Can’t We All Just Get Along?

Moslem and Jew. Windows and Mac. Republican and Democrat. Partisanship and sectarian strife abound but these are nothing, as tame as church picnics, compared to the seething clandestine war being waged in teaching hospitals across the country over whether the house staff should or should not be allowed to wear scrubs as normal attire. At one extreme in this battle are the dark forces of oppression who would make their residents wear a shirt and a tie under their surgical gowns if the those pesky rules about infection control didn’t make it impossibe. At the other are are the noble advocates of personal liberty who believe that attire is a personal decision that each must make according to his conscience.

I try to stay neutral but the case for scrubs is pretty convincing.

First of all, residency training is not totally hygenical and, unless you are one of those no-good lazy bastards in PM&R, you have a pretty good chance of getting something unwholesome on you. I’m not saying that the wards are obstacle courses of flying bodily fluids because they’re not. Even in the Emergency Department, with a little foresight, you can go days without getting slimed. In fact, the nefarious opponents of scrubs will often point out that your low risk for getting sprayed doesn’t justify not dressing up and they scoff at the house staff’s fear of a little accidental goopage. “What, are you a nurse?” they ask with a contemptuous snicker.

But with how much bodily fluid are you comfortable? I’m zero-tolerance myself. Call me squeamish but one drop of vaginal discharge or vomit on my shirt is enough to make me want to change it. I have no desire to either keep a stock of pants, shirts and ties at the hospital or spend the day enjoying the memories. Scrubs, as they are usually supplied by the hospital, are disposable. I once got sprayed with urine and I didn’t think twice about cutting off my scrub top (because I wasn’t going to pull that thing off over my head). I’m not exactly a metrosexual but I’ve been known to pay as much as 30 bucks for a dress shirt. Ruin one shirt a week, and by definition a shirt with any total stranger’s discharge on it can not be washed enough so I will wear it again, and we’re talking some serious money.  I don’t care if it’s a drop of blood on the cuff.  I’m not wearing it one minute longer that I have to.

Advantage: Scrubs.

Hospitals are not offices.  We don’t work in cubicles, sitting in our ergonomic chairs all day except when we make a trip to the candy machine or to the boss’ office to swap some management jargon.  Most of us spend the day walking and most academic hospitals are huge.  Duke is so big, for example, that they have a train running between the main hospital and the clinics.  I once tried to estimate how far I walked every day and it came out to miles. 

Think about it.  If you’re on the second floor on a remote wing and you get paged to the eighth floor on the other side of the hospital, you might have to walk a quarter of a mile, not to mention taking some stairs. I like elevators, don’t get me wrong, but they are usually full of patient’s families and you have to wait for them (patient’s families never take the stairs).  Do this for a thirty-hour call day and you will cover a lot of ground.

Office attire, as it is designed for people who spend their day working on spreadsheets (or whatever they do in offices) is completely unsuited to our nomadic lifestyle.  Scrubs, on the other hand, are light, airy, and they don’t chaff.  And there is no way to wear a tie while wearing scrubs.  I hate ties.  I know the trend is to disparage them as fomites, carriers of pestilence from one patient to another, and I suppose this sounds reasonable.   But I hate ties simply because they are ridiculous and uncomfortable.  Ridiculous because they serve no purpose and uncomfortable for obvious reasons.  I wear a tie to church but that’s because it is uncomfortable and focuses the mind on the evil of earthly things. 

Besides, office attire is typically worn from nine to five.  Most residents work far beyond the typical work day and you start feeling clammy after wearing your church clothes for more than ten hours.  It’s bad enough we have to stay up every fourth night running around the hospital without having to do it clothing we’ve been wearing since the previous morning.

Advantage:  Again, scrubs.

Do scrubs look unprofessional?  It depends who you ask. Your old-school attending regards them with the same loathing he holds for the greasy pants of a urine soaked wino.  He thinks that physicians should dress to impress.  But isn’t that the point?  If I’m to understand him, I need to wear a tie to impress a guy who they found under a bridge, hasn’t had a bath in six months, and drinks Lysol when he can’t afford “Mad Dog.”

Seriously, a clean pair of scrubs under a clean white coat looks professional enough for everybody short of the Pope.  People have been conditioned to expect their doctors to wear scrubs, even without the white coat.  Just tuck in the shirt, avoid the 101 Dalmations print top and you’ll do fine.

Advantage: Still scrubs.

 

Osteopathic Medicine

My mother, who is from Greece, is visiting us and was amazed to hear that our program is a combined osteopathic and allopathic program.  She had no idea that chiropractors were used in the Emergency Department. In Europe, you see, osteopaths are not trained medical doctors but confine their practice to manipulation and other alternative therapies.  In the United States, however, osteopaths, who are conferred the DO degree (Doctor of Osteopathic Medicine) are fully trained medical doctors and are without exception completely interchangeble with allopathic physicians, those with the traditional “MD” after their names.  The confusion arises because osteopaths are far fewer in number than allopathic physicians and in some states, particularly my native Louisiana, are as scarce as hen’s teeth.  I had never heard of osteopathic medicine before I started applying to medical school.

Osteopathy was founded shortly after the Civil War by Andrew Still, a former Army surgeon, in a reaction to the general quackish and barbaric nature of most medicine at that time.  He developed a theory of medicine that, as it was based on the manipulation of bones, did not require drugs or surgery.  His idea was that manipulation could restore the flow of blood and nervous impulses, the interruption of which he regarded as the cause of most diseases.  Osteopathic Manipulative Treatment (OMT) has grown out of his theories into a treatment modality which is still taught at Osteopathic medical schools. 

I say “still taught” because there is little or no good evidence that manipulation does anything other than make the patient feel subjectively better.  Hell, you can get a topless massage in most cities and even a “happy ending” that probably would make you feel as subjectively better without all of the fanfare and the embarrassing questions about your diet and bad habits.   In light of this there is a considerable sentiment among practicing osteopaths and osteopathic medical students that just as modern medicine has moved away from now discredited but once accepted treaments, it may be time to move away from OMT.  I have asked many osteopaths if they use OMT and a typical answer is, “I’m not a believer.”

Whatever the case, except for several hundred hours of training in OMT  the science and clinical curricula are similar enough between ostepathic and allopathic medical schools that graduation from an osteopathic medical school will lead to full licensure as a physician with no restrictions on your practice or the ability to receive additional fully accredited training.  Not only are there osteopathic residency programs in every recognized medical specialty but osteopaths can apply for allopathic residency positions as well (but not vice versa).

Many pre-meds apply to both types of schools to increase their chances of being accepted.  I didn’t because I’m shallow and didn’t want to explain the initials after my name.  This is actually not a problem in some parts of the country, particularly the upper midwest where osteopathic physicians are well known and respected. 

Some people believe that it is easier to get into osteopathic medical schools and decide to use them as “back up” schools.  This is the conventional wisdom but it’s silly if you think about it.

While the objective qualifications of allopathic matriculants (MCAT scores, GPA) are indeed slightly higher on average than their osteopathich counterparts, generally, if you’re not qualified for admission to an allopathic medical school you will not get into an osteopathic one either.  Sure, the fierce partisans are quick to point out the higher average scores but these are the result of outliers.  Like most things, the subjective qualificatons distribute themselves normally and it is only at the extremes where the curves don’t overlap.  For my part, since I was an average applicant (at least by MCAT scores and BPCM GPA), almost half of osteopathic matriculants had better qualifications.

So think about this before you get too cocky.  If you want to be an osteopath go to an osteopathic school.   If you want to have the MD after your name you’d be better served just applying to more allopathic medical schools and taking your chances.  The best osteopathic schools are also better than the worst allopathic schools and they can afford to be more selective.

Osteopathy, aside from OMT, distinguishes itself from allopathy by purporting to be more patient-centered, viewing as they do the patient holisitically and not in the disjointed manner that allopaths are accused of doing.  There is something to this but not enough to get excited about.  Osteopathic schools push primary care hard and they’re serious about it, not just paying the usual lip service offered by people who wouldn’t be caught dead in primary care.  Despite this (or because of it) many osteopaths specialize and have the same reasons to run screaming from primary care as anybody else.  At our local College of Osteopathic Medicine, the students have related to me that they spend close to eight months of their clinical years on mandatory outpatient and ambulatory clinic rotations which will tend to make pathology look mighty good.

Keep this in mind if you think primary care ain’t your bag.

Osteopathy Disadvantages: Metaphysically, none.  Full-fledged physicians in every specialty from neurosurgery to pediatrics.  However, lingering prejudice in some states might make licensure more complicated (the requirement for an extra intern year for example).  Also the COMLEX is reputed to be more difficult thant the USMLE, not to mention that the regulatory body for osteopathic residency programs is a lot more stringent about absolutely everything. (Paperwork, etc.)

Osteopathy Advantages: The ability to match into both allopathic and osteopathic residency programs.  It’s true that you will have a disadvantage, all other things being equal, in the allopathic match but you won’t in your own and the rest is gravy.  Not to mention that osteopathy has a certain retro coolness factor to it.

Physician Defend Thyself

Imagine you are in a rural Emergency Department on a quiet night. The radio crackles. It’s EMS giving a report to the charge nurse. You overhear “snowmobile,” “Loss of consciousness on scene but patient now alert and combative,” “Open fracture of the left femur,” and “Possible ETOH.”

The patient arrives and the history from the paramedics is typical, that is, typical dirtbag typically drinking, typically lost control of his snowmobile after typically saying to his buddies, “Hey watch this!” Somewhat atypically, however, ran his snowmobile into the side of a barn fracturing his femur on his way through.

You evaluate and stabilze the young daredevil who is otherwise uninjured except for minor cuts and abrasions, put the leg in traction, and start the appropriate antibiotics because the end of his fractured bone was sticking out of his thigh when he arrived.

It is time to call an orthopedic surgeon. You don’t just put a cast something like this.

“Good morning, Dr. Smith. Sorry to wake you up but this is Dr. Bear at the County Hospital Emergency Department. I’ve got a 25-year-old gentleman, snowmobile versus barn, with an open mid-shaft fracture of the left femur but otherwise without significant injuries. We have him in a traction splint and his distal pulses and sensation are intact. On the way through the barn he dragged the end of his broken femur through approximately fifteen feet of cow manure and I’m afraid it was about thirty minutes before his drunken friends decided that he probably wasn’t going to walk it off.”

“How’s he doing now? Fine. He’s fully alert and oriented and threatening to sue everybody in the place. Can you come in and see him?”

If you were an orthopedic surgeon, would you come in, especially as you can come up with quite a few good excuses not to?

Don’t answer yet.

First of all the patient does not have insurance. People riding their snowmobiles drunk on a weekday at 3AM never do. It’s axiomatic. He also has a major injury and he is a setup for all kinds of post-operative complications. Not only is he likely an unrealiable patient and will not comply with his medication or follow-up but the jagged end of his bone was dragged through cow manure, rat turds, hay, and every kind of bacterial goodness that you can imagine. The odds of osteomyelitis (infection of the bone) which even the best antibiotics that the taxpayers can buy might not cure are high. The leg might never heal or it may require mulitple revisions to remove and replace infected hardware and bone.

Now consider that the orthopaedic surgeon is of a new breed, operating primarily out of a privately owned surgical center where he can fill his OR slots with hip and knee replacements on insured, compliant, pleasant elderly people or tendon repairs on insured, healthy young atheletes. Coming in to care for this patient is going to set him behind on his schedule, maybe forcing him to cancel some cases or some clinic appointments for his paying customers. Since he doesn’t need to maintain privileges at the County Hospital they have no hold on him and it is only the tenuous grip the Hippocratic oath has on his heart that could compell him to come in.

I say tenuous because not only is the Hippocratic oath not legally binding but it doesn’t even apply in this situation, a case where before the physician “Can do no harm” he first has to symbolically lay hands on the patient by accepting him, thus establishing the sacrosanct doctor-patient relationship. This is not just a techincality. The entire world is not your patient, only your patient is….which should be obvious. If this were not the case, I would have to hang a big sign in front of my house saying “Here There Be a Doctor” and treat anybody who happened to drop by. It would sort of be like EMTALA gone crazy, at least crazier than it has already become.

EMTALA, or the Emergency Medicine Treatment and Active Labor Act mandates (without providing funds, hence the unfunded mandate par exellence) that every patient who presents to the hospital, regardless of their ability to pay, be provided with a screening exam, appropriate medical care to stabilize them, and transfer to a hospital that can provide the appropriate level of care. It sounds reasonable enough but in practice, the law has become the portal of entry into the hospital for anybody with any medical complaint whatsoever, emergent or not. What was originally intended to stop the practice of “patient dumping” has now become a highly inefficient system of charity care.

The key thing to note here is that EMTALA applies to hospitals, not physicians. Because the “takings clause” of the Fifth Ammendment prohibits the government from seizing an individual’s property (in this case the doctor’s work) without just compensation, no law may compel you to work for free…or even work at all if you don’t want to. Emergency physicians see every patient without regard to ability to pay because it is part of their usual and customary duties to see everybody who come through the doors and are compensated by the hospital. An orthopaedic surgeon who has no contractual obligation to the hospital, on the other hand, has no such obligation.

Which brings us back to the Hippocratic Oath and the sense of duty we all feel as physicians to provide care to everybody and devil take the hindmost. Unfortunately, while the legislature is quick to give rights and privileges to patients, it is a little more deliberative when it comes to ennumerating their responsibilites and limitations. Our patient is going to be very grateful, once he becomes sober, for any help he receives. And yet, when he finally goes home and perhaps walks with a permanent limp or just decides that his job at the local plywood mill is too depressing, he will look up to see the gleaming eyes of the legal predators circling his fire and from then on, the orthopedic surgeon is a marked man.

He may never be sued but the risk is so great of providing free care to a population with poor compliance, poor follow-up, and a jackpot mentality reinforced continuously by lawyer’s television advertisements, that even providing this care will force his skittish malpractice carriers to increase his premiums or even cancel his coverage althogether.

So at the very best, the orthopedic surgeon will lose a little bit of his time and some of his sleep, things that most of us don’t really object to losing if there is a clear need. At the worst, however, he can be dragged through the humiliation of a malpractice suit which, even if he is held harmless, will still tarnish his reputation and while it works its way through the courts can damage his abiity to maintian his credentials. It can cost him directly in increased malpractice insurance premiums which, in some states, are as high as $200,000 per year for surgeons. And it can cost him indirectly in lost revenue from work he could have done, the very real concept of “opportunity cost” which most people who don’t work don’t understand.

All of this for a bad outcome which may not have been possible to avoid.

So would you come in?

Strong Medicine

Every now and then my wife and I like to put on our fleece pyjamas and our fuzzy slippers and sit on the sofa with hot cups of herbal tea watching Strong Medicine, an estrogen-charged medical series offered on Lifetime. The show is about a Group of female gynecologists who have somehow managed to take over a hospital where they can be found, day and night, sticking there noses and considerable medical expertise where gynecologists don’t usually stick their noses. 

The show has a science fiction qualilty to it.  Imagine an alternate universe where women run the hospital and men are their preening, self-centered playthings.  But that’s lifetime for you, a network that only has two flavors of men, Bloodthirsty Rapist or Sensitive Metrosexual.  Even guys who are supposed to be manly, such as the suave Dr. Biancavilla, are just a little too put together, a little too fit, and a little too in touch with their feminine side to really be taken seriously as men.  It’s almost like a reverse kabuki play with specially-trained actresses performing the male roles. 

Like most of Lifetime’s shows, Strong Medicine is an unapologetic feminist screed which is its charm.  You will find no subliminal messages here and the characters seem to continuously clench their jaws and curl their fists at every affront to womyn’s right as if to say, “You will take my curette when you pry it from my cold, dead fingers.”  Conservative and old-fashioned as I am, I can appreciate this no-holds-barred, take-it-or-leave-it, in-your-face world-view especially because unlike other medical shows, while the characters often deal with frustrations and conflicts of which good medical drama is made, there is never any angst or self-doubt.  Dr. Cambell (played by Patricia Richardson of Home Improvement fame) for example, plays a former Army physician and no cabal of good-old-boys are going to stand in her way, no ma’am.

The stereotypes and racial profiling on Strong Medicine are as horrendous as anything else on TV.  There is the sassy black office manager who speaks in the third person (“If Lana wants a bagel, Lana will get a bagel”), bobs her head when she talks, and, as she is a recovered prostitute, flaunts her authentic street cred at the smallest provocation.  They have the obligatory young latina doctor passionately fighting for the reproductive rights of her downtrodden patients who are some of the most articulate, responsible, family-centered crack whores I have ever seen.  And they have Ricky Schroder (well known to sitcom connoisseurs from “Silver Spoons”) representing the stone cold white boys. 

I don’t know if his agent billed this as a good career move but an actor’s gotta eat.

It’s ridiculous. Gynecologists do not typically manage traumas and push the pretty-boy Emergency Physicians out of the way.  It’s contrived.  Every woman with HIV has the perfect story of victimization.  It’s stilted.  They don’t so much speak but give speeches to each other.

But it works.  And my wife and I love to watch it while we talk about that French waiter….what was his name?….Jean Luc!

 

Chicago Hope

LA Law set in a hospital.  That’s all you have to know.  I loved that show and we watched it religiously until the siren call of ER lured us away.  Imagine a show that picked one hot-button social issue per episode and had an ensemble of some of the finest actors on televsion beat the hell out of it. 

And beat they did.  We get it.  Discriminating against HIV patients is bad.  Gay men can make good parents. Guns are bad.  Four legs good, two legs better.

Still, it had marvelous acting lead by my favorite actor-whose-name-I-can’t-remember-but-who-I-confuse-with-the-captain-from-the-Love-Boat.  It also had Mandy Patinkin who is one of the most versitile and under-appreciated actors of our time. 

Just a quick bit of Panda Bear trivia.  I don’t know most of the character’s names on any of the shows I watch.  I have a mental block, kind of how I skip over the Russian names in Tolstoy. I have been watching ER since the late 1960s, for example, and I still can’t tell you the names of anybody but Abby and Dr. Carter.  No sooner had I learned “Dr. Green” and they killed the bastard off from cancer, on the beach, in Hawaii.  So Chicago Hope is full of wonderful characters but I tend to think of them as gestalts rather than real characters, principal among them the lead actress who played the very model of a cynical, bitter, bitchy cardiothoracic surgeon who had sacrificed her personal life to her career.

But angst? You could cut it with a knife.

 

Scrubs

People always ask me, on discovering that I am a resident, if residency is really like Scrubs.  The funny thing is that it is.  Not in the sense that life as a resident is one comic situation after an another and not because the residents are continuously verbally abused by their completely over-the-top-even-for-residency attending but because I believe Scrubs is the first medical program to show that doctors, especially young interns and residents, are not perfect and live with a level of self-doubt that most people can’t imagine.  I saw the first season and the show captured perfectly the sense of inadequacy and dread most of us started to feel about twenty minutes after graduation when we realized that shirking responsibility (“Sorry, I’m just the medical student) was now no longer an option.

And it also portrays residents, even though it is a comedy, more realistically than even the more serious television offerings that purport to be showing a slice of reality.  As opposed to the hip-and-cool, edgy residents on ER or the svelte sexy house staff on Grey’s Anatomy, most real residents are geeks to one degree or another. Dr. Dorian is completely realistic in this respect and even his maturation over the years from complete goof to competent but goofy doctor is completely true-to-life. Or consider Dr. Turk (played by the talented Donald Faison) who tries to live the persona of the angry, street-wise black man when he knows (and we know) that white or black, the discipline and studying required to gain admission to medical school and acceptance to a surgey program does not allow for the bohemian lifestyle and the flaunting of authority required of a gangsta rapper.

It is also a very funny show that breaks out of the usual sitcom formula.  I can hardly watch it now that I am a resident.

MASH

I’m probably one of the few people in America who will admit to not liking MASH, one of the most popular shows in the history of television. Although it was ostensibly about a Mobile Army Surgical Hospital in the Korean War, the subtext was Viet Nam, an era in American history when we all decided to become a bunch of pussies. Just another achievement in the legacy of the baby-boomers, perhaps the most self-centered and pampered generation in American history.

All war movies and television shows rely on mythology to make a point. I prefer movies like “The Sands of Iowa Jima” and the “Green Berets” which glorify the American fighting man, not pictures like “Platoon” or “Born on the Fourth of July” which at best potray him as a vicious murderer but usually end up depicting him as a coward, a bum, or some drugged-out, crazy victim of The Man. MASH, a television show inspired by a movie of the same name, on one level was a cheap anti-war comedy that regularly trotted out all of the subjects that even in the seventies were already becoming clichés,

Hey, you have your heros, I have mine. My Company First Sergeant for example, back when I was a young Private First Class in the Marines, had won the Silver Star in Viet Nam for killing a half-dozen Viet Cong with nothing but his entrenching tool, the blade of which he had (with admirable foresight) sharpened to a fine edge. He was a modest, unassuming guy and I’ll take that kind of courage over someone with the courage to sob and moan about their experiences and how the fire of battle had ruined their life.

While I’m sure MASH is a perfectly decent show and will be in re-runs until the cows stop coming home, and while I have seen as many episodes as anybody who is not really a fan, I can never watch it anymore because it bores me to tears. They have maybe five standard plots which are recycled over and over. And then, towards the end when every television show begins to eye the shark swimming in the tank, the show became extremely preachy and serious, finally dying a weepy, silly death but not before millions of people for whom the show had been their only experience of war and the military had their MASH parties.

I get close to 100 channels. There is always something better on. Maybe the show wasn’t really that good. Back when it came out there were, after all, only four networks (yes, kiddies, believe it or not) and there was no television at all after midnight except for Creature Feature which came in really fuzzy on obscure UHF channels. I wonder how MASH would do today up against, say, Iron Chef or MythBusters?

Besides, the sitcom is dead. It’s a wasteland after they cancelled Seinfeld and Frasier.

ER

I watched ER long before I ever even thought about going to medical school and I like it today as much as I ever did. It is probably the best medical show ever produced from the point of view of plot, character development, and premise. The best thing about ER is that you can miss it for a few years and jump right back in with no disorientation whatsoever, except perhaps that the writers have added a few new characters while you were away. On the other hand, sometimes they kill or otherwise get rid of characters who you hated, like the crippled lesbian attending who had a baby with her lesbian paramedic friend, so it’s a wash. The characters don’t matter. The ER is the character and the actors are just vehicles to carry the story of grit and angst forward. I confess I was a little disoriented when I turned it on after a long absence and somehow Dr. Carter was in the Sudan with a highly annoying French chick and some African doctor who opined constantly about the lack of American troops who, being too busy defending Middle-eastern oil, could not be bothered to whip some justice on the local warlords. After a few flashbacks, however, and some nihilistic dialogue I quickly regained my bearings.

You just don’t have to know that much to enjoy ER except that it is, like most televsion shows, a sounding board for muddled knee-jerking of the left. I have no doubt that if we ever sent to troops to the Sudan, the same African doctor, perhaps in a cameo appearance, would complain that the Marines were violating the human rights of the Warlords who are, after all, merely the George Washingtons or Simon Bolivars of their people.

But hell, that’s entertainment.

Even though I am an Emergency Medicine resident and know a little about the subject, I am not one of those doctors who yells at the television when things are not realistic. I appreciate that the show only runs 45 minutes a week (subtracting commercials which we do thanks to magic of DVR, the most important invention of the last 100 year) so all of the traumas and codes have to be time-compressed. The interventions, as far as I can tell, are perfectly reasonable, the script reflects the condition of the patient accurately, and everybody looks like they know what they are doing. Obviously, the show listens to its medical consultants although I’m sure by this time most of the longest-lived actors could probably talk their way though a real trauma, assuming they could handle slowing things down a bit.

The most unrealistic thing about ER is how much everybody knows. Even the medical students can rattle off a differential diagnosis as detailed as it is exhaustive which is a far cry from real life where pimping questions from the attending are usually met with the lonely sound of crickets chirping. Not only that but they argue all the time on ER and take patient advocacy to ridiculous levels. It just ain’t like that in real life, folks. Generally, unless the attending urinates in the patient’s IV bag we’re all pretty much going to do what he tells us. He might even be able to convince us that it is some novel form of pre-renal electrolyte replacement therapy, the details of which will be appearing shortly in JAMA.

So between the sharp-as-tacks medical students, the residents who never find themselves with their thumbs up there asses out of ideas and looking for salvation, and the attendings who are so proficient that they feel comfortable telling the hematologists and nephrologist where they can stick their complicated plan of care, well, you might get the idea that doctors are a lot smarter than we really are.

The other thing the show does not adequately explain is why all of the Emergency Medicine residents are so unhappy. I suppose it is not common knowledge among the public but matching into Emergency Medicine is like hitting the jackpot. Once you get done with intern year (which on ER seems to last anywhere from three months to five years) you are on easy street. Sure you work shifts but it’s not that bad. The ER residents act like they’re working surgery hours which is not even close to how it is in real life. In fact, part of the fun of our job is laughing at those sorry bastards in Surgery and Medicine and watching them sleepwalk through the admissions we throw ’em after we get bored of working up the patient.

They also have impossible career mobility. One of the characters started as a nurse, went to medical school, quit medical school and went back to nursing, and then apparently finished medical school on the self-study track, popping in and out of rotations where her expertise must have been insufferable to everyone around her. She graduated, or didn’t graduate because of a technicallity, but thankfully matched into Emergency Medicine on graduation day. Another character started in Medicine, switched to Emergency Medicine, and is now a surgery resident performing at the attending level.

I wish it were that easy. It took me a year of incredible effort to switch residencies.

Emergency 

Although it seems like prehistory, as late as the 1970s when someone was in a motor vehicle accident no attempt was ever made to stabilize the cervical spine, at least that’s what I remember from watching the landmark television series “Emergency” which debuted in 1972 and did for paramedics what ER did for Emergency Physicians.  As difficult as it is to believe, up until that time ambulances were usually white station wagons with sirens into which the injured patient was thrown and driven as quickly as possible to the nearest hospital.  Speed was the only real intervention and to this day, my mother-in-law still calls paramedics (who are now highly trained medical specialists) “ambulance drivers” because that’s what they were back then and could only be differentiated from hearse drivers because they didn’t wear black suits.

In that age of paternalistic medicine when the doctor was king and nurses dressed like porn actresses, the sticking point was the reluctance of physicians to allow ambulance drivers to perform interventions.  It seems strange today but back then, giving a liter of fluid (or a “quart” if we’re going get technical), something I don’t remember seeing a lot of on the television show, was considered a major undertaking and they weren’t going to allow a bunch of firemen to do it, no sir. 

The pilot for the series, and again I’m pulling this from memory, detailed the reluctance of the authorities to let the paramedics act independently in any capacity.  Eventually the legislature is convinced and from then on, Firefighters Roy DeSoto and Johny Gage spend the next five seasons thrilling us with feats of medical derring-do that only doctors had ever previously attempted.  But they still had to run most things by the old patrician, Doctor Bracket at Rampart Emergency Hospital who stayed in contact through the stunning high technology of a remote cardiac montitor and a radio telephone.

Episodes usually included some banter with the vulpine Dixie McCall, RN, who knew her place even if she did joke with the boys a little. 

I watched an episode recently and it still works.  It’s true that the plots were of the “Jimmy has fallen down a well” variety but the show was more than just action, it was a weekly buddy movie interspersed with old-fashioned heroics and predictable but funny comic situations.   As the years go by, the 1970s seem stranger and stranger.  The cars are starting to look like 1926 Packards must have looked to people in the fifties watching old movies.  Leisure suits were everywhere, woman all wore heavy makeup with their big hair, and the hospital was a black box into which sick patients were fed to emerge completely cured of the simple medical problems that were the bread and butter of our distant ancestors.

(When I first started this blog, I was going to call it “The Slacker’s Guide to Medical School” because as you, my long-suffering readers know, I didn’t exactly cover myself in academic glory.  I decided against calling it “The Slacker’s Guide” for the simple reason that I am not, in fact, a slacker.  I like to work and have worked hard my whole life.  It’s just that much of medical training is so utterly pointless that anybody who has ever worked at a real job could not help but take whatever opportunity presents itself to gain some relief.  I decided on “Panda Bear, MD” instead as we all need a nom de guerre in the blogosphere to protect us from overzealous and vindictive bureaucrats who have still not realized that, to paraphrase the ancient wisdom, God made men but the blog made them equal.  I’m not that anonymous, as a matter of fact, but these kind of things are traditional. Panda Bear, by the way, was my radio call-sign as a young Marine Infantry Squad leader.  Everybody gets bestowed a nickname of some kind or another and I got off light, at least compared to my good buddies “Cat Pussy” and “Sasquatch.”-PB)

Architecture

One of the first things a medical student needs to learn is how to make a clean getaway.  As hard as it for some people to imagine, laden as they are with the guilt of abandoning their patients to the cruel devices of the nurses and residents, there comes a point when it is time to go home.   Identifying this point is the challenge as it is rarely going to be obvious.  Not only will you rotate on countless services over the course of third and fourth year, each with it’s own schedule, but it is an unwritten rule that to merely ask about leaving is considered a sign of weakness.  In fact, to ask will challenge the philosophical underpinnings of much of medical training where the simple question, “When’s quitting time?” is viewed as a thorny philosophical puzzle on the order of “What is the sound of one hand clapping” or “Will Whoopie Goldberg ever make a funny movie?”

It is a mystery.  Nobody really knows except that it will happen at some imaginary point when everything that needs to be done is done, a very unsatisfying answer to a medical student who has ever worked at a real job.  Unfortunately, this imaginary point is often after afternoon rounds with your attending and, because in academic medical centers there is no penalty for being insufferably rude to your subordinates, you may find yourself waiting for hours with no idea of your schedule for the evening because your attending, even though unavoidably and understandably detained, lacked the courtesy that is common among pimps to let his biaches know when he may be expected back on the block.

Not to mention that technically there is always something that needs to be done.  A medical student, if he had no self-respect whatsoever, could ask for and receive scut work enough to keep him occupied until in a sign of incredible weakness, he collapsed from exhaustion four days later.

So you will need to look after yourself.  Rounding, like death, taxes, the latest news on Anna Nicole Smith, and other unpleasantries is unavoidable and you will need to stay to the bitter end as you pretend to manage your resident’s patients.  But often there are no afternoon rounds and you may, like Oliver Twist, screw up your courage to ask your resident, “Please Sir, may I go home?”  As most residents are fairly decent people and realize that you need to study, eat, sleep, or do the hundreds of other things that they used to do before they were sucked into the black hole of residency training, they may say, “Okay, see you tommorrow.”

If they do you need to leave, and quickly.

Sound, at sea level, travels at approximately 750 miles per hour.  An “Oh, by the way” can make it from one end of the ward to the other in less than a millisecond which is a lot faster than you can manage.  You need to quickly put some architecture between you and your resident lest he change his mind or remember some scutty task that is still undone.  I suggest taking the first door, stairwell, or exit even if it is not the shortest way out of the hospital. They give you a map of the place at orientation.  Learn it.  Hell, don’t learn it.  I’d rather be free and  lost for a minute of two than called back for a half hour of scut.

It goes without saying that you need to learn how to turn your pager off faster than someone can pick up a phone and dial your number.  I typically turned mine off at the first hint that we were going to bust out of there.  There is no reason for a medical student to ever answer a page once he has been formally dismissed for the day.  Turning the pager off removes the temptation to return the page and be sucked into writing one more HPI on a patient that just showed up.  Alas, when you are a resident you cannot escape so easily as you are actually responsible for patients.  Even post call I usually keep my pager on me, for a while anyways, because I have a great deal of respect for nurses and I know it makes their jobs easier if they can talk to the guy who admitted or is following the patient on whom they have a question.

Never Look Back

Like Lot’s wife who looked behind her and was turned into a pillar of salt, bad things can happen to the medical student who looks back.  I advocate working hard during the day but I advocate even harder leaving when you are done.  If you are leaving, then leave motherfucker.  There is nothing in that Sodom and Gommorah know as your hospital that should concern you.  Do not turn around to ask your resident if there’s anything else you can do.  Are you crazy? Of course there is.  Asking a resident if you can help him with his never-ending ration of scut is like asking a sailor if he’d like his ashes hauled.

By the same token, once you get moving never retrace your steps to retrieve a forgotten item.  First of all, when you start smelling the barn you need to start planning your escape by collecting all of your gear and stowing it in the pockets of your short white coat.  This is why I don’t advocate bringing a book bag or a “day pack” to the hospital, namely because retrieving it can signal your intentions and give your residents time to think about how nice it would be if you took care of some of their scut work.   I suppose if I had left an expensive gold pen or my PDA where it could be stolen I’d probably suck it up and go back for it.  But I would be a surrepititious bastard and go as ninja as I could.

But the stinking remains of your lunch?  Dude.  Leave it.  First of all, if anybody really wants to steal your Hello Kitty lunch box with the half-eaten tofu sanwich than they should be welcome to it.  Same with your ratty sweater.  You shouldn’t bring anything of value to the hospital anyways unless you carry it on your person.  Just ask yourself this very important question: “It’s four o’oclock.  Miraculously, I have the weekend off and even more miraculously, I am out of here before seven PM.  Is that sweater that my grandma knit for me with her own hands before she died really that important, especially considering that grandma had the palsy and only a blind man would ever even think of stealing it?”

Is it worth an “Oh, I thought you were gone…hey, there’s an interesing chest pain in the ED….”