Many questions from the wife of a medical student
Q: I read about half of your site so far and was wondering if you could please answer a much more specific question? My husband is 27 years old, and has been a type 1 diabetic for 24 years. He is now halfway through his third year of medical school. He is most interested in Emergency Medicine but will not get to do a clerkship until July to find out if it is a good fit for him in general and in light of his diabetes. At that point it will be difficult for him to get different LORS and change his schedule to fit another specialty, apply for different away clerkships etc. before his application is due for ERAS if he decides it is not in the best interest of his health. Basically he needs to know now how his blood sugar would respond in the ER over long hours. Would he be able to control it in an emergency—would it spike or crash? Would he have time to test his blood sugar? Eat if he needs to bring it up?
Answer by Kevin Pezzi, MD: When I began my career in emergency medicine, I generally worked the night shift at a cushy hospital. If there were no patients—and there often were not—I'd head upstairs to my sleeping quarters. They provided me with a very nice bed, which was always lovingly made by Jennifer, a housekeeper who always burst out into a beaming smile whenever she saw me—she was likely too blind to see what I look like! :-) After climbing in bed—alone, not with Jennifer!—I'd watch The Tonight Show with Johnny Carson, have a few laughs, nod off to sleep, and often not wake up until my boss called me to say that he'd arrived, so I could leave. I'd then take a shower, hop in my car, and then go shopping, generally for electronic parts for the myriad electronic stethoscopes, phonocardiographs, and echophonocardiographs that I was working on at that time (I posted a few of them on my first ER site).
Alas, those days are over. There are now fewer hospitals and fewer emergency departments, but more people, and more ER visits per person per year.
A few years later, I worked in a very busy, high-acuity (95th percentile) ER in which I could go 15 hours without eating. (I worked a 12-hour shift, but often had to work overtime [unpaid] to complete pending patient care.) Mary, one of my favorite nurses of all time, would often hand me a can of Ensure with a straw in it so I could suck it down in 5 seconds. I occasionally had time to sit down for a real meal (see this page for my favorite ER meal :-), but as the years went by and that place became ever busier, I gave up on the idea of eating at work and instead brought a can of Ensure to work every day. Ensure isn't my idea of great nutrition or a tasty meal, but it sure beats shaking like a leaf secondary to hypoglycemia when I performed surgery! :-)
So, to answer your question, for ER doctors, the luxury of eating is very much an iffy proposition. Ditto for testing his blood sugar. Could he squeeze in time here and there? Yes, on some days, but there are other days (such as this hectic day in the ER) in which a doctor must choose between taking 15 seconds to empty his bladder (after “holding it” for many hours) or delaying a code for another 15 seconds . . . which isn't a good idea, obviously.
Q: Is he putting patients at risk if his blood sugar is off?
A: Possibly. People vary in their tolerance to hypoglycemia. I read a book about one of my relatives, President Chester A. Arthur, and learned that he was famous for eating just one meal per day—albeit a massive meal that took him hours to consume! Owners of all-you-can-eat restaurants love people like me, because I can't hold much food (unless I'm eating pizza, tacos, cookies, cake, or pie!), but I must eat every few hours to stay sharp.
Q & A continues below this picture
Q: How would the extreme sleep deprivation affect his blood sugar management?
A: Generally, any perturbation of the circadian rhythm, including sleep, impairs blood sugar regulation.
Q: Would he be more likely to be sued if patients knew he was diabetic?
A: Probably not. Patients would likely never know.
Q: As of now, I think he does have the mindset that he will be fine and can get through anything.
A: Ah, yes, the macho “I'm tough, I can take anything” mindset that is so prevalent in medical students and doctors of BOTH sexes. Countless docs act as if eating, sleeping, and R&R are optional, even undesirable.
Q: I'm not as optimistic after reading your site. We don't know any physicians that are type 1 diabetics so it is hard to know how this other factor would affect his ability to perform in the ER? How harmful would it be to his short-term and long-term health?
A: I discussed this in one of my books or web sites. With 15 books and over 20 web sites, I can't always recall exactly where I wrote something years ago, but that is likely in my www.ERbook.net site. To make a long story short, practicing emergency medicine is tough on anyone, even healthy folks. Based on the research I've read, shift workers typically live a few years less than others because chronic circadian rhythm disruption (a.k.a., chronic jet lag) produces so many deleterious effects. Second, ER doctors typically work under intense pressure. It's not just time pressure (which is bad enough)—it's time pressure piggybacked onto the stress of having multiple lives in your hands, often without enough time to do everything that needs to be done—especially for docs who are perfectionists, not ones who think that half-ass results are good enough. If you haven't already done so, read my 15 Minutes in the Life of an ER Doctor essay. That stress spikes the cortisol level and produces other adverse hormonal effects. Incidentally, chronically elevated cortisol is bad for the brain.
Q: We have heard that ER schedules become three 12-hour shifts per week, but I'm afraid that would not be for another ten or so years and at only certain hospitals, but not the norm?
A: That is a typical work schedule for an attending (post-residency) ER doctor, but bear in mind what I said in my ER sites about that: just because you're paid for 36 hours per week doesn't mean that is all of the work you must do. As I mentioned above, it isn't uncommon for an ER doc to work unpaid overtime hours to “clean up” patients (that is, to complete taking care of them), do dictations, sign prior dictations, become intimately familiar with the folks in the medical records department (your husband will eventually see what I mean!), fill out insurance forms, go to ER staff meetings, hospital staff meetings, committee meetings, more committee meetings, CME activities, teaching, and several other things that doctors must do—generally, all of it unpaid.
Q: We have also looked at nearly all of the ER residency programs on AMA FRIEDA and some say the residents average two days off per week. This seems doable but I am skeptical. Are there programs that would promote a healthy, balanced lifestyle during residency, especially for a diabetic? My feeling is even if there are two days off, they will be consumed with paperwork, meetings, etc. and not sleep.
A: You are correct, Emily. Even when residents are now limited to 80 hours per week, that doesn't mean that they can go home and do the 1001 things that make life worthwhile. More often than not, residents have their noses stuck in a book or journal. Medical training is about as far away from a healthy and balanced lifestyle as you can get!
Q: What are your thoughts on a diabetic ER doctor? Can you please be very specific describing what he is up against on a daily, weekly, monthly basis?
A: There are diabetic ER doctors who do just fine, on a short-term basis, anyway. I suspect that they likely aren't quite as resilient as healthy ER physicians in responding to the multiple stresses inherent in emergency medicine. While I don't know of any research that substantiates this, I suspect that the longevity of diabetic ER docs would be reduced even more than it is for ER docs in general.
Q: He thinks Family Medicine would be his backup plan but it does not excite him like EM does. I worry that Family Medicine is not as necessary anymore with so many NPs (Nurse Practitioners), PAs (Physician Assistants), and Wal-Mart, CVS clinics out there.
A: I agree. I don't know why the AMA and other medical groups are so passive in accepting PAs and NPs. There isn't one PA or NP on Earth who knows what I do. Yes, I know all of the talking points they spew about how they're just as good as doctors for treating patients with common problems. Bull. In my www.ERbook.net site, I discussed one of the reasons why this isn't true. Here is an excerpt from a discussion of whether PAs and NPs are as competent as MDs (scroll down to the third topic on that page if you want to see the rest of that discussion):
I have one remaining reservation about PAs, nurse practitioners (NPs), and the endless parade of other professionals and professional wannabes who are increasingly poaching on the territory of physicians. My concern centers around one simple problem: many, if not most, diseases present with common signs and symptoms, even when those diseases are uncommon. So how can a PA or NP who purports to be an expert in common maladies know when the mélange of signs and symptoms now facing her add up to something other than a garden-variety problem? She can't. In short, she's playing Russian roulette: hoping for the right outcome, but having no way of really knowing it. (I have several topics on that page discussing Physician Assistants and Nurse Practitioners.)
Since writing that, I have yet another reason to think that superior training, education, and intellect can result in superior medical care: I (and some other doctors, no doubt) spend an enormous amount of time not just studying medicine per se, but also countless other things that patients can do to foster their health and produce better outcomes for everything from lacerations to infections to weight loss to diabetes and 1001 other topics. By digging deep into physiology, pharmacology, biochemistry, nutrition, chemistry, physics, and many other subjects, I learn more than what PAs and NPs learn—and not just a bit more, but vastly more. Yes, they know about insulin and basic dietary management of diabetes. But do they know everything else I know, or even half of it? Not a chance! If any PAs or NPs wish to dispute that asseveration and put their money where their mouth is, let a disinterested third party select 50 of your cases at random, which I'll review. If I can't find an error or omission in at least 80% of them, or be able to suggest something that could have improved patient care at least 80% of the time, then I'd pay the PA or NP $1,000,000. If I could, the PA or NP challenger would pay me the same amount.
I made a similar offer years ago, and no PA or NP has been willing to accept that challenge. If they spent a few months reading my books and web sites, and if they knew that is just a small fraction of what I know, they'd realize that they wouldn't stand a snowball's chance in hell of beating me. Frankly, I'd be shocked if I couldn't find an error or omission in 100% of their cases.
After reading what I said about PAs in a Men's Health interview years ago, I've had plenty of PAs gunning for me, but none were willing to accept my $1,000,000 challenge. They can pout, scream bloody murder, stomp their feet, and send sick and twisted threatening e-mails (and they have), but they'll never change the fact that their education is inferior to that of doctors, even ones who aren't perpetual bookworms like me.
Note to any irate PAs or NPs who want to rip my spleen out: My interest is in giving patients the best possible care, period. I don't give a hoot who gets the money for taking care of patients: doctors, PAs, or NPs. In my extensive discussion of Physician Assistants and Nurse Practitioners, I explained why I think that your abbreviated educations may be good for you, but not for patients, who often benefit from superior practitioners. In case you wish to dispute this and want to take your shot at becoming an overnight millionaire, see the above offer. If you aren't willing to accept that offer, why not?
UPDATE: Disgusted by how even doctors are doing less than they should to provide optimal patient care, I later explained how PAs and nurse practitioners (NPs) could outperform doctors. My goal is to improve patient care; I don't care who does it, although it would be nifty to see PAs and NPs outshine physicians.
PAs and NPs could become the new super doctors, and the old docs would be sheepishly searching for ways to excuse how they rested on their laurels. Competition is good, but the chasm of prestige and power between physicians and PAs/NPs provides a margin of security so large that many current docs figuratively cruise in neutral when they should be gunning for overdrive. Patients fearing disease and death don't have the margin of safety they crave, so healthcare practitioners need more incentive to give a greater effort.
By giving PAs and NPs a way to leave doctors in the dust, I could be the best friend that PAs and NPs—and patients—ever had.
The tolerance of physicians for suboptimal medical education is evidenced in their obviously defective continuing medical education (CME), which I discussed in these articles:
• Sham CME (Continuing Medical Education)
• Medscape CME problems
• The secret pact of silence in medicine
In addition to improving their own performance, doctors should do more to ensure that other healthcare practitioners give better patient care. You don't always need to visit a hospital to realize that its medical staff is asleep at the wheel. For example, a local supposedly Top 100 hospital permits employees to wear uniforms outside the medical campus, which is a public health hazard. Betsy McCaughey, former lieutenant governor of New York state, a fellow at the Hudson Institute and chair of the Committee to Reduce Infection Deaths, discussed this problem in a Wall Street Journal article: Hospital Scrubs Are a Germy, Deadly Mess.
This Top 100 hospital employs people who seem to know less about germs than some children, as I revealed in these articles:
• Phlebotomist error in a Top 100 hospital
• Infectious disease hazard of transvaginal ultrasound
Q: I like what I've read about Anesthesiology and think he would be able to have a great career and still manage his blood sugar, but it doesn't really sound interesting to him. He says it would feel more like a job just to make money and not helping people. I just know that he won't be happy in EM if he isn't healthy. He is also the kindest, happiest, greatest guy around and I worry how EM would change that (the piñata effect you talked about)?
A: Ah, yes, the piñata effect: After years of being whacked around like a piñata, or kicked like an unwanted dog, ER docs can, and often do, become cynical and embittered. Fortunately, there are many ways to counter that, but I don't have time to discuss them today.
Q: Thank you so much for reading this question and for your advice, and thank you for all of the information you have on your site.
PS: At what point do ER docs typically burn out?
A: It varies, but in general, I'd say that very few ER doctors I knew with over 7 years of experience were very fond of their jobs. They needed a paycheck, so they did it, but I heard far more bellyaching from them than I did anything else. Practicing medicine has many drawbacks, and emergency medicine is even more hectic than most other specialties, but offsetting these myriad disadvantages is one enormous, overriding factor: Medicine just became a much more desirable profession, thanks to the economic crash that devastated our economy in 2008.
I spent several weeks researching what caused the financial Collapse of 2008 because I needed that information to make wise long-term decisions regarding my inventions. I began that research with the same concern that millions of others had about our economy, but emerged from it absolutely horrified at our long-term prospects for a full recovery. It was like surgically opening a patient with a ruptured appendix only to find that he was full of cancer. The appendix may be fixed (the stock market will rebound), but the cancer will remain (the many defects in our economy cannot be fully eradicated).
It was also like discovering that the jet airliner you're riding in was being piloted by a 14-year-old kid wondering what will happen if he flips various switches, not an experienced professional who knows what he is doing and is ready to handle any emergency instead of panicking and crossing his fingers for good luck as he guesses how to best respond.
Consequently, the long-term prospects for our economy are poor. When most people look at our economy, they see only the obvious problem (appendicitis in my above example) without realizing that a much more serious problem—cancer—is lurking below the surface. In researching this, I found that the most optimistic forecasts were given by those who weren't especially knowledgeable or those who had a vested interest in trying to put a positive spin on the economy. The most gloomy forecasts were given by those who are economically savvy with good track records in forecasting economic trends. To see some of the evidence I discovered, read my free e-book, From Bailout to Bliss (here is more info about the book, and here is its download page).
We were raised in a culture that once gave us the ability to essentially go on autopilot and still do OK. Those days are over. Even the smartest people must now carefully analyze whether doing things the old way is still the right way. The answer is often no, but most people don't yet get it. In From Bailout to Bliss and other books that I am now preparing, I will explain how you can sidestep much of the fallout from this economic crisis.
To make a long story short, the pluses of medicine now greatly outweigh the cons of medicine. Consequently, now more than ever, medical careers are a great choice. However, there is something that everyone must never forget: Even if you go into medicine, economic problems will dominate the rest of ours lives—that's how screwed up our economy is. If you read From Bailout to Bliss, you'll know why we cannot rebound from this recession as we have past ones. There may be a slight recovery in mid-2009, but that is just the calm before the real storm.
Rioting (secondary to the economic crisis) recently broke out in peaceful Iceland, which toppled their government. More governments will fall—possibly ours, too. In my book, I suggest how we could not only recover from this crisis but enter a new golden age of prosperity, but what is the chance that President Obama and Congress will listen to me? About one-in-a-million, I'd say.
Unlike the trillions of dollars they're now spending with little or no benefit, my economic recovery plans would produce much better results at zero net cost—in fact, they would save us hundreds of billions (perhaps even a trillion) per year. Residents of Alaska don't pay state income taxes. Everyone, even kids, receives a check every year in which the state divides the proceeds generated from their gas and oil leases. Even after subtracting the money that it takes to run the state, residents each receive thousands of dollars—quite a nice change from paying thousands of dollars to the state in income taxes!
Not every state has such natural resources to exploit, but any state could implement my plans (see From Bailout to Bliss), cancel all of their taxes, give free healthcare and college to everyone, and send each resident a check every year that would make the Alaskan disbursements seem like pocket change. So why don't states do what I suggest? Probably because they are not aware of the fact that there is a better way. Incidentally, if you'd rather receive a check than write a check, tell your Governor and state legislators to read my book. All of it.
Smart leaders, such as Governor Mark Sanford of South Carolina, will like that book and love my ideas. Governors with inside-the-box brains that only know how to tax and spend will wonder why anyone would ever go to the trouble of thinking up new ideas. When they need more money, they just put their hands in the pockets of taxpayers and extract just as much money as they want—which is always more than they need. If my plans were implemented, states would no longer need to leech off their residents, or the Federal government.