Friday, November 30, 2007
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.
Thursday, November 29, 2007
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.
Tuesday, November 27, 2007
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.
Saturday, November 24, 2007
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.
Friday, November 23, 2007
Thursday, November 22, 2007
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.
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?
Wednesday, November 21, 2007
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.
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
Tuesday, November 20, 2007
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.
Monday, November 19, 2007
Thursday, November 15, 2007
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.
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.
Monday, November 12, 2007
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.
Sunday, November 11, 2007
Saturday, November 10, 2007
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.
Wednesday, November 7, 2007
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.
Friday, November 2, 2007
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!
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.