Welcome to Intern Year

(Gentle readers, I present the following which is mostly written in Marine-speak. You have nothing to fear and yet, if you have a weak constitution or are easily upset I implore you to skip this article, perhaps using the time saved to peruse the latest Peanuts comic strip in the newspaper or anything else that is similarly non-threatening.-PB)

Is That Smoke Coming Out of Your Ass or Mine?

You are loved. No doubt about it, the one lesson of your intern orientation is that now, finally, after four years of medical school where you were beneath contempt in the medical hierarchy you are now one of the gang, a valued colleague, someone who will be treated collegially. After all, as the designated speakers will point out with heroic rhetorical flourishes, whereas up until now you didn’t count, now you do and with your great responsibilty as real doctors comes the expectation that you will be treated professionally and courteously.

Then of course you will actually start intern year and they will treat you like a piece of shit, both institutionally and professionally. Need some sleep? “Fuck you.” Want some time off? “Screw you, you big fucking baby.” Don’t know where anything is or how they run the service? “Fuck you, moron. We sent you an email. Didn’t you read it?”

And so it will go. Now, I am not the smartest Asian bear-mammal to ever lumber out of the bamboo grove but I can tell when I am having smoke blown up my furry ass. You can tell me that I’m going to be treated like a valued junior colleague and you can make nice noises but the reality is that for your entire intern year, and possibly your whole residency, the default position of everybody with whom you work will be to treat you like a sweat-shop laborer.

So welcome to the dysfunctional residency training system which was designed, literally, by a cocaine-addicted physician and which has changed very little since its insane beginnings. Sure, some of the hours have been limited but the system still depends on depriving you of sleep and making you work the kind of hours that are considered war crimes in most other countries. Heaven forbid you point this out. Apparently when it comes to an abusive medical training system, everybody is a hoary old conservative protecting their peculiar institution from reform. Swing low, Sweet Chariot. Them residents sure can sing! Why brother, it would be a sin to set ‘em free seeing how happy they are. Lift that bale, tote that barge!

Ol’ Man River he keeps rollin’ along.

This is what they really mean to tell you at your orientation to intern year:

“Welcome to our hospital. We’re so glad you’re here. the first thing I want all of you to do is to reach down and feel your testicles. Ladies, go ahead and palpate your ovaries. Feel those things? Well, we own them. Oh sure, technically they are attached to you but for all practical purposes they are ours and we have them gripped firmly. If you step out of line we will give ‘em a squeeze. Step too far and we’ll tear them out of your body and present them to you a la Bruce Lee before you die.”

“Just wanted to clear that up so you folks don’t get too uppity. Your contract? Hah. We call it a contract but it’s more of a receipt for your indentured servitude. We agree to practically nothing and in exchange you are ours for the duration of your sentence…I mean your training. Don’t like it? I think we can fire you for just about anything and at any time. Not too many other professionals would work under those conditions but as long as there is a steady supply of you stupid motherfuckers ready to mortgage your souls to get into medical school we can pretty much do whatever we want. You can leave of course, but good luck getting another residency position after we shake our heads sadly and opine that you are a trouble-maker. Not to mention that we have the system set up so even if you manage to escape you can only do it one time a year and only if the stars and planets align just right. So shut your stinking gob-holes. You’re in it now.”

“And we don’t give a rat’s ass about your sleep, your rest, your health and your well-being. Oh, we’ll pay the usual lip service to these things and in later orientation lectures we will encourage you to take naps on call and instruct you how to best use caffeine to optimize your wakefulness but the fact is that we are going to beat the crap out of you for at least a year and hopefully for as many years as we possibly can. We just don’t care. Now, because some disloyal pussies couldn’t keep from whining to their mommas and killing themselves on the exhausted drive home from the hospital we are only supposed to work you eighty hours a week. I can not stress enough what a bunch of fucking crybabies that makes you or how sick I am of looking at your fat lazy faces sitting there knowing that you might actually get some time off. It makes me physically ill to think about it so I expect all of you to uphold the highest ethical traditions of the medical profession and lie about your actual hours if it comes to it. I suffered and because I have a personality disorder, you need to suffer too. Besides, everybody knows that we only have to obey rules if we agree with them…and we certainly don’t agree with this one, do we?”

“If you complain too much we will ressurect some dinosaur who trained back in the days when they were still using poultices as a first line therapy to try to shame you into keeping your mouths shut. Obviously everything was better fifty years ago, especially when interns were all geeky white males with no families and no responsibilities outside the hospital. Man! those were the days. We owned those motherfuckers. I mean, we own you but we really owned them. There was so little that could be done for patients in those days that we could waste their time with wild abandon. Those were the golden days of scut work my friends, the likes of which we will not see again.”

“As to your pay, well, the federal government is giving us a shitload of money for your training. Almost twice as much as we are reluctantly going to pay you. We’re going to cry poverty and feed you a line of bullshit as to how expensive it is to train residents, how much you are damaging our efficiency, and how this extra money doesn’t even cover the economic damage you will inflict to our bottom line but this is just fragrant smoke wafting up your ass. Try taking a day off or calling in sick when you have call and see how we are going to panic. As if it isn’t bad enough that many of you little pussies can’t work more than eighty hours a week and we can’t always screw one of your colleagues to cover your call, we may have to actually pay somebody real money to do your job which is really going to eat into our bottom line.”

“And who is really going to suffer? Why, The Patients of course. Your insistence on not working with hospital-grade gastroenteritis or your gay desire to spend a day or two every month with your wife and kids is stealing, yes stealing, precious medical care from the poor underserved wretches frequenting this hospital. Don’t you stupid fuckwits understand that Patient Care comes first? Patient Care is our primary responsibility and with the exception of the nursing staff, the respiratory therapists, the Physician Assistants, the phlebotomists, the lab techs, the janitors, the cafeteria ladies, the attendings, the parking attendents, and those ladies slopping the hash in the cafeteria everybody in the hospital is expected to sacrifice their entire life for Patient Care.”
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“So we need you to work a lot. Unfortunately we have to give you little wimps four (and I weep to think of it) days off every month but we’re going to send you home a little early post call and call this a day off, even if it is less than 24 hours and you will sleep through most of it. Those pesky rules again I’m afraid but we’ll subvert ‘em somehow because you guys are a fucking goldmine. Have you seen what Hospitalists are charging (not to mention PAs and other midlevels who will do in a pinch)? Let me tell you, they ain’t cheap. Not by a long shot. You poor sons of bitches, however, are ridiculously cheap. Insanely cheap. And the more we work you the cheaper you are because, get this, we don’t have to pay you overtime. Try getting the janitor to work some extra hours. Even my taco stuffer gets time-and-a-half if he goes over forty and all he has is a GED.”

“Who’s yer’ daddy now?”

Welcome to Intern Year

Pie Will Out

I’m a Doctor, Not a Magician

I get accused of being a cynic and a realist, especially by people who are themselves self-proclaimed idealists. Why it is wrong to be a realist or cynical is the topic for another day. But I do actually have an idealistic heart and one that would shame the pretensions of even those whose bumpers are festooned with a kaleidoscope of stickers announcing their support for the typical things that pass for idealism nowadays. I just have a different sort of idealism, especially when it comes to the practice of medicine. It’s an old-fashioned idealism to be sure, and one that many may view as being slightly stodgy at best or a throwback to the stone age at worst.

I’m talking, of course, about the difference between reactive and proactive medicine.

In reactive medicine, the traditional model of medical practice, the physician is trained to diagnose and treat the diseases of people who seek him out when needed. This is my idealism and probably why I chose Emergency Medicine as a specialty. Our entire job is to react to medical problems. In this manner I live my ideals in a way that, unless it involves parachuting into the Himalayas, those whose ideals involve freeing Tibet can never hope to do.

Some believe in “proactive” medicine and to a certain extent I can understand and applaud their ideals. Family Medicine, for example, is full of motivated physicians keeping a careful watch on their patients in the expectation of catching and preventing health problems early enough so the treament is a pill instead of a heart transplant. Some work in preventative medicine and struggle to eradicate the common diseases that afflict the human herd.

Idealism is a good thing except when it becomes zealotry at which point (as absolutism brooks no dissent) reason, moderation, and respect for the heretic are abandoned. The hard-core purveyors of proactive medicine long ago passed into zealotry and have never looked back. Many of you have read of my experiences with community medicine at Duke University where the Department of Community and Family Medicine was the beating heart of proactive zealotry and about which I relate the following cautionary tale:

During our orientation as interns, we sat through many conferences extolling the virtues of Community Medicine, the Shining Path of proactivity that involved physicians, mid-level providers, nurses, social workers, dieticians, and various other minor functionaries of the dependocracy in a coordinated effort to bring good health to the to jibbering inhabitants of North Carolina’s urban and rural hinterlands. One such effort involved a pilot project to combat obesity. A local Baptist church was selected as a test site and the obese parishioners were subjected to all manner of testing, nutritional counseling, cooking classes, motivational speakers and everything and everyone that the initial grant money could bring to bear. To say that this group was targeted would be an understatement. They received the full broadside from the great ship of state which, for good measure, came about and raked them from the other side.

You’d think the pounds would have dropped like French soldiers at the sound of gunfire but, when one of the interns tentatively asked if the target group had lost weight, it turned out that the test subjects had no statistically significant weight loss.

There were no outliers. The most lost was a little more than the weight of a couple of pork chops and some actually gained.

Anybody could have predicted this. Most education, like most preaching, is ineffectual. The parson can talk himself blue in the face but the bars will still be open and the fancy women will have no shortage of customers because unless people have some strong personal motivation for change, a motivation which cannot be accessed by the usual uninspired preacher or government scold, they will continue to indulge their immediate gratification at the expense of of some unknowable future punishment.

Late at night, when the motivational speakers have gone home and the skinny lady from the university has stopped trying to extract impossible promises, the siren call of the pecan pie in the refrigerator is irresitable. Pie will out. This simple yet seductive desert will trump our best efforts. When you’re three hundred pounds hoping to lose the fleshy equivalent of a couple of sixth graders, the smooth seduction of caramelized Karo syrup and the smokey crunch of jumbo pecans offers immediate gratification with which no nebulous promise of low blood pressure can hope to compete.

I am a stocky fellow myself and even though I know better, after approximately twenty years of education and a medical degree I still succumb to the demonic allure of baked goods including that of the very arch-devil of pastry, the apple fritter.

You can lead a horse to water and, if you hold his head underwater, he will eventually drink. But you have to stand there and hold him down. Likewise, we can probably modify people’s bad habits but the level of involvement required is immense. If a small platoon of earnest social workers cajoling and lecturing for a month could only show a couple of pork chops for all their effort and a a couple hundred thousand bucks worth of their time, those are mighty expensive pork chops. So unless you’re willing to swallow the cost of providing everybody in the country who needs one with their own personal trainer to hold their head underwater, well, you need to let it go. People are going to do what they want. They’ll suck down crack, inject heroin, free-base Big Macs, and make love to the pastry cart and nothing short of locking them in a jail cell with Richard Simmons and a crate of lettuce is going to make much of a difference. What little difference it makes is probably not going to be worth the gigantic expense of providing nannies to a third of the population.

It’s probably more cost effective to just say to hell with it and confine ourselves to reactive medicine where at least we can make a difference. Remember, no matter how much you spend, it can all be undone by an 89 cent piece of pie.

Pie Will Out

A Letter to an Attending

Who do You Think You Are?

Dear Sir or Madame,

I am exceedingly glad to be done with the rotation. I have been a resident for almost two years and that month was perhaps the worst experience of my medical career. You made what should have been a moderately unpleasant experience which is what we expect on rotations in your specialty into an almost unendurable ordeal which no one in any other career except ours would tolerate with as much good humor as I did.

I have most certainly quit jobs for less, and it is only the iron grip on my gonads enjoyed by the hospital that kept me from telling you to “admit your own goddamn patients.”

Now, the fact that you had it harder when you were a resident, something you pointed out on every possible occasion, is completely irrelevant to me. I don’t care. Let’s just assume I am a pussy and leave it at that. I’m not about to change my ways now just to please you. You’re not my mother. You’re not my father. Hell, you’re not even in my chain of command and your bad evaluation is going to sit in my file doing nothing until, one day, some alien archeologist sifting through the sterile rubble of our planet deciphers it and comments to his collegues that you were a real horse’s ass.

You accused me of being unenthusiastic and on this charge I am completely guilty. I am interested in most aspects of medicine including your specialty but if you expected me to clap my hands and squeal for joy at 4AM when confronted with the twelfth admission of the night it is no wonder you were disappointed. As even you grudingly admitted that I did my job and everything asked of me, I don’t know what else you expected except for me to kiss your ass and pretend I live for every-third-night call

I was also less than thrilled to be pimped over the phone in the early morning hours when all I was trying to do was admit an uncomplicated patient. If you want something other than what I ordered for the patient have the goodness to tell me as I am not a mind-reader. And as I am usually physically ill at that time in the morning from fatigue, dehydration, caffeine, and lack of sleep, just tell me which of many formulas you would prefer for me to use to calculate creatinine clearance and I will use it. Don’t make me decide and then ask me to justify my decision.

Did I mention it was 4AM? I don’t care. We weren’t even talking about a renal patient. On every occasion when we spent an hour on the phone picking the nits off of nits I had a board full of admissions from the other services I was covering and a couple of pagers that that would not stop beeping. If I am to sit under a tree in the agora soaking in your wisdom in the socratic manner than call off the dogs from the other services. We don’t have time. I would have also liked to have layed down for an hour or two after I cleared the board and you were seriously slowing me down.

Additionally, if you were reading the lab values off of your computer at home, why did you have me repeat them to you over the phone? This is just sadism on your part and why, after I found out, I refused to do it. Who do you think you are, anyways? You don’t pay my measly salary, I have sworn no oath to be your little scut whore, I’m about ten years older than you, and there is absolutely nothing in it for me to repeat numbers to you over the phone. And your weasel-like excuse that it was good practice make no sense. Practice for what? My eight-year-old can read numbers over the phone. I reviewed the lab values and the fact that you seemed to think I had not belies the trust you purported to have in me as a fellow physician.

I also didn’t appreciate your patronizing attitude and how you called me “Doctor” in an ironic and insulting manner. On one hand you insisted that you expected a lot out of me (“doctor”) and that you expected me to think independently (“doctor). On the other hand you micromanaged every single decision to the point that when I asked you why you didn’t just come in yourself and eliminate the middleman, I was being completely serious. The premise that you were treating me like a fellow physician was ridiculous. If you treated your colleagues like that I’d be surprised. And as I am working for about a tenth of what you make on an hourly basis, well, the reality is that you treated me and every other resident who has worked with you as low-wage sweat shop labor.

Not to mention that If I was a valued colleague you wouldn’t have been so snotty when I gave you my opinion.

That’s another thing, if you don’t want my opinion, don’t ask for it and don’t get all bent out of shape when I give it to you. In my opinion, my job on the rotation was to provide cheap clerical labor for which you otherwise would have had to pay somebody a decent salary. I think I’m on the money with that opinion, at least from my point of view. If you don’t agree, well, you don’t agree and the fact that I didn’t apologize for my opinion should tell you something.

In the end, I think that’s what really pissed you off. When you called me on the phone at the end of the rotation to express your displeasure with me and my attitude you were probably expecting the usual obseqiousness to which you are accustomed and some sort of apology with a promise to do better.

But you don’t own me. I did my job even though I don’t like you and I’ll be damned if I’ll apologize to make you feel better about your personal control issues. You do your thing, I’ll do mine, and I will never have to work for you or with you again.

Sincerely,

P. Bear, MD

A Letter to an Attending

Obels for Charon

Futility

On the last day of her life, your mother went on a spending spree. I intubated her at around 9AM and for the rest of the day we threw money at her, successfully keeping her alive until about dinner-time when her liver cancer finally had enough, gave us the finger, and showed us who was really in charge. It was not a pretty death, but then I knew it wasn’t going to be when I only just managed to jam the breathing tube through her vocal chords before they were obscured by blood and other unwholesome-looking fluids. Still, over the course of a very interesting day she got an expensive bronchoscopy , five or six lab draws, a central line, an arterial line, three units of blood, a chest x-ray, continuous nursing, pumps, fluids, two consults, monitors, blinking lights, and the usual buzzes and beeps.

We did everything but put a coin under her tongue for the Ferryman which, considering the outcome, would have been just as cost-effective.

The next time, please pay attention to what we have to say when we have “The Talk” like we did two weeks ago to tell you that your mother had passed beyond the limits of our abilities and all we could really hope to do was to ease her suffering as she died. Unfortunately, as we live in an egalitarian age which worships your autonomy, when you seemingly ignored our advice and said, “Do whatever it takes,” our hands were tied and we committed ourselves to two weeks of slowly torturing a dying woman. I understand how you feel about your mother. I have a mother too but you can’t have really wanted this. We coded and shocked her, what? three times in the last eight hours? It had to have hurt her the first time when there was actually something of your mother to bring back. After that, well, I just don’t know.

Not all life is priceless. Not even your mothers. When you said, “Do whatever it takes,” what you really meant was, “Do whatever it takes as long as I’m not paying for it.” But there are very real costs associated with medical care and somebody is paying them. I don’t mean to lay this burden on you but since you want the autonomy to make medical decisions, you need to have all of the facts. Would you have ignored our advice if you had to mortgage your house to pay for your mother’s last two weeks of futile care?

Medical care, like most resources, is scarce and there’s never going to be enough to go around. Somebody has to decide how it’s going to be allocated and for better of worse we seem to have elected you even though you seemingly have no interest or incentive in the matter.

I don’t think you made a good choice here. That’s all. Medical care is for the living. Your mother needed hospice and maybe to die at home peacefully.

This doesn’t mean I don’t think we should spend money on the critically ill. I don’t know how much a year or two of life is worth and we certainly get sick but otherwise highly functional patients who we can return to a happy and meaningful life. I’d hate to make that kind of decision based on simple economics, assessing the value of a year with actuarial exactitude and making decisions accordingly. On the other hand there is a difference between critical care and futile care. Maybe I can’t define the exact line separating the two but I know the difference when I see it. Perhaps you were too emotionally involved to make the distinction and it was unfair to leave it up to you. It’s hard to let go, especially as the popular culture has conditioned us to expect medical miracles although I don’t know what you were expecting with your mother. The eventual outcome had never really been in doubt and you knew perfectly well that you mother was not going to be leaving the hospital this time.

When I pronounced you mother and closed her eyes for the last time, the ancient stillness of the tomb was deafening.

Obels for Charon

Plantation Tales

Swing Low, Sweet Chariot

Old Toby wiped the sweat from his eyes, looked into the fluorescent lights, wiped his eyes again, and turned back to his work. At his side his fellow Resident Duke hummed a quiet spiritual in time to the rhythm of his pen.

“Sho’ is warm in dis’ heah ward, ain’t it Duke? I declare it done be warmer every day.”

Hush yo’ mouth,” said Duke looking around fearfully, “Dat uppity ‘breed oberseeyar done got his eye on me. Oh lawd, I be afeerd sumptin’ awful o’ dat man.”

They both stooped to their work and said nothing for the next few minutes except brief instructions on positioning the ultrasound probe. Old Toby cannulated the internal jugular vein, threaded the guide wire, and let out a long, slow whistle.

“Dat’s as fine as silk and as smooth as buttered cornbread,” he said admiring his handiwork, “Dah Massah gwine to be mighty pleased, mighty pleased to see such a sight.”

Both residents shouldered their stethoscopes and after ordering a stat chest xray (“To see if’n the the cath’ter had done gone down far nuf”) shuffled slowly down the hall to the next patient. Around them, other residents toiled in silence, occasionally shooting fearful glances at Big Tom, Dr. Calhoun’s half breed overseer.

Big Tom slapped his reflex hammer against his scrubs and watched in satisfaction as every resident in earshot jumped. He was a resident himself but rumor had it he was the product of a tryst between Dr. Calhoun, the attending, and Big Tom’s mother.

“Toby,” he yelled, “Quit yo’ dang blamed lollygagin’ and git’ ober’ to da Widow Franklin’s. She be in needs of dat manual disimpaction and it ain’t gittin’ done no how if you be skylarkin’ wit Duke. Git, y’heah?”

“Yassah, Boss,” exclaimed Old Toby as he and Duke broke into a run. Once out of sight of Big Tom, both residents slowed to an easy walk.

“Ah caint hep’ it, Toby, dat Big Tom jes’ askyers me an ah caint take it no mo,” said Duke looking around fearfully. “Ahs been talking to the NRMP and ahs fixin’ to run away.”

“Dang blast it, Duke,” said Old Toby, his eyes wide with fright, “Why you be doin’ a dang fool thing like dat?”

“Coz I be done wore out wid’ da work. When I gets up in da moanin’ I gets me to work straight away an my heart mos’ broke thinking o’ all da work I gots coming. I’s not gittin’ no sleep no how ‘cept fo’ a wink heah and a wink theah. An’t baint near ’nuff fo’ me to live. I be tired all of da time, Toby, tired so’s ah caint think straight an it plumb done wore me out what wid’ the scribbling o’ notes n’ da admitting o’ patients. I axe you, Toby, if it ain’t proper that a resident get him sum sleep an some time t’ sop his biskits n’ gravy?”

“Oh Lawdy! Say you ain’t a gonna do it,” moaned Old Toby, “Ah spec it gwyne to be a pack o’ trouble iffen you do. Remember Mars’ Johnson’s Resident Rex?”

“He done got clean away. I heerd say he lit out mighy quick fo’ a PM&R residency an’ he’s eatin’ high offn’ the hog, dressin’ in his finery and struttin’ around his hospital.”

“Why, if you bain’t nuttin’ but a chuckle-head resident,” said Old Toby, “Laws, he got away fo’ sho’ but da Mars Calhoun made the rest of us hoe his tabacky n’ take his call. Say you baint gwyne t’ run, Duke. The massah gwyne to be mighty perplexed.”

“Dang blame da massah,” said duke in a low voice, “Ahs gwyne t’be a free resident.”

Plantation Tales

Blackwhite

(After two years, I am almost done with call and most of the abusive practices associated with it so you’ll forgive me if I revisit these topics. I have a certain warmth for them and now that I am drawing to the end, I can give you a well-informed opinion. If these topics bothers you or smack of sedition, please skip this article. If not, read on.-PB)

Gulag Archipelago

George Orwell in his classic dystopian novel 1984 invents a nightmarish world where, in the time of Big Brother, the very language was being modified to prevent both the expression of dissent and its conception. In the novel, the Party sought not only to eradicate words that could lead to the discussion of thoughtcrime but to prevent even the possibility of it.

In a similar manner, residents lack the conceptual vocabulary to protest their obvious mistreatment and, because they are unable to frame the debate in any other terms but that of the establishment’s brand of Newspeak, they are reduced to sheepishly shuffling their feet and muttering vague self-centered sounding complaints. Your hospital, for example, may justify depriving you of sleep because some studies show that tired residents don’t jeopardize patient safety. You can cite studies that prove the opposite. But all that can really be proven is that the hypothesis is difficult to prove or disprove and the only result of the debate is that your sleep, a critical component of health, is at the mercy of bureaucrats who are not on your side, would work you (and did, at one time) as much as they possibly could, and will forever justify robbing you of sleep because it is not dangerous for the patients.

The simple and obvious fact that humans need sleep and to deprive them of this is a wrong in of itself (regardless of whether it is safe or not) is never discussed although even convicted felons get their full measure of sleep every night and to deprive them of this is considered a human rights abuse.

The debate is controlled in other ways. Imagine you are an intern in a typical Internal Medicine program pulling your usual every-fourth-day overnight call. Suppose one of your colleagues has his fill of it, successfully scrambles into a less abusive specialty, and decides that since his current intern year counts for nothing at his new program, he will quit a few months early to recover. Your program, following the usual impulses and caring not a whit for their subordinates, assigns his call to the remaining interns and this fellow becomes the enemy, the Emmanuel Goldstein, who is the cause of their suffering.

“We’re sorry,” is the predictable mantra,”But your disloyal colleague left us no choice. There are holes in the call schedule and the rest of you are just going to have to fill them.”

And you hate the disloyal intern and what he did to you. And you are encouraged in this belief. I have heard these sentiments expressed from people who should know better. But think about it. If you were a prisoner in a Soviet Gulag and your entire barracks was punished because one of your tovariches escaped, who is to blame for your punishment and why should his labor quota be divided up among the remaining zeks? Does that make sense, making the prisoners responsible for the injustices committed against them?

Of course it doesn’t. And yet, while most residents could sense this intuitively if they bothered to think about it all, their thinking is cluttered with duckspeak from the medical establishment which not only hides the reality of the situation but sets the conditions of any potential debate to preclude anything but the party orthodoxy.

For the system to change, you need to redefine the terms.

For example, if someone attempts to bludgeon you with “Patient Care” as the debate-stopping, atom bomb of reasons why you are to be routinely over-worked and deprived of sleep, suggest that if patient care were so important, the attendings need to pitch in and pull call and that everyone, from the janitor to the nurses, needs to stay more hours.

The janitors would laugh. They may only have a GED but they’re not stupid and they know when they’re being mistreated.

The fact that your program has bitten off more than it can chew and cannot maintain it’s commitments is not your problem. You are the low guy on the totem pole and are not getting paid to solve the program’s problems. It is actually a leadership problem on the part of the program who are committing the cardinal sin of leadership: Not standing up for their subordinates. The other services clamour for the cheap labor of the program’s residents and instead of protecting you, they say, “Sure, we’ll bravely fill the call schedule with our cannon fodder because, donchaknow‘, we got ‘em by the short hairs”

Here is more doublethink from the Party:

Although the hospital receives an average of $110,000 per year for each resident from Medicare and pays you less than half of this, you are a drain to the hospital and the cost of training you far exceeds the Medicare reimbursement. On the other hand if we didn’t have residents the hospital as it is currently configured would grind to a halt for lack of physicians to take care of the huge numbers of patients we are able to run through here because we have so much cheap physician labor to throw around.

Because residents don’t bill for their time, they don’t make the hospital any money and therefore as you are a drag on the system we might as well extract some cheap labor out of you…but please don’t stop performing valuable work for which we will bill, not to mention performing essential duties that we would have to pay two of the lowliest mid-level providers we could find each at least twice your salary to perform…and we wouldn’t get the $110,000 either (which is just gravy).

A physician is ethical in all things and you are expected to be scrupulously honest and never cut corners…but go ahead and lie about your hours because it’s Okay to lie about certain things if we tell you it’s alright.

Black is white if party discipline demands it.

Blackwhite

On the Shoulders of Giants

Shaman Healer of the Lame Caribou Clan

(After years of research, French anthropologists have managed to translate the famous cave paintings of Lascaux. The full translation will appear in next month’s “Journal of Linguistic Anthropology” but I thought I’d publish a sneak preview. -PB)

Me. Tharg. Shaman Healer of the Lame Caribou clan. Master of the Elk. Spirit-Hunter of the Sky Bison who is called Tharg-Who-Outran-Cave-Bear. I paint this in the Cold Time after the rains when the moon shines like new flint by glow of Brother Flame deep in the caves of our ancestors.

Troubled times. Like mastadon balancing on ice floe is to be Shaman of clan. Precarious, like squirrel caught between tree and wolverine. Like seal pup in path of charging walrus. You get picture.

“New magic salve,” say Olerg, wandering master of lore,”much better old salve. From dung snow fox.”

“Ward off tiger?” Olerg smile too much. Like crazed hyena.

“Tiger? New salve ward off even charging musk oxen. Know Tholar and Gronak?”

“My two brother shaman whose eyes dark from spell at birth?”

“Yes. Salve save them from musk ox. I Swear by Otter spirit. Study was double-blinded.”

Roll eyes. Old salve plenty good.

“Here, have spear with fox totem,” say Olerg offering crappy Neandrathal spear.

“I thank you, oh Olerg, my brother. Have plenty from last visit. But great joy have I for haunch of elk.”

“Oh wonderous spear!” say Otter-spawn, Shaman-to-be, resides-in-cave lo these past winters, “I take?”

Otter-spawn Chief of those-who-reside-in-cave and from me learn dark arts of shaman. Good boy but lazy.

“I go my fire, Otter-spawn. Keep the long watches of the night. Othar has demon of pestilent bowel and need sacred smoke when Sister Moon dips to embrace of far hills. Trulak need horn of great elk when Sister Owl return to tree. Sound ram horn if not work.”

“I abase myself oh Tharg-Who-Outran-Cave-Bear but I, too, go to my fire now,” Say Otter-spawn.

“Who will keep watches of night?”

“Is wonderous puzzlement,” say Otter-spawn, “But great hearth-fire in sky has passed in number like petals of tundra blossom and great spirit commands that He-Who-resides-in-Cave also lie by fire, gnawing rib of great sloth.”

“Does not Cougar-paw reside-in-cave?”

“He reside-in-cave of Bone Diviner in valley of snow hare. Not return for many moons.”

“Twisted-crow?”

“In service of Painted Eagle clan.”

“Go then,” I irritated, “But when Tharg reside-in-cave, took night watches in number like bison on plain.”

“Fetid Badger,” I call. Him best Shaman-pupil.

“I grovel oh Tharg-Who-Outran-Cave bear,” say Fetid Badger. Other pupils cower behind.

“If sky-wolf eat sister moon and woman yet bleed, what cause?” Simple question. They third winter pupils.

“Curse of Otah, the Cave Demon?” Ask Fetid Badger, like tremulous new-born caribou.

“Bah. Laughing Brook?”

Laughing Brook knit sloping brow. “Spell of Wola, the Womb Blighter?”

“Not see picture-on-rock? Not listen song of ancestors?” I irritated again, “Come pupils, hear thunder of hoofs, think bison, not cave yak. Go prepare magic wall picture of many cause womb bleeding.”

Ragrak, Chief of Lame Caribou clan stride into cave. Pupils cower, urinate submissively.

“Tharg Who-Outran-Cave-Bear!” growl Chief, “Ill tidings I bring.”

“What is problem?”

“Know you new female stolen before rains from Clan of Painted Eagle?” Ask Chief.

“Female with hair like mane of horse?”

“That her. And haunches like snow leopard, hips like fertile hills, heavy with promise of many fine sons.” Chief kick last of pupils out cave. Chief old, hair like snow of many winters. See where this going.

“Sometimes brother ferret not want come out of den.” say chief.

“Not understand.”

“No longer rampant stallion but seal pup, soft and helpless.” Chief annoyed.

“Have new salve. Dung of snow fox. You try.”

On the Shoulders of Giants

Clinical Evaluations

Actual Evaluation by My Residents and Attendings

(Just for old time’s sake I reviewed my Dean’s letter. Man, those were the days! -PB)

OB/Gyn: Student is on time and does everything asked of him willingly and with good humor but seemed uninterested in assisting in any more vaginal deliveries than were required to pass the rotation. Actually winced, yes winced, when he was sprayed with urine and feces during one particularly rapid delivery. Commented to me that it was “Nothing like the Discovery Channel.”

OB/Gyn: Student Doctor Bear is on time and cheerful but does not fight hard enough to be the first to see patients complaining of vaginal discharge. I don’t think he should fail the rotation but I am giving him low marks for referring to our weekly STD clinic as “Kooter Patrol.” I also caught him rolling his eyes as I lectured a young, single, G5P4004 on the need for greater personal responsibility. I didn’t quite understand what he meant when he invited me to “repeat my advice to the wall and see if there was any difference” but I think he was making fun of me. Student Doctor Bear also showed no interest in standing around doing nothing while I performed a particularly difficult colposcopy.

General Surgery: Student Doctor Bear did everything asked of him but was singularly unenthusiastic about holding a retractor for six hours. He does not seem to enjoy call and never seems to either know or care about the answers to the random trivia question I ask him just to keep him on his toes.

Medicine: Does not seem enthusiastic. Once actually sat down (!) during rounds…and the attending and all of the residents were still standing! Had an insolent, “you people keep talking while I rest my feet,” expression on his face and ignored every frantic hand gesture to stand up before he made the attending mad. When the attending asked, with admirable sarcasm, “Are you tired, Student Doctor Bear?” he said, “Yes,” and persisted in his sitting position until we had moved to the next patient. And then, oh weep thou heavens and hide thine eyes in shame, when the attending suggested that maybe he wasn’t cut out for internal medicine he replied, “You’re probably right about that.”

Medicine: For reasons unknown to me, Student Doctor Bear is uninterested in electrolytes. Even after spending a brief forty-five minutes discussing a patient’s Potassium (Peace Be Upon Its Holy Name) level his only comment was, “So, do you think we need to supplement it?” Supplement it? Is the wind’s name Mariah? Can we began to explore the intricacies of Potassium (PBUIHN) in the brief time we had between five PM and eight PM when the silly rules require us to let our medical students go home to study?

Pediatrics: A good medical student but he has kids of his own so I don’t think he believes us when we say how great working with kids is. Changes diapers like a pro and is not awkward at all when handling the babies.

Heme-Onc: Did not directly observe the medical student. If you tell me he was on the rotation I’ll believe you and I do seem to remember catching a brief glimpse of him hanging way, way back in the team but when I blinked he was gone. I could probably review the hospital surveillance tapes if you really need an evaluation but I suspect finding more than a few seconds of footage will be more difficult than locating Big Foot.

Surgery: Not a good medical student at all. Despite never having been in an operating room, rotated on a surgery team, observed any operations, or completed a surgery residency, Student Doctor Bear displays absolutely no knowledge of how we do things in the OR, where to stand, and what my favorite music is. And this was his his second day of third year, for crying out loud. And he is woefully ignorant of the collateral circulation supplying the anterior two-thirds of the left adrenal gland even though he should have learned this in first year anatomy.

Family Medicine: I detected a lot of resistance from Student Doctor Bear. He seems reluctant to hug the patients and his sympathetic nodding skills are woefully inadequate. His empathy skills also need work. For example, when a patient complains about knee pain Student Doctor Bear needs to refer her to physical therapy, not comment that it is “No wonder because every time you stand up you squat-press a small German car.”

Family Medicine: He’s not buying it. Student Doctor Bear is not ready to board the Primary Care Mother Ship. Maybe we could have tried sleep deprivation and a low protein diet but he we didn’t have the time.

Clinical Evaluations

Dawn of the Dead

Loaves and Fishes

The body of Mr. Dubois recedes into the shadows as the nurse turns down the lights. His family wants some time with him before he is taken wherever it is we take the bodies of those who finally exhaust our ability to reanimate them. Mr. Dubois did not go quickly or easily. His death has spanned months, if not years. The massive stroke which finally finished him off was just the last in a series of insults, all of which steadily whittled away at his intellect, his quality of life, but never the conviction of his family that he needed to be kept alive at all costs.

The details of Mr. Dubois’ decline are familiar to anyone who has worked in an intensive care unit. Already in poor health from numerous chronic medical problems as well as mildly demented, he suffered a minor stroke and became bed-ridden. His wife, in poor health herself, was unable to transfer him from his bed to a bedside commode and his children eventually moved him to a nursing home where, with the exception of dialysis three times a week, he spent his days laying in his own urine. Over the course of a year he made several visits to the ICU where he was treated for pneumonia and sepsis, urinary tract infection and sepsis, sacral decubitus ulcers and sepsis, and finally a COPD exacerbation with pneumonia and sepsis. This lead to the final, massive stroke which should have finished him off except that after years of neglect, his family was still not ready to let him go.

They were perfectly willing to park him in a nursing home, you understand, as long as they didn’t have to think about him. I’m sure they visited even if the visits eventually tapered off to a hurried fifteen minutes every other week, visits more to demonstrate that they still cared than to look after Mr. Dubois who lay in his bed literally rotting away both mentally and physically.

At the end the family didn’t want Mr. Dubois to suffer, at least not while they were around. I’m sure they didn’t lose sleep over the suffering he endured as an immobile piece of bodily-fluid producing meat in his fly-blown nursing home. But in the hospital, with the doctor and skilled ICU nurses it was all sanctimony and reverence.

The contracted, slack-jawed body of Mr. Dubois continued its leisurely spiral towards death as we used every expensive weapon in our arsenal and spent tens of thousands of somebody else’s dollars in our absolutely inexplicable desire to play along with the family’s delusions.

The family’s delusions, like most, grew in isolation of the basic facts. I suppose if his family had taken care of him at their home as was the case for almost all of human history the story might be different. If they were the ones cleaning his bowel movements, spooning soft food into his mouth, or living with the rotten smell of ulcerating bed sores, one of which had eroded down to his sacral bones, they might have been relieved at his death, both for their own sake and his.

Nor did they give a thought to the cost of his many hospital stays, the total amount of which is almost impossible to calculate. Somebody else will pay, they always do. He’s paid taxes his whole life, goes the mantra, so let Medicare handle it despite the fact that one week in the ICU probably ate Mr. Dubois’ entire lifetime contribution to the system.

A day in the ICU costs several thousand dollars with only a minimal level of care. Then there are the many paid specialists continually consulted to tell us what we already know, namely that Mr. Dubois is dying. The nephrologists shakes his head sorrowfully over his kidneys. The cardiologist writes notes and orders expensive studies which reveal that his heart is bad. The gastroenterologist fails to discover the source of his frequent melanotic stools and the hematologist advises that even though his leukemia is going to kill him in a few weeks (guaranteed) we should go ahead and transfuse four units.

The vascular surgeon, the only realist in the bunch, when consulted for a possible repair of Mr. Dubois’ dangerously bulging abdominal aortic aneurysm says, “Are you fucking kidding me?”

Too bad he can’t write that in his consult note. The dry precision of medical prose gives the illusion that we are in control of Mr. Dubois and could turn him around with a little coordination between the medical specialties. The family certainly buys into this notion. Aren’t all of his medical problems being managed? Don’t doctors have all the answers with their extensive education and big words? Surely all of those monitors, pumps, and flashing lights must be doing something. We’re not asking for loaves and fishes here, doc. Just keep his heart beating.

So that’s what we do. In the end all we are really doing is giving the house staff valuable experience running ACLS codes. We get a carotid pulse back and beam with pleasure at the good thing we have done despite the fact that it is taking three different pressors to keep his blood pressure compatible with life and to remove any one of them will be the end of Mr. Dubois. What we’ve really done is paint ourselves into a corner. He is never coming off the pressors. In about a day, if he lives that long, Mr. Dubois’ toes and fingers are going to start rotting off.

Perhaps then we can withdraw support, if it’s all right with the family that is.

Dawn of the Dead

Mr. Smith Has an Epiphany

I’ve got Your Back

It’s my wife. The pager displays our super-secret marital code for “Everything is all right. I just want to see how you are doing. Call me at home.”

“Hey baby,” I say when my lovely wife picks up, “How’s everything going?”

“I’ll be home in another hour. Sorry. Things are kind of busy tonight and I have a couple of patients I can’t sign out just yet…OK, I’ll see you when I get home…I love you too…bye.”

Mr. Smith sits in his hall bed and gapes.

“Don’t gape, Mr. Smith. Even doctors have families. Hard to believe, huh? You probably think that we live here which is understandable because we’re never closed and there’s always someone here when you come in with one bullshit complaint or another. It’s not like you’ve ever been turned away when you come looking for narcotics. You might not get them every time but somebody always takes you back, treats you with more respect than you probably deserve, and listens intently to your latest drug-seeking gambit.”

“In fact, I even like to go home at a regular hour if you can believe that. Sometimes I can’t because in this department we try to get a disposition on everybody before we leave, something I had almost accomplished until I made the mistake of picking up your chart. But why should I mind? My children will get to bed tonight just fine without me and I certainly spend too much time watching TV with my wife anyways. The importance of your chest pain, on the other hand, does not diminish just because you’ve been here six times in the last two months with a similar complaint. I’m pretty confident that you’re going to be just fine but I’d feel bad chasing you out if this time, and I’m just talking here, it was a real heart attack. I don’t see how the world could get along without your vibrant soul.”

“Oh no. Don’t get up. Sit. Stay a while. I’m on a hunt for cardiac enzymes and this time your blood is going to score! The normal EKG was disappointing, I’ll admit, but your constant “ten-out-of-ten” chest pain radiating up your neck encourages me. This could be the big one. You’ve just got to believe, Mr. Smith.”

“Are you falling asleep? Brave soul! Your pain is so intense that it is no wonder you seek the oblivion of slumber. It was even untouched by the morphine I reluctantly gave you before I realized who you were. I’d give you something stronger but I’m at a loss for what to give except that we both agree it probably starts with a “D”. How can you expect me to remember its name if you can’t?”

“I understand what you mean when you say that you have no power and the man is sticking it to you. On the other hand, here we are. I have a college degree, two years of graduate school, a medical degree and two years of residency training. My attending has all that plus a few years of a fellowship. You may have not graduated from high school and be the most hard-luck guy in town but you have the power to make us dance like trained monkeys just by uttering three little words:”

“My chest hurts.”

“Now that’s power. Not to mention our highly skilled nurses cleaning up your urine and the fine technicians in our lab feverishly analyzing you blood as if you were the great Tsar of Russia himself.”

“So no, I don’t mind seeing you. The paper work is not too bad. I feel kind of silly writing out your discharge instructions seeing as we’ve done it exactly the same many times before. I know you get a good laugh out of “Return to Emergency Department if pain returns and is not relieved by nitroglycerine.” I think it’s funny too. Especially that part about following up with your primary care physician. That guy is always out of town. How on earth can you follow up with him?”

“Don’t worry, Mr. Smith. I got your back. You’re covered. Sleep, gentle spirit. When you awake I hope to give you the good news that your heart is fine and Motrin, not narcotics, will ease the pain.”

Mr. Smith Has an Epiphany