For more Q & A, see my
Test your knowledge of ER terms by solving my ER crossword puzzle that was featured in the Prudential Securities Healthcare Group 2002 calendar. Or take the ER-MCAT to see if you have what it takes to be an ER physician.
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?
Improving MCAT scores
Q: I am a 14-year-old sophomore in high school, and I’ve always wanted to be a trauma surgeon or ER doctor. I am a very intense person with little problem making quick and wise decisions, and I thrive on being active 24/7. I know I have the ability to do it. What classes should I take to prepare for the MCAT?
A: As every sweaty-palmed premedical student knows, the MCAT is the exam that can make or break your career. The only thing I did to prepare for it was to reread a physics book, but since I'm always reading them I can't say what I did was out of the ordinary for me. In any case, it was largely a waste of time. The MCAT doesn't test for an in-depth knowledge of physics, or anything else for that matter. Yes, a good undergraduate education is an essential part of successful preparation for the MCAT, but the MCAT is more a test of sheer brainpower than it is a test of knowledge. The next question is, “What can I do to increase my brainpower?” Fortunately, there is a lot that you can do, and I devoted a chapter to this in my book Fascinating Health Secrets. One of the many helpful adjuncts I discussed is choline, a relatively obscure nutrient that has only recently been popularized by the press as a brainpower booster. However, I wrote about it years ago, so it is not some new flash in the pan supplement or nostrum. Bottom line? That stuff works. So does ginkgo biloba, an herb that you might think, based on the way it's been presented in the press, is intended only for the silver-haired folks. Nonsense. Even young people can get a mental boost out of that stuff—and no, it doesn't take weeks to take effect (another common myth). The only caveats I have about taking such brainpower boosters is:
· If you intend to take more than one (which will be necessary if you want a maximal effect), you should consult a knowledgeable MD beforehand. They might interact with a drug or vitamin you're already taking, or they may interact with one another.
· It is advisable to take them beforehand (say, at a midterm or final exam) so you can judge your response to them. You may need a larger or smaller dose, and the time for such experimentation is not the MCAT. By the way, I think it is a waste of time to take them on a dry run at a time when you are not taking some stressful exam because your hormonal and cerebral milieu changes at those times. You should try to optimize the effect of the brainpower boosters when they are layered upon your test-taking state, not your chilled-out state on Saturday night when you're snuggled up with your honey while guzzling a few beers.
Perhaps I shouldn't reveal such information because its use could enable a person of lesser inherent aptitude to outclass a smarter person on the MCAT. However, some of the brainpower boosters can be taken indefinitely, so I think it is a moot point about whether intellectual augmentation is temporary or permanent.
Q: What volunteer jobs will improve my chances of getting into a good med school? Thanks a ton! Amy
A: Medical school admissions committee members like to see applicants with some exposure to medical environments. However, you can still be accepted if you lack such experience; I know that I was. In reality, having prior experience is a good idea but it will make a difference only if you are a borderline student. If you are not doctor material, you can volunteer for decades and you will never be accepted. On the other hand, if you are a topnotch student with no medical experience you will be accepted anyway.
Even if you volunteer, that will not make you stand out because volunteering is so common. However, if you do something unique, you are bound to attract the attention of the admissions committee. What I have in mind—and I don't know if this meshes with any of your interests—is to build some unique medical device. Now that would make them think very highly of you! As you can tell from my web site, I've built several medical devices and I have ideas for building many more. I cannot do all the work for you (that would be cheating, right?), but I am willing to help give you some ideas, get you started, and help you build the device. By the way, not all of the devices I built were very complex. It is possible to build something unique that provides a useful medical function but is not costly or complex; the main thing it takes is imagination. Also, if you have a Science Fair at your high school, your project would be a good addition to that. If your project is good enough, you might receive a grant or scholarship from some organization.
Q: Wow, that's a great thought. To give me an idea of what I might build, would you mind sending me some of your ideas? Thanks, Amy
PS: You are the only author I know of who has used my favorite word in the English language: “pulchritudinous.”
A: I will do that, but to help narrow down the list please let me know if there is any particular area in medicine in which you are especially interested. Most of my medical ideas pertain to the cardiovascular and pulmonary systems, but I also have some that relate to neurology and other areas, too.
Q: Honestly, I am interested in all body systems (that is one reason why I am attracted to ER: variety). However, I especially like things relating to neurology. If you have any ideas pertaining to that area, it would be great. Amy
A: Here are a couple ideas I had that pertain to neurology:
· A device that quantitates tremor frequency. In neurology, I was taught that different neurological diseases present with tremors of different frequency. However, I will be darned if I (or 99% of the other docs in the world!) can look at a tremor and say that it's “18 Hertz” (or whatever). By the way, Hertz is the scientific term for cycles per second, and it is used in medicine, physics, electronics, and other scientific disciplines. The “KHz” on the AM radio dial is just an abbreviation for kilohertz, meaning thousand of cycles per second. But I digress . . . OK, back to neurology. I think it would be much more scientific and precise to quantitate tremor frequency rather than just guessing if it is a fast or slow tremor. Also, a change in tremor frequency might have therapeutic implications. I don't know, since I don't know enough neurology, but my guess is that even neurologists ignore this (since they can't measure it). If they could measure it, they may be able to determine more rapidly the best drug and dose for a given patient. Or perhaps there is a link between tremor frequency and prognosis, or other things.
· A device that precisely measures skin sensitivity. Currently, we use rather crude techniques such as rubbing a cotton-tipped applicator (a Q-tip) on a patient's skin to test for the ability to perceive light touch . . . but how hard is the doc pressing? And how many fibers from the Q-tip are contacting the skin? One? Twenty? My point is that the current method is very imprecise. Making it objective and precise would make it easier to determine changes in sensation over time in a given patient, as well as being able to more scientifically state that a given patient's sensation is normal or abnormal—and if abnormal, by how much. When we test other sensations (e.g., sharp or dull, hot or cold), we are similarly imprecise.
Do any of these two ideas interest you?
(A few days later.) I surmise that you weren't enthusiastic about the tremor frequency meter project. How about this? Research biofilms. We're just on the cusp of knowing anything about this subject, so if you dig deep into it ASAP and do some research of your own, you could quite likely come up with some new and useful information. In short, medical schools would be tripping over themselves as they rolled out the red carpet for you. You might even win a Nobel Prize . . . imagine that!
Q: Well, I am enthusiastic about the tremor frequency meter (henceforth known as TFM)—I just have not had the time to get into it yet, with the holidays, etc. Researching biofilms sounds like a good idea right now. I'm also planning on talking with some neurologists in my area after Christmas.
How do you think being homeschooled would affect one's chances of getting into medical school?
A: I don't think it'd matter to the admissions committee. Typically, they do not consider your high school record. Thank heavens they never considered mine! I got all A's the last two years, but my grades the first two years were abysmal.
Q: I was looking at some colleges and med schools the other day, and I had a couple of questions. First, do med schools look differently on people who have a degree in premed as opposed to physics or chemistry? Personally, I think that a medical school might think that someone with a degree in premed is just another TV doctor wannabe.
A: I do not know of any college offering a premed degree. That will be your focus of study, but unless things have changed in that regard since I applied, there is no “premed degree.”
Q: Here is my next question. My mom brought up the idea that a medical school might ask me if I watch med TV shows often—which I do, but I wanted to be a doctor before that. Should I answer no, since they might otherwise think that I will just drop out after I realize that it is not like TV? OK, that seems a little farfetched, but I am curious about your opinion.
A: Don't tell them you frequently watch many such shows, but don't tell them you never watch them, either. Just about everyone with a pulse has seen at least one medical show, so if you deny ever watching them they probably won't believe you and you'll come off seeming too highfaluting. In your response, casually mention that your favorite is the one on TLC. Something like, “I like Trauma: Life in the ER because it gives a realistic depiction of medical practice, as opposed to some of the over-dramatized fictional shows.” That last subtle slam against the fictional shows will make the interviewer (most likely a person who fancies himself as a sophisticated person) think that you're sophisticated, too. Yes, you like fiction, I like fiction (some of my favorite television shows are ALF, Unhappily Ever After, and Ed—so that should tell you that I like fiction), and even that sophisticated interviewer likes fiction, too. OK, he or she probably does not share my enthusiasm for the overly imaginative anthropomorphism displayed by ALF and Mr. Floppy on those first two shows, but that interviewer probably laps up the steamy romances that make all our hearts beat a bit stronger. But would he or she ever admit it while sitting in the hallowed halls of a medical school? Nope, it'd be too unseemly. You see, we doctors are people, too, but to make us credible we have to act like doctors—which basically means we have to turn up our nose at some of the base things that interest the proletariat. Golf, yes. Bowling, no. Documentaries, yes. Oversexed doctors and nurses on TV, no. Get the picture?
Q: Regarding your statement about “. . . there is no ‘premed degree.’” That seems odd, since many people refer to themselves as “premed students.”
A: Well, I was a premed student, too. Had I obtained a college degree (that's another story: I never did, because the medical school I attended accepted one person per year with just three years of college if that person had a very high GPA and MCAT scores), my degree would have been in zoology. My brother Ray was a pre-law student, but his degree is in economics. Get the picture? Pre-law or pre-medicine is essentially a way of stating your ultimate career path, but obtaining your undergraduate degree is the actual implementation of that path.
Zoology is the most popular degree for premed students, but some obtain degrees in chemistry, biochemistry, engineering, and so forth.
May I make a personal comment, Amy? If I ever have a daughter, I would be thrilled if she were like you. So many parents worry about their kids using drugs, breaking laws, or getting pregnant—and here you are, with your nose to the grindstone, totally focused on the nitty-gritty of your career! You are quite a role model . . . actually, you should be a role model for most college students! J
Q: Oh, thanks! By the way, you mentioned golf. Are women doctors expected to play golf, too? I hope not. It is not exactly my favorite game.
A: My brother Ray used to kid me that I would never get into the AMA unless I could play golf—not one of my talents, by the way. I do fairly well when I throw the ball around the golf course, but when I use the clubs, that is another story! Let's just say that I lose so many balls I keep the ball manufacturers busy! Seriously, though, most docs I know—male or female—aren't golfers.
Q: What do you think about six-year medical schools (i.e., the schools where you go directly into med school out of high school)? I personally would not go to one of those schools because in most schools like that you start seeing patients immediately. I don't think I would be ready nor do I think they would really take my opinion seriously.
A: As a medical student, you're there to learn, not be an integral part of the diagnostic and therapeutic team. No one counts on your opinion; the patient will always be examined and treated by a licensed physician. Therefore, you needn't worry about your lack of experience. It will come in time.
Q: Is there a good answer to the question, “Why do you want to be a doctor?” I don't know if “I've always wanted to help people” is OK—it sounds kinda corny.
A: It doesn't sound corny if that is what you truly feel. So it is a perfectly adequate answer to give to most people, but you should be prepared to give a more comprehensive answer when you're questioned about that during your medical school admissions interview. If you say, “I've always wanted to help people,” you will likely be challenged with a question such as, “Why don't you become a nurse or a social worker? They can help people, too.”
Q: Are trauma surgeons just regular surgeons who occasionally work ER shifts? If they are not and they work in the ER full-time, then for my residency, do I apply in surgery or emergency medicine? Or can I apply as a surgical student in the ER?
A: ER docs sometimes do trauma surgery (such as when the patient needs major surgery now, not five or ten minutes from now!), but we're not trauma surgeons per se. A trauma surgeon is a surgeon who (hopefully!) has additional training and experience caring for trauma patients. In most community hospitals that do not see many trauma patients, the staff general surgeons are the ones who handle most trauma surgery. Sometimes the ER doc, in conjunction with the general surgeon, will determine that a patient's injuries are severe enough to warrant transferring him to a more specialized hospital that has surgeons with more trauma training. So, if you wish to be a trauma surgeon, you should apply to a surgical residency, not an ER residency.
I would like to take a moment to praise the dedication and skill of some of the trauma surgeons I worked with in Detroit. We would often get very recently shot or stabbed patients in the ER with no pulse or blood pressure. We'd quickly (in a minute or two) start multiple IV's, intubate the patient, draw multiple labs, get an x-ray or two, and run (literally!) that patient to the operating room. The surgeons would work with blinding speed to patch up the usual zillion and one wounds, and in every case I saw, the patients lived.
General surgeons in community hospitals often act as if they are allergic to trauma patients, so trauma patients in those areas are much more likely to die—patients who are critically injured need treatment now, not to be treated as a hot potato or CYA risk by the surgeons. In my next ER book, I explore this topic in more detail.
Q: By the way, my grandfather read somewhere about a bunch of OB-GYNs quitting because the malpractice insurance was so high, they weren't making any money. This seemed exaggerated to me, but I would like to hear your opinion.
A: I've even heard of neurosurgeons quitting because their malpractice insurance premiums were so expensive. Who wants to work several months every year just to pay for that? Recently, the premiums for some doctors skyrocketed so much that they now exceed the doctor’s yearly income. In that case, why work?
On a related note (it may not seem related at first, but just wait), two days ago I received the latest stats on the incoming class at Wayne State University's School of Medicine—the school I attended. Their average age is 24, and 47% of the students are women—I suppose it would be redundant to say what sex the remaining class is comprised of, eh? The most popular undergraduate degrees were biology (including zoology), chemistry, psychology, and biochemistry. The average GPA—ahem, are you ready for this?—was 3.51. Only 3.51 . . . yikes! That is quite a bit lower than it was years ago, and this trend is alarming because it signifies that more of the best and brightest students are finally realizing that medicine is not the grand and glorious career it once was, thanks to politicians, bureaucrats, HMO’s and other insurance companies, hospital administrators who know business but not medicine, nurses and PA’s who are encroaching on our territory, increasingly demanding patients with unrealistic expectations that every disease can be cured and every death prevented, and last but not least the legions of rabid attorneys whose lack of scruples leads them to sue doctors even when those docs performed flawlessly. (Until you've been the target of such extortion, you probably have no idea how infuriating it is. Here is an example of this.)
Collectively, these drawbacks are coming into focus in the eyes of people considering medical careers. I predicted years ago that this would result in a decrement in the average IQ and GPA of medical students in the future because the brightest people, who can do anything, are increasingly reluctant to enter such a noxious career. This may be good news for so-so students who never would have been accepted to med school back in the days when there was fierce competition for admission, but this dumbing-down of medical students is a nightmare for society because it means that tomorrow's doctors will be less intelligent. A grade point average of 3.51 may not seem very low, but remember that it is an average. There still are some super-bright medical students with sky-high undergraduate GPAs, but there are now some decidedly not-so-bright med students with 3.0 GPAs . . . or even lower. Considering the rampant college grade inflation in recent years, this heralds a shocking reduction in medical student brainpower. The fact that medical schools must now accept such people to fill their classes is frightening. Assuming they applied themselves in college (and therefore assuming their GPA is indicative of their academic potential), people with such low GPAs just aren't smart enough to be good doctors. Years ago, before medical schools became desperate for warm bodies, they would not have become medical students. An aside: it is now easier than ever to pass medical school because medical schools (whether they use grades or the pass/fail system) assess medical students by comparing their performance to that of others at the same school. Since medical school classes now include people who would not have been accepted years ago, the competitive pressure is now reduced because the benchmark is necessarily lowered. Medical schools cannot afford to flunk a third of their students.
Being a doctor used to mean that a person was not just smart, but very smart. Consider a person with a GPA of 3.51, who gets about as many 3.0’s in his college courses as he does 4.0’s. Is that person very smart? No, assuming that this GPA reflects his true potential. Two factors conspire to make that 3.51 GPA decidedly unimpressive. One is grade inflation (now at an all-time high), and the other is that more people than ever attend college. The influx of students is not from the ranks of the brightest students (who traditionally were most likely to attend college), it is from the ranks of the less gifted students with average or subnormal intelligence. Consequently, this lowers the competitive pressure in college because there are now more academic pushovers.
Or what about that 3.0 GPA student? Saying that person is very smart is as much of a stretch as it would be for me to claim that I am Tom Cruise or Robert Redford. Doctors need brainpower as much as professional football players need muscles. Here is what I wrote about this topic in 1994:
“You get what you pay for” is an axiom that applies as much to medical care as it does to other things. Nowadays, people who go into medicine are extremely bright. When I was in medical school, the average medical student IQ was 130. On that scale, an IQ of 132 is considered to be a genius-level IQ. Thus, a significant proportion of them were bona fide geniuses. You can't force these people to go into medicine. If you make the field less rewarding, many will choose another occupation. Consequently, the aptitude of the average doctor will fall. A person with an IQ of 100 has about as much chance of being a good doctor as a 98-pound weakling has of becoming a star in the National Football League. If you want a doctor with an IQ of 100 treating your children or yourself, that's your business—but I wouldn't want such a doctor, and I doubt that you would, either.
Here is your chance to rub a crystal ball, and peer into the future. This is a somewhat tongue-in-cheek, but nevertheless sober, depiction of what may result from this gradual erosion of medical student aptitude.
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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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Is it helpful to know a second language?
Q: Hello. My name is Rachel, and I am a high school student who is very interested in becoming a doctor. My best friend Amy has been e-mailing you, and she thought I should e-mail you too with some questions. First, I would like to say that I think it's a wonderful service to the public you are doing by having your wonderful website out there. It is very interesting, especially to me because emergency medicine is the field I am most interested in. I have a few questions, if you don't mind. Thank you so very much for your time, Dr. Pezzi. I appreciate it very much, and I know others do, too. Rachel
Q: Is it helpful to know foreign languages? Which ones?
A: That can be very helpful if you practice in an area in which there is a significant percentage of non-English speaking residents. Actually, speaking a foreign language is helpful in any area, but if you're in an ER in which there isn't a predominant need for a certain language, then there is no way to know in advance what languages you might have a need for. In addition to the obvious (Spanish), I've seen patients who spoke Chinese and several other uncommon (in this country) languages. Fortunately, emergency departments provide their staff with interpreters who are called in as needed. That is good, but there is nothing like being able to speak one-on-one with a patient.
Q: What hospitals have good emergency medicine residency programs?
A: Most of the ER programs are very good. The best advice I can give you pertaining to this is to select a residency that is as similar as possible to the community in which you eventually intend to practice. The big dichotomy here is: are most of its patients derived from the inner city, or the suburbs? I trained in an inner-city program, and that was a big mistake because all the ER’s I worked in after residency were either in the suburbs or in rural, tourist areas. The patients seen in those areas are very different. Obviously, in the inner city we saw lots of trauma—some of which was almost unimaginable. In the suburbs or rural/tourist ER’s there was less trauma and more medical cases . . . and more really goofy cases (the overwhelming majority of the bizarre cases in my first book came from suburban ER’s). When people in the inner city go to the ER, they usually have a good reason for doing that except for a few who feign an illness in order to obtain narcotics. Surprisingly, more suburban patients try to dupe the doc to get narcotics.
Q: I know you get asked this a lot, but what do you think of medical dramas such as ER and M*A*S*H?
A: M*A*S*H was a great show (I watched it when I was your age!), but the writers of that show obviously put far more effort into comedy and general entertainment than they did into medical reality. ER is much closer to the truth of what really goes on, but some of the things they put on that show have no connection with reality. The writers of ER might defend such forays from the truth as being excusable since they are primarily striving for entertainment. However, I contend that truth is stranger than fiction—in fact, I put that on the cover of my first ER book! Some things I've seen in the ER are so strange that no one could dream them up. Before I became an ER doc, I thought I would just be treating victims of trauma, people with heart attacks, kids with rashes, and whatnot. I saw all that and a lot more, thanks to some truly unusual people.
Q: Have you seen Trauma: Life in the ER on TLC? If so, what do you think of it?
A: I've seen it a few times. My impression is that it is fairly realistic, but obviously whitewashed.
Q: How old do you usually have to be to work as a candy striper in the ER?
A: I think most hospitals stipulate a minimum age of 16. By the way, I have a story in my book about a beautiful candy striper who ended up on top of me, unconscious. That just goes to show you never know what might happen in an ER!
Q: Thanks for answering my questions! I have a few more if you don't mind.
What kind of grades do you usually need to get into med school? Right now, I have a 4.29 GPA, and I'm not sure of my class rank.
A: High school grades and class rank are meaningless. What counts is your college GPA. I've heard of some people getting in with relatively low GPAs such as 3.0 (that's on a 4.0 scale, by the way) and in some cases even lower, but in general you should have at least a 3.5. A reasonably strong candidate would have a 3.7 to 3.8 GPA, and an exceptional candidate a GPA of 3.9 to 4.0. What this boils down to is that you need to get an A in almost every class if you want to be an exceptional candidate. That is quite a challenge given the diversity of classes you will take. In my opinion, the easiest classes were math, physics, chemistry, organic chemistry, English, and psychology. What baffled me—and still does!—is humanities. I had a year of that as a required course, and I still have a very foggy notion of what it is and where it fits into the overall scheme of things. Supposedly, humanities is the study of history, literature, the fine arts, and philosophy. In my opinion, that is a strange amalgam of subjects. I can understand history just fine, but some of the more nebulous aspects of humanities left me utterly bewildered as to what we were studying, why it was important (believe me, it isn't!), and what sort of “take-home” message I should have learned from studying that gobbledygook. So, to return to my original point, you'll take a number of subjects in college. It is easy to ace some of them, but excelling in almost every class is tough. The good news is this: if you think college is tough, just wait until you get into medical school! As I've said before, medical school is so much more difficult that it makes college seem like Romper Room!
If you think you can coast after medical school, you're wrong. The 110- to 120-hour weeks you will spend working as a resident make medical school seem pleasant. I spent so much time working that I had virtually no time for my friends, girlfriend, family, or hobbies. To make a long story short, try working a 110-hour week in which you're not just flipping burgers, you're working under intense pressure. You'll find yourself working as fast as you can, but at times you will inevitably fall further and further behind as more patients stream into the hospital. Do they care that you haven't slept in 36 hours and you can barely keep your eyes open? Nope. Somehow, you will need to find some untapped reserve of energy (or use amphetamines, as some of my colleagues did) and keep on going. Doing that for a week is sheer hell on Earth; now try imagining what that would be like doing it year after year. As someone who did that, I can tell you it's absolute torture. What should be the best and happiest years of your life will be spent working like a slave. Can you tell that I am more than just a bit bitter about this? It would be easier to accept if that were the best way to train doctors, but it isn't. Who can learn when they're utterly exhausted? I can't. I can recall driving home from the hospital and being so tired that I could not recall if the traffic light in the intersection I just passed was red or green. If I was so oblivious to something that basic, how could I absorb much new medical information? I was able to graduate in the top 1% of my class in medical school even though I was chronically tired, but the sleep deprivation I endured in residency was unimaginable! Had I worked 40 hours per week in the hospital and then studied at home for another 30 or 40 hours per week, I would have learned a lot more. But residency has very little to do with learning. The real reason you're worked like a slave is simple: you make money for your masters—the hospital and residency program for which you work. In theory, the tacit quid pro quo is this: you'll see untold numbers of patients and make oodles of money for your superiors, and they're supposed to return the favor by teaching you and, after you've completed your period of servitude (residency), turning you loose so you can become a vulture like them or, if you're still sane, running as far away from them as possible.
The legislature in New York was bright enough to realize that these 110-hour weeks are a great way to kill patients, not educate physicians. Consequently, they enacted laws limiting how much residents can work per week. I am sure that other states will enact similar laws in the future as we finally become enlightened enough to put this Stone Age of medical education behind us. However, all the residents in the United States can't be trained in New York. Are you willing to cross your fingers and hope that the state you'll train in will set weekly work limits by the time you're a resident? It's something you should think about. By the way, I am not averse to work. I have so much natural energy that people sometimes ask me what I take (the answer is: nothing now, but I previously used caffeine), and as you can tell by looking at some of the inventions on my web site (some of which took years to research and develop), I am exceptionally productive. I'm not mentioning this to brag; I'm mentioning it to point out if the medical education system is so taxing that it can wear me out, then it can wear out just about anyone. I've done an enormous amount of work in my life and being a workaholic used to come naturally to me, but after so many years of so much work I finally realized that there is far more to life than just working.
Before you decide on a medical career, do yourself a favor and spend a long time thinking about why you want to be a doctor. Do you think the rewards will justify the sacrifices you will need to make? I don't. When you're a doc, you'll see people make far more money than you even though they have far less intelligence, education, responsibility, and spend less time working than you. I can't begin to recall how many times patients bitterly complained to me, “You damn doctors make too much money!” That is, by the way, an exact quote I've heard over and over again. I would respond, “If you had any idea of how hard I worked to become a doctor, you wouldn't complain.” Yes, some people are appreciative of the fact that it takes an enormous sacrifice to become a doctor, but most people do not have an accurate impression of just how much work it takes. The sacrifice isn't just one of time and effort; by the end of medical school many docs owe well over $100,000. When you finish residency, paying off those years of accumulated interest and principle isn't easy because you'll be doing that at a time when you'll likely want to buy a home and car, get married, have kids, furnish your home, etc. Bottom line: count up the years of college, medical school, residency, and early work years until you pay off those loans and finally see some financial reward for your years of hard work. The total? Probably 14 to 17 years after high school . . . that is when you can begin to lead some semblance of a normal life. But remember, medicine is an all-consuming profession, and it'll take far more time than you might imagine. 40-hour weeks? Forget it! Even if you're one of the few docs who works just 40 hours per week (most work 60 to 80, or more), your supposed “free time” is often anything but free. You'll need to attend medical staff meetings, study, attend medical conferences, testify in court, attend various hospital committee meetings, fill out insurance forms, argue with insurance clerks who know nothing about medicine, keep up with your medical records, and so on. Total up all those unpaid hours of what you thought were your free time, and your 40-hour week becomes a 60-hour week, and an 80-hour week becomes a 100-hour week. If you are smart, you will ask yourself, “Hey, wasn't it supposed to get a lot easier after residency?” Yes, it gets easier, but in some ways it also becomes harder. You will face new challenges, such as the fear of frivolous lawsuits (a.k.a., legalized extortion). Do you think you can be insulated from the risk of being sued even if you always do everything perfect? Anyone who believes that is living in a fantasy land.
Frankly, I am baffled that anyone who thinks this through would still want to become a doctor. If you are motivated by money, there are far easier ways of making it. If you put the same time and energy that you'll spend becoming a doc and paying off your loans into running your own business or just plain working and investing your money, you could be set for life by the time you can begin to splurge 14 to 17 years in the future as a doctor. More than one person gave me that sage advice before I began college, but in my youthful zeal and idealism, I thought they were just a bunch of misguided old farts. The older I get, the more I realize that old people are worth listening to. Parenthetical comment: wouldn't this be a great idea for a book: What 1001 Old Folks Now Know That They Wish They'd Known In Their Youth. Then, instead of forcing young people to waste their time studying humanities or some other such nonsense, have them study those lessons.
OK, back on track. Going into medicine to make money is a silly idea simply because there are much easier ways of making it. So why else should you go into medicine? Well, if you want to play doctor there are easier ways of doing that, too, kindly provided by legislatures who are forever looking for ways of reducing healthcare costs. So how can you practice medicine without enduring the torture that it takes to become a doctor? Become a Nurse Practitioner (NP), Physician's Assistant (PA), or nurse anesthetist. And don't forget that some plain ol' nurses with just a 2-year degree can make as much as some docs if they work in an area in which there is a nursing shortage—and they're working less hours, with much less responsibility.
So why should you become a doctor? It's not for money, and it's not because you can take care of patients. As I just pointed out, you can do that without killing yourself for a couple of decades. Perhaps you want to do some aspect of medicine that is still off-limits to NP’s or PA’s. My advice? Cross your fingers again and hope that during your decades of training lawmakers do not enact new laws that allow people with far less training to do your job. In the future, I'm sure we'll see the creation of new paramedical specialties other than NP’s and PA’s in which its practitioners are allowed to practice medicine and further encroach on something that was once the province of MD’s. In some areas, psychologists can now prescribe drugs . . . so why bother becoming an MD and then specializing in psychiatry? In some states, optometrists can also prescribe drugs. I am not bothered by that, because they have appropriate training for the drugs they prescribe. However, I wonder where this trend will end. Will Avon ladies prescribe topical skin drugs such as Retin-A?
If you think I am being too flip about this, I’m not. Why? Because many drugs that were once available only by prescription are now available OTC (without a prescription). Some of these drugs are not innocuous, such as Tagamet. It has a long list of side effects, and it interacts with a number of other drugs. How can a consumer figure this stuff out? He can’t. In response, the drug companies reduced the dose of the nonprescription drugs, thinking this would limit the potential for adverse effects. As an ER doc, I know that many people disregard label directions. The drug companies know that, too. Hence, they know people will get into hot water using their OTC drugs. That isn’t the worse problem, though. The greatest danger is that people will inappropriately treat themselves when they should be seeing a doctor. I am sure that more than a few people with angina or even a heart attack (more appropriately termed a myocardial infarction) mistook their cardiac chest pain for heartburn and treated themselves with Tagamet. To some extent, pharmaceutical companies encourage this self-diagnosis and treatment with the ridiculous ads they’ve produced in recent years.
So what is my point in mentioning these facts? The power of the prescription pad is what once drove many people to see doctors. This power has been reduced by disseminating it to non-physicians and even consumers. Besides the OTC availability of once-prescription drugs, consumers can now obtain just about any drug from Internet pharmacies. Once more consumers grasp this, more will undoubtedly bypass physicians. This will reduce demand for physician services, and hence make it less rewarding to be a doctor.
Q: What sciences are most important to take in high school: biology or chemistry?
A: Take both . . . umm, that is, if you still want to be a doc after reading what I said above! J Be sure to take physics, too.
Q: What kind of ACT scores are needed to get into med school?
A: No medical school that I know of gives a hoot about your pre-college grades or scores, and that includes your ACT or SAT scores. What interests medical schools is your college grades and MCAT scores. If I were on an admissions committee, I would pay more attention to MCAT scores than college GPA because of the grade inflation at many colleges.
Q: Thanks for your insight so far. It's been wonderful. I suppose I should have clarified that some of my questions (ACT scores or GPA) applied more to premed programs. What is required to get into premed programs?
I know you are trying to scare me out of wanting to be a doctor, and I understand and appreciate your motivation. I see far too many people my age who want to be doctors for the money, or because they saw it on TV and it looked cool. But I can tell that almost none of them have what it takes. Now, I don't want to brag either, but I do have what it takes. Someone has to go through the rigorous training, someone has to ace all their classes, and someone has to be able to live on coffee and no sleep, so that someone can be the doctor. We can't all give up. I have the interest, the dedication, the brains, the personality, and the motivation. I have the gifts, and the gifts should not be wasted. So thanks for helping me out. Rachel
A: Premedicine is just one possible educational pathway in college. Since there is no rigidly defined premedical program, any college student can take premedical classes if he or she desires. So what is this premedical curriculum? Essentially, it is just the undergraduate classes required by the medical schools to which you intend to apply. There are minor differences in the requirements stipulated by different medical schools, but in general the core of a premedical program consists of a year of chemistry, organic chemistry, physics, biology, math, and English. Bottom line? Don't worry about getting into a premedical program. If you can get into college, you can decide to pursue a premedical education and no one can stop you.
I think that I am adept at judging intelligence from the way people communicate, and based on that I must say that I agree with you: yes, I think you have the brainpower to be a doctor. One of my motivations in mentioning the drawbacks of medicine is that it is a career with significant rewards and significant sacrifices, and too many people underestimate the sacrifices required. If a person chooses this career, he or she should do so fully apprised of all the positive and negative aspects of that profession. In other words, go into it with both eyes open, not blindly. In my opinion, some of the noxious aspects of a medical career can be mitigated if you can “see them coming,” so to speak. So this is one reason why I do what I do: to help the next generation make a more informed career choice, and then, if a medical career is selected, to diminish the unpleasant aspects as much as possible. Sometimes I spell out what people should do to minimize the drawbacks of medicine, and sometimes I just discuss the drawbacks, thinking that anyone smart enough to become a physician is smart enough to figure out the obvious solutions. If I told you a stove is hot, it would be an insult to tell you not to touch it.
I recently received a letter from a physician who was upset because he thought I might dissuade too many people from choosing to pursue a medical education. In my opinion, most people I scare away from choosing medicine are people who ultimately would be unhappy in medicine. Therefore, I think I am doing them—and society in general—a tremendous favor.
Another reason why I publicize the drawbacks of medicine is to eventually increase the caliber of medical school applicants so that medical schools have a better pool from which future physicians are selected. The number of people applying to medical school has declined for the past four years. Imagine that fewer people ask you for a date, or imagine that your business draws fewer customers every year despite the fact that the population of your city is ever-increasing. Might it be reasonable to ask in such circumstances if perhaps there is an explanation why you are evidently less attractive to the opposite sex or why your business is faltering? Of course.
Clearly, medical schools are now less attractive because the profession of medicine is less attractive than it once was. Income has stagnated or even fallen, the per-patient workload is increasing, the hassles of dealing with mindless insurance companies and government bureaucrats are simply exasperating, and if you're still smiling after all that you won't be the first time a lawyer sinks his teeth into you.
As long as medical schools can fill their seats, why should I or anyone else care that there are fewer applicants? Because the average medical school applicant isn't as bright as his counterparts a few decades ago. Why? As more people become cognizant of the drawbacks of medicine and the rewards of other careers, some of the best and brightest said no to medicine and yes to computer science, law, or business.
You may wonder why I am publicizing the drawbacks of medicine if I wish to increase the number and quality of future medical school applicants. Isn't that the antithesis of what I should do? No. I am not one of those people who rushes for an unsatisfactory short-term solution. I also don't think that ignoring these problems, in the manner of an ostrich, is going to make them go away. They're real, most of them are getting worse, and none of them are going to magically go away unless they are faced head-on and dealt with. The problem is that society is refusing to face the following realities:
· There are several reasons why the practice of medicine is far more noxious than it once was.
· Knowledge of the above is slowly but surely disseminating, and this knowledge is dissuading some of the brightest potential doctors from choosing to go into medicine.
· The practice of medicine is ever more challenging. We don't need less gifted applicants, we need more gifted applicants.
As I pointed out on page 100 of True Emergency Room Stories (in a humorous but pointed manner), the fact that a medical career is increasingly noxious is scaring more and more people away from medicine. I wrote that before the downward spiral in medical school applications was evident, but from what I knew about the reality of medicine, I assuredly predicted that such bad news would eventually spread and deter the best applicants.
I think the survival of our species is not something we can blithely count on. What if the HIV virus mutated so that it could be easily spread by air, as can other viruses? Or far more chilling is the specter of billions of people dying within weeks if a rapidly-fatal virus, such as Ebola, mutated so that it was more easily spread? What then? Well, the answer is simple: we'd be extinct, or virtually so.
Not too long ago, we smugly basked in the delusion that we had conquered infectious diseases. Those scary germs (such as polio, tuberculosis, and the plague) that once evoked widespread fear were licked, or so we thought. We didn't fear the common germs that cause pneumonia . . . nah, we'd just toss some penicillin into the patient and go on our merry way. We'd battled the germs, and we'd won. We had vaccines. We had antibiotics. We were omnipotent. Our species would live forever—ignoring the fact that, judging from history, most species that once existed are now extinct.
Yes, we have technology, but that technology is coming to haunt us. Our overuse of antibiotics spawned the evolution of super germs that are immune to every known antibiotic. Catch one of those bugs, and you're on your own. Your doctor can't help you; if your immune system can't beat it, you're going to die. That happened to the former girlfriend of one of my friends. Although she was young (age 30) and otherwise healthy, she died because her doc didn't have another option to extract from his magical bag of tricks.
Another aspect of how technology is haunting us is that terrorists—and probably a few random psychopaths—are doing everything possible to create ever more virulent germs to create mass casualties. So we now have more to worry about: not only are we threatened by random genetic mutations, we now have people trying to engineer ever more deadly germs and ways of spreading them. Unfortunately, we are only on the cusp of this problem. As we unravel more genomes and discover more powerful ways of manipulating those genomes to produce virtually any desired characteristics, some madman is going to create a super germ that makes HIV or Ebola seem as harmless as the common cold. First, we had desktop publishing, then desktop manufacturing using computer-driven lasers and other gizmos. Eventually, we will have desktop genetic engineering. Once that debuts, you might wonder if it is a wise investment to buy green bananas.
Inevitably, the future will be more challenging, not less. Therefore, we need smarter doctors and researchers to combat the challenges we are sure to face in the upcoming years. We're not going to increase the caliber of those professionals by ignoring the current problems that are causing more and more of them to steer away from medicine. Society must realize that it has a vested interest in doing whatever it can to reward the brightest people so they will choose the career of medicine, and just as importantly, not be burned out by it. That is what society should be doing, but instead it's turning a blind eye to this problem. Not surprisingly, many of the brightest students are avoiding medicine. Unless society begins to make medicine less noxious, this problem will only grow worse in the future.
Q: Kevin, I am very glad that there are people like you trying to dissuade the unqualified from medicine. I also agree with you about medicine becoming more unattractive, which is a shame.
What you said about antibiotics was true. That is one of my biggest pet peeves. I recently shadowed a doctor in a local family practice. No matter what the patients complained of, they always had to add, “Also, I've been feeling really stuffed up. You might wanna give me something for that, too.” Of course, what they really mean is, “I'm sick. I want antibiotics so I can feel better.” The doctor just smiled and gave them a “We'll see . . . ” then walked out of the room and just about ripped her hair out. We talked about how ignorant the public is in thinking that antibiotics are a panacea. They don't understand that they're building up a resistance!
I would really like to read your book. It sounds wonderful. I think I will ask for it for Christmas.
Have you ever read the book The Hot Zone? It's a true story about an outbreak of a strand of Ebola in a Washington, DC suburb. I found it very interesting. I learned some amazing (and disturbing) things about Ebola and viruses in general. Thanks again! Rachel
 This is on a 4.5 scale; most GPA scales peak at 4.0.
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
Why worry about lawsuits?
Q: Why are doctors so worried about being sued? You're covered by malpractice insurance, right? Vic
A: First, there is the obvious: damage to reputation, waste of time, loss of money for the deductible—hey, how would you like to write a check for $10,000 just because someone claimed you did something wrong, whether or not you did? Then there is the not-so-obvious, such as the realization that when they're sued, they're truly alone. In theory, the doc has a lawyer representing him. In reality, that lawyer does not represent the doc, he represents the insurance company covering the doctor. You might think that those interests would be identical, but they're not. For example, the insurance company does not give a hoot about the doctor's reputation. Their overriding concern is avoiding large judgments and they know that juries often sympathetically award money to a plaintiff even if the doc was not at fault, so insurance companies are eager to write sizeable checks to settle cases out of court even if the case is without any merit. The doc may protest that this payoff unfairly disparages his reputation, but given the wording of most malpractice insurance policies, the doc has no say in the matter. More often than not, even when insurance companies know the doctor is not guilty they will in effect be the ones to put that permanent black mark on his record by writing that settlement check. If you think about this, you will realize that malpractice insurance companies do not have an incentive to vigorously defend doctors. After all, if docs were not scared out of their wits about being sued, they would not willingly pay such enormous premiums to the insurance companies. In the end, it is those astronomical premiums that enable the insurance companies to build such fabulous buildings and for their bigwigs to be richer than doctors.
Sounds bad? Just wait, it gets worse. If you get down to the real nitty-gritty, the defense attorney's primary interest is himself, not the insurance company, and certainly not the doctor. If the defense attorney could get a case dismissed in a day, would he? That's highly unlikely, since most are paid by the hour and hence have an incentive for stringing things along as long as possible, not bringing them to a swift end. I was once sued in what must be one of the most frivolous cases of all time, yet even in that case it took two years for me to be dismissed from the case.
When a doctor is sued, “his” attorney will often advise him that he is free to hire an attorney to represent his interests, as opposed to those of the insurance company. I thought, “Why bother? That attorney would just be out for what's best for him, and he too would do everything possible to turn a molehill into a mountain and string the case out as long as possible.” Attorneys love litigation, and doctors don't. The average voter doesn't directly feel the sting of the epidemic of lawsuits flooding our country, so there is no public outcry to rein in these frivolous suits. However, everyone indirectly pays for all this litigation. Add up the cost of all the tort suits in the United States per year, and it comes out to $688 for every man, woman, and child in the country. That is $2752 per year for a family of four. In a decade, it is $27,520. That is a lot of money. You knew you're paying a lot for your house, car, and food, but since this cost of litigation (often called a “tort tax”) is hidden by increasing the cost of every product and service in the United States, you don't realize you're paying it because you don't write a check directly for it. Direct or indirect, you are paying for it. You're paying this money so that lawyers can become overnight millionaires, multi-millionaires, or even billionaires. Still, half of you keep voting for the political party that is in cahoots with the lawyers. That party successfully created a perception that they're out for the little guy. Poppycock. They're out to repay lawyers for being the #1 contributor to their party. Just remember who ultimately pays for lawyers to live like kings: you do. I mention this to emphasize that it isn't just doctors who pay the lawyers, it's all of us. They don't call lawyers bloodsuckers for no reason. They suck almost $30,000 from an average family every decade. Too much?
Malpractice defense attorneys: corrupt, or just incompetent?
Q: I'm an ER doc who has been sued six times—probably average for docs who worked as much as I have in a city where many of our commercials begin with, “Are you the victim of medical malpractice?” Anyway, after becoming so acquainted with the system, I concluded that plaintiffs have better lawyers than we do. What is your opinion on this? Rick
A: I came to the same conclusion. I will give an example. Before I gave a deposition in one case, my lawyer's sole advice was, “Just tell the truth.” What a rocket scientist she was! I thought, “After going to law school, that's all the sage advice you have to offer?” Duh!
A smart defense attorney would inform the doc of questions he is likely to face, and how he should best respond. I know that plaintiff's attorneys coach their clients on what to say and what not to say, and that game can be played both ways. But instead of offering any advice, my attorney just told me to tell the truth. By the way, that was the first day I met her, and hence she had no reason to think that I would not tell the truth. It's a rare doc who'd risk a charge of perjury to add to bogus malpractice charges.
In any event, her performance during the deposition was equally lackluster. She didn't say anything until I prodded her that she might want to quit fiddling with her hair and focus on some of the outrageous crap spewing from the other attorney. My attorney was so incompetent I wondered how she earned her law degree: by passing exams, or by hanky-panky with her professors. She was so gorgeous she made Cindy Crawford look like a Plain Jane.
Or perhaps she was not incompetent, just corrupt. Anyone who doesn't know of the corruption in the legal world doesn't know it very well. Malpractice settlements are often large enough so that a corrupt defense attorney could make hundreds of thousands (or even millions) of dollars per year in payoffs from plaintiff's attorneys as a quid pro quo for offering a lackluster defense that guarantees the doc won't win the case. With such a tempting carrot as that, some lawyers are bound to take the bait. And you thought that only boxing matches and horse races were fixed!
Bottom line? I think some defense attorneys are corrupt, some are incompetent, many are lackluster, and most are out for #1: themselves. If you’re a doc, none of these possibilities is very reassuring.
Comparing Russian and American medical education
Q: In your humble opinion, how do Russian and American medical education compare? Ryan
A: From corresponding with a number of doctors in Russia, I learned that their training is much shorter and less intensive than what we have here in the United States. So are Russian docs not as good as their counterparts in America? I would assume so, but the converse may be true. As I pointed out before, training in America is often too intensive—to the point that docs, their brains numbed by lack of sleep, are almost incapable of learning. I can recall being on rounds at 6 PM after I'd been awake for 38 hours, and all my energy was devoted into not falling asleep instead of listening to a nephrologist babble on and on about the nuances of arcane renal diseases. I'll be darned if I learned one thing after being so deprived of sleep, yet I could soak up info like a sponge when fully rested. I know that I would have learned much more if training was less demanding, and I know I'm not the only person in the world who functions much better when he's rested. Unfortunately, medical students and residents are pressured into never admitting that they are too tired to learn. My future patients and I would have been much better off had I been able to go home and sleep when I was that tired, but I would rather have admitted that I assassinated President Lincoln and stole candy from children than admit I was too tired. When I became an attending physician in a teaching hospital, I did things differently. If someone was clearly exhausted, I'd tell him to go home and sleep. If he had a major exam the next day, I would tell him to go study. If it was Christmas Eve, I told him he should be with his wife. My point is that most doctors in charge are insensitive to the human needs of their students, but they needn't be that way.
Q: I read on the web where most Russians started their med school after high school. While that may sound strange to most Americans, it does seem logical. Since the Russians had one political party, it stands to reason, they had no reason to study politics—American style. Thus, without any reason to study politics, they were free to devote their remaining resources to other scholarly activities such as medicine. With fewer distractions, they could study courses normally reserved for college in America, earlier, and in a less stressful environment. I may be mistaken, but many Russian doctors (male and female) seem to coalesce around this theory. I would love to hear your opinion on this matter. Thank you for your time. Ryan
A: I do not mean to be flip about this, but when I was in college and medical school, my primary distraction was women, not politics. In fact, I cannot recall watching the news or reading a newspaper the entire time I was in medical school. For all I know, there could have been a war between Ohio and Indiana. Medical campuses are very insular environments that reward monomaniacal people, like me, who are oblivious to everything in the world except medicine. Saying that someone is a monomaniac is not a complimentary term, unless you're a medical nerd like I was. I was so focused that I can't recall thinking about snowmobiles for even a split-second during medical school. In retrospect, this seems unfathomable to me because snowmobiling is the thing in my life, and it has been since I was in elementary school. So how could I so completely shut it out? My guess is that it would have been too distracting and painful to think about (because I had neither the time, place, or money to snowmobile in those days), so I unconsciously blocked it. I probably would have banished any thought of women during that time, too, but my gonads never knew they were in medical school so they kept on producing testosterone.
can premed students do if they aren't accepted into medical school?
Comments to a prospective medical student
Q: I hope I don't lose all of my idealism when I graduate from med school, but that's probably like wishing when you were young to make losing virginity a life-altering event.
A: It is tough to retain that idealism. Medical school, residency, and the healthcare system in general are so arduous and in many ways inhumane that expecting doctors to retain their idealism is like expecting a dog to still be friendly after it is beaten for years. Furthermore, medical students are indoctrinated in a system that treats patients like objects, not individuals. This alienation is to some extent codified in laws pertaining to the practice of medicine, and to some extent it is tacitly inculcated by the social pressures extant during medical school and residency.
Q: I met one great doctor, though, who had infinite charisma and energy, and seemed to be unfazed by the abuses and subterfuge.
A: I know one such ER doctor, too. However, I knew him when he had just returned from the Gulf War, and his euphoria and ebullience may have been due to our success in that campaign.
Q: One of my goals in life is to do my part in making medicine more equitable around the world.
A: I hope you retain your idealism. I grew up watching Marcus Welby, MD on television, and I thought I would befriend my patients and be intimately involved in their lives—just like good ol' Dr. Welby.
Q: The patients in China at least are very thankful after being treated by a doctor. They are very respectful and don't sue doctors.
A: Frivolous lawsuits are often appreciated to be an economic drain, but they are far more injurious than that because they insidiously drive a wedge between doctors and patients. Doctors are embittered that society allows such abominable suits to go forward, so docs retaliate with CYA and other measures. The primary beneficiary of this adversarial system is lawyers, of course. Except for a few patients who win Lottery-sized awards, patients don't benefit from the current system because it substantially increases the costs of healthcare insurance premiums and taxes, it leads to patients being subjected to painful and often risky tests as doctors practice defensive medicine, and it malignantly erodes much of the goodwill that should exist between doctors and patients. I rail against this litigious system because it makes practicing medicine less of a joy, and more of a nightmare.
Q: Dr. Pezzi, if you were allowed to live your life all over again, would you still be an ER doctor?
A: No. Emergency medicine has too many drawbacks, and it is just plain arduous. It's fairly easy to muster the required energy when you're young, but after several years of running on overdrive I grew weary of the demands. The same thing happens to most ER docs.
Must doctors be math whizzes?
vague, inchoate question
Some great advice from a great professor
Links to other pages in the More Q&A section:
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