Welcome to the Pandaverse

(The Student Doctor Network has been kind enough to host the archives of my blog and have asked me to write a little introduction. I’m sort of retired as a blogger so in lieu of a post I thought I’d just answer a few questions that people often ask me. I may from time to time write an article but I assure you it will be with nothing like the frequency I used to. I’m enjoying being a former-blogger too much for that. -PB)

Tell Us a Little About Yourself.

I am an an Emergency Medicine Resident Physician in my fourth and final year of training. I am a little older than most residents having come late to the medical profession.

Do you like being a doctor?

Sure. It’s not a bad job. The pay is decent once you get out of residency and despite the conventional wisdom, physicians are almost universally respected. The pay will naturally vary by specialty and the respect depends on your ability to project those intangible qualities that the public expects but it’s not a bad gig if you can stomach some of the less savory aspects of it.

What are some of the less savory aspects?

First you have to realize that most of any doctor’s job is pure bullshit. I can’t exactly quantify how much but it is definitely more than half and probably closer to seventy-five percent. It’s not just the ridiculous bureaucratic obstacle course constructed by the hospitals, the insurance companies, the government, and various quasi-official regulatory bodies like the despicable “Joint Commission” (for whom is reserved a special circle of perdition) that contribute to this huge proportion of bullshit, nor is it the depredations of the legal profession who’s pervasive influence has driven common sense out of the system, but rather the bullshit is a combination of these things and the worst impulses of human nature allowed to run unchecked in a society like ours which has finally liberated its citizens from personal responsibility.

On a practical level, this means that out of every dollar that passes through your hands, seventy-five cents of it may as well have been flushed down the toilet for the all the good it does. Some goes for the reams of useless and entirely ridiculous paperwork that is the joy of administrators and the pushing around of which employs them by the hundreds of thousands. Some goes to completely unnecessary testing which is ordered for the sole purpose of defending ourselves from the inevitable lawsuit that will ensue if we miss either a rare condition or a highly unlikely, exceedingly rare presentation of a common disease. Most of it, however, is spent on the margins either overreacting to fairly trivial complaints or spending large sums of money on therapies and procedures which have limited effectiveness in terms of decreased morbidity or increased quality of life.

Not to mention that the system is fairly corrupt and If you really knew how corrupt it was you wouldn’t be so eager to devote your life to it. For our part, as physicians we shamelessly waste money on unnecessary consults, weak admissions, and redundant tests because that’s where the money is. While some of this can be blamed on the legal profession which forces us to practice highly expensive defensive medicine, we need our paying customers and, insomuch as a weak admission or an unnecessary colonoscopy pays as much as a legitimate one, there is no incentive for doctors to turn patients away, even those who will only benefit marginally or not at all from all the money we dump on them. We revile EMTALA, for example, as it has buried most Emergency Departments in trivial complaints but it is these trivial complaints that are now the lifeblood of our specialty and have made it one of the most lucrative.

On the part of the patients, they are mostly terrifically entitled and want everything done all the time regardless of cost and regardless of effectiveness. They are looking for a magical antidote for what are mostly lifestyle related illnesses and, as they are not directly paying for any of their medical care, have no incentive to not come to the doctor for every little thing.

The industry itself is corrupt because its primary function is to garner as much money from the public as possible. Most pediatric emergency departments, for example, are built for no other reason than to suck up as much CHIP money as can be legally squeezed out of a steady stream of minor complaints.

Wow. Is there anything good about medicine?

Of course there is. We operate in a deeply flawed system but that doesn’t mean we have to either like it or worship at its twisted altar. I try, for example, to practice good clinical medicine and am leery of ordering studies and consults “just in case.” Of course, I have never been sued and human nature being what it is, the first time I am burned the temptation will be to cover my ass with the best of them, spending millions of dollars of your money to protect mine. On the other hand, as our program director often tells us, he’d rather defend himself in court having used good clinical judgment and sound medical practice in the face of a bad outcome than to have “checked every box” on the order sheet hoping to prevent the lawsuit. At least, as he tells us, he can sleep at night.

There is also no question that we occasionally do some good. After a month or two of resuscitating septic, severely demented octogenarians, returning them to their pre-death warehouses for a few more months of laying in their own excrement and gaping at the ceiling, we recently saved the life of a septic teenager who made a full recovery and has nothing in front of him now but his future. And we occasionally get some real medical problems..heart attacks, congestive heart failure, lacerations, trauma…good stuff but watered down by a majority of patients who seem to have shown up at our doors because they really have nothing better to do on a Thursday night. Either that or they have established a parasitic relationship with the vaunted social safety net of which the Emergency Department is the only representative that is open twenty-four hours a day.

Would you do it over again?

No way. In fact, if knew back then what I know now I would have laughed and thrown my medical school application in the trash. Like I said, I like being a doctor but the toll on my family and my marriage has been immense. Things are getting better but as my wife pointed out to me, and which is something that I have heard echoed by many other residents and their wives, when I get home from a shift in the Emergency Department I have given so much to my patients…so much attention, concern, conversation, humor, grief, and every other kind of human interaction…that I have nothing left to give to her. You think of course, you who dream of touching hundreds of lives and doing good in this bad old world of ours, that this is a good trade but I assure you that medicine as a profession will not love you back. You can solve the medical problems of a thousand grateful patients but a few hours after they leave the department or are discharged from the hospital they won’t remember your name or even your face. You will be just another bucket of medical care that they received from the tap like any other public utility.

I also don’t want to discount the tremendous economic toll the last eight years have had on us for which, of course, I have no one to blame but myself as nobody held a gun to may head.  Still, it is hard to know exactly what you you are getting into when you first start.  Certainly as I have a family and the usual responsibilities and expenses that this entails I expect that many of you who do not will not face some of the same challenges.  When medical school and residency is just a continuation of college and you feel comfortable living in a crappy apartment with milk crates for furniture it is probably a lot more bearable from an economic point of view.  Yes, medical school debt accumulates but it’s really not that much all other things being considered and you are actually payed what is technically a decent salary as a resident, at least one upon which a single person with no responsibilities can live.

But as a medical student and resident with a large and growing family?  It is virtually impossible to make ends meet and we have been going steadily deeper into debt for the better part of the last decade.   I have no doubt that we will eventually dig ourselves out but the opportunity cost, a cost which includes lost wages and debt, for this little adventure has been enormous and we will arrive on that fine Summer day next July when I start making a decent salary way, way behind where we should be at this stage of our life and marriage, that is, with no savings and no assets except what’s going to be left in our checking account.

Flat-busted, in other words.

What Do You Think Of Universal Health Care?

Heck, we already have it. What we really need is less of it. For a start everybody should have to pay real money for their own primary care. It is completely ridiculous that we pay for the routine medical care of a growing population of people who will spend three-hundred bucks a month for cigarettes not to mention other irregular pleasures but who regard a twenty dollar copay or a hundred bucks here of there for a visit to a Family Doctor as a monstrous injustice and an assault on their human dignity. Not to mention that we give away free medical care to people who have no business getting it.

I had a young patient the other day who was collecting disability for something we would have laughed at thirty years ago who has used more free medical care, most of it unnecessary I must add, than people four times his age who are really sick. There are probably whole Cuban villages that have collectively used less medical care. And yet he regularly opines that things will be so much better when medical care is free.

What? Are they going to give him a gold-plated bedside commode? Is the nurse going to give him a massage? Will he be seen quicker? Get more narcotics with fewer questions? What more does he want?

What is the Biggest Problem Facing American Medical Care?

Our inability to say, “No.” No, your eighty-year-old severely demented father with a list of medical problems that reads like a pathology textbook cannot get a colostomy to divert his bowel movements away from the large sacral decubitus ulcer eating into his sacrum. No, we will not spend a hundred thousand dollars of critical care extending your life by two months. No, we will not keep your relative on the ventilator until your family can fly in from all over the country to be at the bedside. No, we will not pay for routine pediatrician visits when not only are they not necessary most of the time but cost less than you spend every month for cable television. No, we will not work you up for abdominal pain when you were sound asleep when I walked in your room, surrounded by hamburger wrappers, and all you really want is an ultrasound of your baby to show your friends. No we will not admit you for the eighth time this year for chest pain after seven negative work-ups. No, we are not your drug-pusher and some problems in life, believe it or not, are not medical at all.

Until we learn to say “No,” to ration care honestly and not covertly, we will exhaust the treasure of our nation and further mortgage our prosperity to the Mandarins of China and the Sheiks of Araby who will one day decide that your free medical care is not such a good investment after all.

21 thoughts on “Welcome to the Pandaverse

  1. Crap. Year one and my biggest fear is evident in your statement: “when I get home from a shift in the Emergency Department I have given so much to my patients…so much attention, concern, conversation, humor, grief, and every other kind of human interaction…that I have nothing left to give to her.”

    Tell me that there actually IS a specialty out there in which this is not the case?

  2. Great to hear from you again Panda. Keep up the posts, they are amazing. I have made a point to share your blog with everyone in my medical school.

  3. Hi, Panda. Glad to see your blog is back. I was wondering if you’d be willing to share your thoughts on the upcoming election, as this campaign season draws to a close.

    (As you know, national security and killing terrorists are my Big Issues. With this in mind, the question you have to ask is, “For who would Osama Bin Laden vote and who would the islamofascists prefer as the leader of the only miltary force that can smack them around?” Nothing more need be said.

    My other Big Issue is the economy and on this, I would prefer a low-tax, business-oriented, productive country where people are free to succeed (or fail) as opposed to turning us into just some more Euro-trash dependent on a shrinking productive sector to take care of the ever growing hordes of deadbeats like the ones I see every day.

    On health care, I think we are so ridiculously over-doctored, particularly at the futile and marginal end where five percent of the population account for fifty percent of health spending (most of it wasted as it is only marginally effective from a mortality or quality of life point-of-view), that every current proposal to fix the problem is so completely ludicrous and wrong-headed that I can only shake my head in amazement at the ignorance of the electorate. With this in mind, the only way to end the madness is to severely curtail spending for the five percent, invoking the kind of rationing that is the norm in the Great Mammary States Across the Atlantic. And the rest of you motherfuckers need to pay for yer’ own stinking primary care and other routine health expenditures.

    McCain, definitely, but neither candidate has the guts or the desire to do what is right vis-a-vis health care. -PB)

  4. how much of your opinion do you think is influenced by your choice to work in emergency medicine? i may have only spent a year full time in the ED but i think that seeing that specific patient population (taking into consideration things such as their socioeconomic background, education etc and also the problems that they come to the ED for) and working in that specific format and system drives a lot of your commentary.

    (I have done many “off-service” rotations in everything from General Surgery to Family Medicine. The patients are all the same with the same collection of ridiculous, futile, or marginally treatable complaints. And the bureaucratic bullshit is the same everywhere. Every specialty wastes money hand over fist, some of course are worse than others but it is only a question of degree. -PB)

  5. PandaBear,

    If I were you I would consider collecting your passages into some sort of paperback book, write a little intro, maybe organize them nicely, and sell it for $9.99 at Barnes and Noble with a catchy title. Might help you out with your financial troubles, I’d buy a copy, and as evidence, so might 414,527 visitors (as of this writing).

  6. I agree with ‘holygrail’. This information is gold, and it is being given away for free. Not that I might it is free… 🙂

  7. I have to ask…if you are so miserable as a physician, why are you still working as one? There are a wide variety of positions that you, with an MD, could do, which would pay excellently and have better hours. Management consulting comes to mind, as does working in a biotech company or for a pharmaceutical company. There are many options. Have you considered any of these?

    (The ability to take a medical degree and make “big money” outside of medicine is, for the most part, a myth. Could I make a hundred thousand a year as consultant or as an engineer (which I am) with medical training? Sure I could…but those jobs are not just hanging from the trees and Emergency Medicine pays a lot better (a lot better) anyway. As for “biotech,” I am not a scientist or even interested in research so my odds of being hired to some “cushy job” (which doesn’t pay as well as Emergency Medicine) are effectively zero. As for pharmaceutical sales, if you think you can make a lot of money at it you are mistaken.

    I also want to reiterate that what you may consider a well-paying job, something in the neighborhood of $100,000 per year, considering my debt situation would only put us in slightly better shape than I am today on a resident’s salary.

    There is no great demand for physicians in any other profession but medicine-PB)

  8. thanks for this website. it’s very enlightening for those of us contemplating medicine as a career path. i was recently admitted to a medical school but am having some doubts about whether to go. it could be just cold feet but my fear is that after 4 years of education + 200k debt + lost income that i won’t be able to leave medicine even if i’m unhappy (essentially being stuck)

    what would you advise a friend in such circumstance? is there people who truly enjoy this profession?

  9. Awesome to see you have breathed some life into your blogging again. God, I could not agree more with you. The only thing I take issue with is, that as radiology resident, I come home wiped out with zero energy. Way, way more than I did as a medical intern. Just a thought.

    I totally concur, medicine only trains you to do… Medicine. Those excellent jobs sans patients with great salaries, respect, challenge etc. don’t really exist. I’ve looked

    Panda, we are going to be done about the same time. Please let me know where you work so I can be a radiologist there… I implore you. 🙂

  10. “Either that or they have established a parasitic relationship with the vaunted social safety net of which the Emergency Department is the only representative that is open twenty-four hours a day.”

    Good lord, this is so true.

    Great to see you posting, even if it’s just this one.

  11. I love your honesty Panda. I wanted the MD for a long time but now I’m considering the PA route. It seems the ratio of ability to practice medicine to bullshit is better but then again I’m sure it relates directly to the doctor you work under.

    (This is a myth. Most PAs are hired to do the bullshit that doctors don’t want to do. In other words, it is the PA who is sent down to the Emergency Department to complete the 100,000th History and Physical form for a garden variety “Middle-aged Man with History of Hypertension with Chest Pain on Exertion.” And nobody, but nobody, is immune from the wonderful bureaucratic obstacle course that is Modern American Medicine, not doctors and not especially those PAs who practice more-or-less independently from physician supervision. Additionally, fleeing from responsibility, one of the oft-stated advantages of being a mid-level, is not an enhancement of your ability to practice medicine. -PB)

  12. I wish that advance directives were required by the government. I don’t like the government in my business but just this once could everyone in the USA be required to complete an advance directive and have it notorized. Maybe then at least 40% of the ridiculous treatments that are wanted by families that have not discussed end of life care could be avoided?
    It wouldn’t work because it’s to practical and common sense isn’t big in the people who govern medicine.

  13. Panda,
    As a undergrad considering graduate options I find your blog illuminating and disheartening. I must ask, had you not had a family to support, and all the demands that go with it, would you have a much more positive view of medicine and medical training? In 5 years do you think you will have a different view of the journey, being the long expensive route will be a fading horror? Would you recommend anyone to accept the challenge? Granted its not all roses and you have to put in your time, but there are not many other fields that offer the compensation seen in medicine; even when taking opportunity cost into consideration(this may not apply to all fields such as GP).

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