Residency = Crack!

So I found out some shocking information from a program that I heard on NPR's "Talk of the Nation" about Physician sleep deprivation in residency. Ever wonder just why you guys are working 80-hour weeks with no sleep? Just where did that fun "tradition" come from? I transcribed part of the program...

Spoken by Dr. Charles Seizer, director of the division of sleep medicine at Harvard Medical School.

...the Tradition dates back to 1890, and was started by a pioneer in American medicine: professor William Halstet, from Johns Hopkins, who established the first program in residency training in surgery. He really set the standard for the nation by establishing these marathon 30-hour shifts. It was only revealed this past year in an article in the New England Journal (of Medicine) just how he was able to stay awake for so long.

It turns out he was a cocaine addict.

He had just been discharged from the Butler hospital in Rhode Island where he had been an inpatient for about a year and a half trying to get rid of his cocaine addiction. They were using morphine to treat him so he ended up with a morphine and a cocaine addiction as he took over his role starting up the program.

So we're left with the same traditional schedule in which interns and residents are expected to do 24 or 30-hour shifts and are expected to perform at their best...

So there you have it! According to Dr. Seizer on NPR and his citation of the New England Journal of Medicine, all that intense residency training owes its roots to cocaine addiction! Your wife nagging at you for working such long hours in residency? "Oh honey, don't worry. I'm trying to emulate a crack-head lifestyle, that's all!" Sure, that'll work.

And so, I'm gearing up. After I finish medical school, I get to live like a bona fide crack-head, and I bet after 30 hours and no sleep, you'd probably write prescriptions like a crack-head, too. You might as well bond with that frequent-flyer in the ED and tell him to just stay up for 30 hours straight in the hospital! He'll never snort the white stuff again, and you'll have one less guy to watch over in the ED. He'll probably even go for medical school himself so one day, he too can get his fix in the hospital, just like all the medical residents partaking in the wonderful cocaine-catalyzed "tradition."

Bottom line: A tradition as crazy as medical residency could only be explained by something like a guy on crack. The funny thing? It's true. I guess it's probably not all it's cracked up to be, eh?

No Smoking

And so, there I was. My grand performance, my most challenging summer of all. The times that tried my soul. The best of times. The worst of times.

So I stood there at the Emergency entrance in my big, sore thumb uniform red-coat. Doing what I did best, I was standing out there, idle in the summer heat, MCAT flash-cards in my front pocket but not being glanced at. There was a nice elderly gentleman who drove a parking-lot shuttle (read: long-ass gas-powered golf cart). He did his job religiously, every weekday from 6AM to 3PM, meaning that I always saw him when he'd stop in front of the ED to relax. He was a great guy; handed out stuffed animals to children and stopped people to make light conversation.

Turns out he's an ex-CEO, and he was quite a successful one at that. He owned a huge RV factory in a lucrative area, drove one himself, and payed $600/month to use a Satellite phone (this was back in the 80s when they were OMG expensive). Somewhere along the line, business went bad or was bought out (he did not say) and he basically lost his fortune, becoming a relatively normal guy again. He loved telling me about his time in the Korean War. He loved griping about the reckless young teenagers he'd see walking into the ED. Just don't get him started on politics. He's opinionated and haughty - he'll talk your ear off...which I could afford, being a busy volunteer and all.

So, I forgot his name but we'll call him Earl for now. Earl had left to do his driving and I stood out there thinking about how long four hours is when you do nothing the whole time. As if from nowhere, a woman was standing but 6 feet to my left. Standing directly in front of the NO SMOKING sign, she stood there puffing away; a thin, shaky hand holding a smoldering cigarette. She had dirty-blond hair and dark, leathery, worn skin that made her look older than she probably was (she looked 50 but was probably 35).

I blinked and raised an eyebrow, slightly less-bored than usual, but still abysmally aware of each passing second.

Her other hand rested on her IV pole, which she had so kindly brought outside with her. She raised her cigarette-holding hand up to her lips, a long, wrinkly index finger pressing to her sun-burnt lips.

"Shhhhhhh!" She peered at me cheerfully through glazed eyes.

"You didn't see me out here! A girl needs her simple pleasures and nobody saw me, so I decided to take a little walk!" She huffed out another breath of smoke and took a few steps up the sidewalk, the IV pole obediently rolling along just in front of her.

I was highly amused, but also blank. Smoking while in the hospital seems crazy enough, but escaping with your IV pole and doing it in front of the NO SMOKING sign was just too much. I wish I had a camera. Oh, I've heard worse. I know there have been hospitalized methamphetamine addicts who escape to the parking lot so their "friends" can give them a quick fix. People can be desperate.

Being merely a not-employed-at-the-hospital volunteer, I smiled at her and nodded. I figured I had no responsibility to "stop" her. If someone was doing something blatantly horrendous, like stealing supplies or doing something illegal, I would contact the proper contacts. But this lady was doing her own thing and as far as I could consider, I didn't exist at the hospital, so she may as well have never been seen by me for real. And besides, when she strolled back through her unit, the nurses probably just smiled and waved at her, turned to each other and said, "there she goes...again."

Volunteering...a huge formality.

Five Months and I'm Petrified

Savor the Days

I remember when I got my acceptance letter. After running around my older sister's basement in an ecstatic fit of glee, I calmed down and relished the stress-free months that laid ahead. It's hard to believe that I've already burned 4 of those months down, with only 5 left (less than that before I move to the city where my school is).

I've been so settled into my newfound state of "post-accepted senior" that I've forgotten what it is like to put in a hard day of studying. I live in an on-campus apartment with 2 other fine gentlemen (intended to be a six-person apartment; we have 3 now, had 4 last semester). One of them is a post-accepted Pre-Dental senior and the other is a non-traditional Pre-Med junior studying his butt off for the MCAT in May.

There is something liberating about having time left before the storm. My last months as a truly lay person. Go do what you want to do; travel, see friends and family, live, rave, visit Greece, heck I don't care. But live while you still can! I'm petrified about starting in a measly 5 months. I'm not sure how quickly I'll be able to adjust. In the meantime, I plan on shadowing a few Emergency Physicians, finishing up my undergraduate research involvement (finally), having as much fun as possible, and getting everything ready for the big move.

The Calling

The Calling

Pressure mounts on all medical students to decide on a specialty earlier and earlier these days (the last decade or two). Medicine as a career-choice is not to be taken lightly. You absolutely must be someone willing to sacrifice lots of time and energy for your goals. Not only that, but for many physicians, their family, friends, and social life suffer as well.

I truly believe that medicine has always been a deeply-rooted calling for me. My decision to enter it has been affirmed time and time again every day that I wake up. Sure, medical school will be tough; rotations will screw me over and residency will grind me to the bone. But I've accepted this. 80-hour work weeks in General Surgery rotation with call? I'm aware of this. "You think you know, but you have no idea." I'm aware of this and ready to accept what comes.

But beyond all this, I feel especially called to Emergency Medicine. I know that online medical blogs are no place from which to base real-life experiences or future plans. But they do offer an unedited, unscripted view into a lot of physician/resident/student's lives that you would never know about from medical school itself. Third and Fourth year medical school clinical rotations, as many say, do not give you a complete or accurate picture of life in those particular specialties. Sure, you get exposure and a good idea of what each of those specialties offers, but what about community vs. academic hospitals? What about doing that for 3 decades instead of 3 weeks? What about politics, hospitals, burn-out? The bottom line is that you should not limit your choice of a medical specialty based solely on your clinical rotations in medical school. They are very valuable, yes, but they are to be taken with a grain of salt. This is what I gather from reading many blogs and sites, at least.

I believe that your medical specialty should truly be a personal calling; a deep passion. If it is something you could not imagine doing for 30+ years and waking up every day to, do not do it! A specialty should also be one that appeals to you personally. If you find that patient-interaction is not important to you, you will want to avoid Family Medicine and Internal Medicine. With Emergency Medicine, I find myself rabidly fascinated; I read and keep up with every EM blog I can find online (just look at my links list). I read about EM on the Student Doctor Forums down to the last post and enjoy every bit of information I can read.

I look up information on specialties and read about every one, checking out lifestyle, compensation, nature of the work, residency, etc. I keep an open mind, and time and time again I find myself gravitating towards EM. I find the idea of the field exciting and wonderful for many reasons. I must organize this whirling mess in my head:

Pros

+Personality Match - The kind of guys I got to know through Panda Bear MD, M.D.O.D, Doc Shazam, and Scalpel or Sword (see my links) are a good personality match with me. They're realistic, laid-back, blunt, and seriously great doctors when they need to be. I've never quite fit in with the other pre-meds here; I'm not all 100% serious and anal all the time. These EPs seem to possess that same air of being free and alive that so many medical students lose. I've shadowed EPs (Emergency Physicians) and volunteered in the ED; the docs are really awesome people.

+Lifestyle - Shift-work. EPs are known in medicine for being people who have a true passion for life. They are able to separate their professional responsibilities from their personal life. Now, I'm not trying to shirk the Hippocratic Oath, but personal time is critical to one's happiness as well as their success as a doctor. From the doctorjob.com website:

When most people think of a physician's career, they associate it with long hours, little or no personal or family time, and tireless effort. Many newer physicians entering the workforce are not as willing to sacrifice themselves at the expense of spending time with their loved ones. And rightly so – having a more enriching family life and social life will make you happier and more successful in your professional life as well.

Currently, many physicians are focusing on specialties that have more flexible lifestyles instead of focusing purely on income level and prestige. Some fields of practice that can be considered “lifestyle friendly” are areas such as anesthesiology, dermatology, emergency medicine, ophthalmology, neurology, radiology, and pathology. These specialty areas offer you more control over your hours, and the income can be commensurate with the workload and level of responsibility.

As you can see, EM is consistently considered one of the "lifestyle" specialties, meaning that it allows a physician to have control over his/her hours and actually have a real life outside of the hospital (for general surgeons, internists, and OB/GYNs, this is a foreign concept). I have always been a firm believer in "work hard. play hard." I also like to leave work at work.

Q: You like to leave work at work? You want to have a life outside of medicine? Then why did you go into medicine!

A: My friend. This is precisely why EM has found me.

EPs are always the kind of people with lots of interests outside of medicine. I know an accomplished older EP who also runs his own audio business. He helps do live audio mixing for a very large and well-known Jazz festival near my home every summer. He loves RVs and outdoor living. He has had great success in the software/hardware business. I did not even know he was an EP until long after I heard about his other accomplishments in life. This is what I want - the ability to work hard and be a great physician while returning to my home/family and pursuing other passions!

+No Call - Apparently, call sucks. I've heard it from physicians, friends with physician-parents, and probably worst of all on every med blog I've ever been to. It seems that call is this old-school tradition in medicine where you come into work at 6AM Monday morning and do not leave until Noon on Tuesday (basically a 36-hour shift). I hear that it is not really "just" call, but indeed extended work ( at least for residents). For example, a Family Practice physician will be on call 24/7 and will be interrupted at 3AM, during dinner, during a wedding etc. to act as a consult for one of his/her patients.

Imagine going home from the hospital after a long shift and being able to relax with nothing on your mind. Your mind suddenly shifts to your patients - how are they doing? What kind of medications might they need when you round on them tomorrow morning at 5:30 AM? Yeah right. An EP stays far from this reality!

+No Rounding - Apparently, rounding sucks. Rounding is when you rotate through your roster of patients on the wards. You ask them how they're feeling, check their progress, discuss possible further treatments, and have 2-hour discussions on K+ levels and electrolytes. Again, I have had zero experience rounding, but from what I know and what I know about myself, I'm likely to agree with many that rounding is not the high-point of many specialties. Sure, some specialties do not admit patients too often, but still, why mess with it?

+Short Residency - 3 Years (in some cases, 4) is relatively short for a residency. Compare to 4 for neurology and 5+ for general surgery and its subspecialties. Do you know what a shorter residency means? You'll be out working and paying off those pesky 6-figure loans while your colleagues in cardiology keep training for another 2-3 years after you're out! Get to the point, that's what I say.

+Lots of Procedures - Now, I've developed a taste for working with my hands. I have not been able to suture up real wounds or anything, but I dissect frogs a lot. I enjoy working with tweezers, scissors, scalpels, retractors, surgical silk, etc. I like tying those little knots and poking at soft tissues. I do not want to be a surgeon, but I do enjoy working hands-on. ER offers an insane myriad of procedures from suturing lacerations to splinting broken bones and injecting dental nerve blocks. Did I mention traumas?

+When you're off, you're off - This is something certain people want, others don't. Me personally, I never liked homework much. The ability to leave work at work with a clear conscious (even if it is at 1AM when you get off) is its own beautiful thing.

+Variety - Newborn babies to the elderly, indigent and wealthy, kings and peasants, come one, come all. You get them all in the ED. Drunk or sober, pregnant, raped, stabbed, shot, stomachache. Everything. Not to mention, where else will you read an EKG, and X-ray, and pump someone's stomach on the same day?

+Compensation - It's not everything, but in the face of very high debts, medical students have been seeking higher-paying specialties. Again, while salary is not everything, EM has particularly good compensation.

Cons

-Lack of Continuity - OK. So I suppose I won't be tracking Mrs. Nesbitt's progressive loss of feeling in her extremities over the years. And I won't see Billy grow up into a big man. But it's ok! I really don't mind the idea of no continuity. Some people like the relationships and ongoing stories, but I really just want to practice medicine.

-Working Nights/Holidays/Weekends - All right, well you kind of got me there. Yeah, I love my weekends. But you know what? Loving what you do take precedence over hours. Yeah, staggered shifts from night to day and back are tough. But guess what; EPs tend to work far less hours per week than docs in other specialties (35-40 hours a week are not unheard of). Compare to 55-60 hours a week in other specialties with similar or even lower pay. When the month is said and done, you worked an average of around 40, perhaps 45 hours a week. Big deal. The point is that those hours are self-contained. That is, you worked them and when you went home to your family/recording studio/pets/friends you really went home to them. You didn't go home and spend your remaining hours on call or worrying about what you would come to work and find the next day. Every specialty has a downside; if you have overwhelming positives and love it - do it!

-Indigent/Drunk/Disrespectful Patients - Yeah. You're on the front-lines of medicine, down in the trenches. You get the drunks taking swings at you and the psychotics begging for drugs. You have the guy who got stabbed in the gut screaming the F-word at the top of his lungs while you try to anesthetize his abdomen. It's part of the job and it's reality. Just remember, not everyone is going to be like that.

-Disrespect from other doctors - "He's the whipping boy! He just stabilizes patients and then sends them to us!" Ok, sorry I didn't spend 6 years in residency studying the cardiovascular system like you did. At least I got Mr. Doe stabilized and worked up properly for you, Mr. Cardio. I hear this situation is getting better, as the specialty gains more support and recognition.

Bottom Line: I cannot and do not claim to truly know the ins and outs of this, or any other specialty. Not even close. I understand that I am only a pre-MS1 kid with an idealistic smile and and a lofty head. But you know what? It's never too early to start thinking. You have a personality and you know yourself. You can read up on specialties, talk to docs, think, discuss, ponder. You have every right to say "Hey, this is how I am...this is how these specialties are. I think that, based on what I observe, I would most likely enjoy this specialty the most." And along the way, the additional data keeps reaffirming my EM hypothesis. I am open to whatever comes my way, but I have a hunch, a gut-feeling that I'll end up in this insane place.