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There Are Days…

My Good Friends and Patient Readers,

I’ve decide to stop blogging. Although I have enjoyed writing this blog and mightily appreciate all of you who have taken the time to read and comment upon my many articles, keeping the blog going has taken an appreciable toll on my sleep, studying, and even on my family time. As I am about to enter my last year of residency I will have many new responsibilities to my program competing for my time. Additionally, I have signed a contract for my first job and, as I need to devote my last year of training to ensure that I am completely ready to take care of you, your family, and your friends if you ever end up in a gurney in my trauma bay, I won’t have time to update this thing and I’d rather just end it than let it fade out.

I’m going to pull the plug in a few days. Feel free to copy any articles from my archives to read at your leisure. Remember, however, that all of this stuff is copyrighted. I plan to write a book and have given some thought to its layout and content which may include some of the material from the blog. As to when this book will be ready I don’t know. I like to write but I don’t like to do it under pressure so this might not be for several years. There’s a big difference between writing an article every now and then and carrying a theme across a hundred pages, something for which I may need a lot practice.

As for medical school and residency, there are days when I wonder if it’s been worth it. I look at the financial devastation of the last seven years with every asset we ever had, every dime of equity, and every drop of our savings poured into the bottomless void of medical education and wonder if we’re ever going to recover. As I said, I still have a year left of residency in what will have turned out to be an eight-year ordeal and we are going to arrive at that glorious June day a little more than a year from now with absolutely nothing in the way of wealth to show for it. Just a couple of old cars, some household effects, an empty bank account, and a quarter of million in debt. Comes that June day then one last push before the money starts rolling the other way…one last leap of faith and credit to scrape together the money to pull up stakes and get started in a new town. Just a few more months of distracting the wolves, I promise my lovely and long-suffering wife, of playing the financial shell-game, of sandbagging Peter to pay Paul, before we start to pull back, slowly, from economic catastrophe.

Then there are days, fewer now then previously, when I look up from the petty humilities of working in the academic medical environment with the stifling egos, the petulance, and the sheer bad manners that are a hallmark of this kind of thing and swear that, if I had known the level of disrespect with which medical students and residents are treated, I would have laughed and thrown my medical school application in the trash. Except that most of our attending in my program are easy-going and manage to work in a large amount of teaching despite the constant stampede of patients in our department, dealing with the surprising level of malignancy in this whole system has been almost unbearable. Certainly if I wasn’t trapped like most medical students and residents I would never have put up with it. But what choice do any of us have? By the time you find yourself in third year, where the abuse really begins, you are not only deep in debt but now thoroughly unqualified for any other kind of work. I doubt I am going to work at an academic medical center ever again, even as an attending. I have just had my fill.

And on some days I get the strange sensation that I haven’t really done anything but shuttle one hopeless patient after another into the hospital for one more round of expensive and only marginally effective therapy. Most things are either self-limiting or utterly hopeless and sometimes it seems that the millions of dollars which have poured through my hands have bought nothing real. Just a bunch of redundant tests to confirm that your aged mother (or grandfather, aunt, uncle, brother or sister) is pushing ninety and at this point almost everything we do is more harmful than just letting things run in their natural courses. Either that or the solution, the cure, lies with the patient who could do more for their own health by giving up the smokes and fatty food, not to mention the booze and the drugs, than a whole hospital full of doctors. We’re just putting expensive duct-tape on most of our patients it sometimes seems.

There are days, however, when somebody taps me on the shoulder in the grocery store and says, “You may not remember me, Doctor, but you took care of my mother in the Emergency Room last month. She’s doing great and I just wanted to thank you for everything you did.”

Up and down.

Up and down.

Up and down.

With my Deepest Respect and Gratitude,

Panda Bear, MD

No, I haven’t Disappeared…

Just taking a break from blogging for a couple of weeks. If you want something to read need I remind you, oh my regular readers as well as those who have accidentally arrived at my blog after a fruitless Google search for “stuffed panda bears” or “panda bear mating habits,” that my archives, seldom visited according to my site counter, offer rich provender, almost limitless grazing, even to those who are not obsessed with the insane goat-rodeo-cum-cluster-fuck we call medical training.

I mean, I’ve got, like, 206 articles and about a thousand pages of content. It should keep you busy. I even have some of it categorized…which is kind of the problem. I think I have nothing much more to say about most things and I lack the dedication to carefully research and footnote lengthy articles on health care policy where I prove, using other’s opinions, my particular point of view although the internet is good for that. In fact, other than expanding the frontiers of pornography, the principle function of the internet is to act as an echo chamber where isolated minds can prove that black is white, up is down, and, despite all evidence to the contrary, the government is going to do a fantastic job managing all the medical care in this country.

So stand by. I think Complementary and Alternative Medicine at least still has a little stuffing left to beat out. I had a fascinating conversation with a chiropractor the other day that I might tell you about. He asked me what kind of doctor I was and when I said, with tongue in cheek of course, that I was the kind who proves Darwin wrong every day he took this as a signal that I did not believe in evolution and, with this entre, what followed was the most bizarre diatribe against science, modern medicine, vaccinations, the Pope, the Queen of England, and President Bush that I have ever heard. He professed membership in a cult (Scientology), was taking a correspondence course in Naturopathy (although he already incorporated it into his practice), and bragged that his proudest achievement was adjusting the medication lists of his elderly patients, often removing ten or twelve drugs from their regimen…all without the benefit of any formal training in medicine (A laudable effort, no doubt, but replacing them with Ginkgo Biloba and Foxglove tea is criminal).

Then he tried to recruit me into a multilevel marketing scam.

Absolutely beautiful.

Up and Down and All Around The Pandaverse

I Needed That

Let’s just say I don’t know as much about pediatric resuscitation as I should. I know the basics of course, but there are nuances in the the emergency treatment of children that are not as easy to remember as they are for a standard 75-kilogram adult. We also get many, many more adult trauma and critical patients then we do children so it’s a question of practice. I mention this because residency can be very humbling and never more so when you don’t have a good idea what to do and have to get more guidance from the attending than you probably should. I am extremely glad I have a year of training left because a pediatric respiratory arrest that came in the other night demonstrated, yet again, that despite the agitprop from the mid-levels, there is a purpose to residency training and you cannot just throw somebody out to the public with a couple of years of medical training.

Just to summarize, I asked for the wrong medications for sedation and paralysis, failed to intubate, had to pass it off to my attending, and even struggled to get a central line. Ouch. I have been reviewing Pediatric Advanced Life Support (PALS) since then so some good has come out of a bad experience but it is, as I said, very humbling. The Emergency Department is a team. The nurses know their job as do the techs, respiratory therapists, and everybody else. I don’t think it’s unreasonable that I should know mine.

So I was kind of moping around after that, seeing the drug seekers, emergency colds, constipation, and the only other patients with who I felt I could be trusted when I got called to a code on one of the medicine floors. I was the first one there, got a report from the patient’s nurse who was doing CPR, assessed the patient, and we ran a very strong code that I think gave the patient every possible chance to live even though he did not pull through. I think I successfully identified the problem, took the appropriate steps to resolve it, intubated a very difficult airway on the first pass, and generally did everything I was supposed to do and that I used to watch other residents do three years ago when I was a sheepish brand-new intern just trying to stay out of the way.

Residency is a series of highs and lows, at least for me. Some days nothing happens and I tool along complacently. Sometimes I royally screw up and feel like I’m never going to get it. And then sometimes I discover that I know what I’m doing.

Up and down.

Up and down.

You Have It Exactly Backwards

In regards to a recent article of mine detailing the differences between physicians and mid-level providers, a reader commented that patients neither care what initials are after our names nor about the “expansiveness” of our training but only that they are treated with compassion and understanding. This is another variation of the common mid-level mantra of “Anything You Can Do I Can Do Better Even Though My Formal Training in Medicine is a Small Fraction of Yours.”

The reader has it backwards. The patients don’t care about our initials, whether “MD,” “NP,” or “PA-C,” because they tend to assume anyone with a white coat is a physician. Mid-levels are not exactly quick to identify themselves as mid-levels although to be fair this is mostly because there is no clearly recognizable title that they can use. I walk into the room and say, “Hello, I’m Doctor Bear.” What do you say if you are a Nurse Practitioner? You’re not a Nurse and you’re not a doctor so first names are used and the patient assumes what they will. The key point is the assumption that the person in authority the patient finally sees after all the preliminaries is a physician with whatever training and education the patient imagines a physician should have.

So it’s not that the patients don’t care, it’s only that regardless of the complaining and dark conspiracy theories to which they subscribe when they are not under our care, patients have complete trust in the medical profession when it is up in their face and the mid-levels tap into this trust whether they deserve it or not. Physicians, especially residents, also tap into this trust, the coffers of which have been filled by every honorable physician who has practiced before us. It goes without saying that we may or may not deserve this trust either.

As to not caring about the expansiveness of our training, I am reasonably sure that most patients, if they knew the difference, would much prefer a residency trained physician leading the team resuscitating their drowned child (see the first part of this article) and would not tolerate anybody but a residency trained surgeon removing their gallbladder. Again, there is an assumption of a certain expansiveness and many patients would be appalled to discover that you can be a mid-level provider with only a couple of years of formal medical training. For the information of the laypeople who may be reading, the bare minimum for any physician in any specialty is seven years. I will have had eight years of formal medical training when I’m finally done (I am almost done with my seventh year) and some specialties train for upwards of a decade after medical school.

As for treating patients with compassion and understanding, this is probably the easiest thing about medicine and as it requires no special skills or training, has become the last refuge of egalitarian scoundrels who, when pushed into a corner will come out swinging, brandishing their superior compassion as if long periods of medical training somehow strip physicians of their basic humanity.

People who know me would probably attest that I am a very humble guy who is completely aware of his limitations. This does not mean that I feel compelled to subscribe to some politically correct, totally egalitarian word-view.

Futile is as Futile Does

I like Dinosaur and agree with much of what he says but I feel compelled to comment, yet again, about what I think is his misunderstanding of futile care. Of course we both agree that strictly being elderly is not an indication to pull the plug just as we agree that many of the elderly can walk out of the hospital after treatment for diseases that would have been a death sentence fifty years ago (and still are for the elderly in the Great Freeloader Kingdoms Across the Big Water). But seriously now. I had a patient about a month ago who had suffered a massive stroke a few years before and essentially spent her now diminished life laying in her own stool, breathing through a hole in her neck, eating through a hole in her belly, and making the occasional trip to the Intensive Care Unit when her lungs or upper airway became too full of fluid to be suctioned by the indifferent minimum wage hands in the warehouse where she is stored. She had a pacemaker to keep her heart beating, a defibrillator to jump start it when it didn’t, and a small pharmacy’s worth of medications to ensure that she will shuffle off her mortal coil in fits and starts.

As is common with bed-bound, demented patients who are only infrequently turned and cleaned, she had developed a large decubitus ulcer that had eaten into her back all the way down to her sacrum, the polished bone of which could be seen clearly when the nurse rolled her on her side. This particular ulcer had eroded almost to her anus and was almost impossible to keep clean as every one of her frequent bowl movements poured into and around it. The surgeon who we consulted suggested a colostomy to redirect bowl contents to a pouch on the abdomen as the first step to any definitive treatment.

Perhaps when the next step in your treatment is a surgical re-working of your guts to prevent complications from the complication of having no other function in life but to lay in your own stool staring blankly at the ceiling and all the pretty lights and alarms, well, perhaps it’s time to talk about quality of life and what, exactly, the couple of hundred thousand dollars on the table are buying us and the patient. Sometimes the line between futile care and reasonable medical efforts is not clear and I can’t always discern it. But what we do to some patients is madness. Utter madness.

Randapanda III

A reader comments : “I have serious trepidations about electing a president who was a POW for 5 yrs and remained in solitary confinement for two of those five. I have total respect for the service and valor of John McCain, but I don’t believe you can endure this type of treatment and come out unscathed psychologically. He is famously short-tempered and impulsive. This is not a quality that I want in someone who has substantial control over the free world. I am underwhelmed by the other candidates, but I’ve seen the psychopathology that developed in many of our veterans who served in Vietnam and were not POWs and shudder to think about what McCain has to do in order to get to sleep at night.

The reader, along with many other people, is completely buying into the popular misconceptions about Viet Nam veterans. I, too, have worked at the VA with Viet Nam veterans and you know what? When you question many of these creepy guys about their military service, most of them are so full of shit…and I mean totally full of it…that there is no way possible they were anywhere close to combat. And I doubt some of them even went to Viet Nam. I don’t expect you to know how to tell a plausible war story from a bogus one but I assure you that I have a pretty good idea who is genuine and who is blowing smoke up my ass.

“Where did you go to boot camp?” for example, is a basic kind of question to ask an alleged former Marine who can vividly recall every detail of his super-secret black-ops missions but cannot come up with the name of the base where he trained (Hint: there are only two places a Marine of the post-Korean War era could have gone to basic training) or anything about his unit or specialty that makes sense.

The trouble is that the VA does a very poor job of checking service records. They are not easily accessible and it takes time, money, and staff to interpret them. I guarantee that if I selected any ten frazzled Viet Nam era PTSD patients whose lives have been a shambles since the ‘Nam and scrutinized their record, five of them would have never seen any combat and two or three would probably have never even been overseas or even in the military. You see, to verify combat experience, you have to compare their story to their service record and the patient’s unit’s “Unit Diary,” something that’s impossible to do on a routine basis. A DD214 has very little information on it and people are taken at their word which would be a mistake.

You need to understand the concept of “tooth and tail.” In Viet Nam as in most wars, eighty to ninety percent of those involved were in support positions and the majority of them saw no action at all. Imagine the vast number of sailors, aircraft mechanics, clerks, cooks, radio repairmen, truck drivers, and other specialists required to support one infantryman on the ground. I’m not putting down anybody, you understand, because logistics and support wins wars but for every infantryman, combat engineer, artilleryman or tanker shooting at the enemy, the “teeth”, there is a long, long logistical “tail.” Being anywhere in a combat zone, however, qualifies you as a combat veteran for purposes of VA benefits and no distinction is made between serving on an aircraft carrier in the Gulf of Tonkin or sticking a knife into the enemy at Hue City. Therefore it takes almost nothing to convince the VA that your personal problems, problems that you may have had before you enlisted, are the result of stress from your military service. Free VA medical care is no different from any other government benefit. It attracts the usual freeloaders but in this case, since so many of you have no experience whatsoever with the military you let yourself get browbeaten into believing any war story you are told because you hold your manhood cheap whiles anyone speaks who fought on Saint Crispin’s day (so to speak).

The country is full of people exaggerating their POW status, combat experience, or even their military service. I suggest you read “Stolen Valor,” a book that exposes the depth of the scam in which many of you so intently believe. For my part, I know many Viet Nam combat veterans who are the “real deal” and although their experiences have profoundly changed them, they are not the psychotic druggies that Hollywood and the left love to portray. There is most certainly a disorder known as PTSD and many of our combat veterans suffer from it. But guys who are “put together” well enough to to be Navy Fighter pilots, Rangers, SEALS, Special Forces, Marine Infantryman (the blue collar of the military elite), and other hard-chargers that the drugged-out homeless guys pretend to have been do not turn psychotic. Rather, they struggle with their memories but otherwise live fairly normal lives where they are part of the vast yet unseen foundation of sturdy citizens upon whom is supported the whole circus of dependency that grabs all the headlines.

My point is that Mr. McCain is impulsive and short-tempered, not necessarily bad qualities if channeled properly, because he was a Naval aviator, the kind of guy who could fly an A4 Skyhawk in the teeth of Migs and SAM batteries. He is the real deal and if you prefer an anti-American fuck like Mr. Obama, a guy who won’t wear a flag pin because it makes his anti-American leftist cronies uncomfortable and who has never done a decent thing in his entire self-centered life that didn’t benefit Obama…well…what can I say?

Randapanda II

Actual Patient Encounter:

“I’m really, really annoyed.”

“Really? Why?

“I’ve been sitting here for an hour and you just now walked in.”

“I’m sorry. We’re pretty busy tonight.”

“Well, I’m still annoyed.”

“How annoyed?”

“Like, a 10 out of 10.”

“You know, my Great-grandmother was driven from her home in Asia Minor by the Turks and had to walk two hundred miles to get to Smyrna where she took a ship to Athens. Several of her children died along the way and the Turks wouldn’t even let her stop to bury their bodies. When she arrived in Athens what was left of her family had nothing but the clothes on their backs. As far as being annoyed, to me that’s a ’10 out of 10.'”

“OK, maybe it’s a 9.5 out of 10.”

Speaking of…

Speaking of wait times, the typical non-emergent patient encounter in a busy and understaffed Emergency Department proceeds in a predictable manner full of emotional highs and lows. First comes the interminable ordeal in the crowded, smelly waiting room relieved at last by the hopeful flurry of activity with the triage nurse. Determining however that you are going to live, she sends you back to the waiting room for another stint with the cross-section of the city who have nothing better to do at 2AM. There you stew until, at last being called to “to the back,” you are treated to another optimistic spurt of activity as your nurse asks you all kinds of interesting questions, hooks you up to the lights and whistles, and even draws some blood for some standard lab work associated with your complaint.

Unfortunately you will now have to wait again, rapidly becoming bored with the novelty of your room the type of which you have probably seen many times before. The flat screen television is nice but since you don’t really like The Fresh Prince of Bel-Air, by the time your doctor decides to finish his coffee break, chatting with the nurses, or whatever it is he does to pass the time on his ridiculously easy job you are now at the limits of your patience and wondering to yourself if it wouldn’t be easier making an appointment with your own doctor. Just when your boredom starts to turn to despair however, the doctor walks in and everything seems now to be headed in the right direction. He is professional, calm, listens intently to your complaints, asks probing questions, lays his hands on you like you were his prom date, and finally gives you a learned opinion on what he thinks and what he’s going to do to elucidate and treat the source your problems.

And then the bastard disappears. You are vaguely aware of some frenzied activity in the big mysterious rooms that you passed on your way to your own and your babydaddy (or cousin or friend or whomever came with you) angrily reports that all your doctor is doing is standing at the nurse’s station talking on the phone. In his good time he saunters in, reports that all the tests have been negative, and confirms that not only are you not going to die but the horrific disease that brought you in would be best managed by your own doctor or worse yet, would respond quickly to smoking cessation, weight loss, or a little bit of rest and patience. So long, nice meeting you, and don’t let the door hit you on the ass on your way out.

I mention this because my hospital is making a tremendous effort to decrease wait times. I am completely in favor of this, both because I want my patients to be happy and because a shift is a lot nicer if people are seen, evaluated and admitted or discharged quickly. And as I am currently negotiating a contract where part of my bonus is going to depend on patient satisfaction scores, not only am I going to have pre-printed prescriptions for percocet with my address and pager number in case the patient’s dog eats the pills, but I can see how happy patients are going to be good for my bottom line. On the other hand I work at a busy and completely understaffed hospital and I can only see so many patients per shift. I try to work quickly but we cannot just run the patients in and out like cattle as this would jeopardize their safety. I am also still a resident so every patient I see has to be discussed with an attending, herself fairly busy, before admission or discharge which further slows patient disposition.
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Not to mention that despite a waiting room jam-packed with mostly non-urgent complaints, we occasionally get a really bad trauma (or two or three from the same accident) or a critical patient that sucks up a lot of time. It’s not like I’m just standing around. I think every Emergency Medicine resident who reads my blog can attest that, although our hours are good and we get lots of time off, when we are at work we are usually working at a frenzied pace that sometimes precludes even taking a break to eat or urinate.

So although I am as appalled as the next guy that people occasionally wait an hour or two in their rooms to be seen by a doctor, it’s not my fault and I’ll get to them when I get to them. Additionally, the stream of nurses, patient representatives, and various bureaucrats exhorting me to move my lazy ass will forgive me for not panicking and dropping everything to see the non-emergent patient cooling his heels because I am oh-so-obviously taking my sweet time dealing with the eight patients I am already working on. I suppose I could work a little faster but there is very little incentive to do it. I won’t make a dime more for sprinting from room to room instead of walking and the hospital is already getting a lot of work for the twelve bucks an hour they’re paying me. The expectation that I’ll struggle to justify their poor staffing decisions is asking for a little too much sugar for their dime, even from a resident who is used to being taken advantage of.

Not to mention that the other day when I allowed myself to be browbeaten into dropping everything to see a patient who had been waiting long enough to make Press-Ganey feel a disturbance in the Force, when I asked him how long his back had been hurting he said, “Since high school.”

Piling On

Several readers have commented that it’s time to lay off of chiropractors and other purveyors of Complementary and Alternative Medicine because I have apparently said everything about the subject that needs to be said. While it is true that there are only a limited number of ways to demonstrate the ridiculousness of things like Reiki or acupuncture, I get the same enjoyment from doing it as I get from other equally useless activities such as poking a dead ‘possum with a stick.

As a good Southern boy I have poked plenty of dead ‘possums (and even et me a couple or three) but like poking the glassy-eyed corpus of Complementary and Alternative Medicine, the novelty never wears off. Those things are weird and they don’t usually lay still long enough to be inspected. In fact, I only got a brief glimpse of the last live ‘possum I saw because he was charging at me making bone-chilling enraged ‘possum noises and my dog and I were running away for all we were worth. When we finally got clear of the creature my dog cocked her head, looked at me, and I’m sure she was saying, “Man, that was one crazy marsupial.” It says something about didelphis virginiana that a black lab, a dog that will chase anything that moves, instinctively knows to flee from it.

But I digress. Complementary and Alternative Medicine is incredibly retarded and people who believe in it are operating on the same intellectual plane as people who claim to have been sodomized by extra-terrestrials. The fact that ostensibly educated people like the totally ridiculous folks over at Duke Integrative Medicine embrace completely ridiculous therapies like Reiki and homeopathy only goes to show that on many levels academia is a trailer park, as mired in ignorance and superstition as any collection of movable housing anywhere in America. They’re just a little thinner is all. The squalid academics living in their ivory single-wides can talk a good game of course, but the minute you start to believe in Reiki, a therapy that is nothing more than spiritual fire flowing from some greasy charlatan’s hands, you start to lose credibility rapidly. If the intelligentsia in this country believe in things as ridiculous as Reiki and homeopathy, in what else do they believe and why should I take them seriously?

Randapanda

(I can’t concentrate. I admit it. Sorry. -PB)

Hey…

So I was absent for about a week from my blog and my daily readership actually went up. Clearly there is some optimal number of posts per month that will maximize daily hits and I am usually exceeding it….or maybe if I stopped posting altogether my sitecounter would explode. The end is coming, actually. I can feel it. I don’t know what more I can say about most things without doing some research and producing the kind of footnoted and referenced articles that would delight about six of you and bore to tears the rest. Either that or I could get overtly political which would probably increase readership but I am trying to avoid that kind of thing. I’m not even following the election that closely. I like John McCain of course (without feeling the need to take my ball and go home if he doesn’t exactly mirror my opinions), feel a little sorry for Mrs. Clinton, and think that Mr. Obama is the quintessential empty suit, full of rhetoric that signifies nothing except to draw attention away from his doctrinaire leftists opinions.

I marvel at how quickly the leftigentsia have turned against the Clintons and are only just now discovering that they are both totally corrupt and infinitely corruptable. It’s as if all over the United States old grizzled reporters are slapping themselves on the forehead and saying, with sheepish grins spreading across their once credulous faces, “Man, they sure had us fooled!.”

And I confess some distress. Is being a war hero important this time around? It’s hard to keep track. It was the last time, I’m sure about that, and the Lord Marshal certainly made a big deal about the medals that he threw away…or didn’t. To make matters more confusing, at one time being a draft dodger was de rigueur and then a few years later flying a jet fighter in the Air National Guard wasn’t. All I know is that of the three candidates left in the race, all of them were surrounded by communists when they were young but only one of them fought back.

But I digress. I mightily appreciate all of you who take the time to read my excessively verbose ramblings. I’m not whining, just informing, but producing a blog is hard work. It can be a chore, actually. If I haven’t posted for a while I get the nagging sensation that I am neglecting something important and, although I enjoy writing, I don’t always have the time and feel somewhat pressured to produce. Ridiculous, isn’t it? Except for some minor advertising revenue from Google and the good people at Epocrates, nobody is really paying me that much to write and although it might cause a small stir in a tiny corner of the vast internet, when I disappear no one will be worse for the wear.

I Kept My Mouth Shut

I had a trauma patient the other day who quickly informed me that he was a chiropractor and then rattled off the cervical vertebrae he believed to be injured just to show us that we were dealing with a medical professional and not some yokel. He had fallen off of a ladder and bumped his head. After the usual “pan scan” that the trauma surgeons order on everyone regardless of mechanism or history he was given a clean bill of health and discharged from the department. We usually send these minor trauma patients home with a small prescription for vicodin or percocet even though all most people really need for this kind of thing is some motrin. I have been sticking to the motrin lately because we don’t have to give narcotics to everybody. He flagged me down before he was discharged and demanded something stronger for his pain. I smiled politely and wrote him a prescription for Vicodin. Chiropractor, heal thyself. Doesn’t he have any colleagues that could, I don’t know, adjust him or something?

Chiromancy

Speaking of chiropractors, I have had a run of patients lately who are under their treatment. I keep my face blank and my tongue still but most of them feel the need to apologize which shows you that even most of the chiromancer’s customers suspect that the they are being hornswoggled by this century’s equivalent of the Patent Medicine Man. Look, its not rocket science. You can’t cure an inflamed gallbladder or a pulmonary embolism by adjusting the spine. You can’t actually adjust the spine either because, while I am second to none in admiration for the typical chiromancer’s knowledge of spinal anatomy, all of those ligaments and muscles that they rattle off prevent the kind of movements that they claim to induce. Hell, in my line of work we call chiropractic “spinal adjustment” by its correct term, “trauma,” and it is only the inability of most chiromancers to generate motor vehicle collision-type forces that keep them from hurting more patients than they actually do.

Look…

Despite what Dinosaur thinks, I can tell the difference between an elderly patient who can benefit from medical care and one upon whom dollars fall as ineffectually as autumn leaves on a rusty old car propped on blocks waiting for the time when the junkyard shall give up her wrecks. And I believe I have repeatedly come out in support of providing expensive, high-tech medical care to the elderly. My in-laws for example, two of the finest people you could ever meet, are still in total command of their mental faculties and have benefited mightily from a couple or three artificial knees and the attentions of a cardiologist or two.

But just the other day I had three critical/trauma bays occupied by three patients with a combined age of 288. To keep clear of HIPAA I will just say that between them they had three legs, one working kidney, and the combined ejection fraction (a measure of cardiac output) of a healthy two-year-old. None of them had moved purposefully for the better part of a year and they probably had enough viable brain tissue between them to fit out two border collies or one pharmaceutical salesman of average intelligence. And they were all “full code” and headed to the ICU for an all-expenses-payed sojourn into the belly of our completely out-of-control health care system where I have no doubt that at least one of them will be “saved” and sent back to the warehouse until the next time.

Look, I understand what Dinosaur is saying. But I also think that he doesn’t spend a lot of time with patients at the futile end of the spectrum. I don’t believe anybody is advocating severely rationing care for the elderly like they do in the vast Freeloader Dependocracies Across the Water (although this kind of rationing is inevitable) and I don’t think withdrawing futile care will solve all of our money problems but, my Lord, it would be a start.

My Daughter

My eight-year-old daughter. God bless her. One of her little friends was over and kept calling me “Mister” Panda. My daughter finally had enough and said, “Um, my daddy didn’t go to four years of Evil Medical School to be called ‘Mister.'” We are all huge Austin Powers fans.

(This is the same little girls who, when she was five, was told by her mother that I had been a Marine and, having heard it imperfectly, spent the next year telling her little friends that her daddy had been a “ballerina.” )

Madhouse

It’s Only Getting Crazier

Maybe it’s the change in the weather but our Emergency Department seems to have gone insane. It’s always been pretty busy but since the beginning of this month (and Spring temperatures) it seems like the patient population of our city has exploded as if there is some kind of Vague Abdominal Pain convention or the Grand Conclave of the Knights of Senility in town. We expect the usual increase in trauma, as befits the ability of people to stay out later now that it’s not below zero up here in the great American tundra states, but we’re also seeing an inexplicable increase in complaints of all kinds, from the serious to the futile to the sublimely ridiculous. It’s the usual stuff, you understand, just more of it. Even our attendings are puzzled.

I have been working the 9AM to 9PM shift this week which means that I’m actually working until about 11PM. I stop seeing new patients about half an hour before the official end of my shift but we have been so busy that I need another couple of hours to finish my charts. I get off to a good start at the beginning of my shift but no sooner have I seen one patient and written orders when somebody comes in who needs to be seen right away, say a trauma or a chest pain that turns out to be the real thing, and the chart just has to wait. At the end of the shift today I had about 20 charts to “lock” (or finalize on our electronic medical record system) and five of them had nothing on them but a chief complaint, lab results, diagnosis, disposition, and orders. All of that “History of Present Illness” stuff not to mention documentation of the physical exam was rapidly eroding in my memory because I didn’t have time to document after I saw the patient. This is not a good way to see patients. Ideally a running narrative should be kept of every decision and conversation with an admitting physician or consultant but sometimes all I remember is that I talked to cardiology but not who or when and the documentation can get kind of sketchy even though I try to document the big decisions.

We’re supposed to document rechecks of patients as well but seriously now, when the department is bursting at the seams and you’re constantly being called to do something at different ends of the multi-acre establishment, it’s hard to keep up with the stable ones let alone document it. And because we are so short-staffed for this current deluge, patients are sitting around for a long time waiting for disposition even after all of their lab work and studies are back. Today, for example, I had a whole slew of minor patients languishing while we took care of four traumas and a couple of critically ill patients almost one after another. I intubated two of these patients and you just can’t walk away from them to see how your chronic back pain patient is doing.

I enjoy the fast tempo but I also realize that this is not the best way to practice medicine. It can’t be safe this week to come to our department if you have something serious that presents as something minor. We are just a little more apt to throw a lot of tests at you to temporize, just to put you on the back burner so to speak, and your increased sitting-in-the room-time could be dangerous, not to mention the time you spend in the waiting room which can be hours and hours. Thank god that most of the complaints are still relatively minor. I am a decent guy at heart and I do feel bad about keeping my patients waiting but it’s an Emergency Department and we still have priorities despite the temptations of that Arch-Devil, Press Ganey.

And we still suffer, as a medical system (or whatever you want to call it) from a terrific lack of common sense. We have had the same drunk visit us every day, sometimes twice a day, for the last two weeks. The paramedics keep finding him laying in parks and alleys in an obvious alcohol induced stupor and they keep bringing him in whereupon he wakes up, becomes abusive, ties up a nurse dealing with his demands for some food, and then finally staggers out when he is ready to be discharged only to repeat the little charade twelve hours later. We don’t even bother drawing an alcohol level or any labs. What’s the point? More importantly, why do they keep bringing him to us to use up our finite manpower on a non-acute medical problem? They will have a salad bar in hell before he is cured of his affliction. It is just beyond out power. Better to make sure he has a pulse, prop him up against a wall somewhere, and leave him to sober up on his own. This would be no different conceptually from what we do for him in the department except he wouldn’t get a sandwich and he wouldn’t stink up the whole place.

Even the other patients complain so we’re not talking the usual bad smells of the indigent.

I also don’t quite understand what motivates some people to wait as long as they do with complaints that are amazingly trivial. Maybe American life has been so medicalized that nobody believes they should suffer any discomfort, no matter how minor. Look, I get sick sometimes but if it’s just a cold or a little diarrhea I just tough it out. I’m young, healthy, and camping out in a dirty, crowded Emergency Department waiting room with irate people, some of whom are indeed really sick, is not an appealing prospect. If I were on the public dole because of disability or polybabydadia and could sleep in or rest all day without having to worry about my job I’d be even less likely to come in.

I know we worry about how we would ever handle a mass casualty event but if we just got aggressive with triage and sent some people home to suffer and get better on their own we might be able to squeeze in a surprising number of injured or really sick patients.

My apologies for neglecting the blog this week. Hopefully things will slow down a bit as people come out of their sun shock and I will have some energy to write.

Medical School Pre-Clinical Years: Twenty Questions (Part 3)

What About Student Government in Medical School? Waste of Time or What?

Every medical school has some sort of student government. You will have class officers and the usual student body President, Vice-President and other offices filled by medical students looking for…well…who knows? At the basic level it cannot be denied that the predominant impulse for any sojourn into student governance is one of self-aggrandizement. It looks great on your CV, not to mention that some people just like the illusion of power and control.

I say “illusion” because students are largely powerless at most medical schools and, their pretensions to the contrary, are indulged, tolerated, but never taken seriously by a patronizing administration. The time has not arrived when the crafty academic dinosaurs who have fought and eaten their way to the top of the bureaucratic food chain will take direction from the little proto-mammals scurrying about in the ferns. The faculty will smile pleasantly and praise the dedication of the students but the ragged hanks of rotting flesh clinging to their kitchen knife-sized teeth belie their true outlook. Or, to put it another way, the typical medical student doesn’t know enough about anything to be taken seriously and, even if they did, as they have no control of funding, pay, or policy have absolutely zero influence on the way medical schools are run.

This is a universal truth by the way, that management never really cares what the lower-level employees think. Good managers know that certain allowances have to be made if they are to have happy, productive employees but this almost never involves gaining consensus or acting on input from the employees that will effect how the business is run or the all-important bottom line. That’s the General Manager’s job and he doesn’t seek advice from the janitors. Medical students, in the hierarchy, have less input into the administration of their school than the janitors.

My school, for example, implemented a mandatory attendance policy that was roundly condemned and vociferously protested by the entire student body. Tempers grew hot, meetings were held, but in the end the Board of Governors wanted it and that was that. Value of student input? Exactly zero, especially since medical students don’t have the sense to know that you are not occupying the moral high ground when you agitate for the right to skip class. The input of student government is neither desired nor taken seriously on real issue like this and the best that most of these bodies can do is to rubber-stamp the usual twaddle about celebrating diversity or supporting the rights of the freeloader class to medical care on the taxpayer’s dime. You know, harmless, frothy things. But trying to change real policy? Not a chance. You have to have some influence and, as a medical student, you have exactly none and no recourse but useless protest.

What are the medical students going to do? Quit? Strike? Walk out? Please. Not only are most medical students thankful to have made it into medical school and therefore extremely reluctant to rock the boat but most of them don’t have the time or the energy to get involved even if they wanted to which most don’t. About the only people who care about student government are the ones who run for office. Even their level of caring rapidly diminishes as the months roll by. Typically, the enthusiasm for student government peaks early in first year when egos are at their hottest and it seems like you are going to be in medical school forever. By the end of first year, if not sooner, everybody who is still on board can see what a crock the whole thing is and interest falls off drastically. During third year you are too busy to give a crap and when fourth year rolls around, not only does the whole thing still seem silly but it now becomes pointless as you will be gone in a few short months.

Despite all this, Student government is not completely useless. Within the confines of the possible they can do a few things. You will need a social committee, for example, to organize the occasional party. Student government usually organizes the note-taking service (which is always completely independent from the administration) and ours did a great job getting some money to get our student gym refurbished. We also had a “Challenge Committee” that coordinated challenges to exam questions. (On every exam there are some questions that are either ambiguous or flat-out wrong and you can sometimes get credit for them on a “challenge.” I never really cared because my scores were rarely in the range where a half a point would throw me into the next grade but if you’re jockeying for a Dermatology residency, every little bit counts.)

How About One Piece of Advice For First and Second Year?

If I had one piece of advice it would be to stay healthy. During the first two years there is plenty of time in the day to exercise and it is not necessary to get into the intern mode where you are indeed so busy and tired that you can rationalize not working out and making a meal out of vending machine doughnuts and a Dr. Pepper. I was a runner before medical school and found it easy to continue during first and second year. In fact, although I fell off the running wagon a little during the first few months of medical school, once I got the hang of things I had something of a renaissance and easily put in 30 miles a week. It’s just a question of time management. If you make your own health a priority you can take an hour five times a week for some physical activity. Maybe it will detract from your study time but to my mind, there is nothing worse than sitting in library trying to study while tired and feeling like a disgusting fat body. Sometimes you have to get outside or into the gym to just clear your head. The alternative is to try to study feeling like a sloth.

Now, I’m not waggling my finger at anybody. Although I managed to stay in pretty good shape during the entire four years of medical school, once I hit intern year although I tried to exercise regularly, I eventually gave up even trying. My schedule as an intern was so unpredictable that on the rare day when I got home on time all I wanted to do was rest. And I have always had a crappy diet high in bloody, fatty red meat and fried pastries so you can imagine that in the absence of exercise I put on a little weight. I did two intern years as some of you know and, although I now have a regular schedule and am getting back in shape, I have never been in as poor health as I have been since I graduated medical school. The point is that while maybe you can make an excuse for waddling around the hospital as an intern or even in parts of third year when you will be busy beyond a reasonable doubt, during first and second year your schedule is entirely predictable and there is absolutely no reason not to exercise or eat regular meals.

Hell, one of my motivators for studying was the knowledge that when I was done for the day I could throw a leash on Nora, my my beloved and now long-dead Border Collie and Zoe, my German Shepard (who is fourteen and still with us) and go out for a long run.

You also have to see to your mental health. The best advice I ever got from an upperclassman was to “Be Macho.” By this he meant that no matter what, don’t ever get into the self-pity mode. Medical school, while it has its difficult moments, is not generally that hard. Sure, some of the hours in third year can suck and you will not be treated well by many of those over you but it is important to not let this kind of thing bother you. Bad day? Failed a test? Pick yourself up, laugh, and move on. You can, for example, drive yourself crazy obsessing over a particularly low test score and reap a bumper crop of bitterness or you could just accept it as something that is now ancient history and forget about it.

This is not to say that you have to be a Pollyanna about things. Medical students complain all the time but most of them still manage to have fun, even on the worst rotations. You just have to see the humor in everything and enjoy the ludicrousness of the many strange situations in which you will find yourself.

What About “Gunners?”

A “gunner” is a medical student who is so intent on furthering his own career that he will sabotage other students to ensure that he scores higher on tests or looks better on the wards. Medical student lore is filled with dark tales of gunners sequestering old exam questions on loan in the library to keep them from the rest of the class or not only knowing everything about his own patients but yours as well so he can interject information that you don’t know, making you look bad in the process. I believe these tales to be apocryphal. When you think about it, medical school is not really a team sport and there is not much anybody can do to effect your grade. I cannot, for example, think of a single way anybody in my class could have done anything to effect my grade short of stealing my computer or knocking me over the head, both felonies, and not something that the mythical gunners are known to do. On the wards, if you are an ignoramus your secret will get out without help from anybody else. A gunner calling attention to you is just gilding the lily.

Next: USMLE

Medical School Pre-Clinical Years: Twenty Questions (Part 2)

What About “Early Patient Contact?” Is It Important?

No. “Early Patient Contact,” like “All Natural” and “Holistic,” is a marketing phrase designed to entice earnest pre-meds into one medical school over another. Like “Problem Based Learning,” another slick marketing phrase, if I had my choice I’d flee as if from the Devil himself a school that touted this sort of thing. As if it’s not bad enough that on the first day of third year you have to march around the hospital like a big, fat, ignorant dork, at a school with “Early Patient Contact” you will not even have the benefit of a couple of years of medical knowledge crammed into your head when, like a cheap poseur, you will flit around in a sack-like short white coat, bestowed no doubt in some retarded White Coat Ceremony, trying not to spook the patients.

What’s the point? You will get, like God intended, plenty of patient contact during third and fourth year. The brief exposure to real patients in first and second year will be like studying during the summer before medical school, something anyone will tell you is a useless because even if you studied the right material, you will blow through your entire summer of effort in a few days once you start. In a similar manner, all of third and fourth year will be spent in contact with patients. The little bit of play-acting you do in your pre-clinical years will be a drop in the bucket and not worth the effort. Either that or they will give you a lot of Early Patient Contact and it will seriously intrude on your study time or anything else you wanted to do besides stutter your way through patient encounters with people who have diseases you have never heard of.

I would definitely run from a school that promised some sort of student-run clinic (usually for the indigent who are not particular about their food, sleeping arrangements, or doctors) during first and second year. Maybe I’m a purist but your first two years are best spent learning the theoretical basis of the medical profession, not playing doctor. I know that many of you feel that it is important to “keep your eye on the prize.” You believe that by seeing patients early you will stay motivated for the long struggle. For my part, I saw plenty of the motherfuckers hobbling into the building as I drove past them every morning on the way to the parking lot and that was enough. I like being a doctor but first and second year are probably the last time in your working life you will not spend your day listening and responding to someone’s complaints. Relish it.

Bottom Line? Early Patient Contact is unnecessary. At best it is an annoying distraction but if overdone, has the potential to really eat into your otherwise valuable time.

How Will I Handle Gross Anatomy Lab? Is It As Disturbing As I Imagine?

The hardest part about gross anatomy lab, at least from a psychological perspective, is maintaining the proper respect for your cadaver. Although the body you will be dissecting was once someone’s husband, wife, son or daughter, after a couple of days you will be so used to anatomy lab that the cadaver will begin to seem more like a piece of rancid meat than anything else. This is not to say that anyone is overtly disrespectful to the body. I believe that stories of medical students stealing body parts for use in elaborate practical jokes are mostly apocryphal and I never saw anything of the sort in my class. Rather, you will develop a casual relationship with your cadaver and you will find yourself leaning nonchalantly on the body, idly picking away at some scrap of flesh or another, as you daydream about what you’re going to do over the weekend or about the dinner party you are planning.

As for the initial weirdness of the situation, the sensation that you are doing something completely beyond the pale, that will last about five minutes as will any sensation of revulsion. Familiarity, after all, leads to acceptance and people have gotten used to and even grown comfortable with practices many times worse than dissecting a cadaver. You will, of course, dread your first encounter with the embalmed body of a real human being. Everybody does. It is often the biggest worry of new first year medical students and as you file into the lab for the first time, the tension, manifested by strained jokes and nervous laughter, will be obvious. It will quickly dissipate however as you expose your cadaver for the first time and get to work. To lay hands on the a cold, dead, naked body for the first time and to feel the rubbery texture of long dead muscle is the big hurdle. Once done their is nothing more to it. Certainly in the future you will step back from some particularly revolting procedure, sawing the head and neck in half and opening them like a book for example, to marvel at the creature that you are mutilating but it will be more appreciation than disgust.

As a precaution, you will probably not have eaten breakfast on your first day of gross lab. As the morning wears on you will forget that you were ever worried and look forward to lunch.

What’s Gross Lab Like?

At my school, the lab was in a large, bright, tiled room. There were about thirty “tanks” in the room, something like large stainless steel bathtubs on legs, that held the cadavers. The tanks had mechanisms to raise the cadaver out of the tank. At the end of the day the cadaver was lowered back into the pool of embalming fluid to keep it moist. A dried-out cadaver is hard to dissect and can still rot even though it is “preserved.” We had spray bottle of embalming fluid to periodically wet the areas we were dissecting. We kept the rest of the body covered with an embalming fluid-soaked sheet, not from any sense of propriety but to keep the cadaver, particularly the face and fingers, in good condition.

We had four students assigned to each cadaver. The cadavers themselves were mostly elderly people but there were a few relatively young bodies. Some were obese which makes for difficult and messy dissection as adipose tissue is greasy and difficult to dissect through or around. Some were better preserved than others. The tank next to mine opened their cadaver’s abdomen and were greeted with a flood of putrid goo, all that was left of the body’s internal organs.

Dissecting can be difficult and, particularly for delicate structures like nerves and small blood vessels, can also be extremely frustrating. Imagine trying to pick through a piece of chicken or roast beef looking for something the size of a thread. That’s what a lot of your time will be spent doing. Certainly you will easily appreciate large structures like internal organs and big muscles but the bulk of your time will be spent picking away at little things. You want to avoid using a scalpel for this as much as possible because it tends to cut across planes and distort anatomy. Blunt dissection with your fingers or a small instrument is the preferred method.

I was never very good at dissection. I don’t have the patience and I didn’t like anatomy lab very much so I spent as little time as possible there. In second year I skipped a lot of labs because, well, I was tired of picking at the damn things and smelling like embalming fluid. My wife refused to drive my car because even if you change scrubs, the smell gets into your pores and everything you touch is contaminated. My wife made me strip in the garage when I got home and proceed to the shower without touching anything.

Riding in an elevator with students just out of lab is unbearable and many people get one whiff when the doors open and decide to wait for the next one.

Anatomy lab was low-yield for me. I did very well on all the tests however because I had a good photographic atlas that showed perfectly dissected specimens. Gross Anatomy tests, you understand, are “practicals” where you circulate through the lab from tank to tank, identifying tagged structures on other people’s cadavers. The instructors looked for well-dissected structures that usually looked almost exactly like those in the atlas. If they couldn’t find a good example they dissected one themselves. So you see, my photographic atlas was like anatomy lab without the bad smell.

I did better on the practicals than many people who came in on their own time, after hours and on the weekends, to dissect. You are certainly allowed and even encouraged to spend as much time in lab as you want.

Get some cheap scrubs to wear in lab. We were not allowed to wear street clothes in our lab but even if you are resist the temptation unless you don’t mind throwing them away. I discarded all of my gross lab scrubs when I decided to stop going as well as my shoes.

Your group should get an anatomy atlas to keep in the lab as well as a “dissector,” the book that gives instructions for dissection. We kept ours in a plastic bag in the tank on top of the cadaver. The reason for this should be obvious. Do you really want to study on your kitchen table with a book that is soaked in corpse juice and may have small bits of human flesh stuck to it? Not to mention that it will stink up whatever library or Starbucks in which you decide to study.

Get a turkey baster. keep it in the tank. Trust me, there is nothing better for draining fluid out of body cavities and it beats rolling the body to drain it.

Next: USMLE

Medical School Pre-Clinical Years: Twenty Questions (Part 1)

(With a hat-tip to EMphysician for the idea. -PB)

What’s the Secret to Medical School?

There is really no secret except the obvious. First, you have to be intelligent. Not necessarily Mensa material but smart enough to assimilate the material. Next you have to study…a lot although the actual amount and method will vary. Finally, you have to have the desire. The application process does a good job of selecting for people who fit the profile because not too many people fail out. It’s not that medical school is easy. It’s not. I have a fairly rigorous undergraduate degree but medical school was an order of magnitude more difficult. Rather, medical schools weed out the non-hackers at the front end instead of wasting time and money later on. In the old days, admission was easier but the attrition was much higher and it was very possible that the “person sitting next to you” might not make it past first year. My class started with 102 students and graduated with 98 of the original bunch plus a couple of students who had been held back a year and fell into our class. We had two people (to my knowledge) flunk out and two quit because they couldn’t handle the pressure. One who quit managed to come back the next year.

Is the Material Difficult?

Some of it is. Renal physiology, for example, gave me the heebie-jeebies and I didn’t really get a handle on it until I did a nephrology rotation. For the most part, however, it’s not the difficulty but the tremendous volume of material. When I was in college, I now know that we moved through the material at a leisurely pace. Most classes met three times a week and, in my major anyway, an entire class period might be devoted to solving a couple of the assigned problems. I recall the great pains the professors took to explain concepts and we might dwell on one topic, say lateral torsional buckling of a steel beam, for a week. This is because in undergraduate education, understanding the concept is stressed over memorizing facts. In medicine, while understanding the concepts is important, there are also a lot of straight-up facts that you need to memorize. A whole lot.

Which is sort of the difference between, for example, an undergraduate physiology course and the equivalent material in medical school. In college, you sort of lollygag along learning the big picture with your progress punctuated by the occasional reassurance from the professor that you don’t really have to know this or that. Serious pre-med students (I mean the ones who eventually matriculate and not the ones who decide that a psychology degree is less scary and allows more party time) sleepwalk through this kind of course.

In medical school on the other hand, although the occasional moron asks, “Will this be on the test?” they may as well save their breath because the answer is always, “Of course it will be. We’re not training half-assed doctors here.” Hence, the material comes at you as if from a fire hose (to use the popular analogy) and you do not have the leisure time as you did in college to sort it out before even more is sprayed at you. The syllabus for one course in medical school, I mean if you printed it out (which I never did, preferring to study directly from my laptop), would be a stack of paper the size of a medium-sized city’s phone book. Multiply that by six because several courses run concurrently at most medical schools and you have an idea of the volume of material that you are expected to review and regurgitate on your exams, not to mention retain for the USMLE Step I and eventual clinical practice.

The only class in college I took that even compared to the feel and pace of medical school was a basic circuit analysis course taught by a senile professor who spent the first two weeks teaching an advanced signals processing course instead. It was a week before we decided that something was wrong. The professor would call us to the blackboard to solve incredibly complicated operational amplifier problems and then berate us for not knowing a thing about them. It was two weeks before our complaints were believed and three weeks before the professor grudgingly started teaching the right class. (I failed the class but after making a huge stink got my grade raised to an “B.”) The first couple of months of medical school felt something like that. You look around and wonder if you are really as smart as everybody has been telling you because nothing is clicking and for the first time in your life you are struggling for just a passing score, drowning in the huge volume of unfamiliar and highly intricate information. What you learned in undergrad? Please. As EMphysician points out, they cover that in the first couple of days and then you move on.

On the first day of medical school I was prepared to take notes as I did in college but after ten minutes threw away my pen and never took another note in class again. It’s almost impossible to keep up with the speed of the lectures and take notes at the same time. I don’t have that kind of hand-eye coordination and if I looked down to write, I would have missed something.

How Did You Study

My medical school had most of the course material posted online by the professors. The occasional old-school lecturer still brought his early Bronze Age slide projector and the tired old slides he had been using to teach anatomy since the Kennedy assassination but almost every lectures was on Powerpoint and could be downloaded. Consequently, my preferred study method was to review the lectures on my laptop ten to twenty times in the interval between when they were given and the exam. We had a note-taking service but I never used it because the notes usually just recapitulated the Powerpoint lecture. I had a few of the major textbooks and used these to fill in gaps or when I didn’t understand something and needed a little more depth. For variety, I had the Board Review Series “Gridbooks” for every course and when I got tired of looking at my computer read the relevant sections in those.

Reading textbooks, by the way, was fairly low-yield. Test questions usually came from the lectures and while there is nothing fundamentally wrong with reading a textbook, you can get bogged down in the minutia of the minutia. You just don’t have the time, trust me, to read all 1200 pages of the “required” physiology textbook. What most students do is eschew the voluminous tomes and acquire a set of smaller, cheaper, and more focused review books (like the aforementioned BRS series) and if they must use textbooks, use them for reference. (Hint: Do not rush out and buy all of the textbooks on the “required” list. You can easily drop a thousand or two on books that you will rarely use and can be found in the library when you do need them. Big biochemistry book? $150. Review book? $20.)

I attended almost every lecture because, well, I like lectures and found that reviewing the material later made more sense if I had heard it straight from the horse’s mouth. Some people skipped almost every lecture and studied on their own. You can certainly do this with no penalty. Even at the few schools with mandatory attendance, as long as you are doing well on all the tests the administration will have a hard time making an issue out of you missing lectures. My own routine was to go straight from lecture to a library, any library, in town and study until it was time to go home. At my medical school, the lectures were generally over by two or three PM and I usually studied until five or six. I also studied on the weekends, the hours depending on the proximity of the upcoming exams.

Wait a Minute, You Only Studied Three Hours Per Day?

Yes and no. Remember, I went to every lecture, sat in front, and paid attention. You know, the funny thing is that most of the material is fairly interesting. The professors tend to get carried away in their own area of research but as I wasn’t coming from a background in the biological sciences it was all new and wonderful, even if I knew I’d eventually forget most of the details. So I’m going to count that as study time. Naturally I studied a lot more in the first few months of medical school before I learned what it took to pass the tests. On average, however, I generally couldn’t take more than three hours a day and that was that. Towards the end of second year I studied even less but that’s normal because by that time, you know how to study, what to study, and are generally conditioned to effortlessly assimilate the same large amounts of information that caused you to panic in the first confused days of first year (plus second year course work is more clinically oriented and a lot more interesting anyway).

Did people study more? Of course they did. Some of my classmates lived at the library. Keep a few things in mind, however. First, there is studying and there is studying. If you look, you will see that a lot of “study groups” full of nervous medical students burning the midnight oil as they frantically cram for tests are actually highly inefficient circle jerks. There is studying going on but there is also a lot of socializing, bitching, complaining, and general “grab ass.” You would also notice that some people study inconsistently and may not crack their notes for weeks after an exam. As the next exam approaches, they are thus forced into manic overdrive trying to catch up with all the material. These are the people smuggling their coffee pots into the library and bringing a change of clothes.

Too much for me. Many years ago in my first attempt at college before many of you were born, I used to regularly fall behind with my college classwork and frantically try to cram it all in as the tests approached, often pulling bleary-eyed, extremely non-productive all-nighters in what became an unsuccessful attempt to pass enough classes to not get kicked out of for bad grades. It is far, far better to have the self-discipline to study every day for a set amount of time than to periodically study in a crisis mode which does happen with medical students. Did I cover myself in academic glory as a medical student? No. And as long-time readers of my blog know I probably could have studied a little harder. But after the initial shock of first year, I settled into a very comfortable, low-stress routine and comfortably passed every test I ever took.

I even grew to enjoy the first two years of medical school because sitting in lectures was pleasant, my study method was not difficult or complicated, and as I looked at medical school as nine-to-five job no different than what I had been doing for the previous eight years or so had plenty of free time and was very rarely stressed out.

Things I Did Not Do Even Though at Orientation They Warned Us We Would Need To Do to Pass:

1. Highlight. Not in one color or many. The BRS books and Powerpoint lectures are outlines anyway so it is pointless to highlight.

2. Take notes on notes and then produce written summaries of the notes from my notes, color-coding where appropriate. Vishnu P. Shiva. Who has that kind of time? I did not make flash cards either.

3. Study in a group. Not once. I am not convinced at the utility of group studying. There is the potential for a lot of wasted time not to mention that dealing with other people’s learning styles can be distracting. I did not want to quiz and be quizzed by other people on material that I could learn on my own in a much shorter time seeing as I can read about ten times faster than I can talk.

4. Cram before a test. Look, at my school the tests covered about a month of material. If you haven’t got it on the day before the test, staying up late trying to fit it into short-term memory is only marginally effective. Suppose your cramming nets you a couple of correct answers that you would have otherwise missed. As our tests usually ran to about 200 questions, the real effect on your grade is almost undetectable and you’d probably do better if you came to the testing center fresh and alert after a good night’s sleep. Although it has been close to 25 years, the memories of those sleep deprived nights of futile cramming, nights which soon deteriorated into watching crappy television infomercials or the Reverend Jimmy Swaggart, are still vivid and I abhor losing sleep for any reason.

Did You Do Any Research or Anything Else to Make Yourself Stand Out?

No. Most medical students don’t. If you want to match into something extremely competitive research is a de facto requirement but otherwise you are probably safe to do some bullshit public service activity if you want to buff our resume. Have I ever mentioned that I am extremely jealous of my free time? After a long day of lecture and studying the last thing I wanted to do was to be some professor’s research scut biach. But if you want to match into something like Radiology, Urology, Dermatology, or Opthalmology you need to consider doing some research. Likewise if you have your eye on a particular prestigious program in an otherwise generally non-competitive specialty.

What Was Your Curriculum Like?

Our curriculum was organ-system based. The first six months of first year were devoted to the basic sciences as well as an introduction to gross anatomy. In the second semester of first year we started a Grand Tour of the human body organized by major system with lectures in each block for the physiology, pathology, and pharmacology of each system. In other words, we didn’t have one physiology course for six months that covered everything but instead had these lectures spread out over first and second year. We did the same for gross anatomy with an eight week introductory course in first semester and then a few days in the lab during first and second year for each system. On the cardiovascular block, for example, we dissected the heart in detail.

Some courses were taught en bloc such as Biochemistry, Embryology, and Microbiology but most of the other lectures were organized by organ system.

We had a smattering of Problem Based Learning but only enough for most of us to learn to despise it. We also had a smattering of the usual hand-holding, kumbayah type classes instructing us to celebrate diversity and the other touchy-feely stuff. We had a lot of that kind of thing during orientation but after the real curriculum started these lectures were viewed more as a pleasant break, a diversion if you will, from real lectures that required us to actually learn something other than “You have to respect primitive cultures and their backwards-ass beliefs about medicine.”

Next: Gross Anatomy, USMLE, Early Patient Contact is a Waste of Time

Brief Notes From a Travelling Panda

(I am on vacation and we have made the 1200 mile trek from frozen Yankeeland to Louisiana to visit the family.  Please accept some short observations hastily typed on borrowed computers, apropos of nothing in particular and perhaps not really related to anything you want to read about. -PB)

A Modest Proposal

Although you wouldn’t believe it from the casino billboards that become more numerous the closer you get to Vicksburg, the typical gambler in one of the many riverboat casinos that have docked at the river ports of Mississippi and Louisiana is not a suave, bon vivant dressed to the nines in elegant casual clothes or dapper evening wear.  Nor are they young, fit, tan, and pretty.  In fact, the clientele of a riverboat casino look suspiciously like nursing home patients on holiday, complete with motorized scooters and portable oxygen tanks.  Either that or a cross-section of people who couldn’t get tickets for the tractor pull.  It’s not even the slightest bit glamorous. There are no James Bond characters casually dropping a couple of grand with cultivated indifference but instead mostly just a collection of middle and lower class Americans sweating and smoking as they desperately try to recoup the grocery money that they lost at the blackjack table.

I am ambivalent to gambling. It is, after all, a free country and how people spend their own money, within reason, is their own business.  Even so, there are huge legislative and public relation fights whenever the casinos want to set up shop, usually pitting those with moral objections to gambling against those lured by promises of free money to offset state budget deficits and provide for the economic development of decaying downtown river fronts.  I have a hard time getting excited about protesting gambling even if I know that, despite the promises of money for the sacred public schools or other bloated but still underfunded state activities, as casinos are usually owned by consortia with no ties to the city or the state, any rational person would suspect that the net flow of money is going to be out of the community and not in. The lure of easy money however, of something for nothing, is too appealing to both the gamblers and the government for any group of citizens, even those who have economic and non-religious objections, to prevent the casinos from arriving.

It’s hardly worth fighting as the outcome is almost preordained.

The typical script used to assuage public fears is that, as the gamblers will be mostly from out-of-town or out-of-state, the negative effects on the local economy will be slight or non-existent.  And yet, I have for curiosity’s sake wandered through some of the opulent casinos in Shreveport and I can’t help noticing that most of the gamblers look local.  I mean, they ain’t coming from Iowa but probably from no farther than the neighboring Louisiana parishes or Texas counties. (Shreveport is on the Red River in the Northwest corner of Louisiana and only about fifteen miles from the Texas state line.)  Most of them look like they really shouldn’t be throwing away large amounts of their disposable income in such frivolous pursuits, perhaps instead reserving some of it to pay their medical care, especially seeing how health care is the biggest concern of the electorate and our heads will explode if we don’t get everybody free health care as soon as possible.  I don’t have the statistics to back this up, just intuition, but I have a sneaking suspicion that many of the people I have seen feverishly pulling at the slot machines or rolling the dice with glazed expressions are even part of the Holy 47-million-uninsured.  Either that or they are sucking, literally and metaphorically, on Medicare oxygen as they wheel themselves from the buffet to the blackjack tables.

In short, there’s a lot of money being dropped by people who can’t afford it.  Consider then the problem of getting people to pay for their health care.  Gambling and other vices will always take priority, especially if medical care is free or quasi-free as it is today for the legions of those who know that no Emergency Department can turn them away for any reason regardless of their ability or intention to pay. Under the dual maxims that first, there’s no fighting human nature, and second, if you can’t beat ’em, you may as well join ’em, I propose we open up casinos in our charity hospitals.  That way not only will we save on ambulance costs when an elderly patient living on a fixed income codes in front of a slot machine but the house’s cut, usually fairly substantial, can help defray the costs of providing free care.

It’s win-win, I tell you.

10,000 BC

Social welfare, at least how it has been implemented in the wishy-washy West where we don’t have the gonads to throw troublemakers into a gulag, would have worked a lot better in 10,000 BC, at the dawn of human history when mastodons still trampled the occasional Neanderthal who came a little bit too late to take advantage of early Bronze-age affirmative action. It would have been great. They could have picked some arbitrary age, say 50, after which the rest of the tribe supplied you with bison meat and berries and everybody would have hunted and gathered in security, feeling pretty darn good about themselves, even though nobody, but nobody ever lived that long. Not only could a disease always be counted on to finish what a couple of bad winters started but, as being an active senior meant being able to flee from the saber-tooth cats with the rest of the clan, the odds were against anybody even living to forty. This is how it went for most of human history and, with slight variations, what is necessary on the graveyard end for any system of cradle-to-grave socialism to be sustainable.

The problem today, and surely FDR must be rolling in his grave, is that people refuse to oblige the state by dying at a reasonable age. Where once people routinely expired long before they could collect a single dime of government benefits , now the selfish bastards live many years beyond the time when a good citizen, if he really cared about the financial solvency of his nation, would sheepishly shuffle off his mortal coil to avoid offending anyone. In the United States, most of our socialism is for the elderly and they are voracious consumers of it, everything from Medicare to Social Security, the rich bounty of which many reap in excess to the contributions they have made when they were productive citizens back when Nixon was President. It’s a serious problem. The projected cost of supplying just medical care to the elderly is estimated to be around 40 trillion dollars in the next fifteen years. That’s 40 trillion dollars, most of which we do not have and yet are legally obliged to pay as Medicare, like Jehovah, lives in the Holy of Holies and death will strike down the blasphemer who dares suggest that we cut back on the burnt offerings.

Cut back we must. There is no way to pay this huge and rapidly growing sum. No way at all. Socialism in the United States (and everywhere else), as it is depends on a large pool of young workers paying the benefits for a small group or beneficiaries who play shuffleboard, totter around the house, and then obliging die before they can make too many demands on the system, is unsustainable.   People are just living too long with too many medical problems all of which need to be carefully managed at great expense to ensure their ability to continue to use finite resources.  A bit of a Catch-22 situation, I mean looking at it from a cold-blooded economic perspective.

It’s not that I am against taking care of the elderly.  I’m all for it.  I am just pointing out that shortly, very shortly, the decision not only to do it but to what extent is going to be taken out of our hands by two of the major principles of economics, first that nobody works for free and second, that you can’t pay for things forever with money you don’t have.  You can borrow for a while but eventually your creditors will catch on that you cannot possibly pay them and the ride on the artificial prosperity train is over.  One way or another we are heading for extreme rationing of medical care, either overtly or covertly, because there is no money to pay for unlimited access to all the health care you can eat.  Surely our elected leaders know this but still not only promise to maintain the current levels of medical care to those already eating from the public trough but to extend similar benefits to everyone else.  There is no money.  We cannot add another 40 trillion to the projected deficit  with impunity.  The government does have other obligations, you know.  Like defense, infrastructure, and the other traditional roles of government in free societies.

Liberating Us From Crap (And Other Totally Random Stuff)

Techno-Savvy

I am no Luddite. Like most of the younger physicians today, I grew up with computers. My father had one of those suitcase-nuke Osbornes and I am old enough to remember how cool we thought the Commodore 64 was, what with its sweet cassette tape drive and way cool BASIC instruction set that let you GOTO all kinds of programming bliss. In the now-distant 1980s I was a Computer Science major and did pretty well in those classes even if I failed everything else and ended up being kicked out of the University of Vermont for bad grades. I have written a FORTRAN 77 program on punch cards and even wrote an assembler (a program that converts assembly language into the CPU’s binary instruction set) for the ancient PDP-11. I remember well the DEC VAX, the first version of windows (I preferred DOS until Windows 3.1 which finally closed the gap with Apple for a graphical user interface), and my first real computer was an IBM PS-2 with a giant 5 MB hard drive. I’ve used all the major software; WORD, Excel, and Powerpoint as well as sophisticated structural analysis programs like RISA and STRUDL, not to mention at one time being something of an expert at AutoCAD. My medical school was completely wired and all of the lectures and notes were on line. In fact, mine was the first class were the administration realized that there was no need to have a “This is a Computer, This is an Icon” orientation as everybody in the class had also been raised with computers. On top of that, we use tablets with the T-system at one of our hospitals and I have adjusted to it effortlessly as have most of my colleagues.

I therefore take umbrage to the conventional wisdom that doctors are not technologically adept. I was thinking about this the other day as I manipulated the ultrasound probe to get a better look at my patient’s aorta. It’s not that we’re not adept, it’s that we like to see a return for investment and are well beyond the reflexive, “Golly Gee Whiz” reaction when confronted with something new. We just want the motherfucker to work and by work we mean to simplify our day, not make it more complex. Take for example the typical hospital computer system which is usually an ancient relic from the 1970s, still running on some baroque IBM mainframe and to which has been grafted a modern-looking “front end” to give the illusion that we are, in fact, cooking with future gas. It can’t communicate with any other system, it’s slow, and it can only retrieve a limited amount of information, usually lab values and some dictated notes. Forgive our lack of enthusiasm but there is nothing to get excited about here.

In other words, we are in the doctor business, not the computer business. I don’t really want to learn anything about the equipment except how to get what I need out of it. I don’t trouble-shoot faulty hardware or kludgey software. If the problem can’t be solved by re-booting then I’m done. It’s time to call technical support and let them handle it as that is their business.

Or consider writing notes. Leaving aside issues of legibility and access to your notes by some nebulous doctor in the unforeseeable future, until very recently it was just much easier to open the paper chart and write a note or dictate than it was to find a computer, log in, locate the patient, check this box, click that one, and type the same note, especially on the hospital’s chimera of a system. This is all changing, of course. Windows-based and internet accessible Electronic Medical Records are much easier to use now and very fast but, as the requirement to document for billing and not for medical decision making is driving the EMR business, most of the notes you produce are automatic boilerplate and, except that we must kill what we eat, if it wasn’t for the billing requirement it would still be easier to hand write a quick note on most patients, the important information about which can usually fit on one side of an index card.

I use email and I of course have a blog. I am accessible but for the record I do not routinely carry my cell phone (I have it perpetually charging in my car for the once or twice a week when I use it) and have only a vague idea what a “ringtone” is and if it’s what I think it is, cannot believe that anybody pays money for them. I do not “text message” either and I will ignore anything on my phone written in “Cutesy.” I have a pager and believe me, that’s enough. More than enough. If someone needs to get a hold of me they can and other than that, I guess I just don’t have a lot to say.

On the other hand in our new twenty-acre Emergency Department they have us carry “in house” cell phones and I love these…but only because I can page an admitting physician, for example, and pick up the call anywhere. See? Technology making our job easier and more efficient. (Now that the charts are on the tablets I can also talk intelligently about any patient on the phone from anywhere in the department.)

My point? Nothing, really, except that I am Best Buy’s worst nightmare. I don’t own much in the way of personal electronics, I don’t really listen to that much music, and despite my cell phone having hundreds of features, all I really need is to dial a number every now and then and do not need to be in constant communication with everyone I know all the time. I know how to use all the stuff, I just don’t want to.

Except…I just bought my wife an MP3 player, thirty bucks, one GB of memory, and I’m hooked. I remember when the Sony Walkman first came out and while I eventually bought one, this thing is nothing like that. Keep in mind that most popular music is crap. Utter crap. Filler, compost really, for the one or two good songs on an album (do you kids still call them albums?). Even with the Walkman which I assure you was revolutionary for its time, you still had to buy tapes that were mostly crap to get to the one or two songs that were worth listening to. Come on now. Admit it. Very few artists and bands are consistently good. Maybe the Rolling Stones and the Talking Heads but U2? Madonna? Get real.

Now, on an intellectual level I have known for a long time that you can pick whatever tracks you want to download onto your MP3 player. I just didn’t realize the power of this until I started downloading the songs my wife wanted. She’s into the Latin sound, J-Lo, Enrique Inglesias, Santana’s “Smooth” and the like. I was skipping around her playlist, just sort of checking to make sure everything was there and I realized that every single song, while maybe not exactly my thing, is good. A winner. Worth listening to. (Say what you like about Ricky Martin, that vato can jam.)

Finally, we have been liberated from crap.

Complementary and Alternative Medicine

Maybe I haven’t been clear about the subject of Complementary and Alternative Medicine. Or maybe my articles, as has been suggested by some of my critics, are too long and the reader’s lips and brains are tired by the time they get done with them. Let me summarize:

1. CAM is mostly an expensive, carefully constructed placebo. The major academic centers that sell it to the gullible admit as much but flog it anyways using “well-being” and other nebulous concepts as an alibi (do you really think anybody at the Duke Center for Integrative Medicine with a medical degree, for example, really believes that some yahoo can shoot spiritual fire out of his appendages?). While I rise in support of having a good attitude and a positive outlook, the real medical effects of placebos are terrifically over-rated. You can feel as good as you want about your pancreatic cancer, for example, but it’s going to kill you or not pretty much on its own schedule. The microscopic advantage you may glean by believing that spiritual fire is flowing into your body is nice to have, certainly harmless if not your sole treatment, but not worth the ridiculous expense of having a shaman on the payroll.

2. In other words, even in the real world of medicine, a lot of our therapies and interventions are marginally effective at best and there has to be some consideration of cost versus effect. The effect of most CAM is not even close to being worth the cost as it is mostly entertainment and not medicine. Just because the patients want it doesn’t mean we have to give it them, except of course as part of a customer-satisfaction driven business model which is great…but not on my dime.

3. The CAM that is not pure bunk, some aspects of naturopathy, for example, that use medicinal properties of botanicals and other substances as therapies are unnecessarily complicated, unsafe, and based on a shoddy philosophical basis that makes no sense. “The Healing Power of Nature” is an insipid marketing phrase. “The Vicious Automatic Killing Default Position of Nature” is more apropos as it realistically describes what anybody who has ever watched even a few minutes of the Discovery Channel could tell you. Naturopathy and many of the other bambicentric CAM modalities are political statements, not medicine, and while they may accurately reflect the world-view of their purveyors, are less than optimal therapies in a world that is indifferent to your nature fantasies.

4. In other words, there is no “Mother Nature” or “Planet Earth” who cares about the difference between a quality-controlled dose of digoxin produced by an evil pharmaceutical company or a cup of oleander tea steeped in the hand-made clay urn of a nature-loving hippy. Now, in our Godless and tradition-rejecting society, I can understand the panic that many feel when they look into the void and see nothing. But if you’re going to reject religion, then reject it and grow some gonads. It makes no sense to eschew the irrelevant religious beliefs of your parents but then, without a pause, to eagerly latch on to some hodge-podge of Earth Worship and Eastern Mysticism except that these things don’t require the self-discipline of traditional religions and therefore give you a purpose for life on the cheap.

5. Which is to say that except as it can inform moral decisions, religion has no place in medicine. My priest offers the last rites to our parishioners but he wouldn’t think of recommending ventilator settings. It’s not his job and I wouldn’t dream of asking him. Complementary and Alternative Medicine is a shoddy, cut-rate religion preoccupied with individual ego and, as it doesn’t even offer any moral guidance (except the commandment to recycle) it has even less of a place in medicine than traditional religion. A priest from my old parish often joked that his vestments make him look like Mandrake the Magician. If Reiki healers, homeopaths, acupuncturists, and the like just dressed the part and billed themselves as chaplains I’d be a lot more accepting. I respect everyone’s right to worship or not worship how they please.

6. While it’s true that “Science Doesn’t Know Everything” and even that many things that were once considered preposterous are now generally accepted as true, if you bothered to notice the movement in science is away from mysticism. Science is moving away, not towards, the grand unifying theory that will prove acupuncture, homeopathy, and any other CAM modality devised at a time when science was in its infancy. For most of human history there really was no science as we know it today but only the venerated received wisdom of the ancients, itself based on a faulty view of the natural world. A lot of what was believed to be preposterous was only considered to be because it flew in the face of this received wisdom.

7. A person who believes in homeopathy, Reiki, and the like…I mean really believes and not just keeps his mouth shut because he’s too afraid that his ignorant peers will accuse him of being close-minded….really has no business in the medical profession and should voluntarily surrender their license. Obviously all that medical school was a waste and didn’t really take.

8. On that note, it is possible to be so open-minded that you enter a sort of Twilight Zone, a strange place where the ordinary laws of physics and reason don’t apply and you must contort your mind into impossible positions to accept many strange and often contradictory beliefs. Being open-minded to that extent is no virtue but merely a glorification of chicken-hearted indecisiveness.

Defending the Pie

(The pie is a metaphor. I’m only mentioning this because the last time I mentioned pie, I received several irate emails, the gist of which were that pie is not to blame for the collapse of society. -PB)

Primary Snake Oil

The silliest thing about the practitioners of Complementary and alternative medicine is that they don’t know when to leave well enough alone. Currently, with the exception of the occasional over-enthusiastic chiropractor who breaks somebody’s neck or tears an important artery that he has never even heard of, Complementary and Alternative Medicine is a low-risk enterprise, the business model of which is to take a panel of essentially healthy patients with predominantly psychosomatic complaints, stroke their egos a little, mumble either some pseudo-scientific rigmarole or some whacky Eastern nonsense, and send them on their way totally cured and none the wiser. The worst that could happen is the patient still feels bad but, since lawyers have yet to work out a way to demonstrate in court that your qi was irreparably damaged by your acupuncturist, as long as the needles are reasonably sterile and there is really nothing in your homeopathic pills but sugar and a one-in-one-billion chance of one molecule of sheep spleen, you are as a CAM practitioner (if you will pardon the expression) shitting in high cotton.

It is with great interest therefore that I read about naturopaths and chiropractors, among others, trying to pass themselves off as primary care physicians. I see the usual billboards in my town from the chiropractors advertising themselves as the complete medical solution for the entire family and there is even a small subset of back-crackers billing themselves as pediatricians. Naturopaths, for their part, are even recognized as Primary Care Physicians in some states (particulary in the Northeast) and are attempting the usual inroads elsewhere. Leaving aside the obvious, that chiropractors and naturopaths are physicians in the same way that I am a Starfleet Admiral, it is puzzling that, with such a good racket going, the witchdoctors would be trying to sneak into a job for which their training is inadequate and which opens them up to all of the hassles of real medicine like deadly earnest malpractice suits (not to mention suffocating government control, and declining reimbursements).

Suppose you used a chiropractor or a homeopath as your primary care provider. In the best of circumstances, and loosely following the mid-level model for delivering primary care, the CAM practitioner would be a low-level gatekeeper, assuming they knew their limitations which is not usually the case. The typical education model for a CAM practitioner with an advanced degree in his modality, also known as lipstick on a pig, leans heavily on their own particular flavor of snake oil and throws in just enough of the traditional medical curriculum to say, “See, nobody here but us scientifically trained doctors,” but not enough where anybody should feel confident that they would even know when to refer to a real physician.

Even if you came across the rare naturopath or chiropractor who knows that he is selling hokum and is therefore keenly aware of his limitations, if he wanted to be a primary care physician he would do nothing but add another layer of expensive and completely useless medical care to an already overdoctored society. Except for the rare public service of calling 911 like any good Samaritan would if somebody showed up at his clinic with chest pain, he is contributing nothing, and the only difference between he and his more adventurous and less self-aware colleagues in that he will quickly refer to real primary care physicians for real medical problems while they might sit on the truly sick patient for a long time before getting spooked, scratching their heads and wondering why the Ginkgo friggin’ Biloba isn’t doing the trick.

Benefit to society: Zero. My neighbor can call an ambulance and most people know when to go to the doctor. Hell, the real trick is getting them not to go. There is, you see, more to primary care than referring to a real doctor or a specialist. Certainly knowing when to call a real doctor shouldn’t be all the credentials you need to label yourself as as primary care provider. You do actually have to treat something and adjusting qi to improve the subjective well-being of your bored patients isn’t it.

For their part, the chiropractors and naturopaths will point to the existing mid-level providers, many with only a couple of years of formal medical training who are also making inroads into the primary care field, and invoke the doctrine of “me too,” reasoning that since they have a fancy four-year degree they are more than qualified to work as primary care physicians. Whatever the qualification of Physician Assistants and Nurse Practitioners however, their training at least follows the rational model of medicine and is not encumbered by snake oil. A Physician Assistant may only have only two years of formal training but all of it is good which cannot be said for CAM practitioners. Chiropractic school may be four years long, for example, but as most of it involves instruction in a completely debunked treatment philosophy as well as desultory clinical years where all the student sees are mostly well patients with the aforementioned psychosomatic complaints, it is not exactly medically rigorous and in no way prepares the practitioner to understand, let alone treat, even the simplest of presentations. Not only is their first instinct is to throw useless woo at medical problems, under the theory that if you have a hammer you nail, but they don’t even know enough to know their limitations which is perhaps the most dangerous character flaw in the medical world.

Sure, anybody can see somebody with a cold or some other minor complaint and the odds are good that nothing they do, provided they don’t get too jiggy with it, will do much harm. But let’s suppose that you have never rotated on a medical service or done your share of critical care. Suppose you have never worked in an emergency department or spent a few sloppy months on the labor and delivery floor. Imagine, if you can, seeing a provider for your family’s medical care who is treating your kids but has never had a lick of formal pediatric training or so little that she has never seen the really bad pediatric diseases that look like a little bit of nothing when they first present. Does your chiropractor, for example, know the odds that a fever in a neonate is some flavor of bacteremia that needs aggressive treatment?. Let us further suppose that while your chiropractor has spent hundreds of hours learning how a little normal misallignment in the spine can cause “dis-ease,” he has never had to recognize appendicitis, pancreatitis, or the first subtle hints of colon cancer. In short, while a lot of primary care is routine stuff, little potatoes that the school nurse would have to work at to screw up, not all of it is and if all you’re barely qualified for is to pass sick patients to somebody else as some kind of completely redundant middleman, maybe you should stick to the entertainment business and leave medicine to those with training.

Seriously now, there are whole groups of trained physicians, radiologists and orthopedic surgeons for example, who have not only legitimate training in general medicine but the legal license to practice any kind of medicine in which they feel comfortable who wouldn’t dream of doing pap smears or treating some kid with an ear infection because they are a little rusty in that kind of thing. Internists do not moonlight as obstetricians even if they have delivered a few babies in medical school and for my part, although I have done six months of surgery rotations in my training as an Emergency Physician, I’m not taking out anyone’s gallbladder anytime soon. I’m not adequately trained and I could not look the patient in the eye and ask for their trust.

Remember, also, that your primary care physician has a minimum of seven years of formal medical training. Your family physician has, in fact, done a lot of inpatient pediatrics, internal medicine, and a few months in the Pediatric and Adult Intensive Care Unit. The only legitimate question is whether a residency-trained primary care physician is over-qualified for many of the patients they see. The purveyor of snake oil doesn’t even rise to the threshold of qualification.

Mid-level providers and physicians practice in the real world of medicine and when confronted as we all are from time to time by the limits of our knowledge or abilities refer to a higher level of care. The Complementary and Alternative Practitioner, in a tacit acknowledgment that his therapies are ridiculous, will always defer to real medicine when he at last realizes that he is an ineffectual bufoon but only after exhausting his repertoire of snake oil. The danger is that there is no higher level of care in complementary and alternative medicine, just a hodge podge of smooth-talking clowns to whom the customer may be sent, and unless the chiropractor or naturopath honestly assesses his abilities (which would preclude him from even wanting to be in primary care) we’ll have a subset of sick patients who need real medical attention but are not getting it. Now, while this may be good from a strictly Darwinian point of view, allowing the oldest and sickest to die before they can become to much of a burden on society, this is not exactly a ringing endorsement of Complementary and Alternative Medicine.

Currently, the only benefit at all from CAM is that it keeps otherwise healthy people with no real medical complaints from clogging a medical system that is already overloaded, in part because of patients for whom nothing really needs or can be done. And it’s fine. I have long passed the stage in my life where I view it as a personal mission in life to cure others of their stupidity. It’s a free country and if you think you have it all figured out, then knock yourself out. The only money you are wasting is yours and you obviously have more of it than you know what to do with. The problem comes when public money and “quasi-public” money from private insurance pools is used to pay for this kind of things which is, I suppose, the Holy Grail of the Complementary and Alternative Medicine practitioner. That is, to get their claws into the the trillion dollar pie, which, unlike most economic pies, is indeed finite and not big enough to feed everybody all they want. For my part, I don’t think we even need to eat the whole pie but should instead save some for later.

The trouble is that when you leave a pie out and turn off the lights, the rats will edge towards it for their share. I’d like to protect the pie from the rats, both in real medicine and most especially from the exotic rats in the world of Complementary and Alternative Medicine.

Evidence Based Medicine? We Don’t Need No Stinking Evidence Based Medicine

The Free Netter’s Ain’t Worth It

I am an educated man. I have an extensive liberal education, a degree in Civil Engineering, a Medical Degree, and am almost done with residency training in Emergency Medicine. Just for fun, I read the kinds of books they forced you to read in your long-forgotten English literature course (not that you actually read them but instead passed the course with the help of CliffsNotes and the professor’s fear of damaging your ego). While not an expert in much, I have a good working knowledge of physics, biology, chemistry and enough of the medical sciences where I at least know enough to understand new concepts as they present themselves and when smoke is being blown up my ass.

On the other hand I am also an ordinary guy and have done my share of regular jobs from fast food to landscaping and a lot of things in between. As I may have mentioned once or twice, I was also a United States Marine Infantryman and consequently know which is the dangerous end of a gun and, while I am today just a stocky suburban dad, at one time could and did endure physical hardships that would make the typical malignant Attending Physician, cock-of-the-walk in the hospital chicken house, weep like a little girl.

I have by no means seen and done it all but I have a pretty good idea how things work. I confess, however, that about one of the major underpinnings of the great structure that supports my beliefs, I have been wrong. Completely and utterly mistaken, so much so that if I could, I would find everyone upon whom I inflicted my totally incorrect theory and humbly abase myself in abject and total apology.

You see, for my whole life I have believed, and defended vigorously, the notion that being educated does not preclude one from having common sense. The conventional wisdom is the contrary of course, and I have heard this wisdom expressed often, especially when I was a Marine. “Yeah, he’s book smart,” went the typical conversation, “But that guy can’t find his ass with two hands and a flashlight…couldn’t pour water from his boot if the instructions were on the heel.”

I’m not saying that educated people are immune from stupidity, just that education does not cause stupidity and I have been a champion, a lion, in the defense of education as a complement and even an enabler of common sense. After all, many of the cool kids at my high school who eschewed the Chess Club are currently living in single wide trailers with women who, despite weighing 400 pounds (181 kg), are still trying to cram themselves into the same revealing clothes they wore in their brief flowering of trailer park beauty, those precious couple of years as fleeting as the tundra blossoms, between their first tattoo and their first illegitimate baby.

And then I read, via Orac at Respectful Insolence, about something called the Complementary and Alternative Medicine Leadership Program, sponsored not by some third rate chiropratic mill but by the American Medical Student Association, a splinter group of the august American Medical Association, who have bribed hundreds of thousands of medical students to join their ridiculous organization by giving them a free anatomy atlas (Netter’s).

I wept.

Suddenly, what I once thought to be the stable soil underneath the foundations of my weltanschauung heaved as if nothing more substantial than wet gumbo clay. Maybe smart people are prone to be booger-eating morons after all. I mean, seriously, here’s a group of American medical students who they tell me are drawn from the very top percentiles for intelligence spending their summer sitting at the feet of homeopaths, acupuncturists, and Reiki healers, soaking up the woo like so many lumps of dry cornbread. And they are buying it. Completely and wholeheartedly. The natural skepticism which is the true birthright of an educated man seems to have skipped a generation.

Take something like Reiki, one of the latest and trendiest of the new age Complementary and Alternative Medicine therapies. The Reiki practitioner claims to produce medically significant effects on a patient by shooting sacred fire out of his appendages. That’s it. That’s all there is to it. Once you strip away the Eastern mysticism and flamboyant Asian ambience it’s just a guy shooting spiritual energy into a patient. I told my Heating and Air Conditioning Guy about Reiki and he laughed.

“Hey, maybe you can get a a Reiki healer to shoot some mystical fire out of his ass to fix your furnace,” he said, “But in the meantime I’m still going to have to charge you a hundred and twenty bucks for the new igniter.”

The Good Lord knows that I embrace the concept of Evidence Based Medicine. A lot of what we do in medicine is marginally effective (if at all) and it is sometimes only tradition and a general sense that something should work (even if it doesn’t) that keeps us doing it. Evidenced Based Medicine is a world-view, a system of thought, that allows us to test everything we possibly can and eliminate these therapies that are ineffective or even harmful. But Reiki? With respect to my colleagues investigating every aspect of medicine, I don’t need a double-blinded placebo controlled study, a meta-analysis, or any other proof except the obvious one that some smarmy guy with a mail-order degree in Eastern mysticism cannot shoot spiritual fire out of his hands. First because there is no such thing as spiritual fire and second because, well, he’s some smarmy little fraud with a mail order degree. As I mentioned in another post, res ipsa loquitor; some things just speak for themselves and while I appreciate the zeal of many in the scientific community to test even things that are obviously ridiculous on a fourth grade biology level, I don’t necessarily need a lot of evidence to suggest that magic fairies and pixie dust are not legitimate treatment modalities.

Which is kind of the point of research into things like Reiki and Homeopathy. What on Earth do you expect to find? Even those who are inclined to believe in this kind of nonsense, when pressed, will admit that for any given Complementary and Alternative Medicine therapy the research is generally incredibly shoddy and, even allowing for a generous confidence interval, a blind eye turned towards the biases of the researchers, charitable peer review, publication in journals that are only one step above the supermarket checkout line variety, a favorable wind, planetary alignment, and an early showing by the groundhog, the positive results are slim, barely detectable, and easily ascribed to a placebo effect; something that is controlled for in real medical research and, if detected taints the entire study. In the world of real medical research, you understand, discovering that your prized medication is no better than a placebo is not greeted with war whoops and fists clenched in triumph.

No high fives, in other words. Back to the old drawing board. Things work the other way in the mystical world of Complementary and Alternative Medicine. The discovery of some insignificant statistical anomaly in a poorly designed and non-reproducible study is greeted with the same enthusiasm by the true believers as the discovery of the structure of DNA and we must now run, not walk, to legitimize their particular brand of fairy dust and use it on everybody. Pulling the same trick in real medicine leads to eventual exposure, embarrassment, ridicule, and even criminal charges. While every medical therapy involves some combination of cost and effectiveness, for Complementary and Alternative Medicine the cost (because Reiki healers do not dispense spiritual energy for free) is not even remotely worth whatever miniscule and highly subjective clinical results can be delivered by what is essentially an entertainment modality and not a medical one. You could, for example probably get the same results watching old Kung Fu reruns as you could with acupuncture. Or, to put it another way, acupuncture won’t work if it’s some bored acupuncture tech named Frank doing it, even if he puts the needles in the right spots. Unless he dazzles you with his mystical dog-and-pony show it’s just some paunchy guy smelling of cheap cologne sticking needles in you.

You know, I cannot help but sympathize with the young AMSA scholars. Medical students are not generally the popular kids in high school or college. The demands of making good grades and navigating the poodle-circus of medical school admissions preclude a normal social life. For my part, I was something of a nerd in high school. I was on the Debate Team, for Mohammed’s sake. Can’t get more uncool than that so I understand full well the appeal to you, oh young AMSA scholar, of going to some retreat with a group of your geeky friends lead by a bunch of people who, as you are the future leaders of medicine, will coddle, stroke, and reaffirm how special you are. It probably gives you the same rush you got from representing Cuba in the Model United Nations. But that’s the thing, isn’t it? Complementary and Alternative Medicine at the medical student level is not about the patient but about the medical student who use it as a positive affirmation of their own values; their open-mindedness and their unshakable belief that some Native American Medicine Man chanting around a sacred fire has something legitimate to teach the medical profession. It’s a way to resist the brutal self-discipline required to put away the fantasies of childhood and deal with the World-As-It-Is rather than how you would like it to be.

It also affords you the opportunity to get close to that awkward but reasonably pretty girl who otherwise won’t give you the time of day but who sent shivers up your spine that time she accidentally brushed by you. Dude, that’s why they have Spring Break. Not that I don’t applaud your motivation, especially if you are into earnest chicks who want to save the world but just admit it and stop with the magic fairies.

Housekeeping Stuff:

1. Congratulations to Graham over at Over!My!Med!Body! for matching into Emergency Medicine. Welcome to the club and no matter what they say, all the other specialists secretly wish that they were the combination of poker player, cowboy, daredevil, scholar, and circus clown that it takes to be an Emergency Physician. I can’t imagine doing any other specialty (even though anesthesiology looked mighty good, details in a later post, when I recently did a two week rotation) and once you get through all of the intern year crap you will enjoy yourself immensely.

2. Your comments are appreciated. Please, limit your links to two (2) as my spam filter is on a hair-trigger. No matter what your comment-the cardioselectivity of various drugs, your groundbreaking economic theories-if you use the words Brittney or Spears anywhere in the comment I think it is automatically shredded.

The Best-Laid Schemes O’ Mice an’ Men Gang Aft Agley (And Other Things)

(With apologies to Robert Burns. -PB)

Less is Better

I imagine that some day Graham, the author of the superlative medical blog Over!My!Med!Body, who is just now emerging Siddhartha-like from the palace of his father to see the world-as-it-really-is rather than how he wants it to be, is going slam his imported microbrew down on the bar of his favorite San Francisco bistro and announce to his friends that the problem with medical care is “All them goddamn free-loaders mooching off the system,” after which he will stagger to the registrar of voters, change his registration to “Libertarian,” and have his designated driver scrape the Obama bumper sticker off his Prius. He’s certainly headed in that direction, especially on perusing one of his latest articles on futile care where he correctly identifies the disassociation between cost and effectiveness of much of what we inflict on patients in their twilight years. He’s also slowly gaining awareness that many of our patients, far from being poor-but-noble victims of the brutal society in which we live are, in fact, shameless opportunists who will take and take all of the government freebies social justice that they can get their hands on.

In other words, he is slowly, oh so slowly, seeing the obvious: That the problem is one of demand and cost, not some nebulous failure of social justice or systematic oppression. Sure, we can blame insurance executives with their multi-million dollar severance packages and greedy physicians opening specialty centers and concierge practices but the fundamental problem is that everybody wants all the medical care they can eat but nobody wants to pay for it themselves. Hey, it’s a right after all. We don’t have to pay for our freedom of speech and since burning an American flag only costs a few bucks, why should we pay a dime for medical care?

I mention this because it’s an excellent series of articles, by themselves justification for including him on my blogroll, full of bang-on insights to some of the problems of American medical care, many of which I agree with wholeheartedly. You all know my views on futile care for example but Graham and I also share a disdain for Direct To Consumer drug advertising, a practice which I think is ridiculous on so many levels that I hardly know where to begin. Now, as a rapacious, right-wing, pro-industry capitalist who will kill a million caribou without a qualm to drill for Alaskan crude, like Nixon going to China, I probably have a little more…I don’t know…maybe we’ll call it “authenticity” than Graham when it comes to attacking a cherished part of our capitalistic system but Graham still knows of what he speaks.

My only qualm with Graham is the general impression one gets that every solution to every problem is going to involve a whole lot more government involvement. In other words, to decrease the amount of fraud and abuse in whatever socialized or quasi-socialized (or we-swear-it-isn’t-socialized) system the TPGA-axis eventually forces on us Graham would likely turn to the gubbmint’ to implement some byzantine regulatory solution in whose labyrinth will vanish whatever efficiency, flexibility, and innovation is left in our system. It cannot be otherwise. Governments do not give money to anyone willingly, despite the promises of politicians, and money is scarce and getting scarcer. The fundamental problem, in fact, and almost the exclusive preoccupation of every Western Democracy is how to buy off their citizens, to whom were promised lavish social welfare benefits, with treasuries that are becoming rapidly depleted. Covertly or not, medical care and other freebies need to be rationed and governments, to avoid admitting that they’ll be putting down yer’ granny, disguise rationing behind impenetrable bureaucratic obstacles. In Greece, for example, my ancestral homeland and the poster-child for Socialism Gone Wild, while everybody gets free medical care, unless you can fork over a bribe or belong to one of the 149-or-so trade associations with good insurance plans (kind of like co-ops, many of which have failed to the extent that they are all going to be nationalized shortly into about a dozen broad associations), your wait-time for a major operation that even our winos can get in less than a day can be months or years.

That maybe what we need to do is decrease the amount of government involvement in medical care is never seriously considered by anybody, at least not anybody who has a decent chance of doing anything about it. The conventional wisdom upon which every major politician from both parties operates is that government has to do something, the exact something although it may vary is still usually just a question of how much more, not whether it needs to be done at all. For my part, while I think that both Graham and I agree that few can really afford a major hospitalization or the high cost of getting old and multiply comorbid, I have never understood the lust of the wonketariat to provide comprehensive medical insurance for free to everybody whether they need it or not. Surely we will always have some unavoidable costs in our system that the tax-payers will have to suck up. There are many people in our country who are not only poor but completely helpless, conditioned by years of mammary government to be incapable of solving a single problem in their lives without guidance and support from a bureaucrat. The elderly at the other end of the spectrum, many of whom have not contributed nearly as much into Medicare, both from payroll deductions and premiums, as they will eventually use need to be supported as do those who are struck, from out of the blue, by a debilitating illness that leaves them incapable of productive work. To let people die because they can’t afford life-saving treatment, while not exactly a mortal sin against the capitalist ethos, would nonetheless be demoralizing to our nation and only the most Borg-like of Ayn Rand followers would think otherwise. But why compound the problem, why run up the tab on obligations that we cannot possibly meet, by giving away medical care to those who can pay for it themselves? In other words, why bankrupt the nation to ensure that nobody ever has to decide between cable television and taking their kid to the pediatrician?

Which is kind of the choice many of our citizens make, the mantra of the middle class in particular being “Thousands for Personal Watercraft but not a Dime For My Doctor.” Primary care on an individual basis is not that expensive and we are not a nation of paupers. In a country where even the poor can drop a couple of hundred a month for luxuries, things like ringtones for their cell phones and designer clothes, why Graham or anyone agonizes over the best way to make sure that nobody has to pay a dime for medical care if they don’t want to is inexplicable. They’re just not giving people enough credit, displaying the suffocating paternalism that is the hallmark of those with a religious faith in the power of government to solve problems and whose fear is that most of the sturdy and not-so-sturdy yokels, if allowed to make their own decisions about medical care with their own money, will let their children suffer and their own health deteriorate before they’ll spend a dime of their beer money.

Can’t have that of course. People making rational decisions about how they’ll spend their own money. Pandemonium would ensue! The Apocalypse! Panic in the streets! Human Sacrifice! Dogs and cats living together! But, if primary care is relatively cheap and getting cheaper with the advent of four-dollar generics at the shopping Mecca of your choice, where is written that people need expensive comprehensive medical insurance or that the taxpayers, through the sausage-nozzle of government, have to pay for it? If you give a crap about your health, by definition you will pay a hundred bucks every now and then to see your doctor and twenty bucks a month for the (hopefully) minimum amount of medications she deems necessary to control your potentially dangerous medical conditions. If you don’t give a crap you won’t pay which is a personal problem, nothing more. People don’t want to pay because they have been conditioned, first by fifty years of comprehensive medical insurance as a de facto condition of employment and lately by the munificent hand of government that lets them present to the Emergency Department with a complaint of “My ass is sweating” without being arrested for embezzlement of public funds, to expect medical care to flow as effortlessly and cheaply as water from a tap. There is, you understand, a certain transparency to public utilities. Water comes out of the faucet and is carried away to Candyland by the toilet and people don’t really think about it. These things just exist which is how many in the public would like to view medical care, an endeavor which requires several orders of magnitude more money and effort than providing water.

For both mice and men, the best-laid plans often go astray. Unintended consequences flourish, particularly when government which is largely staffed by people who are not qualified for any other job but public service gets involved and tries to control behavior with complicated schemes. We have a nation of unmarried teenage mothers and ruinously expensive government health care grown to a hundred times its most pessimistic projected cost to remind us that socialism is a moth-eaten, half-starved, unpredictable tiger that once let out of the cage is almost impossible to put back in. It’s an economic theory entirely built on the mistaken idea that people will cheerfully and willingly work long and hard to support people they have never met and who don’t do anything for them in return. It is, finally, a philosophy which is turning the West into a nothing more than a crappy nursing home, full of people without the foggiest notion how to be productive and look after themselves, and paid for by money borrowed from the Sheiks of Araby and the Mandarins of China who will eventually decide that paying for the cradle-to-grave benefits of a French poet or the inhabitants of a trailer park in the vast, empty wastes of Massachusetts is not such a good investment. Unfortunately, Western socialism is financed with borrowed money and is therefore unsustainable, especially as economic growth cannot keep up with the growth of entitlements.

It would be a simpler, cheaper, and, as our country is terrifically overdoctored and overmedicated, probably not even detrimental to the aggregate health of our nation if the government withdrew from as much of the medical industry as possible and instead, if they can’t resist the temptation to tinker, enacted policies that encouraged people to pay for as much of their own medical care as possible. Nobody, for example, except the very poorest (to be determined by Graham’s compassion Gestapo) should have a dime of their primary care paid for by the the government on any level. If you need to go the doctor for a cold or to check your blood pressure, you need to pony up. If the government has to be involved, and as most of us agree that a major illness or two will wipe out most people, it can guarantee the solvency of high deductible, major medical policies that citizens would be expected to buy for themselves and their families. Maybe even make it mandatory, call it a tax, and be done with it. We can always take it out of the Earned Income Tax credit for the majority of Americans who, in fact, pay no income tax whatsoever.

On the carrot side, we can encourage health savings accounts from which primary care and other medical expenses can be payed without involving the complicated dance of the bureaucracy, the idea being to encourage the health care market to be a little more transparent and rational. If you’re spending your own money, maybe you don’t want all of those marginally useful treatments and studies.

Of course, medical care is still going to be horrifically expensive. Things cost what they cost and it is impossible that the elderly and their lobbying groups will accept the kind of rationing that is needed to really control spending. Maybe when I get to be seventy I’ll also want my share of heart caths and joint replacements so all of us have a terrific self-interest in supporting our current high-tech and highly expensive medical system. But if a few simple reforms (simple conceptually but almost impossible politically, I mean) to include tort reform could shave twenty or thirty percent off of our current two trillion dollar per year spending spree, that would be enough to keep things solvent.

Other Blogs You Should Read

The best blog on my blogroll, the Macho Response, is not even a medical blog but rather the observations and reflections of a guy living deep in one of the many strongholds of the lunatic fringe and who is slapping them around as they deserve and to the best of his abilities. I’m sure we don’t agree on everything. The Crack Emcee, as he styles himself, is an artist, a musician, and an atheist while I am tone deaf, art-insensate, and a devout Orthodox Christian…but I ain’t a fascist and there is plenty of room in my mind at least for some reasoned differences of opinion. The Emcee is nothing if not reasonable which is not to say that he doesn’t, in a commendable macho fashion, disembowel the usual sensitivity fascists, self-help gurus, and the obnoxious cult-like behavior that is the norm among many of our elites. Sometimes even reasonable men must run up the Jolly Roger, spit on their hands, and commence to cutting throats (If I can paraphrase H.L. Mencken).

You also need to read, regularly, the Happy Hospitalist. I used to think I could write a good article or two but now I must cower in shame in the long shadow of a guy who can really break things down to their most basic level and demonstrate not only what’s wrong with them but what would be required to fix them. My non-medical readers need to go over there because most people who are not involved in medicine have no idea of the obstacles put in the path of a typical private practice physician by the same people who wonder why there aren’t enough doctors to go around.

I have to plug Kevin, MD of course because he is the Don Vito Corleone of the medical blogosphere and he promised to send some of his capos over to break my kneecaps if I didn’t.

Do It for the Children

I’m still looking for more advertisers. I like writing my blog and I hope you folks enjoy reading it but it can be something of chore, not to mention that my wife wonders why I spend so much time doing it instead of surfing for internet porn like normal husbands. At least if I make some money it won’t seem so weird.

Advertising inquiries can be directed to [email protected] I am getting about 30,000 unique visits a month (according to Sitemeter) so while I am not in the Kevin, MD league maybe we can talk.