Twenty Questions for Dr. Bear (Part the First)

Hey Dr. Panda. I also have a family. My wife and I are raising young children and the cost of day care will eat up a big chunk of my wife’s take-home pay if she gets a job. How are we going to make ends meet during medical school and residency?

You’re not, at least not in the classical sense of balancing income to expenditures. The short answer is that you will have to borrow buckets of money, deplete any and all assets you had before medical school, ask for money from your parents, and eventually, after exhausting every other source of credit, perfect the fine art of shifting credit-card balances from one low interest card to another. If you’re lucky the end of your residency will come before Peter realizes he’s being robbed to pay Paul. This will worry you at first, and it still worries me, but one day you will get used to the wolves prowling outside the door and you will accept this as the normal order of things.

You can economize a little, of course, but the kind of money we’re talking about is impervious to your decision to substitute Hamburger Helper for chuck steak. Naturally you will have to tighten you belt but the hit your lifestyle will take depends on what kind of disposable income and leisure activities you have now. You can, for example, kiss expensive vacations, personal watercraft, consumer electronics, and an overtly materialistic lifestyle good-bye. Pehaps this is a good thing but I’d rather live frugaly because I want to, not because I have to.

The trick is to either consolidate or defer your loans during residency to make either a low payment or no payment at all. Another advantage of consolidating is that you can lock your loans in at a very low interest rate. It’s hard enough to live on a resident’s salary without also trying to service your debt.
Why do you dislike drug-seekers? It’s not like you’re paying for the drugs and at the very worst you can send them home empty-handed.

Every patient involves a certain amount of paperwork. Generally speaking, the paperwork for a drug-seeker takes just as long as the paperwork for a patient with a legitimate complaint. It’s not as if we can just give the addict some vicodin and send him on his way. Very few of them present with a complaint of “I’m out of drugs and I need a fix.” It’s usually chest pain, abdominal pain, or back pain of some sort and even if you know in the deepest pit of you soul that the complaint is bogus, you still have to go through the motions. Even drug seekers occasionally have legitimate health problems and nobody wants to be the guy who dismissed back pain that turned out to be a dissecting aortic aneurysm. So you see, drug seekers impose a certain burden of unnecessary labor on the whole department. For my part this takes the form of unnecessary paperwork and a significant slice of time I could devote to patients who are really sick.

Not to mention that decent people, and most of us are fairly decent people, naturally recoil from dishonesty. Not only is the drug seeker deliberately lying but he is also scheming to turn us into his pusher, a position that most of us do not relish. I once had a drug seeker accuse me of taking pleasure in exercising my medical power to deny him drugs. In fact, I would rather he went to some other emergency department.

The other kind of patient I dislike are the ones with suicidal ideation. Oh sure, I like treating the ones who made a serious attempt but were foiled by circumstances beyound their control but the ones who made a pathetic gesture of one kind or another without any serious thought of really harming themselves really drive me up the wall. First because, as I mentioned before, they suck up just as much administrative time as a patient with a legitimate complaint and second, because most of them claim suicidal thoughts as a means of garnering attention we play right into their hands, enabling the very attention-seeking behavior that we would do better to dissuade. In a perfect world, we’d toss ’em out and say, “Hey, come back when you can execute a better plan than taking a couple of extra valium because yer’ stinking boyfriend doesn’t want to cuddle.”

But the little girls who take a whole bottle of tylenol are sad. It will kill your liver, you know, something that nobody seems to realize and is not, repeat not, a good gesture drug. You might actually succeed in killing yourself but not before you have time to realize that some coolio sleeping with your best friend is so not worth it.

What’s the biggest misconception among medical students?

Wow. There are so many. Two of the biggest misconceptions are that pre-clinical grades don’t matter and its corollary, that people who do well in the first two years of medical school don’t do so well during the clinical years. First of all, for the purposes of remaining competitive for the match, every single grade you get matters. Sure, you may be at a school that doesn’t give traditional grades but nobody has yet explained to me how an “honors,” “high pass,” and “pass” is fundamentally different from an “A,” “B,” or a “C.” Somewhere, somehow, your the Dean of Students is keeping track of your standing relative to your peers and overtly or covertly, your Dean’s letter is going to spell out your class rank. Good luck matching into Radiology (or some other competitive specialty on which you had set your heart) from the bottom of the class. It’s not that it can’t be done, it’s just that even some people with good grades and good board scores don’t match into the competitive specialties. Why hobble yourself right out of the starting gate?

As for people who do well during the first two years of medical school not doing well during the clinical years, this is an urban myth. You know, like the one about Physician Assistant school being able to cram just as much into their two years of training as medical students do into their four years. Generally, people who do well in the first two years do equally well during the second two years and there is no inherent contradiction in doing so. Most medical students, as they are drawn from the ranks of people who did nothing but study during high school and college, lack the mythical people skills and common sense that are supposed to trump book learning so it’s going to be a wash. You will see that the folks who limped along during the first two years perpetually in danger of dismissal will limp along during the clinical year, passing their shelf exams by the narrowest of margins and sweating every rotation.

Another misconception? That medical school will last forever. Now I know, oh you who have just now suffered through you first exam and are still licking your wounds, that four years can seem like an eternity but after you get the hang of it, let’s say around Christmas of your first year, the time will slip by and before you know it you will be staring Step 1 in the face. And no sooner will you have gotten over your initial shyness on the wards when you will be listening to the graduation speakers and realizing that your days of shirking responsibility are over. Nervous first year medical student to nervous intern in the blink of an eye.

Trust me on this.

Would you do it all over again?

Har har. Not a fair question. I’m almost done with residency (21 months to go) and I can see that it will end soon. Medical training has certainly been nothing like I expected. Harder in some ways and easier in other ways. I never thought, for example, that missing sleep would bother me so much. Who, after all, has not stayed up late occasionally and been tired the next morning. The difference in medical training is that there is no respite. You can get tired but, through some freak of scheduling, still have to work four more twelve hour shifts in a row which, I can assure you, will wear you out. Or imagine you have a Friday-Sunday call weekend and you are not able to get a good night’s sleep on Saturday night. You can’t count on getting any rest until Monday afternoon and you’re just going to have to suck it up.

Eventually you build up a sleep deficit that seems to take more than a good night’s sleep to erase. Not to mention that your schedule will be so irregular that your sleep hygeine, the patterns and habits of how you sleep, will be severely dysfunctional. I worked for years as an engineer waking up at seven, working nine or ten hours, and getting to bed by eleven every night. And I got most weekends and many holidays completely off. I was never tired except anecdotally. By contrast, I seem to be perpetually tired nowadays and my sleep hygiene blows. I can never seem to get a good night’s (or day’s) sleep with any consistency. It’s not working shifts so much as it’s the myriad conferences and mandatory residency activities that always seem to be scheduled on either a day off or for a morning when I could otherwise sleep late.

So that was something I didn’t expect even though I am resigned to it. Working shifts, however, has been a tremendous improvment over pulling Q4 call, something I had been doing for the most of the previous two years.

The “Tired Years,” as I like to call them.

(To Be Continued…)

13 thoughts on “Twenty Questions for Dr. Bear (Part the First)

  1. I love the bit on med student misconceptions. I would just add to it the persistant belief that sucking at pre-clincal stuff is somehow predictive of being “great on the wards.” I can’t tell you how many time I’ve heard that one.

  2. “Or imagine you have a Friday-Sunday call weekend and you are not able to get a good night’s sleep on Saturday night. You can’t count on getting any rest until Monday afternoon and you’re just going to have to suck it up.”

    That’s me every week, and the reason that I won’t go to med school no matter how many doctors and co-workers tell me I should. Screw. That. *resumes sitting around waiting for the phone to ring*

  3. As someone once said to me, “There is a light at the end of the tunnel but it is just enough light to see that there is more tunnel at the end of the tunnel.”

    The sleep deficit issue is still a very real problem when you become an attending. Just as it is in residency it is primarily determined by the type of practice you have. Some are better than others and we are all making trade-offs. Shift work will result in better sleep hygiene but probably less autonomy in your practice.

  4. Panda.

    A couple of quibbles.

    First, as a liberal arts major I was way behind my classmates in the first year and my grades, while good, were not great. It was clear at that point that whatever I did after that was not going to put me at the top of my class.

    Second, I do believe that completely bookish folks who crush the basic sciences often do struggle on the wards as they sometimes do not have the best bedside manner nor do they seem to develop it. Not an across the board truism, but I found that 3rd and 4th year I WAS at the top of my class and it had much more to do with being a good scut-monkey and being able to converse well with all manner of patients. The patients liked me and this seemed to matter.

    Also, I believed at the time and still believe that much of what I learned in the first year is useless. Enzymatic pathways? Graduate level genetics and advanced biochem? Give me two years of pathology and a year of lab diagnosis and then we are getting somewhere!

    Finally, at my particular school, which was fantastic by the way, I would have done much better if I had NEVER gone to lectures in the first year. Invariably, the super-star PhDs who taught our basic sciences would come into the classroom and say something like…

    “Today’s lesson is on the physiology of the kidney but that’s all in your text… I want to talk to you today about my research on the mitochondrial analysis of monkey brains.”

    The top student in our class came from the Army special forces and was saavy enough to skip all classes, read the text, and memorize the relevant lecture topics from our note taking service. He also slept a lot more than I did.

  5. one other thing regarding the first question about medical school and finances.

    i went on the government’s dime (health professions scholarship program- HPSP)and would do it again. i had a great time in my military service, met some of the finest folks on the planet, did stuff i would never have been able to do otherwise, and was treated much better there as an internship-only trained medical officer than i was in residency or in practice.

    also, i was out of debt early in residency, a huge bonus. i have heard the argument that it’s a wash financially if you run the numbers out to the ten year mark but that makes a lot of assumptions about one’s progress in the civilian side of medicine that are not necessarily true. ie “i’m going into ortho and i’ll make X and then all is well in four years”.

    well, maybe you love peds and as a fourth year that’s what you decide to do. bummer, now you are going to make X-z. your debt load extends to 15 years post training, you are more limited in your ability to buy a house and support a family, and, heaven forbid, if you get four years into practice and hate it you are 100 grand in the hole (at least).

    i will take this opportunity to tell any of your readers that if they want the skinny on the HPSP program offered by the Army, AF, or Navy to just drop me a comment on my blog and i’ll be happy to respond at length. in fact, i’ll see if i can get a post up on this topic and field any questions there (and there are lots of good questions re the military option).


  6. Important question about #1. Does you wife want to work? If she wants to work then it doesn’t matter if daycare chews up the check, she’ll be happier doing so. If she’s happier you and your children will be as well!

    If she’d rather not work then you’ve got the manager to stretch your limited income right there.

    It’s been my observations that gals who married med students, at least first wives, are pretty smart themselves. If she’s in a good field you can expect her income to rise over the years. It gives you more options.

  7. I agree with 911 doc. The HPSP program worked great for me. My parents couldn’t help me a cent. HEAL loans were somewhere around 11-12%. With HPSP not only did I go to a private med school without debt, I got to serve my country and experience the military. I couldn’t decide on a specialty so I entered as a general medical officer (GMO) and flight surgeon. When I was done I had finally decided on EM as a specialty. I ended up doing 2 intern years like Panda but the first one had a night float system for the whole year so I learned a lot and it was quite painless.

    Yes the finances could be a wash 10 years out, but for me having no debt, and depending on no one, was priceless.

  8. Live frugally or marry rich, haha. I didn’t exactly marry rich, but having someone with a pretty decent income is definitely a plus.

  9. With regards to the sleep deficit issue, the other problem is that should you be able to erase the deficit (as I feel I have just done on a month with a light call schedule), you will then head straight into a heavy-call month, and rebuild that sleep deficit. There’s no way around becoming a walking zombie, I’m afraid.

  10. Interesting post/comments.

    I have heard that sleep deprivation is cumulative. If one doesn’t exercise for months, then exercising for one day will not make up for that. It is the continued patterns over time.

    And so it is with sleep. One good night of sleep does not make up for the many hours of sleep deprivation and so there is the possibility of falling asleep when driving, even though that person thinks that they are rested.

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