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Even more ER questions

Part 3

Paramedics working in the ER
Q:  Hi, I'm a 17-year-old high school student who is interested in becoming a paramedic. I am also thinking about becoming an ER doctor sometime in the future. It is something I really want to do, but know very little about. I am well aware that paramedics don't work in the emergency room, but would being a paramedic give me any experience if I decided on a career in the ER? If you could get back to me, that would be awesome. Thanks for your time!  Alli

A: > I am well aware that paramedics don't work in the emergency room . . .

Yes they do. Some ERs employ paramedics as ER technicians.

> . . . would being a paramedic give me any experience if I decided on a career in the ER?

Definitely. As a paramedic, you'll gain a lot of experience that would be a valuable stepping-stone to becoming a knowledgeable, well-rounded ER doc.

Did I ever freeze?
Can a woman be an excellent ER doc, wife, and mother?
The idealism that impels young people into careers in emergency medicine

Q:  Hi Dr. Pezzi.  My name is Naureen and I am a sophomore in high school.  First off, I just want to thank you for creating your site. It really helped me in rethinking my career choice as an ER Doctor.  If you could answer a few questions of mine, I would really appreciate it.  Have you ever had insecurities of your abilities as a doctor so that you could not treat a trauma patient?  Also, I have read that you are not married yet.  Do you think that if you had met the right person that you would be able to adequately juggle both a family and a career in emergency medicine?

A:  > Have you ever had insecurities of your abilities as a doctor so that you could not treat a trauma patient?

Not me, but I've heard of some ER docs freezing when confronted with a critically ill or injured patient.

> Also, I have read that you are not married yet. Do you think that if you had met the right person that you would be able to adequately juggle both a family and a career in emergency medicine?

I addressed this issue a few times on various pages of my web site, but in a nutshell, here's my opinion on that matter. I know it's trendy for people to think they can "have it all" these days. That is tough for anyone, especially a woman. While this may be unfair, the reality is that women traditionally spend far more time caring for children, doing housework, shopping, and cleaning, even if they work. Unfortunately, there are only 24 hours in a day. I'm still butting my head up against that limitation, and I am single and childless. The constraints of time are far more onerous for someone who is married and has children — again, especially for women. I know that men should share equally in housework and caring for children, but I've seen it time after time: men sitting around while their wives prepare meals, clean the house, or take care of the kids. I don't think the men I've witnessed failing to chip in are lazy or uncaring; I think our society still inculcates some well-defined roles for men and women, despite the lip service given to equality.

The $64,000 question is:  can you do it all? Can you be a topnotch ER doc, a wonderful mother, a good wife, and have some time for yourself? The answer is no, unless you work part-time, or your husband is a househusband.

Frankly, I don't think that emergency medicine is a good career for anyone unless that person has amazingly tough skin. Being an ER doctor is an unbelievably noxious job. The crazy hours. Working on weekends, holidays, and nights. Constant stress. Unfathomable time pressure. Lawyers and their endless shenanigans. Bureaucrats and politicians giving you nightmares. Hospital administrators with room-temperature IQs. Demanding patients. The need to know how to manage anything that walks in the door, in contrast to some other "doctors" who can focus on treating zits or sinus problems, yet be worshipped as a demigod, and are paid better, to boot.

So why are so many people clamoring for a career in emergency medicine? Because young people are typically suffused with an "it won't happen to me" idealism. I was once the same way. I spoke glowingly of how great it'd be to be a doctor, but someone warned me that my dreams didn't mesh very well with reality. So I did what any idealistic person would do:  I ignored their advice, which I thought was the gloomy prognostication of a sourpuss, and I gleefully threw myself into medicine with consummate zeal and dedication. What happened? As I became an ER doc, my dreamy idealism was replaced by a series of lessons in what it's really like to be an ER doc. If you think medical school is tough, just wait until you get into the school of hard knocks.

Drunk docs?
Q:  Recently, I've heard about intoxicated airline pilots, which got me to wondering if doctors ever get drunk on the job.  Do they?  Thanks, doc.  David

A:  Not very often.  I smelled what may have been booze on the breath of one ER doc, whose penchant to pop a breath pill every ten minutes may have been an attempt to camouflage the booze breath.  However, he never acted drunk, and that guy was so high-strung, I'm sure he did a better job with a bit of ethyl alcohol floating in his veins.  Believe it or not, but I'm not being totally facetious.  It's an accepted practice to use something — admittedly, booze is not the drug of choice — to take the edge off people who freeze under pressure; that is, suffer from stage fright.  Inderal (propranolol) is the prototypical drug for mitigating stage fright, but many other drugs also work.  Including booze.

In my first ER book, I told the story of how I once inadvertently had booze-on-board while working.  I was on-call for the plastic surgery service and, for reasons I still don't understand, I forgot I was on-call the minute I got home from the hospital.  You might think that the beeper on my belt would have been a clue, but I forgot being on-call, and had a beer.  In timing that'd be perfect for a Hollywood movie, the second I put the beer can down, my beeper went off . . . and I suddenly remembered I was on-call.  To make a long story short (the entire story is in the book), I went in, and repaired the mangled hand of a man who evidently didn't know that lawn mower blades make it risky to clean the underside of a mower without first stopping the engine.  He thought he could reach in fast enough — optimistic guy, huh?

In my book, I also told the story of a nurse, whose breath and behavior were obvious tip-offs to intoxication.  I informed the head nurse, but she told me to mind my own business.  By the way, she no longer works at that hospital.  Surprised?

Specialize in minor surgery?
Rural surgeons?

Q:  I would like to be a surgeon, but I don't want to go to school for that long. I know most doctors have training in some types of surgery. Can doctors specialize only in minor surgery?  Are surgeons hired at rural hospitals?  Thanks, Tara

A:  You can become a Family Practitioner (4 years college + 4 years medical school + 3 years residency = 11 years total) and do minor surgery, such as repairing lacerations, excision of minor skin cancers, etc. In the same time, you could also become an ER doctor and do surgery in the ER that is typically either minor or major (e.g., opening the chest of a trauma patient).

> Are surgeons hired at rural hospitals?

Yes. Rural hospitals typically have a full complement of specialties, with the exception of things for which the local population base is not sufficiently large to create enough demand, such as neurosurgery, nephrology, plastic surgery, etc. General surgeons, orthopedic surgeons, and gynecologic surgeons practice at virtually every rural hospital, unless the place is really in the boondocks!


ContactMeFree is a dream come true for anyone involved in online dating. If you have your profile posted on a personals site but don't pay for a membership, you know how limited you are in terms of being able to send or receive messages. You probably assume that those limitations disappear if you pay for a membership. Guess what? You are still far more limited than you realize. Frankly, if you knew how limited you were, you would be furious that the personals site was charging you $20 to $50 per month and still keeping the shackles on you! The person who created ContactMeFree was so outraged by those limitations that he decided to do something about it. So he did!

You know that writer's block you get when you sit down to write the essay portion of your personal profile for online dating? And you know the difficulty you have trying to think of a catchy headline? Well, MyProfileWriter allows you to create a profile essay and headline without typing, just by clicking!

Dermabond ads:  Ethicon evidently believes that docs are too stupid to appreciate how great Dermabond is
Q:  I recently saw a magazine that had a full page ad for Dermabond (a medical "super glue" used for repairing some cuts).  How crazy is that?  Amy

A:  Very crazy. And underhanded. And unethical. And, frankly, even slimy. Dermabond SEEMED to be a great product when it came out. However, ER docs have had problems with it, and as a result their enthusiasm for it cooled considerably. In fact, some ER docs refuse to use the stuff at all. Naturally, this doesn't please the folks who make Dermabond — they want to sell it! Since they cannot brainwash docs into believing that Dermabond is great, the manufacturer (Ethicon, Inc., a Johnson & Johnson company) decided to bypass doctors and go straight to the patient to create market demand for Dermabond. While Ethicon would never admit this, their "direct to consumer" marketing tactic is obvious:  have consumers pressure doctors into using Dermabond. Docs ARE susceptible to consumer pressure; witness their acquiescence to demand for antibiotics to treat colds, or their yielding to pressure for the latest drug when they know that a tried-and-true alternative is available that is not only less expensive, but less likely to pose unknown dangers to the patient (you might be surprised by how many supposedly great new drugs are withdrawn from the market after they're discovered to be more toxic or less effective than originally thought).

I was surprised by Ethicon's decision to bypass the docs. First, it was bound to create resentment on the part of doctors — and it did. Second, it sullied the reputation of Ethicon and J&J, who typically make products that are noticeably better than "Brand X" (ever notice how much better a J&J Band-Aid is compared with most generic ones?). My point is this:  if they make a quality product, doctors WILL want to use it. If docs resist using it, it is because they have good reasons for doing so. Did Ethicon figuratively say, "OK, docs, you know best." No, they decided to attempt to cram Dermabond down our throats. Hence the resentment.

You were correct — docs do have it bad!
What is a life worth?
Are doctors underpaid?

Q:  I read an article in the "My Turn" column in the August 22, 2002 edition of Newsweek magazine.  It's written by a woman married to a medical resident in New York, and in it she affirms some things you've said, such as how the process of educating doctors is sheer torture.  She also said that she and her husband once thought the horrors of residency were just an urban legend, but now she realizes they're true.  She had a good point when she mentioned why the general public should care about the plight of overworked residents, because those weary docs work on people who have a vested interest in being treated by physicians who are not exhausted.  Care to comment?  Brenna

A:  The public should not limit its concern to the problems that plague residents.  I've discussed many of the problems that all American doctors face elsewhere in this web site, in my books, and in radio interviews.  I won't repeat those discussions here, but suffice it to say that docs in the United States are whacked around like a pi๑ata.  This affects just about everyone, even people who aren't physicians or a spouse of one.  Collectively, today's docs are cynical, embittered, defensive, and resentful.  While patients are not the source of most of these problems (which are primarily due to politicians, bureaucrats, lawyers, administrators, insurance companies, and judges who are easily duped), doctors do not do a good job of letting the lead fly in the right direction . . . in other words, they don't unleash their wrath at the ones responsible for it.  Instead, docs occasionally vent at nurses, or more commonly, docs are aloof and cold, instead of warm, caring, and responsive.  Most people don't want a robotic doctor who just goes through the motions.  Patients sense such perfunctory behavior, and most don't like it.  But what's a patient to do?  Shop for a different doc, who may be even more gruff?

I've said it before and I'll say it again:  beat a dog, and you can turn the sweetest dog in the world into a vicious creature.  People are no different.  In the process of becoming and being a doctor, physicians are subjected to stresses that are incomprehensible to most people.  How do I know?  Because I now live a normal life, and there is no stress in my life that is anywhere near what I faced as a doctor.  I've worked many jobs in my life, and none of them had associated pressures that were even a tenth of what doctors face.  Considering what it takes to become a doctor and practice medicine these days, I think that doctors are grossly underpaid.  I think that physicians should make a million dollars a year, or even more.  Aren't they worth it?  As an ER doc, I saved hundreds of lives per year.  How can you put a price on life?  Well, juries do that all the time, and judging by their awards, a life is worth anywhere from a few million dollars to over a hundred million dollars, depending on how histrionic the plaintiff's lawyer was.  If those lives are worth that much when those people are dead, they're worth just as much when they're alive.

Most people who go into medicine are caring, idealistic people who genuinely want to help people.  I used to dream of having a Marcus Welby-like relationship with my patients.  I wouldn't just be their doctor, I'd be their friend.  I'd go to bat for them, and bend over backwards to do everything I could for them.  Do you think this description applies to most docs these days?  I don't.  I see what they're like and what they say when the facade they present to patients is gone, and most (I'd say over 90%) are only interested in perfunctory performance that is just good enough to keep them out of trouble, because they're watching the clock and are eager to rush on to the next patient.  As I went through medical school and residency, I witnessed the evaporation of genuine concern in my colleagues.  Who is to blame for this?  The doctors?  That makes as much sense as blaming an abused dog for being mean.  To me, it makes more sense to blame whoever abused the dog.

By the way, here's an interesting observation.  Note that the author of the Newsweek article is married to a resident in New York . . . the state that supposedly enacted a law limiting resident's hours to 80 per week.  I knew that law would be ignored by the slavedrivers who run residency programs.

Review of
TRUE Emergency Room Stories
by Kevin Pezzi, M.D.

Book info  Ordering info

Now available as a free e-book download

What really goes on in emergency rooms?  If you're a fan of the television show ER, you might think that you know.  Not so, asserts Kevin Pezzi, M.D., an ER doctor and author of True Emergency Room Stories.  Pezzi says the show ER only scratches the surface; the truth is far more interesting — and bizarre.  So bizarre, in fact, that the cases could shock even an experienced ER physician.  "I'm now a firm believer in the saying that truth is stranger than fiction," he says.  "I don't think that anyone could dream up such unusual stories."

Pezzi's book is packed with nothing but unusual stories.  There are no "the patient's in v-tach, shock 'em with 200 J and give 'em 100 mg of lidocaine, stat" type of cases.  While such cases are a mainstay of the show ER, Dr. Pezzi believes that they quickly become repetitious.  Instead, he presents an amazing collection of true stories.  The book begins with a story of how he may have saved Michael Jackson's life by averting an assassination attempt by a person who claimed to be a Cosmopolitan cover model, and ends with an interesting tale of how he was propositioned on a beach by a relative of a recent ER patient.  In between, he recounts stories of unusual murders and other crimes, truly odd reasons for dialing 911, unfathomable reasons for visiting the ER, and people with an extraordinary affinity for their pets.  Then there's a shocking end to a pregnancy, a twisted tale of revenge that would be a spellbinding plot for a movie, and the story of a man who attempted to remove his liver at home.

In this book, you'll accompany Dr. Pezzi as he meets the world's unluckiest man and woman, deals with people who have strange requests, and attends to a bride whose genetic disorder wasn't discovered until her wedding night.  There is also the story of the man who didn't know that he had been shot in the head, and the case of the pit bull who picked on the wrong person.

True Emergency Room Stories has something for everyone.  Besides the strange cases, readers will be captivated by dozens of incredible, tragic, humorous, steamy, heartwarming, thought-provoking, and poignant tales.

He's learning that ER is not a bed of roses
How ignoring the tenet of "sunk costs" can ruin your life
The double standard of behavior in the courtroom and the ER
Praise for cops who beat up the scumbags who abuse ER nurses and docs
The Wheel of Misfortune

Q:  I am training to become an ER doc, and as I progress in my education, I'm learning how right-on you are about problems associated with emergency medicine.  Actually, things are so bad that I often wish I'd chosen another specialty, but I think I've invested too much time to switch now.  Therefore, when I complete my training, I want to work to change things.  I've identified several problems that I think need attention, but I wonder what you think needs to be changed, from your perspective as someone who is older and more experienced.  I'd love to hear what you have to say.  Thanks, Paul

A:  Before I delve into that, I'd like to encourage you to reconsider your decision to continue on in your ER career.  One of the main ways that people ruin their lives both personally and professionally is by ignoring the axiom of sunk costs.  Sunk costs means that you've invested time or money or both into something (an investment, a project, some research, an education, dating someone, fixing up a house that may be beyond repair, etc.), and once that investment is made, the time or money spent cannot be recovered.  Here's the mistake most people make:  not wanting to "waste" what they've already spent, they continue on in the endeavor.  This often leads to greater losses.  An example:  me.  After my first year of college, I regretted my decision to go into medicine.  Had I not spent that year taking science classes that were targeted toward that end, I would have happily and easily walked away from medicine and chosen another career.  However, I felt that I'd already invested too much time into this career path, which I did not want to waste.  So rather than waste it, I continued on.  Mistake!  From my current perspective, throwing away one year of college is no big deal, and certainly a lot better than throwing away the next decade in more training just so that one year would not be wasted.  As illogical as this behavioral pattern is, people do such things all the time.  For example, people continue on in bad relationships because they feel they've invested too much time with their partners.  Or investors hang on to bad stocks too long, because they can't bear to sell them and sustain a loss.  As a result, they often lose even more when the stock really plummets.

Whether it means walking away from a bad marriage or walking away from a poor career choice, people are better off if they accept the loss and move on, rather than pouring more time, energy, or money into an attempt to save their original investment.  Rather than saving anything, this often just compounds the loss.  Hence, you should reconsider your decision to continue your ER career.  I realize that many people are forced into continuing a regrettable career choice because they're married and have children.  If that is the case, it's an entirely different situation, and you must often do what is best for your wife and kids rather than what would make you happiest.  In fact, family obligations are the primary reason why many doctors continue practicing medicine.  I wish I had a nickel for every time I heard a doc say, "If I didn't have my family to support, I'd quit medicine."

OK, on to your question about what I think needs to be changed.  Rather than repeat what I've written elsewhere, I will discuss something that I've yet to expound on.  Surely you've noticed how things in the ER can be out of control.  Some of this chaos is an inherent aspect of emergency medicine, but some of it results from the fact that certain people learn they can get away with murder in the ER — so if they feel like acting out, threatening someone, hitting someone, spitting or urinating on someone, or whatever depravity strikes their fancy, they do it.  It is as if the laws that constrain behavior are somehow suspended in the ER.  You can't pee on someone, pull her hair, kick her, or throw a dangerous object at her and be immune to prosecution if you do that anywhere but the ER.  In the ER, you can do all that and more and get away with it, especially if your target is a member of the ER staff.  Why we deserve less protection from the law is beyond me.  Police often ignore events in the ER that'd cause them to slap the cuffs on someone outside a hospital.  In fairness to some police departments, not all of them tolerate abusive behavior in the ER.  Take the Detroit Police Department, for example.  I can't begin to express how grateful I am for such a wonderful police force.  They wouldn't let scumbags whack us around.  If anyone tried, they'd extract that person from the ER, take him to a dark alley, and beat the hell out of him.  The officers knew that most judges would turn a blind eye to dirtbags who abuse ER personnel, so rather than letting the person get off scot-free, they'd administer some justice.  Thank God for cops like that.  All too often, the courts let the riffraff run wild and terrorize law-abiding citizens.  In fact, we're so inured to this abuse that we often fail to consider just how much are lives are affected by criminals.  Everything you pay for, whether it is auto insurance, home insurance, door locks, security systems, or even a can of food, costs more because of criminals.  But the cost of crime is not just financial.  Having sustained thefts before, I now wonder if my possessions will still be there after I go on vacation or just go to town.  You may worry if your children will be kidnapped, or your daughter raped when she goes away to college.

I've HAD IT with criminals!  If our government had any sense, it'd make punishments for serious crimes so severe that no one would dare commit them unless he were crazy.  Our government doesn't do this because our "leaders" fancy themselves as humane, reasonable people.  So, instead of the criminals shaking in their boots, fearing crime, it is us law-abiding citizens who fear crime and suffer the consequences of it every day.  If someone is going to suffer, who should it be:  us, or the criminals.  Our "leaders" think it should be us.  And how do we repay them?  They insist we call them "Your Honor."  They tax us to death.  They pester us with petty regulations that attempt to micro-manage every aspect of our lives.  Frankly, they pick on us, because we rarely utter a peep.  The controlling personalities that draw people into government are more easily gratified by lording over tractable people rather than the intractable criminals.  It's similar to bullies picking on kids they know are easy targets, rather than tough guys who'd fight back.  With such a warped system of justice, ER docs cannot legally test for occult blood in someone's feces by dropping a drop of developer onto a stool sample.  Instead, our brilliant government decreed that only lab techs, who have far less training than doctors, can do this test, which any preschooler could do.  Instead of micro-managing our lives in such insulting ways, our "leaders" should direct their attention to the countless problems they have yet to solve that truly matter.

Some police officers know our system is often so lenient that criminals can run wild with abandon, so the cops administer some justice of their own.  Please don't bother writing to me to lecture me on how this isn't justice when one person is judge, jury, and executioner.  If an officer witnesses a scumbag punching a nurse, does he need a judge or jury to tell him that a crime was committed and the perpetrator deserves punishment?  No way.  How can a judge or jury who hears about this second- or third-hand ever have a more accurate idea of what happened?  Judges and juries are no less biased than the rest of us, and just because they wear a black robe or sit in a booth does not erase the beliefs that color their judgement.  Thanks to judges and juries and their willingness to buy into the lame excuses lobbed up by defense attorneys, criminals can terrorize us with impunity and shatter our lives.  And they call it a "justice system."  When people who abide by the law know that feeble laws and punishments do not adequately protect them, I'd call it an injustice system.

Judges have an interesting double standard when it comes to behavior.  You can't even look at a judge the wrong way, roll your eyes at him, or speak in a tone tinged with scorn . . . even when it is richly deserved.  Judges often act like demigods and threaten people, "You'd better not act that way in MY courtroom, or I'll cite you for contempt of court and throw you in jail."  Yet they'll permit others to inflict incalculably worse offenses, as long as the person being targeted is not a judge.  Some may claim that this intolerance for misbehavior in courtrooms is necessary for the orderly functioning of the court, and to show a proper respect for the law.  I could make a better case that misbehavior in the ER has a more immediate and potentially more severe impact on far more people.  Thus, if we outlaw misbehavior in courts, we should outlaw it in ERs, where it may result in deaths, not just the bruised ego of a judge.  But judges let scumbags do things to ER personnel that they would not tolerate if done to a dog.  Consequently, I'm less than thrilled by the protection given to me by judges, and quite grateful for the protection given to me by police officers who do a far better job of dispensing justice.  Real justice, not just an ersatz veneer of "justice" that is anything but.

With this as a preface (OK, a long preface!), if you want to work to change things, I think you could do a lot of good by lobbying for laws that proscribe behavior that interferes with ER docs and nurses doing their jobs.  Many laws already exist and are almost universally ignored, so the first step might be to encourage enforcement of these laws.  The second step would be to enact new laws that impose penalties on behavior that impedes orderly functioning of the ER.  For example, let's tear a page out of our new law book, and gander at some common sense codification:

Michigan Code of Justice                                                                                                          Page 6371   Volume 88

Section 443.51.22.7:  If a doctor or nurse asks you a question, thou shall answer it promptly, not harangue that person with threats, profanity, or just general venting of your spleen, even if your childhood was not perfect, and even if you have an axe to grind or a permanent chip on your shoulder.  If you want to blow off steam and show how dysfunctional you are, you should do this in a proper venue, such as by appearing as a guest on The Jerry Springer Show.  Failure to comply with this ordinance will subject the perpetrator to the worst of three spins on The Wheel of Misfortune (see below):

Left click to see The Wheel of Misfortune

Is medical school adequate preparation for the real world?
What attributes must a prospective physician possess?
How old is too old?
The value of volunteering, or lack thereof

Q:  I am debating the wisdom of pursuing a medical career.  This will be my second career.  My first was in engineering.  As a consequence of my late start I would be starting med school in my early forties.  From a financial perspective it makes no sense to pursue medicine, but I am still drawn to this profession.

My GRE's indicate I am in the top 5% of all graduate students.  While I have not yet taken biology or organic chemistry, if my performance in my engineering/physics courses are any indication I should do very well.  Academically, I should be well qualified for medical school.  The real question is, "Would I be good at medicine?"

I've discussed the matter with my sister who works in a hospital and below are her comments on the success factors for a doctor:
(1) Clear thinking under stress
(2) Leadership:  nurses and other support staff are looking for direction
(3) Interpersonal skills:  need to be able to work with the other medical staff as well as the patients and their families

I believe I meet all three, although it is difficult to judge number 1.  My military training states that under stressful conditions people fall back on their training. 

Is medical school adequate preparation for the real medical world?  Are there any other success factors needed other than the three I listed above?

I will soon be volunteering at a local VA hospital.  My sister suggested I also volunteer at other hospitals to get a variety of experiences.  How adequate is the volunteer experience in understanding the hospital environment?

Thank you for your time.  I appreciate your input.  Robert

A:  > Is medical school adequate preparation for the real medical world?

No. I don't know where the heck medical schools dredge up their faculty, but they have some bizarre ideas on how to educate physicians. Here is just one example. At the medical school I attended, we spent countless hours studying diseases that were so rare the professors admitted we'd be lucky if we saw one case in our professional careers. Guess how much time was devoted to the common cold and low back pain? Not one second! The profs said we'd learn how to manage such "easy cases" on our own. Easy cases? Managing low back pain is often frustrating for both the patient and the physician, and it would have been helpful to obtain a few pointers from the profs. While most doctors say that there isn't anything that can be done for the common cold, that simplification is not borne out by the facts. There are dozens of things that doctors should teach their patients about the common cold and other viral illnesses, especially in regard to prevention (I mention several in Fascinating Health Secrets). However, medical schools often gloss over or totally ignore this subject so their professors can expound on rare diseases. In my opinion, one of the reasons why medical school faculty are enamored with rare diseases is because it's more of an ego boost to discuss them than it is to discuss common diseases for which there is no cure or entirely satisfactory treatment. A prof can sound so intelligent lecturing on branched-chain ketoaciduria (a.k.a., maple syrup urine disease) caused by a defective enzyme (branched-chain keto acid decarboxylase), but he'd sound far less impressive speaking about some disease for which we don't have a nifty solution or some big words to throw around.

Another beef that I have with medical schools is that they inculcate the notion that health is the lack of disease. In reality, things aren't so black and white. There is a continuum from optimal health to recognizable disease, and many people are somewhere in the gray zone between those two extremes. One may argue that doctors have their hands full treating disease without giving tune-ups to people who are not optimally healthy, but I maintain that a greater focus on health would free doctors from the need to treat so much disease. (In Fascinating Health Secrets, I discuss many ways in which people can feel "great" instead of just "OK.")

Yet another flaw in medical education is the "disease-centric" or "diagnosis-centric" manner of teaching that is so often employed. Traditionally, professors introduce a disease and discuss its incidence, prevalence, etiology, pathology, symptoms, signs, lab findings, diagnosis, prognosis, complications, and treatment. Sounds simple, right? Well, the problem is that patients don't walk in the door with a diagnosis tattooed on their foreheads. After I resigned from one ER, the seasoned head nurse took me aside and said he'd miss me because I was the best diagnostician he'd ever seen, and he added that the ER nurses were often frightened to work with docs who muddled their way through cases because they really didn't know what was the diagnosis — on which everything else hinges. While I appreciated that vote of confidence from the nurse, I readily admit that even I sometimes have difficulty arriving at a diagnosis. In the ER, the doc has very little time to formulate a diagnosis, and he must often base his decision on fragmentary information. The patient may not be able to speak, he may not know his medications or medical history (except that he was "sick" before), he may not know the name of his current doctor, and he may inadvertently omit critical details. If the patient complains of weakness, or nausea, or difficulty breathing, or some other symptom with 1001 possible causes, nailing down the correct diagnosis in a few minutes can be challenging, and sometimes virtually impossible. To compound the difficulty of the diagnostic process, patients often do not present with a classic "textbook" presentation of a disease.

The difficulties of diagnosis are compounded by the disease/diagnosis-centric teaching method because patients present with symptoms and signs, not diagnoses. Disease-centric teaching floods the brains of medical students with millions of facts, but does nothing to help them systematically sort through that information to make a diagnosis. Instead of primarily focusing on diseases or diagnoses, medical education should give greater emphasis to algorithms that present the most logical way to approach a patient presenting with specific symptoms and signs. Algorithms are sometimes taught in medical school, but they're employed too infrequently. I've seen thousands of medical books, but only one with an algorithmic presentation.

Another problem with medical schools is that they usually give short shrift to lawyers and their endless shenanigans. Doctors usually learn these lessons in the school of hard knocks, after they've been sued.

> Are there any other success factors needed other than the three I listed above?

Yes. Here are a few more:
• Doctors must have an almost superhuman ability to tolerate sleep deprivation. Despite the lip service given to restricting the hours of residents, they still work an ungodly number of hours.
• Doctors must tolerate abuse to an almost masochistic degree. During their education, medical students and residents are subjected to frequent abuse that in other areas of our society would result in lawsuits, angry arguments, and fistfights. Some of the professors I trained under were so intense and so sadistic that I bet they'd come in second place in a charm contest if they were pitted against members of Hitler's SS. What's that saying about how power corrupts, and absolute power corrupts absolutely? Medical school professors know they have incredible power to make or break the careers of these students. Most of the profs don't wring this power for all it's worth, and they get their jollies by picking on medical students. However, other profs go much further, sometimes forcing female medical students or residents to choose between a sexual liaison or a ruined career.
• Doctors must be able to forgo fun for a decade or more. The medical education process is very demanding and leaves very little time to sleep, let alone date, see your family and friends, engage in hobbies, exercise, watch television, listen to music, read the newspaper, wax your car, take care of your house, and do the countless other things that contribute to a normal, balanced life.
• Doctors must accept the limitations of modern medicine. All too often, patients think that docs know and can do everything. In reality, our collective knowledge of medicine is far from complete, and in many areas we're still in the Stone Ages. A thousand years from now, when virtually everything will be known about medicine, people will look back at us and see how backward we are, just as we do to doctors who practiced a century ago. If you're a doctor at the dawn of the 21st century, you will be faced with many patients with diseases that we've yet to understand. Even for well-recognized diseases, our treatments are often incredibly nonspecific and iffy. Many people go into medicine thinking that it'll be a science. In some respects it is, but in others it is more similar to voodoo.
• Doctors must not mind that they will be pilloried by the press, politicians, bureaucrats, rednecks, and much of the rest of the population. These folks expect docs to be a notch above perfect, yet they habitually ignore the imperfections of others and their countless errors. Automobile mechanics don't always fix your car correctly, but have you ever heard of one being sued for malpractice? Judges and parole boards frequently make bad decisions regarding when some criminal can be safely released back into society, but are such people ever held accountable for their errors? In contrast, doctors can be hauled into court and lose "big time" even if they haven't made a medical error; frivolous lawsuits are all too common.

> I am debating the wisdom of pursuing a medical career. This will be my second career. My first was in engineering. As a consequence of
> my late start I would be starting med school in my early forties.

Before you invest too much time and emotional energy into this, I suggest you find a medical school willing to accept you. When I went to medical school, 30 was the approximate age limit for incoming students.

> I will soon be volunteering at a local VA hospital. My sister suggested I also volunteer at other hospitals to get a variety of
> experiences. How adequate is the volunteer experience in understanding the hospital environment?

It helps, but it doesn't give you a good idea of what it is like to be a doctor. You can watch someone play chess or have sex, but by watching them, can you understand what they're going through? 98% of what a doctor does is done inside his head, and is therefore invisible to people watching him. Hence, observation isn't worthless, but its value is very limited.

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A typical day in the ER?
Q:  I have to do a report on emergency physicians and I was wondering what does a typical day as an emergency physician involve?  Thank you for your time.  Dorothy

A:  There is no typical day for ER doctors. Every day is different. However, if you average out many of our "typically atypical" days, it is possible to arrive at some averages. Of course, what is average for one ER (say, in an affluent area) will not represent the average for another ER in an urban area, where violence and drug use and just plain stupidity strongly influence the number and types of patients seen. Nevertheless, in general, some of the most frequent presenting problems seen in emergency rooms are:

People who are weak, dizzy, or both.
People with chest pain.
People with abdominal pain.
People who've been in car accidents.
Women with pelvic pain or bleeding or discharge.
Women with bladder infections.
People who are depressed, lonely, anxious, violent, or psychotic (nuts).
People with colds, sore throats, ear aches, or sinus problems.
People with headaches.
Kids with fevers.
People with seizures.
Older folks with strokes.
Diabetics with abnormal blood sugar levels (either too high or too low).
People with cuts, scrapes, and splinters.
People with foreign bodies in their eyes (e.g., metal shavings).
Kids with nasal, gastrointestinal, or ear foreign bodies.
People with muscle, tendon, or ligament strains or tears.
People who are unconscious (e.g., due to a heart attack, drug overdose, or severe metabolic problem).
People who've been shot, stabbed, run over, or otherwise unlucky.
People with skin rashes.
People with asthma and similar diseases.
People with a toothache.
People who are constipated.
People with nausea and vomiting.
People with diarrhea.
People with lice.
People with blood in their stools.
People with insomnia.
People who want a refill for their medication(s).
People who want a work excuse.

Of course, people go to the ER for many goofy reasons, too, as I discuss elsewhere in my web site and books.

Why you're wasting your time in community college
"I have really bad memory . . . am I just stupid?"

Note: I usually edit questions that I post on my web site.  I will not edit the following one, for a reason that may or may not be obvious.
Q:  Dear Doc,

I'm a student who is attending a community college who is very interested in becoming a doctor. However, I am attending a community college who is transfering to a University of California preferably Berkeley or Davis to earn my degree in Biology. I want to become a ER doctor, but in your forum of questions and answers I've read that medical school looks down on students who are attended a community college. Is that always true? And another question I have is: I have really bad memory, and I never seem to know what caused me to have this kind of problem? Is it genetically passed on, or am I just stupid? Is there any way I could drastically improve my memory skills? Thanks a lot for your time.  Raymond

A:  Always? I don't know if it is always true. Perhaps there is some doctor out there who is now on an Admissions Committee who once attended a community college, and he might not discriminate against applicants with a background similar to his. But don't count on this happening to you. I know many doctors, and not one attended a community college.

Don't think that medical schools are being petty by discriminating against former community college students. In reality, they have a good reason for doing this. To understand why, put yourself in their shoes. Since applicants typically apply a year or more before their matriculation date, the Admissions Committee has three years of transcripts to evaluate if you've attended a real college, but only one year if you've attended a "minor league" college (a.k.a., community college) for your first two years. The competition at community colleges is so easy that your scores there are virtually meaningless when it is time to select the next generation of physicians. Community colleges play an important role in furthering the education of many people in this country, but NOT for people who want to become doctors! Someone who received a B+ in chemistry at a real college is likely more knowledgeable than someone who received an A in his community college chemistry class. Furthermore, most successful medical school applicants received an A or A- in chemistry from a real college. Consequently, even if you obtain an A from a community college, you have no real hope of "beating" the applicants from real colleges. If you want to become a doctor, you're just wasting your time in community college.

I am not saying it is impossible to be accepted into medical school after attending two years of community college and one year of real college, but if you do this, you will give yourself a black mark that is difficult to overcome. You're facing some pretty stiff competition from real college students. I wish I could sugarcoat this painful reality, but if I did that, I'd be doing you and others a disservice.

Ultimately, determining who gets into medical school is a decision based on what is best for society — the consumers of healthcare. The collective message from society is that they want the smartest possible doctors. It's easy to understand why. In four years of medical school, you will learn FAR more than you did from birth to the day you graduated from college. Until you've been in medical school, you simply cannot comprehend how much information that is. Even for a college graduate, it is a phenomenal amount. Even after doing all I could to learn about medical school while I was in high school and college, I still had no idea of just how much we'd be expected to learn. It was staggering, and I was shell-shocked. And remember, I graduated in the top 1% of my class in medical school, and received an A on almost every course at a real college . . . while working one or two jobs on the side, and putting up with miscellaneous obstacles such as poverty, occasional starvation, and renting a room from a crazy woman who was so nuts that I feared for my life. So, if I thought medical school was incredibly challenging, I'm sure the folks at the bottom of the class thought so, too.

> And another question I have is: I have really bad memory, and I never seem to know what caused me to have this kind of problem? Is it genetically passed on, or am I just stupid? Is there any way I could drastically improve my memory skills?

Could it be genetic? Yes. It could also be a number of other things, from too much lead in your pipes to too little sleep.

Are you "just stupid"? Memory is but one facet of intelligence. Fortunately, it is the one most responsive to change. If you follow the advice given in my web site, you can substantially improve your memory.

More on the wisdom of taking classes at junior colleges
Do medical schools accept students with debilitating diseases?

Q:  In regard to your statement, "The competition at community colleges is so easy that your scores there are virtually meaningless," I beg to differ.  My mom taught at both a junior college and a 4-year university and her opinion is that in a community college, one actually gets a better education, due to smaller classes, etc.  Obviously this isn't the case in all junior colleges.  Amy

A:  If community college classes were taken in lieu of (or in addition to) high school classes, they're fine. However, if they're taken in lieu of classes at a 4-year college for a person who wishes to attend medical school, they are a problem for the reason I discussed before (the need for medical school Admissions Committees to see how applicants rank relative to the academic cream of the crop). At the risk of sounding like an intellectual snob, there is a stratification of aptitude between students at community colleges versus 4-year colleges. While there are exceptions, on average community college students are not the intellectual cream of the crop.

Furthermore, I'm not convinced that smaller classes necessarily improve learning.  I've had great professors whose classes were so large they were televised on a local cable channel.  They explained everything so well that I soaked it up like a sponge, as would anyone with at least half a brain.  However, if a prof is poor at explaining things, does it matter how many students are in his class?  3000?  300?  30? One?  If a man doesn't have a knack for teaching, his aptitude won't improve just because he has fewer students present.  I can see how smaller class sizes may benefit students who are struggling and need individual guidance, but people who are smart enough to become doctors should require little or no hand-holding along the way.  Hence, class size is immaterial for them.

Q:  I have a new question.  After watching ER tonight (don't groan yet!), I wondered:  would a person with a degenerative disease like Parkinson's even be accepted into medical school?  Thanks so much!!

A:  In general, medical schools do not accept students with debilitating diseases. Their goal is to turn out doctors who will be productive for a long time.

What percent of your cases are actual emergencies?
What are the routine parts of being in the ER that you disliked?
How do you feel that you are perceived by other doctors?

Q:  Dr. Pezzi,
I'm a medical student trying to figure out possible specialties (though worrying about it much sooner than I actually need to), and I'm trying to get an idea of a typical day of an ER physician. What percent of your cases are actual emergencies? What are the routine parts of being in the ER that you disliked? Also, I remember reading an article (albeit a tongue-in-cheek article) about perceptions of doctors. How do you feel that you are perceived by other doctors, as compared to doctors in other specialties?  Thank you! Jane

A:  > what percent of your cases are actual emergencies?

The range is 0 to 100%, but the average is about 7 to 15%. It varies quite a bit from one ER to another.

> what are the routine parts of being in the ER that you disliked?

1. The paperwork.
2. Finding misplaced charts and x-rays (that is surprisingly common in some emergency departments).

> Also, I remember reading an article (albeit a tongue-in-cheek article) about perceptions of doctors. How do you feel that you are perceived by other doctors, as compared to doctors in other specialties?

The public and professional perception of emergency medicine has changed quite a bit over the years. It took a while to eradicate the image of ER docs as being interns, because that was once true. Having been an attending ER doc in a teaching hospital, and having seen the quality of care (or, more to the point, the LACK of quality care) delivered by interns, I shudder to think of how many people were butchered by interns in bygone days when they staffed ERs.

However, if you're an ER doc, you can't count on automatic respect from your colleagues in other specialties.  You can't blame those docs for withholding professional acceptance, because there are more than a few bad ER docs out there.  Frankly, I don't know what compels some docs to be so stupid at times.  I recall one time when I told a co-worker that he was making a huge mistake — I'm talking a multi-million-dollar mistake — and I advised him to amend his errant thought processes and avert years of grief after being sued.  I told him I was 100% certain that he was wrong, but he didn't listen, so I took over that patient's care.  I'm not claiming that I was a perfect ER doc.  Frankly, I don't think anyone is.  How can you treat many thousands of patients per year — often in a rush with an incomplete evaluation and imperfect tests, an incomplete medical record, an incomplete history (some patients are literally morons), and with an imperfect staff in an imperfect hospital — and always do a perfect job?  It's impossible.  (If any ER doc thinks he is perfect, please invite me to review your charts.  If you do a perfect job on every patient, I'll give you a million dollars.  No, make that ten million.  If you make some errors, you give me $10,000.  A deal?)  So, I wasn't perfect, but I think I was a somewhat better-than-average ER doc, and apparently some of the non-ER attendings I dealt with thought so, too, because they'd sometimes say something such as, "Oh, thank God you're on" when they called to say they were sending in a critical patient and I spoke to them on the phone.  Some ER docs really know what they're doing, while others seemingly possess only an ability to shuffle patients through the system and give care that is either perfunctory, lacking in incisiveness, or otherwise less than stellar.  Cognizant of this reality, it is a pipe dream for an ER doc to expect automatic acceptance and respect.  However, the same is true of docs in other specialties.  I know some exceedingly competent docs that I admire, but I know a heck of a lot more quacks who are such dingbats I wonder how they ever got through medical school.

Bra questions
Q:  Hi there! Strange question here, related to a piece of fiction I am working on. You mention in your miscellaneous questions that it only takes a minute to cut a bra off. Is there a standard procedure for this? Is the bra just cut down the middle and moved out of the way, or are the shoulder straps cut as well and the whole thing removed? Is the bra usually cut down the center or on the side to avoid having to go through a wire?

A:  I've never done it myself, because removing bras is within the province of the ER nurses or techs. My focus is on other things. In any case, every time I've seen it performed, the bra is cut in the middle — probably because that is the most accessible area.

Q:  Have patients ever protested?

A:  Nope. They're usually unconscious.

Q:  Have you ever had a patient request that you leave her bra on, and would you allow this if it did not directly interfere with a procedure?

A:  We only cut off bras in dire emergencies, such as when we need to defibrillate ("shock") someone. Generally, we eschew cutting off bras if a woman comes to the ER for, say, an earache. Might raise a few eyebrows.

MD/RN smokers
Q:  Why do you think doctors and nurses smoke, even though they know the side effects?  Amy

A:  Many people — not just healthcare personnel — possess a "it won't happen to me" mindset that enables them to think that bad things happen only to other people. Healthcare providers often take this a step further and subconsciously think that only "patients" get sick . . . not the ones who care for them.

Even more ER questions! Part 1

Even more ER questions! Part 2

Organize your garage beautifully.

If you want a beautiful garage that is easy to keep organized, see the GarageScapes web site:  www.GarageScapes.com.


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