Old School and Other Things

Old School

I admire the physicians of yesterday who practiced at a time before medicine became so technical but I don’t necessarily accept the premise that they were better doctors.  Certainly their physical exam skills were better honed than ours are today as this was often all they had to establish a diagnosis.  They also had a much better grasp of eponyms, being able to rattle off this triad or that pentad  and their significance to the patient; often pointing out some obvious but rare eponymous physical exam finding to nail the diagnosis.  On the other hand I have a sneaking suspicion that their patients weren’t on such a hair-trigger to see a doctor and many conditions probably festered a bit until the constellation of presenting symptoms more closely mirrored what you would expect (and still see) in the textbooks.  In other words, it is one thing to confidently identify a patient deep in the throes of acute hemorrhagic pancreatitis by observing Grey Turner’s Sign (bruising on the flanks) but quite another to diagnose the same in a patient who may be early in the disease and has come to the Emergency Department or his doctor’s office with nothing but mild abdominal pain and a vague history.

Which is how it is nowadays.  In the Golden Age of Medicine, an era that is fading even from the memories of our oldest attendings and in a time before life had become medicalized to the degree it has today, since it was accepted that doctors couldn’t do much patients tended to stay home until something was obviously wrong.  A patient came in with nausea, vomiting, fever, and severe pain in the right lower abdomen and Bam! Acute appendicitis or nothin’.  Today the pain is mild, the location is somewhat more generalized, and while we may not be as ready with the eponym, our differential diagnosis has to be a tad more comprehensive and the work up, because of the legal consequences of missing a diagnosis not to mention the availability of sophisticated tests and imaging as well as appropriate interventions, needs to be more exhaustive.  It is the exhaustive nature of American medicine, the now firmly established belief that everything is an emergency, that contributes to the high cost of everything we do and I’m not sure if the money we spend has really bought us that much, at least not in relation to the vast sums of money that we continue to dump into the sucking pit of medical care.

I mention this not because I necessarily believe that preemptive vigilance is a bad thing, just that it is an extremely expensive way to practice medicine and it may be that a little more of a guarded approach, a commitment to watch and wait might save a lot of money with no effect on morbidity and mortality.  Surely, as an example, every woman early in her pregnancy with some spotting and mild pelvic pain does not need a full workup for an ectopic pregnancy although if you come through our department and have any of these symptoms, even if your chief complaint was a sore throat, you will have a full battery of expensive tests to rule it out.

Do I take ectopic pregnancies seriously?  Of course I do.  But I’d say that I probably initiate twenty negative workups for every ectopic I find and the positive ones are often clinically obvious with the studies ordered to confirm the diagnosis.   The question is whether waiting a day or two would effect the outcome and whether the occasional benefit of early detection is worth the money we spend ruling out the majority that turn out to be nothing but a little bit of pain from a stretching uterus and a bit of normal physiological bleeding.  Like I said, you can present to any emergency Department or doctor’s office with symptoms so vague that a doctor sixty years ago wouldn’t know what to do with you but today receive a full work-up, no different than if you had waited a few days and your symptoms were more classical.

Getting A Job

Just a few observations about looking for my first post-residency job and with a hat-tip to the folks over at M.D.O.D.:   First of all, it was a pleasant experience after applying to medical school and residency to interview for a job from a position of strength.  You essentially have to beg to get into medical school because you hold no cards whatsoever and no matter how stellar a student you were or how winning your personality, there are many more qualified applicants than there are spots and it may as well be somebody else who gets picked.  Likewise with landing a decent residency position which is, like medical school admission, something of a poodle show for graduating medical students as we trot ourselves from program to program trying to convince them that we are good dogs.  Not a lot of negotiating going on, your understand, both medical school and residency being exclusively “take it or leave it” propositions….at least I never heard of fourth year medical student with so much clout that he could negotiate a residency contract (which is not really a contract at all but a documentation of indentured servitude) to his liking.

As a board-eligible physician however it is more of a seller’s market.  In my specialty there are many more jobs than there are Emergency Physicians to fill them so once you get out of the subservience mode (and certainly by the end of your residency you should be pissed off enough to not want to be every body’s little bitch all the time) you can get, within reason, any kind of job with any kind of pay that you want…all you have to do is recognize that your prospective employers need you more than you need them and act accordingly.  I am not, mind you, advocating arrogance or unreasonable salary demands, just that it is no longer necessary to beg.  In the end, you can walk away from any offer with complete impunity and no hard feelings as long as you negotiated in good faith.

Negotiating is the key.  In most cases the first number they slide across the desk or put into a draft contract is a tentative offer and most employers will not be offended by a little dickering.  Likewise with signing bonuses and even simple things like moving allowances.  Sometimes your prospective employers will offer these things up front but if not, there is no harm in asking for them or any other legal and reasonable concession.  The worst they can say is “no” and the worst you can do is respectfully decline their final offer.  Again, no hard feeling, nobody is worse for the wear.

Your room to negotiate also depends on where and for whom you want to work.  Many markets for Emergency Medicine are saturated and if, for example, you just have to live San Diego you may have to settle for a lower salary than your colleagues looking for jobs in Klamath Falls. The rules of supply and demand do not, after all, always work in your favor.  The same would apply if you wanted a junior faculty position at a Big Academic Medical Center in which case you would have to sell yourself shamelessly and probably settle for a good deal less than you could make somewhere else.

There are also many kinds of practice.  You can sign on with an established group with the intent of becoming a partner, you can work directly for a hospital system as their employee, you can work as a free-lance killer-for-hire locum tenums, or you can work for a hospital as an independent contractor to name just a few options.

Obama Watch: The Love That Dare Not Speak Its Name

“Man-caused disaster” instead of “Terrorism” is the latest euphemism to come out of President Obama’s administration, in this case from his Secretary of Homeland Security, and shows, as if you needed any other evidence but the last eight weeks, with what a pack of morons we are dealing.   Maybe they’ll reconsider the term when Obama is surveying the glowing ruins of an American city destroyed by Alleged Foreign Perpetrators or whatever the euphemism will be for the terrorist group that manages to smuggle a nuclear device into Chicago.

I mention this because I live in an area where the Cult of Obama is very strong and yet, the other night I observed my neighbor furtively scraping the Obama bumper sticker off of his Subaru.  I think people are catching on, in other words, although there will always be the die-hard cadre of fanatical followers who dress their children in paramilitary garb and have them chant paeans of love to the Dear Leader.  My neighbor is not that fanatical however and is a decent enough guy even though his political and economic knowledge is sketchy and based largely on earnest but meaningless slogans.  He probably only voted for Obama because he didn’t know what else to do.  Surely he couldn’t have voted for that old, mean Republican who had a clue but didn’t whisper such sweet nothings into his ear.  Now, in the post-coital period when he lies vulnerable and afraid while Obama is in his kitchen drinking his beer and checking his black book my neighbor feels used and a little dirty.  He’s given it up for a guy who is just not that into him and will never return the love that was so desperately given.

Which is also the trouble with the press.  Although Obama is barely two months into His presidency and involved in scandals that make anything since the Nixon administration look like patty cakes, the paleomedia, our own professional cheer leading class, are still starry-eyed and hoping that their lover will come back for one more roll in the hay that will lead to consummation and justification (Peggy Noonan comes to mind).    I mean seriously, the Obama administration and their enablers in congress took bribes from AIG to pay their bonuses from the recent pork-laden stimulus bill, directly adding provisions to the reconciled bill, and the outcry from the press?  Tepid at best.  Politics as usual.  Ho hum.  President Obama gets a pass because, shucks, the bill was a thousand pages long and how could the Smartest and Sexiest Man in the World be expected to know what His own government is doing?  I shudder to think what it would take to get meaningful reaction out of them who were once the savage watchdogs of our democracy but have now abrogated that role to talk radio.

The press now lays prostate and sticky with sweat, wondering if it was worth it and hoping that The One will come to his senses and love them as they love Him.

Old School and Other Things

Skin in the Game and Other Things

Skin in the Game

I had the privilege to work with one of the specialists in town for the last couple of weeks, a gentleman who still takes call for the Emergency Department but only for one week a month after which we have to ship the emergency cases in his particular area of expertise a hundred miles away to the Big University Medical Center.  His specialty is much needed, vital to our patients, and although there are others with the same qualifications in town, their unwillingness to expose themselves to our patients says a lot about the perverse incentives and obvious disincentives of the goat rodeo known as American medicine.

I followed him in his clinic, assisted him in the operating room, and generally learned a lot and had a good time even though he noted that I have no surgical instincts whatsoever, something that I freely admit.  Because he is at the top of the medical food chain and separated from my typical patient population by several layers of lower-order specialties, his patients were a refreshing change for me.  Almost without exception they were polite, well-spoken, and if not always well-educated at least imbued with the native common sense that at one time was highly prized in our country.  Not only that but they were wonderfully, almost unbelievably, compliant with their follow-up and care plans and the most common thing I heard in two weeks at the clinic was some variation of, “It’s getting better and better. Thanks Doc.”

Either that or, mirabile dictu, “Hey Doc, when can I go back to work?”

The only exception to this were some of his patients for whom he was called into the Emergency Department.  Suffice to say that if you sustain the kind of injury for which his services are necessary while drunk and fleeing from the police or beating your lesbian girlfriend at two in the morning you are probably not a model citizen, insured, or likely to be an ideal patient.  We had one patient like this who on follow-up the next day, surrounded by an irate fleshy phalanx of her extended family,  immediately informed me of her intention to sue the motherfucker who had operated on her.   Naturally my specialist is stuck with this lady as he had laid hands on her and now owned her medical problem until the bitter end; neither will he receive a dime for either the procedure, his time rounding on her in the hospital, or for any of her many follow-up visits over the course of the next several months to a year.

Conversely, when we refer a patient to him for a non-emergency complaint, he will not see this patient for free.  He doesn’t take Medicaid either because the reimbursements are so low that he can’t keep the lights on if he gets swamped with this kind of patient.  The bureaucratic requirements for compliance as well as the restrictions on his ability to practice medicine the way he wants are also particularly onerous and contribute to make Medicaid much more than just a money-losing enterprise; accepting it turns a doctor into a poorly-reimbursed indentured servant.  But he does take charity patients, only asking that they make a commitment to him to show that they both respect his time and abilities and have an interest in their own care.  This commitment is 250 dollars up front to get in the door.

Now, to the shrieking harpies of social justice this sounds incredibly crass.  How dare anyone expect the Great Unwashed, the victims of 230 years of institutional oppression, to cough up some money for a basic human right that should flow as easily as water from the tap?  On the other hand, as I have yet to meet a Medicaid or uninsured patient who couldn’t afford cigarettes, liquor, and many of the other irregular pleasures that it is our legal obligation to subsidize, the fact that a referred patient will stand in the waiting room hurling epithets at the receptionist and threatening to sue because he was asked to pay a little bit for a service without which he will be permanently disabled only shows that his priorities are perhaps a little skewed, the motto of The People having now become “Hundreds for luxuries but not a dime for my doctor.”

All that is being asked is that this fellow put some skin in the game.  Of course, “Skin in the Game” is nothing more than the usual doublethink from the Sun king, Ra-Obama and his pantheon of minor governmental deities.  As our country devolves into nothing more than a crappy nursing home for the care and feeding of the chronically helpless, the only people who are really expected to have skin in the game are those who already have a considerable amount of it in the game already.  You can’t, for example, possibly have more skin in the game than I do.  Not only have I spent four years of residency going into debt providing medical treatment for the Holy Underserved but people like me, suckers that we are, have worked our whole lives to support the entire creaking edifice of entitlement and greed that is the modern mammary state.

Exactly How Stupid Are Medical Students?

Medical student debt and the fear of it is a red herring and just another cynical ploy by The Man to punk you. It is no different than trying to make the excessive work hours and sleep deprivation of residency about Patient Care. In the case of excessive work hours and sleep deprivation the argument is always framed in terms of what is best for patient safety; the mantra being that we have to limit hours only because patients are harmed by tired residents and not because sleep deprivation is, by itself, cruel and unusual punishment and a practice that would lead to arrests if it were discovered in some illegal sweat shop.  The problem with using patient safety as a reason to let residents sleep is obvious however.  All The Man has to do is show that patients are not harmed or that the frequent patient hand-offs required when residents work rational hours are more dangerous and you are now stuck working under conditions that are considered war crimes if forced on prisoners. You have unfortunately allowed someone else to dictate the language and subject of your debate.

Now consider medical student debt. Realistically, most medical students don’t incur that much of it, at least to the extent that it is unmanageable. It is what it is and in my specialty with what I will be making,  it is just a a cost of doing business, a fee I will pay every month for access to a lot more money than I could have made at my previous career. Pace the argument that medical student debt is a looming horror that will impoverish us all, I consolidated the federal portion of my loans at a truly ridiculous interest rate which is so low that it makes no sense doing anything other than paying it off with excruciating slowness, always with the very real possibility that I will be dead of old age before I am done.  Actually, a couple or three years of inflation like we had in the seventies and this portion of my debt will, in relation to real income and purchasing power, disappear as a serious concern.

Would I have accepted a pittance from the government as a salary if they promised to make medical school free? Of course not. The very question is also a tool of The Man and his useful idiots in medical education to frame the debate in their terms. You will agree, strictly from an irrational fear of debt, to have your education paid for and in exchange, the sanctimonious government will dictate your salary, paying you less than you would make even subtracting debt.

And you’ll be stuck because you took the money and now you have nothing to say.

Jeez.  Why don’t you all think things through before opening your cake holes?

I’m Back

I am in the final days of residency training having less than one hundred days to go before I am, after eight long years, finally finished with this great ordeal that has cost me almost everything I have and the completion of which is looking to be one of the great anti-climactic experiences of my life.  On June 30th I will finish my last shift as a resident and three days later I will start a similar shift someplace else but for about ten times what I am making now.


I have learned a lot in the last eight years, some of it I didn’t want to know and the ignorance of which was probably better than the full knowledge I am acquiring of it.  I had no idea, for example, how unconcerned many people are about their own health and with what gusto they ignore common sense, their doctors, the frantic signals from their rapidly collapsing bodies, and any crumb of knowledge they may have gleaned from their ineffectual sojourn through that useless warehouse optimistically known as the public schools.  I am also still amazed at how incredibly sick people can be and at how many different diseases and dysfunctional organ systems can be supported in one patient who nevertheless manages to hang on grimly (or maybe obliviously) year after year while an increasing amount of medical care is sprayed on the burning house (metaphorically speaking).

And I have also learned about the corruption of our system, the unavoidable consequence of the many competing players, most of whose interests are irreconcilable and stem largely from the the titanic sums of somebody else’s money dumped into medical care coupled with the public’s insatiable avarice for it.  That most of the money we spend on medical care is wasted is also becoming clear to me and it is on these and other more entertaining topics I hope to continue writing.

I also want to welcome The Macho Response as an official partner of Panda Bear, MD.  It’s hard to exactly describe this blog.  It’s author, the self-styled Crack Emcee, is not a doctor but he does have a common-sense based grasp of medicine.  He is not a scientist but has the intelligence to know both when smoke is being blown up his ass and to point out the hypocrisy and puritanical tendencies of many in the scientific community.  He is an atheist (where I am most certainly not) but he is intellectually consistent in his principles and has not given up “old-fashioned” religion only to latch onto some nutty cult as is too common in our sad and ridiculous age.

The Crack Emcee is an artist of some note, however, and his blog is a sort of collage, an exploration with links, pictures, and music of the truly ridiculous behavior and ideas of those truly ridiculous individuals in the various elites who style themselves our superiors, our protectors, and our benevolant masters.  Be warned, however, that his blog is not for the spineless products of our apologetic and insipid culture.  You will be offended.  You will shriek in dismay as your icons are defaced and your tin-plated heros are gutted in his arena with their entrails left to cook in the hot sand.

Don’t say I didn’t warn you.

Skin in the Game and Other Things