Attending physician

I haven't written much about being an attending. Partly that is because I don't want to reveal who I am, but also, I feel like being an attending is a hard thing to get a good grip on. In some ways, it feels fantastic to be done with training, but it seems like it's actually quite a bit more stress.

As a resident, I had interns below me and attendings above me. There were tons of people whose job it was to question every decision I made. There were other residents around who could provide some input. As an attending, it's just me. There's no one else. It feels quite odd not having to run my decisions past someone else. After my first clinic, I grabbed one of my colleagues and talked about my patients. "Why are you telling me this?" he asked. It just felt so alien to make a decision and not have it questioned.

I feel like an acrobat without a safety net. I know what I'm doing. Heck, I'm board certified. But being an attending is an isolating experience. I miss having someone tell me that I'm doing the right thing. Now, I have to question my own decision making. I sit at home at night asking myself, "Did I really need that stress test?" Worse yet, I've already had a couple mortalities, and I can't blame anyone but myself.

But for those of you slogging through residency, let me tell you that on balance I am very glad to be an attending. All this time, all the work, and now I am the one calling the shots. That has a price, and sometimes I don't call 'em right, but now they are my mistakes to make, and that is both scary and wonderful.

This was supposed to be the post where I shit all over emergency medicine

I wrote a really long, really bitter tirade about my problem with some emergency physicians. It started out as part of the 'choosing a specialty' series, but I realized that my tirade had nothing to do with actually choosing a specialty, but was just my bitterness.

My complaints were not really about ER docs in particular, but were more about doctors who don't care enough to do a decent job. Every field has its flaws. ER is not exceptional in that respect, and it would be unfair for me to single out ER. Someone could write an equally bitter tirade about internal medicine. And in fact, when I was a senior resident, I was far more harsh with my interns who were lazy or tried to pass off substandard work, to the point where I earned a reputation as a hardass.

Maybe an example would make my point better. A friend of mine in the ER, Black Cloud, he is the worst of luck. When I was a resident, he would give me the most admissions, and always the most acute. It was a nightmare every time he was on. But BC always charted accurately, ordered the appropriate tests, and communicated with me personally. I knew that even the sickest patients he called to me were receiving the best care he could provide.

Contrast this with Phoning It In. PII would do whatever it took to avoid work. Charting wasn't done. Appropriate tests not ordered. Consults not called. Cases would be dumped on other ER docs incomplete, and when I came to admit, they had no idea what was going on because PII hadn't given signout. I've had patients of PII's whom I've intubated upon walking into the room because they were seconds away from respiratory failure.

PII was a tremendous white cloud, and calls were easy, but if I had to choose between PII and BC, I'd go with BC every time. Even though the calls were tough, I knew that BC was doing everything he could to take care of his patients. And that's what loving your job is all about.

I will close with this parting shot. I got a LOT of attitude from some (certainly not all) of the ER residents when I was the on call IM resident. They would tell me that IM is cupcake, and imply that they could do my job without breaking a sweat. They would order me around like I was their servant. "You need to admit this guy in 5. The chart's over there. Pfft, I don't know his name, look at the chart! Jeez." This is a direct quote. My favorite call for admission was, "You need to admit this patient. What's wrong with him? I don't know. You're the medicine doc. You figure it out."

To those residents, I want to say that I am now (right now) forgiving you for treating me like shit, but I cannot forgive the disregard you have shown to your patients and the stain you have placed upon the profession of medicine. I was taught that we have a moral obligation to provide the best care for our patients, and I find you lacking.

To all the ER docs out there doing good work and fighting back the tide, thanks. I really do appreciate it, as much as I complain. And it makes me feel fantastic to know that when I send my patients to the ER, they are in good hands.

Choosing a specialty, part 3

So, this will be the last "choosing a specialty" post. I have been asked to render my opinion on emergency medicine, plastics, ortho, and someone couldn't help but pipe up about radiology. These four specialties probably accounted for the career goals of a third of my med school class. I can't stress enough that these are my opinions, and are likely in no way applicable to you.

The most important thing for me to say is that one should not go into ANY profession in medicine with your primary concerns being lifestyle and reimbursement. Those are shitty reasons to do any field of medicine. You should do what you love. You did not go through eight years (minimum) of school plus another three years (minimum) of training to do something that you hate. You'd be a fool.

I remember quite clearly in college I realized that I could actually do anything. It dawned on me that if I put my heart into it, I actually could do anything that I wanted to do with my life: scientist, doctor, engineer, lawyer. That is a privilege that extremely few people have. How dare you waste that privilege doing something just for the money and hours? If you do not want to make use of such a precious opportunity, there are millions of others who would make better use of it. Please, have a better reason for choosing a career than 'shift work.'

People make fun of ortho. Take the smartest and make em the dumbest. FOOBA. Honestly, I'm all right with ortho. I love ortho consults. I get to manage diabetes and high blood pressure, and I don't have to do a discharge summary? Excellent. I couldn't do ortho after I saw one procedure where they were hammering away at a femur. Felt like passing out. I like wood work. Not too crazy about sawing and hammering people.

Plastics is a funny one. Everyone thinks that plastic surgery is all boobs. In reality, the vast majority of plastics is wounds, skin grafts, minor reconstructions, and hands. If you are lucky, you can do some cosmetics, but you're not going to be on Dr. 90210. I still think it's really cool, but there's far more to plastics than making little ones bigger. But I'm no surgeon, so no plastics for me.

Someone mentioned how I knock radiology, which blew my mind. I actually like rads. I wish I could do it, but I needed the patient contact. What kills me about rads is that a lot of my med school colleagues went into rads for easy lifestyle, money, and 9 to 5 hours, and I loved rads far more than them. I was talking Houndsfield units and reviewing criteria for V/Q scans. They couldn't have cared less. And now, they're radiologists? It kills me.

Now, to emergency. I was trying not to comment on emergency medicine, since my opinion of emergency medicine is toxic at best. Keep in mind that my med school class was part of the "ER" tv show boom in emergency medicine interest. I quite clearly remember having ER parties on Thursday nights in college.

I wrote a very long tirade about ER docs, which had nothing to do with my reasons for not choosing emergency medicine, so I have created a separate post for it. I should mention that I do not counsel students at all about ER medicine. I point them as far away from me as possible.

Personally, I had no interest in ER because I liked having continuity of care, and I despise acute care. It was fun, but entirely without satisfaction for me. Also, what I did enjoy about ER was the primary care. Nearly everything I saw in ER was a primary care issue that if they had seen an internist a week before, they could've probably avoided going to the ER. Instead of leg edema, it was decompensated heart failure. Instead of exertional fatigue, it was acute MI. Instead of abscess, it was fasciitis. What ER made me realize is what these people needed wasn't more ER physicians, but they needed a primary care doc.

And so, here I am.


I am finding it harder and harder to write on this blog, as it is very difficult to write and not give away all kinds of personally identifying information. However, I will take this one moment to say thank you to all of our servicemen and women who have given courageously to this country their time, effort, and even their lives. Without the selfless actions of one American GI, my parents would not be alive, and I would not exist.

And I say this for two reasons. (1) Even though we may see our actions as the most trivial of deeds, they can echo throughout eternity. I saved the life of this woman, and I thought to myself: but for the actions of one soldier over 50 years ago. (2) Whatever your political beliefs, please remember that our soldiers have given greatly to this country, putting themselves in harm's way to protect not only our freedom, but freedom itself. That kind of sacrifice should never be forgotten.

I had a patient the other day who was a WW2 veteran. I asked him about his time in the service, and as he was leaving, I shook his hand and told him, "Thank you for your service to this country." He looked at me a little funny, a little nostalgic. He told me it had been years since anyone had paid him such an honor. That's a shame in my eyes.