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ER Questions and Answers

From the annals of unusual 911 calls:  contestant hyperventilates on The Bachelor
Non-emergencies in the ER
Something you'd never see on a soap opera, because it'd seem too unbelievable

Q:  In the first The Bachelor series (a show where 25 women vie to be chosen by a hunk), one of the women "broke down" after being eliminated, and someone called 911 and summoned an ambulance because she was upset, crying, and hyperventilating.  I'm wondering if this was just some dramatic scripted put-on that was intended to increase their ratings, or if things like this happen in real life (the contestants on the show are real, not actors, but since this happened in TV-land, it's not quite "real life").  Thanks doc, Cynthia.

A:  Oh, Cynthia, if you only knew . . . .  Such cases are surprisingly common in emergency departments, and so are even more trivial problems.  In fact, some of the things I've seen are so Mickey Mouse that they make hyperventilation seem like a bona fide emergency.  In fairness to people who hyperventilate, it's worth noting that they can paradoxically feel short of breath, and their instinctive impulse (to breathe even faster) only exacerbates their problem.  Rapid respiration triggers an increase in the blood pH, which affects calcium ionization, which affects neurotransmission, which induces even more alarming symptoms to heighten their panic.  In the grand scheme of things, hyperventilation isn't a serious problem, and it may seem ludicrous to incur a $600 charge for an ambulance (and even more for treatment in the ER) when all that is needed is someone to calm the person down, tell her to breath more slowly, or if all else fails, to have her breath into a paper bag until her respirations normalize.  A fair number of sharp laypeople know how to manage hyperventilation on their own, but some people don't, and when you're near someone who is so anxious, it is natural for some of that anxiety to rub off.  Result?  Someone often races to a phone and dials 911.

I can understand why hyperventilation may seem like an emergency to the patient or bystanders, but I can't understand why some people go to an ER for things that clearly aren't emergencies, such as a man who complained that his penis wasn't as large as it once was.  OK, it's Christmastime, and I'm in a charitable mood, so I'll excuse that as being attributable to his lack of knowledge about choosing an appropriate specialist.  Although I'm imbued with Christmas cheer and goodwill, I still am irked by some goofballs who intentionally create problems.  The most egregious case that I can now think of is when a mother brought her 17-year-old daughter to the ER because she'd contracted genital herpes.  During the exam, the mother left the room.  Shortly afterwards, a nurse knocked on the door, stuck her head in, and told me that the mother was now a patient.  My instincts reflexively told me that this was going to be a weird case, and sure enough, it was.  The nurse said that the mother took an overdose of pills (from a stash in her purse) because she was upset that her daughter was getting all the attention!  I felt sorry for my teenage patient.  Here she was with a life-changing diagnosis at a vulnerable period in her life, and rather than obtaining emotional support from her mother, good ol' histrionic Mom childishly did something so she would be the center of attention.

Napping during the night shift
Sleep inertia

Q:  When you worked the night shift, did you ever get to sleep?  Tim

A:  I've worked in some emergency departments that were so busy it'd be a luxury if I could empty my bladder, but also in slower ER's in which sleep was occasionally possible.  The problem was that I'd never know when the next patient was coming in.  At one hospital, the patients would usually appear like clockwork about a minute after I'd fallen asleep.  That became so annoying that I gave up trying to sleep at that place.

Even in hospitals in which sleep was possible and I'd sometimes snooze for a couple hours, it was always difficult deciding whether or not I should risk sleep.  My primary concern was sleep inertia, the post-sleep grogginess that doesn't dissipate immediately after awakening.  Depending on what stage of sleep I was in at the time the nurse woke me up, it'd take anywhere from a few minutes to 15 minutes to be totally on the ball.  I could have avoided that problem by not sleeping at work, but that would create another problem in that it ensured I'd be perpetually sleep-deprived, thanks to the fact that I could usually sleep for only five or six hours at home, not the eight or nine that I need to feel refreshed.  Hence, it was risky no matter what I chose:  to forgo a much-needed nap that might refresh me and allow me to give better care to subsequent patients, or to take a nap and risk having to initiate patient care while suffering from sleep inertia.

My primary concern about sleep inertia wasn't that I wouldn't ask the right questions and give the correct orders, because those things were so well ingrained in me that I could do them even if I were fully asleep (something I realized from having surprisingly detailed dreams in which I'd easily manage complex cases).  Instead, my concern was that I'd lose the nuances of personal interaction that are critical to a doctor-patient relationship.  Who wants to be treated by a robot?

In most hospitals, napping was possible only in the middle of the shift.  At the beginning of the night shift, the ER is often flooded with patients, and patients usually come in the morning because of heart attacks, car accidents during the commute to work, or assorted other problems.  With each passing year, napping becomes less feasible because the increase in the number of emergency department patients greatly exceeds the population increase.

Treated by a Physician Assistant (PA) in an ER; where is the ER doc?
Are PAs and Nurse Practitioners (NPs) as competent as MDs?
Tacit message from PAs and NPs to physicians:  "We'll take the easy, low-risk cases.  You can have the rest."
Why should patients pay as much to see a PA as an MD?
My encounter with an incompetent, but cute, PA

Q:  I took my son to an ER last night, and he was treated by a PA.  I asked for a physician to evaluate him, but they said they were solely staffed by PAs, not ER doctors.  This morning I called the hospital's administration, and got the impression that they think a PA is just as good as an ER doc.  What gives?  Ryan

A:  Ryan, you just encountered a phenomenon that I've noticed, which is that some hospitals don't give a hoot as to who works for them as long as they have a warm body filling a position.  I am not trying to disparage all PAs, since many of them are usually just as competent as ER doctors when it comes to managing problems of mild-to-moderate severity.  I've worked with a number of PAs during my residency and later as an attending ER doctor, and some of them were smart, knowledgeable, and competent people.  Unfortunately, one was such an incompetent dingbat that it was frightening.  While other doctors were drooling over her pretty face, I was going ballistic that such a person was on our staff.  I went from disliking her competence to disliking her, because it became clear to me that she didn't give a hoot if she gave shoddy care.  Rather than assail her personally, I compiled a detailed factual account of her flubs and presented this to the hospital CEO, who evinced not the slightest bit of concern.  Gee whiz, I wondered, was she banging him, too?  (I suspected that my ER boss not only tolerated her stupidity, but even defended it, because he was either boinking her, or hoping to.)

PAs could probably tell some horror stories about ER doctors, but the fact remains that there is a substantial difference between an ER doctor and a PA.  If you or a loved one is critically ill or injured, you want to be treated by a physician, not a Physician Assistant.  I don't think that anyone, even a PA, would quibble with that.  In the preceding paragraph, I said that PAs are "usually just as competent as ER doctors when it comes to managing problems of mild-to-moderate severity."  However much I think that is true, I have one remaining reservation about PAs, nurse practitioners (NPs), and the endless parade of other professionals and professional wannabes who are increasingly poaching on the territory of physicians.  My concern centers around one simple problem:  many, if not most, diseases present with common signs and symptoms, even when those diseases are uncommon.  So how can a PA or NP who purports to be an expert in common maladies know when the mélange of signs and symptoms now facing her add up to something other than a garden-variety problem?  She can't.  In short, she's playing Russian roulette:  hoping for the right outcome, but having no way of really knowing it.  Fortunately for patients (and PAs, and NPs), most patients present with common problems that they're trained to handle.

When I worked with PAs in the ER, I'd take the more serious cases, and they'd take the easier ones.  However, I'd still see some cases that weren't serious, since sometimes the ER was filled with such patients.  About once per week, I'd have a case that I could solve only by recalling bits of medical minutiae that I doubted any PA or NP would know.  I don't know how to put a price tag on the value of these "saves," but from what I observe from malpractice judgments, it's clear that society places an enormous (and sometimes even ludicrously impractical) value on health.  With this in mind, I wonder if society is getting the bargain it is hoping for by employing PAs and NPs.  Their raison d'être isn't better care, it's cheaper care.

If you analyze the malpractice data, you might obtain a misleading impression that PAs and NPs are doing better than they really are.  I think there are two reasons for this:

  • First, patients don't seem to possess the same animosity toward PAs and NPs that they often do toward doctors; hence, they're less likely to sue.  As I pointed out elsewhere, there is a pervasive resentment of doctors in the United States, especially amongst jealous lowlifes, but such people are apt to serve on juries (where they can vent their wrath by really sticking it to doctors).
  • Second, PAs and NPs minimize their chances of being sued by siphoning off the easier, less risky cases.  If you're just treating things like sprained ankles, rashes, earaches, and bladder infections, it's awfully difficult to be sued.  Every year, PAs and NPs take more of the easier cases, leaving the docs to treat obese diabetics who are turning blue from congestive heart failure while they're seizing from a complication of renal failure.  PAs (and especially NPs) are apt to present themselves to the public as nicer, more caring, and more compassionate than grumpy old MDs.  Incidentally, this diversion of patients is yet another drawback of medicine that should be noted by prospective medical school applicants.  In the old days, docs saw the easy cases, the moderately challenging cases, and the tough cases.  It was a nice mix, and it helped prevent burnout.  Docs were well-paid for their work.  In the years that I've been a doctor, physician incomes have fallen in inflation-adjusted dollars.  We're forced to see patients more quickly, and — thanks to the PAs and NPs who nab the easier and less risky cases — the patients that doctors see are sicker than ever.  No wonder the PAs and NPs are so happy.

When I was an intern, I noticed that the more senior residents often derisively spoke of the Internal Medicine PAs on our hospital staff, mocking them for their overzealous use of K-lyte (an oral potassium supplement).  At times it seemed to them that the PAs did nothing but push K-lyte, so the residents dubbed them the "K-lyte brigade."  I felt this disparaging sentiment was a deliberate caricature because the PAs actually did a lot more, and they weren't responsible for the rampant hypokalemia (low blood potassium level).  What should they have done — ignore it?

In the hospitals I worked, when patients were seen by a PA instead of an MD, they weren't given any discount on their bill.  Frankly, I am surprised that people don't complain about this, since it strikes me as being somewhat of a gyp.  PAs might usually give the same care as a physician, but there are inevitably cases in which the MDs superior education and training is invaluable.  If you need a carpenter to fix a problem at your home, you're going to pay more by summoning This Old House's Norm Abram than just another guy with a hammer, even if the problem is simple.  You're not just paying him for what he does, you're paying for what he can do.  If you won't pay Norm the premium he demands (and is worth), then he won't show up, and you might not benefit from his expertise.  This problem becomes crystal clear if you consider an extreme example.  Some patients see physicians for problems that medical science has yet to find a solution.  The doc will tell you that nothing can be done, and then he sends you a bill.  You could get virtually the same result by asking a high school dropout, who'd shrug his shoulders and say, "I don't know.  Can't help you."  Hence, you're not always paying for what is done, but the expertise that allows more to be done in some cases.  PAs cannot match the ability of physicians to do that, so patients should receive a discount if they see a PA.  This strikes me as being equitable, but in my experience, it isn't done.  I think that any savings should be passed on to the consumer, which is the patient.  Instead, you're billed just as you'd be if you saw a physician, but PAs aren't paid as much as MDs.  Hmm, whose pocket does this money go into?  If you can figure this out, you might realize why hospital CEO's are so apt to overlook even flagrant incompetence on the part of a PA.

In the case that made me wonder if the PA with the cute face had a functioning brain, she was examining a man who'd sustained a neck injury in a car accident.  Such cases are naturally common in emergency departments, and I fail to understand how anyone can purport to be an ER PA without knowing how to evaluate and manage potential neck injuries.  Believe me, it isn't rocket science.  Basically, to evaluate a neck injury, you want to determine if everything "downstream" of the head is OK.  Does the patient have normal strength and sensation in his arms and legs?  Are his reflexes OK?  Stuff like that.  Instead, the cutesy PA just checked his cranial nerves, or said she did.  To begin with, the cranial nerves aren't the primary concern in a patient whose head is fine but whose neck is painful.  Second, I suspected that the PA wrote on his chart "cranial nerves 2 through 12 are intact" without actually checking the nerves, so I asked just what she'd done to check them, but she couldn't answer my question.  Nor could she tell me about the patient's limb strength, sensation, or reflexes.  I told her to return to his room, check those things, and then check his cranial nerves (if she wrote that on the chart, she'd darned well better check them).  To make a long story short, after repeating my request twice more and seeing that she was evidently clueless about what to do, I took over care of this case.  I was stunned, and still am, that a PA could be so ignorant.

Surprisingly, neither the hospital CEO nor my boss seemed at all worried that we had someone working in our ER who apparently knew less than a Boy Scout about patients with neck injuries.  Instead, they told me this was none of my business, stressing that I wasn't her supervisor.  This was news to me.  Since I was the only ER doctor working at the time, I assumed that I was the only logical one to oversee her work.  Oh no, I was told, we've hired a family practitioner to countersign her charts after her shift is over.  I wondered how they thought that was adequate supervision.  It seemed so comically insane and ludicrous that I couldn't believe two sober adult men were saying it to me.  The family doc would come to the hospital a couple times per week, sign the charts of the patients she'd seen, and that was what they called "supervision"?  With a straight face, they said yes.  It's sheer lunacy, and a scam.  Anyone with a room-temperature IQ would realize that the sensible thing to do was to have the PAs supervised by the ER doctors working alongside them, so they could immediately influence care when needed.  However, in hospitals logic does not always prevail.  That buffoon of a PA was allowed to continue working, and her "supervisor" would countersign her charts whenever he'd get around to it.  Great system, isn't it?

UPDATE: Years later (in 2019), I saw a dermatology PA who was impressive. Based upon his interaction with me, Justin's performance was indistinguishable from a dermatologist (MD). Parenthetically, he was also strikingly handsome; I've noticed that people who work in dermatology tend to be more attractive, with that perhaps a result of self-selection with better-looking people gravitating to that specialty because patients expect dermatology folks to have nice skin and overall appearance.

Relevant to that, although dermatology was my first choice, my propensity for bad acne (which persisted decades after it typically resolves) would have made me appear less credible as a dermatologist, so I went into emergency medicine instead.

Interestingly, I (much) later developed an easy way to reverse skin wrinkling. Roughly about a decade ago I developed so many facial wrinkles I couldn't bear to look at myself in the mirror. Those wrinkles were a predictable result of living with multiple chain smokers, spending way too much time in the sun mowing lawns and whatnot to pay my way through college and medical school, burning out multiple sunlamps in a desperate attempt to “burn off” my acne, and enduring decades of stress as I first worried in college that I wouldn't get into medical school, and then when I did, the stress of that coupled with the lack of sleep that stretched into residency and beyond.

I have a decent night of sleep every five years or so, with the rest of the nights being varying degrees of hell. With those and other risk factors for wrinkles, I wasn't surprised that I looked the way I did, but after a year or so of using my innovation, the wrinkling didn't just stop progressing; it actually reversed so much my dental hygienist has repeatedly commented on how young my skin looks.

The moral of the story is that appearance is a terrible criterion to judge people; looks can indeed be deceiving. Although my bad acne would have made me appear as an incompetent dermatologist, I developed a very good solution to wrinkling that doesn't require drugs or surgery, and has other beneficial effects on the skin, which is one of the problems commonly treated by dermatologists.

If you're an irate PA or NP who wants to rip my spleen out, please read this.

Article in Men's Health magazine generates a firestorm of controversy
My response to the PAs and NPs who claim they're as good as doctors, or even better

Q:  Hi Dr. Kevin:  I was perusing your website and, aside from being highly entertained, I was intrigued by your practical experience and ER wisdom.  Hence, I decided to see if you really would respond to my numerous inquiries.  I just graduated with a B.A. in English, but have always wanted to do medicine.  English was just a love of mine, and I chose to do that rather than hate life doing chemistry for four years when I could do it for less.  Now I'm doing the chemistry and, as predicted, hating it.  Therefore, I am looking at Nurse Practitioner (NP) programs, rather than PA programs, which is what I had always considered in the past.  If you could please tell me anything and everything you know about a) the differences between NPs and PAs and b) if you prefer working with one over the other and why, c) how realistic is it for NPs to work in the ER (because that is my real dream, ER medicine), how often do NPs practice ER medicine, how well are they received, etc. and d) any tips you have for helping me decide.  What I am going on right now is that NP schools require only one prerequisite chem class, while PA schools require at least three.  I am a pretty independent person, so I think NP might suit me personality wise better, and that's about it.  Any help, advice, suggestions and information you could send my way would be REALLY GREATLY APPRECIATED and HELPFUL!  Thank you so much for your time, and for the insightful web pages.  Curious and Confused, Evangeline

A:  Your question arrived at an opportune time.  I was interviewed for an article in the current (October 2003) issue of Men's Health magazine, and I received e-mails from a smattering of Physician Assistants who were upset by a comment I made therein about PAs.  In my experience, the range of their proficiency is vast, varying from impressive competence to unfathomable ignorance coupled with a cavalier disregard of patient welfare.  Obviously, I was just speaking of my experiences, and I wasn't trying to paint with a broad brush and assert that it was representative of all PAs.  However, judging from the incandescent diatribes I received, that was how it was perceived.  I know that my experience is not indicative of the average PA competence.  I just happened to witness a distressing amount of incompetence, and when I spoke of it, I thought it would be clear that I was speaking of my experiences.  The average PA does a good job, and some deliver superb care.  Unfortunately, some do not.  I witnessed both ends of the ol' Bell curve.  What is reprehensible is the indefensible PA conduct that I witnessed, not my criticism of it.  The Men's Health article focused on patient safety, not protecting the economic interests of bad PAs.  Some PAs evidently feel that it should be taboo to discuss incompetence in their ranks.  In contrast, physicians have been pilloried in the press so often that we're usually inured to it.  As PAs become a more prominent part of the healthcare system, they are bound to elicit more attention. The public is not well served if problems with any profession are swept under the rug.

I was shocked by what some of the PAs wrote to me.  One PA inundated my e-mail inbox with rambling, seething messages that struck me as deranged rants.  That guy frightened me, and I was relieved when his outpouring of vicious belligerence ended.  Another respondent was actually supportive, and another one disagreed with me, but in a professional manner.  A few respondents made statements that were questionable.  These PAs made claims ranging from "PAs are just as competent as doctors" to "PAs are better than doctors."  I don't mean to be flip, but did someone forget to take his lithium or Haldol®?  The way to produce superior healthcare practitioners is to give them less education and training?  It defies common sense!  According to the American Academy of Physician Assistants, the average PA curriculum is approximately 26 months, and there is no requirement for an internship or residency.  They also say that an essential part of their training involves knowing their limits.  Evidently, some PAs never got this message.

I don't want to risk being misunderstood again, so I will carefully point out that I am speaking of ER PAs and attending ER physicians, since that article focused on emergency departments.  Also, to make this an apples-to-apples comparison, let's consider practitioners who've worked in the ER for the same number of years after graduation.  One PA, evidently fond of apples-to-oranges comparisons, said that an ER PA with decades of experience is usually better than residents who moonlight in the ER.  Gee whiz, I hope so!  Those residents could be psychiatrists in training.  When I was an attending ER physician in a teaching hospital, one of my responsibilities was to oversee residents working in the ER as part of their training, not as moonlighters.  In my experience, the surgery residents did well with the surgery cases, but were frequently clueless about Internal Medicine, pediatric, and psychiatry problems.  Internal Medicine residents often flubbed surgery, but handled the Internal Medicine cases with competence and aplomb.  No one seemed very good (or even passably good) at everything, which is, of course, exactly what attending ER docs see.  After I became acquainted with the overall ER care given by residents, I felt sorry for patients who were treated in emergency departments a few decades ago, before emergency medicine became a specialty and ERs were staffed by doctors trained in that field.  I thought of people I knew when I was a kid who died in the ER — perhaps treated by a fledgling dermatologist.  May they rest in peace.

Some of the PA respondents pointed out that there are incompetent ER doctors.  Of course there are.  There are far more ER doctors than ER PAs, and some of the docs are indeed incompetent.  This may surprise the angry PAs who wrote to me, but I've used far more ink writing about incompetent docs than I have bad PAs.  No one gets a pass from me:  not me (I've written about some flubs I've made), and not my relatives.  In my next book of ER stories I will describe a wild ER case that even Ripley might not believe.  Unfortunately, this bizarre case involved an ER physician who I am related to, albeit somewhat distantly.  In this case, the reprehensible conduct wasn't confined to that doc, but also involved some of the ER staff who could have gone to prison for what they did to the patient in this zany case.  By the way, that abuse was just the tip of the iceberg that started the snowball rolling for the main act.  That's when things really became interesting.  If you want more details, stayed tuned for my next ER book, tentatively entitled ER Doctor. (Who needs fictional ER shows when this stuff is considerably more intense?) If you wish to be notified when that book is published, please visit this page and check the appropriate "notify me" checkbox.

Granted, there are incompetent ER doctors, but their existence does not prove that the average ER doctor is no better, or perhaps worse, than an average ER PA.  In my experience (note how careful I am being about specifying this?), even the best PA I worked with wasn't as competent as an average attending ER physician.  I hate to say this (fearing more wrath directed my way), but the comparison wasn't close.  In every hospital that I am familiar with, the easier cases were triaged to the PAs, and the more critical cases went to the docs.  So, PAs receive less education, less training, and (in my experience) less exposure to life-and-death cases.  With this in mind, how can someone claim that ER PAs are just as knowledgeable, or even more capable, than ER doctors?  It seems sophomoric and ludicrously untenable.  If this were true, it'd be the educational breakthrough of the century.  More training is better?  Heck, no!  Snatch those crayons out of the kindergartner's hand, and give that tyke a scalpel along with a booster stool so he can reach the patient's brain as he performs topnotch neurosurgery.  Sure, I am being facetious, but are the "we're better than docs" PAs also rooted in reality?  Less education, less training, less experience with critical cases . . . and you're better?  Dream on.

Believe it or not, but I am not on an anti-PA jihad.  I'm just having a bit of fun with a few lunatics who are, quite frankly, easy targets.  I have PA friends who I dearly like, respect, and appreciate.  They're talented and do good work.  But confuse them with doctors?  Nope.  There is a difference between PAs and physicians.  This should come as a surprise to no one.  The best ER PAs are undoubtedly better than the worst ER docs.  Is there some overlap of the Gaussian distributions?  Without a doubt.  But let's talk averages.  The average ER PA is not a 100% replacement for the average ER doctor.  Regrettably, some greedy hospital administrators don't see it that way, and they staff pseudo-ER's (more about that term in a minute) with only PAs and no docs to supervise them.

The original intent of PAs was to be physician extenders supervised by physicians, not physician replacements.  But some administrators, thinking that a white coat is a white coat, don't bother with supervising doctors for their pseudo-ER's.  There may be sham supervision (e.g., the "supervising" doc comes in twice per week to rubber-stamp the charts, which is clearly too late for this supervision to be meaningful), but those PAs are on their own in those pseudo-ER's.  What is a pseudo-ER, anyway?  I'll give you a real-life example.  A small local hospital was purchased by a much larger hospital system that is swallowing up every hospital in the area.  Goliath turned David's ER into what amounts to an Urgent Care center for walk-in patients, and ambulances were diverted to the main Goliath ER.  I saw a classified ad a few years ago seeking PAs to staff the pseudo-ER.  No mention of an MD.  My curiosity got the best of me, so I called the administrator looking for a white coat, and asked why they didn't want a doctor.  I was told that a doctor would be fine, if he were willing to work for PA wages.  Don't hold your breath.

I drove by the pseudo-ER a few months later, and the sign with big red letters said "ER."  Not pseudo-ER or Urgent Care.  There weren't any ambulances in sight, and there wasn't any of the hubbub that usually surrounds most ER's:  patients, relatives, and staff smoking just outside the entrance, cars depositing and retrieving patients, cop cars, and the occasional TV news crew.  So, regardless of the ER sign, this wasn't a real ER.  In fact, it looked downright deserted.  Picture a tumbleweed blowing along, and you get the picture.

Obviously, this pseudo-ER wasn't a major cash cow, so I can perhaps understand why the administrator sought a PA instead of a physician.  However, in every hospital and hospital system, there are departments that rake in the money, and departments that hemorrhage it.  The bleeders are kept alive out of necessity for what is best for the patients, not for the balance sheet.  Or, that is the way it should be, as long as the hospital is economically viable, which Goliath was.  Big time, as Vice-President Cheney might say.

In a contemplative mood, I wondered, "If money isn't an issue, why staff the pseudo-ER with an unsupervised PA?"  So they can make a bit more money to lavish on the administrators as perks?  Who knows?

While I drove past the pseudo-ER during an obvious lull, there must have been busier times since this was the chief healthcare facility in the 100 or so square miles surrounding hoppin' Tourist Town, USA.  Fudgies (that's our derisive term for the tourists) tend to eat too much, drink too much, get too much sun, too little sleep, and drive boats and snowmobiles too fast.  The results?  Predictable.  The fudgies usually kept me from sleeping during the night shift, and I'm sure that every day in the pseudo-ER was not a walk in the park for the PAs.

I've worked in large, medium, and small ER's.  I've worked in an Urgent Care center and two occupational medicine clinics (part-time).  From this exposure to different practice environments, I've learned that it doesn't matter what the sign says on the building.  Remember, some people are drunk, on drugs, or just oblivious to the legal distinctions between emergency departments, Urgent Care centers, and whatnot.  If they think there is a white coat in the facility, and it's convenient, they'll likely triage themselves right into the lap of the white coat.  Most of these patients present with problems that a PA or NP can easily handle.  However, there will also be patients who are a few heartbeats away from the graveyard.  Some of these cases will be common enough and straightforward enough so that an ER PA could save the day, even if he is working in a pseudo-ER.  But all cases aren't straightforward.  Some are downright perplexing, even for someone like me (and I graduated in the top 1% of my class in medical school).  Inevitably, there will be times in which knowing more makes a big difference.  Let's say that it occurs only once in a career, and the age of the saved patient is 44 years since that is close to the current median age in the United States.  Saving an average 44-year-old translates into saving over 30 years of life.

I want everyone — PAs, NPs, MDs, and especially you taxpayers, who are paying us — to sit down, take a deep breath, and really think about this.  What is the value of those thirty extra years?  Are they worth a few more years of education and training?  Of course.  So why are we producing practitioners who are usually just as good as MDs, but occasionally are not?  After supervising PAs in countless cases, I know that the extra knowledge I possessed was useful far more often than once in a career.  Sometimes it was once per hour.  Most of those tidbits I gave to the PA were just minor suggestions to produce a better outcome, not grand revelations that saved lives.  However, in an ER in which there is a lot of bad protoplasm that seems hell-bent on dying, extra education and training will make a difference at least every year, not just once in a career.  Now we're talking about a minimum of an extra 900-plus years of life . . . all paid for by a few more years of sweat before donning the white coat.  Is it worth it?

I've heard PAs and NPs make all sorts of claims about their proficiency.  Some of this strikes me as propaganda, and some of it is pure fantasy.  It'll be a cold day in hell before I accept the notion that less education and training produces equally competent practitioners.  Furthermore, there is another factor that enters into the equation:  brainpower.  Oh God, I can already hear the howls by PAs and NPs:  "We're just as smart as doctors."  Really?  Then why do they have lower average GPAs and scores on standardized tests?  When I applied to medical school, the average IQ was 130 (borderline genius).  I haven't read any statistics on the IQs of PAs and NPs, but they're definitely brighter than average. I'd guess 115.  Not 130.

When I was in medical school, I obviously learned more than the folks at the bottom of the class.  We were taught the same material, but I learned more of it.  If I didn't, I wouldn't have been in the top 1% of the class, right?  If you can see where I'm headed with this, you're pretty bright.  If you can't, I'll spell it out:  smarter people get more out of a year of schooling.  If you consider only the additional years of education and training that MDs receive, it is not surprising that there is a competency gap between docs and PAs/NPs.  However, if you also account for the fact that smarter people can learn more in a year, then the competency gap is even wider than it may seem.  Furthermore, I know that medical students have more "nose to the grindstone" intensity than nursing students, and I suspect the same is true of PAs.  I worked 110 hours per week in medical school, which is substantially more than what nurses expend during their training.  Hence, four years of medical school is like eight to eleven years of schooling at a more typical pace.  Therefore, it isn't just the extra years of education and training that docs undergo, or that those years are packed with far more than the usual allotment of information taught each year, or that medical students are smarter and can learn more per year, or that medical curricula are covered in far more depth than what is taught in PA or nursing schools (I've seen their lectures, which seemed very superficial to me).

Considering the foregoing, I don't see how anyone can plausibly claim that PAs or NPs know as much as doctors, or can function in an interchangeable capacity with no adverse effects.  It's just not in the cards.  Nevertheless, I've heard this preposterous claim made by everyone from PAs to nurses (yes, nurses, who are further down the totem pole than NPs).  What on Earth is fueling these baseless but grandiose delusions?  Jealousy?  Self-deception?  It certainly isn't facts.  I've previously told the story of one of the best ER nurses I ever knew.  He had about 20 years of ER experience and was in charge of the night shift.  On one uncharacteristically slow night, he approached me and asked if he could "play doctor":  take a history, examine the patient, generate a differential diagnosis, order tests, x-rays, EKGs (and interpret them), order treatment, decide upon a final diagnosis and disposition, cross your fingers and hope for the best — you know, do what ER doctors normally do.  Since this was a slow night and I could supervise him, I gave him the OK to proceed.  He looked flustered and stumbled on things that were very basic ER cases that he'd seen ER docs handle thousands of times.  When you watch someone do something, it is often deceptively easy to convince yourself that the activity is easier than it looks and that it'd be a piece of cake for you.  I felt bad for this man because, from the hurt look on his face, it was clear he knew he'd stumbled.  He told me later that playing the role of a doctor had long been one of his dreams, and the dream did not turn out as he'd imagined it would.  Had he obtained the same training as me, he could have been a topnotch ER doc.  He had a high IQ, but not the training.

In theory, legislatures have codified the need for supervision of PAs by MDs.  Sometimes PAs are adequately supervised, and sometimes the supervision is distant, perfunctory, and a sham.  Supervised or not, an average ER PA is not as adept as an average ER doctor and the resultant patient care, although usually good, will occasionally suffer.  The MDs don't tag along with the PAs.  Instead, PAs typically give a quick verbal synopsis to the doc.  If needed, the doc will step in to check something on the patient (is that dyshidrotic eczema or eczematous contact dermatitis?), but MDs do not see most of the PA's patients.  Why does this matter when the doc can be summoned?  It boils down to one thing.  If you don't know something, how do you know that you don't know it?  In the course of taking the history and physical, there might be clues that a PA would ignore, but those clues might switch on a light bulb in a doctor's head.  Physicians hear a distillation of what PAs believe are the salient facts.  If a PA does not know that something is important, that tidbit will certainly be omitted from the case presentation to the MD.  Bottom line:  supervision is not a panacea for the educational deficiencies of PAs.

With this as a long preface, Evangeline, let's now get down to the nitty-gritty.  The answer to the question "Should I become a PA or NP?" varies depending on whose interests are given foremost consideration.  Should you do what is best for you, or what is best for patients?  Besides precipitating another round of hate mail from indignant PAs joined by livid NPs, my preceding discussion should have illustrated why patients are best served when their healthcare providers are smarter and receive more education and training.  You can't benefit your patients by opting for a shortcut to the white coat.  Therefore, my advice is simple:  if you will one day hold patient's lives in your hand, you owe it to them to be the best possible practitioner you can be.  And that's an MD, not a PA or NP.

With this in mind, you might wonder why I sometimes advise people to become a PA or NP.  When people write to me for advice, I generally counsel them in terms of what is best for them, not society.  I've recently had a change of heart after pondering this matter, and for that I'd like to thank the PAs who wrote to me for rousing me.  I now can no longer ethically advise anyone to set their sights lower than they should, and deliberately foreshorten their education.  Patient's lives are precious, and saving 900-plus years of life in a career is worth a few more years of sacrifice on your part.  Anyone who doesn't believe that doesn't deserve a white coat in the first place.

In reality, this estimate of saving 900-plus years of life in a career is very conservative.  Let's look at the facts.  An ER doc or PA could see 7000 patients per year.  In all likelihood, the greater competence of ER doctors will enable them to make a lifesaving difference more often than once in 7000 patients.  I think the true figure is closer to ten, but even if it is just one, the justification for employing PAs becomes very shaky.  No one can credibly claim that ER PAs are just as good as ER doctors.  Sooner or later, perhaps just once in 7000 patients, a doc will really prove his worth by saving a life that could not have been saved by a PA.  I've heard the rhetoric about PAs being cost-effective, but I'm not buying it.  I made about $60,000 per year more than the PAs I worked with.  Besides the fact that the PAs and hospital were legally dead in the water without licensed physicians, that $60,000 was a bargain.  It purchased supervision of the PAs that benefited hundreds of patients.  Not in lifesaving ways, but incremental improvements to care that might just make patients feel better or recover more quickly.  Based on the conservative estimate of one additional life saved per year, that $60,000 also bought another 30 years of patient life.  Time to do some ciphering.  $60,000 divided by 30 years equals $2000 per year of life.  Is it worth it?  Are PAs "cost effective"?  Let's bend over backwards to be fair to PAs and say that an ER doc makes a lifesaving difference only once per decade after treating 70,000 patients.  Now the cost per year jumps to $20,000.  Is your life worth $20,000 per year?  Judges and juries evidently think that a year of life is worth considerably more than $20,000.  If my estimate of ten additional lives saved per year is accurate, the figure is a paltry $200 for each additional year of life.  In the rush to economize on healthcare, are we being penny wise and pound foolish?  I am not claiming that there isn't a niche for PAs in medicine, but that niche isn't in the ER.

How do I know that extra knowledge translates into extra years of lives saved?  Besides the fact that this is intuitively obvious, there is a lot of data to support this claim.  Studies have repeatedly shown that better doctors produce better outcomes.  Extra intelligence and knowledge does make a difference.  Give a hundred critically ill or injured patients to two ER docs, one very good and one just so-so, and the better doc will save more lives.  This is inarguable.  Now compare the average ER doctor with an average ER PA.  There is probably more difference in skills between that doc and the PA than there is between the average ER doc and the very good one.  Patient outcomes are affected by differences in competence regardless of whether the practitioner is a physician or a PA.  Ergo, since an average ER doctor receives better education and training than average ER PAs, and likely possesses a higher IQ, he is bound to be more competent and produce better outcomes.  PAs can argue until they're blue in the face, but no amount of foot stomping is going to change the fact that MDs have a competitive edge over PAs.

Most PAs are realistic, and they don't make half-baked claims of superiority over doctors, or bristle with indignation when this fallacy is dissected.  Most of the PAs I've met are smart, decent people, and I liked them.  This is why I don't relish having to point out that an average ER PA is not a substitute for an average ER doctor.  However, since that unjustifiably lofty argument is being made by some elements of the PA lunatic fringe, I think that analyzing this claim is worthwhile.  I don't think that the average patient is fully aware of what practitioners in different fields go through before they don a white coat.  Considering the importance of this, it is crucial that patients know that assuming interchangeability could be a fatal mistake.  Even if this occurs just once in 7000 cases, someone is going to be that numerator, and end up as a statistic.

Although only a minority of PAs claim they're as good as, or better than, doctors, NPs are inculcated with the notion that they can in many ways fill the role of primary care doctors.  Claiming superiority isn't uncommon for them as it is for PAs.  Even some of the "big names" in the NP world, such as Suzanne Gordon, are not at all shy about tooting their own horn.  After reading her NP manifesto entitled Life Support: Three Nurses on the Front Lines, I came away with the general feeling that the impetus behind this boring 328-page book was to convince the public that doctors are the problem and nurses are the solution.

First, recall what I said above:  less years of education and training, less intense and rigorous education and training, less learned per year as a result of a lower average IQ, and less in-depth coverage of just about everything.  Granted, doctors aren't perfect, but the key to improvement is not to whittle away the educational process.  Why on Earth do these new fields seize upon educational shortcuts as some sort of an elixir that magically results in medical care that is just as good or even better?  I don't accept the validity of their absurd  "less is more" claims.  Sure, NPs are careful about specifying where that superiority lies, but even then I choke on what they're trying to cram down my throat.

Let's consider prevention, which is (from the NP propaganda I've read) one of the areas in which they excel.  Are NPs really any more successful than physicians in encouraging people to lose weight?  Obesity is increasing prevalent, and patients of NPs are struggling with this problem just as much as patients of MDs.  At the risk of personalizing this too much, after seeing that many NPs have their own weight problems, I concluded that they don't have any magical answers, either.  NPs often claim that they spend more time with patients on prevention measures.  I believe this.  (I don't disbelieve everything they say!)  But spending more time is not particularly helpful when the message being relayed has such an abysmal track record.  The standard approaches to combating obesity don't work 95% of the time.  People may lost weight, only to gain even more back.  The old ways — dieting and exercise — have very limited effectiveness because they aren't easily maintained.  I've been harshly critical of doctors for doing such a poor job at prevention.  If you read only this topic, it may seem that I have only PAs and NPs in my sights.  Not true.  I applaud NPs for at least trying more, but what matters is results, not effort.

Is there an easy and painless way to lose weight that doesn't require dieting, drugs, herbs, exercise, or surgery?  Yes, there is.  I thought of a way to do this years ago.  It is natural to scoff at something that seems too good to be true, especially when this secret to weight loss has eluded every weight loss expert who wracked his brain trying to think of an easy solution.  In addition to this bombshell tip, I have what I think is the world's best collection of good weight loss tips.  I read extensively (sometimes scouring up to 250 magazines per month in addition to reading countless books and journal articles), and I've never seen anyone bring these tips together as I have.  Alone or in combination with my weight loss breakthrough, shedding fat is easy.  When I was a resident I looked like an over-inflated doughnut.  Now, 16 years later when I could have gained even more weight as so many middle-aged people do, I would not look out of place on the cover of a fitness magazine, although most of the work I do is quite sedentary.

Let's consider another aspect of prevention:  sexually transmitted diseases.  We've all heard the ancient exhortations about abstinence or wearing a condom, but the perennial human quest for pleasure guarantees that this is often "in one ear, and out the other" advice.  Simply harping about it doesn't really help, as countless NPs, MDs, and even the Surgeon General have discovered.  What is needed are a series of breakthroughs that will enable people to do whatever they want in the bedroom and still experience intense pleasure.  Most NPs and doctors have been deaf to this message from patients, which boils down to, "If you rob me of my pleasure, I ain't following your advice."  I wrote about some of these breakthroughs in The Science of Sex, and the next edition of that book will contain even more coverage of this subject.

I mentioned the weight loss and sexual breakthroughs because they pertain to prevention, and prevention is supposedly a forte of NPs.  They might think that a doctor trained in emergency medicine would be very unlikely to individually conceive of more prevention breakthroughs than have been collectively conceived by all NPs in the world.  Let me cut to the heart of the matter.  I don't think it is a coincidence that I have MD after my name instead of NP.  I am obviously a fan of more education, not less.  I fail to grasp why patients are better off with practitioners with limited training.  If you want to stress prevention and spend time educating your patients, you can do that if you're an MD.  That isn't something that is within the sole province of NPs.

The advances in medical science, primarily spearheaded by MDs and legions of underappreciated Ph.D.s, are certainly impressive, but their focus does not exactly parallel what patients want.  They want radiant health, not just absence of disease.  They want to look great, not just have an acceptable body mass index.  They want sex to be intensely pleasurable, not just mechanically possible thanks to drugs like Viagra.  Doctors have largely turned a blind eye to this discontentment.  Predictably, other practitioners have tried to fill the vacuum.  Nurse Practitioners are correct in thinking that there is a need for a new approach, but they are wrong in believing that educational shortcuts won't decimate the effectiveness they're seeking.

Anyone who is familiar with the medical education system knows that it is hidebound.  Nurse Practitioners seem more willing to at least consider a fresh approach when it's clear the old ways of doing things are not good enough.  They're smart enough to know that prevention needs more emphasis, but in my opinion they're not advocating the best possible preventive measures.  In other words, I'd give them a "B," not an "A."  They could do better, and really leave most MDs in the dust when it comes to prevention.  As part of this program of improvement, they'd do well to lengthen their education.  State legislatures impose minimum educational standards.  No one will ever dictate educational maximums.  So why can't Nurse Practitioner programs add training so that their graduates are at least as well trained as physicians?  Wouldn't patients benefit?  Of course they would.

In your case, Evangeline, I don't think that your lack of affinity for chemistry will appreciably detract from patient care.  My knowledge of electron orbitals and covalent bonds wasn't very helpful in treating blue babies or comatose drug addicts.  However, don't overlook the value of struggling to master subjects that don't come easily to you.  One of the primary mistakes that students make is to avoid subjects for which they seem to have little aptitude.  If you're looking to improve your brainpower, you are better off striving to learn those subjects than you are by focusing on courses that are up your alley.  What stimulates the brain isn't doing the same old stuff, but exposing it to new challenges.

I know what I'm talking about.  In sixth grade, my teacher opined that I was "slow."  My only notable talent at that time was the ability to devour an incredible number of Christmas cookies, so he may very well have been correct.  Considering the fact that sixth-grade subject material is not especially challenging, the fact that I was dumb enough to make my exasperated teacher utter the "slow" comment in front of the class doesn't speak well of my brainpower at that time.  So how could I end up graduating in the top 1% of my class in medical school?  How could I go from being slow to improving enough so that the director of my emergency medicine residency program once commented that I was the smartest resident they ever had?  A few years later, my boss said that I was the smartest doctor he ever met.  How probable was it that a kid who struggled in sixth grade would one day receive these accolades?  About as likely as a pipe dream.  So how did I do it?  The answer is two-fold.  First, I stumbled upon various ways to improve intelligence and creativity, which I've discussed in various pages on my web site.  Second, I possess dogged determination.  Whether it is moving a 2000-pound log, or mastering a subject that seems like Greek to me, I never give up.  With enough effort, the brain is sufficiently plastic to reform itself.  With enough reformation, a person could go from being the laughingstock of his sixth grade class to a knowledgeable doctor.  Most people don't experience such radical transformations because they prematurely throw in the towel.  If something is too hard, they shun it, and thereby pass up an opportunity for intellectual betterment.

This glimpse at my past will give you some idea of why I am adamantly opposed to educational shortcuts.  Taking the easy road isn't good for the student, or her eventual patients.

Article: Nurse anesthetist care not equal to physician anesthesiologist-led care, comprehensive evidence-based review finds
Comment: I'm sure the same is true regarding care given by PAs and NPs versus physicians. While some PAs and NPs are smarter than doctors, none have more training, and training definitely makes a difference, especially in challenging cases, not quotidian ones like common infections and diabetes. But while some PAs and NPs are smarter, most are not. Statistically, most PAs and NPs have less intelligence than physicians AND less training, so they cannot deliver the same care in all cases. That's key, because patients don't present with stickers on their foreheads announcing “I have an easy case” or “I have a challenging case.” What appears to be a common, simple case (such as a sore throat) may in fact be uncommon and very challenging. Ditto for rashes, feeling tired or depressed, and on and on.

One of my friends was a nurse anesthetist. She confided in me one day many years ago that she dreamed of becoming a doctor but didn't think she would be accepted into medical school, let alone ace it, but I knew she was smarter than most doctors, so I encouraged her to apply. She is now a neuroradiologist, medical school professor, and president of a prestigious medical organization. She clearly had The Right Stuff, and judging by my track record in assessing intelligence and medical aptitude in her case and many others, I was dead on.

But on the other hand, there is a doctor shortage, and most doctors are not willing to work enough hours so patients receive expeditious care. Thus, there is a patient-need vacuum, and non-physician providers are filling it. Can you blame them?

Mike Grasso, a student at George Washington University School of Medicine, gave me permission to reproduce the following quote from his web site

Some older applicants consider Physician Assistant (PA) programs as an alternative to medical school.  They require only 2 years of training, instead of the 7 or more years it takes to become a doctor.  There is no doubt that PAs provide an important function.  Just be careful that you become a PA for the right reason.  If you enjoy working in a subordinate role with limited autonomy, then becoming a PA may be the right decision for you.  However, if you feel that becoming a PA will be a shortcut to becoming a doctor, you may be making a mistake.  Keep in mind that as a PA, your clinical responsibilities will always be under the direction of an MD.  Even after working in the field for several years, you still won't know as much about Internal Medicine as a second-year resident, and will often have to defer to younger residents in many clinical situations.  In addition, you will only be able to diagnose and treat the more basic cases . . . .

A note to my readers:

This topic has generated more interest from PAs than I ever imagined.  Yesterday I learned that a PA intends to write an article about the two sentences in the Men's Health article in which I discussed incompetent PAs.  My first reaction was, "You're going to write an article about two sentences?  What can you say?  That I shouldn't be critical of bad PAs?"  Defending the indefensible is unseemly, and it will do nothing except disparage the good PAs by association.  They should distance themselves from the ones who, as I suggested in the article, seem to know less than a Boy Scout.  Although that comment may seem unduly flip, if push comes to shove, I will substantiate it by testing some Boy Scouts to see if they could do better.  I have no doubt they could, even if they received no special training or instructions. (If I wanted to be flip, I would sing the Eagles' song that included this line: "Desperado, why don't you come to your senses?")

In fairness to PAs, they have no idea of how bad the PA performances were that I was indirectly criticizing by that comment (I didn't tell the stories in the article, because they'd take up a third of the entire issue).  I wished to save those stories for a future publication, but if needed I will document them now so that everyone can see for themselves if a Boy Scout could truly do better.  In unison, you'll answer, "Of course!"  Actually, why leave this to your imagination?  If the PAs wish to continue making a mountain out of a molehill, I could take video clips of Boy & Girl Scouts demonstrating that what I said, although seemingly flip, is 100% accurate.

I wasn't looking to pick a fight with ER PAs.  To tell you the truth, before this matter cropped up, I never gave them much thought.  I accepted them as part of the ER team, and I worked with good and bad ones.  I was stunned when PAs rushed to defend the indefensible, or at least try to quash any mention of it.  That made me wonder if there is more going on here than I suspect.

If you're an irate PA or NP who wants to rip my spleen out, please read this.

PAs defending the indefensible

Q:  I just read your discussion of how some PAs are bitching because you talked about bad PAs.  After reading your comment about wondering "if there is more going on here than I suspect," I have to ask you a question.  You're a smart guy, but knock, knock, hello Dr. Pezzi, don't you see the obvious?  Their tactics are rather transparent.  They're trying to get you to shut up.  Gary

A:  Yes, I know.  However, their tactics will backfire on them.  Let me give you some background so you can understand why PAs were mentioned in that article.  The focus of the article was on patient safety in emergency departments.  If a patient has a potentially serious or complicated case, he has a better chance of obtaining good care from an ER doctor than an ER PA.  In my experience, I've witnessed more variability in the competence of PAs than I have in the competence of doctors.  Furthermore, attending ER doctors are better educated and better trained than ER PAs.  That is incontrovertible.  Some PAs try to dispute it, but in doing so they're showing just how far they are out in left field.  In the topic immediately above this one, I documented the absurdity of their "we're just as good or even better" proclamations, which are just rodomontade.  Pure bluster.

ER patients rarely know the ER staff, so a patient can increase the odds of seeing a more competent practitioner by requesting an MD instead of a PA.  At the present time, not one PA who wrote to me accepted my offer to respond to the substantive issues I raised.  Instead, most of what I heard is whining.  I realize that I am generally not hearing from the cream of the PA crop.  (The last respondent made nine grammar errors in four short sentences, along with one malapropism.)  As I mentioned in the above topic, PAs are taught to know their limitations.  This seems wise, considering that PA training averages 26 months.  I think consumers might wonder if recipients of such abbreviated training are too big for their britches if they go around making preposterous claims that they're as good or better than doctors.  You might expect to read such an assertion in The National Enquirer alongside recent sightings of Elvis and Bigfoot, but it just doesn't mesh with reality.

UPDATE: Shocking murder of a PA student.

Q:  Whoever came up with the idea of PAs and thought it would be a good idea to have patients cared for by people with less training?  This seems contrary to common sense.  If they needed more doctors, why not build more medical schools?  There is no shortage of medical school applicants.

A:  I don't know who conceived of the PA concept, or why.  Judging from the statistics I've seen, the average person whose application to medical school is rejected is better educated and has higher grades and test scores than the average person who is accepted to PA schools.


This experience has been enlightening because I am shocked by the readiness of PAs to rush to the defense of any PA, no matter how incompetent, unprofessional, or irresponsible.  If PAs were more concerned about the welfare of patients than suppressing any criticism of bad PAs, they would be just as outraged as I am.  Incompetent PAs will give the PA profession a black eye, and reflexive defense of them will only tarnish the reputation of all PAs.  I would love to hear from some of the good PAs who share my viewpoint.  I find it difficult to believe that most PAs condone incompetence or try to shroud any mention of it.  One might expect such actions from a thuggish guild, but not from a professional group.

UPDATE: Two psychologists witnessed a patient having a seizure. The PA disagreed, terming it an “anxiety attack.” The psychologists had seen plenty of anxiety attacks, but nothing that looked like this. From their description, it was obviously a seizure, which an EEG confirmed. This was one of the classic seizure types, so for the PA (who'd witnessed it several times) to diagnose it as an “anxiety attack” shows how little he knows.

Should I go to medical school or should I go to PA school?

Q: I am stuck right now in what seems to be the biggest decision of my life: Should I go to medical school or should I go to PA school? As much as I would love the glory of placing “Dr.” in front of my name, is it really worth it in the long run? I know that it takes a lot of money to become a physician, but when all is said and done (med school, internship, residency, fellowship, debt) is it really worth the money? I mean you're close to $200,000 in debt, and have no time to spend the money. So, is it worth it?

A: In A Guide to Psychology and its Practice (www.GuideToPsychology.com), Dr. Raymond Lloyd Richmond gave a marvelously incisive response to someone who asked a question that is very similar to the one you posed:

Q: Recently I have been told that if I want to go into practice all I need is a MA because of insurance and HMO restrictions on patients being reimbursed for visits to psychotherapists with a PhD. Does the same apply for PsyD holders? While I want to achieve the highest degree in the field that trains me to become the best possible Psychotherapist I can be, I also know that PsyD programs are very expensive. Is it worth it financially to go for the PsyD over the MA? Will I make more money overall with the PsyD canceling out the extra money it takes to get through three more years of school?

A: If your primary interest is money, then become a plumber. Haven’t you ever heard the joke about the man who writes out a check to his plumber and says, “Good heavens, you charge more than my doctor.” The plumber responds, “Yes, I know. I used to be a doctor.”

Now, in all seriousness, your question gets to the fact that in many managed-care systems the reimbursement is about the same for masters level practitioners as doctoral level practitioners. So, in such circumstances, what is the point of getting a doctorate, whether it be a PhD or a PsyD?

Well, there isn't any way to answer that question without offending somebody. So, I will just tell a story (a true story, mind you) and let people take offense as they will.

A man was attending a public event. The man sitting next to him suddenly caught his attention and said, “I have been biting my tongue, but I just have to tell you. How long have you had that blemish on your face? You should get it looked at, because it’s skin cancer. It’s benign, but you should have it removed.” The man who spoke up, of course, was a dermatologist.

So, our friend went to his managed-care medical office. The masters level physician’s assistant who examined him looked at the blemish and said, “It looks like a mole to me. Nothing to worry about.” Our friend, however, insisted that he be seen by a dermatologist. So, eventually a dermatologist came into the room. He looked at the blemish. “Yup, skin cancer. It’s benign. When shall we take it out?”

Now, physician’s assistants can make a lot of money. So is it really worth while to take on the educational expense of becoming a doctor? Does this story have any relevance to psychology? You decide.

Reprinted with permission from http://www.guidetopsychology.com/be_psy.htm#whydoc. Copyright © 1997-2007 Raymond Lloyd Richmond, Ph.D., San Francisco, California USA.

(Parenthetical comment: The above dermatologist case reminds me of what happened to my brother. I spotted a basal cell carcinoma on his neck. He saw his personal physician who (incorrectly) reassured him it wasn't cancer. My brother did not believe him, so he saw a dermatologist who verified that it was indeed a basal cell carcinoma and excised it.)

As I previously mentioned in discussing this topic, additional education is bound to improve patient care and thus benefit patients. Not in every case, but in enough cases to justify the extra time and money required to obtain that education. If you disagree, then you are placing your interests ahead of those of your future patients, which should immediately disqualify you from any healthcare profession.

Could you resist the offer of a
woman hotter than this model?
This is obviously NOT the supermodel patient who made the offer!

Doctors and other healthcare providers have innumerable opportunities to take advantage of patients, many of whom are very vulnerable. Hence, unethical people have no business in medicine because docs can be tempted with things that few people could resist. In my blog, I explained how a woman offered me her stunningly attractive body and a lot of money if I prescribed a certain narcotic for her. Some people might jump at the chance to sleep with a woman hotter than most supermodels, but not me. I love beauty as much as the next man, and I'm very fond of money, but I want both of those things less than I want to do the right thing.

Even if physicians could save only one additional patient per career, that savings translates into an extra 30-plus years of life (given the median patient age of 44). Considering this, your question could be recast into, “Is it really worth it to obtain those additional years of education to give one person 30 more years of life?” As Dr. Richmond put it so brilliantly, “You decide.”

Extra knowledge and intelligence unquestionably improves patient care. This is true not only in the case of MDs versus PAs, but also in the case of good MDs versus not-so-good MDs. Compared with some of my physician colleagues who weren't as proficient as I am, I know that I saved several lives in just a few years that they could not have saved. For example, when considering patients who presented to the ER with a cardiac arrest, my “batting average” (so to speak) in saving those patients was substantially better than average. I've gone over 18 months without losing one patient while other ER docs put patient after patient into the ground. We followed the same basic script (the ACLS algorithms for resuscitating patients in cardiac arrest), yet the outcomes were vastly different. Why? ACLS is poorly taught and woefully incomplete. Passing the course is no guarantee of competency in treating real patients, who often can be saved only by knowing much more than what is taught in ACLS courses. Most people who pass the ACLS course and think they know what they are doing are wrong.

Therefore, considering only this small subset of ER patients, extra knowledge does result in better patient outcomes. If extra knowledge and intelligence makes a difference for MD versus MD (and it does), then it also makes a difference for MD versus PA. Realistically, this additional brainpower would benefit patients not just once per career, but many times even when the analysis is confined to patients in cardiac arrest. Add in the 100,000-plus other patients treated during the course of a career, and the usefulness of knowing more becomes even more apparent.

Considering all of the foregoing, it is definitely “worth it” to become a physician rather than a PA if patients are your foremost priority. If money is your chief concern, you should read one of the topics on my www.ER-doctor.com site (“A Novel Look at Physician Income: Why a medical career is the wrong career if money is one of your primary motives”) in which I proved that physicians can earn less than UPS drivers and many other seemingly less lucrative occupations, such as truck drivers, auto mechanics, contractors, autoworkers, and even strippers.

You are wise enough to consider the importance of money at a young age, while many of your peers have their thinking clouded by idealism that will likely dissipate in the years to come when they realize the benefits of extra income, such as being able to help your elderly parents or another family member in need. Thus, I think that it is perfectly valid to question whether one should go into healthcare when other occupations offer better pay and less investment of time and money. However, for heaven's sake no one should become a PA rather than an MD just to save time and money. You may not suffer, but your patients will.

If any PA wishes to dispute this, take me up on the following challenge: Let me perform a chart review of randomly selected patients treated by PAs, and see how often I could suggest other diagnoses or treatments that could benefit patients. In the above analyses, I bent over backwards to be conservative in discussing the incremental benefit of MDs versus PAs, but the actual benefit is greater than that. How much greater? Close to 100% of the time, and certainly more than 50% of the cases. To make this even more fair, you can select the best PA in the world, and pit him or her against me. If I could not suggest other diagnoses or treatments that could benefit patients in at least 50% of the cases, I'd give $1,000,000 to your favorite PA organization so it could use that money to fund propaganda to, for example, try persuading people that PAs are just as good as MDs. Conversely, if I could suggest other diagnoses or treatments that could benefit patients in at least 50% of the cases, that same PA organization would pay me $1,000,000. Now who wants to lose a million dollars?

No PA or PA organization would be foolish enough to accept that offer (update: over a decade later, none have), because I would not only win convincingly, but I would publicize the results to prove to the public that PAs cannot fill the shoes of an MD.

I wish that I could post the message of the last person who wrote to me contemplating a PA career, but I was so disgusted by what she wrote that I immediately deleted it. Basically, she said that she worked full-time and didn't have the time to become a physician. She wanted to treat patients, but she wanted a shortcut. She acknowledged that PAs are not as good as MDs, but she did not want to make the sacrifices required to become an MD. In other words, she's #1 and patients are #2.

Hmmm, a lazy person unwilling to make sacrifices who is looking for shortcuts? How many patients want to put their health and well-being into the hands of such a person? You decide.

If you're an irate PA or NP who wants to rip my spleen out, please read this.

Physician Assistant eaten by a grizzly bear: Might extra knowledge have saved her life?

Timothy Treadwell rose to fame as the "Grizzly Man," who slept with a teddy bear while living amongst wild grizzly bears in Alaska to photograph and videotape them. Unlike others who've performed similar work, his bizarre videos spent a significant time focusing on Treadwell and his eccentric rants, which ranged from highly questionable speculations about what the bears were thinking to diatribes about the government's National Park Service. Treadwell attracted the attention of numerous people, including Amie Huguenard, a PA from California, who became his girlfriend and lived with him during the summer in Alaska for a few years. During this time, Treadwell gave cutesy names to the grizzlies and crossed the line of common sense by doing things such as touching bears on the nose. Yes, really.

I watched a documentary detailing Treadwell's life with a friend of mine who is a psychologist. Both of us were struck by the fact that he appeared to be mentally ill almost every time he opened his mouth. We were amazed that his girlfriend apparently seemed blind to the fact that Treadwell was more than just passionate about bears: he was obviously in need of a psychiatrist. We wondered how much Huguenard had learned about mental illness during her Physician Assistant training. Not much, we speculated.

The lives of Treadwell and Huguenard were cut short when they were eaten by a grizzly bear in 2003. The sounds of this horrific mauling were captured on videotape that has not been released to the public. That is regrettable, in my opinion, because it would help replace the Walt Disney conception of wild animals that many people possess, and replace it with a dose of reality. To fully appreciate their nightmarish end, that audio should be supplemented by pictures of the remains of Treadwell and Huguenard, such as those extracted from the bear's stomach. The pictures now available tell a misleadingly one-sided story, such as showing Treadwell smiling with sunglasses on, looking like a poster boy for a California surfer dude.

As an ER doctor, I have seen mangled bodies that the public never sees. Newspapers and magazines don't publish such pictures because their editors evidently think they are sparing you by that omission. Rather than sparing you, they are presenting a lopsided view of reality in which you and others never see how life can come to a shockingly brutal end. Seeing that gruesome reality would save lives by increasing awareness of the consequences of a multitude of stupid behaviors.

MD versus PA:  A parallel to RN versus LPN?

Q:  Dear Dr. Pezzi:  I am a registered nurse.  As you probably know, many hospitals have been cutting back on RNs and replacing them with cheaper and less educated LPNs (licensed practical nurses) and NAs (nursing assistants).  We RNs have been up in arms about this because it affects patient care.  As you mentioned in regard to PAs and MDs in the ER, it isn't possible to take a person with more education and replace him or her with one who is not as well trained, and expect that patients will receive the same care.  Therefore, it seems to me that doctors and RNs have some common ground on this issue.  Your thoughts?  Beth

A:  That is an interesting parallel, Beth.  I have some RN friends who are outraged by the fact that they're being shoved aside so that LPNs and NAs can take their place.  RNs are better educated and generally smarter than LPNs and NAs, so the latter two obviously cannot fill the shoes of registered nurses.  This doesn't stop hospitals from trying, because many of them are headed by administrators whose primary concern is the bottom line, not quality of care.

I'll never forget the first time I realized how this problem was so far-reaching.  It was a slow night in the ER, so I moseyed up to the inpatient floor to spend some time at the nursing station.  One of the RNs stopped charting and looked up at me.  I can't recall her exact words, but the gist of her message was this:  We RNs are frustrated.  The hospital is cutting back on RNs and replacing us with LPNs and NAs, but there is no way they can do as good a job as we can.  (She then gave a personal story to illustrate this, recalling how she'd astutely picked up on the fact that a post-surgical patient was deteriorating.  The signs were subtle and likely would have been missed by a less competent practitioner.  She called the surgeon, who trusted her clinical acumen, and he came in to re-operate.  Afterwards, he told her that any more delay likely would have been fatal.)  Patients are bound to suffer as a result.  The cutbacks are destroying the morale of the RNs who are left, because we're being spread too thin to supervise an impossible number of LPNs and their patients.  We used to enjoy bonding with patients, but now our ability to do that is hampered because our patient load is increased.  Bonding is not just a welcome pleasantry for the patient and nurse, but an essential part of good care that enables us to make more subtle analyses sooner — not later, which may be too late.  Some of us are so burned out that we're thinking of leaving the nursing profession.  I'm being asked to supervise and take responsibility for LPNs who aren't as educated or experienced as I am, and I frankly don't trust some of them.

The predicament that RNs face is similar to the situation that doctors encounter in regard to PAs.  The public is being misled into thinking that this substitution has no accompanying risk.  This is ridiculous.  What's next?  Replacing teachers and police officers with people who have a fraction of their training?  Replacing the Special Forces with the National Guard?  Replacing college professors with graduate students?  Education, training, and brainpower make a difference, so unequal substitutions carry an inevitable price.  Consumers are expected to endure these substitutions without recompense.  Whether it is Dannon reducing the size of its yogurt containers without discounting the price, or hospital administrators replacing RNs with LPNs, American consumers are being hoodwinked.

While doctors and registered nurses have some common interests on this issue, I doubt that doctors will readily join forces with RNs to combat it.  As I've previously pointed out numerous times, most doctors are too spineless.  They typically keep taking it on the chin, and won't complain until things get way out of hand.  For example, it has only been in the past year or so that doctors have begun to take a stand on the malpractice crisis, even though it was clear two decades ago that attorneys changed the ground rules from "suing with cause" to "suing because it is profitable."  Even now, as many doctors are forced to cease practicing medicine or move to a less litigious state, doctors capitulate too readily and accept Band-Aid reforms that fail to address the fact that an adversarial system is not the best way to compensate patients for medical errors.

I've railed against spineless doctors because their ostrich mentality is slowly but surely degrading the medical profession.  While medical schools do not have empty seats in their freshmen classes, their enrollment is being maintained at the expense of lowered standards of acceptance for admission (sorry, PAs, but the average medical student is still smarter and better educated than the average PA student).  If RNs could somehow get doctors to wake up and join forces with them, they could be a powerful voice in educating the public and bucking the trend to replace practitioners with less qualified ones.  I think that one reason why physicians often welcome working with PAs instead of branding them as interlopers is because too many doctors don't give much thought to this subject.  They're just happy to have someone there to share the workload.  This gratitude is premature, because if the workload demands more than one practitioner, a doctor could fill that position instead of a PA — and a second doctor could do more to help out the first doctor and the patients seen in that facility.

To allay the suspicions of ER PAs that my interest in this topic is motivated by financial concerns, I should mention that I'd return to work in the ER only if that were my last option for staying out of the soup line.  Anyone who has read my books and web site knows that the practice of emergency medicine is a very noxious one for many reasons.  I broached the PA topic in Men's Health only because I truly believe that education, training, and brainpower make a difference, and I've seen too much readiness to think that a white coat is a white coat.  This is not just a theoretical problem; I've seen mistakes made by ER PAs that I've never seen made by ER physicians, even though I've seen far more ER docs in action.  To make this discussion as fair as possible to PAs, for a moment let's forget about the "even a Boy Scout could do better" actions that I witnessed, and focus on the best PA I knew.  There was still a chasm of difference between him and an average ER doctor!  PAs cannot match physicians in terms of depth or breadth of knowledge.  Any LPN or PA who wishes to sway my viewpoint on this subject is free to try, but in my opinion it is fatuous to suggest that education, training, and brainpower are so inconsequential that unequal substitutions can be made without affecting patient care.

The November, 2003 issue of Reader's Digest included a letter to the editor that made my jaw drop.  The letter was written by an LPN who said that LPNs are sometimes disparaged as "Let's Pretend Nurses" by RNs ("Let's Play Nurse" is another version, according to an RN friend of mine).  She admitted the obvious (that LPNs have less education than RNs), then went on to say that there would be fewer mistakes and needless deaths if hospitals would "give us a chance."  What?  The way to produce better nurses is to give them less training?  Dang!  I knew I should have dropped out of kindergarten!  Had I done that, I'm sure I would have become the world's best doctor!  Yes folks, the PAs and LPNs have finally convinced me that the way to produce superior healthcare practitioners is to give them less education.  And think of the money we'll save on all those useless years of schooling, and tons of worthless textbooks!

If you're an irate PA or NP who wants to rip my spleen out, please read this.

Why do medical schools vaunt the diversity of their incoming freshman class?

Q:  Hi doc.  My name is Renee and I'm in the process of applying to medical school.  I've noticed that some medical schools like to brag about the diversity of their incoming freshman class.  Why?  They want us to have high grades and MCAT scores . . . and be globetrotters, too?

A:  I've often wondered the same thing.  I suspect they tout diversity because it's the trendy thing to do.  I've read several medical school newsletters which boasted that they'd accepted people such as a street luger, a swami, a chef from Bosnia, and a former member of the French Foreign Legion (OK, the last one was a stretch, but the others are very much in line with some of the things I've read).  UPDATE:  A few months after I wrote this, I read an article in U.S. News & World Report in which a medical student mentioned that her classmates included a former deputy sheriff, a homeless-clinic manager, a member of the Puerto Rican national field hockey team, and someone with months of experience scuba diving in Antarctica.

Ironically, however, once those supposedly diverse students are in medical school, they're hammered into a one-size-fits-all mold of what a medical student should be.  I learned early on that professors love robots and despise heretics.  When you're on rounds with a professor of surgery, he doesn't want your cute personality or any hint that you were actually once a real person.  What he wants is for you to stand attentively, clearly and concisely answer his questions when he grills you, and then shut up.  I wouldn't be surprised if Marines in boot camp are freer to express themselves.

The Munchausen syndrome
Munchausen by proxy
An unusual motivation for Munchausen by proxy:  sex?
Yet another example of how hospital administrators corrupt the practice of medicine in their never-ending quest for money

Q:  I am doing a report on the Munchausen syndrome, and I wonder if you've seen any of these cases in the ER?  Thanks, Rick.

A:  Do bears sleep in the forest?  Of course I have!  I could write a book filled with such cases.

The Munchausen syndrome, a.k.a. pathologic malingering, is characterized by the feigning of illness or other incapacity in an attempt to reap some secondary gain, such as the avoidance of duty or work.  The normally staid Merck Manual pejoratively terms people with this condition "hospital hobos."  ER personnel usually aren't fond of highfaluting names, so instead of employing the term Munchausen syndrome, they often prefer a more derisive appellation, "bullshit."

There is a related syndrome, Munchausen by proxy, in which people (typically parents) create problems in others (usually their children) for their own twisted reasons.  These folks often enjoy going to the doctor or hospital, or they love the attention bestowed on them from sympathetic friends or relatives.  That almost seems quaint in comparison to some of the more sinister motivations.

Q:  Such as what?

A:  Money or sex.

Q:  Can you give me an example?  I'd like to include one in my report.

A:  Years ago in the ER, I had a man who'd frequently bring in his adult daughter for treatment.  She was once gainfully employed and living on her own, but once her mysterious illness began (no one ever pinned down its exact cause), she moved back home with him.  His solicitousness went beyond the usual parental concern, and from the way those two carried on in the ER, some of the nurses and I suspected that they were lovers.  I've seen thousand of parents of all ages interact with their children, and this is the only case that struck me as being incestuous.

Since the patient lapped up his affections and their relationship appeared to be outwardly consensual, I didn't bother to stick my nose into the matter.  She was an adult, and seemingly a willing one.  However, now that your question prompted me to reconsider this case, I wonder if the father purposely induced his daughter's condition to create a dependency that allowed him to spellbind her?

Q:  How might he have done that?

A:  By giving her some toxic substance.  Given her symptoms, he had hundreds or thousands to choose from.

Q:  What was his motivation?

A:  I don't know.  However, considering their dramatic displays of affection in the ER, it's safe to assume that this was no ordinary father-daughter bond.  Their relationship seemed mawkish, repeatedly grated on my sense of propriety, and just struck me as being odd.  It's clear that he enjoyed every minute of it.  Perhaps he had no other motivation, but in view of his sappy and overblown affection, every time I saw them I thought, "He's boinking her."

The fact that they seemed to be romantically involved was indisputable; their behavior was so blatant that occasionally another patient in the ER would ask me, "What's up with those two?"  The only thing that is debatable is whether he did anything to create her condition so he could form an unusually affectionate, and perhaps sexual, bond.

Q:  What was she like?

A:  Odd.  While she met all the legal criteria for sanity (thus handcuffing me), there was a regressive aspect to her personality.  This infantilism meshed well with the father's excessive nurturance.  I wonder if she was always that way, or if that regression was due to some mental degeneration that may have been a side effect of the toxin?  Again, it's purely speculation on my part as to whether he'd given her a toxin, but this was such a bizarre pair that it's natural to consider if there was yet another element of strangeness to this story.

Q:  If you thought he may have been doing this, why didn't you do anything about it?

A:  First, at the time I saw that patient, it never occurred to me that he might have induced her condition.  Second, even if I had suspected it, there was no tactful way to broach the subject.  What could I say?  "Excuse me, Miss, but you strike me as being strange and childish.  Were you always that way?"  Keep in mind that this was in the ER, so I didn't have time to pry into their lives.  Even if I had the time, I wouldn't have done it because by then I'd learned that the hospital brass didn't want me to antagonize their customers (my patients), even when I had a clear-cut duty to intervene.  For example, I once had an elderly patient who smashed into two cars when he went outside to move his pickup truck.  From that display of ineptitude, and from my examination, I determined that he was no longer competent to drive.  I requested that he voluntarily stop driving and surrender his license, but he told me to go to hell.  I called the police, and told them to yank his license.  When word of this reached the hospital's administration, they threw a conniption fit.  How dare I deprive a patient of his license!  That patient was more impaired than an average person with a blood alcohol level three times the legal limit, and his condition wasn't reversible, as is intoxication.  Hence, it was my duty as a physician to protect that patient, and to protect others from him.  Nevertheless, the nitwit administrators didn't care if that patient might plow into a dozen kids at a bus stop, they just wanted a happy customer who'd keep coming back.

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

Book info  Ordering info

Now available as a free e-book download

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

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

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

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

The link between nutrition and brainpower
Vitamin B-12 and brainpower
Trans fats:  a nemesis to cholesterol levels and more
Importance of staying healthy
Can cell phones affect learning?

Q:  My goal is to become a physician, and I want to do everything I can to realize that dream.  From reading your web site, it is clear that you advocate good nutrition.  Can proper eating make a tangible difference in mental performance?  Thank you Dr. Pezzi, Brittany

A:  Yes.  This is scientifically proven.  Once you learn biochemistry and neurophysiology, you will realize the critical roles played by various nutrients.  The nexus between nutrition and mental performance isn't nebulous.  It's crystal clear.  All of the processes that directly or indirectly influence thinking are influenced by nutrition.  Thought is just one end product, so to speak, of neurotransmission.  Neurotransmission can have other end products, too, such as muscular contraction or glandular secretion.  It is important to realize that while thought may seem to be some intangible thing that is purely mental and has nothing to do with the body, it is the processes of the body that create the thought.  The mind-body dichotomy is an antiquated concept.

Q:  Can you give me all your nutrition tips?

A:  No, because I could fill a book with those tips.  I included many tips in Fascinating Health Secrets and The Science of Sex.  Interestingly, libido and sexual pleasure are also just end products of neurotransmission.  Many people think that sexual desire and sexual sensations are vague bodily processes whose origin is so indefinite that they seem to be largely immutable.  As a result, many people with diminished libido, sensation, or orgasmic ability go through their entire lives with second-rate sexual enjoyment, because they resigned themselves to thinking that nothing could be done for them.  What a tragedy.  It is also a tragedy when nutritional inadequacies lead to second-rate mental performance.  Granted, everyone does not have a job in which it is critical to maximize brainpower.  However, sexual pleasure matters to just about everyone, and so does feeling good in an emotional sense.  That is also affected by nutrition.

The February 8, 2003 edition of Science News discussed a current theory that high intelligence results from brain cells having a thicker-than-average myelin coating.  Thus, it is advisable to ensure that your myelin production isn't hampered.  That can result from a deficiency of vitamin B-12.  People often assume that only vegetarians need to worry about B-12 deficiency.  Wrong.  Here is an excerpt from The Science of Sex:

Vitamin B-12 is necessary for myelin production.  Myelin is a sheath that encapsulates nerves, and it is a major constituent of the brain.  Myelin is analogous to plastic insulation on electrical wires.  Imagine the havoc that ensues when wires are stripped of their insulation.  A similar breakdown in normal function results when the myelin sheath is disrupted.  This can cause a number of problems, one of which is sexual numbness.  Penile or clitoral sensation is reduced both before and during orgasm.  However, the ability to perceive vibration is affected more than general tactile sensation, so people with a B-12 neuropathy may experience relatively normal sexual pleasure during intercourse, but don't find vibrators as stimulating as they once were.  Just as your camcorder has separate detectors for audio (a microphone) and for video (a photosensitive chip), humans have different types of nerve receptors and separate nerve pathways.  Many neurological diseases target specific aspects of these pathways, and this produces symptoms in some areas but not in others.  This occurs in B-12 neuropathy, in which the ability to perceive vibration is affected in the early stages, accompanied by impaired position sense (the ability to perceive the location of your extremities without visual clues).

Judging by some studies that looked at the prevalence of undiagnosed pernicious anemia (a severe form of vitamin B-12 deficiency), many doctors are not very adept at detecting this. And this, mind you, is even true when some docs are presented with textbook cases, not some vague below-the-belt disappointment.  If you're seeing your doctor for a routine physical and you mention that sex doesn't feel as good as it once did, the chance that your physician would consider a B-12 deficiency in his differential diagnosis is close to zero.

Vitamin B-12 deficiency is most common in older folks, but it can also occur in younger people.  The most frequent cause is an autoimmune atrophic gastritis that results in inadequate production of intrinsic factor, a compound necessary for B-12 absorption.  It may also result from a dietary deficiency due to a strict vegetarian diet, or just a plain ol' crummy diet with too many calories supplied by soft drinks, other junk food, or booze.  Other risk factors are some types of gastrointestinal surgery and malabsorption syndromes.

In the past few years, more foods have been supplemented with folic acid in an effort to reduce the incidence of fetal neural tube defects such as spina bifida and anencephaly (congenital absence of most of the brain).  Unfortunately, folic acid can mask the anemia that often accompanies pernicious anemia.  This may confound the diagnosis, which might remain elusive until neurological changes ensue.  These may be permanent if they are not caught and treated soon enough.

Physicians often use serum vitamin B-12 levels to assess a possible deficiency.  However, even patients with seemingly normal levels can be deficient.  The tissue vitamin B-12 status is more accurately reflected by measuring the serum methylmalonic acid levels, so this test is the new gold standard.  If your doc isn't up to date on B-12, he might order a B-12 level and omit the methylmalonic acid determination, so you may need to suggest this test.

In Fascinating Health Secrets, I went out on a limb and gave some recommendations whose benefits were logically apparent to me, but had yet to be substantiated by scientific studies.  When I'd later see some magazine discussing a scientific study that verified what I said, I'd just smile when they glowingly spoke of that fact as a new breakthrough.  New, I thought?  I've been saying that for years.  With this as a backdrop, I will now make another prediction that I've yet to hear anyone else say, yet I'm convinced that science will sooner or later get around to verifying.  Here is the prediction:  I believe that consumption of trans fatty acids can adversely affect both thought and mood.  Science has shown that trans fats negatively affect cholesterol by decreasing HDL (the "good cholesterol") and increasing LDL (the "bad cholesterol").  Over time, this contributes to heart disease, strokes, and impotence by clogging arteries.  However, I think that trans fats are hurting us in other ways, too.

Why are trans fats bad for you?  Because your body is designed to work with cis fats.  The difference between a trans fat and a cis fat is the spatial orientation of some of its molecules.  To conceptualize this, think of a cis fat as a key, and a trans fat as a mirror image of that key.  Obviously, only the cis key will fit in the lock; its mirror image (the trans key) cannot.

Some dietary fat is incorporated into the body, becoming part of its structure.  Dietary fat can also be converted into prostaglandins, which you can think of as short-range hormones (this is discussed in much greater detail in Fascinating Health Secrets and The Science of Sex).  Dietary fat can also be metabolized to provide energy.  Judging by the damage done by trans fats on cholesterol levels, it is clear that consumption of trans fats can disrupt normal bodily processes, skewing them from normal, optimal functioning to abnormal, suboptimal functioning.  Given the ubiquitous role of fats in our bodies, is it reasonable to assume that trans fats only affect cholesterol metabolism, leaving the zillion other metabolic processes totally unscathed?  I think it is ludicrous to assume this.  I think that the negative consequences of trans fats are far-reaching, impairing our health, brainpower, and mood in many ways.

Some people wait for irrefutable scientific evidence before they adopt a new health recommendation.  That may be wise in some cases (such as when a supplement manufacturer makes unsubstantiated claims about the benefits of one of their products), but not in situations such as this one concerning trans fats.  Trans fats do nothing good for you, and they harm your cholesterol levels.  Thus, if you avoid trans fats, you're better off even if my speculation about their effects on thought and mood are never proven.  However, I am convinced that avoiding trans fats will benefit you in many ways.

To avoid trans fats, you need to read ingredient labels.  Look for the words "hydrogenated" or "partially hydrogenated."  If it's hydrogenated to any degree (totally or partially), that food will contain trans fats because trans fats are created during hydrogenation.  Trans fats are present in many, but not all, processed foods.  If reading ingredient labels is too arduous, just avoid processed foods.

You should shun trans fats, but ensure that you get enough good fats.  Strictly speaking, there are only two fats that your body needs; these are called the essential fatty acids, or EFA's.  There are two EFA's:  linoleic acid and linolenic acid.  However, other fats are also beneficial, such as EPA (eicosapentaenoic acid), DHA (docosahexaenoic acid), and monounsaturated fats.  Some good fat sources are salmon, olive oil, walnuts, and peanut oil (peanut butter is fine if it is natural peanut butter in which the oil separates).

Q:  Have you noticed any personal benefit to avoiding trans fats?

A:  Yes.  I do not like to admit this, given that I am a proponent of healthy eating and I hate to be a hypocrite, but during my residency and the first several years when I was an attending ER doctor, I succumbed to the convenience of processed foods.  During this time, my creativity plummeted to an alarming degree:  from dozens of inventions per year to one or two.  It wasn't as if I was too busy to be creative.  In my first job as an attending, I had plenty of free time—far more than I do now.  However, now that I've been avoiding trans fats for years, my creativity skyrocketed and I sometimes have a dozen inventions per day.  That may be a coincidence, or there may be some causal relationship.  I'm not particularly concerned by this uncertainty, since I'd avoid trans fats just to have a better cholesterol level.

In conclusion, I'd like to leave you with one rhetorical question:  why should you not avoid trans fats?

Q:  I hope that I am not monopolizing your time, but can you give me any more tips?

A:  Yes.  Stay healthy.  If you develop the flu or some other nontrivial infection around exam time, your performance will obviously suffer.  If this happens when you're scheduled for the MCAT exam, it could change your life, or at least set you back a year.  Many young people are very nonchalant about their health.  Most of them are strong and resilient enough so they can get away with it, but I know of some tragic cases.  For example, my best friend's girlfriend contracted what initially seemed to be some nondescript infection, but that settled in her heart and killed her.  Other college students develop meningitis and suffer brain damage or die a half-century too early.

Speaking of brain damage, you might want to limit use of cellular phones to urgent or emergency use only.  Cell phone users breathed a collective sigh of relief when the evidence linking cell phone radiation to brain cancer proved to be inconclusive.  However, subsequent studies suggest that cell phone usage might impair learning and memory.  Here is just one example.  A study by Leif Salford of Lund University Hospital in Sweden showed that a single two-hour exposure to cell phone radiation killed or injured up to 2% of brain cells in rats, even when the exposure was just 100 milliwatts (substantially lower than the 600 milliwatts emitted by most portable cell phones).  Don't take comfort in the fact that you don't have rat brain cells.  The similarities between human and rat biology are far greater than our differences, which is why rats are frequently the subject of scientific experimentation.

Cordless phones are another thing I think should be used only when necessary, not habitually when a corded phone would do just as well.  Cordless phones emit less energy than cell phones, but until this exposure is conclusively proven to be safe, I think it is prudent to think of it as a possible risk.  Many people reflexively assume that unknown risks can be assumed to be safe, but history has shown this can be a risky strategy.

I give several tips for staying healthy on the page of excerpts from Fascinating Health Secrets.  I think it'd be well worth your time to read that entire book, because reading it might take two days, but will likely save you months or years of illness throughout your life.

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

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

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

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

by Kevin Pezzi, MD

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

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