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Part 1

Education increases income. Oh really?
Revamping American colleges: an overhaul is long overdue

Q: My college professor gave us an unusual assignment: to write a paper on one of the most prevalent myths of our society. Honestly, I'm stumped. I can think of trite things like "blondes have more fun," but nothing substantial. Surely there must be some medical myths you can suggest to me as a topic for my paper. Can you help?

A: Yes, there are some medical myths, but I have an even better one for you. Your prof may not like it, but it's true nonetheless. Here is the myth: education increases income. On the face of it, this seems undeniable. People who earn a lot of money are typically more educated than other people. The temptation here is to confuse correlation with causation. Certainly, there is a correlation, but is there causation? That is, was it the additional education that explained why they made more money? Or was it simply because they were smarter? From a SmartMoney article, The Case Against the College Degree: “Elite schools are reduced to machines that cull the bright from the dull and charge mightily to brand them for success, which these students would have achieved anyhow, because they re bright.”

Smart people tend to obtain more education, but they'd make more money even if they weren't educated. Bill Gates is a college dropout, but he's made more money than thousands of college graduates. Perhaps Gates is a poor example, since his wealth is more attributable to good luck and ruthless business practices than it is to sheer intelligence — a fact that should be obvious to anyone who is familiar with the exasperatingly buggy Microsoft software (even Gates is incensed by the junk they sell).

Let's take a more prosaic example: doctors. Sans their education, docs could not practice medicine, so it seems obvious that their education is responsible for their income. Right? Not necessarily. People smart enough to become doctors are also smart enough to succeed in a number of other occupations, even ones that seemingly require little brainpower. Toward the end of my mowing career, I made as much money per hour as I did at the end of my ER career, and I'm not the only example. Years ago, I met a man who made $210,000 per year (adjusted for interim inflation in 2013 dollars) working half the year mowing lawns. Furthermore, he didn't do any mowing himself; he just supervised his work crew. That was more money than I made at the time working 12 months in the ER. Another person I know makes over $390,000 per year (adjusted for interim inflation in 2013 dollars) working just half the year putting in basements.

I have nothing against education. Even years after the end of my formal education, I still voraciously hunger for knowledge, and I begin reading as soon as my eyes acclimate to the morning light. However much I'm enamored with learning, I am certain of one thing: I would have made far more money had I never attended college or medical school. Our diverse economy provides numerous ways for smart, diligent people to succeed. Such people will succeed with or without a college degree. In fact, since certain degrees and professional paths can pigeonhole a person, obtaining a degree can hinder success. This is especially true for people with exceptional intelligence as compared to those with more moderate gifts.

While I love learning, I have strong reservations about the education that students receive from American colleges. One of my primary complaints is that some of the requirements are essentially worthless, such as humanities. Even though I had a year of that subject, I had to consult a dictionary to learn exactly what it is supposed to be about: history, literature, the fine arts, and philosophy. A knowledge of history is undoubtedly important, and I was sufficiently fascinated by it to read about it both before and after college. However, when history is blended with literature, the fine arts, and philosophy, it turns into a nebulous subject that is a watered-down waste of time. Of the information that I learned in those classes, how much was ever useful to me? Not one iota. Isn't this an utter waste of time? The hundreds of hours I spent in class and studying humanities could have been spent in thousands of more productive ways, but this option was not available to me. The collegiate educational system is rigged for the benefit of the professors, not the students. Some professors would starve unless there were warm bodies forced to take their classes so, dang it, students are compelled to do just that for some of the basic requirements that cannot be evaded, no matter what your major. No one else could take you hostage for hundreds of hours, give you no useful information, make you pay an arm and a leg, and get away with it. Except for professors.

Beyond my specific complaints about worthless subjects, I also object to the traditional idea of schooling: attend classes, take notes, read course books, study, and take tests. It's not that this system doesn't work, but it is far less efficient, and far more costly, than it should be. Although it is now the 21st century, today's students go through a routine that hasn't appreciably changed in hundreds of years. Students are paying for this stale system in many ways. Facebook's chief operating officer Sheryl Sandberg agrees with me: “Why do we have lots of college lecturers around the world? Why do we not take the best person and show everyone?” Exactly!

Perhaps the foremost drawback is that a college education costs far more than it should. Instead of Chemistry 101 being taught by a zillion professors scattered around the country, why not have it taught by one of the best and most inspired professors in lectures transmitted on the Internet or television? In an ostensible attempt to provide a quality education, today's colleges often give you professors who have no knack for teaching and Teaching Assistants (TAs) whose command of the English language is often poor. Your assigned textbooks may be excellent — or they may be lackluster ones chosen only because they were written by your third-rate professors. You're often required to live in dormitories that are poor environments for studying but great environments for partying and spreading diseases such as meningitis.* So this is a quality education that either you or your parents will work years to pay for?

* Ever see the Dateline program in which they showed a slew of college students who were either killed or horribly disfigured as a result of Neisseria meningitidis, the germ that causes meningococcal meningitis? According to the Centers for Disease Control (CDC) and The National Meningitis Association, there are approximately 3,000 cases of meningococcal meningitis every year in the United States. About 15% of the cases are fatal, and 15% of the survivors end up with organ damage, brain damage, multiple amputations, or other atrocious permanent effects. UPDATE: A local college student died from meningococcemia.

The cost of a college education is not a trivial concern. It is a major burden for most people, and an impossible obstacle for others that closes the door on their dreams. Even if you disregard the billions of dollars paid by taxpayers to subsidize colleges, and you disregard the student loans that may seem free now but may one day come to haunt you, paying for college is something that everyone should seriously think about instead of just mindless putting up with an antediluvian system. The September 8, 2003 issue of U.S. News & World Report included an article entitled "Great Deals at Great Schools" in which they listed the yearly cost for colleges offering the "best value." The average cost after receiving grants was about $15,000, and many schools approached or exceeded $20,000. Is this a "great deal"? No, it's a great deal of money. And it is highway robbery. However, the primary cost of college isn't money but time: four to eight (or more) years of your life—and not just any years, but your best years.

If we made use of the system that I advocated above, the yearly cost of college could be a few hundred dollars. Furthermore, we could ensure that students were taught by only the best and brightest, instead of by a ragtag group of professors in which quality is very much a hit-or-miss proposition. Furthermore, students could learn at their own pace. If you could master a course in a month, why must you wait to receive credit for it because it takes others 15 weeks to learn it? Why not just fly though college and start making money a few years earlier?

Another advantage of my system is that students could live wherever they wished, instead of being herded like cattle into cities that are the traditional homes for colleges. Students could also easily individualize their schedules. Perhaps you need to take off a few months to care for a dying Aunt as I did, instead of dumping her into a nursing home.

My system is about excellence, freedom, and affordability. The current college system is about hidebound bureaucracies and entrenched special interests (professors) who have you by the balls when it comes to earning a diploma. If American colleges were run by the Mafia and did everything they're now doing, people would be up in arms and there would be Congressional investigations and prosecutions under the RICO statutes. What is the price of maintaining the status quo? Perhaps $60,000 for just a baccalaureate.

Every year the cost of a college education rises by an amount that exceeds the rate of inflation. After seeing this pattern throughout the years since I left school, I concluded that colleges are insatiable and they will keep bleeding you for as long as they can get away with it. It's time to overhaul the system.

I am not the only one questioning whether a college degree is worthwhile. In an editorial, Forbes magazine brilliantly pointed out the folly of thinking that a college degree is a wise investment. And from another seemingly unlikely source to echo this conviction, Reader's Digest published an article entitled "Is College Really Worth the Money?"

After reading about college graduates struggling financially, declaring bankruptcy, and committing suicide, you might begin to understand why I think that college is not an economic panacea. In our culture, we are inculcated with the notion that the way to achieve success is to attend college (unless you possess exceptional sports talent or are a drop-dead gorgeous entertainer). However, this "attend college if you want to succeed" knee-jerk advice is leading many people into making poor career decisions. Americans now owe over $1 trillion in student loan debt that many of them won't be able to repay comfortably or at all. Since student loan debt cannot be discharged via bankruptcy, student loans may haunt you the rest of your life. With my system of higher education, the cost would be so low that student loans would be unnecessary.

I think most people harbor the notion that medicine must taste bad to be good, so they overlook easy ways to make money. For example, you could also make money by marketing one of my many inventions. If you're smart, talented, and interested, contact me for further details.

If you want a more conventional road to riches, consider becoming a UPS driver or truck driver. They can earn more than doctors, as I proved on my www.ER-doctor.com site in this posting.

UPDATE: On 60 Minutes, billionaire Peter Thiel echoed some of what I said above:

Related topics

Obama's plan to limit college tuition price hikes

Perks of being a doc
Why do people often bitch about physician income, but not the income of people who make more and do less?
If you're thinking of perks, you're missing what is really important
How doctors are subjected to injustices that no other group would tolerate
Why ER docs are part-time slaves
An acid test for whether or not you should go into medicine
hy I mention the drawbacks of medicine
Specialties that are far more palatable than ER

Q: I heard through the grapevine that banks, namely Bank of America, cater towards doctors (e.g., does paperwork over the phone, brings papers to the hospital to sign). I don't know if this is the case around the country, or what. Are there any other hidden bonuses to being a doc? I know you've mentioned immunity from speeding tickets, but what about repairmen, stock brokers (ok, maybe not stock brokers), etc.? Thanks! Amy

A: I can only hope that stock brokers would not extend me any "favors." From what I've heard on the news lately about stock brokers and investment bankers and other people who make oodles of money by scamming, defrauding, cheating, swindling, hoodwinking, deceiving, misleading, duping, conning, flimflamming, swindling, bilking, tricking, gypping, screwing, fleecing, robbing, and otherwise victimizing millions of Americans (including my mother), I hope that those crooks rot in prison. And if you weren't 15, I'd tell you what I really think! I saw an interview on the news a few days ago of such a person who sometimes made more money in a day by cheating people than doctors do in a lifetime of helping people! I've seen countless people whine that doctors make too much money, yet I've never heard anyone complain that stockbrokers and others in the far more lucrative money-exchanging professions make too much, even though it's clear that doctors work harder, do more good, and have a much more demanding period of education and training. Last week I heard a redneck call into a radio talk show to bellyache about physician income. Considering that physician income has been eroding for years, and given the seemingly endless scandals involving stockbrokers and others of their ilk, it would have made more sense for the redneck to put those scoundrels in his crosshairs. But do they ever denounce them? Nope. This causes me to wonder just what it is about doctors that incites such criticism. My guess is that doctors are conspicuous, while the moneymen are cloistered in places that elicit no attention from people with room-temperature IQ's. Such mental giants probably cannot comprehend anything unless it is direct, such as receiving a bill from a doctor. The countless billions of dollars that pour into the pockets of stockbrokers or scantily clad singers or sports stars or movie stars — that's indirect, and it takes a millisecond of thought to realize that people pay them, too, via higher costs of goods and services.

Believe it or not, but this diatribe is more than a catharsis. Anyone who is or hopes to become a doctor should spend a few minutes wondering why docs are routinely pilloried, but others with better paying, less demanding jobs are not. Certainly not all stockbrokers are evil, but their work is far easier. I once dated a woman who made over twice the average physician income by working three hours per day as a stockbroker . . . when she felt like going to work. She could call in sick whenever she wished and receive the same salary, even if she was out shopping for her 300th pair of shoes. Tough life, eh? While I worked 110 hours per week for umpteen years to become a doctor, she was partying and having a grand time on her way to a four-year degree. So why did society shower her with money and didn't squawk about her wealth?

OK, on to your question about physician perks. The tidbit about the Bank of America was news to me. Repairmen? I do most of my own repairing, so it's tough to say. The two I recall couldn't care less if I was a doctor. Had I been Britney Spears or Faith Hill, I'm sure they would have been impressed. For years, docs received free pens, note pads, and useless trinkets from pharmaceutical companies, but such largesse is progressively drying up, thanks to the government's typically idiotic solution to control drug prices. People in other industries get all sorts of freebies, so why isn't the government clamping down on them? Coincidentally, this ties in with the topic I just discussed: how docs can literally work harder than slaves, yet be relentlessly criticized for making too much money while others make considerably more and no one utters a peep. The same is true with the government. It lets stockbrokers and investment bankers plunder on and on, forcing people who thought they had enough money for retirement to go back to work, or sell their home, or — in some cases — commit suicide. Eliot Spitzer, the Attorney General of New York State, seems to be the only one making a concerted effort to punish the Wall Street robber barons, but even he won't mete out sufficient punishment. After paying their fines and doing a short stint in a cushy white collar prison if they're really unlucky, those robber barons will resume living like kings. Compared to them, doctors are dirt poor. Yet whenever the geniuses who run our government look for someone to squeeze, they latch onto a convenient target — doctors — instead of the white collar criminals in the money-exchanging professions who make a career out of swindling people. There are millions of hard-working "little guys" in this country who don't realize how they're being screwed and swindled every time they turn around. The amount that people pay to doctors is a drop in the bucket compared to the collective amount they lose to these scammers. Fraud is everywhere. From incomprehensible charges on home loan applications and auto leases, to bewildering phone bills, to claims unfairly denied by insurance companies, the scammers have thousands of ways of pilfering your money. More important than the dollar amount is the fact that physicians work like slaves to become doctors to help people, while the scammers are out partying and dreaming up ways to become fabulously wealthy by screwing people. But who is targeted by the politicians? It's doctors. The government reduced physician payments to the point that they're an absolute joke and, frankly, darned insulting. In the early 1990's I received a check for $7 from Medicaid to pay me for a patient I saw in the ER. I asked my boss (who knew far more than I about billing) if this was a mistake, and rhetorically asked what emergency service I could provide that was only worth $7. He chuckled and said that such trifling payments were common. If you think that $7 is bad, consider this: at that time, we paid $5.50 per patient (it's now a lot more) for malpractice insurance. After deducting that, there was $1.50 left. After deducting for our other expenses (billing company, secretary, corporate overhead, etc.), nothing was left. In fact, I probably paid for the privilege of seeing that patient, and potentially assuming millions of dollars of liability. Furthermore, thanks to the government, I didn't have the option of choosing to see or not see that patient; federal law mandates that I see every patient who comes to the ER (if I tried to say no, they'd slap me with a $50,000 fine). If that's going to be our social policy, it is only equitable to spread the cost for this on society at large, instead of burdening ER docs with paying for their care. The situation is even worse in patients with no insurance, many of whom don't pay their bills. So instead of receiving $7 from them, I get nothing but still pay the $7+ dollars of expenses. As a compassionate person who was once poor, I wouldn't grumble about these losses, but many of these ER visits are utterly frivolous and unnecessary (if they weren't, I couldn't have written True Emergency Room Stories). The closest analogies I can think of that illustrate how this situation is so ludicrous is if the government mandated that restaurant owners were forced to feed anyone who walked in their doors for free even if those people were not hungry, or landlords were forced to provide shelter for people who already had a home. Stealing money from restaurant owners and landlords in this manner is so abominable that it would never be tolerated, but the government does the same thing to doctors and no one bats an eye. Again, what is it about doctors that makes them a virtual piρata? Why not target others who make more and do less, such as the robber barons? Healthcare is less important than the need for food or shelter, so if the government chooses groups who should work without compensation on the basis of need, restaurant owners and landlords should be subject to this confiscation before doctors.

The trivial perks extended to doctors cannot compensate for the injustices imposed on them. You want to be a doctor, and no doubt part of you longs for what's at the end of the rainbow. I hate to burst your bubble, given that you're only 15, but I am morally compelled to inform you that being a doctor is not a dream job. In addition to the brutal period of training and other sacrifices I've discussed elsewhere, sooner or later you'll realize that society will place you in its crosshairs and subject you to things that would literally cause others to riot. Imagine if auto workers were forced to build cars not just for free, but they had to pay for the privilege. If the government, with its characteristic arrogance, demanded that of auto workers and others while threatening a $50,000 fine, I guarantee you that the government would be overthrown in a heartbeat. Even the military and police would point their barrels toward Washington, and with perfect justification. Long ago, our government declared that slavery was an unconscionable national disgrace that would never be repeated, but consider this: the slaves received at least meager compensation for their work in the form of food and lodging. They were never asked to work for free and pay for the privilege. Yet ER doctors must treat patients even if they're not paid or lose money for their services. Is it morally justifiable to do this just because every patient does not cause the docs to lose money? If you believe that, then you shouldn't object to working a few days per week without pay, or you paying for the privilege, all the while knowing that if you say no, the government will take another 50 grand from you.

Given that this bleak situation for doctors will likely only grow worse, your ability to tolerate such an injustice becomes an acid test for whether or not you should go into medicine. If it won't bother you and you aren't dissuaded by the other drawbacks of medicine, have fun as you give up the best years of your life to work 110 hours per week so you can become an ER doctor and then spend the rest of your life hearing people moan that you're paid too much as you receive $7 checks. If you are morally outraged by slavery in all its forms, including being forced to work for free by the threat of a massive fine, then you should choose another career.

Rush Limbaugh speculates that the government's ulterior motive is to socialize medicine by making the practice of medicine so intolerable with bureaucratic meddling and endless lawsuits that doctors will welcome socialization as a means to absolve them of financial responsibility for errors (alleged or real), similar to the immunity enjoyed by judges, who can screw up with impunity and never need to worry about being sued for their mistakes in judgement. They can incarcerate the wrong man, or send him to the gas chamber, or set a child rapist free, and if anyone so much as looks at the judge the wrong way, he can be found guilty of contempt of court. Although our government is incompetent in many respects, the one thing it excels in is in creating a system of unprecedented arrogance that obfuscates injustice. If you wish to become one of the sheep that helps perpetuate this execration, go to medical school and become an ER doctor.

You might wonder why I mention the drawbacks of medicine. Surely I could make more money by selling a more upbeat, "everything is peachy" book. Why should I care how much ER docs are paid or forced to work without compensation? I no longer work in that field. The reason I discuss this is because I think it is my job as an author to give you the unvarnished truth. If you want to spend your money on something which gives you a misleading impression that things are better than they are, go to the nearest street corner with a drug pusher on it and buy some of his happy pills. If you want a Walt Disney "Bambiized" (as in Bambi-ized) depiction of reality, I'm not the one for you. It's my job to inform you of what it is like to be an ER doc, warts and all, even when those warts are morally loathsome and not just a superficial defect. If you then decide to enter that field, at least you cannot say that no one told you what you were signing up for. I suppose I could just toss in a few paragraphs that discuss the drawbacks of ER, but such an extreme synopsis would not adequately convey how noxious the field of emergency medicine can be. I might do that if were writing a short magazine article, but it would be inappropriate to do that in a book. You pay more, you get more. I've discussed the pros and cons of emergency medicine, and I've mentioned ways to sidestep some of its problems, such as by working in an Urgent Care center instead of an ER. If you still decide to work in an emergency room, you'll likely feel better about it because it was an informed decision on your part, not a simple reliance on blind faith that might lead you into something you did not anticipate. Whether it's marriage, buying a home, or choosing a career, the only sensible thing to do is to go into it with both eyes open.

Although this may seem difficult to believe, I was once suffused with idealism and didn't have a cynical bone in my body. But compared to others, I'm an optimist. Recently, while searching the Internet, I came across a woman physician who had over 800 pages on her web site. Those pages were imbued with cynicism, disappointment, and seething rage over her shattered dreams. Clearly, her life turned out to be nothing like what she'd undoubtedly once imagined. The fairy tale that kids usually swallow hook, line, and sinker is that if you follow the rules, be a good person, get a good education, and work hard, you'll have a good life. If only this were always true. Unfortunately, it isn't. While I know a handful of docs who genuinely enjoy their work and are not inordinately affected by the myriad drawbacks of practicing medicine, most experienced physicians are not particularly happy — at least not in emergency medicine.

A few years ago, one of my friends in medical school, Amy, was trying to decide what specialty was best for her. She'd heard my ER horror stories, and finally decided that the field of emergency medicine was not as grand as its reputation. One by one, she considered other specialties: surgery, internal medicine, family practice, neurology, and on and on. Amy spoke to current practitioners in those fields, and their messages were the same, boiling down to something along the lines of, "Oh God, whatever you do, don't pick this specialty!" She panicked as she crossed off specialties and her list of options grew ever shorter. In the end, with a bit of prodding from me, Amy chose Physical Medicine and Rehabilitation (PM&R). Pediatricians are often thought of as the Rodney Dangerfields of the medical profession, since they get little respect from their colleagues (I don't share that sentiment, because I know they do more than take care of diaper rashes, runny noses, and worried parents). However, compared to PM&R docs, pediatricians are practically revered as medical Gods and all-knowing sages. I can't think of any specialty that is held in less esteem by other physicians. Personally, I think that what they do is NOT trivial, but the disparagement of rehab docs is so widespread that Amy was reluctant to enter that poorly revered specialty. Finally, I convinced Amy that there were more important things than whether or not her specialty was fairly positioned on the totem pole of esteem. The last time I spoke with her, she'd completed her residency and was working in her rookie year as an attending PM&R doc. Other than a bit of stress over her responsibilities, she was about as happy as she could be, and she had no regrets over her decision to enter PM&R. In general, I think that most people would be happier if they chose a career other than medicine. However, there are a few specialties that aren't especially noxious. Dermatology is another one, but I've heard some dermatologists grumble about a lack of patients as insurance companies, always looking for ways to economize, increasingly insist that many skin problems be handled by primary care physicians. Allergy & Immunology is another cushy specialty. Granted, those specialties are not as inherently exciting or glamorous as emergency medicine. There will never be a television series called Derm Clinic or Allergy Ward. However, if you are seduced by the glamour of ER, just be prepared to pay for it. It's a much tougher life.

How well do ER docs and nurses harmonize?
Would a nurse ever kill a patient to get back at a doctor?
Institutionalizing policies that harm patients
Hospital administrators killing patients with their ignorance

Q: How well do ER docs and nurses usually get along? Do the medical TV shows accurately portray this?

A: No, they don't. That is quite surprising, especially when you consider the tremendous range of relationships that exist between real doctors and nurses. Some are amicable and marked by mutual respect and affection, while others are overtly hostile and marked by backstabbing and a lack of cooperation. In spite of this variation, television writers have yet to accurately depict how nurses interact with doctors. Instead of giving their viewers fully-dimensional nurses, they present stereotyped images of either what they think nurses are like, or what they think their viewers want them to be. In doing so, they fail to capture some of the best and worst behavior I've witnessed. All too often, nurses are just made out to be handmaidens of the doctors, and their personalities are far more constrained than what I've seen in real life.

Q: Why do so many doctors treat nurses so poorly? Aren't they afraid the nurses will somehow retaliate?

A: I think that physician abuse of nurses is less frequent than is commonly believed. However, when doctors are abusive, nurses sometimes strike back.

Q: Doesn't this discord affect patient care?

A: Sometimes it does. Let me preface what I'm about to say by indicating that this is merely speculation on my part about what happened in a case that I learned of afterwards. An ER doc that I worked with sent a patient home whose EKG showed an obvious MI (myocardial infarction or "heart attack"). Any knowledgeable ER doctor or nurse could glance at that EKG for a split second and detect the MI. It may be difficult for laypeople to appreciate how we can look at all those squiggly lines and make sense of them so readily, but it's possible, trust me. Some EKG findings are subtle and require careful inspection and analysis, but this EKG was anything but subtle: it was one of the most obviously abnormal EKGs I've seen. So, when I saw the EKG and found out that the patient was discharged home and died of his heart attack, I wondered how on Earth that happened. The doc in this case was thoroughly trained and the head of the department, and the nurse had years of ER experience. I find it difficult to believe that an ER nurse could not immediately spot such an MI. I don't expect nurses to be proficient in detecting subtle EKG abnormalities, but this was no subtle finding. Specifically, it was well within the ability of nurses to spot this kind of problem. I know that because I've worked with countless ER nurses, including the nurse involved in this case, as we took care of patients with chest pain. As I examined the patients, the nurse would tear the EKGs off the machine, scan them, and if an obvious MI was present, they'd spot it. Again, reading this EKG was a no-brainer. Imagine that someone held a red ball in his hand, showed it to you for a half-second, then asked if you'd seen a red ball. How could you NOT see it? That's how easy it was to spot this MI! So what is the chance that the nurse didn't detect it? One in a hundred thousand? One in a million? And how could the ER doc not spot it? When we read EKGs, we can't do a cursory analysis; we're responsible for doing a complete reading and detecting even trivial abnormalities. The time that it takes for this is certainly enough time for any ER doc to realize, "Hey, this is a textbook case of an MI!" It would be like a dermatologist inspecting someone's skin for a small pimple, and failing to notice that the patient had horrendous burns over half his body. Now what is the chance that the doc could miss this MI? One in a million? One in ten million? By the way, the doc wasn't drunk (he never drank because of his religious convictions) or sleep-deprived (he never worked nights because he paid me extra to work nights). Multiply the odds of both of them missing the MI on the EKG, and the odds are essentially zero.

Frankly, I find it very, very difficult to believe that either the nurse or the doctor could have been idiotic enough to not detect the MI, and I find it impossible to believe they both missed it. So what the heck went wrong in this case? Now for the speculation. I wonder if the nurse intentionally gave the doc a normal EKG to read, then stuck the true, abnormal EKG in the patient's chart afterwards? Yes, I know about the chaos in emergency rooms and how something might be inadvertently switched. However, unless aliens beamed the EKG of someone else into that electrocardiograph, the nurse would have spotted the MI as soon as the EKG came out of the machine, and she would have, per ER protocol, immediately taken it to the doc. My belief that the EKG was not inadvertently switched with the EKG of another patient is bolstered by a couple of facts: there was no other patient in the ER at that time with chest pain or an MI, nor was any other patient inadvertently linked to the abnormal EKG which eventually turned up. I don't believe the real EKG became a phantom piece of paper floating in the ether while the patient was in the ER and miraculously popped into the patient's chart later on.

You're likely wondering why a nurse would do such a thing. Knowing that doc and nurse, there was certainly a motive. The doc was one of the most arrogant, pompous people I've ever met. He treated people as if there were peons, and he was royalty. It isn't inconceivable that the nurse was peeved and set him up to put him in his place. Next question: the nurse obviously knew she was involved in this case, so why would she do something that would almost certainly result in a lawsuit? First, most nurses know that attorneys usually aren't interested in them; they want the docs — the guys with the deep pockets and big insurance policies. You'd probably be surprised if you knew how often nurses are not sued or even contacted when they are involved in malpractice cases. An attorney once told me why nurses are often ignored and given relative immunity: "Because no matter what happens or who did what, it's the doctor's ultimate responsibility." Just like the captain of a ship in the Navy. Another possibility is that this nurse was so eager for revenge, she was willing to sustain a black mark on her record for inflicting an even bigger one on his record. The temptation to knock that egomaniac off his high horse and put him through the wringer must have been overwhelming. I felt it at times, and so did his business partner, who sometimes told me of the strife between them. Abrasive people usually rub many people the wrong way.

Perhaps you find it difficult to believe that someone would endanger the life of an innocent person just to get back at the real target. But doesn't this happen all the time? Nurses may be a bit more saintly than the rest of humanity, but they're not so perfect as to make it inconceivable that they could never snap. In this case, I think one did. It's a tragedy whenever innocent people are caught in the crossfire and pay with their lives. However, such cases are exceedingly rare in hospitals. I think.

Now that I think of it, I recall numerous times in which I was reading a patient's x-ray and the radiology tech would come up to me and tear off the name sticker on the x-ray and put on a different one, saying, "Oops, I put the wrong sticker on. Sorry." At most hospitals I've worked in, the patient's name, patient number, and date of visit was permanently ingrained in the x-ray at the same instant the x-ray was taken. Such an ID cannot be peeled off; it is part of the film. However, at one hospital, it was standard practice to cover the ID area with a fluorescent sticker identifying the patient. I thought it was idiotic to use stickers, especially stickers that could be removed and reapplied without leaving a trace. Hence, it'd be child's play to trick a doc in this way, intentionally or inadvertently.

Since hospital administrators have usurped power from physicians, it's now their responsibility to institute policies that minimize the chance of patient harm. What do you think of a hospital that allows such a risky practice? I think the clowns who ran it shouldn't be entrusted with managing an ear piercing clinic. The fact that they forced their moronic policies on us is a crime. I possess a visceral hatred of that administration because another of their ill-conceived policies resulted in my nephew experiencing prolonged hypoxia during delivery. Because he went without oxygen for so long, he sustained a severe mental handicap. The administrators deemed that children could only be delivered by doctors. Since the obstetrician wasn't in the hospital, the nurse pushed on my nephew's head to delay his delivery until the doc arrived. By that time, it was too late. My brother said the child wasn't just purple, he looked black — indicating severe hypoxia. It's crazy to insist that babies be delivered only by doctors since obstetric nurses are fully competent to do this . . . if they aren't cowered into kowtowing to the dictates of the administration. However, doctors and nurses no longer have any power. They're controlled by administrators, bureaucrats, politicians, insurance companies, and lawyers. Curiously, all of them know less about medicine than doctors. Does this make any sense?

I could give numerous other examples of how the blunders of that administration endangered lives, but here is one. The administrators stopped purchasing regular aspirin and replaced it with delayed-release aspirin. Not only is this more expensive, it's a disastrous choice for patients with heart attacks. Aspirin is proven to reduce mortality associated with myocardial infarctions, and the sooner it is given and absorbed, the better. When a patient has an MI, you want the aspirin to work now, not a few hours from now. Once I learned that we stocked only delayed-release aspirin, I instructed my MI patients to chew the aspirin to destroy the tablet coating, thereby exposing the underlying aspirin so it could be immediately absorbed. Unfortunately, the other ER docs in my group weren't aware of the fact that whenever they ordered aspirin, patients were given delayed-release aspirin. As a result, over a thousand patients absorbed their aspirin hours after the time when it could have done the most good. Since physicians usually don't see the medicine they order (because it's given by nurses), at the very least, the administrators should have warned the docs about their switcheroo. But since those pencil-pushers were too ignorant to know that their apparently trivial switch to another aspirin type was anything but trivial, they didn't warn us and countless patients received suboptimal therapy. I learned of the switch one day when I saw a nurse giving delayed-release aspirin.

Considering their medical ignorance, it is dangerous to allow hospital administrators with business degrees to make medical decisions. Whoever rules the roost should know what they're doing, but all too often they don't.

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Who is best at suturing? ER docs? Plastic surgeons? Dentists?
A plastic surgeon who was either malicious or incompetent
Practice makes perfect . . . but whom shall we practice on?
I practiced on a beauty queen, and turned her into a former beauty queen
There are rookies everywhere, even in the Ivy Leagues

Q: I hope you read this e-mail soon. My son just cut his forehead, and when my husband arrives home we will take him to the ER. We want him to have the best possible cosmetic result. Who should sew up his cut? Is the ER doc good enough? Should we request a plastic surgeon?

A: In general, plastic surgeons are better at suturing wounds than ER docs. However, you might be surprised to learn that this isn't always true. A few ER docs are surgical hacks, while others can suture better than some plastic surgeons. When people apply for a residency in plastic surgery, they aren't given a test to assess their coordination or surgical skill. Some possess a knack for doing beautiful work, while others do not. I once saw a dentist, in training to become a maxillofacial surgeon, perform a wound closure that was superior to anything I've ever seen done by a plastic surgeon. One of the worst results I've seen was performed by a plastic surgeon on a child with a facial laceration. The child's mother told me that her daughter's classmates often called her "scar face," "monster," or "Frankenstein" because of the poor cosmetic result. In looking at the wounds, it was evident to me that the plastic surgeon didn't properly evert (tent out) the wounds during closure. That is routinely done to counteract the inevitable pulling in when the scars later contract. If a wound is inverted or sutured flat, it will lead to a depressed scar that casts a shadow, making it even more apparent. The result on this child was hideous. I suspect that the doc could have done better, but was pissed that they did not have insurance, so, in retaliation, he purposely didn't try to give her the best result. It's either that, or the guy is a full-time hack. Take your choice; either possibility is frightening.

In my early years in the ER, I took care of even advanced cases (e.g., highly mangled faces from auto accidents). I probably should have turned them over to plastic surgeons, but I took care of them myself. The first such case was just a so-so result, but from that I learned what I was doing, and subsequent ones produced good to great results. (That's not my assessment, by the way. Since we often admit trauma patients for observation, surgeons see the work we do in the ER . . . and surgeons aren't shy about relaying their opinions. I've never received any criticism from a surgeon about my surgery, but I have received praise, and some were astonished that an ER doc could suture that well.) Oh, but that poor first patient. Picture someone who is truly beautiful, such as Helene Eksterowicz from the second The Bachelor miniseries. Now picture someone even more beautiful, if that is possible. Now picture that beautiful face lying before me, shattered with numerous jagged cuts and oozing enough blood to fill a vampire on Thanksgiving Day. Now picture an overeager rookie ER doc who never considered, for reasons I still don't understand, that such an advanced case should be turfed to a plastic surgeon. Now that I know what I'm doing, I realize the suturing I did on Megan wasn't good enough to give her back the beauty she was born with. The fact that I permanently affected her life in this way still haunts me. As I said, it was so-so, and just passably competent. However, people deserve better treatment than that, especially regarding something as cosmetically important as the face.

Nevertheless, there is a drawback to ER docs sending these cases to plastic surgeons. Unless a doc does such cases, he will never become good at doing them. True, Megan was unfortunate to have me be her doc when I was a rookie. However, by performing such surgery and getting ever better at it, I was able to give later patients better results. I've worked at some hospitals in which there was no plastic surgeon available, so I had to take care of everyone. Those people benefitted from my earlier practice. Had I not done it, Megan would likely be happier today, but subsequent patients would not. Elsewhere, I described how thrilled another young lady was about the beautiful work I did on her face after it was tattered in a car accident, and I described how her enthusiastic desire to thank me may have gotten her in hot water with the local prosecutor. In any case, it is a well-known fact that doctors learn by practicing on people, and the first guinea pigs pave the way for others to obtain better results. If you don't believe me, read Complications: A Surgeon's Notes on an Imperfect Science by Atul Gawande, MD, a graduate of Harvard Medical School. What goes on behind the doors of those prestigious Eastern hospitals may frighten and surprise you. Neophyte docs make mistakes everywhere, even in the fabled Ivy Leagues.

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.

Why do residents still work long hours?

Q: Regarding the long hours worked by residents, why is there such resistance to change?

A: Most people agree that this antediluvian tradition is a relic long overdue for extinction. However, there are a few factors that help perpetuate it. One is the fact that residents are a cheap source of labor. When I was a resident, I calculated that I could have made more money by working at McDonald's. Another factor is that during the residency years, there is a tacit quid pro quo between the residents and attendings that goes like this: the attendings agree to teach the residents in return for the residents being their virtual slaves and working hours during the nights, weekends, and holidays when the attendings are absent (except for the ER attendings, who are present 24/7/365). Sans their slaves, the attendings would have to spend more time in the hospital, because patients need care after 5 PM, too.

I think that doctors, bureaucrats, legislators, and the public should ask themselves one basic question: is residency about work, or is it about learning? Most attendings in teaching hospitals would like us to believe that it is about learning. Bull. It's primarily about work, and wringing everything they can from the residents. If residents learn something in the process, that's great, but given the choice between more work and less learning, or more learning and less work, most attendings would likely opt for more work. When I was a resident, I was pushed to keep on working long past the time I could learn anything. Hence, it's a cockamamie assumption to believe that my superiors were more concerned with my learning than the work I performed.

Fortunately, not all attendings are that way. When I became an attending in a teaching hospital, if I saw that a resident was exhausted, I'd tell him to go home and sleep. That's best for him, and best for my patients — I didn't want a zombie killing someone by mistake. I also tried to have a heart at other times, too. For example, on Christmas Eve one year, I told the resident, "Dan, it's Christmas Eve. You should be home with your wife. Go on, get out of here." Or if I knew the resident had a major test the next day, I'd tell him to go home and sleep or study.

From what I hear about medical students these days, it is less common for them to be subjected to tortuous work hours, especially on holidays. Medical students are still students, and I see no reason why they should be forced to work on holidays. Just because I worked almost every holiday of every year doesn't mean that they should be subjected to the same deprivation from their friends and family. Are holidays and traditions any less important for medical students? Not in my opinion.

At this time, there is one state (New York) that legislated a maximum number of resident work hours. Such legislation will likely be passed in other states, too. However, I wonder why attendings in teaching hospitals need to be told what to do by legislators; why can't they do it on their own, now? They can if they wish, and they could if they wanted to decades ago. There is only one thing stopping them: they like having their slaves.

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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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What's "a wall"?

Q: I heard an ER doc being referred to as "a wall." What's that?

A: In the context of emergency medicine, an ER doc who is "a wall" is one who does his best to not admit patients. Residents love such docs, because this minimizes their work load. Thus, whenever a doctor is described by residents as being a wall, it is uniformly stated in a way that reflects gratitude, relief, and sometimes even glee. Lawyers also love ER docs who are walls, because if they do their best to block admissions, they are certain to send some patients home who should have been admitted. Until the day arrives when docs have crystal balls or infallible means to know just who needs admission and who does not, there will always be a gray zone of uncertainty. Raising the admission threshold makes a doc a wall, and thus a prime target for lawyers who, with their 20/20 hindsight, always know who should have been admitted.

Cadavers, dissection, and computer imagery

Q: I've read that medical schools are increasingly doing away with dissections. Instead, their students study on already-dissected cadavers (prosections). I will apply to medical school in two years. Is there any benefit to me to apply to a school in which the students still perform the dissections? Marcy

A: Perhaps. You will likely learn more by doing it yourself. However, the drawback to dissection is that it takes a lot of time if you do a good job and an enormous amount of time if you do a great job. I used to look at the meticulous dissections in some anatomy books and wish I had more time to replicate their fastidious work.

Although cadavers are essential for giving students an idea of what real flesh is like, they aren't necessarily the best tool for learning some aspects of anatomy. When I was in school, I dreamt about computerized representations that could depict anatomy in 3-D, and allow students to view any part of the body from any angle and magnification. Books are limited to static 2-D images, and with cadavers you can only see what is before your eyes. As you dissect into the pelvis, for example, you cannot magically see what the anatomy looks like from behind. It is difficult to conceptualize some of the spaces, planes, and other occasionally nebulous things mentioned in anatomy books. There are a few things in pelvic anatomy, for example, that are difficult to grasp. Even though I received the highest grade in my class on pelvic anatomy, there were still some things that were fuzzy in my mind. Computerized depictions should make such learning easy. They are now available, and are sure to become better in the future.

Nurses masturbating patients

Q: On your page of book reviews, you described the case of a nurse who, on request, masturbated a patient because he was unable to relieve his sexual tension after he'd lost both arms. Is it common for nurses to masturbate patients if they are somehow incapacitated and need a sexual outlet? Would you do it if a female requested it? Thanks, Andrea

A: There isn't much need for that in emergency departments. The few patients I saw in the ER who were champing at the bit for an orgasm didn't seem to need any medical or nursing help. The only exception was a former radiology tech who, after her last shift, went to a bar, got blitzed, and returned to loudly beg an attractive male nurse to boink her.

Would I do it? No, because I like having a medical license. In the ER, the only time I'd get near a woman's pelvic area, even if she was an 88-year-old grandmother, was if I had a chaperone. The primary function of the chaperone is to protect the doctor, not the patient. Perhaps patients need protection from a few rabid docs, but generally it's the docs who need protection from allegations of sexual misconduct. Most women are honest and wouldn't allege something unless it were true, but it takes just one imaginative (or greedy) woman to end a doctor's career. Hence our extreme caution in this area.

With this in mind, I'd have to politely decline a request to masturbate a patient. Faced with that request, I'd recruit a female nurse to do it. I can understand why women would likely prefer to have a man do it, but if they're horny enough to ask a doc for relief, they likely wouldn't complain too much if a woman helped them. Again, this problem would likely never occur in an ER. If a woman is so incapacitated as to be incapable of stimulating herself, it is unlikely that she would exhibit much libido since stress suppresses libido. However, it is easy to foresee how long-term inpatients could develop a need for sexual release.

I took care of inpatients at times during my training, and whenever this problem arose, it was easy to solve because all the patients conveniently had a spouse or partner. I'd just ensure that they had enough time alone, and I'd let them take care of it on their own.

Interestingly, the Ann Arbor News recently reported that a 15-year-old patient at the University of Michigan C.S. Mott Children's Hospital summoned a prostitute from an escort service to his room for sex. According to the U-M Department of Public Safety, a hospital employee notified police after overhearing the two negotiate her fee afterward. (I've never visited a prostitute, but isn't it industry practice to negotiate the fee beforehand?)

While some nurses are considerate enough to masturbate adult patients on request, it is a safe bet that virtually no nurse would do this for a child under the age of consent. Can you imagine the scandal this would engender? The nurse would be fired, her license permanently revoked, she'd end up in prison and would be perpetually labeled a sex offender, and the patient's parents would sue for millions of dollars.

Coming back from the dead

Q: In the last season premier of JAG, Lt. Bud Roberts "came back" after the doctor pronounced him dead. Does this ever really happen? Gary

A: I've heard of a few such cases, but I've never witnessed one. It's fairly common to continue to see some cardiac electrical activity after a person is declared dead, especially if that patient was given a lot of epinephrine (adrenaline) during the resuscitation. However, such electrical activity does not necessarily mean there is a remaining spark of life. If the heart is too far gone to pump any blood, it may retain electrical activity for a while, yet be essentially dead as a doornail. Basically, how we determine when to stop a code and pronounce a patient dead is straightforward: if the patient doesn't respond to the resuscitation and begin pumping his own blood, we give up when there is no reasonable hope of restarting the heart. We don't do heart transplants in the ER, so when the heart is functionally dead, so is the patient. Less commonly, we declare death if there is clear evidence of brain death, even if the heart is merrily pumping away.

The cases I've read about in which patients "came back" after being pronounced dead were due to pronounced bradycardia (slow heart beat). If a person has a very slow heart beat and the doc fails to check the pulse for a sufficient time, he might miss the fact that a pulse is present.

What's it like to be a doc?

Q: On a personal level, what is it like to be a doctor? Charlene

A: In no particular order, here are a few things that come to mind:

  • It is nice to always have a doctor "on call" inside me. Think of the millions it'd cost to pay a doc to tag along with me the rest of my life!

  • I enjoy having knowledge that I can use to help others. For example, while eating dinner at a restaurant recently with my Mom, a young waitress almost passed out, from what I was told. The person who witnessed this (not a doc) checked her pulse and opined that it was "thready" (meaning weak). I checked her pulse for about five minutes, and it was fine in terms of rate, rhythm, and pulse amplitude.

  • It's saved me from being hoodwinked by a prospective sexual partner. While inquiring about her sexual history, she admitted she's had genital herpes. However, she assured me that I wouldn't "catch it." Amused by this false assurance of safety, I asked why. She said that if I picked up what she had, I'd be a "carrier" but wouldn't manifest the disease. Almost laughing by now, I thought, "Did you forget something? I'm a doctor, and you're not. You can't bamboozle me with your attempted factoid." Then, in the nicest way I could, I told her that she was full of shit, and that she'd have to find a more gullible guy. Considering how horny I was at the time, had I not known enough to realize that she was dead wrong, I might have swallowed her medical advice.

  • It's very convenient. For instance, yesterday I called a pharmacy that administers flu shots and learned that their nurse wasn't in that day. No problem, I said. I'm a licensed doctor, so I can pay you for the vaccine, and I'll give myself the shot. The pharmacy owner agreed, so I did it.

  • One of my brothers needs a monthly injection. Rather than making the two-hour round trip to his doc, I give him the shot. It saves time and money.

  • Having a medical background enables me to make sense of all the health information that is floating around these days. Some of it is good, and some of it is nonsense.

  • Medical knowledge is often helpful, even in seemingly non-medical situations. Here is just one example: there are countless chemicals (natural and synthetic) in our environment. Some are benign, and some are potentially injurious. For instance, many common products (such as insect repellants, pesticides, and even some plastics) can cause adverse hormonal effects. Believe it or not, so can drinking from a "styrofoam" (expanded polystyrene) cup. I discuss this, and countless other topics, in my sex book (The Science of Sex: Enhancing Sexual Pleasure, Performance, Attraction, and Desire). Even if you now don't believe my assertion that I know more about sexual pleasure than anyone else, if you read that book, you'll probably agree with me. Had I not had my medical background that served as a starting point for acquiring that knowledge, I would not have possessed any way to assess the veracity of statements made by various authors and television hosts. Unless you're a medical doctor, I feel sorry for you. There is a great deal of misinformation now circulating, thanks to supposed "sex experts" whose training in science is often meager. As I mention in my book, this sometimes leads them to propound truly wacky ideas.

  • It can be comforting (and helpful) for family members in a crisis situation. Shortly before my aunt died of cancer, she visited an emergency room (not mine), accompanied by me. Frankly, I was astounded by the incomplete, apathetic care she received. Her she was, gasping for breath, and the damned nurse acted like I was imposing on him and making great demands just because I asked him to give her some oxygen! How much more basic can you get? I think he was irked by the fact that I had a point, so he threw the oxygen mask at me, bouncing it off my chest, and onto my dying aunt. Not surprisingly, the oxygen helped relieve her air hunger. The nurse insisted that I put the mask on her. That's not a big deal for an ER doc, but I was there to hold her hand and comfort her, not take medical care of her.

Mental practice makes perfect, too

Q: I don't know if you remember me, but I wrote to you a few years ago requesting some advice on improving my grades and MCAT scores. Your tips helped me, and I'm now in medical school. May I ask another favor? Can you give me another tip? I don't specifically know what I'm looking for (if I already knew it, I wouldn't need to ask you, correct?), but it'd be great to have some performance secret that most other medical students don't have. If you can help me, I'll take you out for dinner once I start making money (I'm now broke . . . you know what that's like!). Thank you very much, Mary

A: Here is a tip that will primarily benefit you in your clinical years: until you become very proficient doing something, mentally practice it. Most students fail to appreciate how valuable it is to mentally rehearse things. Here are two examples:

  • When you're learning how to perform physical exams, mentally go through the motions of the exam, and picture yourself doing everything that you'd do during an actual exam. Most students just learn to do physical exams by doing them. That's important, obviously, but to become more proficient more quickly, it helps to supplement actual exams with preceding mental imagery. It takes a while until students can examine a patient skillfully and efficiently. This importance of the latter objective — efficiency — is overlooked by most students. They think that once they can skillfully perform all the elements of a physical exam, they've mastered the process. Not quite. Efficiency is key. As a medical student, intern, resident, and practicing physician, you'll rarely have the luxury of unlimited time for an exam. While most students do not lollygag during physicals, they aren't especially efficient, either. Achieving optimum efficiency is a surprisingly difficult process (for reasons I'll explain in a minute), and any student who leaves this process to chance and hopes to become efficient just by doing more exams is bound to reinforce bad habits, not learn efficiency. To become efficient, you need to consider every motion you make, and every motion you subject the patient to, and take steps to minimize unnecessary movement which wastes time and may unduly fatigue your patients. Some of them will be debilitated, and if you have them repeatedly sit up, lie down, sit up, lie down, roll over, roll back, do it again . . . well, you'll tax them more than you should, and you'll waste your time, too. Most students fail to appreciate how inefficient they are. After all, the patient is basically in one spot, and they don't move too far during an exam (perhaps six feet from head to toe), so how inefficient can they be? Very. Besides subjecting patients to unnecessarily repeated motions, students (and many physicians, for that matter) usually don't consider the optimum order for performing every facet of the examination. Typically, they move in a regimented way as they tick off the various aspects of the exam: this cranial nerve, that cranial nerve, inspect the pharynx, etc. There is often no logical order to the way in which they group things. My physical exam textbook presented separate chapters for the head and neck exam, the cardiac exam, the lung exam, the abdominal exam, the musculoskeletal exam, the genitourinary exam, and the neurological exam. If a student were to mentally paste together all the steps for chapter 1 followed successively by the steps from chapters 2, 3, 4, 5, 6, and 7, he'd perform a very inefficient exam.

Time study engineers have maximized efficiency for workers on assembly lines and in many other work environments. Performing the tasks required of one man on an assembly line is considerably easier and less complex than performing a complete physical examination. Since time study engineers can suggest ways to improve efficiency for assembly line workers (whose jobs may seemingly appear so simple and straightforward that one might think a worker or his boss could intuitively figure out the best way to do it on his own), it isn't surprising that they'd have far more suggestions for optimizing the performance of physical exams. However, medical schools are run by people who are smart, but typically locked into doing things the way they were taught, and the way their teachers were taught, and the way their teachers' teachers were taught, and so on. Since medical schools won't likely invite time study engineers on campus any time soon, you'll have to do your own time optimization. The basics of it are simple: just do things in the most efficient order, so as to minimize motion and the time and effort required for it. Within a few hours, you will likely be able to think of several ways to enhance your efficiency for a complete exam. Here's the hard part: as a medical student, you typically do complete exams on everyone, even if they're admitted for a focal problem. As a practicing physician (in the ER, for example), you will occasionally do a complete exam, but usually do limited exams, depending on what's wrong with the patient. The optimum order for performing the various components of a complete physical exam is often not the optimal order for performing the components of a subset of that exam, or a limited exam. Hence, to optimize your efficiency for a complete exam and the limited exams, you'll need to give some thought as to how you should best organize all those exams. Considering that docs spend a large chunk of their professional time examining patients, it behooves you to learn to do those exams in the most efficient ways.

  • Mental practice can help you master other tasks, too, like tying surgical knots, or intubation, or inserting IV's (especially ones in central veins that require many steps), or the most important motor skill for a doctor (according to my brother): mastering the golf swing. Seriously, mental practice has been shown to improve a variety of motor skills, including ones in various sports and music (e.g., playing the piano). Incidentally, sleep is important for enhancing the benefit of practice, whether it is real or mental. Sleep is known to be essential for memorization, but people often overlook how important sleep is for mastering motor skills, too. If you practice, the best time is in the evening. Research shows that there is a critical time frame after practice in which the body needs sleep so as to reap the greatest benefit from the practice. If you practice in the morning, by the time you sleep the following night, you will have missed the optimal window of opportunity for making the most of your practice. Surgeons at every teaching hospital I've been associated with schedule most of their surgery for the morning. This may be convenient for the attending surgeons, but it is not optimal for the surgical residents who assist with the surgery.

Many More ER Questions and Answers Part 2

Many More ER Questions and Answers Part 3

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