backup plans

When you talk to doctors from my generation, we all had backup plans. I was talking to a colleague, and her plan was to get a PhD in neuroscience. My plan was to work in pharmaceutical development. I was even looking at jobs with a few pharmaceutical corporations, back when my med school app process wasn't going so well. A friend of mine actually got a Pharm D. Another friend pondered social work.

The thing we all appreciated is that being a physician is a privilege and an honor. It's not something you deserve. There was no 'game' or 'trick' to getting into medical school. The entirety of medical school admission can be summed up in one question: why should we let you be a doctor?

Don't become a doctor #15 - Guilty

Recently, I had a patient who died suddenly and unexpectedly after I had seen the patient in the morning for some muscle aches. I reviewed the case to see if there was anything I could have done to prevent it. Did I miss a lab result? Was there some sign that should have been picked up? Were appropriate protocols and guidelines performed? I was convinced I'd find something, some piece of evidence that would've shown that if I had paid more attention, this person would still be alive. It was preventable and avoidable... wasn't it?

One of the strange things about being a doctor is that, despite all the rhetoric about malpractice and liability, it's hard not to feel guilty when bad things happen. You can't walk away without a little blame. This happened on my watch. We go into medicine to help people, so when shit happens, it's hard not to feel responsible. This person trusted me to protect them from a bad outcome, but it happened, and I didn't even see it coming.

A lawyer friend of mine tells me that physicians are terrible in court because we want to take blame. But shouldn't it be my fault? Shouldn't someone be held accountable? And if I'm the patient's doctor, shouldn't it be me?

It took me a long time to figure out that one of my favorite aspects of adult medicine is that so much of it is lifestyle dependent. When something bad happens, I can go home at night and think to myself it may have been something I did, but it may also have been the patient's bacon cheeseburger lunches for 35 years. There is some amnesty in adult care.

If you are disturbed by the thought that your actions (or lack thereof) could hurt someone, or even kill them, then welcome to humanity. But in medicine, even when you are blameless, you may still find some guilt in your heart. And that is medicine. If it happened on my watch, shouldn't it be my fault?

Bachelor's in pre-med

I was reminiscing with a friend about the 'good old days' when we were both chemistry students. He's a chemistry professor now, and complains endlessly about pre-meds. He teaches one of those required pre-med courses.

Pre-meds (and medical students for that matter) are pretty high maintenance. 'Is that going to be on the test?' should be the pre-med motto. There's no learning for learning's sake: everything is goal directed. I need to ace biochem so I can rock the MCAT so I can get into Harvard Med so I can get a residency spot in derm so I can do cosmetic derm and rake in a seven figure salary. At no time is there any enjoyment of the process. It is facts and test material and hoops to jump through.

The pièce de résistance is that some schools offer a degree in pre-med. This is, in my opinion, ridiculous. When I was in college, I took all the tough science courses. I took all the sections for real science majors. This is because I wanted my degree to mean something, and feel like I'd accomplished something. I didn't want to spend four years earning a degree in 'pre' anything.

Learning about electron affinity, valence shells, and lattice structures may be entirely useless to me now, but that doesn't mean that it wasn't worth learning. Reading the Iliad was useless too, but I wouldn't give it up either.

EDIT 1/4/11
When I mention a degree in pre-med, I am referring specifically to a Bachelors in Pre-Medical Studies, which is an actual degree offered by some smaller colleges, but not at most universities.
I know that med school has a lot of requirements. I took them too. But part of life is enjoying the process. I enjoyed organic chem. It was fascinating. I took a geology class and loved it. I got a letter of recommendation from my Communications prof for one course that I got a B in. I took 3 or 4 classes that had nothing to do with my 'hard science' major because I wanted to learn. The point of education is to learn, not to earn a grade.
One of the hardest things to explain to pre-meds is that grades and MCATs aren't nearly as important as being a decent and honorable person. And if you can figure out how to convey that information truthfully to an interview committee, then there isn't a med school in the country that wouldn't accept you.

It's not my fault

Most of the diseases I see are lifestyle related. Diabetes, hypertension, cardiovascular disease, even colon cancer are all heavily influenced by lifestyle. Ultimately, most people earn their way into my care. So, it is pretty frustrating whenever I meet a patient who refuses to take responsibility for their health.

I met someone who took this to comical levels. He had an excuse for everything. No one wrote him prescriptions. He was blacklisted by local doctors. His PCP wrote for the wrong pills. He was never given appropriate dietary advice. He was never told french fries are bad for you. He was told his appointment was for 4 PM, not 3:20 PM. It was our fault. It was his doctor's fault. It was everyone else's fault.

The problem is that I just don't care. People spend so much time worrying about who is at fault, but the only thing I care about are the results. What difference does it make who is to blame? The only thing that matters is that his A1c is 13.6% and is LDL cholesterol is 171.

Your body is like your car: what you do at home has a whole lot more to do with how your car performs than anything a service station does.

Dinosaurs

I am convinced that the folks in Washington do not understand that primary care is currently an intensely unpopular choice of profession. There have been some massive shifts in popularity of some medical specialties, but the universal theme has been that primary care has waned.

People think it's all about debt burden, but it's not. It's nowhere near that simple. And if you want to prove it to yourself, look at the hospitalist vs the traditional internist. Finding traditional internists (folks who do both clinic and hospital work the same day) are a dying breed heading to extinction. In fact, primary care internists are harder to find in general. And it's no wonder.

Seeing hospital patients in the morning, doing clinic in the afternoons, call every 3 or 4 days, who wants that lifestyle? Compare that to the hospitalist, who is on one week, off the next. A week off is virtually unheard of in traditional practices, but it's the norm for hospitalist work. And hospitalist pays better too.

People fondly remember the days of doctors who do home visits, with a nostalgia entirely unwarranted, and I expect that in our lifetimes, patients will reflect on the days when their regular doctor would see them in the hospital too. But that is going the way of the dinosaurs.

And the true shame of it is that a lot of hospitalists burn out, even with the free time and the extra pay. And that's why I tell people to pick something that makes you happy, because money and lifestyle can't make you happy. It just gives you more time and resources to hate your life.