The Paper Trail

I have always been an avid reader. I think that books allow us to slip into the mind of someone else for just a bit, and if you don’t like what is being said, unlike real life, you can just close the cover and walk away. Many of these titles accompanied me to airports, coffee shops, or were read in strange student housing locations in different states by the light of a bare lightbulb, or with the warmth of an electric blanket in a converted garage that had no heating. When I look over the list, unfortunately I don’t remember too much about many of the titles, but several bring back memories of where I was when I purchased them or what I was doing when I read them.

2005 Reading List:

The Old Testament: Genesis - 1 Chronicles

Okay, so in 2004 I read all of the New Testament. I thought I could do the same for the Old Testament, spending just a couple of minutes reading a chapter every night before bed. I guess I should have read 3-4 chapters per night as I still have a long way to go!

Mere Christianity – C.S. Lewis

A good friend of mine lent this to me. It is a collection of essays from a radio series that he did around World War II if I remember correctly.

Bird by Bird - Anne Lamott

This book I had read about quite some time ago from the author of another blog. I remember liking it very much and would highly recommend it to anyone even remotely interested in writing. I will definitely have to read again sometime.

I, Elizabeth - Rosalind Mills

I thought that a switch to historical fiction might be good for me. It was good, but easy to put down and I think I moved on to several other things before finally finishing. I think they made this into a movie about 5 years ago, but I haven’t seen it.

On Writing - Stephen King

I don’t remember much other than he said that writers should put their desks against a bare wall so as to not get distracted by looking out windows. It was not very inspiring.

Corpus Christi - Bret Anthony Johnston

I rotated through Corpus Christi, TX during my 3rd year and picked this up at the Barnes & Noble there. It was a collection of stories that seemed to have a theme about losing family members to cancer. It was neat to read about a setting where I’d lived for a month.

The Sex Lives of Cannibals - J. Maarten Troost

Okay, so I totally got suckered into buying this one because of the title. Unfortunately, I think that was where the excitement ended.

The Dante Club - Matthew Pearl

People are murdered according to punishment schemes from Dante’s Inferno. It incorporated famous literary figures as the main characters. I found it pretty boring for a twisted tale of murder, and it read like a term paper… a really long term paper.

The Five People that You Meet in Heaven - Mitch Albom

This was a very quick, cutesy read. I missed the made-for-TV movie version.

Kill as Few Patients as Possible and Fifty-Six Other Essays on How to be The World’s Best Doctor - Oscar London, MD

Admitedly, some of the rants in here made me laugh, however I couldn’t get over the author’s annoying references to himself as The World’s Best Doctor.

War of the Worlds - H.G. Wells

I wanted to read this before the movie came out.

East of Eden - John Steinbeck

Steinbeck is my fathor’s favorite author. I’ve read several of his shorter titles over the years, and wanted to try this one out. A lengthy tale of two families over the course of several generations. I thought no one would have noticed if he’d cut out a couple hundred pages or so.

House of God - Samuel Shem

People in medicine reference this book all of the time. I thought it was fairly crude and by the end of the book the protagonist, having been broken in spirit by the horrors of his internship year, abandons a career in internal medicine to pursue psychiatry. I guess I went into it with really high expectations and found myself pretty disappointed, much like the main character.

Fast Food Nation: The Dark Side of the All-American Meal - Eric Schlosser

I liked this one, but only remember the really disgusting part about livestock being fed rendered cat and dog parts collected from animal shelters. (I hope nobody’s eating while reading this.) This book reminded me that I haven’t read The Jungle by Upton Sinclair since I was about twelve, and I would like to read that again sometime.

Flowers for Algernon - Daniel Keyes

I absolutely love this book! It is perhaps my all-time favorite. I don’t want to spoil it for you, but the creativity that went into the concept of this book is just amazing.

The Tipping Point - Malcolm Gladwell

I picked this one up on a whim. It is about the three types of persons needed for an idea to spread in epidemic proportions: the connector, the maven, and the salesperson. It was a fun and interesting read, as I found myself associating some of my friends with those archetypes.

The Magician’s Nephew (Chronicles of Narnia) - C.S. Lewis

When I was a child, many family vacations were spent with the five of us packed into our tiny Mazda sedan driving over 2,000 miles to my grandparents’ farm and back. One of the things that my mother wisely did to keep us children from becoming outright homicidal was read us chapters aloud from the Narnia books. I love this series and hadn’t revisited it in years.

The Lion, the Witch, and the Wardrobe (Chronicles of Narnia) - C.S. Lewis

I immediately devoured this one after finishing the above, and just in time for the movie release.

Blink - Malcolm Gladwell

I was expecting great things from this one after reading The Tipping Point and didn’t feel that it was anywhere near as interesting. Oh well.

Wicked - Gregory Maguire

This was on Broadway when I was rotating in NYC and had no idea what it was at the time, so I saw Rent instead, which was fabulous. I tried and tried to read this book, but I guess I am just not that into fantasy. I’m okay from a distance, but when you start delving into the religious beliefs and sexual practices of Munchkinlanders in your imaginary world, you lose my interest. It’s rare that I don’t finish a book, but this one I abandoned 1/3 of the way through.

The Sword and the Scalpel - Frank G. Slaughter

My father picked this one up for me at a used bookstore and has since commenced picking up books written by or involving physicians as characters for me. It was okay, and set during the Korean War. A surgeon meets a show performer who becomes a nurse. She falls in love with his intellect, unfailing ethics, classic good looks, and blah, blah, blah. Unfortunately, I now have 3 more Slaughter books sitting in my reading pile.

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I guess it would have been more appropriate to review the year in January, but I was excited to have stumbled across an incomplete list while cleaning this morning instead of studying. And yes, I am pretty sure I passed my exam in spite of my procrastination.

Being PC

The new preceptor is nice, although I did get a bit of a mini-lecture for describing a patient as being non-compliant during one of my case presentations today. It was in the privacy of his office of course, and his point was that “non-compliant” is not the most politically correct of terms. What? What else do you call a diabetic with a fasting blood glucose of 420 and an HbA1C of 10.5? I call that less than two years away from toe amputations!

His point was that patients tend to sue physicians for saying things that they don’t want to hear. Huh? He gave an example of a physician being sued for describing a patient as being obese. He said that he would prefer that I say things like, “the patient is not actively pursuing a healthy lifestyle,” or “the patient has been advised of lifestyle modifications and medication regimens and is not currently following recommendations.”

What’s the point in being that verbose? I guess I’m more of a blunt person. I have learned over the years to withhold my opinion and often don’t comment if I have nothing constructive to add. However, if you ask for my opinion be it personally or professionally, I’m going to give it to you directly, and probably in ten words or less. I don’t see the point in sugar-coating or diluting information. If I have cancer, I want to know that I have cancer. I don’t want to hear that I have one apparently immortal cell that is reproducing at an exponential and incalculable rate, forming a tumor. Just give it to me straight. Period.

Perhaps I can trace this thinking back to my high school days of working for my hometown newspaper. The local editor, a woman I like to think of as my mentor, told me then to, "Think of every word you use as costing you a nickel. Don't waste your money on words that do not strengthen your position."

Besides, terms like obese can be objective based on calculations like body mass index, which takes height into consideration. Now if I say that someone is grotesque, or scrappy, then I suppose you have the basis for a lawsuit. Frankly, I found his dictation describing a patient as “a nice white lady” more offensive. However, opinions are just that—opinions. There is no right or wrong, even when you are talking about medical and professional opinions, unless of course, the advice is outside the accepted standard of care. If you want to ignore my advice, that’s fine. Even at this stage of my training, I have witnessed miracles in which healing occurred without surgery or medication, despite the recommendations of a specialist. I also have seen it go the other way, where patients expired waiting for a miracle. I suppose that the the fact that today’s recommendations become tomorrow’s contraindications are what drive people crazy about medicine. However, I find that there are few things more motivating than the challenge to keep up with that same plasticity.

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As you can imagine, after essentially being on vacation the past two weeks, I found working 9 hours today especially painful. I was cranky by the time I got to the gym and even more so when I realized I’d somehow left my combo lock at home and ended up bailing on my workout.

Saturday’s long run was painful, as I struggled to even match the week before’s distance. On a happier note, over the weekend I finally found "Anything, Anything" by Dramarama on iTunes. I have been hunting for the song title and band name ever since I heard an opening band cover it at a New Year’s Eve concert a couple of years ago. Sorry, I’d share the actual song, but I don’t know how.

Deliberate Ignorance

So, my simple cold evolved into laryngitis, which although harmless, impressively took my voice away and I was excused from work on Thursday so that I wouldn’t scare the patients. This conveniently occurred after having been given all of Wednesday off and wisely spending the day getting a pedicure and my car detailed! My voice is almost back to normal now, and other than an impressive display of purulent, green mucus in the morning when I wake up, I am feeling pretty good. On Friday we only had one case, and I was dismissed immediately after intubating the patient. I believe that I worked a total of four hours this past week, plus another eight hours of driving to and from locations all over town. Perhaps I should have considered anesthesia more seriously as a career…

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I start yet another rotation on Monday. For some reason, this time one of the local hospitals is requiring me to go through their compliance training. Luckily, the training was all conducted online. However, I spent almost two hours this morning covering such fun topics as fraudulent billing practices and “anti-kickback” laws. Not exactly how I had planned on spending my Saturday, but given my penchant for procrastination, I guess it is entirely my own fault. I did think that the jeopardy session and memory game for matching protected health information topics with their question stems was ridiculous. For all of you computer programmers out there (including my older brother): there is NO POSSIBLE WAY to make this stuff entertaining! I think it is fair to say that most of us would rather just pretend to read the information and take a stab at the online examinations without being forced to play games that may or may not have involved animated fax-machines and paper shredders.

However, I did enjoy the segment on deliberate ignorance. Apparently, not only is it a crime to double-bill people or submit bills for services not rendered, but you also cannot refuse to keep current on billing practices and play dumb. Failure to keep current on coding is labeled “deliberate ignorance” and also subject to penalty by law. So basically, the government's standpoint is: Get the billing done right or else we will either fine you for being a fraud or a dumbass!

As a medical student, I basically pop in and out of patient’s rooms and write progress notes. I never see any part of the actual billing. The preceptor simply signs my note in the chart and then informs his/her office what level of care to bill the hospital visit as. I believe that physicians employed by the hospital have some similar process of logging their work. So for me, I found it somewhat odd to be perusing literature on when to suspect that a physician was turning in fraudulent claims, or what kind of internal referral practices are unethical. Why are they training a whole army of employees to watch over the behavior of physicians? It was almost like an “Us vs. Them” scenario in which I was reading top-secret info from the other side. The training program kept mentioning how nurses, clerks, and physicians could all get themselves into trouble and ultimately result in the facility not receiving reimbursement for Medicare/Medicaid patients, but it clearly leaned towards physicians being the deliberate perpetuators. Interesting, and almost enough to make one paranoid, but then again, my interpretative skills could be a little off right now due to the Nyquil.

What's Grosser than Gross?

Here's something you probably never wanted to think about:

Try wearing a surgical mask when you have a runny nose and aren't able to blow it or touch your mask because you'll contaminate yourself! No eye rubbing, nose itching, or even dropping your hands below the level of the operating area during surgery or you've just contaminated the sterile field. I bet they haven't covered that issue on Grey's Anatomy! That's right-- lots of annoying sniffling sounds coming from the medical student today. Luckily, my preceptor took pity on me and sent me home after our short cases, and didn't make me stick it out for a four-hour back surgery.

Argh!

Yeah, I'm still sick. What a waste of a 3-day weekend!

Most of my classmates have gotten sick during rotations during which they're in contact with a lot of ill patients... pediatrics, internal medicine, emergency medicine, etc. As for me, I manage to get sick during rotations where I have little to no patient contact.

Last year there was the food poisoning incident during general surgery. There's nothing quite like fainting during a case to perpetuate a sexist preceptor's misgivings about women in the OR! Then there was gastroenteritis during radiology over the summer, and now the URI from hell during anesthesia. When I start slacking off during easy rotations does my immune system go on holiday as well?

People always say that van Gogh was crazy to take a knife to his ear, but if I could somehow take a razor to the back of my throat and shave off all of the sensory nerves right now, I'd do it.

10%

Yesterday, I went for a long run on the treadmill. I generally try and vary what I do at the gym, so that my body doesn’t get used to anything. Much of my time during the week is spent doing interval training or increasing the level of difficulty as I progress through my workout. I was able to run 2.25 miles at 5.4 mph without stopping, which isn’t a record for me, but not bad.

After I left the gym, I noticed that my throat was sore and I felt kind of light-headed. Last night, I went to bed early after taking some Tylenol and Theraflu. This morning, I woke up to lancinating pain in my throat with swallowing, and in my left ear. After further investigation, I decided that I only met two out of the four criteria for strep throat and that a trip to Urgent Care for antibiotics would be a big waste of everyone’s time as what I have is probably just a virus. My muscles ache, but I can't tell if it's from lying in bed all day or from yesterday's run.

It figures that I would get sick after making it to the gym every day this past week. I’m starting to actually enjoy running—now that I don’t gasp for air or have to stop after an embarrassingly short period of time. However, the problem with running is that taking a day or two off seems to have much more serious consequences on my conditioning. While I’m able to put on my headphones and power through a workout on the elliptical when I’m not feeling so great, running with a full stomach, headache, or muscle aches is so much more difficult. I think that the hardest part of getting in shape is developing a routine. Once I’ve acclimated to fitting workouts into my daily schedule, it is easy to continue. My problem is always that a couple of days off easily turns into a week, or even a month. Then, before you know it, I’m back to struggling to run a mile without stopping.

So, I’m taking today off and have confined myself to my bed. I guess my evil gym nemesis wins this time. Having an earlier schedule during my current rotation has caused me to run into some new characters at the gym. Just about every day last week, I encountered a rather pixilated woman in the locker room. The first time I saw her, her eyes immediately narrowed and her lips pursed as I made my way to an empty section of lockers. (I think that sometimes it is an unfortunate skill to be able to pick up on body language.) My process is generally to dress/undress with my back turned and get out of there as fast as I can. However, this woman has apparently claimed the locker room as her own, and can often be found squatting completely naked, and slathering lotion all over herself in front of the mirror. I don’t have any problems with nudity—it kind of goes along with my future profession. However, I also don’t want to be made to feel that I’m encroaching on your space when your scrawny, greasy butt is the one parading about in a public locker room.

I don’t understand why with many women there has to be this immediate hostility or judging of appearances. If both of us are there to improve our health, why isn’t there a mutual respect or level of admiration for each other? I don’t know, maybe she feels threatened because I’m younger, or is disgusted by my body compared to her 5% body fat. Or maybe she goes to the gym for social reasons, and figures that another pair of ovaries decreases her odds. I just hate all of the cattiness that so often occurs between women. And maybe I am finding myself reacting to her hostility a little bit by dismissing her as emotionally unbalanced, and a poster child for an eating disorder.

I know that I shouldn’t let little things like this bother me, but having grown up being a people pleaser, sometimes it’s hard to let things go. My high school volleyball coach once said that “No matter how nice you are to everyone else, 10% of people out there aren’t going to like you no matter what you do. So when you encounter a person like that, just shake their hand, say to yourself, ‘Oh, you must be one of the 10%,’ and move on.” That’s something I think that I can still continue to work on. Just doing the right thing, treating others kindly, and not worrying about what their opinion is of me.

Thoughts on Love

With St. Valentine’s Day having come and gone this week, the word love has certainly been thrown around a lot. Jewelers, card makers, and chocolatiers have been advertising in full force, booking a flurry of commercial slots. It seems that when it comes to love and relationships, people are divided into two different camps: those who believe that there is one perfect person for everyone on this planet, and those who believe that love is carefully developed and the result of patience and self-sacrifice.

I prefer to think of myself as being compatible with more than one person. Perhaps I’m being too practical, but with billions of people inhabiting this planet, it seems impossible to believe that each person could only have one “soulmate”. After all, if that were true, then how horrible the odds must be of encountering that one, true love! And what about widowers or divorcees? Is a second- or third-marriage any less meaningful? I don’t think so. How could it be possible to fall in love again and re-marry if there were only one person out there that was meant for you? I know that in some cultures and religions, marriage extends into the afterlife, but that opens up a whole set of situations I don’t even want to think about. I would like to think that most people enter a marriage in love with the person and intending to spend the rest of their lives with them. Sometimes people change or aren’t willing to work on themselves or their marriage to keep things together, but that doesn't mean one can just dismiss them as not having ever been really in love.

Why all the criticism of the perfect person theory? I don’t know—I come from a traditional background. My parents are still married, and perhaps more importantly, are still on speaking terms. However, personality-wise they are so far apart, that as I child I often wondered what they were thinking when they got married. I remember when as a mopey-eyed teenager, my mother once told me to be very careful about choosing a spouse, as she said that was possible to learn to love just about anyone.

At twenty-seven, I have only a couple of relationships to have gained my knowledge base from. I remember the first times that the words “I love you” were exchanged and the giddy feelings that accompanied them. However, I also remember an ex-boyfriend that I was not ready to say that back to the first time that he said it. Despite a somewhat hesitant start, that relationship proved to be the longest one. It was also the most painful when it ended, as by that time I had grown to love him.

I guess what I’m trying to argue here is that love is something that one develops for another person. I don’t think that it has anything to do with “destiny”. While as a Christian, I believe that God has a plan for my life, I don’t necessarily think that it’s a matter of just plucking two people out of their surroundings and putting them together. I think that love is an emotion that can grow with people as they move forward in their lives, and its occurrence is not simply a first-sight, right-place-in-the-right-time thing.

One of my close friends disagrees with me vehemently on this topic, and says that I just need to be more patient, and not waste my time with relationships that aren’t going to go anywhere. She has all sorts of criteria by which she screens out people… age, height, religion, intelligence, etc. That just seems so false to me. I don’t like judging a person’s potential by where they are at now. I know that you shouldn’t enter a relationship expecting to change a person, but isn’t it just as bad to sit back and decide whether or not a person is right for you based on an initial meeting? Maybe she’s right though—maybe my frustration with not meeting the right person is just another part of my own human floundering to control my own life, rather than leaving it up to God.

Never Ask a Pimp for Directions

I know I said I was all done with interviews, but this past weekend I went back for a “second-look” at a program that I’m very interested in. They were friendly, and I got a little bit better feeling as to how the residency program runs, and what sort of patient responsibilities I can expect as I continue on through the program. I actually only spent a few hours in the hospital, and the rest of the time driving around town. I had to reassure myself that relocating across the country wouldn’t be so bad, as long as there were bookstores, a gym, and a Starbucks—yes, I’m aware of how lame that is.

While I was there it snowed lightly—large, perfectly-formed flakes. I always get so distracted watching them swirl and dart out of the current created by my car that it’s a wonder I didn’t get into an accident. Unfortunately, I didn’t bring my camera this time, so no pictures. It was warm enough that they melted as soon as they hit the ground--which I was thankful for, given my flight plans.

I wasn’t really looking forward to this trip, so although I did all the grunt work of printing out airline, hotel, and rental confirmation numbers, I had only printed out driving directions from the airport to the hospital, rather than from my hotel. I thought it would be easy enough to find my way back, but after driving the circumference of the airport and not seeing any hotels, I stopped at a gas station to ask for directions. The clerk gave me this completely blank stare, and then proceeded to ask every other customer in line if they knew where my hotel was. Finally, a tall man wearing quite a bit of sportswear and “bling” said, “Oh yeah, the Ramada? I know where that is… that’s where I put all of my employees.” Employees? Riiight. He then proceeded to give me directions that were completely inaccurate and I wound up on a dark, country road to nowhere.

That’s one of my pet peeves: why do people give you directions when they don’t know what they’re talking about? I won’t be disappointed if you just say “I don’t know.” Is it some instinct to be helpful that makes one spew out something completely incorrect or are they actually being malicious?

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The next day I strategically had booked a four-hour layover so that I could go on a blind date with this guy I’ve been talking to quite a bit over the past few weeks. A mutual friend of ours gave him my contact info, so I had already ruled out him being a serial killer, but I was still nervous about meeting him. After a very messy lunch of BBQ ribs and all of the fixings, we drove around a bit and then he took me back to the airport. I think the date went well enough, but we barely had time to get over our nervous jitters before it was time for me to go. I don’t know that anything will come of it, and I’m not sure that I’m ready for anything serious yet, but it was nice to have someone be so attentive to me.

Lately, my social life has been far from normal. After having ended it with “the one” last year, I welcomed the opportunity to travel for clinical rotations and move from place to place every few weeks. But now, I’m just tired of the instability. I know that over the next couple of months things are going to change drastically. With the outcome of the Match meaning anything from moving out of my friend’s spare bedroom to just a few miles away or relocating completely across the country, the anticipation of those changes is daunting. I guess maybe it is a good thing to have some other distractions.

The Road Not Taken

-Robert Frost

Two roads diverged in a yellow wood,
And sorry I could not travel both
And be one traveler, long I stood
And looked down one as far as I could
To where it bent in the undergrowth;

Then took the other, as just as fair,
And having perhaps the better claim,
Because it was grassy and wanted wear;
Though as for that the passing there
Had worn them really about the same,

And both that morning equally lay
In leaves no step had trodden black.
Oh, I kept the first for another day!
Yet knowing how way leads on to way,
I doubted if I should ever come back.

I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a wood, and I—
I took the one less traveled by,
And that has made all the difference.

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Sorry, no anecdotes today. I had to submit something for a yearbook page, so I went with the above as it has always been one of my favorites. Not to go all "English Lit" on you, but it reminds me of the calm that comes after making a difficult decision. Even the smallest choices we make can put a kink in the pathway of our lives and lead us in a whole new direction.

Lost in Translation

During medical school, they tell us to speak at a level that is comprehensible to our patients. A lot of time and trouble can be saved by just speaking in clear, simple language. That doesn't mean dumbing stuff down, just save the Harvard vocabulary for your classmates. One of my preceptors scolded me last year for saying that my patient had a fast heart rate rather than describing them as being tachycardic. As long as I know that the accepted normal is 60-100 bpm, who really cares what terminology I use? I am certainly not trying to impress anybody, and I think that fancy vocabulary is best saved for research articles, presentations, or speaking with consultants. To be quite honest, many physicians have horrendous spelling, and I feel would be better off keeping it simple. Not to mention the most important thing is that the patient understands what you are saying so that they can make more-informed decisions about their own care.

Today’s first patient was a prime example of what happens when you talk over a patient’s head:

He came into the office for a social security/disability evaluation. After bouncing around from job to job, he had decided that “It would be easier for everyone if I just didn’t work anymore.” My preceptor was well into his background information when he told her that he had been diagnosed with tuberous sclerosis in addition to his well-controlled epilepsy.

“Do you know what that is?” he asked.

“Yes, I’m familiar with tuberous sclerosis.” Slight eye-rolling from my preceptor here.

“Yeah, but do you know how you get it?”

“Yes, it’s a genetic disorder—autosomal dominant, you get it from your family.” She answered.

“No, but do you know how you really get it?”

“I’m not understanding you sir—what are you asking?”

“Well, I was diagnosed by Dr. X years back and he told me that the reason that I have tuberous sclerosis is that somewhere, back generations ago, one of my relatives had sex with sheep.”

At this point, my preceptor turns and gives me her signature deadpan look over the top of her glasses, and I try hard not to laugh.

“I’ve never heard that.” I add.

“I’ve never heard that, either.” she says with a snort.

His neuro exam was completely normal, in case you were wondering. Good strength, reflexes, fully able to walk (ambulate, for you high-brow types), and all that jazz. We filled out the disability paperwork, but are confident that they will reject his claim.

I came home and Googled “tuberous sclerosis sheep sex” tonight and do you know what I got? Something about sex cells from sheep may help researchers better understand tuberous sclerosis! My theory is that someone gave this poor guy a long-winded sermon on research and what he extrapolated was that some relative of his was poking sheep and is to blame for all of his skin lesions. Funny, but bizarre.

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Our second patient today was an elderly Amish woman who has been having problems with her memory. It was interesting listening to my preceptor make slight adaptations to her mental status exam. For example, she had to ask her if she ever gets lost at the produce auction rather than in the grocery store. Or if she had stopped driving the horse and buggy by herself. The woman was in her 80’s and it was just interesting to think about how she’s lived her life cloistered on a farm, with so much going on outside of her community. No internet, no television, no radio… only newspapers.

Today was just weird, and this is one of the things I love about medicine; you encounter all different types of people, and you never know who is going to show up in the office/hospital.

A Funny Thing Happened Down at the Office Today

My doctor and I were talking a little bit today about being single and where to find decent men when she said that she worked in Alaska for a very short time. She said that over there men well-outnumber women. And that's when she said it, the funniest thing I've heard in a long time-- "The odds are good, but the goods are odd."

Benjamins-- or Perhaps Georges

I suppose there are many things that can get on my nerves, but yesterday’s theme seemed to be money. Let’s face it: being a doctor has long been associated with having a good income. Not having any doctors in the family, I was not sure of exactly how much one could expect to earn prior to starting medical school. It is not perhaps the easiest way to make money, but most do pretty well, and there is quite a variance in income between specialties. One thing however, is consistent: hostility between privately practitioners and physicians retained by the hospital. Given the field that I am applying to, I will definitely be among the latter group.

Either path has its advantages. By having one’s own office, you can set your own hours and pretty much work as much or as little as you want to. I have trained with physicians who consistently work 14-hour weekdays, plus additional 6-hour days on the weekends. I don’t really see the point in working so hard that you can’t sit back and enjoy life, but whatever. I am sure that their account balances will be many times more than whatever I will accumulate.

Physicians based out of a hospital tend to be salaried or contracted for a certain number of hours through a large group. And while this method is certainly less lucrative, you don’t have all of the expenses of retaining an office staff and paying for equipment. This choice is much more appealing to me personally, as it means I can focus on seeing and caring for people, rather than worrying about overhead, mortgages, and how long it is taking for insurance reimbursement.

Currently I am rotating through a specialist’s office. While I enjoy the sharp wit of my current preceptor, she was unfortunately out-of-town yesterday, so I worked with her partner. He was very opinionated about my choice of career and clearly not of the same philosophy, and that’s totally fine. However, I did find it completely disturbing that when a new patient walked in stating that he wanted to pay cash for an expensive injection series, this physician completely changed his office protocol in order to accommodate charging the patient’s credit card before he changed his mind. It was hard, but I kept my mouth shut later that afternoon when he complained about how difficult it is for physicians to get reimbursed.

I think throughout the day, we just continued to aggravate each other. Our conversations always remained at a pleasant tone, but somehow he ended up defending his Canadian training-- which I hadn’t even known about, and made a point of letting me know that he was on the admissions committee of a medical school I did not get accepted to four years ago. Isn’t political bullshit fun? He also was charming enough to let me know that he doesn’t take on students as they couldn’t pay him enough to slow his schedule down. Nice. My school does not reimburse clinical preceptors, period. And while I think that policy is due to their inherent greed, and that some recognition is appropriate, I do not think that payment necessarily is. With my current level of training, I am doing quite a bit of work for them—for free. It was annoying to hear him say that after he’d dumped his hour-long new consult appointments on me all day long. He only had to spend 5-10 minutes with each new patient after I had done all of the work of interviewing and examining them thoroughly.

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Later, I went out to dinner with a classmate of mine and we exchanged our current woes. Across the restaurant from us, a local news anchor was dining alone. I couldn’t help but notice after he was gone that he left a $1 tip—for dinner! I couldn’t believe it, so I stood up and peered at the table again. Nope, there was a single dollar there, folded in half by itself. Are you kidding me? How can someone who is bringing in six figures tip a dollar for dinner? Granted it was at a pizza joint, but he had a full meal and a beer. Did he think it was a pleasure for the rest of us to have him in the room with his newspaper? Did he think that the restaurant appreciated losing a four-person table on a Friday night to a single diner? Don’t people know that servers only get paid about $4 an hour and live off of their tips? People always talk about gaps between white and blue collar workers, but I guess I’m just becoming more sensitive to it. And not to be mean, but he was much more scrawny in person than he looks on television!

Am I looking forward to a future of disparity between myself and my colleages? I didn’t grow up with having extra money to throw around. My parents raised three children on a lot less than I’ll be making. I realize that my career choice means that I will be making quite a bit less money than other physicians, but I don’t care. I went into this to help people and because I like challenging myself. I don’t want to ever get to the point where I’m begrudgingly putting down a dollar that took less than a minute’s work to earn at the dinner table for my server. I also don’t want monetary gain for myself or my employer to have any influence on what I do for my patients. While I will have to be financially savvy about not ordering unnecessary tests, or admitting patients for stupid reasons, I don’t want to end up influenced by insurance plans or credit cards.

I know that as a student, I am still quite idealistic, but isn’t that where we all should be? Unfortunately, I know that as I start into my residency training, cynicism and desensitization are coping mechanisms that many young physicians end up turning towards, but I’m not looking forward to it.