Welcome to the Pandaverse

(The Student Doctor Network has been kind enough to host the archives of my blog and have asked me to write a little introduction. I’m sort of retired as a blogger so in lieu of a post I thought I’d just answer a few questions that people often ask me. I may from time to time write an article but I assure you it will be with nothing like the frequency I used to. I’m enjoying being a former-blogger too much for that. -PB)

Tell Us a Little About Yourself.

I am an an Emergency Medicine Resident Physician in my fourth and final year of training. I am a little older than most residents having come late to the medical profession.

Do you like being a doctor?

Sure. It’s not a bad job. The pay is decent once you get out of residency and despite the conventional wisdom, physicians are almost universally respected. The pay will naturally vary by specialty and the respect depends on your ability to project those intangible qualities that the public expects but it’s not a bad gig if you can stomach some of the less savory aspects of it.

What are some of the less savory aspects?

First you have to realize that most of any doctor’s job is pure bullshit. I can’t exactly quantify how much but it is definitely more than half and probably closer to seventy-five percent. It’s not just the ridiculous bureaucratic obstacle course constructed by the hospitals, the insurance companies, the government, and various quasi-official regulatory bodies like the despicable “Joint Commission” (for whom is reserved a special circle of perdition) that contribute to this huge proportion of bullshit, nor is it the depredations of the legal profession who’s pervasive influence has driven common sense out of the system, but rather the bullshit is a combination of these things and the worst impulses of human nature allowed to run unchecked in a society like ours which has finally liberated its citizens from personal responsibility.

On a practical level, this means that out of every dollar that passes through your hands, seventy-five cents of it may as well have been flushed down the toilet for the all the good it does. Some goes for the reams of useless and entirely ridiculous paperwork that is the joy of administrators and the pushing around of which employs them by the hundreds of thousands. Some goes to completely unnecessary testing which is ordered for the sole purpose of defending ourselves from the inevitable lawsuit that will ensue if we miss either a rare condition or a highly unlikely, exceedingly rare presentation of a common disease. Most of it, however, is spent on the margins either overreacting to fairly trivial complaints or spending large sums of money on therapies and procedures which have limited effectiveness in terms of decreased morbidity or increased quality of life.

Not to mention that the system is fairly corrupt and If you really knew how corrupt it was you wouldn’t be so eager to devote your life to it. For our part, as physicians we shamelessly waste money on unnecessary consults, weak admissions, and redundant tests because that’s where the money is. While some of this can be blamed on the legal profession which forces us to practice highly expensive defensive medicine, we need our paying customers and, insomuch as a weak admission or an unnecessary colonoscopy pays as much as a legitimate one, there is no incentive for doctors to turn patients away, even those who will only benefit marginally or not at all from all the money we dump on them. We revile EMTALA, for example, as it has buried most Emergency Departments in trivial complaints but it is these trivial complaints that are now the lifeblood of our specialty and have made it one of the most lucrative.

On the part of the patients, they are mostly terrifically entitled and want everything done all the time regardless of cost and regardless of effectiveness. They are looking for a magical antidote for what are mostly lifestyle related illnesses and, as they are not directly paying for any of their medical care, have no incentive to not come to the doctor for every little thing.

The industry itself is corrupt because its primary function is to garner as much money from the public as possible. Most pediatric emergency departments, for example, are built for no other reason than to suck up as much CHIP money as can be legally squeezed out of a steady stream of minor complaints.

Wow. Is there anything good about medicine?

Of course there is. We operate in a deeply flawed system but that doesn’t mean we have to either like it or worship at its twisted altar. I try, for example, to practice good clinical medicine and am leery of ordering studies and consults “just in case.” Of course, I have never been sued and human nature being what it is, the first time I am burned the temptation will be to cover my ass with the best of them, spending millions of dollars of your money to protect mine. On the other hand, as our program director often tells us, he’d rather defend himself in court having used good clinical judgment and sound medical practice in the face of a bad outcome than to have “checked every box” on the order sheet hoping to prevent the lawsuit. At least, as he tells us, he can sleep at night.

There is also no question that we occasionally do some good. After a month or two of resuscitating septic, severely demented octogenarians, returning them to their pre-death warehouses for a few more months of laying in their own excrement and gaping at the ceiling, we recently saved the life of a septic teenager who made a full recovery and has nothing in front of him now but his future. And we occasionally get some real medical problems..heart attacks, congestive heart failure, lacerations, trauma…good stuff but watered down by a majority of patients who seem to have shown up at our doors because they really have nothing better to do on a Thursday night. Either that or they have established a parasitic relationship with the vaunted social safety net of which the Emergency Department is the only representative that is open twenty-four hours a day.

Would you do it over again?

No way. In fact, if knew back then what I know now I would have laughed and thrown my medical school application in the trash. Like I said, I like being a doctor but the toll on my family and my marriage has been immense. Things are getting better but as my wife pointed out to me, and which is something that I have heard echoed by many other residents and their wives, when I get home from a shift in the Emergency Department I have given so much to my patients…so much attention, concern, conversation, humor, grief, and every other kind of human interaction…that I have nothing left to give to her. You think of course, you who dream of touching hundreds of lives and doing good in this bad old world of ours, that this is a good trade but I assure you that medicine as a profession will not love you back. You can solve the medical problems of a thousand grateful patients but a few hours after they leave the department or are discharged from the hospital they won’t remember your name or even your face. You will be just another bucket of medical care that they received from the tap like any other public utility.

I also don’t want to discount the tremendous economic toll the last eight years have had on us for which, of course, I have no one to blame but myself as nobody held a gun to may head.  Still, it is hard to know exactly what you you are getting into when you first start.  Certainly as I have a family and the usual responsibilities and expenses that this entails I expect that many of you who do not will not face some of the same challenges.  When medical school and residency is just a continuation of college and you feel comfortable living in a crappy apartment with milk crates for furniture it is probably a lot more bearable from an economic point of view.  Yes, medical school debt accumulates but it’s really not that much all other things being considered and you are actually payed what is technically a decent salary as a resident, at least one upon which a single person with no responsibilities can live.

But as a medical student and resident with a large and growing family?  It is virtually impossible to make ends meet and we have been going steadily deeper into debt for the better part of the last decade.   I have no doubt that we will eventually dig ourselves out but the opportunity cost, a cost which includes lost wages and debt, for this little adventure has been enormous and we will arrive on that fine Summer day next July when I start making a decent salary way, way behind where we should be at this stage of our life and marriage, that is, with no savings and no assets except what’s going to be left in our checking account.

Flat-busted, in other words.

What Do You Think Of Universal Health Care?

Heck, we already have it. What we really need is less of it. For a start everybody should have to pay real money for their own primary care. It is completely ridiculous that we pay for the routine medical care of a growing population of people who will spend three-hundred bucks a month for cigarettes not to mention other irregular pleasures but who regard a twenty dollar copay or a hundred bucks here of there for a visit to a Family Doctor as a monstrous injustice and an assault on their human dignity. Not to mention that we give away free medical care to people who have no business getting it.

I had a young patient the other day who was collecting disability for something we would have laughed at thirty years ago who has used more free medical care, most of it unnecessary I must add, than people four times his age who are really sick. There are probably whole Cuban villages that have collectively used less medical care. And yet he regularly opines that things will be so much better when medical care is free.

What? Are they going to give him a gold-plated bedside commode? Is the nurse going to give him a massage? Will he be seen quicker? Get more narcotics with fewer questions? What more does he want?

What is the Biggest Problem Facing American Medical Care?

Our inability to say, “No.” No, your eighty-year-old severely demented father with a list of medical problems that reads like a pathology textbook cannot get a colostomy to divert his bowel movements away from the large sacral decubitus ulcer eating into his sacrum. No, we will not spend a hundred thousand dollars of critical care extending your life by two months. No, we will not keep your relative on the ventilator until your family can fly in from all over the country to be at the bedside. No, we will not pay for routine pediatrician visits when not only are they not necessary most of the time but cost less than you spend every month for cable television. No, we will not work you up for abdominal pain when you were sound asleep when I walked in your room, surrounded by hamburger wrappers, and all you really want is an ultrasound of your baby to show your friends. No we will not admit you for the eighth time this year for chest pain after seven negative work-ups. No, we are not your drug-pusher and some problems in life, believe it or not, are not medical at all.

Until we learn to say “No,” to ration care honestly and not covertly, we will exhaust the treasure of our nation and further mortgage our prosperity to the Mandarins of China and the Sheiks of Araby who will one day decide that your free medical care is not such a good investment after all.

Welcome to the Pandaverse