Medical Student

Looking back on the first three years of medical school, it’s hard to imagine living through the endless days of studying again. Weekends were spent cooped up in the library. There were countless holidays that I wasn’t able to enjoy with my family. Instead, they were spent memorizing indecent aspects of the human anatomy and performing DREs on strangers. There are better ways to get to know a person in the hospital, but sometimes the DRE is the only social tool necessary.

As one peruses the social media outlets about doctors and the medical field in general, the consensus is that there is a feeling of disdain harbored against us. It’s hard to determine why people have such negative views on medicine, maybe it’s because they encountered one of the bad apples, they were injured by a physician, or maybe they weren’t properly educated about their disease and its outcomes. In any case, my class will be entering a field that has very mixed feelings toward us, despite the fact that they know nothing about us.

Just as you may think that you don’t know me, there has been a feeling that I don’t particularly know myself. Have I been changed by the hardships of these past four years? Do I look upon people who do not choose to pursue an MD degree as lesser than I? To answer this question, I do not. However, I do have a different respect for my colleagues; much like a Marine sees the soldier standing next to him differently after surviving the grit and grime of warfare.

There is no doubt that we have changed in these past four years. Fortunately, if there is one time in our career of medicine that we will able to find ourselves again, it is during the fourth year of medical school. Before we walk through the very last threshold to becoming a doctor, I strongly suggest you try to relearn who you once were. Residency will not allot you the time for self-reflection or self-exploration.

There were many things that I had to set aside for medical school. It hasn’t been until now that I am finally able to pick those things back up and appreciate them in a different light. I have always wanted more time to read and write, and now I have it. I have always wanted to push myself physically, thus I completed the 2011 Tri-State Tough Mudder. There is nothing better than feeling the warm morning sunshine on a Spring day, I plan to enjoy many of those soon.

I could calculate the immense amount of time required attaining the status of ‘fourth year medical student,’ but alas I’m in too much bliss from the spoils of being able to go to the gym or read a non-medical book to tax my brain in such a way. Unfortunately, these small elations will not be as easy to come by when July arrives and we become interns.

This is why I was so distraught that I lost my appetite when a classmate recently told me about her day. Apparently, it was a slow morning and my classmate wasn’t learning much more than how long it takes for Benjamin Moore White Satin paint to dry on the wall of the on-call room. Thus, around 1:00pm she concluded that it takes 5 hours and 27 minutes, which was the same time that her resident realized how bored my friend was. The resident asked her if she wanted to take off since there wasn’t anything else to learn. Unfathomable to me, my friend denied the opportunity to be relinquished from utter boredom, choosing instead to stay a few more hours. To this day, I still can’t comprehend her decision.

Therefore, my goal is to spread the message to all upcoming interns to take this chance to relearn who you are and what you enjoy so that you will be equipped to handle the long journey ahead. This will make you a better person so that you don’t burn out or begin despising your patients. In turn, this will help to assuage some of the negativity that surrounds our profession. And believe me, the resident you’re working with right now will encourage you to do the same. They remember exactly how they felt the day the match list came out.

Every medical student is a bit apprehensive when he/she knows they will be assigned a new resident. The same questions always come up…will the resident be nice? Will they understand my busy schedule? Will they make me do a ton of scutwork? Will they make me write all of his/her progress notes? And maybe most importantly, will they let me leave early to study for boards or enjoy the occasional night out? After a year and a half of clinical rotations in various hospitals throughout NYC, I have learned that every resident can fit in to one of three general categories.

The Amazing Resident
The first type of resident is my favorite. He/she is the one that still remembers what it’s like to have freedom and no responsibility as a 3rd and 4th year medical student. They understand that the medical student is strictly there to learn some cool things and see some interesting procedures, then get out of the hospital to study. This resident is almost always cognizant of the fact that the medical student does NOT want to work through lunch to finish a progress note that should be done by the resident to begin with.

I have also noticed that this type of resident is usually more efficient and smarter than his/her colleagues. He/she is able to get their work done without a medical student, therefore does not have to rely on him for help. Since this resident is usually smarter than the average bear, they often times inpart unique clinical knowledge to the student. The funny thing about this resident is that I am MUCH more willing to do the lowest of scutwork to help him/her out because of their teaching and understanding of the medical student’s role.

The Horrible Resident
On the other extreme of the spectrum is the resident that makes the student think that unless you work longer and harder than the resident, then you will ultimately be a horrible doctor and unworthy of the ‘MD’ degree. The darkest of these types of residents will even taunt the medical student’s worst fears by threatening the notion of giving you a bad evaluation if you’re not breaking your back to make their life easier. This means that if you eat lunch before finishing scutwork for him/her despite the fact that you’re about to pass out from hypoglycemia, you are unworthy. This type of resident will berate you if anything goes wrong during their shift. This can include yelling at you for misplacing the central line in the carotid rather than the internal jugular, despite the fact that you were only an observer during the procedure. And for your information, it will always be your fault, thus it is easier not to argue and merely accept the blame and state that you will never do it again.

This type of resident can either be smart or not so bright, but one thing is always true, their idea of ‘teaching’ is very misconstrued. They think that making the medical student call another hospital to get medical records, or calling the primary care doctor regarding a patient that they know nothing about, falls under the category of teaching, Therefore, this fulfills their role as a ‘teacher,’ resolving them of having to waste their time explaining the reasoning for ordering potassium levels Q4H on the DKA patient.

On the other hand, I must admit that this type of resident is not entirely bad. I once had a resident that often left the building before me leaving some of his work for me to complete. He would ask me to get an ABG on his patient with respiratory distress, and then go home while I was in the patient’s room. Although this was incredibly annoying, I did become extraordinarily competent on many procedures. I can now do an ABG blindfolded and I don’t need any assistance other than a nurse to place an NG tube. Thus, I must thank that resident for being a bad teacher and leaving me to learn things on my own.

The Okay Resident
The last type of resident is markedly different than the others, but sometimes has traits of both extremes. I believe the primary problem that undermines this resident is that they aren’t aware of the fact that the student has needs such as going to the bathroom and eating. They tend to forget that the student actually exists and is more than just a fly following them around. This resident is not directly vicious (like the ‘horrible resident’), it’s that they are usually too overwhelmed during the day and just don’t know how to utilize the student effectively. This leads to a medical student that is bored and zones out because he/she is not engaged and is left to stare at the paint drying on the wall.

I don’t want to generalize this category of residents as being not smart, but they don’t get it like many of their colleagues. The fact that they are overwhelmed by work is because they don’t know how to manage their time appropriately and when needed, ask for help from the medical student. I have met quite a few of these residents that are very smart, it’s just that they tend to be thorough with their patients, which doesn’t allow any time for them to think about how to have the student interact. From my experience, it seems that their strict attention to details stems from their paranoia of making a mistake and somehow killing a patient. This leads me to believe they need to read Samuel Shem’s books and grasp the idea that less is usually better in the healthcare world and their meticulousness is hindering rather than helping.

Ben Goldacre is a well-respected psychiatrist in the UK that has grown tired of the misinformation that is presented as fact and the degree to which money is having an effect on the treatment of a patient. He is a man of skepticism, and is using this personality trait to empower the listener with the tools to be able to see through the pharmaceutical (and other medical propaganda) manipulations of research AKA lies. Below is a 15 minute lecture on healthcare research/delivery that I feel every person that considers themself to be scientifically oriented should watch.

In this lecture, Ben Goldacre strives to get the listener (the listener includes everybody from the patient to the doctor) to see through the pharmaceutical sunshine to the depth of understanding the jaded research that pharmaceutical industries choose to report, and more importantly, to not report to the public.

Interestingly, on November 3rd, 2011 the large pharmaceutical company, GlaxoSmithKline, settled a lawsuit with the American FDA for $3 billion dollars (article can be found here.) The lawsuit that was in action against the company was for illegal marketing of a diabetes medication (Avandia) that had been restricted after being linked to heart risks. During the case, it was determined that GlaxoSmithKline had been paying doctors and was manipulating research in order to promote the drug. This very recent example depicts exactly why Ben Goldacre is working so hard to educate the consumer and healthcare worker.

Ben Goldacre: writes a column in the UK Newspaper, The Guardian, called Bad Science. He has also written two books, ‘Bad Science,’ and “The Drug Pushers,’ which can be found on his webpage.

Today, during my psychiatry rotation, a very grateful patient confronted my attending and thanked him profusely for saving him. The patient had been severely depressed and was at his wit’s end before they met. The doctor listened to him, analyzed his situation, and came up with a plan to help which included involving the patient’ family as well as using proper medication. The patient had a great response to this and now wanted to express this to my attending. Thus entered the ‘hospital handshake.’

(pic from

After spending enough time in the hospital, I have come to the conclusion that it’s a dirty place. This was not an epiphany that I experienced; rather, it’s just a simple conclusion after seeing/experiencing the dirtiest parts of people throughout the hospital. I’ve even seen a psych patient throw his own feces at his roommate because he ‘didn’t like the way he was looking at him.’

Therefore, when the grateful patient offered his hand to the doctor to shake as a sign of being thankful, I could sort of understand why the attending hesitated for a second. It was not just the hesitation that tickled me. As we were leaving the floor, the attending walked out of his way to douse his hands in hand cleanser.

A lot of people may have found that action as perfectly reasonable. Especially in this day and age in which around every corner you turn there is a sign about washing hands and stopping infection. And to add to that, I had to complete a form upon starting the rotation that quizzed me on the proper length of time of hand washing (it’s 15 to 20 seconds if you’re curious). However, the attending and I both knew that we were merely heading back to the psych floor where we were going to continue our conversation about his recent trip to India. There would be no spread of infection (there was no reason to believe this patient had an infection anyway) to other patients.

I bring this up not because I have a problem with keeping infection down by hand washing after physical contact with patients. In fact, I think it’s a great habit to get in to. It is because this scene struck me as borderline disrespectful to the patient that I bring it up.

Imagine this, you go to your parents house for Thanksgiving. It’s been months since you’ve seen them and your father has still not thanked you for helping him with a medical problem that he’d been dealing with. He remembers that he forgot to tell you how grateful he was, thus he elaborates his appreciation as you greet each other. He finishes by giving you a stern, fatherly handshake to demonstrate how strongly he feels. In this particular case, neither your father nor yourself have any signs of an infection. Despite this, you walk past him to the nearest bathroom to wash your hands (for 15 to 20 seconds, of course).

Is this something your father would take offense to? If that was my child, I would feel like he just took my sign of appreciation and smacked me in the face with it. So why is this not the case when a patient wants to shake the hand of the caregiver that had such a profound effect on their life?

In this particular interaction with the attending and patient, I did not perceive the attending as respecting the patient. From the hesitation to shake his hand to cleansing the physical contact from himself once he turned from the patient, the attending came across as cold and uncaring.

My fear is that this lack of respect can be extrapolated to all patients. This would be even more prominent on an inpatient psychiatry floor in which many patients do not have a firm grasp on reality. Will I soon find myself losing respect for patients; declining handshakes and ignoring their displays of gratitude? I hope not.

As you may or may not know, I’m a 4th year medical student at a Caribbean school, Saint George’s University (SGU). SGU is affiliated with multiple hospitals in and around NYC which allows us to complete the clinical rotations of our third and fourth years of school. This is a beautiful thing because being affiliated with these hospitals makes it much easier for SGU students to choose electives more freely. This is not the same story at other Caribbean medical schools in which the number of elective spots are limited and students have to fight for them. However, this rant is not about how great SGU is, rather, it is about how disrespectful the employees in the medical affairs departments can be toward students.
Below is the email interaction that occurred between the medical affairs coordinator and myself in which I was inquiring about 4th year electives. For discretionary reasons, I must edit the names of the people and the hospital. The words enclosed by *’s indicate names that I changed.

Sent 9/15/11 at 9:36PM
Dear *Medical Affairs Coordinator,*
I am a 4th year SGU student currently rotating at *blah blah Hospital*. I would like to know if you have any available radiology electives during the months of December, January, February or March. If not, then do you have a list of medicine electives that have not been filled during those same months?
Thank you very much for your time.


Response 9/16/11 at 9:01AM
We do not offer Radiology.

*Medical Affairs Coordinator, with some BS degree*
*Some ridiculously overzealous job title*

Notice in this exchange that the amount of time that passed between sending an email and receiving a response is shockingly quick. This made me a little happy to know that they respond to emails with a fast turn around. However, this happiness was short-lived considering she only answered one of my questions. This is apparently a common occurrence when emailing such departments. They only seem to answer part of an email, and totally neglect everything else. Thus, I asked the question again.

Sent 9/16/11 at 3:56PM
Do you have a list of open electives for the months of January, February and March?
Thank you.


Response 9/16/11 at 5:00PM
Please note the attached. Peds is full til April.

*Medical Affairs Coordinator, with some BS degree*
*Some ridiculously overzealous job title*

At this point, I was even more shocked that I actually was able to have two responses from a hospital in the same day. However, if she wrote more than 9 words in her response (I did not include her actual sign out title and position with the department title and department name and everything else, but suffice it to say, her sign out is much longer than 9 words), then I would have understood why she sent me the hospital orientation packet for medical students. Confused by this, I inquired further.

Sent 9/20/11 at 2:28PM
Hi *Medical Affairs Coordinator, with some BS degree,*
I’m not sure what happened, but somehow you sent me what looks like the orientation guide for rotations.
I was actually asking to see what open 4th year electives you may have in Internal Medicine and the subspecialties of Internal Medicine during the months of January February and March.


Response 9/29/11 at 1:27PM
Hello *Nonmaleficence*:
Page 5 of the student guide, indicates possible rotation. You are required to provide me with a time frame and then I will advise.

*Medical Affairs Coordinator, with some BS degree*
*Some ridiculously overzealous job title*

Okay. I can admit that it was my fault for missing the 1/2 page of listed electives that was in the 25 page orientation packet. I’m a medical student, I should have looked at every inch of that packet and understood what I was looking for using her lengthy prompt of, “Please note the attached. Peds is full til April.”
Also of importance in this particular email exchange is the length of time between my inquiry and her response. It took her 9 days to articulate 2 lines of information to help me. At some point in that prolonged time period, I began to get annoyed. Unfortunately, the medical student is NOT allowed to express such negative feelings toward any individual in the medical community (no matter how despicable that person may be) without receiving repercussions and threats of hurting our career.
After finding the list of 7 electives that obviously could not be typed (or copy and pasted) in an email, I could then request the dates and electives that I was interested in. With my experience from dealing with medical affairs departments, I knew that often times an elective is full, which leads to another set of email interactions taking place in order to settle on an elective and time that is available. Thus, I indicated that I was not picky about the order in which the electives occurred so long as the dates did not change.

Sent 9/30/11 at 7:52AM
Dear *Medical Affairs Coordinator, with some BS degree,*
The dates that I am interested in are:
1/2/12 to 1/27/12
1/30/12 to 2/24/12
2/27/12 to 2/23/12

The rotations that I am interested in are:

Any combination of dates or specialties would work.
Thank you for your prompt response.


Response 10/6/11 at 5:34PM
Please align service with time so there is no misunderstanding. Thanks.

*Medical Affairs Coordinator, with some BS degree*
*Some ridiculously overzealous job title*

My thoughts at this point: seriously? 6 days to tell me that!?
I tend to think of myself as a patient person, but this really pushed me. Again, the medical student is NOT allowed to say how he/she feels. Therefore, I did not respond to her immediately and waited ’til the following day so that I did not say anything inappropriate.

Sent 10/7/11 at 8:16AM
*Medical Affairs Coordinator, with some BS degree,*
I’m sorry my email was too confusing for you. Below I specified 3 of the 9 possible permutations that I was alluding to when I stated that any combination of the three different dates and three different specialties would be great.
Cardiology from 1/2/12 to 1/27/12
Endocrinology from 1/30/12 to 2/24/12
Pulmonology from 2/27/12 to 2/23/12

Thank you again for your continued effort in this matter.


Response 10/19/11 at 4:00PM
Hello *Nonmaleficence*:
In healthcare less is more. It is vital ALL communication is clear and not subject to interpretation. Please note the memo that clearly delineates *blah blah Hospital’s* requirements.

*Medical Affairs Coordinator, with some BS degree*
*Some ridiculously overzealous job title*

Apparently, her last email required 12 days to generate. I’m not even sure if she attached a memo and I don’t care to check/read it. This exceedingly painful process spanned more than a month (9/15/11 to 10/19/11). My story didn’t even end there because I had been accepted for an elective at a different hospital during the month of January, which I had to cancel. This inevitably caused even greater frustration for me. Fortunately, my electives are all set up and I look forward to meeting this wonderful human being in January…

I attended a Caribbean medical school, Saint George’s University, on the island of Grenada. It’s a beautiful place with clean beaches, clear water and enjoyable activites such as leather back turtle expeditions; however it also has aspects that aren’t as charming. In essence, it is a third world country with the same type of begging drug addicts that is seen in your everyday, ordinary country.

Picture from the SGU main page (

One particular night on this island was more memorable than others. My classmates and I were celebrating the end of another round of exams. This is a familiar scene of drunken debauchery that often leads to errors in fidelity. The night started at the night club, ‘Karma,’ in the city.

As the dancing and drinking progressed, the regular hard hitters in my class were slurring their words while those that tend to keep their composure were maintaining with a rum and coke or Carib. By the end, everybody was a sweaty mess due to the heat and humidity of Caribbean climate.

Picture of Karma (from

At 3am it was time to leave and as many of us that could possibly fit plowed into an empty cab. Bodies were stacked on top of each other in this vehicle that resembled the likes of a VW bus. Full of inebriated medical students, the driver took off.

It was the usual cab drive back to campus, flying down narrow one-way roads and veering too close to comfort along cliff edges that ended in the ocean. [Un]fortunately, I was dropped off first because I live off campus in the neighborhood, Lance Aux Epines. He came to a jerking stop at the deserted roundabout next to the Texaco gas station. As my legs hit the ground, he was already speeding off with the rest of the piled bodies in the cab.

When it hit me what had just happened, it was too late. I was a white boy in a third world country with a figurative bulls-eye targeted on my wallet. I quickly put any thoughts of how easily I could be physically overtaken and began to walk toward my neighborhood.

In between the roundabout and Lance Aux Epines there are half-dozen small huts. They’re notoriously festered with bums and drug addicts. The usual, ‘hey white boy, you looking?’ could be heard. On this occasion two gentlemen chose to escort me back to my apartment. The more aggressive of the two locals was notably pushy, and from what I gathered later, more desperate for money. The less desperate chap hung back a few steps, yet remained within 10 to 15 feet of us as at all times.

The aggressive gentleman politely struck up a conversation with me as we continued to walk. “You got an extra couple EC to spare, brother?” This was the usual conversation opener that the locals used when talking to the students. I decided to ignore the polite request and kept moving. I have a strong opinion to not give handouts to leeches because this encourages future requests for more money. However, looking back I may have avoided the later predicament if I had just given him the money.

Ignoring him did not deter the man from following me and continuing the one-sided conversation. In fact, making him walk more must have irritated him as determined by the transition in the conversation. The topic became an argument that I owe him money. This was how these interactions commonly progressed because the locals that chose not to work a normal job for money had a tendency to view us as philanthropists that enjoyed handing out money.  Personally, I am not a man to give away money.

He became increasingly irritated by my lack of generosity. Thus, he began lightly grabbing my right shoulder to get me to pay more attention to him, much like a 3 year old child would do to his mother when he dires his mother’s attention. As I kept walking, the light grabbing of my shoulder became more serious, which meant I had to step up soon.

I stopped. Looked him in the eyes and told him that I didn’t have any money on me. We both knew it was a lie, but the purpose was to inform him that I would not give him any anything.

At this point, the less aggressive local that had been trailing behind us sternly announced to the gentleman tugging at me, “Leave him! You shouldn’t have smoked my stuff if you didn’t have the money.”

After hearing this, I quickly began walking again, for the situation had just elevated to a different level. I understood why the aggressive local was so desperate for my money. He now had to pay this drug dealer and I was his means of acquiring the money to pay his debt.

As well, the desperate local’s urge for me to give him money became more serious. Of the thoughts that were going through my mind, the most prominent one was trying to wrap my head around the idea that this leech somehow thinks I will be responsible for paying his debt when he was the one that didn’t have the self control not to smoke somebody else’s marijuana. I was failing to grasp the extraordinarily loose connection that I had with this local’s inability to delay gratification so that he can get paid at a real job in order to afford his drug habits.

The roundabout and huts were getting further behind us as we entered Lance Aux Epines. The long driveway to my apartment complex was quickly approaching on the left and these two gentlemen were refusing to allow me to carry on alone. I didn’t want to show them where I lived in case they ever sought revenge by breaking in to my apartment. Thus, I stopped just before the driveway. I tried to convince the desperate local once again that I was not going to give him a single penny, but he wasn’t having it. The local that was further behind had now caught up to us and joined in with the other local in harassing me about giving them money. Thus, it became an increasingly frustrating situation in which I owed them money for services I couldn’t recall them performing.

As this twisted conversation continued between the three of us, a Range Rover driving toward us became visible. I thought myself to be lucky since this vehicle would be more likely to help me rather than these drug addicts/dealers. To all of our dismay, he wasn’t there to help any of us except for himself.

The vehicles in Grenada are right hand drive (the driver sits on the right side of the car). The Range Rover was approaching so that the passenger side was toward us, and as it got closer, we could see the window lowering. The vehicle stopped three feet from us. The dim street light up the road barely allowed the passenger to be visible. I could not determine what either of these men were wearing, but it was definitely not police outfits.

The reason that they had stopped suddenly became clear, the passenger quickly pulled a shotgun into visibility and pointed it directly at me. I’m not certain why it was directed at me, but I’ll have to assume it was because I was the only one that stood in place. The two gentlemen that were following me began running past the Range Rover, which forced the passenger holding the shotgun to hand it off to the driver so that he could be free to chase them. The passenger had jumped out of the vehicle in time to catch the more aggressive local by the arm. The other local was fleeing into the nearby brush to disappear. Despite the shotgun switching to the driver’s hands, it remained pointed at me. Being able to see the orientation of the barrel left me without the courage to discuss what they were after. I had never had a gun pointed with intent at me, and it was a chilling experience that made me not want to move.

The man that jumped out of the passenger seat was dressed in inconspicuous long pants and a cotton t-shirt. He was now man-handling the local and yelling at him to strip all of his clothes to the ground. The local undressed with as much resistance as he could manage while he was being repeatedly shoved against the back of the Range Rover. With his pants now completely off, wearing only whitey-tighties and t-shirt, he tried to make another run for it.

He did not get very far when a third man jumped out of the vehicle to give chase. This man had not been visible before because he was hidden by the darkness of the night and the tint of the windows. This was also at the point that some of my questions were answered, but not all of them. The third man was dressed in formal police attire. After giving chase for only a few steps, the officer caught him and proceeded to punch him in the abdomen until the local toppled forward on to the ground. He then dragged the local to the back of the SUV and the stripping continued. It was a very forceful event that included as much yelling as there were punches.

The driver with the shotgun still pointed at me demanded to know if I had bought anything from them. I proceeded to try to explain that I was merely trying to get home when the leeches tried to suck me dry of money and I wanted nothing to do with them. While the driver was distracted by the scene behind the SUV, I decided to move out of the direction that the barrel of the shotgun was pointed.

After stripping the leech completely naked, including whitey-tighties, it did not seem that they found any contraband. I was disappointed by this, but not surprised. The desperate local had been so hard up for money that it was easy to assume that he had used any drug that was in his possession.

The officer, with the help of the other passenger, then threw the local into the back of the Range Rover where there appeared to be a cage set up for such occasions. The shotgun was finally removed from sight, and the men got back into the car without saying another word to me. I wasn’t sure why they thought I was dangerous enough to keep the barrel pointed at me, but it was very effective.

After a year of clinical rotations, I am still not absolutely certain what particular field of medicine I want to enter.  However, I do know that there are fields that I would not want to touch with a ten foot pole:

-Surgery – No thanks. Although I enjoyed cutting in to people and the simplicity of surgery itself, it’s just not for me.  My ego is fine how it is and does not need that extra boost of being able to say, excuse me, I’m a surgeon.  Especially for the price of living a life of 5am mornings and despicable attendings.

-OB/GYN – No thanks. While I appreciate that there is a field for female doctors to think that they are surgeons, I would rather not subject my manhood to the catty girls club that entails OB/GYN.

-Anesthesiology – No thanks.  I don’t understand why some of my best friends desire this field.  They say it has lots of procedures and it’s fun, but all I see is intubations, lumbar punctures, and being the surgeon’s servant.  I’m pretty sure it’s mainly the money and shift work that entices them.

-Pathology – No thanks. I’m not one for looking into microscopes in small dark rooms with little human contact.

-Radiology – No Thanks.  Again, I’m just not a fan of small dark rooms with little human interaction.  The most you ever say to the patient is, ‘please remain still.’

Click on image to enlarge

And then there is emergency medicine.  The residents in this field are stereotyped as the cowboys of medicine.  This allegory is often true; the residents are thrown in situations in which the right decision has to be made quickly.  Do we intubate this asthmatic with a rising pCO2 or not, do we spinal tap this obtunded child with fever and nuchal rigidity or not, do we place a chest tube in this 60 y/o man with acute CHF exacerbation who’s oxygen saturation is 80% due to refractory pulmonary edema.

The problem that I have with emergency medicine is not the field itself; rather, it is the type of patients that you have to deal with which deters my interest in the field.  Everybody knows this patient, even if you haven’t done a rotation in the ER.  She’s the one that doesn’t have health insurance and thinks the ER is a primary care doctor that she can get prenatal care from when she doesn’t have an OB/GYN doc.  Or the non-compliant male that continually returns to the ER in respiratory distress because he refuses to quit smoking, but it doesn’t really matter anyway because his 80-pack/year smoking history has already signed his obituary.

The patient that really tickled my nerves was a man that appeared to be the age of 35 years old.  He was an alcoholic, and openly admitted to it.  As well, he openly admitted to being an ex-heroin addict currently taking methadone.  He was actually a really nice guy and we ended up bonding because he genuinely seemed like he wanted to stop drinking.  My brother is an alcoholic so I shared some of my thoughts and ideas as well as related to him.  The patient has been unable to maintain a job for months because his life has been swallowed by alcohol and he can’t live with out it, much like my brother.  I felt like I was having an impact on this patient as I shared some of my stories with him and he shared his thoughts and troubles with me.

He was brought to the ER with the two large police officers standing on the opposite side of the gurney (who did not deny any of his story).  He was being booked for what I originally had assumed was for drinking in public or some other alcohol related charge and didn’t ask any further questions about it.  While the patient was at the police station, he had a seizure, this being the reason why he presents to me in the ER.  He stated that he had been drinking two pints of blueberry bourbon every day for the past two months.  The seizure was due to withdrawal from alcohol.  The patient stated that this was not out of the ordinary and that he previously had seizures before when he stopped drinking cold turkey.  So I do the normal history and physical, investigating for any other potential cause of the seizure (cranial nerves were intact, no motor or sensory deficits, negative cerebellar signs, no obvious metabolic disorder).

It was not until later on when the patient was giving a urine sample in the bathroom that the police officers spoke up to ask if I knew why he was being booked.  I assume the one officer asked in such an inquisitive manner because I was being nice to the patient rather than treating him like a drug addict or criminal.  The officer continues to explain that he is an ex-heroin addict that is now on methadone (which I had already gathered).  The important part of this is that since he does not have a job and has no means of income, the government steps in and pays for his methadone.  The money that pays for his methadone essentially comes from the police officers, you, me and everybody else who pays taxes.  Now the officer gets to the reason why the patient was being booked.  He states, “we caught him earlier on the street trying to sell.”

Dumbly confused as to why this was significant I pause, then ask, “sell what?” A thought crosses my mind that perhaps I was missing some kind of cop jargon and the patient was actually selling his body on the street for money.

The officer replies, “methadone.”

As I walked away, I wondered why the cop felt it significant to tell me this, then I began to realize.  The patient was receiving methadone from the government, which you and I are paying for.  He is then selling the methadone, which is essentially money from your pocket and mine, and using it to support his disgusting habit of two a day pints of blueberry bourbon.  Unfortunately, it doesn’t end there.  Since he was brought to the ER for having a seizure secondary to alcohol withdrawal, he is wasting even more taxpayer’s money by being in a hospital and wasting the time of the staff and the expenses required to run labs and tests to make certain that he is medically cleared to go to jail.

I find that I am unable to cognitively deal with this type of blatant abuse of a system and still try to say that I am happy with my job.  I know that I’m just turning a blind eye by choosing a different specialty, but it’s what my mind must do in order to keep my sanity.  If you have any better suggestions, then feel free to comment.

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