“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Thursday, April 3, 2008

Regardless of how many times I do it 20 miles is still a long frickin run ...

"The range of what we think and do is limited by what we fail to notice. And because we fail to notice that we fail to notice, there is little we can do to change until we notice how failing to notice shapes our thoughts and deeds."
~R. D. Laing

About 5 years ago, I started running. On a dare, I ran a 1/2 marathon. I needed to be challenged. For someone who had never been a runner, the 13.1 mile distance seemed like an unsurmountable distance. After the race, I realized that it wasn't as difficult as I had expected. It didn't require a lot of training. Like many amateur runners, I quickly made the leap from 1/2 marathon to marathon. I read the books and got training plans. I talked to marathoners. The truth is that the marathon is not just running a 1/2 marathon twice. Most will tell you it is much more; the marathon begins after the 20th mile.

Marathon training can be painful. In the beginning, it's fun. Most of the runs are rather short. The average training plan is about 3-4 months. If you run regularly, the first few weeks are just a continuation of what you have been doing previously. The challenges come when the middle distance run is greater than 8 miles and your long run is greater that 16 miles. Training runs that use to be 30-60 minutes become 1 1/2 - 2 1/2 hrs. Injuries begin to pile up. Your body aches. You ask yourself on a number of occasions the question, why? For me the answer is, because it is there. It is a challenge. I will defeat the 26.1 mile monster. The training is a necessary evil. The long runs of 18-22 miles on a Sunday must be done to prepare me for the marathon day. If I don't prepare, I won't be ready and I will fail.

In one of the early posts, I wrote about how I felt residents and medical students today are soft. Maybe that was a little harsh; they are more like the new, the proud, and the privileged. Some who read this thought I was speaking to the hot button issue of the 80 hour work week. My opinions don't have anything to do with the hours spent in the hospital. It has nothing to do with them wanting to have a life, i.e. not being in the hospital all the time. It has more to do with how they view their chosen career. When you are training, you can't do it part time. Medicine is not a DELL computer where you choose only your favorite components. You can't come into a specialty without having at least a basic knowledge. These basic components become the building blocks for future learning and professional growth.

When I look at my residents and the young medical students, there is an inherent lack of drive to learn their craft. It is no longer a priority. Like many of my generation, Gen X, and even more so in the Mellinial generation, there is a undercurrent of entitlement. It is their right to be taught this information and to do these procedures. They are not here for so called "scut." Heaven forbid we talk about patient care and continuity of care. We are in the era of teams and patient hand offs. No one is responsible for a patient. Patients are handed from one person to another like a hot potato. The residents are well rested but who is actually responsible for the patient. Who is taking ownership? Ah yes, it is the attending's responsibility. So, now if I am going to do everything, why should I teach? And if the attendings and mid level providers are going to be doing a majority of the patient care, are we training 1/2 a physician? Are we training physicians who can pass a test but can't treat a patient?

Regardless of the rules and regulations placed on training, patients still expect you to be a physician. When a patient asks you a question, you can't answer "I missed that lecture because I was over hours." No matter how low the hour restrictions go, physicians in training will still need to gain the experience. They must put in the time to train.

Medicine is mountain, regardless of your specialty. The amount of information that you need to understand is increasing. In todays medicine, the number of known diseases, medications, diagnostic testing, and procedures, are probably double of what they were 20 years ago. The business end of medicine is more complicated. Medical practices have adjusted because of medical legal issues. The style of medicine practiced is affected by both private insurance and CMS. There are regulating agencies, like JCAHO, that make suggestions hospitals have to follow. Then there is the possibility of P4P. You must be a physician, business man, politician, and lawyer. To say we teach them all well would be the understatement of the century.

Like the marathon, medicine requires endurance training. It can be fun, but for the most part it is painful. For clinical medicine, you simply have to get the clinical experience. Book learning helps but experience solidifies the information and places the written word into perspective. Regardless of how smart you are, you still have to put in time outside of the hospital to read. The reading must be not only on clinical and basic science, but also on the business, and health policy, ect. You must train yourself to prepare for the end game, you medical career and practice. Everyday is a school day and contrary to popular belief, your learning and educating does not end at 80 hours; just like my run doesn't stop at 20 miles.

“Never mistake knowledge for wisdom. One helps you make a living; the other helps you make a life.”
~Sandra Carey


Chrysalis Angel said...

It has got to take an extraordinary amount of determination and wanting, I would think. I've often wondered how on earth you keep all that information in your head.

dokidok said...

Hmmm...very interesting post. I am still not even close to your professional and sport level, but I am slowly getting there...
About the marathon...yes, it sounds like a great challenge. This is the only reason I want to do it. I am giving myself 3 years before I run my first marathon. Do you think that when you train, running distances longer than the marathon distance will prepare you better? I know it sounds crazy, but that is what I do with my weight lifting training. If let's say my limit is 250 lbs, I always put another 5 lbs, until I get used to the new weight, and so for.
About the situation in the medical field...it seems like it is getting tougher and tougher. More work, less free time, lots of legal issues and the fear that you can loose everything (license, lifestyle, status). Even the money doctors make are not that much compare to what other people make with less work and sweat.

Taylor's Dad said...

Amen, brother! Warren Buffet was quoted once as saying he could not predict the future, but he knew when something was obsolete. He was answering a question about how he was able to navigate through the financial markets. I find this also applies to the "new model physician". The student or resident who puts his/her training 1st on the priority list is becoming harder to find. We are told that life should be pleasant and our priorities should be balanced and healthy. I agree. But most take this message and use it as an excuse not to commit fully (my opinion only). If one does not fully commit, then potential failure is easier to accept. The selfless provider who is willing to sacrifice for the benefit of a stranger in need is becoming obsolete.
There is a scene in one of my favorite movies, "The Departed", where the captain asks the rookie -"Do you want to be a cop, or do you want to appear to be a cop?" I believe that many of us want the perks, benefits, respect, etc. that go with this profession but I see very few willing to commit the necessary time and spirit to do our task justice. My generation is guilty of this shortcoming and I fear the situation will likely worsen. Maybe I am wrong?

cstew said...

I think you're spot on about medical students having a sense of entitlement, I think that part of the problem is the near complete lack of discipline. You have a bunch of stuck-up, think-the-world-owes-them medical students with administration who don't dare to correct a student or tell them they are out of line because heaven forbid their fragile psyche is damaged. How quickly we forget about the thousands of people beating down the doors to get in to medical school.

I will say that I think part of life is balance, and it seems that good physicians are well balanced physicians that aren't relying solely on their profession as their source of fulfillment/happiness, that said, I think the need for balance should be taken into account when my responsibility as a doctor (future) overlaps with another responsibility, e.g. my responsibility as a husband or father.

Anonymous said...

Being a third year med student, almost done with my core clerkships, I'd like to comment on this from our perspective, and then, from my perspective.

First: Medical students are quick learners to do what is most efficient. We always have our eye on the end game. In college, it was medical school, in medical school, it is residency.

Let's just forget about the first two years of medical school in this talk, because quite frankly, in my opinion, it has little to do with how the students will act, clinically.

Residency is based primarily on your step I/II scores and your grades, most probably, your clinical grades.

In our Surgery clerkship for instance, our grade is basically derived 50% from shelf exam score, and 50% by your ward attending/resident.

We as med students know that if we show up on time, and blend in with our peers, we're going to get 80-85% for our clerkship grade. If our resident/attending likes us, and we're actually halfway competant and helpful, we'll get a grade of 85%-90%. If we're lucky, and the attending is nice, we'll get a grade in the 90's.

If we bust our behinds, work hard, and become advocates for our patients, we're still going to ride that luck factor to get a grade above 90% (which is honors.) I've had attendings/residents praise me, say they've learned more from me than they thought they taught me, and still give me an 87.5. Tell me, what do you expect of me to do well? I've had residents and attendings put down "the best medical student I have ever had" etc. etc. in the their comments, and still give me a 95%, why not a 100%? If I performed above expectations, and was the best you have ever seen, doesn't that logically warrant a grade of 100%?

Granted, I know no one is perfect, and some can be more stringent than others, but seriously, give me a break. I've had (in college and other areas,) people say "I don't believe in giving 100's, no one is perfect." Well, by that same logic, if no one is perfect, and 100% can never be acheived, why have the score there to begin with??? In that case, should it not be assumed that 100% is "just less than perfect" ??

Anyway, enough with that rant :) The point is, in order to do really well in our clerkships, the effort required can be overwhelming. The extra effort required to get into the 90's for our grade is tremendous, and many times, regardless of how well you perform, there's still a significant chance that you won't get an exceptional grade.

We all know this. We've all been there. We know that attending "He's a jerk.. it's not worth it".

In the face of studying for a shelf exam or the myriad of ungraded pass/fail papers that you have us write, I am intelligent, I can balance my time.

Why do I do this? Well, I know that if I do well on the shelf, the 5-10% of the clinical grade that may be impossible to receive, will be easily superceded. Enough said.

So why should I bust my hump.. when I can study more, and make up for it on exam, and then some.

Consider the following (and this isn't me being arrogant or whatever.. this is just how it is):

Unfortunately (or fortunately, depending on how you look at it) my parents instilled a good work ethic in this young doctor. I care.. I really do. I work hard, examining patients, talking to them, building rapport, etc. I showed up 30 minutes before everyone else to preround on my patients, even though no one would ever hear my morning report. Yes, I can hear murmurs that residents can't pick up. Yes, I can put in IV's faster/more efficiently than my interns. Yes, when a patient is desat'ing, I have the ABG kit in my hand, and am feeling for a radial pulse before my resident says "we need an ABG." Yes, I've out diagnosed my resident and my attending. Yes, I paid attention, I read alot, and I understood. If i'm thrown in an ICU/SICU, I can navigate my way around, manage patients, and be confident. No, I know I'm not an attending, I know my limitations, but I also know that they're far beyond that of my peers.

Do I think that's because I am smarter, or better than my peers? No. It's because I know I worked harder to know this. And I damn well have the right to be proud of it. :)

Why did I learn this stuff? Because I think that doctors should graduate and know how to save people's lives. To be useful, and not just know a bunch of facts.

So I bust my hump, etc. And I am proud of myself..But then, I look at a peer of mine:

She shows up late, and does the bare minimum. It's a big month if she actually talks/puts her hands on a patient. She's "going into optho... why should she care?" She leaves early.. and studies while the attending is speaking.

No attending/resident is going to bad mouth her.. they're all too nice. They'll say something benign in her evaluation, and give her a grade of ~85. Then, she'll do well on the shelf.. and get honors.

Her transcript says honors
My transcript says honors.

To the residency world,.. we are equal.

I know more, I worked significantly harder.. but in the end, what difference did it make for the "end game?"

Yes, ideally, we all should be looking for the benifit for the patient.. and should learn to be the best that we can be.. Well, I say fiddle sticks to that.

The most important patient in this scenario is yourself. Who is going to sacrifice in a selfless way before themselves. Yes, there are a few.. but that is certainly not the majority.

So we are in a constant battle. And the grade is king, it truly is.

So, after a year of dealing with this junk.. yes, I now sometimes I find myself debating if I should put that extra effort in. I do it anyway, because I think it is the right thing to do. I feel obligated. I know I am not well accompanied in this thinking.

Most of us learn to just "get by".. and this is evident by the strength of the interns. Most of the interns I've encountered are babbling fools. Why? Because they "just got by" in medical school. It creates a viscious cycle. It sets the stage for residency.

In the wake of the recent match.. I feel bad for the folks who have to decide on these candidates. They all have honors.. they all did well. How do they judge work ethic and good clinical skills? It's almost impossible.

*sigh* what is ahead in the future..


Someonetc said...

Chrysalis: it does take a bit of spirit and courage for both. In the end though, it is all about your heart.

Dokidok: go for it, do the marathon. You will not regret it. As far as preparing for the long distances, unless you are an elite runner, I would not recommend running more than 20 miles for your longest run. My longest run prior to a marathon is usually 22. the point of distance training is to get you use to the distances without getting injured.

And the medical field is only a shell of its past prominence; all we really have left is our professionalism and autonomy. Soon that will be gone.

Taylor’s dad: what up dog? I agree with being well balanced, but at the same time being committed. I love the departed quote.

Cstew: agreed. I don’t think you need to sell your sole to the profession but you should be committed. Balance is key.

Anon (aka p3/4md) I am about to put you on blast because although your rant was not really about what I was posting on, it is exactly what my main frustration is with many (not all) of the medical students that I see and work with.

Alice said...

I think I and the other residents at my program do a decent job of staying beyond the set "shift" when there's more work to do. But I recognize that when we get to private practice, there will be no shifts, and no teammates to take over, and I don't know how well prepared we'll be.

For the medical student: you and that girl you describe sound exactly like two students who just finished a surgery rotation at my hospital. I don't know what's happening to your colleague, but the student at my hospital who behaved like that will either fail, or just barely scrape by. Believe me, we notice the difference between students who care and work hard, and those who are just trying to slide through.

Someonetc said...

alice: you are right, the how shift thing goes away when people are taking care of their own patients. we tend not to hand over our patients to our partners, so you stay until the work is done.

Anonymous said...

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