Final Rambling Conversation With a Lumbering Asian-Bear Mammal

Ever considered any other specialties?

Sure. Everyone does. It is the rare person who arrives at medical school with his future planned to the last detail. Even people who, perhaps through prior work or shadowing experience, arrive with an overwhelming desire for one particular specialty usually change their minds. Orthopedic surgery, as an example, is a specialty which seems so appealing to many first year medical students that it seems half your class plans on matching into it. Once they see the level of commitment required as well as the lifestyle of the residents most decide that their passion was actually a polite interest and match into something else.

I’m sure, for that matter, that everybody has an occasional bad day where the prospect of working at a specialty like Radiology, one with minimal patient contact, can seem very appealing. Now, I know that radiologists can see patients in some settings but if you divide the medical profession into those whose job requires them to routinely stick a finger in a patient’s rectum and those who don’t, radiology is the king of the non-probing careers.

You have to make up your mind about a specialty much sooner than many believe for the simple reason that some are fairly competetive and, all other things being equal, the the guy with the highest board scores is going to land one of the few highly coveted dermatology residency positions. This means that if you are even thinking about dermatology, otolaryngology, urology, or radiology you need to start studying hard from day one and get both excellent grades and exceptional board scores. Are there exception to this rule? Sure there are. I will no doubt be innundated with comments from people relating how a friend of a friend of somebody’s brother matched into dermatology at the bottom of his class after having taken Step 1 twice for failing it the first time.

I also know a guy who was struck by lightning. Spare me.

Let me state Panda’s Axiom Number 1: At the beginning of medical school, and allowing for the questionable admission who managed to matriculate through a combination of luck, computer error, and bureaucratic inertia, any medical student can match into any specialty. Medical school is not hard per se but merely long and tedious. Because (with the aforementioned exception) medical students are drawn from the top one percent of the population for intelligence, there is nothing keeping anybody in your class from being a neurosurgeon except the desire and the willingness to work for it. However, as there is a good deal of self-selection out of potential medical specialties, medical students tend (tend, damn it!) to tailor their efforts towards the level of competitiveness of the specialties that they feel would both interest them and for which they believe they have a reasonable shot with their study habits. I knew early on that I was not destined for a career in neurosurgery both because I had no interest in it and because the amount of work required to get excellent grades was more than I was willing to give. It’s mostly as simple as that.

I will confess my great ignorance when I was applying to medical school about the structure of the medical profesion. I had only a vague idea what specialties where available let alone an idea of what I wanted to do except the nebulous notion that I would end up in internal medicine or family practice. True to pre-med form, the salaries that these specialties promised, salaries that I would view as a personal failure today (see my adventures in Family Practice as detailed in previous articles), seemed a princely sum for a mere seven years of training. We underestimated, you understand, the amount of debt and exactly what it was we were getting into. I didn’t even know that Emergency Medicine was a distinct specialty and never even considered it until the end of third year when, one by one, I decided against every specialty in which I rotated.

Sometimes it’s a process of elimnation.

So what specialties were you sure you wouldn’t do?

Surgery, for one. I admire and respect surgeons but after two months of my third year surgery rotation any small desire to be a surgeon that I may have ever had was beaten out of me. Sure, it’s a cool specialty, perhaps the coolest of the bunch as it combines medicine with dramatic interventions but after seeing how the surgery residents were treated, not only by their attendings but by each other, I said, with gusto, no mas.

Surgeons eat their own. It’s part of their culture to treat each other disrespectfully during training. Whether this is necessary to train a surgeon cannot be known. It’s just the way the system has evolved and it seems to be structured to keep residents perpetually tired and irritated at everyone and everything. If I ask a neurology resident for his opinion on a patient, I will generally have a friendly conversation where he will impart not only his opinion but a little bit of knowledge which is commonplace to him but perhaps new to me. If I ask a surgery resident I am likely to get rolled eyes, condescension, and the not-so-subtle impression that I am an idiot for not knowing as much about abdominal surgery as I’m supposed to. This attitude is extended to their own subordinates. The mistreatment of surgical interns is legendary and if you see some unhappy miserable fellow skulking around the hospital he is probably one of theirs.

So you’re saying that surgery programs are malignant?

Residency programs are often labled as malignant but there is more to it than working long hours and pulling a lot of call. An important feature is how the residents treat each other. In my program, if an intern asks me for some guidance or help with a procedure I don’t cop an attitude and get snotty as I have often both seen and experienced while on surgery rotations. We do not hold it against somebody that they don’t know something and as long as they’re not asking stupid or repetitive questions, they deserve respectful consideration. To berate someone for not knowing something, to throw him to the wolves, so to speak, as appears common in surgery programs is to act contrary to the spirit of residency training which I am told is ideally supposed to be some kind of multi-orgasmic Socratic interlude.

Apparently, many surgery interns are so tired and beat down after the first few weeks of residency that they lose the ability to be civil even to each other. As the years go by they build up a stock of resentment and perpetuate the malignant tradition because it is human nature to validate our own suffering by making others suffer. It takes leadership to break this cycle and as medical schools neither select for nor make any particular effort to instill leadership, you basically have a bunch of people in charge of subordinates for the first time in their lives who haven’t a clue what to do.

Come on now. Isn’t “Leadership” heavily stressed by medical school admission committess?

Leadership is a buzzword, nothing more. Most extracurricular activities are really hobbies in which no one is really in charge of anything. In other words, if your decisions have no consequences for anyone, and show me an extracurricular activity where the participants had anything important at stake, you are not a leader but an enthusiastic participant.

As for other specialties, I decided against OB-Gyn pretty early. It’s a decent specialty but the hours and lifestyle, even after residency, are ridiculous. The only attendings in a hospital at all hours of the day and night are the Emergency Medicine attendings and the obstetricians. But the EM guys are working shifts. The obstetrician has a day job to which he must go after staying up all night delivering babies. Like pediatrics (which suffers from low pay), OB-Gyn almost has to be a calling. You can be a Family Physician or an internist and treat it like a nine-to-five job but you have to love your specialty to be happy as an obstetrician.

Not to mention that they get sued like nobody’s business which has to hurt, especially when some of the mothers suing for bad outcomes smoke, drink, do drugs, and otherwise take no responsibility at all for their contribution to the outcome. Obstetricians are doctors, not miracle workers. Bad protoplasm combined with ignorance is a deadly combination for babies, both in and ex-utero.

I never considered pediatrics. Having my own children has given me a running start at disliking other people’s children so I just don’t have the temperament for private pediatric practice. We see pediatric patients in the Emergency Department but the focus is more on making sure they have no serious illnesses than building a relationship with the parents, something that is essential for private practice pediatricians. To be honest, many of the parents we see are totally unsuited to raise hamsters let alone children and it makes my blood run cold just thinking about it. Unfortunately, the predominantly single polybabydadic mothers who we see, themselves the third or fourth generation of teenage single mothers, haven’t a clue about good parenting. Parenting skills have to be taught and there is a huge knowledge gap which is getting larger every generation.

I’m talking basic stuff like how to roast a chicken and cook up a mess o’ greens instead of raising the little bastards on Froot Loops and Pop-Tarts.

My favorite lie is the insistence that, despite their sociopathic son having gone on a crime spree often involving murder and rape, everybody is a good parent and it is some random act of nature that makes some children into criminals.

Anything you don’t like about Emergency Medicine?

Naw. It’s pretty cool. But I am early in my career and sometimes it’s hard to separate the trials and tribulations of residency from the specialty. As you know, I am a new second year resident so I still get a lot of guidance from our attendings. This is both necessary and appreciated (and we have stellar attendings at my program including some of the pioneers of Emergency Medicine) but I can sense that I will enjoy my job a lot more on that day when I become an attending myself and am granted the double-edged sword of complete responsibility. One of the worst aspects of residency (but necessary, I repeat) is the constant supervision and criticism. Compound this with a work environment where everybody from the janitor to the patient to the attending has a front-row seat to our screw-ups and you can see that working as a resident in the Emergency Department can be like being in a pressure cooker.

The things that many people cite as reasons to dislike Emergency Medicine are actually part of the appeal of the field to me. My creationist friends would love our specialty because we prove Darwin wrong every day. Survival of the fittest my ass.

Any advice to people considering a career in medicine?

My whole blog. Other than that I’d think about it carefully and try to get beyond the undeniable coolness factor of the profession. It’s a hard road and maybe you won’t like it. Hell, you won’t like a lot of it. My wife once explained to me why a lot of marriages don’t work, namely that the person you are attracted to when you are 18 is not necessarily the same kind of person you will be attracted to when you are thirty. It’s kind of the same in medicine. Because of the convoluted admission process, most people have to commit to a medical career shortly after high-school. But you are going to be a different person when you are in your early thirties and finally finished with training.

There are, in fact, other perfectly decent careers out there to which you may find yourself better suited. I highly recommend both the military and engineering which I know from personal experience to be both honorable and useful and neither of which require anything close to the training time. As for other medical careers, I guess we’re supposed to spout the conventional wisdom that being some kind of mid-level providor is just as good as being a physician but I won’t because I don’t believe it. Personally, and this is one of the few times you will hear me issue a caveat, personally, meaning me personally and not you, the idea of being anything other than a physician never occured to me. If you strip away the scope and responsibility of being a physician it’s just a trade, not a profession, and I would have as soon stayed in engineering.

Final Rambling Conversation With a Lumbering Asian-Bear Mammal

Penultimate Rambling Conversation with a Lumbering Asian Bear-Mammal

(Not really medically related. I’m sort of busy this month and don’t have the energy to really organize my thoughts. My apologies but if this kind of thing will make you get all hissy then please come back to my blog in a few weeks when I expect to have more time to write a friggin’ thesis.-PB)

Who has had the greatest influence on your life?

My father, hands down, no question about it, of whom I have only good memories and who raised all of his children right. My father immigrated to the United States in the 1950s and, unusual for a Greek, after a one-day stay in New York and a ten-day bus trip ended up in Idaho. I say unusual because Greeks tend to clump together and form their own communities (as anybody who has been to Astoria can tell you). He had an Uncle in Idaho but let’s just say the state is not exactly a hotbed of Hellenic culture. My father was an engineer and an officer in the United States Navy. If I am half as successful or half as respected as my father when I die I will have had an exceptional life.

My wife, of course. I was nothing when I met her. Just a washed out college student. And I don’t know that I would have had the drive or even the desire to succeed at anything if it wasn’t for the universal desire of good men to impress their wives. But the last six years have been very hard on her which is probably a story I should have been telling you, oh my patient readers. She gave up a lot of security to let me go to medical school. I wouldn’t say we were rich back then but we were not teetering on the brink of financial ruin as we are today. Poverty in marriage is something you expect at the begining, not after sixteen years. I know intellectually that we will do all right in the end, the Good Lord willing and the creek don’t rise, but eight years is a long time and you can only rob Peter to pay Paul for so long before Peter gets wise. We knew it was going to be tough, of course, and it seems like a hundred years ago when we first sat down to plan out the long years of medical school and residency. It didn’t seem as daunting back then and it has been nothing like we expected. Frankly, for my wife it’s been like trying to stuff a tiger in a sack. It can be done but it doesn’t stay sacked long. Without giving away too many personal details, those of you with a family need to consider carefully what you are giving up and what it is going to cost.

My wife’s philosophy is not to let us think too hard about the future. You’ll drive yourself crazy if you do. We have no future. Medical school and residency is so demanding of you and your spouse that, unless you are independently wealthy, it’s best to just muddle through, living one month at a time until, almost by surprise the years have melted away and the end comes into view. This is difficult for both of us because we have always been forward thinking people.

Who are your heros?

Ronald Reagan comes to mind. That guy was a lion. Perhaps the best president and one of the greatest Americans in history. He was a man who came at exactly the right time as those of you who remember the malaise that had settled upon our country after Viet Nam, Watergate, and the lackluster Carter administration can attest. He also brought the Republican Party to the masses wresting it as he did from the so-called “Country Club Republicans.”

I also like Rush Limbaugh. I have been listening to him since he got started almost 17 years ago. Rush made conservatism cool. I mean, there have always been conservatives in American politics but since World War II they tended to be marginalized. Certainly conservative opinion was almost nowhere to be found in the mainstream with the possible exception of The National Review. Just as I am trying to give residents the conceptual framework to discuss their dissatisfaction with the current residency training system, Rush gave conservatives the vocabulary and the awareness to make their opinions known….which explains his popularity. Conservatism is nothing more than common sense writ large and even in this propagandized and in many ways excruciatingly silly age, most people have a deep core of common sense. He’s also a very funny guy, a brilliant satirist, and always highly entertaining. (The reason liberal talk radio has never really caught on is that most liberal talk show hosts can never expunge the bitterness and ill-humor that characterizes the political left.)

I am a great admirer of President Bush and Vice-President Cheney. Mr. Cheney, in particular, is perhaps the most intelligent man in Washington and it is a shame that he is not the kind of guy who could get elected President in our above-mentioned silly and superficial age.

As for heros from sports, well, I am almost completely asportic. I have absolutely no interest in professional sports of any kind and I think the emphasis we place on them as a society is both silly and inexplicable. I understand that the gridiron can be both a metaphor for life and war but…and maybe I just lack imagination…it’s just a leather ball that a bunch of guys are trying to run down the field. I can understand the player’s motivation because they get paid a lot of money to do it but how this translates into anything meaningful for the spectators is one of life’s great mysteries. I’m not against professional sports, and I have no objection whatsoever to atheletes making huge salaries to play what are essentially children’s games, but I just don’t have an interest.

Except for the Olympics. Every four years I go sports mad and, like the salmon, swim furiously up the spectator river to spawn before returning to the tranquility of the deep sportsless ocean. There’s just something about it. My wife and I also get a big kick out of the pagan, Cirque-du-Soleil-inspired opening and closing ceremonies. Proof that bad taste is an international phenomenon. They’ve been trying to upstage Hitler since 1933 and I think the Chinese might finally be the ones to do it.

As for actors, musicians, and the like, with the exception of John Wayne and Charlton Heston they are all pretty much interchangeable. I certainly don’t care about their opinions on anything important simply because they are trained performers. How the ability to play the cello or memorize lines translates into geopolitcal or scientific expertise is a mystery. A lot of my conservative friends have trouble paying to see movies featuring extremely liberal actors but what does it really matter? If I vetted entertainers for political opinions who would I have left? Unfortunately, the talent that allows someone to turn something silly and meaningless into entertainment also means that a lot of entertainers are somewhat silly and meaningless in real life. They can’t help it. The class clown (I went to high school with Greg Kinear, by the way, who was the class clown) or the girl who sings the lead in every high school play are not the kind of people who operate in the concrete world and they don’t necessarily gravitate towards conservatism which is not an ideology for wishful thinkers. So you have to give them some leeway.

Except for Whoopi Goldberg. Good Lord, does that woman grate. As far as I’m concerned she ruined every episode of Star Trek:The Next Generation in which she was featured. I have Tivo just so I can fast-forward through her scenes and I think in the wonderful internet future where we can download the Library of Congress in a couple of seconds someone could go back and seemlessly edit her out of everything.

Any Movies You Really Liked?

I just watched Mel Gibson’s “Apocalypto”. A wonderful picture and not at all the preachy, “White Man Bad, Indigenous Meso-American Peoples Good” slobber-fest I thought it would be. Hey, those Maya were some vicious bastards who cut off their captive’s heads just fer’ fun and sent their decapitated bodies spinning down the steps of their temples, all completely independent of the European mind-control that is usually blamed for recent third-world atrocities.

Not before cutting their hearts out, mind you, which leads me to my only objection to the picture. In one scene the high priest cuts out some poor son-of-a-bitch’s heart and shows it to him. Son-of-a-bitch looks at his heart in terror and then dies. Come on now. Would you really live long enough to look at your heart if somebody ripped it out of your chest?

Only Bruce Lee could do that.

But other than that it’s terrific. A really solid story coupled with a glimpse of a world that we have never seen depicted on the screen, at least not with such realism and attention to detail. Does Mel Gibson take liberties? Sure he does. The Maya weren’t as bloodthirsty as the Toltecs and the Aztecs or as Despotic as the Incas but he’s making a movie, not a documentary and human sacrifice was practiced by various meso-American cultures at different times. Additionally, many of their cultures were imploding by themselves when the conquistadors arrived. Cortez with his 500 soldiers could hardly have subdued an empire that was not already on the verge of collapse.

The guy can make movies. The Passion of the Christ was excellent although I hesitate to say I enjoyed it, or that I would watch it again. It was a little too intense and since I am from the South and the Bible-belt to boot, let’s just say there wasn’t a lot of the usual popcorn eating and chit-chat while it was being shown. We’re all hypocrites, of course, but that doesn’t mean that we don’t believe, a concept that is apparently lost on the entire entertainment industry with the exception of Mr. Gibson. I assure you that thoughtful movies on any number of biblical stories would clean up at the box office if they were presented in a way that was neither patronizing nor written at a teenage level.

I took my four-year-old and seven-year-old to see Disney’s Ratatouille. It was completely enjoyable and believable, which is kind of the point when you’re making a movie about a rat who aspires to be a chef. The kids loved it and were glued to their seats which is not always the case at children’s movies. My daughter likes to help me cook and the funny thing is that you can learn a lot about cooking from the movie. Typical of Disney, while it is a children’s movie, it was not aimed exclusively at children. I can hardly watch movies like Spy Kids which the kids like but have nothing in them at all for adults. They’re just silly which Ratatouille was not…but it is…cause it’s a rat…but it’s believable. The only better Disney picture we have seen lately is “The Incredibles”.

Transformers, which I saw with my oldest son, was fantastic. It’s not “Chocolat” or “The Unbearable Lightness of Being” but the fact that it’s not some arty film in which nothing ever happens except a lot of angst and nihilistic dialogue is a definite plus. Nothing worse than a movie were nothing happens and you dislike all the characters intensely. Give me a good robot movie with heroic Special Forces and lots of things blowing up any time over one that is a chore to watch and requires work to appreciate. Hey, making it entertaining is the directors job. If I have to force myself to enjoy it he has failed.

Not to say I don’t enjoy the classics but they’re classics because people want to watch them.

What does your wife think about doctors now?

The magic is gone, I mean now that she knows what’s involved in our training. We’re just people, after all. Okay, generally more intelligent than most people but still people with all of the faults and defects of any other people. I know she trusted doctors a lot more before I went to medical school. Our pediatrician completely misdiagnosed our newest child with “Reactive Airway Disease” and we tortured her with nebulizer treatments for six weeks before my wife got fed up and demanded the antibiotics which fixed the problem (a croupy, intermittant cough) in about three days. The conventional wisdom seems to be not to give antibiotics to sick kids but in this case the doctor got caught up in his dogma.

She also recognizes all of our tactics, including the “brush off” and the “buck pass.”

On the other hand she has developed some unexpected sympathy for us, especially now that she knows how the business works. My wife knows, for example, that most physicians don’t have all day to chit-chat and they appreciate a patient getting to the point of the visit. A lot of patients don’t realize this and think we have all day for them. In the normal working world, everybody spends some of the work day in idle conversation, surfing the internet, or just pretending to work a la Office Space (another very funny movie) but this is not the case in much of the medical world. When the Emergency Department is busy, for example, we tend to mercilessly redirect rambling patients, something that the older generation who expect their physicians to listen silently for as long they care to talk, neither understand nor appreciate.

It’s not rudeness but the very real demands of the schedule and fifteen minutes wasted in the morning is going to be paid back somewhere else with some other patient who may need the extra time.

My wife sometimes says, when I am not the pillar of stoicism that men are expected to be, “I can’t believe you were a Marine.” Now, when I do something dumb or fail to grasp a concept which she has to patiently explain she says, “I can’t believe you’re a doctor.”
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But we’re not perfect and while I think I’m a good doctor, I’m fairly average when it comes down to it. I have quite a few collegues who are an order of magnitude smarter so you see that perspective is everything. No doubt our patients think we are all Wiley E. Coyote-esque super-geniuses but among ourselves there is definitely some variation.

(To be continued…)

Penultimate Rambling Conversation with a Lumbering Asian Bear-Mammal

More Rambling Conversation With a Lumbering Asian Bear-Mammal

Is there anything you like about residency?

Well, it has it’s moments. I’m the the ICU senior resident this month which is kind of cool, especially because this is one of those rotations where you get paged to make real decisions and not, as is often the case as an intern in the ICU, to be guided to the right decision by the experienced ICU nurses. Not to say that this doesn’t happen but I do know a little bit more than I did two years ago (thanks in part to ICU and ED nurses) so even though the call is just as tiring as any call it’s not that bad. We still work for peanuts but I certainly don’t go home in the morning feeling like I was nothing but somebody’s cheap, place-holding labor. And we have a great set of attendings who give us a lot of latitude to make decisions.

It also affords the opportunity to do a lot of procedures and I haven’t done enough lumbar punctures, for example, to get tired of doing them.

Generally, however, with the exception of working in the ICU and the Emergency Department I have not liked residency all that much. I don’t think anybody does but the culture of medical training makes it very difficult for people to admit that they dislike any if not most of it. People complain about being tired of course but nobody wants to appear weak. As I am confident in my masculinity and so totally not into any of that macho bullshit I can, with confidence, state that I hate being deprived of sleep, treated poorly by people hiding behind their credentials, and working for taco jockey wages. If that disturbs anyone or if you feel that makes me a traitor to the Cult of Aesclepius, well, that’s your lookout. Deal with it. The fact that people have put up with this kind of thing for so long is the real tragedy. But that’s what you got when medical schools were full of people with no other life experience but the slow slog to becoming an attending. Things are different now. Medical training is no longer a monastic experience reserved for young, single, white men. Many of us have families and are not willing to sacrifice them to make the traditionalists feel good about themselves. This explains the popularity of the so-called lifestyle specialties with medical students and the relative unpopularity of specialties that guarantee brutal hours and divorce.

The key point here is that you cannot put your life on hold and say, “I will take my son fishing when I am done with residency.” Those four, five, or six years are precious and once lost are never to be recovered. And that is why, oh you who long for the good old days when residents kept their mouths shut and were prisoners in the hospital, I resent call and pointlessly long hours. It’s like theft. The two extra hours you keep me every evening which contribute almost nothing to my training, taken as a whole, are a large portion of the time I could spend with my family. If you can’t understand this or think that a regard for family disqualifies me for the medical profession, well, you can keep the motherfucker…and lament mightily the flight of otherwise decent, intelligent people from your malignant residency programs.

Now, realistically, as a third-year resident I have it pretty good. I work shifts and while I am worn out when I come home, I get plenty of time off to rest and recover. And while this may not be universal, at my program our attendings work hard to teach us and only ask that we bring our so-called A-game when we are in the department and charge hard for the entire shift. It takes some getting used to but that’s why I like Emergency Medicine. We work towards a goal, we work harder than anybody in the hospital, but I can tell my wife when she can reasonably expect me to be home. Most residency programs could be structured like that if education were the primary goal which is sadly not always the case.

How is Residency Different than the Marines

I compare the two often but mostly facetiously. They are not really similar. Being a Marine Infantryman is several orders of magnitude more difficult than being a resident. Memory being what it is I tend to forget how hard it was to hump (march) twenty miles with a ninety pound combat load or what it was like to be cold to the marrow with no expectation of going indoors in the near future. Residency has never once brought me even close to the limits of my mental and physical endurance, even taking into account that I am twenty years older now and, to be charitable, no longer the fine physical specimen that I used to. I complain about residency but it’s generally because I am annoyed by a lot of it. Some of the things we did in the Marines were so difficult that they were almost beyond rational complaint. So bad that all we could do was grimace and say, “Ain’t it great to be Marine?”
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Marines do whine and bitch about things of course, but mostly about the petty indignities and bad luck that follow the infantry like a plague. When things get really bad we just suck it up. I remember a training operation where my unit came ashore after a twenty mile ride through heavy seas on our unit’s twin-engine boats (my unit was the designated small boat raiding company for the Battalion Landing Team). These boats were modified Boston Whalers and had enough power to jump from wave top to wave top. After a harrowing launch from the well deck of our ship we spent the next hour getting beaten to pieces as we thrashed through the moonless night towards Sardinia. Not only was it bitterly cold (although it didn’t seem that cold while we staged on the flight deck) but the spray soaked everything and I had the wind knocked out of me every twenty seconds or so. Clinging grimly to the rails we finally got under the lee of Capo Teulada and, after a brief run through smooth water, beached the boats and literally crawled ashore as hardly anybody could stand.

An hour into the operation with five days to go most of us had already taken a beating the likes of which many of you cannot imagine. But we unstrapped the guns (I was the Mortar Section Leader at that time), shouldered our packs and moved out for our objective several miles inland. What else could we do?

So my point is that physically and mentally, being a Marine Infantryman is a good deal harder than being a resident. We may complain about being tired but I have never actually gone more than 36 hours without sleep as a resident and at the end of it I knew I could get some sleep in a nice, comfortable bed. As a Marine you often have nothing to look forward to after a week in the field but another week in the field and an uncomfortable couple of hours of sleep, on the ground, with nothing but a poncho liner for warmth. Try thinking coherently after three days of sleep deprivation. What keeps you going is self-discipline and the sure knowledge that if the Marines ever lose their reputation for toughness it won’t be because of you. We’re very idealistic that way.
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Sleep deprivation is required for combat operations. Our military is not that big, especially the pointy end of it, and what we lack in numbers we have to make up in mobility and lethality. That’s just a fact of maneuver warfare and we should train under the same conditions that we fight. Sleep deprivation is not required for medical training. Very few praciticing physicians pull Q3 call or work 100 hours a week doing the kind of labor-intensive administrative tasks that are allowed to exist in the inefficient residency training system.

But I digress. I want to also add that in the Marines, if you complain about how hard it sucks (and in fact we sometimes refer to the Corps as “The Suck”) nobody thinks less of you. You’d have to be a retard or a kiss ass to pretend everything is hunky dory. Of course we also laugh at the complainer and say, “Oh well, I guess it sucks to be you” but as long as that man carries his weight and charges hard when required no one thinks less of him. In the medical world, however, to even suggest that you’re tired of pointless bullshit and would prefer to go home is to invite screeching and hand-wringing from the usual cadre of zealots who are flabbergasted, totally flummoxed, that anybody could utter one single criticism of their precious career.

What Kind of Health Care System do You Favor?

I favor a Cuban-style approach. First, we need to abolish political parties and if necessary imprison, exile, or execute politicians who refuse to accept the new order. Then we should severly curtail the traditional civil liberties that we currently enjoy. I’d start with the press and shut down newspapers and television stations that did not support the government. For good measure I’d gradually abolish private ownership of print and broadcast media turning these into propaganda organs of the state. I’m sure we wouldn’t have to execute too many reporters before they fell into line. Maybe establish re-education camps for those who don’t quite get it.

We would also need to get rid of freedom of speech and the right to protest because these kinds of things are messy and make running a modern utopia impossible. Not to mention that it can be embarrassing to the Leader who is, after all, a perfect father to his people. Religion is unessential and unless it can be corrupted to serve the needs of the Party we can ban it too. It’s just an opiate for the people and restricts our ability to condition them for obedience. We can’t put God in a concentration camp so we will need to make the people forget about Him. A good start would be giant portraits of our Glorious Leader along with other heros of the revolution. You know, to give the people somebody to respect. Oh, and marching, lots of marching. Lots of parades.
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Poverty is also essential. It’s too hard to keep our hands out of the economy. Besides, we know better than anybody else how to run things. We have college degrees. How hard could it be? At least we can ensure that everybody is at the same low level of poverty. It is a lot more fair that way and the people will not be envious. Envy is bad. Inequality is bad. But party members do deserve some perks. Running a country is hard work, harder than cutting sugar cane, let me tell you!

We also need to keep people from leaving. If we lived on an island it would be a lot easier but maybe we could fortify the boarder and put guard towers every few miles or so. It’s regretable that we don’t have 90 miles of shark-infested ocean to keep people honest but we have to work with what we have.

Oh, and we can have free health care. Nothing elaborate, mind you. Just some low level primary care. What are people going to do, complain?

(To be continued…)

More Rambling Conversation With a Lumbering Asian Bear-Mammal

A Rambling Conversation With a Lumbering Asian Bear-Mammal

Why do you complain so much about residency and medicine? It’s not as if you, personally, can do anything about it and besides, aren’t you done with call and most of the other less than savory aspects of medical training?

Like I always tell people, this blog is not about validating any particular point of view (except mine, of course). I call them like I see them using the occasional foray into satire to highlight what I regard as some of the problems of medicine and medical training. Do I expect that my blog will have any effect on the great storm about to break on us all? Of course not. I am just one guy with a little blog on a little patch of hard drive somewhere on the internet tundra and my thousand or so visitors per day hardly make a stir in the vast expanse of the medical world. Still, change is coming. You can feel it in the air. The frustration in the medical profession hangs thickly around us and I am not the only physician to sense this.

What are some of the Frustrations?

They are legion and one hardly knows where to begin but malpractice has to be at the top of everyone’s list. Protestations of various oleaginous lawyers and policy experts to the contrary, litigation and more importantly, the threat of litigation has a profound impact on how medicine is practiced in this country and its increasing cost. While the actual cost of payouts in malpractice suits is fairly trivial compared to the huge amount of money changing hands in the medical industry, the behaviors engendered by the threat magnify the cost tremendously. Can I quantify the percentage of care we deliver that is wasted on so-called “defensive medicine” (that is, medical practices designed primarily to protect us from frivolous suits)? Of course not. One man’s defensive medicine is another man’s justifiable dilligence. On the other hand as I have eyes I can see that we spend a great deal of money in the hopeless quest for perfection, perhaps the worst place to spend money as the incremental increase in health this buys us is hardly worth the tremendous cost to achieve it.
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The fact that I can’t put an exact dollar figure on purely defensive medicine does not mean that there is no problem. Certainly the impact is greater than the combined cost of malpractice insurance and lawsuits and just as certainy if we killed all the lawyers and allowed common sense to work its way back into health care we would save a lot of money in the long run.

Common Sense?

In a perfect world, the public would accept that medical care entails risks and the money we spend protecting them against unlikely consequences would be better spent on medical care that makes a difference. Somebody pays for the drunks that detox in the Emergency Department rather than the police drunk tank, for example. Maybe it’s hard to quantify the cost but protecting these patients from the unlikely risk that they will aspirate vomit takes staff and facilities out of service for other productive medical uses. And the money spent on exclusionary workups which have little to do with the chief complaint has to come from somewhere. Since very few people actually pay for their medical care directly and physicians are under a great deal of pressure to avoid getting sued, there is no organic incentive for anybody to think about cost.

Which leads to another frustration for physicians, namely that while on one hand non-medical adminstrators have increasing influence on how doctors practice, they are not exactly sharing the liability. It is perfectly reasonable, for example, for an administrator to try to curtail the use of expensive studies where they are not indicated. On the other hand the administrator doesn’t provide much cover for the physician who knows perfectly well that he can practice perfect evidence-based medicine and still be dragged through a malpractice trial in which his professional reputation,livelihood, and assets are put in jeopardy.

Yeah, but aren’t doctors just complaining a little too much?

Well, everybody complains about their job. And everybody has to deal with the bean counters. But as the economics of medicine are often at odds with the practice of medicine, there is an adversarial relationship between doctors and the accountants. As I said, controlling costs is perfectly justifiable and in a perfect world we would know with certainty how much to spend on every patient. However, even without the uncertainties of defensive medicine, it is not possible to fit every patient into check boxes and standard forms. Sometimes we have to write outsides the allotted area. That’s sort of the point of having physicians and not self-service computer kiosks where patients enter their symptoms and receive exactly the treatment they need with no wasted effort or money. Now, it may come to that in the future as mid-levels and lower level providors are pushed into the breach to stem the onslaught of the aging baby-boomer hordes, armed as they are with their horrific powers of entitlement and inevitable “free” health care, but the public is going to suffer. Not that most will care or know the difference. They will be getting substandard but free health care. Huzzah!

Besides, physcians with their extensive education and abilities are always a convenient scapegoat for politicians looking to redirect the anger of the mob.

Paranoid, aren’t you?

Not at all. But it is easy for anybody looking to curry favor with the electorate to attack physicians. The public believes that we are all multimillionares without a care in the world and, as a class, too smart for our own good. Disliking someone who is wealthier and smarter than you is a primal urge very common in both the trailer parks and the halls of academia, two disparate places that never-the-less share some of the same provinciality and the overbearing confidence of ignorance.

The fact, for example, that even the lowest paid physician generally has to struggle through at least seven years of exhausting training and that he might just be worth his salary never occurs to either group.

Another thing that should bother everyone in the health care industry is the concept that health care is a right and needs to be provided for free. The insanity of this concept is obvious. Rights do not have to be provided, they exist independently of governments and while they must be occasionally secured by either war or revolution, they are not a commodity to be provided to the public. Nobody’s has to work a twelve hour shift at the Department of Free Speech to keep the dissent flowing.

Medical care, on the other hand, is a service provided by people who expect to get paid. And will get paid except for doctors whose compensation under inevitable government run health care can be legislated as low as the congress thinks it can get away with. What are doctors going to do? Go on strike? Of course not. We’ll just suck it up because our ethos forbids us to harm, even by ommission, any of our patients. Nurses on the other hand wouldn’t put up with an attack on their salary for a minute and as a group, know how indispensible they are and leverage this effectively. And they have pretty good juice with the public. Imagine a suicidal politician proposing that nurses and other hospital workers need to accept less pay for the public good. That man would be tarred, feathered, and run out on a rail.

Money, money, money! Is it that important?

Of course it is. Money drives everything. Even your disdainful college professor preaching the gospel of poverty can only do so because he has waged bureaucratic war for his tenured position, a position which may not pay as well as some other careers but one from which it is almost impossible for him to be dislodged and which provides enough income for him to turn his nose at other people’s money. He’s not working for free and neither does anyone else. This is not a bad thing, either. Societies that try to do away with the individual profit motive are dreary, impoverished places because what works in a small commune or a kibbutz cannot be extrapolated to an entire nation. If there is no benefit to working hard, and no risk in not working, the freeloaders, Alexander Zinovyev’s famous “Homo Sovieticus,” tend to take over.

So the disdain for money is fairly unhealthy even in the medical profession. There has to be an incentive for people to work hard and long. You will always have people willing to be physicians of course, but their enthususiasm for seeng that extra patient or coming in from home to operate on a patient on the weekend will diminsh as the rewards for doing it evaporate. Medicine is a rewarding career independent of money but it ain’t that rewarding. It can be something of a grind as I’m sure many Family Medicine physicians would probably tell you after their thirtieth patient of the day.

Speaking of frustrations, there is probably none bigger than the way physicians are reimbursed. The system is crazy and I have only had a small taste of it. They call medicine a business and patients customers but it’s a strange business with the oddest customers and that’s no lie. (Is medical care a right or a customer-driven business?) First of all, many of our customers not only don’t pay a dime but the very idea that they should have to pay even a fraction of the cost of their care never enters their heads. If medicine were a business this would be called theft. At least shoplifters know they are stealing and try to hide thier crimes which is not the case in the medical world where a family will boldy stride into the ICU and insist that we spend whatever it takes to squeeze a couple more days out of their demented, stroked out, septic, octogenerian grandmother. It’s somebody else’s time and money, what do they care?

On top of this, attached to the most technologically sophisticated industry in the world which performs commonplace miracles that would have been inconceivable just fifty years ago is a system of remibursement straight from ancient Byzantium. A nice system for a courtier, a eunuch, or a lawyer but as adminstrative costs alone are said to gobble up a third of every health care dollar, money that provides no medical care whatsoever, what exactly is the benefit to the public and how can doctors be blamed for the high cost of health care?

It’s not a problem that has an easy solution. The single payer zealots opine that making government the insurance provider will streamline things but all you’ll really get is a clumsy bureacracy looking for ways to not reimburse and holding onto every penny like it was a gold coin. Very similar to a private insurance company except that Aetna cannot kick down your door and raid your house. Insurance companies need to make money for their stockholders. Governments try to dole out scarce money to constituents to buy their votes and there is never enough to go around.

But hell, the public doesn’t care. They want medical care for free no matter how much it costs. We are already conditioned to not care about the price of health care. Very few people actually take out their wallet and pay for even something as simple as a routine doctor’s visit that in an ideal world would cost eighty bucks and, in a country where people pay twice that for a month of cable television, would be considered a good value for the price.

I don’t think we need to do away with insurance but we need a simple law forbiding hospitals and clinics from billing a patient’s insurance company. Especially if it is the government which, along with private insurers, currently pushes the greater share of their administrative overhead onto health care providers who receive no extra money for their troubles. In the old days patients paid their bill and then submitted their claim to their insurance company. Watch how fast things would tighten up if patients were refused reimbursement for the same reasons that doctors are currently refused. You’d have angry patients, angry both at the government and at doctors for not caring about how much things cost which is probably the greatest incentive there is to efficiency and reasonable prices.

(To Be Continued…)

A Rambling Conversation With a Lumbering Asian Bear-Mammal

Tell It To The Marines

The Good Old Days

As some of you know, I spent a considerable part of my misspent youth in the Marines. I enlisted in 1983. Back then they still had something called “mess duty” which many of you probably know as “KP.” Periodically, non-rated Marines would be pulled from the company to work in the chow hall doing all kinds of menial labor, from swabbing the decks to scrubbing pans in the pot shack. It was hard work requiring a young Marine to get up early (early for Marines, you understand, which is extremely early) and to work sixteen-hour days for an entire month without a day off. The Marines are serious about both the quality of our chow and the cleanliness of our mess halls, all of which requires plenty of labor, much of which was traditionally supplied by the line companies.

Generally, a typical non-rated Marine (Private, Private First Class, or Lance Corporal) could expect once a year to do either a month of mess duty or a month of guard duty (walking a post as a sentry). I hated mess duty. Everybody did. The general consensus was that while the life of a Marine infantryman is a hard one requiring endurance and a stoic disregard for personal comfort and safety that many of you can’t imagine, we hadn’t enlisted to scrub floors. Indeed, the recruiters didn’t breathe a word of this to me although to their credit the Marines have never tried to sell themselves as a jobs program or an easy lifestyle.

Retention is important to a military service and in the early 1980s the Commandant of the Marine Corps asked his subordinate generals to find out why Marines weren’t reenlisting but instead leaving in droves after their first four year hitch. The answer was not surprising but probably counter-intuitive to civilians. Historically the units that spent the most time doing hard, meaningful training or on combat operations had the highest retention rates. Reasons given for not reenlisting on exit interviews included, among other things, the military equivalent of scut work, foremost among this being mess duty which, along with the rest of it, in many units seemed to take up more time than training.
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Other reasons included the requirement that young Marines live in the barracks which were even at that time were mostly long open rooms (squad bays) with bunks of the kind many of you have seen in war movies.

The Marine Corps is fairly conservative but is still flexible enough to change direction when required. Marines are famous for pivoting around a bad situation, throwing out the rule book, and adapting the plan to the real situation on the ground. Over the objection of the traditionalists who believed that mess duty was a form of character improvement, something that they had endured and which they believed everyone else should as well, it was abolished as part of a program to improve the quality of life for junior Marines. This included among other things building comfortable modern barracks with rooms to replace the troop barns that had been the previous standard.

You see, America had changed but the Marines had not. The son of an Arkansas sharecropper in the 1950s might look at a squad bay as an improvement and a month in the chow hall as just another struggle in life but the typical recruit of the nineties, while every bit as motivated to kick a little ass was used to a higher standard of living. Mess duty and squad bay living, things of extreme importance to the narrow-minded traditionalists had become obsolete and more importantly, were detrimental to the mission of the Corps, part of which is to retain enough junior Marines to form a cadre of experienced NCOs.

Fortunately, despite the dire predictions, the Marine Corps has survived and still fields the toughest, most disciplined regular infantry on the planet, at least the equal if not better than any previous generation of Leathernecks.

I’m sure many of you can see where I am going with this.

The current system of residency training, like the Marine Corps of the early 1980s, was organized for a different era and a different kind of person. The resident of the 1950s was with few exceptions a young, geeky, unmarried male who’s career was an uninterrupted arc from high school to college to medical school to residency, free from the encumberances of marriage, family, and outside resposibilities that are almost the norm today. Not only that but as medicine was not as highly specialized or even as advanced as it is today a single year of internship was all that was required for a physician to set himself up in private practice. Since medical malpractice suits were almost unheard of and the dangerous interventions that physicians could even attempt were few and mostly the purview of the few specialists, most physicians felt comfortable hanging up their shingles after even this limited training.
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As for the few physicians who pursued advanced training in surgical and medical specialties, the residency training system in which they worked, although designed at the turn of that century, was still fairly well-suited to the pace of an American hospital circa 1950. The explosion in medical knowledge and technology which started in the late 1960s was looming but had yet to take place and hospitals were still generally sleepy boarding hotels for the sick in which nature, not the skill of the physician, had a leading role in the patient’s prognosis. They were not the 24-hour-per-day high volume patient processing mills that they are now become nor were the typical patients nearly as sick as most of our patients are today.
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A multiply comorbid patient who barely raises an eyebrow in 2007 would have been a miracle in the 1950s as surviving even one of the serious conditions of which modern patients commonly have half a dozen would have been impossible.

Both the science and the logistics of medical care have changed radically since the 1950s but the residency training system has not. On top of the huge increase in basic medical knowledge required of a modern physician has been added a paperwork and compliance burden that would have been unimaginable to physicians from that earlier time. Liabilty concerns, for example, have ensured that nothing happens in the hospital, neither a tree fall nor a sparrow perish, without the event being redundantly documented and explained to the lawyers; the true purpose of most medical records. Necessary, perhaps, but this sort of thing takes time and the one thing that we have not yet managed to accomplish is to add more hours to the day or make people function well on less sleep.

Not only do modern residents operate with this increased logistical burden and increasing complexity of patients but there are a host of new interventions of which a resident is supposed to be familiar, hundreds of new drugs, thousands of adverse drug interactions in polypharmic patients, and the expectation of the public that all their medical problems must be addressed immediately or there will be legal hell to pay. There are simply not enough hours in the day and rather than looking for ways to streamline the system, eliminating resident functions that are incidental to medical training, the slack has been taken up by depriving the residents of sleep on a regular basis and ensuring that they get as few days off as their respective residency programs can manage.

“Call,” for example, once a relatively painless nap in the hospital interrupted infrequently for the occasional admission or floor emergency has become “work,” just an extension of the normal day. They might as well even stop referring to it as call. It’s not “call” at all but a continuous grind performed by exhausted physicians being paid less than the janitors. For my part I work harder on call than I do during the day because there is usually the same if not more work to do with a small fraction of the staff.

The older generation laments the seeming lack of interest of the modern resident in conferences, rounding, and the other traditional niceties that were once the foundation of medical education. But since residency training has become nothing more than a poorly paying job with horrible hours (even the vaunted 80 hour work week is ridiculous if you think about it) and a resident is evaluated by how well he moves the meat around on his service, a tired resident will have a great deal of difficulty listening to a lecture when he has been up for thirty hours and every minute of the noon conference is another minute separating him from sleep. You, my long-suffering readers, who have never been sleep-deprived on a regular basis (and I have been regularly deprived for most of the previous two years) cannot appreciate the biological imperative of sleep. Certainly the drone of an uninspired speaker talking over stale pharmaceutical representative sandwiches cannot overcome it nor can any textbook yet written pry open the eyes of a tired resident who has barely had time to sit down, let alone rest, since the shift workers have come, gone home, and returned for a new day.
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In this way has residency training become an obstacle to education. Yet the old guard, the inflexible traditionalists of which there are many, are so afraid of change that the very idea of a resident sleeping every night is viewed as a mortal threat to the practice of medicine and one which will spell the end of the profession. This despite the fact that very few practicing physicians conduct business in a manner even remotely similar to the peculiar way we do it during residency.

There will eventually be a flight of graduating medical students from specialties that subject them to treatment that would be considered war crimes in many countries. Already the smartest medical students gravitate towards the so-called lifestyle specialties or do you really think that they entered medical school with a burning desire to be dermatologists? If physician compensation continues to decrease we will rapidly arrive at the point where rational people decide that the abuse isn’t worth it and it will be surgery programs scraping the bottom of the medical school barrel.

All for fear of a little sleep.

Tell It To The Marines

Welcome to Intern Year

(Gentle readers, I present the following which is mostly written in Marine-speak. You have nothing to fear and yet, if you have a weak constitution or are easily upset I implore you to skip this article, perhaps using the time saved to peruse the latest Peanuts comic strip in the newspaper or anything else that is similarly non-threatening.-PB)

Is That Smoke Coming Out of Your Ass or Mine?

You are loved. No doubt about it, the one lesson of your intern orientation is that now, finally, after four years of medical school where you were beneath contempt in the medical hierarchy you are now one of the gang, a valued colleague, someone who will be treated collegially. After all, as the designated speakers will point out with heroic rhetorical flourishes, whereas up until now you didn’t count, now you do and with your great responsibilty as real doctors comes the expectation that you will be treated professionally and courteously.

Then of course you will actually start intern year and they will treat you like a piece of shit, both institutionally and professionally. Need some sleep? “Fuck you.” Want some time off? “Screw you, you big fucking baby.” Don’t know where anything is or how they run the service? “Fuck you, moron. We sent you an email. Didn’t you read it?”

And so it will go. Now, I am not the smartest Asian bear-mammal to ever lumber out of the bamboo grove but I can tell when I am having smoke blown up my furry ass. You can tell me that I’m going to be treated like a valued junior colleague and you can make nice noises but the reality is that for your entire intern year, and possibly your whole residency, the default position of everybody with whom you work will be to treat you like a sweat-shop laborer.

So welcome to the dysfunctional residency training system which was designed, literally, by a cocaine-addicted physician and which has changed very little since its insane beginnings. Sure, some of the hours have been limited but the system still depends on depriving you of sleep and making you work the kind of hours that are considered war crimes in most other countries. Heaven forbid you point this out. Apparently when it comes to an abusive medical training system, everybody is a hoary old conservative protecting their peculiar institution from reform. Swing low, Sweet Chariot. Them residents sure can sing! Why brother, it would be a sin to set ‘em free seeing how happy they are. Lift that bale, tote that barge!

Ol’ Man River he keeps rollin’ along.

This is what they really mean to tell you at your orientation to intern year:

“Welcome to our hospital. We’re so glad you’re here. the first thing I want all of you to do is to reach down and feel your testicles. Ladies, go ahead and palpate your ovaries. Feel those things? Well, we own them. Oh sure, technically they are attached to you but for all practical purposes they are ours and we have them gripped firmly. If you step out of line we will give ‘em a squeeze. Step too far and we’ll tear them out of your body and present them to you a la Bruce Lee before you die.”

“Just wanted to clear that up so you folks don’t get too uppity. Your contract? Hah. We call it a contract but it’s more of a receipt for your indentured servitude. We agree to practically nothing and in exchange you are ours for the duration of your sentence…I mean your training. Don’t like it? I think we can fire you for just about anything and at any time. Not too many other professionals would work under those conditions but as long as there is a steady supply of you stupid motherfuckers ready to mortgage your souls to get into medical school we can pretty much do whatever we want. You can leave of course, but good luck getting another residency position after we shake our heads sadly and opine that you are a trouble-maker. Not to mention that we have the system set up so even if you manage to escape you can only do it one time a year and only if the stars and planets align just right. So shut your stinking gob-holes. You’re in it now.”

“And we don’t give a rat’s ass about your sleep, your rest, your health and your well-being. Oh, we’ll pay the usual lip service to these things and in later orientation lectures we will encourage you to take naps on call and instruct you how to best use caffeine to optimize your wakefulness but the fact is that we are going to beat the crap out of you for at least a year and hopefully for as many years as we possibly can. We just don’t care. Now, because some disloyal pussies couldn’t keep from whining to their mommas and killing themselves on the exhausted drive home from the hospital we are only supposed to work you eighty hours a week. I can not stress enough what a bunch of fucking crybabies that makes you or how sick I am of looking at your fat lazy faces sitting there knowing that you might actually get some time off. It makes me physically ill to think about it so I expect all of you to uphold the highest ethical traditions of the medical profession and lie about your actual hours if it comes to it. I suffered and because I have a personality disorder, you need to suffer too. Besides, everybody knows that we only have to obey rules if we agree with them…and we certainly don’t agree with this one, do we?”

“If you complain too much we will ressurect some dinosaur who trained back in the days when they were still using poultices as a first line therapy to try to shame you into keeping your mouths shut. Obviously everything was better fifty years ago, especially when interns were all geeky white males with no families and no responsibilities outside the hospital. Man! those were the days. We owned those motherfuckers. I mean, we own you but we really owned them. There was so little that could be done for patients in those days that we could waste their time with wild abandon. Those were the golden days of scut work my friends, the likes of which we will not see again.”

“As to your pay, well, the federal government is giving us a shitload of money for your training. Almost twice as much as we are reluctantly going to pay you. We’re going to cry poverty and feed you a line of bullshit as to how expensive it is to train residents, how much you are damaging our efficiency, and how this extra money doesn’t even cover the economic damage you will inflict to our bottom line but this is just fragrant smoke wafting up your ass. Try taking a day off or calling in sick when you have call and see how we are going to panic. As if it isn’t bad enough that many of you little pussies can’t work more than eighty hours a week and we can’t always screw one of your colleagues to cover your call, we may have to actually pay somebody real money to do your job which is really going to eat into our bottom line.”

“And who is really going to suffer? Why, The Patients of course. Your insistence on not working with hospital-grade gastroenteritis or your gay desire to spend a day or two every month with your wife and kids is stealing, yes stealing, precious medical care from the poor underserved wretches frequenting this hospital. Don’t you stupid fuckwits understand that Patient Care comes first? Patient Care is our primary responsibility and with the exception of the nursing staff, the respiratory therapists, the Physician Assistants, the phlebotomists, the lab techs, the janitors, the cafeteria ladies, the attendings, the parking attendents, and those ladies slopping the hash in the cafeteria everybody in the hospital is expected to sacrifice their entire life for Patient Care.”
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“So we need you to work a lot. Unfortunately we have to give you little wimps four (and I weep to think of it) days off every month but we’re going to send you home a little early post call and call this a day off, even if it is less than 24 hours and you will sleep through most of it. Those pesky rules again I’m afraid but we’ll subvert ‘em somehow because you guys are a fucking goldmine. Have you seen what Hospitalists are charging (not to mention PAs and other midlevels who will do in a pinch)? Let me tell you, they ain’t cheap. Not by a long shot. You poor sons of bitches, however, are ridiculously cheap. Insanely cheap. And the more we work you the cheaper you are because, get this, we don’t have to pay you overtime. Try getting the janitor to work some extra hours. Even my taco stuffer gets time-and-a-half if he goes over forty and all he has is a GED.”

“Who’s yer’ daddy now?”

Welcome to Intern Year