quacks and charlatans who would make the snake oil salesmen of olden days blush from shame. Maybe a hundred years ago you could make a case for magic potions and mysterious cures from the East but today we should know better and only don’t because of a combination of scientific illiteracy and an ingrained bias against rational Western thought. What little benefit patients can derive from most of the quackery being sold to them is not worth a fraction of the money spent and the same effects could be achieved without the smoke and mirrors if people paid as much attention to diet, exercise, and all around clean living as they do to looking for an easy fix. Additionally, while I am a firm believer in the principle of caveat emptor (let the buyer beware), CAM verges on criminality when it fleeces the desperate and the hopeless with promises of cures for terminal diseases. Many spend their life’s savings, money that should have gone to the support of the spouse or the family, on worthless therapies.

CAM exists in an alternate universe from real medicine. It wants to be legitimate but manages to avoid the responsibilities and liability of real medical practice. As most CAM treats nebulous symptoms with equally nebulous modalities, there is no measurable standard for efficacy of any of the treatments. Acupuncturists, for example, diagnose perturbations of “qi,” a mystical life force which apart from serving as the basis for Star Wars has no physiological equivalent and cannot be measured in any way except through the magical powers of its purveyors and the faith of its believers. I imagine it would be impossible to sue your acupuncturist for a bad outcome. There are no bad outcomes just as there are no good outcomes. It’s all highly subjective. If you’re not really treating a disease, you can get away with this and probably why EMTALA does not apply to CAM.

What sets complementaty and alternative medicine apart from faith healing and snake handling are the credentials of its believers. Those who speak in toungues and exorcise demons are simple uneducated people who lead intellectually isolated lives. They believe and need no proof other than faith. The adherents of CAM are educated enough to realize that their beliefs are ridiculous and try to give them the imprimateur of scientific legitimacy, often with shoddily constructed studies. Every major legitimate study on CAM, however, has found very little to substantiate it even though the researching institutions bend over backwards and contort their data to make the best possible case for it. CAM is currently the darling of the medical elites and to say, with confidence, that it’s bunk would be to lose your politically correct credentials.

The real medical profession while imperfect like all human endeavors is not so conservative that ineffective or ridiculous therapies are not discarded. This is the whole basis of evidence based medicine. There is no evidence based Complementary and Alternative Medicine. It exists in the absence of and often despite the evidence. When challenged, its practioners will retreat like the sweaty televangelists to anecdotes and testimonials. Either that or they will cite the placebo effect, that last hope and refuge of medical scoundrels and upon which rock they will cling as their last handhold in the rational world.

The placebo effect is vastly over-rated. Imagine the typical double-blinded placebo controlled study. If the patients in the placebo arm have a benefit it is tempting to interpret the results as proof that the mind has strange powers to heal. All it really means, however, is that some patients would have had an outcome with no treatment whatsoever. What placebo control studies really need is a third arm for patients who don’t know they’re being studied and are not given any intervention. Real or not, the even the most ferverent believers of the placebo effect concede that it has a very small role to play in the management of even subjective diseases. It’s a mighty shakey foundation on which to build a medical career.

Homeopathy: Water Has Memory?

According to homeopaths, to cure a desease one has only to isolate the offending agent, say a toxin or a chemical compound, dilute it with enough water so as to have none of the original compound left, and then rely on the retained memory of the compound in the water to have the desired effect. There are some variations but that’s basically it. When pressed, it’s proponents will mumble something incoherent about immunology and suggest that their cures work in a similar manner to vaccines, showing clearly that a little knowledge is a dangerous thing. Vaccines are nothing like exposing yourself to a random molecule of something unwholesome diluted in a bottle. No one who thinks they are should be allowed to graduate medical school and yet you still see the odd Homeopathic Medicine interest group at even academic medical powerhouses.

If you add the usual holistic mumbo-jumbo and exhortations to well-being and spiritual balance to a bottle or two of over-priced tinctures, that’s homepathic medicine and the fact that people can make a living at it makes me weep for the shoddy condition of the public schools.

Advantages: Easy money. No liability. Good street cred with your crunchy friends.

Disadvantages: Somewhat of a niche market and few Homeopathic practitioners can make a living just from homeopathy. Most people with money enough to burn are not that stupid anyways so you’re fighting for a small patient base. The money is in combining homeopathy with other quackery.

Naturopathy

There are two kinds of Naturopaths, the highly educated kind with a quasi-legitimate degree granted by one of a handful of Schools of Naturopathy and the free-lancer with no formal training except perhaps an easy to obtain mail-order degree. There’s not really a dime’s worth of difference between the the two and discerning it is a little like trying to differentiate a pickpocket and a burglar. Both are thieves, you understand, but one works harder at it.

At the heart of Naturopthy is a flawed belief in the healing power of nature. That nature, red in tooth and claw, also includes deadly natural pathogens, horrific genetic mutations, and single-minded predators (both human and otherwise) seems to have escaped consideration. It’s a Bambi-centric weltanschung to say the least and chief among it’s tenets is a reliance on medicinal botanicals which, as they are untainted by the rapacious talons of the Devil (man) are thought to be more effective in restoring some kind of natural order to the body.

Because they’re natural, you see. Nature good. Man bad.

While there is no dobt that many plants have medicinal properties, this doesn’t mean that plants make good medicines. This should be obvious to anybody who has studied even a little pharmacology. You can take some random preparation of weeds for a condition but why not take a cheaper preparation of a chemical compound with better effects and get the benefit of quality control? The next obvious question is why otherwise cynical people who discount many of the claims of the pharmaceutical industry (and I’m one of those cynics, by the way) and view Medical Doctors with dark suspicion are totally credulous when it comes to advice from someone who prescribes them misletoe for their hypertension and are completely trusting of Steve, the nice Sociology major working at the local holistic food store, when he gives medicinal advice about organic dietary supplements.

It is also true that the body has “healing powers.” Of course it does. But again, Naturopathic healing operates on the fringes, just staying on the safe side of subjective complaints and never bringing it’s natural goodness to bear on objectively bad diseases which would require some sort of unequivocal treatment.

Advantages: Easy money for a minimal investment of time. Good hippy street cred. Your marketing has been done for you as most people instinctively think that “natural is better.” Some states view Naturopaths as primary care providers which if you are in primary care should be gravely insulting.

Disadvantages: You probably have to combine your quackery to make a dishonest living. Maybe work as a chiropractor and do a little naturopathy as a side line. Having to compete with those mail-order wankers.

Acupuncture

Traditional Chinese Medicine (of which acupuncture is a prominent part) is so good that everybody lived long, healthy lives in ancient China before they had access to Western medicine.

Ha ha. No, not really. The chinese, like their European couterparts, until very recently had lifespans a fraction of what they are today and were cut down routinely by things that it took Western medicine to finally defeat. So that’s the rub. Acupuncture, as it predates the scientific method, is based on a metaphor of the body and health that has no association with reality. As soon as those wiley Chinese started using antibiotics…bam…diseases started being cured.

The organizing principle of acupuncture is “qi” or a life force which flow in the body through pathways called meridians. As these meridians predate a knowledge of anatomy and physiology, they do not correspond with nerves, blood vessels, or any known physiological process. The existence of qi can’t be proven and some have likened it to the soul, another metaphysical construct that defies objective proof. Fair enough, and as a good son of the Orthodox Church I believe in the soul. I’m just not trying to stick needles into it.

Think of it as Feng Shui (geomancy, another ridiculous asian import) for the body. Some acupuncturists attach bundles of burning herbs to the needles (moxibustion). Others use electrical currents or vibration. Still others don’t use needles at all but pressure points. There are also different schools of acupuncture each with a different map of the body’s meridians. You might go to five different acupuncturists and get five different nebulous diagnosis and five different treatments for the same complaint. It doesn’t matter because you’re not being treated for anything that requires a discrete diagnosis and if you feel subjectively better for a nebulous complaint I guess we can put that in the win column.

On the other hand it’s part and parcel with the medicalization of life so forgive me if I don’t clap my hands and squeal for joy when the intelligentsia gain relief from their imaginary complaints. It’s nice, it’s fun, but it’s not medicine.

Advantages: Money, of course. In the right market you can do well. It also has the air of legitmacy as many major academic institutions, despite underwhelming evidence, walk on eggshells when they should be merrily kicking the ass of acupuncture (and all CAM for that matter).

Disadvantages: Sticking needles into people is more dangerous than other quackery so the needle-trade is a little more regulated than most CAM. There are a bewildering array of licensing and ceritfication options with a confusing mish-mash of abbreviations and credentials.

Other Medical Careers Part Two: Complementary and Alternative Medicine

The Monkey’s Other Paw and Other Random Things

Grow a Pair

There he lies, six-foot-five inches of corn-fed American manhood, a horizontal slab of sinew and muscle with a chiseled chin, tousled hair, and perfect teeth whining like a little girl because the nurse is late with his pain medications.

For God’s sake buddy, didn’t you get the memo? Of manhood, stoicism is the better part and nothing makes your fellow unreconstructed white boys cringe quite like the sight of you, otherwise unhurt, sniveling like a teenage drama queen. It’s humiliating- maybe not for you but certainly for me because you’re supposed to be storming the beaches of Iowa Jima, not alternately crying and yelling for the dilaudid that someone was fool enough to give you the first time. We expected the wide-shouldered, aggressive dialogue of a 1940s war picture but you’re giving us Cage Aux Folles instead.

The Monkey’s Other Paw

What have you done with Mr. Jones? Where has he gone? Surely this drooling, demented husk staring disinterestedly at us from his ICU bed is not our husband, our father, or our brother. Come on now, they said we were lucky, lucky to get him back at all because very few people ever come back after ten minutes of cardiac arrest. That’s why we called you people. He was just laying there twitching and then he stopped so we figured maybe he needed to be at the hospital.

But that’s not him. It doesn’t even look like him. It’s like someone else is in his skin, some shambling seedy-looking stranger who just took a swing at me. And now he just sits there and gapes malevolently. It’s creepy. Like he was on the other side of the grave long enough for something to take his place. And all he can say is “next week.”

“How do you feel?”

“Next week.”

“Can we get you anything?”

“Next week.”

Don’t you recognize us?”

“Next week.”

Seriously. Where’s the joy? The elation has pretty much evaporated, especially since you’re now telling us that he’s not going to get better. What do you mean by that? You fixed his heart, why can’t you fix his brain? Do you seriously expect us to believe that he will be crapping into adult diapers for the rest of his life and eating mushy food shovelled into his mouth by some minimum wage orderly in a fly-blown nursing home? We’re not buying it. He was mowing his own lawn last week for Christ’s sake. Sure, he smoked a little and maybe he did drink too much but he was a great guy. You should have seen how he and Uncle Frank used to cut up. It was all you could do to keep from blowing beer out of your nose.

Man. The old-fashioned kind of death was better than this.

Too Big to Live

The seat of the wheelchair is about the size of the back seat of a typical compact car. Small for a car, you understand, but big for a wheelchair and some patients barely fit. I don’t know what we’re going to do in a few years because, like old groupers living umolested in the cool deep under the pier, once you top a quarter of a ton you have no natural predators. As we’re doing our part to hold diseases at bay, there seems to be no upper limit to the size of patients.

Which would explain the in-room cranes that are now standard equipment at the best hospitals. Like gelatinous cargo, the patient is suspended from a hoist on a sturdy frame while the bed is wheeled out from underneath. An obvious solution but one I had only previously seen at sawmills where the mighty portal crane lifts massive loads of timber from the backs of trucks.

It has to be humiliating to not fit into the CT scanner and to listen to the earnest doctors and nurses, without trying to be rude, plotting a strategy to deal with your immensity. And there is reproof enough for a thousand other petty sins written in the faces of the six strong people it takes to transfer you to the bariatric hospital bed. Even the cop lends a hand.

The Monkey’s Other Paw and Other Random Things