Psychotic Medical Students

Doctor D gets lots of emails from students considering medical school.

Hey, if the practice of medicine is your dream then you should go for it, but be forewarned it isn't sexy or glamorous like on Grey's Anatomy. It is years of drudgery in which helping patients and feeling awesome about yourself will be the exception rather than the rule.

But I pray to God you never go totally off your rocker and spend your precious days off making videos like these:






Doctor D has more relevant material than silly parodies of parodies of parodies, but unfortunately not the time to post it right now.

He's also about 2 months behind on answering AskAnMD emails. Feel free to chastise him the comments!

My Favorite Patient Died Today

I just got a call from one of his relatives who found my number in his wallet:

“The Dude” was one of Doctor D’s first patients. He was assigned me when I was a new doc starting out in residency.

The Dude was one of those people that we all go into medicine to “help.” He was poor, and on disability, and had never gone any further than high school. The Dude also weighed about 400 pounds and smoked 4 packs a day, and he hated taking medicine ...and it was new Doctor D’s job to “take care of him.”

Medically speaking, I never was much good for The Dude. He kept doing all the things that eventually lead to his demise. In the end though, it was he that did me immeasurable good.

He actually preferred residents to our better-trained teachers, “I love these new Baby Docs when they come each year!” he exclaimed when he met Doctor D. From then on Dr. D and the Dude were always together. The Dude had a lot of office visits and hospitalizations. He was the epitome of the “difficult patient” and D spent his first year as a doctor stressing about how to save The Dude from impending death.

But it was The Dude who won out. His infectious kindness and joy in the face of pain and illness inoculated Doctor D against the harsh medical world around us.

One day D visited The Dude in the ICU and muttered, “How am I going to save you, Dude?”

The Dude let out a gravelly, smokey chuckle, “You don’t need to save me Doctor D! You’re just nice to me and I appreciate that.”

The Dude is laid to rest

Our doctor-patient relationship evolved over our years together. I did less telling him what to do and more sitting at the feet of one of the wisest human beings I have ever known. The Dude lacked any book smarts, but I know he was brilliant. He understood how a joyful attitude can keep you alive when every textbook says you should have died years ago.

The Dude had about the most unhealthy body and physical habits you can imagine, but he had the healthiest soul of any person I have ever met. He taught Doctor D that there is so much more to life than diagnoses and treatments.

The Dude promised he would try to stay alive long enough to see me graduate from my residency. He ended up outliving his promise by years. I moved to another state after graduation, but we stayed in touch. I was no longer his doctor, but we remained friends.

I took my son Little D on a road trip when he was just a baby to meet my sage friend. It was well worth exposing the kid to a little second-hand smoke. It was like taking your child to be blessed by a living saint.

The Dude and I would write or talk on the phone every couple of months. I started this blog with The Dude in mind. I wanted to answer questions for real folks like him that didn’t give a damn about medical stuff, but found themselves stuck in doctors offices and hospitals anyway. He's the only patient I ever cared for in real life who knew about my secret identity as Doctor D. He read regularly.

We last spoke about 6 months ago. I had “Call The Dude” on my long list of things to do last month, but I never got around to it. I sure wish I’d called my jolly, smokey old friend!

It came as a shock that he's dead—which is strange considering I expected him to die at any moment for the first few years I knew him, but once you really love someone you kind of expect them to live on forever.

Now The Dude is in a place where he has no need for doctors or medicines.

Enjoy heaven, my friend! I wish I'd told you that you were the best teacher Doctor D ever had!

I Hate Medicine!

Last week Ella the Med Student wrote brilliant and thoughtful advice on how to be happy in medical school: You need to love medicine.

Now Doctor D has a confession to make:

I hate medicine! Medical school was the worst 4 years of my life.

There, I said it! It felt good to let it out.

But before all of Dr. D’s medstudent fans rush to unfriend him on facebook they should know this: Doctor D not just a good doctor. He is a frickin’ amazing doctor!

How is this possible?

They look so pleased just to be in a hospital!
Doctor D isn't in any photos like this.

How I Learned to Stop Worrying and Hate Medicine:

Ella classified medical students based on their love for medicine with the “miserablites” at the bottom. They are the ones in medicine with ulterior motives. Therefore they hate school from the first cut on the cadaver. They don’t fit in with other medical folks. They don’t like studying diseases or treatments. They can’t wait for medical school to be over.

Yup, that pretty much describes D in medical school!

Young D took one of those aptitude tests administered by the college career counselor. It said that his personality was an awful fit for doctoring. He was warned.

So why did he do it?

Medical School With Ulterior Motives

Doctor D’s ulterior motive for studying medicine was that pesky humanitarian impulse. D loves people. As a student young D worked in homeless shelters and volunteered in 3rd World countries—not to pad a resume for med school, but because he actually liked doing those things. Young D asked himself, “Self, what work should you choose that allows you to help suffering people?” Since D had the book smarts everybody suggested medicine.

On day one of medical school D realized he wasn’t in Kansas anymore. He was surrounded by highly driven people who absolutely loved spending 18 hours a day studying pathophysiology and pharmacokinetics. Ella enjoys kicking back with Robbins Pathology while sipping her coffee in the morning. God bless her crazy ass! Doctor D’s trudge through Robbins was about as enjoyable as the Bataan Death March.

D’s secret fantasy in medical school was that one day he’d go in and give everyone the middle finger and drop out. This thought was the only real pleasure he had for most of med school. It kept him going when times got rough. Every miserable day D told himself, “I’ll quit tomorrow.” He came close to doing this about a hundred times, but never pulled the trigger.

Doctoring with Love and Hate

So D became Doctor D, and lo and behold he was right: All this dull medical science he forced himself to learn is useful—it helps sick people get well, and D really enjoys his job!

The actual practice of medicine allows for amazing connection with other human beings. A caring doctor during the worst and most painful day of your life is really useful. Doctor D always gets along well with patients. One reason Dr. D connects so well with patients is that he never really did connect with other medical folks.

Some doctors love studying diseases and reading the latest medical trials—quite a few retired docs do this years after they’ve seen their last patient. That’s cool and all, but it ain’t me. If Doctor D lost his medical license tomorrow you can bet he wouldn’t read another sentence of medical literature again!

"Yeah, I don't like school either, but some things are worth the misery."

But Doctor D does keep up with all the info on the escalating arms race between diseases and medicine and he'll treat you with just as much skill as the next doctor. In some ways D sees himself as the purest form of doctor:

Some doctors battle illness because they are fascinated with the weapons or with the battle strategy. Doctor D fights because he believes in the cause.

So take courage you med school miserablites—you sad souls who don’t like biochemistry or fit in with your anal classmates—here is hope for you yet! You may yet become a fine MD who loves this crazy job in a way those medical types could never imagine.

PS: If any of you med students do decide to go out in a blaze of glory by telling "the man" to stick it up his rectum and burning your student ID please email Dr. D your story because he would love to live that moment vicariously!

An informal AskAnMD poll:

How many of you medical people actually like medicine vs. those who use medicine for ulterior motives like Dr. D?

How many of you patients would care if you doctor wasn’t actually fascinated with your disease and your medicines?

Will Medical School Make Me Miserable?

Part II of ongoing series: Should I Become A Doctor?

Great question from a potential medical student:

"I got accepted to med school for 2011, but I am scared to commit to this decision. Will medical school suck all life out of me, leaving me passionless, tired and with no ambitions?"

For this question Doctor D called in a consult! Doctor D recruited a real live medical student! Ella the Med Student is a brilliant blogger and a winner of the coveted Big D Award!

Ella's Advice:

Medical school is difficult. It takes tons of time. It's stressful. It is a huge commitment. It's competitive. It is also a million other wonderful things.

Everyone in medical school has essentially the same experience, the same course load, the same time schedule, etc. Yet, you will hear very different opinion from students about their medical school experience... ranging from "it was the worst time in my life" to "this is so much fun!"

The MAJOR factor that contributes to the differences in student's experiences in medical school is why they are there.

"Why am I here?"

Let me describe a pattern I have noticed among medical student. I think there are three main groups of student attitudes about medical school. I'll describe them here...

Ella’s Taxonomy of Medical Students:

The Good

The happiest students are those who are enjoying the journey. They actually love medicine, love the material they are studying, love the lifestyle of continued learning and a high-paced academic environment. Of course, many have other interests and families, but to them medical school is not an obstacle in the way of those things. Med school is an awesome part of their life.

"I'm happier than a pig in mud! Medical school is Awesome!"

Personally, I love reading my huge Robbins pathology book with a cup of coffee in the early morning. I love going to lecture and participating in clinical problem solving. I feel a rush every time I am in the hospital, I talk to my patients for too long, and my brain is always coming up with ideas for projects and research. I look forward to residency and my future career, but I am in no way miserable in school. I absolutely could NOT imagine being anything other than a physician... it took me so much work to get here that I am actually in bliss all the time. I know this sounds weird... but I know a lot of other people like this. If you ask them about medical school, they will describe it just like I have.

The (sort of) Bad

The second group of people are those that like medicine just fine, and it came to it as a reasonable choice. They worked hard in undergrad, and are all around strong academic students. To them, medicine is more of "a good field to be in" but not "the most amazing and only possible career on the planet." They could have been attorneys or engineers or business entrepreneurs or stock brokers and would have been just as happy. They do well academically, but are a bit blase about medicine... often eager to get home, eager to skip extra discussion about a disease or patient, and tend to be a bit frustrated with the rigmarole that comes with medicine. This doesn't make them less of a physician, but they do not enjoy the ride of med school as much as the first group. They are "putting up" with med school... and looking forward to getting out so they can have a family, a paycheck and a steady schedule.

The Ugly

The third group are the Miserablites. They hate medical school. They are barely hanging on by a thread academically, and they are socially and academically absent. They are caught up in the idea that that are in the wrong spot. They've realized that medicine is a lifestyle that doesn't end after medical school... and they expect that stress and academic/hospital nonsense will be a theme in their lives forever.

Some miserablites ended up in medical school because of outside influences. They felt pressured to do something "worthwhile.” Their heart wasn't in it... but they either didn't have another readily identifiable passion, or they felt their other passion didn't hold enough weight.

Other miserablites came to medical school for the money or lifestyle, and quickly figured out that those reasons are not sufficient to motivate you through the insanity of medical school. And they also figured out too late that being a doctor usually doesn't make you rich. 90% of doctors are not free of financial obligations. Student loans, malpractice insurance, etc. make the life less than glamorous.

The miserablites are those who, as you say regard medical school as "sucking all life out of me, leaving me absolutely passionless, tired and with no ambitions." I can tell you I have NEVER even one day felt this way about medical school.

Search Your Soul!

So, you have a lot of thinking to do. I would really consider what this commitment means, and how it will effect your goals. You have already identified some gut feelings about whether this career is a good match for you. I really think you owe yourself, your wallet, your future family, your happiness and your overall sanity some real hard soul-searching.

If you decide not to go into medicine, there is NO SHAME in that!

There are a million other things you can do which are just as rewarding. And if you do choose medicine as a career, choose it because it is best for you. It is indeed a wonderful life, but only if it is the life you really want.

Good luck!

What do you think? Doctor D always loves hearing your thoughts in the comments.

Patients: Would you care if your doctor enjoyed learning medicine?

Medical Students: Where do you fit in Ella's Taxonomy? Any of your Miserablites want to explain themselves?

Go on over to Ella's blog and admire how awesome she is!

Should Fear of Patients Keep You From Medicine?

The first of the series: Should I Become A Doctor?

A confused premed writes Doctor D for advice:

"I really want to be a doctor, but I have a fear of sick people. I don't mind needles or blood and guts, it's just people being physically sick that I am horrified by. It's the only thing holding me back from applying to Medical School. Is this something you think I can overcome?"

Excellent question my young friend!

The good news is that you aren't the only person who feels discomfort in the company of ill people. Many people feel this way to some extent or another. Ask any chronically ill person and they'll tell you how often people squirm in their presence. If you want to be a doctor you will eventually need to work comfortably around sick folks, but first lets examine why people feel this unease...

Why would you be horrified by sick people?

1) You're afraid you will catch their disease.

I suppose this is an understandable concern. But many illnesses aren't contagious and most of the others can be easily prevented with proper hand washing and immunizations. Doctor D has caught more things from his preschooler than he ever caught from patients!

But... I suppose there is always a small chance you will catch a bad illness from practicing medicine. If you aren't willing to take this risk then you should probably stay away from medical school.

2) Ill people remind you of your own frailty and mortality.

If you want to blissfully imagine you will live forever in perfect health the existence of illness in others is a painful reminder of reality. If fear of sick people is an extension of your personal dread of death then by all means stay away from medicine because every day at work will terrify you.

Believe it or not, a lot of narcissists with the this issue are drawn to medicine because they want the MD as a status symbol. They leave medical practice when they realize that the presence of suffering kills their hedonistic buzz. Good riddance!

3) Ill people make you uncomfortable because you feel their discomfort.

Human beings are social creatures. We all to some extent experience the world through the experiences of others. When we are around people who suffer—if we are at all feeling persons—we tend to feel a small amount of their pain.

This is Empathy, and empathy has motivated some truly amazing people to choose medicine as a career. Rather than avoiding the ill because of the sympathetic pain they feel, many empathic people want to help those who suffer.

If you are disturbed by ill people because you feel their pain, then you can become an understanding doctor goes the extra mile to help. We need more doctors like this.

If this is you, then you could have the makings of an excellent physician!

"Trust me kid, I'm more scared of you than you are of me!"

Disclaimer: Empathy Can Be Handicap Too!

If you feel so strongly for ill people that you turn into a puddle of ineffective mush when confronted with the suffering of another person then you aren't much use. Sick people come to doctors for help, and sympathy is an extra—a good extra, but only if it comes with professional help and skill.

Can you calm your emotions enough to think clearly and help people who are suffering greatly?

Also, empathetic doctors tend to get burned out. It's wonderful that you feel for your patients, but you have to realize that disease always wins in the end. You will lose a lot of patients. You will be unable to cure a lot of diseases. If your motivation for being in medicine is helping people's suffering you will have a lot of days you want to just give up. This is called compassion fatigue and it is the bane of kind doctors everywhere.

Can you keep doing your work with sick people and still care even when you lose again and again?

If you can maintain your empathy despite these obstacles you may just find that your initial anxiety around sick people made you into an even better doctor!

What do you think?

Patients: Would you be comfortable seeing a doctor who still sometimes feels uncomfortable around sick people? Would you go see our young premed once she graduates from medical school?

Med Students and Doctors: Have you ever overcome a dread of ill people?

PreMeds: Dr. D loves bringing premeds to the hospital and answering their questions about medicine. He always gives it to them straight about what it is really like to go through the training and then practice. So send him more questions!

Music, Marijuana, and Moving

Okay, this time Doctor D will be asking the questions!

Doctor D isn't answering questions this week because he's trying to take care of patients while packing up all his earthly belongings and he spent all last weekend camping in Tennessee with thousands of Hippies at Bonnaroo Music Festival, and is still recovering from sleep deprivation and a sunburn. But D did get to enjoy some excellent shows.

D got his musical groove on at quite a few shows such as Dave Matthews, Tori Amos, John Butler Trio, Regina Spector, Gillian Welch, Dave Rawlings, and a lot of no-name bands.

What was the best show, you may ask? Actually it was a British band that I had never heard of before: Mumford & Sons. You should check them out:



But even more noticeable than the music was the ubiquitous use of recreational drugs. Apparently D was the only person in the entire festival that was remained sober.

While I really appreciate all the friendly hippies that offered me all the free pot, if Doctor D ever fails a piss test the DEA could take away his prescribing privileges.

All of Doctor D's stoner friends understood and were kind enough to take all the free drugs themselves so as to protect D's license, but what really shocked them was that D had never tried drugs, even in his life before doctoring. They just never appealed to me. I was enjoying life enough without them.

By the way: Have you ever noticed how Baby Boomers (my parents) all say that they "experimented" with drugs in the 60's and 70's? Like it was so scientific! They weren't being irresponsible like kids these days—they were just doing it for science. They are all against drugs now because thanks to their rigorous research the hypothesis that drugs make you high has been proven beyond a doubt.

Doctor D's high friends were outraged that D had never been high. "How can you talk to patients about drugs if you never tried them?!?" They felt D's integrity as a physician was compromised by his lack of experience with recreational drugs.

Now my friends may have been high, but they bring up a legitimate point that a lot of AskAnMD readers have wondered as well:

How can a doctor care for people, when he or she has never experienced what they are going through?

Doctor D has never personally experienced 99% of the conditions he sees.

Of course, no one can experience everything, but why aren't we even trying to integrate personal experience into the training of doctors? Back in the old days they actually valued experience. They even used to intentionally infect medical students with diseases such as Typhoid or Malaria from time to time for research. They figured it was important they knew how it felt to be that sick. I can imagine that program went away after a few students kicked the bucket, but the idea behind it makes sense.

Why aren't medical schools intentionally recruiting students who have been patients with serious illnesses in the past?

What do you think: Should Doctor D try out a relatively benign mind-altering drug such as Marijuana, even if it doen't appeal to him, in order to better understand the experiences and motivations of his stoner patients?

I am eager to hear your thoughts.

...and while discussing:

What do you think of medical marijuana?

More and more states are asking doctors to be the "gatekeepers" for every possible way of getting high. Doctor D is kind of annoyed by this trend.

Doctors have had the pill form of marijuana available for years and its legitimate medical usefulness is very limited. Shift the responsibility to doctors and before you know it our offices get flooded with hippies who suddenly suffer from intractable nausea. If the legislature wants to legalize pot then they should do it in a straighforward manner. Doctor D, for one, will not be writing any prescriptions for weed.

I look forward to our thoughts in the comments. Thanks to everyone for your patience with D's lack of posting this month. The moving truck will be here in a few days and life has been too hectic for regular blogging.

I promise to be back on July 1st with a totally amazing answer post.

The Medical Mafia (Price Fixing in Medicine)

Question for Doctor D:

Why does it cost so much to see a doctor?

Great question! There are lots of good explanations, but Doctor D's gonna give you a revisionist history lesson that will open your mind:

Doctor D's gonna take you way back to the US over a hundred years ago: There were lots of doctors and visiting them was cheap. Doctors made a middle class living and medical schools worked like apprenticeships. Doctors did their best, but they didn't have most of the cool lifesaving stuff doctors have now.

But big change was coming...

New biomedical research was going to alter medical practice forever, and "The Man" saw the opportunity to create a cash cow medical-industrial complex that would swallow the US economy whole. But first The Man had to knock the little guys out of the action...

The newly incorporated American Medical Mafia Association made its move, hiring the intellectual hitman Abraham Flexner to execute their takeover.

That shady Mr. Flexner visited every medical school in the country. He knew exactly how to break the legs of the competition: Science.

The Flexner Report: An offer you can't refuse.

Medical science was bringing wonderful new knowledge into medicine, but in 1910 Flexner demanded that every doctor should be a scientist too. Every doctor must do years and years of basic science training before ever caring for patients. Flexner also recommended in his report that every medical school that wasn't associated with biomedical university research should be destroyed!

The mafia power play worked. The Flexner Report was hugely influential. The American Medical Mafia Association was given control over every medical school in the country. Don Flexner sent almost half the medical schools to "sleep with the fishes." With the little medical schools out of the way, the mafia now had complete control of who got to be doctors.

New Doctors: Nothing personal. It's just business.

The personable old "doc" of the past was replaced with the new scientific physician who knew more about organic chemistry than human interaction. New student doctors were taught to approach their patients with the cold objectivity of a scientist watching an experiment.

With the warmth and kindness of the doctor-patient relationship gone the study-weary doctors had no one to identify with but each other. Doctors became less a part of their communities and more a society unto themselves—making them easier for the medical mafia to control.

With total control the medical mafia cut supply to increase demand. With fewer doctors the price of a visit skyrocketed. Even doctors who might want to work for cheaper couldn't because of the massive debt from their new med-science education.

It's All About Control

The medical mafia keeps a tight stranglehold on medical schools. This country's population has gone way up in the last 100 years, but the medical mafia has been keeping a tight lid on the number of doctors. You might think with the current doctor shortage they would be begging every smart young person to go into medicine. Nope!

You want to be a doctor? You have to get excellent grades in lots of brutal courses, do a bunch of work on cells in a laboratory, be the president of some student organization, study like mad for the MCAT although it has nothing to do with medical practice, and promise them a decade out of the prime your life. Even still they're likely to say "No!" Every year thousands of bright students are refused entry to medical school even though they would make excellent doctors.

Why?

Refusal gives them power. It makes the ones that do get into the club special, powerful, and always in demand. With a stranglehold on the doctoring business the Medical Mafia has its fingers in every clinic and hospital in the country.

Ever wonder why the United States has to import doctors who barely speak English? Now you know. It's the only way to circumvent the Mafia's blockade on doctor supply.

But couldn't we just train more American doctors, shorten the length of medical education and lower its costs, and allow medical visits to be affordable and doctors to return to the middle class? You think The Man would let us get away with that? Forgetaboutit!

Abraham Flexner
"Kiss the ring, bitches!"

So next time you or your insurance shell out $600 for a visit to a specialist remember the Medical Mafia and Abraham Flexner. Don Flexner has been dead fifty years, but trust me he still owns us little guys.

Show some respect! The Medical Mafia is just taking your money for your own protection!

So what do you think? Most of medicine still sees Abraham Flexner as a hero. Doctor D's story may be silly, but most of the facts are true. How do we undo 100 years of history? How do we recreate quality medical care that doesn't bankrupt the country?

Doctor D looks forward to your ideas and observations in the comments.

Teaching Empathy (Fit Doctors and Sick Patients)

A reader asks:

My doctors are all very fit. It would seem that being a doctor is so demanding that it requires good health. Can doctors ever really understand what it's like to be ill?

Of course, doctors understand illness! We spend our whole lives studying it! ...but if you mean personal understanding of what it is like to feel your body betraying you, or the dread of approaching death, or the strained relationships created by severe illness—actually, most of us have never been there.

With a few notable exceptions, most people able to dedicate a dozen years of their prime to the punishing ordeal of becoming a doctor have always been pretty healthy in body and mind.

The worst Doctor D ever felt was a moderate case of sinusitis. I have no idea what how it feels to be in daily pain, to be unable to walk, to face death.

The Need For Empathy

So how do doctors, who are rarely sick, relate to ill patients?

Often poorly ...but if we do relate well it is through empathy: the emotional intelligence that allows us to experience the feelings of others. Doctors must learn the true experience of illness from our patients. Doctors may teach patients the science of disease, but in the experience of illness patients are the teachers and doctors are the learners.

Unfortunately, life in the medical business strains one's empathy. The sheer volume of suffering we see can make us numb. There is also the professional objectivity that we fear will be compromised if we care about your pain too much. Empathy may atrophy till a fit physician can diagnose and treat all day long without connecting with a single ill person in a humane, healing way.

Teaching Empathy

You—the patient—must teach the doctor. Empathy is a lesson physicians desperately need to learn. But how can you teach your MD?

The Direct Approach: Speak directly to your doctor about how uncomfortable your symptoms are and how miserable your illness makes your life. Remind your doctor about how horrible it is regularly, just to make sure they don't forget.

Hate to break it to you, but the direct approach doesn't work. In fact, it has the opposite effect. The more someone talks about their suffering the less we identify with it. Yes it's cruel, but it's human nature.

Remember when you were a kid and that elderly relative complained incessantly about their horrible bowels or joints? Chances are your grandmother really was miserable with those symptoms, but how much did you really empathize with her? Not much right? You just wanted her to stop complaining. It's called “compassion fatigue” and it has infected every doctor by about the 2nd year of medical school.

(By the way, I'm not saying you shouldn't tell your doctor your symptoms and how they affect you. Just don't expect compassion as the natural response to your discomfort.)

The Indirect Approach: Tell the doctors your symptoms and cooperate with them to diagnose and manage your disease. Only mention your miserable experience in passing. Instead, ask about how your physician is managing the stress of his or her life. Your doctor likely has a lot of frustrations despite their healthy body. Even if the doctor's problems seem petty compared with yours try to act like you care that it sucks to miss sleep or leave family dinner to care for a patient.

Believe it or not, this is the best way to teach empathy to doctors. The doctor will empathize with you instinctively.

We all naturally focus on our own sorrows and minimize the suffering of others. We awaken to empathy when we see that others care for us.

Doctors are educated in a system that only cares about how much they know and how hard they work. Few of their teachers care how they handle our rigorous training or the suffering they see. Doctors learn that feelings don't matter.

A caring patient's interest in a physician can teach more empathy than watching a whole world of suffering.

Doctor D has been told by patients that he is a caring physician. If so, it isn't because he has ever been ill himself, or any illness he's seen. It was because my first year of residency a patient with a miserable disease actually made an effort to find out about young D and encourage him. With an education like that how could I not want to understand the experience of every patient I met from then on?

What do you think? Is Doctor D too cynical about human nature? Have any patients out there had success with the “indirect approach” for teaching doctors to empathize? Healthcare people: Has a patient ever taught you empathy? Doctor D always loves to hear your thoughts and stories!

Primary Care: The Best and Worst Job in Medicine

Shawn the medical student asked Doctor D:

As a medical student, I am constantly wondering what type of physician I will become. So my question is, what kind of doctor are you, and how did you decide that field?

Doctor D is a Family Medicine doctor. He chose this career because he is a glutton for punishment! Actually, D chose Family Med because he likes people much more than he likes the technical aspects of medicine. As a jack-of-all-trades doctor I can usually help anyone no matter their age, gender, or medical history, but my knowledge on any specific subject is limited. I can sew up lacerations, give end of life care, deliver babies, prevent future illness, and educate people on how to handle most common medical problems. I did this because I enjoy working with human beings and want to help people with their physical needs.

Should you choose Family Medicine as your specialty you will be constantly looked down upon by other physicians. Even though you probably store more knowledge in your brain than any other doctor, specialists assume you are slow-witted because you don't know as much about their particular disease of choice as they do. You will make much less money than other doctors because insurance doesn't think keeping someone healthy is nearly as worthwhile as doing big tests and procedures. You will constantly be pressed to see more patients in less time because the reimbursement for your work is continually dropping.

After his training Doctor D chose to work in a community health clinic to provide primary care for underserved patients. He absolutely loved his job and the amazing people he cared for. He also learned to hate the medical system and the bean counters that were constantly pushing him to cut corners on patient care. In the end the bureaucrats won and Doctor D quit that clinic rather than choose to hurt the patients he cared about. He is currently working odd shifts as an ER doctor in a tiny hospital in the middle of nowhere to pay the bills till he returns to Primary Care. He blogs about patient-doctor relationships because he misses having patients of his own and still has those crazy ideas about "helping people" with his medical knowledge.

Of Course there are days Doctor D wishes he would have never signed on to be a general doctor (or a doctor at all for that matter). But when I realize I can help nearly every person that walks through my door I am certain that I chose the right career. Family Medicine is one of the most frustrating and rewarding paths in all of medicine. I advise med students to seriously consider general primary care—it is the fullest embodiment of the ideal of doctoring—but only select it as your specialty if you are certain you will love it, because it will probably get harder for primary care doctors before it gets better.

Wow, that was a touchy-feely post! I'm afraid Nurse K is failing to make a good hard-ass ER doc out of me. Quick, someone ask a question that will awaken my god-complex angry doctor side!

Nurses VS. Residents

Question from a reader:

What is the relationship supposed to be between nurses and residents in a large teaching hospital? During a lengthy stay for a surgery, I noticed a tension between these two groups, especially between junior residents and highly experienced nurses. Perhaps it is inevitable?

It wasn't that long ago that Doctor D was a resident in a teaching hospital and he can still recollect old days of being a young doc fresh out of med school and working beside experienced nurses...

The rules of medicine say that the doctor should call the shots, but this can be problematic when a new doc with no experience is giving orders to nurses who have been taking care of patients for years. There will always be some tension. It's like a captain just out of military academy taking command of a group of battle-hardened veterans. The captain may have an officer's rank and a head full of military theory, but the foot soldiers are the only ones who know what it's like to get shot at.

Ideally, this tension will make the team better. The young doctor learns a lot from working with experienced nurses, and the fresh ideas from the newly-educated residents improves the care the nurses give.

Unfortunately people who should be working together sometimes go to fighting amongst themselves. When inflated egos of new doctors or experienced nurses cause trouble and it is patients who can get hurt. Any doctor who doesn't listen to experienced nurses is headed for disaster, and any nurses who abuse new doctors are harming both patient care and medical education. Once the battle gets going, however, it is hard for either side to back down.

The best strategy is to start out on friendly terms and work to stay there. When Doctor D started residency the first advice his attending gave him was, "Be good to the nurses and you'll do well."

Mutual respect and open-communication works best for everyone, including patients. I can tell you it is hard to be nice when an older nurse is giving you shit just for being young. I'm sure nurses can attest that it's equally difficult to refrain from kicking the ass of a cocky resident with a big god-complex and zero inexperience. I have found, however, that if I bite my tongue and act respectful the obnoxious behavior of insecure nurses and doctors usually subsides to a tolerable level.

If you are a patient in a hospital where the tension between residents and nurses has broken into open warfare this is a bad sign. I would advise you appeal to a higher power to intervene, such as an attending physician or head of nursing. Don't take sides--trust me you don't want a part of that battle. Just tell them that you as a patient are worried by the animosity. Usually the responsible authorities can sort out who needs to have "come to Jesus" talk so that both sides can calm down and start playing nice together.

Have you ever witnessed (or been a part of) an interesting Nurse VS. Resident conflict? How was it resolved? I would love to hear your stories in the comments.

Query for Questions (Friday Links)

First of all, thanks to everyone sending in all the great questions. Doctor D has some really interesting questions to discuss over the next several weeks.

Thus far, all the questions on this blog have been from patients. To understand the view from the patient side of the exam room Doctor D is reading some great patient blogs like Queen of Optimism, ∞-itis, and Neo-Conduit.

But Doctor D thought he would use this Friday Links to suggest a few other types of questions he would love to answer:

Dr. D: “Who spends even more time with doctors than patients and often wonders, 'WTF is wrong with these MDs?'”

Student in back raises hand: “Nurses!”

Dr. D: “Right! Nurses have to take crap from annoying doctors all day long! They must have questions about doctors eating at them! Doctor D would love some questions from nurses. He promises not to ignore their questions like the other MD pricks. Hear that, Nurse K? Let Doctor D have it!”

So Doctor D's first Friday Link is a nursing blog. With Nurse K on hiatus, D had to find a new favorite nurse in the blogsphere. Doctor D is really enjoying The Lonely Midwife. D has a special place in his heart for midwifery since a midwife delivered his kid, Little D. Lonely Midwife just passed her boards so go on over there and congratulate her!

Dr. D: “Okay, next question. Who else has lots of questions they're just dying to ask doctors?”

Students shuffle feet and look at the floor.

Dr. D: “Come on! You know this one!”

Students sheepishly avoid eye contact.

Dr D: “Medical Students! You guys are working yourselves ragged trying to become Doctors. I know you've got some wacky doctoring questions you can't ask your attendings. This is your chance to pimp an attending! Doctor D stands ready to assist weary students walking the long road he has traveled before.”

This leads D to our second Friday Link, a really great med student blog he recommends: Journey to MD... and Beyond. Ella must be a frick'n genius to have time to blog during medical school, but we are all the better off for her excellent insights! Doctor D could have never kept up a great blog like that in med school.

Doctor D still loves questions from patients too! He just thought it would be fun to sprinkle a little variety in the questions.

Remember Doctor D doesn't do diagnosis or treatment over the web. But questions about doctors' brains, doctors' mistakes, doctors' behavior, doctors' lives, etc. are all fair game. So keep the questions rolling in!

You can also send your questions to Doctor D via Twitter.
Doctor D also links to great med-blog posts on his Twitter Feed.

Why Are Doctors Such Jerks?

Let's start with a question I know that you have been wanting to ask:

Why are so many doctors jerks?

Excellent question! As any nurse will tell you, doctors are notoriously difficult to work with. We doctors have a much higher percentage of jerks among us than the general population. Even Doctor D (on very rare occasions) has been known to be downright ornery towards patients. There is a epidemic of condescending, difficult, foul-tempered doctors, and you the patient are the one who suffers!

Some doctors have been jerks their whole lives. Maybe they weren't hugged enough as babies. These docs just love having a position of power so they can make others feel small. Such natural-born jerks can be found in any profession, and just one of them (especially as a customer service representative) can make anyone's day miserable. Such doctors will never change. It is best to avoid them whenever possible (unless you need surgery).

But the relatively few natural-born jerks in the world just aren't enough to explain the over-abundance of jerk doctors. This only leaves one explanation: many doctors become jerks by becoming doctors.

The number one reason everyone says they want to go to medical school is "to help people." Believe it or not, we were all once innocent wide-eyed young medical students who really cared about you.

Then they fed us through the decade long meat-grinder of training involving sleep deprivation, endless memorization, calling patients by their diseases, and getting yelled at regularly by our jerk-doctor teachers. At first we hated those other jerk-doctors, then we felt sorry for them. We worked till we were dead tired, and then got told heathcare is cutting back so we had to do the same work twice as fast next time. Patients expect us to work miracles after watching too much TV, and don't see any reason for dieting or quitting smoking since our purpose in life is to cure everything. Despite our good intentions people keep destroying themselves with bad habits, and nice people keep dying, and everyone is angry we can't turn them back into twenty-year-olds. Add to that lawyers promising irritated patients that they can hit the jackpot, if they just sue jerk doctors--It is enough to turn even the nicest medical students into misanthropic bastards.

As a patient that just wants to get your check-up none of this is your fault, but you are going to bear the brunt of this. Your best bet is to look at your doctor, and try to imagine him/her as the kindly, altruistic, and terrified student that showed up on that first day of medical school. Somewhere in your doctor lurks that annoying humanitarian impulse that doesn't die easy.

Look your doctor straight in the eye and say, "Doc, I really appreciate you taking care of me." Only say this and nothing else! Under no circumstances then ask for something or launch into a list of every odd symptom you had in the last year. Just say something nice and leave. A jerk-doctor hasn't seen human kindness and generosity in years might just feel a warm spark of caring in his/her cold heart. Doctors have a bad habit of forgetting we work on real people. Suddenly you become a real person and not just a patient. Trust me, doctors actually care about real people. You just have to remind your doctor that real people exist.

Who knows, your doctor might even be nice to the nurses after seeing you?

Any Questions?