Ask Dr. Bear

(Just some recent questions that showed up in the mail bag.-PB)

What Exactly is Wrong With “Patient Care?” You use the phrase like it were some kind of swear word but isn’t this our purpose as residents?

Of course it is. But “Patient care” is one of those nebulous phrases which encompasses so much in it’s definition that it can mean many different things to different people. In fact, your views on patient care will be radically different depending on how much of it you do and your actual level of responsibility for patients. To the adminstrators of your hospital, patient care means shoving a warm physician body, any body, into a slot in the schedule. If this means that a resident will cross-cover a couple of hundred patients about whom he actually knows nothing then that’s acceptable because the slot is filled.

Many residents, consequently, soon get the idea that residency training has something of a cattle-drive quality to it as our job, especially on call, seems to involve nothing more than wrangling large herds of patients in and out of the hospital. So while Patient Care is the ideal and calls to mind noble images of the selfless physician tending to the afflicted, a lot of it looks and feels more like patient processing. It has to be done of course, but it’s hard to get weepy and emotional about it.

As I have mentioned before, “Patient Care” is also used as a blunt weapon to beat down any reasonable debate on hours and pay. By default, apparently, every single patient in the world would be our responsibility if the hospital could only figure out a way to keep us funtioning without sleep. From this point of view, limiting residents work hours can only be construed as a crime against humanity and for a resident to suggest that he might like to get some rest can only be viewed as rank egotism.

Oh how the hospitals must have cried righteous tears when the current 80-hour rule was implemented.

Besides Patient Care, one of your other responsibilities as a resident is to learn. Unfortunately, the current system of residency training, which would collapse if the hospital was not allowed to over-work and deprive you of sleep, is not really an ideal educational environment. This is obvious to anybody who has ever tried to crack the books when they are post-call.

What, exactly, is wrong with the current system of residency training and how would things work in the Pandaverse?

The current system of residency training was devised over a hundred years ago and has not been substantially modified since then. It evolved from a more informal system of medical training which was almost a master-apprentice relationship. In fact, until the turn of the century, medicine itself was a fairly informal enterprise with very little standardization of training. Times have changed.

My biggest criticism of residency training is that it was devised for a more lesiurely era when the pace of hospitals was a good deal slower than it is today. As I have mentioned before, there were fewer interventions, far fewer medications, and much less to be done for most patients except to observe and hope that the limited supportive care available at the time would give the patient a chance to heal. One of my attendings, for example, related to me that when he was a young resident at our hospital, there were exactly three ventilators in the entire city. One of the jobs of the medical students was to “bag” the patients until one of the ventilators could be secured, often for hours at a time.

Today, the same hospital has close to eighty fully staffed Intensive Care Beds. And they are all occupied, usually by the kind of patient who could not have existed even fifty years ago when people routinely died of things we can treat today and could never have survived to become the kind of multiply co-morbid train wrecks which are now routine. Not to mention the hundreds of regular beds that are full of people who would have been considered insanely complicated patients by our collegues from the 1950s.

This is a good thing for the most part. It is true that we tend to get a little crazy with end-of-life care, often spending hundreds of thousands of dollars to preserve the anatomical functioning of people who maybe should be allowed to die peacefully, but I’m glad that I may have the chance some day to live beyond something that would have killed me if I had been born in the nineteenth century. The result of this is, however, that the hospital has been transformed from a sleepy hotel for the sick and a minor part of the urban landscape into a bustling hive of activity, almost a small city in its own right, and often the biggest employer and largest source of economic activity for many municipalities.

And there is money to be made. Lots of it. Hospitals are money-making enterprises in a way that would have been inconcievable even sixty years ago when medical care was cheap as it didn’t require much in the way of technology or support. The amount of money flowing through hospitals is staggering and represents a substantial percentage of the Gross Domestic Product. This is not necessarily a bad thing. In fact, the economic incentive is a powerful motivator for technologies that improve the standard of living.

But it is money and it is too much to expect a bureaucrat to worship both God and Mamon. Residents, the only employees who can work almost unlimited hours without extra compensation, are an economic boon to the hospital which can only maintain a staggering volume of patients because the majority of its physicians are working for incredibly low and fixed wages. Hell, Residents cost the hospital exactly nothing as the federal government pays them an average of $110,000 per year per resident, roughly twice the cost of their pay and benefits. Hiring an extra phlebotomist is a difficult decision for a hospital and requires budgeting meetings, reams of decision support, and bureaucratic hand-wringing at the highest levels. Covering the wards at night, on the other hand, is an easy decision.

“Make the residents do it. Fuck ’em. It ain’t costing us a dime. We own those suckers and have their gonads firmly grasped.”

Imagine the heartache that would ensue if your hospital had to hire a hopsitalist to do your job.

The net result of all of these factors? Residents have been transformed from low-payed but not particularly busy apprentices working in a system set up primarily for education to low-payed and incredibly busy employees whose primary job is moving the meat and for whom education is secondary and often incidental.

The solution? For the hospital to admit that residents are employees and treat residency training how we do it in Emergency Medicine, that is, a shift system with a dedicated didactic block once a week. maybe residents need to work more than 40 hours a week but even 80 is ridiculous as it necessitates bi-weekly periods of sleep deprivation and profound fatigue that makes education almost impossible.

B-b-but Panda, you can’t possibly train a doctor without working him 80 or more hours a week as a resident. Are you saying that we need to extend residency training?

No. Residency training is hugely and completely inefficient with large blocks of your time frittered away by bureaucratic exercises that contribute nothing to Patient Care. There is, however, no incentive to change a thing in the current system. You aren’t costing your hospital a thing, remember, and even if you were laying in an ICU bed in a profound vegetative state, the hospital would still make $50,000 or so per year on your tube-fed, inert body. The ironic thing is that, with typical bureaucratic short-sidedness, the hospital could extract even more money-making (or money saving) work out of you if they streamlined things a bit.

Hey Panda, I want to do Emergency Medicine but if I can’t match into it, can’t I just match into Family Medicine and then work in Emergency Departments? It’s all just primary care, right?

Like most things, it’s all about money. As you know, Family Practice is probably the lowest payed medical specialty which also partially explains its unpopularity. Emergency Medicine pays, all other things being equal, almost twice as much as Family Practice. In the days before Emergency Medicine became a formal specialty, emergency care was rudimentary and Emergency Rooms were staffed by a motley collection of physicians of varying skill levels, some who liked working in the field and some who really couldn’t do anything else.

As the field of Emergency Medicine has evolved, however, the practice opportunities for non-board certified physicans are shrinking. Emergency Medicine has exploded in popularity (for various reasons which we will discuss in later articles) and securing a residency position leading to board certification has become increasingly difficult leading to an entry barrier to the field which many consider to be unfair.

The key question is whether you believe that Emergency Medicine is a legitimate specialty with its own unique body of knowledge that is not commonly practiced by other specialties. If it is, and I believe it is, then unless you have been working at it for many. many years before there was a specialty, you are out of luck and if you want to be an Emergency Physician, you need to get the appropriate training.

Family medicine concentrates on the diagnosis, treatment, and long-term management of common and non-life threatening conditions. Emergency Medicine deals with the diagnosis, treatment, stabilization, and short-term management of shit that can kill you sooner rather than later. Is there overlap? Sure there is. But there is overlap in every medical specialty. I do a lot of pelvic exams and know how to deliver a baby but I would never bill myself as an OB/Gyn. Where the family practioner sees the forty-year-old otherwise healthy man whose blood pressure has been creeping up and after a paternalistic discussion, prescribes him a regimine of inexpensive anti-hypertensives, the Emergency Physician sees the forty-year old alcoholic with a headache, visual changes, and a blood pressure of 240/130. The first guy can wait a few days to fill his prescription. The second guy is going to start squriting blood out of his ears shortly if nothing is done.

Now, it is true that the conventional wisdom is that Emergency Medicine is just primary care for the uninsured but this is more because the conventionally wise don’t understand what primary care is. We do see a lot of relatively minor things in the Emergency Department but these are fillers and something we do to keep busy in between the real emergencies. I did a year of family medicine. The patients I see in a normal shift in the Emergency Department, those who don’t even raise an eyebrow, are much, much sicker than anything I saw in my 48 Family medicine clinic days. We admit close to 20 percent of out patients. And a good percentage of those go to the ICU.

Can I be any less wishy-washy on the subject than that?

20 thoughts on “Ask Dr. Bear

  1. You inspire me Panda! Thank you! If you get a chance I would really like your opinion on my website. I just recently moved it from MSN to WordPress (mainly because I really liked your format). By the way, we conversed on Student Doctor Network, this is arcin. I’ve been following your blog ever since.

  2. Panda, more smart commentary. My fellow first year medical students and I often speak about your posts, and we mostly agree with what you have to say. Also, I have to admit that EMed wasn’t high on my list of careers until I discovered your blog and read your opinion of the specialty. Keep up this high quality argument, maybe someone with some power will read it someday… riiiiiiight.

  3. Interesting insights into a difficult situation. You must be in a difficult situation. Very bitter about the residency process.

    I am fortunately look back and see what was beneficial. I guess hindsight is 20/20. Some attending physicians are not attuned to the importance of their role as and educator. They should protect you to some extend.


  4. I’m not bitter in the slightest. I just hate working long hours for taco-jockey wages. I don’t know why this is hard for people to understand. There is nothing more metaphysical to it than that.

    As for abuse, well, I’m a former Marine and people tell me I still look and act the part so although I am exceedingly polite to everybody and have a reputation for being one of the most enthusiastic, funny, and considerate resident in the hospital, nobody exactly abuse me in particular. I guess I’m kind of scary looking.

  5. agreed, i hate working long hours for the reimbursements we get today.

    you know for every Illinois public aid patient i see, we come up in the negative.

    that makes me sad.

  6. True, same with medicaid and “self-pay” here. But they don’t ask the nurses, the PAs, the techs, the janitors, or any other employee of the hospital to take a pay cut to subsidize indigent care.

  7. no our hospital requires the to take mandatory time off. this is how they some how balance the books. not really sure how that works though.

  8. I remember being forced to take time off when I was a CNA. Whenever the hospital’s census dropped, I knew that I was getting sent home early—without pay—so that the hospital could save money. Strange, the nurses always seemed to be extremely busy with whatever patients were still left.

  9. This is not uncommon in most industries. In my neck of the woods, however, medical care is a growth industry and we graze on a vast and seemingly inexhaustible prairie of patients, most of them paying customers (GM, Ford, and etc.).

    The nurses have a union and are working under a contract that probably doesn’t permit the hospital to limit their hours to less than forty.

  10. And I’ll tell you what. Pay me what I think I’m worth and if things get slow at the hospital, I’ll stay home.

    Can’t get more fair than that.

  11. now for mandatory time off, our volume hasn’t changed.

    as far as paying you, hmmm. it is hard to figure out what you are worth. i can tell you that for a fellow, we had to produce $120,000 for funding the spot. I think the salary was $50,000. these are not positions funded by the government. now, this is a spine fellowship and malpractice is rather high here.

  12. I don’t think fellows are reimbursed by medicaid. But remember, money is fungible, especially in a hospital and they were probably shaking you down. Other than salary and the other expenses we discussed, what does it cost to keep a fellow? They, surely, must be able to earn their keep as they are attendings in their own right and the rules for billing and etc. probably don’t apply to them.

    Whatever the case, I’m a resident and we have established that it costs the hospital nothing to train me and I do some legitimate work even if it is just filling a spot that a PA could fill.

    Consequently, I want $68,000 per year, benefits, and a 50 hour-per-week schedule (with time-and-a-half overtime for anything over 55) which is what bran-new know-nothing PAs get.

    There, that’s not too unreasonable, is it?

  13. if you are ACGME accredited, fellows can not bill. if not accredited, that is how the position is funded usually. malpractice cost for a new practicing surgeon doing spine 25-50,000 from the insurance company. (now that is a scam)

    i see you 68,000 and offer with 60,000 and 6 weeks vacation, over time at 60 hours a week, benefits, but no 401k matching, and no teaching.

  14. If I were to pay an employee, then they would have been paid. I would have paid that employee. I don’t believe there is a valid conjugation that looks anything like “payed”. You write well, but you’d make your English teacher cry.

  15. The solution? For the hospital to admit that residents are employees and treat residency training how we do it in Emergency Medicine, that is, a shift system with a dedicated didactic block once a week. maybe residents need to work more than 40 hours a week but even 80 is ridiculous as it necessitates bi-weekly periods of sleep deprivation and profound fatigue that makes education almost impossible.

    And that right there is the reason I will never be a doctor. Besides the shit pay during residency (student loans, anyone?), I absolutely cannot function without less than 8 hours of sleep (on average). I wish I could, but I’m a complete mess if I cannot. I’d be a disaster of a resident doctor.

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