Some Simple Math and other Random Thoughts from a Harmless Asian Bear-Mammal

I’m Better, Thanks

Like I said, it’s only in residency training where one could be happy to be sick while on vacation. I am just getting over a bout of what was probably the flu and as there is no practical way to take any time off as a resident, about the only time we can lay in bed or otherwise rest is either on vacation or when our day’s off correspond to our illness. They make a big deal about cautioning us not to work when we are sick for the sake of patient safety, of course. That’s all some of our patients need, to be exposed to their doctor’s gastroenteritis or other noxious infections but realistically, what are we supposed to do? In a pinch we can usually take one or two days off but as this involves screwing over the person assigned to back-up call, there is a tremendous reluctance to do this among residents. In other words, most of us would have to be spitting up blood or passing large chunks of our large intestine in our stool before we’ll call in sick. Still, there is nothing worse than having to work three fourteen-hour shifts in a row while running to the crapper every hour. Far better to be at home on vacation where you can at least relax between bouts and get some rest. Not to mention that my empathy for the typical 3AM vague-abdominal-pain-and-oh-by-the-way-can-I-have-a-sandwich patient, never very strong, is non-existent which is probably unfair to the patient (but if the shoe fits…).

Some residency programs are so small that they really have no backup for their residents at all and calling in sick in that situation will cause a major panic as well as instantly refuting the assertion made by shifty hospital bureaucrats that residents don’t contribute to the running of the hospital and are a burden to the put-upon institution. If this were really the case then the hospital would be delighted if we took a generous helping of sick days as this could only improve their bottom line. As is, however, when a resident unit goes down the service into which it had been installed goes into a major panic mode complete with sobbing and pleas for help. The sad thing is that a lot of residents buy into the notion that they are a liability to their program and act accordingly. Yes, I will grant you that a brand-new intern may appear to be good for nothing but he is actually many times more savvy than, for example, a brand-new PA who is actually paid real money, not to mention that the intern can make medical decisions limited only by his self-awareness of his limitations and his own personal comfort level. And by the time he gets a little experience the intern is a definite asset, many times for all practical purposes running the service at night. Good residents are completely trusted to handle routine admissions as well as routine emergencies and while I have never had an attending physician give me any grief whatsoever for calling him in the middle of the night for advice or to run a difficult patient by him, the expectation is that we should be able to handle most things and maybe the call for a patient admitted at 2AM can wait until 0730.

But most of us, like in any other non-government job, work when we are sick.  What choice do we have?

Some Simple Math To Illustrate Where the Money Goes

“But Panda,” many of my regular readers write, “Surely you are exaggerating the cost of futile care. Is this not a red herring, merely a symptom of your dislike of dealing with living cadavers more than a real problem?”

Let me address this question by making three points. First of all, I am not against providing expensive, high tech medical care to the elderly. How could I be? Not only are the elderly the majority of my patients but most of them are completely lucid, healthy enough to enjoy whatever it is the elderly do for fun in their secret recreational vehicle conclaves, and benefit mightily from the installation of the occasional artificial joint or the correction of a once lethal medical condition or two. While it is true that from a purely economic point of view, it would be better if we all died the day after we retire or from the first major medical problem that blindsides us (whichever came first), we are not pure economic creatures and that two-trillion bucks we’re spending should at least do some good.

Second, while there are gray areas in determining when care is futile, I know real futile care when I see it. The patients I often describe, the ones who are older than dirt, not nearly as responsive, and collections of every major pathology you can imagine but who yet manage to cling to some strict constructionist version of life are distressingly common, so common that I probably see and admit at least one or two of them a week to the ICU. (This is not even considering the patients that are post-arrest or on the losing side of a major cerebral vascular accident accident and who are, in fact, dead except for the polite fiction of ongoing organ perfusion.) Suppose that each of these breathing cadavers is admitted to the ICU and stays for a week before either subverting our best efforts and dying or pulling through and being sent back to their pre-death warehouse until the next time. Suppose also that I work fifty weeks a year and see a hundred of these patients in that time. A week in the ICU probably costs close to twenty thousand dollars, maybe more, maybe less, but probably around that if we add the cost of their passage through the Emergency Department.

Folks, that means that about two million dollars of futile, almost entirely wasted medical spending passes through my humble resident hands every year. There are about 5000 Emergency Medicine residents working at any given time in the United States and through our combined hands, assuming that they all see the same patient mix, must thus pass around 10 billion dollars. And that’s only hospitals with residency programs and not even counting direct admissions to the ICU. Assuming that a year of comprehensive medical insurance (not that I’m into that sort of thing, you understand) costs $12,000-or-so a year for a typical family; that’s about 80,000 families worth of medical insurance. Consider also that only one-fifth of the major hospitals in the United States have residency programs of any kind but most still have the usual ICU facilities and it is not hard to see that the bill for futile, end-of-life care siphons off enough money to pay for all of the medical care for about half a million families (again, not that I think we should do this kind of thing). And that’s just direct hospital costs. We probably spend twice as much in non-critical and non-emergent care in the last long, slow, tango with the reaper.

My third point is that there is no incentive at any level of the medical industry to use a little common sense. At the high end, physicians risk severe legal consequences for not doing exactly what the family wants no matter how unrealistic. So dangerous is the legal terrain in this area of medicine that most hospitals have an ethics committee part of whose purpose is to spread legal responsibility. In many cases, however, there is no financial incentive to withdraw care as Medicare makes no distinction between the living and the living dead. At the patient end, the families have no financial stake in any of the decisions they make. If we but charged the families a small fraction of the cost for futile care or, more diabolically, had payment garnished from the patient’s estate upon their death, the families would be looking for the plug, especially in the cases where the ICU serves as an expensive funeral home where families can meet to see the body. If the family ever says, “We want to keep Uncle Joe on the ventilator until the rest of the family can fly in from Seattle,” they should be responsible for the full cost of the additional stay.

30 thoughts on “Some Simple Math and other Random Thoughts from a Harmless Asian Bear-Mammal

  1. Will someone pleeaasssee think of the children?! Futile medical care extends to little people, too. Earlier this week, a mother brought her two-month-old to the hospital for yet another admission. The child has a rare condition where his skin readily detaches from his body and exposes his inner workings. The child has had multiple encounters with sepsis and has undergone respiratory arrest on more than a few occasions. Each time, physicians gently prod the parents to consider end-of-life care, noting that this baby will likely not live long—and the life that does exist will be quite painful. The reply is always the same: “Do EVERYTHING to keep my child alive.” Now we’re stuck will a very large bill to keep this child breathing for another few days until we can discharge him—only so he’ll return a week later for the next round of sepsis.

  2. I have said this before and I will say this again. It is not the sole responsibility of patients and their families to decide on end of life care.
    It is the doctors job to share and to be honest. Honest right from the start which means right in the ER. The education needs to begin the moment they arrive. And by education I mean to avoid saying what every damn doc says “there is always hope”. Nope, sometimes there isn’t any hope ok? So stop saying that crap.
    Say out loud to the family that the patient is dying and any treatment we can offer will do nothing but prolong death in painful, humiliating ways. Then say I have no treatment to offer other than palliative. Families don’t sue when you have a plan, families sue when you had a plan and the patient didn’t respond to that plan and they are dying anyway and who cares , let’s all hide and not answer the families phone calls and pages. Lets all pretend the family is crrraaazzzzzyyyy and ignore them cause they are a pain in the ass. Sounds familiar right? They feel ignored, slighted and pissed off and then the patient dies…now they are really angry. Too bad you weren’t honest from the start right? And I mean honest, not that mealymouthed bs repeated in family conferences the western world over..the ” oh, she is very sick, let’s give her a few more days to see if she responds to (insert treatment here) and then we will have another conference, cause there is always hope” speech. The speech that says to the family; we have a treatment plan and there is hope!HOPE!.
    But you wont because despite the fact that in a LOT of countries with laws to prevent being sued and laws that define futile care docs still can’t talk to families.
    The living dead, the ones I care for are there because docs are incapable of holding a conversation not laced in cliche and platitudes and because docs just love to play with their pretty, pretty new toys which have big reimbursement rates.
    There is no normal family that wants their loved one to suffer a prolonged, painful death. If we were honest we wouldn’t have so many. For that small percentage of psychotic families who love the ICU environment ? That is what the ethics department and social workers are for.
    I understand that US docs have legal issues to also play with but that is just convenient, sweep aside the legal and nothing will change.
    Docs aren’t taught anything about dying except how to prevent it and view it as the enemy.
    The day education changes is the day the living dead get to be just regular dead people.
    Stop blaming families for not pulling the was your job to tell them it was time too, it was your time to take a stand and say I wont be a party to prolonging the death of this lovely person because I don’t believe it serves any purpose.
    If you are willing to take a stand and tell the family you are willing to get the hell out of the way and stop interfering with an inevitable process they feel empowered to get out of the way too. Some families just need a little solidarity or at the very least less platitude and more reality.


    (You are wrong on so many levels I hardly know where to begin. -PB)

  3. In what I think should become the Grand Panda Tradition of Actual Patient Interactions, here’s one from my shift yesterday:

    “Well, Mrs. Jones, as I suspected, the X-ray of the knee you hurt on the dance floor last night is negative. Based on my exam, I’m pretty sure you have a torn medial meniscus. I’ll give you a knee immobilizer, crutches and some pain medicine. Tomorrow being Monday, you need to call your PCP and arrange to either see them, have them refer you to an Orthopedist or order an MRI for you”

    “I want an MRI today”

    “We have to call the tech in to do an MRI. We only do that when it is absolutely needed in an emergency, like we think your spine is collapsing and you’re about to be paralyzed”

    “This is an emergency”

    “Not being able to walk without a knee immobilizer and crutches is not an emergency. It’s already Sunday afternoon. Not only that, as you can see, there are people waiting to be seen in the bed you are currently occupying with things like heart attacks, hip fractures and the like”

    “I want you to call the coverage for my PCP and have them authorize an MRI today”

    “Sorry, I won’t do that”

    “I want you to call the customer service rep for my health plan and have them authorize an MRI today”

    “Sorry, I have other sick and injured patients waiting to see me”

    “I want your name and a copy of my chart. I’m calling my lawyer”

  4. PAs don’t make medical decisions? That’s a new one to me. Yes, they’re limited to following protocol more than physicians, and when things don’t go according to protocol they then defer to the higher ups, but I’m fairly sure that there is a certain level of decision making involved. It’s not like they go around carrying symptom flow charts with them.

    But yes, I’ve seen PAs who are new to their specialty and they seem to be fairly useless for the good part of a year. And I would assume that an intern would be able to adjust quicker.


    (Hey, what’s up man?  Have you decided against medical school?  I see you’ve changed the title of your blog so I’m just wondering.  Email me if you want to hear some free (and therefore worth every penny) advice. -PB)

  5. As a 30 year (lifetime) PA, brand new PAs and brand new interns are about equally worthless in my book, and the only provider even less worthwhile is a brand new nurse practitioner from one of the “part time programs” (like the one your institution sponsors). First year PAs are at least fully licensed; they’ve passed their boards, they make decisions, and hopefully they have the sense to get backup when they need it. PAs actually operate somewhat more autonomously than interns (who are not fully licensed and not licensed at all in many states) in most situations. I know you know this because of the PAs where you work, some of whom carry as many patients as you do.

    Of course, a brand new PA (and a brand new intern) are good at making decisions on about 7 patients a day, which in an ED is not much help, but since they both get paid pretty dismally, cut them a break. Those first years (for both kinds of providers) are a steep learning curve, which I am sure you can appreciate.

    (I think, after some reflection and some experience, that the conventional wisdom vis-a-vis interns is wrong. Sure, on the first day they arrive on the wards they are not much good for anything but physicians are used to a steep learning curve and after about six months most interns have a fairly good grasp of their basic responsibilities. We tend to forget that interns are individuals who as medical students were drawn from the top percentiles for intelligence which has to count for something. The problem is that many interns are shuttled into and out of different services every month and most of the angst is learning the paperwork and procedures, not knowing what to do for the patients.

    Additionally, new PAs don’t even work close to the hours of new interns and their real salaries on a per hour basis are much, much more than those of residents. 80 hour weeks which were typical when I was an intern worked out to about $9.75 per hour, much, much less than a PA makes who starts in the mid-fifties to sixties per year.

    On another note, PAs can be glib about residency training because they really don’t know, except from external observation which is not a substitute for experience, what is involved.

    At both hospitals where we work, the PAs are generally on the non-acute side. There is plenty of overlap of course, but we get all the critical patients and real emergencies most of the time so “carrying the same number of patients,” not true anyways because you have no idea how many patients I see on a typical shift, is irrelevant. Additionally, no PAs that I know of rotate on the other services in the hospital. In other words, after six months of ICU rotations, an Emergency Medicine resident is expected to to know a great deal about handling the sickest patients on the planet while the PA can always pass them off to his attending or a resident. Does a PA with ten years of experience in the ED have an advantage over an intern or a junior resident? Of course he does…but let’s not get carried away. -PB)

  6. Other than your views on PAs, I do agree with most everything else you say, which is pretty surprising since you are obviously to the right of Atila the Hun and I am one of those tree-hugging liberals. It just goes to show….

  7. Of course residents go to work when they are sick. How I rolled my eyes (and held a grudge) when another resident called in sick because his wife had hyperemesis gravidarum. She was a resident too, so the extra workload was ungodly. (No 80 hour weeks then)So when I got bad nausea/vomiting with my pregnancy (karma?) the nurses helped me get some IV Zofran and D5LR and I kept going. It’s true I was a little shorter on sympathy during that time…

  8. “They make a big deal about cautioning us not to work when we are sick… but realistically, what are we supposed to do? In a pinch we can usually take one or two days off but as this involves screwing over the person assigned to back-up call, there is a tremendous reluctance to do this among residents.”

    Sounds like one aspect uncovered by the infamous Stanford Prison Experiment:

    Prison guards will punish your fellow prisoners (i.e., residents) whenever YOU step out of line (i.e., take a sick day), to the point where you feel pressured not “fuck over” your fellow prisoners.

    They’ve mindfucked you into blaming each other instead of the prison guards, where the blame rightfully belongs. In effect, they turn you into your own prison guards.

    (Well, yeah.  If you read my blog regularly you know that The Man has our shriveled gonads locked in his vice-like grip.  As the AMA pointed out, residency training is the last legal sweatshop in America and we have absolutely no power to change anything…not to mention no incentive because by the time anything changes we’ll be done.  But thanks fer’ ripping the scab off and rubbing salt in the wound. -PB) 

  9. “There is no normal family that wants their loved one to suffer a prolonged, painful death.”
    You are so wrong it’s unbelievable. Come on down to the land of Hospice and Palliative Care consults!

  10. While I am 3rd year IM and not Emergency I completely agree with you about the futile care. Recently the ICU tried to transfer a patient out to us, we refused of course but the history was impossible. Basically he had an MI and was anoxic for 90 minutes until he was brought to the hospital. In Mexico (note he was a Mexican national) they told them, he is brain dead, let him go. The family disagreed, took the patient out of the hospital and drove him to the US border and dropped him out the back of the truck. Then demanded that he be admitted to a US hospital where they continued to demand everything in a futile fashion. Three weeks later they accepted that he was not coming back and decided to withdraw. But now, it had been two days, he hadn’t died, they wanted to go back the other way. Please recall, at this point all his care was free because he was illegal. We are required by LAW to do these things.

    If people had to bear the cost care fewer people would ask for hospital admissions. I have had patients who refuse hospital admission even when they need it because they remember that their 20% of the bill came to over 20K.

    As for preferring to be sick while on vacation, I completely agree. I have never called in myself, even though I have been severely ill. I am still pissed at all the women who decided they would forget their birth control and who I had to cover for because they had pregnancy “complications.” My attitude is, if you can’t remember your birth control, don’t have sex, or shut up and work.

  11. “But most of us, like in any other non-government job, work when we are sick.”

    For the many residents who work at University hospitals and are state employees, it may be more accurate to say something like “But most of us, unlike other government employees, work when we are sick.”

  12. Dude, I read your blog more than I read my own, dammit.

    I’m in a small program and totally relate to the points about the ripple-effect when someone calls in sick. Furthermore, we currently have an intern who is following the letter of the law – using sick time and personal days to the fullest – but totally burning the culture here. He called in “sick” on Christmas Eve, for example. And on Super Bowl Sunday. Fine the next day – maybe a slight cough. In my opinion, I better be rounding on his ass for him to be sick enough to call in like that.

    Still, if we’re strict about it, he isn’t breaking any rules…unless you start getting picky over the definition of “sick”.

  13. “I have never called in myself, even though I have been severely ill. I am still pissed at all the women who decided they would forget their birth control and who I had to cover for because they had pregnancy “complications.” …if you can’t remember your birth control, don’t have sex, or shut up and work.”

    Wow. I hope your parents don’t refer to your birthday as the day “Mom forgot her birth control and got banged by Dad.” Why did you get into medicine in the first place if you feel so tritely about life?

    (Let’s refrain, those of you who are not residents, from impuning the motives of those who are.  When you walk a mile in the commenters shoes you will understand that we don’t necessarily need to love everyone with big, open-mouthed kisses to be good doctors.  Some people are irresponsible, lazy, and selfish.  Pointing it out doesn’t violate the hippocratic oath. -PB)

    “we currently have an intern who is… using sick time and personal days to the fullest – but totally burning the culture here. He called in “sick” on Christmas Eve, for example. And on Super Bowl Sunday… In my opinion, I better be rounding on his ass for him to be sick enough to call in”

    Good for him for ‘totally burning the culture’. What kind of “culture” is it if it punishes others whenever he decides to enjoy a bit of life?

    Blame the AMA for artificially limiting the number of medical school seats, and ultimately the number of available residents. Or blame your cheap, greedy, profit driven hospital for not hiring enough doctors, but don’t blame the resident.

    The man has balls and he’s flaunting it.

    (Look, I understand what you are saying but as his flaunting of his genitalia directly hurts his fellow residents, he needs to stop doing it, especially as there is no chance whatsoever that his actions will cause his program to modify their policies.  There is nothing fundamentally wrong with having your fellow residents on back-up call to cover for you if you really need a day off due to a severe illness or another emergency.  Naturally if you need more than a day or two the hospital needs to suck it up without abusing the residents but one day?  Come on.  This guy is abusing the system, however  Taking a day off just because you want to watch the Superbowl is just wrong, wrong on every level, even if you have a sick day that you can use. -PB)

  14. Next time you have to unexpectedly go in to work on Christmas after planning the day with your family for a month because someone in your group followed the rules to the letter, let me know how happy you are about having a guy “with balls” on your team.

  15. Wait, how does the AMA artificially limit the number of medical school seats? How does the AMA have ANYTHING to do with medical school placement/seats? Did you mean the AAMC? Even so, I can’t see as how they are “limiting” seats, artificially or otherwise. Actually, the AAMC recently asked schools to increase class size where possible – my class size (and subsequent classes as well) is 160, which is up from 150 for the classes above us (they were at 150 long enough that I don’t know how long they were at 150). They increased to 160 because of the AAMC request. There definitely isn’t any more room in the lecture hall or the other spaces where we have small group/PBL sessions. Just trying to clarify where you’re getting that little nugget from.

  16. People that know nothing about medicine like to throw out the AMA as the big “gotcha” line, when anyone that knows a damn thing about medicine knows that has nothing to do with the number of docs practicing. You can’t practice medicine without a residency. Medicare the medical jehovah of the left froze residency spending in 1996. Not physicians, or god awful AMA, The GOVERNMENT, our elected officials have limited the number of physicians currently practicing in the US, not the AMA, AARP, ASS, or any other abbreviation you can think of.

  17. Like any other job, I only take off if I’m truly sick. What would be nice, and will never happen, would be if we were re-imbursed for those sick days that we didn’t use as many companies do in the real world.

    Side note: Did anyone see the piece on 60 minutes on Sunday about providing free care in TN. The charity work by the health care providers was/is admirable, but it of course turned into a piece of everyone getting care for free. I’m interested to hear your thoughts PB.

  18. Panda – I trained at Duke when you were in high school. I did my share of 24 hour on-calls and 100+ hour weeks in various in-patient services during that training, alongside interns and residents. I have worked with truly great physicians, and I have worked with physicians who couldn’t tie my shoes on their best day. For most of my career I have worked in emergency medicine and orthopedic surgery. I relate on a personal level to your blog, and I read it daily. I consider that reading time well spent.
    That said, I would hope that no PA you have encountered has challenged your superior training and unique experience. A well trained and experienced PA would never do that.
    What a good PA would do in the ER for you would be to show up early, leave late, and in the meantime work as your perpetual junior partner to clear the clutter and allow you to do what you were trained to do. I see the URI’s, joint sprains, lacerations, N/V/D so the docs can see the chest pains and major traumas. I can do chest tubes, intubations and life support when needed. The docs can do lacerations when needed. But over 90% of the time, I do the lacerations, and they do the big stuff. They get to do what they do, and I do what I do. We are truly partners, we support each other, and most days go well because of that. When needed, I consult them, and they consult me. Truth is I don’t want their job, but many days they would like to have mine.
    My point? It is not in your present or future professional interest to be so negative about PA’s. In a busy ER we are your best friend and most trusted collegue. We will consult you when there is any doubt about a diagnosis or workup plan. We will help bail you out when there are ten charts in the rack and all the rooms are full. We will make it possible for you to get a half hour lunch on a 12 hour shift. And we will make you money.
    If you need verification for any of the statements made here, I can send you letters from 10-12 experienced, board-certified emergency physicians. In the meantime, keep up the good work.

    (I am not negative about PAs.  I only point out that eight years of training is better than two and everybody has the proverbial cow when I point out what is actually just a question of mathematics. -PB)

  19. OK, so what do I put in an advance directive (or maybe a tattoo on my forehead) so I get treatment reasonably anticipated to return me “to what the elderly do for fun” AND don’t get futile treatment when elderly fun is not in the cards?

    My husband and I have a private agreement that if one of us is choking on a hot dog we definitely want it removed promptly but if a bus runs over our head, let us go. I suspect, though, that agreement is not legally binding in its current form.

    And, Mo, social workers can’t make individuals or families make decisions in any given direction. We can’t even make them stop loving the ICU if that’s how they feel. All we can do is nudge. And keep the conversation going…

  20. Panda, did you actually reveal your place of residence? Pocatello, Idaho? Next time I go to Jackson I’ll have to stop in!

    I agree with you on a universal medical record. How many thousands of hours on the phone are wasted requesting records. Or reams of paper faxing 30 pages of chicken scratch notes when all you care about is the H&H. It’s insane how many resources are wasted due to lack of a universal electronic record. The only way to get this going will be congressional action.

  21. are resident sick days a paid benefit or an ‘insurance policy’ for the hospital? if they are a paid benefit, then you should get reimbursed for the ones you don’t use when you leave, and you use them when you need them. if they are not considered that way, then the abusing resident needs to be reprimanded.

  22. The PA curriculum at Duke is 27 continuious months. The pre-reqs are the same as med school. Admission ratios compared to applications are about the same as the med school. Classroom hours in the Duke Medical School average 25 hrs./week during the first two years. Classroom hours in the PA program average 36 hrs./week during the first 13 months. Many, if not most of those classes include medical students. Same lectures, same tests. 27 months equals 3 academic 9 month years, not 2. That said, I agree that in no way in hell does 2 years (or 3 years)of training equal 8 years. That is not the point.
    I don’t remember the details of the Krebs cycle. I don’t remember because I don’t find it useful in my day-to-day work. Neither do my supervising physicians. But I can in 30 seconds or less recognize a sick patient and do the right thing, every time. So can you. And the “basic sciences” doesn’t really have very much to do with that ability. On the job training and experience has everything to do with it.
    Dr. Stead probably had it right. The Duke Medical School curriculum reflects his ideas:

    Eugene A. Stead, Jr., MD (1908-2005)
    Dr. Stead is recognized as the founder of the PA profession. He was born on the outskirts of Atlanta, Georgia on October 6, 1908. He was one of five children. His parents were hardworking, honest and caring individuals. As a boy, he helped his father sell patent medicines door-to-door in Atlanta neighborhoods. Many of these neighborhoods were poor. He was intrigued that poverty had two effects on people. Either they were consumed by it or they rose to the challenge to overcome it. Later he would apply this same knowledge to his observation of the different patterns of behavior that patients had to illness. It was the patient, not the illness that most fascinated him. Dr. James E. Paulin, Stead’s family physician and his first mentor at Grady Hospital and Emory University in Atlanta, had a profound impact on Stead’s growth as a physician. Dr. Paulin taught residents every Tuesday and Wednesday morning at Grady Hospital primarily to improve his own skills and medical knowledge. He was interested in medical politics in the best sense of the word. Dr. Stead embraced these ideals and came to expect those under his tutelage to do likewise.

    Dr. Stead received his undergraduate and medical education at Emory University and interned at the Peter Bent Brigham Hospital in Boston. He was a resident at the Cincinnati General Hospital and held a faculty position at Harvard and the Boston City Hospital prior to becoming the youngest person to chair the Department of Medicine at Emory University in 1942. He was named Dean of the School of Medicine at Emory in 1946, but left one year later to become Professor of Medicine and Chairman of the Department of Medicine at Duke University. After 20 years, he relinquished his Duke chair to explore other avenues of research and medical care. Although Dr. Stead is internationally recognized as a clinical scientist, educator and administrator, his greatest legacy is the large number of former students who became department chairmen and leading educators and researchers throughout the United States.

    His experience educating physicians at Emory in three years and having to run Grady Hospital with residents and medical students during the Second World War convinced Dr. Stead that physicians learn best by applying their knowledge to meet patient needs. At Duke he learned that community-based physicians were too busy to attend continuing education offerings. However, he was aware that one physician, Amos Johnson, a rural practitioner in North Carolina had trained his own “office” assistant, Buddy Treadwell, to overcome the time constraints of a busy practice. He tried to meet the growing demands for patient care services at Duke by expanding the clinical decision-making skills of nurses. However he failed to gain accreditation for a masters program for nurse clinicians that he and Thelma Ingles, a nurse educator, had established at Duke in the late 1950s. Based upon his and colleagues growing use of ex-military corpsmen in the early 1960s to help run specialty units at Duke, Dr. Stead began to formulate his two-year curriculum to expand the prior education and experience of these corpsmen to become competent physician assistants. With the support of the Duke faculty and administration, he launched the first formal educational program for physician assistants at Duke University in 1965. For the next seven years, Duke University and later the University of Washington (Dr. Richard Smith’s MEDEX program) became focal points for the development of the physician assistant profession. As founder of the Physician Assistant Profession, Dr. Stead is recognized as one of the top educational innovators of the twenty-first century. Although not planned, it is only appropriate that National PA Day (now week) is celebrated each year on his birthday – October 6th.

    Many books have been written about Dr. Stead’s contributions to Medicine. One of the earliest books first printed in 1968 is a compilation of his “sayings” which overtime have been lovingly dubbed “Steadisms.” The book titled Just Say For Me was written by two residents, Earl Metz, MD and Fred Schoonmaker, M.D. during their final year of residency at Duke University. The 342 sayings give insight into Stead’s philosophy about patient care, education, work and life in general. When his residents and he came across a complicated medical case they could not solve, Dr. Stead was often heard to say “What the patient needs is a doctor.” He often reminded his young learners that “A doctor makes a mistake if he thinks he knows more about a patient than the patient does himself.” He gave his best and expected others around him to do no less. He was quick to honor and give credit to others. When asked about his role in helping establish the PA profession, he would quickly shift attention away from himself and mention the contributions of others. He gave most of the credit for the success of the profession to physician assistants themselves.

    Dr. Stead died on July 12, 2005 in his sleep, in his bed, in the lake home that he and his wife Evelyn Shelby Stead and children, Nancy, Lucy and Bill, had built with their own hands. He was 96 years old. His wife of 63 years had died two years earlier in his arms in the same house.

    PA does not equal MD. Never will, never should. But as the patient loads increase, and the MD supply stays static, (and primary care doc numbers go down), and reimbursement goes down, a good PA will probably be your best friend. Rant over.

  23. What is it an old guard hospital perk that everyone gets to say they are above the interns? Because apparently to say that a new intern is better than a new PA is a massive insult to the PA profession judging by the posts above.
    Sorry but average new intern is more functional than the average new PA. It is what it is. No comparing a seasoned PA to a newly minted intern or talking about the benefits of the profession. Thats irrelevant.
    4 is still > 2. In a matter of a week or two most of us can pretty much run a service. Sorry but this generation of med students and residents doesn’t subscribe to the we are lower than pond scum dogma.
    We’re still respectful maybe even more so than older generations because we expect respect ourselves. We don’t go out looking for pissing contests but when someone basically writes off our training to make themselves feel better we will speak up.
    I have no doubt though someone will try and twist this post into a “Dave hates PAs” rant. Well have at it I guess.

  24. (I am not negative about PAs. I only point out that eight years of training is better than two and everybody has the proverbial cow when I point out what is actually just a question of mathematics. -PB)

    Just wondering. What are your thoughts on Navy corpsman?

    (I love Navy Corpsmen.  But they aren’t doctors. -PB) 

  25. PB,
    Having just discovered your blog, I am loving it. But please allow me to be the Queen of Grammar and point out that you “lie” in your bed, while you “lay” your book on the table.

  26. Hmmmmm, i think im going to make it a point to identify political leanings the next time i pick my doctor.

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