12.31.2007

obesity. viagra. heart attack. thrombolytics.

Last night in the ER...
....was very busy. And "busy" in a good way. Lots of codes and respiratory distress. Not so much "weak and dizzy" and "TMD (todo me duele)". The kind of night that reminds you why you chose emergency medicine as a specialty, and not primary care.

Anyhoo, there was this one guy...
A 36 yo morbidly obese Samoan man with a past medical history of diabetes, hypertension, and has lots of 'bad habits', was brought in by paramedics complaining of chest pain which started 10 minutes prior to the 911 call. He was sitting on the sofa watching reruns on TV when he suddenly felt a tightening in his chest. He got up to get a cup of water, and the pain got worse. Then he felt weak and lightheaded so he sat down on the nearest chair. He then called for his wife, and she took one look at him and called 911.

In the field EMS established a very tiny finger IV (because 'his veins could not be accessed secondary to excessive adipose tissue.' i.e. he was too fat). They gave him an aspirin, and after he denied using Viagra, a nitroglycerin sublingual. Immediately thereafter his blood pressure dropped from 150s systolic to low 80s. He became very diaphoretic (lots of sweating), and short of breath.

Upon ED arrival the patient was alert and oriented, but very agitated sitting upright on the gurney, in moderate/severe respiratory distress. He weighed about 450 pounds, and was extremely diaphoretic, and c/o worsening SOB. EKG could not be obtained by the paramedics because the stickers wouldn't stick to the body for all the sweat. Also, the patient was so agitated and anxious that a good reading couldn't be obtained even when the EKG leads were held in place by assistants.

In the ED we attempted to obtain an EKG...for over 20 minutes. We cannot make a diagnosis of acute MI requiring thrombolytics if we cannot obtain an EKG. Afterall, there are other deadly causes of chestpain, some of which absolutely cannot be treated with thrombolytics (or else you kill the patient). It's one thing for someone to die. It's another thing to kill them. So we worked to obtain that EKG...over, and over, and over, and over again.

During this time we worked to establish a better IV with ultrasound guidance. We worked to improve his oxygenation (from 90% on face mask to 95% on non-rebreather). We asked basic questions (allergies, past medical history, medications, *viagra use*). His bloodpressure continued to register in the low 80s (82/64 - narrow pulse pressure, with a heartrate of 120). Are you sure you don't take Viagra (or other 'viagra-like' drugs)? we asked again. He adamantly denies.

I'm so nervous at this point. Here I have a very sick patient, who I think I'm going to have to intubate. He's 450 pounds. His blood pressure sucks. And we can't get a frikin EKG. Agreed, he's likely having an MI...but what if it's an aortic dissection (which could be dissecting up to the origin of the cardiac vessels...causing the MI). On CXR it's possible that his mediastinum is widened. What if he has cardiac tamponade? (the cardiac silhouette is enlarged) I feel stuck without the EKG!!

Finally we get a very crappy EKG. The QRS complexes are very wide, and there are diffuse ST segment elevations. Hmmm....hyperkalemia? Pericarditis? Massive MI? Maybe....TCA toxicity? I give bicarb and fax the EKG to the cardiologist at home after explaining to her the clinical history. She agrees that it is consistent with hyperkalemia. We call the lab..."hey, we so *need* the results of the chemistry ASAP!! please!!" And push more bicarb. He seems to get a bit better. The QRS complexes narrow a bit. He admits to a questionable history of renal disease.

35 minutes have passed. Out of the window of thrombolytics. Now I'm going to have to justify to administrators (and those who wear suits) why I didn't push the thrombolytics in less than 30 minutes. For those that don't know, thrombolytics are very powerful clot busting drugs that have lots of potential deadly side effects. Afterall, they make the blood so "thin" and remove the ability of the blood to clot...and destroy existing clots...that brain bleeds and GI bleeds are not uncommon. And, again, if this guy had an aortic dissection or cardiac tamponade...or pericardities even...I'd kill him with this drug. My biggest source of stress was trying to mentally justify *not* giving this drug in 30 minutes or less (so my chart won't go to 'peer review', or whatever)...which is crazy being that I'm the doctor taking care of him, and arbitrary 'rules' shouldn't apply to individual patients. I should just focus on practicing best medicine, and not doing things simply to make it easier to 'explain' and 'justify' (to non-involved non-physicians analyzing *my* patient thru their retrospectoscopes) my actions after-the-fact. So I hesitate for a second, but proceed doing what I feel is good medicine...and continue trying to obtain EKG #2.

As we 'encourage' the patient to 'just "hold still for one minute," he starts blaming himself for being "so fat", not following his doctors advice...and how he deserves to die. He feels this is the end...

...all doctors know, it's never good when a patient says "I'm going to die." Especially when they're circling the drain.

Suddenly the monitor flickers, the heartrate speeds up, and the patient mumbles, "I don't feel well." Then he becomes altered. The monitors reveal v-tach...so I shock him. He wakes up with the shock. The monitor reveals sinus tach, and he's yells "what tha hell?!"" I breathe a sigh of relief. "Sir, I'm sorry, I had to shock you...your heart started having trouble."

Then it happens again. This time I warn him...."it looks like your heart is doing that thing again...I'm going to have to shock you again, I'm sorry."

"Bring it on Doc!!" he yells.

EKG #2 is obtained (finally)....and seems clear now that he's having an MI. So we get the 'thrombolytic box' out....and fax the 2nd EKG to the cardiologist. She agrees that thrombolytics may help (especially since everything we've been doing so far hasn't helped much....and the patient seems to be getting worse - with the whole v-tach/shock thing). I do a bedside ultrasound and there is no cardiac tamponade, and the heart motion....well, the heart is moving.

I suggest trying to get him to the cath lab instead of thrombolytics since this guy is in cardiogenic shock....and only a cath *may* save him. I was informed by the cardiologist that the cath table can only accommodate up to 350 pounds, so our patient couldn't go for cath. Thrombolytics are the only option for treatment of MI at this point. I ask her to come in to see the patient. She agrees. While she makes her way to the hospital, we obtain consent...and push the thrombolytics....

...30 seconds after the lytics are pushed into the IV, the patient becomes altered, agitated, and his breathing seems (more) labored. I think to myself, I'm just going to intubate him. All of his agitation isn't good for our treatment, but it's also not good for his heart. Additionally, he's nearly 500 pounds so a controlled intubation is preferable. I anticipate a very difficult airway because of his size, the severity of his medical problem, and the fact that he's in cardiogenic shock with frothy sputum coming up his airway.

I intubate him (despite the fat, and thru the pink froth). RT (respiratory therapy) secures the tube. And just then, he's in v-tach again. Before we charge the paddles he deteriorates into asystole. WTF? We'd already given the thrombolytics so I was hoping that this was the 'reperfusion rhythm.' But. It. Wasn't.

We started ACLS...and coded this guy. We got him back....kinda.

The cardiologist comes in and we agree the guy was in bad shape when he arrived. And the fact that he couldn't go to cath lab because of his weight....and the fact that (we later found out) he wasn't honest about his viagra use...and his multiple medical problems, bad habits, etc. made a bleak situation, worse.

In typical fashion, we coded this guy every 45 minutes or so...until he got a CCU bed (maybe 90 minutes later).

He made it to the CCU....and eventually started bleeding from every orifice (including his eyes and ears). It's like he was crying blood. That's what thrombolytics will do. Like most full arrests, he didn't live to hospital discharge.

Most doctors have memorable patients they think about for a long time after their encounter with them. This guy was one of mine.

12.17.2007

The Hospital Credentialing Process Dog and Pony Show!!

So, I've been filling out multiple hospital applications lately. It's not uncommon for physicians to have hospital "privileges" at multiple hospitals, you know? And it's *crazy* what's involved in this process. Addressing this issue would be the perfect 'lifestyle, morale boosting, lovey dovey project' that our professional organizations could tackle, that will validate the membership fee (and PAC contributions) to those of us who are too busy to really get involved in the mundane, ever-changing politics of healthcare. Isn't that their purpose?

Okay, here's how it goes -

First you get this huge packet, maybe 70-100 pages of...who knows what. A piece of paper for everything...completely unnecessary and purely a hospital CYA. Read, sign, read, sign. They ask for accompanying documents, such as a CV, copies of your medical license, DEA, ACLS, PALS, board certification, diplomas, health clearance, etc.

There's a credentialing fee...which is a crock of shit. Aren't these people paid by the hospital to do this job? Why am I being charged a fee? Are other people charged a fee to apply for a job? The nurses....the techs? Everyone wants to be 'treated equal', yes? Where am I supposed to get this fee money? I have no money, hence the application for a *job*!! The fees range from $200 to over $500. Then, you want *me* to gather all the information....and pay the fee to boot?!! If I pay the fee....seems only right that you gather the information. Isn't that what I'm paying for?

The application - requires the standard info like name, address, etc. Then they ask for work history, educational history, and references. It's all on the CV. But they write "do not write see CV". Why not?!! Why ask for the damn thing? My CV has my work history, my references, contact info....all the basic stuff.

Then they ask you *again* (as if to catch you in a lie...as if you're that stupid), your work history....just to be sure there are no gaps. What they really want to know is if you've ever been committed to a psych hospital, or drug rehab...or otherwise MIA due to being "weak" or "crazy." It would be much easier to just write "I have never had a problem with drugs/alcohol, nor am I crazy" than to do this song and dance, that in the end proves nothing.

There's a sedation packet with a quiz...because this makes you "safe" to administer sedatives (can you feel the sarcasm?)

There's a core privileges packet, where you request which privileges you'd like. What the hell? I would like to do everything I'm trained to do, please. ACGME doesn't accredit residency programs, and ABEM doesn't allow one to graduate from a residency program, without showing competence with basic EM tasks. So, by being a graduate of an approved EM training program, I shouldn't have to pseudo-justify my competence in basic shit....like sedation, and ultrasound. Nor should I have to request privileges one by one. Even if I've never done a cric....I need permission to do one if needed. And if you tell me "no", how can I do my job? So...this packet could be eliminated if I'm an ER doc asking for ER privileges only.

Then there's a background check. Makes me wonder what is the Medical Board for, and why do I pay them almost $700 every other year if they can't vouch for me, and their 'blessing' isn't enough to practice medicine in my state's hospitals. It's insulting, and unnecessary.

References - are a joke. I give you 3 doctors....of the 100+ I know. So, what does that prove? Not that I'm a good doctor. Even the worst docs can find/pay 3 people to fill out a form. Then they call these 'references' (over and over and over again) and ask stuff like "would you say she's competent at LPs?" As if they'd know. They are not standing over me...ever...watching my LPs. ER docs don't stand over each other, and honestly have no idea what our colleague is doing 99% of the time.

Then there's the residency verification. Again, board certified should be sufficient to demonstrate my competence in my area of specialty. So why go thru contacting my residency program...and how long do they do that? I mean, my program director is an old guy already...

Then contacting every employer? I don't understand this either. Obviously, by the questions that are asked of them, there is that concern (again) of drug/alcohol use, and mental health issues. It's not like they're interested in "was she a good person....did she work hard?" Nope, the hospital doesn't care about that (the Group might, but they don't contact all prior employers). It's a CYA thing, again...no real value. Again, if I'm okay with the medical board, and my professional organization....board certified and a clean record (which is public and could easily be obtained by the medical office staff , which may begin to justify that $500 fee)...I should be okay to work (from the hospital's point of view).

I thought was ahead of the curve by saving all of my 'important documents' (LoR, malpractice certificates, employment letters, board scores, etc). Not. Get this...the information has to be "primary source information." This means, *they* have to contact someone other than you to get this information. (yep, crazy, I know). But, if they are unable to contact these people (people such as secretaries of departments to "confirm" you actually worked there, and weren't in rehab), they blame you: "I couldn't contact Doctor's Office up the street so we can't verify your credentials." Okay. I know I worked there. You're the one who wants "first hand proof." What the f*ck do you want me to do? You offer up the letter of recommendation from the medical director of that clinic. "Oh it's not addressed to us specifically....and we need to talk to him directly." Seems to me my letter is far more reliable than whomever you happen to get on the other end of the phone. Besides, I think he's probably dead by now....

Then there's the medical malpractice questionnaire. "Please list all of your malpractice carriers for the last 10 years." WTF? I could understand asking about any pending lawsuits...but even that doesn't concern the new job...until the outcome is known. We need a HIPAA for malpractice insurance companies (to protect us from the sharing of sensitive information which would be used to exclude us from being insurable. Afterall, isn't that the original intent of HIPAA? But we've allowed it to go as far as preventing us to obtain vital medical information from the PMD of our comatose patient...who cannot, and I repeat (to the person in charge of the pencils) *cannot* for the love of God, sign a authorization to release medical records right now!!) But I digress.

We have been successful in eliminating the ACLS/PALS/ATLS requirement for board certified ER docs. I mean, what the hell? I'm board certified as an emergency specialist, and you want a little red/white card saying I can complete an online open-book quiz...is that supposed to prove something?

Then they ask for your passport, social security card, drivers license, shoe size...and a strand of hair for DNA testing!!

The process takes a few hours of actual work time to complete...and that's if you have everything readily available at home. It's ridiculous!!

I'm all for interventions that contribute to actual improvement of safety or security. But many of these hoops are akin to the prohibition of lotion and chapstick on airplanes. It's just a hurdle that penalizes "good" people, and does nothing to increase safety or security. It serves to increase the cost of healthcare, and aggravates those of us who are on the front line.

I say, ACEP or AAEM should help us lowly grunt docs streamline this process. Maybe help us implement policies that will allow ABEM to be enough certification of our training and ability by virtue of being board certified. Our medmal should be private. The Medical Board issuance of a license should be sufficient to practice medicine in any hospital in the state. If I have a drug/alcohol problem that's significant to prevent secrecy, the Medical Board should know about it, and my licensure should be adjusted accordingly (understandably the Medical Board needs to be held accountable, which currently they are not). A CV should be sufficient to explain our professional lives (afterall, it's not like I'm writing something 'different' on the application. It's not more 'sacred' or 'accurate' because I write it twice...just more believable). And a 'central databank' would be excellent. One that could be referenced, and taken to be accurate by 'all the bullshit people who interfere with healthcare' (i.e. joint commissions, CMS, etc).

12.14.2007

Here!! Here!!

The New ER Fad

The fad of the day in the ER is some form of Provider is triage, Rapid Medical Screening or whatever name admin can come up with. In their endless search to increase business we are now catering to the very business that is bankrupting us, the med-i-caid or indigent self-pay people that rarely pay their bill. Hospitals are dedicating rooms to prompt care to increase the speed at which we see the dental pain, back pain, cold symptoms crowd while the sicker people, who are having oh, say an emergency are still waiting in the lobby for a bed to open up.

Agreed!! and, I hear you too ER Murse:

The fundmental problem with Provider is Triage where the "Provider" is a midlevel is that the care is biased towards the low acuity patient. The midlevel does not categorize patients correctly in many cases. They get in over their heads when the main ED gets busy and tend to see patients they should not be seeing to help out rather than have the patient wait. Both Provider is Triage and Zero Wait ED's or Triage Bypass plans tend to get rid of an effective Triage systems and once beds are full +1 then there is frequently not an effective way to safetly priortize patients because Triage has been eliminated and the staff are assigned elsewhere. Then the system of prioritizing falls back to first come first serve with higher acuity patients in low acuity areas and low acuity patients in high acuity areas. Yes its a fad and a dangerous one.

Couldn't have said it better myself...

12.11.2007

Have you heard? - Nasty Hotel Glasses



Thanks little brother for the link. I will certainly avoid...getting too comfortable in hotels. Especially cheap hotels!!

12.08.2007

The Oral Exam Results...


"mic check....1-2-3"

"Is this thing on?"

"Excuse me, excuse me...may I have your attention please? From here on out, please refer to me as Dr. Backstage - diplomat of ABEM!!"

"Thank you, thank you very much!!"

I PASSED MY ORAL BOARD EXAMS EVERYONE!! I PASSED!!

I am finally a board CERTIFIED emergency medicine physician. I'm a SPECIALIST in something ya'll!!!

Yay for me...yay for my family...we all passed together!!!

12.06.2007

Healthy toys - Consumer Action report released

Update: Very helpful websites (right at the top of my list as I do my Christmas shopping and such): www.HealthyToys.org, and Not Made in China. If you're buying anything for anyone that still plays with (childhood) toys...you should definitely educate yourself before slowly poisoning them...

...you might be surprised. Disney. Baby spoons. Hannah Montana = CONTAMINATED!! Probably you're not surprised. Why would you be? I'm not.

Contaminated, not just with lead, but arsenic, cadmium, mercury, etc. just as suspected. And, also as suspected, this shit isn't going to come of store shelves until dumb-asses quit buying it (or stores are held accountable via lawsuits and state/federal regulations). Do you really think that all that crap on store shelves is safe just because it hasn't been recalled? If it's made in China, it's shit...period.

Do a little investigating and draw your own conclusions. Then decide if you trust these assholes to *not* chronically poison your babies....rendering them stupid, cancerous, 'autistic', and "hyperactive." Makes you wonder if it's some sort of conspiracy, to destroy a generation of Americans...their minds, health, and ability to maintain their way of life. Would it surprise you? Just delve a bit farther and decide. Go on...

11.28.2007

Seven things about me....

"You've been tagged! Nocturnal RN said it's the law so you have to do it! Write seven things about yourself and then tag seven other people."

If it's the law...guess I'll comply. I apologize if I inadvertently "tag" people who've already been tagged. What happens in that case?? What does 'the law' say about that?

Anyhoo...

1. Although I enjoy doing the doctor thing, I enjoy doing the mom thing so much more!! Actually I do only enough 'doctor stuff' to allow me to do the 'mom stuff' with grace and class (i.e. money and resources).

2. I've never been to the snow.

3. I'm afraid of heights. My feet get all tingly, and I actually start to feel like I'm being pulled to the edge and over the side of the building. So, eventhough I think going on the Amazing Race with my hubby would be tons of fun...I know I'd never be able to finish the race (much less actually win).

4. I love to talk. This is why I started a blog...so I could 'express myself' without subjecting anyone involuntarily to (even more of) my yapping.

5. I'm proud that my son looks like me. When I look in the mirror now, I see him. And I love my own reflection that much more because of it.

6. It makes my heart sing when my daughter tells everyone she wants to be a doctor "just like her DoctorMommy." Makes me feel as though she values what I'm doing, that she respects me...and that I'm setting a great example for her. That makes me feel like a good mother.

7. When I have discussions with my husband, I realize how smart he is...and I fall in love all over again. But, I also realize how little I actually know about anything not related to medicine...and that conjures up feelings of frustration with the 'process of becoming a doctor', which I feel is responsible for my uni-dimensional self, and lack of full development. Sometimes I feel like medicine has 'clipped my wings' and now I must regrow them, and learn to fly properly (i.e. remedial spiritual flying 101).

11.25.2007

Respect level

This is so true.

Emergency medicine is unique in that, in general, the public sees us very differently than other physicians.

What Family/Friends Say
...You must really know a lot to be able to take care of whatever walks through the door.

Respect Level: High, right there with surgeons.


What Non-Emergency Physicians Say
...You guys are a bunch of hacks, basically glorified triage nurses. I can’t believe you know so much less about my speciality than me.

Respect Level: Slumming it with the family docs and psychiatrists.

(as expressed by Dr. Ten out of Ten)

What friends, family, and the general public think is so much more important than what non-EPs think!!

11.24.2007

Our Thanksgiving

Hope everyone had a wonderful thanksgiving!!

This year, for the very first time, I decided to prepare dinner. I mentally planned for weeks...the recipes, the drinks, and how we would accommodate so many more people at our home. I didn't want to spend tons of money, afterall this was something that was supposed to be casual and enjoyable.

And the menu wasn't as simple as one might think. You see, we've been successfully eating almost entirely organic foods (which all seem to be from America), and even managed to cut out most dairy and even lots of gluten/wheat protein (because the ubiquitousness of that crap *cannot be good for the body*). Likewise, it's ridiculous how much high fructose corn syrup is utilized, in almost everything - except in organic foods. So we've inadvertently cut that out too (and I've lost 8 pounds in 2 months as a result of just these simple dietary alterations). It was important to maintain our diet for a guilt-free Turkey day so we got a smoked (antibiotic-free, hormone-free) turkey and ham from Wholefoods. We prepared our pasta (mac n cheese) with quiona and soy cheese. We made gluten-free stuffing and cornbread. Even the salt and pepper were organic. We are very proud to report....we stuck to our diet!! And our guests were very pleasantly surprised when the food was even *more* tasty than their conventional counterparts!!

After dinner, and dessert, we decided to take a trip the park and let the kids play. Everyone ended up involved in a great game of freeze tag (all the adults, and even the toddlers). Once home we were forced to watch Hannah Montana (after finally turning off football)...and shared great conversation!!

We were sad to see everyone go home, but can't wait for Christmas eve when we see everyone again!!

Malibu on fire...again.

Fires in Malibu...again?? I wonder if moving ever crossed the minds of the rich and famous. Maybe they should relocate 'Hollywood' to an area a bit less congested, and where the rich don't feel the need to segregate themselves into seaside hills to avoid the vast majority of ghetto/barrio Los Angeles. I mean, how many fires does it take...how many 'close calls' will they endure?

11.08.2007

Safe (non-toxic) Toys for Christmas

Update: Very helpful websites (right at the top of my list as I do my Christmas shopping and such): http://www.healthytoys.org/, and Not Made in China.


Now there's GHB in our toys...in addition to the other shit, here, here.
As per my 'research' here are a few companies that seem to have a diversity of toys (both age appropriateness, ethnic representation, and price ranges) without added poison...


Ecobusiness also had a link for toys
Organic Toybox (they sell lots of Melissa and Doug toys, that are made in China)*

(*be sure to check the individual toy on the website; some still have supposedly "safe" toys made in China - such as Melissa and Doug; and apparently playmobil sold it's soul by manufactoring some of it's "mini" line in China).

Individual toys:
• Battleship
• Bicycle Playing Cards
• Boggle Jr.
• Candyland
• Chutes and Ladders
• Clue
• Connect Four
• Crayola Crayons *
• Life
• Louisville Slugger
• Monopoly
• Mouse Trap
• Operation
• Parcheesi
• Play-Doh *
• Pop-O-Matic Trouble
• Radio Flyer Discovery Wagon
• Scrabble
• Sorry
• Stratego
• Tri-ominos
• Trivial Pursuit
• Yahtzee
• Melissa and Doug U.S.A.*
-many puzzles
* Some play-doh and crayolas aren't made in America. And Melissa and Doug = made in China too, sometimes. Be sure to check the box on these.

Cool site that my offer help - Multicultural Toybox
Not Made in China is a great site.

Tips for buying toys that don't kill your kids: The Green Guide.

11.06.2007

the process...how long does it take to become an emergency medicine doctor?


I have the pleasure of mentoring students in various stages of "becoming doctors." A common question asked is "wow, how long does it take to become a doctor?" So I decided to break it down for y'all...

Grade school - middle school.
I've always wanted to be a doctor. My grandmother was an LVN, and my mom an RN. So the next 'natural step' was for me to become a doctor.

I've always been a good student, and was placed in "the good kid pile" very early in grade school. Fortunately I had parents who really advocated for me, and essentially *demanded* that I be placed in 'accelerated' classes. This worked to my benefit...and put me on the 'advanced' pathway to college prep.

In high-school.
I was very active. I played varsity sports...and essentially had a major afterschool activity every season. Fall sport, winter sport, spring sport, and summer activities...including band-camp. My mother was able to guide me to good/practical health related 'volunteer opportunities.' I did all of my homework, and never missed an (entire) day of school...since starting school. I took pride in my school work...and was paranoid about a negative smudge on my 9th grade "permanent record". I had a social life via sports and school activities, boyfriends, etc. I was somewhat of a teacher's pet...always. Took some honors classes...avoided AP classes because I wanted my GPA to be as high as possible. And at our school, honors classes were also graded on a 5.0 scale, without the stress of an AP test in the Spring.

Took the PSAT, SAT, and ACT. Applied to tons of colleges. Got into each one I followed thru on. Decided to go 'away from home' to school some 3000 miles across the country. I also had a few sports scholarship offers...but decided I wasn't really that interested in sports and had only participated in sports to have a social life.

In college.
I had a full academic scholarship...meaning I had to work my ass off to maintain eligibility. One C grade (in any class) would cost me my scholarship. In college I did the 'nerd' thing. Vice president of the chemistry club...tutoring...honor societies. But, I also pledged a sorority...and become increasingly popular and involved with Sorority Life. All the while, doing my homework, and going to class. I certainly hadn't moved 3000 miles to fuck around and flunk school.

I did research...published a paper in toxicology. I volunteered. I became a Girl Scout Troop Leader. I honestly didn't do much in the way of healthcare related activities while in school, however, when I came home for winter/summer I'd do a bit of healthcare volunteering.

My major was chemistry. Many people don't realize that a degree in biology isn't necessary (or even preferred) for medical school application. Actually, an undergraduate degree wasn't required at all....just the fulfilment of the prerequisites (but everyone had a bachelors).
Each summer I had an organized 'activity' planned. A summer enrichment program, a research position, a healthcare related job, etc. I did MCAT prep course...and subsequently took the MCAT.

I was invited to apply to a local medical school early, and was accepted. This was awesome, and meant that I would save a tremendous amount of money by subsequently only applying to medical schools I'd prefer to attend. The deciding factor was location...and ultimately I didn't take the early acceptance, and came back home to attend school close to my family.

Medical school.
Most of the students were much older than me. The average age of our first year class was 30 years old. Many students had PhDs, masters, or other awesome and interesting experiences (such as working as an engineer, architect, running a business, computer programmer, etc.) I certainly felt....intimidated.

Despite having taken the required classes, and even having a chemistry degree with a biology minor...the classes were very...detail oriented. Everything that's taught in undergraduate science is covered in the first 3 lectures in medical school...everything!! On day 4, everyone is on equal ground. I actually don't think the undergraduate classes helped at all...because in medical school they teach you everything they want you to know.

My medical school was a very laid back school. Of course there were the gunners, but overall, everyone helped everyone else (beware - this varies widely from school to school). It was important to do well on all tests - especially the first 2 years. And the testing schedule was mid-term and final, twice a year. Not many opportunities for quizzes or extra-credit.
- If you didn't pass an exam (despite the curve), you had retake the course during the summer...and retake that exam thereafter. If you didn't pass the course in the summer, didn't take the course in the summer, or didn't pass the exam you failed previously after completion of the course...you had to repeat the entire year of medical school.
- If you fail 2 exams...you have to repeat the entire year.
- If you fail an exam in a course that's not offered in the summer...you have to repeat the year.
- And finally, if you fail a course...you have to repeat the entire year.

-this happens to a handful of students each year.

There are about 9 classes in year-1. Gross Anatomy (plus lab), physiology, microbiology/histology (plus lab), pharmacology, introduction to clinical medicine, preventative medicine (statistics - which was hard as hell), biochemistry (which was so difficult, even our PhD *biochemsit* had difficulty), nutrition, primary care/family medicine (their lame attempt to try and persuade us to consider a career of horrible lifestyle and inadequate compensation).... In year 2, and the end of year 1, the subjects were organized into organ systems. First year more normal stuff...and second year learning how/why things go wrong. So, you see, it's quite easy to fail an exam...

Before you can do your clinical rotations in 3rd year, you have to take and pass the USMLE Step 1. You get one chance before you fall behind. If you fail a rotation in 3rd year, you have to repeat that rotation. And if you fail the exam at the conclusion of the rotation, you have to retake the exam...possibly repeat the rotation. (The 3rd-4th years of medical school are much easier than the first 2).

In 4th year you take USMLE Step 2. Some schools require you pass this exam before they grant a degree. Ours did not require passage, only that you sit for it. During years 3-4 you're doing rotations that interest you, and trying to pin down great letters of recommendation. You're trying to meet people in your field of interest by going to mixers, and department meetings/gatherings. You're trying to honor the rotation (by doing everything asked of you, being very humble, and taking the abuse). Perhaps, if the specialty is competitive, you're also participating in relevant research that will lead to publications with prominent staff. You may be working to qualify for consideration for an invitation into AOA (Alpha Omega Alpha) the medial honor society that's recognized nationally. The evaluation comments written by your professors/attendings is content for the Dean's Letter (the letter that the medical school will send to the residency programs when you apply...kinda like a final report card).

There's the very cumbersome process of residency application via ERAS. Very expensive interview travel. My specialty choice largely depended on what was locally available as I had no desire to move out of my house, much less to another city or state. In SoCal, everything is available. I matched locally...didn't have to move...and started internship.

Internship.
Was what everyone says it would be. But when you're 26, single, and totally psyched to be a doctor FINALLY...it wasn't so bad. During internship you have to take the USMLE Step 3...and pass it. This must be done to apply for a California State Medical license. And, you have to have a State license to advance to your 3rd post-graduate year (as an American graduate). FMG have an extra year.

-this causes programs here to lose a handful of residents depending on the competitiveness of the specialty. Unfortunately primary care spots have a high proportion of FMGs and consist of more 'borderline' students who may not test well...hence their inability to secure a more competitive residency. So, many of the FM, peds, IM, and psych residencies lose residents as they fail Step 3.

Residency.
In addition to the long hours, and scut work...there are monthly 'progress' exams in preparation for the inservice exam. The inservice is a board-like exam...and some programs will use this exam to determine whether to allow you to graduate from the program. Also, the residency programs have to give you *permission* to sit for your boards after you've completed the program. If you do poorly on the inservice, they may not allow you to sit for the board exam.

While a resident you may decide to work hard for chief resident consideration. This will give you a tremendous edge on fellowship applications, or on specialty job applications.
After residency you become board *eligible*...meaning you're eligible to sit for the specialty board exam. Many specialties only offer the exam once a year, and may consist of 2 or more parts. Written, oral, practical, etc. So, certification may take 2-3 years. And some board exams have an exceptionally low pass rate...so multiple attempts are expected. (All the EM jobs make very little distinction between board eligible and board certified in their hiring practices or priveleges granted...however, some places will pay more once you become certified.)

After residency completion.
For Emergency Medicine, there is an ABEM written exam in November. If you pass it, you then apply for a spot to take the Oral component. The Oral component is offered in Chicago, twice a year. You are randomly assigned to Spring or Fall. If you pass the Oral component...you are then BOARD CERTIFIED - a diplomat of the American Board of Emergency Medicine. After becoming board certified, and meeting other 'experience criteria' you are allowed to add FACEP and/or FAAEM after your "MD" to indicate that you are a residency trained, board certified, practicing, competent, ER doc...(which we all know may or may not be true).
***
So, to go from high school to board certification:
4 years of college - prerequisite classes and the MCAT.
4 years of medical school - Class exams. Rotations. Ass-kissing. USMLE Steps 1 and 2.
1 internship year - USMLE Step 3. Medical license.
2-7 residency years - Inservice exams each year. 80+ hours a week of indentured servitude.
After graduation 1-2 years - Board eligible. Board exam components.
*optional fellowship 1-3 years - take specialty board exam (written and oral); then take sub-specialty board exam after fellowship completion.
Board certification - 13+ years after graduating from high-school. FACEP. FAAEM.

Take a deep breath, relax, and pace yourself...becoming board certified physician is a marathon indeed!!

11.02.2007

Gangs and other Random Stuff

See, it happens even at "good" hospitals. UCLA-Olive View had a young guy drop dead in (near) the ED. Unfortunate, but hopefully helps demonstrate the *widespread* issue of ED overcrowding, excessive/unnecessary work-ups, and highlights the impact of inadequate hospital bed capacity and closure of County EDs and hospitals. It affects everyone, even affluent "Valley folks." It's unfortunate that many people just don't appreciate the full impact of a problem until it affects them directly. I mean, didn't people heed the lesson of WWII?

In Germany, they came first for the Communists, and I didn’t speak up because I wasn’t a Communist;
And then they came for the trade unionists, and I didn’t speak up because I wasn’t a trade unionist;
And then they came for the Jews, and I didn’t speak up because I wasn’t a Jew;
And then . . . they came for me . . . And by that time there was no one left to speak up."


Just maybe..."if (wo)men and elves join together we can protect middle earth", from the Dark Lord Sauron, and his undead Nazgûl servants, instead of "minding our own business" and waiting for *our turn* to be destroyed.

It's not just Olive View, King Drew, or County hospitals. Overcrowding, increased errors, and inadequate care is happening *all over* people...everywhere. This is not a poor people, brown skinned, welfare, housing project, trailer trash, ghetto, problem.

Also interesting in Los Angeles news...

"Racial Cleansing" of African Americans by Mexicans in Los Angeles neighborhoods. You don't have to go to Darfur to get a taste of this...apparently. And this is the city of the rich and famous, where "the streets are paved in gold." Hollywood and Malibu.


And last but not least...Emergency room manners:

If your spouse (usually the sensible one) drags you in for the stroke that you had 3 days ago and you still have facial droop, slurred speech, and one-sided paralysis do not state that “My wife made me come in” when I ask why you’re here. Just tell me what the fuck you’re here for. And after I put you in line to go back to the ER do not send your cringing hand-wringing co-dependant family members up to me every 15 minutes to ask if it’s your turn yet. IF IT WAS YOUR TURN WE WOULD BE CALLING YOUR GOD DAMN NAME. The window for stroke treatment was 3 hours. Now that you’re long past it you’re looking at a lengthy rehab. After 3 days another hour or four won’t make a lick of difference. Your anger, frustration, worry, and regret will not get you in any faster. As the slow truth of your stupidity sinks in do not glare at me.

Do not tell me that you “Can’t breathe” in long rambling 20 word sentences.

Similarly, do not tell me that little Shantiqua is ‘bleeding bad’ with her 1cm cut, that your bullshit pain is 10/10, that you are suicidal when you took 3 Tylenol instead of 2 (gasp!) after mommy grounded you, or that because your emergency is the worse that you’ve ever had, that it’s the worst that could possibly happen in the sum total of human experience. I’m supposed to act like your story is the saddest tale that I’ve ever heard. It’s not.

The worst thing is doctors that not only won’t see their own patients, but they send them into the ER with a wildly unrealistic set of expectations. “My doctor told me to come in right away and to go right back! He said I was too sick to wait in the lobby. He ordered you to do tests, they are (stop me if you’ve heard this one before) ON THE COMPUTER”. I’m not taking shit for orders from some lazy-ass, wart burning, boil lancing, sprained ankle rotating, sore throat examining general practitioner who has assessed you OVER THE PHONE and doesn’t even have ER privileges.
***
I'm still recovering from my ABEM oral board exams (trying to work shifts in order to 1) pay my bills since I've been gone; 2) make money in order to pay down my credit cards after using them to charge everything that taking these exams entail...travel, hotel, suits, board prep courses, exam costs, and so forth and so on....)


More insightful posts forthcoming....

10.22.2007

The White Blue Coat...or better yet, avoid MRSA and wear *no* coat!!


I think physicians should wear long light blue coats (if any coat is worn at all). Where I work, the physicians are the *only* people without a white coat!! (I exaggerate, but only a little). It's unfortunate how obscure our various roles have become to the patients. Isn't it important for the patient to be able to identify their RN vs. housekeeping vs. LVN vs. pharmacist vs. physician? I have patients wandering about the ED, asking everyone from the janitor to the registration folks for pain medications and cups of ice water. When they are subsequently instructed to ask their nurse if it's okay to have food/water, they frequently express frustration in being unable to do so. "Which one is my nurse?" Who are the nurses? I'm not sure either...and I work here.

It's important for patients to know and remember that I am their doctor. That they were, in fact, seen by a doctor, and can ask the doctor questions and follow recommendations. If doctors were the only ones with white coats, this would be easy. I would walk in wearing my coat, and the patient would instantly know that they have been seen by a doctor. As it is, no one has a clue. I remember rounding on my patients one morning as a resident (rotating thru medicine) wearing the white coat, name badge displayed, and always introducing myself as "Dr. Backstage," not allowing others to call me by first name as to not interfere with my efforts to be seen as the doctor...and still, when rounds came with the attending, more than once I've had patients complain "I never see a doctor and I've been in here for 3 days." Of course all eyes turn to me...like, 'you haven't actually seen the patient in 3 days?' At these times I look at the patient and say, "Ma'am, I've been here the last 3 days, multiple times a day...had long conversations with you and your daughter..."

"Oh, you're my doctor? But you look so... young, pretty, nice...(I think the word you're looking for is *female.*)

*sigh*
As a patient, I was very confused laying there on the gurney wondering who's who. Who do I ask for help? Lots of people buzzing around busy, busy, busy...asking me questions and doing things to me. I couldn't remember all their names, and they probably did introduce themselves and stated their role...but...trying to curb my anxiety, cooperate, be well, and remember names/roles is difficult. If the nurses had on a certain color/style/pin it would have been easier to place them. If the doctors were the only ones wearing white coats, I would be able to pick them out. If everyone was proud to display *their* respective roles (instead of everyone pretending to be the physician), it would be easier for the patient, and easier for everyone involved.

This is why I think physicians should wear light blue coats. They are classy, don't look as dirty, complement figures and skin tones better than white, and will allow for easier identification. As more women become physicians, and more men enter nursing the typical gender roles are unreliable predictions of current positions on the healthcare team. Making it that much more important to distinguish who's who for the people we serve.
***

Otherwise, we should opt out of wearing coats altogether - afterall, they impede proper handwashing, are full of MRSA (drug resistant bacteria), and make people sick.

10.15.2007

Working at Kaiser as an Internal Medicine Hospitalist

...finally!!
So many of you have sent me emails asking for this post. Here it is, words of wisdom from Kaiser IM hospitalists...

I have a few friends who are IM hospitalists at Kaiser. This is what they had to say...

What is a hospitalist?
A hospitalist is the primary care physician who focuses on inpatient care. I chose to become a hospitalist because I grew weary of the day to day mad-house of ambulatory (clinic) work. Hospitalized patients tend to be "more interesting", and I feel more 'productive' (like I'm really helping sick people feel better) working in the hospital. Also, the business aspect is less cumbersome. I don't have to deal with managing people, a clinic, a business, etc. Also, since the hospital is open 24/7, the hours tend to be more flexible, and shift-like...which has it's perks.

Does a hospitalist have a patient panel? Do they see their patients once they are discharged? If not, what about continuity of care?
No (thankfully) I don't have a patient panel. I am apart of a group of docs that take turns admitting 'someone elses patients' and caring for them in the hospital. And even in that regard, I only manage their case for the time I'm physically in house, then the person I sign out to takes over. Just like all the other professionals in the hospital.

I do not see patients in the clinic...not even after they are discharged. They go back to their primary doctor. Continuity of care? Well, that's becoming evermore non-existent as it becomes more difficult to convince young adults to give up their lives and become the "small town doc" that's available for his/her patients whenever they need him/her. Just look at OB. Chances are, the doctor that cares for you for 10 months of pregnancy won't be the one who delivers the baby (unless it's surgical, and unless they happen to be on call that day). Medical students and residents are seeking a better lifestyle for themselves. I guess we're finally coming to realization as a group that medicine isn't worth your happiness and sanity. That it's hardly admirable to subject yourself to abuse (by CMS, by DHS, by joint commissions, by society, by medicine) and be absent in the lives of your loved ones. Maybe when doctors were respected, autonomous, and paid well...but now, not as much. When this happens, when docs start seeing themselves as employees with jobs, continuity of care sounds like crazy talk. Think how crazy it would sound if we suggested that nurses (or anyone else on the 'healthcare TEAM') were made to "feel guilty" about going home at night, or chastised for lack of their continued presence in the health management of a stranger/patient. Everyone has a job these days...which is what government created, and physicians (at least the professional societies) have allowed to happen.

Do you miss the clinic?
I do sometimes. Ideally, I think I'd like to have a very small panel of patients, and manage both their inpatient and outpatient health situations. But, at Kaiser, we have panels in the thousands, and you just cannot be available for thousands of patients...and still be true to yourself. Most places it's easier to simply choose, outpatient or inpatient.

Does it require additional training to be a hospitalist?
No.

Do you take care of ICU patients?
I do, at least initially. We have 'intensivists' who take over the ICU patients shortly after they are admitted to the unit. And we pick them back up once they are d/c from the unit. This is good because the last thing you want to deal with while rounding on your patients, and getting hits from the ED (doing initial H&Ps), is a patient in the unit who's trying very hard to die that day.

What is it like at Kaiser, specifically?
Kaiser has it's pluses and minuses, of course.
The minuses first. Kaiser has lots of rules and protocols. Imagine someone telling you how to do everything. How to manage every problem. What paper to write on. As physicians, since they make you a "partner" you have no advocacy. It's like you sign away your ability to unionize, or otherwise advocate because you're vested. But, practically, you're an employee. Your chief gets orders from their boss, and usually s/he will agree to give their docs that 'one more task to complete', 'that one more piece of paper to fill out.' This is how chiefs get their jobs, keep their jobs, and get promoted. Not by saying 'no, I think my docs have enough paperwork to fill out...I think they jump thru enough hoops...why not hire another clerk to do that paperwork.' Can you imagine saying "no" to your boss...even if it's to benefit the people who work under you? And because of this hierarchy (which is necessary), and the lack of advocacy for the physicians within the group (which is not a morale boosting situation), lots of us are less than enthusiastic about our jobs. It's not about the physician-patient relationship, not to the doctor/employee. It's more akin to working at the DMV and with people who come to you for help. And that is unfortunate.

The hours can be very long, and there is no additional compensation for staying late - and with the amount of paperwork required, most docs stay late. Many docs 'volunteer' lots of their time...and that's just wrong, I think, since the corporation is making record "profits" with our sweat. Without the docs, Kaiser could not exist. The organization should reward those physicians who go the extra mile, stay late, come in early, and wrap things up. This results in better patient care...happier/healthier patients, more members/more money for the organization, and better reputation (=more money). But, the docs won't see these positive results. Any extra effort is simply absorbed into the organization...and this isn't good for morale, or dedication.

Minuses - Lack of advocacy. Too many unnecessary, non-physician tasks (scut), long hours/hard work, and no incentives (therefore waxing/waning motivation), low morale, and feeling like you're being used - all which affect patient care.

Pluses.
Flexibility. Kaiser permits you to work part time with benefits, which is nice. Also, flex-time, swing shifts, and longer/shorter shifts can be created to help individual physicians balance family and career. They have quite a few women in high places, and there is great recognition of the need to offer these things to keep (particularly female) physicians quiet enough to conduct business. The pay is comparable to the outside. As a plus I'll also add the long hours and hard work, since that's not only a bad thing. Afterall, having lots to do validates your job. If you stay long enough I hear the pension is one of the better plans. And hospitalists in general have set hours, no call, and flexible schedules.

Pluses - flexibility, benefits, accommodating of family/personal life without much ado.

Overall, would you recommend working for Kaiser as a hospitalist?
Overall, I would. Not all sites, not all groups have the same internal morale issues. I suggest that a person considering a job with Kaiser find someone in the group to give you the low down. The real deal. This isn't going to happen over email, because no one is going to write/document their discontent with their current employer. Be sure to be persistent with that one doctor that seems nice, and interested, but deflects your questions. Call him/her up and ask to meet. How many times have I seen interviewees, and thought to myself "I wonder what they think this is all about?" "I wonder if they knew the truth about this place, would they still want to come here." Just like residency...not every program is good for everybody. Even the great residencies may be horrible for certain personalities, or people in certain social situations, of a certain gender, ethnicity, etc. (parents, gay, married, Jewish, etc).

Kaiser is a nice place to work...but has very real drawbacks. It won't work for everyone. There are lots of rules, and basically you go to work, follow rules, do whatever 'new' thing they have you do (new sheet of paper to fill out, new box to check, new question to ask, new order form, new protocol to follow...always something else they squeeze into our day with no consideration for time/relevance). It's overwhelming at times, but if you don't think about it too much, aren't too passionate about that particular issue...you'll probably do just fine. Personally, it does get to me every so often, but I enjoy my flex time, and the money is comparable to what I feel I could make on the outside...so the benefits outweigh the drawbacks for me.

10.09.2007

The worms.




Horrible case of neurocysticerosis!! We counted the number of active cysts in this patient to be about 65!!! (On these two cuts alone you can see 33!)

Neurocysticerosis is caused by the tape worm taenia solium found in improperly cooked pork that, when ingested, hatch in the stomach, and the larvae crawl thru your intestine, and find a home in your muscles and brain. The resulting inflammation, and possible mass effect/obstruction of the flow of CSF commonly causes headaches and seizures.

We see this quite a bit in Southern California, so when traveling here, don't eat the pork...or drink the water.


Family: Doctor, what's wrong with her?
Me: There are worm cysts in her brain.
Family: oohhhh...the worms!!! She got the worms....



No further explanation was needed, they understood.


10.01.2007

Choosing a Specialty - AAA (All About Anesthesia)

Today, ER doctor asked me to write an entry about anesthesiology. I am an anesthesiologist with a subspecialization in pain management. I work both in the operating room, take trauma call, and in my pain management clinic. I'm a few years out of fellowship...and today, will shed some insight into my professional world.
I decided to become a physician sometime in high-school. There was no magical 'calling', or parental influence. I just had to make a decision. I thought for awhile about my favorite subjects, those I learned with the most ease, and narrowed it down to a few applicable careers. Although nursing crossed my mind, as I learned more about the differences between what nurses did, and what doctors did...I decided I didn't really want to 'nurse' people. I considered PA, but thought to myself...I'll never regret going for the top rung, but I may one day (as a PA) regret not going full-speed to the top, and "settling" for PA. So, physician it was.

With regard to specialty choice, that came later. As a premed (and my first year or two of medical school) I thought family practice was for me. Back in those days there was a big "push" for medical students to pursue careers in primary care. Family practice is "the doctor" I visualized when I thought of "doctor." I liked the idea of treating the entire family, establishing a long-term relationship with my patients, etc.

As I progressed to my clinical years and gained exposure to the 'real practice of medicine.' After having candid discussions with primary care docs...I 'realized' that family practice isn't what many people/students expected it to be. It's very stressful, and doesn't pay well. The physicians didn't seem to enjoy what they were doing...and that bothered me. Haunted me, actually. So I had to consider (for the first time) that family practice wasn't for me.

Anesthesia isn't one of those specialties that students get much exposure to in medical school...unless they actively seek out the experience. So, it's no wonder appreciation for what we do isn't fully realized. For many students, the only exposure they have is via their surgery rotation....or OB with epidurals.

The process of - Passing the Gas
Anesthesiology requires a medical student to complete their degree, their USMLEs, and a preliminary internship (either surgery, medicine, or transitional). After that, you move on to your CA-1 year as a first year anesthesia resident. Training is 3 years after the internship. The first year of training (the CA-1 year), you mostly get acquainted to the anesthesia machine, and do relatively simple cases such as ortho (usually young healthy men), and ophthamologic cases (with sedation). Most cases are short (unless a new surgical resident is learning to do an appy). The CA-2 year consists of more advanced cases, longer cases, and children. OB/epidurals, c-sections, trauma calls. There were more outside rotations for more specialized experience...such as children's hospital, and transplant centers. You do ICU/critical care coverage. CA-2 year is the nitty-gritty of training. The CA-3 year you do advanced cases, such as long transplant cases, long cases in general, complicated cases (like patients undergoing major surgery that are likely to die). Heart transplants, burn cases, brain and spinal cord surgery, etc. The best part is you have more administrative tasks, like running the OR board (deciding if/when the various operative cases go to the OR). You get to choose your electives, and have exposure to those areas that interest you. Subspecialty areas include pain management, hospice/palliative, critical care - officially. There's also areas that aren't "officially" subspecialties but requires experience/training, some offer an exam and may become 'specialty' soon - such as pediatrics, OB, and neuro.

Why I chose anesthesiology.
During my 3rd year of medical school, I was quite convinced that I'd pursue internal medicine, and subsequently subspecialize in....say cardiology. I knew general internal medicine wasn't for me, but with the numerous subspecialty choices in the field, I figured I'd find something I enjoyed. Then, honestly, as a 'easy rotation' to break the monotony I decided to schedule an elective anesthesia rotation near the end of my 3rd year. That is when I learned what anesthesiologists do all day.

I went to medical school, and subsequently trained at a major trauma center. To me, trauma were the most exciting cases. It was during the traumas that 2-4 anesthesiologists were present. One intubating. One doing an a-line. One doing central line. One getting blood/saline and putting it thru the level 1. All working quickly, carrying out their various tasks of stabilization and resuscitation. I fell in love...
Typical OR day. Arrive between 5:30 and 6:00am to pre-op on the day's patients. Introductions. Acquisition of information. Reassurance. Then off to set up the OR. Pulling drugs into syringes. Getting various equipment set up. And above all, checking the anesthesia machine. There's an intimate relationship between the anesthesiologist and the anesthesia machine.

I have 3-4 scheduled cases that ideally end at 3pm or so. I get a couple of short breaks, either between cases, but usually during cases when a colleague comes in to relieve me. I also get bathroom breaks and lunch break if they are unable to be scheduled in between cases. There are times when I'll break the OR for lunch, depending on our staffing levels. There are intermittent emergency cases that supersede scheduled cases, but we usually have someone available specifically to cover those instances. One of us anesthesiologists runs the OR board, and it is up to us to decide who gets surgery that day, and when - despite what the surgeons believe or say. It is our prerogative to cancel cases, close OR rooms, and manage the operative suite.

When there's an airway emergency anywhere in the hospital (excluding the ED), we respond and assist with airway control. We respond to all code blue arrests. We backup the ED...if they have a problem airway, they call us. We also assist with intravenous access and spinal fluid access (for lumbar punctures, or anesthesia administration). We cover OB, do epidurals, and are available for crash c-sections. There is a pediatric 'fellowship' in which we work at Children's hospitals doing typical anesthesiology tasks.

In addition to airway, and emergencies, we do regional blocks to prevent or treat painful conditions. In pain management, we treat patients with chronic pain syndromes. We deal with end of life care, and palliative pain issues via hospice and ICU. And of course, speaking of ICU, we manage critical patients in the ICU - usually surgical, and usually post-op.

What I don't like. What I like.
The lifestyle isn't always great. 6am is a very early start to your day. And 3pm easily and frequently turns into 4 or 5 pm....which makes for a very long day. There isn't a lot of down time because an empty OR is costing everyone money. Eventhough you only have 1 patient at a time, there's a sense of hurry to get cases started, and to leave patients in the PAR (post anesthesia recovery) even if you're not quite convinced you should leave them just yet. Dealing with some surgeon types makes for a very stressful, or negative atmosphere in the OR. There is little exchange between you and your patients (practically speaking) since they're sleeping the entire time. The OR is the same everyday, and somewhat boring. They say it's 90% boring, and 10% "oh shit!!" I think that's true. The solitude behind the blue curtain is nice, mostly, but it can get lonely.

There are a few specialties in medicine known for their "problems". Stereotypes don't apply to individuals, but rumor has it that anesthesiologist tend to have drug addiction issues. I guess passing all that gas, and administering all those drugs, makes access easy. This is a problem that is made clear on day one of anesthesia training. This is a problem on the radar of every anesthesia department. Not unlike radiologists getting blood cell cancers, psychiatrists committing more suicide, or surgeons having more broken families/marriages.

Also, patients (and people in general) frequently are unappreciative of the work we do. It's difficult keeping a patient comatose, paralyzed, with adequate blood pressure; breathe for them, protect their eyes, monitor the blood loss, and then....wake them up *intact* after hours of a human digging around in their abdominal cavity (or brain, or back...). When things go wrong, they go wrong FAST. You need to be aware of many drug actions, interactions, indications for use, and how to deal with pretty much any foreseeable (and unforeseeable) catastrophe. You have to be exquisitely more familiar with the workings (on a mechanical level) of the anesthesia machine than you ever imagined possible. You have to have a grip of physics, and understand the differences in gas pressure and turbulent flow of air thru tubes depending on the atmospheric pressure, type of tubing material, diameter and length of the tubing, and the viscosity of the gas. You have to be familiar with all the different procedures the surgeons are doing...and read up on the procedure beforehand to be sure you can anticipate/prepare for complications of that procedure, and anticipate when significant changes in vitals signs are expected to occur. Some drugs are so potent, that mere drops of it makes a huge difference. There are reactions to blood products, failure of equipment...and surgical complications that affect the well-being of the patient. And when things go wrong, everyone is very quick to blame the anesthesiologist. These factors result in a very difficult board exam - amoung the most difficult of any specialty, and many of us do not pass them on the first 1 or 2 attempts.

The job's both exciting, and frightening. The compensation is great. By working with residents I'm not tied to an OR all day. I get to be present at the start of a case, and at the end of a case. I am not tied to one room, therefore I don't feel the boredom or loneliness. I work at a trauma center, so that's exciting. I also have a pain management practice...so I have more 'patient contact' and continuity than almost any other type of doctor. And, I get paid to see my patients in pain management -unlike primary care docs.

More and more students are choosing anesthesiology, and the specialty is becoming more competitive. For years students were told anesthesia was oversaturated...and that created a shortage that was subsequently filled with FMGs. As more American students choose the specialty, and competitiveness increases....our profile will elevate, and that's a good thing for gaining respect and prestige for the profession.

9.21.2007

Medicine the man-whore

Like many young doctors, I get asked a couple of the same questions over and over and over again.

Would you do it again? Any advice to premeds? Would you encourage your children to become doctors? Or some other variation of "Are you happy doing what you do?"

The short answer is 'yes.' I love being a doctor. I love being called 'doctor.' I am proud to tell people I am a doctor. It makes me feel 'satisfied' to know my parents are proud of me...that I have accomplished (in their mind) the epitome of accomplishments. I love it when patients say "your mother (it's always only 'mother') must be so proud of you!!" Yes she is. It really feels good to hear your loved ones brag about you...simply being a doctor is a big deal to most people.

Becoming a doctor doesn't require one to be a genius. You just have to be focused...and do your homework. In high school - go to class and do your homework. In college - ace your exams and do your homework. Medical school certainly isn't about being 'smart' but rather 'organized' and methodical. Studying smart, concentrating on only the most relevant, high yield material. Doing research, and kissing lots of ass. If you study hard, do research, and get good letters of rec, you'll likely get into the field of your choice (especially if you're willing to move anywhere in the country). Once there...you work your ass off. All of this doesn't require you to be smart, per se, just dedicated, passionate, organized, persistent, etc.

I recommend a student go straight thru the process, and not take breaks. If you finish up residency at 26, you still feel like your young adulthood is yours to experience. As a resident, you can have a life (depending on the specialty, of course). You can still go out with friends, date, and hang out. I even endured 2 pregnancies as a resident (afterall, when are you supposed to have those babies?). Residency isn't about studying and learning....it's about working. If you work, you'll finish. You can always study for a test (boards) later. I found residency less stressful than medical school because...in my mind, I'd 'made it' already. I was a doctor. Simply being a medical student makes you....nothing. No pass = No MD. The fact that I'd accomplished a major achievement by simply graduating from medical school, relieved lots of stress for me.

If you go straight thru, you may graduate residency at 29 years old. That's still plenty young. The sacrifices are much less. Afterall, you don't feel as though you've sacrificed 'your entire young adulthood' to medicine if by 30, you're making 6 figures...like many of your professional friends. (Granted they may not have the debt you have).

If you put off medical school, and do a long residency, by the time you're finished...you may feel you've given too much of yourself, of your life. If you decide to put off relationships, marriage, having kids...you may find yourself in a situation where you *can't* have kids, or the family you always dreamed of. You may miss end of life activities with grandparents/parents. You may miss other significant life events of other family members/friends. And, you'll gradually lose your close friends as they have families, and hang out with other people in similar social situations. You may realize that you're the oldest guy/girl at the club. And, it may become increasingly difficult to find a suitable match as a life partner. Young adulthood is the time to lay the foundation, both professionally, and personally, for the rest of your life. If you are a medical student/resident thru this process, you may find yourself, your life, unbalanced. As you pursue this (arguably) awesome career, you lose the opportunity to experience these other aspects...that are much more important in the grand scheme of things.

Being happy in medicine happens as a result of going into it with accurate information, eyes wide open. Forget about the fuzzy 'feel good' I wanna help people bullshit. Forget about the 'privilege' or 'calling' that some try to say is medicine. Realize it is just a job. It is just one aspect of your being. It, in itself, will not make you happy. Realize that patients are no substitute for family. If you can see yourself doing something else, and being happy doing it...you should strongly consider that option. Medicine is like a sexy man-whore. Attractive, alluring, exciting, and seems to have 'everything you'll ever need'. But, the reality is, he will betray you. He will beat you. He will not keep his word. He will not appreciate your greatness. He is selfish. And basically, not what he appeared to be. Likewise, medicine will not be what you thought it'd be. The patients will sue you. The 'purse-holders' will not appreciate you or value your work. You will see plumbers make more per hour than you do. Medicine will not provide the life you thought it would...and you'll feel betrayed.

You'll be happier if you realize that medicine isn't 'everything.' You will not make even the modest money you thought you'd make. Realize that student loans *are* a big deal, and will not be easy to pay off "on a doctor's salary." Realize that you don't have control, and are at the mercy of the powers that be...and the pig-headiness of some arrogant peers who see no value in unionization and advocating for 'physician rights'. Do not put off things in life that you really want to do, like get married, or have children. Develop outside interests, and don't let medicine become your identity - do this and you'll have a strong defense against burn-out and disenchantment (this is why it's so important for residency to be humane. Medicine isn't what it once was. There is no pot-o-gold at the end of the rainbow if you suck it up and sacrifice your young adulthood like back in the day when docs were respected, and paid handsomely for their services.) If you view medicine as a stable job that pays a decent wage....you'll be happier. Do not try to make the man-whore a loving husband. See him as he is, and either accept it, or move on.

Also important is, finding a specialty that fits your personality. If you want to be an involved parent, surgery isn't for you. If you want to have a comfortable lifestyle, you might wanna rethink primary care. If you like to interact with people, radiology/pathology may not bring you satisfaction.

Don't overwork yourself. Even if you enjoy speeding around the ED running codes and trauma, do it too much/often, and at the expense of personal health, relationships, or other recreational activities....I promise it will cease to be fun quite quickly. The check is nice...but your life is suffering. In the end, many docs decide it isn't worth it....

...all because they haven't achieved balance.

So, in review - to increase the likelihood that you'll be happy in medicine:

-get the training over with while you're young; don't take breaks (or alternatively, wait until you're a bit older)

-keep it in perspective. You are not a saint because you are a doctor (don't be arrogant and think more highly of yourself than you should). It is not a calling. See it as a stable, respectable, secure, job. Your work is valuable, but not more valuable than yourself, or your family.

-know the drawbacks, and balance those with the benefits of becoming a doctor today.

-the money *does* matter (both the student loans, and the eventual salary).

-don't sacrifice having children, visiting aging parents, or other significant life events in lieu of becoming a doctor. It will not be worth that sacrifice.

-Choose your specialty with care. Chose based on your personality...not based on what is most prestigious, what other people want you to do. Your specialty will determine your potential work environments, your pay, your lifestyle, and the number of years you spend 'training.'

-Finally, don't work too many hours. If you do, you'll be more tired, less healthy, and more likely to experience dissatisfaction and fatigue.

9.13.2007

What is it like working for Kaiser as a Pediatrician?


*again, what follows is just opinion from a couple of Kaiser pediatricians.

What do you do for Kaiser?
I'm a pediatrician. I've been working part-time/intermittently for about 20 years.

Do you work other places?
Absolutely.

What are the positive aspects of Kaiser?
For children, Kaiser is a great place. Most kids are healthy, and seeing children for health maintenance is Kaiser's forte. They have same day peds clinic appointments, after hours urgent care that actually stays open long enough for working parents to utilize the service. They have caring physicians, caring nurses, and a wide range of pediatric subspecialists concentrated in a couple of 'pediatric centers'.

You make it a point to mention that Kaiser is good for healthy kids, what about sick kids?
Kaiser is good at preventive care and health maintenance. They have some great docs/departments that treat common diseases very well, like diabetes and asthma/allergy. They're making great strides in treating obesity, childhood HTN, and really promoting health education and healthy lifestyles with their 'thrive campaign.'

However, if a child has a not-so-common disease, children's hospital is always better. If a child has a disease that has lots of research dollars (therefore lots of new research, treatments, etc) Kaiser will be behind the times. Kaiser is slow to change its approved drugs/management plans, so the latest/greatest treatments may not be available to a Kaiser patient that fall into these categories (for instance, cancers, autism, cystic fibrosis, genetic/congenital diseases, etc). Sometimes this makes little difference...but sometimes this can be life altering.

Do patients seem happy with Kaiser?
Absolutely. Those who have Kaiser, seem to really like Kaiser. Kaiser is easy, you know? The patient know exactly where to go for services, how much they are going to pay, what's covered under their plan, etc. Other insurance companies have very hard-to-understand 'networks' and such, with percentage co-pays, and it's not always clear which hospitals are covered, which services in the hospital are covered, etc. I've heard many frustrated Blue Shield patients who are constantly receiving bills from the hospital for the birth of their baby. Anesthesia bill. Pediatrician bill. Bill for supplies. Hospital room bill. OB bill. Some services that are covered, haven't been....and they keep receiving bills, threatening their credit score if not paid...but supposedly covered under their plan. Very frustrating for these people.

Kaiser makes it easy. There is one bill. Everything is on that bill. The bill is expected. It's a set dollar amount and not a percentage of an unknown dollar amount. It's clear.

How's the ancillary staff?
I think they're mostly a great group. Pediatrics tends to bring out more positive than negative, you know. Kids have way of brightening a day....if you truly enjoy them.

What don't you like about Kaiser?
I agree with the EM attending...the lack of self-determination. When I started here I had big ideas. As I spent more time here, I realized that the doctors were starting to lose their fire. Their life-force so to speak. The job became 'just a job.' Everyone clocked out on time...and only did enough to not get fired. Typical employee mentality. I never wanted to be an employee...especially if it meant keeping a timecard. I know docs who used to go on health related missions to other countries, volunteering overseas and such. Young, energetic, and full of life. After being at Kaiser for a few years...they demonstrated less enthusiasm, and just kind of settled into...submission. It's like watching your friends walk into a soul transformer...coming out with no spirit.

Why do you think that happens?
I think it's because they do silence you. It's quite clear to anyone who's been at Kaiser that it's not okay to be....yourself. To have ideas and such. In order to 'be okay with being silenced' many just shut down, never expecting to get satisfaction from the job. Perhaps they seek it elsewhere. EM attending is right, it is an extremely political environment...and doctors don't always do well. If you're on the 'right side of politics' you'll likely be more accepting of it.

I hear Kaiser lacks diversity among the physicians, is this your observation?
That has been my observation. Usually there is more diversity among the primary care physicians than specialists. There is a tremendous amount of diversity among nursing, and other staff. But, among physicians...not much.

It's interesting that Kaiser brags about being such a diverse corporation, but the physician staff is not.
I agree it's misleading. When Kaiser states they are diverse, I guess they are counting the janitors and secretaries, giving the illusion that people of color are actually in high places, and in more 'professional roles' such as doctors. That does bother me since most of our patients are people of color, and I think Kaiser should do a better job of recruiting/retaining a workforce of physicians that more accurately reflects the patient population it serves. There are a multitude of reasons this would be beneficial...both to patient, and physician. Many people seek physicians who they connect with. Ethnicity and gender are major 'factors of connection.' Language, cultural understanding, and simply a demonstration of positive role models in a community is very important for children/families. Kaiser does a very poor job in this area, but 'hide' it by bragging on diversity that primarily exists only among low-level staff.

What's the money like?
The money at Kaiser for a pediatrician is actually very good. Easily equal to (likely better than) colleagues on the outside. Peds is a very low-paying specialty, so Kaiser's salary is good. This is why I continue to work per diem at Kaiser, because the compensation is very good for a pediatrician.

Lifestyle?
Good. We have hospitalist pediatricians, so call is non-existent. You do work 40 hrs/wk for 10/10, and you do go over hours at times. But, because Kaiser doesn't want to pay staff/nursing to stay late (overtime and such), there's a big push to get everyone (else) out on time...which means you get done at a reasonable time. There's mounds of paperwork to do, uncompensated time. And email/messages to respond to from patients (also uncompensated). But, overall, you get your weekends off...nights off....and one half day a week for education/CME. You are scheduled for a lunch hour, but you usually work right thru it. And, there are times where you have (very welcomed) holes in your schedule...

What about having to see a patient every 15 minutes?
I actually can do it without much ado. I'm a very 'to the point' type of guy...and really don't relish in the chit-chat of nervous parents. So, 15 minutes for me, is all I need. And actually its less than 15 minutes...

...but I will say I have a colleague who has great patient satisfaction scores (among the very best), and enjoys spending more time with her patients. Kaiser delayed her ability to fully participate as a partner until she 'sped up' the visits. I say this to share that not everyone enjoys speeding thru patient encounters. Especially, when they aren't making more money to see more patients!!

Why have you only worked part-time for so many years, and never signed on full time?
I still have my fire...even after 30 years post residency. I've accomplished so much more than I would have had I 'settled' for Kaiser. I have a business. I've worked in various cities. I volunteer where ever I want, when ever I want. I teach interns and residents, and am therefore on staff at nearby academic institutions. I make enough money thru other mechanisms to really travel and enjoy life.

Would you recommend Kaiser to a pediatric resident/fellow?
I would want them to know the facts first. To talk to me, and other docs who know, and see if Kaiser can offer what they want. For a pediatrician, Kaiser has a nice mix of money and lifestyle when compared to the outside. The pension is certainly a perk, and there is the opportunity to decrease your work hours to 8/10 or 6/10 time (with comparable drop in pay as a result, of course). It is possible to avoid much of the politics depending on the clinic, and the staff are supportive of each other. The patients are wonderful, and the atmosphere is pleasant.

However, if you have aspirations to do 'something else' with your MD other than practice medicine forever....you might want to think twice. Also, if you want to work at an academic center, maybe mix up your practice a bit between ER, urgent care, clinic, hospital...you may not find satisfaction at Kaiser.

Overall, I'd recommend it for most of the pediatric residents I see graduating today.