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Amy reviews ER computer games
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Why should you follow my advice on how to become a doctor? I explain why in this excerpt from the introduction to my book:
Want to be an ER Doctor?
Is it as horrible to work in the ER as I make it out to be?
Q: Dear Doctor Pezzi: My name is Marianna. I am 15 years old, and I want to become an Emergency Medicine physician. I became very overwhelmed after reading your web site. A week ago, I couldn't wait until I got to medical school. Now, I am scared. Is it really as horrible to work in the ER as you make it out to be? Now, I am not sure I can make it as a doctor in the ER! What advice do you have for me? I would really appreciate it if you e-mail me back. Thank you for your time. PS: I really work hard in school.
A: I wish I could tell you that being an ER doctor is a great job that you're certain to love, but I would be doing you a great disservice by trying to sugarcoat some of the drawbacks of that profession. First, the good news: some ER doctors do enjoy their jobs. However, of all the ER docs I know, I can think of only two who liked working in the ER. The others were frazzled by the stress of dealing with the noxious aspects of emergency medicine.
However, if you are determined to become an ER doc, I'll give you some tips that will increase the chance that you’ll find happiness:
· First, consider working in an Urgent Care Center (UCC) instead of an ER. While UCC's are often denigrated as a “doc in a box,” UCC physicians see many of the same problems that are seen in ER's. The primary difference is that UCC's do not accept patients who arrive by ambulance, so you will see very little major trauma and serious medical problems. The pay is less than in the ER, but the hours are far better (in general, no night shifts) and the pace is usually more humane.
· Carefully choose the area in which you work. I can't give you any set rules on this since it will depend on your personality, but here are some general observations I've culled from my interactions with hundreds of ER doctors:
(1) Some ER docs do not like working with affluent people because they
think they're snooty, demanding, and ask too many questions. Other ER docs do
not like working with poor people, who are more likely to be unkempt, rude,
abrasive, and even threatening (in ER's, death threats are not uncommon).
· Change jobs if you don't enjoy working with the nursing and other personnel in an ER or UCC. I've worked in ER's in which I got along so well with my co-workers that we seemed to be part of a loving family. Conversely, I've worked in other ER's in which the nurses thought I was too much of a perfectionist—as if that's a bad trait for a doctor!—and their mission in life seemed to be to get me to accept that doing things in a half-ass manner was good enough. You probably won't have much luck changing your co-workers, so if you don't harmonize with them you're better off getting a new job.
· Staunchly resist pressures to deliver “cost-effective” medical care if this involves cutting corners. In recent years doctors have been pressured to reduce the number of tests, procedures, and referrals while there has been no corresponding relaxation of the standard of care, nor will there be in the foreseeable future. What this boils down to is that you, as a doctor, will be caught between a rock and a hard place. Insurance companies and the federal government will try to prevent you from doing those things that tend to keep you out of hot water (such as performing tests and referring patients to specialists), but if you accede to their demands you're more likely to be sued—and if you are sued, you're less likely to be capable of mounting a good defense. You're better off fighting a bureaucrat than you are a malpractice attorney, so if you think you need to do a test to investigate a patient's problem or simply to help build a more bulletproof case from a malpractice standpoint, my advice is simple: do the test.
The United States has 96% of the attorneys in the world, and a fair number of them are both brilliant and avaricious. Since there are only so many tobacco companies and gun manufacturers to sue, many skilled attorneys devote their professional careers to attacking American physicians, who are unarguably the best doctors in the world but nevertheless the doctors most likely to be sued. Collectively, physicians in the U.S. tend to be masochistic and possess a somewhat Pollyanna attitude, both of which make them prime targets for malpractice attorneys. Such a fortuitous assemblage of traits is bound to engender a lot of litigation, and it does. No one physician has any chance of changing this system, which has the unfortunate consequence of driving a wedge between a doctor and his patients. Because of their acquiescent attitude, even physicians as a group are unable to muster the resources to stem the tide of malpractice litigation. So my advice is this: if you want to be an ER doctor, you are very likely to be sued even when you did not in fact commit malpractice. If that is going to get under your skin, choose another profession to avoid that risk, or practice in a less-litigious area to minimize that risk.
Coincidentally, as I drafted the answer to your question, I received a message from an Internet emergency medicine newsgroup to which I belong. One of the members of that group began a discussion in which he lamented “the McDonaldization of emergency medicine.” Frankly, there are so many drawbacks to being an ER doctor that it would take me days to describe them all. I am not trying to leave you with the impression that being an ER doctor is an unbroken continuum of gloom. Far from it, in fact. You will have some exciting times, many interesting times, and some priceless times, too. But—and this is a big but—with so many other specialties to choose from, why not go into something that has a better balance of the positive and negative aspects?
A PS about your PS: You said “I really work hard in school.” In the context of what you wrote immediately before that, I read between the lines and inferred that you are asking me a secondary question: namely, if you will be insulated from the noxious aspects of working in an ER if you excel in school. The short answer to that question is no because many of the problems associated with working in an ER are simply not amenable to brilliance. Even if you are the best ER doctor in the world, that is no guarantee you won't be sued. One of my old bosses was certainly a superb ER doctor, but he was sued so many times it was depressing. On the other hand, another doc with whom I worked was basically inept and his patients died like flies, yet he was never sued because he was a really nice guy. Hence, here is another lesson: to minimize your risk of being sued, you are better off putting your energy into being nice than you are into being a first-rate doctor.
Unfortunately, other unpleasant aspects of emergency medicine cannot be erased by academic success. I graduated in the top 1% of my class in medical school, yet that did not make it any easier to deal with a decade of sleep deprivation (I once went for ten years without sleeping eight hours in a row). Unfortunately for ER doctors, some of these problems tend to snowball. For example, try changing your sleep schedule every few days and do that for a few years. After years of inadequate and poor-quality sleep, the chance that you'll be nice is less than it would be if you could sleep normally. Therefore, less sleep = not as nice = patients more likely to sue = even less sleep, and on and on. In short, it's a snowball effect. Why would anyone want to subject himself or herself to such a lifestyle? Why not be a dermatologist, sleep eight hours per night every night, spend the holidays with your family, and make more money to boot?
Q: Dear Dr. Pezzi: It's Marianna again. First, I would like to thank you for taking the time to answer my questions. To tell you the truth, I was very surprised that you took the time to answer my questions in such detail.
If it is not too much trouble, I would like to ask you some other questions. First, if I specialize in Emergency Medicine and end up not enjoying my job after graduating, then what else can I do without going back to school?
A: If you do not work in an ER, the most likely alternative is to work in an Urgent Care Center. However, I've had offers—both of which I declined—from physicians who knew me from the ER to work in their offices. One of the docs was a GP (general practitioner) and the other was a specialist in Internal Medicine. I also had an offer from a psychologist to attend to the medical needs of some of her patients.
With an MD degree and a medical license, you are legally entitled to perform any type of medicine. However, since the advent of specialization, physicians have customarily limited themselves to areas in which they've been trained. However, physicians occasionally foray outside these areas, especially when there is a lot of money to be made. A good example of that is liposuction. Sucking out fat seems to be a very simple operation, so physicians from dermatologists to gynecologists have anointed themselves to be experts in liposuction. I could train a junior high school student to do liposuction because it is indeed a technically simple operation. However, performing that operation and performing it very well are two different things. Most of the dermatologists and gynecologists I know seem to lack the skills to do aesthetically beautiful work of any sort, whether it's liposuction or even something as simple as removing a mole.
Pamela Grim, MD, the author of Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER was an ER doctor who burned out (as happens to most ER docs). In her book she mentioned that a friend offered her a job performing hair transplants, which is one of those procedures that has never been the sole “property” of any one specialty. As a result, all sorts of docs perform it nowadays.
There are a number of options I did not list, but I described the major ones. I should also mention that I know of doctors who are so disgusted by their jobs that they have become everything from police officers to bartenders. I even know of docs who are selling Amway! Clearly, being a physician these days is not what it is cracked up to be. The media continues to glorify the job and they generally give short shrift to the noxious aspects of this profession. However, I do not think it is fair to young people to give them an idealized and sanitized depiction of what it is like to be a doctor and then have them find out it's not so great after they've spent over $100,000 for their schooling and invested many years in training. My brother Ray was very prescient when he warned me years ago that being a doctor in the future was not going to be the grand and glorious job that I once envisioned. In my youthful zeal, I found it easy to ignore such a dire prognostication. I wish I had not, because Ray was correct.
Q: Second, how much do people earn when they work in an Urgent Care Center?
A: About $60 per hour is typical. Of course, if you own an UCC you could make more than an ER doctor. A lot more.
Q: What is the difference between the two jobs except the fact that you generally don't work at night and on holidays in an Urgent Care Center? Thank you for your time and I hope you e-mail me back. PS: I hope you like the card. J
A: In general, the patients are not as sick, there is far less risk of being sued, and the patients are usually not obnoxious. In the ER, you will be subjected to abuse that no one else in the world is expected to put up with. How would you feel if someone tried spitting or urinating on you? How would you feel if a patient slugged you? How would you feel if patients swore at you . . . and not just a few mildly profane words, either. I've heard drunks scream revoltingly obscene words at the top of their lungs for hours. How would you like it if you asked a patient if he was hungry and he responded, “Yeah, I want some milk!” as he grabbed your breast? All of those things and a lot more have happened in American emergency rooms. There are security guards in most ER’s, but many of these cases of abuse occur so quickly that there is no way for a guard to intervene. I worked in one ER that had no security guard, and that led to some situations that spiraled out of control. In fact, in the book of ER stories I am now working on, I included a long story that is one of the most bizarre incidents I've ever witnessed. That fiasco could have been prevented if that ER had a security guard.
Judging from the e-mail I've received from ER docs and nurses around the world, the abuse of ER workers seems to be a problem that doesn't occur very often in ER's outside the United States. People in other countries have the sense to not put up with such unruly behavior, but in America the riffraff know they can get away with virtually anything, so they do it.
Ashley’s perspective on the palatability of ER medicine
I have been reading your Question and Answer site, and I wanted to let you know I fully agree with your attempts to scare people away from working in the ER. My entire high school career has been dedicated to watching ER, reading ER books, and waiting until I could become a paramedic/ER doctor. OK, not my entire high school career. I've obviously done a few other things, but medicine has been one of my major interests. I'm now 17, which is finally old enough to take my EMT class. Last Saturday night I was doing one of my clinicals in St. Joe's ER, and everything started out fun. I learned how to hook up 12-lead EKGs, and was pretty proud of myself. Some doctor showed me the “rabbit ears” on one of the leads and explained about bundle branch block. It was interesting. Then this MVA (motor vehicle accident) came rolling in. It was the first severely injured person I'd ever seen, so I eagerly hurried off to Trauma-2 to observe.
Holy God . . . I suppose as far as traumas go, this one wasn't terrible, but the show ER is most definitely not adequate preparation for something like this. This girl had just turned 19, making her about the same age as I am. She was drunk, but she had a designated driver, and she'd had her seatbelt on. One of the paramedics grabbed me from the side of the room I was on and pulled me over to the other side. “Look! You can see her skull through that laceration!”
Yes, you definitely could. You could see a lot of it, and the sight just about made me fall over. Then the patient puked. People on ER don't puke, but she did and I wasn't ready for that either and it was incredibly gross. At this point I was grabbing the rails of the stretcher with white knuckles, freaking out. One of the nurses helpfully reminded me that if I was going to hit the deck, I should get on my knees first, to reduce the possibility of hitting my head. Um . . . thanks.
Anyway, they got the patient squared away for the minute, cross-table C-spine, NG tube, IV, etc. At this point, I booked it to the paramedic's lounge and sat down with my head between my knees, trying to regain some blood flow. One of the paramedics made me promise that I would take this experience as a sign and do something else with my life. At the time, I promised, but I was under duress. Eventually, I recovered, the shift went on, and I changed bed pans, got puked on, saw people with cancer, sick babies, bad smells, so on and so forth. It was gross.
Then the MVA girl's ICP (intracranial pressure) went up, and she started to lose it, swearing at everybody, slurring, and then picking at her big disgusting “degloving” head laceration like she wanted to get rid of it. That was more disturbing than her injuries, because she was losing who she was.
So I finished my shift and I was really happy until I got in the car to drive home. Then, I cried. I'd never seen anything like what I'd seen on that shift—it was like being painfully hit in the head by a “clue by four.” This is the real world, and the real world *sucks*. You can be out on Saturday night with your friend, not driving drunk, wearing your seatbelt, with nice little panties on, then the next second some doctor is cutting them off and shoving his finger up your ass to check if your spine is damaged. Then you're trying to rip your own skin off, and you'll never again be who you were. In a second. It's some bad stuff out there.
Anyway, I'm not telling you all this because I'm traumatized or whatever. I'll get over it. I just wanted to share my ER experience with someone because my parents/friends/whatever are not going to get it. I didn't get it either, but I get it now. I'm probably going to keep doing what I was doing: trying to get my paramedic license and going to college to become a doctor. But now I know what I'm up against. That's probably a good thing.
So that's my ER story. Keep trying to dissuade everyone who writes to you and wants to be an ER doc. Ashley
 C-spine = cervical spine x-ray.
 NG tube = nasogastric tube (a tube inserted through the nose and into the stomach; intended to evacuate the stomach).
 When physicians perform a rectal exam on a trauma patient, they check for abnormal anal sphincter tone as a sign of a spinal cord injury. They also check for the presence of blood.
Minimizing the risk of lawsuits
Q: I am currently in my third year of medical school and I want to specialize in emergency medicine. However, I know that ER doctors are prime targets for malpractice lawsuits. How can I minimize my risk of being sued? Thanks you for your advice, Dr. Pezzi. Mark
A: You can minimize your risk of being sued either by being very good or by being very nice to patients and their families. However, as I previously mentioned, there is no guarantee that you won't be sued even if you are an excellent doc. Being nice does a lot more to insulate you from rapacious lawyers. Of course, it is best to be both excellent and nice. I think that most people who go into medicine are genuinely nice people, but here is the problem: try putting up with all the crap that ER docs face, and then try being nice 100% of the time. Good luck. I think I was nice about 99% of the time, but that is not good enough. If you're a family doctor or other physician with longstanding patient relationships, if you tick off a patient he or she will likely put up with it in the same way they'd put up with a spouse with a bad case of PMS. ER doctors are generally strangers to their patients, and the patients therefore have no preexisting base of good memories to prevent them from reaching for their gun, so to speak, if something goes wrong or—as so often happens—if they think something went wrong even if it did not.
However, there is a downside to being nice: it takes time. Unless you pare away all the social niceties (courteously introducing yourself, learning the name of not just the patient but all relatives present, patiently listening to what everyone says and never interrupting, answering all their questions and addressing their concerns, thoroughly explaining everything, attending to their physical comfort needs [more blankets or pillows, a snack, or something to drink], and never rushing the patient as they undress, etc.), you could spend over an hour with some patients in addition to the time required for the history, physical, labs, x-rays, and other tests. In a busy ER, you will not have that much time. If you try taking it, the care of subsequent patients will be so delayed that they’ll likely skewer you or end up in the morgue. Hence, you will have to cut back, and hope that being nice for a few seconds to a minute is good enough.
Here is another thing you can do to minimize your risk of being sued: look like a doctor. I realize that physicians are not cast from the same mold, but deep down most people possess a stereotypical image of a doctor as being a late middle-aged man who is balding and fat, or at least portly, like the Pillsbury Dough Boy. Looking young for your age is generally a blessing, but it is a curse to your medical career (especially if you're an ER doc, since almost every patient you meet is meeting you for the first time) because when you meet a patient you have one more burden to bear: namely, convincing the patient that you are truly a doctor. I cannot begin to tell you how many times I introduced myself to a patient who immediately exclaimed, “You're a doctor? I thought you were a high school student!” Even after ten years of ER work, I still often needed to explain that I attended high school a few decades ago. (And besides that, how many high school students moonlight in the ER? “That McDonald's just doesn't pay enough, so I thought I'd work here. The pay is totally awesome.”)
OK, I realize that you probably do not want to go bald and get fat just to look like a doctor, but the next time you wonder if you should have a second helping of blueberry pie and ice cream, you might want to consider the plusses of portliness in your gastronomic calculus.
On to more practical advice. I think all ER docs, and especially those who look young, should dress up while working in the ER (save your scrub suits for impressing people during your off-hours). I realize the ER is probably the last place in the world you want to wear fancy duds, but it is a good investment. Here is the standard of dress to which you should strive: slip off your doctor's smock, and slip on a suit coat. If you look like a corporate CEO, you are dressed appropriately for the ER. Or how about some more blueberry pie? It's your choice.
Another tip: practice in one of the less litigious areas of the country (hint: if you are thinking about Michigan, forget about the Detroit or Flint areas). In general, areas with high population density are more likely to be populated by folks with a propensity to sue.
Yet another tip: if you believe in God, pray. If you don't think that is necessary, try this: flip a quarter ten times, and count how many times it comes up heads. Do several sets of ten flips, and you will see that while the average is five, in some sets you'll get far more or less heads. Approximately once every thousand times you will obtain all heads or all tails. Do you see where I am going with this? Even if physicians were as identical as quarters, some physicians would, by random chance, never be sued and others would be frequently sued. Does this mean that doctors who are sued less often are better? Not necessarily. One of my old bosses once had four lawsuits ongoing at the same time (and I have no idea of what was his career total), and one of my colleagues had never been sued. Yet if I were mangled in a car accident and needed an ER doc who really knew his stuff, I would want the guy who'd been sued to take care of me. Why? Because his knowledge and skills were vastly superior to those of the guy with the “perfect” record. The bottom line is that luck, or the hand of God (or however you choose to look at it), plays a role in the frequency of lawsuits. Averaged out over large populations, this statistical data does have some merit, but for individual practitioners of comparable skills some may have, just like the quarters, no lawsuits while others may have several lawsuits. Just pray that you are one of the lucky ones.
Finally, here is a tip that won't do much to minimize your risk of being sued, but it will make you more popular with the patients and administrators: if a patient wants a narcotic, give it (unless the patient is an out-and-out junkie). In the ER, you will have many patients who fall somewhere between the two extremes of legitimacy (a patient in pain, versus someone who wants either a narcotic buzz or the chance to sell the drugs and make money). It is not always easy figuring out who is legitimate, and who is not. I thought I had a fairly good sixth sense for ferreting out the junkies and pushers, but every so often I'd receive a call from a pharmacist saying that a patient I'd just given a prescription to had filled a half-dozen narcotic prescriptions in the past week. There are many cases in the gray zone: does that woman truly have migraines, or is she just seeking a narcotic buzz to help her cope with a bad marriage? As an ER doc, you will learn many tricks to help differentiate who is legit and who is not. However, some patients are not easy to categorize. ER docs vary in their threshold of credulity for believing what they are told, and they vary in how they handle those situations. I once believed it was my duty to withhold controlled substances such as narcotics if I was more than a tad skeptical about the patient's story. However, this did not win me any brownie points with the patients, the hospital administrators, or the DEA (Drug Enforcement Agency). The DEA cares if you pass out drugs like candy, but not if you occasionally palliate the marital misery of depressed housewives who may or may not have real pain. And administrators? They couldn't give a hoot if half your patients are stoned; they just want happy patients and the revenue they bring. Assuming that you say “yes” to all but the flagrant abusers, your popularity will soar. You will receive fewer patient complaints—remember, no one writes a letter to complain that they were given pain pills. But don't give them? Look out!
 This may seem implausible, so I will explain why. If you are a knowledgeable but cold and uncaring doctor, patients will relish the chance to take a whack at you. Once a medical record is in the hands of an attorney, you will not necessarily be protected even if you did everything perfectly. In theory, malpractice laws do not demand that you do everything with perfection; they require you to perform as well as an average practitioner of your specialty. As I know very well from having served on a committee that reviewed countless medical records, even above-average ER doctors usually fail to do everything right. Perhaps they failed to ask appropriate questions during the history, or failed to check certain things during the physical exam. Or they may not have ordered all appropriate tests, or given every conceivable discharge instruction. Incomplete, imperfect charts are far more common than perfect charts. This does not necessarily mean that the doctor gave poor care, but if a doc did not mind all of his p's and q's, and dot every i and cross every t, an attorney can use those omissions against the doctor. You might be shocked to learn how carefully plaintiff’s attorneys scrutinize a medical record. A rushed ER doc might have a minute or two to dictate a report, but the attorney and his team of experts could pore over that chart for days, searching for some way to assail the care delivered.
OK, few charts are perfect. Nor are all outcomes. Even when treatment is flawless, many outcomes are poor or even horrendous. People die and become disabled all the time from strokes, heart attacks, trauma, and countless other problems. Lawyers may be smart enough to know how to prevent these tragedies, but medical science and God have yet to figure out how to do this. Couple an imperfect chart with an imperfect outcome, and what do you risk? A lawsuit. For that matter, even a perfect chart and perfect treatment does not insulate a physician from being sued because malpractice insurance companies, fearing the jury sympathy factor, often settle baseless claims just to minimize the expense of ongoing litigation and a trial that may result in an astronomical award. Lawyers know this, so a perfect chart may not dissuade them from suing. As licensed extortionists, many attorneys don’t let facts get in their way. Not every malpractice lawyer is an unprincipled plunderer, but there are enough shysters in the United States to give doctors nightmares.
Theoretically, doing everything as well as an average ER doctor should always keep you out of legal trouble. The real world doesn’t work that way. There is no sure-fire safeguard against lawsuits, but the next best thing is for patients to like you. If they do, they are much less likely to sue, so the chart you generated (likely imperfect) will never be seen by an attorney.
 Unless the patient’s problem is minor, nurses are supposed to have the patient undress beforehand and get into a gown. However, this sometimes does not happen if the nurses are rushed or forget. I would often have elderly patients with chest or abdominal pain (and hence absolutely requiring an exam that necessitates disrobing) who were fully clothed, shoes and all, when I went in to see them. Some old folks move as slow as molasses. If I helped them undress, that took a couple minutes. You might think that losing a few minutes should not be a concern. A few minutes here, a few minutes there . . . it adds up. Patients not undressed. Lost charts (that was so frequent I invented a chart locator!). Lost patients. Lost x-rays. Lost EKG’s. Lost lab results . . . .
I worked in some ER’s in which the nurses and staff were virtually perfect, and that made it much easier for me to do a good job. However, I also worked in one ER in which the staff consistently made so many errors that I began to wonder if they had Alzheimer’s disease (in fact, a nurse was belatedly diagnosed with Alzheimer’s after she killed a patient). One ER assistant was notorious for putting a patient in a room, but marking the wrong room number on the chart. When I went into the room and introduced myself, it was the wrong patient. When I could find that assistant, I’d ask him where the patient really was. Unbelievably, sometimes he would be stumped, and have no idea. If I could not find him, I had to search the ER: several hallways, 40 rooms, and umpteen “hiding” areas such as where patients would go to smoke, talk on the phone, get a snack, use a restroom, etc. This search could easily take five minutes.
Miscellaneous questions about ER doctors
Q: Hi, my name is Allie. I am in 12th grade and we have to do a report on a job that we would like to do when we get older. I would like to be an ER doctor. If you have a chance, would you mind letting me interview you? I did obtain some good information from your site—which is really cool. J For my report, I have to know the following: What are your responsibilities?
A: To attend to the medical, surgical, psychiatric, and even social needs of every patient in the ER. That may sound too all-encompassing, but there is no limit on what ER doctors do. Just when an ER doc thinks he has seen and done everything, a patient walks in the door with a heretofore unseen problem or circumstance. That happened to me so many times I gave up thinking that I had seen everything.
Q: What benefits do you get?
A: That varies from job to job; some employers provide nothing but money, while others offer that in addition to the usual range of benefits and educational incentives. Going a bit beyond your original question, the only official perk I received was that one hospital gave the ER doctors assigned parking spots just outside the ER entrance. That was a nice gesture, but it led to some interesting and occasionally incandescent entanglements with patients and their families.
Q: What are the lifestyles of ER physicians?
A: There are as many different lifestyles as there are ER doctors.
Q: I heard that in medical school you have to dissect a dead person. Is that true?
A: Generally, yes. However, some medical schools no longer require (or offer) this, instead substituting prosections in which students view cadavers dissected by the medical school staff.
Q: Is dissection hard (emotionally)?
A: It was for me. Unlike some students, I did not faint, or vomit, or run out of the room. However, I dreaded the idea of inserting a scalpel into the cadaver. While I knew the cadaver was dead and I had legitimate reasons for carving it up, the notion of sticking a knife into a human of any sort gave me the creeps. I suppose most normal people are this way, since we’re taught from Day One not to hurt others. You might think you could undo this programming by telling yourself, “I’m now in medical school. It is part of the curriculum. It’s OK.” Nevertheless, it takes some time to come to grips with this idea. You will eventually get used to it, and then just think of it as an educational experience.
Another distressing aspect of dissection was that it destroyed my appetite because virtually everything I ate reminded me of something in my cadaver. After this went on for a few weeks and I lost several pounds, my girlfriend and I brainstormed on things I might eat that did not remind me of my cadaver. A light bulb went off in my head, and I thought, “Apple juice! That’s it!” This seemed to be a good idea, at least until the glass of juice was about two inches from my lips, at which time I realized that apple juice looked remarkably like the tissue fluid in my cadaver. Back to my old standby, water. However, starvation has a way of displacing these theoretical aesthetic concerns, and substituting pragmatic issues, such as staying alive. A week later, I regained my appetite.
Q: What are the effects of technology on ER docs? What do you think about our present state of technology?
A: The incremental advancement of technology is progressively transforming the practice of medicine from less of an art into more of a science. Most patients are dazzled by today's technology and knowledge base, and consequently assume that modern physicians have all the answers. Not so. To gain some perspective on this issue, go to a library that has old medical books and journals as well as periodicals intended for laypeople, and read them. I did that when I was an undergraduate, and I quickly learned that every culture at virtually every point in history glorifies the knowledge and abilities of their healthcare practitioners. The reason for this is simple. It can be very frightening to be sick and absolutely terrifying to face death even when you believe that your doctor knows and can do just about everything. That fear would be magnified if people realized or could admit to themselves how little their doctors knew. Hence, in a reflexive attempt to mitigate their fear, people put doctors on a pedestal and like to believe in their omnipotence. Even in today's supposedly high-tech world, there is far more that doctors don't know than what they know. A hundred years from now, people will look back at the practice of medicine at the dawn of the 21st century and wonder how we got by with such limited knowledge. For many diseases, physicians can now do nothing except offer symptomatic treatment. That is disconcerting, but far more troubling is the fact that our pace of advancement is not keeping up with the threats that may lie just over the horizon. When penicillin came into widespread use in the 1940's, it was the kiss of death to all sorts of bacteria. Thanks to the overuse of antibiotics and the incorporation of germ-killing chemicals into zillions of household products, we now have bacteria that can chew up and spit out just about every antibiotic we throw at it. Want more bad news? Consider what would happen if the Ebola virus or HIV mutated into a form that could be easily transmitted by air similar to many “cold” viruses. The result? Humans would be virtually extinct. That may sound overly alarmist to some people—the ones who think “it'll never happen to me” in regard to car accidents and the like. Frankly, it is not a question of if it will happen, but when it will happen. There is no law of physics or chemistry which says that it's impossible for an almost universally fatal virus to be easily spread by air. It will happen. It may be tomorrow, or it may be 10,000 years from now. Hopefully, at the time it does occur the science of medicine will be sufficiently advanced so that we can counter virtually every threat. As it now stands, we don't have a prayer if the Ebola virus or something like it began wafting into our bodies from the air. Thus, anyone who believes in the impossibility of a mass extinction is operating on ignorance and blind faith, not science and probability. To counter this threat, I think we should devote more resources to medical research. Americans are of course free to fritter away their money any way they see fit (such as to give untold millions of dollars to sports stars and other entertainers), but if people begin dying by the billions next Tuesday because of a new germ mutation I'm sure that some of the more incisive and reflective members of our species will regret our apportionment of resources. To put it succinctly, we are not out of the woods yet, and there is no guarantee that we will ever be. We might eventually learn everything about the body so that we can counter virtually every threat to health, but presently we owe our continued existence more to luck than to science.
Q: I just wanted to thank you for your help. Thank you *so* much! ~Allie~
A: You're welcome!
it like to be an ER doctor?
Pediatricians in the ER?
Q: Hi, my name is Ashley. I am 17 and a junior in high school. I want to be a pediatrician, but I’d like to work in the ER. Are there places for ER pediatrics? Thanks.
A: Yes, there are emergency rooms that employ pediatric ER specialists. Sometimes such docs are just pediatricians who have a lot of ER experience, and other times they're ER docs who choose to limit the type of work they do which is, understandably, greatly different than adult ER practice.
Q: Hi, I have more questions. I really want to be an ER pediatrician or physician, but I am not receiving good grades in high school. I make C's and D's, but I know I could do better. I just goof off and play basketball all the time. Once I get to college, I will buckle down. Do you have any study tips? Such as how to focus instead of daydreaming?
A: I had an experience similar to yours while I was in high school, especially 10th grade. During that year, I did not try at all. I would go to Chemistry class (but I never studied; I just copied the homework from one of my friends, Jeff Kern), then Jeff and I would frequently skip the rest of the day. We would ride our motorcycles on the trails and on roads, even though neither one of us had a license. I drove home at the time school got off and my Mom would ask, “How was school today, Kevin?” I'd answer, “It was great, Mom!”
I received D's in 10th-grade Chemistry, but I thought I could do better after I stumbled upon a way to serendipitously increase brainpower. My performance skyrocketed after those lessons gelled or coalesced during the summer between 10th and 11th grades. During my last two years of high school, I was tired of goofing off so I attended every class and received all A's. When I graduated from high school, I received the Science Department Key, so I obviously made a considerable improvement. What were some of the factors behind that betterment?
· I applied myself. This is the primary difference between failure and success.
· I applied my techniques of improving brainpower that enabled me to go from dunce to doctor.
· I was genuinely interested in most of my high school subjects. I was blessed with one of the all-time great teachers, John Giese, who instilled in me a love of physics and a love of learning physics. Even to this day, I enjoy reading physics textbooks. That brings me to my next point . . .
· If possible, get a head start on success in college by mastering some subject before you begin college. For example, I had such a good foundation in physics that I knew most everything the college physics professor said even before he said it, and when he'd go through a 20-step mathematical solution to some problem I could automatically see where he was going and I'd think of a way to arrive at the same result much more directly. That was fortunate, because that professor was not very adept at explaining things. Had I not known the material in advance, it would have been difficult to comprehend his circuitous explanations.
· I read The Memory Book.
· I learned how to take tests. Basically, this is just being logical. Most people think tests are a measure of knowledge, but they are also a test of your ability to reason. Even if I did not know the correct answer, I could often deduce it. I became so proficient at this that my brother Ray would sometimes say (half seriously) that I could “absorb” the answers from the test paper.
· I learned how to read people. By attending class, I would obtain a feel for how a teacher thought, and during tests I'd internalize and mirror that person's thought processes since that person was, after all, the person writing the test. If I had some uncertainty about something, I'd just think like that teacher. Of course, I could think like myself, but I could also mimic the way other people think to give them the answer they wanted.
You also asked about improving focus. I once had a terrible problem with concentration. I'd daydream about snowmobiles, women, physics—anything but the matter at hand. This became particularly bad during my second year in medical school while studying neuroanatomy, which is both challenging and very, very boring. Consequently, I'd read a sentence or two in my book, and then—15 minutes later—realize I'd been daydreaming again. That frustrating cycle went on all day long. My girlfriend suggested I try caffeine, which I had never consumed because I did not like either coffee or cola soft drinks. With caffeine in my veins, I felt supercharged and my concentration was fantastic; I could memorize everything by reading it once, and I didn't daydream until my studying was over. As a result, I quickly flew through my homework, and had the rest of the day for hanging out with my girlfriend.
The mistake that most people make is they consume caffeine before that time in their lives when they really need it. Since the effect of caffeine diminishes with continued use (even when the dose is increased), it is wise to avoid it until it is truly needed. I cringe when I see parents allowing 5-year-old children to drink caffeinated soft drinks. Children that age have plenty of energy, and they need caffeine about as much as Hugh Hefner needs a dating service or Bill Gates needs an allowance.
There are some so-called “smart drugs” (I discuss them in Fascinating Health Secrets) that go beyond the effects of caffeine. Some of these are available by prescription only, while others such as choline and ginkgo biloba are available OTC.
Q: Is there camaraderie between doctors and nurses or is it all cutthroat?
A: Generally, doctors and nurses get along quite well, but I had my share of battles with nurses who I thought were incompetent.
Q: What is the best inner city ER to go to? I am sorry I asked so many questions but I'd really like your advice. Please write back soon. Thanks! Ashley
A: As a patient? If you are a patient with a true emergency, the best ER is the closest ER!
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
Difference between a trauma doc and an ER doc?
Q: I am seriously considering a job as an ER physician. What is the difference between a trauma doctor and an ER doctor? I know that trauma doctors deal with more trauma than other doctors, but is there different schooling? Or can an ER doctor be a trauma doctor?
A: Technically, there is no such thing as a “trauma doctor.” ER doctors manage trauma cases and perform some emergency surgical procedures in the ER, but there are also surgeons who specialize in handling trauma and they are sometimes referred to as “trauma surgeons.” However, I never heard any medical person use the term “trauma doctor.”
Q: I find everything done in the ER truly fascinating! I am only finishing my sophomore year in high school, but it is something I really want to pursue. What courses do I need to take now and what courses should I take in college?
A: Don’t try to specialize too early! In particular, I recommend more science and English courses in high school. In college, the primary thing you need to do is to take all courses required by the medical schools to which you intend to apply. Since those vary somewhat, you should contact those schools to ascertain that you take all their required courses.
Q: Have you seen the show Trauma: Life in the ER on TLC? I hate the show ER—it's all so dumb and fake. I think that Trauma is more accurate, but I just want to know what you think. Well thanks for any info. I do not want to inconvenience you in any way so if you do not have a chance to write back, don't worry about it. Thanks for taking the time to read this! Chelsi
A: I watched Trauma: Life in the ER once a few years ago, and from that limited exposure I thought it was much more realistic than ER, which is replete with gross inaccuracies and distortions.
What doctors work in the ER?
Q: I’d like to know what kind of doctors work in the ER? Jan
A: ER doctors. That was the short answer. By definition, any doctor who works in the ER is an ER doctor.
Now here is the long answer, which is probably what you are looking for. Generally, ER doctors are trained in emergency medicine, a specialty that encompasses not just medicine but surgery, too (“medicine” is something of an all-inclusive term, including both medicine and surgery). However, a variety of other doctors work in emergency rooms. Most commonly, these docs are internists, family practitioners, and pediatricians. An occasional surgeon does ER work, but that is rare. Of course, as I explain elsewhere, an occasional surgeon also sells Amway.
Hours? Misconceptions? What's after ER? More advice?
Q: Hi, my name is Kyle. I am doing a project on being an ER doctor and I have some questions I would like you to answer. I know it differs for every week, but about how many hours do you average per week?
A: My average is about 40, but during any one week I might work 80 hours or I may have the entire week off. During training, it is common to work at least 100 hours per week, and sometimes as much as 120 hours. I survived by chewing caffeine pills. In fact, the last thing I would do before sleeping was to unwrap a caffeine pill and place it on my nightstand. When my alarm clock went off in the morning about four hours before my body wanted to wake up, I'd reach over—even before turning on my light or turning off the alarm clock—and pop the caffeine pill into my mouth (no water, just chew and swallow). I carried a pack of caffeine pills with me, and when a prolix nephrologist would launch into an esoteric discussion of renal function on rounds at 5 PM (at which time I may have been working for 36 hours without any rest), I'd surreptitiously pop another caffeine pill into my mouth to keep from falling asleep. Some of my colleagues used amphetamines (“speed”), but I was afraid to use that.
Q: What is the biggest misconception about your job?
A: People harbor many misconceptions of ER doctors. Here are a few:
· ER doctors are geniuses who know everything about every possible condition. Not true. Basically, we're adept at handling all sorts of emergencies and urgent conditions, as well as knowing how to care for a variety of common minor maladies in everyone from infants to elderly patients. The range of what we do is incredibly broad—certainly much greater than in any other specialty. On top of that, some ER doctors possess an affinity toward other aspects of medicine and hence develop greater knowledge and skills in those areas. For example, some ER docs are very knowledgeable about orthopedics, while I have a special interest in nutrition and other aspects of preventive medicine as well as cosmetic surgery. When the ER was slow, I would sometimes operate on nurses who wanted free cosmetic surgery . . . anything to stay awake at 4 AM! I also know far more than an average doctor about sex (although judging by the fact that I am still single, I don’t know much about romance). In the course of his training, every doctor learns about the scientific aspects of sex. The problem is that most physicians do not know enough to be very helpful to their patients, and their advice is often trite and simplistic. My book (The Science of Sex) is anything but trite and simplistic; if anything, the amount of information in it will likely overwhelm some readers.
· Another misconception is that ER docs are idiots who know nothing. Again, not true. This antiquated stereotype developed a few decades ago when emergency rooms were staffed by interns and residents, many of whom learned things the hard way: by making mistakes and killing dozens of people. Emergency departments are now generally staffed by at least one attending ER physician. That doctor may see patients by himself, or he may supervise the ER interns and residents.
· Another common misconception: ER doctors have glamorous jobs. You can thank Hollywood for creating that stereotype. I don't think what we do is particularly glamorous. In fact, much of it is downright disgusting. However, I must admit that I'm fairly jaded to the successes of modern medicine. For example, if I save someone's life I rarely reflect on it for even a second—it's just pick up another chart, and on to see another patient. However, some people think that what we do is truly special. One woman insisted on kissing my hands because, as she phrased it, “your hands have saved so many lives.” I think she felt that what ER doctors do is indeed glamorous, but I do not think that meshes with the ostentatious Hollywood conception of ER glamour.
Q: What other types of careers does your education lead to?
A: Here is one common thought in the minds of ER physicians: having worked so hard to become an ER doc, now that I am one, how can I get the heck out of this line of work? ER medicine has the highest burnout rate of any medical specialty, and if you read my first ER book, you are intimately acquainted with the reasons for this discontentment. Coincidentally, on one of the ER newsgroups to which I belong, one of the group members (who I'd pegged as being a gung-ho and ardent ER doctor) announced yesterday that he's quitting his job—permanently. For him to renounce emergency medicine in such a quantal fashion surprised me as much as I'd be by hearing that Bill Clinton had forsworn his interest in women besides his wife. That doc wondered (aloud) what he would do with the rest of his life. I took two breaks from working in the ER, during which time I wrote extensively, invented, worked as an editor for a snowmobile magazine, and started a few businesses. I cannot say that my ER training prepared me for any of those career tangents (other than giving me lots of unusual stories to write about), but it was an interesting diversion . . . hence, just what I needed.
As for the ultimate career path post-ER, some ER doctors open their own office and function as family doctors, while others seek additional training in another specialty. Still others quit medicine entirely. Some become lawyers, financial advisors, business owners, and who knows what else. I've known some docs (surgeons, by the way) who pitched their supposedly glamorous careers and became everything from a police officer to a bartender. Doesn't that make you wonder if medicine as a career is what it's cracked up to be?
Q: What advice would you give to someone who is thinking of going into this type of career?
A: Think twice.
Grades required for med school acceptance
Q: I am a junior in high school and I’d like to know how good my college grades should be to get into medical school?
A: I have some good news for you. It is now easier than it once was to get into medical school. Relative to the number of available places, there are fewer applicants than there once were. As you might expect, this reduces the competitive pressure, so it is not surprising that the average GPA of accepted students is lower. In recent years, the average grade point average for accepted students is about 3.55, and the average GPA for all applicants is about 3.4. Furthermore, grade inflation is now more rampant, so getting into medical school is not a Herculean task. It isn’t easy, since many applicants are unsuccessful, but it is easier than before. I had a friend in medical school with good MCAT scores and a 3.7 college GPA from the University of Michigan, but he was rejected the first year he applied—or was it the first two years? Very few such students now struggle to get in.
The GPA range for accepted students is probably much wider than you imagine. At least one applicant with a 2.5 GPA was accepted, but it is likely that he had very high MCAT scores or some mitigating factors that explained why his grades were so low. If you have a low college GPA, you can offset some of that impact if your grades significantly improve in time.
Q: Is it hard being an ER doctor? Thank you. Signed, Very interested in becoming an ER doctor
A: Let me put it this way . . . I've had some hard jobs in my life and nothing, I mean nothing, even remotely compares to the stress of being an emergency room doctor in a very busy ER. I used to be the sole doctor working the night shift in a busy urban ER. When I began my shift at 11 PM, I “inherited” all the patients from the two outgoing afternoon shift doctors as well as having to contend with a stream of incoming patients, which often included twenty or so who had been waiting for hours to be seen. Consequently, many of them were incensed, and they would often scream at me when I walked in to see them. Of course, it took time to vent their spleens, which just wasted precious time that could have been better spent taking care of someone.
Emergency medicine is difficult for many reasons. Besides the fact that I’d often have twenty patients who wanted treatment now, working in the ER is challenging because ER doctors must know how to treat a mind-boggling range of conditions. Even though we are theoretically specialists in emergency medicine, many ER patients evidently don’t know what the “E” in ER stands for. As a result, they come to the ER with just about every imaginable medical condition, and a few non-medical ones, too.
I had one patient (and several like him) who had a medical problem that his doctor could not diagnose, so he was referred to the topnotch docs at the University of Michigan. They were stumped, too. Next stop, the Mayo Clinic. They struck out, and the patient returned to Michigan to see some super-specialist. On his way to his appointment, lugging around umpteen pounds of medical records, x-ray copies, and whatnot, the patient inexplicably decided to skip that appointment, and instead pop into the ER! I was dumfounded. I said, “If the doctors at the University of Michigan and the Mayo Clinic could not determine the cause of your problem, how on Earth do you expect me to diagnose you?” I cannot recall his exact response, but it boiled down to his wanting to take a random shot to find a doc who could give him an answer. I can understand his motivation, but why would he pick a small ER in a tourist town in lieu of seeing the super-specialist? It made no sense.
There are several more reasons why it is difficult to be an ER doctor, but I already mentioned some of these reasons, and I am saving others for upcoming topics.
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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
by Kevin Pezzi, MD
Available in printed and Adobe Acrobat e-book versions (will display on any computer)
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How being an ER doc impacts your family life
Q: Does being an ER doctor take away from your family life? Signed, Confused
A: Yes! I am not married, but I have a mother and two brothers, and I know that I missed many holidays with them and countless special occasions (such as weddings) with my friends. Initially, it was painful to say no, and after awhile they stopped inviting me. That was even more painful. Medicine is not a great career to enter if you value your free time. Especially in your twenties—a time when many people relish their freedom—you will be in class, studying, on-call, on rounds, on weekend Grand Rounds, cramming for the board exams, and flopping into bed any chance you get. I attended just one family event in my years of education and training: my brother’s wedding. Had I been less assiduous, I could have spared some more free time . . . but at what cost? I felt morally obliged to be the best doctor I could possibly be. I thought I could do more good by sticking my nose in a book than I could by enriching my social life. Not every medical student feels this way, so you can get by with less intense devotion. However, I think that people who go into medicine should be willing to put the best interests of their patients ahead of their personal interests.
Even if you work only the typical 40 hours per week (and that is after residency; during it, count on 110 hours per week), you will actually work much more than that. Why?
· You must attend staff meetings for the emergency department, as well as general medical staff meetings. Invariably, these meetings are held during the daytime, which might be the middle of your sleep period if you work the night shift, as I usually did.
· You need to attend various committee meetings, and they’re also held during the day. Ergo, that is a double whammy if you work the night shift.
· You must attend CME (Continuing Medical Education) meetings, and engage in independent CME activities.
· Even if you are never sued, the courts will frequently subpoena you to appear as a witness involving patients you treated in the ER.
· Especially if you practice in one of the more litigious areas of the country, as an ER doctor you are quite likely to be sued, even if you did nothing wrong. Being involved in such cases is a huge drain of time and emotional energy.
· If you work in a busy ER you won't be able to keep up with your charting and dictations during your shifts, so you'll need to do them afterward. Count on anywhere from one to three hours per day for that. Want another unpleasant surprise? When you arrive for your next shift, you will be greeted by a thick stack of your dictations from prior shifts. What you should do is read them, make corrections, and sign them. That typically takes an hour (again, if you work in a busy ER). To minimize that time many docs just sign the charts without reading them, but by signing them you are legally attesting to the accuracy of the information therein. How much hot water that might get you in depends on the skill of the transcriptionists. I worked at some hospitals in which they rarely made mistakes and diligently flagged any sentences about which they had questions, but I also worked in hospitals that employed transcriptionists for whom English was apparently a second language. Even when I carefully spelled out any difficult words, they would still often get it wrong and instead substitute a word of their choice! Sheesh!
· If you work the night shift, you will need to sleep during the day. However, your spouse will most likely sleep during the night. Sleeping with your spouse can be a very enjoyable aspect of marriage, and you will quite likely resent missing it. Incidentally, I am not just referring to sex. When you sleep with someone, there's touching, cuddling, talking, and closeness that promotes intimacy and indisputably provides health benefits. Do you want to miss this? Good! Be an ER doctor, and you will miss a lot of it! Even on your off days, you will fall asleep at unpredictable times that do not mesh with your spouse’s sleep schedule.
· That brings me to my next point: do you want to work to live, or do you want to live to work? Medicine has a malignant way of dominating the lives of doctors. Even when you are not at work per se or engaged in one of the many time drains listed above, your mind will often drift to thinking about some aspect of your work rather than focusing on your family life, which is where you'd like it to be. However, blocking out your professional life during your off hours is not as easy as it may seem. About every week or ten days, I had a great shift in which I took care of a reasonable number of primarily pleasant, appreciative patients with genuine problems that were amenable to conventional medical therapy. After such a shift, I went home with a smile on my face and I did not need any time to unwind. More typically, however, I would attend to a flood of patients, some normal but many that were repugnant jerks. Not only does the ER tend to draw such people, but once there they act out in ways that is rarely witnessed outside of an emergency room. If they behaved that way outside of an ER, the police would arrest them for disorderly conduct, but in an ER such vicious behavior is just par for the course. If you watch Cops on the FOX network, you might obtain some idea of how certain people are vicious, aggressive, uncooperative, and intimidating, especially when they are stoned on drugs or booze, or have some mental illness. As an ER doctor, you will not only have to put up with such folks, but get near them to examine them and perform certain procedures. For this, ER docs should receive battle pay and an occasional ribbon or two. Here is one example: one night, one of my patients was a world-champion kickboxer with a head injury. The nature of his problem necessitated thorough neurological and head examinations, including a funduscopic exam (that is the test where the doc uses an ophthalmoscope to peer into eyes from a distance of an inch or so). This leaves the doctor totally defenseless, since he cannot see the patient’s hands. Before I began my exam, the champ informed me that he was in a bad mood, and matter-of-factly told me that he might head butt me, or slug me. Given that this guy was huge, muscular, and a world champion, I thought it was possible that he could kill me before the security guards arrived . . . although I doubted that our 98-pound-weakling rent-a-cops could subdue The Champ. For a moment, fearing death or at least unbelievable pain, I considered quitting medicine. However, I felt obliged to fulfill my duty as a physician to care for him. I will save the ending for another book, but he obviously didn’t kill me. Suffice it to say that this was a menacing situation, and it was not an isolated event.
· Then there is the “what if?” worry factor. Medicine is not a cut-and-dried science. There are many gray areas and other ambiguities in medicine, and after you make a split-second decision in the heat of the ER, for hours afterward you will often fret about whether or not you did the right thing. It is not easy to go home and quickly fall asleep under those circumstances if you truly care about patients. Sometimes it is tough to fall asleep just because you're so wound up from working at a frenetic pace during your shift. If you know anything about the biology of neurotransmitters and hormones, you know that you simply cannot quickly go from a hyper state to a tranquil state. Some ER docs attempt to circumvent this biological reality by taking uppers and downers, but I do not agree with that practice.
· The constantly changing shifts that ER doctors face are taxing both mentally and physically. I will never forget a doc who worked part-time with our ER group (his primary job was being the Chairman of the ER at another hospital). Whenever I saw that fellow, he looked frazzled and told me about how he was being sued or about one of his close calls. He was a very competent and amazingly thorough ER doctor, but he was no match for the lawyers in Michigan. He said he wanted to quit working in the ER, but his wife threatened to divorce him if he did . . . that marriage, at least in her mind, was not based on love (so he should have dumped her in a heartbeat, but he didn't). OK, enough digression. ER work is very demanding. The academic challenges of medical school, which once seemed so insurmountable to me (and remember that I graduated in the top 1% of my class . . . pity the person who graduated last in the class), are a joyride compared to the stress of working in a busy ER. As a result, many of your off hours will be wasted simply because you will be zombied out. Even though I naturally have lots of energy and am quite productive, on some of my off days I was so exhausted I spent most of the day sitting in a chair staring at a wall. Now that's being totally drained, and that is what ER can do to you.
It all boils down to this: your 40 hours of work in the ER will actually be more like 60 when you count all the ancillary requirements that accompany that job. If you include the wasted hours because of a chronic case of jet lag (note that you don't need to travel on a jet to have jet lag; just changing your sleep schedule is sufficient), it's more like at least 80 hours per week. Will you have time to spend with your family? Of course you will, but the time will be less than you'd like, and the quality of the time will be noticeably impaired. Also, do not forget the long-term consequences of chronic sleep deprivation and shift-work: your lifespan will be shortened by a few years. No one is going to give you any bonus points for abusing your body in such a fashion.
You can minimize the impact of the above-mentioned stresses by working in a slow ER, but those emergency rooms are increasingly difficult to find. Emergency rooms that were once great places for doctors to make money while sleeping at night are often packed with patients who think that popping a pimple is a good reason to go to the ER at 3 AM. Over the past few decades Americans have been accustomed to having their needs met instantly, whether it's for food, entertainment, or medical care. Most people still possess a reasonable amount of common sense about what constitutes a valid reason to rush to the ER, but an increasing fraction of our population either doesn't know or doesn't care about whether their ER visit is legitimate or not. Perhaps that is why I had so many goofy patients, such as the lady who called 911 and came to the ER via ambulance because she was concerned about the tightness of her vagina. In any case, taking care of such people (and lots more with somewhat more reasonable complaints, such as “I've had this cold for two weeks”) will make it difficult to find a cushy ER in which to work.
Is working in the ER as bad as I make it out to be? No, it is worse. Try as I may, I cannot convey in writing the emotions you will feel when you discover for yourself the negative realities of working in an emergency room. I do not want to leave you with the impression that being an ER doc is unrewarding, but I think I would be doing you a great disservice by failing to describe what you will face in the years ahead.
(Warning: better pop a Prozac if you're so inclined before reading this paragraph.) Before I end this topic, I would be remiss not to mention the following trend: with each passing year, doctors face increasingly difficult and frustrating challenges from insurance companies, politicians, government bureaucrats, lawyers, hospital administrators, hospital committees, and patients. Every year the screws are tightened just a bit more (and that is intentional: if the screws were tightened all at once, docs would have revolted years ago and read society the riot act). Do you think the insurance companies, bureaucrats, and lawyers will ever wake up and say, “You know, we've been too hard on the doctors. I think it's time to back off just a tad.”? Of course they'll never say that. Consequently, it will never become any easier, and it is bound to get worse, unless doctors take some dramatic action such as widespread striking. Or perhaps society will finally realize that it is in their best interests to once again make medicine an attractive profession so it attracts the brightest students. I can dream, can’t I?
 Say you do not want to work any night shifts? Try telling that to your prospective boss during your interview, and while he or she is laughing, you will be shown the door.
Choosing a medical school: look before you leap
Q: Hello, my name is Brandon. I just finished my first year of college pursuing my bachelor of science degree, and I eventually will apply to med school (most likely U of M). Thus far in my life at the age of 19, I have over 300 hours of volunteer time in an ER, I worked as an EMT for a year, I'm beginning the paramedic program, and I have been accepted into an aero medical service ranked top in the nation in medical vocabulary and current healthcare issues. This may sound like I'm boasting, but do these types of things have a bearing on acceptance?
A: Yes, but grades and MCAT scores are paramount.
Q: Why did you choose the medical school at Wayne State over the University of Michigan?
A: Basically, because I did not know any better.
Imagine that you had to choose a wife based solely on her outward appearance: you haven't spent much time getting to know her, you've never kissed her, and you don't know what really lies beneath her (hopefully appealing) facade. Well, if you can imagine this form of Russian roulette, you can imagine the predicament facing most medical school applicants who make a life-changing decision based on a dearth of information. Most medical students make decisions based on reputation (which may or may not be accurate and justified), hearsay, and blind faith. After I was firmly ensconced at Wayne State, I realized that I made an egregious error by choosing to attend that medical school instead of the University of Michigan Medical School. Why? Read on.
To know why I made a blunder in choosing a medical school, it is helpful to know that medical schools perform only two basic services for medical students:
· They give medical students didactic information.
· They give medical students patients to practice on.
Based on how I did on my National Board exams, I have no gripes about the amount of information that Wayne State managed to cram between my ears in four years, but I do think the patients that Wayne State delivers as fodder for medical students leave a lot to be desired.
Before I continue, I need to preface my forthcoming politically incorrect comments by saying that virtually every medical educator, including those at Wayne State, emphasizes the importance of an accurate and complete medical history in diagnosing patients. I've heard various percentages bandied about, but the most common saying is that “the history is 80% of the diagnosis.” That is, simply by listening to the patient and asking pertinent questions, a doctor's most powerful diagnostic tool isn't a CT scan or even the ever-symbolic stethoscope, it is just listening and asking questions.
After a decade as a physician, I can attest to the importance of the medical history but with one important caveat: the patient must possess enough intelligence to answer basic questions, such as “how long have you been vomiting?” or “where do you hurt?”
Suffice it to say that most patients dished out to medical students by Wayne State would not fare too well on The Weakest Link. As I mentioned before, I had just one patient during medical school who knew the names of her medications, the dose, and why she took them. The other 9999 patients responded with something such as, “I'm on the little white pill.” Why? “I take it 'cause I be sick.” How long have you been sick? “A long time.” How long is that? “A long time—I just done told you that, doctor.” How would you feel if you'd spoken to a patient for 15 minutes, and you didn't know anything more at the end of that time than the fact that the patient is taking an unknown drug for an unknown illness for an unknown duration? Well, it made me feel like a veterinarian, except that vets usually can obtain some useful information from pet owners.
Once I got the heck out of Detroit, I learned that most patients give a perfectly adequate medical history, but for the intellectually challenged residents of Detroit, asking them even simple medical questions can be a frustrating exercise in futility. I am not here to slam them, I'm here to point out their collective deficiencies so that you, the prospective medical student at Wayne State, can run the other way. For medical students in other states, I don't know if you will face a similar problem by attending an inner-city school instead of one that derives most of its patients from the suburbs. In any case, it is important to recognize that patients provide a vital role in physician education, and this function transcends merely being a blob of protoplasm. Patient interaction is key, and the quality of that interaction varies enormously.
Lead as a neurotoxin
Q: Dr. Pezzi, I really, really, really want to be a doctor! I read the tips you gave on this web page, but what else can I do to increase my brainpower? Thank you SO MUCH! Jenny
A: Doctors need brainpower like NFL players need muscles, so preserving and expanding your intellect is vitally important to anyone who aspires to become a doctor or other learned professional. There are literally hundreds of things you can do to maximize brainpower. I don't have the space to thoroughly cover that subject here (I devoted one chapter to it in Fascinating Health Secrets and I'm thinking about writing a book solely on that subject), but I will mention one of the minor factors that you nevertheless shouldn't overlook. If you care about your intelligence, have you ever thought about your faucet? Faucets may not seem to be connected to intelligence, but they are since most faucets contain lead, a known neurotoxin that lowers IQ. The Safe Drinking Water Act mandated that faucets comply with the lead requirements of ANSI/NSF Standard 61, Section 9 by August 6, 1998. If your faucet was sold after that date, you're fairly safe (assuming you didn't buy a faucet that'd been sitting on a shelf for years). Why did I say fairly safe? Because you undoubtedly eat in restaurants and homes that have lead-bearing faucets. Drinking fountains, water coolers, and icemakers are other possible lead sources. Since it is not practical to avoid them, you can minimize your lead absorption by taking a calcium supplement (e.g., Tums®) at the same time. You could also drink bottled water instead of using a drinking fountain, but bottled water is often laced with plastic monomers (non-polymerized plastic residue) and plastic additives that can interfere with some of your hormones. Tough choice, isn't it: lower your IQ, or interfere with your sex life? (If you’re interested, there is more information on this topic in The Science of Sex.)
As will be clear to anyone who read my chapter on brainpower in Fascinating Health Secrets, there are many sources of lead and many strategies for minimizing lead exposure and/or absorption. Lead is probably much more ubiquitous than you think, and if you're not lead savvy your brainpower will be affected. If you follow my lead tips and other suggestions for increasing brainpower, you will have a definite advantage over medical school applicants who incorrectly think that intelligence is a fixed asset.
As a neurotoxin, lead does more damage to developing brains. Thus, minimizing lead exposure is especially critical for children. However, in recent years neuroscientists learned that neural growth occurs even in adults. For this and other reasons, I think that lead never ceases to be a threat to the central nervous system.
A mini-lesson on lead from The Bachelorette mini-series
Q: As a doc, do you ever see people doing things detrimental to their health, besides the obvious things like smoking, using drugs, and eating junk food? Tatum
A: Yes. Here is an example. In The Bachelorette mini-series (one of the things I watch while lifting weights to give me a mental break), I saw Trista Rehn accept a glass of water from one of her dates in his New York apartment. From what I witnessed, it appeared as if he turned the tap on and immediately filled the glass. I don't know any specifics about his apartment, but it is likely that there is lead either in the faucet or in the water pipe joints. Thus, it is prudent to flush the line (for a few to several seconds, depending on where the lead sources are) before filling the glass. Lead is inimical to brainpower and has other adverse health effects. Obviously, one glass of water does not pose much of a risk, but since there is no perfectly safe level for lead, it is best to avoid it as much as possible.
Getting a shot in medical school should be the least of her worries
Q: I want to be an ER doctor but I really hate getting shots. My mom told me that in medical school you have to give shots to yourself and to other students in your medical class. Is that true? Jessica
A: In this message, I will point out that getting a shot should be the least of your worries. Are you ready? Better take a deep breath!
When I was young I was equally terrified of getting shots, so I can sympathize with your concern. The good news is that in medical school you do not have to be on the receiving end of a needle. You cannot graduate from medical school without performing a number of procedures (and giving an injection is certainly the most elementary procedure I can think of), but you don't need to be the guinea pig. In medical school we practiced drawing blood on one another before we treated patients, but if having your blood drawn is something you cannot handle, just explain to your teacher and fellow students that you're terrified of needles. People in medicine are usually very nice and accommodating, so no one will force you into doing something you do not want to do.
By the way, if it is just the needle pain that bothers you, that can be diminished by prior application of everything from an ice cube to a local anesthetic cream (e.g., Emla®). In Fascinating Health Secrets, I discussed other ways of mitigating pain, both acutely and chronically. The pain threshold is easily modifiable.
Unfortunately, the other noxious aspects of becoming a doctor are not so easy to eradicate. For example, the chronic sleep deprivation faced by doctors-in-training is literally torture. If the criminal justice system tried meting out that punishment to convicted mass murderers, the US Supreme Court would order that practice terminated on the grounds it was cruel and unusual punishment—something outlawed by the Constitution. However, in this regard the Constitution only protects people from torture if they are not asking for it—and by applying to medical school, you are not only asking for it, you're paying dearly for it. Going without adequate sleep for one night is bad enough, but going without adequate sleep for years in a row is one of the most horrendous experiences one can endure.
So why would anyone subject themselves to such a noxious experience? Most physicians possess a somewhat masochistic streak; they soak up punishment, and keep on smiling. I think most prospective doctors, deep down, have a poor self-image and they will subject themselves to untold horrors just to experience the positive reward of getting an MD.
Beyond the sleep deprivation, other things will surely make you think twice about your decision to apply to medical school. For example, unless you are content being a second-rate doctor you may as well kiss your parents, siblings, friends, and boyfriend goodbye for a decade or more because you'll rarely see them. If you find the time for normal socialization you are either a heck of a lot smarter than me (and I graduated in the top 1% of my medical school class), or you're not as dedicated to studying medicine as you should be. When you become a doctor, you hold other people's lives in your hands, so if you are not willing to sacrifice your life to become the best possible doctor then you should step aside and let a more dedicated person take your place.
Imagine that you are a patient in an emergency room and the ER doc is fighting to save your life. Would you prefer that this doctor be a laid-back nice guy who took the time to attend the weddings of his friends, go to his class and family reunions, hang out with his buddies, and visit his family on a regular basis? I doubt it. Rather than assuaging his personal desires, you'd likely wish that your doc had his nose glued to textbooks and journals learning facts that might make the difference between life and death. Your life.
This discussion isn't merely academic. I worked with both types of ER doctors—let's call them Type A and Type B—and I know that the laid-back Type B docs send a lot more people to an early grave. To put it succinctly, excellence (or lack thereof) in medicine is palpable, and the consequences are weighty.
This stratification of ability applies to other specialties, too. For example, I know an ICU doc who stunned me with his ability to figure out what toxin induced illness in patients who would present to the ER every so often with mysterious diseases. I’m not taking about carbon monoxide or cyanide or acetaminophen or things that any critical care doc could diagnose, I’m talking about some truly weird stuff that left me wondering, “How on Earth did he know enough to even suspect that was the culprit?” Given that there are a zillion potentially toxic chemicals, physicians cannot test for all of them. This doc knew enough to ferret out the responsible agent. If he saved your life, or the life of someone you love, you would not care that his personality was so drab that he made me seem like an ebullient game show host; you would be thrilled that he sacrificed his personal life so he could become a better, more knowledgeable doctor.
Although you did not address the question of whether it is possible to combine motherhood with a medical career, I will. Right off the bat I'll state that it is impossible to be a first-rate mother and a topnotch doctor. If you want to do both, someone will suffer: either your patients, or your children (unless you somehow invent a way to stretch the allotted 24 hours in a day). Anyone who thinks otherwise is either delusional or fails to appreciate the time it takes to be a great mother or doctor. Here is an excerpt from my review of Walking Out On The Boys by neurosurgeon Frances K. Conley, M.D.:
Now women are told they can “have it all.” A woman can get married, raise a family, watch her kids play soccer, be active in church and other social functions, pursue her individuality through avocational interests and she can be not just a doctor, but just as good as docs who live, eat, and breathe medicine. Dream on! Unless a woman was a genius who never slept, it just isn't possible for her to be SuperMom, SuperDoc, and SuperWife. Still, egged on by the politically correct rhetoric in America, some women pressure themselves to be SuperWoman not realizing that something has to give. Especially in emergency medicine and the primary care specialties (such as Internal Medicine and Family Practice, both of which draw many women) in which a doctor's knowledge base is so diverse, there just aren't enough hours in a day for a woman to be a superb doctor and everything else that society is telling her she should be. It's no wonder why some women feel so pressured.
Do not interpret this as a criticism of women. It's not. On a level playing field, women can be just as competent as men. The problem starts when women begin diluting their professional time—that is when they begin knocking their heads against the “darn, there are only 24 hours in a day” problem. Even if a woman were married to a man who is willing to share housework, the responsibilities of motherhood are not so easily met. If you are a surgeon who gets home at night after your kids are in bed, who is going to hug them when they need a hug? Your nanny? Or if you skedaddle out of the hospital early to greet your kids when they get home from school, who is going to take care of your patients in the hospital? Or do you think that patients develop problems only from 9 AM to 3 PM? Again, something has to give if you try to have it all. You can decide where you want to cut corners, but you cannot avoid the reality that cutting corners will be necessary.
Why am I telling you all this? Getting a shot in medical school should be the least of your worries. Instead, what you should focus on is the fact that medicine is a career that will soak up all of your time and energy. Beyond the bare minimum you need for R&R (and until you've survived internship, you have no idea of just how much that can be pared down), any other time you spend away from medicine will detract from your potential for medical excellence. Consequently, it is a tough choice: the quality of your life, or the quality of the lives of your patients. Some of the truly dedicated “live, eat, sleep, and breathe medicine” doctors I know are incensed about the recent influx of what they term “half-ass” doctors for whom medicine isn't an all-encompassing lifestyle.
I'll never forget the first ER patient who died under my care when I became an attending ER doctor—not just a resident, during which time someone else shouldered the burden of ultimate responsibility. I was utterly devastated, and for the following two weeks I literally felt as if I'd been punched in the gut. I told my boss about the case, thinking that he would lambaste me. Instead, he just chuckled and said that as an ER doc it's not rare to fail to save a patient's life. He didn't see anything wrong with my care since I'd coded the patient according to the standard ACLS (Advanced Cardiac Life Support) algorithms. However, that case devastated me because I suspected that if I had been a bit better doctor I could have saved that patient's life. Indeed, after years of working in the ER, I acquired enough savvy so that saving that man's life would have been a no-brainer. What is the difference between being an average doctor and a doctor who has learned a number of lifesaving tips? Well, the answer is obvious: in this case, the difference was literally life and death.
I suppose we live in a world in which it's tough to get away from the fact that rookies will never be as good as old pros, and any patient who puts his life in the hands of a rookie doctor should know that his death may just be chalked up to one of the lessons learned on the way to becoming a better doctor. If you are a rookie doctor, you should realize that any time you spend pursuing a normal life will simply delay your mastery of your specialty. If you are a party animal, let's pray that you become a dermatologist and not an ER doctor or surgeon.
Here is my ultimate message: if you are smart and you truly care about people, then you should be a doctor. However, bear in mind that if you really care about people you will put their interests ahead of yours, and for that you will personally pay a very high price. On the other hand, few careers are as potentially rewarding as medicine. However, those rewards will accrue to you only if you find reward in helping others. The joy of medicine is the joy of helping others; if you cannot relish that joy, then you are better off in another career.
Obtaining an MD degree in less than 8 years
Q: Hi, my name is Sandy. Is it true that you could actually go straight from high school to a medical school by attending a 7-year “accelerated” medical degree program? If it is, does every medical school offer that program? THANK YOU!
A: In the past, some medical schools offered a 6-year combined undergraduate and medical school program in which students could enroll straight out of high school. I don't know if any of these programs still exist, but I think they're a great idea. For medical students, the educational value of their undergraduate years has less to do with learning facts than with learning how to learn. Some gifted students do not need this instruction, so for them the jump from high school to a 6-year undergraduate/MD program is feasible. However, for an average student (even an average medical student), the jump from high school to medical school would be unbelievably shocking. Medical school makes college seem like Romper Room.
While the United States has for the most part kept undergraduate and medical school separate, in some other countries the programs are customarily integrated. I suspect those programs are not as intensive and rigorous as medical education is in the United States. Russia, for instance, graduates some very young doctors, but Russian medical education is generally not viewed as something to emulate.
It is interesting to note that medical school was foreshortened from four years to three years during World War 2 to ease a doctor shortage, yet I never heard anyone opine that those three-year graduates were any less clinically capable than four-year graduates. How could this be possible? By eliminating the portions of medical school that have little to do with patient care. During medical school, students are given instruction in areas that prepare them to be clinicians (i.e., practicing physicians) and scientists, because a few students become medical researchers and never treat patients. During a World War, the need for clinicians surpasses the immediate need for researchers, so that portion of the curriculum devoted to preparing students to be researchers was omitted—and off to war they went.
Ivy League schools aren't what they're purported to be
Q: If you want to be accepted into med school, do you pretty much have to go to an Ivy League college? Thanks for your time. Katie, 15 years old
A: Not at all. Most medical students did not attend an Ivy League college. Frankly, I do not think that Ivy League graduates are any smarter or better educated than other college graduates. In fact, the ones I know are so decidedly unimpressive that it is hard to believe they have a high school diploma, let alone a college degree from a supposedly elite university. Did you read my review of White Coat: Becoming a Doctor at Harvard Medical School that is posted on my page of book reviews? After reading what I said about the author (or, more to the point, what Ellen said about herself), would you want such a dingbat taking care of you? She is a doctor? And a Harvard grad?
Ivy League schools would like people to believe that they have higher standards of acceptance, better professors, more challenging courses, and hence superior graduates. If that were true, then why did I beat just about every Harvard grad on nationally standardized tests such as the MCAT and the National Board exams? If those exams also tested for practical knowledge, the gap would be even wider. Ellen did not know what Styrofoam is, and making a robot that mowed my lawn was just one of the hundreds of things I designed and built.
By the way, I built that robot from a junked mower that I refurbished, also using parts from a discarded tape recorder, metal detector, and projector along with miscellaneous scraps of wood, metal, and PVC pipe. The three robotic mowers now on the market (20 years after I made mine) are produced by multi-million dollar corporations, yet those robots are so simple that they can only wander aimlessly within a preset boundary—that is child’s play! My robot would efficiently mow in beautifully straight lines, instead of covering some areas dozens of times while leaving other areas totally untouched—as the current robotic mowers do.
I had two separate guidance systems: one for row course correction, and one that used triangulated ultrasonic pulses to provide a way for the mower to determine its position on the lawn. I could have eliminated the need for the latter system by eliminating the bag to collect grass clippings, but I wanted my mower to bag the grass. Since lawns grow at different rates from week to week, there is no way to program in a set point of when the bag is full. I designed the mower to sense when the bag was full, then go to a set spot to dump the grass. Incidentally, this was a friendly mower: it would even put the clippings in a plastic trash bag! Because the mower would depart for the “dumping area” at different points, it needed to know where it left off and how to get back to that point—hence the need for the ultrasonic triangulation.
So what is my point in mentioning this? I took a pile of junk and turned it into a mower that was more advanced than what huge corporations can produce. Could Ellen, or others of her ilk from prestigious universities, do any better? After all, she is a Harvard grad . . . the elite of the elite. If you saw how I poked fun at Ellen in that graphical depiction of a Styrofoam shoe test (if you don't know what I'm referring to, check it out) and think that I am being too hard on her, I'd like to mention that Styrofoam is not some esoteric substance. Such an amazing knowledge gap makes me wonder what else she doesn't know. A doctor needs to know more than just medicine because doctors interact with real people who lead real lives. When doctors take a medical history, what the patients say almost always involves things that are not taught in medical school. If a doctor is clueless about what the patient is describing, how can the doc truly understand what the patient says? If it is an injury, understanding the mechanism of injury is important. If it's an illness, important diagnostic clues might be overlooked unless the doctor possessed a good fund of general knowledge. I once had a husband and wife present to the ER at the same time with fulminant pulmonary edema (i.e., their lungs were filling with fluid). To make a long story short, without ever sitting foot in their house, I strongly suspected (and was later proved right) that their furnace was not operating correctly and was emitting carbon monoxide. Do you think that Ellen, who evidently does not know what Styrofoam is, would be able to diagnose such a furnace problem? I had many similar cases in which an underlying problem required correction. A doc without much general knowledge would just patch up the patient and send him back to the milieu that spawned the problem in the first place. What good would that do? Hence, it is obviously important for doctors to know about many things, not just medicine. The fact that Harvard graduated a person such as Ellen is not a testament to the superiority of Ivy League schools.
Q: I understand and agree with your opinion that Ivy League graduates are not always as intelligent as those graduating from a regular college. However, do med schools realize this, too?
A: I am sure they do.
Q: I am just afraid that if I do not attend an Ivy League school, the medical school Admissions Committees will reject me, giving preference to Ivy League graduates.
A: I don't think so. If I were on an Admissions Committee, my primary criterion for judging Ivy League grads would be their MCAT scores because some Ivy League schools have shocking grade inflation. For example, a week ago on the news I heard that the average grade at Harvard is an A-. Some Harvard official attempted to excuse that by claiming that such a high average grade was justified because their students are so smart. Really? What yardstick are they using? Ellen did not know what Styrofoam is, and as I intimated in my review of her book, her short-term memory seems to be shockingly unreliable. No doubt she has some “book smarts,” but as I pointed out above, it's imperative for doctors to possess a good fund of general knowledge. When I think of Ellen, one word pops into my mind, and that word is “airhead.”
I knew another doctor who did not know what a 2x4 (pronounced, “2 by 4”) is. I'm sorry, but I think that any doc incognizant of Styrofoam or a 2x4 is just too stupid to be a doctor. These things are utterly quotidian, and anyone oblivious to them must have lived such a sheltered life that he or she could not possibly harmonize with future patients who do not live cloistered lives.
Q: If I apply to an Ivy League school and am not accepted, does this indicate that I will not be smart enough to go to medical school?
A: No, it may just reflect that:
· Your parents are not rich enough.
· Your parents do not have the right connections.
· You are not a minority.
· You do not fit their stereotyped image of what an Ivy League student should be.
· You didn’t share your Thanksgiving dinner with homeless refugees from Somalia.
OK, perhaps I am going a bit overboard bashing the Ivy League schools, but some of the more prominent ones are liberal havens with politically inspired acceptance criteria. However, in that respect, they are not unique. For example, the University of Michigan was sued (and the case is now before the Supreme Court) for accepting less qualified applicants just because they were minorities. Racial quotas were banned, but in name only. College admissions officers have all sorts of ruses for giving preference to minorities. As I mentioned before, the university that I attended (and I doubt it is the only one) gave some minorities and athletes an unconscionable academic boost by giving them a way to receive a phony degree in a rigged system (hint to the producers at Dateline, 20/20, and similar investigative news shows: why don’t you do an exposé on this instead of your often soporific topics?). If you aren’t someone given special favors, you must work harder to achieve success. The best time to come to grips with this reality is now, so you have time to do something about it, rather than spending years in litigation. Years ago, before many of you were born, Allen Baake sued because he was not accepted into medical school, even though the school that rejected him accepted less qualified minority applicants. Bottom line? This is not a new phenomenon. It’s been going on for a long time, and it will likely continue for the foreseeable future. If you are a superior student, it will not affect you. If your academic record isn’t stellar, you might be displaced by a less qualified minority or athlete.
Q: Thanks for your time . . . speaking of time, how do you find enough to answer everyone's questions so thoroughly, write books, invent machines, and be a doctor?!
A: I am not married, and don't currently have a girlfriend. It's called “sublimation.” :-)
Q: Please pardon my repetition, but I want to clarify something. If I apply to an Ivy League school and do not make it only because I am not smart enough, then would it be safe to assume I am not smart enough for med school?
A: Not necessarily. Assuming you don't fall into one of the special groups favored by Ivy League schools, they can of course be very selective in terms of academic qualifications. I am certain that some Ivy League rejectees have the brainpower to be a doctor. Let me tell you about one of my classmates, Larry. Larry was something of a legend in our medical school because of his inveterate persistence. Larry applied to medical school ten times before he was accepted, and we admired him for that. Imagine if you applied for nine years, and were rejected nine times—how could you summon the willpower to apply once more? Well, Larry did, and he was accepted. He flunked one year, but he graduated.
Larry had a tough time getting into medical school, and a tough time in it. Some of my classmates called him “The Bag Man.” Not in a disparaging way, because we all liked and admired Larry. They called him The Bag Man because he seemed to be one. As far as what my classmates or I could tell, he was homeless. I'd get to the medical school before 6 AM, and I'd wake up Larry, who'd be sleeping on top of his lab table. Do you know how hard and cold those tables are? Larry would always self-consciously excuse his sleeping on the table by saying that he'd just fallen asleep while studying late the prior night. I didn't want to embarrass him by telling him I did not buy his excuse—who falls asleep on top of a table?
I suppose I would have been better off living in the medical school, too. I spent the first couple of months living in the basement of my girlfriend's parent's home. My girlfriend loved me dearly, but she constantly nagged that I did not spend enough time with her. Well, I spent plenty of time with her because we did just about everything together (she'd sometimes even sit with me during lectures in spite of the fact that she wasn't a medical student!), but we didn't do enough fun activities. Blame the medical school dean for that one. We were told the first day of class that they'd tried lightening up on the preceding class to see if the low-pressure approach was better. Evidently not, they learned, because when the pressure was off, the medical students just slacked off. Hence, the medical school brass decided to employ the opposite approach with us, and they put the screws to us (so much so that a significant portion of my class was eventually permanently expelled from school for not cutting the mustard). I weathered that storm, but at the time I was weathering it, I had no idea I would eventually graduate at the top of my class. Heck, I thought I'd be back mowing lawns in good ol' Milford, Michigan. In any case, I was in no mood to slack off, especially those first few months. Well, as I was studying one Saturday morning, my girlfriend stepped into my soundproof booth (did you read about that on one of my gizmo pages?) and dumped a large bowl of sugar over my head. No “Kevin, we've got to talk,” just five pounds of sugar in my hair and in my textbooks—some of which still taste sweet to this day!
My next boarding situation was even worse. My Aunt Florence arranged for me to rent a room from one of her friends. I hated the area (it was a run-down, grimy old industrial zone too far from the medical school), the house (it was disgustingly filthy), and the coldness of my Aunt's friend. I felt permanently ill at ease there, so I'd get up every morning at exactly 4:44 AM and head for the medical school. Oh, I hated my car, too. In cold weather it'd usually take the transmission 30 minutes to warm up enough to drive the thing, so I wasted an hour per day sitting in my car. The only fond memory I have of that car is that its prolonged warm-up time allowed me to speak longer with one of my classmates, Betsy, who asked for a ride back to her home one winter night. I can't recall exactly what Betsy said, but it was something to the effect (or at least I interpreted it that way) that I was desirable. I was almost certain she said I was “so good looking,” but I found it difficult to believe anyone would think that. My mind was partially wandering when she said it, so I couldn't be absolutely sure. There just wasn't any good way to ask if she really did say it, which would of course given me a perfect opportunity to initiate a relationship with her. Hence, I paid a big price for that moment of inattention.
Back in those days, my self-image was somewhere between being a piece of sh-- and day-old roadkill, and the fact that a goddess such as Betsy would say something nice about me was so incomprehensible that I couldn't believe I'd heard her correctly. I suppose I should have told her that I had a crush on her, but I figured that half the world did, too. She was very smart, of course, beautiful, in great shape (she was a runner), had a fantastic personality, and was always in a good mood. OK, enough rhapsodizing about Betsy.
For the last three years of medical school, I lived with my Aunt Florence. I greatly appreciated her generosity in allowing me to stay with her, but I could never totally relax around her, either. It is nice to have a home in which you can unwind. The constant stress of never being able to chill out was very wearisome. However, the worst part was that my Aunt would frequently knock on my door, tell me a story for 45 minutes, come back in an hour and repeat half the stories she had just told me, then do the same thing an hour after that. Those wasted hours were just that many fewer hours I could study or sleep. I don't know how I made it through medical school. The usual medical school stress was bad enough without having to endure such hellacious experiences in my off hours. I thought of dropping out a few times, but somehow I stuck with it. What an idiot I was! I thought my sacrifices were but temporary burdens that would eventually lead to a life of near-nirvana. Can you imagine that I was once so naive as to think that the life of an ER doc would be blissful? Oh, the naiveté of youth . . . it is what keeps us going.
Q: Wow . . . so Larry was 10 years older than most other class members?
A: He must have been.
Q: I wonder what convinced the Admissions Committee to finally accept him?
A: I never pried into the details, so I don't know for sure. I imagine he took more college classes and his grades improved over the years. Or perhaps he repeated the MCAT nine more times with similar incremental improvement. Or perhaps the Admissions Committee was impressed by his extreme persistence. I suppose it is human nature to be impressed by people who refuse to give up. Look at Edison's invention of the light bulb: he tried thousands of things and trekked over the world searching for just the right filament.
Q: Is it typical for medical schools to accept people who have been out of college that long?
A: No. Most medical schools discourage older applicants because older folks are more likely to be distracted by marriage or parenting, and because older people almost invariably have less energy than younger students. Take me, for example. I have more energy than most people, but I know I'm not the dynamo I was in my youth. If I were starting medical school now, it would be more of a challenge to muster the necessary energy. Another reason why older applicants are not viewed kindly by Admissions Committees is that older people generally have fewer remaining years in which to practice medicine. Medical school is not just a personal investment of time and energy, it's also society investing their resources into doctors who'll care for them in the future. Therefore, from the perspective of society, they can obtain a greater return on their investment by producing younger doctors. However, in fairness to older applicants, I should point out that the arbitrary age cut-offs employed by some medical schools do not make any sense because they fail to individualize for differences in longevity between people of different races or families. If you can prove that most of your ancestors lived to be 100, you would likely have as many productive years as the typical twenty-something applicant even though you were in your forties. In such a case, shouldn't they stop considering your age to be a negative factor? They would if pure logic prevailed, but stereotypes are hard to overcome.
 I explained to that doc that a 2x4 is a common board of varying lengths with nominal cross-section dimensions of 2 inches by 4 inches, but actual dimensions of 1½ inches by 3½ inches, that is usually cut from softwood trees and used in framing homes. That is a succinct but yet comprehensive description of what a 2x4 is, but even when I explained it to that doc, he still did not have the slightest idea of what it was. Perhaps I should develop a MCAST test (Medical College Airhead Screening Test).
Who do ER docs work for? (subtitled, yet another drawback of ER work)
Q: Who do ER docs work for? Who pays them—the hospital? Thanks, Carl
A: It is rare for ER docs to work directly for a hospital. In fact, of all the groups I either worked in or heard about, only one group of docs were employed by the hospital. The most common arrangement is for a doc to work as an employee or independent contractor for a group of ER physicians that has a contract with the hospital to provide ER physician coverage. Groups are generally a benefit only to those who own them, since they can rake in piles of money if the group is profitable. Some groups share some of this profit with the people who earned the money—the ER docs—but other group owners keep every extra penny for themselves. Now for the bad news. All the usual corporate flaws (bureaucracy, pettiness, cliques, lordliness, arrogance, the Peter Principle, etc.) infect ER corporations, and dealing with such things can be annoying. I will give an example.
I used to work for Sterling (not a very apropos name, incidentally), working full-time in one hospital and—after they cajoled me into “helping them out”—part time at another hospital 2½ hours away. They'd sometimes call me at the last minute to fill in at that latter hospital. Here is how one conversation went:
Sterling: Hi, Dr. Pezzi. We need you to work the weekend at Mayo General.
Pezzi: I'm sorry, I can't do it.
Sterling: But we need you!
Pezzi: I can't. I've worked 11 days in a row, I have laundry and shopping to do, bills to pay, and I have a date this weekend.
Sterling: But we don't have anyone else to work it!
Pezzi: (Thinking to myself, “I'm not the ER chief. Isn't this his responsibility: to work shifts he could not fill?”) I wish I could help you out, but I can't.
Sterling: Why not?
Pezzi: I just told you. I'm desperately in need of a couple days off.
Sterling: But you have to work those days! No one else will do it!
Believe it or not, this was just the first minute of a three-hour conversation in which the Sterling rep simply would not take “no” for an answer. Here is the last exchange in the conversation:
Sterling: OK, Dr. Pezzi. What is it worth for you to work the weekend?
Sterling: OK, we'll pay you $5000. Thank you for helping us out. I don't know what we would have done if you didn't cover those two shifts.
End of story? Not quite. I worked the shifts, received my $5000, and from that day on Sterling held an obvious grudge toward me. When this became so glaringly obvious that I was forced to comment on it, I asked about the enmity and was told they were mad at me because they thought I should have been a “good guy” and worked the shifts for my usual wage. Well, I certainly wasn't the one who initiated the practice of wage negotiation at that company—they were the ones who dangled tempting carrots (more money) in front of my face whenever they were desperate for help. I'd helped them out on several other occasions, but this was one weekend I really didn't want to work. However, after I was worn down by that three-hour conversation, I reluctantly agreed. I did not want those shifts and I am sure they weren't thrilled about paying $5000, but it was a quid pro quo. Business is business, right? They are in business to maximize their profits, and I'm in business to maximize mine. In my opinion, it was very petty of them to agree to pay me $5000 and then whine about it afterwards. That is not a very good tactic for building good working relationships. Had they said, “Sorry, we can't pay you that much,” they would have had to pry some corporate bigwig off his yacht that weekend, and I would have obtained some much-needed R&R, did my laundry and shopping, paid my bills, and gone on my date.
 I can't recall the exact number, but it was something like 11 shifts . . . 12 hour shifts, by the way, with, I think, another 7 shifts scheduled immediately after the weekend.
Is it harder to get into an ER residency program?
Q: Dr. Pezzi: As a result of the TV show ER, I heard rumors that emergency medicine residencies are becoming tougher and tougher to get. Do you know if these rumors are true? Thanks, Steven
A: Gaining acceptance to an ER residency program has always been difficult. Why? There are far more applicants than there are positions available—the old law of supply and demand. Consequently, ER programs are very selective in choosing whom they accept. I must tell you, though, that I am not the first ER doc to wonder, “Why did I work so hard—for this?” The television show ER (and others of that genre) have glorified the job of being an ER doc so much that it seems more desirable than a date with Ashley Judd, Cyndi Thomson, Brittany Daniel, or some other impossibly beautiful woman. However, the reality of being an ER doctor is something entirely different. I've tried to paint a realistic picture of what the job is really like, warts and all. Yes, there are some priceless times (be patient; I will eventually discuss more pros to balance the cons), but there are also many negative aspects of that profession. As a consequence of the latter, many ER docs eventually say “to heck with this” and do something else for a living. In my opinion, there is no substitute for experience. Therefore, for its own self-interest, I think that society should do what it can to mitigate some of the noxious aspects of being an ER doc because making the job more pleasant would increase the retention rate. If you're on your deathbed in the ER, would you prefer to have a rookie caring for you, or an experienced doc who had successfully treated many cases similar to yours? That is an obviously rhetorical question, because you would no doubt opt for the veteran.
Let me generalize this topic a bit. Last year, medical school applications fell by 4%, making that the fourth year in a row (!) that applications dropped in spite of the fact that our population continues to increase. Years ago in one of my books, I predicted that this would happen, and I predicted that the average medical student IQ would fall because the brightest people, possessing the brains to do just about anything, are beginning to shun a profession that treats them so poorly. If you can get a better-paying job that is easier, requires less training and sacrifice, and is more conducive to a pleasant family life, then why not do that instead of working like a slave to become a physician and then spending the rest of your life being whacked around like a piñata?
It takes a while for public perception to catch up with reality, but this is happening, slowly but surely. I am certain medical school applications would have fallen even more had the media not glorified the medical profession so much.
If you want to be a physician, I think you should give a great deal of thought as to exactly why you want that job. Are you doing it for financial reasons? Because of the status? Because you want to be treated well? Because you want to be your own boss? If so, you're doing it for the wrong reasons. I have many people write to me (mostly teenage women) bubbling about how they want to be a doctor, and it is clear to me that their dreams are fueled more by idealism and romanticizing than by reality. I am not saying that everyone should avoid medical school, but for heaven's sake, I think people should enter that profession with both eyes open, fully cognizant of all the pros and cons of modern medicine.
Why should one consider a medical career? I think there are only a few valid reasons, and one primary reason that stands head and shoulders above all the others. I will discuss that, but first I'll segue into it by presenting a letter from a patient directed to the administration of the hospital at which I worked:
“My experience with emergency rooms has been, at times, somewhat disappointing when waiting a period of time to see an overworked ER physician who is lacking in either time or interest or both. I cannot express how relieved (and surprised) I was by my visit. I was most especially impressed with the attending physician, Dr. Kevin Pezzi. I have never before experienced such an unhurried manner in an ER physician, and the accompanying feeling for me, as a patient, that he was genuinely interested and concerned in my problem. Furthermore, he was able to immediately diagnose and successfully treat a condition for which my own physician had not done the same. I have on very few occasions felt the trust and confidence in any physician after so little time that Dr. Pezzi immediately instilled. Though my experience with Dr. Pezzi was limited and very brief, I would recommend him most favorably at any opportunity. My only regret is that he is, as an ER physician, not available in private practice, because he would most certainly be my regular physician if he were. I hope that you appreciate Dr. Pezzi . . .” (Signed, A.L.)
Do you have an intense desire to help others? Do you derive a lot of satisfaction and pleasure from helping them? If so, then you have a valid reason for going into medicine. When I read comments like this, it is immensely rewarding to me, and it means far more than money, status, power, and all the other reasons that Hollywood and the media like to portray.
Why do I stress the cons of ER?
Q: Dr. Pezzi: First of all I thoroughly enjoyed discovering/reading your site and reviews of the ER books and your experiences.
I am currently a 4th year medical student who is deciding on residency and future plans. I was always interested in urology, but after a rotation in emergency medicine (in Grand Rapids, Michigan), I have a growing interest in becoming an emergency physician. So lately I've been reading up on the pros/cons. Your site is one of the few discussing the cons and in such a negative tone I've become concerned. Was my experience in that ER not representative of a typical experience? And what do you know about the profession of urology? Would you recommend it over ER? Just curious. Thanks, Jamie
A: It sounds as if you had a positive experience in Grand Rapids. I am not surprised. I had a generally positive experience during my medical student ER rotation, and that was in Detroit! Many of the negative aspects of ER come into focus only when “you're the man” (i.e., you are the ER attending). Second, Grand Rapids has a high proportion of very decent, normal, quality people—in other words, people who are a pleasure to serve. If you are lucky enough to work in such an ER as an attending, you will definitely have a better experience than someone practicing in an area inundated by the dregs of society (“scumbags” in ER lingo). Nevertheless, some of the negative aspects of ER cannot be avoided merely by working in a better area—you still must work crazy hours that change from week to week and sometimes from day to day, you still must work nights, weekends, and holidays, you still must often rush and therefore compromise patient care, you still must worry about frivolous lawsuits, and you still have many of the other drawbacks, such as little or no control over your working environment and staff.
Why does my site stress the cons of emergency medicine more than the pros? Because there are more cons than pros. Why don't other sites present such a viewpoint? Well, the proportion of ER docs with web sites in this genre is tiny: a small fraction of 1%. Think about this: if an ER doc is burned out and really disgusted with ER (as many are), what do you think he will do in his spare time? Spend thousands of hours (as I have) developing an extensive web site and writing books on the subject? Probably not. Most likely, he will watch television, go boating, play with his kids, go out with his wife, play computer games, listen to music—anything but focus on ER! I've known a few ER docs who for the most part loved their jobs, and it is almost always guys like that who put up ER web sites—hence the generally positive spin on ER. Unfortunately for students using web site information to help in a career choice, this results in the cons being underreported.
What do I know about the profession of urology? I know it is a much more tolerable career than ER. I've never heard of a urologist burning out and quitting his job, but burnout in ER is the norm, not the exception.
Good luck in your career—hopefully urology!
Links to other pages in the More Q&A section:
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