Poodle Circus and Other Things (Real Questions From Real Readers)

You seem a little less bitter about residency.  How are things going?

Fine, thanks for asking.  I haven’t had call in about five months and I am gradually starting to forget all about it.  Sleep deprivation has always been my biggest complaint about residency and now that I am getting regular sleep I am pleased to report that I am feeling much better most of the time.  We do not have call in Emergency Medicine and, what’s better, we have a predictable schedule with shifts and conferences clearly layed out.  Oh, I still get tired. Of course I do.  Conferences always seem to fall on a day off or when I am getting off of long night shift and we do in fact work pretty hard. I don’t think there will ever be a resident who isn’t tired most of the time except maybe one of those lazy bastards in Physical Medicine and Rehabilitation.

Not to mention that I feel a lot better about things now that I am actually training for my job.  This is not to say that off-service rotations are not important.  Of course they are.  It’s just that on many rotations the teaching is at a minimum while the work is at a maximum.  There is something to be said for requiring residents to “figure it out themselves” but, and if I’m going way out on a limb here I apologize, doesn’t that sort of defeat the purpose of education?  In other words, if every time I ask an attending a question she snarls and looks at me contemptuously for having the unmitigated gall to not be an expert in a field that I have been exposed to for one week compared to her having studied it for twenty years, well, what’s the point of the rotation?    Whether I can look it up myself is besides the point and my asking for information is not the same thing as being spoon-fed.  I realize that the crusty old-timers are going to snarl and opine that, after crawling to the hospital though snow and broken glass, they had absolutely no supervision and learned it all on their own so I apologize for not being such a fine specimen of prehistoric medical animal.

Medicine is one of the few professions where superior knowledge breeds hostility.  As a Marine infantryman, for example, we never castigated the new guys fresh out of the Infantry Training School for not knowing how we did things in the fleet.  Rule number one is to never bully your subordinates.  You have them at an unfair disadvantage, in the Marines its the Uniform Code of Military Justice, in residency it’s the reluctance of a resident to do anything other than suck it up for fear of being fired.   Either way it reflects poorly on a leader who doesn’t have the empathy to realize this.

Because of the nature of Emergency Medicine residency training we tend to work fairly closely with our attendings for the whole shift.  My program has exceptional attendings all of whom take the time to teach, taking into account of course that we are always extremely busy.  So now that I am being taught the profession instead of just being used as cheap labor to cover call, I naturally feel much better about things.

I assure you however that I occasionally get demoralized and some might even say depressed.  That also seems to be the nature of residency.  You can have a string of good days where you do everything right and feel like you have a pretty good grasp on things only to have a couple of bad shifts, or even a couple of bad patients, where you so obviously show your ignorance and unsuitability for the medical profession that you dread going in for the next shift.  I have had a few shifts like that this week and I am feeling kind of beat down, if you know what I mean.

This is why I laugh at all of the lay people who email me or post snarky comments accusing doctors of being arrogant or having some kind of God complex.  There may be some physicians who have it all figured out to the extent that they always know what to do and never make a mistake but I assure you this is not me and, from discussions with my friends, I am not the only resident who is often humbled by the limits of his knowledge and abilities.  Residency training breeds caution, not arrogance.  If you think your doctor is arrogant it may be because you are, yourself, something of a jackass and cannot handle the fact that patients are not customers, the doctor is not a clerk, and you are not always right. 

I think I want to go to medical school, how hard is it to apply and get accepted?

First you have to get the basics in order which are getting good grades and scoring well on the MCAT.  I don’t have too much advice for that except if you are not incredibly intelligent this is going to require a lot of hard studying in college.  Medical school is pretty competitive and only about half of the college students who apply are accepted.  This might not seem like bad odds at first but you also have to realize that a large number of college freshmen who declare themselves as pre-med discover that they don’t have the right stuff and end up pursuing other careers.  So your odds are pretty good (and I call fifty percent good odds) only once you get through all of the obstacles which include classes like calculus and organic chemistry, the de facto destroyers of medical school dreams at most universities.

It’s not that these classes are incredibly hard, it’s just that the competitiveness of medical school requires that those who make the final cut, the twenty thousand students who matriculate every year, get exceptionally good grades.  When I was working towards my engineering degree, I worked hard but didn’t flinch at a B or even the occasional C.  These are both passing grades and nobody ever asked me about my Grade Point Average when I was applying for engineering jobs.  And there was certainly no GPA requirment for professional licensing as an engineer.  All that was required to sit for the Professional Engineeing Licensing Exam (a test that makes the MCAT look like a pop quiz) was a degree and five years of engineering experience.

But applying for medical school?  You need to get an A most of the time in most of your classes.  Maybe there’s no substantive difference between a 3.7 and a 4.0 GPA but there is a huge difference from an admissions point of view between a 3.2 and a 3.7.  One is an automatic rejection at many medical schools, meaning that your application is automatically shunted into the trash, or at least a big strike against you unless you have an awfully interesting resume (which is how I managed to get in with my GPA).  You definitely have to get very high grades in the BPCM (Biology, Physics, Chemistry, and Math) pre-requisites to even be considered.

The ironic thing is that all you really need to start medical school is the abiity to read and some basic, and I mean basic, biological and scientific knowledge.  In the first couple of days of medical school, for example, you are probably going to cover the equivalent of college semester’s worth of the subject.  You have to understand that college courses, compared to medical school, proceed at a leisurely pace and you will laugh to think that you ever felt college courses to be overwhelming.   The real purpose of the pre-requisuites is not so much to teach you anything but to demonstrate that you have the ability to handle the barrage of material heading your way.  Intelligence aside, if you can’t muster the discipline to do well in college, while you may be able to switch gears in medical school, the conventional wisdom is that you are not worth the risk, especially not when every medical school can find plenty of people who have shown that they can.

I understand that there was once a time when medical school admission was much easier but many matriculants were weeded out in the first couple of years.  As my old professors used to relate, the standard speech to incoming first-years was, “Look to your left…now look to your right.  This time next year both of those people might not be here.”  Now most of the weeding out is accomplished before matriculation and unless you lose that fire, that interest in the profession that keeps even the most jaded medical student slogging through, your chances of not graduating are vanishingly small.  In my class of 100, when all was said and done, only two people didn’t finish.   Several were dropped back a year but they all eventually graduated.

So you see, the big hurdle is getting in, not finishing.  And there are a lot of other hoops to jump through which have nothing to do with grades and make the whole process seem something like a poodle circus.  For the record the requirement for good grades is not a hoop.  It is silly not to have some kind of objective standard of intelligence for people who want to enter what is a highly important, intellectually demanding, and in many ways (as there is a great potential to harm people) a highly dangerous profession.  The real hoops are the nebuluous extracurricular activities that are unofficially offically required by almost every medical school to prove your dedication and your, I blush to call it, moral fitness for the job.

In other words, it is not enough to get good grades and have an inkling that you want to be a doctor because it is a useful, well-paying, interesting career with good job security but you must also prove to the admission committee that medicine is and has been your passion since the second grade and you view it as an almost divine calling to have the opportunity to help your fellow man blah blah blah.  Now, I don’t confess to kow the importance of extracurricular activities to medical school admission.  At some level the members of the admission committee must know that you only went to Zaire to help in a jungle hospital for resume padding.  Maybe American health care is not as advanced as Cuba’s but surely there are not long lines of American residency-trained physicians fighting for visas to practice medicine on the the Dark Continent, Central America, or anywhere else where a young medical school applicant may sojourn for a couple of weeks to demonstrate his commitment to global health care.

In the Pandaverse, if a young medical school applicant mentioned that he had volunteered in Chad the interviewer’s eyes would glaze over and he would ask, “So what does that have to do with practicing medicine in the United States?”  (Hint: Nothing.)

But whatever your feeling about relevance it is understood among the pre-med community that these kinds of activities are required and as the admission community endorses, either overtly or tacitly, this kind of thing you need to put on your frilled ballerina skirt, your ribbons, your muzzle, and jump…I said jump!…jump, poodle through the hoops and count yourself lucky that they haven’t yet lighted them on fire.  The way things are going, it is only a matter of time before an actual medical degree from a Third World country will be a requirement for admission.  Either that or having been intimately involved in the crafting of health care policy for some Brie-eating United Nations Bureaucrat.

Until that day you can probably get by with passing out clean needles to addicts, holding women’s hands at Planned Parenthood while they abort their babies, fetching water for the patients in the Emergency Department, or half a hundred other things that really make no difference and have nothing to do with the practice of medicine.  For my money, the most valuable things you can do are to either shadow a doctor or a resident (to give you a real idea of what is involved) or to get some kind of minor career in the health care industry where you can see if you have the stomach for it.  If you already have such a career then your’re golden because being a Paramedic or a Physical Therapist (for example) speaks for itself about your dedication. 

Research is probably the one thing you can do that will really set you apart from the pack.  Everybody passes out needles.  Hell, there’s nothing to it.  No commitement at all and the self-righteousness you can experience passing out the implements of self-destruction to people who may as well be alien life-forms to you for all you have in common with them is an added bonus.  You also get to practice your faux empathy and it gives you a chance to hate on President Bush for not making Heroin legal.  But the discipline to work for a cantankerous professor, essentially as his bitch, doing his grunt work to have your name on a paper?  That’s what I’m talking about.  It’s difficult and everybody knows it which is why meaningful research as an undergraduate will give your otherwise decent but not spectacular application a boost.

Short of that it’s going to come down to good grades and bogus extracurricular activities of the High School Musical variety, long on talk, short on action, in which you demonstrated some ethereal and hard-to-explain leadership traits.

Any kinds of patients you don’t like?

Naw, I like ‘em all for one reason or another.  The sicker the better.  And I don’t dislike minor complaints either except that sometimes a minor complaint turns into a life-threatening emergency.  Nothing wrong with that actually except if I pick up the chart at the end of a shift.  But the minor complaints, the non-emergent, non-urgent, and sometimes puzzling patients (why on earth did they haul their kids and themselves out of bed at 2AM for a minor cough?) are a large portion of the bread and butter of our specialty and pay the bills, so to speak, that allow us hang around to take care of the two or three patients a shift who are either heading south fast or have arrived and are setting up camp.

(Public Service Announcement: Don’t skip dialysis over the Thanksgiving holiday so you can visit from out of town and eat highly salted holiday foods with your relatives.  I’m just saying…)

But there are, so far, two kinds of patients that annoy me a little.  The first are the drug seekers and frequent fliers who want to jump to the goodies and then get irate if I insist on a history, a physical exam, an assesment, and a plan.  Generally, I am not buying that on each of the thirty times you have presented for your back pain they just gave you some demerol and you were in and out in twenty minutes. 

Lady, the only people who get in and out of here in twenty minutes are the ones heading to the cath lab or the morgue. 

Not to mention that I don’t like being told how I am going to do my job by an amateur (although admittedly an interested one).  I happen to like trying the basic but effective things to break a migraine and 200 milligrams of Demerol is not on the “first do this” list.  I don’t even mind the lies.  Just don’t tell me what to do.  I have the medical degree.  It’s not much but it’s all I’ve got.  

The other kind of patient who annoy me are the ones who are ridiculously impatient.  Now, I understand that a visit to the Emergency Department, particularly a busy one that trains residents, can involve many hours of just sitting around waiting.   The beds are not comfortable and neither are the chairs for the family.  But can’t they get the sense, just by looking around, that we are sometimes insanely busy?  There are not that many doctors. If a trauma or two or a critical patient comes in that’s it for their minor complaint until things settle down again.  I am glad the minor complaints come in, the hospital and the law certainly encourage this kind of thing, but the Emergency Department only functions as your Urgent Care Clinic if there is nobody ahead of you who is sicker.  It’s not first come first served and I sometimes am embarrassed to have to explain it to people.  I apologize for the delay when I finally get around to them because most of my patients are decent people and very understanding but to the minority who are not, if you don’t want to risk the wait then don’t come in with your bogus complaint.  You said you had a problem.  You came to the Emergency Department at 2AM because it couldn’t wait until morning or for an appointment with your own doctor. Consequently, there is a huge prejudice on my part to give you the benefit of the doubt and do a reasonable amount of diagnostic testing and cognitive interpretation. 

Which takes time.  Time for the labs.  Time for the studies.  Hell, time for me to get around to writing up your discharge.  I generally want to get you out as much as you want to go so I can put you in the “win” column but not at the expense of giving you shoddy care.   Don’t keep bugging your nurse.  I have currently and will have in the future a huge incentive to get a disposition on you as fast as possible but a critical patient takes precedence and needs most of my attention until things settle out. 

Poodle Circus and Other Things (Real Questions From Real Readers)

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