Emergency Medicine Residency (Part 2: Event Horizon)

(Once again, a caveat: I am a resident in a medium-sized Emergency Medicine program in an academic setting. Not as academic as Duke or USC but we have most of the players. I have never worked in private practice in Emergency Medicine so while I welcome the comments of those who have, I am describing my views of residency, not private practice. -PB)

The Spice of Life

The other night I was sitting at our PACS workstation (for viewing imaging studies) discussing a fracture with one of the orthopaedic surgery residents. In front of me were the ultrasound pictures of another patient, a woman who I was working up for a possible ectopic pregnancy. I had three charts on the table; one a lower GI bleed, one a headache (cough…drug seeker…cough), and the other a totally lame alleged intentional overdose of Seroquel. I had just discharged a four-year-old who was perfectly healthy requiring only maternal reassurance and I was keeping an eye on one of our habitual drunks signed out to me by one of my fellow residents, to be discharged when he could walk or obtain a ride home.

In no particular order, my other patients on that shift were a minor laceration to the forehead, a couple of nebulous abdominal pains, a few chest pains only one of which would probably pan out (although all were admitted), a possible meningitis requiring a lumbar puncture, a septic shock requiring the works (intubation, lines), a constipation, and a couple of drunks with whom I am on a first name basis.

That’s how I spent my night and that’s pretty typical. An occasional flat-out, full-throttle emergency, a couple of really sick people who might have become real emergencies if they had waited another few hours, some acute but non-life threatening complaints, and a whole bunch of patients who make you scratch your head and wonder what could possibly induce a reasonable human being to leave the comfort of their bed at 2AM to sit in the hall of our department eating cold turkey sammiches’. I mean, without giving too much away, let me just say that I have had vague abdominal pains at one time or another but I have never even considered calling an ambulance to take me to the Emergency Department.

So you see, while Emergency Medicine is a specialty, most of your time is going to be spent on general medical complaints, not actual emergencies. Still more of your time is going to be spent coordinating care; either referring, consulting, or admitting and a surprising amount of working up and treatment goes on before we get to that point. It is hard to get specialists and consultants to come in or admit so one likes to have a rock-solid case before calling. Not to mention that the Emergency Department has become a miniature hospital-within-the-hospital complete with admitted patients and even critical care. Consequently, the consultants and admitting physicians expect us to do a lot before we actually call, sometimes to the point of doing essentially everything for the work-up of a complicated patient including definitive care. When they start asking me the results of C-ANCA studies maybe it’s time for them to admit the patient.
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A typical shift, like March, starts like a lion but goes out like a lamb. On arriving, I grab the first chart on the rack and start the work-up on my first patient. This is the easy part. There is nothing to starting a patient’s work-up. You either have a pretty good idea what’s wrong or you can temporize by ordering studies, a tactic that will buy you anywhere from twenty minutes to an hour (one of our Emergency Departments, if you can believe it, does not have a “stat” lab and the only fast thing you can get are a few lab values off of the ABG on a critical patient). With the first patient comfortably simmering on the back burner, I pick up the next chart and repeat the process. Eventually I have a bolus of six or seven patients waiting for studies and disposition and then things slow down considerably. At a certain point you start getting close to the resident Event Horizon, that point in the space-time continuum where your efficiency drops to zero; as does your ability to see new patients without falling unacceptably behind on the ones you are following. It is surprisingly difficult to keep track of a large number of patients at various stages of their work-up.

Moving patients is complicated by the structure of residency. Our attendings, who see patients themselves, need to lay eyes on every one of our patients and approve the plan. They are as busy as anyone else so while every patient to be discharged or admitted needs their blessing, coordinating this can be difficult, particularly as our attendings are not only seeing their patients but also supervising a couple of other residents.

So if you look at a graph of my productivity, you’d probably see what looks like a huge effort towards the beginning of the shift tapering off to nothing by the last few hours. In other words, while I’m seeing my required quota of patients, once I get a certain number I lose efficiency rapidly. We typically don’t pick up charts on the last hours of our shift but by that time it’s academic anyways as most of our effort is now spent frantically trying to get rid of the ones we have. Another one of the skills our attendings try to teach us is to keep the patients moving through the pipeline without that kind of bottleneck.

Some bottlenecks, however, are unavoidable. Procedures, things like suturing or doing a lumbar puncture, can eat up a considerable amount of time if you a) are not very good at doing them and b) don’t coordinate with your nurse. Coordination is important. The nurses want to move patients as much as you do and if, for example, they have the patient moved to the OB-Gyn room for a pelvic, you need to plan to be available to do the exam when they are ready. You also need to stay on top of the labs and imaging. The sooner you can make a decision the better.
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The other unavoidable bottlenecks are critical patients and trauma, both of which can suck up large amounts of time. Critical care patients in particular, because they are not likely to be taken off your hands by surgery any time soon, can easily set you back an hour, something that many patients in with minor complaints do not understand. Reason number 1024 not to come to the Emergency Department for a minor complaint. It might seem like a good idea when you breeze through triage on a slow night but invariably there will be delays.

Contrary to the popular belief among critics and sour-grapers of Emergency Medicine, although we see some minor complaints (“I couldn’t urinate for an hour but now I can”) we do not do primary care. Oh sure, patients make attempts to get us to manage their chronic problems but you need to avoid the temptation. You cannot do decent primary care on a patient who you have never seen and will probably never see again and certainly not within the confines of an Emergency Department visit. We do not do drive-by pap smears, in other words.

Imagine how things would slow down if we did.

Emergency Medicine Residency (Part 2: Event Horizon)

Emergency Medicine Residency (Part 1.75 A Parable About Trauma and Perception)

Perspective

Consider two separate rooms in the same Emergency Department. In one lies a young man who has been shot in the chest and arrived in full cardiac arrest with the paramedics frantically giving CPR. Red frothy bubbles come out of the gaping hole over his heart whenever the bag attached to his endotracheal tube is squeezed. A Full court press ensues and the trauma bay fills with interested bystanders watching the action as the patient is prepped for an emergent thoracotomy; a procedure where the chest is cut open to expose the heart and allow the repair of any obvious holes (as well as manual compression of the left ventricle to circulate blood).

In another room sits a sixteen-year-old girl, two weeks out from a tonsillectomy, with an emesis basin by her mouth and over which she has coughed or vomitted enough blood to cover the front of her dress. The room is empty except for the Emergency Physician, the nurse, and the anxious family.

Which case is more important? Surely the gunshot wound in the trauma bay is getting the most attention. It is an exciting case after all. It has everything one could possibly want. Blood, gore, violence, the cops, good guys, bad guys, and a young man whose life is hanging by such a fine thread that the Emergency Physician who is not in any way, shape or form a trained cardiothoracic surgeons is preparing to make a very large hole in a chest to perform rudimentary open-heart surgery. This is the stuff of which legends are made.
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“Say, Bob, remember that chest we cracked last month. Man. What a mess that was!”

The young girl in the other room? It’s just a post-tonsillectomy hemorrhage. Not exactly riveting stuff but I submit that this girl is the more important of the two cases. The guy in the trauma bay, after all, is dead and not likely to improve. He’s been shot through the heart or a great vessel and has been without oxygen to his brain for all but the first minute (the time it takes for his heart to pump most of his blood onto the street) of the last official twenty minutes of his life. There is probably nothing left upstairs to save even if circulation is restored. There is literally nothing to lose so everything possible is done and the trauma bay hums with frenzied activity even though the chances of even restoring spontaneous circulation with an emergent thoracotomy in a patient who arrives without vital signs is less than one percent. And only a small fraction of that less-than-one-percent ever leave the ICU except feet first for that last ride to the basement.

And yet this kind of thing defines Emergency Medicine as a specialty. The sixteen-year-old girl? How many of you contemplating Emergency Medicine as a career have ever though about this kind of patient? She seems pretty mundane and yet a patient like this is in mortal danger unless something is done and done quickly.

Everybody knows what to do in an exciting trauma. Big Things. Big Procedures. Lines, tubes, fluids, ventilators. Futile but extremely gratifying. How many of you have even considered how you’d handle a frightened sixteen-year-old rapidly bleeding to death and periodically vomitting another half-pint or two of blood. And no, it’s not as easy as you think. The girl could die. She’s sixteen. She isn’t supposed to die just yet. It’s just a tonsillectomy for which her otolaryngologist humorously prescribed ice-cream to make her throat feel better. If you let her die how will you explain it to the family?

“We did everything we could…I’m sorry,” doesn’t quite cut it in this case.

The moral? Emergency Medicine is not what you think. For every major trauma you are going to see a hundred garden-variety gastrointestinal bleeds, overdoses, strokes, heart attacks, ectopic pregnacies, sepsis and a large variety of other potentially life-threatening presentations. These will be woven into a day mostly spent dealing with relatively minor stuff like vague abdominal pain, headaches, and whatever complaint can be used to access the bounty of The Man. That’s just the way it is.

Emergency Medicine Residency (Part 1.75 A Parable About Trauma and Perception)

Emergency Medicine Residency (Part 1.5: Answering an Important Reader Question)

Whenever you get a major trauma, do you get your fair share of procedures (chest tubes, central lines, etc..) or do the surgical residents tend to take them?
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At our program, because it is a Level I trauma center, trauma surgery is in charge of most of the traumas. The EM residents manage the airway and do the initial assesment and stabilization in theory but in practice it is a joint effort with trauma surgery doing most of the heavy lifting. Trauma is not that complicated at our program. Unstable patients are stabilzed and taken to the OR. Stable patients are “pan-scanned” and trauma surgery elects to either operate, admit, or send home. We just sort of take their lead.

And we don’t get that much major trauma. We get a lot of trauma codes but they usually turn out to be nothing much. A lot of the level 1 trauma patients are actually discharged from the department. Determining the level of a trauma is a judgement call and any high speed rollover, for example, is often called at the highest level (level I) even if everybody was in seatbelts and walking on the scene (They still arrive on a back board, you understand.) It’s also a little bit political because to justify your funding as a Level I trauma center you have to see a certain number of Level I traumas. In other words, trauma patients are often upgraded to the next highest level but they are rarely downgraded.
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I have done some chest tubes but only one on a trauma patient. The rest were on medical codes of which my program sees plenty. Same with central lines and the like. Very few trauma patients get anything more than quick femoral lines which are not hard to place. I have done all of my many internal jugular and subclavian lines on critical medical patients both in the department and the ICU as well as most of the rest of my procedures. The only surgical airway I was in on (and I was just helping) was in the ICU. To date, I intubate more patients in the ICU than I do in the department. I probably intubated two or three times a night when on call in the ICU. A lot of the trauma patients arrive pre-intubated for our convenience as our city has superlative paramedics.
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It’s the medical codes that are difficult. Managing a decompensating dialysis patients with an exacerbation of his congestive heart failure secondary to his smoking crack is a lot more challenging than putting in a chest tube. Sorry. It is. We see a lot of this kind of patient and worse at my program.
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I confess that I am not yet very good at managing trauma patients. There are usually two or three attendings in the trauma bay along with every single surgery resident in the hospital so I’m afraid I am somewhat intimidated…what, after all, do I have to add to the high level brainpower there assembled? It’s a case of too many pimps, not enough hoes. Paradoxically, in the ICU where there are seldom any attendings or other residents around except those standing around waiting for somebody to take charge, I am completely comfortable managing a critical care patient running south for the border. And occasionally when I go up there (the EM residents are on the hospital code team) the ICU nurses take me aside and ask me to put in the lines because they really need access and they’re not that confident that the family medicine and internal medicine residents on call are up to the task of getting them in quickly.

ICU nurses like Emergency Medicine residents because we like to aggressively manage patients and are not afraid of procedures. They don’t like sitting on a dangerously unstable patient with only tenuous peripheral access and a shoddy airway. It makes their already difficult job even more difficult.

Trauma for Emergency Medicine is easy and somewhat over-rated (uh, once you get the hang of it, I mean). It’s just ATLS and that’s about it. Besides, if it’s serious there is nothing to manage as they are quickly taken to the operating room where they become surgery patients. They do not come back to the Emergency Department. The exit is one-way only.

The critical skills (other than not losing your cool) in trauma are managing the airway, recognizing the causes of your patients respiratory and hemodynamic instability, and correcting them. So if you know your ABCs, the skills you need are intubation, needle decompression, chest tube, FAST exam, pericaridocentesis, and central venous access. That will cover you for 99 percent of what you see and then the patient will go to the OR or the morgue.
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We rotate on the trauma service, by the way.
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One of my favorite television programs is “Trauma: Life in the ER.” But to be fair the show should be called “Trauma: Life in the ER as a Trauma Sugery Resident” as that’s who they are usually following. Emergency medicine, except at the big urban war zones, is not really that trauma-intensive. Everybody likes a really goopy gore-fest of course (we’re only human) but most Emergency Medicine residents will see many, many more massive GI bleeds than they will gunshot wounds. Panda’s Axiom Number Two: Blood coming out of a hole in the chest is cool. Out of the rectum not so much.

And a massive upper-GI bleed of which I have seen two in the last week is a lot more unsettling than most traumas.

Emergency Medicine Residency (Part 1.5: Answering an Important Reader Question)

Emergency Medicine Residency (Part 1)

(The following article is directed primarily at those contemplating matching into Emergency Medicine. Those of you who are not may read it but I make no apologies for targeting a particular group of readers. Emergency Medicine has become a very popular specialty lately so I’m sure there is some interest out there. Most of my patients, by the way, even those who know how physicians are trained, don’t know that Emergency Medicine is a specialty. The more chatty ones often ask me what specialty I am going into. Even many of my relatives, and they should know better because I do talk to them now and then, think that Emergency Medicine is something doctors do when they can’t decide on a specialty or if they aren’t smart enough to do anything else.

I am at a small, community program as opposed to a major urban trauma center so our patient mix leans more towards the medical and not surgical/trauma. Not to say that we don’t see some trauma but it’s usually blunt trauma and not penetrating. In other words, I’m just giving you my own perspective. I shouldn’t have to issue any caveats but invariably I’m going to get a ton of irate emails insisting that they do things differently at their program.-PB)

Speed

Emergency Medicine is a specialty of speed. Everything needs to be done not only quickly but with an economy of effort that separates the important things about the patient from those that are interesting but not particularly relevant. Victory is declared when the patient has a quick disposition; either treated and sent home, transfered, or admitted to the hospital. Ultimate victory occurs when the patient actually leaves the department. Take for example the typical suicidal patient who has made a lame, self-centered gesture at self-termination. In medical school you are conditioned to explore this kind patient in incredible detail. Consequently, as a new resident your first instinct is to get a detailed psychiatric history, delving deeply into the mileu of the patient’s life to assess his motivations. In reality however, your meaningful discussion with the patient is useless and is only going to delay his final disposition. You know he is going to be involuntarily committed and the sooner he can get somewhere, anywhere, where he can be evaluated by a skilled psychiatrist the better. It’s the psychiatrist’s job to do this kind of thing and he can run circles around you and your rudimentary knowledge of his field. Not only that but as the patient flaps his gums and you pretend to be interested you are falling way, way behind on the eight or nine patients you are working up.

The relevant questions then become, “Did you try to kill yourself, how many pills and of what type did you take, and what do I have to do and what tests need to be ordered to quickly medically clear you for a transfer to an appropriate mental health facility?” The patient usually wants to spill his guts (and if he doesn’t the parents or the loved ones are happy to oblige) but while it is important to be polite, we don’t have the time to hear how you were mistreated as a child. All I want to know is your acetaminophen level and whether it is rising or falling. Not toxic and decreasing? Nice meeting you. I hope you like mushy food and communal televsion. It’s been real. Buh bye.

The idea is to get a disposition. Since we don’t treat long-term psychiatric problems in our Emergency Departement, there is no point in wasting effort. It’s best just to get them out of the department. On the other hand we do treat a variety of medical complaints and on these you need to use the traditonal physician skills of history, physical exam, assessment, and plan. But relatively quickly. It’s a little more complicated than just differentiating lethal from non-lethal complaints but you need to ellicit a chief complaint and tailor your history and physical exam to expose it. Obviously the history should be the longest component of your encounter but even there you can get carried away. I once found myself sitting at a the computer sifting through a patient’s records trying to determine the dates of his seven heart caths at which point I realized that I was eating up time, I wasn’t a medicine resident, and maybe all I really needed was the date of his last heart cath and an old EKG or two to see if anything had changed.

“History of Coronary artery disease with seven stents, last on 2/5/06″ is perfectly servicable for the purposes of emergency medicine. If we need more detail we can always get it. You cannot do a six-page medicine-style History and Physical on every patient, even the really sick ones. The typical EM physician works on around four patients per hour so you see how this would be prohibitively costly in time. It is true that some patients present with relatively minor complaints but there is a certain baseline level of paperwork involved with every patient independent of the acuity level.

So you need to be quick and that is one of the skills our attendings try to develop in us. This does not mean, however, that you cut corners. You just need to learn what corners to avoid. Being able to juggle a lot of things at one time is also an essential skill. Every resident in every specialty has to do this to a certain extent but what other residents consider a hectic day is just another routine shift for us. That’s the beauty and the curse of Emergency Medicine. The hours are good. Fantastic for residents even by regular job standards. Now that I am working full-time in the department I rarely go over fifty hours a week and some weeks I barely go over forty. The tradeoff is that we work very hard when we are working. There is seldom time to sit down and there is also no such thing as a break. As long as there are charts in the rack (new patients to be seen, I mean) you have work to do. There are always charts in the rack. There’s a crisis out there or didn’t you get the memo?

Emergency medicine isn’t the hardest job in America, not by a long shot, but I think we have one of the few jobs in the developed world where you can get to the end of a twelve-hour day and realize that you haven’t sat down, had anything to drink, or urinated since before you came on. I know that surgery and medicine residents put in more hours and I have nothing but respect for them but being at the hospital is not the same thing as actually working. In fact, many of the residents in the time-intensive specialties spend a good deal of their time sitting around bitching about how tough they have it which is something that Emergency Medicine residents never have time to do. We’re too busy. We complain of course, but not about staying at the hospital for no reason after our work is done. There is always a reason for us to be there when we are at work; they call it the waiting room. We come to work expecting to work.

But we do get to go home. At first I didn’t believe it was possible but now I am begining to accept the fact that nobody expects us to hang around after out shift is over. Sure, we have to tie up loose ends and ensure that our more complicated patients have a disposition but nobody ever says, “Hey, why don’t you stick around an extra four or five hours in case we get busy.”

My point? If you believe that you’d like Emergency Medicine because you don’t have to work hard you are going to be disappointed. If you like to work hard but also like to have regular hours and a predictable schedule with some time off to think about other things, you are going to be very happy as an Emergency Medicine resident. But thinking of Emergency Medicine as a “lifesyle” residency as is common among medical students contemplating specialty choices would be a mistake. It’s only a lifestyle specialty if you like that kind of lifestyle.

(Next: A Typical Shift For a Typical Resident)

Emergency Medicine Residency (Part 1)

Twenty Questions (More or Less) for Dr. Bear (Part the Fourth and Last)

Hey Dr. Bear, what do you really think about Physician Assistants and other mid-level practioners?

Nothing. Why should I? They have their job and and I have mine. The real question that most insecure medical students want answered is this: Is the training required for a physician too extensive and are a couple years of Physician Assistant school out of which all of the “useless stuff” is filtered all that is really necessary? In other words,”Am I wasting my time and enduring all of this crap for nothing?”

This is a ridiculous question, the ridiculousness of which may not be apparent to you when you first start medical school but which will eventually come into sharper focus as you advance through your training.
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Consider the typical medical student. Even late in his clinical years, he is conditioned to respect just about anyone in the hospital who looks like they know what they’re doing. It’s the nature of medical training; there is so much to learn that he never quite feels as if he has a handle on anything. Enter the Physician Assistant or Nurse Practioner confidently striding around in his long white coat effortlessly working at the job to which he has become habituated. That it may be a limited job never enters the medical student’s head because on any particular rotation, the Physician Assistant knows what to do, knows what the attending wants, and knows how to wrangle the all-important paperwork. In other words, he’s running circles around the medical student in his one area of expertise.

Not to mention that medical students are a fed a steady stream of both propaganda and sedition. On one hand they hear the litany from mid-levels that the equivalent of four years of medical school and three to seven years of residency can be crammed into a two-year program. On the other hand they are surrounded by dark whispers from fellow students that most of what they have learned is of no practical value. A medical student might start to buy into the notion that a physician is nothing more than a technician who checks some boxes and that there is really nothing more to it than a few practical skills and some basic medical knowledge.

On starting as an intern, your perspective is even more skewed. It’s the nature of intern year. A Physician Assistant completes his two-years-or-so of training and arrives fully-formed to the medical world ready to earn a decent salary at the specialty upon which he has decided. Sure, there is some on-the-job-training required but it is not nearly the same thing as a rigorous period of residency training. As an intern however, you are usually barely half-finished with your medical training and while the midlevel may not be as well trained or knowledgeable, he is fully trained for the responsibilities of his job. You however, are without a doubt almost completely unsuited for yours.
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Not to mention that interns are almost universely mistreated while Physician Assistants, as they can bloody well quit and go work for someone else, are not. Heck, even the phlebotomist must feel like a highly-trained medical professional compared to the bran-new cadre of scared interns who arrive every July. If you yell at a phlebotomist you can get fired. Yell at an intern on the other hand, and various cronies of the old-school will pump their fists, give each other high-fives, and applaud your hard-line approach to medical training.

So it’s a matter of perspective. As you know, I did two intern years and like most doctors training in the generalist specialties (Internal Medicine, Family Medicine, Pediatrics, and Emergency Medicine), each year was a hodge-podge of wildly diverse rotations. General surgery on one month, Obstetrics the next, followed closely by an inpatient pediatric rotation and a medicine month or two. To be precise, last year I did two months in the ICU, one month of trauma surgery, one month of cardiology, one month of pulmonary, one month in the pediatric ICU, one general medicine month, a smattering of orthopaedics, two weeks of oralmaxillofacial surgery (dental blocks, very important), a month of labor and delivery and two months in the Emergency Department. The year before included three months of pediatrics. Like I said, a hodge-podge. You show up every month and no sooner do you start to get the hang of things when you start all over again on a new rotation.
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My wife, as a matter of fact, correctly diagnosed the source of most of my stress during my first intern year, namely the constant cycle of ignorance that begins every month. The cure, paraphrasing my wife (but only a little): just say “fuck it” and if you don’t know how they fill out their paperwork on a new rotation that’s their problem, not yours.

So you see my friends, if you are a Physician Assistant working with the pulmonologists, it is not very difficult to get a handle on the routine sort of things that go on. Not only are you fairly intelligent to begin with but you know the lingo and the general idea of what you are doing. Enter the new intern who doesn’t even know how to find the parking garage and it is easy for both of you to be deceived as to each other’s capabilities.

Now, are there mid-levels who are smarter than physicians? Of course there are. And there are mid-level providors who, by dint of independent study and natural ability, are better physicians than real physicians. But that’s just life on the old bell curve upon whose difficult slopes each of us finds the pasture to which we are suited. There is probably a lot of overlap between midlevels and physicians on the south side of their respective bell curves. On the north side, not so much.

By the time you get a couple of years of residency under your belt your perspective will change yet again and you will start to feel a lot more comfortable in your medical skin. This is not to say that you are going to become arrogant. It is impossible (well, almost) for a resident to be truly arrogant, especially as our entire job seems to involve being corrected or trying to win approval. But eventually you get the hang of the mundane things and start to notice that you know what to do and to whom to do it. There is a purpose to residency training and medical school after all. I won’t strain my credibility by insisting that everything we learn is necessary and useful but I would cut out a lot less than most of you might imagine.

What Are You Reading Nowadays?

Pudd’nhead Wilson by Mark Twain. The First World War by Martin Gilbert. Just finished Our Mutual Friend by Charles Dickens.

Now Charles Dickens, he could write. The opening paragraph of Bleak House, for example, is one of the most masterful pieces of prose in English literature. I have read almost everything Dickens ever wrote and I have been deeply influenced by both his style and his talent for intricately constructed descriptions of just about anything to which he set his mind.

No, I don’t read crap.

And I don’t read medical novels. I have never read the House of God, the one about the Hmong (whatever it’s called), or any of the other must-reads. I get enough of that sort of thing at work.
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Any Hobbies?

Not really. Just my blog. Can’t afford too much else. My older son and I love Star Wars legos and we build them whenever we can scrape together some money for a set. I used to own a lot of assault rifles but my arsenal has dwindled as of late. Money, you understand.

My dogs, of course; Zoe, Penelope, Daphne, Hector, and Persephone, my faithful black lab.

Twenty Questions (More or Less) for Dr. Bear (Part the Fourth and Last)

Twenty Questions for Dr. Bear (Part the Third In Which I Say Something Nice About France)

Hey Dr. Bear, you are something of a critic of the “old school.” What was wrong with the way doctors were trained in the past and why should we change things if the old ways have worked so well?

When I was a structural engineer, I had an old-school boss who had never quite made the philosophical jump into the computer era. Oh sure, he accepted that computers were essential to the business of engineering but he obviously longed for the Good Old Days when engineers made all their calcuations with a pencil and a slide rule. He often made us check our calculations by hand and barely tolerated the use of a calculator for this purpose. His contention was that engineers were better trained and more capable in the old days and that hand calculations gave one a better feel for the meaning of numbers. The Chrysler Building, he often pointed out, was built in a time when computers were unheard of and all the engineers had were their trusty slide rules and their tables of logarithms.

There is no doubt that the engineering profession is built upon the broad foundations laid by engineers of the past. Nor is there any doubt that a healthy respect for their accomplishments and a knowledge of the basic principles that they formulated is necessary for the education of an engineer. But the engineering profession has moved forward and while respect is necessary, mawkishly worshiping the old ways is impractical and counterproductive. Not only do we know more but new methods of design and analysis have made many of the old methods obsolete. Not to mention that certain economic realities dictate that we can no longer spend a day setting up the math to solve an engineering problem when we can have the result in five minutes using any number of structural analysis and design software packages.

That’s just the way things are. My boss used to insist that if we ever lost electrical power or found ourselves on a deserted island all of us new guys were screwed. The obvious flaw in that threat is that we’re not exactly going to be doing sophisticated engineering while waiting for rescue and if the apocalypse should come, we will be too busy scrounging canned goods and fighting flesh eating mutants to even think about breaking out the slide rule.

Now consider the practice of medicine, another profession which is supported on the broad shoulders of the past. Medicine underwent a revolution starting in the late nineteen-sixties going from a sedate, contemplative profession built on slowly acquired experience to the fast-paced goat-rodeo-cum-chinese-fire-drill it is today; a profession where there is barely time to examine a patient before he is fed into the patient processing plant which most hopitals have become. It is a fine thing to long for the Good Old Days when doctors spun their own urine (whatever that is) and did their own peripheral smears but those days are gone and, to paraphrase The Boss, they ain’t coming back. Likewise, our antiquated system of residency training, as it is was designed for the slow-paced hospitals of the past, is a poor fit for the way medicine is practiced today. In the old days, when patients were usually long-term boarders for whom nothing could really be done, a certain amount of leisure time was built into the system. This leisure time was filled with rounds, grand rounds, conferences, more rounds, spinning urine, making slides, lovingly writing extensive notes, and hour-long physical exams. Now that medicine has become something of a grind, while you could take thirty minutes for a detailed neurological exam to isolate a lesion to the left posterior globus palidus, you can instead send the patient for a CT and save yourself the carfare.

Which is what happens. You can no more practice medicine today like an old country doctor than you can design a skyscraper with a pencil and a slide rule.

What is the biggest problem facing American Medicine?

Let me tell you a story. The other day I had a patient who came to the Emergency Department in the early hours of the morning with a chief complaint of constipation for twelve hours and the subjective sensation of a “turd stuck up there.” “Surely there must be more to this complaint,” I thought to myself and launched into a careful history and physical exam to ellicit something, anything, that might kill the patient or cause him serious morbidity. Nothing. Zero. No abdominal pain. Passing gas. No vomitting or nausea. Appetite good. Abdomen non-tender. No fever. No nothing. There wasn’t even any stool in the vault when I finally did a digital rectal exam in the forlorn hope of finding blood, a mass, or just about anything to rekindle my faith in the basic intelligence of our patients.

Finally, more than a little annoyed I asked the patient what, exactly, he expected me to do for him.
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“I need help taking a crap,” he said as he settled back into his bed.

I gave him a lecture on fiber, told him how to access his local Wal Mart, and sent him on his way.

In a perfect world, this patient wouldn’t have even got through the door. He would have been stopped cold by the triage nurse, rejected at the net, so to speak. I have no doubt that if this same patient had presented to an Emergency Department in France, he would have been subjected to the full brunt of Gallic derision. In the United States, the complete lack of common sense, a trait that has been beaten out of the medical profession by the depredations of the legal profession, ensures that this patient and many like him tie up Emergency Department beds and suck up finite medical resources, principal among these being the time of the physician and the nurse.

It’s not that one patient really has that much of an effect. We have the beds, after all, and the worst that happens is that others who are not acutely ill have to wait. But the over-utilization of the Emergency Department by patients who are not actually sick or have no discernable medical problems for which we can provide treatment forces us to maintain an expensive infrastructure many times the size of what would be required if we limited our attentions to patients with legitimate medical problems.

The consequences of ignoring common sense extend into all areas of medicine. Everything is not a medical problem, even things that are medical problems if you can get your mind around this concept. Knee pain, for example, that is the result of weighing 500 pounds cannot possibly be treated by a Family Physicians, an Orthopaedic Surgeon, an Internist, or an Emergency Medicine Physician. When you weigh a quarter of a ton you are just going to have knee pain. It is, however, the fear of being sued on one hand and the desire for a steady stream of paying customers on the other, that keeps the clinics and emergency departments full. Job security, no doubt, but I’d rather work in a rational system based on common sense than have that kind of artificial job security.

What do I think is the percentage of my patients who have no business getting through triage? It’s hard to say. We see our share of serious medical problems and the acutely ill. But thirty percent would not be an outrageous estimate. If you had a bad payer mix, that is, a high portion of uninsured patients, it would probably be cost-effective to have a physician, and not just any physician but the most experienced one in the department, running triage to quickly winnow the wheat from the chaff, the drug-seeking back pain from the aortic dissection, and the menstrual cramps from the ectopic pregnancy.

So it is the profound lack of common sense that is the biggest problem facing American Medicine. The effects of this lack of common sense, trying to practice zero-defect medicine among a terrifically unhealthy, mostly non-compliant, and litigation-happy patient population are legion and spread their costs and inefficiencies throughout the system. What is most paper-work, after all, other than an attempt to fend off predatory lawyers and their mostly ridiculous lawsuits? There’s a doctor shortage, apparently, but I notice that I spend more time on the patient’s paperwork than I do on the patient and as most of this contributes nothing to his care, imagine how many more patients could be seen or how much more time I could spend with a single patient if we somehow could kill all of the lawyers.

Not to mention the cost of unnecessary tests and treatments undertaken because the wages of intelligent inaction are ruinous while juries, as they are composed largely of people who can take two weeks off pretty much whenever they want, smile favorably on the physician who does something, anything, even if is pointless.

What’s the most ridiculous thing about your job?

Patient satisfaction surveys. Totally meaningless and generally not worth the price of printing them, especially in Emergency Medicine where the patient may rate his visit on the availibility of parking, the alacrity with which the nurse brought him a pillow, and anything other than the quality of his medical care. We saved his life but had to cut off his expensive jeans and it just left a bad taste in his mouth.

Consider a recent patient of mine who presented with diabetic ketoacidosis secondary to not taking her insulin as the price of it seriously ate into her crack cocaine money. We did the usual things, caring for her no differently than if she were our sister and after an hour or so of being grateful, she started to feel better and the complaints and abuse began. I have no doubt that upon her discharge, this polybabydadic mother of six, all in foster care, with no means and no intention of paying a dime for her medical care was presented a patient satisfaction survey courtesy of that modern devil, Press Ganey, and asked to rate her hospital experience. Now, why we should care about the opinion of a non-paying customer who is otherwise habitually to be found turning tricks in parked cars or passed-out drunk in an alley somewhere in the seedy side of town escapes me. What is she going to write that could possibly be of use?

“I’d like to see a better variety of free samiches.”

“More dilaudid, please.”

And yet I have no doubt that each of her complaints would be taken seriously by the shadow bureaucracy that exists to bedevil doctors and nurses. The ridiculous thing is the insistence that medicine is a customer-service business like any other when it is most certainly not. It is nothing like a business. First of all, the customer is not, repeat not, always right. We do not tailor our treatment to fit the patient’s expectations, rather they come to us with a medical problem and we tell them, whether it bothers them or not, what must be done to correct it.

There is also no such thing as a customer in the traditional sense. Most of my patients don’t pay a dime for their visit and don’t expect to either. Asking for their opinion is like asking a shoplifer what he thinks about the decor or the new security arrangements. Even those with that gigantic ponzi scheme otherwise known as health insurance have no idea how much things cost, don’t care anyways, and feel entitled to as much of the health care pie as they can stomach. If there was really a health care crisis, a crisis that is threatening to swamp the system, you’d think we would be trying to discourage customers, not encourage them.

You know, like how MacDonalds has uncomfortable seating to discourage loitering.

Twenty Questions for Dr. Bear (Part the Third In Which I Say Something Nice About France)

Twenty Questions for Dr. Bear (Part the Second)

Any advice for aspiring medical students?

Not much. Everybody is going to have a different experience in medical school depending on their expectations, their past experiences, and their willingness to modify their ideals to conform to the realities on the ground. I’m trying to get away from giving advice in favor of relating some of my experiences and opinions and letting the reader make of them what he will.

But I guess the basics are the most important, that is, to study hard, keep your eyes and ears open, and try not to get so caught up in what is, once you strip away the self-congratualtion, just a somewhat difficult professional school. Medical school doesn’t have to consume you and it is possible to have other interests. This is not to say that there won’t be periods when you will have time for nothing else but you do get to go home. The subject matter is very interesting but it ain’t that interesting all of the time. If it was more people would show up to embryology lectures.

I’d also like to add that, if you consider that most medical students do not work while in school and that you can skip what are generally useless lectures at will, with a good course syllabus there should be ample time to both study and master the material. I was not the best student being something of a slacker (and I should have studied a lot harder) but I comfortably passed everything. There is time enough in the day. With a little self-discipline you should have a low-stress first and second year and still make good grades.
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In other words, keep up with your studies and you can avoid the desperate all-night study groups that blossom like nervous flowers, the tattered petals of highlighted index cards strewn over the tables in the library, as your disheveled peers try to cram a few weeks of material into a frantic string of all-nighters. I never could pull all-nighters. I lack the stamina and, as I may have mentioned once or twice, mightily dislike going without sleep.

But do what works. I’m just suggesting that there is no need to panic like many of you new first years are probably doing right now. Don’t sweat it. Keep plugging away. It is going to get easier and by the middle of second year you are going to be able to cover three times as much material in a third of the time and laugh, yes laugh, that some punk-ass biochemistry course ever intimidated you.

What’s the biggest shock for many medical students?

Not being as smart as you think you are. Let’s face it, most of you have until now been at the top of your class in high school and college. You’ve studied hard and received both excellent grades and frequent validation that your hard work and discipline has set you apart from the lumbering proles who go to college for the chicks and the parties. It’s not as if you become stupid on the day you matriculate into medical school but, as everything is relative, on that day you will find yourself surrounded by a hundred other highly intelligent people getting hosed down with a tremendous volume of information, wondering if you are going to be able to keep up. And you will look around and see your peers apparently effortlessly mastering the material while you desperately struggle for a barely passing grade on the first test. That first “72″ chills your spine, especially if you are used to “high honors.”

When I was in college, I had to take a ridiculously easy Art Appreciation course to sastisfy the distribution requirements for my major. Easy as it was, I was surrounded by students who were really sweating it including a couple of guys in the back regularly formulating cheating schemes whereby they could scrape by with a “D.” Many of you will feel like those guys after the first exam.

Traditional Lecture or Problem Based Learning?

Traditional lecture. No question about it. If you are accepted into more than one medical school and can pick between a lecture-based curriculum or Problem Based Learning, flee as if from the Devil himself the PBL school.

For those of you who don’t know, Problem Based Learning is a fancy word for “Seminars.” Instead of sitting in a traditional lecture following a rational plan of study, you will be divided into small groups and, under the supervision of a faculty member, teach youself the material through the highly inefficient process of self-discovery. It sounds good on paper and the medical schools that have embraced it will try to sell it as if it were going to replace sliced bread. In practice however, it can be a nightmarish voyage into a sea of ignorance on a ship full of clueless people who all want to be captain.

Problem-based learning is an admission by medical schools that most of first and second year is self-study. Instead of following this admission to its logical conclusion, that people should study on their own, Problem Based Learning was devised to justify both freeing up faculty to concentrate on their real interests and to not provide lectures while still collecting tuition. If you look at it like that it almost makes sense because otherwise you would have to believe that many highly intelligent people devised an intricate solution to a non-existent problem.

The fierce partisans of PBL (who make Mac users seem tolerant by comparison) will sneer at the traditonal lecture curriculum which they say “spoon feeds” the student. The implication is that those of us who prefer lectures to seminars are a bunch of big fucking babies. Maybe lecture is “spoon feeding” but Problem Based Learning is like throwing the jars of baby food at the baby and laughing as he struggles to open them. Actually, I don’t accept the metaphor. Like I said, it’s all self-study. Many people don’t even go to lecture but study efficiently on their own which is hardly spoon-feeding. The difference is that a lecture curriculum has a rational plan, starting with the basics and working up to more complex topics which is the ideal model for a curriculum. Why this isn’t obvious only shows that the faculty at many medical schools have mutated to a level of intelligence where their giant brains have crowded out the common sense lobe.

What’s the bottom line? Studying in a group is highly inefficient, often highly annoying, and puts you firmly on somebody else’s schedule for a significant portion of the day. Instead of just studying you are asked to become an active participant in someone else’s group dynamic masturbatory fantasy. My medical school dabbled in Problem Based Learning and by the end of a typical three hour group session I was ready to shoot myself in the head.

I cannot say enough bad things about Problem Based Learning. Almost everybody despises it.
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Podunk or Top Tier?

I am immensely grateful to those who pursue careers in academic medicine, careers that advance the science of medicine and train future physicians, and I am second to none in admiration for the most excellent faculty at my program. With that being said, I have no desire to teach, conduct research, or to become involved with academics once I finish my training. Neither do most physicians for that matter. So with this in mind, what really is the difference between going to your inexpensive, relatively unknown state medical school and a major academic powerhouse?

Not much if you just want to practice clinical medicine. I’m not discounting the value of prestige however. If you want to do a cardiology fellowship at Harvard a medical degree from Yale and a residency at Duke will put you way ahead of some rube coming out of the medical sticks. On the other hand, I rotate at a hospital that most of you have never heard of and probably couldn’t find on a map but it has a cardiology program that turns out first rate cardiologists who have no trouble finding jobs or patients. You just have to know what you want and what you are paying for it. All other things being equal, the more prestigious the program the worse the medical students and residents are treated and the more time you will spend as somebody’s entourage. Consider carefully then your choice. If you know that you want to work at medicine like a regular job it makes no difference where you go and location and lifestyle should trump all other considerations (except for Problem Based Learing).

In the end, it just comes down to what the t-shirt is worth.

Like any rotations?

Sure. I like working in the ICU. I didn’t always, of course, as the ICU is probably the most intimidating rotation for medical students and interns. The patients there are horrifically, almost obscenely, sick and the comforting medical paradigms on which you rely seem to be turned on their heads. This is not, for example, a rotation where you can usually have a polite conversation with the patient and explore, in perfect order, the history and the review of systems. In the ICU the patients often come in with nothing but a vague transfer note and an incomplete list of medications. They can’t talk and there is not always a family member to fill you in on the patient as they head south before your eyes, possibly for the last time.

It is a rotation where you have to do something big, and soon, for most of your patients and this kind of decisiveness is something that doesn’t come naturally. You have to learn, in short, to be the kind of doctor that goes into the patient’s room when something goes wrong, not the kind who leaves the room to get help. Emergency medicine residents tend to like their ICU rotations because this kind of thing is right up our alley. In turn our ICU nurses apparently really like to have the Emergency Medicine residents rotating because we’re not afraid to make decisions and don’t have to call a synod of attendings and residents to do a lumbar puncture or intubate.

How do you feel about pharmaceutical sales reps?

I’m working on an article about pharmaceutical reps. The short answer is that I don’t take gifts from them, don’t need their crappy pens, and as I eat for free at my program don’t need to eat their lunches even if I wanted to (which I don’t). Part of my antipathy is my dislike for bad salesmen which most drug reps are. Give me a good salesman selling a good product in which he believes and with him will I gladly do business. Drug reps however, tend to be smarmy glad-handers peddling products which they do not understand using questionable statistics and glitzy marketing. It’s embarrassing and I cringe to watch a typical drug rep present his little spiel before a noon conference to which he has provided food.
(To be continued…)

Twenty Questions for Dr. Bear (Part the Second)

Twenty Questions for Dr. Bear (Part the First)

Hey Dr. Panda. I also have a family. My wife and I are raising young children and the cost of day care will eat up a big chunk of my wife’s take-home pay if she gets a job. How are we going to make ends meet during medical school and residency?

You’re not, at least not in the classical sense of balancing income to expenditures. The short answer is that you will have to borrow buckets of money, deplete any and all assets you had before medical school, ask for money from your parents, and eventually, after exhausting every other source of credit, perfect the fine art of shifting credit-card balances from one low interest card to another. If you’re lucky the end of your residency will come before Peter realizes he’s being robbed to pay Paul. This will worry you at first, and it still worries me, but one day you will get used to the wolves prowling outside the door and you will accept this as the normal order of things.

You can economize a little, of course, but the kind of money we’re talking about is impervious to your decision to substitute Hamburger Helper for chuck steak. Naturally you will have to tighten you belt but the hit your lifestyle will take depends on what kind of disposable income and leisure activities you have now. You can, for example, kiss expensive vacations, personal watercraft, consumer electronics, and an overtly materialistic lifestyle good-bye. Pehaps this is a good thing but I’d rather live frugaly because I want to, not because I have to.

The trick is to either consolidate or defer your loans during residency to make either a low payment or no payment at all. Another advantage of consolidating is that you can lock your loans in at a very low interest rate. It’s hard enough to live on a resident’s salary without also trying to service your debt.
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Why do you dislike drug-seekers? It’s not like you’re paying for the drugs and at the very worst you can send them home empty-handed.

Every patient involves a certain amount of paperwork. Generally speaking, the paperwork for a drug-seeker takes just as long as the paperwork for a patient with a legitimate complaint. It’s not as if we can just give the addict some vicodin and send him on his way. Very few of them present with a complaint of “I’m out of drugs and I need a fix.” It’s usually chest pain, abdominal pain, or back pain of some sort and even if you know in the deepest pit of you soul that the complaint is bogus, you still have to go through the motions. Even drug seekers occasionally have legitimate health problems and nobody wants to be the guy who dismissed back pain that turned out to be a dissecting aortic aneurysm. So you see, drug seekers impose a certain burden of unnecessary labor on the whole department. For my part this takes the form of unnecessary paperwork and a significant slice of time I could devote to patients who are really sick.

Not to mention that decent people, and most of us are fairly decent people, naturally recoil from dishonesty. Not only is the drug seeker deliberately lying but he is also scheming to turn us into his pusher, a position that most of us do not relish. I once had a drug seeker accuse me of taking pleasure in exercising my medical power to deny him drugs. In fact, I would rather he went to some other emergency department.

The other kind of patient I dislike are the ones with suicidal ideation. Oh sure, I like treating the ones who made a serious attempt but were foiled by circumstances beyound their control but the ones who made a pathetic gesture of one kind or another without any serious thought of really harming themselves really drive me up the wall. First because, as I mentioned before, they suck up just as much administrative time as a patient with a legitimate complaint and second, because most of them claim suicidal thoughts as a means of garnering attention we play right into their hands, enabling the very attention-seeking behavior that we would do better to dissuade. In a perfect world, we’d toss ‘em out and say, “Hey, come back when you can execute a better plan than taking a couple of extra valium because yer’ stinking boyfriend doesn’t want to cuddle.”

But the little girls who take a whole bottle of tylenol are sad. It will kill your liver, you know, something that nobody seems to realize and is not, repeat not, a good gesture drug. You might actually succeed in killing yourself but not before you have time to realize that some coolio sleeping with your best friend is so not worth it.

What’s the biggest misconception among medical students?

Wow. There are so many. Two of the biggest misconceptions are that pre-clinical grades don’t matter and its corollary, that people who do well in the first two years of medical school don’t do so well during the clinical years. First of all, for the purposes of remaining competitive for the match, every single grade you get matters. Sure, you may be at a school that doesn’t give traditional grades but nobody has yet explained to me how an “honors,” “high pass,” and “pass” is fundamentally different from an “A,” “B,” or a “C.” Somewhere, somehow, your the Dean of Students is keeping track of your standing relative to your peers and overtly or covertly, your Dean’s letter is going to spell out your class rank. Good luck matching into Radiology (or some other competitive specialty on which you had set your heart) from the bottom of the class. It’s not that it can’t be done, it’s just that even some people with good grades and good board scores don’t match into the competitive specialties. Why hobble yourself right out of the starting gate?

As for people who do well during the first two years of medical school not doing well during the clinical years, this is an urban myth. You know, like the one about Physician Assistant school being able to cram just as much into their two years of training as medical students do into their four years. Generally, people who do well in the first two years do equally well during the second two years and there is no inherent contradiction in doing so. Most medical students, as they are drawn from the ranks of people who did nothing but study during high school and college, lack the mythical people skills and common sense that are supposed to trump book learning so it’s going to be a wash. You will see that the folks who limped along during the first two years perpetually in danger of dismissal will limp along during the clinical year, passing their shelf exams by the narrowest of margins and sweating every rotation.

Another misconception? That medical school will last forever. Now I know, oh you who have just now suffered through you first exam and are still licking your wounds, that four years can seem like an eternity but after you get the hang of it, let’s say around Christmas of your first year, the time will slip by and before you know it you will be staring Step 1 in the face. And no sooner will you have gotten over your initial shyness on the wards when you will be listening to the graduation speakers and realizing that your days of shirking responsibility are over. Nervous first year medical student to nervous intern in the blink of an eye.

Trust me on this.

Would you do it all over again?

Har har. Not a fair question. I’m almost done with residency (21 months to go) and I can see that it will end soon. Medical training has certainly been nothing like I expected. Harder in some ways and easier in other ways. I never thought, for example, that missing sleep would bother me so much. Who, after all, has not stayed up late occasionally and been tired the next morning. The difference in medical training is that there is no respite. You can get tired but, through some freak of scheduling, still have to work four more twelve hour shifts in a row which, I can assure you, will wear you out. Or imagine you have a Friday-Sunday call weekend and you are not able to get a good night’s sleep on Saturday night. You can’t count on getting any rest until Monday afternoon and you’re just going to have to suck it up.

Eventually you build up a sleep deficit that seems to take more than a good night’s sleep to erase. Not to mention that your schedule will be so irregular that your sleep hygeine, the patterns and habits of how you sleep, will be severely dysfunctional. I worked for years as an engineer waking up at seven, working nine or ten hours, and getting to bed by eleven every night. And I got most weekends and many holidays completely off. I was never tired except anecdotally. By contrast, I seem to be perpetually tired nowadays and my sleep hygiene blows. I can never seem to get a good night’s (or day’s) sleep with any consistency. It’s not working shifts so much as it’s the myriad conferences and mandatory residency activities that always seem to be scheduled on either a day off or for a morning when I could otherwise sleep late.

So that was something I didn’t expect even though I am resigned to it. Working shifts, however, has been a tremendous improvment over pulling Q4 call, something I had been doing for the most of the previous two years.

The “Tired Years,” as I like to call them.

(To Be Continued…)

Twenty Questions for Dr. Bear (Part the First)