Old School

I admire the physicians of yesterday who practiced at a time before medicine became so technical but I don’t necessarily accept the premise that they were better doctors.  Certainly their physical exam skills were better honed than ours are today as this was often all they had to establish a diagnosis.  They also had a much better grasp of eponyms, being able to rattle off this triad or that pentad  and their significance to the patient; often pointing out some obvious but rare eponymous physical exam finding to nail the diagnosis.  On the other hand I have a sneaking suspicion that their patients weren’t on such a hair-trigger to see a doctor and many conditions probably festered a bit until the constellation of presenting symptoms more closely mirrored what you would expect (and still see) in the textbooks.  In other words, it is one thing to confidently identify a patient deep in the throes of acute hemorrhagic pancreatitis by observing Grey Turner’s Sign (bruising on the flanks) but quite another to diagnose the same in a patient who may be early in the disease and has come to the Emergency Department or his doctor’s office with nothing but mild abdominal pain and a vague history.

Which is how it is nowadays.  In the Golden Age of Medicine, an era that is fading even from the memories of our oldest attendings and in a time before life had become medicalized to the degree it has today, since it was accepted that doctors couldn’t do much patients tended to stay home until something was obviously wrong.  A patient came in with nausea, vomiting, fever, and severe pain in the right lower abdomen and Bam! Acute appendicitis or nothin’.  Today the pain is mild, the location is somewhat more generalized, and while we may not be as ready with the eponym, our differential diagnosis has to be a tad more comprehensive and the work up, because of the legal consequences of missing a diagnosis not to mention the availability of sophisticated tests and imaging as well as appropriate interventions, needs to be more exhaustive.  It is the exhaustive nature of American medicine, the now firmly established belief that everything is an emergency, that contributes to the high cost of everything we do and I’m not sure if the money we spend has really bought us that much, at least not in relation to the vast sums of money that we continue to dump into the sucking pit of medical care.

I mention this not because I necessarily believe that preemptive vigilance is a bad thing, just that it is an extremely expensive way to practice medicine and it may be that a little more of a guarded approach, a commitment to watch and wait might save a lot of money with no effect on morbidity and mortality.  Surely, as an example, every woman early in her pregnancy with some spotting and mild pelvic pain does not need a full workup for an ectopic pregnancy although if you come through our department and have any of these symptoms, even if your chief complaint was a sore throat, you will have a full battery of expensive tests to rule it out.

Do I take ectopic pregnancies seriously?  Of course I do.  But I’d say that I probably initiate twenty negative workups for every ectopic I find and the positive ones are often clinically obvious with the studies ordered to confirm the diagnosis.   The question is whether waiting a day or two would effect the outcome and whether the occasional benefit of early detection is worth the money we spend ruling out the majority that turn out to be nothing but a little bit of pain from a stretching uterus and a bit of normal physiological bleeding.  Like I said, you can present to any emergency Department or doctor’s office with symptoms so vague that a doctor sixty years ago wouldn’t know what to do with you but today receive a full work-up, no different than if you had waited a few days and your symptoms were more classical.

Getting A Job

Just a few observations about looking for my first post-residency job and with a hat-tip to the folks over at M.D.O.D.:   First of all, it was a pleasant experience after applying to medical school and residency to interview for a job from a position of strength.  You essentially have to beg to get into medical school because you hold no cards whatsoever and no matter how stellar a student you were or how winning your personality, there are many more qualified applicants than there are spots and it may as well be somebody else who gets picked.  Likewise with landing a decent residency position which is, like medical school admission, something of a poodle show for graduating medical students as we trot ourselves from program to program trying to convince them that we are good dogs.  Not a lot of negotiating going on, your understand, both medical school and residency being exclusively “take it or leave it” propositions….at least I never heard of fourth year medical student with so much clout that he could negotiate a residency contract (which is not really a contract at all but a documentation of indentured servitude) to his liking.

As a board-eligible physician however it is more of a seller’s market.  In my specialty there are many more jobs than there are Emergency Physicians to fill them so once you get out of the subservience mode (and certainly by the end of your residency you should be pissed off enough to not want to be every body’s little bitch all the time) you can get, within reason, any kind of job with any kind of pay that you want…all you have to do is recognize that your prospective employers need you more than you need them and act accordingly.  I am not, mind you, advocating arrogance or unreasonable salary demands, just that it is no longer necessary to beg.  In the end, you can walk away from any offer with complete impunity and no hard feelings as long as you negotiated in good faith.

Negotiating is the key.  In most cases the first number they slide across the desk or put into a draft contract is a tentative offer and most employers will not be offended by a little dickering.  Likewise with signing bonuses and even simple things like moving allowances.  Sometimes your prospective employers will offer these things up front but if not, there is no harm in asking for them or any other legal and reasonable concession.  The worst they can say is “no” and the worst you can do is respectfully decline their final offer.  Again, no hard feeling, nobody is worse for the wear.

Your room to negotiate also depends on where and for whom you want to work.  Many markets for Emergency Medicine are saturated and if, for example, you just have to live San Diego you may have to settle for a lower salary than your colleagues looking for jobs in Klamath Falls. The rules of supply and demand do not, after all, always work in your favor.  The same would apply if you wanted a junior faculty position at a Big Academic Medical Center in which case you would have to sell yourself shamelessly and probably settle for a good deal less than you could make somewhere else.

There are also many kinds of practice.  You can sign on with an established group with the intent of becoming a partner, you can work directly for a hospital system as their employee, you can work as a free-lance killer-for-hire locum tenums, or you can work for a hospital as an independent contractor to name just a few options.

Obama Watch: The Love That Dare Not Speak Its Name

“Man-caused disaster” instead of “Terrorism” is the latest euphemism to come out of President Obama’s administration, in this case from his Secretary of Homeland Security, and shows, as if you needed any other evidence but the last eight weeks, with what a pack of morons we are dealing.   Maybe they’ll reconsider the term when Obama is surveying the glowing ruins of an American city destroyed by Alleged Foreign Perpetrators or whatever the euphemism will be for the terrorist group that manages to smuggle a nuclear device into Chicago.

I mention this because I live in an area where the Cult of Obama is very strong and yet, the other night I observed my neighbor furtively scraping the Obama bumper sticker off of his Subaru.  I think people are catching on, in other words, although there will always be the die-hard cadre of fanatical followers who dress their children in paramilitary garb and have them chant paeans of love to the Dear Leader.  My neighbor is not that fanatical however and is a decent enough guy even though his political and economic knowledge is sketchy and based largely on earnest but meaningless slogans.  He probably only voted for Obama because he didn’t know what else to do.  Surely he couldn’t have voted for that old, mean Republican who had a clue but didn’t whisper such sweet nothings into his ear.  Now, in the post-coital period when he lies vulnerable and afraid while Obama is in his kitchen drinking his beer and checking his black book my neighbor feels used and a little dirty.  He’s given it up for a guy who is just not that into him and will never return the love that was so desperately given.

Which is also the trouble with the press.  Although Obama is barely two months into His presidency and involved in scandals that make anything since the Nixon administration look like patty cakes, the paleomedia, our own professional cheer leading class, are still starry-eyed and hoping that their lover will come back for one more roll in the hay that will lead to consummation and justification (Peggy Noonan comes to mind).    I mean seriously, the Obama administration and their enablers in congress took bribes from AIG to pay their bonuses from the recent pork-laden stimulus bill, directly adding provisions to the reconciled bill, and the outcry from the press?  Tepid at best.  Politics as usual.  Ho hum.  President Obama gets a pass because, shucks, the bill was a thousand pages long and how could the Smartest and Sexiest Man in the World be expected to know what His own government is doing?  I shudder to think what it would take to get meaningful reaction out of them who were once the savage watchdogs of our democracy but have now abrogated that role to talk radio.

The press now lays prostate and sticky with sweat, wondering if it was worth it and hoping that The One will come to his senses and love them as they love Him.