I should probably give myself a pass on blogging the day before intern year begins. Instead, I'll resort to an easy blogger's trick: ranting about something I watched on TV. I shouldn't watch medical shows. I know too much. It's just too frustrating to watch the incompetence of television medicine. I thought they have doctors consult on these things, but I guess they either ignore them, or the doctors that get these gigs are the worst doctors in the world.

There's a new show on the USA Network called Royal Pains. It starts Mark Feuerstein as a concierge doctor in the Hamptons. I don't know any concierge doctors, but I'm pretty sure it's a growth industry, especially if we nationalize health care. Rich people pay a doctor to be on personal call and come to their house to treat them. So the main case in the episode I saw was a high school kid who suddenly gets paralyzed and a whole cascade of catastrophic symptoms. And they run all sorts of tests (with hospital equipment that has somehow found its way into the rich person's house) and find nothing, until the guy's sister mentions the guy fell in the grass the other day-- and-- aha!-- the doctor looks in his ear, finds a tick-- and instantly the kid comes back to life and all of his symptoms go away. This is preposterous on so many levels. It's just not the way illness happens, or gets resolved, and not the way causes are discovered, and not anything remotely resembling a responsible depiction of reality.

Argh.

Just got back from health care orientation. You would think as doctors we'd have an awesome health care plan, but we get the same thing anyone else does. Choice between an HMO and a PPO and just because I'm a doctor doesn't mean I really know the difference. Co-pays, deductibles, I'm sure pretty soon I'll know how to game the system and all the tricks, but right now I'm assuming I'm not going to need much major medical care and I'm going with the low plan. Besides, how would it look if a doctor got sick and the hospital where he works wouldn't treat him? Hey, there's an idea for a movie. Or an instructional video.

My dentist double-bills the insurance company. I questioned my statement after I got it-- thought it was a mistake and I'd be charged more money. Called him up and he got on the line and said he just does it to save the patients the deductible and co-payment. And it's true he hadn't charged me-- I figured he would send a bill. He didn't. He wins and we win. Everyone wins but the insurance company. And who wants insurance companies to win? Well, at least until they go bankrupt or raise their premiums. I don't know what we're supposed to do as doctors, how far we're supposed to go for our patients, where the line is between using the system and misusing the system. As a med student I heard residents on the phone negotiating with insurers, figuring out with the phone representatives how to structure a diagnosis so that it's covered, figuring out that if you give 10 pills now and 20 pills later, they'll be covered but 30 up front won't be. It doesn't make sense. It's too complicated, it serves no one, it's pointless.

Yet at the same time I don't want to reflexively just say we should have government-run national health care without seeing that system in action. For the people who can get care, the care here is pretty darn good. We save people. We do amazing things. That they aren't always able to do everywhere else in the world. Yes, everyone deserves the best care we can give them. And, no, it's not right for one class of people to get "more" medicine than another class. But how to administer a system like that-- I don't know enough yet to know. And how to draw the line between necessary medicine and optional medicine-- well, that's easier, but on the margins it's not always so clear. Gastric bypass? Dermatological procedures? Fertility treatments?

And as far as figuring out how doctors are going to get paid... there's already such a disparity between generalists and specialists, a disparity not always particularly justified by the work we do, that I'd hate to see a new system come in that would make that problem worse instead of better.

But all of this is far enough from being well-informed that I shouldn't even be sharing. Once I'm in the system, I trust it'll at least be easier to feel like I know what I'm talking about. For now, I need to make what's sure to be twelve phone calls in order to get a pager that actually works.

Not to dwell on this part of my life, and especially not this early in the morning, but I fell asleep feeling kind of down that I don't imagine I met my wife at the social event last night. It's this weird sudden pressure, this sudden realization that the "normal" part of my life, at least for a few years, is over, in four days, and the craziness of intern year will begin. And that there's just no way that with my schedule, and with the kind of sleep-deprived, stressed-out person I'm almost certain to become, that any relationship is possibly going to work. And so every night for the next three years, I'm going to come home to an empty apartment, turn on the TV, make myself dinner for one, and collapse in my bed. That's a crappy life. Even if the work part is satisfying, which at this level there's no guarantee it will be. It's admin work, it's writing notes, it's entering orders, it's defensive medicine-- making sure my patients don't get worse. I'm going into primary care because I want to do offensive medicine-- preventative care, quality-of-life enhancement, I want to make people's lives better instead of just reacting to problems that are already too far along for medicine to do all that much. I don't want to spend my career working in a hospital setting. I want to do research, but more than that I want to see patients and develop relationships with them over the course of years and feel like a part of their lives. But if I'm working in an office, if I'm working normal hours-- I also want to have a family and someone to come home to. Which I'm more and more worried I won't.

Part of me knows this is silly, that the right relationship will happen when it happens, and even residency won't stop something that's supposed to happen from happening. And part of me even knows that residency can't possibly be as bad as everyone says it is-- nothing's ever as bad as people say it's going to be-- and I'll be fine. Look, I have colleagues with babies, I had medical school classmates with two kids, it's not easy but they make it work. And if they can make that work then certainly I can find time to go on a few dates or something. I've been to four weddings this year already-- what are they doing that I'm not? (Well, part of what they were doing was looking for a relationship. I only now realize I spent too much of the past ten years just assuming it would find me and not doing much to put myself out there. But that doesn't make me unique....)

I don't usually obsess about this. I think it's just the impending doom of this whole thing starting. It's like this is the last four days I will ever be completely free, ever. I'll have patients, I'll have responsibilities, I won't ever be free again (until I retire?). And so what am I doing with my last free Friday? Surfing the Internet. Ha.

We had a meet-and-greet last night at the Chief Resident's house. By now it shouldn't surprise me, but I'm constantly amazed to see how poorly so many doctors treat their bodies. You would think a hospital-sponsored gathering for incoming residents would at least make an effort to have some food that isn't horrifyingly terrible for you. (I mean, you would think hospital cafeterias would try to be decently healthy, and they're absolutely not at all, so I don't know why it should surprise me that the hopital events wouldn't be either.) All day we're supposed to be telling patients to avoid fatty foods, to wash their hands before they eat, to avoid cross-contamination-- yet all they give us to eat is two big platters, one with pigs in a blanket dripping with grease and the other with what I guess were egg rolls, but who even knows for sure. Everyone's shoving their hands in there trying to grab as many as they can, wiping their germs on all the rest of the food, and then I saw at least half a dozen people double-dipping into the mustard and the duck sauce. Maybe I'm oversensitive to this stuff-- okay, I'm sure I'm oversensitive to this stuff-- but isn't this how we learn disease spreads? I don't want other people's germs in my food-- not that I want this food to begin with.

As a profession, we do a terrible job of leading by example. Look outside any hospital and you see doctors and nurses, in their white coats and scrubs, smoking a cigarette or grabbing a hot dog off a street vendor. We have a discounted gym membership that the gym doesn't even know about because virtually no one has ever signed up to use it. We preach healthy eating and then there's not a place inside the hospital where you can get something that's not either deep-fried or out of a vending machine. We're not allowed to use our daily cafeteria stipend on bottled water, which is the only not-unhealthy thing in there.

The chief resident stepped outside at one point to have a cigarette. Sure, he acknowledged the absurdity of it-- made a joke about how it's the stress of the job, and he knows he should quit, but-- it's not even so much about the hypocrisy of telling our patients one thing and doing another, but merely having gone through med school and seeing actual lungs, and seeing patients in there years before they needed to be, because of choices they made in their lives and how they treated their bodies. If that's not making an impact on someone, then I don't know what they were paying attention to throughout medical school, and I'm not sure I want them as my doctor, honestly.

I'm still hoping to identify the couple of people I think I could really become friends with in this program, the ones I'm going to be able to commiserate with as the hours grow long and we've been standing in people's bodily fluids for hours. Oddly enough, part of why I wanted to be a doctor is the camaraderie I hoped for-- you're part of this exclusive club, you're in the trenches with these other people, fighting for something real. Lawyers don't get that-- they're in offices all day, alone, fighting for some vaguely-defensible client or corporation. You work for a business and it's much the same, you're just in an office, alone, doing your work. But as a doctor, you're supposedly helping people, and you get the adrenaline rush when there's an emergency and you can really, tangibly save someone. It's like team sports, in a way-- everyone's energy focused on the same thing. But even if that's how it looks on TV, it's not how I've seen it so far in reality. Everyone has his own agenda, everyone has his own pride, no one's really working together so much as working in their own bubbles and passing a chart back and forth. And too many people are drawn to medicine by the lure of the paycheck or the power-- not that my motives are any more pure, but still-- that in large part it's a bunch of pompous blowhards walking around thinking they can do no wrong.

I was talking to one of the other incoming residents and happened to ask him why he wanted to be a doctor-- he said he wanted to be a doctor so he could know people's secrets. I thought that was a particularly creepy motivation.

Off to learn how to fill out a W-4 form-- it's bizarre that on the one hand, they assume we're competent and smart enough people to be caring for the health of patients, but on the other hand they don't trust that we can figure out how to fill out a tax form without two hours of an incompetent administrator walking us through it step by step. We have a medical degree, for goodness sake-- we can fill out a W-4 on our own, we can figure out the online pharmaceutical ordering system, we can do a lot of things without being forced to sit through training sessions.

One week until the busiest year of my life begins, and so of course I've decided to start a blog. Personal details out of the way: I'm a 29-year-old guy about to start my intern year at a big-city hospital it's probably better not to name (but you've heard of it). Or maybe I'm not, and I'm just making all of this up. Either way, after four years of the craziness that is medical school, you get like two months to take a deep breath-- before starting all over again from the beginning. Except this time I actually have to know stuff or people could die. Well, sort of. This whole week has been full of people telling us there's a safety net and we're never going to be made to feel like we're in over our heads. We're not going to be able to cause anyone to die, at least not yet. Assuming the system works right. Which of course it won't, because if they can't even figure out how to print our ID badges correctly, I don't have a lot of faith they're going to be able to make sure I'm never put in a position where I can kill someone by accident.

As a potential patient, you should be happy to know that before they let us pretend we're doctors, the number of bureaucratic hoops we have to jump through is staggering. Somehow we're expected to believe that one day patient medical records can be digitized across hospitals such that you can see a patient's entire medical history when he comes into the ER-- except they haven't even figured out how to avoid having doctors fill out an entirely new set of paperwork for every hospital, even within the same system, that we might ever have to visit. There are four hospitals interns in my program will rotate through. For each one, I've filled out the very same forms to get the very same security check and a completely different ID badge. I've taken four tuberculosis tests, given blood four times, and had four drug tests. Drug tests, I feel compelled to tell you, that they've each allowed me to schedule myself. If I were taking drugs-- which I can promise you I'm not, at least not yet-- hopefully I wouldn't be taking so many that I wouldn't be able to figure out that I could schedule the tests all on one day, and just stop taking the drugs for the appropriate amount of time to get them out of my system-- and then once the test is done, just go right back to the regimen. I suppose they're still able to screen out users so screwed up they can't even stop for long enough to take a self-scheduled drug test, but if I'm a patient I'd kind of want the bar to be a little bit higher than that.

I didn't grow up in a family of doctors, I didn't know any doctors when I was a kid except my own pediatrician, who graduated from medical school back when they were still using leeches. So I went into medical school with the same preconceptions patients come into the hospital with-- that doctors are somehow super-human, and special. That's part of what made me want to be a doctor. I wanted to seem special, even though perhaps in reality I'm not. Medical school very quickly kills that notion, and the start of residency doesn't help bring it back. Doctors are like everyone else. Flawed, mostly stupid, and often not even particularly nice. There are exceptions. But, sadly, I've come to believe that most people would decide to chance their luck healing on their own 95% of the time if they really knew the people who they were trusting with their lives. I happen to be starting my intern year at a fine institution, with mostly smart people who all went to perfectly respectable medical schools and who I would probably at least trust to know when they don't know something and not put me directly in harm's way if it could be avoided. But if you live in the middle of nowhere-- or you live in the middle of somewhere but just don't know any better than to go to the closest hospital-- you have a pretty good chance of ending up with a doctor who wasn't smart enough to get into a legitimate medical school and paid $180,000 for a semi-absurd medical education in Dominica. Admittedly I haven't been in the system very long-- but I have never, ever seen a hospital patient ask their doctor where he or she went to medical school. Or college, for that matter. (I've also never seen anyone ask if their doctor is board-certified in whatever it is they happen to be doing for you-- but that's a whole different story.) Like any other profession, there are some who do this well and some who don't. People ask their plumbers for references, but assume their doctor is just fine simply because he puts out a sign. Not all care is the same.

But I've lost track of the initial point. I'm lucky to be at a hospital that acquits itself well when it comes to things like not leaving forceps inside of patients' chest cavities and not cutting off the wrong limb by mistake. I'm amazed, just in these first days of orientation, how much this feels like high school. We're being divided into separate "clans" entirely for social purposes-- a ready-made set of friends, as if any of us are going to even have time to see our real friends, let alone these new folks. And as if any of us are going to want to hang out with doctors when we're not on duty. The last thing I'm going to want to talk about is medicine.

I worry-- and looking at my life now compared to my life four years ago, it's a reasonable concern-- that very soon I'm going to be like the doctors I met when interviewing for medical school, unable to talk about anything besides their patients and some crazy story about a bodily fluid that somehow ended up in a hilarious place (we all love stories about bodily fluids that come out of any and all cavities, unexpectedly and without warning). I used to be interesting (I think). I used to have opinions about things. I used to have hobbies, interests, extracurricular activities. I don't anymore. And I can't see how that's going to change once the 80 hour work weeks start. I'm a bit ashamed to admit-- and I haven't been admitting this during the orientation exercises at all-- that I spent most of these past eight weeks of vacation sleeping and watching the Food Network. Alone. I actually made up a trip. I've been telling people I went to Spain with three friends from college who all lost their law firm jobs with the economy ridiculousness. I looked on Wikipedia and got some details about stuff I could say I saw and did. But I've never been to Spain and don't even really have three friends anymore. Okay, not entirely true-- I have three friends, I just don't see them half as much as I should, because no one ever seems to know when they're going to get off work and once people flake on dinner plans three or four or nine times in a row, you start to lose patience.

I shouldn't be so down on myself-- I have friends. I'm just worried I won't see them anymore. And I'm thoroughly annoyed at myself for somehow getting to this point in my life without having a settled and stable personal life. There are all of these single doctors you meet in med school and the first reaction everyone has is to pity them-- they missed the chance to find a match in college, and now there's really no shot. With the overnight shifts and the 6-day-a-week schedule for the next three years it's impossible to start a real relationship with anyone who isn't on the same schedule. And so to have not locked someone up by now-- to have not settled for something, anything to make sure I'm not going to spend my whole life alone-- it's a failure on my part, and now it's too late to fix it. And if this is all I'm going to have for the rest of my life-- if I'm going to be hanging all of my happiness on being a doctor, and not have the family to go home to-- I worry I'm setting myself up for a bit of disappointment in life. Certainly my parents are disappointed at the prospect of me being 33 when I finish my residency and still no closer to giving them grandkids.

Tomorrow we have a get-to-kn0w-each-other party, following eight hours of CPR training. Trust me, if I'm the one giving you CPR-- you are not in good shape.

Hope I can keep the blog going. Thanks for reading. More soon.