This old white coat
I’m sitting here at my desk looking at my old white coat. I’ve worn this jacket almost every day over the past year. It’s a reminder of the power and trust that physicians instantly hold with all patients. It’s the universal symbol of healing and knowledge. And yet when it comes right down to it, it is barely more than a glorified bed sheet with buttons and pockets.
It is covered with stains from various bodily fluids, food from the cafeteria, and a mysterious orange color that I have yet to identify. Although I’ve washed it regularly it will continue to be synonymous in my mind transference of infections from one patient to another.
This past year will certainly be memorable to me for a very long time. People talk about medicine as if it’s a calling. At no point have I ever felt as if God or any other deity was telling me to become a physician. But I do know that this is the field for me. Nothing else gets me up in the morning so early and so eager as medicine does.
Unfortunately, not everyone feels the same. So many of my classmates have gotten this far only to realize that they have made a very expensive mistake. I know of at least two people who now openly admit that they dislike medicine. Unfortunately, they are now more than $150,000 in debt and cannot leave the profession. They are now stuck in this job field for no other reason than economics. I think that many physicians are similarly trapped because so few other specialties have a high enough payout to clear the necessary debt that comes with this education. So to all of my pre-med readers out there: know what you’re getting into. This is an 80 hour a week job that comes with high emotional strain, abuse from attendings, abuse from patients, threats of litigation, inability to predict whether or not you will be paid, and a constant worry that maybe you didn’t make the right decision with that last patient. But if you like science, are good with people, and enjoy solving puzzles, then maybe you should consider a career in medicine.
Now that third year is over, I’m amazed by the amount of material that I have learned. I wonder why college took so long. If I were to employ the same model of education to my undergraduate degree that I have to med school, I would have earned my bachelors in about nine months. Despite all I have learned, I feel woefully unprepared to start practicing on my own. I started medical school with the realization that there was a gap in knowledge that needed to be filled before I could become a physician. With each rotation I see that there is no knowledge gap. It is a never ending abyss from which I don’t know if I can ever truly master. I have more training than a physician’s assistant, yet the medical community rightfully recognizes that I should not treat patients on my own. And despite similar realizations from physicians at all levels of training, the government and lobbying organizations continue to push for such asinine developments as “doctor of nurse practitioner.”
I look at this old white coat and realize that I have closed the chapter of one of the hardest years of my life. I look at it with a smile knowing that I don’t have to take a shelf exam ever again. I look at it with a frown knowing that one day my signature will be on the prescription pad or the order form—and that I’ll be the one who’s held accountable. I look at it and wonder where the last year has gone.
Prior to third year I used to exercise for a minimum of one hour a day. I was in such good shape that I had a resting heart rate of just over 50 beats per minute. The Air Force even recognized my athletic abilities when I was at officer training. And now, all that has gone away. When I was studying for STEP I, I gave up exercising so that I can free up more time to prepare for the exam. And then I continued not to work out. Due to the time constraints of this past year, I never got a chance to get back into shape. I also took the easy way out with regard to eating and began choosing fast food and microwavable meals over home cooking.
I tried running this week for the first time in almost 14 months. Once I hit the road I knew in less than 20 minutes at the past year has not been good to me. I gained 10 pounds since the start of third year—which is remarkable given that I’ve weighed the same for the previous decade. I started using a new notch on my belt, my blood pressure has risen by almost 20 points, my resting heart rate is up by 30 beats per minute, and there’s no telling where my cholesterol has gone.
I look at this old white coat knowing that I’m going to have to throw it away. It has simply become too filthy with all of the stains I’ve picked up here to continue its usefulness. And yet I hesitate to throw it away. I feel like there should be some kind of ceremony. A funeral. Simply tossing it into the garbage would be akin to shooting a member of the family in the backyard who has outlived his usefulness. And so there it continues to hang by the door where it has greeted me every morning over the previous year.
I look at this old white coat knowing that my training is almost finished. I look at this old white coat and know that I am about to embark upon the next journey—whether it be as a flight surgeon or in some other specialty. And whether medicine is a calling or simply an interesting job, I look at this old white coat knowing that one day soon I’m going to be a doctor.
The fake surgeons
A few months ago I wrote a post about psychiatrists’ being fake doctors. I stated that their inability to manage diabetes and hypertension disqualifies them from using the term “physician.” Today, I would like to extend that similar reasoning to the obstetrician/gynecologist: the ob/gyns are fake surgeons.
All throughout medical school ob/gyns promote their specialty by saying, “We practice both medicine and surgery. We see patients from across the lifespan. Praise us because of our vast repertoire of knowledge.” Things simply don’t work like that.
One immediate example is the multitude of second-year and third-year residents who are unable to tie suture knots. The ability to properly place sutures (“stitches,” as they’re called outside of medicine) is a skill that every doctor needs to acquire before graduating medical school. Certainly, I would expect all surgeons to be able to tie knots and appropriately perform simple surgical techniques. However, I have seen residents who time and time again must be re-taught methods of one-hand and two-hand knot tying. During many of these operations once the attending leaves, the third-year medical student takes over and finishes closing the patient. That perfect line on your belly from your C-section? That was me.
I’ve seen simple surgery such as laparoscopic hysterectomies take many hours solely because the attending in charge does not know how to use the equipment. If you’ve ever seen the bariatric surgeries on television, you’ve noticed that the surgeons hold one instrument in each hand to perform the operation. They then control the movement of the instruments using only fine finger motions. My own attendings are so inexperienced that they grasp the entire instrument with one hand to prop it up, and then use the other hand to manipulate its movement. The result is a need for additional hands (additional surgeons), wasted effort leading to fatigue, and an almost doubling in the amount of time necessary to complete the operation. In one particular case I was extremely annoyed when the attending tried to teach me anatomy by turning around the camera within the patient’s abdomen so that she could point out the liver and gallbladder. Well holy shit, lady! I would’ve never been able to figure out where the liver and gallbladder are. Thank you for halting the operation, singling me out as a medical student, and then showing me such basic anatomy as far as where the liver and gallbladder are. All of that time on my general surgery rotation I had imagined that those organs were within the legs. Thanks for correcting my ignorance.
Due to the need for additional hands (more residents), these cases get so overcrowded that the students take no part. When I did surgery, students typically held retractors and a conversation flowed with the attendings. Now, I don’t touch anything, I can’t see anything, and on several occasions I have had to completely step away from the surgical field because of all of the bodies pressing around the patient.
Perhaps the most annoying comment is the one about treating patients from across the lifespan. Given that they only see women who are of either childbearing age or postmenopausal, I would say that they have a very small subset of the population. Further, their lack of medical knowledge is astounding. For a specialty that promotes itself as performing both medicine and surgery, I would expect them to better able to manage hospitalized patients. When asked on rounds how to work up a patient with tachycardia (a fast heartbeat), my resident replied, “Consult with internal medicine.” His name was instantly added to the growing list of physicians that I would never let my family visit.
Hot off the presses: the Air Force is out to screw medical students
I was browsing through the Air Force’s website for graduate medical education today when I came across a letter from Colonel Hall, the director of physician education. She states that the selection rate for medical students is as high as 75%. What that means is that 1/4 of fourth-year medical students applying to residency will not match. That’s a pretty disheartening statistic to read, especially given that more than 94% of applicants match through the civilian route. I remember being a na‹ve pre-med who bought into the lies told by recruiters that 98% of medical students enter the specialty of their dreams. If I had known then that I’m about to spend several years as a general practitioner, I never would have accepted the scholarship.
Even more disheartening is that this chief does not seem to know how competitive certain Air Force specialties are compared to their civilian counterparts. She writes, “The more competitive or popular specialties such as Anesthesiology, Radiology, Emergency Medicine, and the Surgical sub-specialties have a higher non-selection rate than some of the Primary Care specialties- paralleling the outcomes in the civilian match through the National Residency Match Program (NRMP).” Anesthesiology and emergency medicine are competitive in the civilian world? According to the data published by the AAMC, anesthesiology and EM are only moderately competitive at best. With greater than 90% match rates in both specialties, the average medical student certainly has a shot at getting into these fields.
Christ, why did I ever sign up for this?
Update: you can’t watch television or a movie these days without seeing some high school student boasting to his parents that he can get a free college ride by enlisting in the military. Historically, the Montgomery G.I. Bill has provided educational benefits to veterans in return for their service. Currently, the G.I. requires a buy-in of $100 per month for the first year of service only to provide a little over $1000 monthly in educational benefits after leaving the military. Other than community colleges and a small number of state universities, few places offer annual tuition costs at less than $14,000. Even then, the money does not cover all of the necessary living expenses, books, and equipment that is incurred as the reality of obtaining a college degree. Recently, Senator James Webb of Virginia has introduced legislation which would guarantee four years of tuition at most expensive public schools in addition to living expenses. His reasoning is that the current G.I. bill needs to be overhauled to perform its stated mission. His bill cleared through the Senate with a 75 to 22 bipartisan vote. But guess who is opposed to this legislation: Bush II and Bush III. And I thought medical students had it bad.
The unnecessary cost of technology
Few professions can be as economically wasteful as medicine. Sure, we all love to bitch about politicians, but medicine really should take the award for financial pissing. We build wonderful technologies that can look at the inside of a person’s heart, check the electrical activity of the brain, read any component in a person’s blood, and even watch a baby move inside of the womb. However, all of these devices are made unnecessarily expensive by using non-standardized equipment and are being produced as new models that do nothing to bring down the cost of older versions.
Let’s take a look at the EKG. Any complaints of chest pain or a sensation like the heart is about to leap out of the chest will instantly be met with the EKG. This machine records the electrical activity through the heart and can be used in the diagnosis of arrhythmias, heart attacks, enlarge areas of the heart, and even certain electrolyte deficiencies. At its core, this device is simply comprised of 10 wires that are connected to an oscilloscope (a fancy voltmeter that you probably saw in college physics). I did some searching online and found that an oscilloscope can be had for about $150. The rest of the equipment needed to build an EKG can be found at Radio Shack for pocket change. In the real world, purchasing a new EKG machine runs about $2,000. What’s worse, this device will only print out the tracings of the heart as a snapshot. Getting a machine that uses a screen to show real-time activity of the heart cost even more. Then, once you have this paper-based tracing, you’ll have to insert it into the patient’s paper chart. The only way to get the same result into an electronic medical record is to buy a more expensive upgrade that can connect to a computer. Currently, the total package runs for about $4,500. The end result is that the physician will carry this charge to the patient for about $100 per EKG ($10 after insurance reimbursement). I imagine that an entrepreneur could build an EKG machine that connects directly into the computer’s USB port-complete with interpretation software-for less than $50. The computer’s monitor would serve as the oscilloscope; and a standard laser printer could print out the tracing on paper if desired.
Another unnecessarily expensive piece of medical equipment is the ultrasound. A solid high-resolution machine runs for almost $100,000. That’s a pretty hefty sum for a computer that merely interprets sound waves. One company has released a USB-based ultrasound probe that connects directly into the computer. According to press releases, it sells for just under $4,000. However, looking over these probes I’m concerned about the quality of the images. But the end result is the same: medical equipment can be produced at a cheap cost. The current system does nothing to reward us for developing innovative, cost-effective devices. Instead, we continue to throw away money on machines that can be produced by hobbyists for 1/100 of the cost.
Half MD.com 