I decided not long after I started this blog – quite some time ago now – to never apologize for not writing.  I’m a doctor.  Stuff comes up.

So, I haven’t blogged in awhile.  If you’re still one of the regulars, my thanks.

This latest distraction involved graduation from my residency program.  Or rather, not graduating…the specter of it, at least.  And while the problem is resolved…the emotions on my side still simmer with grim ebullience.

Arriving in the infuriatingly innocuous manner of many catastrophic announcements, I received the news recently that I had not spent a required week with an orthopedic surgeon during this last year of residency.  Setting up that week is one of what feels like 4 bujillion stipulations that lead to graduation.  I’d missed this one, and it was too late to change my schedule to fix it.

Through some fuse-burning mental gymnastics on my part, and some heroic situation-framing on my advisor’s part, the faculty of my program have just decided that I will, in fact, graduate with my class.  In essence, we found a workaround that keeps me on-track to finish with my peers in less that 4 weeks.

This experience however, reignited an old resentment in me that essentially boils down to oft-repeated theme in the “Jason Bourne” movie series about being required to give vastly more than expected when signing up.

The frank truth is that all the permutations of mid-level medical providers – from ARNP’s to PA’s to Dr. RN’s – have one thing in common…they’ve been subjected to roughly 1/3 the amount of training as I have.  Subsequently, they have 1/3 the debt, and probably have 1/3 the family problems, health problems, and 1/3 the incidents of depression, substance abuse and suicidality.

The result of that limited training?  They do the exact same job as me…and get paid about 80-90% what I will make.

Calculate how much money I lose in training when they’re out actually working, and I probably make less than your average P.A. over the course of a career.

I was so upset over this graduation snafu, that I rammed my fist through a wall in our house, and ended up driving hopelessly around the beaches of Washington until 7am this past weekend.  Then, thankfully, I got with the program and figured out a way to address the problem a little more professionally.

No, working an extra week after graduation wouldn’t be the end of the world.  But in so many ways I feel I’ve reached the end of my rope.  And, for lots of logistical reasons, another week of “work” would have really been tough on me and my family (and probably our walls).

I should mention that what I was deficient in – observing an ortho doc – falls into my category of ‘watching doctors be doctors’.  I’m not sure where anyone came up with the idea that people learn from this particular brand of education-theory rack-stretching, but frankly at my level if I don’t have responsibility, I don’t care.  If I don’t care…I don’t learn.

Watching doctors be doctors is  easily the least valuable learning experience I’ve had in my entire medical training…and residency is rife with this vacuous requirement.  I’m quite sure that the endless hours I’ve spent delivering Oscar-level performances of intellectual interest could be completely removed from my training and I would still be the same doctor I am today…just less poor because I would have started working at least 6 months sooner.  Maybe a whole year.

Simply put, I believe that my medical training is outmoded.  It’s destructively expensive.  If people can do my job with 1/3 the training, then I’m effectively over-qualified. 

The backside to this is that M.D.’s themselves will eventually become irrelevant in the marketplace because we’re just too expensive.  We spend so much money on school and inefficient training, that nobody can afford to pay off all of our debts.  How long will it take me to pay off the $330,000 I spent on my training?  How much more do I owe on that since I’ve piddled away another 3 years on training – watching orthopedic doctors and acting interested – while a number that big generated interest on itself?

I’m deeply grateful to my advisor especially in this case, because he presented my situation to our residency faculty in a light that was very favorable to me.  He is probably the reason I’m not in a padded room at the moment. I don’t really blame my residency program, either. 

The problem is the system:  tone-deaf, needlessly arduous, inefficently stubborn.  The mid-level system was created by smart people who realized that it just doen’t take this much to make a doctor.  You shouldn’t have to sell your soul for the honor and burden of taking care of sick people.

In the end, I approach graduation almost devoid of any elation at all.  Instead, I feel like I’m sitting in a field, blood and feces spilling into my lap from the mortal shotgun wound I’ve received to the gut, looking plaintively up at the shadow hovering over me – at my colleague and killer – and wondering aloud, “Look at this mess…look at what they make you give…”

Ode to McDonalds and Cigarettes

You can say you saw it here. This family medicine doctor – supposed bastion of all that is healthy and wholesome – recently found himself encouraging a patient to keep up the McDonald’s and smoking. Instantly after proclaiming my support of these two great sins of the developed world, I heard my program director’s voice in the back of my head saying not unkindly, “Nice job, doctor, good work…we’ll most likely kill you in the morning.” Although never tempted by cigarettes, I frequently fight the urge to hit a McD’s and constantly rail against both as all that is disjointed and wrong with our society (celery is another problem, IMO, but that’s another discussion entirely).

I saw a patient this weekend who unabashedly describes smoking about a half-pack of cigarettes a day, and has been doing it for “goin’ on 50 years now, and I ain’t quittin’ no matter what you tell me.” The patient is 78 years old with advancing COPD. When she inhales, the wispy flimsy breath she drags down into her rapidly deteriorating lungs rattles around aimlessly like a blind baboon in Grand Central Station. She then forces the air back out; little of the oxygen actually used. She is on 14 medications to treat everything from her diabetes to the high amounts of fat in her blood.

“Smoking makes me feel…” She closes her eyes, her face taking on a distant, faraway look as if she just lost herself in recollections of her torrid love affair in Paris on a college philosophy tour, “like I’m surrounded by friends when I’m actually all alone.” How can I beat that?

This patient lived a full life, been smoking for a good majority of it. Now she is stuck in that impartial vice-like vortex of half-life and half-death that American medicine has so expensively provided us. Historically, people just died when they got as sick as her. Today, people linger, in a sort of daily, living suffering. The institutions they inhabit have innocuous-sounding descriptions like “assisted-living communities”, but everyone knows what they really are. Places where the clock of mortality hangs largest on every wall, where the clanging metal hammer pounding on anvil cannot go ignored, but can’t be rushed. It pounds in measured, inexorable rhythms, indifferent to anguish it causes. Hundreds of thousands of Americans waste away in these communal halls, most abandoned by their families, waiting for that final insult and staring droolingly at the wall in the meantime. But when this insult finally does arrive – a heart attack, hemorrhagic stroke, maybe a pulmonary embolism – it shows up with a slouch, hands in pockets, irresolute, nuanced and often as slow as a sadist. These days, the Reaper arrives in a robe of gray, eschewing the dramatic and abrupt pitch black somewhere around the time we invented beta-blockers.

So, go ahead, lady. Smoke to your heart’s content (or infarct). The damage is done, really. If you did stop today, the additional few weeks or maybe even year would be so miserable for someone who loves smoking this much it wouldn’t do much for you. Mortal time isn’t everything. There’s such a thing as life quality, too.

“The other thing I love,” She continued, “is Saturdays.”

Her face, looking like gravity used physical hands to pull her face to the ground for the past 200 years, suddenly filled with a smile. Her losing battle with age suddenly clamoring to a standstill. “My wonderful daughter comes every Saturday and brings me a McDonald’s egg McMuffin sandwich and coffee. I just love that. I look forward to it all week. Say, what day is it? Maybe she’s coming today. Do you know?”

“Well, it’s Saturday night at 11. Maybe she came earlier before your care facility staff thought you needed to come to the hospital.”

“Yes. This could be. You see dear, I can’t really tell the difference between days and weeks and months and years anymore. They’re all sorta the same to me anymore. I just know my Jerry comes on Saturday and we have breakfast together. And you know…that McDonald’s does a lot of good for other people, too. They hire young kids, old folks…give people a start in life, or help them do something worthwhile. The buy all kinds of ingredients from local grocers and farmers. Why, when they moved in here 30 years ago, my son was one of the first they hired. He has his own business today. Employs 30 people.”

“Wow. I’ve never thought of them that way.”

“And them McMuffins…ain’t so bad for you, either. They fill you up, keep you fed through almost a whole day. It’s good food.”

By any primary health care measure, someone who smokes daily and eats fast food at least once a week, is not healthy. But exceptions to every rule emerge in unlikely places. This woman did not come to the hospital to make me re-evaluate my unbending belief in the immutable evils of fast-food and smoking. But her defense of their place in her own life was unassailable. This woman won’t live to be 90 years old. The end may come in the next few days, in fact. But this is true for all of us. This very moment, our lives could be required of us. Should this happen, could you depart with the same gentle serenity?

If deprived of her simple vices, could she?

I found myself answering no to both questions. So this family doctor ended up departing the room, encouraging an overweight patient with COPD and hyperlipidemia to “keep up the smoking and enjoy your McDonald’s.”

I’ll start typing my resume. I hear there’s good jobs in the restaurant business.

Saturday Night Quotes I Like

A compendium of quotes I’ve noticed over the past week that were provocative, thoughtful, interesting, funny or patently absurd.  Sent out (‘Lord tarry and the creek don’t rise’) every Saturday:

“What Mrs. Clinton has that Mr. Obama does not have, Mr. Obama can get. What Mr. Obama has that Mrs. Clinton does not have, she can never get.” – Alec Baldwin

“I have much to thank God for this week. For one, I have so much support for all of my life’s struggles. Secondly, I’m not a patient in the hospital. For another, I’m not on trial for murder.” – Fat Doctor

gaza.jpg“And let’s face it kids, despite the shows on the television, medicine is not sexy. Unless you are a pediatrician, the majority of your patients are going to be elderly and pushing their expiration date.” – Panda Bear, M.D.

“Welcome to America, where your government will pay for both your tracheostomy and your cigarettes.” – Happy Hospitalist

“Life can go by quickly, and if you’re not careful, it will be gone before you have a chance to enjoy diversifying your assets into stocks, stock mutual funds, corporate and municipal bonds, bond mutual funds, international funds, cash equities, exchange-traded funds, life-cycle funds, and U.S. Treasury securities.” Joseph Reed, The Onion

“Our message is clear. It is to break the siege imposed on the Gaza Strip and to motivate the Arab, Islamic and International Community.” – Jamal al-Khudari, leader of the Popular Committee Against the Siege (PCAS)