(I get a lot of questions and comments by email and I thought I’d share some of them with you folks. -PB)
Hey Panda, who are you going to vote for in the 2008 Presidential election?
Good Lord, is it already time for another election? It seems like I have only just recovered from the horrors of the last one although I do remember with great fondness when the Bush National Guard Letter turned out to be an obvious and amateurish forgery which lead to the subsequent collapse of the Kerry campaign’s raison d’etre.
Seriously though, I have not really been following the campaign. I will say that Health Care is not that big of an issue with me, at least not in the sense that I burn with a holy fire to insure the uninsured. I know too many of them to really buy into the notion that they have some kind of inalienable right to my labor. I believe in charity so I have no trouble with the idea of providing aid and comfort to the poor but come on now. Except that there is very little incentive to do it, most people, most of the time, can afford most of their medical care if they got their priorities straight. Best Buy, for example, was packed on the day before Christmas, absolutely packed, with people going into debt for useless consumer electronics. A couple of video games, a Wii, an iPod. Pretty soon we’re talking serious money that people will not, repeat not, even dream of spending for something as useless a visit to the doctor.
Can’t spend money on that shit. Oh no. Everybody knows that medical care just flows effortlessly out of hospitals like water out of a tap.
So like I said, I’m not excited about health care reform as a national issue. Not to mention that giving it away for free, about the only kind of “reform” that is going to be able to run the guantlet of lawyers and other special interests, will do nothing to solve any of the structural problems that make our system so expensive.
My big issue is national defense and fighting the islamofascists so despite being a social conservative, I’m probably going to back Rudy Giuliani. I’m not looking for perfection, you understand, just someone whose heart is in the right place when it comes to killing terrorists. All the other issues? Just fluff mostly. Or schemes to transfer more of the personal wealth of those who earned it to those who not only haven’t but feel entitled to it. That’s what most of politics in the Western world has come down to unfortunately, although the United States is probably one of the last of the Western Democracies where people will get excited about something other than extending cradle-to-grave social benefits.
I’d certainly rather see my tax money going to build and operate a Carrier Battle Group than to enable somebody to get their asthma medications for free rather than having the cost eat into their cigarette money. Aircraft Carrier? Useful in its own right as well as being the modern equivalent of a cathedral if you can stretch your mind around that concept. Free asthma medication? Useful, of course, but unlike national defense, protecting citizens from the consequences of their bad decisions maybe shouldn’t be federal policy. I favor health care reform to take away free medical care from as many people as can pay for it themselves while continuing to support the people who obviously can’t. At the very minimum most people, most of the time, should be expected to pay for most of their primary care while reserving health insurance for catastrophic events. That’s the kind of market force to intoduce into the system, the only kind that will work which is for people to realize that going to the Emergency Department with a chief complaint of “My butt is sweating” is not a good use for their own money. Funny how nobody cares about money if they’re spending somebody else’s.
So I haven’t exactly caught Ron Paul fever. I like the guy, of couse, and he would be a perfectly acceptable candidate despite his opposition to the war in Iraq, but we need a gunslinger in the White House, not a doctor. Naturally, as I am a Broken Glass, Yellow Dog Republican (I’ll crawl through broken glass to vote for the Republican candidate even if he’s a Yellow Dog) I’ll vote for whomever the Republican Party nominates. I think Vice President Cheney is probably the best man for the job but he’s not running, more’s the pity.
So Panda, do you think it’s worth it…medical school and residency I mean?
God, I hope so. I really hope so. But every now and then I have some doubts, doubts that are probably just the residuum of almost seven years of medical school and residency with nothing to show for it but debt, financial ruin, and the sure knowledge that it is this or nothing. I mean, on an intellectual level I know it is probably going to be all right. I have less than 18 months left of residency and I can just about see the faint glimmer of light at the end of the tunnel which represents a time when we can start chipping away at our massive debt and maybe putting some black on the old family balance sheet. But it is eighteen months in the permanent temporal-financial crisis known as medical training which paradoxically seems like either an eternity or the blink of an eye depending on whether you are dreading either another year of debt or the all too imminent end of your ability to hide behind your training status as an excuse for not knowing something.
It’s a hot and cold, love and hate kind of thing. I like being an Emergency Medicine resident but I hate being a resident. I like having the support and guidance of my attendings but I hate that I have close to 12 years of higher education and am making about what I made as a starting Civil Engineer almost fifteen years ago. I worry about the future but on the other hand, as my wife points out, we are in it (and in it good) with no choice but to make a success out of it because there is no other option now. We have burned every bridge, played-out every strike, staked the farm, mortaged our souls, and robbed (no, mugged) Peter to pay Paul. We are in a cage and only time will tell if the bars are gold or common brass.
And no, I wouldn’t do it again if I knew back then what I know now. Don’t get me wrong, medicine is a pretty good job. For my part, I see a fairly broad range of patients, most of whom I like, with every possible complaint you can think of, from the ridiculously pedestrian to the spine-chillngly grim. We also get plenty of respect as physicians, even as residents, so no complaints there. I like it just fine but there is just so damned much of it. I occasionally get a normal weekend off and it is amazing to think that I once took this kind of thing for granted, not having to do anything and more importantly, not worrying about things. You see, I used to be a Structural Engineer and felt pretty good about it most of the time, especially as I was self-employed and within the confines of the need to produce work for my customers did entirely as I pleased.
As to how it feels to practice medicine past residency I can only profess ignorance and remain mute. But medical training is tyranny, a necessary condition for the most part but still tyranny and while I’m glad I did it and look with optimism to the future, I am, in fact, almost done. If I had known nine years ago when I first got the idea in my head to go to medical school (and believe me it seemed like a crazy idea at the time) what it was going to be like I would have laughed and forgotten about it in short order.
“I’d like to go into Emergency Medicine but I don’t think I’d like all of those patients who aren’t really sick. What do you think?”
Grow up. While I’m sure that there may be some physicians whose entire day is spent managing patients on the knife-edge of disaster, where every decision they make is fraught with peril and only made after the ramifications are weighed in their lightning-fast minds, most of us spend a lot of time with patients who are either not very sick or so chronically sick that you have a little bit of time to make decisions. Everything is not an emergency, in other words, even in the Emergency Department. This is not to say that we don’t see a lot of really sick patients but the idea of having residency training is to make even the incredible so mundane that one day you arrive at the point where, when confronted with a dialysis patient in florid congestive heart failure and respiratory distress from cocaine use, you yawn, take the appropriate steps, and wonder if you have what it takes to handle a really complicated patient.
But apart from the obvious abusers of Emergency Services, you are going to see a lot of colds and vague abdominal pains that turn out, after the five-thousand dollar work-up, to have been nothing. You just have to deal with it. It is the steady parade of minor complaints made possible by that Mac Daddy of unfunded mandates, EMTALA, which keeps the doors open and the lights on for the twenty percent of patients who really have medical emergencies. In other words, if it wasn’t for the minor complaints most Emergency Departments would be sleepy little affairs where most of the employees spent most of their time sitting on their hands except, of course, when something big came in. But the four or five big traumas we see every shift or the ten or so bona fide medical emergencies that need immediate management will not keep the doors open at the current levels of staffing. If we turned away the minor complaints (which we could do in theory under EMTALA) or quickly admitted the ones who were really sick but didn’t need any acute intervention, Emergency Medicine as a specialty would be like pediatrics, that is, it would be filled with people for whom the specialty was a special calling and who did it even though it didn’t pay that well.
I rise in support, therefore, of the minor complaint. Chronic pain? Fibromyalgia? Mild asthma exacerbation? Lips tingled a little after eating shrimp but feeling better now? Upon this sturdy foundation is our specialty built and it is the demand for Emergency Physicians, doctors who can handle everything from a common cold to a traumatic evisceration, that keeps salaries at their current level. Like every other specialty, Emergency Medicine is a volume business and the volume has to come from somewhere.
It also helps to keep in mind that most people are fairly rational and, while you may have the occasional patient who makes you scratch your head and wonder how they manage to breath and wipe their ass at the same time, most people will not sit in the waiting room at two in the morning waiting for several hours to be seen if they weren’t concerned about something. In other words, something about their vague chest pain worried them enough to call the ambulance or drive through the snow to see you. If you keep this in the back of your mind you will avoid the dangerous tempation to minimize your patient’s complaints. I can’t tell you the number of times the chief complaint and initial presentation masked a terrifying condition that made me glad and relieved that I not only hadn’t missed it but may have had a part in saving the patient’s life.
A lot of times the big level one trauma coming in turns out to be nothing. It’s the quiet little lady in the distant corner of the department who may be bleeding internally and require your complete attention.