Checking the gunner medical student
Current PGY-3 in IM reflecting on what might not be my best moment. Recently, while on a wards rotation, I had a difficult fourth-year AI medical student. This student had strong medical knowledge, but they completely lacked people skills and were disagreeable with other students and residents. This student would regularly laugh at presenting interns and med students during their presentations and throw interns and other med students under the bus ("X did not actually do XYZ"). They would make open jeers at other med students on my team and other IM wards teams ("I wouldn't want that person as my [future] doctor"). They openly said that nursing school is "a few years of playing grab-ass" in front of RNs and RN students in our ICU. I had a good working relationship with this student and made multiple attempts at coaching behavior through formative feedback, but it fell on deaf ears. The issues were frequent and their cumulative weight grew worse and worse. The other medical student on our service requested to change teams because of this person. My ESL intern cried because this student mocked their English skills openly. That was it - the straws became too many and the camel's back too weak. I went to my favorite open-late coffee shop, opened up my PDF of McGee's Evidence Based Physical Diagnosis, and spent about 4-5 hours studying and memorizing likelihood ratios and other statistics for every relevant physical exam finding on every patient on my IM team's list. The next day, I conjured every condescending bone in my body and proceeded to pimp the absolute shit out of this student in front of the rest of our team and attending. "This person is having a CHF exacerbation because of crackles on exam? Not so fast, dawg - what's the sensitivity of crackles for elevated LA pressure? Don't know? I'll make this easy - what about the likelihood ratio for it when they're present?." "Let's talk about Ms. X, our placement patient awaiting NH. If you were to quantify her dementia, what do you think the inter-observer variability would be for the clock-drawing test on dementia assessment?" "Did they have a Hoover sign?" Et cetera for every patient on our list. It made for a grand last day for this student. Again, probably not my best moment. However, sometimes enough is enough.
It finally happened to me y’all
Last night I responded to a code stroke. Nice little old lady with a UTI confused for 3 days per family. Why was it called? Turns out family rolled into triage proclaiming that “mom is having a stroke!” after reaching this diagnosis with the help of the venerable Dr. ChatGPT. Yep. The chatbot told them her symptoms were probably due to a stroke (surprise, it wasn’t a stroke). Then i gotta explain why this diagnosis they’re dead sold on is plain incorrect. Some people worry about a dark dystopian future of AI. I’m more concerned with the overzealous application of underdeveloped technology for roles it clearly isn’t yet fit to fill. Anyone else getting consults from Dr. AI?
Sad stories that define you.
Some commenters have asked in other threads or DMs that they like my stories and wanted to hear more. There was a really good post maybe a week and a half ago about a medicine person who felt they messed up when they gave false hope to a patient that had a salvage pancreas operation and I was inspired by that person's honesty. I thought I would share one of my many sad stories I've accumulated over seven years too. I invite everyone to share their own stories of medical school or residency that hurt them, if they want. We're human. Anyway, stupid long post inc. ------------------------------------------- It's always the last one that comes in when you're ready to leave that gets you, you know? Was on back-up call one weekend as a PGY-5 where you just come in to round and then help out a bit before heading out. Rounds were done, was on my way out the door when they called level 2 trauma, level 2 trauma, level 1 trauma in rapid succession. This is usually a bullshit call because if you get three level two traumas they automatically upgrade the last one to summon the trauma surgeon from home into the hospital. But, you never know. So I walked back to the ER just to check before I left. First trauma is a woman who's got obvious rib fractures. PGY-4 (chief on for the day) is running it fine so I let her take and and just hover. The second one rolls in maybe ten minutes later and it is her husband. Neither of them speak english (they were Pakistani - we had an intern on that day who happened to be able to converse with them) but they're both pretty disoriented from the car accident. Husband looks like he has at least a few spinal fractures, he can move all four extremities but not without pain in his legs and spine is tender. The women keeps asking about her son. The PGY-4 is still going a good job managing them both simultaneously so I sit back and talk to EMS. "Where's this ladies kid? Is he bypassing us and going straight to Children's?" "Not sure. Thought they were right behind us." First red flag I missed that day. Maybe they were just taking the kid downtown and they weren't going to bring him as the third level two (fake level one) after all. I had them clear out the other half of the bay just in case and told the chief I'd take care of it if he showed up. We moved Dad into the annex one room over since he's stable and start getting them both ready for CT. Right before Mom is to go to CT first, kid comes in. I wasn't a father back then and honestly couldn't tell you how big a one year old was supposed to be. I thought he was two or three. Facts I would learn later. He's being bagged. He's not responsive. Mom hears that there's a child next door and starts shouting if its her son. Chief comes over and asks if she should take care of this but I tell her no, focus on the parents and let me do this. Though the kids vitals were fine at the moment it didn't feel right and she already had a lot on her plate (and still had the rest of the ER to deal with). Red flag number two. It didn't feel right. We pull up the barriers so Mom can't watch and get her wheeled out to CT pretty much immediately. I tube the kid. Attending is on his way in, not there yet, but the peds attending has come down which is good. Because the next minute he drops his blood pressure. I don't remember the numbers; I don't even remember what the numbers are supposed to be, but I remember looking at her and saying "for his size this is hypotension yes?" and she goes "Yea, this is real." So I start blood transfusion. When you're a level two trauma center in a community program you aren't really built for peds trauma. You're designed to be "good enough" that you can stabilize and then get them back in transport to the children's hospital if they're really sick. But the reality is that, in five years, it just doesn't happen very often that you get very real pediatric trauma. I can count on one single hand the amount of kids I've transfused in five years; it was two. It makes it really harrowing when it happens that suddenly you're trying to remember how fast you can transfuse them. That you have to measure blood in CCs, not units. That your "large bore IV" in a one year old is suddenly not what you think it is. That every drug and bolus you're about to push can make it better, or make it worse. This all crosses my mind in ten seconds before the peds attending steps up behind me and says "Its 160cc for the transfusion. You worry about the trauma, I'll do the drugs and fluids." The panic fades. She's the good one who's always helped me before with the kiddos. I'm glad she was there that weekend. He's tubed. He's getting blood. His pressure comes up almost immediately. CXR shows nothing. Abdominal film shows nothing. Pelvis is fine. I've got nothing on my physical exam for why this kid is hypotensive. It must be his head. It has to be his head. Repeat CXR shows ET tube in good position, we're ventilating fine. I asked for the helicopter to get called in the breath after I chose to tube him earlier and the charge tells me now that the team is suiting up and helicopter should be here in 15-20. We have time then. I can help move his work-up along so the real baby trauma doctors can treat him faster when he gets there. This is a neurosurgery case anyway at this point and he's stabilizing. Right? Get him on a monitor. Get mom out of CT scan ASAP. Kid is clearly the most important of the three. Getting ready to wheel out to CT scan and his pressure starts to come down again. Peds attending says give him another "unit (160cc)" of blood. This is weird. I should have seen something on physical exam. He's stable enough though so lets run him through. Take him to CT. Trauma attending shows up as the films are loading up in the CT control room. He's got some fluid in his left chest now but no obvious lung contusion. Head looks fine. Why is the head fine? There's a tiny bit of fluid in his mediastinum. Is this where its coming from...? (Red flag.) His pressure tanks as the team is getting him off the table and I'm looking at the pictures with the boss. Me and the attending take over and get him back to the trauma bay, I task the mid-level/intern to go find a radiologist and figure this out. Start massive transfusion (thinking in my head, what does that even mean in this kid...?) and I start prepping to put in a left chest tube. We lose our access trying to push blood in through peripherals. Scrap the chest tube for a second and switch to the line, the kids prepped from top down at this point and he isn't coding but something is wrong. This kids scans did not have any injuries to support this level of instability. I'm struggling with the line, a lot. The kit is weird because when's the last time you used a central line kit designed for a 1-3 year old? His veins are collapsed and impossible to stick (why is his vein collapsed? Red flag). He codes. I abandon the line. Trauma attending is now running the code and we both immediately agree that left chest tube is more important. Hand the central line stuff to the intern to keep trying and the trauma nurse is doing an IO on the other leg which she gets quickly and is trying to force blood through. I get grab a knife and cut straight into his chest on the left while someone's doing compressions on the right. This isn't the time to be delicate anymore. I get my finger in and I only get small amount of blood. Get the chest tube in and get maybe 35-400cc of blood. Not that much, right? It wasn't until later that I made the connection in my head that a unit of blood for this kiddo was 160cc. Intern gets the line. Chest tube is secured. Somewhere in this chaos I remember telling them to get Children's on the phone for advice because I couldn't understand his injury pattern. I break scrub while attending runs the code and get handed the phone. Two things happen then. The flight team arrives and comes in and is ready to take him if we can get him back. And my midlevel comes back from radiology. I have a pediatric trauma attending on the other end of the phone and let him know we're coding but that his flight team just got here and I think we can get him back, can he wait one second while I hear what radiology had to say. Peds trauma says absolutely and to just get him on the helicopter ASAP. The midlevel tells me that rads says there was an aortic tear. He says radiologist missed it on the CXRs but there was a widening mediastinum on our subsequent films and the scout for the CT. And that's when it all clicks. The worst part was is that we get him back right here. We're massively transfusing and he's got a pulse and a regular rhythm. Maybe. Maybe it isn't too late. Peds trauma says if we can get him down they can operate right away. We start to pack him up. Get him on the flight stretcher. Running blood in through the IO and the central line. More blood starting to come out of the chest tube though. Trauma surgeon asks me to fly with the kid and help and I agree and they give me a cooler full of product. As we're walking out the door, literally out the door to the elevator to the helipad, he codes again. We start over. Peds trauma is still on the phone. I'm frazzled now. I'm upset. I missed the injury. I should have started everything sooner. I could have been faster. I ask peds trauma what else we can do. He says, "I'm sorry." He doesn't come back this time. We tried for forty minutes. We all wanted to keep going, but one by one we stepped away from him. My trauma attending let me run that code as long as I felt I needed to. He asked me if I was ready to stop around 25 minutes and I said not yet, and he said OK, you're right. He knew. I knew too but I wasn't ready. I was the last one to be ready. He was my patient. He was my patient. He died that morning. I went and held his hand and I said the time of death out loud so everyone knew that it was done. That I was done. I went to our workstation outside the trauma bay and just say down and stared at the wall for a little bit. Some of the nurses were crying as they went past. Trauma attending comes and sits with me and says it isn't my fault, that I did a good job. The PGY4 came up then and thanked me for taking care of him for her. I asked her what happened? She told me that they had been driving and kid was crying in the backseat. Mom had tried to get him to calm down but he wasn't having any of it so she unstrapped him from the car seat and brought him into the front seat to hold him. Right after that happened the weather had been bad and Dad lost control and rear ended someone on the interstate. Kid had still been awake at the time so parents thought he was fine but still worried and were asking about him. I'm pretty numb now. Trauma attending tells me to go home, that he'll take care of talking to the parents. But I refuse. I need to finish this. I tell him I'll go with him. Unfortunately there's still a huge language barrier. We tried getting an interpreter on the phone but hadn't had any luck in the last half hour - the only person we had to translate was our intern. I still feel awful about that but it was all we had. I tell the intern before we go in that all he has to do is repeat what we say as plainly and directly as possible and that he's just translating, that he isn't the person talking to the parents. Because I don't want him to go home and beat himself up too. We wheel both of the parents into the annex room. They're both spine immobilized and have spinal fractures, but we put the beds together as best we can. The trauma attending speaks plainly, and the intern interprets plainly. We're sorry to have to tell you this but your son died. We tried everything we could. Mom starts screaming. Dad starts crying. They hold hands. I let the intern know he can leave. We just stand there with them for awhile, maybe ten minutes without saying anything while they grieve in a silent vigil, and then we can't take it anymore either so the trauma attending and I leave as well. There is nothing more we can do to fix that pain. I go home. I fall asleep. I can't talk to my wife about it. I can't cry. I just go into oblivion. In the weeks that followed I get asked to present him at M&M. I don't know why. But I go through the entire series of events from top to bottom again and recall them in front of the entire department, waiting for them to tell me what I did wrong because I already know I fucked up. A one year old died in my hands because I missed his injury. At the end of the presentation, the director of the trauma program stands up and thanks me and says "This case is important because everything went right, and we need to know that. We need to be told that. We made sure to reach out to everyone who participated and allowed them to debrief because its important in these cases to realize the trauma this can have on the providers too." Funny thing about that was, they forgot to reach out to me. As they were discussing the case and how amazing everyone did I just left and went to the call room and I cried the rest of the day. They forgot to reach out to me and I think the only thing they could have done worse than forgetting about me was to ask me to relive it all again in front of a crowd. But it was just a mistake. And we're all human. We all make mistakes. My trauma director made one that day and he still doesn't know it because I didn't want to hurt him - in a lot of other times and places in residency he was one of my rocks that was always there for me and we all make mistakes. I don't fault him at all. The same way I don't fault that boys mom. She made a mistake. There's nothing to be gained from piling onto people's pain, you know? Sometimes you just have to let the mistakes go and sometimes things just hurt. That's what it means to be alive and still be here. But... man. That changed me. That kid changed me. He had a non-survivable injury but I still don't feel like I didn't mess up that day. Its that last thing that comes in through the door when you're ready to leave that gets you, you know?
Merry Christmas to all residents working today (we do this with no extra pay)
I can’t think of another healthcare worker that doesn’t get a holiday pay differential. Residents sacrificing holidays should be getting a holiday stipend. Just trying to bring to attention yet another way we are marginalized, mistreated, and abused by the system. Thanks for listening. And Merry Christmas 🎅🧑🎄🤶
Name and Shame: University Hospitals Cleveland Medical Center GME
Note: Posted this for someone else due to restrictions on accounts less than 72-hours old in r/medicalschool . Name and Shame: University Hospitals Cleveland Medical Center Case Western Reserve University / University Hospitals Cleveland Medical Center (ACGME Sponsoring Institution #380373) https://www.uhhospitals.org/medical-education/graduate-medical-education/ Which program? This post is about the Sponsoring Institution at large as the policies and practices described below affect residents in all programs. The specific program involved in the events described below was the UH Psychiatry residency program (ACGME Program #4003821174). Why are you making this post? This post is made to inform potential residents and current residents about serious issues with the University Hospital's GME policies and practices that violate rights protected by federal and state laws. tldr? Since at least 2012, University Hospitals GME maintained unlawful handbook language that stated “Residents must not join any organization that could consider striking or withholding patient care services as a bargaining strategy.” University Hospitals GME maintains policies allowing them to dismiss residents immediately without due process in violation of ACGME accreditation requirements and AMA guidance on medical ethics. University Hospitals GME used those policies to dismiss a resident immediately and without due process after the resident filed charges with the National Labor Relations Board (NLRB) and Equal Employment Opportunity Commission after GME failed to take appropriate action with regards to grievances. What were the NLRB and EEOC charges? The original charge with the National Labor Relations Board (NLRB) concerned intimidation and interference with resident engagement in discussions about workplace conditions. The charge alleged interference and intimidation by the use of ongoing forced medical examinations to chill protected activity. The original EEOC charge pertained to the pattern and practice of forcing employees to undergo illegal medical inquiries under threat of discharge without the required legal justification. Who Cares About Due Process? You should care about due process because your entire career can be easily derailed by someone (e.g. PD, attending, co-resident, etc.) willing to make false allegations and/or take adverse actions without the protections that come with due process including the right to know the allegations, the right to contest the allegations in a fair hearing with an unbiased decision maker, and some semblance of objective review of the record. In an environment where you can be dismissed from residency immediately without appeal and due process your career is subject to the arbitrary and capricious whims of GME Admin. In such an environment, you cannot be truly free to abide by your obligation to advocate for patient interests including ensuring reasonable (e.g. safe) workplace conditions. The AMA Code of Medical Ethics Opinion 9.4.1 explains: “Fairness is essential in all disciplinary or other hearings where the reputation, professional status, or livelihood of the physician or medical student may be adversely affected. […] Collectively, through the medical societies and institutions with which they are affiliated, physicians should ensure that such bodies provide procedural safeguards for due process in their constitutions and bylaws or policies.” ACGME Sponsoring Institution Requirement IV.D.1.b requires Sponsoring Institutions provide: “residents/fellows with due process relating to the following actions regardless of when the action is taken during the appointment period: suspension, non-renewal, non-promotion; or dismissal.” Link to PDF, see page 14 Got Proof? Previous version of the University Hospitals resident handbook Unlawful language restricting resident rights to unionize on page 41-42 at Section 6.5 Paragraph B. Current version of the University Hospitals resident handbook posted in January 2022 Language describing immediate dismissal without due process language on pages 26-28 at Section 4.1.3 Paragraphs B-D. 2012 University Hospitals resident handbook filed in a court case involving UH GME Unlawful language restricting resident rights to unionize on page 94 of the filing at Section 5.5 Advocacy Efforts. Docket link for the original NLRB Unfair Labor Practice Charge 08-CA-272101 regarding interference with employee rights through intimidation and coercion. Note: The case is marked as closed because the resident withdrew the charge before any merit finding on the advice of attorney later determined to be suffering from scrupulemia and shysteritis. Docket link for NLRB Unfair Labor Practice Charge 08-CA-2280382 regarding interference with employee rights through intimidation and handbook language forbidding unionizing. Docket link for NLRB Unfair Labor Practice Charge 08-CA-287186 filed in response to the retaliatory threat of litigation. Residents have Legal Rights?: Obligatory I am not a lawyer and this is not legal advice. As a resident, you are protected by both the laws that protect the rights of students in programs receiving federal financial assistance (e.g. Title IX, Section 504) and the laws that protect employees (e.g. Americans with Disabilities Act, National Labor Relations Act). Under Section 7 of the National Labor Relations Act (NLRA), you not only have the right to unionize, but also to engage in activity aimed at improving workplace conditions even if your hospital is not unionized. The protection is not limitless, but it is broad. You have the right to discuss work-related issues with your co-residents and to bring those issues to your program director’s attention without retaliation. You have the right to prepare for and seek to induce group action. Any Employer interference with these rights is a violation of the National Labor Relations Act. Handbook language forbidding you from joining a union (e.g. “any organization that could consider striking or withholding patient care services as a bargaining strategy”) is illegal under the National Labor Relations Act. Note: University Hospitals is a private “non-profit” covered by the NLRA. The NLRA explicitly excludes public employees like residents employed by a state university or county hospital. State law generally protects the right of public employees to unionize. If you are employed by the U.S. Department of Veterans Affairs directly, you have the right to unionize under the Civil Service Reform Act of 1978 and that right is protected by the Federal Labor Relations Authority. Under the ADA and once you are working, a program director or hospital is prohibited from asking questions about your health or requiring you to undergo a medical examination absent “business necessity” which legally means damn good reason based on reasonable and objective evidence (e.g. reasonable and objective evidence of substance use at work, threat of harm, etc.). Medical exams that are mandated without "business necessity" constitute unlawful disability discrimination under the ADA. Retaliation and other attempts to interfere with individual rights protected by the ADA are also illegal. What Happened? In May 2020, a UH program director solicited feedback from residents on an ACGME re-accreditation letter where the ACGME Review Committee identified areas of concern including resident dissatisfaction “with the process to deal with problems and concerns” and disagreement with the statement that “concerns can be raised without fear.” A resident responded to the program director in confidence and with constructive suggestions. The program director apparently wounded shared the resident's email without permission resulting in some interesting correspondence between the program director and another individual In August 2020, the program director mandated the resident have ongoing #wellness assessments based on "confidential" “concerns" not reflected in any official evaluations and the May 2020 email. The resident sought help from the GME department and hospital administration who failed to take appropriate action, refused to provide any justification citing “confidentiality”, and instead threatened the resident with dismissal unless the resident submitted to ongoing #wellness assessments. Around February 2021 after repeated failures by University Hospitals GME to address grievances raised by residents in the program, the resident above filed charges with the Equal Employment Opportunity Commission (EEOC) the National Labor Relations Board (NLRB) over unlawful interference with rights via intimidation and retaliation involving unlawful medical examinations and inquiries. After learning of the charge, University Hospitals took adverse action against the resident and dismissed the resident without warning approximately 35 days after submitting a position statement to the NLRB and within 3 days of submitting a position statement to the EEOC. Furthermore, University Hospitals via its Designated Institutional Official denied the resident any due process and review of the decision citing Section 4.1.3 B of the UH resident handbook. The dismissal reason used to justify immediate dismissal and deny due process was later disavowed. In July 2021, the resident filed charges of retaliation over the dismissal with the NLRB and EEOC. In the NLRB charge, the resident explicitly identified the handbook language that stated residents could not unionize. In December 2021, University Hospitals threatened the resident with litigation unless the resident agreed to demands including signing an agreement that would allow the hospital to “file a consent injunction” against the resident at its discretion and providing the hospital with “a list of all UH employees that [the resident] [had] contacted, directly or indirectly” since the dismissal. Accordingly, the resident filed new charges of retaliation over this threat and apparent attempt to identify potential witnesses for the ongoing investigations. In January 2022, University Hospitals posted an updated version of its resident handbook without the language explicitly forbidding residents from unionizing. In the same update, University Hospitals GME Admin maintained and formalized policies allowing for the immediate dismissal of residents without due process in direct contravention of ACGME requirements. Where's the ACGME? The ACGME renewed the Sponsoring Institution's accreditation on January 18, 2022 despite the handbook language allowing the hospital to dismiss residents without due process, but before any formal complaint was filed with the ACGME. The ACGME is the first to remind residents and fellows that it will not weigh in on any individual matters and will not attempt to provide any remedy when a Sponsoring Institution violates accreditation requirements, discriminates, or retaliates. The ACGME does not disclose any findings or information to a resident who files a complaint, current residents, applicants, or the public except for accreditation status changes. The ACGME quickly removes negative accreditation statuses from public view and does not maintain a publicly accessible record of accreditation actions. The ACGME is a non-profit private accreditation body funded by sponsoring institutions and heavily influenced by the AMA, AAMC, ABMS, CMMS, and the AHA as a footnote in the 1999 NLRB Boston Medical Center decision explains: ACGME has five sponsors, each of which appoints members to the council: the American Medical Association (AMA), the American Association of Medical Colleges (AAMC), the American Board of Medical Specialties (ABMS), the Council of Medical Specialty Societies (CMSS), and the American Hospital Association (AHA). ACGME’s sponsoring organizations also review and accredit medical schools. Hospitals, including teaching hospitals, are periodically evaluated and accredited (or re-accredited) by the Joint Committee on Hospital Accreditation. Note that these five sponsoring institutions include the same fine organizations that were involved in the Jung v. AAMC case and last-minute bill rider shenanigans that carved out a legislative exemption for the NRMP. When the NLRB ruled that residents were employees protected by the National Labor Relations Act in the landmark case above, stakeholders including the president of the AAMC criticized the ruling heavily. In sum, the ACGME provides no protection for residents and primarily exists to serve the interests of GME Admin. Given the lack of any transparency, legal force, or remedy through the ACGME, residents are left to fend for themselves. Unionizing is the only way that residents can hope to ensure truly fair mechanisms to address issues without the need to rely on the deliberately indifferent and impotent ACGME. What about the NLRB and EEOC? Investigations are ongoing. Seeking redress through any legal process takes months to years which is all the more reason to fight to ensure fair policies and practices through unionization. An ounce of prevention is worth a pound of cure. Conclusion: Good luck in the match and remember to fight for your rights because no one else will, especially not the ACGME. P.S. Calling u/gme_office
Suicide by doc
Patient with known IPF gets admitted for worsening dyspnoea and cough, HR-CT shows milk ground glass opacities consistent with acute exacerbation. Prednisolone is given and there is an indication for i.v. antibiotics. Upon admission I ask the patient for any known allergies, she mentions CT contrast (iodine). I ask again specifically for reactions to medications - she states she has no medication allergies. The nurses prepare the ampicillin/sulbactam, the first dose I have to administer myself as per institutional policy. I walk into the room, asking once again whether she has ever had a reaction to any antibiotic - just for good measure. She confirms that has never happened. I connect the i.v. tubing, open the three-way-valve, and as my hand hovers over the little wheel she asks what this is. I tell her it's a penicillin antibiotic. 'Oh, but I'm allergic to those!' she exclaims. I ask her what happened when she got one. 'I couldn't breathe and they had to give me all sort of emergency medicine, including a shot in the thigh!' I swear, with some patients I don't know whether suicide by doc is a thing now.
Who writes the most useless notes in the hospital?
And conversely, who writes the most useful notes? Most worthless notes have to be anesthesia pre/post-procedure notes. "Level of consciousness: fully conscious Volume status: patient is euvolemic Cardiovascular status: stable Respiratory status: breathing comfortably Patient is satisfied with level of patient control" When in reality they dropped the patient off in the ICU still intubated with an open abdomen on pressors after coming out from the OR. Most useful notes have to be ED SW notes. If there is tea to be had, it will 100% be in that note including direct patient quotes.
as a patient I just want to say Residents are GOATED
I was stupid and decided to angle grind metal without eye protection. The ER doctor was being very dismissive of my worry because it was a very small piece and she felt if I damaged my eye that I’d be presenting more pain. (Said she cut her eye on a contact one time and knows the feeling) I kept being persistent because my left eye has been blurry, irritated and I could definitely feel something stuck in it. This doctor tried being dismissive but one resident I the ER spoke up saying she thinks she saw something small. My doctor finally paged the eye people and it was after 5 so you know most them were off. A resident took the call and came in after dark, in the pouring rain to open up their eye clinic and double check my eye. She confirmed that my eye was scratched and said that the foreign object may have fallen out but definitely cut my eye a little. She ran a ton of evaluations and got me in for a follow up ASAP just to make sure it’s okay. I think the best part though was how she called the ER doctor to basically tell her that my eye was in fact injured. I could tell by how she worded the call that the doctor probably tried saying there was nothing wrong with my eye. Felt like a Greys Anatomy episode! Lol I got her name and stuff because I plan to shout her out and the young lady in the ER who helped me. It’s not the first time resident or a student has spoke up for me and I wanted to share my story to say that patients see you and appreciate it more than you know! Most ER docs are wonderful to me but we have one locally who seems a little discriminatory towards me but it’s not enough where she could get in trouble. Only reason I haven’t reported ER doc yet is because when she stops gaslighting me she does amazing + I always see her doing a great job helping other patients. Anyways, thanks for what yall do and fighting for patients even the little things. Residents are more amazing than what they get credit for.
Contract Negotiations - A Guide
Since July/August are the time that many senior residents will begin the job search (hint, July/August is the time you should start your job search senior residents) I thought I would try my hand at making a succinct stupidly, unnecessarily long and comprehensive guide to things you should know about the process of negotiating a contract. My background for writing this is a graduated surgical fellow going into a sole practice in a multi-group cancer clinic, so I had quite a bit of learning to do. I will hit everything I can think of, I will freely admit that this is an n = 1 experience, and I strongly encourage other attendings, senior residents, new grads, etc. to contribute. Particularly people who are going through or have just gone through the process. This post will be listed as part of my pet project in the guide post stickied to r/residency; if you're looking for other helpful guides check it out here: https://www.reddit.com/r/Residency/comments/ohjy9v/compendium_of_practical_guides_for_rresidency/?utm_source=share&utm_medium=web2x&context=3 Let's get to it then. Things you have to do and know before you even start: You need a point of reference for how much get paid. You can find an informal reference here: https://www.reddit.com/r/Residency/comments/mmu9ur/how_much_does_specialtyfellowship_make_after/?utm_source=share&utm_medium=web2x&context=3 But you need a FORMAL reference. You really must obtain the following documents so that, if necessary, you can physically show them to a potential employer during contract negotiations and not get fleeced. If you are applying to an academic job the document you need is called the AAMC faculty salary report. It can be purchased by individuals at great personal expense ($1,150 lol). That said, many (all?) academic departments will have an institutional copy. Your department chair is the most likely person to ask to get this information and unless you're applying to a job and staying on as faculty, they will usually give it to you without issue. This will list total compensation based on academic rank. We'll talk about those terms in a bit. Other ways to get this information are to ask co-residents. If that fails, come ask in Reddit. SOMEONE has it and will share it, but employers often have little incentive to share it as it gives you more power to negotiate. I do not believe the AAMC salary report sorts by region, the version I have for my subspecialty does not, but I never got the official version because I didn't need it (non-academic job). If you are applying to a non-academic job which includes private practice, hospital employed non-academic, multi-specialty groups, etc. - essentially, anything that is not teaching faculty, you need MGMA data. We call it MGMA data, but in reality, most employers and even most applicants actually use blended MGMA data. MGMA is one company that collects physician salary data. The two other big ones are AMGA and SCA. MGMA tends to be the highest average numbers but not always. The blended MGMA data averages all three into a single set of data and that will be what you and a potential employer will use as a benchmark. There are two sets of MGMA data - academic and non-academic. Academic MGMA data IS DIFFERENT from the AAMC faculty salary report but it generally describes the same job setting (total compensation however tends to be higher in the MGMA version). This data is primarily used for people who will be productivity/RVU based rather than research/teaching based in a university style setting. You may need both the academic MGMA data as well as the AAMC faculty salary report in your negotiations, and you may also need the non-academic data. It will be between you and a potential employer to argue and justify how you should be classified and reimbursed and why. Knowledge is power here though and the more you have the better off you will be. If you are in private practice, pure productivity, or a non-teaching role you should be using non-academic MGMA data. MGMA data is sorted by region and specialty including subspecialty. It can also be reported nationally. The '50th percentile' numbers that everyone throws around are for 2+ years of experience after graduation. They are NOT for a new grad. Some MGMA reports will actually list starting salary separately for a new grad under a starting compensation section and, yes, this is almost always lower. When a job is advertising "pays 90th percentile MGMA" that means it might pay 90th percentile MGMA if you have experience, but as a new grad it might pay 90th percentile for new grads which could in fact be closer to 50th percentile for 2+ years of experience which is the number you'll see on the MGMA report. This is why you will see a (potentially very large) discrepancy. MGMA data typically will list total compensation, average RVUs, and the conversion factor from RVU to total compensation (how much an RVU is worth) for your specialty MGMA data may, or may not, also list typical signing bonus amount, relocation amount, CME allowance, vacation weeks, and additional call (voluntary call beyond what is stipulated in your contract) by a daily and/or hourly rate. It may also list medical directorship type compensation stipends. The definition of Total Compensation: First thing to know is that this definition CAN AND DOES vary between potential employers. Simply ask them what total compensation includes when they calculate it and they will tell you; it isn't a secret, it just isn't completely standard across institutions or employers. Total compensation is not your salary. Total compensation IS NOT your salary. Total compensation is your salary *and* can also include some of the following things: Vacation time factored in (included) Signing bonus (almost always included) Student loan reimbursement (almost always included) CME money, professional stipend (+/- being included) Guaranteed yearly bonus, quality bonus, or whatever they want to call it (included) Retirement Match (+/- being included) Medical Directorship Stipend (included if applicable) Things that are NOT included in total compensation (usually): Additional/Voluntary Call RVU productivity bonus Things that are variable, but tend not to be calculated in total comp Malpractice coverage Disability Insurance Life Insurance Health Insurance Equipment Costs Definition of Academic Rank: Academic Rank is what dictates a large portion of what level your total compensation will be paid at in an academic setting. Ranks are typically: Instructor, Assistant Professor, Associate Professor, Professor, Chief, and Chair. Be sure to ask and understand what your promotion criteria is in an academic position. Is it based on research and number of publications? Is it based on time? It it based on evaluations from faculty? From students/residents/learners? Productivity? All of the above? This should be clearly spelled out and written down for you in any potential contract. If it is not, that is sort of a red flag and you should ask to have it clarified. Understand the criteria for achieving the beginning academic ranks. In particular, what do you need to do to be hired as an assistant professor or an associate professor rather than an instructor. For a lot of places assistant professor requires only that you are boarded. For others there can be additional requirements including time, experience, research publications. Varies by institution. You should know the following things about yourself before starting the job search: What geographic location are you willing to practice in? If anywhere, great. If its very specific, understand that you will lose a great deal of your negotiating power (sometimes you will have zero negotiating power and only one or two options). Do you want to be self employed, employed, or you don't care? Do you want or need to work towards PSLF? If so, you need to be employed at a non-profit institution. You must be very clear here that you are actually employed by the non-profit. It is not enough to be employed by a private practice who contracts and works out of a non-profit hospital, that will not qualify. Most academic settings and government hospitals are non-profits. Most private practice settings and large corporate conglomerates are not. But there are some exceptions to both. Are you willing to take call? How much? How often? If you are a super specialist, are you willing to take call for whatever you general boarded specialty is? (For example, I am an HPB/surgical oncologist but many job postings require their surgeons to take general surgery call, +/- trauma call). Question for the employer: If you are taking some form of general call, what is the scope of their emergencies and what can you transfer? Do you want to and/or are you willing to supervise/teach? This includes medical students, midlevel students, residents, fellows, and midlevels. For some specialties, you may want or need a midlevel or residency to support you. You should put some thought into this up front (but be aware that you will likely have very limited control to negotiate for this as a new grad). What do you want the scope of your practice to be? What are things you absolutely will not do? What are your red lines? Things a potential employer WILL CHECK about you: They will read your CV They will call some, if not all, of your references They will likely call your program director or at least send a generic form about disciplinary/professional/any other work issues to your residency and fellowship (if applicable) If they know anyone from where you're coming from, they'll probably call them You will get a criminal background check They will inquire into your malpractice history They will inquire into any licensure or board issues If you have a red flag in any of these things it does not mean they are not interested or won't hire you. This is just a heads up that they are going to check all of these things. Be honest and consider being up front about whatever skeletons you might have. At minimum be prepared to discuss any issues a check into any of these things might discover and be prepared to explain yourself and what/if any remediation and solutions you have employed to deal with these issues. Be aware they can ask for additional references. One job asked me to provide contact information for some of my co-residents to ask what I was like to work with The Generic Interview Process: 1st Communication is typically a phone call; they will explain the practice and describe the position, ask some general questions about you, and allow you to ask general questions about the job. This is a high level, broad overview. This can often be with a recruiter first, and then will be repeated with whoever is ultimately in charge of the final decision to hire for the position. 2nd Communication can be a more in depth telephone interview, virtual interview, or in person interview. This is the time where you will discuss details of the job, they will ask more in depth questions about you, your experience, your life/personality, etc. This is when you will ask about job hours, office/hospital commitments, call, salary, benefits, etc. Be aware that some places won't talk about salary until the end. This can be a little weird but it does frequently happen where they want to get through the entire interview process and decide to offer you the position and then they will make you a salary offer (usually via a letter of intent, or LOI) and that's when you start negotiating the salary/benefits etc. Three of five places I interviewed with where I made it to an LOI hadn't actually calculated a salary yet and I had to wait a week while legal/HR did that and then they got back to me. I've no idea if this is normal but it is definitely a thing. 3rd Communication can be an additional in person interview if you're considering accepting the job where they may have a realtor show you around the place, could be contract negotiations prior to signing an LOI, after signing an LOI but before signing a contract, etc, or might be where they actually offer you a job. How to Find Job Postings: Professional Society Job Boards Journal Classified Ads You cold call and/or send letters/emails to program directors, hospital recruiters, etc. (particularly useful if you are region locked) Virtual job fairs Glassdoor/Indeed/Practicelink National/regional meetings Headhunters/Recruiters Personal Contacts/Word of Mouth/Your program director, fellowship director, or chairman Compensation Models: There are multiple compensation models that exist depending on your practice setting. Your ultimate contract may be one of these or a hybrid of any/all of these. You need to very clearly understand the differences between them, and you need to understand how they will change over time. Meaning that when your first contract runs out (typically 2-3 years) what can you expect contract re-negotiations to be like in the future? Fully Salaried: Pretty self descriptive here. You get paid a flat salary where all of your benefits are clearly defined and whether you show up and see one patient or show up and see fifty, you'll be getting paid the same. This model works well in academic positions where there is a significant research component, in some procedural specialties where you may have particularly long, extremely complex, very complicated procedures that mean you see less patients overall and do less procedures but may be working the same time as other docs in your field, for some cognitive specialties that require hours at a time dedicated to a single patient, or if you simply don't want variability in your pay. If you are fully salaried you should either have in a contract when/how/how much your salary will increase, or have language talking about how your salary will be determined in the future at the time of contract renegotiation. This is an employed only model of compensation. Base Salary + Productivity (Hereafter called RVU) Bonus: This compensation model means that you will receive a base salary every year regardless of how many patients or procedures you do. In addition, for each patient/RVU you see over the base salary you will be paid typically a set rate per RVU determined by an RVU conversion factor. The RVU bonus does not kick in until you have seen enough RVUs to meet your base salary (meaning if they did the reverse conversion of your salary into a number of RVUs, you have to do that much work before the bonus starts). The RVU bonus typically will kick in at 50th percentile RVUs on MGMA data, but not always and can be variable. In this compensation model you need to understand how they came up with the base salary, you need to know the RVU conversion, you need to know how many RVUs a typical doctor of your specialty will expect to do in a year, how many you can be anticipated to do in a year, how they chose the RVU conversion number, and when the RVU conversion number starts. Full Productivity/RVU: As it says, you will be paid based on the work you do. This compensation model is straightforward and is referred to as "eat what you kill" colloquially. Some contracts will start with a guarantee for anywhere from 1 to 3 years and then convert to an RVU only model. One huge important caveat of a full RVU model of compensation with no guarantee or base salary is that you need to understand if you are paid based on RVUs BILLED or RVUs COLLECTED!!! I cannot emphasize this enough. RVUs billed means that you are typically employed and you are going to be paid by the employer, the practice, your partners, whatever based on the day you do the work. However in private practice sometimes you can be paid on RVUs collected which means that you won't get paid until the money actually materializes from the patient or insurer and this can be months later. Months. You may go a fair stretch of time with no income. You just need to be aware of this. Salary Floors: Sometimes contracts will stipulate that you need to do X number of RVUs or else. The or else can be variable but can be a reduction in your salary, termination, who knows. I personally didn't receive a contract like that but one of my friends did. The floor is typically VERY low and easy to meet, like 10th percentile RVUs, but this can be an issue if you're starting a service line or practice from scratch. Salary Ceilings: Apparently this is actually pretty common until you become a partner in private practice, and can also be common in bigger system/employed positions. Your RVU bonus can have a cap (sometimes at 75th percentile, sometimes 90th percentile, or sometimes some other arbitrary number) where even if you saw 10,000 more patients, you won't make anymore money. Some non-profits (or even for profits) will attempt to tell you or write into your contract that you cannot be paid more than the 75th percentile OR 90th percentile because of fair market value and their tax exempt status. This is not true. The actual truth is that if you're being paid above the 75th percentile (usually closer to the 90th) you need to be able to justify that additional income by proving you are actually doing that amount of work. If you can't do this then yes, you can actually put them at risk of losing their tax exempt status. However, this is a relatively simple audit process of your productivity that you can request the organization do when it is time for your contract renegotiation. Again, a contract lawyer can sort this out for you - this is where it is well worth the money required to pay a contract lawyer. Non-RVU Based Work: I wanted to put a quick section in on this that you need to understand what your non-RVU obligations are and how you're going to get paid for them. This is way more applicable to academic jobs but is certainly not exclusive to them. To describe this work employers often use the term FTE or FTE Equivalent. FTE stands for Full Time Employee which is a little weird and misleading because they describe MAs and nurses by FTEs, doctors by FTEs, and even chairman/CEOs by FTEs. For your purposes as an attending a 1.0 FTE typically means the hours that an average physician in your specialty would make doing a regular week of clinical work. This matters because your salary will often be a 1.0 FTE, but your actual job duties might not be 1.0 FTE worth of clinical work. Why is this important? Because you may have protected time for your non-clinical obligations and it is typically measured in FTEs. Say you have a 40/60 split on research and clinical work in an academic job. In that case your job will be 0.4 FTE research and 0.6 FTE clinical. For a typical job that works five days a week, 40 hours a week, this means you will spend two days doing research and three days doing clinical work. Another example of this is the trauma/critical care surgeon. They are often broken up into doing a week of ICU, a week of trauma, a week of acute care surgery, and a week of administrative/personal time. Their contract might read as 0.25 FTE critical care, 0.25 FTE acute care, 0.25 FTE trauma, 0.25 research/admin and instead of describing how that time is allocated weekly it is allocated monthly. What things might make up non-RVU work? Admin Time like being a chairman or program director (not sure on chairman, but PD is minimum 0.5 FTE), associate program director (0.1 FTE) Research time, anywhere from 0.1-0.8 FTE depending on the job Education time Other Lastly I want to point out that this is important to understand not just for your initial contract but for as you grow in your job. Using me as another example, I'm working as a clinical HPB surgeon that is salaried. However, if I choose to be an associate program director or a medical director down the road I should get paid for that. When we decide how much I should get paid for that, those roles typically may be a 0.05 or 0.1 FTE. So we take my fully salaried position, multiply it by 0.1, and we should add that amount to my salary to account for my additional duties. It is quite frankly more complicated than that (particularly at a non-profit) because in some places on paper you can't work more than 1 FTE. Your employer will say things about non-profit, fair market value, etc. If you make it this far just get a contract lawyer and they'll sort all that shit out for you - this is mostly just to understand that if you take on additional duties (teaching, admin, directorship, whatever) you can use the FTE system to get a rough idea of how much you can ask to be paid for that extra work. Non FTE/Clinical/RVU Stipends Sometimes instead of going into your salary you get paid via stipend which is one method that we use to pay physicians that gets around the FTE cap I literally just described in one paragraph above. These stipends are usually in your contract but are separate from your salary for... the above reasons. You can get a stipend for admin work, research, teaching, on-call, for owning parts of the practice/being a partner (facility fee type things), consulting work etc. You may or may not have to quantify and justify the time you spend on this. For example, if you're a medical student preceptor, rather than paying you based on how much time you spend each week in the FTE model, they simply pay you a stipend per student, or per week, or per month and you are expected to educate the student and meet the expectations of the additional job duty. Interviewing: This is the only section I'm not going to go into heavy detail into, I just wanted to put a short segment here because chronologically this is where the interviewing piece will fall in your process. If you haven't figured out how to interview by now after medical school, residency, fellowship... I can't help you friend. Wear a nice suit and drink your coffee that morning. Smile a lot. Be excited and actually try to get to know the people you're interviewing with because they will likely be your partners and you genuinely want to know if you'll enjoy working alongside them. Good luck. Contract Lawyer: I'm putting this here because the advice I was given, and the advice I now give, is that THIS IS THE MOMENT you want to get your contract lawyer. Not when you actually have a contract, but right when/shortly before/shortly after you get a term sheet or letter of intent. If you choose to use a contract lawyer, he/she should be knowledgeable (or at least have some idea) about your specialty, have their own version of MGMA/AAMC data to reference, and can offer you advice on things you are going to want to ask about/discuss in a future contract prior to the contract. This is extremely valuable because its easier to ask for things and set expectations (for both you and your employer) up front, and during the LOI negotiation time, then when you get to the actual contract. For example if you sign an LOI saying your salary is 300k and then you get to the contract (which is often done by the legal department and not the people who control the purse strings) and say you want 400k, its going to cause issues and tension which is the last thing you want in your first job contract process. Let's address some specific things in addition: Do I really need a contract lawyer? Look, its up to you. Its your money. The answer is yes 99% of the time. Even if you're staying on wherever you did residency/fellowship, the answer is probably still yes. Your employers are not your friends. They are your bosses. They do not win by giving you extra money or extra perks. No matter how nice they seem or how much they seem to care, their priority is not your well being, it is theirs. Your well being may strongly factor into their offer to you, but it is not and will never be the first priority. If you're really lucky though you're applying to a place where its their second priority. Will a contract lawyer save me/make me money? This is a less straightforward answer. In 80% of the cases the answer is probably yes. For most people the return on investment of a contract lawyer is in orders of magnitude. Using myself as an example, I got offered my dream job at a salary that I felt was EXTREMELY competitive and I would have taken it with zero negotiation. My contract lawyer who cost me a flat $750 told me to ask for 50k, 100k, and 150k more on years 1, 2, and 3 of my salaried job. He said ask in very plain language, do not embellish why you want or need more money or why you deserve it, just plainly state you would like the salary to be X/Y/Z and see what happens. My job came back and offered me 10% more across all three years, at which point my contract lawyer told me "I've worked with your institution before and they always can be negotiated up at least 10%. I thought we would actually get more but this is still really good and in 3 years we can do better." Holy shit was he right because I would have taken their first offer and 10% was a lot of money compared to the $750 he cost me because this is now the floor for my salary at this place for the rest of my life. Over a 10 or 20 year career this will be like an extra million dollars or something silly. In 20% of cases the answer will be no. Some places simply will not negotiate, or you have much less bargaining power (region locked), or they offer all docs a set dollar amount (academic places/large corporations) that don't have variability, or they're just not going to negotiate because they don't have to. Are there reasons to have a contract lawyer review my contract even if they don't help me get a better salary? YES. Your contract lawyer will be able to translate your eventual contracts language around malpractice insurance, vacation, credentialing, HR policies, etc. into language that you can understand. They will alert you to red flags and recommend you ask for changes. They will review the exit clauses - what happens if you quit or the company tries to fire you which are not important until they're wildly important. I hope you find your dream job but everyone who quits their dream job (or gets fired from it) is because sometimes you wake up and you should be prepared for that eventuality even if you don't think it will ever happen. Is there a chance my contract lawyer reviews my contract and I learn absolutely nothing and gain nothing? YES. The only thing you may gain from this process is that he/she regurgitates information you already know because you, too, can read the written english language and already understand what's in the contract. Is it still worth it in this case? I can't answer that for you but my honest opinion is yes. You should want the peace of mind that you completely understand your contract, including any possible pitfalls, before you agree and sign it. Even if you just spent a thousand dollars for that advice and it changed nothing. Can you recommend a contract lawyer? Yes. PM me and I will send you the info for the guy who did mine, he works nationally. The White Coat Investor also has several recommendations. If you're going to find one on your own, my recommendation is that it is someone who has worked with other physicians (ideally at least in your specialty, if not your subspecialty) in your state of future employment unless they are experienced nationally working with multiple systems or physician contract law is all they practice. How much should a contract lawyer cost? I don't know for sure (being honest) but I believe its between $500-1500. The guy I used was $750 per contract but he would discuss letters of intent and job offers for free to help me compare. He would review more than one contract but it would be an additional $750 for each one if that were required. The Term Sheet/Letter of Intent: Some places sent me a term sheet up front at the time of interview or shortly thereafter, others gave me a verbal job offer followed by a letter of intent. Either way pretty much every place will give you some form of a 1-2 page document that is like the future TLDR of your contract. It will generally contain the following elements though some of them omitted parts (like retirement and malpractice which were provided in separate documentation for me upfront prior to the contract): Term of Employment/Agreement (Usually 2-3 years) FTE (Usually 1.0, which is between 32-40 hours of patient contact / week) Total Compensation Annual Base Salary Productivity Incentive/Bonus Quality/Provider/Rando Incentive Bonus Signing Bonus Relocation Assistance Professional Fees/Dues CME Allowance Paid Time Off Call Requirements and Call Bonus for Additional Call Health/Vision/Dental Retirement Non-Compete Malpractice What do you need to know about the LOI? You need to know that you want to have agreement on these top line items BEFORE you sign it, and before you move on to the contract phase. Again, a contract lawyer can be helpful here. You generally say something like "This LOI is very reasonable and I believe we will be able to get a signed contract without issue. After reviewing, I would like the salary to be 400k instead of 300k and would like the vacation time to be 8 weeks instead of 6 weeks. I have no requests for changes on any of the other terms." And then your potential employer will say "Well, I need to talk to so and so and we will consider, I'm not sure we can meet all of your requests but we will look at these items." And a day or two later you'll get a new LOI where the numbers probably went up some, not as much as you asked for, then you sign it and you're off to the races on your contract. This is the part where you agree on the total compensation and salary. If you do nothing else, you really should have this ironed out at this point. Keep in mind that the people who make and write your contract may have had nothing at all to do with the LOI. This was the case for me at the job I ended up taking. My contract was a standard contract for my specialty where the LOI had deviated on the salary and the vacation time. It wasn't a big deal at all, I just wrote to the lawyer people who were writing my contract and sent them a copy of my signed LOI which showed I had additional vacation time and dollars allocated to me. SEE PART TWO HERE: https://www.reddit.com/r/Residency/comments/ojk1fr/contract_negotiations_a_guide_part_2/?utm_source=share&utm_medium=web2x&context=3 I ran out of space. This was a long post.
My Co-Resident thinks he’s a Rizzident. How can I help him see the light!?
Serious case of cocky gen z syndrome. Refers to the nurses as “fyne shit!” He’ll even open with “yo fyne shit what happened to my patients?” Mind you some of these nurses are married or engaged He goes right up to nurses and introduces himself as their next boyfriend. Which has led to many complaints by staff. Whenever he gets rejected which he’s batting 100 on, he’ll go “I need to fugue out a way to rizz better.” Yesterday he asked a nurse, “yo fyne shit how can I rizz you up?” She turned to me and said, “Did he just ask me if he could jizz me up?” I’ve never been so second hand embarrassed. Edit: I just told him to chill out or else he’ll be canned for sexual harassment and he told me, “you mean sexual harizzment?” I can’t with him Edit2: I told him he needs to stop it and he told me he couldn’t because he was too “irrizzistable.” I responded that he was being “irizzponsible” I’m gonna kill him… smh
Fired for silly reasons from residency, need advice
My IM program just let me go, they said it's apparently uncouth to hit on your program director and use racial slurs around my colleagues about patients. I'm wondering if anyone knows any Ivy League programs with open plastic surgery positions? If not, any advice about starting a telehealth pediatric Botox and methadone clinic? I'd like to make at least 500k and work no more than 20 hours a week. Open to suggestions about how to move past this silly little speed bump.
What's the lifestyle habit That your speciality makes you do?
Every specialty has some type of lifestyle habit that promotes good health related to that specialty. This usually happens after seeing countless patients with a bread and butter problem that could have been avoided by practicing that habit. For example, for family medicine, the problem actually is bread and butter. Just kidding, but not really. I'm in dermatology, and for our field, it really boils down to one thing: Wearing sunscreen. Really. If you can wear sunscreen every morning, and then reapply every 2-3 hours when you're in the sun, you will be ahead of 99% of people. Your skin will stay younger appearing and your risk for sun-related skin cancers will be way lower. If people wore sunscreen the way we are supposed to, dermatologists would make 95% less money. The reason I'm asking this question is pretty selfish. I want to know what habit I should incorporate into my life from your specialty. Hit me with your classics. EDIT: Updates from the different comments GI: Get your colon cancer screening. USPSTF recommends starting at 45-years-old for average risk patients. It is a lifesaving screening with strong evidence that it helps people, unlike many other screenings out there. I know it's annoying and a hassle, but it is worth it. GI: Eat fiber. If you can adjust your diet to include high fiber foods, then that is amazing. Things like vegetables, beans, whole grains and quinoa, etc. However, if you can't, then at least take a daily fiber supplement. Not only does it make your GI tract function better and age better, it also just makes the experience of pooping so much more enjoyable. Imagine having the perfect poop every time you poop. It's worth taking the time to incorporate fiber into your diet, either naturally through your diet or artificially through supplementation. Trauma surgery: Never mind your own business at a gas station or street corner. Wear a seatbelt and don't buy a motorcycle. Wear helmets at all activities where it's feasible. And no ATV's / squads, ever. Lock up your guns so your kids don't play with them after school. Anesthesia: Constant forearm and wrist exercises to make sure my veins are absolute pipes. Daily mouth-opening stretches to improve my mallampati score. EM: Always look both ways, make sure my shoes are tied tight, check my rear view mirror often when I’m at a stop sign or red light (to make sure I’m not about to get annihilated by a car behind me), eat healthy and exercise regular to avoid HTN/HLD/DM (I see all the catastrophic consequences of these and trauma). OBGYN: Obgyn: Take prenatals BEFORE you plan on getting pregnant for best results. Also. Please. For the love of God. GET YOUR PAP SMEARS! Please please please get your pap smears and all the recommended follow up. The most devastating patients I’ve taken care of are the women in their 30s dying of cervical cancer. Several that I’ve taken care of were diagnosed in the last 2-3 years and are already dead. Family medicine: Family medicine: Do not: be poor, smoke, drink alcohol, do recreational drugs, have unprotected sexual intercourse, engage in dangerous activities, have an arduous/dangerous manual labour job, be sedentary, eat an unbalanced diet with ultra processed food which lacks minerals, vitamins, fibre and water but instead provides calories that exceed your requirements (ie don’t be fat), have shitty friends and family, ignore invitations for cancer screening, avoid vaccinations (seriously you utter fucking idiots) Neuroradiologist: Avoid ladders and horses. Cardiology: Plant-based diet. (still working on it…) And the 150 minutes of moderate aerobic exercise each week. Neurosurgery: Just a med student, but shadowed a neurosurgeon who focused on spine. 70% of his cases were old people or manual labor workers with spinal degeneration. Scared me into taking flexibility and stretching seriously. It is a big factor affecting quality of life as you get older (especially mobility). And it’s important to start establishing stretching habits early in life, because it’s not something that can be magically fixed once you are a 75-year-old. Ophtho: wear sunscreen, eat leafy greens, wear sunglasses, and don’t get diabetes. And don't sleep in your contacts Addiction med: I don’t recreational touch drugs. Ever. Too many people take them way too casually in my opinion (even things like marijuana but especially prescription opioids). People think it won’t happen to them but it impacts people from all backgrounds/social classes. Many people also think of addicts as your typical stereotypes (homeless, using needles) and don’t realize there is a huge spectrum. A lot of my patients start just using “one time” for fun or casually then it spirals. Primary care: go to your general practitioner at least once a year EVEN if you feel completely normal -- you may feel normal , does NOT mean your internals are normal -- by the time symptoms show up for some condition and diseases, its already too late to treat. Pediatrics: Pediatrics. Don’t be a shitty parent. Psych: I try to never shame my kids, teach them emotional regulation skills, be firm yet supportive, show interest in their interests and above all keep an open dialogue Interventional radiology: Don’t get drunk often. Nephrology: drink water to thirst, avoid getting diabetes, avoid getting htn, get yearly physicals, exercise, plant based diet. Neurology: control your diabetes, cholesterol, and blood pressure. One of my attendings loves to say a CVA is never an accident. Neurology. I NEVER EVER swim in fresh water. I also refuse to eat cow brain (a delicacy in my parent's motherland) Rheumatology: Be lucky to have a normal immune system, don't do hard manual labor, mind your posture, don't be a carnivore ENT: Don't smoke, don't drink a lot, and definitely don't do both. wear sunscreen. wear hearing protection on planes and at concerts/clubs. don't let kids anywhere near button batteries. watch kids like a hawk around any object that could fit in their ear, nose, or mouth IM: Don't smoke, don't drink, take your meds, remain insured.
As a Nurse, I am sick and tired of the constant rizzing from the residents.
Seriously, your game is not good. This one resident won't stop calling me, "fyne shit."Like can you at least use my first name? Also opening by calling someone shit is not a good strategy. Also I told one of the residents the year I was born and they were like oh you're ancient....Im pretty sure they are older than I am.... They are incessant with it. They now only refer to themselves as rizzidents whatever that means.As was explained to me by another nurse I guess its supposed to mean charisma in Gen Z language? I guess I'll have to rizzist your advances. You are not going to get any rizzults with me.Im really starting to rizzent you people.
Some of you need a social media refresher
The amount of people posting pictures on social media of themselves in the OR with a patients belly (or even open abdomen!) commemorating them moving on to the next year of residency is astounding. Seems like day 1 of med school they tell you not to do that
NP inadequacy
I’m an RN (don’t worry y’all, an RN who actually wants to be a nurse). This sub has been eye opening regarding midlevels and has brought a lot to light. But to vent, there are a few NP’s who practice independently in IM on noc that I have to deal with. They’re horrible. And I always thought they were just mean bc they thought they were better than all of us nurses with BSN’s. But it’s evident to me that they are insecure because they LITERALLY don’t know what to do. When I have to call them at re acute changes in patient condition, they DO NOT know what to do, cop an attitude, berate us, and chew our asses out. I could share so many anecdotes but I’ll spare ya. Honestly, it’s highly inappropriate and I’m Fucking sick of the way they speak to me. Half the time I can hear an MD in the background telling them what orders to write. And if he isn’t there then it’s fuck all. Sincerely, A VERY tired RN who is with y’all on this mid level bs
I made a terrible mistake and the patient died as a result
I'm currently an intern in the ER of a very busy hospital in a 3rd world country. A couple of nights ago I was on a night shift with 1 other colleague in a room with 15-20 patients that we had to see at once. A 50 something year old patient comes in complaining that his blood glucose is high and that he's just recently been started on insulin but he hasn't been taking anything for his diabetes for a few days because he doesn't know how to use the insulin. His son tells me that he's wondering if it's better to get him admitted to get his blood glucose under control. The patient says he also feels a bit dyspneic*.His past medical history is only significant for DM, and his RBG was 320 at the time of presentation. I draw an ABG and labs, run 500 ml of normal saline and put him on nebulisers. BP is 120/70. His labs come back normal, ABG comes back (as far as I can remember) pH 7.52 pCO2 28 HCO3 28. RBG goes down to 290 so I give another 500 ml of saline. I ask if his breathing has improved after the nebulisers, he says yes. I check his RBG after the second saline, it's 310. I ask if patient ate anything, and it turns out his daughter came and fed him pasta. I give 20 units of insulin and discharge. About 2 hours later I go to resus to get something from there and I find that same patient's relatives standing outside and sobbing. I walk inside and my patient is there, his eyes are wide open, his lips are blue, and his ECG is flat. My patient died the moment he got home. Looking back I think I did everything wrong. I didn't do an ECG nor did I further question his less than optimal ABG, and I very likely missed a silent MI/gave him too much insulin and discharged without monitoring. I feel so guilty and I'm questioning if I even deserve to be a doctor. I can't help but wish it was someone other than me that night because maybe then he could have been helped.
Humorous Patient-Centered Language
Let’s put aside any feelings we have about the burden of documentation with patient-centered language and enjoy the absurdity. I just heard someone describe a patient as "having difficulty participating in truthful conversations.” Even though it's cringe, in the age of open notes, I do find myself using "non-consensus reality" instead of "delusion." Or, for a patient in 10/10 pain: “Observed to be texting comfortably throughout the encounter.” Patient who is demanding or difficult: "Patient advocates strongly for needs." Any other favorites that you have? Or have found genuinely useful?
To all those saying AI will soon take over radiology
This week, OpenAI's ChatGPT: passed MBA exam given by Wharton passed most portions of the USMLE passed some portion of the bar Is AI coming for you fam? P.S. I'm a radiology resident who lol'd at everyone who said radiology is dumb and AI will take our jobs. Radiology is currently extremely under staffed and a very hot job market.
Are we tolerating the status quo too much? [Serious]
In today's medical culture, are we undervaluing physicians by tolerating the status quo? The status quo of rising medical school costs, poor mental health, mistreatment in residency, broken technologies, inflated administrative costs, etc?... We limit medical student postgraduate options to internship and residency, yet we graduate NPs and PAs to begin supervised practice with a starting average salary of $105,000.1,2 Meanwhile, medical students graduate unable to practice medicine without an internship (that pays an average starting salary of $56K.)3 I'm not arguing against physician extenders or residency. I'm arguing against the status quo in medicine. To be licensed as a physician in most states, you must complete a year-long internship.4 California is requiring multiple years of post-graduate training.5 Our status quo provides no in-between licensure options for medical students, while we are simultaneously graduating NPs and PAs into supervised practice. In 26 states, NPs can practice autonomously in their field immediately.6 Why are physicians that graduate from a US medical school and cannot match into a residency (for whatever reason) less able to practice medicine than NPs and PAs? Is it just the status quo? Right now, of the medical student graduates who do not go to residency, some become scribes, MAs, and consultants. 7 Very few find research jobs, and even fewer gain a temporary license that allows them to practice at the level of a mid-level under the supervision of a physician like you can in Missouri.8 So what are you, the physician, to do? The Flexner report of 1910 gave us the gold standard of medical training for the time,9 yet we act like no future improvements are needed today.10 If you're like me, you have some changes in mind. I can list several improvements I'd like to see. First, rising school costs are trapping students.11,12 Medical school graduates have, on average, $251,600 in debt these days.13 The debt doesn't disappear, either, for those who cannot match into a residency. Medical schools are increasing tuition annually and federal loans accrue interest from the beginning.14 Why do we allow interest to begin accruing so many years before employment is possible, and why do we pay so little? Medical schools should aim to produce autonomous physicians, but not every graduate can achieve an internship. What are they supposed to do? Physicians should create a "supervision-required" midlevel-style license for medical school graduates that haven't completed an intern year. Otherwise, less painful routes to the top of medicine will continue to gain steam. Administrators need to fill gaps in their hospital systems with providers from somewhere, after all. We have a physician shortage, despite an increasing number of medical schools and residencies.15-(16) In fact, the total number of residencies available has increased at the same rate as medical school enrollment.17 However, in 2019 there were still 44,603 students competing for 35,185 PGY-1 spots.18 You have a huge discrepancy between PCPs and subspecialists, so applicants are unevenly applying to the higher-paying fields. Also, IMGs are applying for US residency positions. Then there is the status quo of mental health crises among trainees and other physicians. Still, physicians and students commit a substantial number of suicides every year.19–23 That's not a fun fact. Perhaps you're like me and have known someone to take their own life. Medical training and practice are toxic because of the high stakes. There are board exams used as gatekeepers to certain competitive specialties. You are often sleep-deprived and stressed. Not to mention, if you are careless then someone dies (no pressure). Also, healthcare costs are skyrocketing due largely to administrative expansion.24 Overall, there are fewer and fewer resources for physicians to utilize.25 It's a tough environment right now. We have to buck the status quo. You can fix the illogical things we are doing in medicine, medical education, and healthcare policy without sacrificing quality. Where to start? Talk to each other. Share your goals, struggles, and challenges. Join together. Drop the poisonous attitudes, the fights, and the competition. Smell the roses. It just takes some common sense, optimism, and compromise. It takes all of us. Physicians need to get more active in politics. Policymakers aren't going to require changes without pressure from a coordinated movement by you, the physicians. For example, we have 1,100+ EHR vendors, in 2020, that cannot communicate data between each other. That is the status quo. However, if forced to do it, I argue EHRs could share data. How? If policymakers mandated some standard changes to the requirements for all EHRs. We would need to mandate the creation of a unique identifier that all healthcare providers use to find common patients, a mapping between coding languages, and a system to distribute stored data storage between systems.26–28 Today, I'm hoping to encourage all of you to remember your leadership roles in the hospital, the community, and beyond to seek progress. Physicians need to acknowledge this responsibility before things worsen. If we can do that, we don't have to worry about anything. The problem is, there are very few physicians with enough of a spine to stand up to the status quo. Perhaps you're discouraged, isolated, and overworked. You're not alone. We are waiting for others to fix medicine, but it's got to be us. It's got to be the physicians. The status quo has got to go. How will you stand up to it? References: Pa-C, S. P. Physician Assistant Salary Comparison Table | 2019 Pay by State | The Physician Assistant Life. The Physician Assistant Life https://www.thepalife.com/salary-2015/ (2019). Nurse Practitioner (NP) Salary Data | All Nursing Schools. All Nursing Schools https://www.allnursingschools.com/nurse-practitioner/salary/. Sign Up. Glassdoor https://www.glassdoor.com/Salaries/pgy1-resident-salary-SRCH_KO0,13.htm. Obtaining a medical license. American Medical Association https://www.ama-assn.org/residents-students/career-planning-resource/obtaining-medical-license. California Physician Professional Licensing Guide - Upwardly Global. Upwardly Global https://www.upwardlyglobal.org/get-hired/california-professional-licensing-guides/california-physician-professional-licensing-guide/. State Practice Environment. American Association of Nurse Practitioners https://www.aanp.org/advocacy/state/state-practice-environment. 10 Things To Do If You Did Not Match Into A Residency Position • Student Doctor Network. Student Doctor Network https://www.studentdoctor.net/2018/03/12/not-match-residency-position/ (2018). Assistant Physician Law. Missouri State Medical Association | Jefferson City, MO | https://www.msma.org/assistant-physician-law.html. Duffy, T. P. The Flexner Report--100 years later. Yale J. Biol. Med. 84, 269–276 (2011). Francis, C. K. Medical ethos and social responsibility in clinical medicine. J. Urban Health 78, 29–45 (2001). Kessler, S. Average Medical School Debt In 2017 - Student Debt Relief. Student Debt Relief | Student Loan Forgiveness https://www.studentdebtrelief.us/news/average-medical-school-debt/ (2018). Greysen, S. R., Chen, C. & Mullan, F. A history of medical student debt: observations and implications for the future of medical education. Acad. Med. 86, 840–845 (2011). Carter, M. Average Student Loan Debt for Medical School for 2020. Credible https://www.credible.com/blog/statistics/average-medical-school-debt/ (2019). Learn about interest and capitalization. Sallie Mae https://www.salliemae.com/student-loans/manage-your-private-student-loan/understand-student-loan-payments/learn-about-interest-and-capitalization/. New Findings Confirm Predictions on Physician Shortage | AAMC. AAMC https://www.aamc.org/news-insights/press-releases/new-findings-confirm-predictions-physician-shortage. U.S. medical school enrollment rises 30% | AAMC. AAMC https://www.aamc.org/news-insights/us-medical-school-enrollment-rises-30. Hayek, S. et al. Ten Year Projections for US Residency Positions: Will There be Enough Positions to Accommodate the Growing Number of U.S. Medical School Graduates? J. Surg. Educ. 75, 546–551 (2018). Main Residency Match Data and Reports - The Match, National Resident Matching Program. The Match, National Resident Matching Program http://www.nrmp.org/main-residency-match-data/. Physician Suicide: Overview, Depression in Physicians, Problems With Treating Physician Depression. https://emedicine.medscape.com/article/806779-overview (2019). 1103 doctor suicides & 13 reasons why | Pamela Wible MD. Pamela Wible MD https://www.idealmedicalcare.org/1103-doctor-suicides-13-reasons-why/ (2018). Farmer, B. When Doctors Struggle With Suicide, Their Profession Often Fails Them. NPR (2018). Kalmoe, M. C., Chapman, M. B., Gold, J. A. & Giedinghagen, A. M. Physician Suicide: A Call to Action. Mo. Med. 116, 211–216 (2019). Is your physician colleague at risk for suicide? Signs to look for. American Medical Association https://www.ama-assn.org/practice-management/physician-health/your-physician-colleague-risk-suicide-signs-look. Abrams, A. The U.S. Spends 2,500 Per Person on Health Care Administrative Costs. Canada Spends 550. Here’s Why. Time (2020). The shift to managing more patients with fewer resources. Healthcare IT News https://www.healthcareitnews.com/sponsored-content/shift-managing-more-patients-less-resources-0 (2016). Stephen H. Hanson, P.-C. EHRs Need to Talk to Each Other. (2016). Knowles, M. Patients likely to suffer when EHR systems can’t talk to each other, researcher says. https://www.beckershospitalreview.com/quality/patients-likely-to-suffer-when-ehr-systems-can-t-talk-to-each-other-researcher-says.html. Inability to share information across systems remains major EHR failure. (2017).
Please stand up for your interns
If you are a senior or an attending, please know that standing up for your interns will give them crazy respect for you. We had a patient be really rude to one of the new interns yesterday. The patient was known to be very difficult. Even the nursing staff were complaining and wanted her transferred because they couldn't work with her. I've only seen the PT a couple of times and immediately disliked her when she opened her mouth. Issue is, during morning rounds, the patient complained about the intern who was taking care of her to the attending. I don't know what exactly happened in the room but I know that specific intern is one of our best and can't have done anything egregious. Later, when talking to the intern, the attending followed the route of "what could you have done better?" instead of acknowledging the fact that the patient was very difficult. I do appreciate that every opportunity is a learning opportunity, but please please don't push your residents to become doormats.