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A mold to make ER cookies and ER Jell-O!  Or how about a glow-in-the-dark chest x-ray?


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Do you care if wild animals needlessly suffer and die during wintertime? If so, see www.shelteranimals.org.


Yet Another Page of

ER Questions and Answers
Part 3


Is medicine a good career choice for a creative person?

Q: Do doctors have much opportunity to be creative?  I think I would like to become a doctor, but I want a career in which I can exercise my creativity.  Thanks, Tricia

A: If you engage in research or develop inventions as I do, you can exercise your creativity.  However, there is little opportunity for creativity in traditional medical practice, where what you do might as well be written in stone.  I was utterly amazed by how hidebound the medical system is.  Here is one example that illustrates this rigidity.  In the ER, I used a pen with purple ink.  I had four reasons for this, three of which should have been apparent to anyone:

  • Compared with the usual black ink, purple ink had better contrast with the preprinted black lines, boxes, and text on the ER chart.
  • It was easier to differentiate who wrote what when residents were also writing on the chart, since they used black ink.
  • It made it more difficult for patients to alter prescriptions, such as when they tried to change 10 Tylenol #3's to 100.  Black ink is very easy to match, but the shade of purple that I used was not.
  • I love color.  Black is boring.  Purple isn't my favorite color, but yellow and fluorescent orange pens aren't practical, so purple had to suffice.  My limbic system received precious little enjoyment most days in the ER, so if I could derive a smidgen of joy from looking at purple ink, why not indulge myself with this minor pleasure?

Although I had good reasons for using purple ink, this created controversy that dragged on for years.  From the reaction that it generated, you might think that I proposed something outlandish, such as giving patients soft drinks via an IV (kids, don't try this at home — it's fatal).  The first reaction was, "He's using a purple pen!  That isn't done!  Black is the only permissible color!"  To which I responded, "Why?"  They claimed that purple ink would not photocopy, but I proved that claim was specious when I showed that purple ink photocopies quite well.  I thought this would put an end to the chatter, but it went on for years.  I ignored it, and kept using my purple pen.

Incidentally, I developed a pen that made it very difficult for patients to forge or alter prescriptions.  If you're interested, here is a description of that pen.


Preponderance of male ER physicians
Are men more suited to the job?

Q: I heard from many people that as far as ER docs are concerned, there are many more men.

A: That is true, but it is changing as more women enter medicine.  Some medical school classes are now over 50% women.

Q: I also heard that it's harder for women to make it as an ER doctor because men have an easier time dealing with the stress and the face pace.  Thank you so much for your time.  Sarah

A: I don't think that men necessarily have an advantage over women in dealing with stress and time pressure.  This general impression is substantiated by my observations of female ER doctors, who impressed me as being just as adept as men, and no less likely to wilt under pressure.


A severed hand won't make an ER doctor sweat
What will make an ER doctor sweat

Q: Hi.  My name is Madeline, and I'm in eighth grade.  I really want to be a doctor some day.  I can take the stress, but I'm not sure what I'll do when someone comes into the ER screaming with their hand separated and bleeding in a cooler.  Please email back if you have the time.

A: That's an easy case. Your training will prepare you to handle that with aplomb.  Many people seem to think that the difficult cases are ones involving trauma, heart attacks, codes, etc.  Most of those situations are easy to manage.  In my opinion, the challenging cases are ones that aren't discussed in textbooks, and there is no obvious ideal solution to them.  In the near future, I will upload a long case that perfectly illustrates this management dilemma.


Is is tough to pass medical school?

Q: I am concerned about the difficulty of medical school.  Is passing medical school as hard as you say?  Tom

A: Medical school is difficult, but the primary challenge isn't passing it, it is excelling in it.  I thought medical school was tough, but I usually gave it a 100% effort (within the limitations of my less than ideal living circumstances).  Giving a 100% effort is much more difficult than, say, an 80% effort.  I could have passed with an 80% effort, but I would not have graduated in the top 1% of my class, as I did.  I do not think that medicine is a good career for people who don't want to give it their best shot.  Therefore, I think medical school should be difficult for everyone because they should maximally apply themselves.

Passing medical school is significantly more challenging than passing college.  How can I put this nicely?  Oh heck, I won't even try.  In college, there are a substantial number of academic pushovers (that's a euphemism for dumbbells).  These folks with lackluster mental acumen succeed in lowering the yardstick by which other students are graded.  When the median of the ol' bell curve is depressed, that makes it easier to succeed.  Ultimately, almost everything is graded on the curve because professors assess your performance by comparing it to that of other students.  Thus, even if a given test is not graded on the curve, the benchmark that defines performance is derived from gauging the performance of other students.

There are no dumbbells in medical school.  With rare exceptions, even the people at the bottom of the class were excellent college students.  When the bottom part of the bell curve is lopped off (or truncated, for you good students), this makes it more difficult to succeed because there aren't any pushovers around to lower the standard.


Should addiction medicine be a medical specialty?
How psychiatrists often view addicts

Q: Dear Kevin:  I've been perusing your website during the past couple weeks and have found it to be wonderfully thorough as well as useful.  I enjoy your writing style, which is obviously reflective of your intelligence and sense of humor, and I plan on reading one of your books in the near future.

In the meantime, I have a question for you regarding the area of "addiction medicine":  Do you think addiction medicine should be a medical specialty in its own right (separate from psychiatry, etc.), and, of course, why or why not?  I am curious as to what your thoughts are on this particular category of medical knowledge and practice.

Thank you for your consideration of my question.  Sincerely, Juli


A: Yes, I think so.  Here is my rationale.  Apart from the information that is within the province of the various medical specialties, there is an accompanying set of attitudes and beliefs that colors the mindset of practitioners in those fields.  In dealing with psychiatrists, I noticed that a few of them view addiction as a psychiatric/medical problem to be addressed in the usual dispassionate and professional way, while others routinely inject their personal viewpoints, and assail addicted patients with pejorative phrases like "that person is just a junkie."  Of course, this vituperation is not directly vented on the patient; instead, it is relayed to me, the hapless ER doc who is just presenting the case to the on-call psychiatrist.  If you ever see an ER doctor wincing as he pulls the phone away from his ear, it's a good chance he is speaking with a psychiatrist who is in the midst of venting his spleen. :-)

In contrast to the routine disparagement of addicts that emanates from most psychiatrists, the one addiction specialist I knew (essentially a self-designated specialist) never bothered to throw a temper tantrum when he received a request from the ER to admit a patient.  Instead, he readily accepted the patient, and treated him as someone who needed help, instead of as a degenerate who deserved only perfunctory treatment.

Hence, I think it is likely that specialists in addiction medicine would be more apt to possess a mindset that is conducive to unprejudiced evaluation and treatment.  In the domain of psychiatry, patients whose neurotransmitters need tinkering are not scorned, unless that person is an addict.  However, since neurotransmitter aberrations create the milieu that fuels the development of addiction, it seems to me that this bias is not justifiable.

ContactMeFree is a dream come true for anyone involved in online dating. If you have your profile posted on a personals site but don't pay for a membership, you know how limited you are in terms of being able to send or receive messages. You probably assume that those limitations disappear if you pay for a membership. Guess what? You are still far more limited than you realize. Frankly, if you knew how limited you were, you would be furious that the personals site was charging you $20 to $50 per month and still keeping the shackles on you! The person who created ContactMeFree was so outraged by those limitations that he decided to do something about it. So he did!

You know that writer's block you get when you sit down to write the essay portion of your personal profile for online dating? And you know the difficulty you have trying to think of a catchy headline? Well, MyProfileWriter allows you to create a profile essay and headline without typing, just by clicking!

A beautiful woman wants to know if her looks might repel male patients

Q: I would like to become a physician in one of the primary care specialties, but I am concerned that my beauty might deter men from choosing me as their physician.  I hope you don't think that I am conceited for saying that I am beautiful, but I am (I posted my picture on Hot or Not, and received a 9.9 rating).  You're a man, a physician, and obviously very insightful, so I would like your opinion on this matter.  Thank you.  Molly

A: Beauty draws men like meat draws flies, except when it comes to dropping trousers.  From my experience as a doctor, most men are very uncomfortable with genital or rectal exams.  They protest, whine, squirm, huff, sigh, and avert their gaze in such a regressively stereotyped manner that I think it must be genetic.  I've seen it many times.  Men are even more reluctant to bare all in front of women physicians, especially beautiful ones.  Consequently, it is likely that your pulchritude will cause some men to choose another doctor.

In addition to their discomfort with nudity, male patients are also less comfortable discussing sexual problems with female doctors.  It is one thing to discuss erectile dysfunction with a man (who presumably may have some firsthand awareness of that problem), but it is an entirely different thing to admit some imperfection to a woman.  As a general rule, men strive to impress women — even ones we're not sexually involved with.  Face it.  Men are different.  Strength and success are at the core of masculinity — not crying on Oprah, and not admitting shortcomings to people who are not family members.

A week ago, I visited a local pharmacy to purchase injectable vitamin B-12 that I administer monthly to my brother for pernicious anemia.  The pharmacist was stunning.  Stand her up next to your average model or Hollywood actress, and it's a sure bet that 98% of the male retinas in the room would be locked onto her lovely visage.  If you were a man with a prescription for Viagra, would you prefer that she fill the prescription, or would you feel more comfortable seeing a 65-year-old male pharmacist?

Bottom line?  If men are given a choice, most prefer to see a male physician.  However, this needn't be the knell of death for your career and that of other beautiful women who are prospective physicians.  Your beauty can be an asset in other ways.  For example, studies have shown that babies prefer to look at beautiful faces . . . yes, even babies.  I've noticed this in my own practice.  For example, one night a mother brought her child to the ER.  Try as she did, she couldn't make the baby smile.  I just looked at the child, smiled, and the baby responded with a smile and a look of sheer joy.  I don't think I am good-looking (judge for yourself), but, unlike the baby's mother, my teeth aren't decayed grayish spindles, and my skin looks like I eat nutritious food instead of subsisting on booze, potato chips, and cigarettes, like the mother did.  Coupled with her raspy voice and perpetual scowl, that mother was the antithesis of alluring.

However, most mothers aren't hideous, as that mother was.  Hence, most babies are accustomed to seeing some beauty, and therefore won't go gaga when they see yet another attractive person.  But if a child looked at someone as gorgeous as you (thanks for the picture, by the way!), it'd be difficult to not smile.  The human affinity for beauty is hard-wired in our brains.  It is not, as some suggest, a result of cultural conditioning.

Even in this age of million-dollar high-tech machines, some of the most important diagnostic tools are utterly basic.  ER doctors and pediatricians frequently must differentiate run-of-the-mill infections from serious ones, such as meningitis.  We can't do a spinal tap on every kid, so we use various diagnostic clues to judge the severity of infection.  One of these clues is how responsive the child is to pleasant sights or play.  As a rule, kids with meningitis don't smile when looking at attractive faces — not even you, Miss America, or the ravishing pharmacist I mentioned above.  Hence, you walk around with a useful diagnostic tool.  People who are less attractive, such as myself, cannot rely on our appearance to induce reflexive smiles, so I carried around an ALF puppet that was irresistible to most kids.  For older kids, I used scratch-'n'-sniff stickers, a pocket fan I made, and other entertaining gizmos.

Please don't think that I am trying to steer you into one of the traditionally female medical specialties just because you are a woman.  Most of my friends are women, and I look at women as being fully dimensional and inherently as competent as men.  However, you are not just a woman, but a beautiful one.  Babies will love you.  So will men — just not when they must turn their heads and cough.


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.


Following your dreams
Can you afford to be a doctor?
Why should the US government limit what doctors can charge?
My radical solution to the healthcare crisis
How much an average ER doctor works
Will an ER career interfere with your personal life?
What is a good book that tells what an ER physician needs to know?
Must docs know Latin?

Q:  Hi, my name is Nick.  I am 14 years old and live in Ireland.  My ambition is to be an ER physician.  Your site is one of my favorite places on the web and I thoroughly enjoy reading it, however, strange as it may sound, the reasons you give for not wanting to work in the ER seem to be the reasons for which I think I WOULD like to work as an ER physician.  Let me tell you a bit about myself so you can understand where I'm coming from.

I would like to work in a job that keeps me on my feet (not necessarily literally).  I like helping people.  I have an incredible fascination with weird people.  I am not frustrated easily.  I find the work ER physicians do very interesting.  I find the atmosphere in emergency rooms very exciting (I mean that in the least twisted way possible).  I believe I have the academic ability to achieve this goal.  I am completely aware that the TV show ER is a bullshit portrayal of what it's really like to work in an ER . . . but that doesn't stop me from watching it every week.  I think 140k-200k is a hell of a lotta pay.  Hell, I'd be happy with less than 100k!

Anyway, taking the points I have made about myself above, do you believe that I should follow my dreams or are there some ER disadvantages that I may not be immune to?

A:  Simple answers are not my stock-in-trade.  With that in mind, here goes.  First, as a general rule, I think people should follow their dreams and fulfill their wishes whenever possible.  Many regrets that people have stem not from things they did, but from things they didn't do.  Unless you want to be plagued by those "what if?" doubts, you should take a "go for it" approach to life.  Some things may not turn out to be as wonderful as you imagined, but nurturing a tad of disappointment is preferable to nagging doubts of perpetual uncertainty about the road not taken.

On the other hand, if you become a physician, you may harbor more than a tad of disappointment.  Medicine is now a very troubled profession, and doctors who thought they'd love a medical career have left it, or were forced to by exorbitant malpractice premiums.  Some doctors are taking out loans to pay their premiums, hoping to stay in practice for a better day that may never come.  That is quite a gamble.  One physician's premium rose to one million dollars per year.  Would you write a million-dollar check, knowing that you might lose $800,000 that year, just so you could hope that your premium would be less the next year and that you might eventually make a profit and be able to feed your family?  Things aren't this bleak for every doctor, because most premiums are less than that.  Nevertheless, writing a check for $50,000 or $250,000 is entirely within the realm of probability if you practice in the United States, and there is an even more alarming specter to consider:  you could pay through the nose for malpractice premiums and then have to personally pay for malpractice settlements if your insurance company goes bankrupt.  Unfortunately, that is now a very real possibility.  Considering that the average jury award is approaching four million dollars, your life could be ruined by one mistake — or even one alleged mistake, given that 80% of malpractice suits in this country are frivolous.

Generally, people who assume more risk in society receive enough compensation to make assuming that risk worthwhile.  However, now that ER physicians in the United States receive ridiculously low reimbursements or even no pay for half the patients they treat, it is reasonable to question whether practicing medicine is economic insanity.  In my career, I averaged about $36 in pay per patient visit.  At that rate, I'd have to treat over 111,000 patients just to pay one $4,000,000 verdict.  Bottom line?  I think the compensation that ER doctors receive is far too low to justify assuming enormous financial penalties.  If police handed out $4,000,000 traffic fines, don't you think a person would need to have rocks in his head if he became a cab driver or truck driver?

Frankly, I am peeved that the US government limits what doctors can charge.  Aren't we supposed to be a free market economy?  The US Congress cannot tell Oprah that she doesn't deserve to be a billionaire (which she is), nor can it limit how much money Hollywood actors can charge for exploiting their God-given beauty.  So why can the Congress pass a zillion laws that regulate almost everything physicians do except breathe?  Do physicians with IQ's of 130 really need silver-tongued idiots in Congress telling us what to do?  When asked what her college major was at the press conference announcing her presidential campaign, former Sen. Carol Moseley-Braun (D.-Ill.) was stumped and was quoted as saying "I hate to guess.  I think — I mean, I'm going to guess it was political science, but I'm not sure.  It might have been history.  I'll check.  I hadn't thought of that one."

Forgetting your college major is like forgetting whether or not you're a virgin.  How could anyone forget such a monumental thing?  She was a US Senator whose decisions impacted our lives and the lives of generations yet unborn, and now she wishes to become President?  No wonder our government is so screwed up when imbeciles like her are in charge!

Here is what I think physicians should do:

1. Determine the average jury award for a lost life (it would likely be substantially above $4,000,000, since that figure includes awards for nonfatal errors, such as botched or even allegedly botched toenail surgery).  For simplicity, let's say it is $10,000,000.

2. Whenever a doctor saves a life, bill the patient $10,000,000.  Isn't that fair?  If a life is truly worth ten million, saving a life is worth ten million, correct?  That is indisputable.

3. Forgive 100% of the bill for all but the very wealthy (based on a submission of prior 1040's or other financial records).  Thus, just about everyone would pay nothing to physicians.  Or instead of a fixed $10,000,000 fee, institute a sliding scale based on ability to pay, with a high enough threshold so that 99% of people would receive free care.  Say that Bill Gates was turning blue and gasping for breath in front of me.  Instead of getting my measly $36, I'd charge him ten billion dollars.  On second thought, considering the turmoil his exasperating software and arrogant company has caused me, I'd charge him twenty billion.  Maybe thirty.

4. Since a physician might work years or even decades before he had a tycoon as a patient, the only way to make this feasible would be for physicians to be paid from a pool of these payments.

5. Finally, most physicians would need to agree to participate in this plan so that the government could not penalize physicians for doing so.  Could they put us all in jail, or revoke our licenses?  Nope.

This is a strikingly radical plan for someone who generally opposes discrimination against rich people.  However, the fact that 99% of the population would pay nothing to doctors would make this plan very popular.  If Bill Gates had ten or twenty billion dollars less than he now does, he wouldn't starve.  He could still afford to live like a king and, dare I say, in a lifestyle that is far better than that monopolist deserves, considering the crappy software he foists upon us.  Hmmm, at $36 per visit, 20 billion dollars could pay for 555 million ER visits.  Considering how many billionaires are in the United States, everyone who wasn't a billionaire could obtain free care from doctors.  Heck, we could even give free care to billionaires like Oprah, and just charge the multi-billionaires.

Q:  Also, I would be grateful if you would tell me how many days the average ER physician works a year and how many hours a week?

A:  It depends on the shift length (most commonly 8 to 12 hours), but ER docs average about 200 shifts per year.  Hours per week?  As I discussed elsewhere in far more detail, the average hours per week is about 40 paid hours and 10 to 20 (or more!) unpaid hours for mandatory committee meetings, staff meetings, ER meetings, dictations, miscellaneous paperwork, unpaid overtime, continuing education, keeping bureaucrats happy, dealing with insurance companies and lawyers, testifying in court, etc.

Q:  Another thing that pops into my mind is marriage and relationships.  How understanding are partners?  Have you ever broken up with a partner because she couldn’t cope with the fact that you were always busy?  I’m just wondering if the demanding hours are a serious social problem.

A:  They can  be.  All those unpaid work hours make the job less tolerable than it may seem.  Additionally, ER physicians often suffer chronic sleep problems from their frequently changing schedules.  Thus, on many of my off days, I was zonked out in a chair while the sun was shining and I could have been traipsing about beautiful northern Michigan.

I will now tell you a secret that I've never told anyone else.  I was so disgusted with being an ER doctor that I spent most of my free time doing things (such as writing, inventing, and starting a business) so I could quit working in the ER.  All this work left me with very little time for dating, so I don't have enough experience dating women to give you an informed answer if partners are understanding.  However, if you're willing to keep in mind that this sampling of experiences is too small to be statistically valid, I will present a synopsis of everything in my dating life that pertains to this issue:

Woman #1:  Perhaps it is not fair to mention this, since it preceded my days in the ER.  In any case, in my first year of medical school I lived in the basement of my girlfriend's parent's home.  At that point in my life I found it very difficult to study unless it was absolutely quiet, so I did what any eccentric inventor would do:  I built a sound-proof booth.  I'll skip the tantalizing technical details and cut to the chase.  One Saturday morning, while I was dutifully studying, my girlfriend stepped into my booth, wielding a bowl containing a few pounds of sugar.  Without any warning, she dumped the sugar on my head, righteously huffed, and strode out of the soundproof booth.  I may not be a rocket scientist, but I can put two and two together.  She was irked.  That being obvious, I asked why.  "You've been neglecting me.  All you do is study.  We never do anything fun."  That was a bit of an overstatement, but it was far more true than untrue.

Woman #2:  Repeatedly hinted that she wanted to marry me, but always in an oblique manner.  Didn't seem perturbed by my wacky hours, but let me be frank:  had I not been a doctor, this model look-alike would not have dated me.  Need I say more?

Woman #3:  On my sole day off in the midst of 20 shifts in three weeks at a time when I worked in two ER's, a woman I'd met insisted that we go on a date that day, even though it was my only day for shopping, laundry, housework, and paying bills.  After saying "no" for 90 minutes on the telephone, I decided not to subject myself to nagging in the future.  I'm still single.

Q:  I would be very pleased if you could recommend a CD or book that contains things an ER physician needs to know (preferably a CD).  I am very interested in this profession and would like to get a taste of the type of stuff you have to learn.  THANK YOU SO MUCH for your time and I'd like to wish you all the best!  Your site is fantastic!!!

A:  Thank you for the compliments.  Judith Tintinalli, MD is the editor of a fairly comprehensive study guide used by many (perhaps most) ER physicians.  I purchased a copy of the book during my ER residency, and later purchased that book in a CD-ROM format, entitled Emergency Medicine Plus.  This book is far from everything you need to know, but even Rosen's Emergency Medicine (which weighs enough to double as a ship's anchor) isn't truly comprehensive.  If you dive into either of those books, as I dove into The Merck Manual when I was your age, you will likely find that some of it is about as clear as hieroglyphics.  These books are intended for physicians who already know the basics:  how to read EKG's, what different drugs do, etc.  Nevertheless, I heartily recommend this premature immersion because I think it helps to stimulate brainpower and the subsequent mastery of medicine.

Q:  PS:  I heard somewhere that you have to know Latin (which I don’t study in school) if you want to be a doctor.  Is this true or is it just a load of codswallop?  Thanks again!

A:  Codswallop?  Now that's a regional expression I've never heard!  On to your question.  You do not need to know Latin.  However, unlike politicians, you will need to know your major.


A few community college classes?  Don't sweat it.
A secret weapon to help ensure that you are accepted into medical school

Q:  Hello, my name is Melissa and I am a freshman at LSU.  I was wondering if medical schools look down upon students who go to community college for summer school?  I thought I could catch up on my credits.  I transferred from Ole Miss and two of my grades were too low to transfer and it says that on my transcript.  Should I retake them this summer at a community college?  I am not trying to get into Harvard or Yale medical school.  I love your website!

A:  A few community college classes shouldn't significantly affect your assessment by a medical school admissions committee.  In regard to the committee being aware of the low grades, I would not go out of your way to retake them at a community college.  Just continue on at LSU and fulfill its requirements for your baccalaureate as well as the medical school prerequisites.  Most medical school applicants have at least one blemish on their records.  It even happened to me.  Although my college GPA was 3.94, I received a D in one class because the university said I dropped the class too late.  To make a long story short, one year I decided I wanted to be a CIA agent, so I stopped going to class.  Evidently, I'd accumulated enough points in the short time I had the class to give me a D instead of an E.  In any case, that grade was clearly an anomaly, and the medical school admissions committee never questioned me about it.

You did not ask me about this, but I will give you a secret weapon to help ensure that you are accepted into medical school.  Many schools employ various racial or ethnic quotas.  A friend of my brother (I'll call him Tom) applied to a medical school that gave preference to applicants who were at least one-sixteenth black, red, purple, green — anything but pure white.  Tom knew his undergraduate grades and MCAT scores were likely not high enough to ensure his acceptance, so he said he was one-sixteenth Cherokee Indian . . . one of the many groups listed.  Presto!  He was accepted, and they never bothered to peer into his genealogy.

Some people who read this may think that my recommendation is unethical.  I disagree.  In my opinion, racial/ethnic quotas are unethical, and anything that circumvents them and helps to level the playing field is just fighting fire with fire.  Let me explain.  Tom came from a well-to-do family.  His father paid for his tuition, books, car, food, rent, utilities, and spending money.  My father abandoned my family when I was a child, and didn't pay child support.  My Mom worked at several jobs, and I think her best paying one was working as a grocery store cashier.  She struggled to pay her bills, and giving us a free ride through college (like Tom received) was out of the question.  I worked many jobs in high school and college, but there were times I ran out of money and literally starved.  When I had money, I did everything I could to stretch it.  I bought cheap liver on sale, and figured out how to eat for 6 cents per meal.  I could go on for another hour and tell more tales of woe, but the bottom line is this:  obviously, I wasn't born with a silver spoon in my mouth.

Assuming that Tom was indeed one-sixteenth Cherokee Indian, who was more disadvantaged:  him, or me?  Clearly, it was me.  So why should he be given preference in admissions?  To make up for the disadvantages he faced?  What disadvantages?  Growing up in one of the wealthiest suburbs in the country?  Having everything handed to him on a silver platter?  Never having to work?  Yeah, he had it tough.  He was boinking his girlfriend (who looked like a real-life Barbie doll) while I was working two jobs and studying endlessly, because I wasn't a member of one of the favored racial or ethnic minorities.  If you faced hardships similar to mine, I think you would have every right to not have others gain an advantage over you in admissions just because they're one-sixteenth Cherokee Indian and 100% moneybags.


Contracting HIV from a contaminated multi-use drug vial

Q:  Do you have any good scare stories from the ER?  Jerry

A:  As a matter of fact, I do.  Let me preface this by saying that medical experts sometimes scratch their heads and wonder how a heterosexual person acquired an HIV infection if he wasn't a junkie, did not engage in anal sex, and didn't receive a contaminated transfusion.  I am not quite as baffled by these seemingly inexplicable cases.  People are sometimes exposed to HIV (and other infectious agents) in ways that are virtually unknown and certainly not discussed in the press.  Here is one example.  Years ago, I witnessed a nurse contaminate a multi-use drug vial by reinserting a needle that she had just used to give an IM (intramuscular) injection to a patient.  Alarmingly, she did not discard the bottle.  Evidently, she thought that saying "oops" was good enough.  Speechless, I looked on in horror, then told her to toss it in the garbage.

She is probably not the only nurse or doctor who has done this.  Medical and nursing personnel are often so rushed that it is easy to make such mental mistakes, especially when they are distracted by something else.  In the ER, that is common.


Is a paramedic degree from a community college an impediment to becoming an ER doctor?
Preparing for medical school and ER residency
The central flaw of residency programs

Q:  I am currently pursuing an Associates Degree of Applied Science for Paramedic Medicine, which I have dreamed of for as long as I remember.  This major is only offered at the Community College of Southern Nevada (I live in Las Vegas).  After I become a paramedic, I strive to become an ER physician.  Will my paramedic degree from a community college hold me back?

A:  No, assuming you eventually take enough other classes at a university so that medical school admissions committees don't have to compare apples with oranges when they evaluate your grades vis-à-vis those of other applicants.

Q:  Is there any other advice you can give me regarding the transition from paramedic to ER doctor?  Thank you for your time!  Niki

A:  Yes.  Your intended career path is more circuitous than the typical high school → college → medical school → ER residency.  In all probability, attending community college and becoming a paramedic will delay realization of your dream of becoming an ER doctor.  That is not necessarily bad or good.  It is bad if you are in a hurry to become a physician, but it is good if you want to have a more diversified professional life.  As a paramedic, you will experience things that many ER docs never see.  I know that because I spent some time accompanying paramedics as part of my ER residency program.

However, don't let enhanced diversity be the only benefit of becoming a paramedic.  Use your free time between runs (and much of your off-work free time) to intensively study emergency medicine.  Read Rosen's Emergency Medicine once or twice.  Its 2930 large pages (equivalent to perhaps 6000 ordinary pages) will keep you busy for a long time.  If you memorize much of it, you will have a big head start over other ER residents, most of whom do not read that until their residency — when they're so exhausted and have so little free time that it takes them years to commit that text to memory . . . sometimes after killing a patient or two along the way who may have lived, had the resident known more.  Several years ago, a friend of mine told me about an asthmatic teenage patient she'd treated.  A day after the patient was dead, a cardiology attending took her aside and told her that she and her supervising ER attending made a fatal error in coding that patient.  After your first major medical error, you will surely wish you'd read more sooner.

Some people who read this may think, "What difference does it make when I read Rosen's Emergency Medicine (or a comparable book), as long as I read it?"  I could not disagree more.  Here's why.  During your ER residency, you will encounter countless patients.  That clinical exposure is valuable, but it is even more valuable if your ER knowledge base is strong.  Many ER residents just wing it using information they learned in medical school and a smattering of facts they gleaned from ER attendings.  This is not the way to master emergency medicine, or any other specialty.  The primary responsibility of the ER attendings in teaching hospitals is to ensure that patients receive competent care.  Teaching is just a secondary goal that often gets left in the dust if the ER is busy, as it so often is.  Real emergency rooms can be even more chaotic than is depicted on the show ER.  Do you think that environment is conducive to teaching?

Imagine if you were studying to become a writer and your school told you to sit down at a typewriter or computer and start writing, without first obtaining a comprehensive education in the English language.  Wouldn't it make much more sense to learn the fundamentals of English beforehand?  If you had that preparation, the time you spent writing would be more valuable.  Instead of blindly churning out sentences, you could use your enhanced knowledge to obtain greater insights and make more sophisticated decisions as you wrote.  If your English education came after you wrote, it would be impossible to revisit the countless decisions you made during that time and use your subsequently acquired knowledge so you could make better decisions.  Learning emergency medicine is more complex than learning to write, which is why most writers have a bachelor's degree or even just a high school diploma, while ER physicians have a postdoctoral education.  If it is a good idea for writers to first learn the fundamentals (so they aren't practicing blindly), isn't it a good idea for physicians to do this, too?  Of course it is.  However, residents are slaves, first and foremost.  The didactic portion of the residency is interspersed throughout the program, with the result that residents are bound to learn many topics months or years after they see patients with those problems.  For the benefit of the patients and the resident, didactic learning should precede clinical experience.  However, that is not the way residency programs are structured.  They're primarily about putting in your time as an indentured servant, not learning to be the best possible doctor.

It is interesting to contrast medical school with residency.  Except for occasional patient interactions so students can get their feet wet, the first two years of medical school are devoted to didactic education.  The final two years focus on clinical education.  Doesn't this pattern make sense?  Learn what you are doing, then do it.  Not "start doing it, and we might tell you what you're doing, a year or so from now."  I think it is only logical to structure residency programs so there is, for example, one year of primarily "book learning" followed by two years of primarily clinical experience.  However, with few exceptions, residency directors are incorrigibly hidebound, and there is no indication that they will wake up in the near future and amend residency programs to make learning the supreme goal.  Thanks to overwork and tortuous sleep deprivation, as an ER resident I learned just a fraction of what I could have learned.  I don't think I can adequately describe how bitter and disappointed I am about this.  Much of the work performed by residents has everything to do with cheap slave labor and nothing to do with learning.  This work is often denigrated as "scutwork," but that fails to convey how abominable it is.  Many patients would be alive today had residents been educated in a system that put learning ahead of labor.  Notably, patients are harmed by this antiquated system even after residents graduate and become attending physicians, because it takes years to overcome the effects of a second-rate education.  Hence, my advice is this:  residency directors won't change any time soon, so you should take it upon yourself to hit the books before you need that information.

As I've mentioned before, it is advisable to read The Merck Manual before medical school.  Its 2600+ pages give a good synopsis of general medicine.  Along with Rosen's Emergency Medicine, immersing your brain with so many facts from these books will stimulate your brainpower and give you a good framework for integrating subsequent learning.


Advice for a high school student

Q:  I am a freshman in high school who has always wanted to become a doctor.  Recently, I've wanted to become an ER doc.  I read your book about three months ago and loved it.  It inspired me, made me laugh, and touched my heart.  Now when I sit down in a class, about ten hands reach to grab the book.  So far about 15 of my friends have read it.  Your experiences have touched many lives, but more importantly, YOU have touched many lives through your courage, honestly, sense of humor, assurance in yourself, and your work.  I will never forget some of the things I read, and when I go to medical school one day, I will always remember that all things are possible but, in all situations you have the power to make the best of the situation and change lives.

What would you tell a high school student wanting to go into medicine as an ER doctor?  Thank you and God bless you, Veronica.


A:  Learn everything you can about this profession, as well as other jobs that intrigue you.  Don't base your decision on the overly glorified depictions of emergency medicine that you'll find in many television shows and books.  As an ER doctor, you will have a job that can give priceless rewards.  If you like helping people and saving lives, you will be on Cloud Nine.  You would occasionally have this opportunity if you were a police officer or firefighter, for example, but they might save a life only once every few months or years.  An ER doc might save a life several times per day.  After a while, you may become so accustomed to saving lives that you might not reflect on it as you hurry off to see your next patient.  However, every so often a mother will give you a hug after you save her child's life, and that hug will remind you that you really do make a difference.

Bottom line?  If you want to be a real doctor* and touch many lives, emergency medicine is a great career if you are not repelled by the drawbacks I discussed on my web site.  *Physicians often differentiate between "real doctors" (docs who specialize in emergency medicine, surgery, internal medicine, etc.) and docs who aren't "real doctors" (such as dermatologists and allergists).


She is dating a medical student who wants to be an ER doc, and desires to know if that career is conducive to a good family life
The nightmare of chronic sleep deprivation
A solution to this problem

Q:  I am dating a second-year medical student who wants to be an ER doc.  I was wondering if it is true that ER docs usually work three to four 12-hour days in a row and then get three to four days off, and so on?

A:  That is a fairly common schedule.  However, keep in mind that those 12-hour days are often 13- to 15-hour days.  An ER doc cannot waltz out of the ER the minute the quittin' time whistle blows.  He may be just beginning a long code on a blue baby, or he may have a dozen or more pending patients who can't be turfed to the oncoming doc.  He also may have an hour or two of charting and dictations to do.  Then he may need to visit the medical records department, redo dictations they lost (it happens all the time*), complete and sign charts, etc.  Or he may need to attend some department or committee meeting.

* Oh, about those lost dictations.  Several times, the medical records department managed to lose all of my dictations from a given shift.  They made me dictate them again, and I was of course not compensated for the hours that took.  Annoyingly, in most cases they later "found" the original dictations, then said, "Sorry."  If the original dictation was never located, the second dictation became a permanent part of the medical record.  This isn't good for the patient, or for the doctor.  Given the frantic pace in most emergency departments, docs usually jot down a few notes on the chart, then dictate a thorough record later that day whenever they have a spare minute.  It can be difficult to reconstruct a case a month later, after seeing a thousand patients in the interim.  Hence, these re-dictations are often less complete and accurate, which exposes the doc to increased legal liability.

Q:  Is it true that ER docs are not on-call the days they aren't working?  Thanks, Laura

A:  Yes, unless he is the director of the ER, in which case he should be reachable in case of an unexpected emergency, such as if the current ER doc becomes ill or is shot . . . it happens.

After reading this, you're probably thinking, "Hey, it sounds great!  That lifestyle seems conducive to a happy family life."  My advice?  Read some of the Question & Answer pages on my web site.  I went into ER thinking it'd be a great job.  Now I think it was a nightmare, and the worst decision of my life.  For years, one thought dominated my mind:  how to find a different way to make a living.  Becoming a doctor is hellacious enough.  Once a person becomes an ER doctor, he should be on Easy Street.  He's earned it.  It's a tragedy when someone works that hard to achieve something, realizes that there is no pot of gold at the end of the rainbow, then has to start from scratch on another career.

Q:  So it's not conducive to a happy family life?

A:  Generally, no.

Q:  This is one thing I'm concerned about, so I'm curious what the reasons are for it not to be conducive to a happy family life?

A:  Like many ER docs, I was not inordinately bothered by the weird hours when I first began working (young people can abuse their bodies and usually get away with it), but after several years of doing it, it became very wearisome.  Having a three- or four-day weekend every week seems like heaven to most people.  However, since I worked the night shift, the first day of my "weekend" was spent sleeping.  I'd try to get up earlier than usual so I'd be tired enough to sleep that night.  Perhaps it would have been less physiologically stressful to maintain the night shift schedule even on my off days, but if I wanted to see my friends, shop during the day (not many stores are open during the night), see the sunshine, and not go boating in the dark, I had no choice but to try to stay awake during the day.  After years of doing this, my biological clock was so screwed up that I was rarely fully awake and alert, or fully asleep in a deep, restful sleep.  If your boyfriend works rotating shifts (which is more typical than working all night shifts), then his biorhythms will never settle into any one pattern.

People who become doctors often possess a masochistic streak that makes them reluctant to admit how bad they have it.  In fact, they often revel in the agony and seemingly welcome the abuse.  These psychological ruses are just coping mechanisms that help soften the harsh reality they face.  Unfortunately, coping mechanisms cannot erase the accompanying physical damage.  Studies have shown that night-shift workers are more prone to cancer and premature death.  A few decades from now, I think it will become clear that ER doctors pay a high price in terms of longevity.  In addition to working night shifts, many of their shifts are adrenaline-laced marathon sessions in which the stress never ends.  Current death statistics will not adequately reflect this hazard, because ER work was not always as stressful as it now is.  I began my ER career at the tail end of "the good old days" when the pace was far more tolerable.  From what I've heard from seasoned ER nurses and from analyzing patient census statistics, ER work used to be even easier.  However, in the past two decades, the upsurge in ER patient visits per year has far outstripped the overall population increase.  To compound this problem, many hospitals and their emergency departments have closed, forcing the remaining ones to handle even more patients.  Finding a relatively cushy ER job was once easy.  Not now.  Today's ER docs are almost guaranteed of being subjected to more stress than anyone should have to face.  After years of that stress, it is bound to take a toll.

When a student is young, bursting with energy, and oblivious to the turmoil that awaits him, it is all too easy to trivialize the drawbacks inherent in an ER career.  However, chronic sleep deprivation has a malignant way of making everything less tolerable.  This one fact can suck the joy out of life.  Without adequate sleep, tolerating an average job is tough enough, but tolerating a very demanding career in the ER can be a nightmare.  If you haven't already done so, you should read my description of the stress ER doctors can face, then try to imagine how much worse it would be if the ER doc was chronically deprived of sleep and running on empty.

So, ask yourself this question:  do you want to marry someone who, five years or so after he is out of residency, will turn into a perpetually tired zombie?  Of course, to get to that point, you and he must weather an even more hellacious period:  internship and residency.  I worked about 110-hour weeks.  During my few off hours that I was awake, I'd study.  My girlfriend would sit with me while I studied — which is probably not the intimacy you've dreamt of.  And if he doesn't study . . . well, let me put it this way:  your husband will make some lawyers very happy, and very rich.

If your boyfriend insists on specializing in emergency medicine, convince him to work in an urgent care center instead of an ER.  Urgent care work is far more tolerable.  I discussed this in more detail elsewhere on my web site, so I won't repeat those comments here.


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Enhancing Sexual Pleasure, Performance, Attraction, and Desire

by Kevin Pezzi, MD

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