Get a job

I haven't really talked about it much, but I have a job for July. I've taken a position in general internal medicine, and that's all I have to say, but it was a very trying experience, finding a job in general medicine. There are only so many kinds of jobs in gen med:

(1) The fantastic hospitalist job in the middle of nowhere: $300k, full benefits, an expense account at the local strip club, and free cheese 24 hours a day, but the position is in Nome, Alaska.

(2) The pitiful, pitiful, pitiful position: $100k, traditional, replacing a solo practice doctor in middle of nowhere, Maine, with call every day, in a community of 500, supported by a 10 bed hospital. Part of reimbursement in the form of soy beans.

(3) The position far, far too good for you: $500k, all outpatient, in Laguna Beach, catering specifically to swimsuit models in need of paps/pelvics and breast exams, with pace of 5 patients a day, cappuccino machines in every exam room, secretary to take notes while you see patients, and complimentary trophy wife if you are single (mistress if married). Shorts and t-shirt dress code. Nip/Tuck policy on sex with patients.

(4) The academic position: You don't want to know the money. Publish or perish. Office in ivory tower only available after 15+ years. Clinical acumen not required. Must be able to survive in relative poverty.

(5) The reasonable spot: $150k, good benefits, 1 in 5 call, medium sized town, good schools, great if you have a wife and kids, but you have managed to finish med school and residency and you're still not married, so the idea of white picket fences and little league games makes you a little sick inside.

Are you smarter than a fifth grader?

I watched this new game show, and I experienced a mix of horror / shock / mortification at the stupidity of these people. I mean, how can you CHEAT off of a fifth grader? But really, Americans are pretty stupid. Whenever we talk to patients, the rule of thumb is that we need to speak at a fifth grade level, to ensure that we are understood.

That doesn't sound too bad, but you probably haven't spent any time with fifth graders recently. Keep in mind, these kids are the target audience of shows like Power Rangers. It takes active effort to keep to that kind of vocabulary.

My personal rules are that you shouldn't use any word longer than 3 syllables, and you should use language to talk to families than is similar to talking to children. Now, you shouldn't treat them like children. It's just that your language has to be comprehensible.

I had a patient in the ICU, and the cardiologist spent time with the patient's DPOA and afterwards, I talked to the DPOA as well.

Cardiologist: Your brother had two lethal arrhythmic events, likely from acute MI. We've coded him twice now, and we did stenting on the LAD. Right now, he's on two pressors and he's hypotensive. I think that you should think about making him DNR.

me (after the cardiologist left): So, did you get any of that? [DPOA shakes head no]
Alright, your brother had a heart attack, [pause while she soaks it in] and his heart rhythm became so messed up from the heart attack that his heart stopped pumping blood two different times. We gave him CPR and shocked him, and the heart doctors opened up one of his arteries.
His heart is beating now, but at this point, we have to give him two emergency drugs to keep his blood flowing. Does all this make sense? [DPOA nods yes]
If his heart stops again, I'm not sure that we'd be doing him any favors by doing CPR or shocking him. We're already doing a lot of last resort types of things. You should think about what he would have wanted.

Seems like I said almost twice as much as the cardiologist, but to his credit, he did take it a step in the right direction. After all, this is how I signed this patient out to the on call resident: 58 male s/p v.fib x2, now s/p LAD stent. Maxed on dopamine and levo. Full code for now.


I thought I put this up a while ago, but I guess not. Here we go. I wrote this like a year ago...

When I was a medical student, I worked with one senior resident, Dr Hardass. He really pushed us, and it was a really tough month. He did however teach us almost continuously, and he made us really excited about medicine. I couldn't say enough about the guy. He was what I wanted to become. I wanted to be that good, and that dedicated. He was the ideal senior resident. I wanted to do well to prove myself to him.

So, when I became a senior resident, I thought of him while working with medical students and interns. I was tough on my interns, and I held my interns to a high standard. Some complained, but others really responded to the tough love.

In the end however, I felt vindicated. Some of the students and interns thanked me. They were so happy to be held to a high standard. I would tell the students that they had it easy, and they challenged me. They took on bigger patient loads, wrote sharper notes. It was impressive.

It was my belief that I have to hold people to a high standard, not just acceptable but excellence. If you only ever expect passable effort, that's all you'll ever get. Holding people to excellence breeds excellent effort.

There are no exceptions, especially for myself. I set out to be like Dr Hardass, and I think I did a decent job getting there, and now I'm considered by a lot of students to be their favorite resident. It's an honor.

The weird thing about being a resident is that it's a chance to be a mentor, and that really is a sacred duty, because your actions are the basis for students' view of what being an excellent resident is.

One of my friends told me that I'm an exceptional leader because I listen to others, always try to do my best, and trust others to rise to the occasion. And those who've worked with me felt they should excel too, not just for the sake of excellence, but also because they didn't want to let me down. That's an awesome feeling.

Yeah, I'm a hardass, but that's DOCTOR Hardass to you.

Visions of the future

The dumbest questions sometimes are the most obvious ones. When I was interviewing for a job after residency, I interviewed with a few private practice groups. They were a mix of very, very eager to mildly indifferent. Their questions mainly centered on the most obvious issues: will you stay with us?

They got to the point in a multitude of ways. One interviewer wanted to know if I had family in the area, or what I thought of their city, or whether I liked their local sports team.

The dumbest question I got though was a common residency interview question: "Where do you see yourself in five years?" Now, this seems like a good question, right? But really, when you're interviewing for private practice jobs, there's no such thing as advancement, just partnership. If they hired me on, I'd be doing the same thing in five years, but hopefully as a partner. It'd be like asking retirees where they see themselves in five years: hopefully not dead, hopefully still retired.

My reply? "Umm... working for you?" I didn't know what he wanted me to say. Did he want me to say, "Well, I thought I might meet the girl of my dreams while wandering the clean streets of your fair city, and we'd fall in love, attend performances by the local symphony orchestra, and have a child who will one day attend the local university."

Maybe he wanted a more truthful answer: "I hope to be the first person to have full season ticket packages in baseball, football, and hockey all at the same time." Or perhaps something better? "I see myself driving a BMW and eating fruit off the breasts of a $10,000 hooker." I just don't see the point to his question.

I think the nice thing about private practice interviews is that people can talk straight, no bullshit. For example, one place I interviewed at handled the question like so: "Alright, you seem like a good guy. If we take you on, are you gonna stay here, or are you gonna leave after 2 years?" If only all intereviewers could be this clear.

The story of Ximelagatran

People complain all the time that pharmaceutical companies are ripping us off, and that they spend millions wining and dining doctors, money that is better spent giving us cheap medications. Instead, Big Pharma is buying doctors houses and speed boats and private islands while charging $1 zillion dollars for life saving meds.

I am not a fan of Big Pharma. I barely take anything from pharmaceutical corporations except a meal every now and then. I do not believe in taking pens or whatever else. However, I can't help but defend them a little, because I think that it's only fair.

And a nice summary of the story of Big Pharma is the story of Ximelagatran, a direct thrombin inhibitor. It was developed by AstraZeneca, and every physician for the last 10 years knows about it, because it was heralded as the nail in the coffin of Coumadin. Coumadin, derived from rotten sweet clover silage, used for decades as rat poison, is the bane of every physician. Drug interactions, a narrow therapeutic range, side effects, there are so many reasons to hate Coumadin.

So, when the initial trials came out for Ximelagatran, we collectively wet ourselves. This was going to be a whole new world for anticoagulation. As trial after trial came out, we became more and more excited. A lot of us bought AstraZeneca stock because if this was true, this drug would be the biggest thing since sliced bread. Every doctor would be prescribing it.

It came out in Europe, but as usual, the FDA took their time, and their caution paid off. Ximelagatran caused a lot of liver toxicity, and it was withdrawn from market and is now a historical footnote. From development to testing to marketing to commercial sale, I can only guess that AstraZeneca spent close to a billion on this drug. And the result? Nothing.

The real crime is that it's still probably safer than coumadin.

Saving grace

Sometimes, call is nice. Sometimes, call is tough. Sometimes, call is just motherfucking awful. And I've had my fair share of nice calls, but in my 3rd year now, my calls have been absolutely miserable.

I have not been dealing well with the stress. It's tough work, and it's a lot of weight to carry. And the only thing that keeps me going is coffee. I need coffee to survive these calls, because after 24 hours of living hell, I can't make it another 6 hours without some help, and the cafeteria doesn't carry amphetamines.

And then, I had my worst call ever. I was covering the ICU, and capped out with really sick patients. I had in one call: 2 family meetings, 3 patients terminally weaned off the ventilator, 4 or 5 central lines, a couple codes... It was that nightmare call you pray never happens to you. It was the Moby Dick of calls. I had one code while I was intubating another patient. The only worse thing I can imagine is simultaneous codes (I've had that happen to me too, but not this time).

And when the worst of it was over, all I wanted was a cup of nice, decent coffee. So I went to the cafeteria at 5AM and poured myself some coffee. It was burnt, nasty, and tasted miserable. It threw me over the edge. I was yelling at staff, critical of my interns, and my signout to the on-call senior was: "You take care of them. I'm fucking done with this."

Everyone knows me, though, and knew that I had gone through hell that night. But we cut each other a lot of slack post-call, because we all know that calls can suck, and sometimes suck very hard. And sometimes without that little saving grace, it's easy to be crushed.

I apologized to one nurse the next day, as I had yelled at her, and implied that she had no idea what she was doing. Her reply: "Oh, don't worry about that. If I had the night you did, I'd be running around shooting people!"

A rose by any other name

I was talking with some nurses, and a couple of them were pregnant. So, the all important topic of names came up. I'm always so interested in naming, but I was horrified by some of the girls names they were throwing out: names like Mercedes, Jasmine, Crystal, Summer, Taylor, Porsche, Briana, Tiffany, Brandy... it was like a role call at a strip club!

I think that our names say a lot about us, in spite of the fact that most of us had absolutely no input in choosing our names. It's like that line from the Simpsons about gays: "[Gays] ruined all our best names, like Bruce and Lance and Julian! Those were the toughest names we had!" To some extent, our names are who we are.

So, I wonder if in the not so distant future, there will be a flood of strippers. At least it might help combat the obesity problem in America. But then what will be stripper names? Maybe your next lapdance will be from Gertrude or Beatrice.