Reservations for one

place setting by paul goyette

One thing I love is good food. I am a bit of a foodie, and I have expensive tastes at times. Whenever I go out to eat, I can taste the good food. It's not too hard to tell when food has been frozen or pre-made. It's even easier to tell when something is burnt.

The problem with a love of food is that I can't eat at nice places. I don't mind eating by myself. I do it all the time. I tend to get a lot of work done when I eat out. And I don't mind going to slow restaurants and generating some easy money for wait staff. However, good places are busy, and busy places don't want to see 'party of one' on their booking. I know places that won't take that reservation.

There are many reasons why. One person's food takes as long as two, so the turnover on the table will be similar, meaning the restaurant loses the revenue of an entree and drinks. The server still gets a tip, but of a lower total. One person (if they're not a pro and bring some homework with them) has nothing to do but watch the clock, so they will notice late service. There are all kinds of reasons why a restaurant doesn't want my business.

But it's a little sad. Every time I go out to eat, it's frozen food, hastily prepared, without creativity or thought. It's depressing. I have to go home to eat well. When you've been single as long as I have, you start to miss things like eating at nice restaurants.

Experience points

I get a lot of hits from a link in this pre-medical student forum, and reading through it, I was actually quite horrified. My Don't Become a Doctor series is all about the downsides of the practice of medicine, but I didn't think people were actually sitting down and calculating the costs, trying to balance out MBA vs JD vs MD. A word to the wise, DDS wins that contest every time.

The prevailing argument throughout the forum revolves around whether physician compensation is adequate to defray the costs of medical school and residency. I think that you can add and subtract all the dollar figures you wish, but that's not the cost of medicine.

The real cost of medicine is not that I will make only ~$130k as a general internist. The cost to me is that from the age of 21 to 29, I was doing nothing but studying and working. My friends got jobs, got married, bought houses, and in some cases had kids. I did none of these things. My single friends spent their evenings hanging out in the social scene, developed big networks of associates. I don't know anyone outside of health care.

Undoubtedly, you'll say that there are plenty of docs who got married in med school, had kids in med school or residency, and have all the things that I mentioned: a wife, a home, a family, a big network of friends and social support. This is true. But do you think any of those new spouses or new parents wanted to spend 80 hours a week in the hospital away from their families? Many of my friends with kids never saw their child's first words or first steps. As I like to say, one of my colleagues celebrated the birth of his child by taking an afternoon off. I tell people this jokingly, but it's true. He took a half day.

Who cares about the money? Medicine cost me my twenties. I can't put a dollar figure on that. While other people were backpacking Europe, I was scouting out the best spot in the library to study. While everyone else was amassing a treasure trove of experience points and leveling up, I've been sitting at lvl 1.

If you ask me today if it was worth it, I'll say yes. I am doing something that I love, and I am getting paid handsomely for it. I have reached a point in my life where I am finally reaping the benefits of all that sacrifice, but the thing about sacrifice, you have to give up something good to get something good.

Shiny new toys

CLK + wind turbine by Jasmic

Someone in my hospital bought a new Mercedes CLK AMG convertible. It's almost a crime to be driving it outside in the weather we've been having. Still, it's managed to keep its shine, despite some mud splatter and water spots. I saw it in the physician parking area while I was heading in, and I couldn't help but stop and gawk.

One of my colleagues spotted me in the parking lot and caught up to me. He saw what I was looking at and whistled. "Man, that's a beautiful car." We both stood there for a while, in awe of such a fine piece of German engineering.

When I became an attending, I bought a fancy car. It wasn't too fancy, but certainly was not entry level. In the parking lot, it's very respectable, but clearly shows that I am not a subspecialist. I have nothing to be ashamed of. Considering my salary, it's quite a nice car, but my car's sticker price isn't even half of the CLK AMG cabriolet. This person laid out near $90k and is driving it in winter weather in the Midwest.

Every now and then, I think that I could be making more money. I could be working better hours. I could have an easier life. I have certainly earned it. And when I see something so gorgeous, that I can probably never own, it hurts sometimes. I think my colleague saw me comparing the Mercedes to my car.

"Y'know," he noted. "It's too bad that you can't judge a physician by the car he drives. Then it'd be really easy to find a good doctor." We both got a good chuckle and headed inside.

One of the things that I realized during medical school is that the value of something can seldom be measured with dollars. Doing something I love, that is worth a CLK AMG Mercedes. It's worth a Lamborghini Murcialago. It's worth an Aston Martin DB9. It's worth far more to me than 4 wheels and some metal. I can't really quote scripture and verse, but there is one line from Isaiah (55:2) that I like: "Why spend your money for what is not bread; your wages for what fails to satisfy?"

Sure, I'd like a fancier car and a bigger TV and a fancy house. I'd like a lot of things. But at the end of the day, they are things. And things cannot bring happiness. Joy is doing, not owning.

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.