Random Ramblings

That Doctor

It’s official, I have become “That Doctor.”

You know, the guy who told them that their father only had three months to live and here he is, six months later, being wheeled in by his triumphant family. I mean, he looks almost the same as when I saw him the last time, maybe a little more cadaverish, perhaps a little less animated than I remember but still clinging gamely to life as only the terminally ill can. And I’m not disappointed in the slightest because he is a fine fellow and the family could not be more pleasant or good humored, a real pleasure to have in the department.

But to set the record straight, I did not say their father had three months to live. I said that the oncologist believed that their father had less than three months to live. But it doesn’t matter. I am now “That Doctor,” the guy who their father has outsmarted and outlasted and they are not shy to remind me of this, a remonstration that I take in the same good spirit it is given. Because I don’t mind. I have arrived. The family is profoundly grateful to all of us for our efforts on behalf of their father and I am flattered to be regarded as a wise physician who was never-the-less outwitted by their crafty old dad.

Preliminary Hell

You should see my private email. I have a fan club of sorts who think I am the very Devil and are very defensive about the current state of residency training. They take particular umbrage to my often stated opinion that academic hospitals view residents as nothing more than cheap labor and extract much more value out of them than they end up paying in salary and benefits. My critics insist that even with the large sum of money paid to the hospital by the government for each resident (an average of $100,000 per year), if you take into account the overhead, the increased liability, and the inefficiencies that are unavoidable in teaching residents the hospital actually loses money and is doing us a favor by letting us tag along.

For my part, because I can add, subtract, multiply, and even have some facility with multiplication’s tricky cousin, long division, I have a pretty good idea how much we are actually worth to the hospital. My critics usually have no idea of this themselves and even the fact that the hospital receives federal money for residents is often a revelation.

But I can end the debate with two words:

Preliminary Surgery.

Was there ever a bigger scam than this? Here you have a collection of disposable residents to whom is owed even less, if possible, than to categorical residents. They’ll be gone in a year, some to their real training that required a preliminary year and some to programs into which they match after another go at ERAS. Consequently, their education is viewed with profound indifference by their employer whose only goal is to extract as much medical labor out of them as possible.

I complain about residency but I have it easy compared to those sorry individuals. I once met a preliminary surgery intern who along with another preliminary intern was in the middle of three months of Q2 call. This means, for those who don’t know, that he alternated 24-hour shifts with his fellow serf.

“But Panda, that’s not that bad,” you say, “He gets every other day off.”

Maybe in a perfect world, one where call was actually call and not an extension of the work day, this would be true but the two interns in question essentially missed sleep every other night, went home exhausted, and came in the next morning as if nothing had happened. It is not like working as a fireman, for example, where you may be at the station but if nothing is going on you can eat, sleep, or just hang out. It was a day of the usual rounding, admitting, and scut which only intensified when everyone else went home.

The fact that they also had to stay a few hours extra past the nominal changing of the guard is of no concern to most people who, as they work at normal jobs, are somewhat cavalier about an hour or two. But this little chunk of time is precious to an intern. Be that as it may, this abbreviated day counted as their day off and their hospital could no doubt point proudly to their compliance with the ACGME work hour rules.

Think about it. If you work Q2, you will work approxmately 96 hours on one week and 72 on the next which, with some creative lying about hours which all surgical residents are strongly encouraged to do, can almost be called 80 hours per week averaged over four weeks with at least one full day off every week and at least ten hours between duty periods. It’s diabolical. Their program, smarting from the ACGME’s smackdown devised a way to work the crap out of the help while following the letter, if not the spirit, of the law.

Is it Too Popular?

Emergency Medicine, once a sleepy little-respected specialty which was regarded as something somebody did if they couldn’t do anything else, has enjoyed a tremendous increase in popularity among American medical students to the point that it is now as competitive as some of the surgical specialties. I think it is lifestyle, more than anything else, that is driving this.

Medical students rotate through the specialties and begin to realize that most of medicine, far from being the glamourous career of which they dreamed, is a grind, a slow slog, or a medical Bataan death march. Then they do a month in the Emergency Department where, while also not exactly what they expected, they see a world where the pace is faster, the decisions are quicker and, wonderous to behold, the hours are regular and you can forget about work when you go home as there is nothing to follow up.

It also feels more like real medicine because, unlike most other specialties where the patients all have baggage from half a hundred previous admissions and hundreds of pages of advice from the small squad of doctors who follow them, it is possible to see a patient who is completely terra incognito and upon whose body no physician has yet planted a flag.

So Emergency Medicine has a tremendous appeal, especially for people with a low tolerance for bullshit and wasted time. On the other hand, it’s not for everybody. I mention this because my program has lost several residents recently who decided that Emergency Medicine wasn’t really what they wanted. All fine guys, don’t get me wrong, but after a little exposure it was either the pace, the shifts, or the obvious lack of depth (compared to, let’s say, cardiology) which lured them away.

I happen to like the pace and the lack of depth as I am (true to the cliche about Emergency Medicine) easily bored and have a short attention span. And I don’t mind working shifts because (as I have mentioned a time or two) all I really want is the chance to sleep every day. I also like to be at home when other people are at work.

But like I said, it’s not for everybody. Unlike the traditional lifestyle specialties, Emergency Medicine is only a lifestyle specialty if you like that kind of lifestyle. You trade relatively benign hours and high pay for continuous work while you are at work and a schedule that only a vampire could love. It also has a very reasonable lifestyle in residency once you clear all of the hurdles of intern year which is important but should not be the most important factor in your selection of a specialty. (Unless of course you are one of those lazy bastards in PM&R in which case you probably laugh and point at the rest of us idiots.)

I think we may see a backlash because Emergency Medicine’s popularity is insane and doesn’t make any rational sense. It’s a good specialty but 20 percent of my graduating class went into it. It’s not that good.

27 thoughts on “Random Ramblings

  1. I looked at Careers in Medicine today and saw that EM has grown in popularity substantially over the past year. Nearly 100 more American seniors and 200 additional applicants applied this year over the previous cycle. Granted, while the number of spots available for EM also rose, only 82% of U.S. seniors matched. Luckily, there is still a 1:1 ratio of spots per American applicants.

  2. I worked as an ER scribe for the better part of a year. In our hospital, the shifts that the docs worked seemed totally scattered and random: 6PM one day, 9AM two days later, 9PM the day after that, etc. Is this type of scheduling standard in all EDs, or are there some that opt for more rational scheduling? EM seemed to be quite an enjoyable specialty with this being the one of the only big drawbacks as far as I was concerned.

  3. It all depends on your group. I have a friend who just took a job where he works five 8-hour shifts and then gets five days off. And he will make pretty good (ridiculously good)money too.

    Also, within a group, physicians have a lot of leeway trading shifts among each other (or that’s my understanding). We certainly do a lot of horsetrading at my residency program.

  4. “So Emergency Medicine has a tremendous appeal, especially for people with a low tolerance for bullshit and wasted time.”

    Ha, sign me up. EM is definitely one of my top choices, the more I think about it.

    20% of your class is incredible though – my school sent 7% of the class into EM.

  5. dr. bear,

    please don’t lead your young flock astray in believing that there is no BS in EM. it is like all other specialties that have to deal with business bull crap and malpractice issues as you discussed in your previous post.

    the popularity of EM is no suprise with many people wanting to have more control of their time. i am suprised that more don’t do locums.

    problem for me with EM is you are the jack of all trades an master of only a few things (i’ll give you that). EM is also kinda like mercenary medicine. doc in the box type stuff. hard to have a love for something you don’t see to the end.

    but other areas are becoming popular again even more so the EM because of the financial side. remember the ROADs.

    but as always my specialty is always and will always be the best and most sought after (big cheesy grin)

  6. Other downsides to EM:

    1. Dealing with EMTALA, and even further extensions. Out here in LA they are proposing a fine of 10k for ED docs who discharge a homeless patient that is stable that just doesn’t want to go or have a place to go. You’re right I guess I could take them home with me.

    2. As a hospital based physician you have to put up with administrative bullshit that other specialists couldn’t dream of.

    3. Hospital quality measures are one small example of what administrators cram down your throat without logic. Almost anyone with chest pain, SOB, or cough gets a dose of levaquin at triage. Terrible medicine, but is satisfies the bean counters.

    4. No control whatsoever on hiring and firing the staff you work with. Many times you will be stuck with lazy incompetent help that you would never tolerate if you ran your own show in the office.

    5. There is no occupation on the planet that requires more multitasking and interruptions while making critical decisions.

    6. High risk. Physicians in my group get sued once every 7000 patients or roughly one every other year.

    7. The ER is the canary in the coalmine for all that is wrong in medicine and in society.

    8. You are only as good as your last shift and can be terminated with little notice. The whole group could be gone with 30-90 day notice.

    9. Getting paid. We struggle to collect 24 cents on the dollar billed.

    10. Society: The ravages of alcohol, drugs, crime, violence, child abuse, ignorance starts to jade.

    11. Drug seekers, pseudoseizures, made up complaints for work notes, etc…….

    12. defensive medicine

    13. futile medicine

    14. Call panel crisis (lack of call panel help)

    15. Dealing with condescending specialists.

    16. Ungrateful patients

    17. Working Christmas, Thanksgiving, July 4.

    18. The smell of pelvic exams with discharge or foreign bodies, sputum, vomit, pus, and C dif.

    19. The noise of drunk psychotics.

    20. HIV, Hep C infected blood.

    21. Coding 500 pounders.

    22. Constant subpeopnas from the DA’s office to testify in criminal cases

    23. fibromyalgia at 4am.

    24. rectal FB’s

    25. JCAHO

    I stop at 25 only because I am dead tired from working 4 nights in a row.

    Nevertheless, after 13 years of practice I think I am glad that I am doing it because practicing EM is humbling, challenging, and if I wasn’t so acutely aware of how terribly tragic life is, I may not truly appreciate how precious life it really is.

  7. EM is rivaling things like derm and ortho in my class, not kidding. It is the hours, the pay and the decision making. Also being a jack of all trades appeals to a lot of people.

  8. It’s wierd. Now, seriously, a lot of those things detailed by Jerry while true are endemic to most of medicine. The ones that aren’t provide the unique charm of the specialty. I just don’t think a lot of people know what they’re getting into.

    I have to defer to Jerry’s much greater experience, however.

  9. Among the items listed by Jerry I found out extremely quickly that I HATE dealing with people who aren’t appreciative, who I don’t know, drunks, etc. I had high hopes for entering EM, but once 3rd year began I quickly lost those hopes. Anesthesia is the golden road for now – otherwise I’ll end up in the dungeons in radiology or path.

  10. dr. bear,

    as you alluded to, there is a lot that medical school and residency does not prepare you for. the politics of the physician-physician, physician-hospital, physician-patient, and physician-insurance company can be frustrating. i remember thinking that once residency was over that all the BS would be gone. hmmm no to much. for those in training, your percption of the interworkings of the complex medical relationships is very limited. once you go to the darkside you realize “i have been sold damaged goods.” aahh, isn( medicine grand.

  11. Goddamnit, I am not naive and I have not only worked in the real world but was the principal (owner) of a real Structural Engineering firm that billed n’ everything. I have a pretty solid understanding, generally, where the money comes from, where it goes, and who blows who.

    And I never said the BS would be gone. I don’t know how many times I have to say this but the only objection I have is that I am getting paid peanuts and work like a slave. I am pretty level-headed, a combat veteran of the United States Marine Corps, and nothing really bothers me except making taco-jockey wages for Tortugan sugar plantation slave hours. Pay me a couple of hundred thousand a year and I my tolerance for all manners of BS goes way, way up.

  12. uuhhh, where did that come from? my statement was not directed at the you you, it was at you general you. in my eperience, personal and observing others go through the painful process of adjusting to both private, academic, and employee, residency in itself leaves you unequiped for what is to come. as jerry pointed out some of his frustrations, i can point out many frustrations with the institution of medicine as well. one significant point of frustration is hospitals making deals for medicatiom and implants without the physicians input. just one of may things that folks in residency and medical school are not so much aware of. insurance companies looking and physician an hospital outcomes and stopping the relationships based on that alone. again, this is adressed to the general you. dr. bear do realize the most in med school and residency are not as wise as you. many have not had the other experiences. that is why you blog is so refreshing. eventhough you keep beating up on me (cheesy grin) i will keep coming back.

  13. (Jerry cracks me up.)

    But speaking of “why” people prefer Emergency Medicine, should I mention the “unspoken” quality that one finds in those poor souls? And it applies to not only the docs, but the nurses and everybody else. Which is, everybody I’ve always known always said that “ER people are crazy”. (And I certainly never considered myself very high on the sanity scale during the years I worked ER…)

  14. Speaking as one of the grunts living in the trenches, I cannot help but applaud Panda’s sentiments. I am a surgical preliminary intern. I live the scut that he is referring to. Daily I am told how lucky I am that I have the privilage to work q3 for months a time….that I am privilaged to work for 120hr shifts….bascially, that I should feel privilaged to be slave labor. Myself and my other comrades work like a dog but have no guaraenteed job because of it. How is this not an abuse of the system? AND, who says residents aren’t profitable? Hoover at medschoolhell played with the numbers…he figured that that the average wage for an 80hr resident was about $9hr….imagine my sorry bankaccount when you consider my salary of about $5/hr X 120hrs. Good thing I don’t have time to spend it.

  15. i forgot about that whole preliminary surgery statement i could not agree with you more on that statement. we see so many who do not match and choose that as a way to possibly get into an ortho 2nd year spot only to find out they don’t even have the ortho prerequisites for the ortho year and therefore are ineligible for the ortho PGY 2 spot. those general surgeons just make you their bitch for the whole year. that really sucks.

  16. I was an intern twice. After my first internship I took a 4 year vacation in the Navy which gave me another 4 years to decide on a specialty. My second internship was the first year of my EM residency, which at times was Gawd awful painful for reasons Panda states.

    I chose EM in large part because I think EM is full of practical, no nonsense, down-to-earth, hardworking, humble people. I can go to our national meetings and feel perfectly comfortable wearing sandals and bermuda shorts. Somehow I dont think the same causualness characterizes the American College of Dermatology or Neurology. And yes, we are crazy. Any other specialty just seemed too easy, narrow, or boring. Or in the case of surgery, training is too self dehumanizing to tolerate for 5 or more years of residency.

    Even though I could make my list above to a hundred, I am glad of where I am at.

    However, med students who think it is a good choice solely based on the “lifestyle” are underestimating what full time EM practice demands.

    One thing to realize about EM is that annual earnings peak shortly after leaving residency. Most groups offer full partnership within 2-4 years. Graduates can make a lot of money right out of the gate compared to other 3-4 year residencies, especially if you continue to work hours like a resident. Most can’t keep up that pace however, and with EM you do not build up any “equity” in your practice that is of any real value when you retire.

    My thoughts.

  17. It always baffles me why some people decide to do a surgery prelim when they don’t have to (I am not talking about those have to scramble). I have run into people who were shooting for rads ann optho and for some unknown reason also interviewing for surgery prelim. Can someone enlighten me please?

  18. 1) Prelim surgery is a total scam. A year of medical torture, and no skills afterwards. It should be against the law.

    2) Panda Bear, I hope you don’t mind, but your blog intrigues me so much, I just tagged you with a meme. I’d love to hear 5 reasons why you blog. 🙂

  19. Those people who are going for rads or ophtho require a prelim year in something before they start their actual specialty training. Maybe they go for a surgery prelim because generally those kinds of programs have a lot of unfilled spots after the Match. I think they have more unfilled spots than prelim medicine programs.

  20. Also, the fact that surgery prelim programs have a lot of unfilled spots after the Match probably makes it easier to match into one of them.

  21. Interesting, as usual.

    What do you mean by backlash? (against who? can you be more specific).

    My understanding was that since EM is a pretty young field the US is still quite a ways from being saturated with EM trained EM docs.

  22. Hi Panda

    I happened upon your blog a couple of weeks ago, and have joined your (what seems like) legions of fans. Your writing and your perspective is refreshing, somewhat brash, but sometimes truth hurts. I just wanted to let you know I enjoy reading your well thought out and articulate, intelligent blog.

    I felt compelled to chime in on this post because despite nearly 15 years of high acuity, community hospital EM practice, and despite being dragged through a lawsuit from begin to end (trial), I still love EM. Each time I go to a medical conference (just returned from one), I feel acutely rejuvenated and proud to be an emergency physician. To me, the medicine is still absolutely fantastic and interesting and rewarding. It’s the non-medicine crap that takes away from the enjoyment of the specialty.

    So thanks, Panda. Keep up the good blogging.

  23. Even pathology has its problems, especially when one is in a private firm, non-medical priorities drive the speed and volume of workflow (to which good work is inversely proportional), and one only infrequently meets the surgeons and gynaecologists whose stuff one is processing. At least in a hospital, when request forms come unsigned or clinical details are absent, or the specimen is poorly oriented/unlabelled, there is an intern or resident to hunt down (and terrorize) who can frequently clear things up, but given that path residents do most of the cutup and might scarcely meet the clinicians, let alone be willing to phone up surgeons they’ve never met, it can get quite frustrating sometimes, especially when one is a “cut-up slave” with little opportunity for reporting/training activities.

  24. To add to the discussion, PM&R, esp inpatient, is not as cush as many would like to believe. Inpatient rehab units are filled with chronically ill stroke, spinal cord injury, brain injured, burn, etc, etc who are going to have chronic PNA/UTI/wound problems. Additionally, the idea that only medically stable pt get admitted to rehab is a myth. Surgery and medicine sometimes dump step-down level pts on us. Rehab doesn’t work that well when you’re still in acute heart failure or hypotensive.

    Of course, outpatient sports med or pain avoids a lot of this, but these are highly competitive fields with LOTS of other practitioners (EM, FP, ortho for sports, and anesthesiology for pain).

    Anyways, no specialty or job is totally golden, and i’m doing what i enjoy.

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