From the monthly archives:

October 2008

So You Want to Be a Doctor?

by Brian Carty, MD, MSPH
10-27-2008

A couple of years ago I worked as an internist in a small town in Wisconsin and spent weekends in Madison, a college town, where the U. of Wisconsin is located.  While drinking coffee at Starbuck’s one morning, I noticed a couple sitting next to me, and the young man, in his late teens or early twenties, was studying organic chemistry.

 I made a friendly comment about organic chemistry and asked whether he had a test coming up.  He answered no; he was studying for the MCAT, the Medical College Admission Test, and was applying to medical school.

I suggested that medicine is a less attractive career than it once was.  His girlfriend had apparently heard this before.  She gathered herself up, her face contorted by rage, stood up and slammed her notebook on the table.  She said “I don’t want to hear it!  Don’t even talk about it!”  I apologetically mumbled that I was a physician and was only trying to be helpful.

She turned and stomped out into the snow-covered street.  Her boyfriend sheepishly collected his things and walked out after her.

For the past several months, Medscape, the online medical education website, has been running a blog titled “So You Want to Be a Doctor?”  There are hundreds of entries from practicing physicians on the subject of whether they would advise young people to pursue a career in medicine, and whether they would still become doctors if they knew what they know now.

From this series, there seems to be agreement among the physicians on several issues.  First, most of the physicians find medicine a rewarding (but not necessarily financially) and enjoyable profession.  Here is a representative post:

I do agree with many of the negative opinions expressed here, but I think about our message to younger persons who approach us asking if medicine may be a good choice for them. I’d tell them that “Medicine is a calling more than a profession” (William Osler). If the individual who is asking the question feels a calling for medicine, regardless of remuneration and demands on personal time for family and leisure, I’d say “Go for it, by all means, and there will be no greater happiness” for saving one life is like saving the entire world. I’d also advise those who don’t feel such calling or who wish to make money to stay away from medicine. And finally and above all: One should be prepared to serve people and have humility.

Second, most of the dissatisfaction in the medical profession is due to interference in the delivery of care and limitation of income by the government and by insurance companies.

Many physicians would not enter medicine if they had it to do over again.

That’s very nice, but I do not believe that any of these visionaries had working for serf-wages while Insurance company execs make millions off our collective toil, and Medicare unloads their burden on us - at our expense - in mind when they stated these platitudes. It’s hard to believe in a higher calling, when you can’t even pay the bills. I do not believe that it is somehow against a higher principle to be able to pay your mortgage, kids’ educations and put money away sensibly for retirement rather than proving a burden on the society you served, in your waning years. I am not a Plastic Surgeon, I don’t drive a Mercedes (it’s a Subaru and its 5 years old, my other car is a 20 year old Dodge hatchback) and I did not make even six figures much less seven. No, in my last year of primary care in internal medicine I made less than $30,000. No; rather, like 70% of my colleagues, I would steer the prospective medical student in another direction.

I wonder what happened to the young man I met at Starbucks.  Immediately after the couple left, I felt guilty.  Many physicians are ambivalent about recommending that young people apply or not apply to medical school.  Many of these docs give a lengthy, nuanced description of the pros and cons of a medical career, without clearly recommending or not recommending medicine.  I am usually, but not always, in this camp.

Maybe the premedical student from Starbucks is in medical school now.  When I was applying to medical school, I remember how hurt and indignant I felt whenever anyone suggested that there were other desirable careers besides medicine.  This is an obvious truth, but such comments were mainly meant to comfort people who weren’t accepted to medical school.  However, in the 70s, it would never have occurred to anyone that medicine might not be a well paid career.  I hope it occurs to people now. 

Still, no path in life guarantees against hardship.  Pope Benedict recently said that the current financial crisis shows that money is an illusory goal.  I don’t think he meant to minimize the sufferings of poverty.  He also said that “Whoever builds his life on this reality, on material things, on success…builds (his house) on sand.  Only the word of God is the foundation of all reality.”

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Hot Medical Mishmash

by Brian Carty, MD, MSPH
10-23-2008

Here’s another medical joke:

 Q:  When Mary and Joseph went to Bethlehem, why did Mary have Jesus in a manger?

 A:  They had Aetna HMO.

Enema Nation

In the Russian city of Zheleznovodsk, a monument has been dedicated to a medical procedure popular at local health spas, the enema.  The statue is a bronze enema syringe supported by three cherubs.  Dozens of spas in the surrounding Caucasus Mountain region give enemas from the area’s mineral springs.  (Internal Medicine News: 7/13/08)

Barack Obama and his advisors were in the area recently on a fact-finding tour to help them design a new government-run health care plan for the US.  Obama said “I’m an enema freak from way back.  I’ll bend over to make sure enemas are included in my new health plan.”

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In a new book of essays by nurses, “Reflections on Doctors” (2008), nineteen essays show physicians as the corrupt, dishonest, homicidal misfits that they really are.  Not really; that’s a spoof.  The essays are intelligent and well written, but do address some important issues.

Doctor-Nurse Relationship is Like a Marriage         

The doctor-nurse relationship is in many ways a marriage writ large, with love, hate, mutual dependence, ambivalence, and uncertainties about power and responsibility.  As in many marriages, though, the two parties would sometimes like to take separate vacations and have separate checking accounts.

“Smart Enough Not to Be a Doctor”

One essay is titled “Smart Enough Not to Be a Doctor.”  The author, Pamela Gonzalez, RN, says that she has been told repeatedly throughout her career that she is “smart enough to be a doctor.”  She considers this an insult. 

Are Doctors Smarter Than Nurses?

Ms. Gonzalez complains that “This backward compliment suggests that choosing a professional path in the nursing field is for those with less intellectual abilities (sic) than those who choose to go to medical school.”   Ms. Gonzalez says that she wants to reply “Yes.  I was smart enough - and I chose not to be a doctor.” 

Ms. Gonzalez graduated from an Ivy League college and had good grades and test scores. She writes well and sounds like a very competent professional.  All of which suggest that she probably would have done well in medicine.

Some Aspects of Nursing Are More Appealing

So why didn’t she go to medical school?  Ms. Gonzalez gives some supposed advantages of being a nurse rather than a doctor, such as being more directly involved with patients.  She believes that patients will confide sensitive information to a nurse which they won’t disclose to a physician.  Still, it’s hard to imagine a relationship which requires more trust and disclosure than the doctor-patient relationship, so these arguments aren’t very convincing.  There may have been other reasons why she preferred nursing to medicine.  

In Some Ways Medicine Is Not So Appealing

According to Ms. Gonzalez, becoming a doctor requires spending years training before seeing patients, and HMOs often control the time physicians spend with patients.  Also, she wisely does not place much value on a high income.  These reasons seem a little closer to the mark.   I suspect, but cannot prove, that the reason Ms. Gonzalez didn’t go into medicine was the often extreme demands placed on physicians. 

Besides, what’s wrong with being a nurse?  Ms. Gonzalez must know that many physicians are unhappy with their pay and working conditions.  Whether medicine is still a wise career choice is a complicated issue which cannot be discussed here.  Ms. Gonzalez says she was “smart enough not to be a doctor.”  Perhaps many doctors now practicing wish they had been that smart.

There Is Something to Be Said for a Job Which Doesn’t Consume Your Life

My father was an engineer.  No weekend call, no 3 AM phone calls, no 80 hour work weeks.  He didn’t have the status, income, or maybe even the job satisfaction of a physician, but he went home every day at 5 o’clock, and then his time was his own.  I think there’s a lot to be said for that.

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Smart Drugs

by Brian Carty, MD, MSPH
10-18-2008

I heard a radio ad last week for something called “IQ Enhance” to “increase your brain power in 7 minutes.”  If it were that easy, wouldn’t “all” students be “above average,” to quote Governor Richard Perry of Texas and Garrison Keeler?

Maybe you’re old enough to have seen the TV series “The Outer Limits” in the 1960s.  I remember an episode in which an average guy is subjected to a process which increases his intelligence at a tremendous rate.  As his IQ goes up his head gets bigger, so that he looks like an alien with a huge head.  At the end of the show, he’s in a chamber which resembles an elevator with flashing lights.  Some forty years later, has science advanced enough so that we can accomplish the same thing by just taking pills, “smart drugs?”

Not exactly, but there has been some progress in that direction.  There are, of course, drugs which enhance mental performance in people with a variety of diseases.  However, to enhance mental performance in normal people, that’s the meaning of the term “smart drugs.”

Modafinil (Provigil) is an alertness-promoting drug which can be used for people with excessive drowsiness associated with shift work disorder .  This disorder affects 5-10% of night shift workers and involves excessive sleepiness during night shifts and insomnia during the day, when night shift workers usually sleep. Because modafinil also improves the deficits seen in normal people with sleep deprivation, it is inevitable that this drug will be used for fatigue or sleepiness in normal people.

Both amphetamines and modafinil are sometimes used in the military to counteract the effects of fatigue and sleep deprivation.   Nicotine and a drug used to treat Alzheimer’s disease, donepezil (Aricept), both enhanced the performance of pilots in flight simulation tasks 

Scientists are always on the lookout for new candidates for use as smart drugs.  Some researchers think that Salvia Divinorum, the most potent hallucinogen known, may eventually have a variety of uses in treating depression and other diseases.  However, I can’t think of any drug which makes people hallucinate and see little green men, as did one loser, or user, which later turned out to be a useful drug.

Many users have documented their Salvia trips on You Tube.  Some criticize the “Tubers” as people who use the drug frivolously.  “They’re not really taking it as a tool to explore their inner psyche,” said Daniel J. Siebert, a Californian who pioneered the production of Salvia extracts.  “They’re just taking it to get messed up.”   So what’s the difference?

As for exploring your “inner psyche,” some years back a drug user told me of a great revelation of truth he had while using a psychedelic drug.  Despite the intense hallucinations caused by the drug, he managed to write down his revelation.  The next morning, he found a scrap of paper which read “This room smells funny.”

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What Part of “Moral Hazard” Don’t You Understand?

by Brian Carty, MD, MSPH
10-13-2008

“How can you say to your brother, ‘Let me take the speck out of your eye,’ yet you fail to notice my baseball bat upside your head?”

According to George W. Bush, “When somebody hurts, government has got to move.”  Doesn’t that make you cringe?  It seems that whenever the government moves, somebody gets hurt or even squashed.

I'M FROM THE GOVERNMENT   I'M HERE TO HELP
I’M FROM THE GOVERNMENT - I’M HERE TO HELP YOU

What is “moral hazard?”

Government programs often cause perverse and unintended consequences by creating “moral hazard.”  This term refers to the fact that insulating a person from the consequences of risk may have bad results.  The person may behave differently from the way the person would behave if fully exposed to that risk.  Here’s a familiar example: If you insulate people from the consequences of taking financial risks, they may behave recklessly and borrow or loan money for home mortgages which can’t be paid back.

I know you’re tired of hearing about government screw ups, but here are some outrageous government sponsored moral hazards I bet you haven’t heard about.  They all involve our health care system.

In 2005 it was discovered that in 14 states Medicaid was paying for Viagra for sex offenders.   In another example, in 1994 it was discovered that in many states Medicaid paid for infertility treatment for welfare mothers.

Wow!  That (fill in the blank) program didn’t work out as well as we thought it would!

Of course, bureaucrats and politicians were shocked, SHOCKED, to find that Medicaid was paying for Viagra for rapists and infertility treatment for welfare mothers.  But isn’t that the point?  Don’t these social engineering programs often cause negative, unintended consequences?

I’m having a crack attack, so give me my government check

Hospitalization from cocaine abuse peak after checks are issued

Hospitalizations from cocaine abuse peak after checks are issued

Here’s another one.  In a study of veterans with schizophrenia published in the New England Journal of Medicine in 1994, researchers found that cocaine abuse and hospitalizations secondary to cocaine abuse increased at the beginning of each month when disability checks were issued, cashed and, presumably, used to buy cocaine.  In fact, cocaine abuse and cocaine-related hospitalizations decreased towards the end of the month but then began to increase again just before the first of each month when the checks are issued.  This suggests that drug dealers considered recipients of government checks good credit risks (”full faith and credit”).

Of course, members of Congress were shocked, SHOCKED, to discover this.  They promptly set about “fixing” a problem they created in the first place.  Doesn’t that remind you of OJ searching for the real killer or Barney Frank suddenly claiming to have a tight sphincter (which medical experts know, on the contrary, to be hard used, gaping and patulous) about finding the cause of the current financial meltdown?

In another study, using data from computerized death certificates for the entire US, researchers found that there were more deaths in the first week of the month from substance abuse.  Suicides, homicides, and deaths from accidents, all often related to substance abuse, were also more frequent in the first week of the month.  Of course, it’s impossible for this study to prove that drugs and alcohol bought with government money caused the increase in deaths at the beginning of each month.  But doesn’t it seem like an explanation worth considering?

Got our checks this morning.  Spanish Eddy was here an hour ago.  Gotta piece of the rock, things are very smooth now…

In fact, according to an article in the Los Angeles Times, government checks fuel the drug culture.  According to this report, “Mother’s day takes place early each month.  It’s the day when welfare checks arrive - a day when drug dealers know the extra money means more drug sales.”  (LA Times 7/8/99)

Is Uncle Sam failing upward?

Even though the federal government has wrecked our economy and almost everything else it has touched, many Americans want to let the feds work their magic on our health care system.  In fact, our government seems to be following that uniquely American trajectory, “failing upward.”  In Andrew Ferguson’s memorable essay “McNamara’s Brand,” failing upward refers to America’s curious tolerance, even friendliness, especially in politics, towards those who fail.

Where’s Bob McNamara when we need him to really louse things up?

Ferguson’s cardinal example of failing upward is the career of Robert McNamara, probably best remembered as President Lyndon Johnson’s Secretary of Defense during the Vietnam War.  McNamara consecutively screwed up the Ford Motor Company, the Vietnam War, and the World Bank, with promotions following each disaster.

Ferguson aptly depicts failing upward with the workaday example of the unbearable houseguest:

 Imagine a friend who comes to visit. The first night he cooks you dinner and sets fire to the kitchen. The next morning he accidentally electrocutes the cat. He blows his nose in the curtains and never flushes the toilet. He borrows your car and drives through the garage door, then spreads a rare contagion to your kids. By the third day you make the decision: You ask him to move in with you.

I’m tired of chewing my own food.  Can’t the government do it for me?

Many people seem to believe that no difficulty is too large or too small for the government to fix.  But isn’t it absurd to look to the government to solve our personal economic problems, end tyranny throughout the world, and heal the sick, to mention just a few unrealistic expectations?

Isn’t it time for some personal responsibility?

We once looked to our own personal resources, or to our religious communities and families to try to meet our needs.  With those institutions on the wane, many people seem to have developed utopian expectations of a flawed, often ineffective institution - government, which Thomas Paine described as “at best, a necessary evil, at worst, an intolerable one.”

 

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