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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 4


Is a nursing degree a good premedical degree?
Unemployed and impoverished doctors

Q:  I am very interested in becoming an ER doctor.  My plans are to receive my BS in Nursing (BSN), then apply to medical school.  Do you think this is a good plan or is there an easier way or better bachelor's degree I could receive before applying to medical school?  Thanks!  Chris

A:  There are pros and cons to using a BSN as a premed degree.

Here are the cons:

  • I hate to admit this, but there is still something stigmatizing about having a nursing degree — at least in the minds of some doctors (just hope that they're not on the Admissions Committees of the medical schools to which you apply!).  In their minds, having a nursing degree (BSN, RN, or LPN) brands you as a nurse, and therefore as a member of an inferior species.  I do not share that sentiment, but keep in mind that some doctors are prejudiced against nurses.
  • Some of the BSN courses won't help fulfill the medical school admission requirements.  Therefore, your undergraduate education could take longer, or you could have a heavier course load.

And here are the pros:

  • If you do not make it into medical school, or if you are not accepted the first year you apply, having a BSN gives you a great backup career.  Everyone who plans on a medical career should choose their college major with the realization that they might not make it into medical school.  Most premed majors don't make it, so their Plan B is very important.  Their undergraduate degree will be in one of two things:  a saleable field in which they're interested, or it could be something that doesn't truly interest them, and something they did only as a stepping stone to medical school.  If that degree is their fallback, it'll either be a waste of time and money, or the first step for getting a job they don't like.  I was accepted into medical school after three years of college because I had very high grades and MCAT scores, so I did not obtain an undergraduate degree.  Had I obtained one, it would have been in zoology.  I chose zoology only because that was the most popular major at the time, which was a poor reason.  If I hadn't made it into medical school, there wasn't anything I could have done with that degree that interested me, so I probably would have returned to my old job, mowing lawns.
  • Obtaining a BSN, and working as a nurse, will give you valuable healthcare experience.
  • If you earn a BSN and an MD degree, you will likely be more readily accepted by nurses with whom you'll work in the future.  Just as some doctors are prejudiced against nurses, some nurses are prejudiced against doctors.  Doctors often think that nurses are cliquish, and too eager to turn any discord into a doctor-versus-nurse dispute in which other nurses reflexively give their allegiance to the involved nurse.  Doctors aren't the only ones who think that nurses will blindly side with other nurses in any dissension which has even a hint of an "us versus them" angle.  I have a friend who works as an ER secretary, and she says this tendency is readily apparent.  For that matter, I've even heard some nurses bitterly complain about how their nursing colleagues are cliquish.  Some doctors can be perversely cliquish, too.  For example, one of my former bosses once told me that I shouldn't eat lunch with "the help."  In his mind, "the help" were the nurses, assistants, and technicians with whom I worked, and he evidently felt that doctors should not associate with them.  In my mind, those people were my friends and I enjoyed their company, so why on Earth wouldn't I want to eat with them?
  • Being a nurse and a doctor will enable you to see things from a nurse's perspective when you're a doctor.  This is important, because medical schools typically ignore this topic.  My medical school went to extreme lengths to get us to see things from the patient's perspective (even going so far as to have us get up on a pelvic exam table and spread our legs), but they completely disregarded the subject of what it is like to be in a nurse's shoes.
  • A BSN degree will allow you to earn good money before you begin medical school, and during the little free time you'll have in medical school.  Furthermore, even if you become a doctor, you might actually prefer — or be forced — to work as a nurse.  This may come as a shock to people who think that being a doctor is a road to riches and inevitable nirvana, but the medical profession is beset by a number of problems.  I've detailed the problems of being an ER doctor in my web site and books, but other specialties have their drawbacks, too.  For example, the Homepage of the Committee for Improvement in the Pathology Job Market indicates that the job prospects for new pathologists is dismal.  Imagine going to school for umpteen years only to scan the want ads to see if Burger King is hiring.  The percentage of involuntarily unemployed ER docs is very low, but you might dislike the job so much that you eagerly join the ranks of the voluntarily unemployed ones who seek another career in medicine or elsewhere.  Back in the good old days, there were about as many poor doctors in the United States as there were ugly Playboy Playmates.  Times change.  Some doctors now receive no net income from their practice because their overhead is enormous, primarily due to exorbitant malpractice premiums.  Other docs actually lose money, and keep practicing medicine only because they're hoping that things will improve.  The prospect of a zero or negative income does not affect ER doctors, most of whom are paid an hourly wage by their employer, who pays malpractice premiums and overhead expenses.  Don't assume that this rosy situation will inevitably endure.  If malpractice premiums continue escalating at the same rate they have been recently, it won't be long until every doctor and company employing doctors will go broke.  Remember when the American Medical Association vigorously fought against socialized medicine?  Some people suspect that the government's unwillingness to enact significant tort reform* is an underhanded means of pressuring doctors to knuckle under.  In a few years, things could be so bad that doctors actually beg for socialized medicine!

*Recently proposed malpractice caps limit liability for only one aspect of liability, while others remain unlimited.  Thus, these caps are a Band-Aid solution that will, at best, delay the day when medicine is no longer a viable profession.  I hate to keep bringing up the subject of malpractice, but this issue is central to the practice of medicine and its future.  Authors who ignore it or give it short shrift have their best interests at heart (selling more books by writing overly optimistic ones that gloss over problems), not your best interests.

As for whether or not another undergraduate major would be a better choice for you, I can't say without knowing more about you.  If you love engineering, as I do, a degree in that might be a better choice.


How can a student with borderline qualifications increase her chance of acceptance into medical school?

Q:  Your website is the best.  :-)  I have a friend who got her degree in biology, but was not accepted to med school so she went to nursing school instead.  She plans on applying to med school again next year.  If I am not accepted right away, what should I do to strengthen my credentials?  One person told me to go to the Peace Corps or a post-baccalaureate program; should I?  Sincerely, Sara

A:  Your friend made a wise choice, for reasons that I enumerated above.  In regard to your situation, I answered similar questions elsewhere, (including here in regard to activities like the Peace Corps, and in several other topics in regard to post-baccalaureate programs).  Joining the Peace Corps would be a plus, but a minor one.  Compared to other options that you could choose, it is less effective, more arduous, and certainly more dangerous in this post-9/11 world in which misguided religious zealots think that becoming a suicide bomber is all that it takes to spend eternity with 72 beautiful virgins in heaven.  Even apolitical, non-American human aid workers are now fair game in their eyes.  So should you risk your life for something that likely won't make a tangible difference in your career?  I don't think so.

For a moment, put yourself in the shoes of a medical school admissions committee member.  You have an applicant with Peace Corps experience.  What does that tell you about the applicant?  It speaks well of the applicant's desire to serve others, but says nothing about their brainpower.  Becoming a doctor is so intellectually demanding that medical schools must emphasize the importance of good grades and MCAT scores.  They can't risk filling their seats with students who might stumble academically, even if those applicants are as dedicated as Mother Theresa.

The key to getting into medical school is to impress the admissions committee with your intelligence.  Most students do this with grades and MCAT scores.  Weaker applicants often seek to impress the admissions committee with activities that suggest, "I'm a good person.  I'm willing to help others."  Think about this.  Is it really the best strategy?  If they have doubts about your brainpower, the way to impress the committee is to convince them that you are smarter than they think you are.  Some ways to do that are time-consuming and difficult (e.g., getting a master's degree or Ph.D.), and some are not.  For example, you could invent and make a medical device, as I discussed here, here, and here.  That could take anywhere from a few days (if you did it with me) to a few months if you started from scratch and did it all on your own, but that is cheaper and quicker than obtaining a post-baccalaureate degree, and possibly more effective.  Unless you excel in a post-baccalaureate program, the admissions committee will probably just yawn and go on to the next file in their mountainous stack of applications; they see applicants with post-baccalaureate degrees all the time.  You need to stand out from the crowd, and make them say, "Wow!"  If you can do that, you can begin shopping for a white coat, a stethoscope, and other MD accouterments.  If you invent and make a new medical device, you are bound to impress the admissions committee.

Besides brainpower, one of the essential attributes that doctors must possess is dedication and the willingness to work hard.  Inventing and making a medical device is far easier than you probably imagine, but it does require more work than some people are willing to expend — but those people will never become doctors.


Emergency departments:  where the wild, wild west lives on
Guns in the ER?
Tasers in the ER?

Q:  I want to become an ER doctor.  From what I've read, working in the ER can be a wild experience.  Just how out of control can things get, anyway?  Tim

A:  Probably more than you could ever imagine.  It was certainly more than I ever imagined!  To obtain some idea of what you will eventually encounter, turn on the Fox network's Cops series, then try to envision how unruly ruffians can be when the police are no longer around.  Most hospitals employ security guards, but when facing an enraged musclebound 300-pound patient, security guards often devise some clever strategies for shirking their responsibility.  For example, I've had security guards tell me, "You're the doctor.  You go get him."  There were times when I feared for my life, and I've seen tough, experienced nurses frightened out of their wits.  ER personnel are sometimes murdered at work.  I once worked in an ER in a pleasant, upscale tourist town.  If you saw this place, you might think that it was Shangri-la . . . until you saw the bullet holes in the glass door.

Some ER doctors tuck a pistol under their waistband.  I never did, but there are ER personnel who might still be alive if they had a handgun for self-defense.  I think that all ER workers should have immediate access to a Taser, especially if no security guards are present.


Do ER docs always work at a breakneck pace?
My second-longest hug
* in an ER

Q:  I read your 15 minutes in the life of an ER doctor essay, and I'm frightened, considering the fact that emergency medicine is my career aspiration.  Are things always that bad?  Sharon

A:  Of course not.  There were also times in which a beautiful young woman gave me a long hug, and later thrust a note into my hand saying that she was grateful for what I did and that she would do anything for me, followed by her phone number.  "Anything" was underlined twice.  The message was unmistakable.  This is getting off track, but some of you are likely wondering if I took her up on her offer, so I'll spill the beans before I continue.  No, I never called her, but I was very tempted.  I think it is important for doctors to always do the right thing and avoid situations in which someone might misconstrue their motivations.  In this case, the young lady (I'll call her Megan) was in the ER to visit a terminally ill relative who had only months to live.  I pulled her through this episode, but the grandmother's chronic lung disease and continued smoking indicated that the writing was on the wall.  When I confirmed Megan's suspicions that recovery was hopeless, she began hugging me.  At first, I thought she just wanted consolation, but the hug turned into something much longer than I'd imagined.  From the way that she kept pulling me in, she obviously did not want to let go.  Neither did I, but I wasn't being paid to hug nubile women.  Megan left the ER and returned an hour later, bearing the note, but less clothing.  She now had on a tight, skimpy dress that revealed an exquisitely attractive body, and her eyeglasses were gone, exposing even more of her gorgeous face.  I'd never before had a patient's relative go home and change just to impress me.  Believe me, I was impressed.  Inside, I was almost apoplectic.  I hadn't had a girlfriend in years, and here was a stunning woman practically throwing herself at me.  Had I accepted her offer, I'm sure my next weekend off would have been much more exciting.

My hesitancy to pursue Megan The Magnificent stemmed from a concern that someone might misconstrue my motivation for hugging her.  While my intentions were purely professional (I've hugged more than my share of women at work who are not attractive), I did not want to create a situation in which someone might think that hugging a beautiful young woman was just a calculated step to move in on the relative of a patient.  I've become friends with patients before, but only when I thought there wasn't the slightest hint of impropriety.  Considering the fact that my standards are much more restrictive than even some Presidents, I sometimes wonder if I am being too circumspect.  Perhaps that is why I am still single.

With this as a preface, it is clear that every minute in the ER is not torturous.  However, the chaos depicted in my "15 minutes in the ER" essay occurred too often in my career.  It isn't just me who doesn't like to be rushed so much.  I somehow survived at that hospital for 5½ years before I quit, but we recruited ER docs from other trauma centers who were so exasperated by the pace that they quit after anywhere from one day to one week.  That might explain why I could get a $20 per hour raise just by telling my boss that I was pissed and thinking of quitting.

In retrospect, that was a dumb career move.  My tolerance for working in an ER likely would have been longer had I accepted less pay at a hospital with a more humane pace or, better yet, just worked in an Urgent Care center.

* Oh, in case you're wondering about my longest hug:  I'll tell that story another day.  Right now, I'm really missing the ER.  I'm not kidding.  Sure, emergency departments can be real hellholes, but they are also places in which you can experience life at maximum intensity.


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.


Solidifying memories

Q:  I don't think I can adequately express how much I enjoy your writings.  You have so many interesting stories to tell, and lots of advice for students with an eye on a medical career.  That is why I am writing today:  to ask for another tip on memory (I read your other ones).  Is there anything you haven't yet covered?  Jeff

A:  Oh, yes!  I have plenty of pending topics, but just 24 hours in a day to write and perform other jobs.

Here is a tip that may seem incredibly basic, yet it is something that most students don't do.  Research (and experience) has shown that memorization is solidified if people review new information soon after they are first exposed to it.  Some evidence suggests this review should occur within 24 hours, but I think that time varies from person to person.  In medical school, my routine was to not review anything until the weekend, at which time I did a comprehensive review of everything covered the preceding week.
 


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

by Kevin Pezzi, MD

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Are the expectations of patients realistic?

Q:  I am writing an article on how patients view their ER experiences, and I have a question for you.  Do you think that the expectations of patients are realistic?  Thank you, Linda

A:  Sometimes yes, and sometimes no.  As an example of the latter, it never ceased to amaze me when patients and their families would complain about the evaluation "taking so long" when we could perform countless lab tests, x-rays, EKGs, CT or MRI scans, ultrasounds, and sometimes even nuclear medicine tests and consultations by various specialists — all within a few hours!  To stop their whining, I'd sometimes explain that if they had the same workup performed as an outpatient, they'd spend far more time over the next few weeks making appointments, driving to and from the test sites and doctors' offices, and waiting their turn at each facility.  It's a miracle that we can compress so much medical care into such a short time, especially considering the fact that we're often juggling a couple dozen patients at any one time.  However, not one patient ever expressed gratitude or even understanding of this.  Instead, all I heard was bellyaching.


Are all drug reps gorgeous?
A hospital that preferred to hire stunning women

Q:  I just read your discussion of beautiful drug reps.  As a male who hopes to become a doctor one day, I must admit that I find this topic intriguing.  Are all drug reps gorgeous?  Charlie

A:  No.  There are only so many supermodel clones available who are smart (pharmaceutical companies do not hire dumbbells) and in need of a job.  However, a disproportionate number of female drug reps are indeed stunningly attractive.  Of the remaining, most are either very attractive or attractive.  A few are Plain Janes, but they're usually relegated to the backwater.  This banishment from the upscale metropolitan areas is necessarily subtle, so as to avoid meddling by nasty governmental bureaucrats and lawyers who'd relish the chance to make millions from suing for discrimination.  Years ago, I had a friend who was a Plain Jane drug rep, and she gave me a verbatim account of how her boss kept her exiled in the less lucrative areas of the state.

Now that I'm on this subject, I should point out that drug companies aren't the only ones who use pulchritude as one of their main hiring criteria.  I once worked in a hospital in which a significant proportion of the female employees were drop-dead gorgeous.  I'm not talking about everyday attractiveness, I'm talking about women so ravishing that they were more beautiful than most Hollywood actresses.  Judging from the rarity of finding captivating women in the surrounding areas, it was obvious to me that whoever did the hiring at that hospital went out of his way to find arresting women.
 

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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!

Interested in an OB/GYN career?  Better think twice.
Another frivolous lawsuit
Why many doctors are saying good-bye to medicine

Q:  Hello.  I'm a senior in high school, and I would like some information on being an OB/GYN, and what's required.  You will help me in my future career goal by answering.  Thank you!  Ana

A:  Most of the information that I gave in regard to pursuing a career in emergency medicine is also pertinent to careers in other specialties because of similar college and medical school pathways.  The obvious difference is a different residency program.

One thing that must be mentioned in regard to a career in obstetrics and gynecology is that OB/GYN docs are, and have been, leaving that specialty in droves.  This exodus is primarily fueled by frivolous malpractice suits initiated by attorneys who have made billions of dollars by claiming that obstetricians are responsible for disorders such as cerebral palsy.  Sometimes botched deliveries can cause mental impairments.  It happened to a relative of mine, although this was due to a nurse blindly following an idiotic hospital policy, not a physician error.  While physicians are not perfect, when this problem was analyzed by Dr. Dean Edell and other people with expertise in interpreting data, they concluded that most cases of cerebral palsy result from problems that have nothing to do with obstetric care.  For example, the mother may have contracted an illness during pregnancy that caused fetal harm (some infectious diseases that are trivial for adults can induce profound fetal disorders).  Bottom line?  Most cerebral palsy lawsuits are frivolous ones that attempt to extort money from hapless obstetricians.  This raises their malpractice insurance rates so much that many cannot afford to deliver obstetric care, and it saps the morale of doctors.

Unless you've been sued for something that you are innocent of, as I have, you have no idea how devastating such an allegation can be.  Three days ago I received a package in the mail from an Internal Medicine physician I don't know (I'll call him Dr. Clark).  Inside was a letter of introduction, his business card, and a partial manuscript of a book he is writing.  He explained that he was sued for a frivolous reason, and how emotionally wounded he was by the experience.  It began with the shock of receiving the certified letter informing him of the lawsuit and trumped up allegations, after which his heart was no longer in the practice of medicine.  Dr. Clark stopped seeing new patients, became depressed, and his outlook on medicine was forever sullied.  He was once a hardworking, diligent doc who strove to give his patients the best and most attentive care possible.  This frivolous lawsuit dashed the comforting buffer that makes medical practice tolerable:  the expectation that not screwing up will shield doctors from being sued.  Whether it is practicing medicine or raising children, humans implicitly expect that doing the right thing safeguards us from allegations of misconduct.  Imagine how devastated you would be if you were a loving parent but the state alleged that you were a child abuser.  How would you feel?  Outraged at the iniquity of the unjust charges?  Saddened that your reputation was being falsely maligned?  One thing is certain:  once you've been wrongly accused of a serious charge, you've been the victim of a tragedy that no one should have to endure.  Your general anxiety level will ratchet up a notch or two, because you can no longer assume that doing a good job will shield you from baseless charges.

Judging by the allegations, Dr. Clark suspected (as other physicians have) that the plaintiff's attorney was not just aggressive and willing to pursue a meritless claim, but also guilty of suborning perjury by coaching his client on what to say.  The motto of these Create-A-Case lawyers is, "If you don't have a case, invent one."

I strongly believe that people who've been falsely accused should not just slink away once the ordeal is over.  That makes it too easy on the mudslingers.  Attorneys have made careers out of being irresponsibly on the offensive, knowing that they can usually get away with slander because their victims are too meek to do anything except defend themselves.  If someone faces an unjust allegation, what is called for is not just a defense, but also a punitive offense.  Bullies aren't dissuaded from pummeling people who put up their arms to shield them from blows; they're dissuaded when someone turns the tables on them and punches them in the nose.  Figuratively speaking, many attorneys need a good punch in the nose, and Dr. Clark decided to do just that by writing a book to expose how some attorneys in Michigan will sue without cause if they think they can extort money.  Attorneys have learned that such extortion is more profitable than robbing banks, and it carries a veneer of legality so those thugs can continue to ride roughshod over justice without many repercussions.  However, as I've said before, I think the heyday of getting away with such extortion will end in the not-too-distant future.  Some doctors are suing attorneys for legal malpractice (I tried that, but my attorney dissuaded me by saying that it is almost impossible to successfully sue for this), and others are writing books as I and Dr. Clark have done.  Sooner or later, I predict that a doc won't stop with such measured responses.  He'll knock on the attorney's door, and go postal on him.  The legal system could avoid this crude Smith & Wesson way of getting even by providing us with justice in the courtroom:  if we're falsely accused, let us have a fair shot at suing the careless and unprincipled attorneys.  However, the legal system is one in which legislators (primarily attorneys) write laws that make it easy for their brethren to plunder at will with virtually no fear of retaliation.  Those laws are interpreted by judges who are also attorneys.  Do you now realize how one-sided this system is?

Doctors have been sitting ducks, but this won't continue forever.  A "perfect storm" of discontentment, shattered dreams, and outrage over maliciously untrue allegations will provoke some docs to not take it on the chin and figuratively walk away with their tails tucked between their legs.  Medicine used to be a great profession.  Once you became a licensed doctor, you were on Easy Street.  Now becoming a doctor can be the first step into a nightmare of bewildering bureaucracy and perpetual unease that results from the recognition that doing a good job is no protection from lawsuits.  Then there is the hectic pace often mandated by profit-hungry administrators, and perhaps even difficulty in finding a job (as many pathologists have discovered in recent years).  Some doctors are now paying so much for malpractice insurance that they could literally do better by working in a fast-food restaurant (n.b., this isn't hyperbole; I've documented it elsewhere).  Who wants to go to school for a few decades only to get whacked around like a piρata and become a scapegoat for every worldly imperfection?

With the foregoing as a long preface, Ana, you should stop and ask yourself this question:  is it wise to pursue a career that is so noxious that it causes practitioners of it to retire early or otherwise voluntarily refrain from it?  Medical students have written to me saying that they decided against an OB/GYN career because of what they've seen and heard from current and former obstetricians.  This is a double-edged tragedy because it also hurts expectant mothers and their babies.  Mothers sometimes must travel long distances to obtain obstetric care.  That is a major inconvenience during pregnancy, but at delivery it could prove tragic.  Obstetricians don't spend a third of their lives training for a specialty that they can later walk away from without regret, but vicious attorneys have forced many to do just that.  It's a shame for everyone involved, except the avaricious attorneys.

Let me be blunt.  Those doctors who are saying to heck with practicing obstetrics know much more about the realities of that profession than you do.  Do yourself a favor and don't neglect the valuable lesson they're giving you.  While medicine is an increasingly troubled profession, there are some tolerable specialties, but OB/GYN is not one of them.  Neither is emergency medicine, unless you take the advice that I give on how to make it bearable.

When I was in medical school, I recall listening in utter amazement to classmates describe how they decided to specialize in something that was lucrative, such as ophthalmology, only because it was lucrative.  I thought (and still think) that this is a dumb reason to do anything.  I just wanted to do something that was tolerable, helpful to others, and provided me with enough money so that I could buy a tractor, a snowmobile, and lots of parts to make various gizmos.  Considering that I was willing to spend my life saving lives and helping untold numbers of people while making sacrifices such as giving up holidays and time with my family, I don't think that I was asking too much in return.  I treated many patients for free not because I was a dreamy idealist but because it was the right thing to do and how I'd want to be treated if I were in their shoes (the Golden Rule).  Thus, I entered medicine with a reasonable idea of what constituted a fair exchange between myself and society.  I was smart, responsible, exceptionally diligent, and willing to sacrifice some of the best years of my life so I could spend 110 hours per week training to become a doctor.  I'm certainly not perfect, but society would have to look long and hard before it would find a better candidate to become a dedicated doctor.  Perhaps that is why I graduated in the top 1% of my class in medical school, and why my residency director once claimed that I was the smartest resident they'd ever had in their ER program.  I am not mentioning this to brag; I am mentioning this to point out that there aren't many candidates who were more promising than me.  Patients should realize that it is in their best interests not to make the practice of medicine so noxious that people like me are so disgusted by it that we walk away from our careers.

A few years ago a local businessman mentioned how he was troubled by a numb finger.  He said that he'd cut his finger some time ago, and went to the local ER (the place I once worked) to have it repaired.  The ER doc asked him if he could open and close his fist, and when he could, the doc just sutured his wound and reassured him that the ability to open and close his fist meant there was no internal damage.  Did this doctor graduate from medical school, or just Romper Room?  Anyone with an MD after his name should know that finger strength and sensation are entirely separate.  Every such injury demands a thorough examination, and that includes assessing sensation.  I tested this man's sensation by doing a two-point discrimination test (in which the ability to perceive skin contact from two points is tested as the distance between those points is varied), which is the same test I would have performed in the ER.  Any competent ER doc would do the same thing.  But not this doc, who was filling my shoes — or trying to — after I walked away from my medical career so society could shower its gratitude on someone else.  I am not perfect, but I am smart and diligent enough not to make such an inexcusable error.  I've previously documented cases in which less thorough doctors have made errors that did everything from kill patients to rob a young child of one of his eyes.  So while I am far from perfect, I am thorough enough so that these tragedies could have been averted if I'd treated those patients.  Consequently, I contend that society is paying a price for making some dedicated and diligent doctors say "to heck with medicine."  If that happened to me (someone who was once as dedicated to medicine as a person could be), it could happen to anyone.  Even you, Ana.  We're all human, and we want to be treated with fairness.  When we're subjected to injustices, it is natural to rethink whether it is wise to subject ourselves to possible future mistreatment.  That is why Dr. Clark stopped seeing new patients, why I quit working in the ER, and why hordes of obstetricians would rather be unemployed than delivering babies.  We're not cruel, and we're not blind to the patients we're neglecting.  I still care about patients, and would gladly treat many for free if I did not have to risk a shakedown from an attorney.  I truly enjoy helping people; to me, it is one of the most rewarding things in life.  But society has turned its back on doctors and trivializes their desire for justice, so we've turned our backs on patients and said good-bye to medicine.  This isn't good for doctors or patients, but it is great for attorneys.  When will voters realize this?


A second opinion on the palatability of practicing medicine

A few days ago I heard radio talk show host Dr. Dean Edell discussing how most medical students in the United States are now female.  Is this cause for celebration?  No, explained Dr. Edell, because those women are just filling a vacuum left by men.  He mentioned how most practicing physicians in the old Soviet Union were female.  Why?  Because it was a great job?  No, because there were more desirable jobs for men.  Dr. Edell then said that medicine in America is in many ways a "lousy profession."  Dr. Edell was so disgusted by it that he walked away from his practice and segued into being a talk show host.  Unfortunately for today's students, practicing medicine is now far more noxious than when Dr. Edell quit.

If I were married and had kids (as do most ER docs), I would still be practicing emergency medicine.  That career wouldn't be any more tolerable, but like most people who are forced to do unpleasant work to support their families, I'd do it.  Sans student loans and a mortgage, I suspect that far more ER docs would skedaddle.  In view of this, you shouldn't look at the numbers of still-practicing ER docs and conclude that it couldn't be that bad of a job.  Trust me, it is.

If you want yet another opinion, listen to what Dr. Voelker said.  He read True Emergency Room Stories and then ordered a second copy of it from Amazon.com's Marketplace.  I e-mailed him to ask if this was a new order, or perhaps a snafu from Amazon repeating the first order. He responded:

"Yes, it's a new order. Having been a residency-trained, board-certified ER doc for 22 years (one of the first), I wanted to keep the first one for myself, and loan out the second to various people, including one of my fighter pilots who is going to attend med school and wants to be an ER doc despite my dire warnings. Great book!!! Your writing sounds exactly like many of the "sermons" I've been giving for years. Your use of the exact same language was uncanny. I've experienced almost everything you've written about in the book in my 26 years of ER work. Thanks for putting it in writing so I can tell people to read it if they want to know what my life is like. Thanks again for the awesome book."

CDR William Voelker, MD, MC (FS/VFC-13) USNR, FAAEM
Medical Director, Emergency Department, Enloe Medical Center, Chico, California


Responding to a reader who thinks that I could have done a better job

Intro by Dr. Pezzi:  I sporadically receive abusive and obviously unsolicited e-mails from a person who both idolizes me and loathes me because I can't, and won't, reciprocate any personal interest.  A few days ago she sent me an e-mail in which she questioned whether she were mentally ill, then today she sent another strange missive in which she opined that I did a good job with the technical aspects of working in an ER but that I could have done a better job leading the nurses.  I do not know why this person feels qualified to judge me, considering the fact that she has no medical training, is unemployed (yet receives money from her rich Hollywood parents), and spends most of her life literally holed up underground living in a fantasy world.  You might wonder why I would waste my breath responding to these rants, but she pays me for the answers.  So I did.  I won't bother you with the others, but this one is worth reading.

A:  Could I have done a better job?  Certainly.  If an ER doc worked just one shift in his career, armchair experts, such as yourself, could look back at his myriad actions that day and, with your amazing 20/20 hindsight, judge which were perfect and which were not.  After thousands of shifts, many of which were worked while being utterly fatigued from chronic sleep deprivation such as what I endured (or tried to) for 16 years, mistakes were inevitable.  I'm human, not an indefatigable robot.

Sponging off your parents and being unemployed as you are gives you the ability to do nothing, and therefore to never do anything wrong.  The rest of us, who actually do things, take the risk that our human imperfections will sometimes ensure that we slip up.  I am reminded of this quote from Theodore Roosevelt:

"Far better it is to dare mighty things, to win glorious triumphs even though checkered by failure, than to rank with those poor spirits who neither enjoy nor suffer much because they live in the gray twilight that knows neither victory nor defeat."

I don't think that working in the ER is grand enough to warrant the "dare mighty things" bit, but we do sometimes "win glorious triumphs" when we save lives and otherwise make a big difference in people's lives.

I will now address your assertion about the nursing leadership.  First, judging from what you said, I think you based it on some of my stories describing contentious interactions I had with nurses.  Let me point out something that should be utterly obvious:  Turn on the news, and what do you see?  Bad news.  Why?  Because when things go OK, it's not news.  When a gasoline tanker truck delivers its fuel to a gas station and the driver goes home and enjoys a meal with his family, it isn't news.  But if that tanker explodes into a fireball on a freeway, it's news.  Get the picture?  So when I wrote about my interactions with nurses, I usually wrote about the newsworthy ones.  If a nurse did his or her job, is it worth writing about?  "I ordered an injection, and the nurse correctly gave it."  Spellbinding!  But if a nurse gave the wrong drug or otherwise made a mistake, that is newsworthy.  When nurses made mistakes (and especially when they tried to defend their indefensible errors!), that can be legitimately criticized, and I did that.  What you don't know is that most of the "nurse interaction" stories to which you refer happened at one hospital in a circumscribed period of time in which the "nurse problem" was at least partly traceable to an abominable nurse administrator (since fired, thankfully) and her pathetic lack of management skills and common sense.  However, even at that hospital there was a core group of good nurses (primarily consisting of older experienced nurses) with whom I had excellent relationships.  In fact, the head nurse on my shift told me how confident he was in my leadership skills.  Having said that, he segued into a discussion of how alarmed he was by the lack of leadership evinced by another ER physician in my group.  That's a story I will leave for another day.

I do not suffer fools gladly.  If you are familiar with that idiom, you know it means that I refuse to tolerate stupidity.  Yes, anyone can make a mistake, but that is not the same thing as stupidity (for an example of stupidity, see below).  When I saw nurses make mistakes, part of my job was to inform them, for obvious reasons.  A doctor who lets errors slide isn't doing his job as a leader.  However, for this interaction to work correctly, the nurses must be receptive to hearing what they did wrong.  With good nurses, I had very few occasions to correct them because they knew what they were doing and they did their job well.  We worked together like a well-oiled machine.  But the bad nurses?  Yes, I clashed with them.  Take the case of the numskull nurse with the perverse habit of touching things (with unwashed hands and no gloves) in the sterile field while I was operating.  This is such an egregious error that it should never arise, but it did, again and again.  Of course, I'd tell him not to do it and explain why, but this bozo would just argue with me that what he did was OK (now this is stupidity).  One might legitimately wonder what ELSE this nitwit did not know if he thought that contaminating a sterile field was acceptable and even so desirable that he insisted on doing it for no good reason when he should have been doing something else.  One might also wonder how negligent the administrators were at that hospital when they refused to reprimand him and other "WAY out of control" nurses who were on the warpath and apparently had their own agenda for sabotaging patient care.  Here is what should have happened:  first, nurses don't like it when doctors go running to the administration to say that someone did something wrong.  So, I'd deal with the matter privately, if possible, by telling the nurse of the error.  However, in a few memorable cases, the nurses doggedly resisted suggestions on how to do things better even when they were so far out in left field that their actions were intentionally felonious and not just incompetent, such as in the case of the nurse who just had to touch sterile fields with dirty hands.  After learning that this jerk was a danger to patients and incorrigible, I took the matter to the administration.  Here is what should have transpired:

Administrator:  Dr. Pezzi notified us that you've been touching sterile fields while he is operating when your hands were not washed and gloved.  He also said that he explained to you why this is not permissible and how it can endanger patients, but that you persisted in doing it anyway.

Nurse:  Yes.  As I explained to him, it doesn't matter if I touch the sterile field . . .

Administrator:  Pardon me?  It DOESN'T MATTER?  Yes, it does matter.  Anyone who works with patients should understand why we go to great lengths to ensure sterility during surgery, and anyone who knowingly and repeatedly violates this basic principle is a black mark on the nursing profession.  You're fired.

That is what should have happened, but it never did, at least not while I was there.  I also smelled what I believed to be alcohol on that nurse's breath on various occasions, and when I told the chief nursing administrator overseeing the ER about it, she told me that it was none of my business.  Imagine that!  A doctor has no right to speak up when a nurse working with him is apparently guzzling booze during his breaks?  It's insane!  Incidentally, I heard that this nurse was fired by General Motors when he worked on the line for them.  This is surprising, because GM is far too lenient in retaining drunk employees (for proof of this, read Rivethead: Tales From the Assembly Line by Ben Hamper who, coincidentally, used to be married to my sister-in-law).  From what other nurses told me, this bad apple was too much for GM to handle, so they canned him but apparently helped him obtain a new career (probably directly or indirectly due to UAW pressure).  I think it is bizarre that anyone would believe that nursing is a good refuge for drunks who are so unmanageable that they can't be trusted to work on an assembly line, no doubt after being given chance after chance to reform.  So I was now fighting this wayward alcoholic, and the administration went out of its way to protect him.  Nuts.

I should not have had to fight those battles.  But I did, so I wrote about them because they are newsworthy.  There are many problems in the healthcare professions that somehow slip under the radar screen of the mainstream media.  Like a broken record, they keep harping on and on about issues that have been rehashed so many times that their readers have become inured to them, and so bored that they rarely give them much attention.  I would love to see Ed Bradley of CBS's 60 Minutes ask that administrator why she said it was none of my business if that nurse was working while apparently intoxicated.  He'd receive a pathetic response, and then give his trademark "Uh huh" followed by a tilt of his head, a pause for effect, and an incredulous look on his face that lets the viewers know that the administrator's response was ludicrous.  And stupid.

That nurse was clearly marching to the tune of his own drummer, or Jack Daniel's, or some mental demons that made him do bizarre, inexplicable things.  I tried to lead him, but dealing with boozing GM-rejects who needed detox and probably psychotropic medicine is just too much to ask of a doctor working in a busy ER.  That nurse needed a pink slip, not leadership.  In the ER, I did not have the time to deal with nurses who needed such basic remediation.  However, from your unique vantage point (I'm now speaking just to the person who posed this question to me), I can appreciate why you may think that tolerance should have no limits.

In my opinion, the good nurses didn't need much leadership.  They knew what they were doing, and they did it.  They didn't need me to hold their hands.  Legally, they just needed orders, and I gave them.  Incidentally, the experienced head nurse on my shift said that I was the best diagnostician he'd ever met . . . and trust me, that nurse knows far more about my ER performance than you could ever learn from reading my stories in which I have for the most part intentionally selected the ones in which things did not go well.  Some of the less experienced nurses had to get more reassurance from me and ask me more questions, which I was happy to give since that was part of my job.  No one is born experienced; we're all rookies at some time.  Well, those of us who actually do things.  Ahem.  However, some nurses needed an unreasonable amount of leadership.  Besides the aforementioned boozer, there were others, such as one nurse who followed me around like a puppy and asked so many questions that I thought she either had a crush on me, or she did not know very much.  According to what some nurses told me about her, she recently graduated from nursing school at the top of her class but yet had no confidence in her skills so she asked me countless questions in order that she could document "Dr. Pezzi said this . . ." and therefore absolve herself of the need to make judgments.  A good ER nurse can and does make countless judgments on her own without pestering the ER doc with hundreds of questions per day.  If every nurse did that, the ER would come to a standstill.

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