Welcome to Intern Year

(Gentle readers, I present the following which is mostly written in Marine-speak. You have nothing to fear and yet, if you have a weak constitution or are easily upset I implore you to skip this article, perhaps using the time saved to peruse the latest Peanuts comic strip in the newspaper or anything else that is similarly non-threatening.-PB)

Is That Smoke Coming Out of Your Ass or Mine?

You are loved. No doubt about it, the one lesson of your intern orientation is that now, finally, after four years of medical school where you were beneath contempt in the medical hierarchy you are now one of the gang, a valued colleague, someone who will be treated collegially. After all, as the designated speakers will point out with heroic rhetorical flourishes, whereas up until now you didn’t count, now you do and with your great responsibilty as real doctors comes the expectation that you will be treated professionally and courteously.

Then of course you will actually start intern year and they will treat you like a piece of shit, both institutionally and professionally. Need some sleep? “Fuck you.” Want some time off? “Screw you, you big fucking baby.” Don’t know where anything is or how they run the service? “Fuck you, moron. We sent you an email. Didn’t you read it?”

And so it will go. Now, I am not the smartest Asian bear-mammal to ever lumber out of the bamboo grove but I can tell when I am having smoke blown up my furry ass. You can tell me that I’m going to be treated like a valued junior colleague and you can make nice noises but the reality is that for your entire intern year, and possibly your whole residency, the default position of everybody with whom you work will be to treat you like a sweat-shop laborer.

So welcome to the dysfunctional residency training system which was designed, literally, by a cocaine-addicted physician and which has changed very little since its insane beginnings. Sure, some of the hours have been limited but the system still depends on depriving you of sleep and making you work the kind of hours that are considered war crimes in most other countries. Heaven forbid you point this out. Apparently when it comes to an abusive medical training system, everybody is a hoary old conservative protecting their peculiar institution from reform. Swing low, Sweet Chariot. Them residents sure can sing! Why brother, it would be a sin to set ’em free seeing how happy they are. Lift that bale, tote that barge!

Ol’ Man River he keeps rollin’ along.

This is what they really mean to tell you at your orientation to intern year:

“Welcome to our hospital. We’re so glad you’re here. the first thing I want all of you to do is to reach down and feel your testicles. Ladies, go ahead and palpate your ovaries. Feel those things? Well, we own them. Oh sure, technically they are attached to you but for all practical purposes they are ours and we have them gripped firmly. If you step out of line we will give ’em a squeeze. Step too far and we’ll tear them out of your body and present them to you a la Bruce Lee before you die.”

“Just wanted to clear that up so you folks don’t get too uppity. Your contract? Hah. We call it a contract but it’s more of a receipt for your indentured servitude. We agree to practically nothing and in exchange you are ours for the duration of your sentence…I mean your training. Don’t like it? I think we can fire you for just about anything and at any time. Not too many other professionals would work under those conditions but as long as there is a steady supply of you stupid motherfuckers ready to mortgage your souls to get into medical school we can pretty much do whatever we want. You can leave of course, but good luck getting another residency position after we shake our heads sadly and opine that you are a trouble-maker. Not to mention that we have the system set up so even if you manage to escape you can only do it one time a year and only if the stars and planets align just right. So shut your stinking gob-holes. You’re in it now.”

“And we don’t give a rat’s ass about your sleep, your rest, your health and your well-being. Oh, we’ll pay the usual lip service to these things and in later orientation lectures we will encourage you to take naps on call and instruct you how to best use caffeine to optimize your wakefulness but the fact is that we are going to beat the crap out of you for at least a year and hopefully for as many years as we possibly can. We just don’t care. Now, because some disloyal pussies couldn’t keep from whining to their mommas and killing themselves on the exhausted drive home from the hospital we are only supposed to work you eighty hours a week. I can not stress enough what a bunch of fucking crybabies that makes you or how sick I am of looking at your fat lazy faces sitting there knowing that you might actually get some time off. It makes me physically ill to think about it so I expect all of you to uphold the highest ethical traditions of the medical profession and lie about your actual hours if it comes to it. I suffered and because I have a personality disorder, you need to suffer too. Besides, everybody knows that we only have to obey rules if we agree with them…and we certainly don’t agree with this one, do we?”

“If you complain too much we will ressurect some dinosaur who trained back in the days when they were still using poultices as a first line therapy to try to shame you into keeping your mouths shut. Obviously everything was better fifty years ago, especially when interns were all geeky white males with no families and no responsibilities outside the hospital. Man! those were the days. We owned those motherfuckers. I mean, we own you but we really owned them. There was so little that could be done for patients in those days that we could waste their time with wild abandon. Those were the golden days of scut work my friends, the likes of which we will not see again.”

“As to your pay, well, the federal government is giving us a shitload of money for your training. Almost twice as much as we are reluctantly going to pay you. We’re going to cry poverty and feed you a line of bullshit as to how expensive it is to train residents, how much you are damaging our efficiency, and how this extra money doesn’t even cover the economic damage you will inflict to our bottom line but this is just fragrant smoke wafting up your ass. Try taking a day off or calling in sick when you have call and see how we are going to panic. As if it isn’t bad enough that many of you little pussies can’t work more than eighty hours a week and we can’t always screw one of your colleagues to cover your call, we may have to actually pay somebody real money to do your job which is really going to eat into our bottom line.”

“And who is really going to suffer? Why, The Patients of course. Your insistence on not working with hospital-grade gastroenteritis or your gay desire to spend a day or two every month with your wife and kids is stealing, yes stealing, precious medical care from the poor underserved wretches frequenting this hospital. Don’t you stupid fuckwits understand that Patient Care comes first? Patient Care is our primary responsibility and with the exception of the nursing staff, the respiratory therapists, the Physician Assistants, the phlebotomists, the lab techs, the janitors, the cafeteria ladies, the attendings, the parking attendents, and those ladies slopping the hash in the cafeteria everybody in the hospital is expected to sacrifice their entire life for Patient Care.”
“So we need you to work a lot. Unfortunately we have to give you little wimps four (and I weep to think of it) days off every month but we’re going to send you home a little early post call and call this a day off, even if it is less than 24 hours and you will sleep through most of it. Those pesky rules again I’m afraid but we’ll subvert ’em somehow because you guys are a fucking goldmine. Have you seen what Hospitalists are charging (not to mention PAs and other midlevels who will do in a pinch)? Let me tell you, they ain’t cheap. Not by a long shot. You poor sons of bitches, however, are ridiculously cheap. Insanely cheap. And the more we work you the cheaper you are because, get this, we don’t have to pay you overtime. Try getting the janitor to work some extra hours. Even my taco stuffer gets time-and-a-half if he goes over forty and all he has is a GED.”

“Who’s yer’ daddy now?”

46 thoughts on “Welcome to Intern Year

  1. An awesome read as always. Scares the hell out of me too seeing as I am a medstudent

  2. Oh, Dear God – I cackled my way through this entire post (probably because my first hitch was with the Marines, and I appreciate the humor). Dr. Bear, you may aver that you have no talent for writing – but posts like this give the lie to that supposition. Ironically, med students LOVED rotating through the Army ER I was a shift leader for – because they actually got to put their hands on people for a change. The wage differential aside, I completely understand why so many choose to do their internship and residency as Soldiers and Sailors – at least there they’re paid a living wage, get SOME modicum of respect (hey you gotta call ’em Sir and Salute ’em) – so life for them may not be the Hell you so eloquently describe. Well done, Sir!


    USMC Infantry Veteran
    Medic, TX Army National Guard

  3. Just got off from a non-call day at the VA — 13.25 hrs on an “easy” service.

    This has to be your best post ever. You’ve got to put this up on the sidebar somewhere.

  4. Love it, wish I could send this out as a mass email to my med school class. Of course the next day I would be overrun with angry letters from self flagellating classmates and probably a letter from the dean to see me in her office.

  5. Naps? I could go on and on but you have done it for me, with the exception of the question of naps.

    During the first few months of residency, in my limited wisdom I took as many catnaps in the call room as possible, so if I got called to a code blue in the middle of the night when I comatose I might be able to remember who I was. You know, provide Care.

    Some motherfucking RESIDENT reported me!! I fell asleep too easily during the day, and too often, it made him wonder…

    And yes, the residency director asked me not to take any more naps in daylight hours, even when I had any down time and was sitting upright in the chair in the call room. It was a “special year”, as i recall his rationale.

    I still think about how much time I missed with my oldest boy, now eighteen, and I recoil, hissing with regret and resentment…yeah yeah, I know, it was my choice.

    And the payoff is experience like no other.
    Frankly, I’m so brainwashed at this point I can’t even imagine enjoying my life doing something else.

    Except maybe taking fun, adventuresome fat people to France for a stomach balloon placement, then eating out with them in some shady arrondissement, something really good and greasy, and then smoking a cigar afterwards.

  6. Your illustration of residency makes it sound like an extended vacation in the Bahamas.
    What do you think should be done to push for more reforms to which hospitals will actually comply?

  7. As true as all of this is about residency, I don’t think it gets much better as an attending. I think this applies to everyone.


    (Bull.  As an attending you can choose to work yourself to death or not.  Residents have a highly limited choice often made with erroneous or even deceptive information and having chosen are stuck, for all practical purposes, unless they can move heaven and earth to get into another position which may be as bad as the first.  Not to mention that attendings get paid considerably more than residents.

    I have a friend who is a new EM attending and works eight 24-hour shifts per month for which he is paid in the low 200’s.  That’s eight shifts, long ones I’ll grant you, with 22 day off a month.  I’d trade his schedule for mine in a heartbeat even for the same salary I am getting now.-PB)

  8. Great post. Reading this I am reminded of something that happened during my intern year. There was one intern, an FMG (foreign medical grad), who absolutely sucked. The man was supposedly a fully trained doctor in his home country, but he was a total moron. He had poor English and even worse medical knowledge. The internal medicine program kept him on all year, then fired him on the second to last day of internship – they got labor from him all year (albiet crappy labor) and kept him from saying he completed an internship.

  9. Dr Nic, the residency program I attended did that constantly. They even did it to a third year resident 2 months shy of completion.

    I must be a masochist, I worked as an attending for two years (primary care sucks nasty wet monkey patties) and am back in fellowship training now.

    I adore you Panda.

  10. Dear Panda:

    I have enjoyed reading your posts. You have great insight and outstanding prose.

    You do sound way too frustrated with residency and attendings. Is there another way? What are the alternatives?
    Perhaps, you might CHILL OUT and calm down about training and ___hole attendings [we can’t choose relatives and colleagues, or should it be the other way around?]. How many more years? Pretty soon you will be an ER attending, and could change the world! Or maybe not, if you become too jaded and follow the path of physician colleagues who grow more pompous as they age…
    Have a great 4th of July!

  11. ‘So welcome to the dysfunctional residency training system which was designed, literally, by a cocaine-addicted physician and which has changed very little since its insane beginnings.’

    Ha, yeah I heard that story– Bill Halstead or somethin’ or another was his name right, that crazy nutcase specialty surgeon at Johns Hopkins in the late 1800’s? Got so totally hooked on cocaine that his buddies at Hopkins had to conceal him from the public?

    Apparently, this Hopkins surgeon guy– who all of us, in *every* specialty (not just surgery) have to thank for founding the residency madness– basically doped himself on cocaine and a couple other drugs in the cocktail, sorta like angel dust, so he could operate night and day. Of course he killed a few patients and was hardly coherent while he was high (let alone in withdrawal).

    But supposedly, this guy was seen as “super-surgeon” and his training program established as the standard in US medical education, with the, uh, minor details– i.e., all the killed and maimed surgical patients and his own weird behavior– kept secret in the process.

    So like you say, what amounts to this late 19th-century nut’s neuroses and frank substance abuse-induced mental illness, has thereby become the basis of training US doctors.

    And why does it persist? And in even non-surgical specialties? 2 words: “Cheap labor.” After all, why should a hospital actually hire more staff when there’s already a sleep-deprived, overtime-denied, burned out but utterly powerless underpaid resident to do it for them? The Hopkins guy’s system works perfectly in a sweatshop economy.

    The even bigger dips**t irony of this system, is that this Halstead guy apparently got this idea of the residency from Germany– Germany after all was the world leader in, well, just about every med/sci/engineering specialty in the late 1800’s, and it’s where all the brightest doctors in the USA went to train.

    That’s why all us surgeons talk so much about the Billroth procedure or Kocherizing, why the medical people talk about Kussmauling or Alzheimer’s, why the Ob/Gyn’s do their Pfannenstiel incision thing and Kleihauer-Betke tests– the Germans just utterly ruled modern medicine at it’s inception, so all the Hopkins bigshots went to Germany or Austria to get inspired.

    Problem is, half the time, the guys like Halstead did superficial observation and totally screwed things up when they brought the German ideas back to the USA. Halstead was apparently an idiot in this respect– the Germans never had a crazy residency system like that. The German surgeons and IM folks busted their behinds, but even back then they had semi-reasonable hours. And hospitals weren’t the multiple-comorbidity mills they were today– the patient population was smaller and more manageable, and even the surgeons on call generally got to sleep when they were on, and go home to their wives, kids, girlfriends, mistresses whatever and actually have a life.

    Halstead seems to have missed the point that the German system was an apprenticeship, not an utterly f***ed up sweatshop like the one he created in the USA.

    And what’s even more unbelievable is that today, Germany is one of the industrialized countries with one of the most humane (though still intense and high-tech) medical residency programs– you work maybe 50-60 hour weeks at most, have reasonable call without the sh*t-rolling down the hill like in the US, get home, get vacation, and actually have something like a semi-normal existence. I’ve even known some US docs who– fed up with all the accumulated crap we have in the US system– have somehow managed to pick up German in their limited spare time and moved there. They seem to be pretty happy and doing well overall.

    I guess this is what happens when you have the unholy duet of a cocaine-addicted nut’s ridiculous idea and the modern economics of cheap-labor medicine dancing together. You get the crap-pile we call medical training here.

  12. Yeah, I was real excited that I showed up at 430am on 1 July only to be berated for being late, as I had 10 patients to see before 7.
    I went home at 1pm on Monday.

  13. Thank you so much for cutting through the BS. Keep telling it like it is! You hit the nail on the head about calling in sick. My husband was called back 3 days early from sick leave; the chief resident and the department head knew about his surgery months in advance and STILL didn’t bother to plan weekend coverage. I had no intention of waking him up for this, but when he heard me tearing the chief resident a new one, he dragged himself out of bed and into work. He was such a mess that they sent him home an hour later. I’m getting an eyelid twitch just from thinking about all this crap again–aaaarrrghhh!

    Anyway, I never knew Halstead was a cokehead–that explains a lot.

  14. And yet, while I admit is is not all bad, people think I am making this stuff up.

  15. Your rants are getting old. If you fantasize about being a drill seargent, go back to the Marines, but please–and I know I’m not alone here–please post something insightful once in a while. The first few “old man Panda” posts warning the younger generation were funny and interesting. Now, you’re just sounding tired and bitter while pretending to give advice.

    (I don’t rant.  I comment on the conventional wisdom.  If it’s too much for you to handle then you may take your happy ass to some other blog as this one is not a public service and I am under no obligation to make you feel good about yourself.  As for posting something insightful…well, you are an ungrateful fuck.  I have about 140 posts on this blog, enough for a pretty good sized book, and if you think it is possible to load each and every one of them with absolutely original, never-been-heard, breathtakingly insiteful commentary to keep your jaded ass entertained then why don’t you try doing it?-PB)

  16. That’s because it is so unbelievable.

    No normal job would treat you like my program treated me this past week. I had zero training on the computer system, couldn’t access it because I did not have codes AND yet the attendings expected me to have the paperwork down perfectly on day 1. I was told my work was unacceptable.

    Ok, so it was, but without showing me how to do what is acceptable…how am I to figure this out?

    Osmosis, I guess.

  17. Speaking of being perfect from day 1, I’ve had the same scenario although I’m a 3rd-year medical student. I’m on surgery right now and have to arrive at the hospital by 5AM six days a week. I usually leave around 7PM. Since today was a holiday, I only had to work 6 hours instead of the usual 12-15. My attendings scream at the residents, who push work onto the residents, who order the interns to do their work, who eventually shovel everything onto the medical students. By the order of the clerkship coordinator, med students are not supposed to pre-round. Strangely, the two of us medical students generally arrive an hour before the interns to write 15 SOAP notes.

    As has been said by others, no other profession would go through this kind of experience. I forgot where paperwork = learning.

  18. so i am post-call from a night in the icu and am now about 10 days into internship, 3calls down, so many hours i stopped counting, yes like many of you others had the joys of no codes for things you are expected to access, not knowing that there was a transfer order ‘sheet’ and being told that the way i was doing it was not right even though the orders had the exact same info, caught between seniors talking sh*t about each other, and on and on and on. this post is great and unfortunately so true…i have not wanted to quit medicine as many times over the past four years as i have during the past ten days…so hopefully some sleep will change this perspective to start the day all over again tomorrow…in a few hours that is. thanks panda bear MD

  19. “What days are these? The days 53 years ago when I was a medical intern in the main teaching hospital of a state university.”

    That’s the quote from the “resurrect some dinosaur” article. So, the interns worked every day and every other night, and when they did go home, it was from 8-9pm until 7am. If anyone thinks we should go back to that, they can kiss my ass (as I quickly sign the divorce papers and tell my entire family I’ll see them in four years). I don’t think Halsted was the only one on coke.

  20. The ironic thing Scalpellin is that I’m learning German myself right now with the exact same idea in mind…feel free to let me know how the US docs made the transition over to Germany. If the idiots have their way (and there’s too many of them for them not to), in ten years medicine will probably be socialized and worthless in the US whereas it will be well on the way to being privatized (or already there) in Europe.

  21. Panda,

    You hit the nail on the head! The residency (and fellow) training system is nothing but exploitation. But, as you can even see in the some of these responses, some residents develop a “Stockholm Syndrome” type mentality. To embrace the truth is too painful, better to just identify with your tormenters…

  22. Panda Bear,

    This is somewhat off topic, but what is your opinion of medical school debt? Do you know of any horror stories? How did it affect you, if it all? I’ve tried to look through your posts (maybe you could point me to them) but I couldn’t really find much about the debt burden specifically. Tuition has been skyrocketing and it’s one thing that the current generation of med students faces that is somewhat unique – I don’t believe any generation has faced debt like we will, especially when considering the stagnant salaries.

    Thanks for the blog

  23. God bless you and keep you Panda. Does your residency know you write this blog? No one outside this system knows or can appreciate that by the time we finish residency most of us are bitter, jaded, tired, excellent physicians who would quit if we could afford it. One question I hope you will answer is this: How does your experience in medical training compare to the deprivations and physical challenges of USMC training? My guess, having lived one and witnessed the other, is that it’s a much different kind of pain and perhaps worse in that, while no one is shooting at you in residency, you are powerless to fight your tormentors in any way.

  24. The total training for an infantryman in the Marines is six months which includes three months of boot camp and about three months of the infantry training school. Both are physically and mentally demanding but you are treated much better in Infantry Training School than you are in boot camp. Training, however, is continuous with most units having a full schedule of exercises and deployments when not at war.

    Except for the obvious rigors of boot camp, I was never, in almost eight years as a Marine treated with even a small fraction of the condescension with which I have been treated by many attendings and senior residents. In the Marines, while we may rib the new guys a little bit, we never look down on them because they are new. Everybody was once a green Private First Class and we never forget it. We are also always happy to have the new guys in the unit and they are treated like Marines from their first day.

    It’s a hard life being a Marine but we don’t make it harder by pointlessly abusing the new Marines. I don’t care what you think you know about the Marines, the yelling is pretty much confined to boot camp.

    The Marine Corps stresses leadership development at all levels. One of the most important responsibilities of a leader, from the Battalion Commander to a fireteam leader, is to look after the welfare of his Marines, meaning that he needs to ensure that when possible they get chow, rest, mail, and liberty. The most important responsibility of a Marine unit leader is to train his subordinates which is not the case in residency where not only is the welfare of a resident of no importance to his superiors but even training is not guaranteed and is often sacrificed to the need to keep the breathtakingly inefficient teaching hospitals creaking along.

    This is not to say that we didn’t work long hours, lose sleep, and endure great physical and mental hardships in the Marines (try conducting any activity after three or four days of no sleep whatsover) but not only was this kind of endurance required by necessity for the job but every single Marine in the Battalion, from the Colonel to the lowest PFC was in the same boat. The Battalion Commander ate cold MREs and lived in the mud with the rest of us.

    Sleep deprivation is not required for medical training and in fact is highly detrimental to it. Interestingly enough, the Drill Instructors in boot camp never interfered with our sleep. I got almost eight good hours of sleep a night and woke up at 0530 every morning feeling rested and ready to take on the day. The Marine Corps is smart enough to recognize counterproductive training methods which is why they moved away from depriving recruits of sleep.

    The failure of leadership in most residency programs is the unwillingness to look after the welfare of their residents, sacrificing it as they do to the economics of the hospital. Call it necessary, call it inevitable, call it whatever you like but as it is the sacrificing of what is right to expediency, it’s incredibly shoddy leadership for which many should be ashamed. And the tired excuse, “Well, I had it harder,” is the kind of thing pussies say to avoid having to do the right thing.

  25. That’s another thing. Marine recruits are accused of being brainwashed but it is a funny kind of brainwashing that involves eight hours of good quality sleep a night (I went out like a light at taps and slept solid until revielle), provides three substantial meals a day, vigorous exercise,and builds self confidence and pride.

    Medical training runs on sleep deprivation, hurried nutrionally bankrupt meals eaten furtively at irregular hours, continuous petty humiliation, and no allowances for physical fitness unless it cuts into scarce sleep time. So who’s brainwashed?

  26. EMT Tim,

    The vanguard of this professional shift to a handful of Euro countries (mostly Germany/Austria from what I understand) seems to be in the computer/engineering industry from what I’ve heard.

    When outsourcing to India/Russia/Pakistan/wherever else really caught on in Silicon Valley after around 2003 or so, essentially you had all these unemployed super-trained techies, up to their eyeballs in college debt (though they’re lightweights compared to us MD’s), with shrinking earnings and little in the way of long-term career prospects, pushed into nasty 80-hour week schedules for lessening pay– though again not as piss-poor as your workaday surgical/IM/ED intern in the States.

    Germany apparently has a much more hopping IT industry than I ever thought they did, centered around Heidelberg/Stuttgart/Dortmund from what I’ve heard, and so a number of enterprising US-trained engineers took some German language courses or did some tapes, something like that, and hopped a 747 across the Atlantic. (Also, Eastern Germany– places like Leipzig, where Bach came from– are also picking up, in part due to lower costs of living and cheaper rent there.)

    Germany and Austria apparently have some seriously sweet incentives for technical people trained in North America, the UK or Australia who (a) want to start a business or (b) fill certain niches (the industry apparently expanded beyond the numbers of fully-trained engineers) so Germany’s been eagerly soaking up US talent since then– even if your German is just basic/intermediate, they’ll actually pay for the requisite language courses and help get you situated.

    Apparently, word got around from the engineers to their long-suffering technical professional colleagues on the medicine side, so it sounds like we’re seeing the same phenomenon gradually starting up here– a few people from the Midwest IIRC made the leap over there to Frankfurt I think (which is easier due to the military base connections), and from there the North American/UK/Aussie trainees are fanning out.

    I’d guess that there’s maybe something similar for a few other countries there like Belgium, the Netherlands, Scandinavian countries– basically the ones with mixed systems that have a wider insurance net, but aren’t hyper-socialized as in France (and thus also encourage medicine-related private enterprise, especially in the Germany/Austria/Belgium triad).

    It’s a bit more complicated to cross the Atlantic for medicine than for the computer/engineering folks due to the boarding and certification requirements, language proficiency needs, credit transfers, exams and so forth.

    But depending on where you are in your training, it’s not nearly as bad as I thought. If you can pass the USMLE exams and demonstrate proficiency in US hospitals, they don’t put you through the wringer there– they presume that you’ve succeeded at the highest level already and know your stuff, and if you’ve done, say, 2 years of an IM residency, there’s apparently a “transitional” year to get you re-oriented to the German system (which does have a few salient differences), German language proficiency training as needed, and there is a need to pass one board exam in German. (Though again, not as hard as it sounds– German, like English, basically has a Greek-Latin medical vocabulary, so it’s not too difficult to transfer your knowledge over.)

    Sorry if this was long-winded, just trying to piece together the fragments that I know of– it’s still not very common especially for US-trained docs to head to German cities, so I’m sure there’s a lot still being worked out. But the engineers and computer whizzes now in Stuttgart and Heidelberg– let alone eastern Germany where things are cheaper still– are apparently making bank these days. They still put in >50 hours a week but they truly get paid for it, they’re getting businesses started, they’re able to save up money *and*– not to be outdone– they get a bank deposit in Euros, so whenever they trek back to NYC or Chicago on vacation to visit their suffering compatriots back home, they get the conversion-rate boost and can start shopping in Saks Fifth Avenue.

    Honestly, if you’re thinking about making the leap to Germany it sounds like a decent idea. Germany is one of the countries with a mixed system, with many of the capitalistic aspects of the USA though thankfully free of the adversarial legalistic bulls**t and teaching hospital exploitation that plagues the US medical system. The taxes in Germany have long been a pain in the ass, but apparently the CDU (the center-right party that’s now in power in Germany) has been helping to relieve that– seems to vary depending on the province.

    And the German docs that I’ve met, the ones who train in the USA for a couple months, have been awesome people overall– they seem like they’re tough as nails, enough to eat lead for breakfast, but invariably respectful and with a much better sense of teamwork, less backstabbing and undercutting. (IOW they seem to have more of the Marine ethic going, I guess.)

    Also, I really don’t think Germany cares much about ethnic background in the immigration requirements anymore. I mean, if you can bring up old family pictures showing some remote Germanic connection with somebody in Finland or Britain or the Netherlands (let alone some German-American ancestry) it might help a bit, but at least for professional immigration, Germany really does seem to be opening up its doors– the medical schools in Germany have lately been filling up with Korean, Chinese and Indian kids, so the ethnic factor seems to be getting downplayed. They just want skilled, talented people there, and at least for medical training and even after residency, they seem to be offering better prospects than their American cousins these days, at least for some specialties.

  27. Surely you’re exaggerating, PB. I agree that some programs (usually involving the surgical specialties and sometimes IM) can be exploitative and abusive at times, but if that were the usual way of doing business, few programs would survive and there would be a larger intern drop-out rate.
    I do agree that there is a better way of doing things, and it mostly relates to failure of leadership and lack of support services and manpower. I recall that when my training hospital finally instituted an IV and blood drawing team, my quality of life as an intern got a lot better. Also, the amount of help I got from my senior residents and the nurses on the floor made a big difference. If everyone pitched in, even a little, instead of letting the interns do all of the work, it wouldn’t be so hard.

  28. Scalpellin’ Steve: It is apparent to me that you haven’t spent too much time in Central Europe. There are too many docs chasing too few jobs, especially at the junior levels. Plenty have decamped to Britain and the US.

    And as far as taxes go, there’s simply no comparison.

  29. I appreciate the long-winded reply Scalpellin’ Steve, that just reinforces the logic behind me currently learning German, since I doubt the US system will be any better in ten years (in fact it’ll probably be fubar).

  30. Scalpellin’ Steve and EMT Tim, methinks you are both dreaming. As a (rusty) German speaker, I can tell you that the future ain’t so bright in Germany for doctors.

    As bad as things are in the US, one still enjoys the following advantages (of course, short of a fully socialized system coming into place in the next Clinton administration):

    Any attending with some business sense can make very competitive wages in our current system. Our marginal tax rate even at the high end is much, much lower than the German one. Our cost of living is generally lower than theirs, even in our coastal cities.

    And on top of all that, our economy continues to grow. Theirs is stuck in the doldrums and unless they experience a baby boom will remain there forever.

    Learn all the German you want, but I doubt that you’ll ever put it to use.

  31. aha! just what i thought. glad to have you confirm it for me. i was six years active and worked closely with the marines. i love the marines. when i went from active duty to residency the change was incredible. no point in detailing it here because you have already done it.

  32. PGY1 scut slave, you obviously have more confidence in the American people than I do, because as far as I’m concerned, there’s more than enough dumbasses who are registered to vote who will happily vote in a socialized health care system in the next 4-8 years…that’s the whole point of me learning German. Sure, the German system may not be as good as the US one, but if the US system goes socialized, it’s going to crumble so horribly that any country in Europe will look ten times better than the US.

    It’s not the present that matters, its the future that I’m wary about.

  33. PGY1 scut slave, are you really as clueless as you sound? Here, let’s just pick out one of your less-than-well-founded statements:

    “And on top of all that, our economy continues to grow. Theirs is stuck in the doldrums and unless they experience a baby boom will remain there forever.”

    WTF???!! The USA this past year especially, has had among the slowest growth in the entire industrialized world. Europe, in contrast, has actually been experiencing quite a bit of a rebound– in fact, growth in the Eurozone is far outpacing that in North America of late, and the gap is only growing wider. Take a look, references even from the FT (IMHO the best financial newspaper), and there are thousands of other articles to document this if you want to nitpick:

    In fact, the oft-parroted and little-checked claim (by people such as yourself no less) that the Eurozone is sluggish and in the doldrums, while the USA is dynamic and advancing, has long been a heaping pile of bull: If you actually look at the two economic zones over the past couple decades, Europe’s actually been outpacing us overall.

    Even the oft-cited higher tax burden of the EU vs. the USA is crap– corporate and small business taxes are much worse in the USA than anywhere in Europe, even compared to the socialized Scandinavian countries and France, and in fact for the higher income brackets there’s not all that much difference between the respective tax numbers, with some variation from Euro country to Euro country.

    Also, WTF does a baby boom in the Eurozone have to do with anything here? The world’s population can’t keep expanding forever in the midst of finite resources– every single country, including the USA and the Eurozone, is going to hit a max population and stabilize, or else wind up with shrinking land and other resources with 2X the number of miserable, impoverished people as opposed to 1X the number of people better off. Growth and economic prosperity are no longer tightly linked to sheer numbers– it’s a matter of human capital now, and in terms of population, more is definitely not necessarily better.

    Besides, the Eurozone population is not shrinking as you seem to think. I in fact have been to Germany several times before (as well as to France, Italy…) and even though their native-born population is shrinking, they have very high immigration levels of co-ethnics elsewhere in the world.

    For example, you seem to forget that there are twice as many ethnic German people in North America (especially the USA– something like 75-80 million IIRC), South America, Australia and especially eastern Europe as in Germany proper, and who knows how many more millions of “ethnic Germanics” who (at least under the old system) had a leg up in getting residency and work permits, though it’s now more of a skills issue. Plus, millions of non-ethnics from Eastern Europe and the Americas have immigrated there in the past few years alone. Ditto for France, and for Italy (Italian-Americans can apparently get a pretty sweet villa in Trieste if they come with skills there).

    Why, Scut Slave, do think that the Euro is basically taking the dollar’s place as the world’s reserve currency? And if you’ve got any doubts SS, go and check what currency all those, uh, less “savory” business transactions like drug deals and arms purchases are being conducted in. It’s probably the best metric, since the criminal types don’t give a crap about pie charts or some CNBC analyst’s bloviations– they go straight for the currency that’s got the best footing and that they can rely on, and Interpol among others has pointed out that the “underground economy” now is overwhelmingly in Euros rather than dollars.

    IOW, you obviously don’t have the foggiest idea what you’re talking about, and you give away the game by the fact that you repeat common stereotypes and Europhobic politico talking points that are easily debunked with a bit of simple research. You showed your cards from a mile away.

    This isn’t to say that the EU is a paradise, not by any stretch, and there’s plenty of bureaucratic idiocy there is well. But the EU definitely has its act together in more ways than we often think, and it’s this very fact that’s made it a viable alternative and attracted so many US-trained professionals there in recent years.

    And when it comes to medical training– how could you get worse than the USA? The combination of our horribly inefficient training regimen and abysmal compensation, gratuitous humiliation, idiotic hours, total indifference to patient safety (try explaining to poor Mr. Gordon why a surgical resident who’s been up for 27 straight hours is doing his jejunostomy procedure), medicolegal stupidity and costs of defensive medicine (in contrast to the more sensible no-fault/training-emphasis system used in places like Germany), plus the ever-dwindling reimbursement prospects for just about every specialty, and you get the Perfect Storm that is the medical field in the United States. Maybe back in the good old days we were the world’s bellwether– now, we’ve screwed everything up in so many areas, we’re essentially the model of how not to run a medical training regimen in a developed nation.

  34. BTW Scut Slave, if you’ve ever worked a 24+ hr shift and then visit your patients when the dewdrops are on the branches– come in and done your hi, how are yous to your Mr/Ms Smiths, Joneses, Gordons, Johnsons, Caseys, whatever– and think that you can brush off the effect your sleep deprivation is having on you, you can’t. Trust me, they know. THEY KNOW, both they and their families.

    This is true for surgeons, where your jittery hands and bloodshot eyes are a dead giveaway of your sleep deprivation to patients and family– you ain’t foolin’ anybody. It’s also true for IM’s and EM’s and their medicine-ish cousins, who stumble in like drunks from Times Square to blabber on about this or that physical exam finding, check how they’re doing or whatever in the a.m. This is not exactly a smart way to build up patient’s confidence in their care team.

    I know some attendings (by no means all) like to talk up the crazy hours they worked in their good old days, 80-100 and beyond.

    But back in those good old days, you didn’t have anywhere near the severity and frequency of patient illness that you do today, and even on-call at night, things really tended to quiet down. Hospitals didn’t go 24 hours at full bore as they do today.

    (If there’s one thing that’s changed, that’s it and I beat this point it seems in almost every post.  It’s one thing to talk up the good old days when residents were on Q2 call all the time but if all you are doing is sleeping at the hospital it isn’t as bad as Q4 call where “call” is actually “work.”-PB)

    IOW, we have a medical system that’s a relic of a bygone, quieter, simpler time that no longer remotely exists, yet shoehorned and joined to the need for fresh labor such that it’s almost impossible to reform.

    This is something that I’ll definitely give the Euros credit for, whatever their flaws elsewhere– they’ve actually listened to common sense and come to realize that the old models of medical training don’t apply to the 24-hour triple-decker-super-duper-gazillion morbidity patient population of today’s hospitals. So they’ve made sensible reforms.

  35. Steve: I just came to the US from Europe.

    Despite what you may think, opportunities are far brighter here than there and will be for some time to come.

    Here’s one reason: Demographics.

    Without an increase in population, there hasn’t been an economy on the planet that has grown consistently in the long run. Take a long look at native fertility rates in Germany…not so hot, so a poor outlook for the future. Unless, of course, you speak Turkish. (Last time I was in downtown Frankfurt, my German skills seemed completely useless as Turkish appeared to be the lingua franca of the Zeilweg.)

    As far as the other stuff in your post, believe what you want, I (and plenty of other European trained physicians in residency programs) have voted with our feet, which I think counts far more than meaningless propaganda.

  36. I agree with the demographics argument. There is no way that a country with zero or negative population growth can compete in the future with other countries that have moderate growth.
    As an aside, while I enjoyed your post PB, together with all the comments, I have to admonish you for the graphic at the end of the post. This was probably done tongue-in-cheek, but I hope you realize that the miseries of an internship year in no way can be compared to the abominations of slavery, and the use of the graphic detracted from your otherwise excellent post.

    (You’re kidding, right? Of course I am not comparing residency to slavery but it is one of the closest things to it in the normal working world…which is sort of the satirical point.  If you can produce any former plantation slaves I will be glad to apologize but since the last one probably died in the early twentieth century I think we are safe.-PB)

  37. This is the best post I’ve read in a long time. I have spent the first month of my residency in the CCU at the VA. All I want to do after my 33-35 hour calls is go hide in my room after repeatedly running over my pager. It really can only get better from here….God willing…

  38. Meg, once you get the hang of critical care you will love rotating in the ICU, especially as a senior and especially if you have autonomy while on call. It’s intimidating when you don’t know anything but once you get the hang of things it’s fun being in charge (our attendings are not in-house after 5PM). Learn how to manage airways, how to place lines, and few other procedures that a lot of residents shy away from and if you have a good understanding of shock and sepsis you will have 90 percent of it licked.

  39. hey Panda,

    We communicated before on studentdoctor.net and I always find your viewpoint refreshing. I’m an intern now and I was perusing your site in order to procrastinate on some dictations, when I happened to click on the “some old dinosaur” link” above.

    Hilarious. I went to UT-Houston where Dr. Fred is a much feared institution. As med students we were required to participate in Fred rounds, where he pimped us mercilessly. Just to paint a picture of the terror he inspired let me describe him. Dr. Fred is very short, about 5′ and has extreme old-man kyphosis to point of being a hunchback. And he only has one good eye. His signaature move is to cock his head to side (since he can’t lift it) and use his beady black eye to peer into the depths of your soul. Seriously, it’s like something out of a medieval fantasy. Dr. Fred will tear out your spine if you used anything more complicated than a stethoscope in the patient workup. I still remember one time when he berated me for 15 minutes because we ordered a renal ultrasound when apparently, the renal bruit he appreciated was so obvious that the most retarded med student back in his day would have figured it out.

    After being subjected to this treatment, our class produced mostly anesthesiologists, psychiatrists, pathologists, PMR, and radiologists. Not a single graduating med student opted to go to our own internal medicine residency, of which he is the director. Shocking.

  40. I love the post, however, I have a problem with the references throughout the post about slavery – particularly the African American experience . I also dont understand why the image you put at the end of the post is that of a black man in chains- its almost like a mockery!!

    (You’re pulling my leg, right?  Of course it’s a mockery. -PB)

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