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More advice on becoming an ER doctor

Part 2

Suing for better pay and working conditions
Residency:  what is it like?
Flaws in the residency system

Q:  I heard Dr. Dean Edell discussing on his radio program about a possible lawsuit to help resident doctors gain better pay and working conditions.  He mentioned that resident hours are universally long, and the pay is universally low.  Since most residency positions are assigned through The Match, that match seems to be part of an organized anti-competitive price-fixing scheme.  What is your opinion on this?  Matt

A:  It is obvious that the postgraduate medical education system is rigged to limit pay and impose draconian hours and working conditions.  There is no other profession in which its trainees must endure such brutal and inhumane treatment.  The perennial justification for this is that it helps train better doctors.  Hogwash.  To begin with, it takes a group of basically nice people and puts them through enough hell so that many of them become somewhat emotionally calloused.  Secondly, learning is seriously impeded by the chronic sleep deprivation and chronic overwork that limits the number of hours they could study effectively.  Anyone with a room-temperature IQ who dispassionately analyzed this system would realize how counterproductive it is.  Yet it persists.  Why?  Primarily because it benefits the attending doctors who control the postgraduate medical education system.  They profit from it by having the worker bees the residents toil for them days, evenings, nights, weekdays, weekends, holidays, you name it.  The residents do the work, and the attendings get to bill for it.  When someone works his fingers to the bone and someone else profits from it, it almost smacks of slavery, doesn't it?  The attending physicians who rig this system excuse it by pointing out a quid pro quo:  yes, the residents are working for us, but we're teaching them.

Really?  Let me show you how effective this teaching can be.  Let's turn the dials on the ol' time machine and join me when I was a resident in 1987.  It's 6 PM on a Tuesday, and I've been working for 37 hours straight.  Dealing with that sleep shortfall is more difficult than you might imagine because I began the latest on-call period utterly exhausted since I'd not yet recuperated from preceding months of working 110 hours per week.  I'm now on rounds with a team of residents trailing the attending physician, a nephrologist, who is blabbering on and on about esoteric details of some arcane renal disease.  As his discourse winds down, I wonder, "Is this it?  Are rounds over?  Can I now go home and fall into bed?"

Not quite.  We go on to see another patient in his room and then, in the time-honored fashion, exit the room and stand just outside its doorway as the attending chooses yet another topic that is tangentially related to that patient's condition.  Oh God, another lecture is beginning, and I am so tired that I worry about falling asleep and dropping to the floor.  Since that would manifest a no-no not paying attention and hence not availing myself of the pearls of knowledge emanating from the attending I reached into my pocket where I had my stash of caffeine tablets and, when I thought no one important was looking, I popped a Vivarin into my mouth and began chewing.  No water, but I was used to this, and looking forward to the effects of having 200 milligrams of caffeine surging through my veins.  Relief arrived within a minute, and the danger of falling asleep had abated.  A new fear gripped me.  Perhaps the attending would, as they are wont to do, ask me a question.  How could I respond when my mind was so numbed from lack of sleep that I hadn't the foggiest idea of what his question was?

Believe me, this was not uncharted territory.  I'd been in this situation many times before, and I'd developed what I thought was a certain flair for getting the attending to restate his question without having it appear that I hadn't the slightest awareness of what the question was.  But, mercifully, the attending grilled another resident.  I tried to pay attention to the ongoing dialogue, but it was hopeless.  Perhaps they were discussing information that might be useful to me and my future patients, but my mind was in shut-down mode.  Food, sex, money, friends, family, hobbies, success, the drive for excellence none of that mattered now.  I just wanted to go home and flop into bed for a few hours.

Not yet.  We're seeing another patient?  I dreaded each hallway mini-lecture.  Why the hell couldn't we sit in a classroom and take notes when we're well-rested, like other students do?

And another patient?  I glanced at the hallway clock, which registered 7:33.  The nephrologist's words now began to grate on me.  Why must I put up with this charade of learning?  Why couldn't I excuse myself and get some sleep when I'd reached the point where learning was impossible?  Such an admission was taboo.  I'm sure we all felt it, but no one ever mentioned it.  In addition to being slaves of the attendings, one of the unwritten rules of residency was that we had to pretend that we were soaking up knowledge even when that was a fanciful notion which ignored the human need for sleep.

To put it succinctly, the system sucks.  Nowhere is the need for better education more clear than in the field of medicine.  If our brains are on pause when we're supposedly being taught some lifesaving tidbit, then future patients may suffer.  And they do.  Yes, American doctors are certainly good, but they could be even better.  I graduated in the top 1% of my class in medical school, and my ER residency director once claimed that I was the smartest resident they'd ever had, yet I am bitter because what I learned was only a fraction of what I could have learned, had I been taught in a system in which learning, not adherence to antiquated traditions, was paramount.

So do I support a lawsuit to force change?  You bet I do.  The people in power won't relinquish it without a fight.  The medical education system is outmoded.  Today's physicians need to master an unprecedented amount of material.  Considering the backward system in which we're taught, we do a good job of learning, and certainly we're not the incompetent fools that malpractice lawyers often subtly suggest that we are.  However, we could be even better.  Yet physicians in training will not be able to further excel in the acquisition of knowledge until current flaws, such as sleep deprivation marathons, are relegated to the scrapheap of history.

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You will have sex about 10,000 times during your life.

Doesn't it make sense to read a book that can maximize your enjoyment, and the enjoyment you give to your partner?

Cast away your preconceptions of sex books as being a rehash of things you already know and hence a waste of time.  By reading this book, you will learn many things that Dr. Ruth and other sexologists have never considered.

The Science of Sex
Enhancing Sexual Pleasure, Performance, Attraction, and Desire

by Kevin Pezzi, MD

Available in printed and Adobe Acrobat e-book versions (will display on any computer)

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Taking Prozac to enhance memory?

(I paraphrased the following question.)
Q:  An article in the December 15, 2000 The Journal of Neuroscience entitled "Chronic Antidepressant Treatment Increases Neurogenesis in Adult Rat Hippocampus" found that chronic antidepressant treatment increased the proliferation of hippocampal cells.  Since the hippocampus is vital to memory formation, would it be advantageous for students to take an antidepressant such as Prozac, which was one of the drugs studied and found to be effective?  Gerald

A:  You're writing to the wrong person if you're looking for someone to give you the green light to take Prozac for this reason.  I will explain why I am not a Prozac fan.  To begin with, I think the drug is overprescribed for depression.  Too many doctors and patients look to it as a quick fix for a variety of troubles.  It seems to me that it is too often used as an emotional bandage to cover up problems of living that could be better solved by addressing the root causes of those problems.

Second, I've noticed that Prozac users are more likely to have a "Prozac personality" in which their neurological reward systems are too internal.  You might think, "Well, Prozac is intended to ameliorate depression, so why should Pezzi object to the fact that it makes people feel better?"  Mitigating depression is fine, but in my experience Prozac and similar drugs solve one problem (depression) and create another:  excessively internal reward.  If you think of how our brains are naturally programmed to feel good, you will notice one common element:  doing something that is beneficial for us, those around us, or the propagation of our species.  Reward systems are engineered to provide positive feedback for doing good so that we're more likely to engage in that adaptive behavior in the future.  People not on antidepressants get their positive strokes, so to speak, by doing various gratifying things:  hugging, having an enjoyable conversation, doing a good job at work, excelling in school, taking care of the house and kids, and so on.  While antidepressants do not erase the drive to obtain reward by doing external things, based on my observations it seems to me that Prozac users have a self-stimulating reward system that lessens their drive to do the things that humans normally do to feel good.  I don't claim that they never do those things, just that they do them less often, especially if the dose is too high.  You might counter, "Yes, but once their depression abates, their behavior is more adaptive and their seeking of external reward increases."  That is true in cases of serious depression in which an antidepressant is clearly needed, but all Prozac users are not seriously depressed people whose initiative is frozen as a result of their disease.  Furthermore, Prozac users do not possess a monopoly on distressing problems.  Most people face countless problems in their lives that they solve on their own, or with the help of their friends and family not with the little green and white pill, Prozac.  Unbeknownst to them and their pill-pushing doctors, many if not most Prozac users are basically normal people who could, with the right support, solve their problems without using pharmaceutical crutches.  When inappropriately used in such cases, Prozac and its chemical cousins can decimate the drive to seek external reward in adaptive ways.

As a doctor, I've taken care of Hollywood celebrities, sports stars, assorted luminaries, and other people that society puts on a pedestal.  Guess what?  They have problems, too!  If you knew about them, some of those problems would shock you.  Bottom line?  We all have problems, and solving them is one of the most central elements to life.  I'm not suggesting that we embrace problems, but since we all face problems and solving those problems is one of the things we can do to feel good, taking Prozac in questionable cases can be quite maladaptive for the users, and distressing to people they're around.  I like to see people with initiative, energy, and a dynamic drive to get things done.  Isn't that what life is all about?  Doing things.  Accomplishing goals.  Achieving objectives.  Fulfilling one's potential.  Not going through life in neutral while others are zipping past.

While Prozac can be a godsend to people with major depression, its overutilization in people with rather quotidian problems makes them feel better because it strokes their internal reward systems, but it tends to shove their transmissions into neutral (figuratively speaking, of course) so the external world is relatively neglected.  Consequently, the Prozac users I've known have frittered away their potential and coasted through life.  Notwithstanding any questionable benefit to hippocampal neurons and hence some conceivable augmentation of memory, decimating initiative and drive is not a recipe for academic success.  Hence, in my opinion, taking Prozac is more likely to hinder success than it is to foster it. As the United States became a nation hooked on Prozac and drugs like it, our economy sputtered. The last really big idea that improved our lives was the Internet, and that was decades ago. Significant progress depends on frequent breakthroughs, not the profusion of little ideas that now passes for innovation. Prozac-like drugs are certainly not the sole reason why the U.S. is failing, but they are one piece of the puzzle.

Coincidentally, Dr. Dean Edell discussed a study on his radio program this morning that studied the effectiveness of Zoloft (an antidepressant related to Prozac) in children.  In this double-blind study, 69% of Zoloft users experienced a positive response.  Sounds impressive, doesn't it?  Not so fast.  59% of those given a placebo also experienced a positive result!  Dr. Edell opined that the marginal increase in response wasn't worth it because of all the side effects associated with Zoloft usage.  He did not mention cost, but that is another potential consideration in a world in which money does not grow on trees.  We're spending billions of dollars on antidepressants.  Judging from this and other studies, most of that money is wasted.

UPDATE: I later discovered a way to substantially improve mood so that I could go from feeling neutral (neither depressed nor elated) to feeling bliss all day long. Anxiety? Gone! Self-doubt? Gone! Fretting about the usual BS? Gone! Interestingly, my mood booster did not decimate initiative; in fact, it enabled me to focus better and hence be more efficient in accomplishing goals. This feeling was so pleasurable that I'd rather go through life being dirt poor and feeling that way than having the riches of Bill Gates and feeling like most of us feel, which isn't very good. How many people seem genuinely happy? I live near a yuppie town filled with people who have more than average education and money. They live in a beautiful area that draws tourists from several states, and the local allure is sufficient to serve as a magnet for various Hollywood celebrities, yet when I look at this mélange of people, rarely do I see anyone who seems to be in a great or even good mood. Instead, I see empty, perfunctory smiles: people just going through the motions of putting on a good face. The last loving couple I saw was . . . gee whiz, when was that? I don't expect public displays of affection, but if a couple has a great relationship, there's a certain sparkle in their interactions that is obvious.

A loving . . . couple? :-)

Most people would pay $1 per day to feel like a million dollars, so let's do the math: even if I consider only the number of people in First World countries, that could be over one billion dollars per day. If I knew how to market my ideas, I could be rich! :-)

Are you skilled at marketing and looking to make more money?

If so, I want to speak with you.  I have several hundred inventions (a few of which are pictured on my web site), but not enough time to market very many of them.  I am looking to partner with marketing professionals who possess the skills required to introduce new products into the marketplace.  In return, I offer you a substantial percentage of the income generated. Contact me via this page: www.MySpamSponge.com/send.php?handle=erdoc

Physician naval aviators?
Does a medical degree expire?

Q:  Dr. Pezzi, I have a question.  Can an ER doctor be in the Navy and fly aircraft?

A:  Yes, you can even become an astronaut, as Dr. Jerry Linenger did.  He attended Wayne State University School of Medicine a few years before I did (I found that out from a friend of mine who was in his class and had a major crush on him).  While the Navy does not prohibit physicians from being pilots, you'll fly only when they tell you to fly.  For obvious reasons, the Navy prefers that most of their doctors spend most of their time practicing medicine.

Q:  I would also like to know if a medical degree expires?  P.S.: Your site is the coolest.

A:  A medical degree never expires.  Once a doctor, always a doctor.  However, to practice medicine, you'll need a medical license, and that expires every three years and must be renewed (in Michigan and many other states, although the time period may vary somewhat from state to state).  To renew, you need to complete (again, in Michigan) 150 hours of CME (Continuing Medical Education), pay the state a small boatload of cash, and be a reasonably upstanding citizen that is, we can't kill more than a dozen attorneys in any 3-year period.  Personally, I'm disappointed by this low bag limit.  OK, OK, I'll be serious.  :-)

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

Available in trade paperback, e-book, and excerpted on audio cassettes.

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.

Will smart drugs increase everyone's intelligence?

Q:  I will begin college next year, and I want to do everything possible to excel academically.  Do you think that taking "smart drugs" might help me?  Thank you, Stacey

A:  Perhaps.  I discussed smart drugs (drugs that can enhance brainpower) in Fascinating Health Secrets.  Some work, and some are over-hyped.  One critical point that is often overlooked is the following:  even if a drug is generally effective, it may not be effective for you.  Too many supposed experts mistakenly assume that all brains respond in the same way to smart drugs.  This is a naive and false assumption.  The response to other drugs that affect thought (for example, antidepressants and anxiolytics that affect mood, which is one type of thought) varies, so it is reasonable to expect that the response to smart drugs will not be the same for everyone.  This theoretical expectation is substantiated by marked variations in response to smart drugs in different people.  Understanding why this is true is very complicated, but the following simplification will illustrate it.  Imagine that optimal thinking requires different concentrations of various neurotransmitters at specific sites in the brain:


Site A

Site B

Site C

Concentration of neurotransmitter 1




Concentration of neurotransmitter 2




Concentration of neurotransmitter 3




Amongst people with suboptimal thinking (and that's all of us, since even the smartest geniuses have room for improvement), sometimes there is too much of a neurotransmitter at a specific site, and sometimes there is too little.  More may be generally good for some things, but not for neurotransmitters, where more may be too much.  Furthermore, neurotransmitters are just one factor that affect thinking.  When you consider all of these factors, it is clear that optimal (or even near-optimal) thinking requires fine-tuning several variables.  It is unreasonable to expect that giving a smart drug to a hundred people, each of whom possesses different settings on their brainpower variables, will help all of them.  As a general rule, people who are naturally exceptionally intelligent have less to gain from using smart drugs than less gifted people.  The way I usually explain this is to consider how tinkering might benefit two watches:  one finely tuned, and one in need of work.  If you are toying with a watch in near-perfect tune, you are more likely to do more harm that good.  However, if the watch is a clunker, sometimes even crude manipulations may help it, such as by freeing up a rusty gear.  Another way to conceptualize this is to consider how a plastic surgeon could do more to improve the appearance of an unattractive woman than a gorgeous one.  If a woman is already stunning, changing her appearance may not be beneficial or even if it is, the results may be trifling.  The bottom line is that change is more likely to help people who really need it.


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Organize your garage beautifully.

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

Copyright © 1995 – 2011 by Kevin Pezzi, MD • Terms of use