There Are Days…

My Good Friends and Patient Readers,

I’ve decide to stop blogging. Although I have enjoyed writing this blog and mightily appreciate all of you who have taken the time to read and comment upon my many articles, keeping the blog going has taken an appreciable toll on my sleep, studying, and even on my family time. As I am about to enter my last year of residency I will have many new responsibilities to my program competing for my time. Additionally, I have signed a contract for my first job and, as I need to devote my last year of training to ensure that I am completely ready to take care of you, your family, and your friends if you ever end up in a gurney in my trauma bay, I won’t have time to update this thing and I’d rather just end it than let it fade out.

I’m going to pull the plug in a few days. Feel free to copy any articles from my archives to read at your leisure. Remember, however, that all of this stuff is copyrighted. I plan to write a book and have given some thought to its layout and content which may include some of the material from the blog. As to when this book will be ready I don’t know. I like to write but I don’t like to do it under pressure so this might not be for several years. There’s a big difference between writing an article every now and then and carrying a theme across a hundred pages, something for which I may need a lot practice.

As for medical school and residency, there are days when I wonder if it’s been worth it. I look at the financial devastation of the last seven years with every asset we ever had, every dime of equity, and every drop of our savings poured into the bottomless void of medical education and wonder if we’re ever going to recover. As I said, I still have a year left of residency in what will have turned out to be an eight-year ordeal and we are going to arrive at that glorious June day a little more than a year from now with absolutely nothing in the way of wealth to show for it. Just a couple of old cars, some household effects, an empty bank account, and a quarter of million in debt. Comes that June day then one last push before the money starts rolling the other way…one last leap of faith and credit to scrape together the money to pull up stakes and get started in a new town. Just a few more months of distracting the wolves, I promise my lovely and long-suffering wife, of playing the financial shell-game, of sandbagging Peter to pay Paul, before we start to pull back, slowly, from economic catastrophe.

Then there are days, fewer now then previously, when I look up from the petty humilities of working in the academic medical environment with the stifling egos, the petulance, and the sheer bad manners that are a hallmark of this kind of thing and swear that, if I had known the level of disrespect with which medical students and residents are treated, I would have laughed and thrown my medical school application in the trash. Except that most of our attending in my program are easy-going and manage to work in a large amount of teaching despite the constant stampede of patients in our department, dealing with the surprising level of malignancy in this whole system has been almost unbearable. Certainly if I wasn’t trapped like most medical students and residents I would never have put up with it. But what choice do any of us have? By the time you find yourself in third year, where the abuse really begins, you are not only deep in debt but now thoroughly unqualified for any other kind of work. I doubt I am going to work at an academic medical center ever again, even as an attending. I have just had my fill.

And on some days I get the strange sensation that I haven’t really done anything but shuttle one hopeless patient after another into the hospital for one more round of expensive and only marginally effective therapy. Most things are either self-limiting or utterly hopeless and sometimes it seems that the millions of dollars which have poured through my hands have bought nothing real. Just a bunch of redundant tests to confirm that your aged mother (or grandfather, aunt, uncle, brother or sister) is pushing ninety and at this point almost everything we do is more harmful than just letting things run in their natural courses. Either that or the solution, the cure, lies with the patient who could do more for their own health by giving up the smokes and fatty food, not to mention the booze and the drugs, than a whole hospital full of doctors. We’re just putting expensive duct-tape on most of our patients it sometimes seems.

There are days, however, when somebody taps me on the shoulder in the grocery store and says, “You may not remember me, Doctor, but you took care of my mother in the Emergency Room last month. She’s doing great and I just wanted to thank you for everything you did.”

Up and down.

Up and down.

Up and down.

With my Deepest Respect and Gratitude,

Panda Bear, MD

There Are Days…

No, I haven’t Disappeared…

Just taking a break from blogging for a couple of weeks. If you want something to read need I remind you, oh my regular readers as well as those who have accidentally arrived at my blog after a fruitless Google search for “stuffed panda bears” or “panda bear mating habits,” that my archives, seldom visited according to my site counter, offer rich provender, almost limitless grazing, even to those who are not obsessed with the insane goat-rodeo-cum-cluster-fuck we call medical training.

I mean, I’ve got, like, 206 articles and about a thousand pages of content. It should keep you busy. I even have some of it categorized…which is kind of the problem. I think I have nothing much more to say about most things and I lack the dedication to carefully research and footnote lengthy articles on health care policy where I prove, using other’s opinions, my particular point of view although the internet is good for that. In fact, other than expanding the frontiers of pornography, the principle function of the internet is to act as an echo chamber where isolated minds can prove that black is white, up is down, and, despite all evidence to the contrary, the government is going to do a fantastic job managing all the medical care in this country.

So stand by. I think Complementary and Alternative Medicine at least still has a little stuffing left to beat out. I had a fascinating conversation with a chiropractor the other day that I might tell you about. He asked me what kind of doctor I was and when I said, with tongue in cheek of course, that I was the kind who proves Darwin wrong every day he took this as a signal that I did not believe in evolution and, with this entre, what followed was the most bizarre diatribe against science, modern medicine, vaccinations, the Pope, the Queen of England, and President Bush that I have ever heard. He professed membership in a cult (Scientology), was taking a correspondence course in Naturopathy (although he already incorporated it into his practice), and bragged that his proudest achievement was adjusting the medication lists of his elderly patients, often removing ten or twelve drugs from their regimen…all without the benefit of any formal training in medicine (A laudable effort, no doubt, but replacing them with Ginkgo Biloba and Foxglove tea is criminal).

Then he tried to recruit me into a multilevel marketing scam.

Absolutely beautiful.

No, I haven’t Disappeared…

Up and Down and All Around The Pandaverse

I Needed That

Let’s just say I don’t know as much about pediatric resuscitation as I should. I know the basics of course, but there are nuances in the the emergency treatment of children that are not as easy to remember as they are for a standard 75-kilogram adult. We also get many, many more adult trauma and critical patients then we do children so it’s a question of practice. I mention this because residency can be very humbling and never more so when you don’t have a good idea what to do and have to get more guidance from the attending than you probably should. I am extremely glad I have a year of training left because a pediatric respiratory arrest that came in the other night demonstrated, yet again, that despite the agitprop from the mid-levels, there is a purpose to residency training and you cannot just throw somebody out to the public with a couple of years of medical training.

Just to summarize, I asked for the wrong medications for sedation and paralysis, failed to intubate, had to pass it off to my attending, and even struggled to get a central line. Ouch. I have been reviewing Pediatric Advanced Life Support (PALS) since then so some good has come out of a bad experience but it is, as I said, very humbling. The Emergency Department is a team. The nurses know their job as do the techs, respiratory therapists, and everybody else. I don’t think it’s unreasonable that I should know mine.

So I was kind of moping around after that, seeing the drug seekers, emergency colds, constipation, and the only other patients with who I felt I could be trusted when I got called to a code on one of the medicine floors. I was the first one there, got a report from the patient’s nurse who was doing CPR, assessed the patient, and we ran a very strong code that I think gave the patient every possible chance to live even though he did not pull through. I think I successfully identified the problem, took the appropriate steps to resolve it, intubated a very difficult airway on the first pass, and generally did everything I was supposed to do and that I used to watch other residents do three years ago when I was a sheepish brand-new intern just trying to stay out of the way.

Residency is a series of highs and lows, at least for me. Some days nothing happens and I tool along complacently. Sometimes I royally screw up and feel like I’m never going to get it. And then sometimes I discover that I know what I’m doing.

Up and down.

Up and down.

You Have It Exactly Backwards

In regards to a recent article of mine detailing the differences between physicians and mid-level providers, a reader commented that patients neither care what initials are after our names nor about the “expansiveness” of our training but only that they are treated with compassion and understanding. This is another variation of the common mid-level mantra of “Anything You Can Do I Can Do Better Even Though My Formal Training in Medicine is a Small Fraction of Yours.”

The reader has it backwards. The patients don’t care about our initials, whether “MD,” “NP,” or “PA-C,” because they tend to assume anyone with a white coat is a physician. Mid-levels are not exactly quick to identify themselves as mid-levels although to be fair this is mostly because there is no clearly recognizable title that they can use. I walk into the room and say, “Hello, I’m Doctor Bear.” What do you say if you are a Nurse Practitioner? You’re not a Nurse and you’re not a doctor so first names are used and the patient assumes what they will. The key point is the assumption that the person in authority the patient finally sees after all the preliminaries is a physician with whatever training and education the patient imagines a physician should have.

So it’s not that the patients don’t care, it’s only that regardless of the complaining and dark conspiracy theories to which they subscribe when they are not under our care, patients have complete trust in the medical profession when it is up in their face and the mid-levels tap into this trust whether they deserve it or not. Physicians, especially residents, also tap into this trust, the coffers of which have been filled by every honorable physician who has practiced before us. It goes without saying that we may or may not deserve this trust either.

As to not caring about the expansiveness of our training, I am reasonably sure that most patients, if they knew the difference, would much prefer a residency trained physician leading the team resuscitating their drowned child (see the first part of this article) and would not tolerate anybody but a residency trained surgeon removing their gallbladder. Again, there is an assumption of a certain expansiveness and many patients would be appalled to discover that you can be a mid-level provider with only a couple of years of formal medical training. For the information of the laypeople who may be reading, the bare minimum for any physician in any specialty is seven years. I will have had eight years of formal medical training when I’m finally done (I am almost done with my seventh year) and some specialties train for upwards of a decade after medical school.

As for treating patients with compassion and understanding, this is probably the easiest thing about medicine and as it requires no special skills or training, has become the last refuge of egalitarian scoundrels who, when pushed into a corner will come out swinging, brandishing their superior compassion as if long periods of medical training somehow strip physicians of their basic humanity.

People who know me would probably attest that I am a very humble guy who is completely aware of his limitations. This does not mean that I feel compelled to subscribe to some politically correct, totally egalitarian word-view.

Futile is as Futile Does

I like Dinosaur and agree with much of what he says but I feel compelled to comment, yet again, about what I think is his misunderstanding of futile care. Of course we both agree that strictly being elderly is not an indication to pull the plug just as we agree that many of the elderly can walk out of the hospital after treatment for diseases that would have been a death sentence fifty years ago (and still are for the elderly in the Great Freeloader Kingdoms Across the Big Water). But seriously now. I had a patient about a month ago who had suffered a massive stroke a few years before and essentially spent her now diminished life laying in her own stool, breathing through a hole in her neck, eating through a hole in her belly, and making the occasional trip to the Intensive Care Unit when her lungs or upper airway became too full of fluid to be suctioned by the indifferent minimum wage hands in the warehouse where she is stored. She had a pacemaker to keep her heart beating, a defibrillator to jump start it when it didn’t, and a small pharmacy’s worth of medications to ensure that she will shuffle off her mortal coil in fits and starts.

As is common with bed-bound, demented patients who are only infrequently turned and cleaned, she had developed a large decubitus ulcer that had eaten into her back all the way down to her sacrum, the polished bone of which could be seen clearly when the nurse rolled her on her side. This particular ulcer had eroded almost to her anus and was almost impossible to keep clean as every one of her frequent bowl movements poured into and around it. The surgeon who we consulted suggested a colostomy to redirect bowl contents to a pouch on the abdomen as the first step to any definitive treatment.

Perhaps when the next step in your treatment is a surgical re-working of your guts to prevent complications from the complication of having no other function in life but to lay in your own stool staring blankly at the ceiling and all the pretty lights and alarms, well, perhaps it’s time to talk about quality of life and what, exactly, the couple of hundred thousand dollars on the table are buying us and the patient. Sometimes the line between futile care and reasonable medical efforts is not clear and I can’t always discern it. But what we do to some patients is madness. Utter madness.

Up and Down and All Around The Pandaverse