Getting Better Care

Concierge medicine or retainer medicine has been discussed by other, far more eloquent bloggers. I suggest that you read their material before continuing with this thread – but that’s just my humble opinion (don’t expect this to tell you much of anything about the topic as I really haven’t researched it to the Nth degree - more just my opinion than anything).

What I understand of the problems with primary care medicine has a lot to do with reimbursement and physician/ patient dissatisfaction. Considering that you have to deal with insurance company flunkies telling you that you’re not getting paid for some obscure reason or having a jackass with no medical education whatsoever pouring through years of medical files in order to request that you pay back the meager amount of money they considered adequate you can begin to understand why medical students throughout the US are avoiding primary care like the plague (now that’s a long sentence).

You should also be able to see that a doctor, burdened with these restrictions, increasingly diminishing returns for each patient, and the increasing cost of keeping a business running feels that they have to take care of patients in less than an optimal manner. Because of these feelings the physician becomes depressed, hates his profession and field, and ultimately leaves medicine earlier than planned.

Enter the new breed of physician. One who realizes that their time is not being spent wisely, that the insurance companies are forcing doctors to practice dangerously in order to make ends meet, or that docs all over are just opting out of medicine altogether. Some of these younger physicians, strained by the largest debt load ever encountered for their education, have decided to throw off the traditional shackles bestowed upon them by the myopic, arrogant, older generations and take their businesses back.

Retainer medicine is a form of this revolution. I remember seeing a report, long before medical school, about a doctor who performed house calls, saw ten or fewer patients a day, and was loved by his patients. It was surprising to learn that he required all his patients to pay a monthly premium, regardless of their usage, and was not considered “greedy” by those he treated. This was my first encounter with retainer medicine and it honestly made a lot of sense.

My understanding (faulty perhaps) is that a doctor, refusing to take insurance, asks his patients to pay a sum each month for services – regardless of whether the patient uses them or not - wherein the physician enters into a contract with them. The patient then has the ability to see the doctor when they need them and both parties can “fire” the other based on contractual agreement. This allows the physician to see fewer patients in their clinic, take as long as needed with each patient, and manage them to both the physician’s and (major plus) the patient's satisfaction.

You see, paying doctors per visit or procedure, as is done by most insurance companies, only forces primary care docs to see more patients each day – thus reducing their ability to care for their patients as they desire. It is hurtful to each, but the doctor suffers greatly from a feeling that they are betraying their patients in order to stay in business or meet every absurd insurance mandate. In effect they are at war between taking care of the people entrusting their care to them and the compensatory aspect that is absolutely mandatory to medical care. Concierge or retainer medicine reduces this because the patient pays the doctor, not their insurance, and they can treat the patient as they feel is necessary.

For primary care doctors, I feel that this a tremendous advantage to provide quality healthcare. At the same time it allows the patient to be more involved with their care, enables them to get a clearer understanding of their diseases and medications, and decreases feelings that they aren’t being cared for appropriately.

Some argue that there is an ethical disparity inherent in this program. Essentially their argument centers around the idea that the poorer populations will not be able to receive the same care and they feel that physicians who employ this form of practice are not allowing indigent populations access to healthcare. While I do understand this concern I don’t agree that the physician who decides to practice retainer medicine is being unethical. In fact, I feel they are more ethically motivated as they are now able to see and care for their patient based entirely on their training and medical expertise – not a medical officer hundreds of miles away who never sees patients.

I offered you two opposing view points earlier. Clearly I feel that Dr. Centor makes a valid observation and clearly illustrates reasons that this form of medicine allows for better health care. Given his years of experience, both personal and second hand, I feel he understands this concept more fully than the opposing view offered by Graham.

My appreciation of Graham is that of a medical student who, being a very bright and energetic individual, still completely buys into what’s being sold him by the old guard. While I’ve enjoyed some of his posts, I feel that Graham’s ideas are erroneous and posses a great deal of martyrdom to them that's bereft of responsibilities beyond them. There is absolutely no reason that a physician, regardless of their ability, should be required to care for people who can’t offer adequate compensation. I certainly applaud those who wish to help those who can’t pay, like Graham who states that he enjoys the prospect of EM because “seeing uninsured patients, [is] something I love about the field”. That’s great, but don’t force others to commit to providing less than stellar care to their patients just to see patients who can’t pay.

Scary as Hell

Here are a couple pics of a car that my family and I saw while shopping the other day. This spot, in case you can't tell, is a handicapped parking spot that's supposed to be lengthwise - like a spot for a large van or bus. However, this individual parked as if it was a pull in (similar to the cars opposite it). What's even better is the fact that, even though they parked like it was a pull in spot, they were still a mile away from the pole where the "Van Accessible" handicap sign was posted...ass hanging out all over the place. Despite being humorous (we all had a great laugh going in and coming out) I find it very scary that someone who can't figure out how to park in a single handicapped spot is still allowed to drive.

If you're curious, no, we didn't see who was driving. And yes, we were at Target.

Avarice and Health

Many bloggers are discussing the nature of people going into extreme debt at this time of year – procuring expensive electronic items with little to no argument about the cost. It is, of course, only natural to make the connection between the money spent on frivolous expenditures while we wring our hands over what to do about the poor and healthcare. What must be seen, if you haven’t already seen the absurd juxtaposition is this: these same people, who spend several hundreds to thousands of dollars for one day’s avarice are the exact same who bemoan the cost of healthcare and villify the physician.

Personally I have changing views on the subject. I used to believe that universal coverage was the best option – in effect, socialized medicine. Then I began reading about the Canadian and the NHS, their troubles, and realized that, even though their citizens are covered, they had harder times getting people to use the system correctly, providers throughout all spectrums were incredibly taxed to work "within" the system, and the outcomes were not much improved. Now I find myself less inclined towards universal healthcare, but struggling to find a plan that makes the most sense.

I do know that some of the political ideas of taxing physicians in order to help cover healthcare for the poor are just monstrously ignorant. Why should those who have to suffer direct losses from this patient population be forced to incur further decompensation simply because of their profession? Do we honestly expect doctors, the one profession that has little to no say in what they receive in reimbursement, to keep allowing insurance companies to decrease their payments precipitously while, at the same time begin taxing them for indigent populations for whom they've never received compensation? Would lawyers be so willing, I wonder, to take hits in the same respect as that offered by some of their colleagues? We all know the answer to that.

The idea of requisite health insurance seems more on the right track. We require people to have car insurance based on the degree of risk inherent with owning an automobile, so why not coverage for their health needs? Certainly people realize that at one time or another they’ll need the healthcare industry – either for minor ailments or severe conditions – and should be more capable of contributing towards their care. We are, as humans, inherently at risk each and every day.

Making people comprehend that they are responsible for covering their asses won’t be easy though. Massachussets has had significant backlash regarding their plan, some due to the significant cost of covering oneself, but a great deal from the parasitic nature of lower income and young populations. The idea of having to pay for something that one might never use has been routinely touted as a justifiable reason to avoid insurance mandates by those refusing to buy into the idea.

Despite the problems encountered by Massachussets, I feel its ideals are on the right track – shifting the responsibility onto those who are actually culpable for their actions and less on those who just have to deal with them. People are so eager to get the newest cell phone accessory, iPod, or fanciest TV regardless of their income level, but refuse to spend a few bucks each week towards their healthcare. Cigarettes continue to increase in price, yet the 1+ pack per day smoker doesn’t cut down on their habit, just their luxuries – like bills and responsible spending. I cannot count the numerous times I’ve seen someone with little to no insurance, complaining about the cost of their care, with a fancy cell phone, cigarettes, and a tricked out car who inevitably heads to the nearest fast food chain for lunch. It’s actually quite ironic to consider that the money spent on these gadgets and behaviors actually decreases one’s health (cancer, hearing loss, obesity, HTN, heart disease, etc.).

While I certainly don’t have the answer, I do feel socialized medicine is not the option that’s best for this country. As a 4th year medical student, it’s hard for me to even begin to understand the complexities of payments, billing, and the business of medical care, but I have been able to gather enough information to understand socialized medicine will only fail patients and providers together.

Bandwagoneer

A list of the top grossing movies over 2007. Of interest to me is the fact that I either purchased tickets or the DVD to see every single one except 300* and Wild Hogs. Who says I don't follow the crowd?

* Currently on Netflix account...will arrive someday.

To Do List

The family had a terrific Christmas yesterday. The kiddies were very excited Christmas Eve and were awake by 4am Christmas morning! Coffee, needless to say, was mandatory. Stepson was with us from Monday till noon on Christmas before he went to his dad’s. Once there he called after a couple hours and asked for us to bring over some of his gifts – he was bored. All I could think was, yes!

Wife, Daughter and I went to see a movie as well. We saw The Water Horse which was an OK kids movie. Daughter really liked it, but it had some weird parts where I thought, that's a little dark for a kids movie...but whatever. It was nice though, to get out of the house in the evening. Wife feels that Christmas evening is always a bit anticlimactic, especially since we don't have anyone we spend it with, and getting out of the house shakes things up a bit.

So I wish that I could relax today, but here is a small list of the items that I realized I have to accomplish by the end of this week (or maybe next week):

1) Register my car. I would like to avoid getting a ticket for expired registration by one day - like what happened last year - on the way to my first day of a rotation. I can use $140 for better things than citations.
2) Take Daughter to her doctor’s office. She has been sick for over a week now and I can no longer convince myself that it’s simply a viral URI. Especially since she started to complain about her ear hurting and, upon inspection, I found it to be angry, bulging, and red looking. Amoxicillin, 60-80 mg/kg bid-tid for 5-7 days, if I remember correctly.
3) Order copies of my birth certificate and have it express mailed. I was looking at my driver’s license the other day and realized that after 8 years without having to obtain a new one this expires in 2 weeks. Unfortunately in this state I have to have my first renewal at the DMV (bastards!) and can’t just get a mail-it-in renewal. I also realized that I can’t dawdle on this since I have to fly to a few more interviews in January, with one being the 6th-8th, and an expired license will no longer be accepted as identification! Crap.
4) Hang out with freaks at the DMV…see above.
5) Find out if my next rotation starts next week or the week after. An e-mail sent out last week stated we were starting 5 days later than the scheduled by the school. I’ll be out of town on that date and don't want them cutting me out of the class if I don't show the first few days.
6) Plan Wife’s birthday party and get reservations for dinner.

So as you can see…a few things to do. Some more important than others, but all important.

Jealous

Here is a pic of one of the coolest damn tattoos I've seen. There are many others listed at this site that I've looked at from time to time. I wish that I could get something like that, but, you know...medicine and all. I don't think it would go over well - even if it is anatomically accurate.

Stereotypes

The trail d'interview has taken some time off, at least for the next couple weeks. Thank God. I have never had to sleep in an airport – ever - until interview time began. I can now say that one of the more uncomfortable, annoying, and stupefying processes I’ve experienced is being stuck in an airport for 24+ hours. I really wish those seats could be converted into something you could recline on. Makes sense…I think.

Anyway, while out at other hospitals of various cities I’ve noticed a trend. You can always tell who the medical students, nurses, residents, and attendings are in the hospital. Just a little musing of mine, done at 3am while wishing to fall asleep on a very uncomfortable airport chair, but I thought that some of the non-med people might enjoy knowing how to tell the difference:

Medical Student: Of course, as if you required any other method to identify the future of medicine (laugh now…not so funny when they’re actually docs), the med studs are easily identified wearing the traditional, ass-enlarging, short white coats – stuffed full of books, tools of unimportance, and papers. They go about their business, eyeing everyone, but taking care to not be seen staring at particular individuals. If you needed anything more to identify the one person who has no authority over your care whatsoever we’d have to put an “I’m with stupid shirt” underneath the coat. The short coat has never and will never look good. On anyone. Often med students are seen as you are first admitted, getting the long and very detailed H&P in a haphazard fashion. They’re also seen very early in the morning and before dinner trying to get ready for rounds – you’ll most likely be sleeping when encountering them. After that you won’t see them unless a painful or humiliating procedure is about to be performed.

Nurse: This is a bit trickier, since this is more or less a gender and floor based observation, but they often wear the “fun scrubs”. You know the kind: cartoon animals, hobby oriented, bright, multi-colored garments that, for reasons unknown to me, are reserved for the nursing profession (like a white man trying to wear urban clothing, anyone else just doesn’t look right wearing these). I’ve seen nursing students wear mono-colored, dark apparel that suddenly transforms into the “fun nurse” scrubs upon graduating. I’ve also seen nurses who wore this festive garb (at least in their older pics) who, upon entering medical school, ditched them for the more restrictive patterns of hospital issued wear. There also seems to be a proclivity towards wearing scrubs with multiple pockets in them – like the front of the shirt or all down the side of the pants. Another trait inherent to the nurse is the ability to talk about more than just medicine. They have lives, are aware of the outside world, and can make your day with their humorous, if not off-colored jokes. However, since you’re going to have more interaction with these healthcare professionals than almost anyone else, you’d have to be in a coma to not know who the nurses are in charge of your care.

Resident: Depending on the degree of training they’re at, residents come in multiple forms. Interns are worn out, haggard, shells of human beings. Often they carry tremendous amounts of paperwork, small books, and 3-4 pagers/ cell phones/ shackles on them at all times. Like the medical student they hold almost no power, but are in charge of a lot of your care. Very similar to medical students, they also obtain your intake H&P, do most of the procedures and embarrassing jobs, and wake you from sleep. You can identify them, if for nothing else, by the fact that they have a long white coat and a name tag with an MD or DO following their name – often with a deer in the headlights look 24/7. Having survived the intern year, residents are more confident appearing, have less and less crap occupying their pockets, and see you less. If they see you in morning, you’ve already been awakened by a lower member of the team. They can also be identified by their position when a large mass of white coats enters your room – the more senior residents get to follow behind “your doctor” more closely. The intern is just before the medical student…the shame.

Attending: This can be “your doctor”, the one that you’ve seen regularly as an outpatient who admitted you to the hospital or is going to cut on you and take care of that problem. This may also be someone that you’ve never met before, but is in charge of your care – albeit from a distance. They bill you, are seen the least out of everyone involved in your care, and often are the oldest of the group. When the mass of white coats enter your room, they are first – always. If they begin to talk while others are talking, everyone else shuts up or laughs at their stupid jokes. We smile as they discuss their lovely weekend and “hop to it” when they ask for anything. Beyond that, look for the wet spots on their rears as the “team” kisses their ass multiple times during the day.

My First Time

I remember my first inpatient experience well. The patient is burned into my mind as a constant declaration of the ignorance that I held entering the clinical aspects of medicine. To be honest I found this person disgusting, repulsive, and inhuman. A perception that I did not wish to have betrayed to my superiors or my patient.

This feeling was uncomfortable and appaling. Over the last 2 years I’d been indoctrinated with the ideals of the “ethical physician” and the “professionalism” I must inculcate before meeting real patients. Despite the many fantastic thoughts and discussions we as a class had entertained, these forums, as well meaning as any, were utterly useless upon this first meeting.

Homeless, IV drug addicted, and crippled with disease, the patient came to us earlier that morning while I oriented to the inpatient wards. Upon entering the room I beheld a haggard, disheveled, and desperate form. Reeking of a filth known only to years of hardened drug use, I realized and withheld the primordial urge to retch and vacate the room.

“A full history and physical.” was the task charged me by my senior resident. "You will need to get a full H&P, write it out, and present it to me later today along with a differential and plan." Considering I'd never done a full blown physical, I knew I would need at least an hour with this patient and was not looking forward to our prolonged encounter.

Even though the intern was finishing up his H&P when I entered, I had to revisit every last detail already procured. The patient, clearly upset over this obvious intrusion, deferred several questions, cursed my stupidity readily, and resisted any attempts at a full physical. The anger inherent in the eyes was penetrating. Trust was not given nor expected, just more hurt, and he wished to inflict it before receiving.

Over the next week and a half “my patient” grew more tiresome. Pre-rounding was endless, useless, and ultimately absurd. The only information gathered was from forcing myself on the chest wall, abdomen, back, and head in order to elicit the heart sounds, breath sounds, and other physical tasks requisite of me after questioning the lethargic night nurses for overnight events.

Once able to hold a semblance of conversation, my patient soon withdrew from everyone and became mute. On one occasion I found my senior yelling in exasperation as she attempted to get consent for treatment. She no longer rounded unless the attending requested – leaving only the intern and I looking after the patient in the early mornings. The hate emanating from those eyes was palpable. We all felt it.


Regardless of the hate, the battles, and the apparent lack of concern about their declining condition the patient did not leave. Eventually a surgeon at another hospital agreed to fix the problem, and they were thankfully transferred off our service.

A month later, while on surgery, I heard a coarse, rough, and demanding voice yelling from a room.

“NURSE!” it boomed out of the darkened room. Despite the days of silence, I still instantly recognized it as my former patient’s.

My first instincts were to walk away and ignore the voice. I was no longer on this service and thus, not responsible for this patient anymore. However, for reasons still unknown to me, I walked into the room.

Upon my entrance I felt the same misgivings I had previously. There the patient was, improved in some ways, but in others very similar. I wondered if the reasons for another hospitalization were due to drug use and thought quickly about the cost of treatment they’d received that would surely never be collected.

I informed my former patient that I was not the nurse, but would let them know they were needed. Then, turning to leave, I said as calmly as I could:

“I hope that you’re doing everything you were asked to get better. A lot went into your care to get that surgery and I don’t think you realize how hard it was to get that taken care of…don’t blow it.”

I then walked out. A part of me felt vindication – speaking out against the wretch who hated those trying their best to improve a hopeless life. However, another piece of me knew that my innocence of doctor-patient politics had been forever lost. The urge to “want to help those in need” had been challenged and clearly weakened. By saying what I did I had only perpetuated its decay, amongst both parties. Despite knowing that I should have remained silent, I felt the need to let this person know were tried for them. We worked hard, against a system designed to hinder progress and I was upset by their seeming displeasure of my team's daily work.

This patient still haunts me. I’ve not seen them since, but I frequently think of them. I did not hate this person, but I entertained such desires at times. In my innocence, as a 3rd year medical student, fresh on the hospital wards, I wanted my patients to want to be helped. Furthermore I hoped that they would appreciate our efforts. Unfortunately I learned that it’s not that simple and patients, like those caring for them, are people first and foremost. Some are just better than others.

Hard to Let Go

If you're anything like me then you have a favorite clothing item that you refuse to throw away. These shoes, over 2 years old, are the most comfortable footwear I've had in a long time. Wife hates them, asks me when I'm going to get rid of them, and blushes in shame if I wear them anywhere with her. They're well worn, dirty, and greyed, but are just not going anywhere. They've stood up to long hours retracting in the OR and have dealt with the ignominy of the OB "incident". I'll toss almost anything else, but I just can't seem let these go.

Weekend Laziness

I have a confession: I was one of the millions who went to see the Chipmunks movie on opening day. There, I said it.

Actually I was one of those parents who, being a very loving parent, takes their kids to some crappy movie just to make them happy. Because it was crappy. Really crappy. There was such an abundance of crapitude in the movie that I began wondering who else wanted their soda to be spiked with hard liquor to ease the cerebral pain. A couple things that I just couldn’t get over, amongst the plethora of issues (would you say I have a plethora – sorry, just had to), were these items:

First: Dave got way to comfy with having talking Chipmunks in his house. Just like, eh whatever, lil’ dudes. Make me money! In fact, everyone was a little too comfy with talking rodents.

Second: I feel bad saying this, as I’m a big fan of Jason Lee’s, but he did not get the Alvin yell down – at all. It sounded completely phony and forced. Like he wasn’t actually yelling at anything (you know, like there wasn’t an actual talking chipmunk causing chaos in front of him). I guess some people are just better at pretending they're interacting with something that will be added later while others are stiff. Lee was stiff.

Another movie I saw over the weekend (yes, productive) was ‘I am Legend’. Good movie overall, lots of suspense, superb acting by Will Smith, and a post-apocalyptic/ zombie background – awesome. I do have one thing I’d like to say, though. Even though this was a movie I’d definitely want to see again, I wish movie makers would realize that not seeing every detail actually makes creatures scarier. At the end you’ve seen the zombies so much that you’re no longer jumping at them and actually laugh a couple times.

Oh yeah, I also got much needed maintenance done on my car. Like belts replaced, new tranie fluid, brakes, etc. So it wasn’t a completely wasted weekend. What did you do with your time?

Oh Dear

Stepson came up to me and asked me a rather innocent question:

"How did Dairy Queen get pregnant?"

Oh god, I thought...here it comes.

"I have no idea." I stated, waiting for the obviously adolescent punch line.

"Because Burger King couldn't keep his whopper in his pants!"

Ah, yes, middle school.

I'm Getting Nothin' For Christmas...

Dropping off Daughter at her preschool the other morning she began to tell her teacher about all the presents under our tree. She then explained that there were 3 presents for her, 3 for Stepson, and 2 for daddy. Her teacher, apparently oblivious to men’s penchant to shop at the last minute, asked where mommy’s gifts were. Daughter looked at her with a remorseful look and, in her most grave voice, said:

“They’re gone. She doesn’t get any 'cause Santa’s mad at her. She not be good.”

I guess I’d better get to it and get at least one thing under the tree.

Crazy Bitch

I’d heard that you can run into people that you’ve seen at external rotations or at other interviews on the interview trail. Certainly I've had a few encounters beyond the initial, but the other day I ran into a female student whom I’d interacted with during my 1st external rotation.

She, being on a Psych rotation, had been in the ORs occasionally when ECT treatments were being administered. We had talked, because we were curious of the process, and during that time our interactions were professional, brief, and pleasant. Running into her during a prolonged wait in an airport somewhere in the US, however, had a very different feel.

Now, I must inform you that she was quite comely. She also held the rare ability to take over a room upon her entrance and smells great. She is, essentially, a siren of healthcare. Patients loved talking to her, having her around, and she was always loved by the healthcare team. When I ran into her she still held this essence. What changed, though, was her demeanor.

She was nuts. Not just a little, either, but full blown crazy! She began by yelling "HI!" loudly, trying to hug me, which I deferred, then ran into a non-stop regurgitation of her interviews. She talked with great enthusiasm about the other candidates and what she thought about each and everyone, her voice reaching levels so high that I found others watching us. As I tried to get a word in edge-wise she launched into her time at the external hospital, how much fun she had, and the (here it comes) intimate interactions she had during that rotation.

I wanted to stop her, but she continued. Continued to let me know that she had met several nice people, they’d partied, and ultimately fucked. Hard - and long – and over and over again. She was detailed to the point of obscene at points, and I finally had to tell her my flight was close, said goodbye, and walked away. She again tried to hug me and I walked faster. A small crowd of lustful men and astonished women had formed a semi-circle around us, making my departure even more frustrating.

My mind was screaming – what the hell was that! Why did she feel that she needed to inform me of her “activities”? Why did she keep trying to hug me? Damn!

Thankfully I did not see her again, as I still had 3 more hours of waiting before my flight boarded, but I was looking around like mad. I didn’t want another encounter, with an X-rated description of her debauchery, and the expected attempts at physical interaction. Yikes!

Certainly Not

So I was in Philadelphia the other day and, well, just loved it. That is to say I loved hating the hell out of it. Large cities and me do not mix well at all - I hated being honked at for not trying to run down pedestrians, hated having to hide my GPS so that I wouldn't get jacked while navigating streets around the airport, and hated the dirty look of the city - I mean, how many industrial plants do you have?

During this process of hating this area I had to consider doing a residency there. Certainly you jest. Come on now, if I hated it that much during the brief period I was there, imagine my misery 4 years later. No rank for you.

H.U.A

HUA = head up ass.

Mr. Bush has certainly qualified for this distinction in the past, but he's never deserved it more than he does now. Despite intelligence reports stating that the state of nuclear affairs in Iran is not as bad as previously believed, the "president" continues to make threats:

Bush said the new intel "contradicting earlier US assessments...would not prompt him to take off the table the possibility of pre-emptive military action against Iran."

Um, excuse me, Mr. President...just when are you going to learn from your mistakes? Is this not the same bullshit you tried to spin about Iraq? Do you really think you have enough trust with the American public and congress to actually try and start a 3rd front? No, sir, you do not.

You're acting like a child - refusing to hear the truth with your fingers in your ears chanting "nyah, nyah, nyah, I can't hear you". Why don't you sit down and take a time out? Please, for the love of God, just stop!

It's Christmas Time!

This year, Christmas has been very fun for our family. Daughter, being 3, has developed quite the interest in the holiday and has wanted to participate in every aspect of decorating and getting the apartment fit for Christmas. Along with Stepson who continues to try and prove to us he still believes in Santa (which he doesn't, but he wants to get presents) they are an interesting duo to observe during this time of year. Daughter can often be found looking at the tree and running around screaming with glee: "It's Christmas time! It's Christmas time!"

What’s been great is that we have a few of the traditional Christmas DVD’s that Daughter has, prior to this year, not been interested in watching. However this year she’s watched Rudolph the Red Nosed Reindeer, Santa Claus is Comin’ to Town, and The Grinch Who Stole Christmas (the real one and not that crappy remake with Jim Carrey) over and over again. She loves them.

While I was out interviewing Wife took her to Build a Bear and they purchased the Rudolph and Clarice reindeers. Daughter takes them to bed with her nightly and sits with them while watching any movie about Santa. It’s been a lot of fun and I know that this will be the last year where I can take more time to appreciate her interest fully. Thankfully I took this month off for interviewing to have the holiday season to myself without worrying about some damn rotation and their stupid requirements - I'm not interested in faking it right now.

7 Things

Even thought I wasn’t officially tagged, I kinda like the 7 things about me meme I read on a few blogs and will be taking Dr. Liana up on her suggested tagging.

1) I won’t read a blog if it has South Park characters or Looney Toons cartoons on the personal info area. Really. How can I take you seriously if I keep seeing some kid on South Park or Bugs Bunny to the left or right of your most recent post? I can’t, just can’t…so I don’t. Regardless of the content – I cannot get past that.

2) I have problems with my body image. Sounds like a girl issue, but in all honesty I’ve never been comfortable with how I look. I think it stems from where I grew up and the constant harassment I dealt with by my neighbors and classmates regarding my “weight issue”. Even when I was quite fit I thought I had to improve and have since realized that at times I had eating disorders. I’ve gotten a little better, but I’m constantly judging how I look, how fat I feel, and change clothes frequently based on what I think. I also find myself constantly looking at others and evaluating them just to compare. It's juvenile, stupid, and it gets old fast.

3) I’ve been a commissioned artist. While in high school and a couple times in undergrad while pursuing an art degree I had people request and purchase specific pieces from me. It was not a lot of money, but I loved doing it. One of the first that I did was when I was in middle school and my uncle wanted a watercolor of the Starship Enterprise fighting off a Klingon cruiser - he still has it in his theatre room near some memorabilia which is really nice of him. Now, thanks to medicine, I haven’t drawn or painted anything substantial beyond quick sketches in the last four years. Thanks a lot med school– well rounded personalities my ass!

4) To help with my image issues I’m also going bald. Wife has pointed out a little freckle on the top of my head that we’ve used as a reference point in pictures and while looking in the mirror when I buzz my hair*. The hairline keeps retreating, but only in certain spots, leaving me with an ‘M’ shaped hairline. Attractive.
* 4a - I cut my own hair

5) I have 4 tattoos – one unfinished and 2 that I’ve tried to have removed, but are still visible. I wear long sleeved shirts all the time in order to avoid having them seen, but at times in the OR I’ve had to expose them. For a while I was called "Dr. Tattoo" by some nurses. It got old quick.

6) I constantly evaluate people’s hands. I try to see how worn they are, do they fidget, do they keep them in their pockets, or are they sweaty? I inspect their nails and determine how clean they are, are they well maintained, does the person bite them, or are they dirty? Since doing some anesthesia rotations I've now begun to look at their veins as well in order to assess how large an IV I could use. I think hands tell a lot about a person without too much being said by anyone and are less likely to make someone nervous if you're looking at their hands for a minute or so.

7) I grew up a Mormon. Being from Utah that’s kinda the standard for a large percentage of the population and I was no different. I’m inactive now, but my name is still on their records and every now and then I get some call from someone who is supposed to check up on me. A lot of my family is still active and practicing in the church, but I’m under the belief that most religion is full of personal agendas and no one religion is correct. Therefore I’m agnostic – and loving it.


I won't tag anyone because I feel that you should just do these based on an interest. Go ahead or don't, I don't care (actually I do, but I don't want to seem needy).

You Don't Have Cancer

During my 3rd year surgery rotation I was allowed to work in our “ED” for 2 weeks. While it was called an Emergency Room it was really nothing more than an urgent care clinic for the homeless and stupid, but it’s what we had. I had some thoughts of entering this field, but had been wavering since beginning my clinical rotations. The cases regularly seen by our department and the nature of the work soon wore on me and forever soured me against this specialty.

However, despite the absurd complaints, the runny noses, the drunks, and the pride-swallowing displays I saw on a regular basis there was one encounter that made me realize that EM was truly not suited for me.

I arrived, late one day due to a morning conference, and found the usually cheerful chairman in a very foul mood. Thinking that his anger was due to our tardiness I tried to explain where we’d been. He quickly told me he didn’t care, told me to see patients, and walked into an exam room.

A few minutes later, while talking to an EMT student, I heard this doctor and a patient yelling at one another in a room. The chair left the room, clearly upset, followed by a strung out, gaunt, crazy-looking woman crying afoul.

“You’re heartless! I have cancer! I have cancer and you’re not doing anything for me! I always get this for my pain! You’re an asshole. I’m calling your supervisor and getting you fired!”

Chair, turning around quickly, pointing his finger at her: “No you don’t! You do not have cancer, there is not a shred of proof you have (certain type of) cancer, and I don’t care anymore. Go ahead and complain, I’m the highest you’ll get in this department and I’m done listening to you!”

With that he turned, finishing her discharge. When she tried to yell at him further he threw his hand up, like a teen-aged girl expressing her worldly wisdom with a quick “talk to the hand” and summarily dismissed this woman. She, furious, stormed away, paper in hand, cursing loudly and threatening to sue the “whole fucking bunch of you assholes!”

I was slack jawed - amazed at this seeming display of physician cynicism and the fact that he had actually thrown up his hand to shut her up. An hour later, as he predicted after she left, an administrator came down to the ED with the patient and confronted him.

Admin: “Why didn’t you take this patient seriously? How can you be so certain that she doesn’t have cancer? I want you to take care of her and do as she requests.”

This was all said to the chairman of the ED, with the patient acting like a spoiled child, arms folded over he chest and displaying a most distasteful “I told you so look”, while the staff stood around, trying to look busy, but clearly watching to see what would transpire.

The chair didn’t budge. He called out the administrator, asked what degree he had that conferred upon him the power to diagnose this woman with cancer when several physicians agreed that there was no evidence, and told him to write the script himself because he would not – he was not a drug dealer. He then added that, if this was the type of support they could expect from the administration and CEO they’d been promised during their monthly meeting, this would be his last shift.

Of course the administrator, trying to remain calm but clearly unnerved, relented and informed the woman that, unfortunately, they would not be able to help her at this time. They walked away and a nurse said he was inviting her to fill out a survey in order to help “increase efficiency”.

Aside from the humorous and tragic aspect of this case, this settled any desire to enter emerg for me. There was no way that I would tolerate that kind of abuse, by people who held MBAs or MPHs and knew nothing of actual medicine and only cared about customer service and maintaining a "hotel" image. There was no way I could stand up to that form of degradation regularly and feel that my sacrifices had been worth it. Medicine is not in the business of letting people "have it their way" only to get sued for complications. While it's not for me, I applaud anyone who can look at that on a daily basis and come back for more.

Wonderful World of Traveling

Driving over 1500 miles in 4 days for 2 dinners and 2 interviews, followed by a day’s break after which I then will drive a few hundred miles more to take Step 2 CS has made me edgy, dizzy, nauseous, and out-of-sorts. Plus being cooped up in a small rental car for hours and hours on end with no CD player and only the radio is enough to drive anyone crazy! I’ve come to find that I talk to myself a lot while driving – lovely. My advice? If you have more than a 4 hour trip by car - just fly. It's really not worth saving money if you think you'll throw an embolism from sitting so long or have to take hourly breaks to avoid the vertigo you get while driving in a thunderstorm, at night, with large trucks wizzing past you, and only your headlights to see.

In spite of this post-trip funk, the programs that I’ve interviewed with have been tremendous and really are screwing with my previous idea of what I would rank and where. I will have to take a long, hard, and completely honest look at all options and have insight from Wife before making any final commitments – what I thought would be high is being moved around a bit and programs I was a little wary of have been quite impressive. Damn...so tempting, but are they right for me? For us?

The interview trail is actually quite fun since you get to see a new city, meet some interesting people, and hear about interviews they've finished. The other day I heard about a program I'm interviewing at this month with the discussion being between two large city dwellers. Their focus was on the program's small city location and the interesting fact that, at times, it smells like chocolate. These candidates found it to be a tremendous program, but the area was just too small for them to consider it. They need a larger environment and this was more of a family place, I guess, so it might just be perfect for us - plus I've seen that there are lots of places where Wife could work within 30 minutes of the area...so it's all good.

What is the most fun, however, is to observe how people start acting weird once their level of anal-sphincter tightness declines. Sometimes they turn into real jackasses, helping you look a lot better and sometimes they are really cool and easy conversationalists. I'll be glad to have some time to just crash and not feel evaluated all the time, though. I really hate those dinners, not for the food, but for the forced social interaction with people I've never met and are judging me. For all their infamy, the interviews are nothing compared to those dang dinners - at least for me.

I've also had some programs ask me in a rather round-about way to explain why I'm at my school. It's not well known and has a somewhat, um, less then stellar rep in the medical field. I spin it very well, I think, but I find it interesting that I have to explain it at all. Perhaps they're wondering why someone with all of my obvious talent and wisdom wouldn't be at a more prestigious school - yeah right.

Debt Discussion

Further follow up from the last post is needed since there were some interesting comments about debt. I don’t think that the public is aware of the amount of money that medical education requires, how it increases regularly, and the overall push by the current administration to decrease or eliminate certain loans for this type of education.

The amount of debt you have varies based on several factors, but some of the more common include whether you’re in a state or private school (private usually being more expensive), if you have a family or are single, if you’ve been able to save prior to med school or have family that’s helping out, and if you’re married to another medical student. Being at a private school my tuition is 2-3 times higher than some state schools and therefore my amount of debt is that much higher as well. The average of $150,000 is based on all these factors, government incentive programs, and does not clearly account for many medical students.

Take me as an example: I have a family, attend a private school, and have only been able to qualify for a few small scholarships that are sometimes shared amongst several medical students (political reasons are mostly to blame for my pitiful scholarship awards). My tuition has ranged from $35,000 to $45,000 over the last 4 years and I have to max out on loans in order to be able to support my family.

My wife’s income has helped, but we ran out of our savings quickly in the first year and have to rely on my refunds at this point to pay rent, bills and put food on the table - all of which totals my overall loans out to about $55,000 on average per year. Now, multiply that by 4, add in some undergrad debt, and you can see how I’m looking at about a quarter of a million in student debt which doesn’t include mortgages, car payments, or other financial strains - like credit cards.

Many people aren’t aware of these astronomical burdens carried by new physicians, often deferred through residency (since you’re making like $8-9/hr), with increases each time your interest is capitalized. Many people in the healthcare industry don’t realize these costs either - since I’ve heard nurses call residents “overpaid”.

Once you leave residency this places a tremendous burden on your shoulders and has become a main reason many medical students are staying away from primary care. You can’t make enough to pay these bills, your overhead, and yourself anymore. After all of this sacrifice there is a need, completely understandable and quite appropriate, to be compensated adequately. But the idea of docs being rich right out of the starting gate is really just not true. I'd also bet that there are a lot of physicians out there that have been in practice for some time and still barely scrape enough together to have a decent lifestyle - probably primary docs mostly.

Debt to No Income Ratio

In an all too common occurrence, I've been reflecting on the amount of money I owe. It’s quite terrifying to think about the amount of debt that I’ve accumulated in the 8 years of pre and post graduate training I've endured. What’s even more fun is to think about gathering even more since I’ll most likely have 4 years or more with my residency/ fellowship all within the same area and have a distinct chance of staying on as faculty after finishing, at least for a year or two...so why not buy a house?

When I see the amount of debt that I have, what we owe on my wife’s car, and the credit cards (oh so stupidly used at times) I have flat out panic attacks. I freak out, consider the option of getting a part time job on the weekends, and briefly ponder robbing a bank. Briefly, people, briefly, but I still think about it.

I know that there are residencies out there where you can moonlight or earn extra money working past a certain time of day, but these are clearly not readily available nor are some of the programs tolerable beyong this fact. While these types of programs are quite tempting to apply to or rank highly I realize that residency is transient and a horrible training experience will only sour me on my profession, my chosen field, and the patients I care for. Plus my marriage will get the shit kicked out of it for a few extra bucks and a divorce would only increase the debt burden.

What frightens me the most, though, is the notion that I can’t make more money during this training. It’s not like I can get a 2nd job when times get tight or when unexpected bills fall on you. Not like medical school where an additional loan here or there could be applied for or the occasional male-strip club dancing that netted me a little fortune here and there from fat, desperate women (ala Dr. Hibbert).

I just keep hoping that my car will last long enough to make it through residency. I hope that the kids won’t need braces or any expensive medical care during this time. And I sure as hell hope that all the talk my wife does about once we “have money” is just talk and not serious – because it just makes me freak out more.

Attitudes: Surgeon and Anesthesiologist

Let me preface this post by saying I have a great deal of respect for surgeons and anesthesiologists. I entertained thoughts about both specialties and believe I would have made a great surgeon, but having decided to go to the other side of the blood-brain-barrier I have to make some effort to respond to these comments seen over at Dino's blog:

Hey you want that lab, you order it and deal with the result before you screw up the surgery schedule for everyone including the patient! I wonder how many anesthesiologist's are only children (I had to reply to this comment with the surgeon temper tantrum - children indeed)?

To this day I remain dumbfounded at how an anesthesiologist can walk into a room cold, review some pertinent facts on a patient and decide that administration of anesthesia won't be problem.

Having done a couple anesthesia months allowed me to see a little into the surgeon-anesthesiologist contest that constantly occurs, often behind the smoke and mirrors of surgical holding areas where patients sit anxiously awaiting. Most patients probably don’t even think about the anesthesiologist until they meet them right before they head back for surgery. Their surgeon is often the only doctor that they’ll remember from the entire event – unless something goes wrong and they try to sue everyone – but they don’t realize that the interplay between their surgery happening and staying alive during the case is often held in the hands of the “Gasman” and not the surgeon.

You see the anesthesiologist is often considered the “internist of the OR”. They check out patients the night before if they’re inpatients or review their history prior to the first meeting in order to optimize their anesthetic plan. This is done in order to understand what direction to take, what drugs to be wary of, whether another induction agent should be used over “white magic”, the medical illnesses a patient has that might need more attention in the OR, or if there are conditions that need to be evaluated further prior to anesthesia being delivered.

They are responsible for keeping the patient alive, not the surgeon (despite surgeons notoriety for saving people’s lives), and there are sometimes tests that have to be performed or evaluations done before surgery can commence to reduce morbidity or mortality. The problem that many surgeons have, at least from what I’ve seen, is the seemingly arbitrary demands that an anesthesiologist may have for a patient evaluation.

Well, it's a little more complicated than these two surgeons assume. Let's consider a 35 year old patient who is scheduled for an elective procedure related to gallstones. In the H&P the surgeon notes a congenital abnormality of the spine, but does not follow up more. The anesthesiologist reviews the abnormality the night before when they receive their case assignments, realizes that the location involves the cervical spine with potential for disasterous outcomes during intubation, and sees that the last check on the C-spine was over 2 years ago.

Had an anesthesiologist been able to see the patient in their preop clinic they could have anticipated the demand more than a surgeon concerned more about the chole and had a C-spine evaluation performed. However, because this outpatient surgery center or hospital doesn't require this before surgery the anesthesiologist often times only has the night before to be even aware of the cases scheduled and must attempt to obtain labs and other tests the day of surgery. The surgeon, however, sees only a delay and the lazy gasman as the cause.

This situation can be extremely frustrating to all involved, with the surgeon wondering how anyone can cancel or delay a case when only “seeing the patient for the first time and only for 5 minutes”, the patient is upset, hungry, and bewildered as to the delay, and the anesthesiologist wonders why in the hell this patient wasn’t properly preop’d as he's scapegoated by all involved.
Some surgeons call anesthesiologists lazy bums because of the belief that they sit and read or simply “watch the surgeon work”. There are some surgeons who believe, honestly, that they can administer anesthetics and operate at the same time. What they don’t understand is the fact that if it appears this way, then the anesthesiologist is doing their job well.

A patient who is tolerating anesthesia and has a rather stable operations is not just an everyday occurrence as many people believe – it requires diligence, understanding of complex physiology and pharmacology, and the training to maneuver through complications seemingly with ease. Just as an anesthesiologist shouldn't pretend to know how to perform surgery a surgeon shouldn't assume they know how to deliver anesthesia.

I’ve seen it go bad, though, when the patient crashes, things are going wrong, and the surgeons look wide-eyed as the anesthesiologist attempts to combat the grip of the reaper - sometimes after a completely uneventful operation. At these times the surgeons may offer advice, but more often than not they stand back and watch. Many times these events were unexpected, but occasionally there are hints that were overlooked in the original H&P that could have steered the anesthesiologist on a different course to avoid complications.

This has lead some hospitals to require preop evaluations by both the surgeon and anesthesiologist, since they often have differing needs and questions prior to surgery and this maximizes good outcomes. However, at least at the academic settings I've been involved, the cases are not listed until the late afternoon or early evening, are subject to change and add-ons, and often leave the anesthesiologist in the dark if the patient didn't get an anesthestic evaluation.

Of course both fields are necessary for surgery to take place and it would behoove all involved that the two fields work together. Yet, more often than not, surgeons consider anesthesiologists as part of their OR team, and therefore beneath them while some anesthesiologists refuse to cater to this demeaning attitude and believe that they are the primary since they manage the patient while the surgeon “fixes a problem”. Both lines of thought are, of course, erroneous, but continue to persist.

What I have seen, though, is that there are residents in anesthesia who jumped ship from other specialties. Often times a surgical intern or second year resident realizes their folly in entering surgery and comes to the other side. More often than not I saw people coming to anesthesia rather than abandoning it for greener fields which speaks volumes of a specialty. I actually think that there's a lot of bitterness on the surgeons part - for whatever reasons - that leads to some of their attitudes.

The reason for writing this, in part and beyond the comments read at Dino's, is because of a couple of my friends stuck to general surgery as their residency of choice while I went another way. Sometimes they’ll poke fun at my decision with the occasional “did the patient get antibiotics?” or “table up, please!” commands while we're hanging out. I often will reply “I’ll do it when I’m damn good and ready!" or "whatever, you don’t order me around!” Of course this is all done in fun, but hopefully this isn’t a sign for our attitudes later in our careers – that would be just sad.

Automatic Automatons - Perfectly Said

I found this great post about the difference between "providers" and physicians. The Happy Hospitalist has said what I could not, because of the vast distance between our training, about why NPs and PAs are cookbook providers while physicians are artists. I couldn't agree more.

Makes You Think

I've been known to complain a bit about trivial stuff. However, seeing this poor guy the other day, walking in a good drenching rain with a walker, made me realize that life is often pretty good and there are lots of people worse off then me.

Interview Dribble and Random Thoughts

I recently cancelled some interviews. I was giving the dates that I’d be out to Wife in order for her to adjust her schedule for work and she began to freak. Six different dates in December, her biggest month and also the time of year when she has to work overnight per company guidelines, were just too much for her. I looked at the interviews, realized that I had one every Tuesday and Friday with dinners the night before during the next 3 weeks, some with 3 days of travel (flight cheaper that way), and analyzed my options.

I cancelled those that I could – those that weren’t as high on my list already or didn’t have a nonrefundable flight attached to them. If I hadn’t worried about rising gas prices a month ago I would have gone to a Texas program over one in Pennsylvania that I've already purchased a ticket for, but I’m stuck now.

For a pre-birthday gift Wife purchased me a Magellan Maestro GPS unit to help navigate during this time. Since I’m driving to a large amount of these programs it helps to have something that can get me around town and this is a great gift! I used it a lot this last week just to see how it works, going to places I knew how to get to already, but seeing where it would take me and if there were any problems. Dead-on every time and it worked quickly most of the time. A few times it stalled getting my information, but during the trips it was fantastic.

Getting an idea from GruntDoc, MD, I decided to do a dead blog update of my own. Basically if there hasn't been any activity for 2 months I deleted you from my sidebar. Those considered dead are:

• Adventures in Medical School
• Parcho, MD (let me know if you start again)
• Scutmonkey (went private)

So, being in an after turkey-day malaise, tomorrow I plan to get out the Christmas decorations, start to get the tree put together, study for my Step 2 CS in a week, and eat a lot of leftovers. On Sunday interviews begin - oh yeah.

That’s How It Is In The Hospital

So Stepson has a little quirk about him: he loves the TV show House, MD. God, what a shame.

The other night he was watching while I was next to him on the couch reading my Currrent’s Medical Diagnosis and Treatment. I’d seen some diseases in the SICU that morning that I was a little unfamiliar with and wanted to get boned up on them before tomorrow. During a commercial he turned around and asked me:

“Are you seeing what he has in your book? What do you think it is?”

I stopped, looked at him, and pointedly said:

“I hate House. I don’t know what this guy has, nor do I honestly care. I’m studying some stuff I saw today and need to know for tomorrow.”

He shrugged his shoulders, turned around, and said:

“Well I freaking love this show. It’s so awesome! I bet that’s how it is in the hospital, huh?”

To which I had to inform him that there is no way that a doctor, no matter how talented, gets to walk into an OR where the patient’s abdomen is wide open without a surgical cap, mask, and sterile gown and be allowed to place their hands directly into an open wound – even if he had on sterile gloves - which he didn't (event occurred just prior to commercial where he made these remarks). So, no, it’s all crap and that is what I hate about it.

He didn’t seem to care, and watched the remainder of the show intensely. At least he enjoys himself, but damn! Why does he have to like that show?

Hot Doc Getting His Just Desserts

Thought I'd let everyone know about a little interesting comment from a reader related to my favorite medical student: Hot Doc (AKA worst medical student ever):

hey man just wanted to let you know that "hotdoc"'s car got keyed twice
since you posted that pic of the license plate...now I know that wasn't your
intention...but....

See what happens when you're an ass? Now I didn't suggest that happen, but clearly he's upset some people and they decided to take it out on his car.

Automatic Automatons Part Deux

“Sweeping generalizations should not be made about any [field of medicine]”.

I couldn’t agree more with that statement. The premise to the last post was not to slam nurse practitioners and physician assistants, but rather identify the flaw inherent in the retail clinic model of healthcare reform.

Often these clinics are staffed by younger, less seasoned professionals who are not well supervised and often work within the shadow of the behemoth that employees them. They feel the pressure to move patients, treat them similarly based on error prone algorithms, and give drugs for anything that looks infectious. That is not simple hyperbole, but a fact. I’ve been informed by several people who’ve either worked in or for these types of clinics of these types of pressures and have experienced a similar form of medicine early in my third year of medicine in an office that employed two PAs and 1 NP so that the doctor could manage his “businesses”. The pressures levied on those three providers to get as many people in and out as possible was tremendous. I could understand, as faulty as it was, to give amoxil for a 12 hour case of sore throat.

What scares me is the fact that you are being treated by people with less education than I’m at currently and have to deal with administrative bullying. When I enter the medical field as an intern I will have some autonomy, but leveled with so much restriction and guidance it will make me feel powerless - like a med student again. By it's nature, a residency allows young doctors the chance to improve slowly, while their training and skills are evaluated and redirected as needed by more experienced faculty. They are taught to be brutally critical of their and other's performance as it related to outcomes and current clinical practices.

I don’t feel that someone with three years of post graduate education who receives little to no feedback on their patient performance beyond “move more meat!” can be expected to improve. In fact I feel that these clinics will only dampen the skills these providers have developed in order to get patients in and out more quickly.

Certainly there are physicians out there that are less than admirable about their patient encounters and prescribing practices (since I’ve worked with a few I should know), but I truly and honestly believe that once they completed their education they were far more capable of handling patient’s complaints and evaluating them properly using evidence based medicine than a 3rd year medical student. Because that’s honestly what you’re getting with a retail-clinic provider fresh out of school.

Are You Smart Enough?

Thanks to Medblog Addict for this.

Automatic Automatons

There are some things in medicine that irk me beyond rational thought. These quick, “urgent care” clinics are definitely a topic that incites rage and hatred in me. They are, to a word, pathetic. Pathetic excuses for healthcare, pathetically trained or motivated people caring for patients, and pathetic attempts to “fix” the healthcare system in the US.

Part of the reason they are such a poor medical facility is due to the people treating most of the patients. NPs and PAs, free from a great deal of medical supervision, are often found handing out erroneous and falsified diagnoses - only to then treat everything with antibiotics or other unnecessary medications. An example of this irresponsible behavior is a story I heard recently encompassing most of these qualities:

A mother whose adult son had a sore throat and was too busy to get it evaluated, went to an urgent care clinic knowing that she could fake his symptoms and receive a Z-pack. This was done because her doctor wouldn’t normally give medicines unless specific tests were positive. She, of course, received the antibiotics (despite having ANY illness) and proceeded to give it to her adult son.

This kind of malpractice (for it really is irresponsible medicine) only increases the drug resistant bacteria that we’re seeing and encourages patients to demand drugs they don’t need. What’s worse is the notion that medicine is like a cookbook and all symptoms should be treated the exact same, regardless of testing and patient profiles.

For all the complaining patients do about their long waits, the doctor’s refusal to give them some drug they read or heard about, or their increasing dubious belief that they are as able to diagnose themselves as effectively as their PCP these clinics are not the answer.

Consider the story above: what if the antibiotics given reacted badly with another medication, or had to be altered due to liver or renal failure, or caused a severe allergic reaction? All things that a PCP would most likely catch through charting or questioning but would characteristically be missed by a NP or PA trying to get as many people in and out of their fast-food-medicine chain as possible.

“What the hell do I care about giving medicines without proper test results? It’s a pain in the ass to do it any other way and it takes up valuable time. That's not what Walmart/ Walgreen's/ Target is paying me for”.

Instead of responsible and smart medicine, what you have are people who will not use medical evidence to properly treat patients and essentially run a medical McDonald’s – have it your way. Sore throat? STREP! Neck hurts? LORTAB! Sniffles? SINUSITIS! To add to this obvious disparity is the fact that these clinics are often owned by corporations who want people to be sick and have to go to their pharmacies. It's not rocket science to see how there's a conflict of interest.

Now I don’t think NPs, PAs, and CRNAs are entirely bad - quite the opposite. They are important in that their job role allows overworked physicians time to focus on the more complicated patients and running their practice while more minor ailments and procedures are analyzed and treated - after a quick review with the physician. However what I do find absurd is the idea that they can take care of patients without strict physician guidance as often occurs in these retail medical centers. Regardless of their time, they haven’t received the training requisite in order to differentiate between disease processes that appear very similar, nor is it expected.

If you still haven't jumped on the bandwagon, realize this: a nurse is trained in a very different way than a physician. They are not expected to figure out the pathophysiologic basis of a disease, the subtle interactions between comorbidities, the ever increasing need to be smarter about treating seemingly simple infections, and the evidence that alters treatment regimens amongst patients. Their training is based on recognizing a defect or a problem, alerting the appropriate people, and following a procedure or "order". If a patient has X, then give Y. If this happens, call the house officer or the patient’s doctor for direction. Adding a couple of years to the training does not inculcate the need to think beyond this automatic process, no matter how much you “shadow” a physician.

Experience certainly lends itself to making people think they know more than they really do. Twenty years in the ICU will definitely make you appear smarter than the intern or second year resident rotating through that service, but only for a brief period of time. Of course you’re going to know more about vent settings, how to respond to codes, etc. than a newly minted MD; but a seasoned physician, who has spent some of their time in the critical care arena will run circles around you - no matter how long you've worked there.

The physician trains in a wide array of specialties for which they are expected to understand a great deal of complexities, is responsible for the outcomes of their patients, and understands more about the overall process leading up to and currently occurring in that patient than an NP, PA, or tenured nurse could hope. A few decades of experience does not overcome the difference in education. A physician with twenty years including residency will always come out on top.

Residency is designed towards this goal. It is the resident’s training, adding on top of the knowledge procured through four intense years of medical school, that makes a physician more than just a “medical mechanic”. Performing a task a million times is not the same as medical knowledge. It is habit, and, as often seen when new policies are passed, is often hard to break.

Urgent care clinics are not the answer to the healthcare crisis. If we expect to take care of patients in better ways, to reduce drug resistant bacteria like the current MRSA “epidemic”, and have more advantagous outcomes we must realize that physicians are not replaceable by technicians. The years of training that doctors receive and the strict environment that they receive their education in makes a physician far more capable of truly evaluating patients. What you are receiving when you see a physician is a decade or more of increasingly detailed knowledge and arduous training that enables them to treat people effectively. Four to six years of training is not even close.

More Money

How much do I want to party? Is it worth $100 or more for a bash?

Our class dues this year were elevated to help pay for some items that the senior class has traditionally done. This includes a class gift, planning an event the day of match as a celebration for 4 years of hard work, etc. However, I have recently seen that the dues are to be increased by over 200% for the year to pay for these “responsibilities”.

I was planning on paying for the initial class dues this year, but more than $100 is way too much for this guy. I mean, God, I’ve had to increase my debt further in order to even interview this year since the school’s tuition hike killed any travel money I was set to receive. I have a couple private loans that will be due upon graduation and cannot be deferred through my residency. The fact that the “elected” class officials (ran unopposed) are now increasing the amount they want from us in order to throw some fucking party irritates me.

I guess I just won’t plan on going to our match celebration if this is how they’re going to try and fund it. Citing low class participation in fundraisers as a reason to increase the amount needed as an entry fee isn’t reason enough. There are people who are on aways, are too busy with life, and just don’t care anymore about helping “the class” out anymore. Personally, I’ve been trounced one too many times in the past to give a shit now.

It’s sad to think I won’t be able to hang with some of my friends and celebrate our accomplishments, but I thought the amount last year was ridiculous and we’re doing the exact same thing here.

Lo Siento - mi amigos

If you haven’t noticed, which I’m sure most of you are painfully aware, the posts recently have been…well…of a poor variety. I attribute this to a phenomenon that I call “blog running.”

Blog running is essentially trying to keep a blog updated regularly, regardless of the content, while being too busy to really formulate anything of substance. The last few months I have been either too busy or too involved with interview crap to really do much meaningful writing. Unfortunately I don’t see that changing too soon – at least until my break in December (when I’ll be interviewing through most of the 1st 2 weeks so you're still SOL).

Part of the blame lies in the fact that I’ve tried to post while at home, when Wife is around, and have just typed as fast as I could while trying to not get caught. Remember, she still doesn’t know about this little project and I like it that way. So whenever I’m on the computer and believe I can get something posted in less than 5 minutes I try to get something out.

So I have to apologize for the lack of substance recently. I will try to keep some backburner drafts going in order to at least have one or two interesting articles.

BFE

Image of the parking lot at the hospital where I’m doing a rotation. I have to catch the shuttle from here to get to the hospital. Clearly the lot is so far away from any building that they feel porta-potties are needed – since you won’t be able to hold it.

One Down - Many More to Deal With

Interview season is already quite strange. I see people behaving in ways that are clearly not acceptable and seem quite immature, but they seem to not care. Chewing gum while talking with a director, leaving to take a call during a presentation on the program, and getting wasted at dinner in front of the residents (only to continue to get wasted as the night goes on afterwards and end up sleeping in another candidates room because you pass out) – all of which don’t seem to phase these candidates.

It makes me feel rather superior to them based on a certain level of maturity, gathered from years of real world employment and family responsibilities, but who really knows. Perhaps that’s what programs want – young blood. Certainly there’s enough old curmudgeons out there so who really wants one more?

Anyway, I feel the interview went well and am looking forward to being done already – very tiring process.

Getting Back To Basics

So here’s the thing. I like writing posts where I know there might be some reaction. I like checking the comments to see who’s upset or what agreement, if any, there is amongst my few readers. It’s fun.

The last post was for me, but also for that simplistic pleasure. That’s part of the reason the heat gets going as a post continues– to get a rise out of you. Unfortunately I may have caused some of my med school buds to feel I don’t support starting a family while in school. Simply put – I completely support anyone who can juggle this craziness with kids. I don’t have any qualms about women having children during residency or afterwards either. My beef was not with med students taking time to have children or their need to have accomodations afterwards. My beef was with the student in question only - because she sued. What does that say about her? That was my point.

So, that’s that. If you’re still upset or irked then there’s nothing I can do. It’s my blog and I write what I want.

Anyways, the Tassimo poll has completed and basically more people have no idea what Tassimo coffee is than those who either love it or hate it (which tied BTW). No idea where to go with this information, but at least I know that I'm not the only one who loves it...

…and I’m looking at my veins as I type this dreaming about sticking large bore IV’s in those juicy ass rivers of blood. Part of wanting to be an Anesthesiologist I guess. 2 days from my first interview and I'm wondering why all of this is necessary. $4,000 in travel expense thus far without hotels for most trips - yet. Damn.

Not Enough, Too Much

Since I am a member of AMSA I receive their monthly love-fest newsletter, The New Physician. Often this is just a sounding board for medical students trying to show that they care about patients more than the medical education system that tries to destroy that bond and are fighting “The Good Fight” for patients and students alike.

Mostly, however, I find it to be just a whine fest with people complaining about shit that I don’t care about. Their most recent issue, though, sparked some anger in me (yeah, I know, big whoop).

What got me upset was a short letter about a medical student who sued the NBME because she didn’t get additional time to pump her breast milk while taking Step 2 CK. On the outside it seems quite agreeable – I mean who wouldn’t want to have a few extra minutes to avoid soaking the front of your shirt all the while obtaining that precious fluid for your child?

The issue I had was the fact that she sued at all. Apparently this student has a some issues related to ADHD and dyslexia and had received 8 additional hours to take the exam, encompassing 2 days. Because of her concerns she took the test in an isolated environment and was allowed to have her breast pump with her in her room, all prior to her suing.

Her complaint? She wasn’t allowed enough time for breaks to pump her breast milk!

WTF? Seriously, what’s this girl's problem? How are you going to handle regular resident duties if you can’t handle 2 days, 16 hours, and accommodations that were more than reasonable to take a fucking exam? The fact she sued and the people at The New Physician are supporting her demonstrates a great deal of the medical student attitude that’s concerning medical educators. The whole "hold my hand with everything" demeanor.

The fact that she won her lawsuit simply shows how screwed up the legal system is in this country as well. Where has common sense gone? Why are we allowing crap like this to be taken seriously? For all of us who've taken this exam we know that the time she received was more than adequate.

So, to this princess, this coddled little bitch, I'd like to ask: How much more time do you need to take a damn test!?! Do you think you're going to actually be able to take care of more than one patient at a time while a resident? I'm sure you're residency programs will be dying to land you and your suing ways! GOD!

Catching Up

Halloween has come and gone. Unfortunately we live in a rather humdrum apartment complex where the only partying going on is the college-aged crowd who either, a) don't believe in giving out candy b) are too wasted to care about giving out candy 0r c) have spent all their money on beer and drugs and can't possibly come to the door out of shame and intoxication.

Yes, another Halloween where we had to uproot and go somewhere else for the trick-or-treating that is apparently becoming less and less important these days. I feel that the generation of tomorrow is going to fuck us all over because they're far too involved with themselves to give a shit about anything else.

Daughter had a great time, despite the expedition, and was very excited to get her candy. She went as Jessie the cowgirl from the Toystory movies and was adored by almost everyone. Stepson was with his dad, but I heard he had a good time with his friends.

I would like to post some pics, but because I don't want to have my daughter's face on the internet for any pervert to, um, enjoy I won't.

Waiting, Just Waiting

I still haven't heard from the AOA committee. I heard that they might have been meeting last week, but it wasn't for sure. I know that those elected are informed quickly, so I've begun to think I wasn't elected in - again.

...anyone know a good lawyer?

*** Update: I was elected into AOA! Found out a couple days ago, but have been too busy to post recently.***

Poll

Noel thought it might be a good idea to see where people stand on the Tassimo coffee debate. Since there were only his response and mine I'm not sure how well this will go, but let's try out this new Blogger feature!

The poll is a little down on the sidebar, below the disclaimer. You can vote as often as you want.

ER Abuse

Scalpel has been talking about the pain scale and pain-seekers recently. Reading these entries got me thinking about a trip I had to an ER during med school and the lasting impression it left with me.

Between 1st and 2nd year I had a research project that fell through. Since this occurred late in the year I decided to just get a job and work over the summer. I don’t really like research anyways and my Orthopeadic frenzy had significantly subsided so I didn’t feel research was absolutely mandatory at that time.

I returned to work for the company I’d been with prior to med school and was given a job in the backroom where I would stock and pull items for the salesfloor. This entailed some heavy lifting which aggravated my back already damaged from poor weight lifting during high school. I began taking Aleve in the mornings before arriving to work in order to move better and decrease the stiffness I was appreciating in the morning. This seemed to be working well until 4 weeks into the job.

One Saturday morning I awoke with a great deal of pain. I found that I had a significant amount of trouble getting out of bed and walked bent over since straightening caused a great deal of discomfort. Some NSAIDs and attempts to stretch out my back resulted in little improvement. Deciding to rest my back, I laid down for a period of time, hoping for a “miraculous” improvement. Instead my decreased range of motion and pain only increased.

I found that I couldn’t stand up at all. In fact, trying to walk resulted in me crying out briefly a rather nasty curse and falling to the floor. Wife found me crawling on the floor, unable to get out of this position, heading to the living room to sit. She decided that there was something very wrong and that I needed to go the ER. I resisted, thinking it weak and pointless; after all this wasn’t an emergency – right?

She persisted and I finally caved. The ride to the ER was torture, with every bump knifing through my back. In order to decrease the pain I was in the fetal position the whole ride. On arrival I tried to get out of the car, only to fall on the sidewalk from the pain. Wife ran in and found a volunteer who brought out a wheelchair. Humiliated, I again resisted, but eventually had to sit and be wheeled into the ER. They wouldn't let me crawl.

The staff was courteous and quick (not very busy at that time of day), but I continue to feel that they thought me a druggie. I rated the pain a 5/10 since I didn’t want the stigma of being a “seeker” and tried to be as helpful as possible in relating my history, but when everyone who wants drugs mimics this kind of pain I just knew they were talking about the “drug seeker” with lower back pain in room 12. It was frustrating to know that I was in very serious pain, had fought seeking treatment, and just wanted to be able to walk without severe shooting pain, but that because of parasites in society I was most likely considered an addict.

After some x-rays, a perfunctory exam by an NP (I wasn’t even taken seriously enough for an MD to waste his time on), and a shot of narcotic in the ol’ butt, I was discharged to follow up with my doc.

The narcotic and muscle relaxants worked wonders, allowing me some increased motion, but I was unable to return to work. An MRI done later per my PCP showed osteoarthritis of the lumbar spine with small herniations. I was informed that the kind of work I was performing was out of the question with my back and physical therapy was eventually needed for me to regain my normal mobility.

Now, I tell this story not as a lesson to be learned for all ER docs. Rather it is the reason that I find so many of the patients I’ve seen - who claim 10/10 pain, want Lortab or Dilaudid since they have “allergies”, and abuse our system - completely abhorrent.

It is the reason I decided to opt out of Emergency Medicine. I was just too jaded. It is because of patients like these that those who truly need the services of the ER are often initially considered addicts. It's because of asshole patients, cyring wolf constantly, who abuse our system that ER's are practicing defensive medicine. It's the reason I think ER's should get a free pass for all frequent flyers who they don't believe who present with an actual problem. You weren't believed? Too fucking bad!

Game of Chicken

I was appalled to see that a program that I had been considering withdrawing my application from sent me a rejection letter yesterday.

“Wait a damn minute!” I said out loud to no one in particular. “I was going to dump you!”

I sat there for a few minutes, pondering over the short, formal, and quietly condescending letter informing me that I wasn’t good enough. The tone was professional, but at the same time I perceived an underlying sensation that they’d looked at me and scoffed.

“What the hell does he mean applying here? Doesn’t he know we’re [Rocky Mountain Program]?! Begone with all inferior applicants!”

This letter was unexpected. While not being completely egotistic, I did feel that the programs I’d applied to would be offering me interviews – every one of them. I felt that I had a notable application which, like the airbrushed women on magazine covers, made me more appealing than perhaps in real life. At least you'd want one date before deciding otherwise.

In order to stop this from happening again I withdrew from another program that I’d grown less fond of over the last month and had been harboring thoughts of disatisfaction. I knew full well that the distance and cost was going to be more than I wanted to take on and had planned, if invited, to regretfully decline anyway. Instead I drew first blood. I didn’t want to be the loser in that break up as well.

Auscultung!

Liana’s post here had a somewhat off topic interest for me: how do you wear your steth?

For me it’s always been cumbersome and rather weighty around the neck. After 12 or more hours that relatively light piece of equipment begins to bore into the back of my neck, causing stiffness and discomfort. For a while I tried to just keep the ear pieces wrapped around my neck while the heavier piece dangled around my stomach, like a tie. However, apart from feeling like I was being strangled, I found this quite absurd when trying to write and bending over a patient during exams. Swoosh. Careening completely out of control whilst knocking the shit out of a patient or two.

I’ve seen those who favor wrapping their steths around their waists, using the drawstrings of their scrubs as a type of belt. It seems, however, that unless you are a tall, yet petite female, a very effeminate male, or have an instrument that’s so absurdly long you couldn’t hear a train while auscultating this just isn’t feasible.

There has been a resident or two whom I've seen wear a type of device they clip onto their belt or scrub pants that allows you to “holster” your steth. Apart from being a little odd looking I found this a fantastic device; keeping the cumbersome, yet completely necessary tool at one's side without taking up much space. Considering this, I have still not procured one for my own use - yet.

What I currently prefer, based on a surgical resident’s insight that "surgeons don't wear stethoscopes", is to just simply wrap it around itself as demonstrated below, and stuff it into my large white coat pocket. Out of sight, out of mind.


Now there are some disadvantages to this - like getting the ear pieces hooked on a piece of furniture and getting pulled to the floor as you run for that code, or eventual damage to the tubing necessitating another purchase - but for the most part I find it a helluva better alternative than wrapping it around my neck or having an episode of vasovagal syncope from bilateral carotid massages.

Selfish and Not

Chart up another tough day. Wife is feeling the pressures of the interview season as yesterday I tried to negotiate the most practical terms for my interviews. A week at one spot for 3 interviews seemed too much, so I plan to cancel one after more offers are laid out. Another week Daughter will fly out with me for 5 days of interviews so Wife won't be completely overwhelmed.

As we have often done recently we talked about the discouraging condition we find ourselves. Unsure of what’s coming, our future, and the potential of any stability that we once knew I find myself wishing it was March 20th already and I had opened my letter just to have this done and over with.

The season of interviewing is at the worst time for us – retail being extra hard on their employees during the 4th quarter (aka The Holidays). Comments of a job “required” and “puts food on the table” were lobbed at me like dangerous hand grenades. One wrong move and it could all be done.

I tried to carefully navigate the mine strewn waters, avoiding my innermost desires to become defiant, upset, and declare my innocence in this plot against her. But I remained still, listening to her frustrations paralleling mine, all the while knowing that we’re both right while both being wrong.

For what it’s worth, 8 years have come and gone with her by my side and only one of us has “grown”. Long ago we agreed that her dreams had to come when and where they could, but that this path, the 12 years of medical training, was first and foremost. This was discussed pointedly before we married, before Daughter was born, and before residency interview season approached.

This still doesn’t assuage my appreciation of her sadness and feelings of imprisonment in her job. Requisite, though it may be, every day slowly kills her. Hopefully as I progress in residency and Daughter enters grade school she can begin to branch out more, find what she wants, and discover her passions. Otherwise what’s the point?

Frenchy

I love coffee. Fortunately my wife decided that she would get me a Tassimo coffee maker for Christmas last year and I have loved it ever since. Yesterday she called me from the grocery store to alert me to a fantastic find – French Vanilla coffee.

Our apartment smells great after brewing a T-disc and it tastes grand! No need for creamer at all. Just a little sugar and you're solid.

If you have the chance to procure one, I highly advise you getting a Tassimo coffee machine. They are great and have a lot of good options – kinda pricey, but well worth it.