Hey Dr. Bear, you are something of a critic of the “old school.” What was wrong with the way doctors were trained in the past and why should we change things if the old ways have worked so well?

When I was a structural engineer, I had an old-school boss who had never quite made the philosophical jump into the computer era. Oh sure, he accepted that computers were essential to the business of engineering but he obviously longed for the Good Old Days when engineers made all their calcuations with a pencil and a slide rule. He often made us check our calculations by hand and barely tolerated the use of a calculator for this purpose. His contention was that engineers were better trained and more capable in the old days and that hand calculations gave one a better feel for the meaning of numbers. The Chrysler Building, he often pointed out, was built in a time when computers were unheard of and all the engineers had were their trusty slide rules and their tables of logarithms.

There is no doubt that the engineering profession is built upon the broad foundations laid by engineers of the past. Nor is there any doubt that a healthy respect for their accomplishments and a knowledge of the basic principles that they formulated is necessary for the education of an engineer. But the engineering profession has moved forward and while respect is necessary, mawkishly worshiping the old ways is impractical and counterproductive. Not only do we know more but new methods of design and analysis have made many of the old methods obsolete. Not to mention that certain economic realities dictate that we can no longer spend a day setting up the math to solve an engineering problem when we can have the result in five minutes using any number of structural analysis and design software packages.

That’s just the way things are. My boss used to insist that if we ever lost electrical power or found ourselves on a deserted island all of us new guys were screwed. The obvious flaw in that threat is that we’re not exactly going to be doing sophisticated engineering while waiting for rescue and if the apocalypse should come, we will be too busy scrounging canned goods and fighting flesh eating mutants to even think about breaking out the slide rule.

Now consider the practice of medicine, another profession which is supported on the broad shoulders of the past. Medicine underwent a revolution starting in the late nineteen-sixties going from a sedate, contemplative profession built on slowly acquired experience to the fast-paced goat-rodeo-cum-chinese-fire-drill it is today; a profession where there is barely time to examine a patient before he is fed into the patient processing plant which most hopitals have become. It is a fine thing to long for the Good Old Days when doctors spun their own urine (whatever that is) and did their own peripheral smears but those days are gone and, to paraphrase The Boss, they ain’t coming back. Likewise, our antiquated system of residency training, as it is was designed for the slow-paced hospitals of the past, is a poor fit for the way medicine is practiced today. In the old days, when patients were usually long-term boarders for whom nothing could really be done, a certain amount of leisure time was built into the system. This leisure time was filled with rounds, grand rounds, conferences, more rounds, spinning urine, making slides, lovingly writing extensive notes, and hour-long physical exams. Now that medicine has become something of a grind, while you could take thirty minutes for a detailed neurological exam to isolate a lesion to the left posterior globus palidus, you can instead send the patient for a CT and save yourself the carfare.

Which is what happens. You can no more practice medicine today like an old country doctor than you can design a skyscraper with a pencil and a slide rule.

What is the biggest problem facing American Medicine?

Let me tell you a story. The other day I had a patient who came to the Emergency Department in the early hours of the morning with a chief complaint of constipation for twelve hours and the subjective sensation of a “turd stuck up there.” “Surely there must be more to this complaint,” I thought to myself and launched into a careful history and physical exam to ellicit something, anything, that might kill the patient or cause him serious morbidity. Nothing. Zero. No abdominal pain. Passing gas. No vomitting or nausea. Appetite good. Abdomen non-tender. No fever. No nothing. There wasn’t even any stool in the vault when I finally did a digital rectal exam in the forlorn hope of finding blood, a mass, or just about anything to rekindle my faith in the basic intelligence of our patients.

Finally, more than a little annoyed I asked the patient what, exactly, he expected me to do for him.
.
“I need help taking a crap,” he said as he settled back into his bed.

I gave him a lecture on fiber, told him how to access his local Wal Mart, and sent him on his way.

In a perfect world, this patient wouldn’t have even got through the door. He would have been stopped cold by the triage nurse, rejected at the net, so to speak. I have no doubt that if this same patient had presented to an Emergency Department in France, he would have been subjected to the full brunt of Gallic derision. In the United States, the complete lack of common sense, a trait that has been beaten out of the medical profession by the depredations of the legal profession, ensures that this patient and many like him tie up Emergency Department beds and suck up finite medical resources, principal among these being the time of the physician and the nurse.

It’s not that one patient really has that much of an effect. We have the beds, after all, and the worst that happens is that others who are not acutely ill have to wait. But the over-utilization of the Emergency Department by patients who are not actually sick or have no discernable medical problems for which we can provide treatment forces us to maintain an expensive infrastructure many times the size of what would be required if we limited our attentions to patients with legitimate medical problems.

The consequences of ignoring common sense extend into all areas of medicine. Everything is not a medical problem, even things that are medical problems if you can get your mind around this concept. Knee pain, for example, that is the result of weighing 500 pounds cannot possibly be treated by a Family Physicians, an Orthopaedic Surgeon, an Internist, or an Emergency Medicine Physician. When you weigh a quarter of a ton you are just going to have knee pain. It is, however, the fear of being sued on one hand and the desire for a steady stream of paying customers on the other, that keeps the clinics and emergency departments full. Job security, no doubt, but I’d rather work in a rational system based on common sense than have that kind of artificial job security.

What do I think is the percentage of my patients who have no business getting through triage? It’s hard to say. We see our share of serious medical problems and the acutely ill. But thirty percent would not be an outrageous estimate. If you had a bad payer mix, that is, a high portion of uninsured patients, it would probably be cost-effective to have a physician, and not just any physician but the most experienced one in the department, running triage to quickly winnow the wheat from the chaff, the drug-seeking back pain from the aortic dissection, and the menstrual cramps from the ectopic pregnancy.

So it is the profound lack of common sense that is the biggest problem facing American Medicine. The effects of this lack of common sense, trying to practice zero-defect medicine among a terrifically unhealthy, mostly non-compliant, and litigation-happy patient population are legion and spread their costs and inefficiencies throughout the system. What is most paper-work, after all, other than an attempt to fend off predatory lawyers and their mostly ridiculous lawsuits? There’s a doctor shortage, apparently, but I notice that I spend more time on the patient’s paperwork than I do on the patient and as most of this contributes nothing to his care, imagine how many more patients could be seen or how much more time I could spend with a single patient if we somehow could kill all of the lawyers.

Not to mention the cost of unnecessary tests and treatments undertaken because the wages of intelligent inaction are ruinous while juries, as they are composed largely of people who can take two weeks off pretty much whenever they want, smile favorably on the physician who does something, anything, even if is pointless.

What’s the most ridiculous thing about your job?

Patient satisfaction surveys. Totally meaningless and generally not worth the price of printing them, especially in Emergency Medicine where the patient may rate his visit on the availibility of parking, the alacrity with which the nurse brought him a pillow, and anything other than the quality of his medical care. We saved his life but had to cut off his expensive jeans and it just left a bad taste in his mouth.

Consider a recent patient of mine who presented with diabetic ketoacidosis secondary to not taking her insulin as the price of it seriously ate into her crack cocaine money. We did the usual things, caring for her no differently than if she were our sister and after an hour or so of being grateful, she started to feel better and the complaints and abuse began. I have no doubt that upon her discharge, this polybabydadic mother of six, all in foster care, with no means and no intention of paying a dime for her medical care was presented a patient satisfaction survey courtesy of that modern devil, Press Ganey, and asked to rate her hospital experience. Now, why we should care about the opinion of a non-paying customer who is otherwise habitually to be found turning tricks in parked cars or passed-out drunk in an alley somewhere in the seedy side of town escapes me. What is she going to write that could possibly be of use?

“I’d like to see a better variety of free samiches.”

“More dilaudid, please.”

And yet I have no doubt that each of her complaints would be taken seriously by the shadow bureaucracy that exists to bedevil doctors and nurses. The ridiculous thing is the insistence that medicine is a customer-service business like any other when it is most certainly not. It is nothing like a business. First of all, the customer is not, repeat not, always right. We do not tailor our treatment to fit the patient’s expectations, rather they come to us with a medical problem and we tell them, whether it bothers them or not, what must be done to correct it.

There is also no such thing as a customer in the traditional sense. Most of my patients don’t pay a dime for their visit and don’t expect to either. Asking for their opinion is like asking a shoplifer what he thinks about the decor or the new security arrangements. Even those with that gigantic ponzi scheme otherwise known as health insurance have no idea how much things cost, don’t care anyways, and feel entitled to as much of the health care pie as they can stomach. If there was really a health care crisis, a crisis that is threatening to swamp the system, you’d think we would be trying to discourage customers, not encourage them.

You know, like how MacDonalds has uncomfortable seating to discourage loitering.

Any advice for aspiring medical students?

Not much. Everybody is going to have a different experience in medical school depending on their expectations, their past experiences, and their willingness to modify their ideals to conform to the realities on the ground. I’m trying to get away from giving advice in favor of relating some of my experiences and opinions and letting the reader make of them what he will.

But I guess the basics are the most important, that is, to study hard, keep your eyes and ears open, and try not to get so caught up in what is, once you strip away the self-congratualtion, just a somewhat difficult professional school. Medical school doesn’t have to consume you and it is possible to have other interests. This is not to say that there won’t be periods when you will have time for nothing else but you do get to go home. The subject matter is very interesting but it ain’t that interesting all of the time. If it was more people would show up to embryology lectures.

I’d also like to add that, if you consider that most medical students do not work while in school and that you can skip what are generally useless lectures at will, with a good course syllabus there should be ample time to both study and master the material. I was not the best student being something of a slacker (and I should have studied a lot harder) but I comfortably passed everything. There is time enough in the day. With a little self-discipline you should have a low-stress first and second year and still make good grades.
.
In other words, keep up with your studies and you can avoid the desperate all-night study groups that blossom like nervous flowers, the tattered petals of highlighted index cards strewn over the tables in the library, as your disheveled peers try to cram a few weeks of material into a frantic string of all-nighters. I never could pull all-nighters. I lack the stamina and, as I may have mentioned once or twice, mightily dislike going without sleep.

But do what works. I’m just suggesting that there is no need to panic like many of you new first years are probably doing right now. Don’t sweat it. Keep plugging away. It is going to get easier and by the middle of second year you are going to be able to cover three times as much material in a third of the time and laugh, yes laugh, that some punk-ass biochemistry course ever intimidated you.

What’s the biggest shock for many medical students?

Not being as smart as you think you are. Let’s face it, most of you have until now been at the top of your class in high school and college. You’ve studied hard and received both excellent grades and frequent validation that your hard work and discipline has set you apart from the lumbering proles who go to college for the chicks and the parties. It’s not as if you become stupid on the day you matriculate into medical school but, as everything is relative, on that day you will find yourself surrounded by a hundred other highly intelligent people getting hosed down with a tremendous volume of information, wondering if you are going to be able to keep up. And you will look around and see your peers apparently effortlessly mastering the material while you desperately struggle for a barely passing grade on the first test. That first “72” chills your spine, especially if you are used to “high honors.”

When I was in college, I had to take a ridiculously easy Art Appreciation course to sastisfy the distribution requirements for my major. Easy as it was, I was surrounded by students who were really sweating it including a couple of guys in the back regularly formulating cheating schemes whereby they could scrape by with a “D.” Many of you will feel like those guys after the first exam.

Traditional Lecture or Problem Based Learning?

Traditional lecture. No question about it. If you are accepted into more than one medical school and can pick between a lecture-based curriculum or Problem Based Learning, flee as if from the Devil himself the PBL school.

For those of you who don’t know, Problem Based Learning is a fancy word for “Seminars.” Instead of sitting in a traditional lecture following a rational plan of study, you will be divided into small groups and, under the supervision of a faculty member, teach youself the material through the highly inefficient process of self-discovery. It sounds good on paper and the medical schools that have embraced it will try to sell it as if it were going to replace sliced bread. In practice however, it can be a nightmarish voyage into a sea of ignorance on a ship full of clueless people who all want to be captain.

Problem-based learning is an admission by medical schools that most of first and second year is self-study. Instead of following this admission to its logical conclusion, that people should study on their own, Problem Based Learning was devised to justify both freeing up faculty to concentrate on their real interests and to not provide lectures while still collecting tuition. If you look at it like that it almost makes sense because otherwise you would have to believe that many highly intelligent people devised an intricate solution to a non-existent problem.

The fierce partisans of PBL (who make Mac users seem tolerant by comparison) will sneer at the traditonal lecture curriculum which they say “spoon feeds” the student. The implication is that those of us who prefer lectures to seminars are a bunch of big fucking babies. Maybe lecture is “spoon feeding” but Problem Based Learning is like throwing the jars of baby food at the baby and laughing as he struggles to open them. Actually, I don’t accept the metaphor. Like I said, it’s all self-study. Many people don’t even go to lecture but study efficiently on their own which is hardly spoon-feeding. The difference is that a lecture curriculum has a rational plan, starting with the basics and working up to more complex topics which is the ideal model for a curriculum. Why this isn’t obvious only shows that the faculty at many medical schools have mutated to a level of intelligence where their giant brains have crowded out the common sense lobe.

What’s the bottom line? Studying in a group is highly inefficient, often highly annoying, and puts you firmly on somebody else’s schedule for a significant portion of the day. Instead of just studying you are asked to become an active participant in someone else’s group dynamic masturbatory fantasy. My medical school dabbled in Problem Based Learning and by the end of a typical three hour group session I was ready to shoot myself in the head.

I cannot say enough bad things about Problem Based Learning. Almost everybody despises it.
.
Podunk or Top Tier?

I am immensely grateful to those who pursue careers in academic medicine, careers that advance the science of medicine and train future physicians, and I am second to none in admiration for the most excellent faculty at my program. With that being said, I have no desire to teach, conduct research, or to become involved with academics once I finish my training. Neither do most physicians for that matter. So with this in mind, what really is the difference between going to your inexpensive, relatively unknown state medical school and a major academic powerhouse?

Not much if you just want to practice clinical medicine. I’m not discounting the value of prestige however. If you want to do a cardiology fellowship at Harvard a medical degree from Yale and a residency at Duke will put you way ahead of some rube coming out of the medical sticks. On the other hand, I rotate at a hospital that most of you have never heard of and probably couldn’t find on a map but it has a cardiology program that turns out first rate cardiologists who have no trouble finding jobs or patients. You just have to know what you want and what you are paying for it. All other things being equal, the more prestigious the program the worse the medical students and residents are treated and the more time you will spend as somebody’s entourage. Consider carefully then your choice. If you know that you want to work at medicine like a regular job it makes no difference where you go and location and lifestyle should trump all other considerations (except for Problem Based Learing).

In the end, it just comes down to what the t-shirt is worth.

Like any rotations?

Sure. I like working in the ICU. I didn’t always, of course, as the ICU is probably the most intimidating rotation for medical students and interns. The patients there are horrifically, almost obscenely, sick and the comforting medical paradigms on which you rely seem to be turned on their heads. This is not, for example, a rotation where you can usually have a polite conversation with the patient and explore, in perfect order, the history and the review of systems. In the ICU the patients often come in with nothing but a vague transfer note and an incomplete list of medications. They can’t talk and there is not always a family member to fill you in on the patient as they head south before your eyes, possibly for the last time.

It is a rotation where you have to do something big, and soon, for most of your patients and this kind of decisiveness is something that doesn’t come naturally. You have to learn, in short, to be the kind of doctor that goes into the patient’s room when something goes wrong, not the kind who leaves the room to get help. Emergency medicine residents tend to like their ICU rotations because this kind of thing is right up our alley. In turn our ICU nurses apparently really like to have the Emergency Medicine residents rotating because we’re not afraid to make decisions and don’t have to call a synod of attendings and residents to do a lumbar puncture or intubate.

How do you feel about pharmaceutical sales reps?

I’m working on an article about pharmaceutical reps. The short answer is that I don’t take gifts from them, don’t need their crappy pens, and as I eat for free at my program don’t need to eat their lunches even if I wanted to (which I don’t). Part of my antipathy is my dislike for bad salesmen which most drug reps are. Give me a good salesman selling a good product in which he believes and with him will I gladly do business. Drug reps however, tend to be smarmy glad-handers peddling products which they do not understand using questionable statistics and glitzy marketing. It’s embarrassing and I cringe to watch a typical drug rep present his little spiel before a noon conference to which he has provided food.
(To be continued…)

Hey Dr. Panda. I also have a family. My wife and I are raising young children and the cost of day care will eat up a big chunk of my wife’s take-home pay if she gets a job. How are we going to make ends meet during medical school and residency?

You’re not, at least not in the classical sense of balancing income to expenditures. The short answer is that you will have to borrow buckets of money, deplete any and all assets you had before medical school, ask for money from your parents, and eventually, after exhausting every other source of credit, perfect the fine art of shifting credit-card balances from one low interest card to another. If you’re lucky the end of your residency will come before Peter realizes he’s being robbed to pay Paul. This will worry you at first, and it still worries me, but one day you will get used to the wolves prowling outside the door and you will accept this as the normal order of things.

You can economize a little, of course, but the kind of money we’re talking about is impervious to your decision to substitute Hamburger Helper for chuck steak. Naturally you will have to tighten you belt but the hit your lifestyle will take depends on what kind of disposable income and leisure activities you have now. You can, for example, kiss expensive vacations, personal watercraft, consumer electronics, and an overtly materialistic lifestyle good-bye. Pehaps this is a good thing but I’d rather live frugaly because I want to, not because I have to.

The trick is to either consolidate or defer your loans during residency to make either a low payment or no payment at all. Another advantage of consolidating is that you can lock your loans in at a very low interest rate. It’s hard enough to live on a resident’s salary without also trying to service your debt.
.
Why do you dislike drug-seekers? It’s not like you’re paying for the drugs and at the very worst you can send them home empty-handed.

Every patient involves a certain amount of paperwork. Generally speaking, the paperwork for a drug-seeker takes just as long as the paperwork for a patient with a legitimate complaint. It’s not as if we can just give the addict some vicodin and send him on his way. Very few of them present with a complaint of “I’m out of drugs and I need a fix.” It’s usually chest pain, abdominal pain, or back pain of some sort and even if you know in the deepest pit of you soul that the complaint is bogus, you still have to go through the motions. Even drug seekers occasionally have legitimate health problems and nobody wants to be the guy who dismissed back pain that turned out to be a dissecting aortic aneurysm. So you see, drug seekers impose a certain burden of unnecessary labor on the whole department. For my part this takes the form of unnecessary paperwork and a significant slice of time I could devote to patients who are really sick.

Not to mention that decent people, and most of us are fairly decent people, naturally recoil from dishonesty. Not only is the drug seeker deliberately lying but he is also scheming to turn us into his pusher, a position that most of us do not relish. I once had a drug seeker accuse me of taking pleasure in exercising my medical power to deny him drugs. In fact, I would rather he went to some other emergency department.

The other kind of patient I dislike are the ones with suicidal ideation. Oh sure, I like treating the ones who made a serious attempt but were foiled by circumstances beyound their control but the ones who made a pathetic gesture of one kind or another without any serious thought of really harming themselves really drive me up the wall. First because, as I mentioned before, they suck up just as much administrative time as a patient with a legitimate complaint and second, because most of them claim suicidal thoughts as a means of garnering attention we play right into their hands, enabling the very attention-seeking behavior that we would do better to dissuade. In a perfect world, we’d toss ’em out and say, “Hey, come back when you can execute a better plan than taking a couple of extra valium because yer’ stinking boyfriend doesn’t want to cuddle.”

But the little girls who take a whole bottle of tylenol are sad. It will kill your liver, you know, something that nobody seems to realize and is not, repeat not, a good gesture drug. You might actually succeed in killing yourself but not before you have time to realize that some coolio sleeping with your best friend is so not worth it.

What’s the biggest misconception among medical students?

Wow. There are so many. Two of the biggest misconceptions are that pre-clinical grades don’t matter and its corollary, that people who do well in the first two years of medical school don’t do so well during the clinical years. First of all, for the purposes of remaining competitive for the match, every single grade you get matters. Sure, you may be at a school that doesn’t give traditional grades but nobody has yet explained to me how an “honors,” “high pass,” and “pass” is fundamentally different from an “A,” “B,” or a “C.” Somewhere, somehow, your the Dean of Students is keeping track of your standing relative to your peers and overtly or covertly, your Dean’s letter is going to spell out your class rank. Good luck matching into Radiology (or some other competitive specialty on which you had set your heart) from the bottom of the class. It’s not that it can’t be done, it’s just that even some people with good grades and good board scores don’t match into the competitive specialties. Why hobble yourself right out of the starting gate?

As for people who do well during the first two years of medical school not doing well during the clinical years, this is an urban myth. You know, like the one about Physician Assistant school being able to cram just as much into their two years of training as medical students do into their four years. Generally, people who do well in the first two years do equally well during the second two years and there is no inherent contradiction in doing so. Most medical students, as they are drawn from the ranks of people who did nothing but study during high school and college, lack the mythical people skills and common sense that are supposed to trump book learning so it’s going to be a wash. You will see that the folks who limped along during the first two years perpetually in danger of dismissal will limp along during the clinical year, passing their shelf exams by the narrowest of margins and sweating every rotation.

Another misconception? That medical school will last forever. Now I know, oh you who have just now suffered through you first exam and are still licking your wounds, that four years can seem like an eternity but after you get the hang of it, let’s say around Christmas of your first year, the time will slip by and before you know it you will be staring Step 1 in the face. And no sooner will you have gotten over your initial shyness on the wards when you will be listening to the graduation speakers and realizing that your days of shirking responsibility are over. Nervous first year medical student to nervous intern in the blink of an eye.

Trust me on this.

Would you do it all over again?

Har har. Not a fair question. I’m almost done with residency (21 months to go) and I can see that it will end soon. Medical training has certainly been nothing like I expected. Harder in some ways and easier in other ways. I never thought, for example, that missing sleep would bother me so much. Who, after all, has not stayed up late occasionally and been tired the next morning. The difference in medical training is that there is no respite. You can get tired but, through some freak of scheduling, still have to work four more twelve hour shifts in a row which, I can assure you, will wear you out. Or imagine you have a Friday-Sunday call weekend and you are not able to get a good night’s sleep on Saturday night. You can’t count on getting any rest until Monday afternoon and you’re just going to have to suck it up.

Eventually you build up a sleep deficit that seems to take more than a good night’s sleep to erase. Not to mention that your schedule will be so irregular that your sleep hygeine, the patterns and habits of how you sleep, will be severely dysfunctional. I worked for years as an engineer waking up at seven, working nine or ten hours, and getting to bed by eleven every night. And I got most weekends and many holidays completely off. I was never tired except anecdotally. By contrast, I seem to be perpetually tired nowadays and my sleep hygiene blows. I can never seem to get a good night’s (or day’s) sleep with any consistency. It’s not working shifts so much as it’s the myriad conferences and mandatory residency activities that always seem to be scheduled on either a day off or for a morning when I could otherwise sleep late.

So that was something I didn’t expect even though I am resigned to it. Working shifts, however, has been a tremendous improvment over pulling Q4 call, something I had been doing for the most of the previous two years.

The “Tired Years,” as I like to call them.

(To Be Continued…)

Moonlighting

I have been doing a little bit of moonlighting lately and I have to say, it just feels different getting paid six times as much for doing the same work. Sorry, it just does. What’s a chore for twelve dollars an hour is decent work for eighty.
.
As one of my readers pointed out, moonlighting in Emergency Departments for residents and non-Emergency Medicine board certified physicians is a controversial topic, primarily because of the supposed contradiction of non-qualified physicians working in a field for which the American College of Emergency Physicians believes that stringent qualifications are required. General Surgeons, for example, don’t moonlight as pediatricians so how can, say, a Family Physician or even an incompletely trained Emergency Medicine resident feel comfortable moonlighting in an Emergency Department? If anybody can do it, after all, why require board certification?

The point is not whether anybody can do it. Anybody can actually do it. Just like anybody can do internal medicine, family medicine, and any of the other specialties provided they have the training and the experience. There is nothing magical about Emergency Medicine. You put your head down, open your eyes and ears (uh, with your head down), and muscle through enough cases where you start to get a good handle on the knowledge and procedures that are typically required of an Emergency Physician. The best way to gain this experience however, and for most people the only practical way, is to complete a certain period of residency training where through a combination of formal didactics and supervised clinical training you gain the experience to handle the wide range of real, honest-to-Allah, potentially lethal patient presentations that you will likely encounter.

On the other hand, since there is a lot of overlap between medical specialties and also because Emergency Physicians have now become the closest thing we have to General Practioners (especially as the office-based primary care specialties start punting more and more of their complicated and thus unprofitable patients to the Emergency Department), there is a lot of basic doctoring going on in emergency rooms. Consequently, many physicians with minimal training can gain the illusion of comfort in that kind of environment. Most emergency departments also see a lot of urgent care where the stakes are low and a couple of vicodin or a prescription for amoxicillin covers a multitude of sins.

But that’s not really what Emergency Medicine is about. Those patients are fillers, people who we are happy to see and get the best care we can possibly give but who are dropped like a bad habit when something serious comes in the door. I work at a very busy, high acuity department but if you walked through the halls and didn’t know at what you were looking you’d think it was a just a busy community health clinic. That’s because the really sick people are in the trauma bays or behind curtains. The people in the halls are just hanging out while their work-up proceeds on autopilot, getting angrier and angrier as they mentally compose the scathing letter they are going to write to the hospital’s Patient Relations Department. We get to them when we can because time is money even in medicine. They are seen as quickly as possible given the regrettable fact that every patient does not get their own personal doctor and nurse to hold their hand and chit-chat while the labs cook.

At my program, we generally do in-house moonlighting, filling gaps in the schedule where we work more as physician extenders than regular doctors. In fact, most of our sanctioned moonlighting is in the urgent care side of our department where we pick up physician assistant shifts (and, it is my understanding, make the same hourly rate) working with the same attendings with whom we work during our regular shifts. The point is that even though I can work my way through most common gynecological, pediatric, or medical complaints and would feel comfortable doing it if I were moonlighting solo at an urgent care, at this stage of my training I would feel uncomfortable, almost suicidal, working on my own in an emergency department. Not to mention that it would be unfair to a critically injured or terrifically sick patient to have someone who was less than qualified in charge of his life. Now, sometimes this is unavoidable. If there are no physicians, emergency medicine trained of otherwise, willing or able to staff a sleepy one-horse emergency department in the fly-blown wastelands of Massachusettes they will have to take what they can get and an experienced ATLS-trained resident or Physician Assistant is better than nothing.

And yet, just because it can be done doesn’t mean it should be done or that it is an optimal solution. The optimal solution is to have formally trained Emergency Physicians staffing emergency departments. Allowances need to be made of course because nothing in this bad old world of ours is optimal. Not only is there a shortage of board-certified Emergency Physicians but many non-Emergency Medicine trained physicians practice emergency medicine and have a tremendous amount of talent and experience in it. (The American College of Emergency Physicians did, in fact, have an extensive period where the old hands who pioneered the specialty could become board certified without having done a residency) However, as money drives everything in this aforementioned bad old world of ours and many of the primary care specialties are not paying what they used to, many physicians see a segue to Emergency Medicine as an opportunity for better pay and better hours, both of which are excellent motivations but not things that should be achieved at the expense of patient safety.

Board-certification in any specialty is just a marker, however imperfect, of qualification. By nature it is exclusionary and a little unfair to the minority of otherwise qualified but non-certified individuals who can do the job. But that’s life. As a guy who has had to suck up a lot to both go to medical school and match into Emergency Medicine, while I don’t think it is unreasonable for a residency-trained physician in other specialties to be able to gain board certification in Emergency Medicine after a reasonable period of training, a one year fellowship with minimal hours and scant didactics structured for the fast track to certification isn’t going to cut it.

Emergency Department Crowding

Let’s face it, many of the patients in the Emergency Department at any given time are not really that sick. Many people show up with complaints that seem fairly promising but turn out to be nothing. I can’t tell you the number of chest pains I have seen that have turned out to be dry holes. Even the patients with serious diseases and dozens of frightening comorbidities aren’t usually so sick that they are in imminent danger of death. They’ve been sick for years and their occasional visits are merely opportunities for the rapidly approaching grim reaper to take his government mandated coffee breaks. But people still come and the conventional wisdom is that these patients use the emergency department because they lack health insurance.

Many of these patients, however, do have health insurance and many have their own doctors. So why, I once asked a patient, did he come in and wait three hours to be seen and then six hours in the department when he had excellent health insurance and is a patient of one of the finest physicians in town?

The answer was surprising because it is so obvious. So obvious that I am almost afraid to mention it for fear that you, my wise and long-indulgent readers, will roll your eyes and accuse me of being a simpleton. As my patient related to me, in order to see his doctor he has to make an appointment which is often weeks to months in the future. On the day of his appointment, even if he shows up on time he will usually have to wait an hour or two because the doctor is always running late. Then he will spend a brief ten to fifteen minutes with his doctor who will order a slew of tests and imaging studies, many of which will have to be completed at a different location. He may, for example, have to drive across town for a CT scan and it is usually scheduled for a different day, often weeks in the future.

Then, as my patient explained, he must wait several weeks for his next appointment where his physician will explain the results and finally initiate either definitive treatment or, as is often the case, referral to another specialist who will repeat the time consuming process.

I know this is true on a personal level. I recently had a colonoscopy (everything is fine, by the way and they can still write “no significant past medical history” on my chart) and from my inital visit to my internist to finally getting the results of a post-procedure CT scan from the gastroenterologist took close to six weeks and four separate trips each of which sucked up a big chunk of my infrequent days off.

My patient also confided to me that even getting the results of studies and imaging was not guaranteed. Although we are all quick to relay bad news, apparently follow-up is not that pressing to many physicians if the results are normal. (I still have not actually been infomed of the results of my CT scan and only know it was normal because I walked across the hall and asked the radiologist to look at it for me.)

Consider now a visit to the Emergency Department. First, my patient did not need an appointment. While it is true that he was triaged to a low acuity and had to wait a while, at certain times of the day the waiting times are not that much longer than the typical wait for his delayed primary care physician. Second, the lab tests he needed were drawn on the spot and the results reported within an hour even though he was a low acuity patient. Our goal, you understand, is to discharge or admit as fast as possible. Likewise his imaging studies were obtained, read, and reported quickly. Finally, if anything serious has been discovered he would have been admitted within hours. More importantly to my patient, since everything was all right he knew fairly quickly instead of biting his nails for a couple of months.

As to the cost, even though the same complaint in the Emergency Department costs four times as much as it does at his primary care physician’s office, my patient has insurance and the cost of the work-up is of little concern to him because it costs him roughly the same either way, especially considering that he only has to make one visit versus three or four.

So you see, Emergency Medicine is a victim of it’s own success and, as Emergency Departments begin to look more and more like self-contained hospitals-within-hospitals complete with admitted patients (waiting for rooms, you understand) and even critical care patients being managed for most of the initial five or six hours in which everything important is usually done, the problem of overcrowding is only likely to get worse. Add to this the growing reluctance of office-based practices to handle really complicated patients when it is ridiculously easy to divert them to the Emergency Department and a steadily worsening shortage of primary care physicians, while the situation is no doubt great for my personal job security it is hardly the best way to do business.

Or maybe it is. Maybe what people want is the speed of the Emergency Department, or at least some semblance of it. The problem is that maintaining the infrastructure that lets us move patients quickly is also horrifically expensive.
.
Pandictionary

Come on now. Surely someone has some original slang. I repeat, to be included the word has to be truly original or at least funny enough where it doesn’t matter. Again, I want to give proper credit. I believe I invented “polybabydadic,” “dependocracy,” and “homo polycomorbidus.” The rest are unattributed because I truly do not know form whence they came.

I’ll be taking a blogcation until the the end of this month.  Keep checking back and as always, don’t forget to look back at my extensive archives.

On another note, I’m looking for new and unique medical slang to put into the Pandictionary. I will give proper credit and remember, it has to be original.  “GOMER,” “CTD,” and the like are well-known and done to death so we’ll skip those.

Feel free to email me at [email protected] if you have a particular topic or question you would like to see discussed.

Ever considered any other specialties?

Sure. Everyone does. It is the rare person who arrives at medical school with his future planned to the last detail. Even people who, perhaps through prior work or shadowing experience, arrive with an overwhelming desire for one particular specialty usually change their minds. Orthopedic surgery, as an example, is a specialty which seems so appealing to many first year medical students that it seems half your class plans on matching into it. Once they see the level of commitment required as well as the lifestyle of the residents most decide that their passion was actually a polite interest and match into something else.

I’m sure, for that matter, that everybody has an occasional bad day where the prospect of working at a specialty like Radiology, one with minimal patient contact, can seem very appealing. Now, I know that radiologists can see patients in some settings but if you divide the medical profession into those whose job requires them to routinely stick a finger in a patient’s rectum and those who don’t, radiology is the king of the non-probing careers.

You have to make up your mind about a specialty much sooner than many believe for the simple reason that some are fairly competetive and, all other things being equal, the the guy with the highest board scores is going to land one of the few highly coveted dermatology residency positions. This means that if you are even thinking about dermatology, otolaryngology, urology, or radiology you need to start studying hard from day one and get both excellent grades and exceptional board scores. Are there exception to this rule? Sure there are. I will no doubt be innundated with comments from people relating how a friend of a friend of somebody’s brother matched into dermatology at the bottom of his class after having taken Step 1 twice for failing it the first time.

I also know a guy who was struck by lightning. Spare me.

Let me state Panda’s Axiom Number 1: At the beginning of medical school, and allowing for the questionable admission who managed to matriculate through a combination of luck, computer error, and bureaucratic inertia, any medical student can match into any specialty. Medical school is not hard per se but merely long and tedious. Because (with the aforementioned exception) medical students are drawn from the top one percent of the population for intelligence, there is nothing keeping anybody in your class from being a neurosurgeon except the desire and the willingness to work for it. However, as there is a good deal of self-selection out of potential medical specialties, medical students tend (tend, damn it!) to tailor their efforts towards the level of competitiveness of the specialties that they feel would both interest them and for which they believe they have a reasonable shot with their study habits. I knew early on that I was not destined for a career in neurosurgery both because I had no interest in it and because the amount of work required to get excellent grades was more than I was willing to give. It’s mostly as simple as that.

I will confess my great ignorance when I was applying to medical school about the structure of the medical profesion. I had only a vague idea what specialties where available let alone an idea of what I wanted to do except the nebulous notion that I would end up in internal medicine or family practice. True to pre-med form, the salaries that these specialties promised, salaries that I would view as a personal failure today (see my adventures in Family Practice as detailed in previous articles), seemed a princely sum for a mere seven years of training. We underestimated, you understand, the amount of debt and exactly what it was we were getting into. I didn’t even know that Emergency Medicine was a distinct specialty and never even considered it until the end of third year when, one by one, I decided against every specialty in which I rotated.

Sometimes it’s a process of elimnation.

So what specialties were you sure you wouldn’t do?

Surgery, for one. I admire and respect surgeons but after two months of my third year surgery rotation any small desire to be a surgeon that I may have ever had was beaten out of me. Sure, it’s a cool specialty, perhaps the coolest of the bunch as it combines medicine with dramatic interventions but after seeing how the surgery residents were treated, not only by their attendings but by each other, I said, with gusto, no mas.

Surgeons eat their own. It’s part of their culture to treat each other disrespectfully during training. Whether this is necessary to train a surgeon cannot be known. It’s just the way the system has evolved and it seems to be structured to keep residents perpetually tired and irritated at everyone and everything. If I ask a neurology resident for his opinion on a patient, I will generally have a friendly conversation where he will impart not only his opinion but a little bit of knowledge which is commonplace to him but perhaps new to me. If I ask a surgery resident I am likely to get rolled eyes, condescension, and the not-so-subtle impression that I am an idiot for not knowing as much about abdominal surgery as I’m supposed to. This attitude is extended to their own subordinates. The mistreatment of surgical interns is legendary and if you see some unhappy miserable fellow skulking around the hospital he is probably one of theirs.

So you’re saying that surgery programs are malignant?

Residency programs are often labled as malignant but there is more to it than working long hours and pulling a lot of call. An important feature is how the residents treat each other. In my program, if an intern asks me for some guidance or help with a procedure I don’t cop an attitude and get snotty as I have often both seen and experienced while on surgery rotations. We do not hold it against somebody that they don’t know something and as long as they’re not asking stupid or repetitive questions, they deserve respectful consideration. To berate someone for not knowing something, to throw him to the wolves, so to speak, as appears common in surgery programs is to act contrary to the spirit of residency training which I am told is ideally supposed to be some kind of multi-orgasmic Socratic interlude.

Apparently, many surgery interns are so tired and beat down after the first few weeks of residency that they lose the ability to be civil even to each other. As the years go by they build up a stock of resentment and perpetuate the malignant tradition because it is human nature to validate our own suffering by making others suffer. It takes leadership to break this cycle and as medical schools neither select for nor make any particular effort to instill leadership, you basically have a bunch of people in charge of subordinates for the first time in their lives who haven’t a clue what to do.

Come on now. Isn’t “Leadership” heavily stressed by medical school admission committess?

Leadership is a buzzword, nothing more. Most extracurricular activities are really hobbies in which no one is really in charge of anything. In other words, if your decisions have no consequences for anyone, and show me an extracurricular activity where the participants had anything important at stake, you are not a leader but an enthusiastic participant.

As for other specialties, I decided against OB-Gyn pretty early. It’s a decent specialty but the hours and lifestyle, even after residency, are ridiculous. The only attendings in a hospital at all hours of the day and night are the Emergency Medicine attendings and the obstetricians. But the EM guys are working shifts. The obstetrician has a day job to which he must go after staying up all night delivering babies. Like pediatrics (which suffers from low pay), OB-Gyn almost has to be a calling. You can be a Family Physician or an internist and treat it like a nine-to-five job but you have to love your specialty to be happy as an obstetrician.

Not to mention that they get sued like nobody’s business which has to hurt, especially when some of the mothers suing for bad outcomes smoke, drink, do drugs, and otherwise take no responsibility at all for their contribution to the outcome. Obstetricians are doctors, not miracle workers. Bad protoplasm combined with ignorance is a deadly combination for babies, both in and ex-utero.

I never considered pediatrics. Having my own children has given me a running start at disliking other people’s children so I just don’t have the temperament for private pediatric practice. We see pediatric patients in the Emergency Department but the focus is more on making sure they have no serious illnesses than building a relationship with the parents, something that is essential for private practice pediatricians. To be honest, many of the parents we see are totally unsuited to raise hamsters let alone children and it makes my blood run cold just thinking about it. Unfortunately, the predominantly single polybabydadic mothers who we see, themselves the third or fourth generation of teenage single mothers, haven’t a clue about good parenting. Parenting skills have to be taught and there is a huge knowledge gap which is getting larger every generation.

I’m talking basic stuff like how to roast a chicken and cook up a mess o’ greens instead of raising the little bastards on Froot Loops and Pop-Tarts.

My favorite lie is the insistence that, despite their sociopathic son having gone on a crime spree often involving murder and rape, everybody is a good parent and it is some random act of nature that makes some children into criminals.

Anything you don’t like about Emergency Medicine?

Naw. It’s pretty cool. But I am early in my career and sometimes it’s hard to separate the trials and tribulations of residency from the specialty. As you know, I am a new second year resident so I still get a lot of guidance from our attendings. This is both necessary and appreciated (and we have stellar attendings at my program including some of the pioneers of Emergency Medicine) but I can sense that I will enjoy my job a lot more on that day when I become an attending myself and am granted the double-edged sword of complete responsibility. One of the worst aspects of residency (but necessary, I repeat) is the constant supervision and criticism. Compound this with a work environment where everybody from the janitor to the patient to the attending has a front-row seat to our screw-ups and you can see that working as a resident in the Emergency Department can be like being in a pressure cooker.

The things that many people cite as reasons to dislike Emergency Medicine are actually part of the appeal of the field to me. My creationist friends would love our specialty because we prove Darwin wrong every day. Survival of the fittest my ass.

Any advice to people considering a career in medicine?

My whole blog. Other than that I’d think about it carefully and try to get beyond the undeniable coolness factor of the profession. It’s a hard road and maybe you won’t like it. Hell, you won’t like a lot of it. My wife once explained to me why a lot of marriages don’t work, namely that the person you are attracted to when you are 18 is not necessarily the same kind of person you will be attracted to when you are thirty. It’s kind of the same in medicine. Because of the convoluted admission process, most people have to commit to a medical career shortly after high-school. But you are going to be a different person when you are in your early thirties and finally finished with training.

There are, in fact, other perfectly decent careers out there to which you may find yourself better suited. I highly recommend both the military and engineering which I know from personal experience to be both honorable and useful and neither of which require anything close to the training time. As for other medical careers, I guess we’re supposed to spout the conventional wisdom that being some kind of mid-level providor is just as good as being a physician but I won’t because I don’t believe it. Personally, and this is one of the few times you will hear me issue a caveat, personally, meaning me personally and not you, the idea of being anything other than a physician never occured to me. If you strip away the scope and responsibility of being a physician it’s just a trade, not a profession, and I would have as soon stayed in engineering.

(Not really medically related. I’m sort of busy this month and don’t have the energy to really organize my thoughts. My apologies but if this kind of thing will make you get all hissy then please come back to my blog in a few weeks when I expect to have more time to write a friggin’ thesis.-PB)

Who has had the greatest influence on your life?

My father, hands down, no question about it, of whom I have only good memories and who raised all of his children right. My father immigrated to the United States in the 1950s and, unusual for a Greek, after a one-day stay in New York and a ten-day bus trip ended up in Idaho. I say unusual because Greeks tend to clump together and form their own communities (as anybody who has been to Astoria can tell you). He had an Uncle in Idaho but let’s just say the state is not exactly a hotbed of Hellenic culture. My father was an engineer and an officer in the United States Navy. If I am half as successful or half as respected as my father when I die I will have had an exceptional life.

My wife, of course. I was nothing when I met her. Just a washed out college student. And I don’t know that I would have had the drive or even the desire to succeed at anything if it wasn’t for the universal desire of good men to impress their wives. But the last six years have been very hard on her which is probably a story I should have been telling you, oh my patient readers. She gave up a lot of security to let me go to medical school. I wouldn’t say we were rich back then but we were not teetering on the brink of financial ruin as we are today. Poverty in marriage is something you expect at the begining, not after sixteen years. I know intellectually that we will do all right in the end, the Good Lord willing and the creek don’t rise, but eight years is a long time and you can only rob Peter to pay Paul for so long before Peter gets wise. We knew it was going to be tough, of course, and it seems like a hundred years ago when we first sat down to plan out the long years of medical school and residency. It didn’t seem as daunting back then and it has been nothing like we expected. Frankly, for my wife it’s been like trying to stuff a tiger in a sack. It can be done but it doesn’t stay sacked long. Without giving away too many personal details, those of you with a family need to consider carefully what you are giving up and what it is going to cost.

My wife’s philosophy is not to let us think too hard about the future. You’ll drive yourself crazy if you do. We have no future. Medical school and residency is so demanding of you and your spouse that, unless you are independently wealthy, it’s best to just muddle through, living one month at a time until, almost by surprise the years have melted away and the end comes into view. This is difficult for both of us because we have always been forward thinking people.

Who are your heros?

Ronald Reagan comes to mind. That guy was a lion. Perhaps the best president and one of the greatest Americans in history. He was a man who came at exactly the right time as those of you who remember the malaise that had settled upon our country after Viet Nam, Watergate, and the lackluster Carter administration can attest. He also brought the Republican Party to the masses wresting it as he did from the so-called “Country Club Republicans.”

I also like Rush Limbaugh. I have been listening to him since he got started almost 17 years ago. Rush made conservatism cool. I mean, there have always been conservatives in American politics but since World War II they tended to be marginalized. Certainly conservative opinion was almost nowhere to be found in the mainstream with the possible exception of The National Review. Just as I am trying to give residents the conceptual framework to discuss their dissatisfaction with the current residency training system, Rush gave conservatives the vocabulary and the awareness to make their opinions known….which explains his popularity. Conservatism is nothing more than common sense writ large and even in this propagandized and in many ways excruciatingly silly age, most people have a deep core of common sense. He’s also a very funny guy, a brilliant satirist, and always highly entertaining. (The reason liberal talk radio has never really caught on is that most liberal talk show hosts can never expunge the bitterness and ill-humor that characterizes the political left.)

I am a great admirer of President Bush and Vice-President Cheney. Mr. Cheney, in particular, is perhaps the most intelligent man in Washington and it is a shame that he is not the kind of guy who could get elected President in our above-mentioned silly and superficial age.

As for heros from sports, well, I am almost completely asportic. I have absolutely no interest in professional sports of any kind and I think the emphasis we place on them as a society is both silly and inexplicable. I understand that the gridiron can be both a metaphor for life and war but…and maybe I just lack imagination…it’s just a leather ball that a bunch of guys are trying to run down the field. I can understand the player’s motivation because they get paid a lot of money to do it but how this translates into anything meaningful for the spectators is one of life’s great mysteries. I’m not against professional sports, and I have no objection whatsoever to atheletes making huge salaries to play what are essentially children’s games, but I just don’t have an interest.

Except for the Olympics. Every four years I go sports mad and, like the salmon, swim furiously up the spectator river to spawn before returning to the tranquility of the deep sportsless ocean. There’s just something about it. My wife and I also get a big kick out of the pagan, Cirque-du-Soleil-inspired opening and closing ceremonies. Proof that bad taste is an international phenomenon. They’ve been trying to upstage Hitler since 1933 and I think the Chinese might finally be the ones to do it.

As for actors, musicians, and the like, with the exception of John Wayne and Charlton Heston they are all pretty much interchangeable. I certainly don’t care about their opinions on anything important simply because they are trained performers. How the ability to play the cello or memorize lines translates into geopolitcal or scientific expertise is a mystery. A lot of my conservative friends have trouble paying to see movies featuring extremely liberal actors but what does it really matter? If I vetted entertainers for political opinions who would I have left? Unfortunately, the talent that allows someone to turn something silly and meaningless into entertainment also means that a lot of entertainers are somewhat silly and meaningless in real life. They can’t help it. The class clown (I went to high school with Greg Kinear, by the way, who was the class clown) or the girl who sings the lead in every high school play are not the kind of people who operate in the concrete world and they don’t necessarily gravitate towards conservatism which is not an ideology for wishful thinkers. So you have to give them some leeway.

Except for Whoopi Goldberg. Good Lord, does that woman grate. As far as I’m concerned she ruined every episode of Star Trek:The Next Generation in which she was featured. I have Tivo just so I can fast-forward through her scenes and I think in the wonderful internet future where we can download the Library of Congress in a couple of seconds someone could go back and seemlessly edit her out of everything.

Any Movies You Really Liked?

I just watched Mel Gibson’s “Apocalypto”. A wonderful picture and not at all the preachy, “White Man Bad, Indigenous Meso-American Peoples Good” slobber-fest I thought it would be. Hey, those Maya were some vicious bastards who cut off their captive’s heads just fer’ fun and sent their decapitated bodies spinning down the steps of their temples, all completely independent of the European mind-control that is usually blamed for recent third-world atrocities.

Not before cutting their hearts out, mind you, which leads me to my only objection to the picture. In one scene the high priest cuts out some poor son-of-a-bitch’s heart and shows it to him. Son-of-a-bitch looks at his heart in terror and then dies. Come on now. Would you really live long enough to look at your heart if somebody ripped it out of your chest?

Only Bruce Lee could do that.

But other than that it’s terrific. A really solid story coupled with a glimpse of a world that we have never seen depicted on the screen, at least not with such realism and attention to detail. Does Mel Gibson take liberties? Sure he does. The Maya weren’t as bloodthirsty as the Toltecs and the Aztecs or as Despotic as the Incas but he’s making a movie, not a documentary and human sacrifice was practiced by various meso-American cultures at different times. Additionally, many of their cultures were imploding by themselves when the conquistadors arrived. Cortez with his 500 soldiers could hardly have subdued an empire that was not already on the verge of collapse.

The guy can make movies. The Passion of the Christ was excellent although I hesitate to say I enjoyed it, or that I would watch it again. It was a little too intense and since I am from the South and the Bible-belt to boot, let’s just say there wasn’t a lot of the usual popcorn eating and chit-chat while it was being shown. We’re all hypocrites, of course, but that doesn’t mean that we don’t believe, a concept that is apparently lost on the entire entertainment industry with the exception of Mr. Gibson. I assure you that thoughtful movies on any number of biblical stories would clean up at the box office if they were presented in a way that was neither patronizing nor written at a teenage level.

I took my four-year-old and seven-year-old to see Disney’s Ratatouille. It was completely enjoyable and believable, which is kind of the point when you’re making a movie about a rat who aspires to be a chef. The kids loved it and were glued to their seats which is not always the case at children’s movies. My daughter likes to help me cook and the funny thing is that you can learn a lot about cooking from the movie. Typical of Disney, while it is a children’s movie, it was not aimed exclusively at children. I can hardly watch movies like Spy Kids which the kids like but have nothing in them at all for adults. They’re just silly which Ratatouille was not…but it is…cause it’s a rat…but it’s believable. The only better Disney picture we have seen lately is “The Incredibles”.

Transformers, which I saw with my oldest son, was fantastic. It’s not “Chocolat” or “The Unbearable Lightness of Being” but the fact that it’s not some arty film in which nothing ever happens except a lot of angst and nihilistic dialogue is a definite plus. Nothing worse than a movie were nothing happens and you dislike all the characters intensely. Give me a good robot movie with heroic Special Forces and lots of things blowing up any time over one that is a chore to watch and requires work to appreciate. Hey, making it entertaining is the directors job. If I have to force myself to enjoy it he has failed.

Not to say I don’t enjoy the classics but they’re classics because people want to watch them.

What does your wife think about doctors now?

The magic is gone, I mean now that she knows what’s involved in our training. We’re just people, after all. Okay, generally more intelligent than most people but still people with all of the faults and defects of any other people. I know she trusted doctors a lot more before I went to medical school. Our pediatrician completely misdiagnosed our newest child with “Reactive Airway Disease” and we tortured her with nebulizer treatments for six weeks before my wife got fed up and demanded the antibiotics which fixed the problem (a croupy, intermittant cough) in about three days. The conventional wisdom seems to be not to give antibiotics to sick kids but in this case the doctor got caught up in his dogma.

She also recognizes all of our tactics, including the “brush off” and the “buck pass.”

On the other hand she has developed some unexpected sympathy for us, especially now that she knows how the business works. My wife knows, for example, that most physicians don’t have all day to chit-chat and they appreciate a patient getting to the point of the visit. A lot of patients don’t realize this and think we have all day for them. In the normal working world, everybody spends some of the work day in idle conversation, surfing the internet, or just pretending to work a la Office Space (another very funny movie) but this is not the case in much of the medical world. When the Emergency Department is busy, for example, we tend to mercilessly redirect rambling patients, something that the older generation who expect their physicians to listen silently for as long they care to talk, neither understand nor appreciate.

It’s not rudeness but the very real demands of the schedule and fifteen minutes wasted in the morning is going to be paid back somewhere else with some other patient who may need the extra time.

My wife sometimes says, when I am not the pillar of stoicism that men are expected to be, “I can’t believe you were a Marine.” Now, when I do something dumb or fail to grasp a concept which she has to patiently explain she says, “I can’t believe you’re a doctor.”
.
But we’re not perfect and while I think I’m a good doctor, I’m fairly average when it comes down to it. I have quite a few collegues who are an order of magnitude smarter so you see that perspective is everything. No doubt our patients think we are all Wiley E. Coyote-esque super-geniuses but among ourselves there is definitely some variation.

(To be continued…)

Is there anything you like about residency?

Well, it has it’s moments. I’m the the ICU senior resident this month which is kind of cool, especially because this is one of those rotations where you get paged to make real decisions and not, as is often the case as an intern in the ICU, to be guided to the right decision by the experienced ICU nurses. Not to say that this doesn’t happen but I do know a little bit more than I did two years ago (thanks in part to ICU and ED nurses) so even though the call is just as tiring as any call it’s not that bad. We still work for peanuts but I certainly don’t go home in the morning feeling like I was nothing but somebody’s cheap, place-holding labor. And we have a great set of attendings who give us a lot of latitude to make decisions.

It also affords the opportunity to do a lot of procedures and I haven’t done enough lumbar punctures, for example, to get tired of doing them.

Generally, however, with the exception of working in the ICU and the Emergency Department I have not liked residency all that much. I don’t think anybody does but the culture of medical training makes it very difficult for people to admit that they dislike any if not most of it. People complain about being tired of course but nobody wants to appear weak. As I am confident in my masculinity and so totally not into any of that macho bullshit I can, with confidence, state that I hate being deprived of sleep, treated poorly by people hiding behind their credentials, and working for taco jockey wages. If that disturbs anyone or if you feel that makes me a traitor to the Cult of Aesclepius, well, that’s your lookout. Deal with it. The fact that people have put up with this kind of thing for so long is the real tragedy. But that’s what you got when medical schools were full of people with no other life experience but the slow slog to becoming an attending. Things are different now. Medical training is no longer a monastic experience reserved for young, single, white men. Many of us have families and are not willing to sacrifice them to make the traditionalists feel good about themselves. This explains the popularity of the so-called lifestyle specialties with medical students and the relative unpopularity of specialties that guarantee brutal hours and divorce.

The key point here is that you cannot put your life on hold and say, “I will take my son fishing when I am done with residency.” Those four, five, or six years are precious and once lost are never to be recovered. And that is why, oh you who long for the good old days when residents kept their mouths shut and were prisoners in the hospital, I resent call and pointlessly long hours. It’s like theft. The two extra hours you keep me every evening which contribute almost nothing to my training, taken as a whole, are a large portion of the time I could spend with my family. If you can’t understand this or think that a regard for family disqualifies me for the medical profession, well, you can keep the motherfucker…and lament mightily the flight of otherwise decent, intelligent people from your malignant residency programs.

Now, realistically, as a third-year resident I have it pretty good. I work shifts and while I am worn out when I come home, I get plenty of time off to rest and recover. And while this may not be universal, at my program our attendings work hard to teach us and only ask that we bring our so-called A-game when we are in the department and charge hard for the entire shift. It takes some getting used to but that’s why I like Emergency Medicine. We work towards a goal, we work harder than anybody in the hospital, but I can tell my wife when she can reasonably expect me to be home. Most residency programs could be structured like that if education were the primary goal which is sadly not always the case.

How is Residency Different than the Marines

I compare the two often but mostly facetiously. They are not really similar. Being a Marine Infantryman is several orders of magnitude more difficult than being a resident. Memory being what it is I tend to forget how hard it was to hump (march) twenty miles with a ninety pound combat load or what it was like to be cold to the marrow with no expectation of going indoors in the near future. Residency has never once brought me even close to the limits of my mental and physical endurance, even taking into account that I am twenty years older now and, to be charitable, no longer the fine physical specimen that I used to. I complain about residency but it’s generally because I am annoyed by a lot of it. Some of the things we did in the Marines were so difficult that they were almost beyond rational complaint. So bad that all we could do was grimace and say, “Ain’t it great to be Marine?”
.
Marines do whine and bitch about things of course, but mostly about the petty indignities and bad luck that follow the infantry like a plague. When things get really bad we just suck it up. I remember a training operation where my unit came ashore after a twenty mile ride through heavy seas on our unit’s twin-engine boats (my unit was the designated small boat raiding company for the Battalion Landing Team). These boats were modified Boston Whalers and had enough power to jump from wave top to wave top. After a harrowing launch from the well deck of our ship we spent the next hour getting beaten to pieces as we thrashed through the moonless night towards Sardinia. Not only was it bitterly cold (although it didn’t seem that cold while we staged on the flight deck) but the spray soaked everything and I had the wind knocked out of me every twenty seconds or so. Clinging grimly to the rails we finally got under the lee of Capo Teulada and, after a brief run through smooth water, beached the boats and literally crawled ashore as hardly anybody could stand.

An hour into the operation with five days to go most of us had already taken a beating the likes of which many of you cannot imagine. But we unstrapped the guns (I was the Mortar Section Leader at that time), shouldered our packs and moved out for our objective several miles inland. What else could we do?

So my point is that physically and mentally, being a Marine Infantryman is a good deal harder than being a resident. We may complain about being tired but I have never actually gone more than 36 hours without sleep as a resident and at the end of it I knew I could get some sleep in a nice, comfortable bed. As a Marine you often have nothing to look forward to after a week in the field but another week in the field and an uncomfortable couple of hours of sleep, on the ground, with nothing but a poncho liner for warmth. Try thinking coherently after three days of sleep deprivation. What keeps you going is self-discipline and the sure knowledge that if the Marines ever lose their reputation for toughness it won’t be because of you. We’re very idealistic that way.
.
Sleep deprivation is required for combat operations. Our military is not that big, especially the pointy end of it, and what we lack in numbers we have to make up in mobility and lethality. That’s just a fact of maneuver warfare and we should train under the same conditions that we fight. Sleep deprivation is not required for medical training. Very few praciticing physicians pull Q3 call or work 100 hours a week doing the kind of labor-intensive administrative tasks that are allowed to exist in the inefficient residency training system.

But I digress. I want to also add that in the Marines, if you complain about how hard it sucks (and in fact we sometimes refer to the Corps as “The Suck”) nobody thinks less of you. You’d have to be a retard or a kiss ass to pretend everything is hunky dory. Of course we also laugh at the complainer and say, “Oh well, I guess it sucks to be you” but as long as that man carries his weight and charges hard when required no one thinks less of him. In the medical world, however, to even suggest that you’re tired of pointless bullshit and would prefer to go home is to invite screeching and hand-wringing from the usual cadre of zealots who are flabbergasted, totally flummoxed, that anybody could utter one single criticism of their precious career.

What Kind of Health Care System do You Favor?

I favor a Cuban-style approach. First, we need to abolish political parties and if necessary imprison, exile, or execute politicians who refuse to accept the new order. Then we should severly curtail the traditional civil liberties that we currently enjoy. I’d start with the press and shut down newspapers and television stations that did not support the government. For good measure I’d gradually abolish private ownership of print and broadcast media turning these into propaganda organs of the state. I’m sure we wouldn’t have to execute too many reporters before they fell into line. Maybe establish re-education camps for those who don’t quite get it.

We would also need to get rid of freedom of speech and the right to protest because these kinds of things are messy and make running a modern utopia impossible. Not to mention that it can be embarrassing to the Leader who is, after all, a perfect father to his people. Religion is unessential and unless it can be corrupted to serve the needs of the Party we can ban it too. It’s just an opiate for the people and restricts our ability to condition them for obedience. We can’t put God in a concentration camp so we will need to make the people forget about Him. A good start would be giant portraits of our Glorious Leader along with other heros of the revolution. You know, to give the people somebody to respect. Oh, and marching, lots of marching. Lots of parades.
.
Poverty is also essential. It’s too hard to keep our hands out of the economy. Besides, we know better than anybody else how to run things. We have college degrees. How hard could it be? At least we can ensure that everybody is at the same low level of poverty. It is a lot more fair that way and the people will not be envious. Envy is bad. Inequality is bad. But party members do deserve some perks. Running a country is hard work, harder than cutting sugar cane, let me tell you!

We also need to keep people from leaving. If we lived on an island it would be a lot easier but maybe we could fortify the boarder and put guard towers every few miles or so. It’s regretable that we don’t have 90 miles of shark-infested ocean to keep people honest but we have to work with what we have.

Oh, and we can have free health care. Nothing elaborate, mind you. Just some low level primary care. What are people going to do, complain?

(To be continued…)

Why do you complain so much about residency and medicine? It’s not as if you, personally, can do anything about it and besides, aren’t you done with call and most of the other less than savory aspects of medical training?

Like I always tell people, this blog is not about validating any particular point of view (except mine, of course). I call them like I see them using the occasional foray into satire to highlight what I regard as some of the problems of medicine and medical training. Do I expect that my blog will have any effect on the great storm about to break on us all? Of course not. I am just one guy with a little blog on a little patch of hard drive somewhere on the internet tundra and my thousand or so visitors per day hardly make a stir in the vast expanse of the medical world. Still, change is coming. You can feel it in the air. The frustration in the medical profession hangs thickly around us and I am not the only physician to sense this.

What are some of the Frustrations?

They are legion and one hardly knows where to begin but malpractice has to be at the top of everyone’s list. Protestations of various oleaginous lawyers and policy experts to the contrary, litigation and more importantly, the threat of litigation has a profound impact on how medicine is practiced in this country and its increasing cost. While the actual cost of payouts in malpractice suits is fairly trivial compared to the huge amount of money changing hands in the medical industry, the behaviors engendered by the threat magnify the cost tremendously. Can I quantify the percentage of care we deliver that is wasted on so-called “defensive medicine” (that is, medical practices designed primarily to protect us from frivolous suits)? Of course not. One man’s defensive medicine is another man’s justifiable dilligence. On the other hand as I have eyes I can see that we spend a great deal of money in the hopeless quest for perfection, perhaps the worst place to spend money as the incremental increase in health this buys us is hardly worth the tremendous cost to achieve it.
.
The fact that I can’t put an exact dollar figure on purely defensive medicine does not mean that there is no problem. Certainly the impact is greater than the combined cost of malpractice insurance and lawsuits and just as certainy if we killed all the lawyers and allowed common sense to work its way back into health care we would save a lot of money in the long run.

Common Sense?

In a perfect world, the public would accept that medical care entails risks and the money we spend protecting them against unlikely consequences would be better spent on medical care that makes a difference. Somebody pays for the drunks that detox in the Emergency Department rather than the police drunk tank, for example. Maybe it’s hard to quantify the cost but protecting these patients from the unlikely risk that they will aspirate vomit takes staff and facilities out of service for other productive medical uses. And the money spent on exclusionary workups which have little to do with the chief complaint has to come from somewhere. Since very few people actually pay for their medical care directly and physicians are under a great deal of pressure to avoid getting sued, there is no organic incentive for anybody to think about cost.

Which leads to another frustration for physicians, namely that while on one hand non-medical adminstrators have increasing influence on how doctors practice, they are not exactly sharing the liability. It is perfectly reasonable, for example, for an administrator to try to curtail the use of expensive studies where they are not indicated. On the other hand the administrator doesn’t provide much cover for the physician who knows perfectly well that he can practice perfect evidence-based medicine and still be dragged through a malpractice trial in which his professional reputation,livelihood, and assets are put in jeopardy.

Yeah, but aren’t doctors just complaining a little too much?

Well, everybody complains about their job. And everybody has to deal with the bean counters. But as the economics of medicine are often at odds with the practice of medicine, there is an adversarial relationship between doctors and the accountants. As I said, controlling costs is perfectly justifiable and in a perfect world we would know with certainty how much to spend on every patient. However, even without the uncertainties of defensive medicine, it is not possible to fit every patient into check boxes and standard forms. Sometimes we have to write outsides the allotted area. That’s sort of the point of having physicians and not self-service computer kiosks where patients enter their symptoms and receive exactly the treatment they need with no wasted effort or money. Now, it may come to that in the future as mid-levels and lower level providors are pushed into the breach to stem the onslaught of the aging baby-boomer hordes, armed as they are with their horrific powers of entitlement and inevitable “free” health care, but the public is going to suffer. Not that most will care or know the difference. They will be getting substandard but free health care. Huzzah!

Besides, physcians with their extensive education and abilities are always a convenient scapegoat for politicians looking to redirect the anger of the mob.

Paranoid, aren’t you?

Not at all. But it is easy for anybody looking to curry favor with the electorate to attack physicians. The public believes that we are all multimillionares without a care in the world and, as a class, too smart for our own good. Disliking someone who is wealthier and smarter than you is a primal urge very common in both the trailer parks and the halls of academia, two disparate places that never-the-less share some of the same provinciality and the overbearing confidence of ignorance.

The fact, for example, that even the lowest paid physician generally has to struggle through at least seven years of exhausting training and that he might just be worth his salary never occurs to either group.

Another thing that should bother everyone in the health care industry is the concept that health care is a right and needs to be provided for free. The insanity of this concept is obvious. Rights do not have to be provided, they exist independently of governments and while they must be occasionally secured by either war or revolution, they are not a commodity to be provided to the public. Nobody’s has to work a twelve hour shift at the Department of Free Speech to keep the dissent flowing.

Medical care, on the other hand, is a service provided by people who expect to get paid. And will get paid except for doctors whose compensation under inevitable government run health care can be legislated as low as the congress thinks it can get away with. What are doctors going to do? Go on strike? Of course not. We’ll just suck it up because our ethos forbids us to harm, even by ommission, any of our patients. Nurses on the other hand wouldn’t put up with an attack on their salary for a minute and as a group, know how indispensible they are and leverage this effectively. And they have pretty good juice with the public. Imagine a suicidal politician proposing that nurses and other hospital workers need to accept less pay for the public good. That man would be tarred, feathered, and run out on a rail.

Money, money, money! Is it that important?

Of course it is. Money drives everything. Even your disdainful college professor preaching the gospel of poverty can only do so because he has waged bureaucratic war for his tenured position, a position which may not pay as well as some other careers but one from which it is almost impossible for him to be dislodged and which provides enough income for him to turn his nose at other people’s money. He’s not working for free and neither does anyone else. This is not a bad thing, either. Societies that try to do away with the individual profit motive are dreary, impoverished places because what works in a small commune or a kibbutz cannot be extrapolated to an entire nation. If there is no benefit to working hard, and no risk in not working, the freeloaders, Alexander Zinovyev’s famous “Homo Sovieticus,” tend to take over.

So the disdain for money is fairly unhealthy even in the medical profession. There has to be an incentive for people to work hard and long. You will always have people willing to be physicians of course, but their enthususiasm for seeng that extra patient or coming in from home to operate on a patient on the weekend will diminsh as the rewards for doing it evaporate. Medicine is a rewarding career independent of money but it ain’t that rewarding. It can be something of a grind as I’m sure many Family Medicine physicians would probably tell you after their thirtieth patient of the day.

Speaking of frustrations, there is probably none bigger than the way physicians are reimbursed. The system is crazy and I have only had a small taste of it. They call medicine a business and patients customers but it’s a strange business with the oddest customers and that’s no lie. (Is medical care a right or a customer-driven business?) First of all, many of our customers not only don’t pay a dime but the very idea that they should have to pay even a fraction of the cost of their care never enters their heads. If medicine were a business this would be called theft. At least shoplifters know they are stealing and try to hide thier crimes which is not the case in the medical world where a family will boldy stride into the ICU and insist that we spend whatever it takes to squeeze a couple more days out of their demented, stroked out, septic, octogenerian grandmother. It’s somebody else’s time and money, what do they care?

On top of this, attached to the most technologically sophisticated industry in the world which performs commonplace miracles that would have been inconceivable just fifty years ago is a system of remibursement straight from ancient Byzantium. A nice system for a courtier, a eunuch, or a lawyer but as adminstrative costs alone are said to gobble up a third of every health care dollar, money that provides no medical care whatsoever, what exactly is the benefit to the public and how can doctors be blamed for the high cost of health care?

It’s not a problem that has an easy solution. The single payer zealots opine that making government the insurance provider will streamline things but all you’ll really get is a clumsy bureacracy looking for ways to not reimburse and holding onto every penny like it was a gold coin. Very similar to a private insurance company except that Aetna cannot kick down your door and raid your house. Insurance companies need to make money for their stockholders. Governments try to dole out scarce money to constituents to buy their votes and there is never enough to go around.

But hell, the public doesn’t care. They want medical care for free no matter how much it costs. We are already conditioned to not care about the price of health care. Very few people actually take out their wallet and pay for even something as simple as a routine doctor’s visit that in an ideal world would cost eighty bucks and, in a country where people pay twice that for a month of cable television, would be considered a good value for the price.

I don’t think we need to do away with insurance but we need a simple law forbiding hospitals and clinics from billing a patient’s insurance company. Especially if it is the government which, along with private insurers, currently pushes the greater share of their administrative overhead onto health care providers who receive no extra money for their troubles. In the old days patients paid their bill and then submitted their claim to their insurance company. Watch how fast things would tighten up if patients were refused reimbursement for the same reasons that doctors are currently refused. You’d have angry patients, angry both at the government and at doctors for not caring about how much things cost which is probably the greatest incentive there is to efficiency and reasonable prices.

(To Be Continued…)

Free at Last, Free at Last

After six years of screwing around, I finally have a job. As many of you know I had to repeat my intern year because of a little something I like to call The Biggest Fucking Mistake of My Life. I won’t mention where I did my first intern year because its very name would serve as chum to attract the fearsome creatures guarding its reputation, not to mention awakening Those Who Guard The Sacred Flame of the specialty from whose clutches I barely escaped.
.
So I’m done with off-service rotations and as of July first will be a fully functioning second year Emergency Medicine Resident (but a PGY-3, you understand). The best thing about this is that I will be working predictable shifts for the rest of my residency with no call and the ability to sleep every day. I actually finished my off-service rotations a few months ago and have been working in this manner ever since. It’s pretty cool but I want to caution those of you thinking of matching into Emergency Medicine because you don’t want to work hard to think again. While it may be true that at most programs you will get what seems to be a ridiculous amount of free time (we work 14 shifts per 28-day block), at the end of a stretch of four shifts you are going to be wiped out, in a good way mind you, but wiped out none-the-less.

The pace at a typical Emergency Department that can support a residency program is relentless. I don’t deny that other residents work hard. I’ve done enough off-service rotations to know that they do. On the other hand the long days of, say, an internal medicine resident are broken up a little with conferences, the occasional slow clinic day, and frequent lulls in the action where one may take a breather which is not the case in the Emergency Department.

In Emergency Medicine when we are at work we are working, usually flat out, for the whole shift. As most residency programs are in what amount to charity hospitals there is never a shortage of patients and they will keep coming and coming, at all hours, and for a terrific variety of chief complaints. If you are ready for this and don’t mind multi-tasking then you will enjoy it. If not, this is not the specialty for you.

.
I Try to Be Empathetic But Come On Now….

I actually have a great deal of sympathy for addicts. It’s hard not to as they are some of the most miserable human beings you will ever meet. It can’t be much of a life bouncing around the various Emergency Departments in town looking for your next fix, getting more feral as the delay between presentation and your lucky strike, a new resident who has never seen you before, stretches to minutes and then hours.

Where addicts get the money for their habits in between emergency department visits is sometimes a question you do not want to ask. While it is true that some have money from disability and some have family or friends from whom they steal, many do unspeakable things for their drugs, things that would curdle your blood to think about.
.
There are two distinct philosophies regarding drug seekers. One school of thought believes that it is easier to give them a little morphine or vicodin with the goal of getting them the hell out quickly before they become a space occupying lesion. The other school believes that giving narcotics to the addicted enables drug-seeking behavior and encourages the waste of resources, sometimes leading to delays in treatment for people who are really sick. I probably lean towards the former school of thought because my first instinct is to give everyone the benefit of the doubt. Laughable as it may seem, even drug seekers may occasionally have a real medical problem so I try to be open minded.

But for God’s sake, “Rectal Bleeding” is not the thing to fake if you want drugs. Not only does it involve a complicated and expensive workup but it is going to require me to stick my finger up your ass, not something I generally like doing. And when I get your stat hemoglobin and hematocrit and it is normal I am going to be both disappointed and angry. It’s not as if your stable vital signs and completely benign appearance didn’t tip me off at the beginning of our visit. Indeed, the fact that you couldn’t prounounce the name of the only pain medication to which you weren’t allergic, something starting with a “D,” made me a little suspicious. And then when I discovered that you had a complete workup for rectal bleeding three days before with no findings whatsoever it was disappointing…and embarrassing for me because I was really gung ho to save yer’ friggin’ life until I got the old chart.
.
I also want to point out that if you are an addict and present with constipation after going on an oxycontin binge, reaching back and pulling feces out of your ass is not going to make me want to help you. You accused me of not caring but there is no way I am going to get close to you until you put your hand, the one covered in fresh manure with half-inch long nails under which is packed several year’s worth of other unspeakable things, down on the bed and stop trying to grab me. If you tried that on the “skreet” you’d get your ass kicked or arrested. Why is it all right in the Emergency Department? I understand that you’re jonesing but it is too much to expect of nurses and doctors to put up with this. If I made the rules I’d taser you and throw you back out on the street.
.
Wille Sutton robbed banks because that’s where the money is so I guess it makes sense for you to come to the Emergency Department because that’s where the drugs are. But being your dealer is not really our job and athough this would shock you, neither is taking care of you in the hospital or solving your personal problems.
.
And don’t kiss my ass either. I am not the best doctor in the world and your telling me I am just reminds me how crappy it is to be a resident at the bottom of a steep learning curve. Thanks for ripping that scab off and rubbing salt in the wound. If you just kept your mouth shut and complained of back pain like every other drug-seeker I would have probably given you something…except for that thing with your ass of course.

Silver Bullet

I am no luddite. While I am not on the cutting edge of technology I generally embrace it willingly when it is mature enough to simplify my work. Lately however I’ve had a change of heart about PDAs. Oh, I was enthralled four years ago when I was first introduced to them. Here at last, it seemed, was the one device that would put the bewildering immensity of medical knowledge at my fingertips and eliminate the need to carry the myriad pocket reference books that never really seemed to contain what I actually needed to know.

That’s all most us want. A simple reference book to carry around. A silver bullet, if you will, the one thing that will do the trick. The PDA is not it. Maybe it’s because the thing is so expensive. I already dropped one and fractured the screen. I got a new one from my program but it’s only a matter of time before it is damaged or stolen leaving me $300 in the hole if I want to replace it. Perhaps I have grown to dislike the complexity of the device, especially downloading software which never seems to work for me and my seven-year-old Toshiba laptop. It probably takes less authentication and verification to launch a nuclear missle then it does to download Epocrates. And the silly thing keeps begging me to update it, to synchronize it, and to hold its hand and comfort it.

Supposedly using the PDA to keep track of your patients is all the rage now but unless you are at a hospital that is totally committed to integrating medical records wirelessly and uses bullet-proof software, it is probably more trouble than it’s worth. An index card with the patient’s sticker at the top is actually a lot quicker, especially if you learn to only recored pertinent information. I also find that I can remember the important things about my patients and I don’t need to write much at all.
.
So I have ditched the PDA and most of my pocket reference books. In their place I carry a Tarascon Pocket Pharmacopia for a drug reference and the most excellent Tarascon Adult Emergency Medicine Pocketbook. The Emergency Medicine Pocketbook in particular, while as compact as all of Tarascon’s Pocketbooks, is packed with nothing but useful information. It at least tells you how to start the workup for the great majority of presenting complaints. Anything else you probably have time to look up later.

Just something to think about, especially those of you starting intern year in a couple of weeks. The Internal Medicine/Critical Care pocket book is a pretty good reference for most of your rotations.