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.
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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…)