Necessary

I've often wondered if the 4th year of medical school is really necessary. Many medstudents spend the majority of this year taking electives in their respective desired fields, easier rotations during interview season, and often have months off with little to no patient interaction leading up to July. It's clearly no wonder that a July syndrome is often seen in many incoming interns.

I've been reviewing over the last few months, but it's hit and miss. There are things that come up and I feel guilty trying to study about diseases and physiology when the family has come home - I won't have this much time with them again in, well, probably ever. So I close the review books (because by now I've admitted that I just really should review the basics again before getting too in depth on anything) and head outside to play one-on-one with my son, teach my daughter how to ride a two-wheel, or take care of wife.

I think that a full year of 4th year, while nice in the time off you often get, really is a hinderance to many students. I knew far more and was multitudes more ready to enter the "real world" of medicine last July, not this one.

Personally I think it would be better for programs to have earlier interview times in the early fall, find out where you matched in December, and then enter your program in January or February. The students would be better prepared, less rusty, and far more capable of handling the first couple weeks of internship. The syndrome would still be in place, but not as pronounced as it is currently.

Hell, if there was a real consideration to drop the 80 hour work week to 56 we could lengthen the residency training based on reducing some of the 4th year requirements and letting med students into training 6 months earlier.

So, is a full 4th year really necessary? I don't think so.

Hoping Beyond Hope

There are several items that I hope don't happen - even though I know there's a very good chance that they'll occur anyway. Like gas stopping its ridiculous and out of control move towards $4 and $5 a gallon.

What I really hope is just merely a rumor mill is this, a cut of work hours from 80 to 56 per week. I found this link from Medschool Hell - who, naturally, is in support of the move.

I've already blogged about this topic in the past, so I will allow you to read over that post and refresh yourselves. Clearly I do not believe cutting the work-hours anymore will lead to significant changes for the better.

What it will do is just lengthen an already long process with residencies adding additional years, create further punch-clock mindsets in residents entering the work-force, and leave a large topic of discussion still on the table: debt repayment.

Hell, as it is the government has been trying to get underpaid residents to pay back on loans by reducing the years that they can defer or forbear or simply removing the option of "economic hardship" from the list of reasons. So adding more years will do what? Create more financial burdens, reduce the chance to moonlight, make residency akin to a 40 hour a week job where-in doctors will become even more hesistant to do anything past 5pm? Is that what we really want?

Think about it before you'd say that working a few less hours isn't that bad.

Death Rattled

A face to face encounter with death is something not normally undertaken by most people. I’ve begun to see enough of the haggard face of Death that I’m getting slightly immune – slightly, not completely.

It used to transfix me, watching someone die – especially in the ICU where so much seemed to be happening. Now I go about my business, still checking in to see if Death, with his icy, skeletal fingers, has deposed a soul of their body, but I no longer hang around and wait.

Gasping for breaths, eyes lolling absently within the skull, chest and abdomen heaving from the physiological desire to increase the body's blood-oxygen - not normally a pleasant view to observe. I think I’ve seen enough to remain interested, but not morbidly fascinated - as if I'm witnessing my own mortality through another life’s culmination.

I do know that the exposure has solidified any unnecessary desire in me to seek heroic interventions for own life. Do what you can, without going overboard - that's my take on it. These people who spend days to weeks in the hospital are, for the most part, already door nails (if you get my drift) – we just fool ourselves while the machine works.

To further these considerations I have decided that I should attend an autopsy - offered at certain times for those students/ nurses interested to which I was heretofore unawares - while on this rotation to finally deal with Death's throes over life. Seeing the completeness of a body emptied, lifeless, being quickly but systematically cut open in an attempt to understand the "flawed defect" that resulted in death should be riveting. And an experience that teaches how fragile life is - in spite of our societal denial that death is the inevitability of life.

The Sitter

Today I figured I'd cury some favor from the nurses and spent about 2-3 hours babysitting a patient. They were there for several days while we attempted valiantly to wean them off some sedatives and get them up to the floors secondary to severe alcohol abuse. Unfortunately there were an infinite number of sick patients (it is the ICU after all) and the nurses had not been able to keep their attention on this patient when they were out of bed – so they sedated more and kept asking for restraint orders. It's easier if they can't move, ain't it?

Finally today the attending asked for us to take shifts and watch. And since they were mine, I took first shift – which showed a very coachable, easily manageable patient who needed to get the hell out of the ICU and go to the floor.

I try to not think about the cost to me in dollars for an education where I babysit patients, but then again, I had nothing else to be doing at that time anyway. I should appreciate these times more. Plus I looked good in the eyes of the nursing staff - which will mean that they'll watch out for me for the next couple weeks - hopefully.

Hysterical Blindness

Visibly shaking, the envelope in hand, he tried to muster up something to say as he fumbled with the tape sealing his future. Some snarky comment arose, followed by the crowd’s mixed laughter and sighs, all of which he didn’t appreciate as he finally opened the envelope without mutilation and removed the contents.

Folded lengthwise in two places making three equal compartments, the paper was ironically non-distinct. He trembled, struggling to remain calm, but realizing the sudden finality and enormity of what he was holding.

Seconds ticked by as he stared at the bolded writing, unreadable in his current state. He vaguely recalled a condition in which people lose their vision when confronted with a stressful event. He read the first part.

“Anesthesiology” was written on the middle portion of the paper. The line directly underneath slowly came into focus. He wondered why the seemingly mundane and simple task he had witnessed the year before was proving to be so arduous.

Finally, after what seemed to him to be an eternity, where the crowd, he felt, grew concerned, whispering and murmuring about the delay, his cognitive abilities returned enough to comprehend.

“It’s a good day.” he finally managed to say. More grains of sand fell as a wave of absolute relief and gratitude overcame him, bringing water to his eyes. He held them back.

“I’m going into Anesthesiology at my first choice…Major Academic Center of Excellence!” Applause resounded in the auditorium which was rendered indistinct by his euphoria.

Refolding the paper and stuffing it awkwardly back into the envelope he proceeded with the ceremonial ritual. His hands still shook, but this time from pure and unmitigated joy.

*****

Yes, that’s right. I matched into my first choice. Once I returned to my seat and watched others of my class go through the traumatic opening of our letters in front of hundreds of people I had to reread my letter, just to make sure. I’ve never been so nervous and I didn’t understand why.

And while we rejoiced I was saddened to learn of those who didn’t match even after scrambling. One of my good friends was amongst these unfortunates and I couldn’t express my sorrow fully enough.

We matched at 85% overall. We were told that the US average was around 73%. When the NRMP comes out with the data I will delineate a little further with our results and the numbers going into each specialty – but it was very Medicine, OB/GYN, and Gen Surg heavy. We only had 3 enter Anesthesia, though I know that another two matched at preliminaries and will have to try and match to a PGY-2 anesthesia position next year.

A Lost Opportunity

The student had met her earlier last week. During that time she had been quite charming, quick minded, snarky, but with a compassion beyond belief. She had insisted that the doctor come to her home, once she was discharged, and sample some of her homemade jam recipes. She proudly recalled that she grew her own ingredients and her jars of jams and other treats were the talk of the neighborhood. Her daughter smiled lovingly at her. She was decisively independent in action and thought, but euphoric about her improvement. Traits that endeared her to the student and he hoped that he'd see her again when he returned the next week.

Upon the student’s return he found her in an opposing condition. That Friday she had been planning to go home, doing well and feeling optimistic about her time left, but now she was besieged like a cornered animal, clinging to an oxygen mask as life sustaining gas was pumped through at more than 7 liters a minute. Her eyes were screaming at him: “Help. I can’t breathe. Help!” and he recalled seeing that her oxygen saturations had dropped over the weekend to precariously low levels. The room, once full of euphoria, was now transformed into a dark, humorless, shadow full of dispair and exhaustion. The student felt a unique sense of vertigo, as if his entire world was being lost along with her's.

With this remarkable uneasiness that assailed him from every corner of the room, he examined her. He instantly recongnized the revulsion that had grown up in him and stood as a palpable lump in his throat. He found it hard to talk, even when just telling her what he was doing.

As the student arrived at the abdomen he discovered that the once soft, obese stomach was now a massively enlarged, rock hard, mound with discernible peaks and valleys. He could not appreciate any bowel sounds – an ominous sign. She had stopped producing urine and her eyes were no longer white, but were markedly yellow. His horror magnified as he examined these eyes, noting the distinct despair and cries that were manifested there within.

He knew from last week that she had undergone a major surgery to remove cancerous tissues. They had hoped that there hadn’t been any spread, but clearly the truth was here for the student to behold: The tumor had survived and was assaulting the woman from within; taking control of her body, plaguing her kidneys and liver, and making breathing an incredibly laborious effort. She was drenched with sweat from the effort of living. The student felt the sudden need to leave. He did not know what to do.

The morning rounds consisted of lengthy discussions between the doctor and her residents as well as with the family and the patient. The main topic focused on her sudden and clearly unexpected change. He found somewhere during this time that a party had been for her return and the banners still hung in her living room. "I doubt she'll see them" he had thought.

Radiographic films were viewed with the family in the physician’s lounge and the doctor explained the findings. The student already knew – large amounts of a homogenous, grey material obscured large amounts of the normal anatomy, interspersed with tumor. Her abdominal wall was caked in oppressive and magnificent abnormal cellular reproduction that constricted her diaphragm and reduced the patient's ability to move air.

“Metastasis. Outcome looks bad. Kidneys have begun to stop working”.

The family received these messages with stunned silence; then the daughter, the loving woman whom had been at the patient’s side when he initially met her, began to cry. The student looked away. He was surprised to find that he was fighting back tears as well – tears for a patient he’d only met once. Yet he knew what all of this meant.

In the span of 3 days she had fallen down the potential abyss that many patients navigate unscathed. She had “decompensated” and he knew there was nothing more to be done. She was going to die and he felt the acutely ironic scenarios play out before him.

****

She died later that week - a full code despite the attempts to obtain a DNR. He had avoided talking with the family or seeing the patient since that day unless he absolutely must. The situation was uncomfortable and the interrogations he received or perceived frustrated and confused the student. He didn’t know what to do, nor what to say. The doctor should be doing that. He was angry at the situation and the distinct perception that he was absolutely and completely ignorant of how to proceed. "How is it that after all this time I have no idea what to do"? he would often find himself asking aloud. His mind swam with guilt.

Now, as the student surveyed her lifeless body, tracheal tube still in place, eyes fixed and staring, chest exposed with the disproportions of her abdomen starkly evident, he was disgusted. A sudden and uncontrollable compulsion welled up within him. “I must get out of here!” he thought and he looked longingly at the door and the sanctuary of the nurses station. There he would be safe from the woman’s gaze, from his guilt.

Fighting off this instinct, the student stayed. He stayed when the doctor and residents lefts, he stayed when they cleaned up the woman. He even stayed when the family came in and burst forth in tremendous sobs. He persisted, in spite of himself. He had not been there for them before, but he wanted to be there now. Not so much for them, but for himself. If the student ran from this, then he had utterly failed in his duty.

The day culminated in a total of 20 hours. He had not needed to stay and had been released earlier. Yet he persisted. Wanting to stay and learn from his mistakes he remained and accompanied her to the morgue. He had avoided Death, but clearly it could not be brushed aside. It must be faced, and he had not performed admirably during the patient’s transition.

Though he desired to view her autopsy, he knew that this was an intrusion he could not perform. He had not been there with her during life, surely he should not be there when she was dissected and the tense abdomen exposed - it felt too intimate. He heard the next day that when the pathologist intially began she gushed liters of fluid. Metastatic ovarian cancer with mets all over her body.

At least she’s at peace, he thought. If there is a heaven, then surely she’s making her famous jams. The student smiled, and went about the rest of his day.

Like a First Year

The last couple days of my mandatory, don’t come and you’ll not graduate, “Doctoring” class are this week. Ah, it’s been an adventure. I’ve learned so much. I’ve come away with a great deal of useful knowledge that wasn’t already learned on the wards or from reading resident’s blogs. I feel like a first year – everything had weight to it, everything was important, and I love being a medical student…but not really.

4 weeks of this class and I really think it could have been condensed into one week. It was very disappointing – it had a great deal of potential, but as usual we’ve been led astray. At least I was able to catch up with some of my classmates and hear about where they’d like to be going.

Despite this farcical educational process, I did learn a couple of important items:

1) Sipping caffeinated drinks over an hour will keep you going longer than if you chug. Caffeine downregulates itself and if consumed in large quantities (as I’m wont to do when on call) it actually diminishes sooner, leaving you dead tired in 1-2 hours. Good to know.

2) Get through the first day and you’ll be OK. Expect to be on call – many interns start out on call.

3) OB/GYN residents (at least here) are very pessimistic.

4) Money scares the hell out of me – at least knowing what to do with it outside of paying off stuff.

5) You will get very depressed – most likely in the winter months.

6) Discharge planning starts at the time of admission – and sucks ass.

7) Government funded healthcare has already suffered from poor resources and funding – so why do we think that we can cover everyone?

And that’s about it. Aside from learning that a couple people are matching into specialties that I didn’t ever think they’d go into and getting the final touches on my case report done so that it can actually get published this month has been a waste. At least I don’t have to take senior Psychiatry!

Revelation

At a family dinner my uncle asked me a question:

“Would you do it all again?”

Simple question, hard answer. My parents, grandmother, brother, and various other family members were there – all awaiting what, I'm convinved, they were sure they’d hear. Instead I dropped a blow. After refusing to answer at first and being cajoled into answering I replied:

“It’s not that I wouldn’t, but right now I’m not sure. It’s really not been worth it and it’s a helluva lot harder than anyone understands. I don’t know…I don’t think I’d do it again. I know I wouldn't want my kids doing this.”

Almost everyone sat there, rather stunned. I’m sure they thought they’d hear me praise my training and the love that has grown inside me for medicine. Instead I was honest. Honest about the hardship, the frank disappointment, the depression that had set in many times, and just let them know I wasn't sure if I'd made a good decision. My uncle, who is by trade a lawyer, looked at me and shook his in agreement.

He then went on to expound on how he hated being a lawyer for the first 10 years following law school, which his wife agreed completely. This received incredulous replies from my grandmother and mom, to which my uncle and aunt echoed my frustrations - debt, disappointment, pressure, self-doubt, and the feeling of accepting a lie. He explained how the debt, the lack of esteem, and overall bullshit that he had to endure while fresh out of school made him almost quit several times. He expounded on how he hated people assuming he was "rich" because he was a lawyer and that he had originally believed he'd be wealthy when he entered law school. The harsh fact was, that for many years, they barely could afford to live.

He then looked at me directly and proceeded to inform me that it got better. It took time, but once you find what makes you happy it makes the job fantastic. He now loves what he does – though it wasn’t what he initially thought he’d be doing.

That was, for me, the only time that I truly felt that someone in my family understood what I felt. The sad part is that the only reason he understood it was because he had to endure something similar. You just can’t explain this to people who haven’t dealt with the process. They all look at you like you’re crazy and talk about the money, the prestige, and the myths that shroud the professions of medicine and law.

I hope that I'll find the peace and happiness that he has in law. I would really like to wake up most days and want to go to work. Right now I don't.

Power Whore

There’s something about power that makes people crazy. The other day I had to take a senior OSCE that was supposed to help us get ready for Step 2 CS. However, many of the participants that day had already taken and passed the exam, therefore making this just another useless exercise. To add to this day was the fact that Wife was trying to get seen for an illness and I wanted to be there, but couldn’t.

The day started out on a bad note – those in charge were running around, barking orders, and trying to look organized while they were, in fact, the opposite. Threats of 5 points off the total grade were tossed at us because some students didn’t bring more than a stethoscope. The 10 students in attendance tried to remain in good spirits, regardless of the absurd nature of the requirement, but soon realized that we were dealing with power whores and this would not be fun.

The man in charge of the standardized patients was by far the worst. He actually believes he is a doctor – though I’ve never seen any proof beyond his proclivity to wear long white coats while he yells rules at students. He proceeded to yell at us about everything, claim that we weren’t being “professional” (once again, I completely hate it when anyone uses that as an excuse to blame students for being human), and told us that no one could talk. At all.

“No one should be talking. This is a serious exam and if you fail because you can’t keep quiet and remain professional, well…that’s on you.”

“Excuse me! I’m talking. Table all conversations!”

Various re-utterances were heard of the above for almost 2 hours while we were oriented. Yes, it took them 2 hours to get us through the orientation. We had 10 cases to get through at 25 minutes a piece. Everyone of us knew that it was going to be a long day. Preparation for Step 2 CS? Hardly.

And that’s where I get a little miffed. People in these kinds of positions have lauded their authority over us for the last 3.5 years. We’re close to being done. We’ve passed every examination that’s been required and we’re over the threats. What? You’re going to fail us because we wouldn’t sit in fear while you assaulted us with rules and regulations – all of which we’ve already heard numerous times?

Power corrupts. In this case it made people who have low self worth try to use it to swell their image. I see this quite a bit, but that day it was just a little too much to deal with.

More About Balancing Life and Medicine

Yet another comment has fueled some need to post within me. Essentially the comments from my last discourse were interesting. Receiving a hint of disdain for my belief that a medical career is just a...gasp... J.O.B. I wanted to touch a little more on what makes my day (and maybe not disdain, but a certain level of disbelief that a medical student didn’t want to put medicine first was clearly evident).

The other night I was in Daughter’s bedroom, reading a couple bedtime stories to her. While I was leaning against her bed reading, she lovingly placed her head on my shoulders, stroked my hair, and kissed me several times on the head. After I finished she rolled over and said sleepily: “I love you Daddy”. My heart melted.

This happens on a regular basis when I’m home. I have memories that make me smile, laugh, and occasionally make me sad. I relish them, but realize that almost all of them are from the 3rd and 4th years, where, after spending most of my time in the school studying during the first couple years, I decided that I needed to spend a lot more time at home. I’ve done well throughout, but I certainly have more fond recollections of my times at home than freaking out over some quiz or test.

Now this being said, let me explain that at the same time I have always been committed to the patients I’ve worked with. I read a lot at home, about diagnoses and treatment plans that related to diseases I’ve seen or will see the next day, and never abandoned my duties in order to get home sooner. However, I do not have a great deal of memories from the hospital that would make me want to replace anytime spent with the wife and kids. I’m sorry, but patients just don’t fill a need in me the way my family does.

Other physicians and medical students may find that they have no better times than being in the hospital. While I applaud them and thank them for their dedication, I feel sorry for those who sacrifice their family life in order to obtain this satisfaction. I won’t state that I feel certain careers shouldn’t have families involved, but I think they’re more apt to be strained and the relationships more miserable regardless of the persona involved. I didn’t want that…that’s where my decision came into place that ultimately steered me away from a surgical career and into the anesthesia field. Others may decide that medicine is their priority and they’ll sacrifice everything else towards that end. So be it.

Yet, despite my understanding that some people love being at work, I find the most pleasure, solace, and love when I’m home, not amongst the sick. My favorite place in the world is not in the hospital, that in and of itself is proof enough that a career as a surgeon should not be attempted, but with my family. A quote I heard during interviews described my situation perfectly:

“If your favorite place in the hospital is the OR, then anesthesia is the right path for you; if your favorite place in the world is the OR, then be a surgeon.”

Perfectly Said

A comment on OB/GYN really hit the nail on the head for me. From Agraphia:

I divorced my husband during the third year of obstetric residency, which was a second residency. My daughter and I hardly missed him by then. He never made it to her school functions, recitals, science fairs, ever. But, I think that was just him. He found time for things he wanted, like on the phone and hanging out rehashing the political garbage of residency with his “family” of residents. He was rarely home when he was there. He was chronically exhausted, mean, and self-focused. He became obsessed with malpractice issues and how to keep everyone from getting his money. I started the first residency “with him” and my focus was appreciating him when he was there, not bitching like I heard so many wives. Our lives were on hold all of the time … at age fourteen his daughter doesn’t know him and doesn’t want to. Nothing is more sad or tragic. I know it would be that way either way. The system of training, indoctrination, and expectations beyond what is humane is the cause. Why do people go along with it … and lose their loved ones/families? It is so unnecessary .. it is about control of money and litigation. He went from being disturbed about the way women and babies were treated and wanting to get a journalist to cover it in his first year, to becoming shut-down and numb so he would become stuck in the financial obligations that keep them there.

If the system would allow real midwifery, the load of the care needed could be divided between doctor, nurse, and midwife. A midwife is glad to be a woman’s primary caregiver and be there throughout, which is really important emotional support. Doctors have to be in the office doing monthly exams, available for surgery and births night and day. It’s crazy-making for everyone except the hospital coffers. If nurses and midwives helped play a part in the care of pregnant women, it would be acceptable for the doctor to just show up at the last minute, do the medical deeds and move on.

Of what service is the current system to women? They are forced to accept only the care of an OB, that when all is said and done is so inadequate and minimal. The tragedy from my perspective is seeing a man turn into someone so nasty to women. Why do we expect them to be all to everyone … so that end up tragically giving such poor quality to all?

The reasons that I feel surgery wasn’t for me drew along very similar concerns. Having a family, who doesn’t want you home, being completely consumed by your job and having nothing to do with people outside of the hospital are absurd events that many residents go through when entering demanding fields. To me, it’s just not worth it. I feel, and hopefully will always feel this way, is that there is no failure more complete and absolute than to fail as a parent.

Sexual Harassment

An interesting topic was generated by Hoover over at MedSchoolHell. It discusses some of the sexual harassment that many medical students have to endure during their clinical years. While I've seen some forms myself (and been a victim once) I don't recall anyone reporting the events. All too often I've found that surgeons tend to be the greatest offenders (lots of inuendos during surgical cases - what with the "suck this" and all), but many other professions are also culpable. What I find interesting is the SDN feed that he links - the mindset of many students is to just let it go and be "professional".

You know what? I'm really sick of that catch-phrase being tossed around to shame medical students into submission.

I agree with the suggestions of going to the legal department and risk management. Your dean's office or coordinators are not going to be able to help you. They'll sweep the incident under the rug.

Obligatory Comment Induced Post

In reflection on my post dealing with Psychiatry I found the responses completely perceptable. Of course, having dealt with similar forms of misunderstanding or degrees of complete arrogant ignorance directed towards my chosen specialty I can understand the knee-jerk reaction towards my apparently incendiary comments.

They were expected. I anticipate more, perhaps as others are directed towards the jerk med student who knows nothing about psychiatry. Imagine if I’d bashed acupuncturists or homotherapeutics – we’d be swimming in the assaultive commentations.

Yet the fact remains – my experiences, my teachings in a school of medicine by residents, attendings, and social workers demonstrated a very sad state of affairs. The social workers were more involved in talking with patients than the doctors who, instead, spent a great deal of their time reading or leaving early. Patients improved here and there, but there were very rare circumstances where a physician actually worked hard at understanding the patient’s needs or point of view. Unfortunately, this is all too common in other areas of medicine, but damnable from a psych perspective. If my exposure has been insufficient to truly warrant a degree of opinion, I am aware.

Yet, even friends entering the psychiatric field have expounded on the degree of psychiatric training they've tried to avoid. They agreed with my perceptions of the residency we rotated through and noted some others where they'd interviewed whose residents actually would state: "we need to get a real doctor's opinion". That's where my concern for Psychiatry lies - in the apparent loss in some training programs in keeping their residents grounded in their medical school knowledge.

****

There have been discussions regarding the desire of psychologists to receive training to begin prescribing medications. If what I’ve heard, that being drug management is more lucrative than couch talk, I can understand their wishes. However, and let me be clear on this, I do not think that psychologists should be giving out drugs, regardless of my perception of the state of Psychiatry. If for what little medical treatment and disease pathophysiology psychiatrists actually recall, they received 4 years of post-graduate training revolving around the medical needs of patients in all arenas. Their understanding of pharmacology, side effect profiles, and dosing have been inculcated during this process and they are, therefore, more likely to be able to understand the toxic-therapeutic ratios, effective dose over lethal dose, and other nuances that a physician must evaluate when prescribing medication.

As little of the understanding of psychologist training I do know I don’t feel that they are as well prepared to be able to understand, nor be able to review, drug interactions and potential dangers as a psychiatrist. And perhaps it is the 4 years of residency training that I bemoaned earlier, focusing on the drug management more than psychoanalytical jargon, which further qualifies the psychiatrist from those who want to be included.

But what of the additional year or two that psychologists have suggested that will enable them to understand these concepts? They still lack the fundamentals, ingrained throughout 4 arduous years of medical school, that all physicians rely upon. Rather than being on the same footing they've already started behind and, worse yet, have years of training that have narrowed their mental process towards what they studied.

Overall, medical training allows the students and residents more capacity to understand where, when, and how to obtain vital information – regardless of specialty. What's more is the fact that these same students and physicians have a less focused perspective as they've been trained in broad strokes from the getgo.

Yes, we all forget how to manage certain diseases (I can’t for the life of me recall how to classify Salter fractures from surgery nor what the management would be), but we have studied them before and understand enough to be able to review with better efficacy. It's like riding a bike - you never really forget, but it's harder to teach an old dog new tricks.

What’s more is that through this process we’ve been able to interpret more readily what we don’t know. I’ve felt that a PhD enables someone a great deal of knowledge about a very precise and minute area of science. Truly they are experts in a small area. The problem that occurs is all too often someone with a specific focus begins to believe that they can do more without realizing their limits. I do not agree that a PhD enables anyone the option of performing as a physician – the training is to myopic. In fact, I find it disturbing to know that some professions are actively trying to erase or blur the fine line between the physician title of “doctor” and their own within medical settings. Because, unlike a rose, a doctor by any other name is not the same.

Wouldn't Know the First Thing

Rather than post about the continuing discussion regarding my rank list with Wife I will instead post about some other topics until I feel I can discuss the situation with more perspective.

With that being said...

A post from T at Anesthesiobiost (a rather interesting blog about an Anesthesiologist living in, I think, Philly, who is trying to learn the Oboe) illustrated a point that I’ve made to some of my colleagues regarding Psychiatry.*

Unlike Kris Kringle in Miracle on 34th Street who holds a great deal of respect for Psychiatry, I do not. Perhaps my experiences have been dominated with poor understanding or observation of the absolute worst form of practice, but I truly don’t feel Psychiatrists should be held in the same realm as physicians.

For that matter I don’t understand why they need to attend medical school in order to become head shrinkers.

Consider the experiences I’ve seen:

- Patients in an acute Psych ward were treated only by the nurse practitioner for diseases like high blood pressure, diabetes, and headaches. The psych residents and attending were unable to treat these diseases and frequently asked for “med consults” when these “problems” arose. They would then ask the students about the medications and what they did as they didn't know.

- During an ECT day while on an Anesthesia rotation, we were forced to wait for the Psychiatrist to arrive 30 minutes late for the last ECT (consider that we were scheduled in another room after we finished). Once he arrived we were once again appalled to see him spend another 30 minutes talking to the patient about why they were happy having not eaten that morning (as per OR guidelines – NPO after midnight). Then, without alerting the OR team or anesthesia team, this guy allowed the patient’s family to enter the room and observe the procedure. Afterwards he described what they had done and feebly tried to recall the reason for the anesthesia team’s involvement. He fucked up the basic physiology and pharmacology so badly I lost absolute respect for him.

- Whenever a Psych consult was requested at my main teaching hospital additional measures had to be taken in order to get a resident or attending to see the patient within the week. On OB/GYN we had to personally track them down and walk them to the patient floor in order to see mothers before they were discharged. They always acted put out and asked ridiculous questions about the patient’s disease or status (like did they look tired when they delivered – of course they did!).

- An attending stated that psychologists are better talkers than psychiatrists. The job of the psychiatrist had moved from “the couch” to the pharmacy. “Let the psychologists handle the psychoanalytical discussions with the patients, they’re better trained at doing that now than we are anyway. We deliver the drugs that help people”. No, really, he actually said that.

- I spent 2 days being lectured on Freud despite many of his ideas being disproved. They guy was a fucking coke addict with a major sexual compulsion – why are we still being taught about him?

I completely agree with T’s anger over the issue she describes. I don’t understand psychiatrist’s need to attend medical college – because they sure as hell forget about disease processes when they enter residency and apparently are just glorified drug pushers.

* I am not sure what T's opinion of Psychiatry is and am not trying to make any references to the like. Her post only allowed me a moment to reflect on the level of absurdity I feel with Psychiatry.

Back at It

Well, after a lovely couple weeks break from interviewing and 5 weeks from medical school I'm back at it. Last weekend (yes, an interview on Saturday - I've got a couple places doing those) I interviewed at a nice enough program, but - and thankfully - I knew that I wouldn't rank it high. I've vacillated enough about my rank list already and I really didn't want some place that I wasn't keen on to begin with to suddenly astound me and fuck things around again.

Today I'm supposed to start my Radiology rotation. Supposed to. But, I'm several thousand miles away for an interview tomorrow. I had to fly out yesterday in order to ensure that I could make it to the dinner and the interview since the weather out in the west has been lovely.

Of course, trying to get information on the rads rotation, the change in our starting date, and attempting to alert the coordinator that I will be out for the next 2-3 days (remember, the last time I flew through this area I had to sleep in an airport for another flight) I have, naturally, not received any reciprocating e-mails from this rotation.

Sigh...

I wonder when the school will realize that I'm paying you to help me here, it's part of your job. Some assistance would be nice - but then again, I'll have a quarter of a million in debt for a study-at-home medical degree. YES!

I'll be glad when interview season is over. It was fun at first, but having time off has made me realize that it's hard to try and kiss ass all the time and appear interested in anything being said.

***Addendum: I received an e-mail from the coordinator regarding my first e-mail, 2 weeks ago. She wants me to call her and explain myself. Hey, I tried to get to you already, now you'll have to wait.

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.

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.

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.

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.